Knowledge, attitude, and practice (KAP) of primary health physicians towards self-glucose monitoring in patients with type2 diabetes mellitus in Palestine.

doi:10.21203/rs.3.rs-4969187/v1

Background: Type 2 Diabetes Mellitus (T2DM) stands as a significant global health challenge, exerting profound effects on individuals and societies. In the context of Palestine, this condition affects 9.2% of the population and contributes to a relatively high complication rate. Diabetes management strategies need to be optimized to improve patient outcomes and alleviate the strain on the healthcare system. One of these strategies is self-glucose monitoring. One of the physicians’ roles in T2DM management is explaining and guiding patients towards the integration of self-glucose monitoring into their personal diabetes management routine.

This study assess knowledge, attitudes, and practices of physicians who care for (T2DM) patients in primary healthcare clinics in the West Bank regarding self-glucose monitoring.

Methods: A cross-sectional study, it was applied to 300 physicians working in PHC centers. The study period was from January to March 2024 Data was collected through a self-administered questionnaire.

Results: A total of 300 doctors participated in this study. The median age of the doctors was 35.0 [30.0, 41.0] years. Of the doctors, 180 (60.0%) were male. The median duration of practice as a doctor was 9.0 [5.0, 15.0] years. Most, 252 (84.0%), were general practitioners, 38 (12.7%) family medicine specialists, and 10 (3.3%) other specialties. Female doctors and those who saw more patients reported better knowledge (p < 0.05). The majority believed that self-glucose monitoring can improve patient outcomes, knew values of self-glucose monitoring that corresponded to HbA1c control and the microvascular consequences of diabetes, and realized the important of self-glucose monitoring for patient. Regarding the doctors’practices, 39.3% of the doctors stated that they would recommend self-glucose monitoring to newly diagnosed type 2 diabetes patients more than one time a day.

Conclusion: Primary healthcare physicians had adequate knowledge and positive attitudes towards self-glucose monitoring, but 40% not confident or somewhat confident about interpreting self-monitoring data and adjusting treatment plans. Physicians’ practices related to self-glucose monitoring was less than optimal. Future studies should investigate knowledge, attitudes, and practices of physicians who care for the patients in the private sector. ALSO call for more frequent continuing education.

Type 2 Diabetes Mellitus

Glucose Monitor

Primary Healthcare

Diabetes Mellitus Type 2 (T2DM) has a major impact on the health of individuals and societies worldwide [1]. In 2021, the global cost of diabetes was $966B/year taking into account the cost of treating conditions caused by diabetes, which ultimately led to death [2].

In Palestine, T2DM is a major public health concern affecting 9.2% of the general population [3]. In addition, T2DM complications in Palestine are relatively high, with microvascular complications affecting 38.7%, and macrovascular affecting 15.7% of diabetic patients [4]. The high rate of T2DM complications in Palestine suggests a clear deficiency in disease management in Palestine and the need for more management strategies. One of these strategies is self-glucose monitoring. [5, 6].

Self-glucose monitoring refers to the practice where individuals with diabetes measure their own blood glucose levels using a personal glucose meter [5, 7, 8]. Through the past years, and with more effort being put into managing T2DM, self-glucose monitoring became the cornerstone for diabetes self-management and has been shown to be effective in improving diabetes outcomes [5].

New research emphasizes the importance of self-glucose monitoring in T2DM management [9].

As T2DM is prevalent in Palestine, and many patients suffer from its complications [3, 4], the research team investigated a cornerstones of T2DM self-management, self-glucose monitoring. Many studies investigate patients’ KAP in T2DM management. The research team wanted to examine the other aspect of any disease management, the primary healthcare physicians’ approach toward incorporating it into their practices. Sufficient knowledge, appropriate attitudes, and comprehensive practice by physicians are critical to giving the patients the tools and skills to incorporate self-glucose monitoring into their self-diabetes management.

To date, little is known about the knowledge, attitude, or practice among primary health physicians in Palestine regarding the use of self-glucose monitoring for T2DM patients.

The findings of this study may help to define the key barriers and facilitators that influence the adoption of self-glucose monitoring in clinical settings among primary health physicians and to propose actionable strategies to address the identified barriers, and promote the identified facilitators, to ensure improved adoption and implementation of self-glucose monitoring for T2DM management in Palestine.

