Getie et al.

BMC Public Health (2020) 20:1232

https://doi.org/10.1186/s12889-020-09338-5

RESEARCH ARTICLE Open Access

Self- care practices and associated factors

among adult diabetic patients in public
hospitals of Dire Dawa administration,
Eastern Ethiopia
Asmare Getie1*, Biftu Geda2, Tadesse Alemayhu2, Agenehu Bante1, Zeleke Aschalew1 and Biresaw wassihun1

Abstract
Background: Diabetes is a huge growing problem, and causes high and escalating costs to society. Self- care
practice for adults with diabetes is not well addressed in sub-Saharan Africa including Ethiopia. To prevent serious
morbidity and mortality, diabetes treatment requires a commitment to demanding self-care practice. This study
aimed to assess self- care practices and its associated factors among adults with diabetes in Dire Dawa public
hospitals of Eastern, Ethiopia.
Methods: A cross-sectional study was conducted among 513 adults with diabetes. The study participants were
selected through systematic random sampling. Data were collected from February 1st to March 1st, 2018. Patients
were interviewed using a structured questionnaire. Data were entered into Epi-data version 3.3.1 and exported to
SPSS version 22.0 for analysis. Bivariable and multivariable logistic regression with crude and adjusted odds ratios
along with the 95% confidence interval was computed and interpreted accordingly. Good self-care was defined
based on mean calculation; a result above the mean value had a good self-care practice, and a P-value of < 0.05
was considered to declare a result as statistically significant.
Result: The result of the study showed that 55.9%, (95% CI: 51.4, 60.3) of participants had good self-care practices.
Good self-care practice was associated with having family support, treatment satisfaction, diabetes education,
having glucometer, higher educational status, duration of the disease, high economic status, and having good
knowledge. Self-care practice was significantly associated with good diabetes knowledge (AOR = 2.14, 95% CI: 1.37,
3.35), family support system (AOR = 2.69, 95% CI:1.56, 4.62), treatment satisfaction (AOR = 2.07, 95% CI:1.18, 3.62),
diabetes education (AOR = 2.21, 95% CI: 1.35, 3.63), high economic status (AOR = 1.89, 95% CI: 1.01, 3.48), having
glucometer,(AOR = 2.69, 95% CI:1.57, 4.63),higher educational status (AOR = 2.68, 95% CI: 1.31, 5.49), and duration of
disease greater than 10 years AOR = 2.70, 95% CI: 1.17, 6.26).
Conclusion: In this study, a large number of adults had poor self-care practices which are very significant in
controlling diabetes. Providing diabetes education, about self-care practices to the respondents and their families
should be considerable.
Keywords: Diabetes mellitus, Self-care practice, Dire Dawa

* Correspondence: [email protected]
1
College of Medicine and Health Sciences, Arba Minch University, Arba
Minch, Ethiopia
Full list of author information is available at the end of the article

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Getie et al. BMC Public Health (2020) 20:1232 Page 2 of 8

