Application of the Summary of Diabetes Self-Care Activities Questionnaire in Evaluating the Self-Care of People with Diabetes

Abstract

Objectives: This uncontrolled open study aimed to measure the levels of self-care of patients before and after education, their initial knowledge, and their knowledge two months after interacting with healthcare providers using the Summary of Diabetes Self-Care Activities (SDSCA) questionnaire. Methods: The data for this study were collected over 14 months from 396 patients with diabetes. This study was conducted in three phases: initial questionnaire testing, education, and retesting after two months. The education included specific diabetes-related topics: nutrition, exercise, self-monitoring of blood glucose, foot care, and smoking. Results: The results showed that all self-care activities between the first and second assessments were different. The initial assessment showed that the more successful the general diet, the specific diet, and physical activity were, the better the hemoglobin A1c value was. When considering the impact of gender on self-care effectiveness results, it was noted that women were more successful in foot care and specific diet in the initial testing, while men excelled in physical activity. The most successful age group in the scales of general diet, physical activity, and blood glucose testing was 31–45 years. Those with type 1 diabetes (36% of the study population) were more successful in self-care in the first and second measurements but without any differences in self-care in the retesting. Conclusions: our study observed a difference in self-care results between the two measurements of self-care activities in patients with diabetes, evaluated by the SDSCA questionnaire.

1. Introduction

Diabetes is a group of metabolic diseases characterized by hyperglycemia, with a significant increase in the number of affected individuals aged 20–79, as well as in the cost of treating its complications [1]. The fundamental principles of treating and managing individuals with diabetes, in addition to pharmacological treatment, are education and support immediately following diagnosis.

Lifestyle management is a fundamental aspect of diabetes care, encompassing education and support for diabetes self-management, nutritional management, physical activity, smoking cessation, and psychosocial care. Educators assess diets, lifestyle, therapy adherence, and self-monitoring [2]. Additionally, evaluating self-care abilities is necessary due to the impact of stress and social support on self-care activities and their relationship with glucose control. Lifelong education for individuals with diabetes involves adopting self-care activities so that the responsibility for self-management and decision-making regarding their condition is transferred from the educators to the individual [3]. Starting from the initial comprehensive assessment, ongoing monitoring and evaluation are needed to track the development of complications, manage chronic conditions, and address other comorbidities to improve diabetes care [4,5,6,7,8].

Self-care in diabetes allows individuals to significantly contribute to their own care. Daily self-care interventions include lifestyle adjustments, blood glucose testing, dietary and physical activity changes, foot care, and smoking cessation [9]. Throughout their lives, people with diabetes develop and refine their self-care skills. It can be said that these skills evolve alongside their ability to manage diabetes from diagnosis to end of life, with psychosocial support from family and educators being crucial for glycemic control [10].

Several systematic reviews of diabetes self-management measurement tools confirm that while many different instruments have been developed, most have been used in only a limited number of studies and their measurement properties have often been inadequately evaluated [11,12]. The Summary of Diabetes Self-Care Activities (SDSCA) questionnaire is a concise yet reliable and valid self-reporting tool for assessing diabetes self-management, making it valuable for both research and clinical practice [13]. In our study, we used the SDSCA questionnaire in order to test this tool and, based on this assessment, adjust it for future national studies. This included addressing the importance of the educational process, examining various forms of education tailored to national needs, and developing tools for future self-care assessments where gaps exist.

Croatia is facing a growing problem of obesity and diabetes. Over the last five years, Croatia has ranked first in Europe for diabetes-related mortality and, along with Malta, first in terms of obesity. In 2011, more than 15,000 patients with type 2 diabetes participated in nursing evaluations and education programs, with the majority being assessed as well-informed and knowledgeable about diabetes self-management behaviors [14]. However, over 60% of patients in Croatia, most of whom were treated with traditional oral antidiabetics, did not achieve adequate disease control [15]. Considering these factors, any new tool that can improve glucose control and reduce the risk of death from diabetes and its complications is welcome, and additional efforts are essential to improve diabetes control and outcomes.

Our study aimed to take the first step in evaluating the self-care abilities of people with diabetes before and after personalized education using the SDSCA questionnaire. Additionally, it was important to describe the sample of people with diabetes in Croatia, their initial knowledge, and their knowledge two months after interaction with healthcare providers.

