ABSTRACT
There is limited information on how well or otherwise
diabetics in Ghana manage their condition and the impact of that on their
glycemic control. Using a retrospective design, this study sought to measure
the prevalence of poor glycemic control among diabetes patients in Ghana and
also to ascertain how diabetes self-management in the past, diabetes-related
distress and diabetes non-acceptance affected glycemic control (glycated
hemoglobin levels). Study participants were known diabetics attending two diabetes
clinics in Ashanti region of Ghana. We calculated a sample size of 103 and
collected data between September and December, 2015. Structured questionnaire
was used to collect socio-demographic information and validated Diabetes
Self-Management Questionnaire (DSMQ), Diabetes-related Distress Scale (DDS) and
Acceptance and Action Diabetes Scale (AAD) were used to collect data on each
participant. Anthropometric data (weight and height) were collected using
weighing scale and Stadiometer and recorded to the nearest 0.1kg and 0.1cm
respectively. The Fast Ion-Exchange Resin Separation Method was used to
determine glycated hemoglobin levels of participants. Patients’ folders were
also reviewed to retrieve their clinical information. A glycated hemoglobin
(HbA1c) level > 6.4% was considered as poor glycemic control according to IDF
guidelines. 115 participants completed the study. Greater than half (56.5%) of
the participants had HbA1c levels above normal (mean of 7.2%), indicative of
poor glycemic control. Mean BMI was higher in females than males (28.2 versus
24.6 kg/m2. Females diabetics had slightly lower HbA1c than their
male counterparts (p = 0.080); younger participants and those with normal BMI had
better glycemic control compared to older and overweight/obese participants.
Overall score for Diabetes Self-Management was 80.2, implying that majority of
the patients had good diabetes management. However comparing
the four subscales within DSMS, glucose management had the highest mean score
(87.4%) whilst dietary control recorded the lowest (74.2%), with no significant
gender or age variations. About 1 in 20 participants (5.2%) had severe
diabetes-related distress using a cut-off point of ≥ 3 and patients with good
glycemic control had less distress than poorly-glycemic controlled participants
(p = 0.006). Mean score for diabetes acceptances was 2.5 and although no age,
gender, BMI nor duration of DM differences were observed, participants with low
diabetes acceptance were more likely to have poor glycemic control (77% of poor
acceptance compared with 48.9% of good acceptance participants had poor
glycemic control). When controlled for socio-demographic characteristics, DSMS
was significantly negatively correlated with HbA1c. Regression analysis with
diabetes distress, diabetes acceptance and diabetes self-management in the
model showed DSMS as the only significant predictor of HbA1c levels
(exponent = -.563, 95% CI -0.09-0.015). In conclusion, the diabetics involved in
this study had general high self-management, low distress and good acceptance
of their condition and scores of these influenced glycemic control.
CHAPTER ONE
INTRODUCTION
1.1 BACKGROUND
Diabetes is a significant international health challenge as
it affects a large proportion of the world’s population, which is estimated at
approximately 18.3%. Of the types, type 2 diabetes, represents up to 95% of
diabetes cases in adults (Sicree et al., 2009). The prevalence of DM has
reached a nearly epidemic level with about 382 million people in the world
having the disease. This figure is expected to increase up to 592 million by
2035 (Lee et al., 2015). The developing world is not left out in this epidemic
as it has been reported that the prevalence is increasing considerably in
developing countries (Wynn et al., 2010).
In Ghana, the International Diabetes Federation reports that
a total of 440,000 representing 3.35% of adult age 20 years to 79 years were
estimated to have diabetes in the year 2013. Ghana also recorded 8,529
diabetes-related deaths in the same year. These figures are expected to double
over the next two decades, thereby threatening most of the development success
attained by Ghana and Africa at large (IDF, 2013).
Diabetes mellitus management aims at glycemic control,
prevention of acute and chronic complications and enhancing quality of life for
patients (Wattana et al., 2007) and currently, diabetes self-management
education programmes is becoming the interest of health care providers
especially in the management of type 2 diabetes (Khunti et al., 2012).
