How To Increase Health Education In Black/Ethnic Groups To Stop Death Caused By Diabetic Ketoacidosis?

What Can Be Done To Increase Health Education In Black & Ethnic Minority Groups (In Uk) To Help Stop Unnecessary Death Caused By Diabetic Ketoacidosis?

Chapter 1: Background

Introduction of Reducing Diabetic Ketoacidosis Deaths Through Culturally-Sensitive Health Education

Diabetic ketoacidosis in recent days is the leading cause of death in people with diabetes. It is primarily associated with both Diabetes insipidus and Diabetes mellitus. The effects of the disease can vary in different ethnic groups and in black people and minority groups the severity of the disease is more than in white people. The research will focus on how unnecessary deaths in the black community can be stopped. It will also discuss the potentialities of health education as a tool of awareness to decrease the death rate among black and minority groups. This chapter will focus on the immediate data and information that are related to the pace of diabetic ketoacidosis in black and minority people. It will also contain the research aim, objectives, and hypothesis of the research which will help to give the research a particular direction and structure. This chapter will deal with the necessity of the research along with its specific significance.

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Background of the research

Diabetes ketoacidosis is a complex case of Diabetes and is life-threatening in a majority of cases. It develops in diabetic patients who do not have sufficient insulin due to which blood sugar is not taken up by the cells as the source of energy. In this case, instead of blood sugar, body fat is broken down by the liver, and ketone bodies are generated. These ketone bodies start to build up, these bodies segregate in blood at higher levels making the blood acidic (Misra et al. 2021). The symptoms of this disease start with frequent urination and excessive feeling of thirst. Along with that, the patients feel dry-mouthed and have fruity smell breath. Nausea and vomiting are also associated with it causing a loss of minerals and electrolytes from the body. Diabetic ketoacidosis is found in 66% of patients diagnosed with type I diabetes whereas the rest of the 34% are patients with type II diabetes (Diabetes.org.uk, 2022). It is found that type II diabetic patients can develop diabetic ketoacidosis under stressful conditions such as anxiety, tension, post-surgery, or infections. Severe hypoglycemia in many cases has been found to be responsible for ketoacidosis.

Figure 1: Prevalence of Diabetic ketoacidosis in black and white people in the UK in 2019 and 2020

(Source: Diabetes.org.uk, 2022)

Over the years it is found that the tendency and prevalence of diabetic ketoacidosis are most in the black and minority group of people. In the past two years, the number of cases of diabetes has increased in the UK. Ethnicity and the probability of developing complexion of diabetes are higher in the black African, African Caribbean, and south Asian groups (Dhatariya et al. 2016). The rate of diabetic ketoacidosis has increased in black communities. The increase is majorly due to the cultural differences and ethnic differences between the weight and the back communities. The rate of hospitalisation has also been high in the past years. A study by Zhong et al. 2018 shows that the rate of hospitalization increased from 2005 until 2011. The number of cases also went up in 2020 during the spread of Covid 19. There seems to be a close relationship between the severities of diabetic ketoacidosis with the black community people. It is mainly due to cultural differences and differences in management techniques.

Figure 2: Rate of hospitalisation of diabetic ketoacidosis patients in England over the years from 1997 to 2013

(Source: Zhong et al. 2018)

The above graph shows that the rate of hospitalisation has certainly increased over the years making the disease complex and morbid. Diabetic ketoacidosis management is the technique through which patients can successfully manage their conditions. There is no such treatment technique or procedure now for DKA (Diabetic ketoacidosis) (Diabetes.org.uk, 2021). However, management strategies and restrictions can reduce the risks of DKA. In the case of black communities the people suffering from DKA need to be included in the management and separate techniques need to be applied that will effectively help in reducing the DKA complications in them.

Research aim and objectives

Research aim:

The research aims to explore the current health management strategies for Diabetic ketoacidosis evident in the UK among the black communities and recommend ways to increase health education as a strategy for reducing DKA in them.

The objectives of the research are as follows:

• To determine the current rate of Diabetic ketoacidosis evident in black communities of the UK.
• To identify the current health management strategies of DKA practiced in the UK
• To state the relationship between the education level, culture, and diet with the rate of DKA.
• To judge the impact of health education in reducing the rate of mortality in DKA black community patients.
• To recommend ways for increasing health education for DKA among black people to reduce the rate of mortality among them.

Research questions

The research question would be based on the targeted population and the outcome of the exposure. In this case, the questions are to be developed from the research objectives. Along with that, a PEO is developed in order to identify the targeted population, exposure, and outcome regarding the selected health issue.

The research questions are as follows:

RQ1: How many patients of DKA are currently there among the black communities of the UK?

RQ2: What are the evident health management strategies that are in practice for the management of DKA in the UK?

RQ3: What can be the correlation between education, culture, and diet with the rate of mortality in black people patients of DKA of the UK?

RQ4: How much impact does health education have in reducing the rate of mortality of black DKA patients?

RQ5: What recommendations can be provided to increase health education regarding the management of DKA so that mortality can be reduced in black community people in the UK?

The PEO for the research can be stated as

Population	Exposure	Outcome
Black and ethnic minority	Diabetics resulting in DKA	Increased health education/reduction in death/reversal of the disease

Table 1.1: PEO

(Source: Self-prepared)

Justification: The selected population is the black and ethnic minority patients of DKA as the research aims to identify the impact of health education in reducing the mortality rate among them. As stated earlier, the rate of mortality and hospitalised has increased over the past few years in black and minority communities. Along with that, the trend of DKA is also high in non-white people in the UK (Diabetes.org.uk, 2021). The major focus is to increase the level of education and awareness among black and minority people so that the rate of mortality is reduced for DKA patients.

Research hypothesis

The hypothesis developed for the research is as follows:

H0: There is a strong correlation between the diet, level of education, and culture for the severity of DKA and high mortality in black communities.

H1: There is no correlation between diet, level of education, and culture for the severity of DKA and high mortality in black communities.

Rationale

The management of Diabetes is considered to be very important for straining many other health complications. However, diabetes itself is very difficult to manage at its severity and brings many complications among which Diabetes ketoacidosis is a major one. Diabetic ketoacidosis has become more common in the later 2000s due to its high and increasing cases among Diabetic patients (Varadarajan et al. 2017). It is frequent in both type I and type II diabetic patients. Now many organizations and health institutions have published guidelines regarding the management of Diabetic ketoacidosis in the UK. The major interventions are based on ketone management or ketoacidosis than glucose or insulin management. It has been found in many studies that black and minority people tend to suffer from this disease more than white people (Diabetes.org.uk, 2022). In the study by Ooi et al. 2021, it was found that a lot more patients of DKA belonged to the Latino-American or African-American communities that were residing in the UK. Apart from that minority South Asian people from China, Pakistan, Bangladesh and India also suffered from this disease. Their work also revealed that these patients had a prolonged phase of treatment for the cure or either died during the treatment tenure.

The prolonged study phase has revealed that there is a connection between ethnicity, culture, diet, and educational level among the people. It is evident that the management strategies were not as effective in black and minority communities as in white communities. Hence it can be identified that the significant cause lays in their cultural, ethnic, and food consumption differences. The cultural effect on the diet pattern of black and minority people is one of the significant reasons for the high number of ketoacidosis in diabetic patients (Vellanki and Umpierrez, 2021). Brandstaetter et al. 2019 have stated that racial differences in the control of glucose are evident in black people. It can be stated that it is associated with cultural, ethnic, and diet differences.

In this case, the lower level of awareness and education also plays a poignant role in the level of ketoacidosis and glucose management. African and black community people are unaware of the fact that food items rich like rice and wheat are not the only ones rich in carbohydrate content but rather vegetables like a pumpkin also are high in sugars. Multiple programs in practice focus on fluid management and ketone management in patients with DKA (Brandstaetter et al. 2019). However, the issue of lack of education and awareness regarding management remains unresolved. It is thus highly essential that the communities are made aware of the required management practices and changed lifestyle patterns that will be effective in reducing the risk of mortality in them.

Significance

Diabetes ketoacidosis is a complex disease that occurs in the majority of Diabetic people. It is found that approximately 13.7 per 1000 people in the world. The statistics show that this disease has raised concerns over the years. Also, it is associated with high mortality rates in patients. In the UK, people belonging to black communities and minority groups seem to suffer more from the disease than white people (Goldman et al. 2020). This research is significant in identifying the main reasons why the rate of mortality is high in these community people than the white people. The research would pinpoint the cultural differences and educational differences due to which the rate of DKA has increased over the years in minority and black communities. The research will also shed light on the management strategies that are majorly adopted to control the disease. Along with that, the research will emphasize the importance of education and awareness regarding the DKA in the black community people. With the aim to suggest ways to increase education regarding DKA management, this research will be impactful in increasing awareness of DKA and its correct management. It would be also beneficial for reducing the mortality rate of black people in the UK.

