Diabetes Self-Care Activities and Glycaemic Control among Adults with Type 2 Diabetes in Sri Lanka: A Cross-Sectional Study

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Journal of Biosciences and Medicines, 2019, 7, 99-111
http://www.scirp.org/journal/jbm
ISSN Online: 2327-509X
ISSN Print: 2327-5081
DOI:
10.4236/jbm.2019.75013 May 17, 2019 99 Journal of Biosciences and Medicines
Diabetes Self-Care Activities and Glycaemic
Control among Adults with Type 2 Diabetes in
Sri Lanka: A Cross-Sectional Study
Meerigama Arachchige Rasoda Saumika1, Thamara Dilhani Amarasekara2, Rasika Jayasekara3
1Department of Nursing, Faculty of Health Sciences, The Open University of Sri Lanka, Sri Lanka
2Department of Nursing& Midwifery, Faculty of Allied Health Sciences, University of Sri Jayewardenepura, Sri Lanka
3School of Nursing and Midwifery, University of South Australia, South Australia, Australia
Abstract
The prevalence of Type 2 Diabetes Mellitus (T2DM) and its complications
continue to rise across the globe including Sri Lanka. Diabetes Self-care activ-
ities (DSCA) are promising behaviors to reduce complications and to achieve
good glycaemic control. There is a lack of data regarding DSCA and its asso-
ciation with glycaemic control among adults with T2DM in Sri Lanka. A de-
scriptive cross-sectional study was conducted among purposively sel
ected
adults with T2DM (n = 300) in a teaching hospital,
Sri Lanka to determine
the association between DSCA and glycaemic control. Apre-tested interview-
er-administered questionnaire which includes socio-demographic, di-
abetes-related information and Summary of Diabetes Self-care activities ques-
tionnaire was used to collect data. Data were analyz
ed by using descriptive
statistics and Chi-square test
.
General diet (Healthy eating plan) (OR = 3.04,
95% CI = 1.04 - 8.88, p = 0.034), Physical activities (OR = 2.26, 95% CI = 1.29 -
3.97, p = 0.004), Medication adherence (OR = 2.87, 95% CI = 1.24 - 6.64, p
=
0.011) were significantly associated with HbA1c.
Medication adherence was
significantly associated with poor fasting blood sugar (FBS) (OR = 1.90, 95%
CI = 1.07 - 3.37, p = 0.028). The findings highlight the need for health profes-
sionals to implement health education programs on diabetes self-care activi-
ties for adults with T2DM to enhance their adherence to DSCA,
as well as to
maintain glycemic control.
Keywords
Diabetes Self-Care Activities, Glycemic Control, Adults, Type 2
Diabetes Mellitus, Sri Lanka
How to cite this paper:
Saumika,
M.A.R.,
Amarasekara,
T.D. and Jayasekara, R.
(201
9) Diabetes Self-
Care Activities and
Glycaemic Control among Adults with
Type
2 Diabetes in Sri Lanka: A Cross
-
Sectional
Study
.
Journal of Biosciences and Medicines
,
7
, 99-111.
https://doi.org/10.4236/jbm.2019.75013
Received:
December 27, 2018
Accepted:
May 14, 2019
Published:
May 17, 2019

