https://doi.org/10.15218/ejnm.2023.17 Erbil j. nurs. midwifery, Vol. 6, No. (2), Nov 2023 Original Article Impact of Self-Efficacy Intervention Program on Caregivers Adherence toward Home-based Care Children with Type I Diabetes Mellitus ABSTRACT Background and aims: Diabetes is a metabolic disorder associated with many complica- tions; caregivers’ self-efficacy is essential for sustained home management. The study aimed to find out the effects of nursing intervention programs on caregivers’ self- efficacy regarding adhering to home-based management of child to type1 diabetes mellitus. Methods: A quasi‐experimental study design on home-based nursing intervention was conducted and recruited 60 caregivers who took homecare for their diabetes type 1. The systematic sampling method was used to select the participants Who were divided into two groups (30 in an intervention group and 30 in a control group) and who were regis- tered at the Gulan General Hospital in Akre / Duhok city of Iraqi Kurdistan region. Verbal consent was obtained. starting from 3rd of January to the end of 5th September 2022.The home-based lesions were adopted for 5 months, Mann-Whitney U test, and T- Test ware used to identify the comparison between the variables. A p-value of ≤ 0.05, considered statistically significant. Results: There is no significant association between the control and study groups at the pretest before conducting the intervention program, while after conducting a home- based program for the intervention group, the results show that there was a highly sig- nificant difference between the pre and post test, the result reflects and successful pro- gram to change the self-efficacy of the caregivers from intervention, and it means a pro- vided compared with the control group ( non-intervention group), at a p-value of ≤ 0.05. Conclusion: The results show that the caregivers who participated in the program (Intervention group), were successfully adapted to the self-efficacy program. Applying the program to a wider range of caregivers, to adhere to the caregivers and improve their self -efficacy toward home-based management of type 1 diabetes mellitus. Keywords: Impact; Self-efficacy; Caregiver; Home-based care; Type 1 Diabetes Mellitus. Shevan Younis Othman; Department of nursing, Akre Technical Institute, Duhok Polytechnic University, Duhok, Kur- distan region of Iraq. (Correspondence: shevan.osman@dpu.edu.krd) Shukir Saleem Hasan; Department of Nursing, College of Nursing, Hawler Medical University and Tishk International University, Erbil, Kurdistan Region, Iraq. Nadir Abdullah Garjees; Department of Pediatric, College of Medicine, University of Duhok, Duhok, Kurdistan region of Iraq. 158 Received: 03/05/2023 Accepted: 19/07/2023 Published: 30/11/2023 Copyright ©2022 The Author(s). This is an Open Access article which licensed under the terms and conditions of the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License. It permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. mailto:shevan.osman@dpu.edu.krd?subject=shevan.osman@dpu.edu.krd mailto:shevan.osman@dpu.edu.krd https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2023.17 Erbil j. nurs. midwifery, Vol. 6, No. (2), Nov 2023 Original Article Diabetes mellitus is the general name for a group of chronic metabolic diseases char- acterized by high blood glucose levels that result from defects in insulin secretion and/or action. The two main forms of dia- betes are insulin-dependent diabetes melli- tus (IDDM) or type 1 diabetes and noninsu- lin-dependent or type 2 diabetes. Type 2 diabetes is more commonly diagnosed in adulthood and is characterized by the body’s inability to use insulin properly. Alt- hough type 1 diabetes can be diagnosed in adulthood, it usually develops and is diag- nosed in childhood and adolescence [1]. Currently, type 1 diabetes affects 1 in every 400 to 600 children, and more than 13,000 children are newly diagnosed each year [2]. The total population of Iraq is over 32 mil- lion, a diabetes prevalence of 9.1% in 2011 [3]. In updating prevalence in this 2019, rate lowered to 8.8% (ages 20 to 79) [5]. and will be expected to reach 10.4% by 2030; in 2017 the number of diabetic cases in Iraq was 1,411.5. The estimated national prevalence of T1DM increased from 7.8 per 100,000 children (aged under 15) in 1995 to 14.2 in 2000, and 24.7 in 2014 [5]. The average annual incidence rate of T1DM was 7.4 per 100,000, which takes place in the intermediate group [2]. The increase in rates of diabetes across the globe brings with it an increase in diabetes complica- tions. Poor diabetes management, whether through lack of education, limited