DIABETES SELF CARE PRACTICES AND ASSOCIATED FACTORS AMONG TYPE 2 DIABETIC PATIENTS IN TIKUR ANBESSA SPECIALIZED HOSPITAL, ADDIS ABABA, ETHIOPIA- A CROSS SECTIONAL STUDY

DIABETES SELF CARE PRACTICES AND ASSOCIATED FACTORS AMONG TYPE 2 DIABETIC PATIENTS IN TIKUR ANBESSA SPECIALIZED HOSPITAL, ADDIS ABABA, ETHIOPIA- A CROSS SECTIONAL STUDY

Kalayou Kidanu Berhe*¹, Asrat Demissie ², Alemayoh Bayeray  Kahsay ¹ and Haftu  Berhe  Gebru ¹

Department of Nursing, College of Health Sciences, Mekelle University ¹, Tigray, North Ethiopia

Department of Nursing and Midwifery, College of Health Sciences, Addis Ababa University ², Addis Ababa, Ethiopia

ABSTRACT

Background: Diabetes is a group of metabolic disorders that affect the body’s ability to process and use sugar (glucose) for energy. Type 2 diabetes mellitus resulting from the combination of resistance to insulin action and inadequate insulin secretion. The success of long-term maintenance therapy for diabetes depends largely on the patients’ adherence with self-care practices.

Objective:  The aim of this study was to assess diabetes self-care practices and associated factors among type 2 diabetic patients in Tikur Anbessa Specialized Hospital, Ethiopia.

Method: institutional based cross sectional study was employed and 320 study subjects were selected using systematic random sampling technique. And the data was collected using interviewer administered structured questionnaire; data was analyzed and cleaned using SPSS version 16. Scoring method was employed to classify patients’ self-care practice level as adhered or not adhered to self-care practices.

Results: Of all respondents 167(52.2%) female. Mean age of the respondents was 55.03±10.7 years with minimum age of 30 and maximum age of 85. The mean duration of diabetes was 12.3±7.6years with minimum of 6 months and maximum of 41 years. Respondents’ self-care practices were, the majority 270 (84.4%) respondents were not adhered to Self-Monitoring of blood glucose practice. A total of 311(97.2%) respondents were adhered to anti-diabetic medication. The majority 252 (78.8%) respondents were not adhered to recommended diet management practices. There was a significant association between Level of education, monthly income, Presence of glucometer at home, marital status, diabetic complication, age and gender and self-care practices. But there was no significant association between duration of diabetes, Occupation and family history of diabetic and self-care practices.

Conclusion: findings of this study indicated that majority patients had poor adherence to self-care practices especially in self-monitoring of Blood Glucose and diet management practices.

Self-care management

INTRODUCTION: Diabetes is a general term for a group of metabolic disorders that affect the body’s ability to process and use sugar (glucose) for energy. The three most common forms of diabetes are type 1 diabetes, type 2 diabetes, and gestational diabetes. Type 2 diabetes mellitus comprises an array of dysfunctions resulting from the combination of resistance to insulin action and inadequate insulin secretion. It is characterized by hyperglycemia and associated with micro vascular (i.e., retinal, renal, possibly neuropathic), macro vascular (i.e., coronary, peripheral vascular), and neuropathic (i.e., autonomic, peripheral) complications.

The prevalence of diabetes has reached epidemic proportions.  According to IDF diabetes Atlas, 5^th edition 2012 report, currently, more than 80% of people with diabetes live in Low and Middle Income Countries. An estimated 366 million people were living with diabetes in 2011. The number is expected to grow to 552 million by 2030 and the largest age group currently affected by diabetes is between 40-59 years. The African region is expected to experience the highest increase in coming years with estimated increase in prevalence rates of 98% for sub-Saharan Africa, and 94% for North Africa and the Middle East ^{1, 2, 3, 4}.