2. Materials and Methods

2.1. Sample

The sample consisted of 396 individuals diagnosed with type 1 and type 2 diabetes, hospitalized at the Vuk Vrhovac Clinic for Diabetes, Merkur University Hospital, Zagreb, between January 2019 and April 2020. The patients were not necessarily hospitalized due to their chronic conditions but were admitted specifically for education and the evaluation of potential complications. Hospitalization at our clinic, which is a referral center for diabetes in Croatia, is a standard protocol for patients from various parts of the country. All patients aged over 18 years and hospitalized during the 14-month period were included. The exclusion criteria were patients with acute complications of diabetes and those with acute psychiatric conditions.

2.2. Measurement Instrument

The SDSCA questionnaire was used to assess self-care behaviors. This questionnaire underwent two validity checks: one from three studies in 1994 by Toobert and Glasgow and another from seven studies in 2000 by Toobert, Hampson, and Glasgow. The latest validated version of the SDSCA questionnaire is brief yet reliable, valid for assessing self-care in individuals with diabetes, and useful for both research and practice. The latest, revised version recommends the use of this instrument in diabetes self-management studies [13]. The questionnaire has been translated into multiple languages, including Croatian. We used this questionnaire in our study for several reasons. The first reason is its simplicity and efficiency in assessing the self-care activities of individuals with diabetes. The second reason is that the questionnaire has been translated into Croatian. The third reason concerns the methodology of data collection in the second measurement, where patients completed the questionnaire after two months and returned it by mail. We believe that a larger number of questions might have reduced the number of questionnaires returned.

The scale measures how often per week (0–7 days) individuals adhere to recommendations related to diet, exercise, blood glucose testing, foot care, and smoking. The self-care questionnaire consists of 11 items. The diet domain includes four questions, exercise two questions, blood glucose testing two questions, foot care two questions, and smoking one question. Each domain is scored by the average rating of responses. A higher score indicates more adequate self-care. Only question number 4, on specific diet, is reverse-scored (0 = 7, 1 = 6, 2 = 5, 3 = 4, 4 = 3, 5 = 2, 6 = 1, 7 = 0).

The continuation of testing was carried out on the basic self-care subscales: general diet, specific diet, physical activity, blood glucose testing, and foot care. The general diet domain included two questions: “How many of the last SEVEN DAYS have you followed a healthy eating plan?” and “On average, over the past month, how many DAYS PER WEEK have you followed your eating plan?”. The second scale, specific diet, included the questions “On how many of the last SEVEN DAYS did you eat five or more servings of fruits and vegetables?” and “On how many of the last SEVEN DAYS did you eat high-fat foods such as red meat or full-fat dairy products?”. The physical activity scale included the questions “On how many of the last SEVEN DAYS did you participate in at least 30 min of physical activity? (Total minutes of continuous activity, including walking)” and “On how many of the last SEVEN DAYS did you participate in a specific exercise session (such as swimming, walking, biking) other than what you do around the house or as part of your work?”. The blood glucose testing domain included the questions “On how many of the last SEVEN DAYS did you test your blood sugar?” and “On how many of the last SEVEN DAYS did you test your blood sugar the number of times recommended by your health care provider?”. The foot care scale included the questions “On how many of the last SEVEN DAYS did you check your feet?” and “On how many of the last SEVEN DAYS did you inspect the inside of your shoes?”.

2.3. Research Process

The research was conducted in three stages. The first stage involved an initial assessment of the self-care activities of all participants using the SDSCA questionnaire (Questionnaire 1). Based on these results, an individualized education plan was developed for all participants according to their needs indicated in Questionnaire 1. The second stage consisted of a three-day education session following the protocol. After this session, the same questionnaire (Questionnaire 2) was administered to all participants. They were asked to complete Questionnaire 2 after two months and mail the completed form to the researcher. In the third stage, we received Questionnaire 2 filled out by 396 participants after two months. Finally, in our analysis, we included only the patients who completed both questionnaires (1 and 2). Given that two months had elapsed between the first and second measurements, and that the second measurement was not taken on site but was instead sent by mail from the participants’ residences, the number of responses received was expected.

