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PREDICTORS OF DIABETES SELF-MANAGEMENT AMONG TYPE 2
DIABETES PATIENTS IN KUCHING AND SAMARAHAN DIVISIONS
Azylina Gunggu
Master of Science (Nursing)
2015
Faculty of Medicine and Health Sciences
Faculty of Medicine and Health Sciences
PREDICTORS OF DIABETES SELF-MANAGEMENT AMONG TYPE 2 DIABETES
PATIENTS IN KUCHING AND SAMARAHAN DIVISIONS
AZYLINA GUNGGU
A thesis submitted in fulfilment of the requirements for the
Master of Science (Nursing)
Faculty of Medicine and Health Sciences
UNIVERSITI MALAYSIA SARAWAK
2015
FAKTOR-FAKTOR PENENTU BAGI PENGURUSAN KENDIRI DIABETES
(PENYAKIT KENCING MANIS) DI KALANGAN PESAKIT KENCING MANIS DI
BAHAGIAN KUCHING DAN SAMARAHAN
AZYLINA GUNGGU
Tesis yang dikemukakan untuk memenuhi keperluan
bagi Ijazah Sarjana Sains (Kejururawatan)
Fakulti Perubatan dan Sains Kesihatan
UNIVERSITI MALAYSIA SARAWAK
2015
i
ACKNOWLEDGEMENTS
Above all, I thank God the almighty, for His grace, love and constant presence in my life and
my journey throughout this study.
My greatest gratitude to Associate Professor, Dr. Chang Ching Thon (UNIMAS), my
principal supervisor and Dr. Faridah Said (UPM) for their constant guidance, supports and
encouragement through my course of study. Without their critical evaluation, feedbacks and
inspiring discussion, this thesis would not be possible.
For those who had involved direct and indirectly during the data collection, especially staffs
in Diabetes Clinics at Klinik Kesihatan Kota Samarahan, Klinik Kesihatan Jalan Masjid,
Hospital Serian and Hospital Bau. Their kind hospitality, informative sharing and constant
co-operations during my presence at the clinics had made the study enjoyable. Deepest
appreciations dedicated to all of them.
This study could not have been completed without the kind support from the respondents.
Thanks to them for the time spared.
My sincere thanks to all friends who had provide assistance and emotional supports. It is hard
to put all names here but thanks for being supportive throughout all my endeavours.
ii
Lastly, I would like to dedicate this thesis to my parents, my husband, my sisters and my
children. The unconditional love that ties us had sustained me through the journey. Especially
for my husband, thank you for being at my side through the ups and downs of my life. I am
grateful that God gave you to me.
iii
ABSTRACT
Diabetes mellitus (DM) is a significant global health problem and the prevalence of type 2
diabetes mellitus in Malaysia has increased by 31.0% over the period of five years (2006 –
2011). Uncontrolled DM often leads to many complications such as heart disease, stroke,
renal problem, amputation and blindness, thus, adherence to diabetes self-management
(DSM) is the cornerstone in diabetes management. Incorporating DSM regimens which
includes taking medications, engaging in physical activity, regulating diet, foot care and self-
monitoring of blood glucose into daily routine among type 2 diabetes people is essential to
maintain good glycaemic control. However, performance of DSM in Malaysia is suboptimal
and yet to be studied locally in Sarawak, Malaysia. Therefore, this cross-sectional study
aimed to determine the current status of DSM and the predicting factors. A total of 400
respondents participated in the study who were recruited from four randomly selected
governments’ diabetes clinics at Kuching and Samarahan Divisions. Among four DSM
assessed in the study, taking oral anti-diabetic medication account for 84.2%, whereas
engaging in physical activity showed the lowest percentage (29.1%). Performing foot care and
diet control were reported at 33.5% and 60.8% respectively. Fasting blood sugar, belief in
treatment effectiveness, family support and knowledge were predictive of DSM performance
(R2 = 0.165; F=15.56; p < 0.001). The findings of this study provided further information
about the current DSM status and the predictors that affect the behaviour. Healthcare
members who manage patients with type 2 diabetes mellitus should consider those predictors
in their diabetes management.
