Diabetes, Metabolic Syndrome and Obesity: Targets and Therapy Dovepress

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ORIGINAL RESEARCH

Diabetic Self-Care Knowledge and Associated

Factors Among Adult Diabetes Mellitus Patients on
Follow-Up Care at North Shewa Zone Government
Hospitals, Oromia Region, Ethiopia, 2020

Lidya Zerihun Sahile Background: Inadequate diabetes self-care knowledge leads to developing diabetic com­
Mengistu Benayew Shifraew plications and death. Diabetic complications are directly related to the patient’s level of
Mehiret Zerihun Sahile diabetic self-care knowledge.
Objective: The purpose of this study was to assess diabetic self-care knowledge and its
Department of Nursing, College of
Health Sciences, Salale University, Fitche, associated factors among adult diabetes mellitus patients on follow-up care at North Shewa
Ethiopia Zone government hospitals, Oromia Region, Ethiopia, 2020.
Methods: An institution-based cross-sectional study was employed using a consecutive
sampling technique from January 1 to February 30/2020 among 245 adult diabetes mellitus
patients on follow-up care at North Shewa Zone government Hospitals, Oromia Region,
Ethiopia. We used Epi data version 3.1 to enter the data and SPSS version 25 for analysis.
Both bivariable and multivariable logistic regression was used to identify significant factors
for knowledge of diabetic self-care.
Results: In this study, from a total of 245 diabetic patients, 230 participated giving a
response rate of 93.87%. More than half of the study respondents, 156 (67.8%), had good
diabetes self-care knowledge and variables such as being employed (AOR; 0.146, 95%; CI
0.18–0.94), having information on diabetic self-care (AOR; 3.003, 95% CI 1.24–5.3) and
urban residency (AOR; 0.27, 955 CI 0.099–0.532) were found to be independent factors
affecting diabetic self-care knowledge.
Conclusion: The magnitude of diabetes self-care knowledge was not adequate and some
critical knowledge gaps were also identified in specific areas which reflect that there is a need
to improve diabetic self-care knowledge among patients by implementing adequately and
continuous diabetic self-care education programs.
Keywords: diabetic mellitus, patients, self-care, knowledge

Introduction
Diabetes mellitus (DM), which is described by an increased blood glucose level, is
a metabolic disorder of multiple etiologies resulting in disturbances of carbohy­
drate, fat, and protein metabolism due to dysfunction in insulin secretion, insulin
action, or both.1 This long-lasting high blood glucose level and the resultant
metabolic deregulations is associated with secondary damage in multiple organ
Correspondence: Mengistu Benayew systems, specifically the kidneys, eyes, nerves, and blood vessels.2 Furthermore,
Shifraew
Email [email protected] diabetes mellitus increases the risk of developing coronary artery and

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cerebrovascular disease.3 Worldwide, approximately Ethiopia. According to 2007 Central Statistics Agency
75–80% of people with diabetes die due to cardiovascular (CSA) report, the zone had a total population of
complications.4 Diabetes mellitus, especially, Type 2 DM 1,431,305. The zone has fourteen woreda, three town
is increasing much more rapidly because of increasing administrations, and four government hospitals, 268
obesity, reduced activity levels as countries become more kebeles, 64 health centers, and 272 health posts. There
industrialized, and the aging of the population.5 Diabetes are a total of 550 adult diabetic patients on follow-up
mellitus is a complex chronic illness demanding continu­ care at those four government hospitals.
ous medical and self-care.6 According to Orem’s defini­
tion, self-care is a personal activity to take care and Sample Size Determination
maintain one’s own health and prevention of disease- To determine the final sample size, single population pro­
related complications.7 portion formula was employed by taking an assumption of
Diabetes self-care, which includes activities such as 95% CI, 5% margin of error, and 58% prevalence of
healthful eating, regular physical activity, foot care, med­ diabetic self-care knowledge from a study done in Addis
ication adherence, and self-monitoring of blood glucose, is Ababa.15
very important to keep the disease under control.8,9 The
ðZα=2Þ2 Pð1 PÞ
American Diabetic Association underlined that diabetic n¼
d2
self-care is necessary to limit potential organ damage,
and it can reduce the likelihood of hospitalizations and Where, n= required sample size, Zα/2 is a critical value at
emergency visits.10 Patient knowledge concerning disease 95% CI (1.96), and at 5% margin of error (d = 0.05), and p
is the prevalence of self-care knowledge=58%.
and self-care practices for patients is important to achieve
2
the desired treatment targets and for the appropriate man­ Accordingly, n ¼ ð1:96Þ ð0:05Þ
0:58ð1
2
0:58Þ
¼ 374
agement of their disease.11 However, the source population is less than 10,000
Studies had highlighted that factors such as diabetes adjusted formulas were used.
knowledge, physical activities, social support, and self-
ni
efficacy can affect self-care practice.12,13 nf ¼
½1 þ ni=N�
In Ethiopia, Studies showed that the feature of self-care
practices towards diabetes mellitus was not adequate.12–14 Where
Another study conducted in Addis Ababa, Ethiopia on nf = final sample size, ni = initial sample size=374, and
diabetes self-care knowledge reflected that overall knowl­ N = the source population=550.
edge about diabetes self-care was not adequate; some 374
Accordingly, ¼ 1þ 374 ¼ 222
critical knowledge gaps were also identified in specific 550

