Factors Associated with Self-Care Practice among Adult Diabetes Patients

Abbreviations

AOR: Adjusted Odd Ratio

COR: Crude Odd Ratio

CI: Confidence Intervals

ETB: Ethiopian Birr

FDRE: Federal Democratic Republic of Ethiopia

DM: Diabetes mellites

IDF: International Diabetes Federation

Kg: Kilogram

SNNPRE: Southern Nation Nationality Peoples of Ethiopia,

WHO: World Health Organization.

Introduction

Diabetes Mellitus (DM) remains a worldwide public health prob-lem and is currently one of the primary causes of morbidity and mortality in both developed and developing countries [1]. Accord-ing to the International Federation of Diabetes (IDF), approximate¬ly half a billion people live with diabetes mellitus, and about 80% of the diabetes burden was estimated from low and middle-income countries including Ethiopia [1,2]. Currently, the prevalence of di¬abetes mellitus-related morbidity and mortality is rapidly increas¬ing in Ethiopia, which is the second-largest population in Africa. Evidence reveals that at least 3.9% of the Ethiopian population suffer from diabetes mellites DM [3]. Specifically, the prevalence of diabetic foot ulcers was estimated to be 11.2 % [4]. This can significantly reduce patients ’quality of life and also dramatically increase healthcare costs [5].

However, diabetes mellites is considered a reasonably preventable disease as long as optimal self-care strategies are employed by dia-betic patients [6]. A patient’s commitment to both physical and be-havioral self-care practices is needed to improve diabetic-related problems [7]. This means regular self-care practice is a backbone to achieving h a healthy productive life, reducing diabetes-related morbidity and mortality, decreasing unnecessary healthcare costs, and improving quality of life [6,8].

Moreover, self-care practice are the primary objective for prevent-ing and controlling vital organ damage and other complications associated with diabetes [8]. This requires that the patients must implement various self-care activities including adherence to medications dietary intervention [9,10]. Continuous monitoring of blood sugar and regular physical exercise [11,12]. In addition, ef-fective foot self-care interventions have been noted in several stud¬ies [4,13]. Despite, numerous self-care practice and technologies exist to prevent diabetes-related complications, these interven¬tions remain largely inaccessible to patients who live in develop¬ing countries including Ethiopia [9,12,14]. There are many factors associated with the poor self-care practice. Duration of diabetes treatment and lack of family support, low educational level, lack of adequate knowledge about diabetes self-care practice, patients age, lack of personal glucometer and lack of nearest diabetic clinic for routine follow up, living in a rural area and having diabetes-re-lated complication and poor medication adherence was among commonly identified factor affecting self-care practice [9,14-20]. All of these are considered as contributing factors affecting the quality of life in DM patients. Hence, maintaining optimum self-care practice is very important for the prevention of DM- associ¬ated challenges.

Even though self-care practice are a key strategy for the prevention of diabetes-associated morbidity and mortality, the burden of dia¬betes-related complications is still high in Ethiopia [3,4]. This in¬dicates that the implementation of diabetes self-management is not well addressed across the region. Moreover, the level of self-care practice and its associated factors are not well studied at the zonal and regional levels of Ethiopia. So, understanding the current level of self-care practice among diabetic patients living in a rural en¬vironment is vital for developing innovative educational methods that are used for improving patients’ awareness. Therefore, this study aimed to evaluate the level of self-care practice and its as¬sociated factors among adults with diabetes mellitus follow-up at Tercha zonal diabetic care center: in Southern Ethiopia.

Method and Materials

Study Design, Setting and Populations

The hospital-based cross-sectional study design was conducted among adults with diabetes mellitus visiting Dawro Tercha zonal diabetes care center from June to August 2020. Tercha zonal dia¬betes care center is the largest zonal referral diabetes care center in Southern Nation, Nationalities, and Peoples of Ethiopia. It was found in Dawro Zone which is located 490 km away from Addis Ababa capital city of Ethiopia. The inclusion criteria of this study were adults with DM (18 years and above) and attending Tercha referral and zonal diabetes-care center for follow-up. All patient who was critically ill, and those have mental and visual problems, and gestational diabetes was excluded from the studies.

