Balisa and Mohammed
Balisa and Mohammed
Abstract
Objective: To assess the self-care practices and associated factors among diabetic patients in West Ethiopia.
Results: A total of 252 study participants were included in the study, of this 54.8% were male. Of the participants
more than half 150 (59.5%) had poor glycemic control and 153 (60.7%) of the participants had good self-care. Major-
ity of the study participants 209 (82.9%) had adequate foot care and more than half 175 (69.4%) and 160 (63.5%)
had adequate dietary plan and exercise management respectively. However of the total diabetic patients only 38
(15.1%) had adequate blood glucose testing practices. On multivariable logistic analysis poor self-care practices
were more likely to occur among male patients (AOR = 5.551, 95% CI = 2.055–14.997, p = 0.001), patients living in
rural area (AOR = 5.517, 95% CI = 2.184–13.938, p < 0.001), patients with duration of diabetes < 6 years (AOR = 41.023,
95% CI = 7.373–228.257, p < 0.001), patients with no access for self-monitoring blood glucose (AOR = 9.448, 95%
CI = 2.198–40.617, p = 0.003), patients with poor knowledge about diabetes (AOR = 67.917, 95% CI = 8.212–561.686,
p < 0.001) and patients with comorbidities (AOR = 18.621, 95% CI = 4.415–78.540, p < 0.001).
Keywords: Diabetes mellitus, Self-care practice, Diabetes knowledge, Glycemic control, Ethiopia
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Dedefo et al. BMC Res Notes (2019) 12:212 Page 2 of 7
Main text blood glucose testing, and foot care [18]. Details about
Methods and materials self-care activities were collected using the Summary
Study design and period Diabetes Self-Care Activities (SDSCA) [19] questionnaire
A facility based cross-sectional study was conducted after minor changes were made to it to suit the Ethiopian
from February 20 to May 20, 2016. context. Four domains (diet, exercise, foot care and blood
glucose testing) of self-care practices were used to assess
Study population the self-care practices of diabetic patients to diabetes. For
Adult diabetic patients who were on active follow up in all domains frequency of self-care activity in the last 7 days
DM clinic during the study period, Nekemte Referral were measured. For each domain the mean was calculated
Hospital. and categorized as adequate for scores above mean value
and unsatisfactory for scores less than mean value and
Sample size determination and sampling technique presented as tables in result. Accordingly after calculating
The required sample size was determined by considering mean score, patients had adequate diet plan if scored ≥ 4,
the following assumptions for interview questionnaires: patients had adequate foot care if scored ≥ 7, patients had
Sample size is calculated by taking the proportion of poor adequate exercise if scored ≥ 4, patients had adequate
glycemic control which is 73.1% on diabetes patients at self-blood glucose testing if scored ≥ 1. The overall mean
Diabetes Clinic of Jimma University Specialized Hospital score was calculated by summation of the mean score for
(JUSH) [11]. With 95% confidence level and 5% margin of diet, exercise, foot care and blood glucose testing divided
error to get an optimum sample size. by the sum of number of questions under each scale. After
calculating an overall mean score, it was classified as hav-
(Z − α/2)2 P(1 − P) (1.96)2 0.731(1 − 0.731)
n= = = 302 ing good self-care practice if the patient scored ≥ 4 or
d2 (0.05)2 poor self-care practice if the patient scored < 4.
Since the source population consisted of less than
10,000 respondents, the sample size was adjusted by Glycemic control Glycemic control was assessed by
using correction formula using Fasting Blood Glucose (FBG) level. The glycemic
recommendation for non-pregnant adults is in between
nf = n/1 + n/N 70 and 130 mg/dl, when the patients FBG was beyond this
where nf = the final sample size, n = desired sample size value we considered as poor glycemic control according
302 and N = total diabetic patients (941). The calcu- to ADA [3].
lated sample size was nf = 229. Considering a 10% non-
response rate, 252 diabetic patients were included in the Diabetes knowledge The Diabetes Knowledge Test
study. (DKT) was utilized to assess diabetic patients’ general
understanding of their disease and treatment recommen-
Inclusion and exclusion criteria dations. The DKT was developed and tested for reliability
All diabetic adult patients of age greater than or equal to and validity by the University of Michigan scholars and
15 years who attended chronic care department for dia- was adapted for the Ethiopian context. DKT consisting of
betic care at least for 1 year were included while diabetic 23 questions has been shown to adequately estimate gen-
patients who were critically ill, psychotic and/or unable eral patient knowledge of diabetes. Only the first 14 ques-
to communicate with data collector due to other underly- tions were applied to patients who do not use insulin and
ing medical disorder were excluded. the entire questionnaire were administered to patients
who use insulin. The score for each participant was deter-
Data collection tool mined by dividing the number of correct answers by the
To collect primary data, questionnaires and interview total number of questions (14 for those receiving only oral
was used in the study. Data collection format was devel- hypoglycemic agents and 23 questions for patients tak-
oped by the principal investigator to collect the blood ing insulin). To assess the level of knowledge of diabetes,
glucose measurements and anti-diabetic medications we recorded the patients’ level of knowledge into three
used by respective study subjects. The questionnaire was groups on the basis of their DKT scores: as good, accept-
developed after literatures were reviewed thoroughly able and poor knowledge if their overall score is ≥ 75%,
[10–16]. 60–74%, and ≤ 59%, respectively. The scores were used to
determine overall knowledge level [20].
