Self-care knowledge and contributing factors among ambulatory diabetes mellitus patients in North-Central, Ethiopia: a facility-based cross-sectional study

¹Armaeur Hansen Research Institute, Ministry of Health, Addis Ababa, Ethiopia, ²Department of Public Health, College of Health Science, Debre Berhan University, Debre Berhan, Ethiopia, ³Ethiopian Field Epidemiology and Laboratory Training Program, Ministry of Health, Addis Ababa, Ethiopia, ⁴Department of Human Nutrition, Menelik II College of Medicine and Health Science, Kotebe Metropolitan University, Addis Ababa, Ethiopia

^&Corresponding author
Marekegn Habtamu, Department of Human Nutrition, Menelik II College of Medicine and Health Science, Kotebe Metropolitan University, Addis Ababa, Ethiopia

Introduction    

Diabetes Mellitus (DM) is a serious chronic medical condition that occurs either when the pancreas fails to generate enough insulin or when the body fails to use it effectively. Therefore, clinically, it is identified as a raised level of blood glucose (hyperglycemia). DM is broadly categorized into type I, which contributes 10% of the total prevalence of the case, and type II, which is the most common type of diabetes and accounts for about 90% of the total prevalence [1]. This long-lasting metabolic disorder and uncontrolled blood sugar levels affect multiple organ systems. It can lead to serious microvascular and macrovascular complications. Microvascular complications include neuropathy, nephropathy, and retinopathy. Macrovascular complications include cardiovascular disease, stroke, and lower limb amputation [2-4].

According to the International Diabetes Federation (IDF) Diabetes Atlas, 10^th edition 2021 report, globally, 537 million adults aged 20-70 are living with diabetes in 2021. This is equivalent to 10.5% of total adults in this age group. More than 80% of people with diabetes live in low- and middle-income countries. According to the aforementioned report, Africa is home to 23.6 million diabetes cases, which is the least as compared to other continents. However, this number is expected to more than double by 2045. In Ethiopia, a similar report revealed that the overall prevalence of DM in adults was estimated to be 3.3% [1]. This magnitude is greater than the prevalence that had been reported in previous reports.

Due to the chronic nature of the disease, the majority of patients receive ambulatory care daily. This calls for encouraging and strengthening the self-care behaviors of all diabetes patients. Diabetes patients serve as their own primary care providers [5,6]. Evidence suggests that patients' understanding of the diseases, proper self-care practices, and dedication to take part in disease management are crucial in getting the intended treatment outcome [6-8]. Diabetes self-care practice depends on patients' understanding of both self-care practice and the disease condition as a whole. As literature from Ghana explained, patients´ knowledge about the disease had a direct impact on how often they exercise self-care [9]. Likewise, cross-sectional research undertaken in Ethiopia depicts a direct correlation between patients´ self-care practices and knowledge about the disease [10,11].

Despite the numerous studies conducted to examine the extent of self-care practice and associated factors, there is scant evidence of diabetes self-care knowledge and determinant factors in Ethiopia. Thus, this study aimed to bridge the gap by assessing the magnitude of diabetes self-care knowledge and driving factors among type II diabetes patients in North Central Ethiopia.

Methods     

Study design, area, and period: a facility-based cross-sectional study design was employed. The study was conducted in Shewa Robit and Kewot District, North Central Ethiopia, from March 22, 2022, to April 30, 2022.

Study population: the source population was all adult patients with diabetes who had regular outpatient follow-up in the selected health facilities at Shewa Robit Town and Kewet District in North Central Ethiopia.

Eligibility criteria: adult diabetic patients who had regular follow-up during the study period were included in the study. Patients who were critically ill and had hearing impairment were excluded from the study.

Sample size determination and sampling procedure: the sample size was estimated using the single population proportion formula, considering the prevalence of diabetes patients´ self-care knowledge (70.4%), which was taken from a study conducted in Ayder Comprehensive and Specialized Hospital in North Ethiopia [7] with the assumptions of a 95% confidence interval, 1.96 standard normal variable (Z-score), 5% margin of error, and adjusting 10% of non-response rate, the final sample size was 355.

Eight private and public health facilities were found in the study area. Four of them were selected by employing a simple random sampling approach. To allocate proportionally to the size, the total patient flows of each health facility were identified from the patient registration charts. Eventually, every fifth patient was selected for interview using a systematic sampling procedure. The first patient was chosen using a simple random sampling technique.

Variables

Dependent variable: level of self-care knowledge of diabetes patients.

Independent variables: socio-demographic factors like age, sex, religion, educational status, marital status, and monthly income. In addition, clinical and healthcare-related factors include duration of diagnosis, family history, and type of DM, received health education, and source of health information.

Operational definitions: self-care knowledge of diabetic patients who responded greater than 50% was considered as having good knowledge. Whereas respondents who scored 50% or less were considered to have poor knowledge [12].

Data collection instrument: the data were collected by using a pre-tested, validated, and standardized questionnaire through face-to-face interviews. To maintain the validity of the tool, the questionnaire was adopted from the standard and translated into Amharic, and to verify consistency, translated back to English. The instrument comprised three sections: sociodemographic, health-related characteristics, and information source, and Diabetic Self-Care Knowledge Questionnaire (DSCKQ-30) item questions.

