Awareness And Adherence To Self Care Activities Of Type 2 Diabetic Patients Attending Diabetic Clinics At Two Tertiary Hospitals

CHAPTER ONE
INTRODUCTION
Background to the study
Diabetes mellitus (DM) is a chronic progressive metabolic disorder characterized by high blood glucose `mainly due to absolute or relative lack of a hormone known as insulin (Shrivastava and Ramasamy, 2013). The Centre for Disease Control and Prevention  (CDC, 2012) defined it as a group of diseases characterized by high blood glucose. Diabetes mellitus is a systemic disease that is chronic and severe. The disease occurs when the body cannot use the insulin it produces effectively or when the pancreas cannot produce enough insulin (World Health Organization (WHO, 2009).  Other cardinal symptoms of diabetes mellitus include excessive thirst, excessive urination and excessive hunger. Death rates for heart diseases and the risk of stroke are about 2 to 4 times higher among adults with diabetes mellitus than among those without diabetes (CDC, 2011).
The disease is difficult to detect as some people do not have any symptoms or the symptom develop slowly. The symptoms that occur are increased thirst, urination, physical and mental fatigue (Magnusson, 2009). The patient can be diagnosed as having DM by three features viz: fasting blood glucose of above 7.0mmol/l at two times; non-fasting glucose of above 12.2mmol/l and same value after an “oral glucose load’’ test.
Diabetes mellitus is one of the most common non-communicable diseases (NCD) globally.  WHO estimates that more than 346 million people worldwide have diabetes mellitus and this number is likely to double by 2030 if there is no intervention (WHO, 2013). The reason for this increased prevalence is the growing population of people over 65 years old, physical in-activity, urbanization and obesity (Wild, Roglic, Green, Sicree & Kings, 2005). This disease is most common in Europe and United States of America (USA). However, a large increase is expected in the developing and newly industrialized countries (International Diabetic Federation, (IDF), 2013). The increasing trend is specific in type 2 Diabetes Mellitus. This is closely related to or associated with urbanization, large population size, genetic pre-disposition, westernization, changing of life style and mechanization. The increase is also related to dietary habits and physical inactivity. The long term complications of Diabetes mellitus type 2 may increasingly devastate the health care system in developing countries if their governments do not prioritize this emerging disease (Ochram, 2005).
Diabetes Mellitus is the fourth leading cause of death in most high income countries and now there is substantial evidence showing that it is an epidemic in many economically developing and newly industrialized countries (IDF, 2013). WHO (2008) reported that 228 million people suffer from diabetes mellitus in developing countries while only 72million suffer from the disease in developed world.
Africa is a multi-cultural, religious and ethnically diverse continent traditionally dominated by infectious diseases, but with rapid urbanization, non-communicable diseases are quickly becoming a priority health problem in this continent with an estimation of about 14.7 million adults being diabetic in 2011 and a projection of 28.0 million by the year 2030. IDF,( 2013)’s financial estimate of Africa alone indicates that at least 2.8 billion US dollars was spent on health care due to diabetes mellitus alone in 2011. This is expected to rise to 61% in 2030.
In sub Saharan Africa, Diabetes mellitus, in 2000, affects 7,020,000 people and is projected to affect 18,234,000 people in 2030. Algeria had 426,000 in the year 2,000 and is expected to have 203,000 by 2030. South Africa 814,000 in the year 2,000 and is expected to have 1,286,000 by the year 2030. In the same vein, Cameroon had 70,000 in 2,000 and is expected to have 171, 000 by 2030 if uncontrolled. Nigeria had 1,707,000 in 2,000 and is expected to have 4,835,000 by 2030 if uncontrolled (IDF, 2013). Nigeria has the highest number of people with Diabetes Mellitus (about 1.2 million) in sub-Saharan Africa. Adebayo (2013) stated that more Nigerians die of Diabetes mellitus than HIV/AIDS. Chinenye (2011) stated that the incidence and prevalence of Diabetes mellitus have continued to increase in Nigeria despite a great deal of research and resources. The disease has reached an epidemic proportion in Nigeria. It has even resulted to permanent disabilities like blindness, amputation of limbs, impotence, kidney failures, still births, pregnancy wastages etc (Chinenye, 2014).
The needs of diabetic patient are not limited to blood glucose control. They extend and cover other essential need activities which include prevention of complications, limitation and rehabilitation of disabilities and risk reduction behaviours among others. There are seven essential self care behaviours identified by the American Association of diabetes educators (2013). The seven self care behaviours were generally observed in people with diabetes illness. Indeed, the self care needs were noted to result in good outcomes for diabetic patients who adopt and put into practice the principles of the seven self care behaviours. All these seven self care behaviours have been found to be positively correlated with good blood sugar control, reduction in the incidence of complications and improvement in quality of life. Individuals with diabetes mellitus have been shown to make a dramatic impact on the progression and development of their disease by participating in their own care.
The seven notable self-care behavioral activities whose concepts are described in chapter two include: Healthy eating, being physically active, monitoring of blood sugar, compliance with medications’ good problem solving skills, healthy coping skills, risk reduction behaviour. (American Association of diabetic educators ( AADE), 2013).
Diabetic patients are expected to follow a complex set of behavioural actions to care for their diabetes on daily basis as reflected in the above enumerated seven self care needs. Ironically as noted by AADE (2013), adherence with self-care needs is generally low among diabetic patients. The low compliance is realized by the failure to find in the patients the attainment of the expected long term changes. This low compliance has been of great concern to the researcher because good glycaemic control remains the cornerstone of managing type-2 diabetic patients (Shrivastava, 2013). Good compliance will prevent or delay the onset and progression of diabetic complications. It was against this background that the present research was undertaken to investigate the awareness and adherence of self care activities among adult type 2 diabetes mellitus patients attending diabetic clinic in two tertiary health facilities in Imo State.
Statement of the Problem
In Nigeria, the incidence and prevalence of diabetes have continued to increase, despite a great deal of research and resources (Chinenye, 2011). Also, as stated by Adebayo (2012), more Nigerians die of diabetes than HIV/AIDS. Chinenye (2014) stated, also, that diabetes disease has reached an epidemic proportion in Nigeria and has resulted in permanent disabilities like blindness, amputation of limbs, impotence, kidney failures, still births, pregnancy wastages etc. The prevalence of diabetes is due to shift in dietary habits, developments and urbanization.
Self-care is the most important treatment of the disease. Self – care is very important in many aspects, both for the individual well-being and also from the socio-economic perspective. Non implementation of self care can lead to various complications and increase the patients’ sufferings from the disease (Quittenbaum, 2007)
Non-adherence to diabetes self-care activities has led to many death and complications of diabetic patients in Nigeria. The low adherence to self care is a source of worry to the researcher who lost his senior brother due to his inability to adhere to his self care needs. One wonders what could account for the non adherence. It was against this background that the researcher wants to know the patient’s level of awareness of these essential self-care activities and why their low adherence.
Purpose of the Study
The purpose of the study was to assess the level of awareness and adherence with self-care activities of type 2 adult diabetic patients attending the diabetic clinics of two tertiary health institutions in Imo State, Nigeria.
Objectives of the Study were to:

