Africa Zanzibar 2018

The University of Dodoma
University of Dodoma Institutional Repository http://repository.udom.ac.tz

Health Sciences Master Dissertations
2018
þÿThe effect of caregivers level of

knowledge on blood glucose control in
children with type one diabetes mellitus
in Zanzibar
Salim, Nunuu A
The University of Dodoma
þÿSalim, N.A. (2018). The effect of caregivers level of knowledge on blood glucose control in
children with type one diabetes mellitus in Zanzibar. Dodoma: The University of Dodoma
http://hdl.handle.net/20.500.12661/1750
Downloaded from UDOM Institutional Repository at The University of Dodoma, an open access institutional repository.
THE EFFECT OF CAREGIVERS LEVEL OF KNOWLEDGE
ON BLOOD GLUCOSE CONTROL IN CHILDREN WITH
TYPE ONE DIABETES MELLITUS IN ZANZIBAR
NUNUU ALI SALIM
MASTERS OF SCIENCE IN PEDIATRICS NURSING
UNIVERSITY OF DODOMA
OCTOBER, 2018
THE EFFECT OF CAREGIVERS LEVEL OF KNOWLEDGE ON
BLOOD GLUCOSE CONTROL IN CHILDREN WITH TYPE ONE
DIABETES MELLITUS IN ZANZIBAR
BY
NUNUU ALI SALIM
A DISSERTATION SUBMITTED IN PARTIAL FULFIMENTS OF THE
REQUIREMENTS FOR A DEGREE OF MASTERS OF SCIENCE IN
PEDIATRICS NURSING
THE UNIVERSITY OF DODOMA
OCTOBER, 2018
DECLARATION
AND
COPY RIGHT
I, Nunuu Ali Salim, declare that, this dissertation is my own original work and that it has
not been presented and will not be presented to any other university, for a similar or any
other degree award.
Signature …………………………..
No part of this dissertation may be reproduced, stored in any retrieval system, or
transmitted in any form or by any means without prior written permission of the author or
the University of Dodoma. If transformed for publication in any other format shall be
acknowledged that, this work has been submitted for degree award at the University of
Dodoma”.
i
CERTIFICATION
The undersigned certify that they have read and here by recommend for acceptance by the
University of Dodoma, a dissertation entitled: The effect of Caregivers Level of
Knowledge on Blood Glucose Control in Children, with Type One Diabetes Mellitus in
Zanzibar” in partial fulfillment of the requirements for the award of Masters of Science in
Pediatric in Nursing.
Dr. Stephen Kibusi (Supervisor 1)
Signature ………………………….. Date…………………………..
Dr. Mariam Muyogwa (Supervisor 2)
Signature ………………………….. Date…………………………..
ii
ACKNOWLEDGEMENT
All Praises to God who has helped and protected me with a good health to complete this
task. My sincere appreciations, is due to my supervisors; Dr. Stephen Kibusi, Dr. Shakilu
Jumanne, and Dr. Mariam Muyogwa for their guidance, support, and tireless
encouragements, which have helped me towards the completion of this research report.
My gratitudes are also extended to Dr. Faiza Kassim, Dr. Miskiya Ali, Dr. Khamis Abeid,
staff of the Mnazi Mmoja , and Abdallah Mzee hospital diabetic clinics, for their support
and help, during the period of data collection. I acknowledge all caregivers, children, and
the adolescents whom volunteered their time and agreed to participate in this study.
I also wish to thank the University of Dodoma and The Revolutionary Government of
Zanzibar through its Ministry for Health, for the permission to pursue this higher degree of
MSc. in Pediatrics Nursing. Needless to say my appreciation also goes to my classmates
for their support and encouragements, in performing this task throughout my two years of
study.
Lastly but not least, I am grateful to my lovely husband, Dr Ally Said Ally for his support
with thanks to our beloved sons.
However, it should be noted that, any short comings on this research are entirely belong to
me.
iii
DEDICATION
This dissertation is dedicated to Ashraf, Arif, Affif, Ahnaf, and with love.
iv
ABSTRACT
Background: The caregivers’ level of knowledge on T1DM plays a major role in the
management of affected children. However, limited studies have evaluated the knowledge
of caregivers on type one diabetes mellitus. The objective of this study was to assess the
effect of caregivers’ level of knowledge on blood glucose control in children with type
one diabetes mellitus in Zanzibar.
Methods: A cross- sectional study was carried out at the diabetic clinics hospitals in
Zanzibar. A convenient sampling technique was used to select 134 children and used to
collect data from caregivers. Caregivers’ knowledge on T1DM was measured by Michigan
Diabetes Research and Training Centre, blood Pressure and blood glucose control, was
measured by CDiC case record form. The data were processed and analyzed by SPSS
version 20.
Results: Sixty seven percent (67.2%) of caregivers had a good knowledge (AOR=0.278,
P=0.0049) and 32.8% poor knowledge. Prevalence of complications which were
developed by children was loss of vision 38.1%, numbness 30.6%, and chronic ulcers
18.7%, lower limb swelling 9% and constipation 2.2%. Out of the 134 children, 66
(49.3%) had hyperglycemia and 68 (50.7%) had a normal blood sugar level. The risk of
having hyperglycemia was significantly lower among children whose caregivers had a
good knowledge on T1DM (AOR=0.356, P=0.0192). Furthermore, almost 25% of the
children had a high blood pressure and 75 % normal blood pressure (AOR=0.176,
P=0.0002).
Conclusion: This study has found out that, majority of caregivers had a good knowledge
on type one diabetes mellitus and it was also found that, old age and higher education
were factors which were significantly associated with levels of knowledge of caregivers.
Furthermore children with T1DM, employed and higher education were observed and
found to have associated with good control of blood glucose and blood pressure.
v
TABLE OF CONTENTS
CERTIFICATION ................................................................................................................. i
DECLARATION AND COPYGHT...................................................................................... i
ACKNOWLEDGEMENT ...................................................................................................iii
DEDICATION ..................................................................................................................... iv
ABSTRACT .......................................................................................................................... v
TABLE OF CONTENTS ..................................................................................................... vi
LIST OF TABLES ............................................................................................................... ix
LIST OF FIGURES .............................................................................................................. x
LIST OF ABBREVIATIONS AND ACRONYMS ............................................................ xi
OPERATIONAL DEFINITIONS .......................................................................................xii
CHAPTER ONE ................................................................................................................. 1

INTRODUCTION ................................................................................................................ 1
1.1Background information .................................................................................................. 1
1.2Problem Statement ........................................................................................................... 4
1.3Significance of the Study ................................................................................................. 5
1.4Broad Objective ............................................................................................................... 5
1.4.1Specific Objectives ....................................................................................................... 5
1.5Research Questions .......................................................................................................... 6
CHAPTER TWO ................................................................................................................ 7

LITERATURE REVIEW ..................................................................................................... 7
2.1 Magnitude of Diabetes .................................................................................................... 7
2.2Type One Diabetes Mellitus ............................................................................................ 9
2.3Management of Type 1 Diabetes Mellitus ....................................................................... 9
2.4 Blood Glucose Monitoring ........................................................................................... 10
2.5 Blood Pressure .............................................................................................................. 11
2.6 Diabetes Knowledge ..................................................................................................... 11
2.7 Factors Associated with Caregivers Knowledge .......................................................... 12
2.8 T1DM Related Complications ...................................................................................... 12
2.9 Theoretical Conceptual Framework .............................................................................. 14
2.9.1 Health Belief Model ................................................................................................... 14
vi
CHAPTER THREE .......................................................................................................... 17
METHODOLOGY ............................................................................................................. 17
3.1 Description of the Study Area ....................................................................................... 17
3.2 Study Design ................................................................................................................. 18
3.3Study Population ............................................................................................................ 18
3.3.1 Inclusion Criteria ....................................................................................................... 18
3.3.2 Exclusion Criteria ...................................................................................................... 18
3.4 Sample Size Estimation ................................................................................................ 18
3.5 Sampling Technique ..................................................................................................... 19
3.6 Data Collection Techniques .......................................................................................... 19
3.7 Data Collection Tool ..................................................................................................... 19
3.8 Methods of Data Collection Questionnaire ................................................................... 19
3.9 Data Processing and Analysis ....................................................................................... 19
3.10 Variables ..................................................................................................................... 21
3.10.1 Dependent Variable ................................................................................................. 21
3.10.2 Independent Variable ............................................................................................... 22
3.11 Validity and Reliability ............................................................................................... 22
3.12 Ethical Issues............................................................................................................... 22
CHAPTER FOUR ............................................................................................................. 24

RESULTS AND STUDY FINDINGS ................................................................................ 24
4.1 Respondents Social Demographic Characteristics ........................................................ 24
4.2 Levels of Knowledge on T1DM among Caregivers of Children Attending Diabetic
Clinics in Zanzibar....................................................................................................... 26
4.3 Factors Related to Caregivers Knowledge Levels ........................................................ 27
4.4 Factors Associated with Knowledge on T1DM ............................................................ 30
4.5 Fasting Blood Sugar Level of the Children and Adolescents Attending Diabetic Clinics
..................................................................................................................................... 32
4.6 Factors Related to Hyperglycemia on Fasting Blood Glucose Level, among Children
and Adolescents Attended Diabetic Clinic .................................................................. 32
4.7 Factors Associated with Hyperglycemia on Fasting Blood Glucose Levels of Children
and Adolescents Attending Diabetic Clinics ............................................................... 35
4.8 Blood Pressure Level of the Children and Adolescents Attending Diabetic Clinics .... 36
vii
4.9 Factors Related with Blood Pressure Level of Children and Adolescents Attending
Diabetic Clinics ........................................................................................................... 37
4.10 Factors Associated to High Blood Pressure Levels among Children and Adolescents
Attending Diabetic Clinics in Zanzibar. ...................................................................... 39
CHAPTER FIVE .............................................................................................................. 43

DISCUSSION ..................................................................................................................... 43
5.1The Levels of Knowledge on T1DM among Caregivers ............................................... 43
5.2 Factors Associated with Caregivers’ Knowledge Levels of T1DM, among Children
and Adolescents ........................................................................................................... 43
5.3 The Association of Knowledge Levels of Caregivers, on the Control of Blood Glucose
Level ............................................................................................................................ 44
5.4 The Association of Knowledge Levels of Caregivers on Control of Blood Pressure
Level ............................................................................................................................ 46
5.5 Prevalence and Pattern of T1DM Complications, among Children and Adolescents .. 46
CHAPTER SIX ................................................................................................................. 48

CONCLUSIONS AND RECOMMENDATIONS OF THE STUDY ................................ 48
6.1Conclusion ..................................................................................................................... 48
6.2 Recommendations ......................................................................................................... 48
6.3 Study Limitation ........................................................................................................... 49
6.4 Strength of the Study .................................................................................................... 49
REFERENCES .................................................................................................................. 50
APPENDINCES ................................................................................................................ 54
viii
LIST OF TABLES
Table 1: Caregivers, Children and Adolescents Social Demographic Characteristics

(N=134) ................................................................................................................ 25
Table 2: Clinical Findings of the Children.......................................................................... 26
Table 3: Cross Tabulation of Factors related with Caregivers Knowledge Levels on T1DM
(N=134) ................................................................................................................ 28
Table 4: Crude Odds Ratios of Factors Associated with Caregivers Knowledge Levels on
T1DM (N=134) .................................................................................................... 29
Table 5: Adjusted Odds Ratios (AOR) of Factors Associated with Knowledge Levels of
Caregivers on T1DM ............................................................................................ 31
Table 6: Cross Tabulation of Factors Related with Hyperglycemia on FBG Levels of
Children and Adolescents Attending Diabetic Clinics (N=134) .......................... 33
Table 7: Crude Odds Ratios of Factors Associated with Hyperglycemia on Fasting Blood
Sugar Level (N=134) ............................................................................................ 35
Table 8: Adjusted Odds Ratios of Factors Associated to Hyperglycemia on Fasting Blood
Glucose Level among Children and Adolescents Attending Diabetic clinics ..... 36
Table 9: Cross Tabulation of Factors Related with High Blood Pressure, among Children
and Adolescents.................................................................................................... 38
Table 10: Crude Odds Ratios of Factors Associated with High Blood Pressure Levels
among Children and Adolescents Attending Diabetic Clinics in Zanzibar.......... 40
Table 11: Adjusted Odds Ratios of Factors Associated with High Blood Pressure Level
among Children and Adolescents Attending Diabetic Clinics. ............................ 41
ix
LIST OF FIGURES
Figure 1: Conceptual Framework ....................................................................................... 16