iv
ABSTRAK
Diabetes mellitus (DM) atau lebih dikenali sebagai penyakit kencing manis merupakan salah
satu masalah kesihatan global dan di Malaysia prevalens penyakit diabetis jenis-2 telahpun
menunjukkan peningkatan sehingga 31.0% dalam tempoh lima tahun (2006 - 2011). Penyakit
kencing manis yang tidak dikawal boleh mengakibatkan banyak komplikasi seperti penyakit
jantung, strok, masalah ginjal, amputasi dan buta, dengan itu, mematuhi pengurusan kendiri
diabetis adalah tunggak utama dalam pengurusan penyakit diabetis. Pengamalan setiap
aspek dalam pengurusan kendiri diabetis, seperti pengambilan ubat, terlibat dengan aktiviti
fizikal, penjagaan pemakanan, penjagaan kaki dan pemantauan sendiri paras glukosa darah
dalam rutin harian di kalangan penghidap penyakit kencing manis adalah penting bagi
mengekalkan paras optima glukosa darah. Di Malaysia, pengamalan penjagaan kendiri
diabetis di Malaysia masih lagi di tahap suboptimal, manakala tiada kajian berkaitan pernah
dijalankan di Sarawak. Oleh itu, kajian secara “cross-sectional” ini adalah bertujuan untuk
mengetahui status penjagaan kendiri diabetis serta faktor-faktor yang mempengaruhinya
(“predicting factors”). 400 orang responden telah direkrut dari empat buah klinik diabetis
kerajaan yang telah dipilih secara rawak di Bahagian Kuching dan Kota Samarahan bagi
menyertai kajian ini. Berdasarkan empat amalan penjagaan kendiri diabetis yang dikaji,
pengambilan ubat anti-diabetis mencatatkan peratusan sebanyak 84.2% manakala,
penglibatan dalam aktiviti fizikal menunjukkan peratusan yang paling rendah (29.1%).
Penjagaan kaki dan penjagaan makanan masing-masing melaporkan peratusan sebanyak
33.5% dan 60.8%. Bacaan gula dalam darah semasa puasa (FBS), tahap kepercayaan
terhadap keberkesanan rawatan, sokongan keluarga dan tahap pengetahuan merupakan
faktor-faktor yang boleh mempengaruhi pengamalan penjagaan kendiri diabetis (R2=0.165;
v
F=15.56; p < 0.001). Hasil kajian ini menunjukkan status semasa penjagaan kendiri diabetis
serta faktor-faktor yang boleh mempengaruhinya. Oleh yang demikian, ahli-ahli pasukan
kesihatan yang terlibat dalam mengendalikan mereka yang menghidap penyakit kencing
manis ini perlulah mempertimbangkan faktor-faktor ini dalam pengurusan diabetis.
vi
TABLE OF CONTENTS
Acknowledgement i
Abstract iii
Abstrak iv
Table of Contents vi
List of Tables x
List of Figures xi
List of Abbreviations xi
CHAPTER 1: INTRODUCTION
1.0 Introduction 1
1.1 Background of study 1
1.2 Problem statement 4
1.3 Aims of the study 6
1.3.1 Research question 6
1.3.2 Research objective 7
1.4 Significance of the study 7
1.5 Operational definition 9
1.6 Organization of the thesis 11
CHAPTER 2: LITERATURE REVIEW
2.0 Introduction 12
2.1 Conducting the literature review 12
2.2 Diabetes self-management 13
vii
2.3 Factors predicting DSM 26
2.3.1 Demographic characteristics and health profile 26
2.3.2 Self-efficacy 29
2.3.3 Belief in treatment effectiveness 33
2.3.4 Knowledge 36
2.3.5 Family support 38
2.3.6 Healthcare provider and patient communication 41
2.4 Research framework 44
2.5 Summary 45
CHAPTER 3: METHODOLOGY
3.1 Research design 46
3.2 Research setting 46
3.3 Sampling 47
3.3.1 Sampling methods 48
3.3.2 Sample size 48
3.4 Research instruments 50
3.4.1 Questionnaire 50
3.4.2 Translation of questionnaire to Malay language 55
3.5 Ethical considerations 59
3.6 Data collection 59
3.7 Data analysis 60
3.8 Summary 60
CHAPTER 4: RESULTS
4.0 Introduction 61
viii
4.1 Characteristics of the respondents 61
4.2 Health profile and treatment options of the respondents 62
4.3 Mean score for DSM 63
4.4 DSM status 64
4.5 Mean differences between DSM with demographic characteristics and
health profile variables
65
4.6 Factors related to DSM 66
4.7 Predictors of DSM 68
4.8 Summary 71
CHAPTER 5: DISCUSSION
5.0 Introduction 72
5.1 Major findings of the study 72
5.1.1 Diabetes self-management 72
5.1.2 The predicting factors of DSM 76
5.2 Implication of the study 81
5.2.1 Implication for nursing practice 82
5.2.2 Implication for future research 83
5.3 Limitations of study 84
5.4 Conclusion 84
REFERENCES 86
Appendices
Appendix 1 Permission to use questionnaire 101