M. A. R. Saumika et al.
DOI:
10.4236/jbm.2019.75013 100 Journal of Biosciences and Medicines
1. Introduction
T2DM has become a global epidemic that affects over 377 million people world-
wide, with estimated prevalence rates rising to an alarming 642 million people
by 2040 [1]. Most people with diabetes live in low- and middle-income coun-
tries, and these countries will experience the highest increase in cases of diabetes
over the next two decades [2]. Diabetes Mellitus (DM) is a group of illnesses
characterized by high blood glucose levels that result from defects in the body’s
ability to produce and/or use insulin. T2DM is the most common form of dia-
betes in which the body is unable to produce adequately to overcome insulin re-
sistance and affects various organs and systems [3]. In Sri Lanka, DM is a sig-
nificant health problem; with an unprecedented current level of prevalence [4].
According to a recent study, the age-adjusted prevalence for T2DM was 20.3%
for males and 19.8% for females in an urban cohort, and of those diagnosed with
T2DM, only23.8% were optimally controlled [5]. However glycaemic control has
an effect on improving diet, exercise, medication, foot care efficacy and behav-
iors [6]. As there is no cure for diabetes, self-care activities are promising activi-
ties in blood sugar control among patients with T2DM. In Sri Lanka, the major-
ity of the adults with T2DM did not involve recommended DM management
strategies including restricting refine sugar, regular exercises or checking blood
sugar regularly [7] and the majority of adults with T2DM did not achieve desired
glycaemic control [8].
2. Literature Review
Several previous studies have shown that high levels of patients adherence to
diabetes self-care behaviors resulted in better metabolic control [9] [10] [11] [12]
and self-care skills play a crucial role in optimal diabetes control [13]. Diabetes
self-care Activities (DSCA) include a range of activities such as self-monitoring
of blood glucose, eating a healthy diet, being physically active, taking the rec-
ommended medication and consulting health care professionals [14]. A Chinese
study revealed that; effective-patient communication, social support, and higher
self-efficacy were associated with performing diabetes self-care behaviors; that
were directly linked to glycaemic control [15]. A study suggested that interactive
health education programs should be introduced to increase patient adherence
to the treatment, and the importance of family members’ involvement in en-
couraging patients’ glycaemic control [16].
According to studies, Sri Lanka is among the countries with the highest dia-
betes prevalence rates in the world [17]. Sri Lankan studies revealed that one in
five adults has either diabetes or pre-diabetes condition [18]. A national survey
conducted in 2005 to 2006, explored that the prevalence of T2DM was twice as
high in persons from urban areas (16.4%) as compared to persons from rural
areas (8.7%) [18]. In 2016, the number of death attribute due to the high blood
glucose level in Sri Lanka was 4660 males and 2470 females of the age limit be-
tween 30 to 69 which is significantly higher compared to the universal figure of

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2860 males and 1740 females [19]. In the same year, the prevalence of diabetes in
Sri Lanka was among males 7.3% females, and 8.4% [19]. Further, the research-
ers revealed that the incidence of diabetes risk factors such as the prevalence of
overweight among males was 18.9%, and females 32.9% [19]. Prevalence of obe-
sity among men was 3.5% and among women was 10.0%. Prevalence of physical
inactivity is higher in women (30.2%) compared with men (16.9%) [19]. There is
an apparent deficiency in self-care practices; medication adherence, dietary
practices, physical exercises, foot care practices and identification and preven-
tion of complications among patients with diabetes; however the majority of the
participants in their study preferred to learn more about how to control their
DM [20]. Self-care activities are much crucial to glycaemic control among adults
with T2DM. Hence it is important to determine the association between DSCA
and the glycaemic control.
3. Method
3.1. Design
A descriptive, cross-sectional design was used and 300 purposively selected
adults with T2DM were selected based on inclusion and exclusion criteria.
3.2. Participants and Setting
This study was conducted at a diabetic clinic at Sri Jayewardenepura General
Hospital (SJGH), Colombo, Sri Lanka which provides care for the large number
of adults with T2DM. The Diabetic clinic runs only 2 days per week (Wednesday
and Thursday) and usually, 30 patients attend the clinic per day.
This study included adult participants (age 18 and above) with a diagnosis of
T2DM, and a minimum duration of >6 months of diagnosis was required be-
cause the participants need some time to adapt to their illness and to practice
diabetes self-care. Adults with T2DM who had physical or cognitive impair-
ments, pregnant women, adults who have diagnosed with diabetes less than six
months and adults who were severely ill were excluded from the study.
3.3. Data Collection
An Interviewer-administered questionnaire was developed by the researcher,
using the revised version of the Summary of Diabetes Self-care Activities
(SDSCA) that is used to measure self-care activities of diabetic patients [14]. The
author permission was obtained to use the SDSCA for this study. The question-
naire used in this study contains three parts namely: Part-A sociodemographic
information, Part-B Diabetes related information (duration of having diabetes,
family history of diabetes, HbA1c investigations etc.) and Part C consisted of a
validated summary of diabetes self-care activities (SDSCA). The SDSCA scale is
a self-reporting measure of the DSCA: diet, exercise, blood glucose testing,
medication taking, foot care, and smoking behaviour. The SDSCA asked the
participants to report the frequency in which they perform the above-mentioned

