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Background: The prevalence of diabetes in sub-Saharan Africa has increased rapidly over the last years. Self-management is a key element for the proper management, but strategies are currently lacking in this context. This systematic review aims to describe the level of self-management among persons living with type 2 diabetes mellitus in sub-Saharan Africa. Method: Relevant databases including PubMed, Web of Science and Google Scholar were searched up to September 2016. Studies reporting self-management behavior of people with type 2 diabetes mellitus and living in sub-Saharan Africa were included. Results: A total of 550 abstracts and 109 full-text articles were assessed. Forty-three studies, mainly observational, met the inclusion criteria. The studies showed that patients rarely self-monitored their glucose levels, had low frequency/duration of physical activity, moderately adhered to recommended dietary and medication behavior, had poor level of knowledge regarding diabetes related complications and sought traditional or herbal medicines beside of their biomedical treatment. The analysis also revealed a lack of studies on psychosocial aspects. Conclusion: Except for the psychosocial area, there is a good amount of recent studies on self-management behavior of type 2 diabetes mellitus sub-Saharan Africa. These studies indicate that self-management in sub-Saharan Africa is poor and therefore a serious threat to the health of individuals and the health systems capacity.
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R E S E A R C H A R T I C L E Open Access
Self-management of diabetes in Sub-Saharan
Africa: a systematic review
Victor Stephani
1*
, Daniel Opoku
1
and David Beran
2
Abstract
Background: The prevalence of diabetes in sub-Saharan Africa has increased rapidly over the last years. Self-
management is a key element for the proper management, but strategies are currently lacking in this context. This
systematic review aims to describe the level of self-management among persons living with type 2 diabetes
mellitus in sub-Saharan Africa.
Method: Relevant databases including PubMed, Web of Science and Google Scholar were searched up to
September 2016. Studies reporting self-management behavior of people with type 2 diabetes mellitus and living in
sub-Saharan Africa were included.
Results: A total of 550 abstracts and 109 full-text articles were assessed. Forty-three studies, mainly observational,
met the inclusion criteria. The studies showed that patients rarely self-monitored their glucose levels, had low
frequency/duration of physical activity, moderately adhered to recommended dietary and medication behavior, had
poor level of knowledge regarding diabetes related complications and sought traditional or herbal medicines
beside of their biomedical treatment. The analysis also revealed a lack of studies on psychosocial aspects.
Conclusion: Except for the psychosocial area, there is a good amount of recent studies on self-management behavior
of type 2 diabetes mellitus sub-Saharan Africa. These studies indicate that self-management in sub-Saharan Africa is
poor and therefore a serious threat to the health of individuals and the health systems capacity.
Background
Although the true burden of diabetes in sub-Saharan
Africa (SSA) is unknown, it is recognized as a serious
challenge to health systems [1,2]. Current prevalence-
estimates range between 2.1 and 6.0%, and the number of
people suffering from the disease is likely to double within
the next 25 years [3]. In order to reduce the burden posed
to health systems and affected individuals, patients with
diabetes need to adopt certain self-management behaviors.
The American Diabetes Association (ADA) has therefore
defined a list of essential self-care behaviors, which have
been found to be positively correlated to good glycemic
control and a reduction of complications [4,5]. Diabetes
Self-Management Education (DSME) is critical for
informing patients about these essential self-care behav-
iors. Currently, DSME in most African countries is limited
in scope, content and consistency and it is not clear how
patients from SSA manage their diabetes [68]. Therefore,
the aim of this systematic review is to assess the status of
self-management of people with diabetes in SSA, and to
analyze to what extent they follow the recommended
self-management behavior.
Method
Search strategy and screening procedure
A preliminary search was performed in order to find ap-
propriate terms. The final search strategy was discussed
among the authors (VS and DO). Search term categories
belonged to: Diabetes,Sub-Saharan Africaand Self--
management. Databases included in the search were
PubMed, Web of Science and Google Scholar. In addition,
reference lists of screened studies were checked. An ex-
ample of the performed search and the key words used is
provided in Additional file 1.
The search-strategy yielded 741 publications (MEDLINE
436, Web of Science 232, Google Scholar 50). After re-
moval of duplicates, 550 studies remained. VS and DO
* Correspondence: victor.stephani@tu-berlin.de
1
Department of Health Care Management, Technical University of Berlin,
Berlin, Germany
Full list of author information is available at the end of the article
© The Author(s). 2018 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0
International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and
reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to
the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver
(http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.
Stephani et al. BMC Public Health (2018) 18:1148
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reviewed titles, keywords and abstracts independently and
discussed the eligibility for full-text inclusion.
After discussing results and resolving disagreements, full
texts of the remaining 109 publications were screened for
eligibility. The overlapping rate of included and excluded
studies was 87% between both authors. Disagreements
were discussed and resolved by consensus, resulting in
forty-three articles included in this review.
Inclusion criteria
Studies were included for this review if they met the
following inclusion criteria:
They took place in at least one country from sub-
Saharan Africa, as defined by the World Bank [9]
Participants were people living with type 2 diabetes
mellitus (which accounts for 90% of all diabetes
cases in SSA [10])
The study analyzed self-management behavior of
type 2 diabetes patients as defined by the American
Diabetes Association (ADA) as described in Table 1.
If a study analyzed both, type 1 and type 2 diabetes,
it was only included if the outcome measures (or
self-management behavior) for patients with type 2
diabetes were presented separately
Published anytime before September 2016 (with no
limit concerning the start date)
The study was published in English or German
Table 1presents all self-management related outcome
categories and specifies them according to the recom-
mendations given by the ADA [11].
Data extraction, analysis, and synthesis
Two data extraction templates (using Microsoft Excel) were
developed to gather all data relevant for the analysis. One
template was used for collecting characteristics of included
studies (e.g. year of publication, country, number of partici-
pants, number of woman/man, age); study results and rele-
vant information on self-management were collected in a
second template. Qualitative and quantitative results were
combined and summarized according to their specific area
of self-management. Quantitative results were rounded to
the nearest full percent and study-size-weighted arithmetic
averages were calculated if eligible.
Risk of bias was assessed and information about the
quality of the included studies were derived from the
text using quality-assessment tools for cross-sectional
studies [12], pre-post studies [13] and randomized con-
trolled trials [14]. Additional file 2contains the full de-
tails of a PRISMA checklist for this review and the full
risk assessment of the included studies can be found in
the Additional files 3,4,5.
Results
The final analysis included forty-three studies. Figure 1
illustrates the literature search and selection process.
Common reasons for exclusion were: lack of results,
reports from non-SSA countries, or focus on other dis-
eases than type 2 diabetes mellitus. Publication dates were
between 2002 and 2016. The majority of studies (n=33)
were published after 2010.
Description of included studies
Study characteristics such as the year of publication, sam-
ple size, study design and the measured outcome parame-
ters of the forty-three included studies are summarized in
Table 2. Most studies took place in Nigeria (n= 13) and
South-Africa (n=11), followed by Ghana (n=6), Uganda
(n= 4), Ethiopia (n= 3), Cameroon (n= 2), Tanzania,
Kenya, Sudan, Zimbabwe (n = 1 each). Thirty-five studies
were observational (mostly cross-sectional, only one longi-
tudinal study [15]), while six studies were experimental
(two studies described the same intervention [16,17]).
Table 1 Specification of categories and included outcomes used for the analysis of self-management as given by the ADA [5]
Category Specification Included Outcomes
Healthy eating General awareness of its importance, awareness of importance
of measuring and portioning meals, adherence to an eating plan
Eating behavior, knowledge on diet recommendations,
presence of and adherence to a diet plan
Being active General awareness, existence of and adherence to an activity plan
(with information on frequency, intensity, time and type of activity),
glucose checking before and after sports
Knowledge on activity recommendations, presence of
and adherence to an activity plan
Monitoring General awareness, conducting SMBG (including information on
frequency), keeping record of results, ability to analyze results
Awareness of SMBG, Availability of a glucose meter at
home, frequency of SMBG
Taking Medication Awareness of the kind of prescribed medicine, adherence to
the medication plan
Prescribed medication, medication adherence, awareness
that medication needs to be taken throughout the
life-time
Reducing Risks Awareness of possible complications, tobacco consumption,
regular doctor appointments, taking care of feet
Awareness of consequences of uncontrolled Diabetes,
consultations of specialists, self-care behavior,
cigarette intake
Psychosocial Aspects Environmental, social, emotional burden of diabetes Support by relatives, emotional and environmental
aspects
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8281 participants with type 2 diabetes were included with
an average age above 50 years, and out of which 4676
were women (3 studies did not indicate how many men or
women were included). People had been living with their
diabetes on average over 5 years. Most studies dealt with
the self-management area of medication (n= 26), followed
by the assessment of nutritional intake and the engage-
ment in physical activity (n=21 and n= 20). Fifteen stud-
ies were about risk reduction and self-monitoring of blood
glucose, respectively. Only three studies considered psy-
chosocial aspects of people with diabetes.
