Diabetes Self-Care Practice, and Associated Factors Among Type 2 Diabetic Patients in Public Hospitals of Tigray Region, Ethiopia

Background: The prevalence of Type 2 diabetes is increasing steadily at an alarming rate and Ethiopia is placed fourth among the top ve countries of the Africa region according to the International diabetes federation. Regardless of its burden, the self-care behaviors are still unknown. This study is aimed to determine the level of diabetes self-care practice and factors associated with among Type 2 diabetes mellitus patients in public hospitals of Tigray region. Methods: Institution-based, cross-sectional study was conducted in six selected hospitals of Tigray region from January to February, 2020. Data was collected by trained nurses with a face to face interview method using Summary Diabetes Self-Care Activities (SDSCA). Bivariate and multivariate logistic regression was used to identify factors associated with self-care practices. Statistical signicance was declared at P-value < 0.05. Results: A total of 570 patients with type 2 diabetes were included in this study. The mean age of the participant was 46 ± 14.6 years. Less than half (46.7%) of the participants has good diabetes self-care practices. Urban residency (AOR=2.79, 95% CI 1.858-4.205), age group above 64 years (AOR=2.384, 95% CI 1.258-4.518), not having formal education (AOR=2.616, 95% CI 1.337-4.518), having family or social support (AOR=1.878, 95% CI 1.243-2.837), duration DM above 10 years (AOR=2.325, 95% CI 1.224-4.418), having personal glucometer at home (AOR=5.9, 95% CI 2.790-12.764) were determinant factors of good diabetes self-care practice. Conclusion: the diabetes self-care practices in the region was found to be low. Health care providers might have identied self-care the caring giving follow up adults a rural Self-management strategies such as self-monitoring of blood glucose, dietary restrictions, regular foot care, and have been shown to markedly reduce the incidence and progression of DM Self-care practices and lifestyle modication remains the mainstay of T2DM This study was aimed to assess the level of self-care practices and associated factors among T2DM patients in public hospitals of Tigray region, showed that less half had good self-care of 2 This was with However, it was higher compared to other Bahir and Harar But, the nding of this study was lower than a study Nekemte, 60.7% This difference could be due to variation in cultural, and socio-economic aspects of the society as Ethiopia is a diverse country The majority of participants in our study were from a rural area and they might be faced with diculties in getting health care and opportunities for on the management of their disease.


Introduction
Diabetes is one of the fastest-growing global health emergencies of the 21 st century (1,2). According to the International Diabetes Federation (IDF) report in 2019, estimated 463 million adults aged 20-79 years worldwide have diabetes and by 2030 this gure is projected to be 578.4 million, and by 2045, 700.2 million (2). Ethiopia is placed fourth among the top ve countries of IDF Africa members (32 countries) having 1.7 million people with diabetes (age 18-99) (2).
Self-care practices remain the mainstay management of diabetes as the majority of the disease management is carried out by patients themselves or their families (3). Diabetes care is more demanding and complex which needs a better understanding of the disease beyond monitoring blood glucose level (4). The cornerstone of managing type 2 diabetes is a healthy lifestyle, which includes a healthy diet, regular physical activity, not smoking, and maintaining a healthy body weight (5,6). Even though adherence to diabetes self-care practice has shown a remarkable reduction in the incidence and progression of DM complications (7), there is a poor habit of self-care practice reported in different parts of Ethiopia (8)(9)(10). From previous studies, factors like duration of diabetes (early ages), living in a rural areas, male gender, lack of family support, having comorbidities, poor knowledge about diabetes, lack of selfmonitoring glucometer, were found to affect the diabetes self-care practices (8,9,11,12).
Hence most studies are done in other parts of Ethiopia and little is known about the self-care practice at the regional level, this study is aimed in assessing the level of self-care practice and associated factors among T2DM patients in government hospitals of Tigray region.

Method
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% con dence interval, 5% margin of error (d), and the 50.2% proportion T2DM patients with a good level of diabetes selfcare 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 speci c 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 Page 4/14 scale. After calculating the overall mean score, it was classi ed 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 rst 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).

Data analysis
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 signi cance was declared at p-value <0.05.