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DSCA over the past 7 days. If they were sick during the past 7 days, they were
asked to reflect on the 7 days before they became ill. The questionnaire was
pre-tested among 10 patients with T2DM to determine acceptability, feasibility,
comprehensibility and appropriateness and these participants did not participate
in this study.
3.4. Ethical Considerations
Ethical approval was obtained from the Ethics Review Committee of Faculty of
Medical Sciences University of Sri Jayewardenepura, Sri Lanka and Ethics Re-
view Committee of SJGH. Without disturbing to the clinic routines, the conven-
ient time for participants was used for data collection. Informed written consent
was obtained from all participants after a detailed explanation of the purpose
and procedures used for the study. All the participants were informed that the
privacy and confidentiality would be ensured during all steps of the study.
Hence, all the participants had the right to avoid participation at any time of the
study. All data collected were treated as private and confidential to maintain
anonymity. Data were stored on password secure digital storage which could
only be accessible for the investigators.
3.5. Data Analysis
Sample characteristics were analysed by using descriptive statistics, by using
SPSS (Statistical Package for Social Sciences) 20.0 version. The association be-
tween level of self-care practices, HbA1c, FBS, BMI, and socio-demographic
factors was tested by using Pearson’s Chi-square test. Results were presented by
using descriptive statistics including percentages and graphs. A confidence value
of 95% and the probability of <0.05 were considered statistically significant for
all tests.
4. Results
4.1. Socio-Demographic Characteristics of Adults with T2DM
As presented in Table 1 the majority of participants were female (n = 206;
68.7%), and 253 (84.3%) were married. Nearly 48% (n = 143) participants be-
longed to the 50 - 64 age group. More than half (51.3%) were educated to Ad-
vance Level (high school) and above and 60% had an income more than Rs
40,000 (46.3%, 139) were housewives, and 84 (28%) were retired.
4.2. Diabetes-Related Information of Adults with T2DM
Clinical characteristics of adults with T2DM are presented in Table 2. Nearly
half of participants (44.7%, 134) had been diagnosed with T2DM for 2 - 10 years.
Most participants (73%) had a family history of diabetes. More than half (51.7%)
had a normal BMI (18.5 - 24.99) with a mean of 24.66 (standard deviation [SD] =
4.51). Nearly half of participants (52.7%, 158) adults had a good fasting blood
glucose level (≤126 mg/dl); however, 75.7% of participants demonstrated HbA1c

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Table 1. Socio-demographic characteristics of adults with T2DM (
n
= 300).
Characteristics.
Frequency
Percent (%)
Gender
Female 206 68.7
Male 94 31.3
Age (years)
18 - 29 8 2.7
30 - 49 59 19.7
50 - 64 143 47.7
65 - 70 67 22.3
≥71 23 7.7
Ethnicity
Sinhala 273 91.0
Tamil 13 4.3
Muslim 12 4.0
Burgher 2 0.7
Educational status
Not attained to the school 1 0.3
Grade 1 - 5 3 1.0
Grade 6 - 10 40 13.3
Ordinary level 102 34.0
Advanced level 99 33.0
Higher education 55 18.3
Marital status
Single 10 3.3
Married 253 84.3
Other 37 12.3
Occupation
Professional 21 7.0
Technical & clerical 13 4.3
Vendors & sellers 21 7.0
Skilled manual workers 12 4.0
Unskilled manual workers 5 1.7
Retired 84 28.0
Unemployed 5 1.7
Housewife 139 46.3
Average monthly income for the family
(In Sri Lankan Rupees)
Less than 29,999Rs 25 8.3
30,000Rs - 40,000Rs 95 31.7
40,001Rs - 60,000Rs 109 36.3
60,001Rs - 80,000Rs 48 16.0
More than 80,001Rs 23 7.7