access to care, or undiagnosed conditions, means diabetes complications are a real problem in most countries [5].Due to the behaviors, abilities, and knowledge gaps that cause non-adherence to treatment and a consid- erable rise in long-term consequences, managing the condition effectively in chil- dren and adolescents has proven difficult [8]. It can cause major coping issues in chil- dren. [9]. The difficulties in educating chil- dren with diabetes about nutrition are frequently tied to their ages and reflect the differing nutritional and developmental needs ; they are shown to be influenced by family functioning and interactions during mealtimes [10].The aim of the study is to find out the effects of home-based nursing intervention programs on the self-efficacy of caregivers regarding based home care of children with T1DM. A quasi-experimental (pre/post) research design was utilized to accomplish the aim of this study. A home-based intervention program was carried out. Sixty (60) patients were selected based on the simple random sampling methods, from the list of all patients, listed in Gulan General Hospital in Akre Dohuk Governorate, Kurdistan Region, Iraq, until the list of 60 caregivers was completed. The caregivers were split into two groups: one group of 30 caregivers who participated in the nursing intervention program was designated as the intervention group, and the other group of 30 caregivers was designated as a control group. The study's entire time frame spanned eight months, starting on January 3 and ending on September 5, 2022. The researcher collects the data, maintaining the privacy and anonymity of the information. The data collecting form was used without stating the participants' names, sensitive cultural considerations were considered, and approval was acquired; from the Duhok University Ethics Committee at the College of Nursing to perform the study. A non-probabilistic (purposive) sample of 60 (caregivers) was recruited for the study. Patients and their caregivers for outpatient treatment and regular follow-up at the Gulan General Hospital in Akre, the investigator, after obtaining consent to conduct home visits for each study sample, all caregivers. 159 METHODS Copyright ©2022 The Author(s). This is an Open Access article which licensed under the terms and conditions of the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License. It permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. INTRODUCTION https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2023.17 Erbil j. nurs. midwifery, Vol. 6, No. (2), Nov 2023 Original Article caregiver occupation, the result reveals that, majority (80.0% and 73.2% respec- tively) of caregivers were out of work in both control and intervention groups re- spectively. Moreover, it shows that mar- riage is 90.0% in control groups and 93.4% in intervention groups, respectively. Re- garding residential areas, most of them are distributed to sub-urban (40.0%) in control Groups; however, in intervention groups, most of them are in urban (43.4%%). Most caregivers have one child with DMT1in both control and intervention groups (76.6% vs. 73.4%). Concerning the care- giver's socioeconomic status, most of them are middle-class in control and interven- tion groups (50.0% vs. 33.4%) respectively (Table 1).Regarding the biographical infor- mation of the diabetes child patients the study found that the highest percentage (63.4% vs. 70.0% respectively) of the T1DM patients ages were between 9 and 12 years old in both the control and inter- vention groups and most of them were fe- male (66.6% vs. 53.4%) respectively. Con- cerning school attendance, the patients in the control group had the highest percent- age of not attending school (56.6%) while in the intervention groups, most of them were not regular attendees (53.4%) and the lowest of them in both groups were regular attendees (0.0% and 10.0%) re- spectively. Regarding the family history of diabetic disease, most (53.4% and 46.6%) respectively of children in both the control and intervention groups have a positive family history, such as (an uncle, grandfa- ther, or one of the parents). regarding BMI the highest percentage (53.4%), in both groups were within acceptable weight (Table 2). The researcher wrote down their phone number. The caregivers who have patients with T1DM, aged less than 13 years, who are interested in participating in the study, the patient is registered at Gulan General Hospital in Akre city were included. Then the investigators were obtained oral con- sent to allow the study group to visit home. Home based visit was obtained for all the participants (intervention and