Abstract
Purpose
The main goal of managing diabetes is to achieve glycemic control. However, the glycemic level of most diabetic patients is shown to be poorly controlled mainly due to poor adherence to self-care practices. This study aims to assess the level of self-care practice and glycemic control among type 2 diabetes patients on follow up in a resource limited country.
Methods
A four-month prospective observational study was conducted among type 2 diabetes patients from February 1 to May 30, 2021. Data was collected using a data abstraction checklist and structured questionnaire. The data was entered into Epidata version 4.4.6 and analyzed with SPSS version 26. Glycemic control and its predictors were determined using binary logistic regression. P-value less than 0.05 was considered as statistically significant.
Results
A total of 138 patients were included in the study. Nearly three-fourths (74.6%) of patients had poor glycemic control and the majority of patients had poor self-care practice. 78.3%, 98.6%, 96.4%, and 55.8% of patients had poor adherence to diet, exercise, self-monitoring of blood glucose, and medications respectively. Importantly, 85(79%), 102(75%), 99(74.4%), and 65(84.4%) patients with poor adherence to diet, physical activity, self-monitoring of blood glucose, and antidiabetic medications had poor glycemic control. On multivariate logistic regression, BMI (AOR 4.1, CI:1.20–14.11, p = 0.024) and drug adherence (AOR 3.08, CI:1.22–7.08, p = 0.017) were factors associated with poor glycemic control.
Conclusions
A higher proportion of patients had low-level of self-care practice and poor glycemic control. This highlights the need to improve patients’ awareness about the importance of self-care practice to maintain good glycemic control and prevent adverse outcomes associated with the disease.
Supplementary Information
The online version contains supplementary material available at 10.1007/s40200-022-00995-4.
Keywords: Diabetic self-care, Glycemic control, Type 2 diabetes, Ethiopia
Background
Diabetes is a major chronic global public health problem associated with mortality and morbidity. The global diabetes prevalence is estimated to be 9.3% in 2019, rising to 10.2% by 2030 [1]. There are four types of diabetes; type 1 diabetes, type 2 diabetes, gestational diabetes, and Specific types of diabetes due to other causes. Type 2 diabetes accounts for 90–95% of all diabetes [2].
The prevalence of type 2 diabetes is increasing across all regions of the world and is expected to be higher in low to middle-income countries due to aging populations, increasing urbanization, reduced physical activity, and unhealthy lifestyle and behavioral patterns [1, 3]. Type 2 diabetes is associated with increased morbidity and mortality. More than one million deaths were attributed to this condition in 2017 alone, ranking it as the ninth leading cause of mortality [4].
The majority of patients fail to achieve good glycemic control levels, the main goal of treatment for all diabetes patients to prevent adverse outcomes. The reasons for poor glycemic control are complex and multi-factorial [5, 6].
In Ethiopia, the blood glucose level of most diabetic patients is shown to be ineffectively controlled. A systemic review and meta-analysis on glycemic control and associated factors among diabetic patients in Ethiopia showed that; the prevalence of poor glycemic control is 65.6%. Residence, dyslipidemia, and diet adherence were associated with poor glycemic control among diabetic patients [7]. Other studies done in Shanan Gibe, Dessie, and Gonder hospitals showed that 59.2%, 70.8%, and 64.7% of diabetic patients had poor glycemic control respectively. Poor adherence to diet and antidiabetic medications, level of education, and duration of diabetic treatment were shown to be associated with poor glycemic control [8, 9, 10].
Most patients with diabetes can avoid the risk of developing complications by improving self–care activities in terms of adherence to diet, medications, physical activity, and blood glucose monitoring. Self-care practices are vital for diabetes management. Therefore, self-care activities should be monitored regularly, especially for patients at risk of poor glycemic control [11, 12, 13]. Little is known about diabetic self-care practice and glycemic control of type 2 diabetes patients in the study area. Therefore, this study aimed to assess diabetic self-care practice and glycemic control status of type 2 diabetes patients on follow-up at Gebre Tsadik Shewa General Hospital, Southwest Ethiopia.
Methods and materials
A hospital-based prospective observational study was conducted among type 2 diabetes patients on follow-up at the diabetic clinic of Gebre Tsadik Shewa General Hospital from February 1 to May 30, 2021. The hospital is found in Bonga Town, Kaffa zone, Southwest Ethiopia. The hospital provides both in-patient and outpatient services. All adult type 2 diabetes patients who fulfill the inclusion criteria were recruited consecutively to the study. All type 2 diabetes patients on follow-up and age greater than 18 years, and patients who consented to participate were included in the study. Patients with type 1 diabetes and patients who were not willing to participate were excluded from the study.