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Table 2. Diabetes related information of adults with T2DM (
n
= 300).
Characteristics.
Frequency
Percent (%)
Duration of diabetes
6 - 12 months 11 3.7
1 - 2 years 30 10
2 - 10 years 134 44.7
>10 years 125 41.7
Family history of Type 2
diabetes mellitus
Yes 219 73
No 80 26.7
Don’t know 1 0.3
BMI (body mass index
) 23 7.7
Under weight < 18.50 155 51.7
Normal 18.50 - 24.99 85 28.3
Overweight 25 - 29.99 37 12.3
Obese ≥ 30
HbA1c value.
Good Control < 7% 73 24.3
Poor control. ≥ 7% 227 75.7
Fasting blood sugar value.
Good Control ≤ 126 mg/dl 158 52.7
Poor control > 126 mg/dl 142 47.3
Medication
Oral pills only 216 72.0
Oral and Insulin 71 23.7
Insulin only 13 4.3
value (≥7%). Majority of participants (72%) controlled their blood glucose levels
using oral hypoglycaemic agents.
4.3. Summary of Diabetes Self-Care Activities of Adults with T2DM
According to the results, 262 (87.4%) of the adults with T2DM followed General
Diet (Healthy eating plan) and 170 (56.6%) not followed a specific diet (fruits
and vegetables, less meat and dairy products), 3 or more than 3 days from 7
days. Exercise regimen (30 minutes and specific exercise) was followed by 166
(55.3%) participants on 3 or more than 3days in the past 7 days, and 71 (23.7%)
did not follow exercise regimen in even a single day. More than half (60.3%) of
the participants did not perform self-monitoring of blood glucose (SMBG) even
a single day while 59 (19.7%) performed SMBG 3 or more than 3 days in the past
7 days. Nearly half (49.7%) did not perform foot care (Checked feet, wash feet,
soak feet, dry between toes after washing) even a single in the past seven days.

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Only 131 (43.7%) followed foot care 3 or more than 3days in the past 7 days.
Majority of the participants (80%) reported adhering to medication regularly. A
small percentage of the participants smoked at least 1 puff (4.7%) in the past 7
days.
Socio-demographic characteristics are not significantly associated with
HbA1c, FBS, Diet, SMBG and Medication adherence. Associations of
socio-demographic characteristics with physical activity are presented in Table
3. People; age ≤49 years had good physical activity when compared to people
≥50 years. Age was significantly associated with physical activity (OR = 2.46,
95% CI = 1.37 - 4.44, p = 0.002). As shown in Table 4 female participants
showed good foot care practices when compared to male participants. Gender
was significantly associated with foot care (OR = 1.68, 95% CI = 1.01 - 2.78, p =
0.043).
4.4. Associations of DSCA with Glycemic Control
Associations of DSCA with Glycemic control are presented in Table 5. Partici-
pants who have followed the general diet and specific diet showed good glycemic
control when compared to adults with poor self-care activities in general diet
and specific diet. General diet was significantly associated with HbA1c (OR =
3.04, 95% CI = 1.04 - 8.88, p = 0.034). Physical activities also significantly associ-
ated with HbA1c (OR = 2.26, 95% CI = 1.29 - 3.97, p = 0.004). Both general diet
(OR = 3.64, 95% CI = 1.70 - 7.79, p = 0.000) and specific diet (OR = 2.37, 95% CI =
Table 3. Associations of socio-demographic demographic characteristics with physical
activity (n = 300).
Good
(3 - 7 days)
Poor
(0 - 2 days)
OR
95% CI
Lower
Upper
Age
18 - 49 (Years) 48* 19 2.46 1.37 4.44
≥50 (Years) 118 115
Gender
Female 121 85 1.55 0.95 2.53
Male 45 49
Education Level
≤Ordinary level 75 71 0.73 0.46 1.16
>Ordinary level 91 63
Monthly income
≤40,000Rs 66 54 0.98 0.61 1.56
≥40,001Rs 100 80
Marital status
Married 141 112 1.108 0.59 2.07
Single and Other 25 22
*p < 0.05, **p < 0.001 level of significance.