Variables

The self-care practice among adults diagnosed with Diabetes Mel¬lites (DM) was the dependent variable. But, demographic factors such as age group, sex, level of education, marital status, Occupa¬tion, and clinical factors such as the family history of diabetes, du¬ration of diabetes, type of diabetes, patient’s body weight, presence of diabetes complications, and presence of glucometer, history of smoking, social support, and were treated as independent factors.

Sample Size Determination

The sample size was calculated by the using single population proportion formula, n=(Zα/2)2p(1-p)/d2, where n = minimum sam¬ple size required for the study, Z = standard normal distribution (Z = 1.96) with CI of 95% and d = is a tolerable margin of error (d = 0.05), P = estimate of our target population having poor di¬abetes self-care practice of 38.1% which was taken from related studies conducted in Harar and Dire Dawa hospital, eastern Ethi¬opia [21].

n=(1.96)2 0.38(1-0.38) )/(0.05)2 = 362

During the time of data collection, a record from the patient profile indicates that a total of 621 adult patients with diabetes mellites were being followed up at Tercha diabetes care center. Since the total number of the study population is less than ten thousand, we used an adjustment for finite population correction formula (Nc =n/ (1+n/N) Where, n= sample size calculated, Nc= sample size after use of correction formula, and N= number of the source population. (Nc=362/ (1+362/621) = 229. Assuming a 5% non-response rate: (0.05) * (229) = 240 was calculated for the study. Using systematic random sampling techniques, every third patient who fulfill the inclusion criteria was invited to participate in the study.

Data Collection Tools, Procedure and Quality Assurance

The data collection tool was developed based on previous similar literature [16,18,21]. Initially, the questionnaire was prepared in English Language and translated into Amharic. A forward-back-ward translation approach was applied in accordance to the World Health Organization’s procedures [22]. Before initial data collec¬tion, we mended the questionnaires based on expert opinion.

Then, the content validity index of the study tool was calculated and rat¬ed at 0.86. Based on the result of the pretest, ambiguous questions were modified for clarity and consistency. The Amharic version was pilot tested in a similar hospital but outside of the study area with 25 adults with diabetes. Then, the structured questionnaires had three main categories:

1. Socio-demographic questionnaires (age, sex, place of residence, income, occupation, educational status, and marital status) were measured using nine questionnaires.

2. Diabetes-related clinical characteristics (presence of diabet¬ic-related complications, body weight, types of DM, Family his¬tory of DM, history of smoking, social support, and presence of glucometer,) were measured using ten questionnaires.

3. A Self-care activities questionnaire that is concerned with diet, physical activities, SMBG, foot care, and medication adherence were measured by five items, and had Yes and No responses for each item.

Three nurses with BSc degrees and two nurses with MSc were recruited for data collection and supervision respectively. The data collectors were provided with one day of intensive training about the data collection procedure, (how to administer the self-admin-istered questionnaire, informed consent, keep confidentiality, and respect the right of the participants). The completeness and con¬sistency of the collected data were checked daily and closely su¬pervised by the principal investigator. Since data were collected during the COVID-19 pandemic, the World Health Organization (WHO) Safety guidelines and protocols were strictly followed at all times.

Operational Definitions

In this study, the proportion of participants with good and poor self-care practice was computed. The sum of the variable between diet, exercise, SMBG, Foot care, and medication adherence was calculated. Then we used the mean to dichotomize the self-care score. Those who scored above the mean in the overall self-care score were categorized as having good self-care practice and those who scored below the mean score were categorized as having poor self-care practice.

Data Entry, Processing, and Analysis

The data were verified, coded, and entered into Epi data 4.6 soft¬ware and then exported to Statistical Package for Social Sciences, (SPSS) version 25.0 Software for analysis. Descriptive statistics such as frequency, percentages, mean, standard deviation (M+ SD), and ranges were used for the interpretation of outcome vari¬ables. A cross-tabulation was computed for the cross-comparison of dependent and independent variables needed for graph and lo¬gistic regression. A binary logistic regression and multivariate lo¬gistic regression analysis were carried out to determine the associ¬ation between dependent and independent variables. The variable in bivariate analysis with p-value < 0.25 was entered into mul-tivariate logistic regression. A statistically significant association was declared at a P-value less than 0.05 in multivariable logistic regression analysis. The strength of the association of factors with knowledge and practice was demonstrated by computing the odds ratio (OR) and the adjusted odds ratio (AOR) with a 95% confi¬dence interval (CI).