areas and there is a need to improve diabetic self-care By adding 10% of the non-response rate, it gives a final
knowledge.15 Most studies are done on patients with type sample size of 245 diabetic patients.
2 diabetes and little is known about the factors associated
with knowledge of diabetic self-care with diabetes in Sampling Procedures
Ethiopia. Therefore, this study aimed to assess diabetic There are four hospitals and we include all of them in our
self-care knowledge and the associated factors to improve study. First, we identified the number of diabetic patients
self-care knowledge among diabetes patients attending of each hospital and then based on their numbers we
proportionally allocated the sample size.
North Shewa Zone Hospitals.

Sampling Technique
Methods To select the final sample size, we employed a consecutive
Study Area and Design sampling technique. Study participants were selected when
An institution-based cross-sectional study was conducted they came for follow-up care (Figure 1).
from January 1 to February 30/2020 among 245 adult
diabetic patients on follow-up care at North Showa Zone Source Population
government hospitals Oromia Region, Ethiopia. North All diabetes mellitus patients in North Showa Zone
Showa is one of the zones of Oromia regional states in Hospitals.

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Lists of hospitals

Fitche General Hospital, Kuyu General Hospital, Muke Turi Primary

Hospital, and Dera Primary Hospital.

Fitche General Kuyu General Muke Turi

Hospital Hospital Dera Primary
n=218 Hospital Primary
n=226
n=49 Hospital
n=57

Sample size was proportionally allocated for each hospital.

n=101 n=97 n=22 n=25

Consecutive sampling was employed to select study participants

nf=245

Figure 1 Sample flow chart.

Study Population ketoacidosis, who were mentally impaired, and cannot

All diabetes mellitus patients in North Showa Zone hospi­ hear.
tals during the study period.
Study Variables
Inclusion Criteria Dependent Variable
Diabetic self-care knowledge.
The study included all diabetes patients that are diagnosed
as having diabetes mellitus for at least 6 months.
Independent Variables
Demographic factors: Age, Sex, Ethnicity, Educational
Exclusion Criteria status, marital status, Occupation, Residence, Clinical
The study excludes those diabetes patients admitted due to and other related factors (duration of after diagnosis, dia­
severe acute complication like hypoglycemia, diabetic betic-related long term complication, type of

