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. 2020 May 1;15(5):e0232524. doi: 10.1371/journal.pone.0232524

Predictors of self-management practices among diabetic patients attending hospitals in western Oromia, Ethiopia

Dereje Chala Diriba 1,2,*,#, Tariku Tesfaye Bekuma 3,#, Firew Tekle Bobo 3,4
Editor: Wen-Jun Tu5
PMCID: PMC7194359  PMID: 32357177

Abstract

Background

Diabetes Mellitus recognized as one of the emerging public health problems in developing countries. Self-monitoring needs to be individualized and should assist people with diabetes. This study aimed to assess the predictors of self-management practices among diabetic patients attending hospitals in western Oromia, Ethiopia.

Methods

A facility-based cross-sectional study was conducted from November 2017 to February 2018 in hospitals located in western Oromia, Ethiopia. An interview was made with a total of 400 diabetic patients attending the diabetes center and admitted to ward in the study hospitals. The data were entered into Epi Info software version 3.5.4. Data analysis was made using a statistical package for the social sciences (SPSS) version 20. Odds ratio (OR) was used to show the association. The statistical significance was considered at P<0.05, and potential confounding variables were controlled using logistic regression. The analyzed data were presented in texts and tables.

Results

From a total of 398 interviewed patients, 129 (32.4%) practiced diabetes self-management. About 63.6% of the study participants’ self-management practice was good. Most 103 (79.84%) of those who practiced self-management were presented with one of diabetes mellitus-related complications. Logistic regression analysis results showed that merchants were about six times higher in self-management practice [AOR of 5.945 (1.177–30.027 at 95% CI)] and those having family support in diabetes practiced self-management 2.87 times than others [AOR of 2.835 (1.386–5.801 at 95% CI)].

Conclusions

Compared to the findings of previous studies, diabetes self-management practices of the participants was good. The study participants regular physical activity, food intake, medication adherence, and foot self-examination were moderate. Two variables, being a merchant and having family support were found to be the predictors of self-management practices. Predictors of self-management should be considered to boost self-management practice.

Introduction

Diabetes Mellitus (DM) refers to a group of common metabolic disorders that share the phenotype of hyperglycemia [1]. It is one of the four common non-communicable diseases causing major morbidities and mortalities [2–4]. World Health Organization (WHO) estimated that 422 million adults had diabetes in 2014 [5]. International Diabetes Federation (IDF) estimated this number to be 629 million by 2045. In Africa, the prevalence of diabetes adults between 20–79 years was 16 million in 2017 and projected to be 41 million in 2045. About 69.2% were undiagnosed. Africa attributes 77% of the deaths under 60 years to diabetes mellitus. The figure is the highest proportion in the world. International Diabetes Federation in 2015 estimated that 5.2% of Ethiopian adults had diabetes [6].

Self-management is the ability of the patient to deal with all that a chronic illness entails, including symptoms, treatment, physical and social consequences, and lifestyle changes [7, 8]. Since health care cost for the treatment of acute and chronic complications of diabetes is high [9], self-management is compulsory. Ethiopia is one of the low-income countries [10]. Thus, supporting patient self-management practice plays a key role in effective chronic illness care and improve patient outcomes. Effective management of diabetes requires predominantly self-directed practices, where the individuals become responsible for the day-to-day decisions related to controlling their disease [11–14]. The emerging evidence supports the implementation of practice strategies that are conducive to patient self-management and improved patient outcomes among chronically ill patients [15]. Implementation of self-management needs to be individualized, and people with diabetes should be assisted to understand the impact of medication, food and physical activity on blood glucose control. Adequate self-management can minimize the disease and disease-related complications, while the frequency of self-monitoring can be determined based on the individual’s self-management goals [16]. The key goal of self-management is controlling blood glucose, improving quality of life and reduction of diabetes-complications [17]. A systematic review conducted in 2018 in Sub-Saharan Africa on self-management of Type 2 diabetes shows that patients rarely self-monitored their glucose levels; had low duration/frequency of physical activity; moderately adhered to recommended dietary and medication behavior and had a poor level of knowledge about diabetes complications [18].

Numerous studies conducted in different parts of Ethiopia shows slightly more than half of patients living with diabetes had good self-management practice [19–21]. Different cross sectional survey indicated that dietary and medication adherence of diabetic patients was low [20–22]. Internationally, only two-thirds of diabetic patients perform daily self-monitoring of blood glucose [17]. However, self-monitoring of blood glucose was good in Ethiopia [22]. Inadequate attention to diabetes center and lack of knowledge about self-management was reported as main factor in Ethiopia [23].

Self-management practice in clients with chronic diseases is essential to maintain good health while taking the medications. However, the practice may vary from client to client due to several factors. Different researches have investigated that age, current occupation, lack of awareness, absence of self-practice health education, years of suffering from DM, having family members suffering from the illness and lack of knowledge about the illness were the factors that affect the level of self-management behaviors [24, 25]. Besides, belief in treatment effectiveness, family support, self-efficacy, awareness about the disease and social support were also the factors that affect self-management practice [26, 27].

Despite the knowledge about the factors that affect self-management practice, there was no comprehensive study conducted on self-management of chronic illness especially DM covering the different hospitals located in western Oromia, Ethiopia, as far as the researchers’ knowledge is concerned. This study thus focused on the assessment of self-management practice and its predictors in the study facilities. The findings of this study believed to give useful input for policymakers mostly in enforcing and establishing self-management practice interventions which, in turn, may encourage immediate health care providers to consider it in their routine care practices.