Study Design and Settings

The study was designed as a cross-sectional survey targeting primary physicians in public primary health care centers and UNARWA clinics in the West Bank. The study duration was January to March 2024.

Population

All primary health physicians actively practicing in the West Bank who managed or had the potential to manage patients with T2DM were potential participants. This includes general practitioners (GPs), family medicine specialists, and other specialists who manage patients with T2DM. Palestine had 765 of primary health care centers, of which 606 centers were in the West Bank [3].

Sample Size and Sampling Technique

According to the Palestinian Ministry of Health, there are approximately 510 physicians [3, 4]. The sample size was calculated using a 95% confidence level, and a 0.05 absolute precision. Because the prevalence of the dependent variable was unknown, we assumed the effect size to be 50%, which was the maximum variability. The target sample size was 300 physicians.

Measurement tools and data collection

The questionnaire was derived from the literature, and reviewed and modified several times by the research team [2, 7]. The questionnaire was piloted with 30 primary health physicians to evaluate the tool's comprehensibility, validity, and estimated completion time., refinements were made to the questionnaire based on the feedback. The Cronbach's Alpha was calculated at 0.79, indicating acceptable internal consistency of the questionnaire. These rigorous steps in the questionnaire's development, piloting, and refinement ensured the tool's validity. The tool's accessibility and reach were increased by using web link to an online self-reported questionnaire using “Google Forms”, Facebook, WhatsApp and other social media. The links were sent to the potential participants who were invited to participate in the study.

Data Analysis

The data collected were entered into a statistical software package (Statistical Product and Service Solutions SPSS). Descriptive statistics like frequencies, percentages, medians, and interquartile range [Q1, Q3] were calculated. Differences in the knowledge scores were tested using Mann-Whitney U test and Kruskal Wallis test. A p of < 0.05 was considered statistically significant.

Ethical consideration

The participants were informed about the purpose of the study, their rights to decline or withdraw at any point, and the confidentiality of their responses. The Institutional Review Board (IRB) at An Najah National University approved the study.

Characteristics of the participants

A total of 300 doctors participated in this study. The median age of the doctors was 35.0 [30.0, 41.0] years. Of the doctors, 180 (60.0%) were male. The median duration of practice as a doctor was 9.0 [5.0, 15.0] years. Of the doctors, 252 (84.0%) were general practitioners, 38 (12.7%) were family medicine specialists, and 10 (3.3%) were of other specialties. More than 90% of the doctors stated that they see more than 10 diabetic patients in their clinics per week for management and treatment of their condition. Of the doctors, 30 (10.0%) reported never having attended a diabetes education workshop after graduation. The detailed practice and demographic variables of the doctors are shown in Table 1.

Table 1. Detailed practice and demographic variables of the doctors

Variables	Frequency (%) n = 300
Age (years) < 35	139 (46.3)
≥ 35	161 (53.7)
Gender Male	180 (60.0)
Female	120 (40.0)
Duration of practice as a doctor (years) < 10	158 (52.7)
≥ 10	142 (47.3)
Specialty GP	252 (84.0)
Family medicine	38 (12.7)
Other	10 (3.3)
On average, how many diabetic patients do you see in your clinic each week for management and treatment of their condition? < 10	25 (8.3)
11-20	91 (30.3)
21-30 31-40	86 (28.7) 45 (15.0)
> 40	53 (17.7)
When was the last time you attended a diabetes education workshop after graduation? Never	30 (10.0)
More than 5 years	161 (53.7)
In the past 3-4 years	73 (24.3)
In the past 1-2 years	36 (12.0)

Sources of information used by the doctor to obtained knowledge about diabetes

Of the doctors, 227 (75.7%) stated that they used sources published by the WHO and 168 (56.0%) stated that they used UpToDate. The sources stated by the doctors are shown in Table 2.