The IDF Atlas 5^th edition 2012 report (ARF) revealed that in 2011, 14.7 million adults in the Africa Region are estimated to have diabetes, with a regional prevalence of 3.8%. The top six countries with the highest number of people with diabetes make up just over half of the total number in the region. This would rise to 28 million by 2030 with prevalence of 4.3%, an increase of 80%, as such exceeding the predicted worldwide increase of 55%.  Type 2 diabetes is responsible for 85-95% of all diabetes in high-income countries but Type 2 diabetes accounts for well over 90% of diabetes in Sub-Saharan Africa.  Based on the IDF Atlas 5^th edition, 2012 report ,number of cases of diabetes in Ethiopia to be  estimated about  1.4 million in 2011 ^{5, 6}.

When it is not prevented and properly managed diabetes is one of the major causes of premature illness and death worldwide. Non- communicable diseases including diabetes account for 60% of all deaths worldwide and more than 80% of diabetes deaths occur in low- and middle-income countries According to IDF Atlas 5^th edition 2012 report Diabetes caused 4.6 million deaths in 2011 globally. World Health Organization projects that diabetes deaths will double between 2005 and 2030.  Statistics for medical complications from diabetes are also concerning. Proportions of patients with diabetic complications in sub Saharan region ranged from 7-63% for retinopathy, 27-66% for neuropathy, and 10-83% for nephropathy.

Diabetes is likely to increase the risk of several important infections in the region, including tuberculosis, pneumonia and sepsis. Diabetes being a chronic illness requires continues self care practices by sufferers so that they can contribute meaningfully in the management of their lives. A situation where diabetes patients visit clinics regularly and their blood glucose levels still remain high despite the treatment they receive is a problem that calls for attention. This is a very common observation in many diabetes patients. A good number of them  report to the hospital with severe complications, like gangrene that may lead to amputation and possible premature death, this might be because of lack of appropriate self care practices ^{5, 7, 8}.

Despite the benefits of engaging in a recommended self-care regimen, research remains limited on determining recommended self-care practices level and its associated factors among diabetes patients. The Behavioral Risk Factor Surveillance System for North Carolina revealed that 83% of respondents with type 2 diabetes mellitus performed blood glucose monitoring and more than 93% had visited a health care provider for diabetes care in the past year.

Other researchers have suggested that self-care activities vary extensively according to the nature of the activity itself, with taking of medication often occurring as recommended and exercise frequently falling below recommended levels. For example, results from one study showed that 97% of respondents with diabetes always or usually took their medication, whereas only 41% always or usually exercised, as cited by Nancy E. Schoenberg ⁹.

Furthermore, although the studies have begun to illuminate our understanding of some of the predictors of differences in diabetes self-care, we currently lack an in-depth understanding of level and associated factors of type 2 diabetes patients to ward diabetes self-care practices. The major problematic condition about diabetes self care practices is that there are limited research findings on patients who are found in sub Saharan Africa especially in Ethiopia, even there is no enough published material and little research is done. To address these deficits, this research explores patient’s level and associated factors to diabetes self-care regimens in Tikur Anbessa Specialized Hospital endocrinology unit, Addis Ababa City.

METHODOLOGY:

Study setting: The study area, Tikur Anbessa Specialized Hospital is found in Addis Ababa City, Lideta Sub City. The hospital has been inaugurated by the title “Prince Mokonnen” Memorial Hospital on 3/11/1973. On 24/5/1975 named as Tikur Anbessa Hospital. Endocrinology unit is one of the specialty units of the hospital, which provide service for total of 3186 Type 2 diabetes patients in 2003 E.C as new and follow up cases. According to the 2007 census report by Central Statistical Agency of Ethiopia (CSA), the dominant ethnic group of Addis Ababa City is Amara, language is Amharic, religion is Orthodox and the other dominant ethnic groups are: Oromo, Gurage, Selte, and Tigry respectively. The study period was from September 2011 to May 2012.

The study design was institutional based cross-sectional study design. The source population was all patients who visit the endocrinology unit of the hospital during the study period. The study population was all Type 2 diabetic patients who visit the hospital’s endocrinology unit at the time of data collection period and fulfilling the inclusion criteria. The sample size for the study was determined using single population proportion and correction formulas. Data was collected using standardized structured questionnaire and two diploma completed Nurses were recruited.