Methods and materials

Study design and setting

A hospital-based cross-sectional study was conducted among diabetic patients on follow-up at diabetic centers from November 2017 to February 2018 in public hospitals found in western Oromia, Ethiopia, namely Nekemte specialized hospital, Gimbi general hospital, and Nedjo general hospital.

Source population

All diabetic patients on follow-up attending hospitals were considered as source populations.

Study population

All diabetic patients attending diabetic centers and wards of the study hospitals during the study period were subjects of the study.

Eligibility criteria

Known diabetic patients who visited the diabetic centers for follow-up and wards to receive care were included in the study while patients with diabetic emergencies like diabetic ketoacidosis and diabetic coma were excluded.

Sample size determination

A single population proportion formula was used to determine the sample size. The proportion of patients who performed self-management practice (54.7% according to a study done at Nekemte referral hospital, Ethiopia in 2013) was considered in sample size calculation [19]. Marginal error between sample size and population parameter of 5%, and 95% confidence level, and 5% non-response rate was considered. A total of 400 patients with known diabetes mellitus participated in the study.

Sampling techniques

All known diabetic patients visited the study hospitals for follow-up, and those admitted to the wards were taken into consideration. The average monthly client load was taken from the daily average DM client flow of the hospital and the registry book. Systematic random sampling was used. The interval was calculated at each hospital. The sample was allocated proportionally to the client flow of the respective facilities. The first client who arrived at the waiting area on the first day of data collection, and who met the eligibility criteria was taken as the first candidate for the study. This process continued until the desired sample size was attained.

Data collection tools and methods

The data was collected directly by interviewing diabetic clients after getting informed consent. The questionnaire was prepared in English by modifying from different literature sources with similar areas of interest. It was translated from English to Afaan Oromo, a local language, and re-translated back to English to ensure consistency. The questionnaire was pre-tested in Dambidolo hospital. Three trained diploma nurses were used as data collectors under the close supervision of one B.Sc degree nurse, and the data were collected in a face-to-face interview. For the presence of co-morbid, we had observed the patent’s folder. The only physician confirmed and recorded disease(s) was taken as a co-morbid disease.

Data processing and analysis

Data were entered into Epi Info 3.5.4 software package and cleaned first. Then, the analysis was made using a statistical package for the social sciences (SPSS) software package version 20. Analysis of overall self-management practice was done by transforming the scores on closed-ended questions related to self-management practices. Using the odds ratio (OR) with a 95% limit of the confidence interval, the association of dependent and independent variables was analyzed, and their degree of associations was computed. Potential confounding variables were controlled using binary and multivariate logistic regression. Statistical significance was considered at P<0.05. Finally, the analyzed data were presented using frequency, percentage, and texts.

Data quality control

A pre-test was conducted at Dambidolo hospital on 5% of the total sample size to check clarity, understandability, and consistency of the data collection tool. Then, the necessary amendments were made to the questionnaire before the full-scale data collection was implemented. Data collection was conducted under the close supervision of supervisors and the collected data were checked for completeness.

Study variables

Dependent variable

Diabetes self-management practice.

Independent variables

Sociodemographic characteristics like sex, age, occupation, marital status, religion, level of education, lack of self-management education, patient education, getting family support, presence of DM-related complications and other health problems.

Operational definitions

Self-management: The practice of diabetic patient’s self-initiated and performed activities to control disease and maintain life, health, and wellbeing.

Good self-management practice:—Diabetic patients with average and above scores on closed-ended questions related to self-management practices.

Poor self-management Practice:—Diabetic patients with less than average score on closed-ended questions related to self-management practices.

Hyperglycemia—an abnormally increased concentration of glucose in the blood (≥ 126 mg/dl at FPG).

Ethics statement

Ethical approval was obtained from the Research and Ethics Committee of Wollega University. An official letter was written to each hospital to get official permission. Participants were informed that privacy and confidentiality were maintained. Written consent was taken from the study participants.

Results

Sociodemographic characteristics of the respondents

Table 1 depicts the overall characteristics of the study participants. A total of three hundred ninety-eight diabetic patients participated in this study, raising the response rate to 99.5%. More than half of the respondents were male (225, 56.5%). The average age of all respondents was 41.33 ± 18.93 (SD) years. Majority of the participants were married (255,64.1%), Oromo people (377, 94.7%), living in urban area (204, 51.3%) and Protestant Christians (219, 55.0%). The remaining (106, 26.8%) were single, 20 (5%) Amhara people, (194. 48.7%) living in rural areas and (136, 34.12%) followers of Orthodox Christian religion. One hundred eighteen (29.6%) respondents had attended college/university, whereas about 92 (23.1%) can not read and write, and only 20.4% had attended secondary school education.

Table 1. Socio-demographic characteristics of the study respondents attending hospitals at western Oromia, Ethiopia, 2018 (n = 398).