Data collection, procedure, and analysis
Data abstraction checklist and structured questionnaire were developed from a review of literature [14, 15]. A structured questionnaire was used to collect sociodemographic characteristics, self-care practice and behaviors (smoking, alcohol consumption, medication adherence, self-monitoring of blood glucose, adherence to diet, and physical activity). The Summary Diabetes Self-Care Activities (SDSCA) questionnaire was used to assess details about self-care practice of patients [16]. Data abstraction format was used to collect the current medication regimen, the number of medications, laboratory and clinical data (comorbidities, duration of diabetes, complication) from patients’ medical records. The data collection tool was pretested on 7 (5%) of patients at Mizan-Tepi university teaching hospital to check its consistency and clarity before the actual data collection. Epi data version 4.4.6 was used to enter, encode and clear data. Then the data was exported to SPSS version 26 for analysis. Descriptive statistics, such as frequency, proportion, mean, and standard deviation was used to summarize patients’ baseline and clinical characteristics. Binary logistic regression analysis was used to determine factors associated with poor glycemic control. Statistical significance was considered at a p-value <0.05.
Outcome measurement
The primary outcome variables were the level of diabetic self-care practice and status of glycemic control. The average of three fasting blood glucose measurements was used to determine the patient’s glycemic control status.
Definition of terms
Glycemic control was assessed by using fasting blood glucose (FBG) levels. Good glycemic control was defined as the three-month average fasting blood glucose 80–130 mg/dl and poor glycemic control is defined as the three-month average fasting blood glucose>130 mg/dl according to the American diabetic association (ADA) [2]. Knowledge of optimum blood glucose level: Patients’ understanding of optimal or target blood glucose level. Adherence to diet: Patients who reported an average of 4–7 days of information to the questions on diet were classified as having good dietary practice; those reporting less than four days were classified as having poor dietary practice. Adherence to physical activity: Patients who reported at least 30–60 min of moderate aerobic activity per day or ≥3 days per week. Medication adherence: Patients who took all the prescribed antidiabetic medications during the last 7 days were considered adherent. Self-monitoring of blood glucose (SMBG): Patients who performed SMBG at their respective homes for greater than 3 days in the last 7 days were considered adherent to blood glucose measurement. Co-morbidity: Chronic illnesses that coexisted in patients with type 2 diabetes. Polypharmacy was defined as the use of greater than five medications [17, 18].
Result
Sociodemographic and clinical characteristics of participants
The study included a total of 138 type 2 diabetes patients over four months. More than half, 82(59.4%), of patients were males and 72(52.2%) were in the age 60 years and above. The mean age of patients was 49.35± 11.58 years, range from 30 to 81 years. More than a third, 51(36.9%) were illiterate. The mean (± SD) BMI of patients was 26.24± 3.22. Fifty (36.2%) patients were overweight and 30(21.7%) patients had obesity. The mean (±SD) duration of diabetes was 6.21 ± 4.34 years. Seventy-four (53.6%) patients had a diabetic duration of less than five years. More than half of patients 78(56.5%) reported a history of alcohol consumption and 2(1.4%) reported a history of smoking. Twenty (14.5%) patients had diabetic-related complications. The most common complications were neuropathy,10(7.24%) followed by nephropathy 4(2.89%), retinopathy 2(1.44%), and neuropathy plus nephropathy 4(2.89%). The majority of patients, 83(60.15%) had at least one comorbidity. Hypertension, 43(31.1%), and heart failure, 21(15.2%) were the most common comorbidities (Table 1).
Table 1.