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complications, information about diabetic self-care, source Additionally, a pretest was conducted before actual data
of information). collection on 5% (12) of the samples in Chancho Hospital,
and any ambiguity, confusion, difficult words, and differ­
Operational Definition ences in understanding were revised and corrected.
Good Self-Care Knowledge
Refer to those study participants who answered more than Data Management and Analysis
or equal to 70% of knowledge questions correctly. On the Data were entered into Epi data version 3.1 and analyzed
contrary, those study participants who answered less than by SPSS version 25 statistical software. Descriptive statis­
70% of knowledge questions were poor Self-Care tics such as frequency and percentage have been presented
Knowledge.17 Exposure to diabetic health education: if a using tables and text. A binary logistic regression model
client has received health education about diabetes and was used to identify the potential predictor variables for
self-care, he is said to be exposed to diabetic health diabetics’ self-care knowledge. Variables with a p-value of
education. less than 0.2 in the binary logistic regression analysis were
Duration after diagnosis: it was the total period after entered into multivariable logistic regression analysis.
the client has been medically confirmed to be a diabetic Then Adjusted Odds Ratio (AOR) with 95% CI and
patient. p-value < 0.05 were used to identify factors significantly
associated with diabetics’ self-care knowledge.
Data Collection Tools
The structured and pre-tested interviewer-administered Ethical Approval Statement
questionnaires developed from previous studies was used An ethical clearance letter was obtained from the Ethical
to collect data.16,17 The tool has three parts: Part one is Review Committee of Salale University. Permission letter
Sociodemographic characteristics with six questions; Part was obtained from Oromia Health Bureau and each
two includes clinical and other related factors with 5 respective hospital. The study was conducted according
questions; and Part three is about diabetic self-care knowl­ to the Declaration of Helsinki. Participation in this study
edge with DSCKQ-30 item questions. The DSCKQ-30 was voluntary, and information was collected anon­
item questions was used to assess knowledge of diabetic ymously after obtaining written consent from each respon­
patients on modifiable lifestyle, adherence to diabetic self dent by assuring confidentiality throughout the data
care, and consequence of uncontrolled blood sugar level. collection period and explained the importance and pur­
The tool was validated with Cornbrash’s alpha of 0.967; pose of the study. Any potential identifiers were eliminated
the relevance of all items of the questionnaire was from the questionnaires to ascertain confidentiality.
checked, and it was translated by a language expert.

Results
Data Collection Procedures
To collect the data, first, we briefly explain to the respon­ Socio-Demographic Characteristics
dents the purpose of the study. Next, we took a written From a total of 245 study participants, 230 had partici­
informed consent from those who voluntarily participated pated with a response rate of 93.87%. The mean age of
in the study. Sociodemographic and knowledge-related study participants was 47.24 (SD ±15.24) with 72 (31.3%)
data were collected by interviewing the study participants of respondents aged 40 years and below. Of the study
wherea; clinical and other related data were collected by participants, 142 (61.7%) were female, and nearly most
reviewing patients’ charts. of them, 172 (74.8%) were urban residents. Regarding the
educational status, 48 (20.9%) above the secondary school
(Table 1).
Data Quality Control
To assure data quality, four BSc degree holders for data
collection and two MSc nurses for supervisors were Clinical and Other Related Factors of the
recruited and nine day training and orientation was given Study Participants
by the principal investigator. The tools were first organized Among the total of 230 study participants, 112 (48.7%)
in English language and translated into the local Afan and 67 (29.1%) had a duration of the disease less than
Oromo then back to English to ensure its consistency. 5 and between 5 to 10 years, respectively, with a mean

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Table 1 Sociodemographic Characteristics of Adult Diabetes participants. Of the total study participants, 149
Mellitus Patients in North Showa Zone Hospitals, Oromia (64.8%) of them had experienced medically confirmed
Region, Ethiopia, 2020 (n=230)
long-term complications of the disease; of them, 85
Variable Categories N (%) (37.0%) had diabetic retinopathy followed by diabetic
Sex Male 88(38.3) foot ulcer 59 (25.7%) (Table 2).
Female 142(61.7%)

Age ≤ 40years 72(31.3) Participants’ Diabetes Self-Care

40–49 58(25.2)
50–59 52(22.6)
Knowledge
≥60 48(20.9)
In this study, the overall knowledge of study partici­
pants towards diabetes self-care was 67.8%. Similarly,
Educational status Cannot read and write 44(19.1)
the overall self-care knowledge of study respondents
Read and write 47(20.4)
Primary (1–8) 44(19.1)
on modifiable lifestyles, adherence to diabetes self-
Secondary (9–12) 47(20.4) care, and consequence of uncontrolled blood glucose
Above secondary 48(20.9) level was 67.3% 72.3%, and 71.0% respectively
Marital status Single 41(17.8)
(Tables 3,4–5).
Married 126(54.8)
Divorced 34(14.8)
Factors Associated with Diabetic Self-
Widowed 29(12.9)
Care Knowledge
Occupation Employed 140(60.9)
A binary logistic regression model was applied to identify
Unemployed 90(39.1)
the potential predictor variables that affect diabetics’ self-
Residence Urban 172(74.8) care knowledge. Variables having a p-value less than 0.2
Rural 58(25.2)
in the binary logistic regression were entered in the multi­
variable logistic regression model. In this study variables
duration of 6.79 (SD 4.68). More than half of the study that showed significant association were occupational sta­
participants, 133 (57.8%), had received information tus, residence, and received diabetes self-care information.
about diabetes self-care. The source of information Unemployed study participants have 58.4% reduced odds
was health care professionals and mass media which of diabetic self-care knowledge (AOR; 0.146, 95% CI;
accounts for 170 (73.9%) and 60 (26.1%) study 0.18–0.94) as compared with study participants who