Summary

The chapter focuses on the need and importance of the research topic of diabetic ketoacidosis and its high prevalence in black people in the UK. The research aim and objectives are developed in this chapter which has helped in developing the research questions and PEO for the research. This further would help provide direction to the methodology of the research where the ways and methods would be defined for conducting the research. Along with that, this chapter is impactful in determining the significance of the research. The research hypothesis framed in this chapter would help to conclude the observation that is found later in the research. Also, this would be helpful in determining the particular hypothesis which is the driving factor behind the research aim.

Chapter 2: Methodology

Introduction

The chapter deals with the methods adopted for the conduction of research. The methodology chapter would consist of the research design, philosophy, and approach which are the basic pillars of any research method. The chapter would present the process of searching for evidence or data that are required for the research. A critical appraisal tool that is selected for the selected journals and articles is also described here. The chapter would highlight the ethical aspects of this research that are to be considered. Also, inclusion and exclusion criteria are presented to elaborate on the criteria included for the selection phase of the journals and articles.

Research design

The proposed study will be developed systematically in order to analyse the relatedness of the study. It can be stated that the selection of an appropriate research design would help in identifying the plan and process of the study (Pandey and Pandey, 2021). In this case, a descriptive research design will be opted for determining the necessary steps required to administer and empower educational programs for the awareness of Diabetes ketoacidosis. In the views of Siedlecki, 2020, a descriptive research design can be identified as a process that aids in systematically describing the selected population and outcomes. In this research, a framework called PEO is applied to develop the research question of interest (Rethlefsen et al. 2021). The use of a descriptive design would help in elaborating the cause of severity and mortality in black community people. It would be effective in identifying the strategies used for the lowering severity of ketoacidosis in diabetic patients (Duran and Pérez-Stable, 2019). A research design is not only helpful in the synthesis of the entire research work but is also important in selecting the emphasised areas. In this case, the emphasis would be put on the necessity of education and strategies that could be undertaken to increase education and related programs amongst the black community people.

Research philosophy

This section of the methodology focuses on the philosophical aspect that would be adopted for the research. Majorly three philosophies are used in systematic reviews, positivism, realism, and interpretivism. The philosophical framework that is followed for this research is interpretivism. Tamminen and Poucher, 2020 have opined that a philosophical framework helps in aiding the process development and outline of the research structure. The ideas developed in this research will be of interpretive nature. The research philosophy is of crucial importance because the predictions and assumptions made in the research are dependent on it (Newman. and Gough, 2020). A major skill required for the implementation of the chosen philosophy is the understanding of the distinct procedures that are used in the method section (Mishra and Alok, 2022). In this case, the interpretivism philosophy would be impactful in assessing and interpreting the shreds of evidence collected from the articles. It would also be significant in evaluating the strategies that can be adopted for educational programs for DKA.

Research approach

The research approach adopted widely is of two types inductive and deductive. The research approach adopted in this research is the deductive research approach. The deductive research approaches are used widely in the case of systematic reviews a deductive research approach helps analyse the existing data from which the information is collected. This approach is utilised for the research because it uses numerous data and facts that are based on DKA and its prevalence in black communities. The approach is appropriate to suggest the importance of educational awareness and requirements for reducing mortality in black community DKA patients. This approach is also based on hypothetical circumstances because the pieces of evidence are based only on real happenings and real-life events. The approach is also useful in predicting the outcome of the study as the outcomes depend on the variety of resources collected for the analysis of data.

Search strategy

Database	Keywords	Filters	Boolean operators	a Resultant number of articles
PubMed	“Diabetes ketoacidosis” AND "DKA in the black community in the UK"	Custom date, free full-text	AND, WITH	373
NICE guideline	"Prevalence of DKA in the UK" OR "Prevalence of DKA in minority groups"	For the last five years	WITH	10
Google Scholar	"Increased mortality rate in black and minority people due to DKA in the UK" AND "Role of Cultural, ethnic and educational differences in an increased number of DKA patients"	Since 2018, including citations and reviewed	WITH, OR	521
Cochrane Library	“Educational programs for DKA” OR “Impact of educational programs in controlling morbidity rate for DKA”	Free-full text	AND, WITH	453

Table 2.1: Searching strategy with the help of Boolean operators

(Source: Self-prepared)

Boolean operators like AND, OR, and WITH are used for the search for appropriate research articles and journals. These operators were used on selected research platforms like PubMed, NICE, Cochrane, and Google scholar. The search results generated multiple articles from where the filters were used for the selection of the latest and updated journals (Gusenbauer and Haddaway, 2020). This entire search process was done with the help of keywords as mentioned in the above table.

Database	Searching techniques	Rationale
Google Scholar	Reference list checking and use of key terms	The identified database may give full-texted and up-to-date articles which may make the research appropriate.
PubMed	Reference list checking and suggestions from teachers	The identified database may help the researcher to get sciatica information along with medical information about any health issue such as autism.
NICE guideline	Reference list checking	The appropriate medical guideline will be get from the identified database
Cochrane Library	Reference list checking	A large number of articles will get as options for the present research

Table 2.2: Literature database and searching techniques

(Source: Self-developed)

The selection of a literature database for the selection of articles is also essential as it serves as the deciding factor for the basis of the research. Gusenbauer and Haddaway, 2020 have stated that Databases like PubMed and Cochrane publish the majority of scientific work that has a high impact and relevance in the recent research field. More databases contain huge numbers of articles that help in the screening and selection process. This also ensures that all relevant articles are generated for synthesising the analysis of the research.

PRISMA

A PRISMA framework is a screening tool used for the screening of selected articles and journals. In this systematic review, the entire data collection is done with the help of PRISMA screening. A total of 10 articles will be selected at the end of the screening process. These 10 articles will be helpful in presenting relevant information for the research. The PRISMA is depicted through a flowchart which is later illustrated. This PRISMA framework would be helpful in selecting the literature for the later chapters.

Inclusion and exclusion criteria

The inclusion and exclusion criteria are the two criteria which are used for the search of the articles and journals. These criteria decide the keywords and other factors which help in proceeding with the research work.

Criteria	Inclusion	Exclusion	Rationale
Selected language	UK English	Australian English, USA English or others	UK English is identified as a global language, therefore, the selected factor helps the researcher to understand the topic clearly,
Time-Period	Last seven years	Before 2016	The data will be up to date
Data source	Google Scholar, PubMed, NICE guideline and Cochrane Library	Proquest, or other unauthentic articles	The factors help to get appropriate and authentic data about health-related issues
Key search terms	"Prevalence of DKA in the UK", "Impact of educational programs in controlling morbidity rate for DKA", "Increased mortality rate in black and minority people due to DKA in the UK"	Others	The selection of appropriate key terms will help to identify appropriate articles
Study type	Primary studies, scientific articles and authentic journals	Doctoral dissertation, letters and blogs	The selection of appropriate data sources
Texted	Full-texted and reviewed	Others	The factor help to get completed research
Aim	The research aims to explore the current health management strategies for Diabetic ketoacidosis evident in the UK among the black communities and recommend ways to increase health education as a strategy for reducing DKA in them.	The research will be completed with a systematic review and collection of data from primary articles and thematic research.	The identified aim will help to focus on the appropriate area of research.
Country	UK	Other countries	The identified factor helps to get country-specific data and appropriately develop the research.

Table 2.3: Inclusion and exclusion criteria

(Source: Self prepared)

Critical appraisal tool

A critical appraisal tool is a tool that is being utilized for the analysis of the selected articles and journals involved in research. It consists of certain criteria and conditions which are needed to be fulfilled in order to generate a rank or a score. This rank or score decides the authenticity, validity, and relatedness of the selected articles and journals with the research work (Casp-uk.net, 2022). A critical appraisal tool (CASP) would be appropriate for the analysis of the quality of the articles selected for the study. As the CASP tool generates criteria through the help of pre-set of 10 questions, the determination of the quality of data remains equal for all the articles irrelevant to their context and study type (Casp-uk.net, 2022). A critical appraisal tool or CASP is a very common tool used for the quality appraisal of health-related research works and qualitative or systematic literature evidence. The systematic review world is originally based on the notion to collect quantitative shreds of evidence from RCTs. This also answers the questions related to the effectiveness of the selected area of research.

The applicability of CASP in the selected articles not only helps to assess the quality of the study but also brings forward the best aspects of the research. It also helps to prove the relativity and relevance of the research with the topic of research (Casp-uk.net, 2022). In the CASP tool, a score is generated after the analysis of the pre-set 10 questions which helps in scoring the best articles.