Continuous follow up and supervision was made by the principal investigator throughout the data collection period. Data collection was accomplished within six weeks duration (March 1^st week to April 2^nd week, 2012). interviewer administered structured questionnaire data collection tool was used, it contains three parts, Part I was used to collect socio demographic data, part II was used to collect clinical status data of the study subjects and part III is the original SDSCA, which was used to measure five areas or domains of diabetes self care practices.

The independent variable were Socio-demographic characteristics, Age of diabetes onset, Duration of the disease, Family history of diabetes, Complications of diabetes, Treatment intensity and The outcome variable was self care practices of the patients.To assure data quality, training and orientation was given for the data collectors by the principal investigator. The questionnaire was initially prepared in English and then translated in to Amharic version. The Amharic version was again translated back to English to check for consistency of meaning.

Moreover questionnaire was pre-tested and necessary corrections and amendment was considered. The collected data was reviewed and checked for completeness and consistency by principal investigator on daily bases at the spot during the data collection time. The data was entered in to EPI-INFO version 3.5.1, exported to SPSS then the data was cleaned and analyzed using SPSS version 16 software statistical packages. Ethical clearance was secured from the AAU-college of health science department of Nursing and Midwifery IRB (research committee).

Respondents were informed about the purpose of the study then information was collected after obtaining verbal consent from each participant. Respondents were allowed to refuse or discontinue participation at any time they want. Information was recorded anonymously and confidentiality and beneficence was assured throughout the study period. The total score of each item of the questionnaire was calculated out of 100. Considering to the total score, the level of self-care practice was classified into: Not adhered (<49 and below), or adhered (50 and above)

RESULTS:

Socio-demographic Characteristics: A total of 323 male and female adult type 2 diabetes patients were interviewed using standardized structured questionnaire and included in the analysis. Three respondents were excluded from the analysis for gross incompleteness and inconsistency of responses, made a response rate of 99.1 %.

Of all respondents 167(52.2%) and 153(47.8%) were Female and Male respectively. The majority of the study participants 232 (72.5%) were in the age group of 30 to 60 years. Mean age of the respondents was 55.03 ± 10.7 years [(95% CI) (44.33-65.73)] with minimum age of 30 and maximum age of 85. Most of the respondents 257(80%) were orthodox Christian by religion and Amara184 (57%) by ethnicity. A significant number 182 (57%) of the respondents did attend formal education. Two hundred forty six (77%) of respondents were married currently. From the total respondents two hundred eleven (66%) were unemployed and majority of the study participants 139(43%) were had very low monthly income (Table 1).

TABLE 1: SOCIO DEMOGRAPHIC DATA OF TYPE 2 DIABETES PATIENTS IN TASH ENDOCRINE UNIT, ETHIOPIA, 2012 (n=320)

*   Monthly income category: Very Low <445 Birr, Low=446-1200Birr, Average=1201-2500Birr,

Above Average= 2501-3500Birr and High >3501Birr (Based on the Ethiopian Civil service monthly salary for civil servants)

Health Status data: The mean age in which diabetic disease started was 42.5+10.03 years [(95% CI) (32.2-52.53)] with minimum age of 30 and maximum age of 75. The mean duration of diabetes was 12.3± 7.6years [(95% CI) (4.7–19.9)] with minimum of 6 months and maximum of 41 years. The majority of the study participants 205 (64%) had multiple injection treatment (two injections per day). Of all respondents 101(32%) and 14(4%) had oral hypoglycemic agent or both treatment intensity respectively. Two hundred twenty six (71%) of the respondents did not have family history of diabetes and only 119 (37%) respondents had glucometre at home. Almost half of the participants 157 (49%) had long term diabetic complication confirmed medically. Only six (2%) of all respondents have the habit of Smoking and thirty seven (12%) had history of smoking in the past (Table 2).

TABLE 2: PATIENT HEALTH STATUES DATA OF TYPE 2 DIABETES PATIENTS IN TASH ENDOCRINE UNIT, ETHIOPIA, 2012 (n=320)