This is a brief description of the intervention: A three-day individual education session was conducted, covering general information about diabetes, its complications, and therapy. The education also included specific diabetes-related topics: nutrition, exercise, self-monitoring of blood glucose, foot care, and smoking. The intervention followed a planned structured protocol. The content of the intervention included interactive teaching methods; training in the techniques of insulin/injectable preparation administration, glucose monitoring with a glucometer, and continuous glucose monitoring; and the use of food models and the plate model for nutrition education. The “problem-solving” method was used to teach independent problem-solving skills. The diabetes educators had formal education, with bachelor’s degrees in nursing; informal education through international and national institutions; and many years of experience as diabetes educators.

2.4. Statistical Analysis

This study is based on a quantitative research approach. Numerical variables were described using measures of central tendency and dispersion. Frequency was measured within appropriate confidence limits. Numerical variables were tested for normality of distribution using the Shapiro–Wilk and Kolmogorov–Smirnov tests. Before analysis of the results of self-care obtained from the questionnaire, a test of normality of distribution was conducted for the questionnaire items. The Kolmogorov–Smirnov test performed on all questionnaire items for both the first and second assessments showed significant deviation from normal distribution (p < 0.001), necessitating the use of non-parametric statistical analyses. Non-parametric tests such as the Mann–Whitney U or Kruskal–Wallis test were used to test group differences. The McNemar test was used for the significance test for the self-care item on smoking. The Mann–Whitney U and Kruskal–Wallis tests were used to compare the ordinal variables. The reliability of the questionnaire was measured using Cronbach’s Alpha test. Spearman’s correlation coefficient was used to explore the relationships between the observed variables. Data processing was conducted using SPSS version 26.

3. Results

The characteristics of the respondents are shown in

Table 1. Sociodemographic characteristics of patients.

			N	%
Hemoglobin A1c	<6.5%		80	20.2%
	6.5–7.5%		134	33.8%
	>7.5%		182	46.0%
	Total		396	100.0%
Type of diabetes	1		143	36.1%
	2		253	63.9%
	Total		396	100.0%
Duration of diabetes	<5 years		52	13.1%
	6–10 years		67	16.9%
	11–20 years		145	36.6%
	>20 years		132	33.3%
	Total		396	100.0%
Family status	Single		70	17.7%
	Lives with family		326	82.3%
	Total		396	100.0%
Employment status	Employed		97	24.5%
	Unemployed		49	12.4%
	Retired		250	63.1%
	Total		396	100.0%
Education level	Without education		7	1.8%
	Elementary		70	17.7%
	High		224	56.6%
	College		88	22.2%
	Master’s degree		6	1.5%
	Doctorate		1	0.3%
	Total		396	100.0%
Income (respondents’ opinion)	Adequate		113	28.5%
	Average		192	48.5%
	Inadequate		91	23.0%
	Total		396	100.0%
Movement problems	Yes	134	33.8%
	No	262	66.2%
	Total	396	100.0%
Vision problems	Yes	232	58.6%
	No	164	41.4%
	Total	396	100.0%
Hearing problems	Yes	108	27.3%
	No	288	72.7%
	Total	396	100.0%

. It can be observed that the largest share of respondents (46.0%) falls into the hemoglobin A1c (HbA1c) > 7.5% category. Overall, it can be concluded that only 20.2% of respondents have HbA1c within the target range of <6.5%. In analyzing types of diabetes, 63.9% have type 2 diabetes. Regarding the duration of diabetes, the largest percentage of respondents falls into the 11–20 years category (36.6%). When asked about their living arrangements, 82.3% reported living with family. In terms of employment status, 63.1% are retired. The majority of respondents have a high school education (56.6%), while a low percentage have no formal education (1.8%). Average income was reported by 48.5% of respondents. Difficulties with mobility were reported by 33.8% of respondents, 58.6% reported vision difficulties, and 27.3% reported hearing difficulties (Table 1).

The patients with type 1 diabetes have longer durations of diabetes. The ratio of men and women is similar to type 2 diabetes; HbA1c is approximately the same, but those with type 2 diabetes are older, with shorter durations of diabetes. There are 168 subjects (42.4%) on insulin therapy, and 228 (57.6%) were treated with oral hypoglycemic agents (

Table 2. Characteristics of patients depending on the type of diabetes and diabetes therapy.