Table 2. Sources of information used by the doctor to obtained knowledge about diabetes

#	Source	Frequency (%)
1	UpToDate	168 (56.0)
2	American Diabetes Association	118 (39.3)
3	American Academy of Family Physicians (AAFP)	68 (22.7)
4	American College of Endocrinology	54 (18.0)
5	Live Continuing Medical Education	15 (5.0)
6	Pharmaceutical industry representatives	34 (11.3)
7	The World health Organization (WHO)	227 (75.7)
8	Journal articles/reviews	39 (13.0)
9	DynaMed	13 (4.3)
10	American Association of Clinical Endocrinologists (AACE)	11 (3.7)
11	American Association of Physician Assistants (AAPA)	19 (6.3)
12	American Association of Nurse Practitioners (AANP)	7 (2.3)

All doctors listed 3 signs of hyperglycemia. Of the doctors, 186 (62.0%), 65 (21.7%), and 49 (16.3%) thought that false-positive hyperglycemia was caused by contaminated gluco-check slides, patient malpractices, and post prandial rise in blood glucose, respectively.

The doctors answered a knowledge test about the fasting blood glucose, random blood glucose, glycated hemoglobin HbA1c, and self-glucose monitoring. The answers of the doctors are shown in Table 3.

Table 3. Answers of the knowledge test

#

Source

Frequency (%)

1

What is the cut-off value for diabetes in "Fasting blood glucose" test (mg/dl)?

95

100

125

126

140

146

200

3 (1.0)

14 (4.7)

1 (0.3)

266 (88.7)

12 (4.0)

1 (0.3)

3 (1.0)

2

What is the cut-off value for pre-diabetes in "Fasting blood glucose" test (mg/dl)?

95

100

125

126

140

146

200

19 (6.3)

232 (77.3)

4 (1.3)

25 (8.3)

10 (3.3)

3 (1.0)

7 (2.3)

3

What is the cut-off value for diabetes in "Random blood glucose" test (mg/dl)?

95

100

126

140

146

180

200

3 (1.0)

7 (2.3)

30 (10.0)

4 (1.3)

2 (0.7)

251 (83.7)

4

What is the cut-off value for pre-diabetes in "Random blood glucose" test (mg/dl)?

95

100

126

140

146

110

199

200

2 (0.7)

13 (4.3)

32 (10.7)

113 (37.7)

122 (40.7)

1 90.3)

5 (1.7)

12 (4.0)

5

What is the cut-off value for diabetes in "Glycated Hemoglobin HbA1c" test (%)?

5.5

5.6

5.7

6.4

6.5

7.0

7.5

7 (2.3)

1 (0.3)

24 (8.0)

1 (0.3)

255 (85.0)

10 (3.3)

2 (0.7)

6

What is the cut-off value for pre- diabetes in "Glycated Hemoglobin HbA1c" test (%)?

5.0

5.5

5.7

6.4

6.5

7.0

3 (1.0)

21 (7.0)

238 (79.3)

5 (1.7)

31 (10.3)

2 (0.7)

7

Which of the following glucose monitor values is considered an emergency and necessitates immediate medical attention?

130

200

350

500

2 (0.7)

25 (8.3)

63 (21.0)

210 (70.0)

8

What is the definition of self-glucose monitoring?

A technique for patients to monitor their own blood glucose levels at

Home

A method of measuring blood glucose levels with a continuous monitoring device

A laboratory test used to determine the body's insulin levels

232 (77.3)

59 (19.7)

9 (3 .0)

9

What is the difference between self-glucose monitoring and laboratory-based glucose testing?

Self-glucose monitoring provides immediate results, whereas laboratory testing takes longer

There is no distinction between self-glucose monitoring and laboratory-based testing

Self-glucose monitoring is more precise than laboratory testing and it is not commonly used in clinical practice

253 (84.3)

13 (4.3)

34 (11.3)

10

Which of the following is NOT a commonly used technique for self-glucose monitoring by type 2 diabetes patients?

Urine glucose testing

Flash Glucose Monitoring (FGM)

Continuous Glucose Monitoring (CGM)

Fingerstick blood glucose testing

196 (65.3)

20 (6.7)

39 (13.0)

45 (15.0)

11

According to your knowledge, self-glucose monitoring helps in reducing the chance of which of the following complications?

Incomplete answer

Cardiovascular disease, kidney failure, blindness

128 (42.7)

172 (57.1)

Association between the doctors’ variables and knowledge

There were significant differences in the knowledge scores of the doctors in relation to gender, the average number of diabetic patients seen per week, and attending an education workshop after graduation. Female doctors and those see more patients demonstrated higher knowledge. The associations are shown in Table 4.