Table 2 Clinical and Other Related Factors of Adult Diabetes Mellitus Patients in North Showa Zone Hospitals, Oromia Region,
Ethiopia, 2020 (n=230)
Variable Categories Number Percentage

Duration as diagnosed Diabetes Mellitus <5 years 112 48.7

5–10years 67 29.1
>10years 51 22.2

Any diabetic-related long term complication Yes 149 64.8

No 81 35.2

Type of complications Diabetic nephropathy 33 14.3

Diabetic neuropathy 29 12.6
Diabetic retinopathy 85 37.0
Diabetic foot ulcer 59 25.7
Diabetic related heart 24 10.4

Received information about diabetes self-care Yes 133 57.8

No 97 42.2

Source of information Health professional 170 73.9

Mass media 60 26.1

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Table 3 Overall Performance of Respondents on Modifiable Lifestyles in North Shewa Zone Government Hospital, 2020 (n=230)
Questions Responses Correctness

Yes No

Blood glucose level should be measured before and after every physical activity. (Yes) 183(79.56%) 47(20.43%) 183(79.56%)

A fasting blood sugar (FBS) test can be used to monitor blood sugar control for 2–3 months. (No) 132(57.39%) 98(42.60%) 98(42.60%)

A person with diabetes should take care of his/her teeth and brush and floss his/her teeth every 209(90.86%) 21(9.1%) 209(90.86%)
day. (yes)

Tight elastic hose or socks are not bad for a person with diabetes. (No) 79(34.34%) 151(65.65%) 151(65.65%)

Self-blood glucose monitoring (SBGM) enables a person with diabetes to monitor and react to 202(87.87%) 28(12.17%) 202(87.87%)
changes in his/her blood sugar levels. (Yes)

Only the doctors should make plans on how a person with diabetes can achieve his/her target 103(44.78%) 127(55.21%) 127(55.21%)
goals. (No)

Maintaining a healthy weight is not important in the management of diabetes. (No) 66(28.89%) 164(71.3%) 164(71.3%)

Self-blood glucose monitoring (SBGM) allows the doctor and other healthcare teams to gather 200(86.95%) 30(13.04%) 200(86.95%)
data for treatment planning. (Yes)

No person should check the blood sugar and blood pressure of a diabetic patient except the 126(54.78%) 104(45.21%) 126(54.78%)
qualified medical doctor and other health personnel in the hospital. (yes)

Having a physical activity for 20–30 minutes per session at least 3 days per week is essential. 212(92.7%) 18(7.82%) 212(92.7%)
(Example of physical activities: Brisk walking, house activities, climbing staircase). (Yes)

A person with diabetes should report any change in his eyesight to his doctor. (yes) 214(93.04%) 16(6.95%) 214(93.04%)

There should be a mutual agreement between a person with diabetes and the doctor if he/she 214(93.04%) 16(6.95%) 214(93.04%)
cannot change a particular lifestyle. (yes)

A person with diabetes should take extra care of his/her feet especially when cutting his/her toenails. (yes) 167(72.60%) 63(27.4%) 167(72.60%)

Regular exercise does not reduce the need for insulin or other diabetic drugs. (No) 214(93.05%) 16(6.95%) 16(6.95%)

A person with diabetes should only ask for help when he/she feels sick from his/her healthcare 216(93.915) 63(27.39%) 63(27.39%)
team. (no)

