Peer Reviewed Article on How to Correctly Care for a Type One Diabetic Foods

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Open Access

Peer-reviewed

Research Article

Self-Care Practices among Diabetes Patients in Addis Ababa: A Qualitative Study

• Yemane Berhane

Self-Intendance Practices among Diabetes Patients in Addis Ababa: A Qualitative Study

• Dagmawit Tewahido,
• Yemane Berhane

x

• Published: January iii, 2017
• https://doi.org/x.1371/journal.pone.0169062

Figures

Abstract

Background

Cocky-intendance practices that include self-monitoring of blood sugar level, diet management, physical exercise, adherence to medications, and human foot care are the cornerstones of diabetes management. However, very little is known about self-care in developing countries where the prevalence of diabetes is increasing.

Objective

The objective of this report was to describe self-intendance practices among individuals with blazon Two diabetes in Addis Ababa, Ethiopia.

Methods

A qualitative method was used to gather data from type 2 diabetes patients. Patients were recruited from the outpatient diabetes clinics of two public hospitals in Addis Ababa. Information were nerveless using a semi structured interview guide. A thematic assay arroyo was used to process the data.

Results

Overall self-care practices were not adequate. Most patients reported irregular self-monitoring of blood sugar. Dietary and physical practise recommendations were inadequately adept by nearly of the participants. Most patients better adhered to medication prescriptions. Patients generally lack proper data/knowledge regarding the importance of self-care and how it should be implemented. Based on reported behavior nosotros identified 3 main categories of patients; which are those 'endeavor to be compliant', 'confused' and 'negligent'.

Conclusion

Diabetes patients largely depend on prescribed medications to command their claret saccharide level. The importance of proper self-intendance practices for effective management of diabetes is not fairly emphasized in diabetes care centers and patients lack sufficient noesis for proper self-care.

Citation: Tewahido D, Berhane Y (2017) Self-Care Practices amid Diabetes Patients in Addis Ababa: A Qualitative Study. PLoS ONE 12(1): e0169062. https://doi.org/10.1371/journal.pone.0169062

Editor: Stephen L. Atkin, Weill Cornell Medical College Qatar, QATAR

Received: July sixteen, 2015; Accepted: December 12, 2016; Published: January three, 2017

Copyright: © 2017 Tewahido, Berhane. This is an open access article distributed nether the terms of the Creative Commons Attribution License, which permits unrestricted apply, distribution, and reproduction in whatever medium, provided the original author and source are credited.

Data Availability: Interview transcripts cannot be fabricated public without participant consent due to ethical reasons due to confidentiality issues, every bit required past the Addis Continental Found of Public health Institutional Review Board. Data will exist made available upon request at the following contact: Dagmawit Tewahido, e-mail: Dagmawit.tewahido@gmail.com, tel. 251 911 472 281, Po. box: 24123/yard, Addis Ababa, Ethiopia.

Funding: The authors received no specific funding for this work.

Competing interests: The authors have declared that no competing interests exist.

Introduction

Globally over 14 million people die each year from non-infectious disease such as diabetes mellitus betwixt the ages of 30 and lxx, of which 85 per cent are in developing countries [1]. Federal democratic republic of ethiopia is among the top five countries with the highest number of people affected past diabetes mellitus in Sub Saharan Africa [2]. Every bit a consequence hospital admissions for diabetes management has been rising in recent years [3, four].

Effective management of diabetes requires strong and consistent cooperation of the patient [5]. Oft the complications associated with diabetes management are highly owing to the failure to comply with self-care recommendations [6]. The poor self-discipline, and lack of support from family members and/or physicians, poverty and lack of access to health facility are some of the major for failure to comply [7].

There are well recognized and specific cocky-care components to prevent and/or filibuster complications and possibility of early decease associated with diabetes. The components are self-monitoring of claret glucose level, diet command, optimum physical exercise, adherence to medication/s and proper foot care [viii]. Various strategies were adopted in different countries to help people with diabetes amend their cocky-intendance practices depending on the context [9]. Implementation of a comprehensive patient pedagogy plan was reported to accept enhanced diabetes cocky-care practices [10]. Improved social support for patients with diabetes has facilitated diabetes self-care and achieve improved glycemic control [11]. Task shifting is some other approach successfully implemented to amend self-care in places where doctors take heavy piece of work load; either nurses or other health professionals were specifically trained to provide proper information to the patient instead of the decorated doctor [12]. Agreement patients self-care cultural and value systems is some other important cistron to designing a responsive plan that can influence their diet and exercise choices, tendency of blood glucose monitoring, and compliance with prescribed medication regimens [9]. While the burden of diabetes is increasing in Ethiopia, studies conducted to empathize self-intendance practices are very limited. Thus the aim of this study was to describe the diabetes cocky-care practices and identify facilitators and barriers to the practice among type II diabetes patients attending follow-up in public hospitals.