Table 4. Association between the variables of the doctors and knowledge

Variables	Knowledge score
Variables	Median [Q1-Q3]	p-value ^a
Age (years) < 35	70 [50-80]	0.146 ^b
≥ 35	80 [60-80]	0.146 ^b
Gender Male	70 [50-80]	<0.001 ^b
Female	80 [60-80]	<0.001 ^b
Duration of practice as a doctor (years) < 10	70 [50-80]	0.973 ^b
≥ 10	70 [60-80]	0.973 ^b
Specialty GP	80 [60-80]	0.374 ^c
Family medicine	70 [60-80]
Other	70 [50-80]
On average, how many diabetic patients do you see in your clinic each week for management and treatment of their condition? < 10	80 [60-80]	0.018 ^c
11-20	70 [50-80]
21-30	80 [60-80]
31-40	80 [50-80]
> 40	70 [60-80]
When was the last time you attended a diabetes education workshop after graduation? Never	80 [80-80]	0.001 ^c
More than 5 years	80 [80-80]
In the past 3-4 years	80 [80-80]
In the past 1-2 years	80 [70-80]

^a The bold values indicate p <0.05

^b Statistically significant values were calculated using the Mann–Whitney U test

^b Statistically significant values were calculated using the Kruskal–Wallis test

Attitudes of the doctors towards self-glucose monitoring

The doctors regarded self-glucose monitoring as beneficial to the quality of life of the patient. Only 8.0% of the doctors stated that they would not routinely recommend self-glucose monitoring to their patients. Similarly, the majority believed that self-glucose monitoring improveed patient outcomes, believed that the values of self-glucose monitoring correspond to HbA1c control and microvascular consequences of diabetes. The majority were confident in their ability to educate the patients about the use of self-glucose monitoring devices. See Table 5.

Table 5. Doctors’ attitude about self-glucose monitoring

#

Item

Frequency (%)

1

How beneficial do you think self-glucose monitoring is for increasing patients' quality of life?

Somewhat beneficial

Beneficial

Extremely beneficial

28 (9.3)

201 (67.0)

71 (23.7)

2

Would you recommend self-glucose monitoring to all of your T2DM patients on a regular basis?

No

Yes, but only for certain cases

Yes, for all

24 (8.0)

143 (47.7)

133 (44.3)

3

I strongly believe that self-glucose monitoring improves patient outcomes in type 2 diabetes therapy by allowing for improved glycemic control and lowering the risk of complications.

Disagree

Neutral

Agree

Strongly agree

7 (2.3)

35 (11.7)

174 (58.0)

84 (28.0)

4

Rate your belief that your patients' self-glucose monitoring values correspond to their HbA1c control and microvascular consequences of diabetes

Not sure

Poor

Good

Strong

10 (3.3)

18 (6.0)

174 (58.0)

98 (32.7)

5

I am confident in my abilities to educate patients on the use of self-glucose monitoring devices.

Disagree

Neutral

Agree

Strongly agree

9 (3.0)

63 (21.0)

144 (48.0)

84 (28.0)

6

I realize the importance of self-glucose monitoring not only as a diagnostic and therapeutic tool, but also as an important component of patient education, assisting patients in understanding the impact of lifestyle choices on diabetes care.

Disagree

Neutral

Agree

Strongly agree

11 (3.7)

41 (13.7)

181 (60.3)

67 (22.3)

7

I recognize the importance of self-glucose monitoring in improving patient compliance and medication adherence, and I am committed to resolving any impediments or challenges that my patients may have in efficiently using these monitoring methods.

Disagree

Neutral

Agree

Strongly agree

13 (4.3)

43 (14.3)

194 (64.7)

50 (16.7)

Doctors’ self-glucose monitoring practices

Regarding the doctors’ practices, 39.3% stated that they would recommend self-glucose monitoring to newly diagnosed type 2 diabetes patients more than one time a day. More than half (54.0%) of the doctors stated that they would educate and coach patients on proper self-glucose monitoring techniques during follow-up visits. More than a third, 40.0% stated that they always give their patients glucose level goals for self-monitoring, and 25.3% stated that they always reviewed the self-glucose monitoring data during consultations. When asked about their confidence in their ability to interpret self-glucose monitoring data and modify treatment plans accordingly, 12.3% of the doctors stated that they were very confident. More than half (58.0%) offered training or instructional courses to their patients about self-glucose monitoring. More than half stated that 25% of their patients returned to clinics with diabetes-related complications. Less than half reported that their patients highly or very highly adhered to the prescribed treatment plan. See Table 6.