Data Collection

Author	Year of Publication	country	Study setting	Study design	Population	Result and outcome	Extracted area
Misra et al. 2021	2021	UK	UK Hospitals	Primary	DKA patients	DKA admissions were 6% higher in the first wave of Covid 19 pandemic and 7% higher in the second wave. The median age was found t be 34 who had a previous history of type I diabetes. There was no difference in median age in patients with type II diabetes before the pandemic; however, it was found that patients above 50 years increased during the pandemic period.	Results and Discussion
Bouldin et al. 2017	2017	USA	Different health centres in King County	Primary	Diabetic patients receiving care	Caregivers can reduce the impact f diabetes and can help with continued medication and health management	The result, Discussion and Introduction
Bradford et al. 2017	2017	USA	US tertiary academic medical centre	Primary	DKA patients	The risk of recurrent hospitalisation is more in patients who are depressed; have poorly controlled diabetes, drug and alcohol abuse etc. It was also found that patients coming from black native communities had more relapses of DKA than white.	Introduction, Results and discussion
Dhatariya et al. 2016	2016	UK	72 hospitals in the UK	Primary	DKA patients were admitted to hospitals 1st May to 30th November 2014.	The patients admitted tending to have poor DKA management and a lack of awareness regarding it.	Introduction, Methods and discussion
Zhong et al. 2018	2018	England	England, Scotland, Wales, and Northern Ireland	Primary	Patient record from the 684 general practices record in England in January 2015.	The trend of hospital admission increased in DKA patients due to poor management, lack of education and ethnic differences.	Research design and method, Results and conclusion
Bergmann et al. 2022	2022	USA	Hospitals of USA	Primary	Children and adolescents who are younger than 21 years and have DKA.	The trend and causative factors for the readmission in DKA patients and the role of ethnicity and race behind it.	Results and discussion
Maxwell et al. 2021	2021	Canada	Cincinnati Children’s Hospital	Primary	439 patients with T1D; the population studied in children with a median age of 14 years	Children coming from black, Hispanic and Asian tend to suffer more from DKA. Also, the impact of poverty plays a major role in the recurrence of DKA.	Methods, Results and discussion
Lavik et al. 2022	2022	USA	Longitudinal data from 7 large medical centres in the USA	Primary	Children and adults with T1D and DKA during the Covid 19 period (2020 year)	DKA increased in 2020 during the Covid-19 pandemic and the people affected were majorly from black, Hispanic and Asian communities.	Results and discussion
Al Kaabba et al. 2022	2022	Riyadh	Riyadh city	Primary	399 caregivers from participated in this study who were from Riyadh	Diabetic type I caregivers have the knowledge and awareness regarding DKA management and hence the manifestation of DKA was lesser in their patients.	Introduction, Results and discussion
Odeh et al. 2022	2022	Jordan	Jordan	Primary	341 children and adolescents were diagnosed with T1D and DKA between 2015 and 2019	DKA is highly seen in patients with T1D. Prevention campaigns and educational awareness can reduce the severity of DKA in multiple communities.	Introduction, Results, and discussion

Table 2.4: Data collection

(Source: Self prepared)

Data analysis

The data extracted for the research are all primary studies that were done previously by researchers on the topic of diabetic ketoacidosis and its prevalence in diabetic patients. The collected articles also contained information about the severity of DKA in black communities in the UK. Along with that some articles are collected on the pieces of evidence of the importance of educational awareness regarding DKA management in patients. Each article contributed to the essence of the research and accordingly, the parts from where the data are collected are mentioned under the extracted area (Gusenbauer and Haddaway, 2020). The collection of data from the primary articles made the authenticity more approvable as primary analyses are majorly based on exploration and analyses of real-time data. All the chosen primary articles have ethics approved and are based on real-time data. The data are either collected from the medical databases from the hospitals or a primary study was conducted to obtain real-time data.

The collected information from the primary articles will be analysed with the help of the CASP tool. The CASP would help to produce an effective score for each article. After the analysis of each article, relative themes would be generated which would further help in the elaboration of different views and approaches. The use of the CASP tool along with the descriptive analysis would help to generate valid and strong arguments aiding in the outcome of the study (Casp-uk.net, 2022). The majority of the articles are chosen with a background of Type 1 or Type 2 Diabetes and Diabetic ketoacidosis. The country of study of the selected articles is majorly the UK. Some of the articles are from the USA; one is from Riyadh, Jordan, and Canada respectively. The information that is being taken into account is from the Introduction, Methodology, results, and discussion chapter of the articles.

Ethical considerations

Systematic research faces many issues regarding the ethical considerations regarding the involvement of participants as well as the data collection process. In this piece of research, the selected population is the patients who are suffering from Diabetic ketoacidosis. The research will not involve any personal details of the patients and all sensitive data regarding their health will be put under confidentiality under the Data Protection Act of 2018 (Gov.uk, 2020). This act would help in providing guidelines regarding ethical issues and would guide the entire data collection process. Also, to maintain similarity in the search process keywords related to the research work would only be used at the search platforms. The data collected for the research would be stored under password-protected folders and would not be shared with any other party except for the participants (Drolet et al. 2022). To ease the process of data collection, only free published articles are selected for the main study so that they are easily accessible to others and one can evaluate them for the authenticity of this research. This would also help in avoiding any ethical or copyright issues in the future. It would be seen that all the authors are cited rightly for their work at relevant data mentions and no disparity is recorded for it.

Summary

The above chapter detailed the methodological approach for the research where interpretivism philosophy, descriptive research design, and a deductive approach would be adopted for it. This chapter helped to shed light on the search strategy and data collection process. The search strategy being an integral part of the research provided information on how it was used for including and excluding topics for the research. The inclusion and exclusion criteria set for the research also helped to identify the sorting process of the search strategy. The entire chapter focused on the tool used for critical appraisal where the CASP tool was revealed to be used. The data collection process showed the selected 12 articles and provided basic information about them where it was recorded that all the chosen articles were primary articles. Lastly, the chapter discussed the ethical issues that were required to be considered in the entire study. All these pieces of information are helpful in developing the next chapter which is the product of the entire methodology chapter.

Chapter 3: Results

Result of search strategy

The search strategy adapted in the methods section describes the entire procedure that has been followed in the research. The result of the search strategy is discussed in detail here. This contains information about the participants, interventions, and outcomes of the 10 selected primary articles.

Articles	Participants	Interventions/exposure	Outcome
Misra et al. 2021	Patients with Type 1 and type 2 diabetes with DKA have a median age of 34.	Prevalence of DKA in type 2 diabetes patients during the Covid 19 pandemic period.	DKA admissions were 6% higher in the first wave of Covid 19 pandemic and 7% higher in the second wave.
Bouldin et al. 2017	Diabetic patients under care in hospitals of King county	The severity of DKA and Diabetes in patients under the lookout of caregivers.	Caregivers can reduce the impact of diabetes and can help with continued medication and health management
Bradford et al. 2017	DKA patients who are depressed, have poorly controlled diabetes, and are under drug and alcohol abuse with recurrent hospitalisation.	The hospitalisation rate of DKA patients who are depressed, under drug abuse and have poor management.	The risk of recurrent hospitalisation is more in patients who are depressed, have poorly controlled diabetes, drug and alcohol abuse etc.
Dhatariya et al. 2016	DKA patients who were admitted to hospitals between 1st May to 30th November 2014.	The impact of awareness regarding DKA management.	The patients admitted tending to have poor DKA management and a lack of awareness regarding it.
Zhong et al. 2018	DKA and diabetic patient record from the 684 general practices record in England in January 2015.	The trend of hospitalisation in different groups of people of different ethnic backgrounds due to poor management of DKA	The trend of hospital admission increased in DKA patients due to poor management, lack of education and ethnic differences.
Bergmann et al. 2022	Children and adolescents who are younger than 21 years and have DKA.	Recurrent hospitalisation in children with DKA coming from particular ethnic backgrounds and their causative factors	The trend and causative factors for the readmission in DKA patients and the role of ethnicity and race behind it.
Maxwell et al. 2021	439 patients with T1D were selected; the population studied is children with a median age of 14 years	The impact of poverty on the recurrence of DKA in T1D children from adverse backgrounds.	Children coming from black, Hispanic and Asian tend to suffer more from DKA. Also, the impact of poverty plays a major role in the recurrence of DKA.
Lavik et al. 2022	Children and adults with T1D and DKA during the covid 19 periods (2020 year).	Association between T1D and DKA and the effect of Covid 19 pandemic	DKA increased in 2020 during the Covid-19 pandemic and the people affected were majorly from black, Hispanic and Asian communities.
Al Kaabba et al. 2022	399 Caregivers in Riyadh with knowledge of T1D and DKA management	Impact of the awareness and management of caregivers on DKA management	Diabetic type I caregivers have the knowledge and awareness regarding DKA management and hence the manifestation of DKA was lesser in their patients.
Odeh et al. 2022	341 children and adolescents who are diagnosed with T1D and DKA between 2015 and 2019	The necessity of educational campaigns and health programs to reduce the mortality and severity of DKA in different communities.	DKA is highly seen in patients with T1D. Prevention campaigns and educational awareness can reduce the severity of DKA in multiple communities.