Background It has 9 urban kebeles (small administrative units of

Self-car is an individual’s adherence to a diabetes self- Ethiopia) and 38 rural kebeles. The City has given health
management regime, which is imperative to maintain care services for the catchment population in different
glycemic control all-encompassing of diet, maintaining disciplines. The hospitals have provided services for
physical activity, daily monitoring of blood glucose adults with diabetes in the diabetic clinic. The service is
levels, adhering to medication therapy and foot care [1]. given by physicians, and 2171 adults with diabetes were
Self-care is considered crucial for all people with dia- registered for follow-up in the past one year.
betes for monitoring the disease process, prevention of
complications, and glycemic control which improved Study design
quality of life [2]. Institutional based cross-sectional study design was
Globally, an estimated 422 million adults were living conducted.
with diabetes in 2014 [3]. Two-thirds of the global dia-
betes population lives in the developing world [4]. Based Inclusion and exclusion criteria
on the IDF Atlas 9th edition, the number of cases of dia- Inclusion criteria
betes globally was 463 million and Ethiopia was esti- All adults with diabetes who had one year follow up and
mated at 1.7 million in 2019 [5]. Diabetes is one of the came into diabetic clinics were included in the study.
most challenging health problems in the twenty-first
century. It costs at least 548 billion dollars in health ex- Exclusion criteria
penditure in 2013 which is 11% of total health spending Those adults with diabetes who are critically and men-
on adults [6]. When it is not prevented and properly tally ill, pregnant women’s and newly diagnosed adults
managed, diabetes is one of the major causes of prema- with diabetes were excluded.
ture illness and death worldwide which resulted in 5.1
million deaths in 2013. Poor self-care practice increases Sample size determination and sampling procedures
the incidence and prevalence of complications resulting The required sample size is determined by using a for-
in increased morbidity, and mortality [7] To reduce mula for single population proportion by taking different
morbidity and mortality different studies were con- p values from different studies; and the sample size for
ducted in different parts of the world. Although there some of the factors for diabetic self-care practices ob-
was significant variation across countries, self-care prac- tained from different pieces of literature was calculated
tice on diabetes is less than optimal in all countries. by Epi Info 7 menu statically, by considering the follow-
More than one-third of US adults with diabetes have ing assumptions: confidence level 95%, power 80% and
poor self-care practices [8]. Diabetic’s self-care practices exposed to the unexposed ratio of 1. So, the sample size
in Ethiopia is still low, which is in the range of 39–63.3% for this study was 466 and after adding a non-response
[9]. Despite the great strides that have been made in the rate of 10% the final sample size became 513.
treatment of diabetes in recent years, many patients do
not achieve optimal outcomes and still experience devas- Sampling procedures
tating complications due to inadequate self-care practice, In the study area there are two governmental hospitals
and there is little information in the study area. Hence (SGH=Sabian General Hospital and DCRH = Dill Chora
the finding of the study provides and fills the gap-related referral hospital) and these two governmental hospitals
to the level of self-care practice. Therefore, this study were selected purposively. These two hospitals have sep-
aims to assess self-care practices and its associated fac- arate clinics for diabetes follow-up. The number of study
tors among adults with diabetes in Dire Dawa city Ad- participants from the selected health facilities was deter-
ministration Eastern Ethiopia. mined from the previous total number of diabetic pa-
tients who have followed up which is 2171 in the two
Methods hospitals.
Study area and period Samples were allocated to each of the selected hospi-
The study was conducted in Dire Dawa Administrative tals based on proportional allocation to sample size. The
city from the1st of February to the 1st of March 2018. lists of respondents or sampling frames were obtained
Dire Dawa is located in the Eastern part of the country from the updated registration books of each follow-up
enclosed by Ethiopian Somalia and the State of Oromia. clinic of the hospitals. After establishing the sampling
It is 515 km from Addis Ababa and 47 km from Harar frames of respondents, a simple random sampling tech-
town. It has a hot temperature with a mean of 25 de- nique was used to identify the study unit to be included
grees centigrade. Based on the 2007 Census, the total in the study. Adults with Diabetes were selected by com-
population of Dire Dawa Administrative city is 395,000 puter method using updated registration books as a sam-
of which females account 51.6%. pling frame until a sample of 513 was reached.
Getie et al. BMC Public Health (2020) 20:1232 Page 3 of 8