All experimental studies tested various forms of DSME
programs, with either a pre-post design [18,19], or a con-
trol group [16,17,20] study-design. One intervention was
done by counselling and educating the patients on medi-
cation adherence at the beginning of the study [21]. In an-
other study [18] patients attended a one-day education
program. Two studies tested the impact of 4 one-hour
group education sessions about the importance of nutri-
tion, physical activity, adherence to medication and risk
reduction [19,20]. A more comprehensive intervention
tested the outcome of weekly group education sessions on
nutritional aspects, combined with monthly follow up ses-
sions plus education in vegetable gardening [16,17].
Study results on self-management
Healthy eating
Twenty-one studies included information on healthy eat-
ing self-care behaviors. Participants understood that un-
healthy eating is a dominant cause of diabetes [16,22,23]
and that it is important to take aspects such as the sugar-,
salt- or fat-level of consumed food into consideration [19,
22,2426]. However, misconceptions and gaps of know-
ledge were present; particularly about the definition of
high risk food [19], the sugar-level of food [24,27] and the
underlying diabetes related metabolic mechanisms [24].
As found in one study, respondents did not know the pro-
portion of food they were allowed to eat [24]. And another
study showed that mostly men talked about regular meals,
while most women did not [28]. Positive dietary behavior
changesbecause of their diabetes were reported by 33%
of Nigerian [29], 51% of Ghanaian [30] and most of South
African [16] participants. Regarding the adherence to a
certain diet plan, 60% [31], 70% [32]and87%[33] stated
that they followed an eating plan.
Four experimental studies assessed the impact of coun-
seling sessions on the adherence to diet plans. Two inter-
ventions assessed the impact of four one-hour group
education sessions on nutritional aspects: One increased
the level of adherence significantly from 4.8 to 5.9 days
per week [19] and one decreased the adherence
non-significantly from 4.8 to 4.6 days per week [20]. The
third intervention, which combined weekly group educa-
tional sessions on nutritional aspects with monthly follow
up sessions and education in vegetable gardening, signifi-
cantly reduced the intake of energy and starchy food [17].
The fourth intervention, which consisted of weekly con-
tacts among the patients over a period of four months,
was found to improve the healthy eating habit of patients
significantly from 11.5 points to 22.4 points (out of 25
total points on the Diabetes Self-Management Assess-
ment and Reporting Tool)[18].
noitacifitn
e
dI
Abstract
Screening
Full text
screening
Full
inclusion
Medline (436 titles) Web of Science
(232 titles)
23 studies identified
through reference
search
Records after duplications
removed (n=550)
Records screened
(n=550)
Records excluded:
- No f ocus on diabetes (n=186)
- Lack of results (n=120)
- Non- SSA countries (n=79)
- Other reasons (n=56)
Full-text articles assessed
for eligibility (n=109)
Records excluded:
- Lack of results (n=38)
- No f ocus on type 2 diabetes (n=24)
- Other reasons (n=4)
Studies included (n= 43)
Google scholar
(50 titles)
Fig. 1 Literature screening process
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Table 2 Characteristics of included studies
Author Year Country Study Type Sample characteristics Reported outcomes
Sample
size
Male Female Average age Healthy
eating
Being
active
Monitoring Medication Risk
Reduction
Psychosocial
Observational
studies
Awah [57] 2008 Cameroon cross-sectional 20 11 9 62.5 x
Awah [15] 2009 Cameroon cross-sectional 65 30 35
Kassahun [43] 2016 Ethiopia cross-sectional 309 189 120 50 x x
Sorato [31] 2016 Ethiopia cross-sectional 194 95 99 50.3 x x x x
Wabe [42] 2011 Ethiopia cross-sectional 384 186 161 48.3 x x x
Bruce [50] 2015 Ghana cross-sectional 200 95 105 xx
de-Graft Aikins [23] 2014 Ghana cross-sectional 20 2 18 60 x x x x
Doherty [27] 2014 Ghana cross-sectional 30 10 20 48.7 x
Mogre [30] 2016 Ghana cross-sectional 222 74 148 48.4 x x
Obirikorang [54] 2016 Ghana cross-sectional 630 243 387 55.2 x
Obirikorang [26] 2016 Ghana cross-sectional 543 232 311 51.1 x x x
Matheka [44] 2013 Kenya cross-sectional 187 –– – x
Adibe [38] 2011 Nigeria cross-sectional 314 136 178 43 x x
Adisa [24] 2009 Nigeria cross-sectional 121 60 61 xxx x
Adisa [29] 2011 Nigeria cross-sectional 114 51 63 61.3 x x x x
Awotibede [37] 2016 Nigeria cross-sectional 299 105 194 51.9 x
Ezuruike [48] 2016 Nigeria cross-sectional 112 43 69 46 x
Iwuala [47] 2015 Nigeria cross-sectional 100 38 62 59.9 x
Jackson [51] 2015 Nigeria cross-sectional 303 171 132 54.5 x
Ogbera [40] 2011 Nigeria cross-sectional 150 50 100 69.9 x x x x
Onakpoya [49] 2010 Nigeria cross-sectional 83 32 51 57.5 x x
Oyetunde [52] 2014 Nigeria cross-sectional 102 35 67 59.6 x
Yusuff [46] 2008 Nigeria cross-sectional 200 110 90 xx
Jackson [36] 2014 Nigeria cross-sectional 303 132 171 50 x x x x
Adeniyi [22] 2015 South Africa cross-sectional 17 6 11 58.5 x x x x x
Haque [53] 2005 South Africa cross-sectional –––– x
Matwa [55] 2003 South Africa cross-sectional 15 5 10 61.4 x
Mendenhall [56] 2015 South Africa cross-sectional 27 27 59 x
Nthangeni [33] 2001 South Africa cross-sectional 288 133 155 62 x x
Okonta [39] 2014 South Africa cross-sectional 217 –– 51 x x
Steyl [35] 2014 South Africa cross-sectional 26 11 15 58.9 x x x
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Table 2 Characteristics of included studies (Continued)
Author Year Country Study Type Sample characteristics Reported outcomes
Sample
size
Male Female Average age Healthy
eating
Being
active
Monitoring Medication Risk
Reduction
Psychosocial
Abdelgadir [45] 2006 Sudan cross-sectional 193 95 98 50 x
Kamuhabwa [32] 2014 Tanzania cross-sectional 469 171 298 54.9 x x x x
Hijelm [34] 2008 Uganda cross-sectional 25 10 15 xx x x
Mayega [28] 2014 Uganda cross-sectional 96 48 48 47.5 x x
Nielsen [41] 2016 Uganda cross-sectional 10 6 4 65.6 x x x
Hijelm [25] 2010 Zimbabwe cross-sectional 21 10 11 48 x x x x
Experimental studies Awodele [21] 2015 Nigeria pre-post,
quasi-experimental
152 47 105 65 x
Baumann [18] 2015 Uganda pre-post,
quasi-experimental
25 7 18 53 x x x
Mash [20] 2014 South Africa RCTs 1570 411 1158 56.4 x x x x
Muchiri [16] 2015 South Africa RCTs 41 5 36 59.4 x
Muchiri [17] 2015 x
van der Does [19] 2013 South Africa RCTs 84 68 16 51.6 x x x x x
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Being active
Seventeen observational studies assessed physical activity
behaviors and three interventional studies tested the im-
pact of group educational programs.
The majority of participants in six studies were aware
of the importance of being active and of doing regular
aerobic exercises (such as brisk walking or climbing
staircases) as part of their non-medical treatment [22,
25,3437]. However, respondents in three studies
showed that a majority did not understand the relevance
of physical activity as part of their glycemic control and
therefore revealed gaps in knowledge on recommended
type, frequency and duration of physical activity [24,38,
39]. In addition, men and women were not always
equally well-informed [34].
No study mentioned that participants had an activity
plan or kept records of type, frequency, time and intensity
of all exercises, or did glucose checking before and after
doing sports.