Type of Diabetes	Gender		Average HbA1c (%)	Average Age (y)	Average Diabetes Duration (y)
	M	F
Diabetes type 1	53%	47%	7.6	54.9	21.9
Diabetes type 2	58%	42%	7.7	65.5	16.2
			N		%
Diabetes therapy	Insulin		168		42.4
	OHA		228		57.6

).

The descriptive results (

Table 3. Self-care—descriptive data of the first and second measurements.

	1st Measurement				2nd Measurement
	N	Percentiles			N	Percentiles
		25th	50th (Median)	75th		25th	50th (Median)	75th
How many of the last SEVEN DAYS have you followed a healthy eating plan?	396	3.00	4.00	5.00	396	4.00	5.00	7.00
On average, over the past month, how many DAYS PER WEEK have you followed your eating plan?	396	2.00	4.00	5.00	396	4.00	5.00	7.00
On how many of the last SEVEN DAYS did you eat five or more servings of fruits and vegetables?	396	2.00	3.00	5.00	396	3.00	5.00	6.00
On how many of the last SEVEN DAYS did you eat high-fat foods such as red meat or full-fat dairy products?	396	2.00	4.00	5.00	396	3.00	5.00	6.00
On how many of the last SEVEN DAYS did you participate in at least 30 min of physical activity? (Total minutes of continuous activity, including walking)	396	2.00	4.00	6.00	396	3.00	5.00	7.00
On how many of the last SEVEN DAYS did you participate in a specific exercise session (such as swimming, walking, biking) other than what you do around the house or as part of your work?	396	0.00	2.00	4.00	396	0.00	3.00	6.00
On how many of the last SEVEN DAYS did you test your blood sugar?	396	4.00	7.00	7.00	396	6.00	7.00	7.00
On how many of the last SEVEN DAYS did you test your blood sugar the number of times recommended by your health care provider?	396	2.00	5.00	7.00	396	5.00	7.00	7.00
On how many of the last SEVEN DAYS did you check your feet?	396	2.00	5.00	7.00	396	4.00	6.00	7.00
On how many of the last SEVEN DAYS did you inspect the inside of your shoes?	396	0.00	1.00	5.00	396	1.00	3.00	7.00

) of the self-care assessment, expressed as the medians and interquartile range (IQR) for the first and second assessments, show that the lowest median is 1 day for the question “On how many of the last SEVEN DAYS did you inspect the inside of your shoes?” The next lowest median is 2 days for the question “On how many of the last SEVEN DAYS did you participate in a specific exercise session (such as swimming, walking, biking) other than what you do around the house or as part of your work?” The highest median value is 7 days for the question “On how many of the last SEVEN DAYS did you test your blood sugar?” The second measurement showed that extra physical activity and checking the inside of shoes were still the worst self-care activities. The highest median values (seven days) were achieved for both questions about blood glucose testing. The only self-care activity that worsened according to the median value was the intake of fatty foods, contrary to the received recommendations.

For the self-care item about smoking, regarding the variable “Have you smoked a cigarette—even one puff—during the last SEVEN DAYS?”, no difference was observed in the assessments for both the first and second measurements. In other words, there was no difference in self-care activities related to smoking cessation after the education. Eighty percent of participants who were on insulin therapy measured their blood sugar levels during the 7 days of the week in the initial measurement and ninety percent in the repeated measurement (

Table 4. Number of days of the week with blood sugar measurement in participants on insulin therapy.

	Days	1st Measurement	2nd Measurement
On how many of the last SEVEN DAYS did you test your blood sugar?	0	3%	1%
	1	1%	1%
	2	2%	0%
	3	1%	2%
	4	5%	1%
	5	5%	3%
	6	3%	3%
	7	80%	90%

).

Examining the impact of HbA1c on self-care indicators, this research found that HbA1c levels were associated with self-care activities. Individuals with HbA1c levels below 6.5% exhibited better self-care. The people with type 1 diabetes had better self-care compared with those with type 2 diabetes. Women were more successful in specific diets and foot care than men, while men were more successful in physical activity than women. Individuals aged 31–45 were more successful in general diet, physical activity, and blood glucose testing than other age groups. Unemployed individuals were more successful in general diet and exercise than employed individuals and retirees. Family status and personal income did not impact self-care. Educational level showed an impact on physical activity and foot care, with higher education correlating with better self-care.