Sociodemographic and clinical characteristics of type 2 diabetes patients
| Variables | Category | Frequency | Percent (%) |
|---|---|---|---|
| Sex | Male | 82 | 59.4 |
| Female | 56 | 40.6 | |
| Age | <60 | 66 | 47.8 |
| ≥60 | 72 | 52.2 | |
| Level of educational | Illiterate | 51 | 36.9 |
| Primary education | 22 | 15.9 | |
| Secondary education | 35 | 25.4 | |
| College and above | 30 | 21.7 | |
| Alcohol consumption | Yes | 78 | 56.5 |
| No | 60 | 43.5 | |
| Cigarette smoking | Never smoke | 126 | 91.3 |
| Previous smoker | 10 | 7.3 | |
| Current smoker | 2 | 1.4 | |
| Duration of diabetes | ≥10 years | 24 | 17.4 |
| 5–10 years | 40 | 29 | |
| <5 years | 74 | 53.6 | |
| Diabetic complication | Yes | 20 | 14.5 |
| No | 118 | 85.5 | |
| BMI (Kg/m2) | Healthy weight (18–24) | 58 | 42 |
| Overweight (25–29.9) | 50 | 36.2 | |
| Obese (≥30) | 30 | 21.7 | |
| Presence of Comorbidities | Yes | 83 | 60.15 |
| No | 55 | 39.85 | |
| Type of comorbidities | Hypertension | 43 | 31.1 |
| Heart failure | 21 | 15.2 | |
| Hypertension +Heart failure | 11 | 7.9 | |
| Others | 8 | 5.8 |
*Others -CKD=3, IHD=3, dyslipidemia=2
Self-care practice and glycemic control of type 2 diabetes patients
Self-care practice and glycemic control status of type 2 diabetes patients is shown in Table 2. Only 30 (21.7%) of the respondents adhered to their general diet recommendations. Almost all patients (98.6%) were not doing adequate physical exercise performed at least 30-60 min per day or ≥3 days per week during the 7 days preceding the study period. The majority,133 (96.4%), of respondents were not testing their blood glucose level. Seventy-seven (55.8%) respondents were not taking their medication as recommended by their physician. Seventy-one (51.4.0%) of the respondents do not know the optimum blood glucose level for diabetes management. Regarding self-care practice and status of glycemic control, eighty-five (79%) patients with poor diet adherence, 102(75%) patients with inadequate physical activity, 99(74.4%) patients with non-adherence to self-monitoring of blood glucose (SMBG), and 65(84.4%) patients with drug non-adherence had poor level of glycemic control.
Table 2.
Self-care practice and glycemic control of type 2 diabetes patients
| Variables | Category | Glycemic control status | Total n (%) |
|
|---|---|---|---|---|
| Poor | Good | |||
| Diet adherence | Good | 18 | 12 | 30(21.7) |
| Poor | 85 | 23 | 108(78.3) | |
| Physical activity | Adequate | 1 | 1 | 2(1.4%) |
| In adequate | 102 | 34 | 136(98.6%) | |
| Adherence to SMBG | Yes | 4 | 1 | 5(3.6%) |
| No | 99 | 34 | 133(96.4%) | |
| Drug adherence | Yes | 38 | 23 | 61(44.2%) |
| No | 65 | 12 | 77(55.8%) | |
| Knowledge of optimal blood sugar | Yes | 59 | 12 | 71(51.4%) |
| No | 44 | 23 | 67(48.6%) | |
Abbreviations SMBG, Self-monitoring of blood glucose
Medication use pattern among type 2 diabetes patients
Out of the 138 patients, oral antidiabetes medications were prescribed to 102(74%) of patients, 60(43.5%) were on metformin and glibenclamide, and 42(30.4%) respondents were taking metformin only. Twenty-two (16%) patients were taking metformin and insulin. Enalapril,34(56%) and Enalapril + HCT,13(21.7%) were most common prescribed concomitant medications. Twenty-six (18.8%) patients were prescribed polypharmacy. Statin and aspirin therapy were initiated for 2.2% and 5.6% of participants, respectively (Table 3).
Table 3.
Medication use pattern among type 2 diabetic patients
| Variables | Category | Frequency | Percent (%) |
|---|---|---|---|
| Antidiabetic medications | |||
| Insulin alone | Yes | 14 | 10 |
| No | 124 | 89.9 | |
| Metformin alone | Yes | 42 | 30.4 |
| No | 96 | 69.6 | |
| Insulin + metformin | Yes | 22 | 16 |
| No | 116 | 84.1 | |
| Metformin + glibenclamide | Yes | 60 | 43.5 |
| No | 78 | 56.5 | |
| Concomitant medication | Yes | 60 | 43.5 |
| No | 78 | 56.5 | |
| Type of concomitant medication | Enalapril | 34 | 56.6 |
| Enalapril + HCT | 13 | 21.7 | |
| Enalapril + Atenolol | 6 | 10 | |
| Others* | 7 | 11.7 | |
| Polypharmacy | Yes | 26 | 18.8 |
| No | 112 | 81.2 | |
| Aspirin therapy | Yes | 5 | 3.6 |
| No | 133 | 96.4 | |
| Statin therapy | Yes | 3 | 2.2 |
| No | 135 | 97.8 |
Note: *Others-Amlodipine = 4, Metoprolol = 3, HCT-Hydrochlorothiazide
Glycemic control and its associated factors
The mean (±SD) baseline FBS level was 191.44±62.22 mg/dl and the mean (± SD) of three months average FBS was 181.64± 54.42 mg/dl. The average three-month FBS measurement revealed that only 35(25.4%) patients had good glycemic control. The majority of patients, 103(74.6%) had poor glycemic control. The rate of glycemic control was 25.4%. On multivariate logistic regression, BMI (AOR 4.1, CI:1.20–14.11, p = 0.024) and drug adherence (AOR3.08, CI:1.22–7.08, p = 0.017) were factors associated with poor glycemic control (Table 4).