Variables Categories Frequency (%)
Residence area (home town) Urban 204 (51.3)
Rural 194 (48.7)
Sex Male 225 (56.5)
Female 173 (43.5)
Religion Orthodox 136 (34.1)
Protestant 219 (55.1)
Muslim 39 (9.8)
Catholic 2 (0.5)
Others * 2 (0.5)
Ethnicity Oromo 377 (94.7)
Amhara 20 (5)
Gurage 1 (0.3)
Educational status Can’t read and write 92 (23.1)
Grade 1–4 41 (10.3)
Grade 5–8 66 (16.6)
Grade 9–12 81 (20.4)
College/university 118 ()29.6
Marital status Single (never married) 106 (26.6)
Married 255 (64.1)
Divorced 5 (1.3)
Widowed 32 (8.0)
Occupation Housewife 81 (20.4)
Government employee 81 (20.4)
Merchant 50 (12.6)
Student 86 (21.6)
Local drink seller 8 (2.0)
House servant 1 (0.3)
Daily laborer 41 (10.3)
Patient to family relation Husband/wife 297 (74.6)
Grandparents 6 (1.5)
Son/daughter 91 (22.9)
Sister/brother 2 (0.5)
Home servant 2 (0.5)
Family economy versus neighbor Very poor 21 (5.3)
Poor 122 (30.7)
Middle 215 (54.0)
Rich 39 (9.8)
Very rich 1 (0.3)
Need for family support Yes 362 (91.0)
No 36 (9.0)
Ever supported by family Yes 262 (65.8)
No 36 (34.2)
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*Waaqefataa (it is a religion)

Student patients were relatively high (21.6%) followed by housewives (20.4%) and government employees (20.4%). Based-on participants’ believe, more than half, 54%, of the participants had a middle-level income compared to their neighbors. About 30.7% of the participants were poor and a very small proportion of the participants were very rich (0.3%). The average family size was 5 ± 2 (SD). About three fourths of the participants (74.6%) were husbands and wives in the family, followed by sons and daughters (22.9%). Most of the study participants (91.0%) reported that they need family support for disease treatment. About two-thirds of the participants (65.8%) received support from their families.

More than half of the participants, 220 (55.3%) did not know the type of diabetes they have. One hundred twenty-three (31.0%) of the participants had Type 1 diabetes, while the other had Type 2 diabetes. One hundred eleven (28.0%) had the disease for more than a decade, whereas about 72% live with DM for less than a decade. One-third of the study participants (66.8%) believe that they can cured of the disease, and the majority (71.6%) thought that the medication they were taking could cure them. Near half of the participants, 195 (49.0%) believe that health care providers had a good approach towards them. And two-thirds of the participants, 266 (66.8%) alleged that they would recover from the disease while others did not.

The majority of the participants (93.8%) had either of the following chronic illnesses: hypertension, cancer, edema, Human Immunodeficiency Virus/Acquired Immunodeficiency Syndrome (HIV/AIDS), dyspepsia and bronchial asthma. About three-fourth (74.1%) of them had diabetes-related manifestations and complications. Again, more than half of the participants had shock (55.9%) followed by diabetes ketoacidosis (52.9%). Some of the respondents also reported nerve (32.9%) and eye problems (23.4%) (Table 2).

Table 2. Diabetes-related complications among diabetic patients attending hospitals in western Oromia, Ethiopia, 2018 (n = 398).

Variables Categories Frequency (%)
Presence of DM-related complications Yes 295 (74.1)
No 103 (25.9)
Presence of shock at any time Yes 165 (55.9)
No 130 (44.1)
Diabetic ketoacidosis (DKA) Yes 156 (52.9)
No 139 (47.1)
Nerve diseases Yes 97 (32.9)
No 241 (67.1)
Eye problems Yes 69 (23.4)
No 226 (76.6)
Foot ulcer Yes 60 (20.3)
No 235 (79.7)
Kidney diseases Yes 54 (18.3)
No 241 (81.7)
Hyperglycemic hyperosmolar non-ketotic state (HHSS) Yes 19 (6.4)
No 276 (93.6)
Heart diseases Yes 8 (2.7)
No 287 (97.3)
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Study participants had practiced different self-management interventions. They had also been taking medications and most of them had a monthly follow-up. About half (49.7%) of them had been taking insulin regimen followed by oral hypoglycemic agents (39.7%) for treatment and glycemic control. Only 42 (10.6%) were taking combined medications. The adherence to medication was varying. About the participants’ diet intake, the participants had been consuming food three times a day with the different food menu. However, only one-third of them used the food menu. About half of the respondents used to consume vegetables followed by starch at lunchtime. At dinner, 39.2% of them used starch, while the others (43.0%) used vegetables. Close to three-fourths of the participants (72.4%) did not use to consume snacks, and starch was the most consumable food item. About half (52.0%) of them performed regular physical activity while the remaining did not (48.0%). Again, more than half of the respondents (57.8%) performed regular foot care, whereas 168 (42.2%) did not. Participants did not perform annual foot care check-up.

Predictors of self-management practice

Overall, about 63.6% of the study participants self-management practice was good, while 36.4% self-management practice was poor. One hundred eighty-four (46.2%) of the participants knew about diabetes self-management management, of which 129 (32.4%) were practicing it. Cross-tabulation of the variables showed that those who are female, living in urban, married, rich and merchant tended to practice diabetes self-management. Females practice self-management more than males, 74.2% and 68% respectively. The magnitude of self-management practice was relatively higher among married clients (73.5%) than never married (66.7%). About 73.7% of participants from urban and 64.3% of rural had practiced self-management. No difference in self-management practice was observed between participants who had developed DM-related complications and who had not. Self-management practice was high in participants who believed DM is curable, than those who did not believe so. Participants who were merchants practiced more diabetes self-management, followed by daily laborers (79.2%). Those economically rich tended to practice more self-management than their poor counterparts (Table 3).

Table 3. Cross-tabulation of selected variables with diabetes self-management practice amongst diabetic patients attending hospitals in western Oromia, Ethiopia, 2018 (n = 398).