Result

Socio-Demographic Characteristics of Study Participants

In total, 213 diabetic patients participated in this study with a response rate of (89%). Table 1 shows the socio-demographic characteristics of participants. The mean age of participants was 44.4+14.2 years. The male population outweighed by 114 (53.5%). A significant number of the respondents 169 (79.3%) were mar¬ried and 112 (53.1%) of them were rural residents. The majority 94(44.1%) of the respondents had attended primary education and 88 (57.7%) were civil servants. Nearly o-thirds of 145(68.1%) of the participants had low income.

         Table 1: Socio-Demographic Characteristics of Study Participants, SNNPR, Ethiopia: 2020 (n=213)

Clinical Characteristics of Study Participants

Table 2, presents the diabetes-related clinical characteristics of the respondents. About 77 (36.2%) of respondents’ duration of dia-betes was 10 years and above. More than half 134 (62.9 %) of respondents had no family history of diabetes. The mean of re-spondents’ body weight was 64.9 + 12.6 Kg. Nearly, three-fifth 126(59.2%) of participants had type-II DM and about 131(61.5%) developed diabetes-related complications. Approximately three-fourths 159(74.6%) of the participants had no glucometer in their home. A vast majority 201(94.4) of the respondents had social sup¬port

         Table 2: Diabetes-Related Clinical Characteristics of Study Participants, SNNPR, Ethiopia: 2020 (n= 213)

The level of Self-Care Practice among Study Participants

Figure 1, shows the self-care activities of the study participants reported on four major self-care practice parameters. Concerning dietary parameters, the majority of study participants 154 (72.3%) have no healthful eating plan every week and a significant number 172 (80.8%) of them did not perform a low level of physical exer¬cise. About 164 (77.0 %) did not test their blood sugar every week and 155 (72.8%) of them did not check their foot on weekly bases and 137 (63.3%) of them were not adherent to their antidiabetic medications.

SMBG= Self- monitoring blood glucose, SNNPR= Southern nation nationality and peoples of Ethiopia.

Figure 1: Domains’ of Self-Care Practice Among Diabetes Patients on Follow-Up at Tercha Zonal Diabetes Care- Center, Snnpr, Ethi-opia: 2020, (N=213).

Regarding the status of self-care practice of the respondents, only 84 (39.4%) diabetic patients had a good level of self-care practices and from the total of respondents, 129 (60.6%) had poor levels of self-care activities (Figure 2).

<img src="https://www.opastpublishers.com/scholarly-images/6960-6a27cde5967f2-factors-associated-with-selfcare-practice-among-adult-diabet.png" width="500" height="300">
Figure 2: Overall Self- Care Practice of The Study Partcipants (N= 213), SNNPR, Ethiopia, 2020

Factors Associated With Self-Care Practice Among Adults With DiabetesPatient

As presented in Table 3, seven variables (age, body weight, ed-ucational level, place of residence, having diabetes complica-tions, type of DM, and having private glucometer) were used as candidate variables (at P-value <0.25) and entered together into a multivariate logistic regression. A P-value < 0.05 in multi¬variate analysis was taken as a cut-point value to be statistical¬ly significant. Accordingly, bivariate logistic regression analysis revealed, attending primary education [COR= 7.971, (95% CI: 1.020-62.264), P= 0.048], Secondary education [COR= 18.452, (95%CI:2.327-146.326), P= 0.006] and college and above educa¬tion [COR=100.571, (95% CI: 11.547- 875.969), P <0.001] were found more likely to have good self-care practices compared to those who were illiterates respectively. However, being an urban residence[COR=0.431,(95% CI:0.244-0.760), P=0.004], hav- ing DM complication [COR= 0.531, (95 %CI: 0.302 – 0.934), P=0.028], Having Type-II DM [COR=0.536,(95% CI:0.306- 0.938), P= 0.029] and absence of private glucometer [COR=0. 387, (95% CI:0.200– 10.750), P=0.005] were found less likely to have good self-care practice compared to those who were ru¬ral residents and did not develop DM related-complication, with type-I DM and had private glucometers respectively.