Definitions of terms
Self‑care practices Self-care practices refer to behaviors Body mass index (BMI) Body mass index (BMI) was
such as following a diet plan, increased exercise, self- categorized as normal weight if BMI was 18.5–24.9,
Dedefo et al. BMC Res Notes (2019) 12:212 Page 3 of 7
Underweight if BMI was < 18.5, overweight if BMI was Table 1 Socio-demographic and clinical characteristics
25–29.9 kg/m2, and obese if BMI was ≥ 30 kg/m2 based of diabetic patients on follow up at Nekemte Referral Hospital,
on the World Health Organization criteria [21]. West Ethiopia, from February 20 to May 20, 2016 (n = 252)
pants 52.0% were in the age range of 30–60 years. More > 60 32 12.7
than half of the study participants were unemployed Educational status No formal education 70 27.8
Primary school 97 38.5
131 (52.0%) and 129 (51.2%) were from urban (Table 1).
Secondary school 48 19.0
Majority of the study participants 188 (74.6%) had
College/University 37 14.7
no family/social support and most of them 220 (87.3%)
Occupation Employed 48 19.0
had no family history of diabetes. More than half 61.1%
Unemployed 131 52.0
of the participants treated for diabetes mellitus for less
Farmer 73 29.0
than 6 years. Only 10.3% of the participants had access
Residence Urban 129 51.2
for monitoring their blood glucose. About 159 (63.1%)
Rural 123 48.8
of the patients were taking only insulin. Majority 169
BMI < 18.5 (Underweight) 17 6.7
(67.1%) of the participants had poor knowledge about
18.5–24.9 (Normal 142 56.3
diabetes. Of the participants 159 (63.1%) patients had weight)
type 1 DM. More than half of the participants 150 25–29.9 (Overweight) 50 19.8
(59.5%) had poor glycemic control. One hundred fifty- ≥ 30 (Obese) 43 17.1
three (60.7%) participants had good self-care (Table 1). Family/social support Yes 64 25.4
Regarding self-care practice domains of diabetic No 188 74.6
patients majority of them 209 (82.9%) had adequate Family history of Yes 32 12.7
foot care and more than half 175 (69.4%) and 160 diabetes No 220 87.3
(63.5%) had adequate dietary plan and exercise man- Duration of diabetes < 6 154 61.1
agement respectively. However of the total diabetic 6–10 69 27.4
patients only 38 (15.1%) had adequate blood glucose > 10 29 11.5
testing practices (Table 2). Number of medications 1 138 54.8
Variables like sex, educational status, occupation, taken ≥ 2 114 45.2
residence, BMI, knowledge of diabetes and type of DM Access for self-monitor- Yes 26 10.3
ing blood glucose
had shown statistically significant association (p < 0.05) No 226 89.7
with self-care practices in bivariable analysis. In this Hospitalization due Yes 53 21.0
to diabetic related
study, variables with p-value < 0.25 were entered into problem
No 199 79.0
multivariable analysis to identify independent predic- Knowledge of diabetes Good 30 11.9
tors of poor self-care practices among diabetic patients Acceptable 53 21.0
(Table 3). Poor 169 67.1
According to the result of multivariable logis- Anti-diabetic medica- Metformin 57 22.6
tic analysis poor self-care practices were more likely tion Insulin 159 63.1
to occur among male patients (AOR = 5.551, 95% Insulin and metformin 10 4.0
CI = 2.055–14.997, p = 0.001), patients living in Metformin and Glib- 21 8.3
rural area (AOR = 5.517, 95% CI = 2.184–13.938, enclamide
p < 0.001), patients with duration of diabetes < 6 years Glibenclamide 5 2.0
(AOR = 41.023, 95% CI = 7.373–228.257, p < 0.001), Presence of comorbidi- Yes 75 30.6
ties
patients with no access for self-monitoring blood No 175 69.4
glucose (AOR = 9.448, 95% CI = 2.198–40.617, Type of diabetes mel- Type 1 159 63.1
litus
p = 0.003), patients with poor knowledge about diabe- Type 2 93 36.9
tes (AOR = 67.917, 95% CI = 8.212–561.686, p < 0.001) Glycemic control ≤ 130 102 40.5
and patients with comorbidities (AOR = 18.621, 95% > 130 150 59.5
CI = 4.415–78.540, p < 0.001) (Table 3). Self-care Poor self-care 99 39.3
Good self-care 153 60.7
Dedefo et al. BMC Res Notes (2019) 12:212 Page 4 of 7
Table 2 Distribution of self-care practice domains diabetic findings were reported from Ayder Comprehensive Spe-
patients on follow up at Nekemte Referral Hospital, West cialized Hospital [27] and Bangladesh [26].