Data collection tools Knowledge about diabetes

Six trained nurses conducted the interview using a struc- This is measured by fifteen items in yes/no format. The
tured pretested questionnaire for one month. The prin- correct answer will be given “1” and “0” is given for in-
cipal investigator and an assistant supervised the data correct and don’t know. Then a total score is computed
collection. Face to face interviewer-administered vali- out of fifteen marks (with the range of 0–15) those who
dated questionnaire was used to measure self-care prac- score mean and above the mean have a good knowledge
tice, which was contextualized to the study area. It was whereas those who score below the mean value have no
prepared originally in English and was translated to Am- good knowledge [11].
haric, and then translated back to English for checking
the consistency of the questionnaire. The questionnaire Results
consisted of socio-demographic variables (8 items), Socio-demographic characteristics of the participants
health-related variables (14 items), diabetic knowledge A total of 513 diabetic patients were approached, among
(15 items), treatment satisfaction (6 items), and self-care which all, but 7 consented and complete the interview.
practice (15 items). The seven interviewees consented, but could not finish
the interview, giving a 98.6% response rate. From the
Data collection technique total respondents, 279 (55.1%) were females and
The data collection was conducted in an institution- 227(44.9%) were males. More than half of the respon-
based exit interview by using pre-tested Amharic, and dents (56.7%) were Orthodox, 170(33.6%) Muslims, and
English questionnaires. The training was provided for 47(9.3%) Protestants, regarding ethnicity 217 (42.9%)
the data collectors and supervisors by the principal in- were Amhara and 190 (37.5%) were Oromo. More than
vestigator. All adults with diabetes who are selected and half of the respondents (54.5%) were married, 71(14%)
fulfill the inclusion criteria were interviewed. Confidenti- single, 53 (10.5%) widowed, and 106(20.9) were sepa-
ality and privacy were kept. rated. The Mean age of the respondents was 51.48 (SD ±
14.75) years with a range of 18 to 86 years. From the
Data analysis total respondents one hundred seventy-two (34%) were
The collected data were cleaned, coded, and entered into self-employed (Table 1).
Epi Data 3.3.1 statistical software package. The statistical
analysis was done using SPSS version 22. Frequency dis-
tribution for selected variables was done. The statistical Health status of the study participants
significance and strength of the association between in- The majority of the respondents, 378 (74.7%) were type
dependent variables and an outcome variable were mea- 2 diabetic patients, 60.7% of the respondents had no his-
sured by the bivariate logistic regression model. A tory of co-morbidities, and most of the patients (61.3%)
variable P-value less than 0.2 was candidates to multivar- were on oral hypoglycemic agents and 24.3% were on in-
iable logistic regression model and a p-value less than sulin medication.
0.05 was considered as significantly associated. Finally, Only 34 (6.7%) of the participants were members of
the results of the study were presented using tables, fig- the Ethiopian Diabetes Association. The majority of the
ures, and texts based on the data obtained. participants (77.5%) had family support. About 231
(45.7%) of the participants usually received diabetes edu-
Operational definitions cation and more than half of the participants (53.6%)
Self-care practices were knowledgeable. The diabetic treatment satisfaction
It is the practice of activities that individual diabetics will rate was 81.6% (Fig. 1).
initiate and perform on their behalf in controlling their From the total respondents, one hundred fifty-one
disease, maintaining life, health, and wellbeing [10]. (29.8%) had a family history of diabetes and nearly one-
fifth of the respondents (18.8%) had glucometer at home.
Good self-care practices More than one-third of the participants 199 (39.3%) had
individuals who have scored mean and above the mean long term diabetic complications confirmed medically
value of the total 15 self-care practice questions. These and almost all 187(94%) have hypertension (Table 2).
15 items evaluate the status of patients’ self-care during
the last seven days. Responses in each subscale were The magnitude of self care practices
based on 7-days, ranged from 0 to 7, the higher number Overall self-care practices were calculated using 15 self-
was indicative of days reflecting better self-care oper- care assessment tools with a total score of 105. Using
ation. The minimum score is 0 and the maximum score this, the overall mean score for self-care was 43.5(SD ±
in this tool is 105, which is indicative of the highest 10.9) and range from19–69 points. Two hundred eighty-
quality of self-care. three subjects (55.9%) scored above the mean value from
Getie et al. BMC Public Health (2020) 20:1232 Page 4 of 8

Table 1 Socio-demographic data of adult diabetic patients in More than half (54.9%) of the study participants did
Dire Dawa public hospitals 2018, (n = 506) not adhere to the recommended diet management prac-
Characteristics Alternative response Frequency tices which means below the mean value. Around two-
No % thirds (62.1%) of the respondents had practiced the rec-
Sex Male 227 44.9 ommended diabetic foot care, which scored mean and
Female 279 55.1
above the mean. From the total respondents, 386
(76.3%) had washed their feet all days of the week, 273
Ethnicity Amhara 217 42.9
(54%) of diabetic patients had checked their feet on all
Oromo 190 37.5 days of the week. More than half, (55.7%), of the respon-
Tigre 17 3.4 dents, performed daily foot inspection, and nearly
Gurgie 53 10.5 greater than half (51%) of respondents reported that they
Somali 29 5.7 dried between their toes after washing their feet
Religion Orthodox 287 56.7
(Table 3).
Muslim 170 33.6
Discussion
Protestant 47 9.3 In this study, the current self-care practices of peoples
Other 2 .4 with diabetes in Dire Dawa public hospitals and factors
Marital status Married 276 54.5 that contribute to the self-care practice of diabetics were
Single 71 14 investigated. The finding of this study was addressed fac-
Widowed 53 10.5
tors that were not well studied by other studies like foot
care practice and it provides pertinent information to
Separated 106 20.9
the population in the study area as well for the scientific
Level of education Cannot read cannot write 130 25.7 society since there were no previous local studies. Over-
Read and write 70 13.8 all, Self-care practices among people with diabetes were
Primary school 101 20 found to be good at 55.9%, (95% CI: 51.4, 60.3) of the
Secondary school 120 23.7 study participants.
College and above 85 16.8
The predictors of self-care practices were: getting an
education from health professions, having glucometer at
Occupation Self-employed 172 34
home, having knowledge about diabetes, treatment satis-
Employed 105 20.8 faction, duration of disease, having family support, edu-
Unemployed 161 31.8 cational status, and family wealth index.
Student 26 5.1 The overall recommended self-care practice was
Housewife 42 8.3 (55.9%). This finding was in line with the results of the
Wealth index Low 170 33.6
studies conducted in Addis Ababa (60.2%) [12]. However,
the finding of this study was greater than the study con-
Medium 193 38.1
ducted in Harar, Eastern Ethiopia (39.2%) [13]. This
High 143 28.3 discrepancy may be due to some improvements in the
health care systems (related to the period gap) and vari-
ation of cutoff point to classify good and poor self-care,
the total self-care questions. As a result, 55.9%, (95% CI: mean, and 50 % of total self-care practices, respectively.
51.4, 60.3) have good self-care practices. Sample size variation may also attribute to this difference.
Regarding adherence to regular exercise, 294 (58.1%) On the contrary, the finding of this study was lower
of the respondents adhered to the recommended daily than the study conducted in Eastern Nepal of which
regular exercise; nearly more than half (53.8%) of the re- (70%), of the study participants, had good self-care prac-
spondents practiced a physical activity of at least 30 min tices [14]. This variation could be due to socio-cultural
on all days of the week and twenty-five (5%) had A sep- differences. The majority of the study participants in
arate exercise session more than 3 days per week apart Nepal had a high income, so that they could afford their
from their day to day physical activities. own glucometer and easily get a healthy diet. This find-
Regarding medication, the majority (91.7%) of the ing is also lower than the study which was conducted in
study participants adhered to the prescribed medication Dilla, South Ethiopia which had 76.8% good self-care
on all days of the week. The majority, (78.5%), of the re- practices. Methodological and sample size variation may
spondents, didn’t practice the recommended self -moni- also account for this discrepancy [11].
toring of blood Glucose which means, monitoring their This study revealed that those who had family support
blood sugar level less than the mean value. were nearly three times more likely to have good self-
Getie et al. BMC Public Health (2020) 20:1232 Page 5 of 8