Figure 2: The Levels of Knowledge onT1DM among Caregivers of Children Attending
Diabetic Clinics (N=134) ................................................................................... 26
Figure 3: Fasting Blood Sugar Level of Children and Adolescents attending Diabetic
Clinics (N=134) .................................................................................................. 32
Figure 4: BP Level of Children who was Attending Diabetic Clinics (N=134) ................. 37
Figure 5: Children with Type 1 DM who Developed Complications in the past One Year
............................................................................................................................ 42
Figure 6: Distribution of Complications among Children and Adolescents Attending
Diabetes Clinics in Zanzibar (N=134) ................................................................ 42
x
LIST OF ABBREVIATIONS AND ACRONYMS
ADA American Diabetes Association

BP Blood Pressure
CDC Centers for Disease Control
CDiC Changing Diabetes in Children
CTC Counseling Treatment Center
DKA Diabetic Ketoacidosis
ENT Ear, Nose and Throat
FBG Fasting Blood Glucose
HbAIc Glycosylated Hemoglobin
IDF International Diabetes Federation
IFG Impaired Fasting Glucose
ISPAD International Society for Pediatric and Adolescent Diabetes.
MMH Mnazi Mmoja Hospital
NCDs Non- Communicable Diseases
OPD Out Patient Department
SPSS Statistical Package for the Social Sciences
T1DM Type one Diabetes Mellitus
T2DM Type two Diabetes Mellitus
WHO World Health Organization
ZSGRP Zanzibar Strategy Growth and Reduction Poverty
xi
OPERATIONAL DEFINITIONS
Type 1 diabetes mellitus: This is a chronic illness characterized by the body’s inability,
to produce insulin due to autoimmune destruction of the beta cells in the pancreas.
Caregivers: an individual, such as a family member or guardian who takes care of a child
or dependant adult.
Children: the convention on rights of the child (CRC), defines a child as any human
person between the stages of birth and puberty.
Glycated hemoglobin: is a form of hemoglobin which is measured primarily, to identify
the three-month average plasma glucose concentration. The test is limited to a three-month
average because the lifespan of a red blood cell is four months (120 days).
Diabetic ketoacidosis: is a serious complication of diabetes, which occurs when the body
produces high levels of blood acids, called ketones. The condition develops, when the
body cannot produce enough insulin; your body begins to break down fat as fuel.
Adolescents: is a transitional stage of physical and psychological development that
generally occurs during the period from puberty to adulthood.
Blood pressure : A pressure that is exerted by blood upon the walls of the blood vessels
and especially, arteries and varies with muscular efficiency of the heart, the blood volume
and viscosity, the age and health of the individual, and the state of vascular wall.\
Fasting blood glucose: is the result of fasting testing with respect to normal blood glucose
level in the body is 3.9-6.5mmol/l (70-100mg/dl).
xii
CHAPTER ONE
INTRODUCTION
1.1Background information
The World Health Organization (WHO), defines diabetes mellitus (DM) as a metabolic
disorder of multiple etiologies characterized by chronic hyperglycemia, with disturbances
of carbohydrate, fat and protein metabolism resulting from defects in insulin secretion,
insulin action or both (Moawad, Badawy, Al-saffar, Al-hamdan, & Awadien, 2014).
Diabetes is the one of the most common diseases in school aged children. Type 1 diabetes
mellitus is characterized by hyperglycemia, caused by an absolute insulin deficiency,
usually diagnosed in childhood and adolescents. It was previously known as Juvenile
diabetes to distinguish it from type 2 diabetes, which generally has a later onset (Barnard
et al, 2010).
Type I diabetes causes an estimated 5–10% of all diabetes cases or 11–22 million
worldwide. Studies have shown that the rate of new cases in many countries is higher
among children. For instance, it is estimated that 490,100 children below the age of 15
years, are living with type 1 diabetes Mellitus (TIDM) (International Diabetes Federation,
2011a).
In the United States of America, almost 208,000 young people under the age of 20 had
diabetes in 2012, and it is expected that 5million people will have TIDM by 2050
(National Center for chronic Disease Prevention, 2014). An estimated of 24% of all
children with TIDM live in the European region. South East Asia, follows Europe with
23% of young people with TIDM and North America and the Caribbean, with 19 %
(International Diabetes Federation, 2011b).
1
The African continent counts approximately 13.6 million living with diabetes, whereas
Nigeria has the highest number of people with diabetes, approximately 1,218,000
(International Diabetes Federation, 2005). In Sub-Saharan Africa, the 2010 estimate was
predicted to almost double in 20 years, reaching 23.9 million by 2030. Because of the lack
of data in many countries, the assessment of the prevalence and incidences of diabetes in
Sub-Saharan Africa is extremely difficult (Mbanya et al, 2010). It is estimated that 6,100
new cases of TIDM are diagnosed each year in sub-Saharan Africa, contributing to a total
of 35,700 recorded cases in the whole region although that may be an underestimation
(Ramaiya, 2010).
In Tanzania mainland, the incidence was estimated to be 1.5/100,000 per year in 1991
(Noorani et al., 2016). Mean while, according to HMIS (2009) Zanzibar reported 130
cases of type 1 diabetes mellitus in 2008.
Diabetes management often has negative consequences on parents well –being. New
routines must be introduced and maintained, new knowledge learned and coping strategies
developed to adapt to life with child with type one diabetes mellitus. The management of
diabetes involves continuous medical care and patient self management education in order
to prevent acute complications. However, pediatric diabetes management has remained a
major challenge to the patient, the health care provider as well as family members of the
patients (Niba, 2016).
The main task of managing diabetes is to keep the blood glucose level within a specified
range in order to avoid short term problems due to hyperglycemia or
hypoglycemia(Monaghan & Baumann, 2016)
2
The general rules of management for type one diabetes mellitus in children, which include
insulin therapy as well as self-management, require that, parents know how to prepare and
give insulin injection, monitor blood glucose and urine ketones, record blood level values,
manage diet (Ayed, 2015).
One of the recommendations from the statement of the American Diabetes Association is
education, this education is best provided with sensitivity to the age and developmental
stage of the child, with regards to both educational approach and the contents of the
material delivered. The guidelines recommendations for every patient diagnosed with
diabetes mellitus should receive diabetes self-management, which is the educational
intervention facilitating knowledge, skills and ability to diabetes and pre-diabetes for self-
care with the overall aim of primary care, prevention of complication, control glucose in
the blood and reducing cost (ADA, 2016).
However in Tanzania, challenges which CDiC has noticed are mis diagnosis, low public
awareness, and stigma especially in the reproductive age/adolescent groups. Poverty
causes loss to follow-up, lack of recommended nutrition and poor insulin storage. Trained
staffs at clinics also pose a threat in terms of retention and are sometimes transferred to
other departments. The poor commitment of the government to the program leaves the
program dependent on donors and hence, the threat of sustaining services for children with
T1DM exists. Other challenges include poor control of HbA1c among children, poor
adherence to insulin injections in terms of dose, time and frequency, lack of proper meal
and adult supervision, mixing other treatment modalities and poor record keeping of blood
glucose measurements (Muze & Majaliwa, 2015).
3
1.2Problem Statement
In Zanzibar, the number of adolescents and children diagnosed with T1DM has increased.
The HIMS, 2009 report shows an increase from 98 to 144 cases in 2006 and 2007
respectively (HIMS, 2009). An accessible comprehensive care accompanied with up to
date and high range health technology offered to children with T1DM in developed
countries helps to achieve encouraging outcome (International Diabetes Federation, 2011).
On the other hand, proper management of the disease in adolescents and children has been
a challenge in developing countries including Sub-Saharan Africa.
In Tanzania, the existing evidence shows that, type one diabetes have very poor glycemic
control and suffer from chronic complications of diabetes at a very early age despite of the
government efforts to provide free medical services and education to caregivers (Noorani
et al., 2016).
To a large extent, this is contributed by inadequate knowledge, non- adherence to
treatment, lack of proper meal, inadequate parental supervision, mixing with other
treatment modalities, and poor record keeping of blood glucose measure (Karilena et al.,
2016).
Research indicates that, 74% had knowledge about T1DM among caregivers would
assist in the management and hence, minimization of both short-term and long term
complications among adolescents and children (Noorani et al, 2016). However, this area
of research has not attracted an attention of large research effort and deliberations.
Therefore, the current study was intended to investigate about the effect of caregivers’
level of knowledge on blood glucose control in children with T1DM in Zanzibar.
4
1.3Significance of the Study
Despite of the efforts of providing free medical services and educational courses to
caregivers to help control of blood glucose level, there is an increase of type one diabetes
mellitus related complications. The aim of this study was to assess the effect of caregivers’
level of knowledge on blood glucose control in children in Zanzibar. This would provide a
baseline data and give an insight about the levels of knowledge of caregivers and help on a
future designing of education intervention programs to caregivers. It would cover the gaps
of knowledge identified, and empowering family members to improve the management
and prevention of T1DM related acute and long-term complications.
Moreover, it would motivate further research into the field of diabetes, particularly in
Zanzibar and help in improving the management of the disease and the quality of life of
the patients. It would also be beneficial for Pediatric Diabetic Management team in
diabetic clinics to build up knowledge and evidence based practice on areas related to
T1DM management. This entails a lot of co-ordinate research which requires a lot of
funding and increased efforts by various governments, to improve education intervention
and empower patients to afford the quality of care.
1.4Broad Objective
To assess the effect of caregiver’s level of knowledge on blood glucose control in children
with type one diabetes mellitus in Zanzibar
1.4.1Specific Objectives
1. To determine levels of knowledge of T1DM among caregivers of children and
adolescents, attending diabetic clinics in Zanzibar.
2. To identify factors associated with levels of knowledge of T1DM, among caregivers
attending diabetic clinics in Zanzibar.
3. To determine the association of blood glucose and blood pressure control, with
5
levels of knowledge of T1DM among caregivers attending diabetic clinic in
Zanzibar.
4. To determine the prevalence and pattern of type 1 diabetes mellitus complications,
among children and adolescents.
1.5Research Questions
1. What knowledge do caregivers have on T1DM among children and adolescents,
whom were attending diabetic clinic in Zanzibar?
2. What factors are associated with caregivers’ knowledge of T1DM, among children
and adolescents whom were attending diabetic clinic in Zanzibar?
3. What is the association between blood glucose and blood pressure control and levels
of knowledge of caregivers?
4. What is the prevalence of type 1 diabetes mellitus complications, among children
and adolescents?
6
CHAPTER TWO
LITERATURE REVIEW
2.1 Introduction
This section, presents the literature related to the study, focusing on the magnitude of
diabetes, management of diabetes, blood pressure and blood glucose monitoring, diabetes
knowledge, factors associated with caregivers knowledge as well as type one diabetes
mellitus related complications. Also discusses the theoretical and conceptual frame work.
2.2 Magnitude of Diabetes
Diabetes mellitus is a group of diseases characterized by high levels of glucose in the
blood resulting from defects in insulin production, insulin action or both (National
Diabetes Statistics Report, 2014). Diabetes mellitus is a growing public health problem
affecting people worldwide, both in developing and developed countries (Buowari, 2013).
It is one of the four priority non-communicable diseases targeted for action by world
leaders. An estimated 422 million adults globally were living with diabetes in 2014 and
caused 4.9 million deaths. 522 million people are expected to be affected by 2030 (World
Health Organization, 2016). According to the World Health Organization, in the 21st
century, diabetes has become a major challenge for health care system worldwide. It the
seventh leading cause of death in developed countries (American Diabetes Association,
2016).
Studies have shown that, the rate of new cases in many countries is higher among children.
For instance, it is estimated that 490,100 children below the age of 15 years, are living