Data collection procedure: prior to collecting the data, briefly explained to the respondents the overall purpose of the study. In the end, written informed consent was secured from those who voluntarily participated in the study. Sociodemographic and knowledge-related data were collected by interviewing the study participants. Whereas clinical-related data were collected by reviewing patients´ charts.

Data quality assurance: the tool was originally developed in English, translated into Amharic, and back-translated into English to check consistency by different translators. To assure the quality, three diploma-holder nurses for data collection and one BSc-holder health office were recruited and trained for two days about the general objective of the study, data collection system, and supervision process. Additionally, a pretest of the tool was conducted around 18 diabetic patients from Ataye Town in neighboring districts to the study site to check clarity, understandability, completeness, reliability, and consistency, and necessary revisions were made. Eventually, the principal investigator and supervisor checked the collected data for completeness, and corrective measures were taken accordingly.

Data management and analysis: data were entered into EpiData version 4.6 and transferred into SPSS version 23 for statistical analysis. Frequency tabulation was undertaken to identify inconsistencies and missing values prior to running any analysis. Data distribution was checked using the Shapiro-Wilk normality test. Categorical data were presented using descriptive statistics, frequency, and percentage. Whereas continuous variables were presented as mean ± SD. A binary logistic regression model was used to identify potential predictor variables for diabetic self-care knowledge. Variables with a p-value of less than 0.2 in the binary logistic regression analysis were entered into the multivariable logistic regression analysis. Then Adjusted Odds Ratio (AOR) with 95% CI and p-value < 0.05 were used to identify factors significantly associated with diabetic self-care knowledge.

Ethical approval and consent form: this study was undertaken in compliance with the guiding principles of the Declaration of Helsinki. An ethical clearance letter was granted from the institutional review committee of the College of Medicine and Health Science of Debre Berhan University. A permission letter was secured from Shewa Robit Town and Kewot District Health Office and respective health institutions. Prior to commencing the actual data collection, the purpose of the study and the rights of participants were explained to the study subjects. Written informed consent was obtained from the study participants, and the respondents were told that the information obtained from them would be kept with full confidentiality.

Results     

Socio-demographic characteristics of participants: from 355 study participants, 340 of them have responded, making a response rate of 95.8%. The majority of the study participants, 267 (77.1%), were urban residents. And one hundred twenty-seven of the participants (37.4%) were 50 years old and up. More than half (65%) of the research participants were male, and 247 (72.6%) of the respondents were married. About 190 (55.9%) of the study participants were orthodox religious followers. In terms of educational attainment, 127 (37.4%) of the participants had a college diploma or above. Around 156 (46.4%) of the participants were government employees, and 155 (45.6%) of the respondents had a monthly income of less than 1000 birr (Table 1).

Clinical characteristics of participants: over half of the individuals in the research, 199 (58.5%), had diabetes for fewer than five years. Among the participants, the majority (254 or 74.4%) of the respondents had regular follow-up in diabetic clinics, and three-fourths (75.3%) of participants had received family care. The highest number of respondents, 265 (77.9%), had ever received diabetic-related health education. Of those, 174 (65.7%) of respondents had received health education from health professionals.

Participants' self-care knowledge: in this research, more than half, 186 (54.7%) of the study participants had good knowledge of diabetes self-care. Correspondingly, overall self-care knowledge of respondents on modifiable lifestyles, adherence to diabetes self-care, and consequences of uncontrolled blood glucose level was 58.1%, 57.5%, and 60.4%, respectively (Table 2, Table 3, Table 4).

Factors associated with diabetic self-care knowledge: a binary logistic regression was undertaken to identify potential predictor variables that affect diabetic self-care knowledge. Variables with a p-value of 0.2 or less in binary logistic regression were fitted into a multivariate logistic regression model. In this study, variables that showed a significant association were educational status, monthly income, regular diabetes follow-up, and having ever been in diabetes health education found to have a significant association with good self-care knowledge.

Respondents with a diploma and above educational level were 3 times more likely to have good self-care knowledge compared to those who cannot read and write (AOR=3.407; 95% CI=1.337, 8.684). Study participants, who had a monthly income above 2,000 birr, were 4 times more likely to have good self-care knowledge than those who had a monthly income below 1,000 birr (AOR= 4.384; 95% CI=1.548, 12.411). Respondents who had regular follow-up were 9 times more likely to have good self-care knowledge compared to those who didn´t have regular follow-up (AOR=8.910; 95% CI=2.903, 17.349). Ever being in diabetic health education revealed a consistent significant association in both bi-variable and multivariable analysis; those who had ever been in diabetic health education were 5 times more likely to have good self-care knowledge than those who had never been in diabetic health education (AOR=5.554; 95% CI=1.820, 16.953) (Table 5).

