This section gives a brief description of self-management of type 2 diabetes in the region of Pakistan, the concept of self-management and difficulties and barriers the population is facing in managing the diabetes. The patients in Pakistan with type 2 diabetes require self-management education and understanding of this disease which in itself poses a great challenge. The country is facing the greatest challenges for its primary healthcare system in managing the chronic diseases where diabetes is considered a “self-inflicted” disease and there is stigma attached to this disease in the society. The stigma of being “sick person” also affects the diabetic person all his life as a result of being seen as “different” by his colleagues, friends, teachers and community members in all the stages of life cycle.

It is well understood and agreed that―“self-management is required for control of chronic diseases and for prevention of disease complications; however, patients generally do not adhere to self-management recommendations” [1] - [3] . The adherence to the recommendations and barriers are both problematic for “lifestyle” behaviour such as eating patterns and physical activity rather than medication adherence [4] - [6] . This is evident from the culture, tradition and life style behaviour of the people of Pakistan that both the eating patterns and physical activity are posing a great deal of difficulties to middle-aged population in the self-management of their diabetes.

Marzilli [7] has indicated that eating behaviours of others can influence eating behaviours of diabetic patients, especially if they live together; which is the case in Pakistani society where there is a joint family living system. Ecological perspectives also point to the importance of access to key resources in self-management [8] . Healthy eating patterns and physical activity levels are not likely to occur or persist without convenient sources of healthy foods and attractive safe settings. There is a growing interest on the impact of “built environment” on physical activity in recent years [9] [10] . For example, studies have demonstrated the strong negative and positive effects that access to resources for physical activity [11] [12] and consumption of food purchased away from home [13] have on overweight and obesity.

It is now well known that “Diabetes Mellitus” is one of the main threats to human health (14). Whiting et al. (16) indicated in the recent estimate of International Diabetes Foundation (IDF) that “worldwide there were 366 million people with diabetes in 2011 and 371 million people with diabetes in 2012, with China (92.3 million), India (63 million) and the United States (24.1 million) leading the way and 4.8 million people died due to diabetes and also 4 out 5 people with diabetes live in low and middle income countries” [14] [15] .

The cost impact of diabetes is enormous as it causes more than 471 billion dollars to spend on healthcare globally. The prevalence of diabetes in the world is 8.3% and in comparison the prevalence rate in Pakistan is 7.89%, and in Australia the prevalence of diabetes has reached to 9.55% [15] . The global projection for the diabetes epidemic and per region from 2015-2040 is shown in Figure 1. The increase in the prevalence of type 2 diabetes is the main concern in Pakistan as its middle-aged population is facing the onslaught of obesity and overweight due to lack of physical activity. In addition unhealthy eating habits making it more difficult for this population to control their weight [6] .

The prevalence of Type 2 diabetes in Pakistan is in the range of 7.6% (5.2 million populations) to 11% [16] - [18] and it is estimated that in 2030 it will increase to around 15% (14 million populations) and as such Pakistan is ranked 7^th on diabetes prevalence list by the World Heath Organization [19] and it is among the top 10 countries in the world for people with diabetes aged 20 - 79 years [19] . Jafar et al. [20] has indicated that on the “age-specific prevalence’ of overweight and obesity, more than 40% of women and 30% of men aged 40 - 60 years were classified as overweight or obese in the population of Pakistan. The category of overweight and obesity was defined as a BMI of 23 kg/m² or greater. This definition, based on the revised criteria for Asian populations [21] was lower than the conventional cutoff value of 25 kg/m² for populations of European origin. Obesity was defined as a BMI of 27 kg/m² or greater

This low ranking of health care system of Pakistan in the world is a great concern and challenge for the country. A variety of factors can be identified here as the leading causes of low ranking such as poor utilization of primary health care services, including poor socio-economic status, lack of physical accessibility to health system, gender disparity and inequity in healthcare system, low level of education, high unemployment, an ageing population making the problem more complicated [22] [23] .

Hakeem and Fawwad [24] have mentioned that the epidemiology of diabetes in Pakistan has a combination of risk factors such as strong gene and environment interplay along with in-utero programming in context of low

birth weight and gestational diabetes are the main contributors of a high prevalence of type 2 diabetes in Pakistan. The real burden of diabetes is due to its chronic complications leading to increased morbidity and mortality.

On the basis of the highest age-specific prevalence of diabetes (40 - 60 years) in the country and in line with the latest estimates of International Diabetes Federation on the greatest number of people with diabetes between 40 - 59 years [15] , while this review considers diabetic patients in general population, it will specifically focus on the middle-aged population of Pakistan.

The Government spending on healthcare of Pakistan is about 0.8% of GDP which is lower than some neighbouring countries such as Bangladesh (1.2%) and Sri Lanka (1.4%) [27] . In Pakistan, only 3.1% of the total annual budget is allocated for economic, social and community services, and 43 % is spent on debt servicing [28] . In most of the developing countries of South Asia, out-of-pocket household expenditure on health is at times as much as 80% of medical expenditure [29] . For health expenditure in Pakistan, it is about US$ 17 per head per year, out of which $13 is out-of-pocket private expenditure [30] . The country spends 80% of its health budget on tertiary care services, which are utilized by only 15% of the population. In contrast, only 15% is spent on primary health care services, used by 80% of the population [31] .