with type 1 diabetes Mellitus (TIDM) (International Diabetes Federation, 2011a).In the
United States of America, almost 208,000 young people under the age of 20 had diabetes
in 2012, and it is expected that 5million people will have TIDM by 2050 (National Center
for chronic Disease Prevention, 2014).An estimated of 24% of all children with TIDM,
7
live in the European region where that is the burden of diabetes. South East Asia follows
Europe with 23% of young people with TIDM and North America and the Caribbean with
19 % (International Diabetes Federation, 2011b).
The African continent counts approximately 13.6 million living with diabetes, whereas
Nigeria has the highest number of people with diabetes, approximately 1,218,000
(International Diabetes Federation, 2005). In Sub-Saharan Africa, the 2010 estimate was
predicted to almost double in 20 years, reaching 23.9 million by 2030. Because of the lack
of data in many countries, assessment of the prevalence and incidences of diabetes in Sub-
Saharan Africa is extremely difficult (Mbanya et al, 2010). It is estimated that 6,100 new
cases of TIDM are diagnosed each year in sub-Saharan Africa, contributing to a total of
35,700 recorded cases in the whole region although that may be an underestimation
(Ramaiya, 2010).
In Tanzania, there were more than 822,800 cases of diabetes in 2015. According to the
World Health Organization diabetes mellitus death reached 9,257 or 2.59% of total deaths
(World Health Organization, 2014). The estimated diabetes prevalence in Zanzibar stands
at 7% and IFG at 11%. It is assumed that more than half of diabetes cases are undetected.
However, there are some data gaps, including inaccuracy of data that limit a systematic
and comprehensive monitoring of Non-communicable disease (Ministry of Health
Zanzibar, 2012).
There are two types of diabetes mellitus. Type 1 diabetes mellitus results from a cellular-
mediated autoimmune destruction of the B-cells of the pancreases. Type 2 diabetes
encompasses individuals who have a relative insulin deficiency at least initially and often
throughout life time. Up to 95% of people have type 2 diabetes (American Diabetes
Association, 2010a). Diabetes mellitus may present itself with characteristic symptoms
such as thirst, polyuria, blurring vision, and weight lost but T1DM vary according to the
8
rate of beta cell destruction. In general, the rate is rapid in infant and children and slow in
adult (Sleire, 2011).
2.3Type One Diabetes Mellitus
Type 1 diabetes mellitus, is characterized by hyperglycemia, caused by an absolute insulin
deficiency, and usually diagnosed in childhood and adolescents (Barnard et al, 2010).
Type 1 diabetes mellitus (T1DM) accounts to 5-10% of the diabetes worldwide (American
Diabetes Association, 2010b). In Sub-Saharan Africa (SSA), it has been estimated that in
every year almost 6,100 children are diagnosed with type 1 diabetes mellitus (Ramaiya,
2010). In Tanzania mainland, the incidence was estimated to be 1.5/100,000 per year in
1991 (Noorani et al, 2016). The cause of diabetes is complex and not fully understood.
The cause of type one diabetes mellitus is largely unknown, but it is thought that a genetic
predisposition, environmental factors, and distinctive metabolic changes are involved in
the initiation, development, and progression of the disease (Bailey & Day, 2008). It occurs
most often in children and young adults; children may present the symptoms of polyuria,
weight loss, and blurred vision (Umar, 2016b).
2.4 Management of Type 1 Diabetes Mellitus
Diabetes management often has negative consequences on parents own well-being. New
routines must be introduced and maintained, new knowledge learned and coping strategies
developed to adapt to life with a child with type one diabetes mellitus (Barnard et al,
2010).
The management of diabetes involves a continuous medical care and patient self-
management education in order to prevent acute complications such as diabetic
ketoacidosis and hypoglycemia, which are the major causes of morbidity and death in
younger patients and the risk of long term complications (American Diabetes Association,
2015). Therefore, the prevention of long term complications is the major focus of diabetes
9
management in younger and adolescent patients with longer duration. However, pediatrics
diabetes management has remained a major challenge to the patient, the health care
provider, as well as family members of the patients (Borus and Laffel, 2011).
The proper management of the disease in children and adolescent has been a challenge
because of the presence of behaviors, skills and inadequate knowledge that contribute to
non-adherence to treatment and the significant increase in short and long-term
complications (Karilena et al, 2016).
The general rules of management for type 1 diabetes mellitus in children which include
insulin therapy as well as self-management require that, parents to understand how to
prepare and give insulin injection, monitor blood glucose and urine ketones, record blood
level values, manage diet including meal plan, manage exercise, and manage acute
problem particularly hypoglycemia (Ayed, 2015).
To have an effective management of diabetes, the education component management such
as blood glucose monitoring, insulin replacement, diet, exercise, must be delivered to the
family (Couch et al, 2008). Therefore, public education strategies, consensus about
treatment recommendations, use more flexible insulin regimens, and devices for home
monitoring are necessary (Majaliwa et al., 2008).
2.5 Blood Glucose Monitoring
Self monitoring of blood glucose is an essential part of the management of type 1 diabetes.
According to the American Diabetes Association, which outlines specific blood glucose
level and glycemic control goals for children < age 6. The goals include maintaining blood
glucose level between 100-200mg/dl and glycemic level below 8.5 %, frequent blood
glucose monitoring for children and blood glucose checks are recommended at least four
times daily (before meal and bed time), and engaging in healthy eating habits with
adequate intake of vitamins and minerals. Less frequent blood glucose monitoring has
10
been found to be a predictor of poor glycemic control (Niba, 2016).
2.6 Blood Pressure
Blood pressure should be measured at each routine visit. Children found to have a normal
blood pressure (systolic blood pressure or diastolic blood pressure) ≥90 percentile
according to age, sex and height or hypertension ≥95 percentile for their age, sex, height
should have confirmed on three separate days. Evaluation should proceed as clinically
indicated and treatment is generally initiated. (Mashall, 2013).
2.7 Diabetes Knowledge
Knowledge is considered as one of the important causing factors for people to behave in
certain way. Gaps in knowledge can result in destructive health behaviors. On the other
hand, the educator to achieve the goal of health education, s/he has to identify the needs
and interest, also identify the knowledge deficit of the client and identify the relevant
content of instruction for the program (Abebe, 2016).
There is increasing amount of evidence generally, to suggest that patients education for
people with chronic disease such as diabetes, is an essential component of disease
management. Diabetes knowledge of caregivers plays an important role in improving the
glycemic control of children with type 1 diabetes mellitus (Moawad et al., 2014).
Evidence has shown that parents/caregivers/mothers with more knowledge of diabetes
and better education lower HbA1C level of their children (Al-odayani et al, 2013). A study
by Heptulla and Hassan found that, literacy and numerical skills of caregivers influence
significantly the glycemic control of children with type 1 diabetes mellitus (Hassan and
Heptulla, 2010b).
In contrast, an Indian study by Vimalavathini and colleges observed that, a planned
educational intervention programs on attitudes, knowledge, and practices of type 1
11
diabetes mellitus result in a significant improvement in knowledge and attitude but with no
improvement in HbA1C levels (Vimalavathini, Agarwal, & Gitanjali, 2008). According to
a study of Shenouda and others, there were highly statistical differences between total
knowledge of caregivers and level of education, residence, occupation, and income
respectively (Shenouda, Ahmad, & Mohammed, 2012b).
2.8 Factors Associated with Caregivers Knowledge
In a study conducted in the Kingdom of Saudi Arabia about the relationship of caregivers’
knowledge and young children with diabetes it was found that, there was a significant
variation in the knowledge of diabetes among mothers of different ages. Old age mothers
and widowed were better informed. However, the difference was not statistically
significant (Al-odayani et al, 2013).
A study in USA indicated that higher caregivers’ knowledge is associated with higher
income levels and being married, and the study in Saudi supports this idea in that mothers
with high level of knowledge about their child diabetes are the ones with higher level of
education (Al-odayani et al, 2013).
A study done in Egypt, on the knowledge and Practices of Juvenile Diabetes caregivers at
home in Minia University hospital found that, family caregivers with high level of
education have a good knowledge and practices which affect positively on expected
complications and health and wellness of their children (Shenouda, Ahmad, &
Mohammed, 2012a). According to the study of Shrestha (2015) which found that,
occupation was significantly associated with knowledge (Shrestha, Yadav, Joshi, & Patel,
2015).
2.9 T1DM Related Complications
Type one diabetes mellitus, is a serious condition associated with significant morbidity
and mortality because of its short and long term complications. The most frequent short
12
term complications include hypoglycemia, hyperglycemia, and diabetic ketoacidosis; and
common long-term complications include Retinopathy, Neuropathy, Nephropathy and
cardiovascular disease (American Diabetes Association, 2010).
Since diabetes in children has been given less attention, we are likely to have more
children that die early with complications. In the few studies available on diabetes in
children, most of them show a high prevalence of complications at a very young age
(Majaliwa et al., 2008).
The age onset of chronic complications in T1DM is variable. Whereas hyperglycemia in
children can lead to DKA; it is characterized by elevated blood glucose levels
(>250mg/dl,>13.9mmol/l) and the presence of ketones in the blood and urine. Symptoms
include polyuria, hyporventilation, dehydration, fruit odor and fatigue. In Tanzania
diabetic ketoacidosis was found to be presenting feature in 75% of diabetic children and
adolescents (Noorani et al, 2016).
Nephropathy: diabetic nephropathy is a major cause of morbidity and mortality among
young adult with type 1diabetes mellitus. Nephropathy is characterized by progressive
kidney disease caused by angiopathy of capillaries in the glomeruli. It is defined as
persistent protenuria which is greater than 300mg/24hours or albuminuria greater than
300mg/24hours. In Tanzania, microalbuminuria which is a marker of nephropathy had a
prevalence of 29.3% (American Diabetes Association, 2012).
Retinopathy is an eye disease. It is among the leading cause of blindness and can cause
micro vascular retinal changes and lead to visual impairment and blindness. Majaaliwa et
al (2007) also reported a prevalence of diabetic retinopathy of 22.68% among children and
adolescents in Tanzania and it is higher in age before puberty. Neuropathy can affect any
nerves in the body, and this can lead to pains, tingling, and loss of sensation. Diabetic
neuropathy can cause morbidity with significant impact on quality of life of the person
13
with diabetes, and can result in early death. The major morbidity is foot ulceration, which
can lead to gangrene and loss of limb (Majaaliwa et al, 2007).
2.10 Theoretical Conceptual Framework
Is a theory refers to a calculated guess that explains why some events occur or possible
relationship between cause and effect (Jones and Bartlett, 2003). To understand this
problem, a number of researchers have attempted to develop different theories.
2.10.1 Health Belief Model
The Health Belief Model (HBM) is a psychological model that attempts to explain and
predict health behaviors. This is done by focusing on the attitudes and beliefs of
individuals. Health belief model is a popular model applied in nursing, especially in issues
focusing on patient compliance and preventive health care practice. It addresses the
relationship between a person’s beliefs and behavior as well provides a way to
understanding and predicting, how clients would behave in relation to their health and how
they would comply with health care therapies (Jones and Bartlett, 2003).
A study of Moawad et al., (2014), which used Health Belief Model (HBM) as a
framework on the assessment of knowledge among Saudi diabetic children and adolescent
at Riyadh city that was explained that health belief model helps to understand why patients
may accept or reject preventive health services or adopt healthy behaviors. Health belief
model had six major concepts (Moawad et al., 2014).
Perceived susceptibility refers to a person’s perception that a health problem is personally
relevant or that diagnosis of illness is accurate.
Perceived even when one recognizes personal susceptibility, action will not occur unless
the individual perceives the severity to be high enough to have serious organic or social
complications.
Perceived benefits refers to the patients that a given treatment will cure the illness or help