Independent Variables Self-Management practice
Yes No
Sex
 Male 83 (68%) 39 (32%)
 Female 46 (74.2%) 16 (25.8%)
Residence
 Urban 84 (73.7%) 30 (26.3%)
 Rural 45 (64.3%) 25 (35.7%)
Marital status
 Single 40 (66.7%) 20(33.3%)
 Married 86(73.5%) 31(26.5%)
 Others 3(42.9%) 4(57.1%)
Occupational status
 House wife 8(50%) 8(50%)
 Government employee 39(73.6%) 14(26.4%)
 Merchant 21(87.5%) 3(12.5%)
 Student 31(63.3%) 18(36.7%)
 Daily laborer 19(79.2%) 5(20.8%)
 Others 11(61.1%) 7(38.9%)
Relative economic status
 Very poor 11(78.60%) 3(21.40%)
 Poor 15 (11.60%) 17(53.10%)
 Medium 80(74.10%) 28(25.90%)
 Rich 23(79.30%) 6(20.70%)
 Very rich 0 1 (100%)
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The logistic regression analysis results indicated that only two variables, namely occupation and having family support had shown statistically significant association with the practice of self-management management in both binary and multiple logistic regressions. Accordingly, merchants were observed practicing self-management about six times higher than clients with other occupations with AOR of 5.945 (1.177–30.027 at 95% CI). Clients who had family support in DM-related care were again observed practicing self-management 2.87 times more than those who had no family support with AOR of 2.835 (1.386–5.801 at 95% CI). No difference was observed among other variables entered into the regression model (Table 4).

Table 4. Binary and multi-logistic regression of selected variables with diabetes self-management practice amongst diabetic patients attending hospitals in western Oromia, Ethiopia, 2018 (n = 398).

Variables Self-Management practice P-Value COR at 95% CI AOR at 95% CI
Yes No
Occupation Gov’t employee 39(73.6%) 14(26.4%) .082 2.786 (0.878, 8.839) 2.492 (0.745, 8.337)
Merchant 21(87.5%) 3(12.5%) .014 7.000 (1.476, 33.207) * 5.945 (1.177, 30.027) *
Student 31(63.3%) 18(36.7%) .350 1.722 (0.551, 5.380) 1.424 (0.384, 5.282)
Daily laborer 19(79.2%) 5(20.8%) .060 3.800 (0.947, 15.250) 2.871 (0.658, 12.527)
Others 11(61.1%) 7(38.9%) .516 1.571 (0.402, 6.142) 1.024 (0.244, 4.3)
Constant 8(50%) 8(50%) 1.000 1.000 1.00
Ever family support Yes 97 (77%) 29 (23%) 0.003 2.718 (1.4, 5.28) * 2.835 (1.386, 5.801) *
No 32 (44.8%) 26 (55.2%) 1.00 1.00
Presence of other health problems Yes 50 (73.5%) 18 (26.5%) .438 0.769 (0.395, 1.495) 1.419 (0.612, 3.292)
No 79 (68.1%) 37 (31.9%) 1.00 1.00
Presence of DM related complications Yes 103 (70.1%) 44 (29.9%) .981 0.99 (0.45, 2.2) 0.896 (0.38, 2.11)
No 26 (70.3%) 11 (29.7%) 1.00
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*Statistically significant association

Discussion

Among 398 study participants, 63.6% of them had good self-management practice. Self-blood glucose monitoring, physical activity, diet adherence, medication adherence, and foot care are the components of self-management practice. This finding is comparable with the finding from Northern Ethiopia [28]. The result of this study demonstrates that self-management practice of people living with diabetes mellitus attending hospitals in western Oromia is higher than the result of previous studies conducted in Nekemte referral hospital [19], Jimma University teaching hospital [21], and Harar, Ethiopia [20], and Lesotho [29]. This maybe due to day to day improvement of awareness of the disease management and cultural variation.

Physical activity believed as essential in controlling blood glucose. The result of this study revealed that more than half of participants practiced regular physical activity. The participants level of physical activity is greater than the finding of the study conducted in Harar, Ethiopia [20]. This discrepancy may be due to increased awareness regarding diabetic self-management and differences in the measurement tools. American Diabetes Association (ADA) recommends that physical activity performance five days/week that lasts for 30 minutes [30]. In this study, only half of the respondents self-reported as they perform regular physical activity which is inconsistent with the recommendation of ADA. Under performance of physical activity perhaps a lack of awareness about recommendations on physical activity and lack of infrastructures. ADA recommends diabetic patients should perform a comprehensive foot evaluation at least annually to identify risk factors for ulcers and amputations [31]. More than half of diabetic patients performed foot care. Foot care practice is less than the practice of community-dwelling Philippine diabetic patients [32], and adult patients attended Black lion hospital, Ethiopia [33]. On the other hand, foot examination and foot self-management were not consistent with recommendations of ADA [34]. This may be due to a variation in awareness creation, poor income, and increased age of the participants.

World Health Organization recommends the consumption of a healthy diet. A healthy diet includes consumption of fruit, vegetables, legumes, nuts, and whole grains; less than 10% of total energy intake from free sugars; 30% of total energy intake from fats and less than 5g of iodized salt [35]. American diabetes food pyramid recommends bread, rice, pasta, and rice as the first food menu, followed by vegetables and fruits [36]. The majority of the participants were not using the food menu which is inconsistent with the recommendations of WHO and ADA [35, 36]. The result of this study is unlike the results of the studies from Northwest Ethiopia [37], and Harar, Eastern Ethiopia [20]. Inconsistency on food menu may related with a level of awareness, the purpose of using food menu, absence of diabetes food education, and difference in data collection tools. This implies the participants had no awareness about food menu.