Table 4.
Factors associated with poor glycemic control among type 2 diabetic patients
| Univariate logistic regression | Multivariate logistic regression | ||||
|---|---|---|---|---|---|
| Variables | Category | OR (95%CI) | P-value | AOR (95%CI) | P-value |
| Age in years | ≥60 | 2.5) 1.11–5.63( | 0 0.027 | 0.4(0.16–1.008) | 0.052 |
| <60 | 1 | 1 | |||
| Duration of DM in years | ≥10 | 2.06) 1.07–5.42( | 0.14 | 2.6(0.85–8.23) | 0.09 |
| 5–10 | 0.51) 0.18–1.40( | 0 0.194 | 0.5(0.17–1.53) | 0.231 | |
| <5 | 1 | 1 | |||
| BMI | ≥30 | 3.06)1.003–9.36( | 0.049 | 4.1(1.20–14.11) | 0.024* |
| 25–29 | 1.170 ) 0.36–3.74( | 0.79 | 1.7(0.49–6.32) | 0.381 | |
| 18–24 | 1 | 1 | |||
| Drug adherence | Yes | 1 | 1 | ||
| No | 2.45)1.07–5.61( | 0.034 | 3.08(1.22–7.08) | 0.017* | |
| Knowledge of optimal blood sugar | Yes | 1 | 1 | ||
| No | 2.57) 1.15–5.71( | 0.021 | 0.4(0.17–1.01) | 0.054 | |
Note: *Statistically significance
Abbreviations: BMI, Body mass index, DM, Diabetes Mellitus
Discussion
Diabetes mellitus remained a major public health concern, especially in developing countries. To prevent serious adverse outcomes associated with the disease, patients are required to adhere to diabetic self-care practice, the mainstay of management to maintain good glycemic control. Good self-care management focusing on diet, medication, regular exercise, and self-monitoring of blood glucose is important to maintain optimum blood glucose level and prevent complications results from hyperglycemia. However, poor adherence to self-care practices persists as the main problem of most diabetic patients [19, 20].
In our study; regarding self-care practice, 78.3%, 98.6%, 96.4% of participants had poor adherence to diet, exercise, self-monitoring of blood glucose respectively. Patients’ non-adherence to diet, exercise, and SMBG in our study is higher than findings reported from other studies done in Ethiopia, where the level of non-adherence to diet, exercise, and SMBG were 75.9%, 53.7%, and 83.5% in Addis Ababa and 58.8%, 60.9%, and 59% in Metu respectively [17, 18]. The variation with these studies might be due to differences in the educational status of participants, lack of educational sessions for diabetic patients, and lack of glucometer for self-monitoring of blood glucose in most diabetic patients. Knowledge of diabetes and its disease process, having a glucometer at home, and a high level of education are shown to be positively associated with proper self-care practice and glycemic control of patients [21]. The level of non-adherence to exercise and diet is also higher than results reported from a study done in Nepal, where only 32.4% and 10.1% of participants were shown to have inadequate practice towards exercise and dietary recommendations [19]. In our study, we found that 55.8% of participants didn’t adhere to their anti-diabetic medications. The magnitude of non-adherence to antidiabetic medications in our study is higher than 4.3% reported from a study done in Addis Ababa [18], 8.2% Dire Dawa [21], 39% Tigray region [22], and 54.4% Cameroon [23]. The variation with these studies might be due to the absence of counseling on medication adherence and diabetic educational session. In comparison to this finding, previous studies in Ethiopia showed a high self-reported non-adherence rate, 58.8% southwest Ethiopia [17] and 63.9% Northern Ethiopia [24]. The discrepancy with these studies could be attributed to the difference in sample size and study design (single-center vs. multicenter). In general; regarding self-care practice and glycemic control status, 79%, 75%, 74.4%, and 84.4% of patients with poor adherence to diet, physical activity, SMBG, and prescribed medications respectively, had poor glycemic control.