Five observational studies indicated a low engagement
in practicing exercises: 29% mentioned to practice exer-
cise[29], and only 25% [19], 27% [37], 33% [32] and
46% [40] said they were engaged in exercises on a regu-
lar basis. The most common type of exercise among par-
ticipants was brisk walking [26,37].
Less than half of the people who were engaged in
regular exercises did their exercise daily [26] and only
39% at least in 30 min of duration [37]. In one study
[31], 50.5% of respondents from Ethiopia reported to be
engaged in at least 30 min of physical activity for total of
3 days per week.
Interventions with frequent group education sessions
had mixed results based on the studies identified. One
study found a significant increase in physical activity
from 3 to 4.5 days per week [19], one found a
non-significant increase from 4.1 to 4.5 [18], and one
found a non-significant decrease from 4 to 3.9 days per
week [20].
Monitoring
Fifteen observational studies reported on patientsbe-
havior regarding monitoring of blood glucose. The vast
majority of respondents from Nigeria [24] and
Zimbabwe [25] reported to not be aware of SMBG.
Thirteen studies observed how many of the study partic-
ipants had the possibility to self-monitor their blood glu-
cose level and had access to a glucometer at home
(Fig. 2). The results indicate a very low degree of SMBG,
ranging from a study from Uganda, where none of the
patients had access to a glucose meter at home [41]to
one study from Nigeria with 43% of all patients doing
glucose testing at home [40]. On average only 15% of all
patients were able to test his or her blood glucose level
at home [23,25,29,31,32,4047].
Most patients, who had access to a glucometer at
home, checked their glucose level only once a month or
at no regular interval [21,45,47]. Only 1% [21] and 2%
[45] of respondents measured their glucose level on a
daily basis. One study mentioned that women did SMBG
more regularly than men [47]. Another study reported
that half of those people who performed SMBG, also
kept records of their results [40]. Most importantly, no
study reported patientsability to analyze test results and
whether they know what to do if their glucose numbers
are off target.
Medication
Twenty-three observational and three experimental
studies included information on peoplesawareness and
adherence to prescribed medication. The most common
type of medication prescribed were oral hypoglycemic
agents (OHA): On average, 86% were on OHA alone,
while 7% were on a combination of OHA and Insulin
and the remaining 7% were on Insulin alone [29,3133,
40,42,46,48,49]. The fact that diabetes drugs need to
be taken throughout the life-time was known by the ma-
jority of patients in Nigeria [24,29,36] and Uganda [34].
Fig. 2 Percentage of people who are able to self-monitor their blood-glucose level at home
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Six observational studies assessed patientsmedication
adherence by using the Morisky Medication Adherence
Scale (MMAS). It entails (8 or 4, depending on the
MMAS-version) questions about the self-reported med-
ical adherence. A perfect medication adherence is having
a full score on the MMAS (meaning 8 or 4 points). Set-
ting a cut-off point at 75% of the MMAS (indicating a
moderate level of adherence), the adherence rate is on
average 64% (see Fig. 3)[29,32,43,46,50,51].
Six other studies asked for the non-adherence (instead of
adherence) without utilizing a standardized questionnaire.
The results ranged from 20% of people who had a lack of
adherence[52], to 21% who stated that they missed the
medication[42], to 35% who were classified as having a
poor adherence[22], to half of all participants who re-
ported that they forget sometimesto take their medica-
tion [24]andwhodonottake the drugs on time[40].
One study [53] asked the responsible diabetes doctors
about their perception on patientsadherence to pre-
scribed medication. They concluded that the majority of
all patients are non-compliant with the pharmacotherapy.
All three experimental studies improved medication
adherence. A one-day education program in combin-
ation with weekly contacts among participants improved
the frequency of missed medicationfrom 1.9 to 1.6 (1
never, 5 daily) [18], and the four one-hour group educa-
tion programs about self-care behaviors improved the
medication adherence from 6.3 to 6.5 days a week [19]
and from 6.8 to 6.9 [20] days a week. However, all of
these improvements resulted to be non-significant.
Risk reduction
Thirteen observational studies and two interventional
studies dealt with risk reduction. Participants had vari-
ous levels of knowledge about general consequences and
complications of uncontrolled diabetes. All respondents
from Ghana attributed complications to medical
non-adherence [23] and most patients from a South Af-
rican study [22] connected their already developed com-
plications (e.g. foot problems, sexual dysfunction) to
uncontrolled diabetes. However, only few participants
were aware of the specific complications that could de-
velop: the most frequently named complications were
foot ulcers (on average named by 45%) and retinopathy
(on average 36%) [42,46,50,54,55]. Other complica-
tions named were neuropathy (31%), sexual dysfunction
(26%) [50,54], or nephropathy (18%) [42,50,54]. The
prevalence of cigarette smoking, which contributes to
developing complications, appeared to be not very
present and accounted on average for only 10% of all
participants [18,20,3133,36,43,50,54].
Having regular appointments at medical specialists
(e.g. eye-doctor or dentist) is an important aspect of risk
reduction. 77% of patients in one Nigerian study knew
that they should go to the doctor when they have
changes in their eyesight [38]. In another study 29%
stated that they had previous dilated eye examinations
[48]. On average, 80% [36,38] of participants knew that
they should take care of their teeth. No study assessed
the frequency of visits at medical specialists.
Proper foot care is also critical for the reduction of risks.
Most Nigerian diabetes patients knew that they have to
take extra care of their feet [36]. In Zimbabwe only half of
one group had been informed about foot care, and only
with a limited content [25]. There was also a men-women
discrepancy in one Ugandan study: women were better in-
formed on how they should take care of their feet then
men [34]. In one South African study all respondents re-
ported that they adhered to the recommended foot care
[55]. Two studies looking at group education programs
about self-care behaviors, improved the foot care of partic-
ipants non-significantly from 5.5 to 5.7 days per week [20]
and significantly from 4.5 to 5.8 days per week [19].
Psychosocial aspects
Only three observational studies reported about the psy-
chosocial aspects of having diabetes.
One study mentioned that the majority of patients re-
ceived support from their family [22]. Stress and insuffi-
cient sleep due to the diabetes appeared to be below 1%
among South African patients [19] and another study re-
vealed a moderate level of emotional distress [40]. How-
ever, no study on environmental or other social aspects
of living with diabetes was identified.
Alternative medicine
Although not included in the ADA framework (Table 1), al-
ternative medicine was seen as an important component in
Fig. 3 Morisky Medication Adherence Scaleresults showing the percentage of people with a moderate medication adherence (> 75%
of adherence)
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SSA for self-management: Eleven studies addressed the
utilization of alternative medicine by study participants.
This shows that the western based model of
self-management fails to describe the entire
self-management behavior of diabetes patients in SSA. 11%
of South African patients sought traditional healers [56]
and many respondents from Cameroon stated that they
used traditional diagnostic tools, such as tasting their urine
for glucose [15]. Herbal medicine was equally valued with
biomedical therapy [57] and frequently used [25]. The use
of herbal medicines as part of the diabetes treatment was
on average 32% [21,34,46,48]. For some participants, it
was grounded on their negative feelings and dissatisfaction
towards biomedicine [15]orthebeliefthatdiabetesisa
supernatural problem caused by witchcraft or fate [23,25,
55]. To others, the willingness to treat diabetes took them
to a 'modern' health facility but the willingness to cure
diabetes took them to a traditional healer [15,33,56].
Discussion
Main findings and recommendations
This is the first systematic review which analyzes the
self-management behavior of people with diabetes in SSA.
Studies which analyzed nutritional aspects (n= 20) re-
vealed a moderate level of adherence to recommended
diet plans, with adherence rates ranging from 33 to 87%
[16,2933]. Moreover, patients demonstrated a basic un-
derstanding of the right eating habits [16,19,2226], but
also revealed several gaps in their knowledge (e.g. regard-
ing the sugar-level of food) [19,24,28]. Those which ana-
lyzed physical activity aspects of self-management
behavior (n = 20) found that most patients were aware of
the importance of aerobic exercises [22,25,3437].
However, adherence rates to exercise plans varied between
29 and 46% [19,26,29,31,32,37,40]. Studies with
information on the medication (n= 26) showed that
Medication-adherence, measured by the MMAS question-
naire, was on the average 64% [29,32,43,46,50,51].