control group), The health promotion model (HPM) was adapted for applying the education Program “notes that each person has unique personal characteristics and experi- ences that affect subsequent actions“ was used as a guide for designing effective home care intervention programs, adher- ing to interventions, and removing barriers to delivering interventions. The researcher prepared the tools depending on the dia- betes rating skills (DBRS) available at: https://scholarscompass.vcu.edu/etd/185). Data were analyzed using the statistical program for social sciences (SPSS) version 25. The researcher used frequency and percentage to describe the demographic variables and distribution of the sample in each group. To compare the nursing inter- vention programs between the control and intervention groups (pre-test and post- tests 1 and 2), Mann-Whitney U, and T- tests were used;, a p-value of ≤0.05 is con- sidered significant difference. The present study shows that most (46.6% %) of the caregivers were mothers in the control group and 40.0% in the interven- tion groups a respectively. Regarding the caregiver's age in both groups, most (43.4% vs. 33.4%) were between 40 and 45 years old in both groups. Regarding the care- giver’s level of education in the caregivers in control and intervention groups in the highest percentage had primary school de- grees (56.6% vs. 63.4%). Concerning the 160 Copyright ©2022 The Author(s). This is an Open Access article which licensed under the terms and conditions of the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License. It permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. RESULTS https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2023.17 Erbil j. nurs. midwifery, Vol. 6, No. (2), Nov 2023 Original Article 161 Copyright ©2022 The Author(s). This is an Open Access article which licensed under the terms and conditions of the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License. It permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. Table 1: Socio-demographical characteristics of the caregiver Socio-demographical characteristics Control Intervention No.( %) No.( %) The main caregiver Mother 14(46.6) 12(40) Father 13(43.4) 16(53.4) Brother 3(10) 2(6.6) Age of the caregiver/year Above 45 8(26.6) 9(30) 40 to 45 13(43.4) 10(33.4) 35 to 39 8(26.6) 10(33.4) Less than 35 1(3.4) 1(3.4) Level of education Illiterate 2(6.6) 0 Can read and write 7(23.4) 7(23.4) Primary school 17(56.6) 19(63.4) Secondary school 2(13.2) 1(3.4) Higher education 2(13.2) 3(20) Caregiver occupation Public Employed 4(26.6) 6(40) Unemployed 4(26.6) 2(13.2) Out of work 12(80) 11(73.2) Housewife 9(60) 8(26.6) Retired 1(3.4) 3(10) Marital status Married 27(90) 28(93.4) Single 3(10) 2(6.6) Residential area Urban 10(33.4) 13 Rural 8(26.6) 10(33.4) sub-urban 12(40) 7(23. 4) No. of children with Diabetic Mellitus Type1 in the family One patient 23(76.6) 22(73.47) More than one patient 7(23.4) 8(26.6) Socio-economic status High 4(13.4) 3(10) Middle 15(50) 10(33.4) Low 11(36.6) 17(52.6) https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2023.17 Erbil j. nurs. midwifery, Vol. 6, No. (2), Nov 2023 Original Article 162 5 times per week most caregivers do not Apply it their child (66.6%) in both groups, (52.6% vs 66.6%) of participate do not use anything for his child to pre- vent blood sugar level from dropping when exercising in the control and inter- vention groups. About (70% vs 40%) of participants do not know what to do when their child’s blood sugar levels goes higher or lower than it should be, most (36.6% vs 70%) of caregivers in both groups have not judged when the chang- es in his child’s illness mean should visit the doctor and about (66.6% vs 76.6%) of participants in the control and interven- tion groups. Most caregivers do not con- trol their child’s diabetes so that it does not interfere with the things they want to do (Table 3). Concerning the assessment of self-efficacy for diabetes scale of caregivers of interven- tion and control group pre-test the, majori- ty (76.6%) vs (53.4%) of control groups the caregivers not applicable for their child about eating meals every 4 to 5 hours eve- ry day, including breakfast every day while of intervention strongly the caregivers disa- gree regarding his child eat meals every 4 to 5 hours every day, including breakfast every day about (53.4% vs 86.6%) of partic- ipate don’t obligated to prepare the diet for his child when must prepare or share food with other people who do not have diabetes in both groups (46.6% vs 76.6%) Caregivers in both groups do not choose the appropriate food for a child to eat when are hungry (for example, snacks), Re- garding exercise 15 to 30 minutes 4 to Copyright ©2022 The Author(s). This is an Open Access article which licensed under the terms and conditions of the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License. It permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. Table 2: Assessment of biographical information of the Diabetes child patients (n= 60) Diabetes Patients Demographical characteristics Control group Intervention group No.