At the initiation of insulin therapy for a person with diabetes who may require it, appropriate 202(87.82%) 140(60.86%) 202(87.82%)
advice on Self-blood glucose monitoring (SBGM) and diets should be given to the person. (yes)

Cigarette smoking can worsen diabetes. (yes) 202(87.82%) 19(6.08%) 202(87.82%)

Monitoring blood pressure is not as important as monitoring blood glucose in a person with 157(68.26%) 73(31.73%) 73(31.73%)
diabetes. (No)

Overall correctness 67.3%

were employed. Similarly, the odds of diabetic self-care Discussion

knowledge among urban residents study participants was In Ethiopia, few studies address diabetic self-care knowl­
73.1% higher (AOR; 0.269, 95% CI 0.099–0.532) than edge level. Moreover, no studies were conducted in the
study participants who were rural residents. Furthermore, study area. This study tried to assess the level of diabetes
study participants who have received diabetic self-care- self-care knowledge and its associated factors in the study
related information were three times more likely (AOR; area. Overall diabetic self-care knowledge of participants
3.003, 95% CI 1.24–5.3) to have good diabetic self-care in this study was 67.8% (95% CI; 62–74%). When com­
knowledge when compared with their counterparts pared to other studies, it is in line with a study finding in
(Table 6). Ethiopia at Ayder Hospital in the Tigray region (70.4%).17

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Table 4 Overall Performance of Respondents on Knowledge of Adherence to Diabetes Self-Care in North Shewa Zone Government
Hospitals, 2020 (n=230)
Questions Responses Correctness

Yes No

Regular medical checkups are not essential when a person with diabetes is feeling well. (No) 75(32.605) 155(67.39%) 155(67.39%)

Dietary instructions should be written out, even if the person with diabetes is illiterate: someone 149(64.78%) 81(35.21%) 149(64.78%)
at home should be available to interpret it for him/her. (yes)

Instructions about drugs and other self-care practices should not be strictly followed. (No) 73(31.73%) 157(68.26%) 157(68.26%)

Taking a low dose Aspirin tablet every day decreases the risk of having a heart attack and stroke. (yes) 126(54.78%) 104(45.21%) 126(54.78%)

A person with diabetes taking medicines when he/she feels good is a waste of money. (No) 39(16.95%) 191(83.04%) 191(83.04%)

Being drunk while on diabetic drugs is not a serious problem. (No) 33(14.34%) 197(85.65%) 197(85.65%)

Diet and exercise are not as important as medication in the control of diabetes. (No) 52(22.60%) 178(77.39%) 178(77.39%)

Diabetes drugs are not taken throughout the lifetime of a person with diabetes. (No) 53(23.04%) 177(76.95%) 177(76.95%)

Overall correctness 72.3%

Table 5 Knowledge of Respondents on Consequences of Uncontrolled Blood Sugar Level North Shewa Zone Government Hospitals,
2020 (n=230)
Questions Response Correctness

Yes No

If blood sugar is close to normal, a person with diabetes is likely to have more energy, feel less 195(84.78%) 35(15.21%) 195(84.78%)
thirsty, and urinate less often. (yes)

Prolonged high blood sugar levels can cause eye problems or even blindness. (yes) 206(89.56%) 24(10.43%) 206(89.56%)

Prolonged uncontrolled blood sugar levels can cause heart attack, stroke, and kidney problems. (yes) 212(92.17%) 18(7.82%) 212(92.17%)

Shaking, confusion, behavioral changes, and sweating are signs of high blood sugar. (No) 189(82.17%) 41(17.82%) 41(17.82%)

Overall correctness 71.0%

Table 6 Bivariate and Multivariate Analysis of Factors Associated with Diabetic Self-Care Knowledge Among Adult Diabetes Mellitus
Patients in North Showa Zone, Oromia, Region, Ethiopia 2020 (n=230)
Variables Knowledge COR (95% CI) AOR (95% CI) P-value

Good N (%) Poor N (%)

Occupation Unemployed 50(61.0) 40(29) 1 1

Employed 106(95.0) 34(45) 0.401(0.227–0.707) 0.416(0.18–0.94) 0.023*

Residence Urban 123(116.7) 49(55.3) 1.902(1.027–3.522) 0.269(0.099–0.732) 0.010*

Rural 33(39.3) 25(18.7) 1

Duration of DM <5 years 75(76.0) 37(36.0) 1 1

5–10years 55(45.4) 12(21.6) 2.261(1.081–4.73) 0.64(0.16–2.54) 0.523
10>years 26(34.6) 25(16.4) 0.513(0.26–1.008) 0.804(0.193–3.35) 0.764

Got diabetes self-care information Yes 105(90.2) 28(42.8) 3.38(1.9–6.01) 3.003(1.24–5.3) 0.015*
No 51(65.8) 46(31.2) 1 1
Note: *Showed variables that significantly associated in the logistic regression analysis at p-value < 0.05.