Table 3.1: Result of search strategy

(Source: Self prepared)

Result

The articles selected for the study are based on the prevalence of DKA in diabetic patients. In the majority of the papers, the main focus was kept on the diabetes issue and the associated problems of DKA. The symptoms of DKA are noticed in severe cases of lack of insulin and the risk of developing hypoglycemia or hypokalemia. In the UK, the survey for the past years has shown that the number of patients has been increasing. In the work of Dhatariya et al. 2016, it has been mentioned that in 2011, a National Diabetes audit committee reported that in England and Wales, at least one episode of recurrence of Diabetic ketoacidosis has been found among the 7608 adults in the assessment year 2011-12. Recently the mortality rate has also increased and has reached 2% in DKA patients. Bergmann et al. 2022 have stated that the risk of DKA and its high prevalence is associated with many other factors such as ethnicity, cultural background, food habits, and management techniques for diabetes control. In his study, a direct link was found between ethnicity and DKA occurrence. It was found that in 72,726 patient encounters, 600 belonged to Asian communities, 9969 belonged to the black Hispanic group, 16876 to non-Hispanic black, 40129 to non-Hispanic white, and 5152 to other races or ethnicity (Bergmann et al. 2022). Hence, it can be observed that the occurrence of DKA is more in the black community and people coming from different ethnic backgrounds.

In the UK, the joint British Diabetes societies published guidelines for the management of DKA and identified that a "blood pH of <7.3, a blood glucose level of >11.0 mmol/l, and a ketone of >3.0 mmol/l would be considered ketoacidosis". The guidelines are based on the importance of ketone level management and reduction in blood along with insulin management (Dhatariya et al. 2016). It suggested administering IV insulin in patients with extremely low insulin levels (Hurst et al. 2020). Also, the replacement of fluids is essential in the case of DKA as most of the electrolytes and fluids are lost due to frequent urination in diabetes. In the study of Dhatariya et al. 2016, it was found that in 2013 most of the patients developed hypokalemia and ">25% of patients developed hypoglycemia". Hence, the management strategies needed to be revised, and much stress was required on the prevention of hypokalemia in DKA patients as it was the primary cause of death among them.

It is noted that the prevalence of DKA is associated with several other factors like race, ethnicity, awareness, and food habits. It is not only the occurrence of Diabetes that affects the rate of DKA in patients. In the work of Bergmann et al. 2022, it is mentioned that non-Hispanic black children had a two-fold risk of increase in diabetes and an increased risk of death due to DKA than non-Hispanic white children. The paper successfully found a strong interaction between the socio-economic status and cultural effect on the recurrence of DKA in non-Hispanic black children. Hospital readmissions are significant in assessing the quality of care and management in DKA patients. Hence, the readmissions not only indicate that the DKA is poorly managed but also show the prevalence in black communities. The racial linkage is strongly associated due to food habits that differ from the white people (Bergmann et al. 2022). Deprivation and lack of protein-rich food in the black communities of the USA indicate that their food consumption is majorly the cheaply available foods like bread. On the contrary, white people due to up levelled of socioeconomic status can afford the changed dietary habits and hence are able to control their diet (Bradford et al. 2017). This study also found that people who were taking regular insulin pumps and were on continuous glucose monitoring (CGM) exhibited lesser chances of having DKA. This method of CGM alongside insulin pumps reduces the adversities of T1D and its associated complications. This study also found that the rate of DKA is two-fold higher in black communities than the white. The pattern of DKA is dependent on the racial background. T1D is found to be more severe in Asian, American- African, Hispanic, and African communities. The severity leads to death in 3% of cases of DKA. The rate of mortality is approximately 17% higher in black communities than in white. In the study by Bouldin et al. 2017, it was found that the mortality rate can be reduced in DKA patients if the management and care are appropriately provided. The level of education and awareness is also a prime factor in reducing the severity of DKA.

It is found that regular and continuous monitoring of blood glucose levels, diet management, and electrolyte and fluid replacement can effectively manage DKA. This is effective only when the patient possesses full knowledge and education about the proper management of DKA and diabetes. As viewed by Bouldin et al. 2017, social support and self-care are most effective in managing DKA and diabetes. Self-care management includes medication adherence and self-care activities. Social support like motivation, empathy, instrumental support, and care can also effectively control DKA. The self-care activities that are associated with the management of DKA include: eating a healthy diet, regular foot checkups, blood glucose monitoring, and electrolyte replenishment. Eating a healthy diet includes eating fewer carbohydrates and sugars and the inclusion of minerals and protein-based diets. In diabetes patients, the glucose level always remains high due to a lack of adequate insulin (Lee and Lee, 2018). Hence it is necessary to check the intake of glucose and eliminate those food items which are rich in carbohydrates. One of the preliminary causes for the mismanagement of glucose control lies in the dietary habits of Asians, Hispanic, African- American and African black communities. They tend to be dependent on carbohydrate-based food like rice, wheat, maize, etc. Their staple diet includes these and some vegetables like potatoes, pumpkins, carrots, etc which contain a lot of sugar in them. Hence, due to the dependency on the basic staple diet available to them, the majority of the coloured and black communities have a poorly controlled diet.

Similarly, regular foot checkups are necessary because diabetic patients tend to develop foot ulcers which are a very common symptom and related disease with diabetes. The nerve endings become less functioning and stimulating due to extreme glucose and low insulin levels. This causes tingling sensations and less oxygen supply leading to ulcerations in body extremities like feet (Zhong, et al. 2018). Hence regular checkups can prevent foot ulcerations in diabetic patients. Earlier to prevent diabetic ketoacidosis it was necessary to have insulin injected into the body of patients who have very low levels produced in them. Later the guidelines by the Diabetes society, in the UK changed the focus to glucose monitoring rather than IV insulin injections (Varadarajan et al. 2017). Blood glucose monitoring has been effective in managing diabetes. Monthly blood glucose tests, both fasting and postprandial are done in patients with Diabetes to keep track of the changes in blood glucose level. According to the blood glucose level, the level of insulin dosage is fixed.

In the case of diabetic patients, another symptom that is commonly seen is frequent urination. In both T1D and T2D, the patients frequently urinate leading to a loss of bodily fluids and necessary electrolytes like sodium and potassium. Vellanki and Umpierrez, 2021 has found that Insulin deficiency and increased activities of counter-regulatory hormones of insulin-like cortisol, growth hormones, and catecholamines along with peripheral insulin resistance lead to the pathophysiology of DKA. Hyperglycaemic conditions increase the lipolysis in the body leading to the production of free ketones. Maxwell et al. 2021 has opied that extreme loss of essential electrolytes disbalances the body's functions leading to impairment in heart, nerve, and brain functioning. Also, loss of water can increase the concentration of sugar in the blood, which in normal cases helps to dilute the blood sugar. A very little level of insulin also lowers the electrolyte levels in the body. Hence, electrolyte replenishment and fluid replenishment are two essential parts of diabetes and DKA management.

Many management strategies have been adopted to reduce the effect of DKA on patients. Fluid therapy is one such therapy. Approximately 6- 9 litres of fluid is lost on a daily basis in DKA patients. So, “boluses of isotonic saline (0.9% NaCl)” are injected intravenously in DKA patients in fluid therapy. Similarly, insulin therapy is another strategy to control DKA (Ooi et al. 2021). The administration of insulin promotes the utilisation of glucose in the peripheral tissues and helps in controlling ketogenesis. Lavik et al. 2022 has stated that for electrolyte maintenance, potassium, phosphate, and bicarbonate therapy is another management strategy adopted for DKA. Monitoring of serum potassium should be done in DKA management as administration of insulin alongside the acidemia correction drives the intercellularity of potassium ions which may result in hypokalemia. This may further develop chances of arrhythmia and cardiac arrest in DKA patients. Apart from these regular performances feedback is another strategy that can be used for the management of DKA (Misra et al. 2021). It is usually provided by a caregiver or the physician where the observations are recorded and a final statement related to progression is provided to the patient. Self-awareness, education, and management have been considered the best self-evaluation and control strategy as it not only helps in long-term treatment progression but gives a faster recovery to the patients.

Assessment of study quality (CASP score)

	Misra et al. 2021	Bouldin et al. 2017	Bradford et al. 2017	Dhatariya et al. 2016	Zhong et al. 2018	Bergmann et al. 2022	Maxwell et al. 2021	Lavik et al. 2022	Al Kaabba et al. 2022	Odeh et al. 2022
1. A clear focus on the issue	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes
2. Selection of papers	Can’t say	Yes	Yes	Can't say	Can't say	Yes	Yes	Yes	Can't say	Yes
3. Inclusion of relevant studies	Yes	Yes	Yes	Yes	Can't say	Yes	Yes	Yes	Can’t say	Yes
4. Conclusion development	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes
5. Reasonable results	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes
6. Interpretation of results	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes
7. The precision of findings	Can’t tell	Yes	Yes	Can’t say	Yes	Yes	Yes	Yes	Can’t say	Yes
8. Application of results	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes
9. Ethical consideration	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes
10. Benefits	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes
Total score (10)	8/10	10/10	10/10	8/10	8/10	10/10	10/10	10/10	7/10	10/10

Table 3.2: CASP score

(Source: Self prepared)

The CASP score is essential to evaluate the quality of the articles selected for the study. The CASP score indicates the level of appropriateness and highlights the criteria that have been fulfilled to meet the quality of the study (Newman and Gough, 2020). In this section, a majority of the articles exhibited a full score of CASP which indicates that the quality of the present study will also not be compromised and will reflect the correct data and their analysis.