( %) No.( %) Age/year Less than 4 years 3(10) 0 4 to 8 years 8(26.6) 9(30) 9 to 12 years 19(63.4) 21(70) Gender of patient Male 10(33.4) 14(46.6) Female 20(66.6) 16(53.4) School attendance Regular 0 3(10) Irregular 13(43.4) 16(53.4) No attendance 17(56.6) 11(36.6) Family history for Diabetic disease Father 3(20) 3(20) Mother 2(13.2) 2(13.2) Others 16(53.4) 14(46.6) No history of diabetes in the family 6(20) 9(30) Parents 3(10) 2(6.6) BMI Underweight 5(16.6) 2(6.6) Acceptable weight 16(53.4) 16(53.4) Overweight 9(30) 12(40) https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2023.17 Erbil j. nurs. midwifery, Vol. 6, No. (2), Nov 2023 Original Article 163 Copyright ©2022 The Author(s). This is an Open Access article which licensed under the terms and conditions of the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License. It permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. Table 3. Assessment of self-efficacy for diabetes scale of caregivers of intervention and control group (pre and post-test) (n= 30). Case-control Items Control Intervention Strongly Agree Agree Disagree Strongly Disagree N/A Strongly Agree Agree Disagree Strongly Disagree N/A 1 Eat meals every 4 to 5 hours every day, including breakfast every day? 0 0 1 (3.4) 11 (36.6) 23 (76.6) 0 0 7 (23.4) 16 (53.4) 4 (13.4) 2 Follow diet when you must prepare or share food with other people who do not have diabetes? 0 0 3 (10) 7 (23.4) 16 (53.4) 0 0 26 (86.6) 4 (13.4) 0 3 Choose the appro- priate food for your child to eat when you are hungry (for example, snacks)? 0 0 1 (3.4) 6 (20) 14 (46.6) 0 0 23 (76.6) 5 (16.6) 2 (6.6) 4 Exercise 15 to 30 minutes, 4 to 5 times per week? 0 0 4 (13.4) 6 (20) 20 (66.6) 0 0 20 (66.6) 8 (26.6) 2 (6.6) 5 Do something to prevent your blood sugar level from dropping when you exercise? 0 0 4 (13.4) 2 (6.6) 17 (52.6) 0 0 20 (66.6) 9 (30) 1 (3.4) 6 Know what to do when your child’s blood sugar level goes higher or lower than it should be? 0 0 0 3 (10) 21 (70) 0 0 0 (0) 12 (40) 7 (23.4) 7 Judge when the changes in your child’s illness mean you should visit the doctor? 3 (10) 0 2 (6.6) 5 (16.6) 11 (36.6) 0 0 21 (70) 6 (20) 3 (10) 8 Control your child diabetes so that it does not interfere with the things you want to do? 0 0 2 (6.6) 1 (3.4) 20 (66.6) 0 0 23 (76.6) 6 (20) 1 (3.4) https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2023.17 Erbil j. nurs. midwifery, Vol. 6, No. (2), Nov 2023 Original Article between the self-efficacy for diabetes scale of caregivers before conducting the pro- gram ( pre-test) at p-value 0.953 (Table 4). two months of applying the intervention programs between pre and post2. but in control groups there are no-significant differences between pre and post-test 1&2 in the assessment of self-efficacy for the diabetes scale of caregivers (Table 5). Concerning comparing domains between the intervention and control groups before conducting the program ( pre-test), the study found non-significant differences In terms of comparison between self- efficacy for the diabetes scale of the care- giver’s domain, pre- and post-tests 1 and 2 show that there was a highly significant difference between the intervention group at P value < 0.001 and 0.008. However, there is a non-significant difference after 164 Copyright ©2022 The Author(s). This is an Open Access article which licensed under the terms and conditions of the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License. It permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. Table 4. Compare of domains between intervention and control group before conduct the program (pre-test) ( n= 60 ) Self-efficacy N Mean SD P-Value (Mann-Whitney U) Assessment of self-efficacy for diabetes scale of caregivers Control 30 2.088 0.986 0.953 (NS) Intervention 30 2.033 0.512 Table 5. Compare between self-efficacy for diabetes scale of caregiver’s domain pre and post -test 1 and 2 ( n= 30) Interventional groups Pre-test and post-test 1 Pre-test and post-test 2 Self- Efficacy for Diabe- tes Scale of care- givers Mean SD t-test d.f. P-Value Mean Std. Devi- ation t-test d.f . P- Value 2.033 0.512 -32.311 29 < 0.001 2.033 0.512 -0.249 29 0.008 3.533 0.325 2.046 0.937 Self- Efficacy