Fig. 1 Self-care practice distribution with treatment satisfaction among adult diabetic patients in Dire Dawa public hospitals Eastern Ethiopia, 2018

care practices than those who did not. This is consistent

Table 2 Health status data of type 2 diabetes patients in Dire
with a study conducted in Addis Ababa [12] and Kenya
Dawa public hospitals, 2018 (n = 506)
[15]. Individuals who have family support could have
Characteristics Alternative response Frequency
better information related to disease, have a chance to
No %
get an education, and may have got a good income.
Knowledge of diabetes Good 271 53.6 Those who had received education from health care
Poor 235 46.4 professionals were almost two times more likely to have
Duration of diabetes 1–5 years 215 42.5 good self-care practice than those who didn’t. This find-
6–10 years 240 47.4 ing was comparable with the study conducted in Addis
Greater than 10 years 51 10.1
Ababa [12] and Harari [13].
Respondents who had a higher level of education were
Comorbidities Yes 199 39.3
nearly three times more likely to be engaged in self-care
No 307 60.7 practices when compared with respondents who were
Current treatment Oral 310 61.3 unable to read and write. This finding was congruent
Insulin 123 24.3 with the studies conducted in Black Lion, hospital, and
Both 73 14.4 study conducted in Gondar [7, 12]. This implies that
Having glucometer Yes 93 18.38
education is the base for a diabetic patient to understand
the disease process and to provide own self-care prac-
No 413 81.62
tice, because they may be able to read and become more
Getting DM education Yes 231 45.7 informed of the benefits of adherence.
No 275 44.3 Knowledge of diabetes and its disease process was
Members of Diabetes association Yes 34 6.7 found to be positively associated with self-care practice.
No 472 93.3 Individuals who were knowledgeable were nearly two
Treatment satisfaction Yes 413 81.6
times more likely to have good self-care practice than
those who had less diabetes knowledge. This finding was
No 93 18.4
in line with the finding from Addis Ababa, Malaysia, and
Having family support Yes 392 77.5 the Harari Region of Eastern Ethiopia [8, 12, 13]. The
No 114 22.5 possible justification is that the right knowledge about
Having support from society Yes 19 3.8 diabetes and its self-care practice creates a clear under-
No 487 96.2 standing and avoids confusion about the practice and
Alcohol drinking Yes 35 6.9
the disease condition.
Respondents who have glucometer at home were
No 471 93.1
nearly three times more likely to have good self-care
Getie et al. BMC Public Health (2020) 20:1232 Page 6 of 8