The vast majority of diabetic patients (74.1%) had diabetes mellitus-related manifestations and complications. More than half of the participants had diabetes-related shock and diabetic ketoacidosis. The prevalence of DM-related complications was higher than the results of the study conducted at Jimma University teaching hospital [21]. Nerve diseases were reported by one-third of the study participants which was slightly higher than the study done in Jimma, Ethiopia. However, the reported DM-related eye problems were more prevalent than the result of the study conducted in Jimma university referral hospital [21]. High prevalence of eye problems may be be due to the public awareness about diabetes-related complication and lack of consistent health education. This implies that diabetes self-monitoring of blood glucose was poor in the participants of this study.

Being female, living in urban, married, rich, merchant and having family support were associated with self-management practice. Occupation and family support were tended to be the predictors of self-management. The finding of this study shares a similarity with that of studies done in Iran and Malaysia [26, 27] Family support was reported to increase adherence to self-management. Increase in self-management practice is comparable with the finding of the systematic review and meta-analysis which reported the social support significantly improved self-management [38]. However, these factors were inconsistent with factors reported by Amente, Belachew [19], Kaehaban, Hongsranagon [24] and Formosa and Muscat [39] from Ethiopia, Thailand, and Malta, respectively. This variation may be demonstrated due to day to day changes in diabetes education that increases awareness and culture variation.

The present study has some strengths. First, the response rate was high. Second, it tried to find out the predictors of self-management practice using appropriate data analysis methods. Limitations of the study were using unstandardized and validated tools.

Conclusions

Compared to the findings of previous studies, the diabetes self-management practice of the participants of this study was good. The study participants’ regular physical activity, food intake, medication adherence, and foot self-examination was moderate. Being a merchant and having family support were found to be the predictors of self-management practice. Randomized controlled trials involving the participants is needed to proof. Predictors of self-management should be considered to boost self-management practice.

Supporting information

S1 File. Study questionnaire English version.

(PDF)

Click here for additional data file. (440.9KB, pdf)
S2 File. Study questionnaire Afaan Oromoo version.

(PDF)

Click here for additional data file. (639.6KB, pdf)
S1 Dataset

(SAV)

Click here for additional data file. (235.7KB, sav)

Acknowledgments

Our gratitude goes to the study facility administrators, service providers and participants for their collaboration and information. The authors would also like to thank colleagues who contributed their valuable suggestions throughout this research work.

Abbreviations

ADA

American Diabetes Association

AOR

Adjusted Odds Ratio

CDC

Centre for Disease Control

CI

Confidence Interval

DKA

Diabetes Ketoacidosis

DM

Diabetes Mellitus

IDF

International Diabetes Federation

OR

Odds Ratio

SBGM

Self-monitoring of Blood Glucose

SPSS

Statistical Package for the Social Sciences

WHO

World Health Organization

Data Availability

All relevant data are within the manuscript and its Supporting Information files.

Funding Statement

Authors DCD TTB, and FTB received funding from Wollega University (https://www.wollegauniversity.edu.et/). Grant Number: WU: 109,161/Research1-26. The funder had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.

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Decision Letter 0

Solomon Assefa Woreta

31 Oct 2019

PONE-D-19-26947

Predictors of self-management practice among diabetic patients attending western Oromia hospitals, Ethiopia

PLOS ONE

Dear Dereje Chala Diriba

Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process.

==============================

The topic appears to be the most studied in most part of Ethiopia including Oromia region.

Abstract:

The methods are very short sighted to provide proper information. The result looks fragmented. The conclusion drawn not based on the finding?

Introduction:

This section included literature review from different part of the world including Ethiopia. I found this necessary to make a strong argument in the discussion section. However, the write up looks very inconsistent and juggling from the beginning to the end. You should follow introduction writing guide line. Since, the topic is highly researched in various part of Ethiopia I recommend authors to incorporate as many literature from Ethiopia as possible.

Methods:

I have noticed similar study had been conducted one year prior to this study in Nekemet, Western Oromia region. What is your rationale to Nekemete Hospital in this study?

How you operationally defined the study variables in this research? What is your dependent and independent variables?

How you developed the questionnaire? How you validate your questionnaire? Where you pretested the questionnaire?

Result:

The socio-demographic section seems to have included junk of information and redundancy. You must take account of socio-demographic variables than unrelated information. In general, the result section is full of in consist, in comprehensive and fragments of data. Most of the paragraph appears to have a copy and paste. I would recommend the authors to give appropriate time to evaluate the manuscript from the beginning to the end before submission to make sure the information built-in is clear and vivid information to understand.

Discussion:

As it has been said this topic is one of the most studied, hence the chance to get appropriate literature to make a strong argument on the finding is likely very high even in Ethiopia. However, the arguments are shallow, not based on evidence and weak. Why you cited literature which doesn’t have any similarity to the study setting, for instance America and others. This makes the discussion very shallow and inadequate.

What is the limitation of this study?

Conclusion:

How do you measure whether self-care is good or bad? There is no single statement in the methods section that clearly defined self-care and how it was measured. Overall, the conclusion not inferred from the analyzed result.