for Diabe- tes Scale of care- givers Control groups Pre-test and post-test 1 Pre-test and post-test2 Mean SD t-test d.f. P-Value Mean Std. Devi- ation t-test d.f . P- Value 1.183 0.249 < 0.001 29 1.000 1.183 0.249 < 0.001 29 1.000 1.183 0.249 1.1833 0.249 https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2023.17 Erbil j. nurs. midwifery, Vol. 6, No. (2), Nov 2023 Original Article groups. According to marital status, the current result shows that most caregivers were married in control groups and inter- vention groups respectively. Correspond- ingly a study was conducted in Baghdad, found that almost all caregivers were out of work [14]. Regarding the residential ar- ea, the study reveals that most of the sam- ples were distributed into sub-urban con- trol groups and urban intervention groups. These results are the opposite of a study by [15], who found that most of parents were lived in urban. Concerning the num- ber of children affected by DMT1 in the family, the result shows that most of the caregivers have one affected child with DMT1 in both the control and intervention groups. This result is in disagreement with a study conducted by Keklik et al., (2020), who reported that 51.8% of the families had more than two affected children with T1DM. Concerning the caregiver's socio- economic status, the results who that most families lived in the middle of socio- economic status (SES). Our results were in agreement with the results of a study con- ducted in Baghdad – Iraq and who found that most participants lived in middle SES in this study conducted in Baghdad [15]. Concerning the biographical information of the patient’s current study it indicates that the highest percentage of the age of pa- tients were 9 to 12 years old in both the control and intervention groups and most of them are female. The results of the cur- rent study were in agreement with a study conducted in Addis Ababa, Ethiopia in 2021 in which it was found that 54.9% of age patient were about 5 to 12 years old and found 56.6% female [15] .Concerning school attendance in the control group, the highest percentage is not attendance while, in the intervention groups, most of them are not regular attendance and the lowest of them in both groups regular attendance. The opposite result was also The findings of the present study show that most of the caregivers in the control groups were patients’ mothers, but in the intervention Groups, they were fathers. A study confirmed that the18 caregivers who represented the study of children with T1DM, there were 12 of the partici- pants were mothers’ children [11]. This may be attributed to the males' desire to participate in the program more than fe- males. As they have sufficient and appro- priate time to participate compared to fe- males, on the other hand, the, social, cul- ture, customs, and traditions of our socie- ty, do not allow strangers to visit him in her home and communicate with females. Concerning the caregivers’ age group, the study reveals that the majority of partici- pants were between 40 and 45 years old in the control and intervention groups, respectively. When compared with the results of [2], they found that most of the mothers’ age was over 41years old in both the control and intervention group . While this result is in contrast with a study which found that the age of the caregivers was between 36 to 40 years old, they added with respect to their level of education, the present study found that the highest percentage of caregivers were primary school graduates. In contrast with the cur- rent result a study reveals that forty-two percent of caregivers had a secondary school education, 21.9% had some form of higher education [13 &14]. A cross- sectional study conducted in Addis Ababa, Ethiopia, entitled Health-related quality-of -life and associated factors among children and adolescents with type 1 diabetes mellitus: a cross-sectional study, found that the most of caregivers were private employees. This result is in contrast with our result which reflects that majority of the caregivers were out of work in both 165 Copyright ©2022 The Author(s). This is an Open Access article which licensed under the terms and conditions of the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License. It permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. DISCUSSION https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2023.17 Erbil j. nurs. midwifery, Vol. 6, No. (2), Nov 2023 Original Article intervention program, the present study found that there is a highly significant difference between pre and post-tests1&2 in the intervention group compared to the control group regarding