to prevent it.
14
Perceived cost refers to the complexity, duration, and accessibility of the treatment.
Motivation includes the desire to comply with a treatment and the belief that people
should do what.
Modifying factors include personality variables, patient satisfaction and
sociodemographic factors.
Conceptual Framework: A conceptual framework is interrelated concepts or abstractions
assembled together in a rational scheme by virtue of their relevance to a common
theme(Denise & Cheryl, 2003).
15
Factors
 Education level
 Age
 Marital status
 employment
Control
Complications
Knowledge
 Hypoglycemia
 Hyperglycemia
 High
blood
Pressure
 Neuropathy
Figure 1: Conceptual Framework
Source by researcher
This conceptual framework shows how variables interact one to another. The socio
demographic factors which have been showed above can influence poor or good
knowledge to the caregivers. Good knowledge can enhance to control blood glucose,
blood pressure, hypoglycemia and other complications. If the caregivers’ knowledge is
poor, children might end up with hyperglycemia, high blood pressure and other
complications
16
CHAPTER THREE
METHODOLOGY
Introduction
This part presents the methodology of the study. It describes the study area, study design,
study population, sample size estimation and the sampling technique, data collection
methods and methods which were used for data processing and analysis. It ends by
describing the ethical consideration during the study.
3.1 Description of the Study Area
The study was conducted in Zanzibar. Zanzibar is a semi-autonomous part of Tanzania in
East Africa. It is composed of the Zanzibar archipelago in the Indian Ocean, 25 to 50
kilometers off the coast of the mainland, and consists of many small Islands and two large
ones, Unguja and Pemba. The population currently is estimated to be 1,303,569 and the
average annual growth rates of 3.0%. The percentage of the males is 49. 1% and female is
50.9% The total number of children is 307,309 which is 24% (NBS, 2014).
There are eleven hospitals, both in Unguja and Pemba Islands; eight of them are owned by
the government while four hospitals are owned by private institutions, however, there is
referral hospital in each island.
Diabetic clinics for children and adolescents, are conducted once a week at Mnazi Mmoja
hospital and Abdallah Mzee hospital in Unguja and Pemba respectively. Education on
diabetes to caregivers of children and adolescents whom are diagnosed with diabetes is
given. Baseline investigations is also offered, vital signs are taken, urine for ketones and
blood glucose monitoring is measured. In addition, children and adolescents are examined
for retinopathy through fundoscopy, nephropathy by
measuring creatinine and neuropathy through muscular and neurological examinations.
Insulin, glucose monitor, and strip for self-monitoring and recording at home are also
17
provided at no cost.
Diabetic clinic at Mnazi Mmoja hospital had five permanent nurses, one pediatrician and
allocated doctors; whereas the diabetic clinic at Abdallah Mzee hospital, has one nurse and
one doctor. A total number of 134 children and adolescents attended the two diabetic
clinics.
3.2 Study Design
This study was cross-sectional study design with quantitative approach used. A cross-
sectional study is a study which gathers information at only one point in time, and
measures the exposure and outcome; which involves a quantitative method to analyze in
statistical form, to measure various variables by collecting data through questionnaires for
a period of one month (Denise & Cheryl, 2003).
3.3Study Population
Respondents, were caregivers of children and adolescents with T1DM attending the
diabetic clinic at Mnazi Mmoja and Abdallah Mzee Hospitals in Zanzibar.
3.3.1 Inclusion Criteria
Included were caregivers with children and adolescents with T1DM whom have been on
treatment for not less than 3 months. These were children and adolescents with type 1
diabetes mellitus of ages 7 up to 19 years.
3.3.2 Exclusion Criteria
Children with T1DM and other co-morbidities like HIV, sickle cell disease
3.4 Sample Size Estimation
All children were enrolled to the sampling who qualifies inclusion criteria. One
hundred and thirty four children and adolescents whom attended diabetic clinics were
recruited in the study. Those whom were newly diagnosed were excluded and there were
no children with co-morbidities.
18
3.5 Sampling Technique
A Purposive sampling technique, was used to select the Referral hospitals in Zanzibar,
which were Mnazi Mmoja Hospital for Unguja and Abdallah Mzee Hospital in Pemba
because were the only hospitals, which had diabetic clinics in Zanzibar. A convenient
sampling technique was used to select all children and adolescents attending diabetic
clinics in Zanzibar.
3.6 Data Collection Techniques
Data were collected July 2017, one month was used to collect data of this study, and 2
research assistants were trained for data collection. Quantitative data method was obtained
through face to face interview questionnaires, and questionnaires were translated from
English to Kiswahili.
3.7 Data Collection Tool
Data were collected by the researcher by using face to face administered questionnaires.
This was administered to the caregivers because the study intend to caregivers.
Questionnaires consisted of four parts, part one for Socio demographic information, two
for diabetes knowledge of caregivers, and were measured by Michigan Diabetes
Knowledge test tool which is published in 1998 and validated to 2008, three concerning of
diabetes related practices and the last part four was diabetes related complications this was
assessed by using Changing Diabetes in Children case record forms.
3.8 Methods of Data Collection Questionnaire
Data were collected by the researcher by using semi-structured questionnaire. They were
face to face administered questionnaires. Questionnaires were modified from the Michigan
Diabetes Research and Training Centers Brief Diabetes knowledge test; to assess
caregivers’ knowledge on T1DM. Type 1 diabetes mellitus were measured by changing
diabetes in children (CDiC) case record forms. Also questionnaires were adapted to CDiC
19
and modified. They were translated into Kiswahili. Caregivers’ knowledge score on
T1DM was created based on 46 questions, and score were dichotomous denoting poor and
good knowledge. Participants whom scored below 27, the average of the knowledge score,
were considered to have poor knowledge, and above 28 averages were considered to have
a good knowledge related to T1DM, according to (Moskovitz, Ms, Frydman, Allen, &
Tonyushkina, 2018) used average score to categorize the diabetes knowledge level of
adolescents and parents. Regarding the BP level among children, children with systolic
blood pressure >120 or diastolic blood pressure >80, were considered to have an abnormal
blood pressure level indicated a high blood pressure levels. With respect to FB level, a
fasting blood sugar level of 126 mg/dL (7.0 mmol/L) or higher indicates type 1 diabetes
(hyperglycemia) while children with 3.5- 6.5mmol/L fasting blood sugar were considered
to be normal.
3.9 Data Processing and Analysis
Data analysis were done by using SPSS software package version 20, and the processing
and cleaning were done and imported to SPSS. Demographic data were analyzed by
descriptive statistics, and the categorical data were tested by using chi- square. A
continuous variable was summarized by Mean for the normal distributed and median for
non-normal distributed. Bivariate and multiple logistic regression analysis, were used to
determine the association between caregivers’ knowledge and T1DM among children and
adolescents. Simple correlation analysis was employed to determine the relationship
between the caregivers’ knowledge on type 1 diabetes with its complications. A partial
analysis was applied to control the covariates. Data were summarized by using frequencies
and distribution tables, to show dependent and independent variables. Results were
presented in graph and tables, where as statistical significance was assessed with 95%
confidence interval and the P-value of less than or equal to 0.05 was considered
significant.
20
Logistic regression analysis was applied to assess factors associated with knowledge on
T1DM among caregivers attending diabetic clinics, BP, and FB level among children with
T1DM. A simple logistic regression model was first fitted for each study variable so as to
identify the independent variables which were associated with knowledge on T1DM,
among caregivers attending diabetic clinics, BP and FB level among children with T1DM.
Variables that were significant in simple logistic regression model were then included in a
multiple logistic regression model, in order to examine the impact of each independent
variable on where knowledge on T1DM among caregivers attending diabetic clinics, BP
and FB level among children with T1DM account for other potential confounders. Results
of the model were presented by using odds ratios (OR) and 95% confidence interval. An
estimate of OR
> 1 indicates that the risk of having success (good knowledge on T1DM, hyperglycemia
and an abnormal blood pressure level), at a given level of the independent variable was
greater than that for the reference category. An estimate of OR < 1 similarly, specifies that
the chance of having success at a given level of independent variable was less than that for
the reference categories.
3.10 Variables
A variable is a characteristic or quality which takes one different value (Denise & Cheryl,
2003).
3.10.1 Dependent Variable
The dependent variable is a behavior, characteristic, or outcome the researcher is
interested in understanding, explaining, predicting, or affecting. In this study, the
dependent variable is blood glucose control and blood pressure.
21
3.10.2 Independent Variable
The independent variable is the presumed cause of, antecedent to, or influence on a
dependent variable. In this study, the independent variable is caregivers’ level of
knowledge on type 1 diabetes mellitus.
3.11 Validity and Reliability
Before data collection, a pre-test was conducted at Dodoma general hospital to test the
tools (questionnaires) to be used in the study .It was two weeks before and 20 caregivers
whom had children with T1DM were selected. Face to face administered questionnaires
were given to the selected participants to test the validity and reliability of the
questionnaires before the actual data collection from the study area.
Questions which were misunderstood were corrected so as to bring out the intended
information. Missing and necessary information was noted and added to the questionnaires
to improve its validity and reliability.
3.12 Ethical Issues
Ethical clearance was sought from the University of Dodoma Research and Ethical
Review committee. Permission to conduct the study was also requested from Mnazi
Mmoja and Abdallah Mzee Hospital administration. Participants, were given informed
consent forms which written on both languages English and Swahili before deciding on
their participation of the study, through oral and written consent form were informed
clearly about the aim of the study. Efforts were made and names were not recorded in the
questionnaires. Participants were guaranteed of confidentiality on the details acquired
during the study.
3.13 Dissemination of Findings
After the completion of the study, the dissemination of findings was in the form of report.
Findings were presented in a Nursing Conferences and others conferences within the
22
country. The report would be disseminated to the Nursing and Public Health Department
of the University of Dodoma (UDOM) to fulfill the requirements of Masters of Science in
Pediatric Nursing.It will also be submitted to the authority such as Ministry for Health in
Zanzibar, Mnazi Mmoja and Abdallah Mzee Hospital.
23
CHAPTER FOUR
RESULTS AND STUDY FINDINGS
Demographic information of respondents is very important in addressing validity by
involving the relevant respondents’ in the study. Data had a total number of 134
respondents, whom participated in the study, and were both males and females.
4.1 Respondents Social Demographic Characteristics
Respondents included in the study were both males and females, whereby males were to
40.3 % (n=54) and females 59.7% (n=80). They were ranged into age groups from 7-19
years (children and adolescents) of whom 15-19 years were 65.7 % (n=88) and 7-14 years
34.3 % (n=46). The body mass index of children and adolescents with a normal weight,
was 73.1 %,( n=98) while the underweight was 26.9 %.( n=36)
The frequency of fasting blood glucose level was 49.3 % (n=66) for those with a high
glucose level and with a normal blood glucose was 46.3 % (n=62). Respondents whom
had a normal blood pressure was 75.4 %( n= 101), where by the abnormal blood pressure
level was 24.6 % (n= 33). Children and adolescents whom were cared for biological
parents as by their caregivers, were 82.1 % (n=110) while others accounted for 17.9 %
(n=24).
The education level of their caregivers varied from no school to primary education which
was 47.0 %( n=63), while secondary education and above were 53.0 % (n=71), while
married respondents were 76.9 % (n=103), and unmarried were 23.1 % (n=31).
The occupational status of the caregivers showed that, the respondents whom were non
employed were 73.1 % (n=98) while the employed were 26.9 % (n=36).
Results for the social demographic and related characteristics are indicated in Table 1
below.
24
Table 1: Caregivers, Children and Adolescents Social Demographic Characteristics
(N=134)
Variable Frequency (n) Percent (%)