Methods

The study was conducted in Addis Ababa, the capital city of Federal democratic republic of ethiopia. There were five public hospitals that ran a special diabetes follow upward clinics at the time of the study where patients are appointed every four to six months to see their doctor and receive services in outpatient departments. The clinics provide diabetes pedagogy on self-care practices and on proper self-injection techniques. We selected Menelik II and Zewditu memorial hospitals for this study. These two hospitals have been running a carve up diabetes follow up clinics for more than three decades. In Ethiopia all public hospitals provide consultation and anti-diabetes medications complimentary of charge. However additional diagnostic handling services may not necessarily exist gratis unless the patient has a 'certificate of poverty' from local administration.

The report participants were patients with type II diabetes that came to follow up clinics between Nov 2013 and Feb 2014. The inclusion criteria were having been diagnosed with type II diabetes for at least five years and being between the ages of 35 and 65 years. Patients who were not in a good physical/mental condition during the report fourth dimension were excluded. As the aim of the study was to describe the solar day to day self-intendance practices of patients with diabetes, newly diagnosed patients were not included in the study.

A purposive sampling procedure was used to recruit patients for the written report based on their age, sexual activity, educational level, income level, elapsing of diagnosis/follow up and patient'due south personal behaviors. This was washed to be able to run across the different forms of self-intendance practices from different perspectives. The doctors and nurses working in the follow up clinics helped in identifying patients that fulfil the inclusion criteria of the report. We tried to include patients believed to be interactive, open up minded and those who were willing to participate in the study. Each person identified as potential respondent was then individually asked for consent after being informed nearly the purpose and the required procedures.

The semi-structured interview guide used for data drove was developed by reviewing relevant literatures. In addition, participants were encouraged to speak up their mind in example they had anything further to tell related to the topic. A pilot was conducted in another public hospital to assess the acceptability and ease of understanding the interview procedure. Then interview guide was revisited to brand the necessary changes and modifications before conducting the actual interviews included in the analysis.

All interviews were conducted by the first author in a individual space within the hospital compound. The interviews were conducted in Amharic language, which is the national language of Federal democratic republic of ethiopia. All interviews were tape recorded with exact consent obtained from the study participants. In add-on relevant notes were taken during the interview to certificate key bug and observations. Interviews took approximately 45–60 minutes. Interviews were conducted until the betoken of relative saturation with regard to the issues being discussed.

All interviews were transcribed verbatim in Amharic and then translated into English for data analysis. The translated content was coded manually and entered into a estimator software (open-code) used for qualitative data sorting. Codes were given and grouped into categories that were predefined based on the objective of the report. The field notes were included in the memos section of the software. Coding started by a thorough reading of each interview material, followed by line-past-line flagging of each of the interviews. A coding procedure was established jointly past the co-authors.

A thematic analysis approach was used to categorize the codes thorough several iterations. The thematic areas were diet, physical exercise, medication adherence, self- monitoring of blood glucose and foot care. Patients were identified and labeled as "Negligent", "Confused" and "Endeavour to exist compliant" based on their personal coping methods with respect to their self-intendance practices that emerged during the analysis procedure.

Upstanding clearance for the report was obtained from Institutional Review Board of Addis Continental Institute of Public Health and permission to acquit the written report was granted past the Addis Ababa metropolis administration Health Bureau. Interviews were conducted after participants provided verbal informed consent. The interviews were conducted in manners that assured privacy for the respondents. Access to raw data was restricted only to the study investigators.

Results

A total of 13 in-depth interviews were conducted with type Ii diabetes patients. All participants have had diabetes for at to the lowest degree 5 years. Seven of the participants were female. All respondents were between the age of 35and 65, and nine of them were married. With regard to their educational dorsum ground, i has attended college, six had elementary to loftier schoolhouse education, and three could not read and write. Participants were from various religious and ethnic groups. None of the patients invited for the study refused to participate in the study.

Self-monitoring of blood saccharide

Participants generally reported that they practise not regularly check their claret glucose level. Even patients who had their own gluco-meter car at home reported testing their claret carbohydrate one time every iv–vi vi weeks. Those who exercise non own the glucometer machine at abode reportedly become to either a nearby private clinic or laboratory only when they feel ill. Nearly a tertiary of the report participants reported checking their blood sugar level only during their follow up visits to the infirmary, which is every three to 4 months. These findings betoken claret sugar monitoring is irregular and the loftier risks to develop long term diabetes complexity due to poor glycemic control.