The patients with type 1 diabetes were more successful in self-care compared with those with type 2 diabetes in both the first and second measurements, except in the area of specific nutrition. However, it should be noted that there was a visible lack of difference in self-care in the second measurement compared with the first measurement among the patients with type 1 diabetes (

Table 5. Relation between type of diabetes and self-care assessment.

1st Measurement					2nd Measurement
	Type of Diabetes	N	$\bar{\mathbf{x}}$ Ranks	p	$\bar{\mathbf{x}}$ Ranks	p
General diet	1	143	218.07	0.010	215.98	0.021
	2	253	187.44		188.62
	Ʃ	396
Specific diet	1	143	202.76	0.575	197.56	0.902
	2	253	196.09		199.03
	Ʃ	396
Exercise	1	143	224.20	0.001	216.85	0.016
	2	253	183.97		188.13
	Ʃ	396
Blood glucose testing	1	143	259.28	0.000	237.63	0.000
	2	253	164.15		176.38
	Ʃ	396
Foot care	1	143	219.75	0.005	215.24	0.027
	2	253	186.49		189.04
	Ʃ	396

).

Table 6. Correlation between self-care variables of differences in two assessments.

		General Diet	Specific Diet	Exercise	Blood Glucose Testing	Foot Care
General diet	r	1.000	0.185 **	0.029	0.249 **	0.188 **
	p	.	0.000	0.565	0.000	0.000
	N	396	396	396	396	396
Specific diet	r	0.185 **	1.000	0.044	0.134 **	−0.017
	p	0.000	.	0.387	0.008	0.740
	N	396	396	396	396	396
Exercise	r	0.029	0.044	1.000	0.089	0.130 **
	p	0.565	0.387	.	0.076	0.010
	N	396	396	396	396	396
Blood glucose testing	r	0.249 **	0.134 **	0.089	1.000	0.236 **
	p	0.000	0.008	0.076	.	0.000
	N	396	396	396	396	396
Foot care	r	0.188 **	−0.017	0.130 **	0.236 **	1.000
	p	0.000	0.740	0.010	0.000	.
	N	396	396	396	396	396

Abbreviations: **, correlation is significant at 0.01; r, correlation coefficient.

shows that a positive correlation was recorded between the differences in the self-care variables in the two assessments. The highest correlations can be noted between the self-care activities of general diet and blood glucose testing (r = 0.249; p < 0.01) and between general diet and foot care (r = 0.188; p < 0.01). Physical activity correlates well with foot care (r = 0.130; p < 0.01). Similarly, there are good correlations between glucose testing and foot care (r = 0.236; p < 0.01) and between glucose testing and specific diet (r = 134, p = 0.08).

4. Discussion

The results of our study, which included 396 patients with diabetes who were educated on specific diabetes-related topics by healthcare providers, suggest that the levels of self-care before and after education, as measured by the SDSCA questionnaire, differed. Education for individuals with diabetes is an integral part of a comprehensive treatment approach. Alongside pharmacological treatment, self-monitoring, and exercise, education serves as the foundation of independent disease management. Its goal is to enable individuals to become active participants in their treatment, capable of contributing to the success of their therapy through self-care activities. Measurement tools for evaluating self-management behavior are valuable for both diabetes research and clinical practice. Our study included patients with both type 1 and type 2 diabetes, with a mean age of 61 years, who were admitted for hospital evaluation of chronic complications. Elderly individuals typically have a burden of comorbidities, reduced mobility, impaired vision, and cardiovascular diseases, which can complicate the education process but also make it more efficient in hospital settings [16]. A planned hospitalization lasting 2–3 days provides an opportunity to evaluate the chronic complications of diabetes, assess existing therapy, and educate patients on self-care and disease management. It also allows educators to enhance motivation and strengthen self-efficacy.