Other studies, which utilized other (non-MMAS) methods
confirmed these moderate results [22,24,40,42,52]. Risk
reduction was assessed by 15 studies. Patients connected
complications to uncontrolled diabetes, but only few were
aware of the specific complications that can be developed
[22,23,42,46,50,54,55] and how they can be prevented
[25,34,36]. There was no study assessing the frequency of
visits at medical specialists (such as an eye doctor or
dentist) and only one study mentioned that all patients ad-
hered to the recommended foot care [55]. Only three
studies reported on psychosocial aspects.Theyindicated
that people with diabetes seem to have a very low
emotional distress level [19,22,40]. Although not part of
the ADA self-management guidlines the use of herbal
medicine and traditional healers was frequently men-
tioned [21,25,34,46,5658]. Lowest adherence rates
were assessed for patients ability to self-monitor their
blood glucose. On average, only 15% were able to test the
blood glucose at home [23,25,29,31,32,4047]and
only very irregularly [19,21,45,47]. Studies which tested
DSME programs (n= 6) showed significant improve-
ments for eating and activity habits [16,18,19], medica-
tion adherence [21] and risk reduction behavior [19].
Improvements were ascertained for the adherence to ac-
tivity and medication plans [1820] and risk reduction be-
havior [20], but without significance. Also without any
significance, negative effects were shown in only one study
for eating and activity behaviors [20].
This review is important because it shows that
self-management of diabetes in SSA is insufficient. Par-
ticularly, the lack of physical activity, the inappropriate
risk reduction knowledge and behavior, and the missing
ability to self-monitor blood glucose are a serious threat
to good glycemic control. Medication and nutritional ad-
herence appeared to be better but are still sub-optimal.
By comparing the results with results from other coun-
tries outside SSA, we observe a similar ranking:The
three elements physical activity,risk reductionand
SMBGare also the most critical parts of
self-management outside SSA (adherence rates of 45
54%), while the adherence to medication and nutrition
plans is better: outside SSA medication plans are
followed by 87% (vs 64% in SSA). And diet plans are
followed by 76% outside SSA (vs 72% in SSA) [59].
Second, the review revealed that the (western-based)
ADA model of self-management fails to describe all
self-care activities in SSA. One third of all patients sought
alternative medicine beside of their biomedical therapy (in
non-SSA countries this is done by 8% [59]). For many
people it is therefore part of the self-management. Future
research should focus on the (unknown) ingredients of
herbal medicines and their interactions with other taken
medicines, such as OHA.
Third, the provision of structured DSME programs in
SSA is found to be effective. Most of the measured
self-management behaviors, such as the adherence to
medication or diet plans, were significantly improved by
DSME programs. This supports the existing literature,
which has proven that DSME is effective in non-SSA
countries [60]. Therefore, we recommend to improve the
current distribution of structured context-adapted DSME
programs in SSA. Important factors, such as the low ac-
cess to blood glucometers or the utilization of alternative
medicines, need to be considered when conceptualizing
these programs. Other factors, which have not been ad-
dressed in this review, need to be considered as well, e.g.
the shortages of healthcare workers [61] or the lack of
medicines [62]. Moreover, the implementation of struc-
tured DSME programs could be supported by technology.
So called mobile health (mHealth) solutions, which have
Stephani et al. BMC Public Health (2018) 18:1148 Page 8 of 11
Content courtesy of Springer Nature, terms of use apply. Rights reserved.
shown to be effective against non-communicable diseases
[63], could be used to guide health professionals through
the education process and to follow up with patients.
Last, our results showed that there is only very limited re-
search on psychosocial aspects in SSA. In contrast to all
other self-management factors, we identified only three
studies on psychosocial aspects (e.g. 21 studies on nutri-
tional behavior or 15 studiesaboutSMBG).Therefore,fu-
ture research should put a higher emphasis on the
assessment of the psychosocial situation, because factors
such as stress or the missing support by the family can have
ahighlynegativeimpactonpeoplewithdiabetesandare
associated with non-adherence to medication regimen and
other self-management behaviors [64].
Limitations
An important limitation of this review is that it combines
studies from 10 countries, which are culturally and eco-
nomically diverse. The generalizability of the results is
therefore problematic, because it was not always clear
whether the individual study results were representative
(see risk of bias assessment, additional files 3-5). The stud-
ies also differ in their objective, e.g. while some evaluated
DSME programs, others measured the adherence to OHA.
However, combining studies from various countries with
heterogeneous objectives is not unusual for reviews on
diabetes in SSA [65]. Furthermore, methods applied to
measure outcome-parameters varied among included stud-
ies. One example is the medication adherence: in some
studies people where simply asked whether they missed
medicationor forget sometimeto take their medication,
while other studies used the standardized MMAS scale.
Moreover, the analysis considers only patients who have
been diagnosed with diabetes. It is estimated that around
two thirds of all people who suffer from diabetes in SSA re-
main undiagnosed [3]. Another limitation concerns the
method used by all included studies: most of the measured
outcomes were self-reported. The use of self-reported mea-
sures, such as the medication adherence may underestimate
the non-adherence of patients [52]. Multiple methods may
be required to detect those who report adherence but who
may in fact be non-adherent.
Conclusion
There is a good amount of recent studies on self-
management behavior of type 2 diabetes in SSA. These
studies indicate that self-management in SSA is poor and a
serious threat to glycemic control. Particularly, self-
monitoring of blood glucose, physical activity and risk re-
duction behavior are insufficient. More research on the psy-
chosocial situation is needed. Future efforts and resource
investments in public health systems need to strengthen
the distribution of strucutred DSME programs which need
to be adapted to the SSA-context.
Additional files
Additional file 1: Search strategy used. (DOCX 12 kb)
Additional file 2: PRISMA checklist. (DOCX 26 kb)
Additional file 3: Risk assessment for cross-sectional studies. (DOCX 21 kb)
Additional file 4: Risk assessment for pre-post studies. (DOCX 14 kb)
Additional file 5: Risk assessment for RCTs. (DOCX 13 kb)
Abbreviations
ADA: American Diabetes Association; DSME: Diabetes Self-Management Edu-
cation; MMAS: Morisky Medication Adherence Scale; NCD: Non
Communicable Diseases; OHA: Oral Hypoglycemic Agents; SMBG: Self-
Monitoring of Blood Glucose; SSA: Sub Saharan Africa
Acknowledgments
The authors thank John Armstrong for helping with the extraction of
characteristics of included studies (Table 2) and Prof. Reinhard Busse for
providing guidance to the research.
Funding
This research received no specific grant from any funding agency in the
public, commercial, or non-profit sectors.
Availability of data and materials
The datasets supporting the conclusions of this article are included within
the article and its Additional files 1,2,3,4,5.
Authorscontributions
VS conceived the idea, collected data, participated in analysis and drafting of
manuscript. DO collected data and participated in analysis. DB participated in
analysis. All authors read and approved the final manuscript.
Ethics approval and consent to participate
Not applicable.
Consent for publication
Not applicable.
Competing interests
The authors declare that they have no competing interests.
PublishersNote
Springer Nature remains neutral with regard to jurisdictional claims in
published maps and institutional affiliations.
Author details
1
Department of Health Care Management, Technical University of Berlin,
Berlin, Germany.
2
Division of Tropical and Humanitarian Medicine, University
of Geneva and Geneva University Hospitals, Genève, Switzerland.
Received: 23 March 2018 Accepted: 20 September 2018
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... These five selfcare behaviours were based on the key indicators for self-care behaviour as suggested by the IDF and AADE [9,10]. Furthermore, these domains of self-care were also assessed by several review studies on self-care among people with T2DM in other settings [11,[22][23][24][25]. Studies not mentioning the type of diabetes examined, studies based on the same data set, and studies without a full-text publication available were excluded. ...
... A data extraction template similar to the one used in the systematic review of Stephani et al. [24] was developed in Microsoft Excel to collect information from the selected studies for the analysis. Information on the primary author, publication year, country, study design, sample size, demographic characteristics of the population (eg, age, gender, and other contextual information), and reported self-care behaviours were extracted. ...
... Adherence to self-care behaviour prevents T2DM-associated morbidities and mortalities [14,15]. The systematic reviews that included studies from Ethiopia [22,23], Sub-Saharan Africa [24], and LMICs [25] reported the poor practice of self-care behaviours among the people with T2DM and stressed the need for developing and implementing interventions to improve self-care behaviour. South Asians are at higher risk of developing NCDs, including type 2 diabetes [5], and the health care resources in this region are limited [128,129]. ...