Discussion     

Diabetes is a chronic and complex metabolic disorder with multiple long-term and short-term complications. In order to maintain the desired outcomes of treatment and quality of life, patients´ involvement in the management plays a prominent role. Hence, assessment of the patient´s self-care knowledge is an important first step in designing an appropriate diabetes education program. Therefore, this study was conducted with 340 participants to assess their level of knowledge towards diabetes self-care. This study found that one out of two DM patients has good knowledge of diabetes self-care. However, our finding is relatively lower than the study conducted in North Shoa, Oromia region of Ethiopia [13]. Mekele Ayder Comprehensive Hospital in North Ethiopia [7], Jimma Medical Center, Southwest Ethiopia [14], and Arsi, Zone Southeast, Ethiopia [15] which were 67.8%, 70.4%, 63.3%, and 64.8%, respectively. This discrepancy could be due to differences in the sociodemographic characteristics of the study participants. Furthermore, living closer to the capital city provides the chance to frequently access medical services.

This study also discovered that educational level, monthly income, regular follow-up and having ever had diabetic-related health education were factors significantly associated with good diabetic self-care knowledge. According to this study, participants who had a diploma and higher educational level were three times more likely to have better diabetes self-care knowledge than those who could not read and write. This finding agrees with a cross-sectional study conducted at Jimma Medical Center (JMC), Ethiopia [14]. A study from Nigeria, Thailand, and Brazil also revealed that those who had a higher academic level had better self-care knowledge than their counterparts [8,16,17]. It may not be surprising that knowledge is acquired through education. Moreover, individuals who have a higher academic level have a greater chance of obtaining knowledge from various sources, like mass media, reading materials like books, and the internet.

The present study discloses that an individual who earns a monthly income of greater than 2000 birr is four times more likely to have good knowledge of diabetes self-care as compared to those who earn a monthly income of less than 1000 birr. This discovery is consistent with findings recorded in other studies. A cross-sectional study in Nigeria indicates that participants with higher income have good knowledge of diabetes self-care [8]. The possible justification could be that making a higher monthly income could open up the opportunity to access relevant information about diabetes self-care.

According to the findings, participants who had regular follow-up were nine times more likely to have diabetes self-care knowledge as compared to those who did not have regular follow-up. Despite the fact that there is little evidence to compare our findings with others, several studies have shown that diabetes patients with a longer duration of disease and regular follow-up had better knowledge about the disease and its complications than newly diagnosed patients. A cross-sectional study from Northwest Ethiopia showed that patients with a longer duration had better knowledge than their counter group [18]. Similarly, research from Benin and Sri Lanka revealed that study subjects with longer duration and regular follow-up had better knowledge about the disease and complications due to poor management [19,20]. On the contrary, a study from Kuwait indicates that patients with a lower duration of disease had a lower level of knowledge regarding the disease and were less likely to comply with treatment recommendations [21]. This is partly explained because these patients gained better and up-to-date information from health professionals and peers regarding diabetes mellitus.

This study demonstrated that patients who had ever received health education about diabetes had better knowledge regarding diabetes self-care than those who had not attended diabetes health education. This finding is in line with a cross-sectional study conducted in North Shewa, Ethiopia, and South Western Uganda [13,22]. Apart from these observational studies, trial studies from Nigeria and Bangladesh proved that precise and patient-friendly diabetes health education enhances their knowledge about self-care and the disease overall [23,24]. This similarity might be explained that health education is the fundamental way to acquire knowledge. Hence, patients who have had previous exposure to diabetic health education have a better understanding of self-care than those who do not have diabetes-related health education experience.

Limitation of the study: despite this study having some strengths, this study has several limitations. A cross-sectional study was employed to undertake this investigation. It does not provide the ability to infer temporal relations. The use of the mean score to dichotomize the score obtained from the tool can be considered a limitation. However, we were forced to use it due to the absence of a suggested cut-off point.

Conclusion     

The finding from this study discloses that more than half of the study participants had good knowledge regarding diabetes self-care. Furthermore, this study suggests that participants with post-secondary education, better monthly income, and attending diabetes health education are important predictors of good diabetes self-care knowledge.

Competing interests     

The authors declare no competing interests.

Authors' contributions     

Tomas Getahun: designed the study and adapt tool; Yonas Abebe: data analysis and wrote methodology; Woldu Gebrehiwot: supervised data collection, data entry, and analysis; Marekegn Habtamu: reviewed the analysis and wrote the main text of the manuscript. All the authors read and approved the final version of this manuscript.

Acknowledgments     

We are grateful to thank the study participants, Debre Birhan University, and health facility administrators for their willingness to participate in this study.

Tables     

Table 1: socio-demographic characteristics of diabetic patients at health facilities in Shewa Robit Town and Kewet District, North-Central, Ethiopia, 2021 (n=340)

Table 2: diabetes self-care knowledge modifiable lifestyle items of diabetic patients at health facilities in Shewa Robit Town and Kewet District, North-Central, Ethiopia, 2021

Table 3: diabetes self-care knowledge adherence to self-care practice items of diabetic patients at health facilities in Shewa Robit Town and Kewot District, North-Central, Ethiopia, 2021

Table 4: knowledge level of adherence to self-care practice items of diabetic patients at health facilities in Shewa Robit Town and Kewet District, North Shoa Zone, Amhara Region, Ethiopia, 2021

Table 5: factors associated with good self-care knowledge

References