The World Health Organization (WHO) ranked Pakistan 122^nd in overall health system performance among 191 countries [32] . The health indicators, health funding, and health and sanitation infrastructure are generally poor in Pakistan, particularly in rural areas. About 19 percent of the population is malnourished of which 30 percent of children under age five are malnourished. The leading causes of sickness and death include gastroenteritis, respiratory infections, diabetes, congenital abnormalities, tuberculosis, malaria, and typhoid fever. The United Nations estimated that in 2003 Pakistan’s HIV prevalence rate was 0.1 percent among 15 - 49, with an estimated 4,900 deaths from AIDS. Hepatitis B and C are also rampant with approximately 3 million cases of each in the country at the moment.

The burden of disease due to communicable and non-communicable disease is 52.8% and 39.4% respectively with total DALY’s 56.1% and 34.2% [33] . According to official data, there are 127,859 doctors and 12,804 health facilities in the country to cater for over 170 million people [34] . In 2007 there were 85 physicians for every 100,000 persons in Pakistan that is one doctor for 1225 people.

According to the Ministry of Health Pakistan statistics, there were 13,937 health institutions in the country including 945 hospitals (with a total of 103,285 hospital beds), 4755 dispensaries, 5349 basic health units (mostly in rural areas), 903 mother and child care centers, 562 rural health centers and 290 TB centers [35] [36] . There is an inequitable distribution of GP’s in the country, with 70% practicing in urban areas where only 30% of the population lives: in addition, only 10% to 15% of GP’s in rural areas are females.

There are no initiatives taken by the government to implement established evidence-based guidelines for self- management of diabetes [37] and practice recommendations’ translation to care in Asian countries [38] , and as well as in developed countries [39] . Therefore, the need of self-management approaches is much more important for patients with type 2 diabetes and the assessment of quality of diabetes care in the community.

The studies on diabetes knowledge, beliefs and practices among people with diabetes [40] provided further evidence that there was a lack of information available to people with diabetes in Pakistan as the large population has never received any diabetes education at all [40] . This study was carried out in an urban university hospital, where diabetes education may be more readily available as compared to rural areas where people have less access to information and will have even poorer diabetes perception and practices. The other studies carried out in Pakistan on diabetes education and awareness suggested that level of awareness at both physicians and patients along with other community people was very low [41] - [48] .

Fisher et al. [49] suggested that the “quality clinical care and self-management are compatible and dependent on each other and without sound care, patient’s efforts may be misdirected and expert clinical care will fall far short of its potential, through patient failure to use prescribed medications to control his/her blood sugar or to implement its management plans” [49] .

Wagner et al. [50] developed a framework for integrating the resources and support for self-management with key components of clinical care in their chronic care model. A number of studies have also suggested that patient understanding and beliefs about health and illness may be shaped by historical and local contexts [51] , whether respondents are thinking about health or behaviour in general or about their own [52] , and personal experience and observation [53] .

In Pakistan, the diabetes management programme in the community health clinics are not in a position to help and support the patients of diabetes and the health services in the community are not adequate. There is a great shortage of community doctors and expensive consultations with private doctors pose many problems to patients. The chronic disease care is mostly integrated into the public health system through primary health care. Usually, people with diabetes are referred from primary health-care clinics to specialist diabetes centers.

There are two reasons for this approach. The first reason is that the health care interventions to manage diabetes cases starts with the registration of the patient in a primary health care clinics and the issuing of diabetes card. Medical diagnosis includes a physical examination and laboratory studies. These clinics in Pakistan face special challenges to provide diabetes care to the poor patients as most of these clinics do not meet the evidence- based quality of care standards as compared to the targets established by the American Diabetes Association [54] .

In Pakistan, basic health units are seeing an average of 20 - 25 patients per day where each basic unit has about 10 staff members. The primary care delivery system and satisfaction level have largely remained unchanged during the last three decades. The recent surveys indicate that nationally, not more than 20% of the people used the first level public sector network for their health care needs [28] [35] . Therefore, the economic constraints, lack of good governance and inability to deliver public goods have led to the concept of unleashing the primary care to contracting services in Pakistan [55] - [57] .

This primary care contracting was initially implemented in one of the cities in Pakistan and received good results, the situation in the city was improved in terms of utilization of basic health services, community satisfaction, out of pocket expenditure and quality of care. This contracting of primary health care service has been extended to several cities and the provinces and is a major change in public sector health system especially for the people living in rural area of Pakistan.

The morbidity is a multidimensional concept, and time trends in the different dimensions can vary [58] . Increases in physiological dysregulation, disease onset, functioning loss, and frailty are all parts of the process of health change that can precede death [58] . The patterns of morbidity in the population of Pakistan include cardiovascular diseases, chronic obstructive pulmonary disease, heart failure, diabetes and depression. CVD is a major cause of morbidity in this population followed by diabetes and its complications.

In the past, the studies carried out in the region of Pakistan highlighted the morbidity patterns presented at the primary health care centers in association with the socio-demographic characteristics [59] . In comparison of American population with that of Pakistani population, it was demonstrated that Pakistani population had higher rate of under nutrition and hypertension. There are urban and rural differences and economic gradients in indicators of under nutrition and risk factors for heart disease and cancers.

The population of Pakistan has two levels of trends in morbidity namely the macro level and micro level which has triggered changes to primary health care in this population. At a macro level, the trends included an increase in ageing population with chronic and complex diseases and require comprehensive care. At a micro level, the trends increased in coordinating care, managing the comorbidity and teams and making the time to build trust and relationship [60] . These patterns of morbidity have an overall impact on general practice in terms of maintaining the important characteristics of primary health care. These changes in primary health care are posing great challenges and require developing primary health care research to address the challenges of care for people with comorbidities.