After controlling some confounders, the multivariate logistic re-gression analysis revealed that attending secondary education [AOR=16.015, (95% CI: 1.925-133.251) P =0.01] and college and above [AOR= 89.553, (95%CI:9.732 – 824.021), P <0.001] were found more likely to have good self-care practice compared to those who have no formal education respectively. However, the odds of participants who did not develop DM complications [AOR=0.412, (95% CI:0.204 – 0.832), P=0.013] were found 0.412 times less likely to have good self-care practice compared to those who developed DM complications.

Table 3: Bivariate and multivariate analysis to identify factors associated with self-care practice among diabetic patient attend­ing Tercha diabeteic care center (n=213)

Discussion

In recent times, the incidence and prevalence of diabetes mellites is rapidly increasing in Ethiopia, which is the second largest pop-ulation in Africa [3]. Therefore, this study aimed to evaluate the level of self-care practice and its associated factors among adult diabetes patients in zonal diabetes care centers of Ethiopia. Based on the results of the current study, mastery of self-care practice among diabetes patients might be determined by educational level and having diabetes complications. Our study participants showed poor results regarding self-care practice in the control and manage¬ment of diabetes mellites.

Bearing in mind, the higher prevalence of diabetes mellites and its related complications in Ethiopia, it is worrisome that this study found only (39.4%) of diabetes patients had good self–care prac¬tice [3,4]. This seems a significant number of study participants were lack good self-care practice for the prevention and manage¬ment of diabetes-related complications and this can negatively im¬pact the quality of life of DM patients. The poor self-care practice among diabetes patients found by this study is in line with stud¬ies conducted in northern Ethiopia (46.7%), in Western Ethiopia (39.8), Eastern Ethiopia (38.1%), in Zambia (38.7%) and India (32.5%) [15,18,19,21,23]. This might be due to a lack of adequate information and the misconception that diabetes mellitus is only managed at a healthcare institution. However, the finding of our study was significantly lower than studies conducted in Thailand (76.8%), and Vietnam [24,25]. The discrepancy might be due to differences in cultural and socio-economic aspects. Because low economic status and poor resources could undermine self-care activities among people living in low-income countries [26]. An¬other discrepancy could be due to a low level of knowledge about health literacy. It is undeniable that the majority of our study par- ticipants were rural residents (53.1%) and the majority of them have attended only primary educational level (44.1%). Thus, It is expected that their knowledge level regarding self-care practice in the reduction of diabetes complications was inadequate in all aspects.

Furthermore, the finding of this study indicates that (59.2% )of study participants had Type-II DM. Additionally, our study indi-cates that only a few respondents (22.1%) had access to a private glucometer that might have low practice of self-monitoring blood glucose levels. The patients’ access to private glucometer does not only promote diabetes self-management but provides them with the knowledge and ability to effectively adhere to treatment [8]. The majority of the uncomplicated management of diabetes mel¬lites is carried out by patients themselves. So, the availability of a private glucometer at home is one of the best strategies for reduc¬ing the incidence and progression of DM complications [23].

It has been revealed from this study that participants who didn’t develop a complication were found 0.412 times less likely to have good self-care practice compared to those who developed DM complications. This finding is in agreement with the study con¬ducted in eastern Ethiopia[21]. This signifies that patients who de¬velop diabetes complications probably had a better knowledge of self-care practice. in fact, it has been described that most patients come to health institutions after developing complications [5]. However, patients’ awareness of preventive practice is vital to help them cope with the burdens of diabetes-related complications [27].

In line with previous studies, this study found a statistically sig-nificant association between educational level and self-care prac¬tice [15,16,18,21]. It has been revealed from this study that pa¬tients with higher levels of education were more likely to perform a self-care practice when compared to those who were illiterate. Having low educational background was frequently reported as one of the basic causes of poor self-care practice among DM pa¬tients [9,15,21]. In another hand, a high level of health is report¬ed among well-educated and experienced people than among less educated people [16,21]. Therefore, educated people reflect a low level of disease-related morbidity and mortality. Inversely, low educational attainment is associated with poor health and shorter life expectancy [9]. Since diabetes self-management education is generally considered an integral part of diabetes care, providing updated information and awareness for all diabetic patients is vital for the prevention of diabetes-related complications [28]. Unlike the findings of a cross-sectional study conducted in the West Shoa Zone, Oromia region of Ethiopia, this study found no statistically significant association between social support and self-care prac¬tice [18]. This could be due to variations in the study population, sample size, study area, and measurement tools used in the study. Additionally, this study also found no statistically significant asso-ciation between age and self-care practice. This is also contrasting with the study finding from Ghana, and Cameroon, whereby pa-tients’ age has been significantly associated with good self--care practice in diabetes self-management [9,14]. We, therefore, argue that during the study period, the senior study participants might have had a poor perception regarding diabetes self-care practice for the treatment and prevention of diabetes mellites. But it is un¬deniable that the prevalence of diabetes mellitus rises with increas¬ing age [8]. Indeed, senior peoples are more expected to have a good experience in the control and management of chronic disease than younger people.