Table 6. Doctors’ answers on the practice items

#

Item

Frequency (%)

1

How often do you recommend self-glucose monitoring to newly diagnosed type 2 diabetes patients?

Never

Only during specific circumstances (e.g., illness, medication changes)

At every visit

Several times a week

Once a day

More than one time a day

4 (1.3)

40 (13.3)

27 (9.0)

36 (12.0)

75 (25.0)

118 (39.3)

2

How frequently do you educate and coach your patients on proper self-glucose monitoring techniques?

Never

At the time of diagnosis only

During follow-up visits as needed

Regularly during scheduled diabetes education sessions

I refer patients to diabetes educators for this purpose

17 (5.7)

41 (13.7)

162 (54.0)

41 (13.7)

39 (13.0)

3

Do you give your patients particular goal glucose levels for self-monitoring (e.g., fasting, pre-meal, post-meal) to help their monitoring effort?

No, never

No, not usually

Yes, in specific cases

Yes, always

7 (2.3)

44 (14.7)

129 (43.0)

120 (40.0)

4

During consultations, how frequently do you review your patients' self-glucose monitoring data?

Never

Rarely

Sometimes

Often

Always

4 (1.3)

26 (8.7)

64 (21.3)

130 (43.3)

76 (25.3)

5

How confident are you in interpreting self-glucose monitoring data and modifying treatment plans accordingly?

Not confident

Somewhat confident

Confident

Very confident

30 (10.0)

88 (29.3)

145 (48.3)

37 (12.3)

6

Do you offer self-glucose monitoring training or instructional courses to your T2DM patients?

No

Yes

126 (42.0)

174 (58.0)

7

How many of the patients diagnosed with diabetes at your facility have returned with diabetes-related complications?

I'm not sure/not appropriate

No diabetic patients have returned with complications

Less than 25% of diabetic individuals have returned with difficulties.

Between 25% and 50% of diabetic patients have returned with problems

More than half of the diabetic individuals returned with difficulties

36 (12.0)

9 (3.0)

98 (32.7)

129 (43.0)

28 (9.3)

8

How would you assess the adherence of your diabetic patients to their prescribed treatment plans on average?

None of the patients adhere

Low: Only a few patients continuously adhere to their treatment plans

Moderate: Approximately half of the patients stick to their treatment plans

High: The vast majority of patients follow their treatment plans

Very high: Most patients adhere to their treatment plans religiously

7 (2.3)

43 (14.3)

131 (43.7)

105 (35.0)

14 (4.7)

Correlation between the doctors’ knowledge and practice

There was a statistically significant correlation between knowledge and practice scores (r =0.172) (p < 0.003).

Self-glucose monitoring has been shown to be effective in reducing HbA1c levels and achieving glycemic control in T2DM patients who were not insulin [10]. In addition, T2DM patients who self-monitor their blood glucose levels were expected to have higher awareness of the impact of lifestyle on blood glucose levels and achieving glycemic control [11]. This study was conducted to assess the knowledge, attitudes, and practices about self-glucose monitoring of primary care physicians in the West Bank who care for T2DM patients. This is the first time this has been assessed. The findings of this study could inform strategies to promote achieving glycemic control among T2DM patients in Palestine.

In this study, the majority of the physicians reported using the publications issued by the WHO and UpToDate as the main sources of information about T2DM. UpToDate is a main clinical decision support system that provides evidence-based information to healthcare providers. The WHO provides healthcare providers with valuable resources and publications about T2DM. The main purpose of these publications and resources is to support physicians to prevent, manage, and treat T2DM. The main publications of the WHO include the global reports on diabetes, definitions, diagnosis, and classification of diabetes and diabetes-related complications, among others. The physicians who were included in this study were aware of the signs of hypoglycemia. Recognizing the signs of hyperglycemia can facilitate timely intervention and initiation of treatment or management. In addition, recognition of signs of hyperglycemia can also help prevent severe hyperglycemia, diabetic ketoacidosis, which is a medical emergency,[12, 13] Moreover, recognition of signs of hyperglycemia can help physicians individualize the treatment for each patient case that ensures preventing the long-term T2DM-related complications [13].