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Table 4. Associations of Socio-demographic demographic characteristics with Foot care
(n = 300).
Foot care
Good
(3 - 7 days)
Poor
(0 - 2 days)
OR
95% CI
Lower
Upper
Age
18 - 49 (Years) 28 39 0.91 0.52 1.57
≥50 (Years) 103 130
Gender
Female 98* 108 1.68 1.01 2.78
Male 33 61
Education Level
≤Ordinary level 56 90 0.66 0.41 1.04
>Ordinary level 75 79
Monthly income
≤40,000Rs 53 67 1.03 0.65 1.65
≥40,001Rs 78 102
Marital status
Married 108 145 0.78 .42 1.45
Single and Other 23 24
*p < 0.05, **p < 0.001 level of significance.
1.48 - 3.79, p = 0.000) were highly significant with FBS. Medication adherence
was significantly associated with both HbA1c (OR = 2.87, 95% CI = 1.24 - 6.64, p =
0.011) and FBS (OR = 1.90, 95% CI = 1.07 - 3.37, p = 0.028). Other DSCA out-
comes are not significantly associated with Glycemic control.
5. Discussion
Even though this study findings clearly indicate more than half of the partici-
pants had good FBS level; the majority of the participants had poor HbA1c
value. Results from other studies have also reported poor glycaemic control
among adults with T2DM.According to another Sri Lankan study, most partici-
pants did not achieve the recommended fasting blood glucose level (<126
mg/dL) [8]. Iranian study also indicated 42.9% did not reach the target FBS level
[21]. In this study, the majority of the participants had a family history of diabe-
tes. Another cross-sectional national survey which was conducted among 5000
adults in Sri Lanka have also shown, the prevalence of diabetes was significantly
higher in patients with a family history (23.0%) than those without (8.2%) family
history (p < 0.001) [22]. The current study findings also revealed that more than
half (51.7%) had a healthy BMI (18.5 - 24.99). This finding is consistent with an-
other study that showed nearly half (48.3%) of the study participants had a
healthy BMI (18.0 - 24.9) [8].

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Table 5. Association of DSCA with glycemic control (n = 300).
Glycemic control (HbA1c)
Glycemic control (FBS)
Good
Control
<7%
Poor
control
≥7%
OR
95% CI
Good
Control
≤126 mg/dl
Poor
control
>126
mg/dl
OR
95% CI
Lower
Upper
Lower
Upper
General Diet
Good
(3
- 7 days) 69* 193 3.04 1.04 8.88 148** 114 3.64 1.70 7.79
Poor
(0
- 2 days) 4 34 10 28
Specific Diet
Good
(3
- 7 days) 36 94 1.38 0.81 2.34 84** 46 2.37 1.48 3.79
Poor
(0
- 2 days) 37 133 74 96
Physical
activities.
Good
(3
- 7 days) 51* 115 2.26 1.29 3.97 90 76 1.15 0.73 1.81
Poor
(0
- 2 days) 22 112 68 66
SMBG
Good
(3
- 7 days) 10 49 0.58 0.28 1.21 32 27 1.08 0.61 1.92
Poor
(0
- 2 days) 63 178 126 115
Foot Care
Good
(3
- 7 days) 36 95 1.35 0.80 2.30 72 59 1.18 0.75 1.86
Poor
(0
- 2 days) 37 132 86 83
Medication
adherence
Good
(All 7 days)
*66 174 2.87 1.24 6.64 *134 106 1.90 1.07 3.37
Poor
(0
- 6 days) 7 53 24 36
*p < 0.05, **p < 0.001 level of significance.
In the present study, even though the majority (87.3%) of the adults followed
General Diet 3 or more than 3 days in the past 7 days (Healthy eating plan),
56.7% not observed specific diet 3 or more than 3 days in the past 7 days. As the
Sri Lankan diet is high in calories from carbohydrates, the main message for
dietary change should focus on the reduction of rice consumption with supple-