==============================

We would appreciate receiving your revised manuscript by Dec 06 2019 11:59PM. When you are ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file.

If you would like to make changes to your financial disclosure, please include your updated statement in your cover letter.

To enhance the reproducibility of your results, we recommend that if applicable you deposit your laboratory protocols in protocols.io, where a protocol can be assigned its own identifier (DOI) such that it can be cited independently in the future. For instructions see: http://journals.plos.org/plosone/s/submission-guidelines#loc-laboratory-protocols

Please include the following items when submitting your revised manuscript:

  • A rebuttal letter that responds to each point raised by the academic editor and reviewer(s). This letter should be uploaded as separate file and labeled 'Response to Reviewers'.

  • A marked-up copy of your manuscript that highlights changes made to the original version. This file should be uploaded as separate file and labeled 'Revised Manuscript with Track Changes'.

  • An unmarked version of your revised paper without tracked changes. This file should be uploaded as separate file and labeled 'Manuscript'.

Please note while forming your response, if your article is accepted, you may have the opportunity to make the peer review history publicly available. The record will include editor decision letters (with reviews) and your responses to reviewer comments. If eligible, we will contact you to opt in or out.

We look forward to receiving your revised manuscript.

Kind regards,

Solomon Assefa Woreta

Academic Editor

PLOS ONE

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Additional Editor Comments (if provided):

The topic appears to be the most studied in most part of Ethiopia including Oromia region.

Abstract:

The methods are very short sighted to provide proper information. The result looks fragmented. The conclusion drawn not based on the finding?

Introduction:

This section included literature review from different part of the world including Ethiopia. I found this necessary to make a strong argument in the discussion section. However, the write up looks very inconsistent and juggling from the beginning to the end. You should follow introduction writing guide line. Since, the topic is highly researched in various part of Ethiopia I recommend authors to incorporate as many literature from Ethiopia as possible.

Methods:

I have noticed similar study had been conducted one year prior to this study in Nekemet, Western Oromia region. What is your rationale to Nekemete Hospital in this study?

How you operationally defined the study variables in this research? What is your dependent and independent variables?

How you developed the questionnaire? How you validate your questionnaire? Where you pretested the questionnaire?

Result:

The socio-demographic section seems to have included junk of information and redundancy. You must take account of socio-demographic variables than unrelated information. In general, the result section is full of in consist, incomprehensive and fragments of data. Most of the paragraph appears to have a copy and paste. I would recommend the authors to give appropriate time to evaluate the manuscript from the beginning to the end before submission to make sure the information built-in is clear and vivid information to understand.

Discussion:

As it has been said this topic is one of the most studied, hence the chance to get appropriate literature to make a strong argument on the finding is likely very high even in Ethiopia. However, the arguments are shallow, not based on evidence and weak. Why you cited literature which doesn’t have any similarity to the study setting, for instance America and others. This makes the discussion very shallow and inadequate.

What is the limitation of this study?

Conclusion:

How do you measure whether self-care is good or bad? There is no single statement in the methods section that clearly defined self-care and how it was measured. Overall, the conclusion not inferred from the analyzed result.

[Note: HTML markup is below. Please do not edit.]

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #1: Partly

Reviewer #2: Yes

Reviewer #3: Partly

**********

2. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: Yes

Reviewer #2: No

Reviewer #3: Yes

**********

3. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #1: No

Reviewer #2: No

Reviewer #3: No

**********

4. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #1: No

Reviewer #2: No

Reviewer #3: No

**********

5. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: This is a study on self-management practice among diabetes patients in Ethiopian hospital setting. The authors do a great job in providing the big picture of diabetes in Ethiopian context and identifying those predictors of self-management practice. They followed a rigor procedure in their study design, analysis and reporting. This study adds a valuable information in the management of diabetes in western Oromia hospitals by providing some predictors for self-management practice.

This study has several issues that need to be addressed before being considered for publication.

• The introduction is well written but does not inform the reader about the importance of measuring the self-management practice among diabetes patient. Why we should seek to measure the self-management practice of diabetes among other chronic illness should be explained.

• What self-management is not described to a reader in the introductory section, rather the definition happened in a latter section of the manuscript (at the beginning of the discussion). This is not good without introducing the concept at the beginning but presenting the result and defining the term in the discussion.

• As the authors reviewed there are several studies conducted in Ethiopia (Harar, Nekemte, Addis Ababa). Therefore, why they are interested to do same topic in Ethiopia at western Oromia is not clear. The justification made as to why this study is conducted is not very convincing. For instance, 45% of participants at Nekemte referral hospitals had poor diabetes self-management though 54.3% of them had diabetic related knowledge, it worth doing a study why such level of practice with higher level of knowledge and what are the factors for such low self-care practice using other study design such as case-control than repeating same study in same place.

• The last section of introduction mentioned the absence of diabetic self-management education program in the country. However, the relevance of mentioning this concept in this section is not explained. The authors know this idea in advance and makes them even to forward a recommendation on establishing the education center. The claims are not placed properly in the context of the previous literature. Generally, the introduction should be re-written signifying the importance of doing this study in the light of “effective patient self-management is necessary to prevent adverse health outcomes of diabetes” among diabetes patients in lower-middle income countries including Ethiopia.

Reviewer #2: Abstract:

• Under method section number of study participants needs to be included

• Under result number of those who have either good or poor self care management needs to be indicated.

• The conclusion should be in line with the pertinent finding described under abstract

• Recommendation is not in line with conclusion.

Introduction

• Definition of self care management needs to be included.