Ethiopia, from February 20 to May 20, 2016 (n = 252) Patients with shorter duration of diabetes had shown
Self-care practice domains Adequate Unsatisfactory significant association with poor self-care practices. Sim-
ilar findings were reported from Ayder Comprehensive
Diet 175 (69.4%) 77 (30.6%) Specialized Hospital [27], Bangladesh [26] and United
Exercise 160 (63.5%) 92 (36.5%) Arab Emirates [28]. The reasons for poor self-care in
Foot care 209 (82.9%) 43 (17.1%) patients with shorter duration of diabetes could be due
Blood glucose testing 38 (15.1%) 214 (84.9%) to less regular counseling and contact with health profes-
sionals that may help them to create their awareness for
self-care practices.
Patients with no access for self-monitoring blood glu-
Discussion
cose were 9.448 times more likely to had poor self-care
Self-monitoring of glycemic control is a cornerstone
practices than those who had access for self-monitoring
of diabetes care that can ensure patient participation
blood glucose. This finding is consistent with studies
in achieving and maintaining specific glycemic targets.
done at JUSH [23], California [29] and United Kingdom
Self-monitoring provides information about current
[30]. The reason for no access of self-monitoring blood
glycemic status, allowing for assessment of therapy and
glucose could be because of low socioeconomic status of
guiding adjustments in diet, exercise and medication in
the study participants and lack of their awareness on the
order to achieve optimal glycemic control [22].
use of glucometer.
This study revealed that the self-care practices of dia-
Poor knowledge about diabetes was associated sig-
betic patients accounts for 60.7%. Self-care practices
nificantly with poor self-care practices. This finding is
in this study is higher as compared to previous done
consistent with other studies done in Tikur Anbesa Spe-
studies in Harari [17], JUSH [23], India [24], which
cialized hospital [16] and Bangladesh [31]. This could be
reported 50.9%, 39.2%, 46.4% of self-care practices; but
explained as patients with poor knowledge about diabe-
lower than study done in Nigeria [25] which reported
tes are less compliant to their medication and self-care
79.5% of self-care practices. The differences in self-care
practice and this will result in poor glycemic control [10,
practices could be due to easier access to health-related
32, 33].
activities and higher proportions of literate population
in the present study setting as compared to previously
done studies in Ethiopia. Conclusion
This study showed that male patients were 5.551 The present study concluded that self-care practices of
times more likely to had poor self-care practices as study participants were poor. In particular blood glucose
compared to female patients. This finding is consistent testing domain of self-care practice was very poor and
with that reported by other studies from Tikur Anbesa relatively there were good foot care among the study par-
Specialized hospital [16], Nigeria [25] and Bangla- ticipants. Thus we recommend that health care provid-
desh [26]. This difference in gender shows difference ers should begin by taking time to evaluate their patients’
in awareness over self-care practices and commitment perceptions and make realistic and specific recommenda-
for adhering to the self-care practices, thus education tions for self-care activities.
on self-care practices has to be provided for all diabetic
patients. Limitations
The living places of the patients had shown significance Data about diabetes and self-care knowledge were self-
association with poor self-care practices. Patients living reported; this method has the disadvantages of recall
in rural areas are 5.517 times more likely to develop poor bias and eliciting only socially acceptable responses and
self-care practices than those living in urban. Similar hence, may, lead to overestimation of some of the results.
Dedefo et al. BMC Res Notes (2019) 12:212 Page 5 of 7
Table 3 Logistic regression analysis of factors associated with self-care practices among diabetic patients on follow
up at Nekemte Referral Hospital, West Ethiopia, from February 20 to May 20, 2016 (n = 252)
Variables Categories Self-care COR (95% CI) p value AOR (95% CI) p value
practice
Good Poor
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