Appendix 2 The research instrument 102
Appendix 3 The Malay version of research instrument 107
ix
Appendix 4 Ethical approval from ethical committee UNIMAS 113
Appendix 5 Ethical approval from Medical Research & Ethics
Committee (MREC)
114
Appendix 6 Informed consent form 115
Appendix 7 The Malay version of informed consent form 117
x
LISTS OF TABLES
Table 2.1: MOH’s recommendations for SMBG 21
Table 3.1: Reliability test of DSM, belief in treatment effectiveness, self-
efficacy, family support, healthcare team provider-patient
communication and knowledge questionnaire based on pilot study
56
Table 4.1: Demographic characteristics of the respondents (n=400) 62
Table 4.2: Health profile of respondents (n=400) 63
Table 4.3: Mean and standard deviation of the DSM (n=400) 64
Table 4.4: DSM status of the respondents (n=400) 64
Table 4.5: Mean differences between DSM with demographic characteristics
and health profile (n=400)
66
Table 4.6: DSM Pearson Product-Moment Correlation (n=400) 67
Table 4.7: Factors predicting the DSM by Multiple Linear Regressions 70
xi
LISTS OF FIGURES
Figure 2.1: Research framework of the DSM 44
LISTS OF ABBREVIATIONS
DSM Diabetes self-management
SMBG Self-monitoring of blood glucose
Edu Years of education
BTE Belief in treatment effectivenes
SE Self-efficacy
FS Family support
1
CHAPTER 1
INTRODUCTION
In this first chapter, an overview of the background of the study is outlined in Section 1.1.
Section 1.2 presents the problem statements, followed by the aims of the study in Section 1.3.
In Section 1.3, there are two subsections, which presents the research question (Section 1.3.1)
and the research objectives (Section 1.3.2). Subsequently, Section 1.4 describes the
significance of the study, while Section 1.5 provides the operational definition of terms.
Lastly, Section 1.6 presents the organization of the thesis. As acknowledgement, the
referencing style used in the preparation of this thesis is based on the UNIMAS Post Graduate
studies regulations (2009) and the sixth edition of the Publication Manual of the American
Psychology Association (American Psychological Association, 2010).
1.1 Background of study
Diabetes mellitus is a significant global health problem (Wu, Courtney, Edwards, McDowell,
Shortridge-Baggett, & Chang, 2007). It is a chronic disease caused either by inherited and/ or
acquired deficiency in the production of insulin by the pancreas, or by the ineffectiveness of
the insulin produced (World Health Organization [WHO], 2006). In other words, when there
are defects either due to insufficient insulin secretion, resistance to insulin action, or both,
would lead to hyperglycaemic condition (American Diabetes Association [ADA], 2009),
where the level of fasting serum glucose would be raised above normal. The common
2
symptoms presented by the patients diagnosed with this disease include polyuria, polydipsia,
tiredness and sudden weight loss (Ministry of Health Malaysia [MOHM], 2009).
International Diabetes Federation (IDF, 2012) classified diabetes mellitus into three main
types; namely type 1, type 2 and gestational diabetes mellitus (GDM). Type-1 diabetes is also
known as insulin dependent diabetes mellitus. Type-1 diabetes is a disease resulting from the
destruction of beta cells of the pancreas. It is commonly diagnosed before the age of 40 years
(Nazarko, 2009). Global statistic indicated that type-1 diabetes accounts for 5% to 10% of the
total patients with diabetes mellitus (Deshpande, Harris-Hayes & Schootman, 2008).
The most common diabetes mellitus is the type 2 diabetes that affect more than 90% of all
diabetes patients. It is also known as non-insulin dependent diabetes mellitus (NIDDM).
Type-2 diabetes or NIDDM predominantly affects adults over the age of 40 and generally do
not require insulin therapy. However, insulin may be utilized in an effort to control the
sustained elevations of glucose in the blood (ADA, 2009). Risk of developing type-2 diabetes
is higher among adults who are overweight, physically inactive, consuming high fat and less
fibre food (Malaysia Ministry of Health Clinical Practice Guidelines [MMOHCPG], 2009).