Chapter 4: Discussion

Discussion of heterogeneity

The heterogeneity of the collected data was found in the case of the awareness and knowledge about the management of diabetes in the case of caregivers, patients, and family members. In the study by Al Kaabba et al. 2022, it was found that the majority of the caregivers were aware of the management procedures for type 1 diabetes but in the majority of the cases, the caregivers were unaware of the management of DKA cases of Type 2 Diabetes. This study also highlighted that though the management procedures do not vary much in both cases, the knowledge gap is persistent in the caregivers. A similar kind of situation is also found in the case of the mothers of children who were suffering from diabetes and diabetic ketoacidosis (Al Kaabba et al. 2022). The other group of patients consisted of mothers whose children had DKA but they were aware of the management techniques and precautions (Odeh et al. 2022). This thus made the children less vulnerable to the adversity of the disease. The mothers' knowledge level, better educational level, and socio-economic status helped in minimising the actual complications of both diabetes and diabetes ketoacidosis in children.

In the majority of the studies, the occurrence of diabetes ketoacidosis is stressed with type 1 Diabetes. In 78% of the cases, DKA occurrence is found to be with type 1 diabetes (Fagherazzi and Ravaud, 2019). However, it is not that DKA patients are not found in the case of T2D. DKA can occur both in the case of T1D and T2D. The presumption is made in many papers about the occurrence of DKA in only T1D patients and not in T2D patients. This brings heterogeneity in the entire dissertation which affects the outcome of the study. Apart from that, Dyson et al. 2018 has observed that in the case of management techniques for DKA in patients, a majority of the papers have focused on insulin intake rather than glucose monitoring. A monthly glucose evaluation of the DKA patients is essential rather than insulin administration because it would help to keep a profile of the glucose levels of the patient (Holman et al. 2020). It would further help to check the status of diabetes and the physician can always compare the levels with previous statements. The heterogeneity is also found in the case of electrolyte balancing. Many authors have focused on the point of the administration of potassium, chloride, and phosphate in the body and others have just grouped all the electrolytes together. This statement provides an unclear view of the exact electrolytes that are to be administered to DKA patients for electrolyte rebalance and replenishment (Holman et al. 2020). Hence multiple heterogeneities are found in the papers that are selected for supporting the findings of this research.

Sensitive analysis

The sensitive analysis is done to relate the dependency of the independent variable against the dependent one. It is done to determine the effect of independent variables on the dependent ones. In this case, the independent variables are lack of insulin, diabetes, lack of education and awareness and the dependent variables are ketoacidosis, and electrolyte imbalance (Pal et al. 2020). The sensitive analysis shows that the dependent variables are related to the independent variables. In the findings of Palermo et al. 2020 it has been found that diabetes is a clinical condition where a lack of insulin raises the amount of blood sugar in the patients. Diabetes is of two types- Diabetes mellitus, also called Type 2 Diabetes, and Diabetes insipidus, Type 1 Diabetes. The disease brings after many other diseases like foot ulcers, retinopathy, ketoacidosis, etc. The dependent variables are the effects of the independent variable. Therefore, it can be concluded that the independent variables are strongly related to the dependent variables.

The strong correlation between the dependent and independent variables makes the research sensitive and more justifiable. The analysis presents that diabetic ketoacidosis is related to diabetes occurrence and lack of insulin production in patients. The alternative that might be seen only in the case of type 1 diabetes is discarded because of the fact that ketoacidosis is equally relevant in type 2 diabetes cases (Palermo et al. 2020). The presumption of the occurrence of ketoacidosis in only T1D patients affects the sensitivity of the research and later on analysis it has been found that T2D also affects the rate of ketoacidosis in patients. Apart from that, the management strategies have a separate effect on the dependent variables. The management strategy of fluid therapy is aligned with the electrolyte imbalance whereas another target of glucose monitoring aligns with diabetes conditions (Kuppermann et al. 2018). Hence after careful analysis of the sensitive issues, it can be stated that the independent variables have a direct and related effect on the dependent variables.

Discussion

Theme 1: Black community people predominantly suffer from ketoacidosis more than the white people

The prevalence of Diabetes is found in all communities over the world irrespective of community, gender, and ethnicity. Both type 1 diabetes and type 2 diabetes are predominantly evident in people and both are considered to be strongly associated with the occurrence of diabetic ketoacidosis. It is found in many government and agency reports that people from coloured communities and black communities are more prone to develop diabetic ketoacidosis and the severity is also higher in them (Zhong et al. 2018). Oskarsson et al. 2018 has expressed that comparatively white people do not have the tendency to develop fatal conditions regarding ketoacidosis and hence the mortality rate is lower in them.

In the last few years, black people have died majorly due to ketoacidosis. It has been found that they are unable to manage the glucose level in their blood and their diabetes is uncontrolled (Reddy et al. 2020). The occurrence of ketoacidosis is strongly associated with the community because of certain other factors like ethnicity, genetic changes, and food habits. One genetic theory behind the occurrence of high diabetes in black communities is G6PD deficiency in African Americans (Drummond et al. 2018). The risk increases with a Western diet pattern that is followed by them and acts as a risk factor for type 2 diabetes. The study has focused only on ethnic and food habits and multiple observations have been noted in these cases. It is prominent that Asian people, Hispanic people, American African blacks, and black people of Africa suffer more from the disease. The reason can be related to cultural habits as the majority of these communities do not have a controlled diet and due to cultural reasons, they consume a lot of food that is the cause for increasing glucose levels in the blood (Ehrmann et al. 2020). The other reason which is often overlooked in this case of racial disparity is the unavailability of equal healthcare facilities in hospitals across the UK (Reddy et al. 2020). The research data shows that the healthcare facilities are not equal in the case of these communities as many of them come from different nations and in black communities the lack of insulin and obesity plays a major role in increasing the glucose level in blood in diabetes.

Theme 2: There is a relationship between ethnicity, culture, and diet with the prevalence of diabetes ketoacidosis

Ethnicity, culture, and dietary pattern play a key role in the promotion of glucose in the blood. A majority of patients with type 2 diabetes are found to have obesity and insulin resistance. Obesity is more prone in African American people than in white people. Physical inactivity is the other reason for the occurrence of diabetes in them. Cherubini et al. 2019 has opined that there is a decreased amount of physical activity recorded in African American women and adolescent girls of this community. It has been also found that the offspring of African people having diabetes also tend to suffer from diabetes or show early onset of diabetes. Increased insulin resistance is the major defect seen in them.

The strong affinity of diabetes with ethnicity and diet shows that the severity is based on the habits and practices shown by the communities. A report from the Institute of Medicine (IOM) tells about the severity of diabetes in America where it was noted that all racial minority communities receive a lower quality of healthcare services, insurance coverage, and educational awareness (Misra et al. 2021). African and African American people were found to have fewer "glycosylated haemoglobin measurements, lipid testing, or ophthalmological visits" (Pasquel et al. 2021). The food habits of black people are also responsible for the increased glucose levels. The African people have suffered long-term scarcity of food and a sudden influence of the western food culture elevates their blood glucose level (Maxwell et al. 2021). The consumption of white bread, corn, and maize predominantly increase the amount of glucose in the blood (Dyson et al. 2018). Traditional food dishes also contain a lot of sugar and thus glucose management is not properly done. Fagherazzi and Ravaud, 2019 has found that the consumption of traditional dishes and drinks and irregular checking of sugars and calories lead to uncontrolled diabetes. Hence the high mortality rate is also related to this community.

Theme 3: The management strategy of insulin dosage, glucose monitoring, and fluid therapy is beneficial in the reduction of ketoacidosis

Diabetic ketoacidosis leads to the production of ketone bodies in the blood along with the loss of electrolytes from the blood. It is the amount of ketone and essential electrolyte loss from the body which leads to mortality in the patients. Studies of diabetes management have shown that approximately 74% of people show a high risk of ketone body production due to a lack of insulin in the body and improper management of glucose (Candler et al. 2018). Due to the loss of insulin, the majority of the glucose is consumed quickly and for further energy, fat is metabolised. This metabolization of fat leads to ketone body formation. The effective strategies which are in practice for diabetes management include insulin therapy and glucose monitoring (Drummond et al. 2018). A continuous glucose level check helps to keep vigilance on the blood sugar levels (Bradford et al. 2017). In this case, a fasting and postprandial blood glucose test is helpful. Tyndall et al. 2019 has opined tha apart from that, rapid HbA1c assays are also helpful for the assessment of glycogen levels in the body.

In the case of patients with a lack of insulin production, it is necessary to inject insulin shots regularly to keep a balance of the glucose levels. "Subcutaneous insulin infusion (CSII) via insulin pumps" has been reported to be effective in both black and white people (Tyndall et al. 2019). As stated by Candler et al. 2018, in the case of children and other adults who show a tendency, the lack insulin is advised a metformin therapy where pharmacological options are given for the oral ingestion of metformin (Oskarsson et al. 2018). Continuous and comprehensive glucose monitoring is hence effective in lowering blood glucose levels.