Article
Full-text available
Background: The burden of Type 2 Diabetes Mellitus (T2DM) in South Asian countries is increasing rapidly. Self-care behaviour plays a vital role in managing T2DM and preventing complications. Research on self-care behaviours among people with T2DM has been widely conducted in South Asian countries, but there are no systematic reviews that assess self-care behaviour among people with T2DM in South Asia. This study systematically assessed the studies reporting self-care behaviours among people with T2DM in South-Asia. Methods: Adhering to the PRISMA guidelines, we searched six bibliographic databases (Scopus, PubMed, CINAHL, Embase, Web of Science, and PsychInfo) to identify the relevant articles published between January 2000 through March 2022. Eligibility criteria included all observational and cross-sectional studies reporting on the prevalence of self-care behaviours (ie, diet, physical activity, medication adherence, blood glucose monitoring, and foot care) conducted in South Asian countries among people with T2DM. Results: The database search returned 1567 articles. After deduplication (n = 758) and review of full-text articles (n = 192), 92 studies met inclusion criteria and were included. Forward and backward reference checks were performed on included studies, which resulted in an additional 18 articles. The pooled prevalence of adherence to blood glucose monitoring was 65% (95% CI = 49-80); 64% for medication adherence (95% CI = 53-74); 53% for physical activity (95% CI = 39-66); 48% for diet (95% CI = 38-58); 42% for foot care (95% CI = 30-54). About a quarter of people with T2DM consumed alcohol (25.2%, IQR = 13.8%-38.1%) and were using tobacco products (18.6%, IQR = 10.6%-23.8%). Conclusions: Our findings suggest that the prevalence of self-care behaviours among people with T2DM in South Asia is low. This shows an urgent need to thoroughly investigate the barriers to the practising of self-care and design and implement interventions to improve diabetes self-care behaviour among people with T2DM in South Asia.
... In Sub-Saharan Africa, like Ethiopia diabetes self-care practice was poor, affectation a serious threat to the health system of the population [18]. However, in a developing country like Ethiopia, where resources are limited and treatment costs are rising, focusing on self-care management may result in improved treatment outcomes and lower drug-related costs. ...
Article
Full-text available
Background Diabetes is a chronic disease that requires lifelong medical treatment and lifestyle modifications. Even though patients often neglect their own needs, self-care is an important factor in preventing and delaying complications related to diabetes. There are limited studies about self-care practice, and most of the studies conducted in Ethiopia focused on some parts of the recommended self-care practice. Therefore, this study aimed to assess the self-care practice and associated factors among diabetic patients in Gurage zone, south Ethiopia. Methods An institution-based cross-sectional study was conducted from February 6 to March 29, 2021. A systematic sampling method was employed to select 420 study participants. The data were collected using a pretested interviewer-administered questionnaire. All variables with P < 0.25 in the bi-variable logistic regression analysis were entered into multivariable logistic regression analysis. The statistical significance was declared at a p-value < 0.05. Results A total of 384 diabetes patients participated with a response rate of 91.4%. This study showed that more than half (60.4%) of the study participants had poor self-care practices. Being female (AOR: 2.40; 95% CI:1.31–4.40), rural residence (AOR:7.16;95% CI: 3.31–15.46), duration of diabetes treatment 5–10 years (AOR: 0.03; 95% CI: 0.1–0.11), duration of diabetes treatment ≥ 10 years (AOR:0.8; 95% CI: 0.03–0.21), haven’t social support (AOR: 0.10; 95% CI: 0.05–0.23), haven’t got health education (AOR: 0.17,95%CI 0.09–0.32) were factors significantly associated with self-care practice. Conclusions Despite, the importance of diabetes self-care practice for the management of diabetes and preventing its complications, a high number of diabetes patients had poor self-care practices. Female, rural residence, duration of diabetes mellitus, lack of social support, and not get of health education were significantly associated with poor self-care practice. Therefore, health care providers should give attention to diabetic patients with the aforementioned factors that affect diabetic patients’ self-care practices.
... Both healthcare and non-healthcare professionals provide DSME and social support [15]. For instance, reviews [16,17] report the use of medical professionals-led [18][19][20][21] and non-medical professionals-led support programs and those employing multidisciplinary teams [22][23][24]. Most interventions employ group meetings in tandem with home visits and mobile phone support [25][26][27]. ...
Article
Full-text available
Background Diabetes mellitus is a growing worldwide health challenge especially in sub-Saharan Africa. While the use and effectiveness of diabetes self-management interventions is well documented in high-income countries, little information exists in sub-Saharan Africa. Therefore, this study attempted to synthesize information in the literature on the use and efficacy of peer support and social networking in diabetes self-management in Kenya and Uganda. Objective The purpose of this scoping review is to summarize research on the extent of use and efficacy of peer support and social networking interventions in diabetes self-management in Kenya and Uganda. Design We searched PubMed, ScienceDirect and Cochrane Library databases for articles reporting peer support and social networking interventions in Kenya and Uganda published in English between 2000 and September 2021. Key words encapsulated three major themes: peer support, social networking and self-management. Hand searches were also conducted to select eligible papers. Data was extracted using a form prepared and piloted in line with PRISMA-ScR guidelines. Results Thirteen peer reviewed articles were selected for analysis. Eleven studies reported peer support interventions while two focused on social networks in diabetes self-management. Peer support and social networking interventions incorporated microfinance and group medical visits, diabetes self-management education, telephone support and Medication Adherence Clubs. Most interventions were delivered by multidisciplinary teams comprising nurses and other professionals, peer educators, peer leaders and community health workers. Most interventions were effective and led to improvements in HbA1c and blood pressure, eating behaviors and physical activity and social support. Conclusions The limited studies available show that peer support and social networking interventions have mixed results on health and other outcomes. Importantly, most studies reported significant improvements in clinical outcomes. Further research is needed on the nature and mechanisms through which peer support and social network characteristics affect health outcomes.
... Nevertheless, the full integration of exercise into routine healthcare in Africa is challenged by poor knowledge and attitudes of patients and healthcare providers [127]. In the same way, self-management of diabetes is poor in Africa as it faces numerous barriers [128,129]. Peersupport interventions have been increasingly recognized worldwide, but one may note that the transferability of interventions across different cultures might be difficult [24]. Research is needed to identify effective interventions to optimize glycaemic control in the context of sub-Saharan Africa. ...
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Background There is an increased burden of diabetes globally including in sub-Saharan Africa. The literature shows that glycaemic control among type 2 diabetes patients is poor in most countries in sub-Saharan Africa. Understanding the factors influencing glycaemic control in this region is therefore important to develop interventions to optimize glycaemic control. We carried out a systematic review to determine the prevalence and factors associated with glycaemic control in sub-Saharan Africa to inform the development of a glycaemic control framework in the Democratic Republic of the Congo. Methods We searched five databases (African Index Medicus, Africa-Wide Information, Global Health, PubMed, and Web of Science) using the following search terms: type-2 diabetes, glycaemic control, and sub-Saharan Africa. Only peer-reviewed articles from January 2012 to May 2022 were eligible for this review. Two reviewers, independently, selected articles, assessed their methodological quality using Joanna Briggs checklists, and extracted data. A meta-analysis was performed to estimate the prevalence of glycaemic control. Factors associated with glycaemic control were presented as a narrative synthesis due to heterogeneity as assessed by the I ² . Results A total of 74 studies, involving 21,133 participants were included in the review. The pooled prevalence of good glycaemic control was 30% (95% CI:27.6–32.9). The glycaemic control prevalence ranged from 10–60%. Younger and older age, gender, lower income, absence of health insurance, low level of education, place of residence, family history of diabetes, longer duration of diabetes, pill burden, treatment regimen, side effects, use of statins or antihypertensives, alcohol consumption, smoking, presence of comorbidities/complications, and poor management were associated with poor glycaemic control. On the other hand, positive perceived family support, adequate coping strategies, high diabetes health literacy, dietary adherence, exercise practice, attendance to follow-up, and medication adherence were associated with good glycaemic control. Conclusion Suboptimal glycaemic control is pervasive among patients with type-2 diabetes in sub-Saharan Africa and poses a significant public health challenge. While urgent interventions are required to optimize glycaemic control in this region, these should consider sociodemographic, lifestyle, clinical, and treatment-related factors. This systematic review and meta-analysis protocol is registered in PROSPERO under CRD 42021237941.