Diabetes can also be hereditary where individuals with family history of the disease are at the
higher risk of developing diabetes compared to those with no family history (Nazarko, 2009).
In addition, pregnancy may attribute to high risk of diabetes mellitus. Women who are first
diagnosed with diabetes during pregnancy are said to have gestational diabetes mellitus
(GDM). This usually occurs in late pregnancy and arises because the body is unable to
produce sufficient insulin to meet the demand of a pregnant woman. Women with GDM
3
require strict glycaemic control and management in order to prevent complications in the
developing fetus. Normally, those women are advised to go for healthy diet despite being
prescribed with insulin or oral medication (IDF, 2012). GDM in pregnant mothers normally
disappear after birth. However, these women are at a higher risk of developing type-2 diabetes
in the future. According to Deshpande et al (2008), women with GDM have an increased risk
of 20% to 50% to be diagnosed with type 2 diabetes in later life.
Globally, prevalence of diabetes mellitus showed a rising trend due to factors such as
increasing population growth, aging, urbanization and increment in the prevalence of obesity
and physical inactivity (Hussein, 2008). IDF (2012) reported the estimated numbers of adults
living with diabetes had soared to 366 million, representing 8.3% of the global adult
population in 2011. It is estimated that the total number of people with diabetes would rise to
522 million by 2030, or 9.9% of the adult population. This number equates to approximately
three persons are diagnosed with diabetes every 10 minutes (Nazarko, 2009). Nazarko (2009)
also revealed that the greatest numbers of people with diabetes are those aged between 40 to
59 years old and 80% of people with diabetes mellitus worldwide are from developing
countries.
In Malaysia, the prevalence of diabetes is in the epidemic proportion and the numbers
continue to rise. According to National Health Morbidity Survey (NMHS) 2011 and
projections by the Disease Control Division, Ministry of Health, by the year 2020, the
prevalence of diabetes among the Malaysian adults is projected to rise to 21.6% (Feisul &
Azmi, 2013). NMHS (2011) also reported that the prevalence of diabetes in Malaysia had
increased by 31.0% within a five years period, from 11.6% (2006) to 15.2% (2011). Based on
4
the National Diabetes Registry Report from 2009 to 2012, Sarawak, ranked the fifth highest
number of type 2 diabetes patients (43, 333) compared to the other states in Malaysia with a
prevalence of 6.6% of the total registered type 2 diabetes patients (653, 326) (Feisul & Azmi,
2013).
1.2 Problem statement
Diabetes mellitus can give rise to health complications such as heart disease, stroke, kidney
disease, limb amputation and blindness as well as infant mortality (which is associated with
deliveries that involved the diabetic mothers) (Amoo, Green & Raghupathi, 2014).
Individuals with this condition are required to have a life time commitment to maintain good
glycaemic control through behaviour and lifestyle changes which can be very challenging
(Delamater, 2006).
People with diabetes need to adhere to a complicated regimen through self-management such
as eating healthily, be physically active, monitoring blood glucose and taking medication
(Sousa, Hartman, Miller & Carroll, 2009). Adherence to self-management is considered to be
the cornerstone of overall management of diabetes and it is believed that those who perform
diabetes self-management (DSM) effectively achieve better both in short- and long-term
health (Tang, Funnell & Oh, 2012).
Although DSM is considered critical for diabetes control, regimen adherence problem is
common among individuals with diabetes which often frustrates the health care professionals
5
(Delamater, 2006). It was reported that among 29% of insulin-treated patients, 65% of those
on oral medications, and 80% treated with diet alone had never performed self –monitoring of
blood glucose or monitored it less than once per month (Harris, 2001). Poor regimen
adherence in relation to diet and exercise were also reported among diabetes patients (Peyrot,
Rubin, Lauritzen, Snoek, Matthews & Skovlund, 2005).
In Malaysia, Ministry of Health (MOH) has embarked on various strategies to tackle the
diabetes-associated problems such as education and counselling. Besides, for those patients
who cannot afford to perform self-monitoring of blood glucose due to financial constraints,
they may have their blood checked at the clinics or hospital. However, performance of DSM
by diabetes patients is still suboptimal. Majority of diabetes patients did not have their disease
under control, in which, 61.1% of patients was found to have their HbA1c level greater than
8.0% and Malaysia was ranked number one in diabetes mellitus induced kidney failure
(Salmiah & Kamaruzaman, 2009). Though various strategies had been carried out to improve
the quality of life of the diabetes patients to reduce further complications, there are other
factors that may contribute to the suboptimal performance of DSM. Self-efficacy, knowledge,
patient’s belief in treatment effectiveness and social support may affect one’s DSM
performance (Xu, Toobert, Savage, Pan & Whitner, 2008a).