Sex of the child
Females 80 59.7
Males 54 40.3
Age of the child

7 – 14 years 46 34.3
15 – 19 years 88 65.7
Current Marital status

Married 103 76.9
Not married 31 23.1
Age of the caregivers

20-30 years 29 21.6
31-40 years 51 38.1

40+ 54 40.3
Primary caregivers
Biological parents 110 82.1
Other relatives 24 17.9
Occupation of caregivers
Employed 36 26.9
Non Employed 98 73.1
Education level of caregivers

No Formal/ Primary education 63 47.0
Secondary/Higher education 71 53.0
25
Table 2: Clinical Findings of the Children
Parameter Frequency (n) Percentage (%)

BMI
Underweight 36 26.9
Normal 98 73.1
Blood Pressure
Normal 101 75.4
High 33 24.6
FBG (mmol/L)
Normal 68 50.7
High 66 49.3
4.2 Levels of Knowledge on T1DM among Caregivers of Children Attending Diabetic
Clinics in Zanzibar
The knowledge scores ranged from 20-36, while the mean score was 28 with a standard
deviation of ±3.55. When the knowledge score was dichotomized based on the mean
value, as described in the methodology section, 90 (67.2%) of the caregivers, had a good
knowledge and 44(32.8%) poor knowledge regarding T1DM as shown in Figure2 below
80
67.2
70
60
50
40 32.8
30
Percent
20
10
0
Poor Good
Figure 2: The Levels of Knowledge onT1DM among Caregivers of Children
Attending Diabetic Clinics (N=134)
26
4.3 Factors Related to Caregivers Knowledge Levels
Based on the current marital status, the unmarried caregivers had shown to have a high
level of knowledge (67.74%) with regards to T1DM when compared to married (66.99%),
though it was not significant (x2 = 0.0061, P = 0.9377). Respondents whom aged 40
years and above had shown a significant level of knowledge (79.63%) with regards to
T1DM,when compared to those under 40 years (58.62%), and there was a significant of
(x28.0126, P= 0.0046)
With regards to the occupational status of caregivers, respondents whom were employed
have shown to have a significant level of knowledge (86.11%) with regards to T1DM,
when compared to non employed (60.20%) (x2 = 8.0126, P = 0.0046).
On the other hand, the educational levels of caregivers, for those whom had secondary
education and above, revealed to have a good level of knowledge (76.6%) with regards to
T1DM, when compared to those with no formal/Primary education. Besides it has shown a
significant relationship of (x2 = 5.4144, P = 0.0200)
27
Table 3: Cross Tabulation of Factors related with Caregivers Knowledge Levels on
T1DM (N=134)
Variable Knowledge level Chi-square
Poor Good (P-value)
N (%) N (%)
Married 34 (33.01) 69 (66.99) 0.0061 (0.9377)
Not married 10 (32.26) 21 (67.74)

20-30 years 12 (41.38) 17 (58.62) 6.3733 (0.0413)
31-40 years 21 (41.18) 30 (58.82)
40+ 11 (20.37) 43 (79.63)
Employed 5 (13.89) 31 (86.11) 8.0126 (0.0046)
Non Employed 39 (39.80) 59 (60.20)
Education level of
caregivers
< Primary school 27 (42.86) 36 (57.14) 5.4144 (0.0200)
> Secondary school 17 (23.94) 54 (76.06)
As described in the methodology part, both simple and multiple logistic regression models
were employed in order to identify factors associated with knowledge on T1DM, among
caregivers of children attending diabetic clinics in Zanzibar. The crude odds ratios (OR),
95% CI together with the associated p-value of the fitted simple logistic regression models
are presented in Table 4 below. Results have shown that, caregivers age (p=0.0462),
occupation (p=0.0071), and the education level (p=0.0213) were significantly associated
with the knowledge on T1DM among caregivers of children, attending diabetic clinics. On
28
the other hand, the current Marital status (p=0.9379) is not a significant predictor of
knowledge on T1DM. Regarding the effect of age, it was noted that caregivers aged 20-30
years (OR=0.362, P=0.0450) and 31-40 years (OR=0.365, P=0.0227) are significantly less
likely to have a good knowledge as compared to caregivers aged 40 years and above. The
odds of having a good knowledge among the employed caregivers was almost 4 times
when compared non employed counterparts (OR=4.098, P=0.0071). This means that, the
proportion of caregivers with a good knowledge on TIDM was significantly higher among
the employed than the non employed persons. With respect to the caregivers education,
results have shown that, those with no formal or primary education, were significantly
less knowledgeable on T1DM, in comparison to those with secondary or higher education
(OR=0.420, p=0.0213).
Table 4: Crude Odds Ratios of Factors Associated with Caregivers Knowledge
Levels on T1DM (N=134)
Variable Crude OR 95% CI P-Value

Married Reference
Not married 1.035 [0.439, 2.440] 0.9379
20-30 years 0.362 [0.134, 0.978] 0.0462
31-40 years 0.365 [0.154, 0.869]
40+ Reference
Employed 4.098 [1.467, 11.449] 0.0071
Non Employed Reference
No formal / Primary education 0.420 [0.200, 0.879] 0.0213
Secondary/higher education Reference
29
4.4 Factors Associated with Knowledge on T1DM
Three independent variables (age, occupation and the education level) were included in
multiple logistic regression models, as were significant in the simple logistic regression
model (Table 5) below. Results of the multiple logistic regression model have revealed
that, the included variables, that is age (p=0.0101), occupation (p=0.0384), and the
education level (p=0.0049), were significant predictors of knowledge on T1DM among
caregivers of children attending diabetic clinics in Zanzibar. For the caregivers with the
same occupation and education level, the results of multiple logistic regression model
revealed that the adjusted odds of having good knowledge among caregivers were aged
20-30 years (AOR=0.244,p=0.0124) and 31-40 years (AOR=0.230,p=0.0053) were
significantly lower than that of the caregivers aged 40 years and above. Employed
caregivers were significantly more likely to have a good knowledge on T1DM, in
comparison to non employed caregivers (AOR=3.161, p=0.0384). In addition, caregivers
with No formal/ or primary education were significantly less prevalent to have a good
knowledge on T1DM, when compared to those with secondary or higher education
(AOR=0.278, p=0.0049).
30
Table 5: Adjusted Odds Ratios (AOR) of Factors Associated with Knowledge Levels
of Caregivers on T1DM
Variable Adjusted 95% CI P-Value
OR
20-30 years 0.244 [0.081, 0.737] 0.0101
31-40 years 0.230 [0.082, 0.646]

40+ Reference
Employed 3.161 [1.064, 9.396] 0.0384

No formal / primary education 0.278 [0.114, 0.679] 0.0049
31
4.5 Fasting Blood Sugar Level of the Children and Adolescents Attending Diabetic
Clinics
Out of 134 children whose caregivers attended diabetic clinic, 66 (49.3%) were having
hyperglycemia and 68 (50.7%) had a normal blood glucose level.
51 50.7
50.5
Percent
50
49.5
49.3
49
48.5
Normal Hyperglycemia
Figure 3: Fasting Blood Sugar Level of Children and Adolescents attending Diabetic
Clinics (N=134)
4.6 Factors Related to Hyperglycemia on Fasting Blood Glucose Level, among
Children and Adolescents Attended Diabetic Clinic
The distribution of children FBG levels (Table 6) below reveals that, male children had a
high prevalence (53.7%) to get hyperglycemia in comparison to females (46.25%), even
though, it was insignificant (x2 = 0.7166, P = 0.3973) on fasting blood glucose level.
Moreover, on the age of children, 15 to 19 years had a high prevalence (55.95%) of
getting hyperglycemia when compared to 7 to 14 years. This is a significant towards
fasting blood glucose level (x2 = 4.0415, P = 0.0444)
With regards to the occupational status of caregivers, employed (33.33%) had
significantly less prevalence to get hyperglycemia, when compared to non employed
32
(55.10%), and there was a significant relationship with fasting blood glucose level (x2 =
4.9917, P = 0.0255).
On the other hand, on the educational status of caregivers, respondents with no
formal/primary education, had a high prevalence (73.02%) of getting hyperglycemia,
when compared to those with secondary education and above (28.17%), and there was a
highly significant towards fasting blood glucose level (x2 = 26.8606, P =< 0.0001).
Table 6: Cross Tabulation of Factors Related with Hyperglycemia on FBG Levels of
Children and Adolescents Attending Diabetic Clinics (N=134)
Variable FBG level Chi-square

Normal Hyperglycemia (P-value)
N (%) N (%)
Sex of the child
Females 43 (53.75) 37 (46.25) 0.7166 (0.3973)
Males 25 (46.30) 29 (53.70)
Age of the child
7 – 14 years 31 (62.00) 19 (38.00) 4.0415 (0.0444)
15 – 19 years 37 (44.05) 47 (55.95)
Employed 24 (66.67) 12 (33.33) 4.9917 (0.0255)
Non Employed 44 (44.90) 54 (55.10)
Education level of
caregivers
No formal / primary 17 (26.98) 46 (73.02) 26.8606
education (<0.0001)
Secondary/higher 51 (71.83) 20 (28.17)
education
Knowledge level
Poor 13 (29.55) 31 (70.45) 11.7809
(0.0006)
Good 55 (61.11) 35 (38.89)
33
For fasting blood sugar , results of the fitted simple logistic regression models (Table 7)
below indicates that, the age of a child (p=0.0458), caregivers occupation (p=0.0277) ,
education level (p<0.0001), and the knowledge on T1DM (p=0.0008), were significantly
risk factors associated with fasting blood sugar level among children and adolescents. The
effect of sex (p= 0.3977) was not associated with fasting blood sugar level. With respect to
age, results have shown that, respondents aged 7-14 years (OR=0.483, p=0.0458) were
significantly less to be at risk of having hyperglycemia in comparison to those aged 15-19
years. Similarly, children and adolescents whose caregivers are employed have
significantly lower prevalence of hyperglycemia than those with non employed
(OR=0.407, p=0.0277). Regarding to the caregivers education, results have shown that,
the odds of having hyperglycemia among children and adolescents whose caregivers had
no formal / primary education, were almost 7 times than of children under caregivers with
secondary/higher education (OR=6.9, P<0.0001). Furthermore, children and adolescents
whose caregivers had a good knowledge on T1DM (OR= 0.267, P=0.0008) were
significantly less likely to have hyperglycemia than children of the caregivers with a poor
knowledge.
34
Table 7: Crude Odds Ratios of Factors Associated with Hyperglycemia on Fasting
Blood Sugar Level (N=134)

Sex of the child
Females Reference
Males 1.348 [0.675, 2.694] 0.3977
Age of the child
7 – 14 years 0.483 [0.236, 0.987] 0.0458
15 – 19 years Reference
Employed 0.407 [0.183, 0.906] 0.0277
No formal / primary education 6.9 [3.228, 14.747] <0.0001
Knowledge level
Poor Reference
Good 0.267 [0.123, 0.579] 0.0008
4.7 Factors Associated with Hyperglycemia on Fasting Blood Glucose Levels of
Children and Adolescents Attending Diabetic Clinics
Results of the fitted multiple logistic regression models (Table 8) below have revealed
that, by incorporating all variables which were the significant multiple logistic regression
model; age of the children and adolescents (P=0.2946) and the caregivers occupation
(p=0.4420), were no longer significant risk factors of children to develop hyperglycemia.
The caregivers education level (P<0.0001) and knowledge on T1DM (P=0.0008) were a
significantly associated with a normal blood glucose level. The chance of having
hyperglycemia among children and adolescents whose caregivers had no formal / primary
education was significantly higher than that of children under caregivers with
35
secondary/higher education (AOR=5.883, P<0.0001). Likewise, children and adolescents
under caregivers with good knowledge on T1DM (AOR= 0.356, P=0.0192) were
significantly less prevalent to have hyperglycemia than those of the caregivers with a poor
knowledge.
Table 8: Adjusted Odds Ratios of Factors Associated to Hyperglycemia on Fasting
Blood Glucose Level among Children and Adolescents Attending Diabetic clinics
OR
Age of the child
7 – 14 years 0.637 [0.274, 1.481] 0.2946
Employed 0.688 [0.265, 1.786] 0.4420