Results
Socio-demographic characteristics of the participants Out of the 576 participants interviewed 570 of them have responded making a response rate of 99%. The mean (± SD) age of the respondents was 46 ±14.6 years, with majority (32.1%) were within the age range of 34-48 years and more than half (55.8%) of them were males. where 351 (61.6%) of the participants were married. Regarding their educational status, 165 (29%) did not have formal education, and 104 (18.2%) had degrees and above. Almost all 537 (94.2%) of them were Tigrians and nearly two-third (64.7%) of them were urban residents [ Table 1].  Regarding the diabetes self-care practice domains, more than half of the patients had poor diabetes self-care practice across all domains except for foot care (43%) [ Table 3]. Table 3 Distribution of diabetes self-care practice domains (n=570) Patients with family or social support were also 1.8 times more likely to have good self-care practices than their counterparts (AOR=1.878, 95% CI=1.243-2.837, p=0.003). Participants who were living with DM for more than 10 years were 2.3 times more likely to have good self-care practices compared to those with less than 5 years (AOR=2.325, 95% CI=1.224-4.418, p=0.027). Having a personal glucometer at home was also another factor associated with good self-care practices. In which patients with personal glucometer at home were 6 times more likely to have good self-care practices than their counterparts (AOR=5.9, 95% CI=2.790-12.764, p<0.0001) [ Table 4]. *p-value <0.05: **p-value<0.0001, AOD: adjusted odd ratio, COR: crude odd ratio CI: con dence interval

Discussion
Self-management strategies such as self-monitoring of blood glucose, dietary restrictions, regular foot care, and ophthalmic examinations have been shown to markedly reduce the incidence and progression of DM related complications (7,17). Self-care practices and lifestyle modi cation remains the mainstay treatment of T2DM (17). This study was aimed to assess the level of self-care practices and associated factors among T2DM patients in public hospitals of Tigray region, Ethiopia.
This study showed that less than half (46.7%) of the participants had good self-care practice of type 2 diabetes. This was consistent with studies conducted in the Oromia region, Adama (49.1%) (18), and southwest of Ethiopia (49.2%) (13). However, it was higher compared to other studies conducted in Bahir Dar, northwest of Ethiopia, which was only 28.4% (9) and Harar 39% (19). But, the nding of this study was lower than a study from in Nekemte, western Ethiopia 60.7% (8), This difference could be due to variation in cultural, and socio-economic aspects of the society as Ethiopia is a diverse country (20). The majority of participants in our study were from a rural area and they might be faced with di culties in getting access to health care services, and opportunities for education on the management of their disease.
In the present study, self-care practice was signi cantly associated with age and duration of diabetes as predictors, where better self-care practice was seen among the age group greater than 64 years, and duration of diabetes greater than 10 years. Similarly, a study from India (21) and Egypt (20) also showed an increase in age and duration of diabetes were associated with good self-care practices. This might suggest that the longer they stay with the disease, the more they become conscious and aware of their health and adjust their lifestyle.
This study found that those with no formal education were more likely to adhere to diabetes self-care practice. On the contrary, other studies found that the higher the educational status it is likely to have good self-care practice (9,13,19). This might be justi ed regardless of their educational status patient might adhere to self-care practices based on the information they receive from health care providers or the media.
As the management of diabetes is more complex and multifaceted family and social support play an important role on patients treatment adherence (17). In line with this, we found that patients with a family or social support were more likely to have good diabetes self-care practice. This was supported by other studies conducted in Gondar, Ethiopia (22) and Malesia (22). A study done in Thailand on family oriented selfmanagement program also showed that engaging family support for individuals with T2DM has the potential to reduce the demands on diabetes educators and health services by providing additional support and potentially reducing complications (24) which could be due to good a self-care practice.
The availability of personal glucometer at home was very low (11.9%). Similarly, a systematic review of sub-at home (11). In the present study, the odd of good self-care practices were high among patients who have personal glucometer at home. This nding is also supported by other studies conducted in, central zone of Tigray, Ethiopia, (12) and western Ethiopia (8).
This study showed that patients from urban areas of residency were more likely to have good diabetes selfcare practices compared to rural residents. This was in line with studies conducted in different parts of Ethiopia, such as Mekelle (25), Harar and Dire Dawa (19), Gondar (22) and India (22). It was found that there is a misconception, poor knowledge both on the treatment and self-care practices of diabetes among rural residents (27,28). This variation could be explained due to easy access to information through Medias, internet, and health care facilities of urban residents.

Limitations
First, since this was a cross-sectional study, the causal effect relationship between variables couldn't be established. Secondly, as the study asks the self-care activities of patients for the past seven days and there might be a recall bias among respondents.

Conclusion
In conclusion, the level of diabetes self-care practice among T2DM patients in the Tigray region was found to be low. Urban residency, Older age >64 years, duration of diabetes >10 years, having family or social support, not having a formal education, and having personal glucometer at home were predictors of good self-care practices. This suggested that clinicians and nurses might have to consider giving emphasis on caring and giving follow up services to DM patients coming from a rural areas. All stakeholders dealing with this issue should work together to close these gaps. A written signed consent for participation was obtained before the data collection. Participant autonomy was maintained by telling them that they can refuse or stop participation at any time. To maintain con dentiality of the participants no personal identi ers were used.