... Studies show that focusing on the current attachments and prioritizing what is being done in the present make people give up their efforts to accomplish more far-fetched and logical goals, and people who cannot resist their inner temptations are more likely to procrastinate [29]. Following a proper diet, eating the right amount, and quitting bad eating habits are the principles of controlling blood sugar and studies show that dietary non-adherence or poor adherence are common in diabetic patients [30,31]. ...
Article
Background and objectives:Health-related procrastination refers to a delay in the performance of health-related activities, which is a rather neglected subject despite being critical. Due to the adverse effects of procrastination on the care and treatment of patients with type-2 diabetes, it is necessary to explore procrastination among this group of patients through in-depth studies. The present research was conducted to explain different types of health-related procrastination in patients with type-2 diabetes.Materials and methodsThis qualitative study applied content analysis with 13 patients with type-2 diabetes selected via purposive sampling. Data were collected through individual and semi-structured interviews. The data were then analyzed using Lundman and Graneheim content analysis method.Findings:Based on the analysis of the data, instances of health-related procrastination in patients with type-2 diabetes were classified into six main categories, including minimizing self-care, poor adherence to treatment, poor nutritional habits, poor adherence to drug regimen, disregard for disease monitoring, and a sedentary lifestyle.Conclusions The results of this study provide an in-depth understanding of the various forms of health-related procrastination in patients with type-2 diabetes. These findings can be employed in the design, implementation, and monitoring of treatment and care programs targeting these patients.
... Despite the prevailing clinical importance of TCAM usage in the management of DM, further studies investigating the impact of TCAM on DM control and management are warranted [27]. In Africa, it remains unclear how patients manage their diabetes in light of combining TCAM and clinical therapy [35,36]. A paucity of information exists regarding the comparison of treatment approaches and methods used by DM patients due to various cultures and environments in South Africa, more specifically, KwaZulu-Natal, where DM is common among all race groups [37]. ...
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Background. Traditional medicine (TM) is widely used in both developing and developed countries to assist in the attempt to curtail the prevalence and increase in diabetes mellitus. Approximately 53% of South Africans use TM to prevent and treat their diseases. There is no conclusive evidence regarding the safety and effectiveness of TM versus prescribed medicine. The most common therapies used by diabetics in Africa include herbal treatments, nutritional products, spiritual healing, and relaxation techniques. Therefore, this study aimed to evaluate the use of TM in patients with T2DM who are on chronic therapy and living in KwaZulu-Natal. Method. This cross-sectional study was conducted at a district hospital, in which purposive sampling was used to recruit participants and data were collected using a structured questionnaire. Information collected included demographic data, information pertaining to home remedies/TM, and self-care practices employed by participants while using TM. Data were analyzed using Pearson’s chi-squared test, t-test, and multivariate logistic regressions to determine predictors of TM usage. Results. Only 92 (27%) of 340 participants reported using TM, with Indians being the most frequent users (58.24%). Approximately, 83.72% (n = 72) used TM in conjunction with prescribed medication. Most participants (56.32%) acquired TM knowledge from family. The most frequently used TM was lemon and honey, Aloe vera, bitter gourd, green tea, and cinnamon. Traditional medicine use among African participants was 0.56 times (OR = 0.56, 95% CI = 0.34, 0.93) lower than Indian participants. There were no significant predictors for TM usage among the variables tested. Conclusion. A low prevalence rate of TM usage in T2DM patients was found. A significant correlation was noted between ethnicity and TM use. Large-scale studies are required to determine the additive and synergistic effects of TM in health care. Consideration should also be given to integrating TM into mainstream health care.
... As such, individuals with diabetes need to acquire sufficient knowledge and skills about, and positive attitudes towards diabetes self-management. Unfortunately, ample researches have shown that individuals with diabetes, especially those with newly diagnosed diabetes, had suboptimal self-management knowledge and competence [6]. ...
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Background International guidelines advocate providing prompt structured education to individuals with diabetes at diagnosis. However, among the few eligible structured education programs, heterogeneous intervention regimens and inconsistent findings were reported. Eligible programs for Chinese individuals with diabetes are lacking. This study aimed to investigate the effects of a nurse-led integrative medicine-based structured education program on self-management behaviors, glycemic control and self-efficacy among individuals with newly diagnosed type 2 diabetes. Methods Employing a randomized controlled trial, 128 individuals with type 2 diabetes diagnosed in the preceding three to nine months were recruited from four university-affiliated tertiary hospitals in Xi’an City, Northwest China, and randomly allocated to the intervention or control groups after baseline assessments. Participants in the intervention group received a 4-week nurse-led integrative medicine-based structured education program, which is theoretically based on the Health Belief Model and Self-Efficacy Theory, in line with updated diabetes management guidelines, and informed by relevant systematic reviews. Participants in the control group received routine care. Self-management behaviors and self-efficacy were measured with the Summary of Diabetes Self-Care Activities and the Diabetes Management Self-Efficacy Scale at baseline, immediate post-intervention and 12 weeks following the intervention while Glycated Hemoglobin A was measured at baseline and the 12th-week follow-up. The intervention effects were estimated using the generalized estimating equation models. Results Participants in the intervention group exhibited significantly better self-management performance in specific diet regarding intake of fruits and vegetables at both follow-ups (β = 1.02, p = 0.011 and β = 0.98, p = 0.016, respectively), specific diet regarding intake of high-fat foods at the immediate post-intervention follow-up (β = 0.83, p = 0.023), blood glucose monitoring at the 12th-week follow-up (β = 0.64, p = 0.004), foot care at both follow-ups (β = 1.80, p < 0.001 and β = 2.02, p < 0.001, respectively), and medication management at both follow-ups (β = 0.83, p = 0.005 and β = 0.95, p = 0.003, respectively). The intervention also introduced significant improvements in Glycated Hemoglobin A (β = − 0.32%, p < 0.001), and self-efficacy at both follow-ups (β = 8.73, p < 0.001 and β = 9.71, p < 0.001, respectively). Conclusions The nurse-led integrative medicine-based structured education program could produce beneficial effects on multiple diabetes self-management behaviors, glycemic control and self-efficacy. Trial registration This study was retrospectively registered in the ClinicalTrials.gov . on 25/08/2017; registration number: NCT03261895 .
... knowledge about general complications of uncontrolled diabetes [23,24]. Therefore, studies conducted among T2DM patients in Ghana have focused on medical compliance [25], factors that affect patients' compliance to self-care activities [26], and a combination of both medication adherence and self-care behaviours [24]. ...
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The promotion of Diabetes Self-Management (DSM) practices, education, and support is vital to improving the care and wellbeing of diabetic patients. Identifying factors that affect DSM behaviours may be useful to promote healthy living among these patients. The study assessed the determinants of DSM practices among Type 2 diabetes mellitus (T2DM) patients using a model-based social cognitive theory (SCT). This cross-sectional study comprised 420 (T2DM) patients who visited the Diabetic Clinic of the Komfo Anokye Teaching Hospital (KATH), Kumasi-Ghana. Data was collected using self-structured questionnaires to obtain socio-demographic characteristics, T2DM-related knowledge, DSM practices, SCT constructs; beliefs in treatment effectiveness, level of self-efficacy, perceived family support, and healthcare provider-patient communication. Path analysis was used to determine direct and indirect effects of T2DM-related knowledge, perceived family support, and healthcare provider service on DSM practices with level of self-efficacy mediating the relationships, and beliefs in treatment effectiveness as moderators. The mean age of the participants was 53.1(SD = 11.4) years and the average disease duration of T2DM was 10 years. Most of the participants (65.5%) had high (>6.1mmol/L) fasting blood glucose (FBG) with an average of 6.93(SD = 2.41). The path analysis model revealed that age ( p = 0 . 176 ), gender ( p = 0 . 901 ), and duration of T2DM ( p = 0 . 119 ) did not confound the relationships between the SCT constructs and DSM specified in the model. A significant direct positive effect of family and friends’ support ( Critical ratio (CR) = 5 . 279 , p < 0 . 001 ) on DSM was observed. Self-efficacy was a significant mediator in this relationship ( CR = 4 . 833 , p < 0 . 001 ). There were significant conditional indirect effects (CIE) for knowledge of T2DM and family and friends’ support at medium and high levels of belief in treatment effectiveness (p < 0 . 05) via level of self-efficacy on DSM practices. However, no evidence of moderated-mediation was observed for the exogenous variables on DSM. Diabetes-related knowledge of T2DM, family and friends’ support, level of self-efficacy, and belief in treatment effectiveness are crucial in DSM practices among Ghanaian T2DM patients. It is incumbent to consider these factors when designing interventions to improve DSM adherence.