No formal / primary education 5.883 [2.674, 12.947] <0.0001
Knowledge level
Poor Reference
Good 0.356 [0.150, 0.845] 0.0192
4.8 Blood Pressure Level of the Children and Adolescents Attending Diabetic Clinics
Results have revealed that (n=134) respondents, almost (n=101) 75.4% had a normal
blood pressure level as compared to those who had abnormal (n=33)24.6%.
36
80 75.4
70
60
50
Percent 40
30 24.6
20
10
0
Normal Abnormal
Figure 4: BP Level of Children who was Attending Diabetic Clinics (N=134)
4.9 Factors Related with Blood Pressure Level of Children and Adolescents
Attending Diabetic Clinics
The distribution of children and adolescents BP level (Table 9) below has revealed that,
male children had a high prevalence (27.78%) to develop high blood pressure level, when
compared to females (22.50%), even though there was no significant relationship
(x2=0.4838,p=0.4867). Children aged 15 to 19 years had a high prevalence (34.52%) to
develop a high blood pressure when compared to 7 to 14 years and there was a significant
relationship (x2=11.8793,p= 0.0006).
However, on the occupational status of caregivers, non employed had a high prevalence
(27.55%) to develop a high blood pressure when compared to employed (16.67%), even
though there was no significant relationship (x2=1.6804,p=0.1949).
On the other hand, on the educational status of caregivers, respondents whom had no
formal/primary education had a high prevalence (33.33%),to develop a high blood
pressure when compared to those with secondary education and above (16.98%), those
was a significant relationship (x2=4.8556, p=0.0276).
37
Table 9: Cross Tabulation of Factors Related with High Blood Pressure, among
Children and Adolescents
Children and caregivers characteristics
Variable BP level Chi-square
Normal Hypertension (P-value)
N (%) N (%)
Sex of the child
Females 62 (77.50) 18 (22.50) 0.4838 (0.4867)
Males 39 (72.22) 15 (27.78)
Age of the child

46 (92.00) 4 (8.00) 11.8793
7 – 14 years
(0.0006)
15 – 19 years 55 (65.48) 29 (34.52)
Employed 30 (83.33) 6 (16.67) 1.6804 (0.1949)
Non Employed 71 (72.45) 27 (27.55)
Education level of
caregivers
No formal / primary 42 (66.67) 21 (33.33) 4.8556 (0.0276)
education
Secondary/higher 59 (83.10) 12 (16.90)
education
Knowledge level
Poor 23 (52.27) 21 (47.73) 18.8334
(<0.0001)
Good 78 (86.67) 12 (13.33)
38
4.10 Factors Associated to High Blood Pressure Levels among Children and
Adolescents Attending Diabetic Clinics in Zanzibar.
To identify factors associated with blood pressure, logistic regression model was also
employed. Table 10 below, displays the crude odds ratios, 95% confidence interval
together with the associated p-value of the fitted multiple logistic regression model. It was
found out that, children and adolescent blood pressure was significantly associated with
their age; in which children and adolescents aged 7-14 years (OR=0.165, p=0.0016) were
significantly less likely to have an abnormal blood pressure level in comparison to
children and adolescents aged 15-19 years, also another risk factor was the caregivers’
education level. Regarding the caregivers education, results have shown that, the odds of
having an abnormal blood pressure level among children and adolescents under caregivers
with no formal / primary education, was significantly greater than children under
caregivers with Secondary/higher education (OR=2.458,p=0.0300). Additionally, children
and adolescents whose caregivers had a good knowledge on T1DM (OR=
0.169,p<0.0001) were significantly less likely to have a hypertension/high blood pressure
than children of the caregivers with poor knowledge. However, sex of children and
adolescents (p=0.4873) as well the caregivers occupation (p=0.1997) were not significant
predictors of children blood pressure.
39
Table 10: Crude Odds Ratios of Factors Associated with High Blood Pressure Levels
among Children and Adolescents Attending Diabetic Clinics in Zanzibar.

Sex of the child
Females Reference
Males 1.325 [0.599, 2.930] 0.4873
Age of the child

7 – 14 years 0.165 [0.165, 0.504] 0.0016
Employed 0.526 [0.197, 0.197] 0.1997

Knowledge level
Poor Reference
Good 0.169 [0.072, 0.393] <0.0001
In the multiple logistic regression model it was noted that, children age (P=0.0026) and
caregivers knowledge on T1DM (P=0.0002), were significant risk factors associated with
a blood pressure among children and adolescents. Caregivers education level (P=0.1456)
was no longer an important predictor of children blood pressure (Table 11) below. The
prevalence of abnormal blood pressure level was significantly lower among children and
adolescents aged 7-14 years (AOR=0.159, P=0.0026) than children and adolescents aged
15-19 years. Moreover, children and adolescents whose caregivers had a good knowledge
on T1DM (AOR= 0.176, P=0.0002) were significantly less likely to have an abnormal
blood pressure when compared to children under caregivers with a poor knowledge.
40
Table 11: Adjusted Odds Ratios of Factors Associated with High Blood Pressure
Level among Children and Adolescents Attending Diabetic Clinics.
OR
Age of the child
7 – 14 years 0.159 [0.048, 0.525] 0.0026

Knowledge level
Poor Reference
Good 0.176 [0.071, 0.436] 0.0002
4.11Complications of Children and Adolescents Attending Diabetic Clinics Results
have revealed that, almost (61.2%) of the respondents (n=134) had developed
complications when compared to those without complications (38.8%).
41
38.8%
61.2%
Complication No Complication
Figure 5: Children with Type 1 DM who Developed Complications in the past One
Year
Almost 61% of children with T1DM have been reported to experience at list one
complication in the past one year. Loss of vision and numbness were the most common
complications with prevalence of 38.1% and 30.6% respectively. Change of bowel habit
was the least (2.2%), chronic ulcer 18.7% and 9% lower limb swelling as shown in figure
above.
38.1%
30.6%
18.7%
9%
2.2%
Loss of vision Numbness Chronic ulcer Lower limb Constipation

swelling
Figure 6: Distribution of Complications among Children and Adolescents Attending
Diabetes Clinics in Zanzibar (N=134)
42
CHAPTER FIVE
DISCUSSION
This chapter presents discussions of the findings of the current study. It is organized with
the reflections from the specific objectives of the study. The discussions are divided /
organized into; general observation of the levels of knowledge on T1DM among
caregivers, factors associated with caregivers’ knowledge levels of T1DM, the associated
of blood pressure and blood glucose control, and the prevalence of T1DM related
complications among adolescents and children.
5.1The Levels of Knowledge on T1DM among Caregivers
Out of 134 caregivers recruited in this study, 67.2% had a good knowledge on type 1
diabetes mellitus, similar to a study done in Kuwait (Al-hussaini, 2016) which showed
that, almost 71% of the participants had a good knowledge on T1DM. In contrary, a study
done by Fikrtemaria about knowledge and the association factors of type 1 diabetes
mellitus among children and adolescents attending diabetic clinic in Addis Ababa had
revealed that, 45% had a good knowledge on type 1 diabetes mellitus (Abebe, 2016).
5.2 Factors Associated with Caregivers’ Knowledge Levels of T1DM, among
Children and Adolescents
In this study, it was found out that, caregivers aged between 20-30years were less likely to
have a good knowledge on the control of type 1 diabetes mellitus, when compared to those
whom were 40years and above. These findings are similar to a study done in Saudi Arabia
which found out that, old age mothers and widowed mothers were better informed (Al-
odayani et al, 2013). Another study showed that, there was no significant association
between age or duration of diabetes and glycemic control (Niba, 2016). Employed
caregivers were more likely to have a good
knowledge when compared to non employed. These results are similar with a study done
43
by Shenouda et al (2012) who found out that, there were highly significant differences
between the total knowledge and level of education, residence, occupation, and income
(Shenouda et al., 2012b).
Caregivers with secondary/high education level were more likely to have a good
knowledge on T1DM, when compared to others without such levels or with low levels.
These results are similar with ones in a study done by Mohammad Al Agha (2017) which
suggests that, parents whom had a good educational level and occupational status, had a
positive relation with children’s metabolic control (Alagha et al., 2017). A study
conducted in Saudi Arabia also, supports this idea in which it shows that mothers with
high levels of knowledge about their children’s diabetes, were those whom had high levels
of education (Al-odayani et al, 2013). Thus, as the educational levels increases they
became more aware of the diseases.
This study has found out that, the caregivers whom had no school and primary education
were less likely to have a good knowledge, on the control of type 1 diabetes mellitus in
children and adolescents. These results are consistent to a study which showed that,
literacy and numerical skills of caregivers significantly influenced glycemic control of
type 1 diabetes (Hassan & Heptulla, 2010).
Results have shown that, the parent’s age, occupation, and the educational level were
significantly associated with a good knowledge on T1DM, among caregivers of children
attending diabetic clinics.
5.3 The Association of Knowledge Levels of Caregivers, on the Control of Blood
Glucose Level
The current study, has found out that children aged between 7-14 years were less likely to
develop hyperglycemia when compared to those aged between 15-19 years. These
findings are similar to a study done in Wales to identify factors associated with glycemic
44
control. They reported that, glycemic control was worse among older children compared
to younger ones (Harvey, 2010). On the other hand, studies in UK and France also showed
that older age and longer duration of diabetes were associated with poor glycemic control
(Clements et al., 2014). These differences could be explained due to the decrease in
treatment compliance and less care givers supervision.
Employed caregivers are less likely to develop hyperglycemia when compared to non
employed. In a study by Majaliwa et al (2008), neither parents or guardians education nor
occupation were associated with complications and glycemic control (Majaliwa et al.,
2008). This could be explained by the fact that, employed caregivers in the most African
setup including Zanzibar are those with higher education.
This study found out that, the chance of having hyperglycemia among children and
adolescents whose caregivers had no formal/primary education was significantly higher
than children under caregivers with secondary education and above.
Likewise, children and adolescents under caregivers with a good knowledge on T1DM are
significantly less prevalent to have hyperglycemia than children of parents with poor
knowledge. On the other hand, a study done in Saudia Arabia in 2013 reported that
mothers with more knowledge of diabetes and better education maintain a better glycemic
control of their children and decreased acute and chronic complications of diabetes (Al-
odayani et al, 2013). These findings are similar to the study by Noohu et al (2015) which
reported that, the improvement in diabetic patients’ knowledge, awareness and attitude
about the disease could do productive changes in glycemic control (Dhnapal, Noohu
,Venkatachalam , Khalid, 2015)
45
5.4 The Association of Knowledge Levels of Caregivers on Control of Blood Pressure
Level
The prevalence of an abnormal blood pressure level was significantly low among children
and adolescents aged 7 to 14 years when compared to children and adolescents aged 15-19
years. Children and adolescents whose caregivers had a good knowledge on T1DM were
significantly less likely to have an abnormal blood pressure level when compared to
children of the parents with poor knowledge. Studies in the UK and France show that
older age and longer duration of diabetes are associated with poor glycemic control
(Clements et al., 2014). On the contrary, age is not associated with poor glycemic control
in the studies from Australia and New Zealand (Niba, Aulinger, Mbacham, & Parhofer,
2017).
The differences could be explained by the fact that, children between 7-14 years were still
in a close monitoring by their caregivers, whereas adolescents between 15- 19 years are
under self monitoring.
5.5 Prevalence and Pattern of T1DM Complications, among Children and
Adolescents
Despite of the good knowledge on diabetes education which caregivers might have, still
children develop complications. This shows that the development of complications in
T1DM patient does not depend on the knowledge of diabetes which caregivers might
have. This study shows that caregivers may have a good knowledge on diabetes but still
many children developed complications like retinopathy, neuropathy and nephropathy.
This is similar to the study by Majaliwa et al (2008) which show a high prevalence of
retinopathy in prepubertal children compared to pubertal group (Majaliwa et al., 2008).
This might be because of the late diagnosis of the disease and poor control of blood
glucose level of children.
46
In addition, studies have found out that, parental diabetes knowledge has an effect on
glycemic control. They advised continuing parental involving especially in our society and
should be more involved in their children’s diabetic management (Toromanovic, 2014).
However, a study by Hassan & Heptulla found out that, even though caregivers got
diabetes mellitus education, if they failed to comprehend the provided diabetes education,
poorly controlled diabetes may occur (Hassan &Heptulla, 2010b). There is also the lack of
resources (gluco meter), which these caregivers cannot monitor the blood glucose level as
recommended.
47
CHAPTER SIX
CONCLUSIONS AND RECOMMENDATIONS OF THE STUDY
6.1Conclusion
This study has found out that, majority of caregivers had a good knowledge on type 1
diabetes mellitus and it was found out that, old age, employment, and higher education,
were factors significantly associated with the level of knowledge of caregivers. It was also
found out that, younger children, employment and higher education levels of caregivers
were associated with a good control of blood glucose levels and blood pressure of children
with T1DM.
Therefore, the knowledge of caregivers plays an important role in controlling blood
glucose and blood pressure level in preventing acute and chronic complications.
6.2 Recommendations
It is recommended that, health care providers should emphasize on the caregivers close
supervision and monitoring of children with type 1 diabetes mellitus.
The hospital should formulate the policy for health educational program.
Health care providers in diabetic clinics should educate caregivers on how to prevent,
recognize, and monitor complications in children and adolescents as well should give a
continuous and ongoing diabetes education to caregivers of adolescents and children with
type 1 diabetes mellitus.
The Government should introduce new diabetic clinics to other health facilities close to
the community and supply enough equipment, including insulin therapy and gluco meter,
the service should be extended to most hospitals and health centers country wide to curb
the disease.
48
The government should be an extensive training for competent human resources up to the
village level since the disease is becoming rampant.
Further research/studies, should be done to find factors associated with the occurrence of
complications to T1DM in children and adolescents
6.3 Study Limitation
The fact that a cross-sectional study design is employed makes it difficult to draw a cause
and effect relationship.
6.4 Strength of the Study
Study was conducted in Zanzibar and involved two Islands of Unguja and Pemba. The
researcher managed to collect data from a large area. In addition, the study involved both
sexes by a cross-sectional design so as, to achieve information from a large group of
participants. Tools used to collect data were questionnaires which helped to have different
information from different people with current information.
49
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53
APPENDINCES
APPENDIX 1: QUESTIONNAIRES (ENGLISH VERSION)
STUDY TITTLE: THE EFFECT OF CAREGIVERS LEVEL OF KNOWLEDGE
ON BLOOD GLUCOSE CONTROL IN CHILDREN WITH TYPE ONE
DIABETES MELLITUS IN ZANZIBAR
Part 1: Socio-demographic Data - Caregivers/Adolescents
Questionnaire number…………………… Date of interview…………………………
1. Age of child
2. Sex of child F M
3. Age of caregiver
4. Sex of caregiver F M
5. Primary caregiver – caregivers/parents
a. Mother
b. Father
c. Sibling
d. Others specify …………….
6. Marital status of caregiver
a. Married
b. Single
c. Divorced
d. Widow
54
7. Family structure
a. Both parents living together
b. Single parent
c. Orphan
d. Others specify …………………………….
8. Highest level of education of caregiver
a. No school
b. Primary school
c. College
d. Others specify …………….
9. Caregivers occupation
a. Civil servant
b. Self-employee
c. Business
d. Peasants
e. Others specify ……………….
10. Means of transport from home to the hospital Yes No
a. Walking
b. Public transport
55
c. Own transport
d. Others specify ……………….
11. Physical examination- children/adolescents
a. Height
b. Weight
c. BMI
PART 2: Level of Knowledge of Caregivers/Adolescents on T1DM and its
Complications
12. According to my understanding diabetes is Yes No
a. High blood sugar in the body
b. Lack of effective insulin in the body
c. Failure of kidney to keep sugar out of the urine
13. What are the symptoms of type 1diabetes? Yes No
a. Weight loss
b. Constipation
c. Hyperglycemia
d. Excessive tiredness
14. What are likely complications uncontrolled of diabetes? Yes No