"If my saccharide reads in a higher place 250 when I get it tested, I accommodate my dose; accept a little bit more than of my insulin since the electric current dose is manifestly not plenty for me. And when it gets down, I lower it back to the previous dose. They tell you not to do that but I take been monitoring my sugar like that for all these years." 58-twelvemonth-oldf self-monitoring male person participant

Another patient described her feel of self-monitoring of her blood saccharide as frustrating. She felt that controlling her blood sugar was beyond their capability.

"My claret sugar fluctuates a groovy deal. No matter what I practise to command information technology, nothing prevents it from shooting upwards high. It's out of my control. And so I've left it for the doctors to accept intendance of it. All I tin can do is take the prescribed medications." 44-year-sometime female respondent

Dietary practices

Nigh written report participants recognized nutrition as an essential component of cocky-care practice for people with diabetes. About all respondents reported to have totally avoided taking tabular array sugar and minimized intake of sugariness drinks and food. Well-nigh all participants described their usual nutrition to consist of Injera (a staple food in most parts of Federal democratic republic of ethiopia which is made of a locally grown grain 'teff') every day of the week. A diabetes friendly meal plans were not widely recognized by most patients. But one participant had an idea of the gauge amount of proteins, carbohydrates and fats recommended for people with diabetes. None of the participants reported any kind of organisation/meal programme that considers their diabetes. The following are illustrative quotes on dietary practices:

"…I don't similar stressing likewise much over what I eat. Like I told you, as long every bit you lot avoid sugary foods and drinks…" l-year-former male participant

"Carbohydrate for a 'sugar' (diabetic) patient? That is like facilitating your journey to your grave…

Everybody hither knows that sugar is absolutely to be non touched …" twoscore-year-old female person participant

"Starchy foods are not allowed for us (patients with diabetes)…I try to be careful with food items such as potatoes, wheat and corn." 56-twelvemonth-old female respondent

Lack of sensation/data was the most common reason mentioned for not following a diabetes friendly diet. Other reasons include inconveniences at workplaces, personal nutrient preferences, family meal preparation habits, low income, negligence, and temptations.

"Up to at present, I have non retreated from what I like to eat. I consume like everybody else. I eat what I similar and don't want to be picky saying 'I am diabetic patient' every time I sit for a meal." 45-year-old female respondent

The pressure level during social gatherings was a concern to some study participants. Sharing food during social gathering in Ethiopia is considered a manner of expressing respect and affection to 1 some other and refusing to swallow from a common dish is 'unacceptable'.

"I tin can't go to a 'mahber' (social outcome) for case and say 'I won't eat or drink'. I have what they give me with pleasure because information technology is non appropriate to reject, as the maxim goes, 'yeweledutin kalsamulet, yakerebutin kalbelulet', (a invitee is disrespectful… if failed kissing the host's children or if refused eating nutrient served by the host) therefore I go and I consume what they have prepared. A social life is essential for us." 56-year-old female person respondent

Preparing separate meals for one person in a family is a applied challenge. In improver equally the Ethiopian civilization does non encourage men to participate in food grooming or to be seen in the kitchen. That means a homo with diabetes has to eat whatever is served to the family.

"I eat what my husband and children eat. I cannot prepare a separate meal only for myself; y'all know it simply is non convenient." 45-year-old female participant

Some of the participants also reported that adhering strictly to diabetes dietary recommendations is boring and practically incommunicable; food restrictions intensify their cravings and make life more stressful.

"I am not going to prevarication to you, I like alcohol. The physician e'er warns me that 'arekie' (a local Gin) is worsening my illness, and I know how my sugar increases after drinking. Merely I am fed up of living everyday thinking nigh my illness. So when I get bored I say to myself 'If I am going to die anyway, why not enjoy life a scrap' and I get out to drink." 52-yr-old male participant

Practices with regard to regular concrete exercise

Nearly all informants admitted that they practice not exercise regularly. The most unremarkably mentioned reasons for not doing regular physical exercise were lack of interest, lack of motivation, busy work schedule, non being able to afford gymnasium fees and not convinced that exercise is of import.