The American Diabetes Association (ADA) recommends certain content and timing of diabetes education. This content includes information on diabetes, nutrition, medication administration, exercise, and self-monitoring [17]. Additionally, interventions for decision-making in various glycemic states are employed. The ADA advises that education be conducted immediately upon the diagnosis of diabetes, at annual check-ups, when complications arise, and during transitions from one life stage to another. The Croatian guidelines for the pharmacological treatment of type 2 diabetes provide, alongside treatment recommendations, information on sociodemographic influences on glycemic targets and the significance of self-care in achieving optimal control of metabolic parameters in individuals with type 2 diabetes [18]. Nursing evaluation and education carried out in our population of over 15,000 patients with type 2 diabetes in 2011 suggested that most patients were assessed as well-informed and knowledgeable about diabetes self-management behaviors. However, in reality, Croatia faces the highest mortality rate from diabetes in Europe [14,15]. All these factors indicate that additional efforts must be made to improve diabetes control and outcomes. Life expectancy may contribute to a lack of motivation, inertia, and the prevalence of depressive symptoms in this population [19,20]. On the other hand, individuals in this age group have developed habits and attitudes that must be considered when designing educational programs aimed at changing behavior. These individuals generally adhere to instructions regarding medication and insulin intake but often maintain other habits, such as a sedentary lifestyle and the consumption of fatty meals and sugary drinks, that do not contribute to their health [21].

In our study, nearly one-fifth of the respondents lived alone, while the remainder lived with their families. Diabetes is a chronic disease in which personal engagement and family support play a crucial role in managing the condition. This support is especially beneficial in diabetes self-management education, contributing significantly to the improvement of self-care among individuals with diabetes [22]. However, in our study, family status and personal income did not have impacts on self-care. A quarter of the respondents were employed, while more than two-thirds were retirees, which was consistent with the average age of the participants. More than one-fifth of the respondents reported their financial situations as poor. Personal income and employment status significantly affect the quality of life for individuals with diabetes, influencing their responses to education and their ability to engage in self-care [23]. Such barriers to education and self-care can sometimes result in attempts to shift the responsibility for self-care from the individual to the educator [24]. However, the majority of our respondents had completed high school education, suggesting that the initial conditions for education were met. For individuals with low literacy, pictorial materials were utilized during the educational process. In addition to education, demographic, social, and cultural factors also influence positive diabetes outcomes [25]. Therefore, these factors should be taken into account before the educational process begins to ensure that the education is appropriately adapted.

In examining the average indicators of diabetes regulation, specifically HbA1c, it can be concluded that the studied population primarily consists of individuals with poor disease management. Elevated HbA1c levels, along with glucose variability due to glucotoxicity, contribute to the development of microvascular and macrovascular complications of diabetes [26,27]. The average duration of diabetes among the participants was nearly 20 years. While it might be expected that these respondents possess considerable experience and knowledge about self-care, they may also have a significant number of diabetes-related complications that could hinder their educational progress and self-care efforts [24].

Among the physical aspects of health that could interfere with self-care and education, over one-third of the respondents reported difficulties with mobility, more than half reported vision difficulties, and nearly one-third reported hearing difficulties. We included patients with vision impairments in the education program because medication packaging and insulin pens are designed for use by blind individuals and self-monitoring devices for blood glucose are available for completely blind individuals in the form of talking devices. Both the individuals and their families were educated about these tools [28]. For individuals with limited mobility due to diabetic foot issues and lower extremity amputations, education was conducted at the bedside, with the duration adjusted according to the respondents’ conditions.

Self-care for individuals with diabetes is a demanding daily commitment. The activities they perform are integral to their lives and routines, defining their lifestyle and incorporating modern technological aids such as glucose monitoring devices, mobile applications, and continuous glucose monitors (CGMs) [29]. In diabetes, self-care activities play a more significant role in determining disease outcomes and prognosis than in most other diseases [30]. Self-care behavior is very complex, as it encompasses several aspects, including medication adherence, healthy eating, physical activity, monitoring, risk reduction, problem-solving, and healthy coping [31]. The data obtained from the initial assessment, where respondents reported how many days per week they adhered to specific self-care activities, showed that they were most successful in monitoring blood glucose levels and caring for their feet. Important decisions regarding self-care are based on blood glucose control [32,33]. Consequently, foot disease can be very difficult for them to endure. In addition, foot care reflects hygienic habits related to maintaining healthy feet. Self-care activities for foot care contribute to the prevention of diabetic foot complications, including the most severe outcome: amputation [34,35,36].