Fluid therapy on the other hand is essential in case of severe cases of electrolyte imbalance and loss because a lot of essential electrolytes are lost through urine and create stress on the kidneys. Hence fluid therapy of chloride ions, potassium ions, and phosphate ions is necessary for the patients (Pal et al. 2020). The therapy helps to retain the electrolytes and also helps in the filtering of excess ketone bodies through urine. Fluid therapy is considered a vital point in reducing the mortality rate in black patients.

Theme 4: Educational and management awareness can effectively reduce the adversity of Diabetic ketoacidosis in patients

Diabetic ketoacidosis reaches its severity due to the lack of awareness about its management and self-care practices. Barron et al. 2020 has reviewed that patients suffering from both type 1 and type 2 diabetes require having a piece of full comprehensive knowledge about the care and management techniques. Also, it is essential to know about the importance of diet management for the control of diabetes. The study shows that a majority of the black community people suffer from diabetic ketoacidosis due to a gap in knowledge about its management techniques (Rabbone et al. 2020). The lack of self-care and timely assessment of body vitals leads to negligence and reach to the severity of ketoacidosis. The government of the UK has taken several steps to increase awareness about management techniques and self-management in the case of diabetes (Ehrmann et al. 2020). The diabetes society takes care of educational awareness programmes. Many interventions have been developed for the control of diabetes in the UK. However, there are fewer management techniques known for ketoacidosis management in the case of diabetic patients. It is essential to promote education and management strategies about ketoacidosis.

In many studies, it has been found that the family members and the caregivers who have knowledge about the control and management strategies can effectively help the patients to control their diet and teach them self-management. In the study by Bouldin et al. 2017, it was found that the mothers of children who had knowledge about diabetes control and blood glucose monitoring successfully saved their children from diabetes over a long term of treatment procedures. Apart from that, it is also evident that the knowledge level of the caregiver can also help in the reduction of ketoacidosis. The patients can learn about self-management which helps manage their conditions in the future.

Theme 5: Educational campaigns, government-aided advertisements, and therapy counselling at hospitals are necessary to promote awareness of diabetic ketoacidosis management

Diabetes is a common apathy in many households in the world. Half of the population in the world is either suffering from type 1 or type 2 diabetes. Hence the disease is not rare but rather common and popular. However, the disease is just only popular by its name as many people do not know the exact causes and treatment options for the disease (Rabbone et al. 2020). The prevalence of diabetes is severe in black communities because of a lack of awareness and education about the disease. Similarly, ketoacidosis management is unknown to them. The government of the UK needs to adopt certain strategies that would be beneficial in increasing awareness regarding diabetic ketoacidosis in black communities. As viewed by Cherubini et al. 2020, one of the key strategies through which awareness can be spread is with the help of educational campaigns. Educational campaigns teach about the disease, its severity, and the factors that are associated with it. The campaigns provide expert advice and lectures about the management of the disease. Through these campaigns, the government can reach every single person belonging to the black community (Cherubini et al. 2020). Also, the estimation of data of people belonging to the black community who are suffering from diabetes and ketoacidosis can be calculated. It would be beneficial to keep a close eye on their health status and progress through this.

Another strategy through which awareness can be spread is through government-aided advertisements in print and broadcasting media which has a lot of consumer base. It would be helpful in spreading the word regarding the necessity of diabetes and ketoacidosis treatment in patients (Rabbone et al. 2020). The other strategy which would bring remarkable changes is diabetes and ketoacidosis counselling at hospitals. The hospitals providing counselling to patients of ketoacidosis would have a physician who would guide the patients regarding their diet and health management and would help them in controlling their blood glucose and fluid management (Rabbone et al. 2020). Apart from that, weight management is also considered to be necessary for diabetes. Hence, counselling provisions at hospitals would not only provide equal treatment facilities to all sections of communities but would also promote the management and education about diabetic ketoacidosis. It would be significant in lowering the mortality rate of patients with diabetic ketoacidosis belonging to the black community.

Implications of findings of the review

For practice

The findings that were gathered in the review section focus on the essence of the research which is the management of Diabetic ketoacidosis in black patients. It has been reviewed that the current management practices followed for the treatment and control of DKA are not sufficient to stop the mortality rate in black communities. There is a lack of awareness of black patients and they tend to be unequally treated in the case of medicinal facilities and treatment options in the UK (Ehrmann et al. 2020).

The implications that can be put into practice include glucose management and monitoring and its education in the black community. Black people need to be made aware of the complications that arise with diabetes (Goldman et al. 2020). Hence for practice, an awareness program can be included under the health policy or the diabetes policy of the government. Goldman et al. 2020 also stated that another option that can be kept under practice is fluid therapy. It is widely known that diabetic patients lose a lot of water and essential electrolytes from the body due to frequent urination. Hence it is important to replenish the amount lost and this can be done through electrolyte drinks or health drinks that are rich in chloride ions, potassium ions, sodium ions, phosphate ions, etc. The government can promote the consumption of these drinks to boost the water balance in the body so that the patients do not go under hypovolemic shock (Kuppermann et al. 2018). This would in turn reduce the rate of mortality in black patients.

For research

In the case of the research aspect of the summary of findings, it can be correlated that diabetes is an ailment with multiple side effects and ketoacidosis is one of them. The prevalence of DKA is seen as higher in black patients. It is observed that this severity is related to the background, ethnicity, and food habits of the community (Holman et al. 2020). Apart from these factors, two other factors are strongly associated with it. One of the factors is the tendency of obesity in black people and the other is the changed gene patterns in them (Hurst et al. 2020). The genetic factors are also related to the high occurrence of DKA in black and coloured patients. This study can offer future research in studying the impact of obesity on DKA in black patients and the relationship of DKA with the genetic constitution of black people (Oskarsson et al. 2018). Apart from this, Dyson et al. 2018 has expressed that an entire research can be built upon the food habits seen in the black community and the nutritional aspects associated with them, which leads to an increased glycogen content in the blood.

Strengths and weakness of the review

The present study is based on the data gathered in previous research. This study has derived and synthesised the formations from the data and accordingly set observations and findings. The study has certain strengths and weaknesses which make the study impactful as well as vulnerable to changes. The strength and weaknesses of the review are

Strength: The strength is strongly built upon the data and information available on the prevalence of DKA in black patients. It strongly reflects the number of patients who are being affected by DKA in the UK and the high mortality rate that is noted among the black community. The selected articles present a brief overview of the clinical aspects of diabetes type 1 and type 2 (Barron et al. 2020). The ailments that are associated with diabetes are discussed in detail. Also, the ailments that lead to the development of DKA are highlighted in this study. The study has kept its focus on the DKA prevalence and mortality rate in them (Holman et al. 2020). The study has successfully found the associated factors with the mortality rate which are high amounts of glucose, lack of insulin, fluid loss, hypovolemic shock, lack of management strategies, uncontrollable diet, and ethnicity of particular people. The study has highlighted the management strategies that are currently in practice and that can provide a wide scenario of the clinical and management aspects of DKA. The study has shown that the higher mortality rate is associated with the lack of education and awareness regarding DKA management and diabetes management (Reddy et al. 2020). The strength of the study lies in the recommendations which are suggested to increase the importance of education and awareness about DKA and its management in black patients.

Weakness: The study has been built upon the available facts and figures on the prevalence of DKA in the black community. This itself acts as the biggest weakness as the chances of lack of accuracy are high in these cases. The study is secondary research and no primary data collection has been followed. Although the selected articles are built upon the primary findings, it still creates a lot of gaps in the understanding and presentation of data (Reddy et al. 2020). Another major weakness of the study is that it considers only black communities in the UK. The study should consider other communities like the Asian communities which also face similar health complications and there is a lack of knowledge about diet management in them too (Ehrmann et al. 2020). The recommendations made in this study are very general and do not specify any action plan for their implementation. Hence the recommendations can only be considered to be applicable but their applicability is not yet specified (Pasquel et al. 2021). The lack of an action plan makes the recommendations weak and unspecified as it is without proper measurable outcomes and a time plan.

Chapter 5: Conclusion

Conclusion

The above chapters present a detailed overview of the condition of ketoacidosis in black patients and communities in the UK. It can be stated that the relation of the disease with the black community is due to several factors which play a role in its prevalence. The relationship with the severity of the disease lies in the ethnic and cultural background of black people. Along with that food habits or diet also plays a vital role in the progression of the disease. It has been evident in the discussion that glucose monitoring, fluid therapy, and insulin doses can effectively reduce diabetic ketoacidosis in patients. However, the majorities of the black community people is deprived of health facilities and have a lack of knowledge about the correct management procedures for diabetic ketoacidosis. The focus must be kept on increasing the awareness level of black people. The study has presented several strategies like awareness and educational programmes, counselling, and advertisements in the discussion which can be adopted to increase mass awareness in the black community across the UK so that the rate of mortality can be reduced in the black diabetic ketoacidosis patients.