• References needs to be in logical order.

Methods

The study setting is not well described.

Tools used to assess self care management was not clearly indicated.

Analysis method for self care management is not indicated.

Under ethical clearance future tense was used.

Result

• Standard deviation of mean age should be reported in plus or minus, not only plus

• Under table 1 you put asterisk on the other category of religion, but not define it below the table as footnote.

• Eye problems which is considered as one complication of DM is indicated by two different numbers.

• Rather than including other information better narration follows similar table.

• There is redundancy of narration about patients believe of diabetic treatment before and after table 2

• Under statements which is written above the title “predictors of self management” under result section, there is a statement which says figure 2, but there is no figure in the document.

• Better you include all variable you consider for logistic regression to table 3 with their respective confidence interval and odds ratio rather than duplicating it under table 4

• How you found at the end two predictor variable using logistic regression is not clearly explained.

• Revise your interpretation of logistic regression especially your comparison of occupation.

• How self care management is measured?????????? And classified as good and poor under the title “level of self care practice” are not clearly indicated.

Discussion

Your discussion needs revision. Implications given by the researcher is not satisfactory.

Conclusion

The conclusion is not in line with that of the title of the study and there are repeated copying and pasting of what is already described under result section.

Reference

Some of the references listed are not utilized for preparation of the manuscript

Finally competing interest and list of abbreviations/acronyms are not included to the manuscript

Reviewer #3: The authors tried to make allignment between title, objective, results and conclussion . However the manuscript need further revision and modification particularly the reporting format and language used during reporting.

**********

6. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files.

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Reviewer #1: No

Reviewer #2: No

Reviewer #3: Yes: Markos Desalegn Beyene

[NOTE: If reviewer comments were submitted as an attachment file, they will be attached to this email and accessible via the submission site. Please log into your account, locate the manuscript record, and check for the action link "View Attachments". If this link does not appear, there are no attachment files to be viewed.]

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Attachment

Submitted filename: reviewer comments on predictors of self managment among diabetic patient.docx

Click here for additional data file. (14.1KB, docx)
Attachment

Submitted filename: Manuscript review feed back dm.docx

Click here for additional data file. (15.5KB, docx)
PLoS One. 2020 May 1;15(5):e0232524. doi: 10.1371/journal.pone.0232524.r002

Author response to Decision Letter 0

24 Dec 2019

We really appreciate the genuine comments of the editors and reviewers. For the comments given by reviewers and editor, we reacted and corrected promptly. We are ready to correct if any further comments provided. The point by point response to reviewers commented was uploaded.

Attachment

Submitted filename: Responses to Reviewers comment.docx

Click here for additional data file. (16.7KB, docx)

Decision Letter 1

Solomon Assefa Woreta

5 Feb 2020

PONE-D-19-26947R1

Predictors of self-management practices among diabetic patients attending hospitals in western Oromia, Ethiopia.

PLOS ONE

Dear Dr. Dereje Chala,

Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process.

==============================

I gain would like to applaud for putting together the effort to make the necessary improvement on the manuscript. Most of the comments and feedback that have been given by reviewers appears to be corrected and incorporated accordingly, but there are few issues need to be addressed in order to proceed to the next step. For instance, the definition used to describe knowledge has a preconceived notion. Did you evaluate knowledge based on individual question mean or the summation mean of the knowledge questions? Secondly, the argument used to discuss the finding seems to be so frail and not enough to provide vivid clarification. In general, this section needs to have literary supported evidence with clear reference or citation for your argument. For example, the first paragraph in the discussion section has compared and contrasted other studies with your current, but the statement used to ornate the argument read as “This could be related to change to diabetic education in different ways. Thus, sustainable scheduled diabetic education is very crucial to increase self-management practice.” Where did you get this information? Is this information research driven or based on the predetermined knowledge? Hence, all the argument you might reach need to have study based explanation or argument. Make sure you make the necessary changes in this section to eliminate the inconsistency.

==============================

We would appreciate receiving your revised manuscript by Mar 21 2020 11:59PM. When you are ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file.

If you would like to make changes to your financial disclosure, please include your updated statement in your cover letter.

To enhance the reproducibility of your results, we recommend that if applicable you deposit your laboratory protocols in protocols.io, where a protocol can be assigned its own identifier (DOI) such that it can be cited independently in the future. For instructions see: http://journals.plos.org/plosone/s/submission-guidelines#loc-laboratory-protocols

Please include the following items when submitting your revised manuscript:

  • A rebuttal letter that responds to each point raised by the academic editor and reviewer(s). This letter should be uploaded as separate file and labeled 'Response to Reviewers'.

  • A marked-up copy of your manuscript that highlights changes made to the original version. This file should be uploaded as separate file and labeled 'Revised Manuscript with Track Changes'.

  • An unmarked version of your revised paper without tracked changes. This file should be uploaded as separate file and labeled 'Manuscript'.

Please note while forming your response, if your article is accepted, you may have the opportunity to make the peer review history publicly available. The record will include editor decision letters (with reviews) and your responses to reviewer comments. If eligible, we will contact you to opt in or out.

We look forward to receiving your revised manuscript.