1. Determine level of awareness of self care activities among adult type 2 diabetic patients attending clinic at 2 tertiary health institutions in Imo State.
2. Elicit diabetic patients awareness of complications associated with neglect of diabetic self care activities.

• Determine the level of adherence of diabetic patients to their self care activities.

1. Identify factors that affect diabetic patient’s adherence behaviour with self care activities.

Research Questions

1. To what extent are adult type 2 diabetics patients aware of their self care activities.
2. To what extent could they elicit the complications that are associated with neglect of self care activities.

• Are the diabetics patients adherent with their self care activities.

1. What factors affect their adherence behaviour with self care activities.

Research hypothesis

1. H₀: There is no significant statistical relationship in the level of awareness of self          care needs of type 2 adult diabetic patients and the practice of self care
2. Ho: There is no significant statistical relationship between the knowledge of type 2       adult diabetic patients and self care adherence.

Significance of the Study
The information generated from this study will serve as
Baseline data on self care for use in the formulation of policy and strategy in the management of type 2 adult diabetes mellitus patients.
The data will also be available for use in the development and conduct of studies in the academia.
Findings from this study will add to the existing body of knowledge about self-care needs of type 2 adult diabetic patients.
It will further buttress how non practice of self-care activities has resulted to too frequent hospital visit, even in very bad conditions like comatose state etc.
This study will help health care givers to prioritize patient’s education on self-care, as this will reduce morbidity and mortality of the disease.
To the society, practice of self-care activities by the patients will reduce disability due to diabetes thereby affording the patients more opportunity to live more productive lives and contribute to national economic growth.
Scope of the Study
The study was delimited to the awareness and practice of self care activities of adults who have been diagnosed with Type-2 diabetes mellitus and attending clinic at the Federal Medical Centre, Owerri and the Imo State University Teaching Hospital, Orlu – Imo State. It was also limited to the two tertiary health institutions in Imo State. Both of them are teaching hospitals and run diabetic clinic in their setting.
Operational Definition of Terms
Self care adherence: This is to stick to a set of behavioural actions (Healthy Eating, Being Physically Active, Monitoring of Blood Sugar, Compliance with Medications’ Good Problem Solving Skills, Healthy Coping Skills, Risk Reduction Behaviour) in order to care for their diabetic problems on a daily basis.
Self care awareness: In diabetes, self care awareness is the ability to express understanding about the diabetic self care actions.
Diabetic self care activities: These are behaviours undertaken by people with diabetics or at risk of diabetics in order to successfully manage the disease on their own. E.g diet, healthful eating plan, engaging in exercise e.t.c. Activities of interest in this study were;
Adult Type 2 diabetics:  This refers to individuals above the age of 18 years diagnosed by doctors as having diabetes mellitus and receiving treatment either at the Federal Medical Centre, Owerri or Imo State University Teaching Hospital, Orlu-Imo State. This is referred to as more insulin dependant, it occurs when there is insulin resistance in the peripheral tissues due to insulin secretory defect of the beta cells. It develops very slowly and it is most common.