Summary of validity of findings

The validity of the findings can be proved by aligning the data with the statistical data punished by the government sites. The majority of the data is taken from the primary researchers which have either conducted surveys or questionnaires and have duly formed the ethical forms. The null hypothesis H0 developed at the first chapter is hence proved in the review. Hence the validity of the findings can be said to be unbiased and real.

Summary of the relevance of findings for practice and research

The findings for the practice and research obtained are relevant to the study as the research has kept its focus on the DKA and its management. The findings are relevant to develop further research topics and can also be used to highlight the areas which still need focus (Duran and Pérez-Stable, 2019).

Linking with objectives

Linking with objective 1:

The objective of relating the current rate of diabetic ketoacidosis in the black community of the UK has been fulfilled successfully as the study has determined the number of patients who suffer from both diabetes type 1 and type 2 along with the patients of DKA who belong from the black community (Cherubini et al. 2020). The governmental data along with the primary findings shed light on the prevalence of DKA among the black people of the UK. Hence the first objective has been fulfilled and we get to know about the information in the second, third, and fourth chapters of the review.

Linking with objective 2:

The second objective of determining the current health management strategies has been fulfilled as the study has identified three major strategies- glucose monitoring, fluid therapy and insulin doses for the patients of DKA. These three strategies are widely followed in the UK and the government has also focused on these for the elimination of DKA complications (Misra et al. 2021). The physicians have recommended monthly glucose monitoring along with medicines like metformin in the progressive stages of diabetes. The major focus is kept on diabetes control so that other complications like ketoacidosis do not arise in the patients.

Linking with objective 3:

It has been found in the review that the level of education plays a prime role in the management strategy for DKA. Along with it, the dietary pattern seen in the black community leads to an increase in glucose levels in the blood (Bouldin et al. 2017). The severity is associated with race and ethnicity. Hence the third objective has also been fulfilled in the review.

Linking with objective 4:

It has been found in the study of Al Kaabba et al. 2022 and Odeh et al. 2022, that educational campaigns and awareness of management strategies have a severe impact on reducing DKA complications in patients. The third objective to identify the educational impact has been fulfilled from their observations which provided that the mothers of children who are aware of the management and care practices suffered less and lesser hospitalisation were seen in their children. Also, the caregivers who were providing services from the early period to the DKA patients had no issues of severity or mortality (Odeh et al. 2022). Hence it can be stated that the impact of education and awareness had been highlighted in the discussion chapter and thus this objective has been successfully fulfilled.

Linking with objective 5:

The present review has recommended the strategy to increase awareness regarding DKA management through campaigns and advertisements. The initiative is to be taken from the government and the hospitals need to implement counselling for patients of DKA regularly. However, the recommendations do not provide any action plan for its implementation. Hence, this objective has also been achieved in this study.

Recommendations

The study has been derived from the evident data and management practices that are still followed for the treatment of diabetic ketoacidosis in patients in the UK. From the above discussion, it can be recommended that the government needs to bring focus on the increasing death rate due to ketoacidosis in black patients. The government of the UK needs to bring these black communities under an umbrella program that will provide equal benefits and opportunities for health and management (Rabbone et al. 2020). It is also necessary to understand the ethnic roots of the community as the main cause behind the uprising is also associated with their culture and background. Awareness campaigns and programmes should be promoted with the help of the media so that it reaches a wide number of people across the country. Bradford et al. 2017 has strongly argued that stress should be kept on self-management practices that teach the patients about self-monitoring and evaluation for diabetes and ketoacidosis.

It can also be recommended that the hospitals should provide free blood glucose checkups to new patients with diabetes so that they remain motivated for its control. The children should be also kept under focus as they are at the developing or preliminary stages and with effective treatment options and careful strategic management their conditions can be reversed and brought back to normal (Odeh et al. 2022). In the case of children, the awareness levels of the mother play a central role in the management and reduction of diabetes (Bergmann et al. 2022). Another strategy that can be recommended includes weight management as black people tend to be obese. The majority of black people are not conscious of their weight and tend to be obese due to uncontrolled eating and lack of exercise. Candler et al. 2018 has opined that Exercise and a controlled diet are suitable to reduce obesity and in turn, also help to control diabetes and diabetic ketoacidosis.

Future scope

The study successfully attracts attention to the severity of diabetic ketoacidosis in black community people. It is impactful in presenting detailed information about the prevalence of diabetic ketoacidosis in black patients in the UK. This study would bring out future scopes for highlighting the advanced treatment options that are under research as well as available in the market for reducing diabetic ketoacidosis. It would also help drive the focus to impactful alternate treatment options that can be adopted for black patients keeping in consideration their ethnicity, background, and culture. This research will open the scope of awareness programmes and policies that are required to be developed for the control of diabetic ketoacidosis in the country (Lavik et al. 2022). It can be stated that the government can also benefit from this study to understand the cause of the necessity to increase awareness about diabetic ketoacidosis management among people in the black community.

The study would be beneficial in highlighting the strategies that can be adopted to increase awareness regarding the need for the management of diabetic ketoacidosis. It would also help to spread the information that it is a serious condition with a huge risk of mortality. This would in return make the people aware and help the black people to change their views regarding the treatment options (Al Kaabba et al. 2022). The study can also help develop interventions and nursing models for the care of diabetic ketoacidosis patients. The hospital management can also gain information about the necessity to include counselling and therapy for diabetes and diabetic ketoacidosis management. Hence it can be concluded that the study has not only aimed at the control of the disease but also has focused on its prevention and future study scopes.

References

Books

Mishra, S.B. and Alok, S., 2022. Handbook of research methodology.

Pandey, P. and Pandey, M.M., 2021. Research methodology tools and techniques. Bridge Center.

Selected articles

Al Kaabba, A.F., Alzuair, B.S., AlHarbi, Y.F., Alshehri, J.A., Almalki, H., Alsalman, R., Alsubaie, S., Alkhatabi, R.A. and Hussein, G., 2022. Knowledge and Awareness of mothers and caregivers of Diabetic Children about clinical features and complications of Diabetic Ketoacidosis in Riyadh City: questionnaire study. Middle East Journal of Family Medicine, 7(10), p.51.

Bergmann, K.R., Nickel, A., Hall, M., Cutler, G., Abuzzahab, M.J., Bretscher, B., Lammers, S., Watson, D. and Hester, G.Z., 2022. Association of Neighborhood Resources and Race and Ethnicity With Readmissions for Diabetic Ketoacidosis at US Children’s Hospitals. JAMA Network Open, 5(5), pp.e2210456-e2210456.

Bouldin, E.D., Trivedi, R.B., Reiber, G.E., Rosland, A.M., Silverman, J.B., Krieger, J. and Nelson, K.M., 2017. Associations between having an informal caregiver, social support, and self-care among low-income adults with poorly controlled diabetes. Chronic illness, 13(4), pp.239-250.

Bradford, A.L., Crider, C.C., Xu, X. and Naqvi, S.H., 2017. Predictors of recurrent hospital admission for patients presenting with diabetic ketoacidosis and hyperglycemic hyperosmolar state. Journal of clinical medicine research, 9(1), p.35.

Dhatariya, K.K., Nunney, I., Higgins, K., Sampson, M.J. and Iceton, G., 2016. National survey of the management of diabetic ketoacidosis (DKA) in the UK in 2014. Diabetic Medicine, 33(2), pp.252-260.

Lavik, A.R., Ebekozien, O., Noor, N., Alonso, G.T., Polsky, S., Blackman, S.M., Chen, J., Corathers, S.D., Demeterco-Berggren, C., Gallagher, M.P. and Greenfield, M., 2022. Trends in Type 1 Diabetic Ketoacidosis During COVID-19 Surges at 7 US Centers: Highest Burden on non-Hispanic Black Patients. The Journal of Clinical Endocrinology & Metabolism.

Maxwell, A.R., Jones, N.H.Y., Taylor, S., Corathers, S.D., Rasnick, E., Brokamp, C., Riley, C.L., Parsons, A., Kichler, J.C. and Beck, A.F., 2021. Socioeconomic and racial disparities in diabetic ketoacidosis admissions in youth with type 1 diabetes. Journal of Hospital Medicine, 16(9), pp.517-523.

Misra, S., Barron, E., Vamos, E., Thomas, S., Dhatariya, K., Kar, P., Young, B., Khunti, K. and Valabhji, J., 2021. Temporal trends in emergency admissions for diabetic ketoacidosis in people with diabetes in England before and during the COVID-19 pandemic: a population-based study. The lancet Diabetes & endocrinology, 9(10), pp.671-680.

Odeh, R., Gharaibeh, L., Daher, A., Albaramki, J., Ashour, B., Al Barakat, F., Dahabreh, D., Hadadin, H., Melhem, T. and Alassaf, A., 2022. Frequency, Clinical Characteristics and Predictors of Ketoacidosis at Diagnosis of Type One Diabetes Mellitus in Children and Adolescents from Jordan. Journal of clinical research in pediatric endocrinology, pp.0-0.