The majority of the physicians who were surveyed in this study were aware of the cut-off values for T2DM in fasting blood glucose, random blood, and HbA1c tests. Recognizing these cut-off values can help physicians effectively and timely diagnose patients with T2DM and those at risk for developing T2DM [14]. It is important to mention that failure to diagnose T2DM can delay initiating treatment and can increase the likelihood of developing T2DM-related complications.

The majority of the physicians in this study were also aware of self-glucose monitoring, the difference between self-glucose monitoring and laboratory-based glucose testing, the types of self-glucose monitoring techniques, and the benefits of self-glucose monitoring. The findings reported in this study were not surprising as the physicians included were those who provided care for T2DM patients [14, 15]. Female physicians reported higher knowledge compare to male physicians in this study. A previous study failed to detect a difference in the quality of care received by T2DM patients who were treated by female or male physicians [16]. Moreover, knowledge was also affected by the number of patients with T2DM cared for. These findings were not surprising as knowledge is expected to increase with the increasing interactions with patients with T2DM.

In this study, the physicians expressed positive attitudes towards self-glucose monitoring. The physicians believed in the benefits of self-glucose monitoring for the quality of life of the patients, and patient outcomes. The physicians also expressed positive attitudes towards recommending self-glucose monitoring for their patients and educating the patients about self-glucose monitoring. These positive attitudes could be used to promote and improve self-glucose monitoring among the patients. When inquired about their practices, recommending frequent self-glucose monitoring for newly diagnosed patients, conducting regular training sessions on self-glucose monitoring, always setting goal glucose levels, always reviewing the monitored glucose levels, feeling very confident in modifying the treatment plan according to the monitored glucose levels, and offering monitoring training were not optimal as reported by the physicians surveyed in this study. These findings indicate that efforts need to be made to improve practices of the physicians caring for T2DM patients in Palestine with regard to self-glucose monitoring [16, 17]

Limitations

This study was conducted as a cross-sectional survey. Cross-sectional studies are merely observational and compared to interventional studies, the conclusions drawn from observational studies are less rigorous. The physicians who care for patients with T2DM in primary healthcare clinics were included in this study. The study does not examine patient outcomes related to effective management of diabetes. Future studies should include physicians in private clinics as a considerable percentage of the patients with T2DM in Palestine could be care for by physicians in the private sector. Moreover, the data collected in this study were self-reported. These data could be affected by recall bias and desirability bias.

The physicians in the primary healthcare clinics had adequate knowledge and positive attitudes towards self-glucose monitoring. On the other hand, the practices of the physicians with regard to self-glucose monitoring was less than optimal. Future studies should investigate knowledge, attitudes, and practices of physicians who care for the patients in the private sector.

Author contribution: All writers have contributed to their commitment to their work, including writing, analysis, and interpretation of the data.

Ethics approval and consent to participate: An-Najah National University institutional review board approved the study. All subjects involved in the study were invited to participate on a voluntary basis after the study purpose, risk, and advantage of participation were clarified. Informed consent was obtained from all participants. Interviews were carried out in accordance with the Code of Ethics of the World Medical Association (Declaration of Helsinki).

Data Availability: The dataset supporting the conclusions of this article is included within the article and its additional file.

Competing Interest: The authors declare that they have no competing interests in this section.

Funding: No funding was received for conducting this study.

Authors contribution :

Suha Hamshari : develop the research questions review and edit the questionnaire, and write the manuscript .

Sondos Hamadneh : review and edit the questionnaire, write the manuscript.

Afnan Morshed Ajlone : review and edit the questionnaire, write the manuscript.

Ahmad Wajdi Mashni : review and edit the questionnaire, write the manuscript.

Mohammad Asem Jubeh: review and edit the questionnaire, write the manuscript.

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No competing interests reported.

Knowledge, attitude, and practice (KAP) of primary health physicians towards self-glucose monitoring in patients with type2 diabetes mellitus in Palestine.

Status:

Version 1

Abstract

Introduction

Material and Methods

Study Design and Settings

Population

Sample Size and Sampling Technique

Measurement tools and data collection

Data Analysis

Ethical consideration

Results

Characteristics of the participants

Sources of information used by the doctor to obtained knowledge about diabetes

Association between the doctors’ variables and knowledge

Attitudes of the doctors towards self-glucose monitoring

Doctors’ self-glucose monitoring practices

Discussion

Limitations

Conclusion

Declarations

References

Additional Declarations

Status:

Version 1