a. Poor wound healing
56
b. High blood glucose level
c. Low blood glucose level
d. High temperature
15. How does the child present symptoms of acidosis? Yes

No
a. Fast breathing
b. High blood sugar
c. Low blood sugar
d. Others specify………………………..
16. Have you received any health education on DM?
a. Yes b. No
17. Where did you get the health education? Yes No
a. Clinic
b. Media
c. Others specify …………………………..
18. How often have you attended the clinic in the past 3 months?
a. 2
b. 4
c. >5
57
19. Can diabetes be treated and cured?
a. Yes
b. No
20. What causes of high blood glucose level Yes No
a. Not enough insulin
b. Skipping meals
c. Delaying your food
d. Others specify…………
21. What do you do when the child blood glucose is high? Yes No
a. Inject insulin
b. Give more food
c. Provide meal
d. Others specify………………..
22. How do you suspect that your child blood glucose is high? Yes No
a. Loss of consciousness
b. Sweating
c. Increased urination
d. Weight loss
58
e. Others specify………………..
23. Low blood glucose level may be caused yes No
a. Too much insulin
b. Too little insulin
c. Too much food
d. Too little exercise
24. What is the advantage of physical exercise on blood glucose control? Yes No
a. Lowers it
b. Raises it
c. Has no effect
25. How can you identify if your child blood glucose level is well controlled?
a. Playing with their friends Yes No
b. Doing his/her work
c. Going to school as usual
d. Others specify………………
26. What are the foods recommended to keep blood glucose controlled?
a. High in carbohydrate Yes No
b. Less in protein
c. Less in carbohydrate
d. Less in sugar
59
e. Others specify…………….
27. What other strategy do you use to keep your child’s blood glucose controlled?
a. Inject insulin daily Yes No
b. Attend diabetic clinic
c. Check blood glucose
d. Assess the injection site
PART 3: Practices of Parents towards T1DM Control for their Children
28. How often (in days) has your child missed an insulin dose in the past 1 month?
a. None
b. between 1-3
c. 4-6
d. More than 7
29. What was the reason for missing the dose? Yes No
a. Absence of caregiver
b. Caregiver forgot
c. Insulin was out of stoke
d. Others specify ………………….
60
30. How frequently do you check your child’s blood glucose at home daily?
a. 3 times
b. 1 -2 times
c. Once a week
d. Others specify …………………………
31. How often does the caregiver inject/supervise injection insulin to the child?
a. Once
b. Always
c. Never
32. What regimen is the child on for his/her condition? Yes No
a. OADs
b. Neutral Protamine Hagedorn
c. Mixed insulin
d. Short-acting insulin + NPH

Part 4: Frequency of T1DM Related Complications Caregivers/ Adolescents
33. Has your child been admitted to a hospital in the past six months?
a. Yes
b. No
61
34. What was the reason for admission? Yes No
a Ketoacidosis
b. Hyperglycemia
c. Hypoglycemia
d. Others specify…………………
35. How long was the child admitted?
a. Two days
b. One week
c. Two week
d. Month
Others specify ……….
36. Has the child missed school because of diabetes complications?
a. Yes
b. No
37. How did the child miss school due to diabetes complications in the past 3
months?
a. None
b. One week
c. Two weeks
62
d. More than three weeks
e. Others specify………………..
38. What was the complication that can lead the child to miss? Yes No
a. Ketoacidosis
b. High blood glucose level
c. Low blood glucose level
d. Typhoid
39. Has your child ever developed any of the following problems in the past one
year? Yes No
a. Vision loss
b. Numbness
c. Body or lower limb swelling
d. Constipation/fecal incontinence
e. Chronic ulcers/wound
63
APPENDIX 2: QUESTIONNARES (Swahili version)
STUDY TITTLE: A: THE EFFECT OF CAREGIVERS LEVEL OF
KNOWLEDGE ON BLOOD GLUCOSE CONTROL IN CHILDREN WITH TYPE
ONE DIABETES MELLITUS IN ZANZIBAR
A: DEMOGRAPHIA
Namba ya dodoso ………………..
Tarehe ya usaili ……/……/…………
1. Umri wa mtoto
2. Jinsia ya mtoto Mme Mke
3. Umri wa mzazi/mlezi
4. Jinsia ya mzazi/mlezi Mme Mke
5. Uhusiano wa mgonjwa na anaye muhudumia nyumbani
a. Mama
b. Baba
c. Ndugu /jamaa
d. Mwingine: taja ………………………..
6. Hali ya ndoa
a. Ameolewa/ameoa
b. Mlezi mmoja
64
c. Ameachika /ameacha
d. Mjane
7. Familia
a. Wazazi wote wanaishi pamoja
b. Mzazi mmoja
c. Yatima
d. Mwingine: taja ………………………..
8. Kiwango cha elimu ya mzazi/mlezi
a. Hajasoma
b. Elimu ya msingi
c. Chuo kikuu
d. Nyingine: taja …………………………..
9. Ajira ya mzazi/mlezi
a. Mtumishi wa umma
b. Amejiajiri mwenyewe
c. Mfanyabiashara
d. Mkulima
e. Nyingineyo: taja ………………………..