... Health education and self-management (SM) are among key strategies for T2D and HTN management according to the WHO [7], aimed at reducing disease complications. Self-management however, is considered poor in Sub-Saharan Africa [8] and challenging in South Africa [9]. Physiological benefits to patients in SM programmes are documented but harm can occur if SM is not patient-specific [10]. ...
... Type 2 diabetes (T2D) is the most common type of diabetes that highly affects low-and middle-income countries (LMICs). 1 According to the International Diabetes Federation (IDF), an estimated 537 million adults aged 20-79 are living with diabetes while about 240 million have undiagnosed diabetes worldwide. 2 Even though self-care practice is a key component of diabetes management to prevent patients' morbidity and premature death, 3 it is affected by patients, health care providers, and system-related barriers. 4 Moreover, prolonged hyperglycemia increased the risk of chronic complications. ...
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Background: Diabetes, together with its complications, has a considerable negative influence on people's quality of life and healthcare delivery and raises diabetic mortality. However, there is limited information about the diabetes-associated chronic complications in the study setting. Therefore, this study aimed to determine the burden and factors related to the chronic complications among patients with type 2 diabetes (T2D) in Eastern Ethiopia. Methods: A hospital-based cross-sectional study was conducted among 879 patients with T2D at two public hospitals in Harar. The data were collected through interviews using a structured questionnaire. Data related to the diagnosis of chronic complications and biochemical tests were extracted from medical records. The outcome variable was the number of chronic complications that happened to the patients. A generalized Poisson regression model with robust variance estimation was used to investigate the association of independent variables with chronic complications. An adjusted prevalence ratio with a 95% CI was reported to show an association using a p-value ≤0.05. Results: One or more chronic complications were presented in 43% of T2D (95% CI: 39.65, 46.19). Macrovascular and microvascular complications were found in 27.6% and 23.5% of patients, respectively. Urban residence (APR = 2.64; 95% CI: 1.54, 4.54), low wealth status (APR = 1.80; 95% CI: 1.17, 2.76), diabetes duration ≥5 years (APR = 1.46; 95% CI: 1.05, 2.01), hypertriglyceridemia (APR = 1.48; 95% CI: 1.07, 2.09) and poor self-care practices (APR = 1.62; 95% CI: 1.18, 2.23) were factors significantly associated with the chronic complications. Conclusion: The burden of chronic complications was high, with nearly half of T2D patients experiencing one or more chronic complications. Almost one in ten patients suffered from multiple chronic complications. The complications were mainly influenced by being urban resident, low wealth status, and poor self-care practices. Therefore, health care providers need to educate patients and promote self-care practices and healthy lifestyles to achieve treatment goals and lower the risk of chronic complications.
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Abstract Background Diabetes mellitus (DM) is increasing globally, with the greatest increase in Africa and Asia. In Zimbabwe a threefold increase was shown in the 1990s. Health-related behaviour is important in maintaining health and is determined by individual beliefs about health and illness but has seen little study. The purpose of the study was to explore beliefs about health and illness that might affect self-care practice and health care seeking behaviour in persons diagnosed with DM, living in Zimbabwe. Methods Exploratory study. Consecutive sample from a diabetes clinic at a central hospital. Semi-structured interviews were held with 21 persons aged 19-65 years. Data were analysed using qualitative content analysis. Results Health was described as freedom from disease and well-being, and individual factors such as compliance with advice received and drugs were considered important to promote health. A mixture of causes of DM, predominantly individual factors such as heredity, overweight and wrong diet in combination with supernatural factors such as fate, punishment from God and witchcraft were mentioned. Most respondents did not recognize the symptoms of DM when falling ill but related the problems to other diseases, e.g. HIV, malaria etc. Limited knowledge about DM and the body was indicated. Poor economy was mentioned as harmful to health and a consequence of DM because the need to buy expensive drugs, food and attend check-ups. Self-care was used to a limited extent but if used, a combination of individual measures, household remedies or herbs and religious acts such as prayers and holy water were frequently used, and in some cases health care professionals were consulted. Conclusions Limited knowledge about DM, based on beliefs about health and illness including biomedical and traditional explanations related to the influence of supernatural forces, e.g. fate, God etc., were found, which affected patients' self-care and care-seeking behaviour. Strained economy was stated to be a factor of the utmost importance affecting the management of DM and thus health. To develop cost-effective and optimal diabetes care in a country with limited resources, not only educational efforts based on individual beliefs are needed but also considering systemic and structural conditions in order to promote health and to prevent costly consequences of DM.
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It is becoming increasingly evident that patients with diabetes do not rely only on prescription drugs for their disease management. The use of herbal medicines is one of the self-management practices adopted by these patients, often without the knowledge of their healthcare practitioners. This study assessed the potential for pharmacokinetic herb-drug interactions (HDIs) amongst Nigerian adult diabetic patients. This was done through a literature analysis of the pharmacokinetic profile of their herbal medicines and prescription drugs, based on information obtained from 112 patients with type-2 diabetes attending two secondary health care facilities in Nigeria. Fifty percent of the informants used herbal medicines alongside their prescription drugs. Worryingly, 60% of the patients taking herbal medicines did not know their identity, thus increasing the risk of unidentified HDIs. By comparing the pharmacokinetic profile of eight identified herbs taken by the patients for the management of diabetes against those of the prescription drugs, several scenarios of potential HDIs were identified and their clinical relevance is discussed. The lack of clinical predictors points toward cultural factors as the influence for herb use, making it more difficult to identify these patients and in turn monitor potential HDIs. In identifying these possible interactions, we have highlighted the need for healthcare professionals to promote a proactive monitoring of patients' use of herbal medicines.
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Background: Diabetes mellitus (DM) appears to be a global epidemic and an increasingly major non-communicable disease threatening both affluent and non-affluent society. The study aimed to determine the knowledge of diabetic complications among diabetes mellitus clients visiting the Diabetic Clinical at Sampa Government Hospital, Ghana. Method: This questionnaire-based descriptive study recruited a total 630 patients visiting the Diabetes Clinic at the Sampa Government Hospital. Structured questionnaire was used to obtain information such as socio-demographic and knowledge on complications of diabetes. Results: Out of a total of 630 participants, 325 (51.5 %) knew diabetic foot as the most common complication followed by hypertension 223(35.4 %), neuropathy 184 (29.2 %), hypoactive sexual arousal 160(25.4 %), arousal disorder 135(21.5 %), eye diseases 112(17.7 %), heart disease 58(9.2 %), and renal disease 34(5.4 %). Comprehensive assessment of level of knowledge on the complications showed that majority 378(60.0 %) of T2D patients did not have knowledge on diabetes complications, 169(26.9 %) had inadequate knowledge on diabetics complication while 82(13.1 %) had adequate knowledge. The risk factors associated with the level of knowledge of diabetic complications were female gender adjusted odd ratio (AOR) =2.31 (1.56-3.41) married participants AOR = 3.37 (1.44-7.93), widowed AOR = 2.98 (1.10-8.08), basic level of education AOR =0.18 (0.082-0.50), Junior High School (JHS) and above of education level AOR = 0.035(0.017-0.75), 5-9 years of T2D duration AOR = 0.31(0.018-0.57), ≥10 years T2D duration AOR = 0.042 (0.02-0.10) and urban dwellers AOR = 0.36 (0.22-0.68) respectively. Conclusion: Participants knew the individual complication of diabetic mellitus but lack an in-depth knowledge on the complications. Further expansion of diabetic educative programs like using mass media and involving national curriculum of education can improve self-regulatory awareness of diabetic complications which may reduce the morbidity and mortality of diabetic patients.
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Background: The reasons of deaths in developing countries are shifting from communicable diseases towards non-communicable diseases (NCDs). At the same time the number of health care interventions using mobile phones (mHealth interventions) is growing rapidly. We review studies assessing the health-related impacts of mHealth on NCDs in low- and middle-income countries (LAMICs). Methods: A systematic literature search of three major databases was performed in order to identify randomized controlled trials (RCTs) of mHealth interventions. Identified studies were reviewed concerning key characteristics of the trial and the intervention; and the relationship between intervention characteristics and outcomes was qualitatively assessed. Results: The search algorithms retrieved 994 titles. 8 RCTs were included in the review, including a total of 4375 participants. Trials took place mostly in urban areas, tested different interventions (ranging from health promotion over appointment reminders and medication adjustments to clinical decision support systems), and included patients with different diseases (diabetes, asthma, hypertension). Except for one study all showed rather positive effects of mHealth interventions on reported outcome measures. Furthermore, our results suggest that particular types of mHealth interventions that were found to have positive effects on patients with communicable diseases and for improving maternal care are likely to be effective also for NCDs. Conclusions: Despite rather positive results of included RCTs, a firm conclusion about the effectiveness of mHealth interventions against NCDs is not yet possible because of the limited number of studies, the heterogeneity of evaluated mHealth interventions and the wide variety of reported outcome measures. More research is needed to better understand the specific effects of different types of mHealth interventions on different types of patients with NCDs in LaMICs.