The self-care results from the repeated questionnaire, administered two months after the education, show an improvement in diet, indicating that the respondents understand the importance of food in maintaining health, achieving metabolic control goals, and preventing diabetes complications. Saumika and colleagues [37] reported somewhat worse results in their study compared with those of this study, even though the measurement instrument in both studies was the same. The weakest results in the second assessment of the self-care activities were related to physical activity exceeding 30 min and checking the insides of shoes. As observed in the first assessment, physical activity remains a significant challenge for respondents in this study. Similar findings of poor adherence to physical activity guidelines have been reported in studies using the same measurement instrument [38]. After the conducting of personalized education, respondents showed significant improvement in all self-care activities except for smoking [39].

Changing dietary habits is difficult, and a single educational session is unlikely to alter established eating patterns. Diet is a habit cultivated from birth within the family. The culture of eating emphasizes sharing food and emotions simultaneously, accommodating guests at social gatherings, and prioritizing tasty food over healthy options, often neglecting the needs of individuals with diabetes [40]. It can be said that the respondents in this study were inclined to change their eating habits except for their consumption of fatty foods. In our study, the most challenging behaviors to change were the consumption of fatty foods, increasing physical activity, and smoking. Regarding the consumption of fatty foods, we should consider whether the issue arose from a potentially unclear question. Our results are consistent with another study conducted on patients with diabetes in Greece, which suggests that even small interventions can yield the desired results. However, perseverance and the adaptation of programs to the specific characteristics and cultural beliefs of patients are necessary [41]. Physical activity has proven to be the most challenging habit to change, as the decision to engage in it is influenced not only by physical health and an understanding of its positive effects but also by internal motivation and empowerment [42]. A recently published study on patients with type 2 diabetes also found that the physical activity levels among these patients were unfavorable. Additional efforts must be made to emphasize the role of physical activity in preventing cardiovascular disease and diabetes-related complications in this population [43]. In contrast, physical activity has significantly increased among individuals with type 1 diabetes over the last 10 years [44]. Smoking is the only self-care activity for which no difference was observed before and after education. Other studies also indicate that educational programs on diabetes are not an effective method for changing smoking habits in individuals with diabetes [45]. The co-occurrence of smoking, one of the major modifiable risk factors for mortality, with diabetes is common. A recently published study found that over 37% of men with diabetes smoke, and all healthcare providers (nurses, dietitians) should receive additional training to assist those who smoke in quitting [46].

Numerous studies show similarities with the results obtained in this research: self-care activities are influenced by various predictors, but self-care can be significantly improved through the educational process [47,48,49,50,51]. In our study, the scales for specific diet and physical activity did not show satisfactory consistency in the questionnaire. The latest revision of the SDSCA questionnaire, conducted by Toobert et al. [13], made changes to some parts of the questionnaire that exhibited inconsistency, aiming to establish it as a reliable instrument for measuring self-care. This research highlights the need for further studies to potentially revise the questionnaire in Croatian for better comprehension. Testing the differences between the self-care assessments across all five scales—healthy eating, specific diet, physical activity, blood glucose testing, and foot care—revealed differences after the second self-care assessment when the questionnaire was used and analyzed according to group parameters.

5. Limitations

The research was conducted under hospital care conditions, with a time frame of several days for personalized education. The second assessment was conducted two months after the education. It would be interesting to conduct a longitudinal study to evaluate the results of self-care after several months or a year.

6. Conclusions

Effective self-care and self-care activities are crucial for positive diabetes outcomes. The initial measurement of self-care indicated that the participants were most successful in monitoring their blood glucose levels and in foot care. A difference in self-care results, evaluated by the SDSCA questionnaire, was observed. Less difference was observed in those with type 1 diabetes. It would be interesting to investigate type 1 and type 2 diabetes separately in future studies. However, the most challenging behaviors to change were the consumption of fatty foods, increasing physical activity, and smoking. These results suggest that greater emphasis should be placed on these self-care activities in educational interventions.