Diabetes mellitus is a chronic metabolic syndrome or disease
with abnormally high levels of sugar in the blood stream. In people with this
disease, the body is not able to properly use and store glucose and this may be
because insulin production is inadequate, or because the body has become
insensitive to insulin, or both (Thenmozhi, 2015). This causes sugar in the
blood to surge, which if not controlled can cause damage to various organs in
the body, and is a major reason for the rise in cardiovascular diseases
(Wattana et al., 2007).
Notwithstanding the tremendous advances that have been
achieved in the area of diabetes treatment in recent times, a lot of patients
are unable to attain best possible clinical outcomes leading to serious
complications and decrease in the quality and length of life (Funnell &
Anderson, 2004). Health care providers especially in resource limited setting
often make strenuous efforts to provide the recommended diabetes care for their
client. Moreover, the current health care system in Ghana is mostly oriented
towards delivering acute, symptom-driven care, making ineffective in treating
non-communicable diseases like diabetes that needs multifaceted management
approach.
1.2 NATURE OF DIABETES
Patients with high levels of glucose in their blood will
usually experience polyuria (frequent urination), they will become more and more
thirsty (polydipsia) and have intense appetite for food (polyphagia). It has
been estimated that up to 10% of all diabetics worldwide are type 1 whereas 90%
to 95% of all cases are type 2. A third type which is the gestational diabetes
occurs up to 15% of pregnant women world (IDF, 2013). The cardinal symptoms
exhibited by diabetics includes frequency of urination and extreme thirst, hunger and fatigue, dry mouth,
itchy skin and blurred vision. If not managed properly, the injurious
effect/complications of prolonged hyperglycaemia and poor glycaemic control
among diabetics can be grouped into macrovascular and microvascular
complications. The microvascular complications include diabetic retinopathy,
neuropathy and nephropathy whereas the macrovascular complications resulting
from prolonged hyperglycemia include stroke, coronary artery and peripheral
arterial diseases.
1.3 MANAGEMENT OF DIABETES
Despite the devastating consequences of prolonged or chronic
hyperglycemia, diabetes mellitus can be managed using a multifaceted approach
which includes; medication, psychosocial management, lifestyle modification,
monitoring of biochemical markers, counselling/education and diabetes
self-management education (Alrahbi, 2014). The foremost aim of educating
patients on how to manage their condition is to increase metabolic control and
improve quality of life, so as to delay the onset of acute and chronic
complications in a cost-effective way (Norris et al., 2002). Diabetes
Self-Management Education (DSME) has been associated with cost-effectiveness in
the sense that it reduces hospital readmissions and also reduces projected
quality and length of lifetime healthcare costs (Powers et al., 2015).
Self-management of diabetes is seen as the most critical
aspect of diabetes management and it is linked to increased quality of life,
prevention and reduction in severity of diabetes-related complications
(Alrahbi, 2014). Self-Management of diabetes is a set of complex regimental
self-care behaviours which include; adherence to medication, following a
dietary plan, periodic monitoring of blood glucose, being physically active and
seeking help from healthcare professionals in a sustainable manner, which are necessary to achieve good clinical outcomes
among diabetics (Heisler et al., 2003). Although effective, DSM is also
stringent and rigorous.
In response to these rigorous demands in the self-management
of diabetes, many diabetics go through emotional distress that has to do with their
physician, interpersonal relationship, diabetes regimen or emotional burden.
The undesirable emotional burden resulting from diabetes are referred to as
diabetes-related distress and have been shown to have negative correlation with
clinical consequences such as glycemic control and value of life (Polonsky, et
al., 1995).
Another important aspect of diabetes management is
acceptance. It is reported that for diabetes self-management to be effective
and good glycemic control achieved, the diabetic patients must accept their
disease and integrate well into their new life (Schmitt et al., 2014). Schmitt
and colleagues found that low acceptance of diabetes predicted poor diabetes
self-management and HbA1c, and that if patients’ are assessed on their acceptance
of diabetes, it could lead to early identification of those who stand a high
risk of undesirable clinical outcomes (Schmitt et al., 2014). A
randomised-control trial involving acceptance and commitment therapy reported
an effect in reducing depression among diabetics (Hor et al., 2014).
From the aforementioned, it is clear that proper diabetes
management require consistent adherence to diabetes self–management regimen,
prevention and management of diabetes-related distress, and acceptance of the
disease among sufferers.
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