"I know that practise is necessary. I accept also been told to exercise since I besides have high claret pressure. I have started many times to regularly exercise, but information technology doesn't last. I go tired of information technology fast, or something comes upwards to force me stop. There subsequently it is just also discouraging to beginning all once again." 56-yr-former female participant

"I don't exercise regularly. I take occasional walks when I take the fourth dimension but serious sport is non in my schedule." 52-twelvemonth-old male respondent

"Fifty-fifty if I was committed to regular do, it is not convenient. There is no place to exercise in the city and the gyms are not affordable." 44-year-old male respondent

"Practise at my age?! What departure would it make afterward all these years, unless I want to break my sometime basic?!…" 58-twelvemonth-sometime male participant

Taking diabetes medication regularly

Most of the respondents consider their anti-diabetes medications as the virtually vital element of the diabetes management and their survival. The majority reported they are complying most with instructions regarding medicines more than than any of the other components of self-care practices.

"I never omit my medication on purpose. I know going on and off on diabetic medications put your life in dangerous situations similar adventitious fainting or even death." 56-twelvemonth-old female participant

The participant stated erratic use of medications and adjusting doses by themselves, is a common occurrence to brand up for their unhealthy dietary practices and to correct blood sugar levels.

"I mostly follow the doctor's orders. But when information technology (blood saccharide) is unacceptably high, let'southward say above 250, then I slightly increase the dose." 58-year-onetime male person participant

Most participants who were on insulin also mentioned missing their doses when traveling abroad from abode due to lack of cold storage/fridge.

"When I get out for a field work (away from home) for two or 3 days, I may not have my insulin with me. It'due south non comfortable to become around with injection equipment. Besides at that place isn't refrigerator and stuff…for keeping the medication" 38-year-sometime male person participant

Another common challenge mentioned past many participants was the injection site hurting and abscess resulting from the daily insulin injections. Patients were frustrated and scared when the pain became too much and especially when they faced visible signs such every bit swelling and abscess, at the injection sites.

"…not faced abscess so far but the hurting is unspeakable. And pricking yourself like a piece of clothing all your life is not something enjoyable. My thighs and abdomen bruise from time to time." 52-year-former male person participant

"…a couple of years agone my thigh got irritated and had pus. It was terrible. It took it a while to heal only I never forgot the pain, and what kills you more than is the fear of that pus never drying and costing you your leg…" 60-year-onetime female person participant

More than one-half of the written report participants reported taking additional medication to control/treat other related atmospheric condition such every bit hypertension, high cholesterol and other heart weather, which they mentioned could be barriers to adhering to their anti-diabetes medications. The patients widely mentioned cost and availability of medications as a serious challenge in addition to pain and abscess at injections sites.

"…The drugs are non affordable…too diabetes doesn't come solitary. There'southward the cholesterol and hypertension that come along. I struggle to cover all that with my government salary." 52-year-old male participant

Regular foot care

Foot care was the to the lowest degree recognized self-intendance practice by the study participants. Most accept non even heard of what foot care is, although many of them have reported human foot injury as one of the common health issues for them.

"I know I accept to be careful of sharp things and 'enqfat' (street hurdle) when I walk in the street since injury to my pes can eventually develop into gangrene. But information technology is impossible to always move flawless…" 56-year-old female participant

Female study participants more than than male written report participants reported to have been caring about foot hygiene and give more attention to choosing advisable footwear.

"Well-nigh evenings after I am done with my firm work, I wash my feet and dry them. I spotter for any 'chok' (fungus) betwixt my fingers. I use nail clippers to cut my nails regularly…" 45-year-old female person respondent

A few participants had experience of some bad foot wound; one of them had to have leg amputation due to severe complication. Study participants said pes ulcers were inevitable to a person with diabetes sooner or later on.

"…if you are unfortunate like me, a nutrient ulcer can pb to your leg cut off" 50-year-old male person participant

Participants experiences of the self-intendance practices

We observed that study participants behaved in different ways in coping with their affliction and diabetes self-care. We categorized them into three dissimilar groups based on their utterances as: 'Negligent', 'Dislocated' and 'Endeavour to be compliant'. This grouping helps to see their relative level of self-care in relation to their illness coping strategies, as well as their mental attitude towards cocky-care (Tabular array 1).

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Overall, a comprehensive self-care do among diabetes patients was uncommon. Most of the respondents entirely depended on their medications to manage their illnesses and tend to undermine the importance of the other elements of self-care either due to lack of resource/poverty, lack of awareness, lack of back up or negligence [5].