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Background: Diabetes self-care behaviour adherence is considered to be the cornerstone in diabetes care. Hence, the success of long-term maintenance therapy for diabetes depends largely on the patients’ adherence with self-care behaviour. Objective: To assess Levels and Predictors of Adherence to self-Care Behaviour and Glycaemic Control among Adult Type 2 Diabetics at Arba Minch General Hospital, Southern Ethiopia. Method: An institutional based cross sectional study was conducted from [15th-February to 15th-March, 2015] and data were collected by using interviewer administered questionnaires. The data were entered into EPI-DATA version 3.1, and analysed by Statistical Package for Social Science (SPSS) version 20.0. Descriptive statistics were used for most variables; a bivariate analysis was employed to determine the presence of association between adherence to self-care behaviour with other variables at P-value less than 0.05. Multi-variable logistic regression was performed to identify independent predictors of glycaemic control and self-care behaviour adherence. Results: One hundred ninty four type 2 diabetics were participated in this study and 99 (51.0%) were Females. Mean age of participants was 50.3(±13.2) years, and 41.2% had good self-care behaviour adherence. Above one half (57.2%) had diabetes duration less than five years, with mean duration of diabetes 5.02 ± 3.8 years. Most of patients 169 (87.1%) were on oral anti diabetics Age 35-44 years [AOR=13.4, 95% CI=1.582, 113.56], Monthly income<750.00 birr [AOR=0.340, 95% CI=0.119, 0.976] and age at diabetes onset 15-24 years [AOR=11.3, 95% CI=2.621, 49.065] were independent predictors of self-care behaviour adherence. Conclusion: In our study area adherence to self-care behaviour of the study subjects were low. So strategies that can improve these discrepancies like provision of diabetes self-care education and counselling especially on importance of self-monitoring of blood glucose, physical activity and problem solving should be considered by responsible bodies.
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Aims: Exercise plays significant role in the health outcomes of patients with diabetes, however, little is known about patients' knowledge of exercise for plasma blood glucose control among patients with type-2 diabetes (T2D). This study investigated knowledge, attitude and practice (KAP) of exercise for plasma blood glucose control among patients with T2D. Materials and methods: This cross-sectional study recruited 299 patients with T2D (male=105; female=194) from selected government hospitals in Osun State, Nigeria using purposive sampling technique. Validated questionnaires were used to assess of exercise for plasma blood glucose control and socioeconomic status (SES) of the patients. Data were analysed using descriptive and inferential statistics. Alpha level was set at <0.05. Results: The mean age of respondents was 51.9±9.8 years. A majority, 245(81.9%) were married individuals and more than half, 195(65.3%) were in the low SES. One hundred and forty-eight (49.5%) had good knowledge of exercise whilst 269(90.0%) had negative attitude to exercise practice. Less than a third, 82(27.4%) engaged in exercise practice for plasma blood glucose control. There was significant association between knowledge and practice of exercise ((2)=12.535; p=0.002). Furthermore, significant associations were found between knowledge and gender ((2)=11.453; p=0.003), and socioeconomic status ((2)=29.127, p=0.001) but not associated with attitude towards exercise (p>0.05). Conclusion: Patients with demonstrated good knowledge of exercise for plasma blood glucose control but reported negative attitude and poor practice of exercise.
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This study aimed to determine the knowledge and prevalence of obesity among Ghanaian newly diagnosed type 2 diabetics. This cross-sectional study was conducted among diagnosed type 2 diabetics. Structured questionnaire was used to obtain data. Anthropometric measurements and fasting blood sugar levels were also assessed. Participants had adequate knowledge about the general concept of obesity (72.0%) and method of weight measurement (98.6%) but were less knowledgeable of ideal body weight (4.2%). The commonly known cause, complication, and management of obesity were poor diet (76.9%), hypertension (81.8%), and diet modification (86.7%), respectively. The anthropometric measures were higher among females compared to males. Prevalence of obesity was 61.3% according to WHR classification, 40.8% according to WHtR classification, 26.1% according to WC, and 14.8% according to BMI classification. Being female was significantly associated with high prevalence of obesity irrespective of the anthropometric measure used ( p < 0.05 ). Taking of snacks in meals, eating meals late at night, physical inactivity, excessive fast food intake, and alcoholic beverage intake were associated with increased prevalence of obesity ( p < 0.05 ). Prevalence of obesity is high among diabetic patient and thus increasing effort towards developing and making education programs by focusing on adjusting to lifestyle modifications is required.
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Africa is confronted by a heavy double burden of communicable and non communicable diseases. Cost effective interventions that can prevent the disease burden exist but coverage is too low due to health systems weaknesses. This editorial reviews the challenges related to leadership and governance; health workforce; medical products, vaccines and technologies; information; financing; and services delivery. It also provides an overview of the orientations provided by the WHO Regional Committee for Africa for overcoming those challenges. It cautions that it might not be possible to adequately implement those orientations without a concerted fight against corruption, sustained domestic and external investment in social sectors, and an enabling macroeconomic and political (i.e., internally secure) environment.
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Objective: The objective of the study was to explore the views and experiences of adults with type 2 diabetes mellitus on a nutrition education programme. Design: Interpretative phenomenological design. Setting: The setting was two community health centres in Moretele, North West province, South Africa. Subjects and outcome measures: The study subjects were adults with type 2 diabetes mellitus (n = 41, aged 40–70 years) participating in a nutrition education intervention (one-year randomised controlled trial). The intervention was based on the assessed nutrition education needs of the target group, and included the provision of nutrition education materials. Data were collected at the end of the training intervention (eight weeks) and at the end of the study (12 months). A self-administered, open-ended questionnaire was used at eight weeks (n = 31). Five focus group discussions were conducted at 12 months. A framework thematic analysis technique was employed. Results: The majority of participants indicated that they enjoyed the nutrition education programme at the two time periods. They were satisfied with its content and delivery. The education materials (pamphlet and fridge or wall poster) were seen as useful for the whole family, and as constant reminders of positive behaviour. Benefits indicated by the participants included a gain in health knowledge and skills, positive dietary changes, and improved health and family support. Participants also recommended the programme to other people with diabetes mellitus. Positive educator characteristics, such as competence, patience, being respectful and approachable, were cited as desirable. Conclusion: Participant-customised nutrition education can contribute to programme satisfaction, perceived benefits and adherence to the programme. The provision of education materials should form part of such programmes. Facilitators of nutrition education programmes should take responsibility for employing desirable personal attributes as this can enhance client participation.
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Background: Health professionals assign diabetes patients "homework" in that they give them instructions on how to manage diabetes, recognizing that most diabetes care takes place in the home setting. We studied how homework is practiced and whether knowledge and behavioral practices related to diabetes self-management diffuse from patients to their housemates. Method: This mixed-methods study combined quantitative data from a household survey including 90 rural Ugandan households (50% had a member with type 2 diabetes [T2D]) with qualitative data from health facilities and interviews with 10 patients with T2D. Focus for data collection was knowledge and practices related to diabetes homework. A generalized mixed model was used to analyze quantitative data, while content analysis was used for qualitative data analysis. Results: Patients with T2D generally understood the diabetes homework assignments given by health professionals and carried out their homework with support from housemates. Although adherence to recommended diet was variable, housemates were likely to eat a healthier diet than if no patient with T2D lived in the household. Knowledge related to diabetes homework diffused from the patients to housemates and beyond to neighbors and family living elsewhere. Knowledge about primary prevention of T2D was almost absent among health staff, patients, and relatives. Conclusions: Homework practices related to T2D improve diabetes-related knowledge and may facilitate healthy eating in nondiabetic housemates. These findings suggest that having a chronic disease in the household provides an opportunity to improve health in the entire household and address the lack of knowledge about prevention of T2D.