Zhong, V.W., Juhaeri, J. and Mayer-Davis, E.J., 2018. Trends in hospital admission for diabetic ketoacidosis in adults with type 1 and type 2 diabetes in England, 1998–2013: a retrospective cohort study. Diabetes care, 41(9), pp.1870-1877.

Other Journals

Barron, E., Bakhai, C., Kar, P., Weaver, A., Bradley, D., Ismail, H., Knighton, P., Holman, N., Khunti, K., Sattar, N. and Wareham, N.J., 2020. Associations of type 1 and type 2 diabetes with COVID-19-related mortality in England: a whole-population study. The lancet Diabetes & endocrinology, 8(10), pp.813-822.

Brandstaetter, E., Bartal, C., Sagy, I., Jotkowitz, A. and Barski, L., 2019. Recurrent diabetic ketoacidosis. Archives of endocrinology and metabolism, 63, pp.531-535.

Candler, T.P., Mahmoud, O., Lynn, R.M., Majbar, A.A., Barrett, T.G. and Shield, J.P.H., 2018. Continuing rise of type 2 diabetes incidence in children and young people in the UK. Diabetic Medicine, 35(6), pp.737-744.

Cherubini, V., Grimsmann, J.M., Åkesson, K., Birkebæk, N.H., Cinek, O., Dov?, K., Gesuita, R., Gregory, J.W., Hanas, R., Hofer, S.E. and Holl, R.W., 2020. Temporal trends in diabetic ketoacidosis at diagnosis of paediatric type 1 diabetes between 2006 and 2016: results from 13 countries in three continents. Diabetologia, 63(8), pp.1530-1541.

Cherubini, V., Marino, M., Carle, F., Zagaroli, L., Bowers, R. and Gesuita, R., 2020. Effectiveness of Diabetes Symptoms Awareness Campaigns on Preventing Diabetes Ketoacidosis at Diagnosis of Type 1 Diabetes: A Systematic Review and Meta-Analysis. Available at SSRN 3738079.

Desai, R., Singh, S., Syed, M.H., Dave, H., Hasnain, M., Zahid, D., Haider, M., Jilani, S.M.A., Mirza, M.A., Kiran, N.F.N. and Aziz, A., 2019. Temporal trends in the prevalence of diabetes decompensation (diabetic ketoacidosis and hyperosmolar hyperglycemic state) among adult patients hospitalized with diabetes mellitus: a nationwide analysis stratified by age, gender, and race. Cureus, 11(4).

Drolet, M.J., Rose-Derouin, E., Leblanc, J.C., Ruest, M. and Williams-Jones, B., 2022. Ethical Issues in research: perceptions of researchers, research ethics board members and research ethics experts. Journal of Academic Ethics, pp.1-24.

Drummond, R., Malkin, S., Du Preez, M., Lee, X.Y. and Hunt, B., 2018. The management of type 2 diabetes with fixed?ratio combination insulin degludec/liraglutide (IDegLira) versus basal?bolus therapy (insulin glargine U100 plus insulin aspart): A short?term cost?effectiveness analysis in the UK setting. Diabetes, Obesity and Metabolism, 20(10), pp.2371-2378.

Duran, D.G. and Pérez-Stable, E.J., 2019. Science visioning to advance the next generation of health disparities research. American Journal of Public Health, 109(S1), pp.S11-S13.

Dyson, P.A., Twenefour, D., Breen, C., Duncan, A., Elvin, E., Goff, L., Hill, A., Kalsi, P., Marsland, N., McArdle, P. and Mellor, D., 2018. Diabetes UK evidence?based nutrition guidelines for the prevention and management of diabetes. Diabetic medicine, 35(5), pp.541-547.

Ehrmann, D., Kulzer, B., Roos, T., Haak, T., Al-Khatib, M. and Hermanns, N., 2020. Risk factors and prevention strategies for diabetic ketoacidosis in people with established type 1 diabetes. The Lancet Diabetes & Endocrinology, 8(5), pp.436-446.

Fagherazzi, G. and Ravaud, P., 2019. Digital diabetes: Perspectives for diabetes prevention, management and research. Diabetes & metabolism, 45(4), pp.322-329.

Goldman, N., Fink, D., Cai, J., Lee, Y.N. and Davies, Z., 2020. High prevalence of COVID-19-associated diabetic ketoacidosis in UK secondary care. Diabetes research and clinical practice, 166, p.108291.

Gusenbauer, M. and Haddaway, N.R., 2020. Which academic search systems are suitable for systematic reviews or meta?analyses? Evaluating retrieval qualities of Google Scholar, PubMed, and 26 other resources. Research synthesis methods, 11(2), pp.181-217.

Haw, J.S., Shah, M., Turbow, S., Egeolu, M. and Umpierrez, G., 2021. Diabetes complications in racial and ethnic minority populations in the USA. Current diabetes reports, 21(1), pp.1-8.

Holman, N., Knighton, P., Kar, P., O'Keefe, J., Curley, M., Weaver, A., Barron, E., Bakhai, C., Khunti, K., Wareham, N.J. and Sattar, N., 2020. Risk factors for COVID-19-related mortality in people with type 1 and type 2 diabetes in England: a population-based cohort study. The lancet Diabetes & endocrinology, 8(10), pp.823-833.

Hurst, C.P., Rakkapao, N. and Hay, K., 2020. Impact of diabetes self-management, diabetes management self-efficacy and diabetes knowledge on glycemic control in people with Type 2 Diabetes (T2D): A multi-center study in Thailand. PLoS One, 15(12), p.e0244692.

Kuppermann, N., Ghetti, S., Schunk, J.E., Stoner, M.J., Rewers, A., McManemy, J.K., Myers, S.R., Nigrovic, L.E., Garro, A., Brown, K.M. and Quayle, K.S., 2018. Clinical trial of fluid infusion rates for pediatric diabetic ketoacidosis. New England Journal of Medicine, 378(24), pp.2275-2287.

Lee, J.Y. and Lee, S.W.H., 2018. Telemedicine cost–effectiveness for diabetes management: a systematic review. Diabetes technology & therapeutics, 20(7), pp.492-500.

Newman, M. and Gough, D., 2020. Systematic reviews in educational research: Methodology, perspectives and application. Systematic reviews in educational research, pp.3-22.

Ooi, E., Nash, K., Rengarajan, L., Melson, E., Thomas, L., Johnson, A., Zhou, D., Wallett, L., Ghosh, S., Narendran, P. and Kempegowda, P., 2021. Clinical and biochemical profile of 786 sequential episodes of diabetic ketoacidosis in adults with type 1 and type 2 diabetes mellitus. BMJ Open Diabetes Research and Care, 9(2), p.e002451.

Oskarsson, P., Antuna, R., Geelhoed-Duijvestijn, P., Kr?ger, J., Weitgasser, R. and Bolinder, J., 2018. Impact of flash glucose monitoring on hypoglycaemia in adults with type 1 diabetes managed with multiple daily injection therapy: a pre-specified subgroup analysis of the IMPACT randomised controlled trial. Diabetologia, 61(3), pp.539-550.

Pal, R., Banerjee, M., Yadav, U. and Bhattacharjee, S., 2020. Clinical profile and outcomes in COVID-19 patients with diabetic ketoacidosis: a systematic review of literature. Diabetes & Metabolic Syndrome: Clinical Research & Reviews, 14(6), pp.1563-1569.

Palermo, N.E., Sadhu, A.R. and McDonnell, M.E., 2020. Diabetic ketoacidosis in COVID-19: unique concerns and considerations. The Journal of Clinical Endocrinology & Metabolism, 105(8), pp.2819-2829.

Pasquel, F.J., Lansang, M.C., Dhatariya, K. and Umpierrez, G.E., 2021. Management of diabetes and hyperglycaemia in the hospital. The Lancet Diabetes & Endocrinology, 9(3), pp.174-188.

Rabbone, I., Maltoni, G., Tinti, D., Zucchini, S., Cherubini, V., Bonfanti, R. and Scaramuzza, A., 2020. Diabetic ketoacidosis at the onset of disease during a national awareness campaign: a 2-year observational study in children aged 0–18 years. Archives of Disease in Childhood, 105(4), pp.363-366.

Reddy, P.K., Kuchay, M.S., Mehta, Y. and Mishra, S.K., 2020. Diabetic ketoacidosis precipitated by COVID-19: a report of two cases and review of literature. Diabetes & Metabolic Syndrome: Clinical Research & Reviews, 14(5), pp.1459-1462.

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Varadarajan, M., Patel, M., Kakkar, N., Sin, E.L.P.W.P., Maxey, D., Nunney, I. and Dhatariya, K., 2017. Are the results from the 2014 UK national survey on the management of diabetic ketoacidosis applicable to individual centres?. diabetes research and clinical practice, 127, pp.140-146.

Vellanki, P. and Umpierrez, G.E., 2021. Diabetic ketoacidosis risk during the COVID-19 pandemic. The Lancet. Diabetes & Endocrinology, 9(10), p.643.

Websites

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