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This might be due to similarity in socio-demographic study finding from Egypt.18 The possible justification
characteristic of study participants. It is lower than the might be that unemployed persons will not have access
study findings in Ethiopia, Oromia Region, and Nigeria to meet with different individuals which limits access to
(77.6%, 79.5%).18,19 However, it is higher than a study get information from colleagues.
finding in Addis Ababa (58%)15 and India (44.2%).20 This
discrepancy might be due to differences in the socio-eco­
Conclusions and Recommendations
nomic status of respondents, access to diabetic informa­
In this study factors like occupation status, residence, and
tion, and educational level. Besides, the magnitude of
having information about diabetes self-care were signifi­
items of diabetic self-care knowledge for modifiable life­
cantly associated with diabetic self-care knowledge.
style was 67.3%. This result is lower than a study result in
Knowledge of the study participant’s about diabetes self-
Addis Ababa and Nigeria (73.2%, 81.6%).15,16 Similarly,
care was not adequate where there is a need to improve
the magnitude of items of knowledge of adherence to
diabetic self-care knowledge. This study recommends that
diabetic self-care was 72.3%, which is almost in line
nurses and doctors who work in the chronic outpatient
with a study result in Addis Ababa (70.4%),15 and lower
department should educate diabetic patients through the
than a study finding from Nigeria (77.2%).19
application of visual, auditory, and tactile aids to improve
The magnitude of knowledge for consequences of
self-care knowledge in the study area.
uncontrolled blood sugar level was found to be 71%,
which is almost congruent with a study finding in Addis
Ababa (72%),15 and lower than a study from Nigeria Limitation of the Study
(77.5%).19 This inconsistency might be due to differences Due to the nature of the cross-sectional study design, the
in study populations. accuracy of the response might be compromised and the
This study also identified that being employed, precedence of outcome or exposure is not clear.
urban residence, and having prior diabetic self-care
knowledge were factors significantly associated with Abbreviations
diabetic self-care knowledge of the study participants. DM, diabetes mellitus; DSCK, diabetic self-care knowl­
According to the current study participants that have edge; IDF, International Diabetic Federation; FBS, fast
received information about diabetes self-care were blood sugar; WHO, World Health Organization.
3.003 times more knowledgeable about diabetic self-
care than those who have not received any information
about diabetic self-care. A similar finding was obtained Data Sharing Statement
from a study done in Addis Ababa.15 The possible Except with reasonable request, data supporting this study
reason for this similarity could be information is one cannot be made available at present time.
way by which knowledge is acquired so those partici­
pants that have exposure to diabetic self-care informa­ Acknowledgments
tion have a better knowledge of self-care than those First of all, we would like to thank Salale University for
who do not have any information. funding this study. Secondly, we would like to acknowl­
The study result revealed that the odds of diabetic edge the Oromia Regional Health Bureau for sharing the
self-care knowledge among urban residents study parti­ necessary data for the success of our work.
cipants were 73.1% higher than study participants who
were rural residents. This finding is in line with the
study in Tigray Region Ethiopia and Egypt.17,18 The
Funding
Salale University funded this research work however, had
possible reason for this similarity might be due to parti­
no role in the decision to publish it.
cipants from Urban areas having more opportunities for
diabetes self-care information through the mass media,
books, and the internet. Likewise, unemployed study Disclosure
participants have 58.4% reduced odds of diabetic self- All the authors reported no conflicts of interest for this
care knowledge as compared with study participants work and declare that they had no competing interests
who were employed; this finding is in line with a regarding the publication of this paper.

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12. Shrivastava SR, Shrivastava PS, Ramasamy J. Role of self-care in

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