Kind regards,

Solomon Assefa Woreta

Academic Editor

PLOS ONE

Additional Editor Comments (if provided):

I gain would like to applaud for putting together the effort to make the necessary improvement on the manuscript. Most of the comments and feedback that have been given by reviewers appears to be corrected and incorporated accordingly, but there are few issues need to be addressed in order to proceed to the next step. For instance, the definition used to describe knowledge has a preconceived notion. Did you evaluate knowledge based on individual question mean or the summation mean of the knowledge questions? Secondly, the argument used to discuss the finding seems to be so frail and not enough to provide vivid clarification. In general, this section needs to have literary supported evidence with clear reference or citation for your argument. For example, the first paragraph in the discussion section has compared and contrasted other studies with your current, but the statement used to ornate the argument read as “This could be related to change to diabetic education in different ways. Thus, sustainable scheduled diabetic education is very crucial to increase self-management practice.” Where did you get this information? Is this information research driven or based on the predetermined knowledge? Hence, all the argument you might reach need to have study based explanation or argument. Make sure you make the necessary changes in this section to eliminate the inconsistency.

[NOTE: If reviewer comments were submitted as an attachment file, they will be attached to this email and accessible via the submission site. Please log into your account, locate the manuscript record, and check for the action link "View Attachments". If this link does not appear, there are no attachment files to be viewed.]

While revising your submission, please upload your figure files to the Preflight Analysis and Conversion Engine (PACE) digital diagnostic tool, https://pacev2.apexcovantage.com/. PACE helps ensure that figures meet PLOS requirements. To use PACE, you must first register as a user. Registration is free. Then, login and navigate to the UPLOAD tab, where you will find detailed instructions on how to use the tool. If you encounter any issues or have any questions when using PACE, please email us at figures@plos.org. Please note that Supporting Information files do not need this step.

PLoS One. 2020 May 1;15(5):e0232524. doi: 10.1371/journal.pone.0232524.r004

Author response to Decision Letter 1

11 Mar 2020

Question 1: Did you evaluate knowledge based on individual question mean or the summation mean of the knowledge questions?

Response: Thank you for thorough evaluation and observation. We didn’t evaluate the diabetes knowledge score; however, we reported the general knowledge about diabetes management. Thus, we have removed from operational definition part.

Question 2. Secondly, the argument used to discuss the finding seems to be so frail and not enough to provide vivid clarification. In general, this section needs to have literary supported evidence with clear reference or citation for your argument.

Response: Thank you for your comment. We noted that our discussion is weak, thus we made modifications with implications of the results. We also cited the literature we have used.

Attachment

Submitted filename: Response to Reviewers last.docx

Click here for additional data file. (13KB, docx)

Decision Letter 2

Wen-Jun Tu

17 Apr 2020

Predictors of self-management practices among diabetic patients attending hospitals in western Oromia, Ethiopia.

PONE-D-19-26947R2

Dear Dr. Diriba,

We are pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it complies with all outstanding technical requirements.

Within one week, you will receive an e-mail containing information on the amendments required prior to publication. When all required modifications have been addressed, you will receive a formal acceptance letter and your manuscript will proceed to our production department and be scheduled for publication.

Shortly after the formal acceptance letter is sent, an invoice for payment will follow. To ensure an efficient production and billing process, please log into Editorial Manager at https://www.editorialmanager.com/pone/, click the "Update My Information" link at the top of the page, and update your user information. If you have any billing related questions, please contact our Author Billing department directly at authorbilling@plos.org.

If your institution or institutions have a press office, please notify them about your upcoming paper to enable them to help maximize its impact. If they will be preparing press materials for this manuscript, you must inform our press team as soon as possible and no later than 48 hours after receiving the formal acceptance. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information, please contact onepress@plos.org.

With kind regards,

Wen-Jun Tu

Academic Editor

PLOS ONE

Additional Editor Comments (optional):

Reviewers' comments:

Acceptance letter

Wen-Jun Tu

22 Apr 2020

PONE-D-19-26947R2

Predictors of self-management practices among diabetic patients attending hospitals in western Oromia, Ethiopia.

Dear Dr. Diriba:

I am pleased to inform you that your manuscript has been deemed suitable for publication in PLOS ONE. Congratulations! Your manuscript is now with our production department.

If your institution or institutions have a press office, please notify them about your upcoming paper at this point, to enable them to help maximize its impact. If they will be preparing press materials for this manuscript, please inform our press team within the next 48 hours. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information please contact onepress@plos.org.

For any other questions or concerns, please email plosone@plos.org.

Thank you for submitting your work to PLOS ONE.

With kind regards,

PLOS ONE Editorial Office Staff

on behalf of

Dr. Wen-Jun Tu

Academic Editor

PLOS ONE

Associated Data

    This section collects any data citations, data availability statements, or supplementary materials included in this article.

    Supplementary Materials

    S1 File. Study questionnaire English version.

    (PDF)

    Click here for additional data file. (440.9KB, pdf)
    S2 File. Study questionnaire Afaan Oromoo version.

    (PDF)

    Click here for additional data file. (639.6KB, pdf)
    S1 Dataset

    (SAV)

    Click here for additional data file. (235.7KB, sav)
    Attachment

    Submitted filename: reviewer comments on predictors of self managment among diabetic patient.docx

    Click here for additional data file. (14.1KB, docx)
    Attachment

    Submitted filename: Manuscript review feed back dm.docx

    Click here for additional data file. (15.5KB, docx)
    Attachment

    Submitted filename: Responses to Reviewers comment.docx

    Click here for additional data file. (16.7KB, docx)
    Attachment

    Submitted filename: Response to Reviewers last.docx

    Click here for additional data file. (13KB, docx)

    Data Availability Statement

    All relevant data are within the manuscript and its Supporting Information files.

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