10. Umbali kutoka nyumbani mpaka hospitali anapopata huduma
a. Unatembea kwa miguu Ndio Hapana
65
b. Unatumia usafiri wa umma
c. Unatumia usafiri wako mwenyewe
d. Nyingineyo: taja ……………………………….
11. Uchunguzi wa mwili kwa ujumla
a. Urefu sentimita
b. Uzito kilogram
c. Ulinganisho wa mwili (BMI)
Sehemu2: Kiwango cha Ufahamu juu ya Ugonjwa wa Kisukari cha Aina ya
Kwanza na Madhara Yanaweza Kutokea Usipojihadhari Nao.
12. Kulingana na ufahamu wako kisukari ni Ndio Hapana
a. Wingi wa sukari mwilini
b. Ukosefu wa ufanyaji kazi wa insulin mwilini
c. Kushindwa kwa figo kutoa sukari kwa njia ya mkojo
13. Nini dalili za ugonjwa wa kisukari Ndio Hapana
a. Upungufu wa uzito
b. Kutopata choo kikubwa
c. Kiwango cha sukari kuwa juu
d. Kuchoka haraka
14. Ni Madhara yapi yatatokea iwapo ugonjwa wa kisukari haukudhibitiwa
a. Kidonda hakitapona
66
Ndio Hapana
b. Kiwango cha sukari kitaongezeka
c. Kiwango cha sukari kitapungua
d. Joto la mwilini litaongezeka
15. Mtoto anaonesha dalili zipi akipata madhara ya asidosis Ndio Hapana
a. Kupumua kwa haraka
b. Kuongezeka kiwango cha sukari mwilini
c. Kushuka kiwango cha sukari mwilini
d. Mengineyo: taja
……………………..
16. Je! Umepata elimu ya afya juu ya ugonjwa wa kisukari
a. Ndiyo
b. Hapana
17. Elimu hiyo juu ya ugonjwa wa kisukari uliipatia wapi? Ndio Hapana
a. Kliniki ya kisukari
b. Chombo cha habari
c. Kwengineko: taja
…………………………
18. Katika kipindi cha miezi mitatu iliyopita umehudhuria kliniki ya
kisukari mara ngapi?
a. 2
b. 3
c. 4
67
d. Zaidi ya mara 5
19. Je! Kisukari kinatibika na kupona kabisa?
a. Ndio
b. Hapana
20. Nini sababu ya kupanda kwa kiwango cha sukari mwilini
a. Insulin si ya kutosha Ndio Hapana
b. Kukosa mlo
c. Kuchelewa kula
d. Nyenginezo: taja
………………………….
21. Unafanyaje pale kiwango cha sukari cha mtoto kinapokuwa kikubwa
mwilini?
a. Ninamchoma sindano ya insulin Ndio Hapana
b. Ninampa chakula cha uwanga zaidi
c. Ninampa chakula
d. Nyengineyo: taja
………………………….
22. Unapata viashiria gani kujua sukari ya mtoto ipo juu? Ndio Hapana
a. Kupoteza fahamu
b. Kutoka jasho jingi
c. Kukojoa sana
68
d. Kupungua uzito
e. Nyengineyo: taja ………………………………..
23. Sukari kuwa chini/kupungua mwilini husababishwa na nini? Ndio Hapana
a. Matumizi kwa kiwango kikubwa cha insulin
b. Matumizi kidogo ya insulin
c. Kula kupita kiasi
d. Mazoezi kidogo ya viungo
24. Nini faida ya kufanya mazoezi ya viungo katika kudhibiti kiwango cha
sukari mwilini Ndio Hapana
a. Hushusha sukari mwilini
b. Kupandisha sukari mwilini
c. Haina athari yeyote
25. Ni chakula gani kinacho shauriwa katika kudhibiti kiwango cha sukari Ndio Hapana
a. Kiwango kikubwa cha uwanga
b. Kiwango kidogo cha protein

c. Kiwango kidogo cha sukari
d. Nyengineyo: taja …………………………………
26. Ni njia zipi unazitumia katika kudhibiti kiwango cha sukari? Ndio Hapana
a. Sindano ya insulin tu
b. Kuhudhuria kliniki ya kisukari
69
c. Kupima kiwango cha sukari
d. Kuchunguza sehemu ya kuchomea sindano ya insulin
Sehemu3: Matendo ya Wazazi katika Kudhibiti Ugonjwa wa Kisukari Aina ya
Kwanza kwa Watoto
27. Mara ngapi (siku) mtoto wako alikosa dawa ya insulin kwa mwezi mmoja
uliopita?
a. Hakuna
b. Kati ya mara moja mpaka tatu
c. Kati ya mara nne mpaka sita
d. Zaidi ya mara saba
28. Sababu ya kukosa dawa
a. Mzazi /Mlezi hakuwepo
b. Mzazi /mlezi alisahau
c. Nyengineyo: taja ………………………………

29. Je! Kiwango cha sukari kinapimwa kwa usahihi akiwa nyumbani
a. Ndio
b. Hapana
30. Mara ngapi unampima mtoto wako kiwango cha sukari ukiwa nyumbani
a. Mara tatu kwa siku
b. Mara moja mpaka mbili kwa siku
70
c. Mara moja kwa wiki
d. Nyengineyo: taja ……………………………………..
31. Ni mara ngapi mzazi/mlezi humchoma/kusimamia uchomaji insulin kwa mtoto
a. Mara moja
b. Mara zote
c. Hajawahi kumsimamia
32. Mtoto wako yupo kwenye aina gani ya matibabu kulingana na hali yake?
a. Dawa za kumeza tu za kisukari Ndio Hapana
b. NPH
c. Mchanganyiko wa insulin
d. Insulin ya muda mfupi na NPH

Sehemu ya 4: Idadi ya Madhara Makubwa Yahusuyo na Ugonjwa wa Kisukari
33. Je! Mtoto wako ameshawahi kulazwa hospitali katika kipindi cha miezi sita
iliyopita?
a. Ndio
b. Hapana
34. Kama mtoto wako aliwahi kulazwa, ni nini sababu ya kulazwa? Ndio Hapana
a. Ketoacidosis
b. Sukari kuzidi kiwango
c. Sukari kushuka kupita kiwango
71
d. Nyingineyo: taja
………………………………
35. Kwa muda gani alilazwa hospitali?
a. Siku mbili
b. Wiki moja
c. Wiki mbili
d. Mwezi mmoja
e. Nyingineyo: taja ………………………………..

36. Je! mtoto ameshawahi kukosa kwenda shule kwa sababu ya madhara
yatokanayo na kisukari
a. Ndio
b. Hapana
37. Kama ndiyo, kwa siku ngapi alikosa kwenda shule katika miezi mitatu iliyopita?
a. Hakuna
b. Wiki moja
c. Wiki mbili
d. Zaidi ya wiki tatu
38. Ni madhara gani yaliyo sababisha kukosa shule? Ndio Hapana
a. Asidosis
b. Kiwango cha juu cha sukari
72
c. Kiwango kidogo cha sukari
d. Homa ya matumbo (typhoid)
39. Je! Mtoto wako amepata moja kati ya haya katika kipindi cha mwaka mmoja
uliopita? Ndio Hapana
a. Uoni hafifu au kutokuona kabisa
b. Kuhisi ganzi mwilini
c. Kuvimba miguu au mwili kwa jumla
d. Kukosa choo au kupata choo kwa taabu
e. Kuwa na vindonda
73
APPENDIX 3: INFORMEDCONSENT FORM
My name is Nunuu Ali Salim. I am Pursuing a master’s degree in pediatric nursing at the
University of Dodoma, College of Health and Allied Sciences. I am conducting a study to
assess the effect of caregivers’ level of knowledge on blood glucose control in children
with type one diabetes mellitus in Zanzibar.
I would like to ask you to participate in this study.
I, therefore, request you to participate in my study by responding to a couple of questions
about you/your child’s condition.
The findings of this study will be used to improve the quality of care given to children
with T1DM.
Confidentiality will be maintained.Data will be carefully handled and used only for the
purpose of this study. Code numbers will be used instead of names.
You will suffer no financial costs for your participation in this study, and no payment will
made to you.
Participation is voluntary, and you may refuse to participate or withdraw at any time in
the course of an interview.
I agree to participate …………………………… Participants
signature…………………………………. Researchers
signature……………………………………….
74
APPENDIX 4: Kibali cha Kushiriki katika Utafiti
Jina langu ni Nunuu Ali Salim, ninatoka Chuo Kikuu cha Dodoma katika Idara ya Afya.
Ninaomba ushiriki wako katika utafiti wangu unaohusu kutaka kujua mafanikio ya elimu
kwa wazazi wenye watoto wenye kisukari Zanzibar.
Naomba ushiriki wako katika utafiti huu.
Njia nitakazotumia kukusanya taarifa ni majadiliano na kujaza fomu zenye maswali.
Matokeo ya utafiti huu yatasaidia katika kuiboresha afya ya mtoto mwenye kisukari
Usiri utazingatiwa kwa kuandika namba badala ya majina kwa washiriki kwenye fomu za
maswali na zitatunzwa vizuri.
Mshiriki ataruhusiwa kuuliza maswali kama utahitajika ufafanuzi zaidi Kwa kushiriki
kwenye utafiti huu hutolipa wala hutolipwa chochote.
Ushiriki wako ni wa hiyari na utaruhusiwa kujitoa wakati wowote. Nakubali
kushiriki……………………..
Sahihi ya mshiriki………………………… Sahihi ya mtafiti……………………………
75
Figure: Map of Zanzibar
76
77
78
SCHOOL OF NURSING AND PUBLIC HEALTH
DEPARTMENT OF PUBLIC HEALTH
SN COMMENTS Candidates Location or page in

Response/Corrections revised Dissertation
1. Name the terms as operational definitions Definition of key terms Definition on page xiii
has been written now it
reads operational
definitions.
2. Provide figure/statistical required Figure has been shown Problem statement on page
quantifying the knowledge level. from the problem 4.
statement.
3. Brief explanation of variables from Variables from Conceptual frame work on
conceptual framework conceptual frame work page 16.
has been explained
4. Recommendation Recommendation has Recommendation on page
been written clearly. 47-48.
Name of the Candidate Reg. No ………………………
Signature ……………………..
Name of the Supervisor Signature………………….
Date ………………………………
79

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The University of Dodoma

University of Dodoma Institutional Repository http://repository.udom.ac.tz

þÿThe effect of caregivers level of

ON BLOOD GLUCOSE CONTROL IN CHILDREN WITH

TYPE ONE DIABETES MELLITUS IN ZANZIBAR

NUNUU ALI SALIM

MASTERS OF SCIENCE IN PEDIATRICS NURSING

BLOOD GLUCOSE CONTROL IN CHILDREN WITH TYPE ONE

DIABETES MELLITUS IN ZANZIBAR

NUNUU ALI SALIM

A DISSERTATION SUBMITTED IN PARTIAL FULFIMENTS OF THE

REQUIREMENTS FOR A DEGREE OF MASTERS OF SCIENCE IN

THE UNIVERSITY OF DODOMA

other degree award.

No part of this dissertation may be reproduced, stored in any retrieval system, or

University of Dodoma, a dissertation entitled: The effect of Caregivers Level of

Dr. Stephen Kibusi (Supervisor 1)

Signature ………………………….. Date…………………………..

Dr. Mariam Muyogwa (Supervisor 2)

Signature ………………………….. Date…………………………..

MSc. in Pediatrics Nursing. Needless to say my appreciation also goes to my classmates

with thanks to our beloved sons.

CHAPTER ONE ................................................................................................................. 1

CHAPTER TWO ................................................................................................................ 7

CHAPTER FOUR ............................................................................................................. 24

CHAPTER FIVE .............................................................................................................. 43

CHAPTER SIX ................................................................................................................. 48

Table 1: Caregivers, Children and Adolescents Social Demographic Characteristics

Figure 1: Conceptual Framework ....................................................................................... 16

ADA American Diabetes Association

person between the stages of birth and puberty.

Glycated hemoglobin: is a form of hemoglobin which is measured primarily, to identify

Adolescents: is a transitional stage of physical and psychological development that

generally occurs during the period from puberty to adulthood.

level in the body is 3.9-6.5mmol/l (70-100mg/dl).

disorder of multiple etiologies characterized by chronic hyperglycemia, with disturbances

mellitus is characterized by hyperglycemia, caused by an absolute insulin deficiency,

usually diagnosed in childhood and adolescents. It was previously known as Juvenile

(International Diabetes Federation, 2011b).

cases of type 1 diabetes mellitus in 2008.

to prevent acute complications. However, pediatric diabetes management has remained a

patients (Niba, 2016).

range in order to avoid short term problems due to hyperglycemia or

hypoglycemia(Monaghan & Baumann, 2016)

manage diet (Ayed, 2015).

diabetes mellitus should receive diabetes self-management, which is the educational

the blood and reducing cost (ADA, 2016).

awareness, and stigma especially in the reproductive age/adolescent groups. Poverty

glucose measurements (Muze & Majaliwa, 2015).

respectively (HIMS, 2009). An accessible comprehensive care accompanied with up to

countries helps to achieve encouraging outcome (International Diabetes Federation, 2011).

a challenge in developing countries including Sub-Saharan Africa.

To a large extent, this is contributed by inadequate knowledge, non- adherence to

level of knowledge on blood glucose control in children with T1DM in Zanzibar.

of knowledge identified, and empowering family members to improve the management

and prevention of T1DM related acute and long-term complications.

funding and increased efforts by various governments, to improve education intervention

and empower patients to afford the quality of care.

with type one diabetes mellitus in Zanzibar

1. To determine levels of knowledge of T1DM among caregivers of children and