In our study, we found that nearly three-fourths (74.6%) of patients had poor glycemic control. This proportion is higher than findings from previous studies done in Ethiopia, 64.9% western Ethiopia [6], 68.3% Addis Ababa [25], 59.2% Shanan Gibe [8], and 64.7% Gonder [9]. The result is also higher than results reported from other studies, 69.7% reported from Tanzania(26) and 60.8% reported from Jordan [27]. The reason might be due to the presence of poor adherence to the components (diet, physical activity, SMBG, medications) of self-care practice in our study compared to these studies. Therefore, strategies should be developed to improve the self-care practice of patients. The result is comparable with 72.7% report from a study done in Southwest Ethiopia [17] and 74.9% from a study done in Saudi Arabia [28]. However, this finding is lower than that found from another study in Ethiopia, reported as 81.7% Jimma [29] and 84.3% Uganda [30]. The variation might be due to differences in study design, sample size, and type of diabetic patients included (type 2 only vs. both type 1 and type 2), type of treatment (insulin-treated vs. both insulin and oral antidiabetic medications) in these studies when compared with this study.
Poor adherence to antidiabetic medications is a major problem in the management of patients with diabetes. We found that patients who didn’t adhere to their antidiabetic medications had poor glycemic control(p<0.05) and patients with poor adherence to their medication had significantly high poor glycemic control status than patients with good adherence to medications. Many studies showed non-adherence to antidiabetic medications to be associated with poor glycemic control [26, 31, 32], and other adverse outcomes such as mortality, hospitalizations, complications, and increase in LDL levels [33, 34, 35]. Therefore, educational strategies should be developed and provided to patients with a focus on the impacts of the disease and the importance of adherence to their prescribed medications. Patients’ knowledge about diabetes and higher medication adherence are significant predictors of good glycemic control [36].
In our study, BMI was associated with poor glycemic control. Unlike healthy weight and overweight patients, obese patients had poorly controlled glycemic levels. Similarly, previous studies showed obesity to be associated with poor levels of glycemic control [25, 26, 29, 37]. The reason might be due to the patient’s poor self-care practice such as poor adherence to dietary recommendations and inadequate physical activity. Proper self-care management strategies focusing on diet and exercise should improve patients’ level of glycemic control. Moderate physical activity and adherence to dietary recommendations are shown to be associated with good glycemic control [22].
Conclusions
In conclusion, the findings of the study showed that nearly three-fourths of patients had poor glycemic control and the level of self-care practice was poor. The majority of patients did not adhere to recommended diet, physical activity, antidiabetic medications, and self-monitoring of blood glucose and most of them had poor glycemic control. On multivariate logistic regression drug non-adherence and BMI were found to have a statistically significant association with poor glycemic control. The study emphasized the need to improve awareness of type 2 diabetic patients with education on the importance of self-care practice and glycemic control. This may help to prevent adverse outcomes associated with the disease.
Electronic Supplementary Material
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Abbreviations
- ADA
American diabetic association
- BMI
Body mass index
- DM
Diabetic Mellitus
- FBS
Fasting blood sugar
- IDF
International Diabetic Federation
- WHO
World Health Organization
Author contributions
All authors made a significant contribution in the conception, study design, execution, acquisition of data, analysis, and interpretation of the study reported, drafting, and editing of the final manuscript. All authors read and approved the final manuscript. All authors agree to take responsibility and be accountable for the contents of the article.
Funding
Not applicable.
Code availability
Not applicable.
Declarations
Ethical consideration and consent to participate.
Letter of permission was obtained from the school of pharmacy (Reference number 038/2013), and official permission was obtained from the hospital clinical director before data collection begins. The patient’s written informed consent to participate in the study was obtained after a comprehensive explanation of the purpose of the study. Data collection was done anonymously by coding data collection formats using non-identifiable code. The study meets the ethical and scientific standards outlined in national and international guidelines.
Data sharing statement
The datasets used and analyzed during the current study are available from the corresponding author on reasonable request.
Consent for publication
Not applicable
Conflicts of interest/Competing interests
The authors report no competing interests in this work.
Footnotes
Publisher’s Note
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Contributor Information
Abinet Abebe, Email: abinetabebe.21@gmail.com.
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