The irregularity of blood sugar monitoring was the master shortcoming of diabetes control in this report. This is a precursor to the evolution of long term diabetes complications of diabetes. As reported elsewhere in sub Saharan Africa and in Federal democratic republic of ethiopia, irregular blood sugar measurement was related with the lack of personal glucometers or lack of like shooting fish in a barrel access to health facilities and laboratories [viii]. Long intervals between dispensary appointments was besides reported as one of the reasons for taking the responsibility of self-adjusting medication dosages past patients with diabetes. Provision of a comprehensive education plan and task shifting from physicians to nurses or to a person specifically trained to perform a limited task such every bit commitment of diabetes instruction was found to exist helpful improving patients care in decorated diabetes clinics in Sub-Saharan African countries [13].

Nutrient habits in the family and personal nutrient preferences were amidst the serious challenges which made dietary adjustment difficult for people with diabetes. Participation in social gatherings and food related socio-cultural norms could pose serious impediments to effective diabetic control in Sub-Saharan Africa [9, 12]. In addition shortage of cash to purchase food items appropriate for persons with diabetes, peckish for cultural/traditional food and limited availability of variety of food items in the local marketplace are barriers to dietary cocky-care practices equally seen from this as well as other studies in similar settings [12].

Concrete do, regardless of weight or body mass index, is critical to effectively control blood sugar level and in reducing persistent hyperglycemia [two, 12]. Lack of appropriate data and lack of motivation to engage in a regular concrete exercise are common short comings of diabetes self-care practices [14]. Although nigh people in Africa walk on foot every mean solar day, disease and sometime historic period tin somewhen significantly reduce patients' ability to walk as usual [12]. For aged and ill individuals going to a gym regularly may not exist feasible due to either cost or physical distance. Thus, advisable guidance needs to be given for the kind of exercise that can be done at domicile [15].

Injection site pain and abscess are common side furnishings that impede strict medication adherence among people with diabetes [xvi]. Yet, adherence to anti-diabetes medication was better of all self-care practices [17]. This could be due to either over reliance on medication or its free availability, or the ease to exercise it compared to the other components which require more than commitment [eighteen].

Foot care was the least adept diabetes self-intendance in our setting. This could be due to lack of proper understanding of its importance or the consequences by persons with diabetes [eighteen]. In Sub-Saharan Africa pes wound gets often complicated resulting in severe infection/sepsis gangrene [two]. A proper diabetes didactics has shown a promising comeback on foot cocky-care practice [19].

Studies show that persons with diabetes experience disproportionately high rates of social and emotional difficulties compared to the general population. Negative emotions such every bit frustration and feeling of helplessness contributed to poor self-care practices including poor blood sugar monitoring [7, 20].

Nosotros grouped the behavior of persons with diabetes in to three based on their utterances: The 'Effort to exist compliant' accomplish out to other people and diabetes association to discuss their condition and could build their motivation for positive self-care practices [21].

Those grouped under 'confused' were more often than not the ones who seemed to be lacking information, although they keenly wanted it. Even if some knew almost diabetes association, they were not acquainted with any do good that they could individually get from them. This lack of information is unremarkably observed in both developed and developing countries [11]. These patients are tangled in fear and defoliation that their self-care practices are not sufficient to aid their diabetes control. This group are likely to be very frightened of the perceived complications [xviii].

The third grouping, 'Negligent', appeared to resist self-intendance recommendations; consequently their cocky-care practice is very limited and uncommitted. These patients ignore their status (diabetes), and equally a issue refuse to discuss most information technology either with peers or bring together diabetes association. Glycemic control in such patients tend to be poor and their chance of developing complications early is high [18].

In conclusion, Diabetes self-care is more often than not poor mainly due to bereft guidance and back up provided to persons with diabetes. Greater attention needs to be given to improve patient education and support in diabetes clinics to ensure amend cocky-care practices and avoid early development of complications.

Strengths of the written report

The study took a fresh approach of cocky-care practices by choosing a qualitative methods from patents' perspective in their own words; thereby addressing previously unseen sides. In that location was minimum recall bias due to chronic nature of affliction. Diabetes self-care is a relatively non-sensitive issue for patients to freely discuss about, and what'south more, patients were interested and eager to converse virtually their conditions which facilitated in generating rich data.

Limitations of the study

Absence of multiple data collection methods, which is limited to interviews to patients enrolled merely from public hospitals was a limitation of this study. In addition, social desirability bias may be introduced despite the cautions taken during the interviews.

Writer Contributions

1. Conceptualization: DT.
2. Data curation: DT.
3. Formal analysis: DT.
4. Funding conquering: DT.
5. Investigation: DT.
6. Methodology: DT YB.
7. Project administration: DT.
8. Resources: DT YB.
9. Software: DT.
10. Supervision: DT YB.
11. Validation: DT YB.
12. Visualization: DT.
13. Writing – original draft: DT.
14. Writing – review & editing: DT YB.

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