self-efficacy for the diabetes scale of caregivers). This re- sult is supported by a study that was con- ducted an intervention program on chil- dren with TIDM, found that there were highly significant differences between pre and post-tests (1 and 2) regarding the self- efficacy for diabetes scale of caregivers in the intervention group, and they found there were non-significant differences be- tween pre and post-tests (1 and 2) in con- trol groups [21] , The majority of caregivers of children with type 1 diabetes mellitus improved their self-efficacy about the disease, and disease management performed by these caregiv- ers is satisfactory in general after being exposed to nursing intervention programs. However, there is a need to intervene in some ways, changing attitudes to cope more adequately with the disease as well as improving the effectiveness of diabetes education. The authors would like to express their heartfelt gratitude to all the caregivers who participated in the study. This study has been approved by the ethi- cal committee at Duhok University, College of Nursing. The au- thors declare that they have no conflict of interest. documented by Alabedi, 2020, whose study found that most participation in reg- ular school attendance is about (9.4% vs. 15%) in both groups. researcher's opinion that the family fears the complications, especially hypoglycaemia. Regarding fami- ly history for diabetic disease, most of the children in both control and intervention groups have a family history. these find- ings agree with Qadir & Zangana, 2020, who concluded that most of the partici- pants have a family history entitled the effect of swimming program on glycaemic control in male adolescents with type 1 diabetes mellitus).with regard to BMI the highest percentage in both groups is ac- ceptable weight. Some of them are over- weight; this result is the same with [19]. He found that in children with diabetes type, about 29% were obese or over- weight. Regarding the assessment of the self-efficacy of the intervention and con- trol group pre-test. In this study, the re- searcher found that most of the caregiv- ers' answers were not applicable in both groups. These results are in agreement with a study conducted in Egypt [20], which conducted a health educational pro- gram for DM caregivers and found before the intervention programs, the patients had poor self-efficacy. The same result was found in a result of a study which showed that patients with diabetes had poor self- efficacy [21]. Concerning the comparison of overall domains between the interven- tion and control groups before conducting the program (pre-test) the study indicates that there are no significant differences between all domains in intervention and control groups before intervention pro- grams. The present results agree with the study by Gürkan et al., 2019, who stated that no there was no significant differ- ences in the diabetes behavior rating scale and self-efficacy domain in the control and intervention groups. After the nursing 166 Copyright ©2022 The Author(s). This is an Open Access article which licensed under the terms and conditions of the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License. It permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. CONCLUSION ACKNOWLEDGEMENT ETHICAL CONSIDERATION CONFLICT OF INTEREST https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2023.17 Erbil j. nurs. midwifery, Vol. 6, No. (2), Nov 2023 Original Article p.https://doi.org/10.1016/ j.cobme.2021.100312 [10] Smart CE, Annan F, Higgins LA, Jelleryd E, Lopez M, Acerini CL. 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Health- related quality-of-Life and associated factors among children and adolescents with type 1 diabetes mellitus: A cross-sectional study. Pediatr Heal Med Ther. 2022;243–56. DOI: https://doi.org/10.5812/compreped-134561 [15] Shukur SJ, Hussein WA, Kadhum NL. Quality of Life of Parents of Children with Type I Diabetes Mellitus, Baghdad 2017. Al-Kindy College Medical Journal. 2021;17(2):107–14. DOI: https://doi.org/10.47723/ kcmj.v17i2.536 [16] Keklik D, Bayat M, Başdaş Ö. Care burden and quality of life in mothers of children with type 1 diabetes mellitus. Future Journal of Pharmaceutical Sciences. 2020;40(3):431– 5.https:// doi.org/10.1080/17482631.2018.1487758. [17] Alabedi RF. Comparative study between multiple daily injections and conventional insulin regimens in iraqi children and adoles- cents with type 1 diabetes mellitus. Ann Trop Med & Public Health; 2020;23:218–31. https://doi.org/10.36295/ ASRO.2020.2312018 [18] Qadir KJ, Zangana KO. 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