Table 3 Self-care practices among adults with diabetes and factors associated with self-care in Dire Dawa public hospitals, 2018
Variables Self-care practice COR; 95% CI AOR; (95% CI
Good N (%) Poor N (%)
Duration of disease in Year
1–5 16(39) 25(61) 1.00 1.00
6–10 years 90(51.75) 84(48.3) 0.146(0.84–3.35) 1.56(0.99–2.46)
> 10 years 177(60.8) 114(39.2) 2.426(1.24–4.74) 3.339(1.51–7.38)
DM Education
Received 153(66.2) 78(33.8) 2.188(1.52–3.13) 2.20(1.34–3.62)*
Not received 130(47.3) 145(52.7) 1.00 1.00
Sex
Male 143(63) 84(37) 1.00 1.00
Female 140(50.2) 139(49.8) 1.69(1.182–2.416) 0.906(0.55–1.48)
Disease knowledge
Good 188(69.4) 83(30.6) 3.338(2.31–4.81) 2.144(1.37–3.34)*
poor 95(40.4) 140(59.6) 1.00 1.00
Glucometer at home
Yes 78(83.9) 15(16.1) 5.27(2.93–9.47) 2.69(1.56–4.62)*
No 205(49.6) 208(50.4) 1.00 1.00
Mode of treatment
Tablet 167(53.9) 143(46.1) 1.00 1.00
Insulin 116(59.2) 80(40.8) 0.80(0.56–1.15) 0.97(0.61–1.54)
Educational level
Not read and write 62(47.7) 68(52.3) 1.00 1.00
Read and write 26(37.1) 44(62.9) 0.64(0.35–1.17) 0.77(0.36–1.63)
Elementary school 58(57.4) 43(42.6) 1.48(0.87–2.49) 1.55(0.75–3.17)
Secondary school 74(61.7) 46(38.3) 1.764(1.066–2.92) 1.95(0.95–3.95)
College and above 63(74.1) 22(25.9) 3.14(1.73–5.69) 2.70(1.17–6.25)*
Marital status
Married 162(58.7) 114(41.3) 1.53(0.97–2.49) 0.77(0.42–1.39)
Single 44(62) 27(38) 1.75(0.78–3.21) 0.859(0.36–2.00)
Widowed 26(49.1) 27(50.9) 1.038(0.53–2.00) 0.747(0.33–1.69)
Separated 51(48.1) 55(51.9) 1.00 1.00
Family support
Having 246(62.8) 146(37.2) 2.28(1.52–3.43) 2.69(1.56–4.62)*
Not having 37(32.5) 77(67.5) 1.00 1.00
Treatment satisfaction
Satisfied 240(58.1) 173(41.9) 1.61(1.02–2.53) 2.06(1.18–3.61)*
Not satisfied 43(46.2) 50(53.8) 1.00 1.00
Wealth index
Low 76(44.7) 94(55.3) 1.00 1.00
Medium 123(63.7) 70(36.3) 2.1(1.42–3.31) 1.47(0.85–2.53)
High 84(58.7) 59(41.3) 1.76(1.12–2.76) 1.88(1.02–3.47)
*Statistically significant at P < 0.05
Getie et al. BMC Public Health (2020) 20:1232 Page 7 of 8

practice when compared to those who didn’t. This find- Availability of data and materials
ing was in line with the finding of the study which was The datasets used and/or analyzed during the current study are available
from the corresponding author on reasonable request.
conducted in Black Lion Specialized Referral Hospital,
Addis Ababa [4]. Ethics approval and consent to participate
In this study participants who had high income were Officially written approval letter was obtained from the Institutional Health
Research Ethical Review Committee (IHRERC) of the College of Health and
two times more likely to have good self-care practices Medical Sciences, Haramaya University. Besides, an official letter was issued
than those who had low income. This finding was in line from the College of Health and Medical Sciences, Haramaya University to the
with the study conducted in Dilla University Referral director of each hospital. After securing permission from each hospital
administrator, the actual data collection commenced after obtaining written
Hospital and Arba Minch General Hospital [10, 11]. and signed voluntary consent from each study participant. All information
Respondents who were satisfied regarding treatment collected from the participants was kept confidential.
were nearly two times more likely to have good self-care
practices than their counterparts. This finding was con- Consent for publication
Not applicable.
gruent with a study conducted in Nigeria [16]. Since pa-
tient satisfaction is directly associated with the degree of Competing interests
satisfaction with expected care and is linked with cogni- The authors declare that they have no competing interests.
tive evaluation and emotional reactions to the compo- Author details
nents of care services. 1
College of Medicine and Health Sciences, Arba Minch University, Arba
Minch, Ethiopia. 2School of Nursing and Midwifery, Department of public
health, College of Health and Medical Sciences, Haramaya University, Harar,
Conclusions Ethiopia.
In this study, a large number of adults had poor self-care Received: 15 August 2019 Accepted: 3 August 2020
practices which are very significant in controlling dia-
betes. Providing diabetes education, about self-care prac-
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