Study setting and period
An institution-based cross-sectional study was conducted in public hospital in Tigray regional state. Administratively, the region is divided into 7 Zones, and those selected hospitals were found in six of these seven zones. The region has an estimated population of 5 million. An estimated 80.5% of the populations live in rural areas and the majority of them were Orthodox Christian. The study was conducted from January to February 2020.
Study population and size
Sample size was calculated using a single population proportion formula by assuming 95% confidence interval, 5% margin of error (d), and the 50.2% proportion T2DM patients with a good level of diabetes self-care activities, from a study conducted in the southwest of Ethiopia (13). By using design effect of 1.5, the total sample was 576. Patients ≥18 years, diagnosed with T2DM, and who had follow up for at least six months were included. Subjects diagnosed with gestational diabetes or mental disorders were excluded.
Data collection procedure and tool
The study was conducted in randomly selected 6 hospitals (4 general hospitals; Wukro general hospital, St. Marry general hospital, Axum, Sihul general hospital, Shire, Lemlem Karl general hospital, Maichew and 2 specialized hospitals; Ayder comprehensive specialized hospital, Mekelle and Axum university referral hospital) of the Tigray region, northern Ethiopia. Participants were recruited from regular outpatient departments and diabetes clinics of the selected hospitals using a systematic random sampling method. The data were collected by eight trained nurses.
The English version standardized instruments were translated into local language Tigrigna and then translated back to English. The tool contains information on socio-demographic, clinical characteristics, Summary of Diabetes Self-Care Activities (SDSCA) instrument (16). SDSCA is a self-report measure with four components of diabetes self-management (diet, exercise, blood sugar testing, and foot care). The respondents were asked to rate how many days during the past 7 days did they performed a specific self-care behavior. The scale ranges from 0 to 7, whereby higher scores correspond to higher diabetes management activities. A mean score is calculated for each domain (diet, exercise, blood glucose testing, foot care, and smoking), whereby the scores were categorized as “good” for scores above mean value and “poor” for scores less than the mean value. The overall mean score was calculated by summation of the mean score for diet, exercise, foot care, and blood glucose testing divided by the sum of the number of questions under each scale. After calculating the overall mean score, it was classified as having “good self-care practice” if the patient scored ≥ 3 or “poor self-care practice” if the patient scored < 3.
For the knowledge test, the University of Michigan Diabetes Research and Training Center, diabetes knowledge test (DKT) was used (14,15). The DKT is a 23-item multiple-choice test designed to assess knowledge about diet, exercise, blood glucose levels, and testing, and self-care activities have been adopted and tested (13). Each item has three or four multiple choices with only one correct answer. The first 14 items are designed for all adults with diabetes, while items 15–23 apply only to those taking insulin (15). Scores on the DKT was computed for each participant. The score was determined by dividing the number of correct answers by the total number of questions (23 questions for patients taking insulin and 14 for those receiving oral hypoglycemic agents). Scores ≥75 %, 74-60 %, and ≤59 %, respectively, were labeled as high, medium, and low knowledge on diabetes (14).
The data was cleaned, coded, entered into Epidata.3.1, and then exported into SPSS version 25 for analysis. Descriptive statistics including mean, median, standard deviations, and range values for continuous data as well as percentage and frequency tables for categorical data were computed. Variables with p-value less than 0.25 on bivariate analysis were subjected to multivariate analysis and multivariate logistic regression was used to identify factors that were associated with diabetes self-care practices. The level of significance was declared at p-value <0.05.