6
1.3 Aims of the study
As the prevalence of diabetes mellitus in Malaysia is increasing, examining the contributing
factors or predictors for DSM in Malaysia is necessary. However, studies focusing on this
area were limited. Most studies reviewed were conducted in other countries, in which findings
may not be applicable to Malaysian patients due to socio-cultural differences. To improve the
health outcomes among Malaysians with diabetes, it is important to understand the underlying
reasons that influence the individuals on whether to adopt and maintain DSM or not.
Identifying the predictors of DSM may aid in developing effective interventions to promote
optimal health and the quality of life among these patients.
1.3.1 Research question
Thus, this study is to answers the research question below:
1. What is the DSM status among type 2 diabetes patients?
2. Are there any mean differences between DSM with demographic and health profile
variables?
3. What are the factors associated with DSM?
4. What are the predictors of DSM?
7
1.3.2 Research objective
The general objective for this study is to assess the status of DSM and predicting factors
among type 2 diabetes patients. The specific objectives are as follows:
1. To assess the DSM status among type 2 diabetes patients.
2. To determine the mean differences between DSM with demographic and health
profiles variables.
3. To examine the factors associated with DSM.
4. To determine the predicting factors of DSM.
1.4 Significance of the study
The prevalence of diabetes in Malaysia is on the rise, which warrants strengthening of the
prevention and control programme. Ideally, once diagnosed, a diabetic patient must be given
prompt and adequate treatment to prevent or delay complications. Adherence to DSM could
reduce the risk of diabetes-related complications.
Healthcare providers play an important role in educating patients with diabetes mellitus in
terms of promoting healthy lifestyle and improving their quality of life. Patient education is
crucial if patients with diabetes are expected to perform effective DSM. In addition, there
may be other factors that may influence their DSM performance. Thus, examining predictors
8
of DSM in this study is intended to contribute to the existing knowledge in management of
diabetes in Malaysia. Health care providers can use this study’s findings to further improve
the current interventions in relation to the assessment of DSM performance and its predictors.
By, acknowledging the predictors of DSM may results in better adherence of DSM, and
reduced the occurrence of diabetes complications. With the good control of the disease and
its complications, medical cost can be reduced. This study’s finding could also provide a basis
for further research in this area.
9
1.5 Operational definition
1. DSM
2. Diabetes mellitus (DM)
3. Type-2 diabetes patient
:
:
:
DSM is defined as behavior that needs to be performed
by diabetes patients to manage their illness/ condition.
There are five behaviors involved namely: regulating
diet, engaging with exercise, taking diabetes
medications, self-monitoring of blood glucose, and
maintaining foot care (Xu et al, 2008a). A set of
questions from Xu et al (2008a) was used to assess
respondents’ DSM behaviors in this study.
DM is a chronic disease caused by
(i) inherited and/or acquired deficiency in
insulin production by pancreas; or
(ii) ineffectiveness of insulin produced.
(Nazarko,2009)
Type-2 diabetes develops due to abnormal increased
resistance towards insulin action and body cannot
produce enough insulin to overcome the resistance. In
this study type-2 diabetes patients were patients
diagnosed to have this condition by a doctor and were
attending follow-up treatment in the selected clinics.
10
4. Predictors of DSM
5. Belief in treatment
effectiveness
6. Diabetes knowledge
7. Self-efficacy
:
:
:
:
In this study, predictors DSM included demographic
characteristics, health profile, belief in treatment
effectiveness, diabetes knowledge, self- efficacy,
social support and provider-patient communication
Belief in treatment effectiveness refers to how diabetes
patients perceived the importance of DSM in their
diabetic control. In this study it was assessed using a
set of questionnaire adopted from Xu et al, 2008a.
Diabetes knowledge is defined as patients’
understanding of information in relation to diabetes
and its management. The level of knowledge in this
study was measured using a set of questionnaire
adopted from Gazmararian, Williams, Peel and Baker
(2003)
Self-efficacy refers to patients’ confidence in their
ability to perform health behaviors (Sarkar, Fisher &
Schillinger, 2006). The level of self-efficacy in this
study was measured using a set of questionnaire
consisting seven items adopted from Xu et al, 2008a.