Strengths and limitations

Despite the strengths of the study such as determining the preva¬lence and conducting the study in a rural area, our study had also some limitations: First, the use of self-reported methods to evalu¬ate patient’s self-care practice could have resulted in overestima-tion or underestimation of the level of self-care practice, which is difficult to avoid response biases due to misunderstanding of the questionnaire items, or what they perceived to be socially desir¬able. Second, this study is conducted only in one regional diabe¬tes-care center, so the conclusion of this study may not be general-izable to other settings. However, the focus on self-care practices and policies of hospital administration in the country indicated that our sample was likely to be representative.

Conclusion and Recommendations

The study concluded that a significant number of the study partic¬ipants have poor self-care practice in preventing and controlling diabetes mellitus. This finding is bothersome in the increase in prevalence and incidence of DM in the country (Ethiopia). Further educational level and the development of diabetes complications were found statistically significantly associated with good levels of self-care practice implemented by study participants. Therefore, there should be an intervention that mediates the factors affect¬ing participants’ self-care behaviors regarding the prevention and control of diabetes mellites. Moreover, all frontline health care providers (nurses, and diabetes educators) should routinely assess self-care behavior and provide basic information regarding diabe-tes self-care activities. Additionally, the researcher should conduct observational and mixed studies, since there is a series shortage of literature on this area in Ethiopia.

Ethical Approval and Consent to Participation

Before the start of the study, ethical clearance was obtained from the Institutional Research Ethical Review Board (IRERB) of the College of health science, Addis Ababa University, (with protocol number: 037/20/SNM, meeting number: 09/2012E.C), in accor¬dance with the declaration of Helsinki. After ethical clearance was obtained, a letter of support was written from Addis Ababa Univer¬sity, School of Nursing and Midwifery to Tercha Referral Hospital. Then, permission was obtained from the diabetic care- center of Tercha Referral Hospital. Study participants were asked for their willingness to participate in the study. All the reasons why the par¬ticipants were selected and why the research was being conducted were explained verbally to the study participants. The participants were fully explained that they have the right not to participate, to discontinue at any time in between, or has a right not to an-swer any questions they were not willing to answer. Both verbal and written informed consent was obtained from the study partic¬ipants. For participants who cannot read and write, verbal consent was obtained from their parents and legal guardians in accordance with the FDRE National Research Ethics Review Guideline. This procedure was discussed with Tercha Hospital adminstrators and approved by the Institutional Research Board of Addis Ababa Uni¬versity, College of Health Science. Participants were assured of confidentiality and anonymity of their responses. Indentification number and codes were used in the survey questionnaires.The col¬lected data were stored and kept on a password-protected comput¬er. Only the principal investigator had access to the computerized data.

Acknowledgments

The authors would like to acknowledge data collectors, supervi-sors, and the study participants for their valuable contribution to the study. We would also like to extend our gratitude to the medical directors and managers of Tercha Referral Hospital for their unre¬served support.

Author Contributions

All authors made a significant contribution to the work reported. Boka Dugassa Tolera, Zeleke Argaw Menji, and Buzayehu Atinafu Ataro conceived the research idea, and were involved in setting study design, fieldwork, data analysis, and report writing, Yakob Lencha Leka, Temesgen Geta Hardido and Getachew Nigussie Bolado have participated in the overall supervision of all research activities such as setting study design, data analysis, and manu¬script preparation. All authors have reviewed and approved the final version of the manuscript.

Availability of Data and Materials

The datasets used and/or analyzed during the current study are available from the corresponding author upon reasnalble request.

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