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mentation of more portions of vegetables and green leaves [23]. However, a Sri
Lankan study has shown the majority of participants (71.7%) practised some
dietary control [8]. According to another Sri Lankan study, among the partici-
pants, 56.7% had poor dietary practices in relation to T2DM [21].
The current study also revealed more than half of participants (55.3%) fol-
lowed exercise regimen on 3 or more than 3 days in the past 7 days. Even though
adults with T2DM have poor knowledge regarding exercise, the majority had an
adequate level of physical activity during their daily activities, and they have a
positive attitude towards physical activity [24]. In a Sri Lankan study, among the
participants, 34.56% followed the recommended exercise [21]. However, a Sri
Lankan study has shown the majority of participants (85.2%) did not practice
any form of exercise [8]. In this study more than half of the participants not
performed SMBG even a single day. According to another Sri Lankan study of
146 adults with T2DM, only 5 (3.6%) have practised SMBG (at least monthly)
[25].
Nearly half (49.7%) did not perform foot care even a single day in the past
seven days. Only 43.7% followed foot care 3 or more than 3 days in the past 7
days. In similar to the present study another Sri Lankan study also showed a
large proportion (75.3%) of the participants have not engaged in foot care ade-
quately [21]. However, in the current study, a majority of the participants who
participated in foot care were women. This may be due to, females more concern
of their body and as most of the women in the sample are housewives as they
have more time to engage foot care practices. In Oman, of 350 adults with
T2DM, 73.9% followed foot care practices and Omani adults’ foot care practices
were high when comparing to the current study [26]. This may be due to lack of
foot care clinics in Sri Lanka. As similar to the present study, the same Omani
survey has shown, significant associations between gender and foot care [26].
Even though the present study showed the majority of the participants (80%)
adhered to medication regularly, in contrast to these results another Sri Lankan
study revealed, among the participants, 59.73%, showed poor medication prac-
tices [21]. According to the Omani study medication adherence was 77%, 3 or
more than 3 days in the past 7 days [26]. The Omani study further reviled, less
than half percentage (45.5%) of the adults smoked at least 1 puff in the past 7
days [26]. In contrast to this study, among the Omani adults smoking was high.
This may be due to the Sri Lankan government’s new legislation that enforced to
include graphic warnings covering 60% of the surface area of packets of ciga-
rettes. A Sri Lankan study also reviled 71.93% of the 119 participants were of the
view that the demonstrated pictorial warnings would persuade the smokers to
give up smoking [27]. In this study, general diet, physical activity and medica-
tion adherence were significantly associated with HbA1c. According to the re-
sults of a cross-sectional study; its bivariate analysis indicated the same three
variables were significantly associated with HbA1c: adherence to diet, physical
exercise, and medication-taking regimen [16].

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This study had some limitations in the assessment of glycaemic control, in
that FBS and HbA1c were done in different laboratories. In Sri Lanka, such test-
ing might not have uniform standards. The study was conducted in a Colombo
based teaching hospital, and there is reduced the ability to generalize findings to
the whole country. As weight and height also recorded by patient’s medical re-
cords, inconsistency may be high.
6. Conclusion and Implications for Practice
According to the findings, the majority of the participants followed the General
Diet and more than half not followed a specific diabetic diet. A considerable
amount of adults did not pursue an exercise regimen for even a single day. More
than half of the participants did not perform SMBG even a single day. Nearly
half of the participants did not perform foot care even a single in the past seven
days. Majority of the participants, (80%) reported adhering to recommended
medication regularly. Nearly half of the participants had a good fasting blood
glucose level (≤126 mg/dl) while the majority (75.7%) demonstrating poor
HbA1c value (≥7%). Both general Diet and specific diet were highly significant
with FBS. Physical activities were significantly associated with HbA1C. Female
participants showed more adherence to foot care practices compared with male
participants. Age was associated with considerably physical activities. Thus all
these findings indicate that adults with good control of HbA1c and FBS reported
better adherence to DSCA.
The findings prove that there is an urgent need for improving DSCA among
adults with T2DM. This study can guide diabetes nurse educators to understand
the extent to which different self-care behaviors that affect glycaemic control.
Health educational interventions are necessary to improve glycaemic control.
Most of the adults’ SMBG practice was poor. This may be due to financial cost.
Therefore health policies should introduce to facilitates SMBG. We suggest fur-
ther improvement into this model with a prospective and longitudinal study to
observe the association between SDSCA and HbA1c in the long term.
Acknowledgements
Deep gratitude is expressed to the study participants for their participation and
support to this study.
Conflicts of Interest
The authors declare no conflicts of interest regarding the publication of this
paper.
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