The study aimed at assessing the knowledge and attitudes of diabetes clients on self-management practices in public hospitals in the Upper West Region of Ghana. The research was a cross-sectional survey. It adopted stratified sampling technique to select 201 respondents. A questionnaire was used in the study for data collection with a reliability coefficient of 0.8.The data was analysed using the SPSS version 21. The findings of the study revealed that diabetic patients are highly knowledgeable about the disease. Also to a greater extent patient demonstrated a positive attitude toward diabetes. The study also revealed to a significant extent that patients hadfew barriers regarding self-management practices. The clinics provided several services to diabetic patients. It was also evident that diabetes patients to a greater extent adhere to prescribed self-management practices. There was also significant relationship between knowledge and attitudes of diabetes clients and self-management practices. It further revealed that demographic factors have no effect on self-management practices. Finally, there was a significant difference among the hospitals and their self-management practices.

According to Berhe, Demissie, Kahsay and Gebru(2012), 60% of all deaths globally are as a result of non-communicable diseases including diabetes. It is further stated that 80% of deaths due to diabetes occur within low and middle income countries, of which Ghana is no exception.This study is related to several

previous works done by other researchers such as Rodrigues,, Zanetti,, dos Santos, Martins, Sousa, & Teixeira(2009) on knowledge and attitude: important component in diabetes education and that of Mohammadi, Karim, Talib&Amani (2015) on knowledge, attitude and practices on diabetes among type 2 diabetic patients in Iran.

Background to the Study
According to World Health Organization (WHO) (2014), Diabetes mellitus (DM) is a chronic progressive metabolic disorder characterized by hyperglycaemia mainly due to absolute or relative deficiency of insulin hormone. Because of the hyperglycaemia, diabetes mellitus affects every system of the body especially if maintaining a normal glucose level is not achievable. There are three most common types of diabetes mellitus namely; type 1 diabetes, type 2 diabetes and gestational diabetes (Berhe et al.,2012.). Type 2 diabetes mellitus is mostly associated with resistance to insulin action and inadequate secretion of insulin. It is characterized by hyperglycaemia and also associated with several complications such as vascular, macro vascular and neuropathic complications (Berhe et al.,2012).

A WHO (2011) Global status report on Non-Communicable Diseases (NCDs), postulated that NCDs including type 2 diabetes mellitus (T2DM) will become the leading cause of death on the African continent by 2030. There has been a drastic increase in the prevalence of type 2 diabetes over the past decades due to the perpetual increase in obesity (Kyrou & Kumar, 2010). Adisa, Alutundu and Fakeye (2009) added that there has been a continuous increase in the incidence of type 2 diabetes globally.
Diabetes mellitus seems to be a major emerging clinical and public health problem. According to WHO estimates in 2007, 190 million people suffer from diabetes world-wide and about 330 million are expected to be diabetic by the year 2025 (Lorenzo, Williams & Hunt, 2007). It is the leading cause of blindness, and lower-limb amputations. Concerning mortality, adults with diabetes have rates of stroke and death from heart disease that are about 2 to 4 times higher than adults without diabetes (Soderberg, Zimme, &Tuomilehto, 2005). According to World Health Organization (2006), at least 171 million people worldwide suffer from diabetes and it is more prevalent in developed countries. The American Diabetes Association (2006), reported about 20.8 million people with diabetes in United States alone, while in developing countries, increase in prevalence is expected to occur especially in Africa, where most cases are likely to be found by 2030. This increase in incidence of diabetes in developing countries follows the trend of urbanization and lifestyle changes including perhaps and most importantly a “Western – Style” diet, WHO (2006).

The prevalence of diabetes mellitus is high among populations in the Middle-East countries despite the fact that all researchesshowed that diabetes remains under diagnosed in this part of the region (Al-Adsani, Moussa, & Al-Jasem, 2009). Egypt had been estimated to be the 9th country in the prevalence of diabetes in the world. Recent changes in physical activity and dietary patterns have promoted the development of diabetes and if different preventive and control activities are not adopted, by the year 2025, more than 9 million Egyptians (13% of the population above 20 years old) will have diabetes (Tan, Yong, Wan, & Wong, 2007). In Nigeria though no estimate of the individuals suffering from diabetes has been made, in a recent screening exercise carried out in Warri and Sapeleinvolving 787 people, 65% were diabetic and hypertensive (Urhobo National Association of North America, 2004). Also at University of Nigeria Teaching Hospital in Enugu the number of patients that attend the Wednesday diabetic clinic is alarming.

According to Berhe et al. (2012), 85-95% of all diabetes cases in high-income countries are Type 2 and that 90% of all diabetes cases in Sub-Saharan

Africa including Ghana is also type 2. The 6th edition of the International Diabetes Federation (IDF) Atlas (2013) reported that figures regarding diabetes in Africa arequite startling. It stated that over 21 million people within the ages of 20-79 years had diabetes with a prevalence rate of 5.1% and this figure is projected to double by the year 2035. This means that currently, 1 in 20 adults have diabetes. It was estimated that the cost of total diabetes related health expenditure was 4.5 billion USD and is expected to increase to 6.4 billion USD by the year 2035. The report adds that 480,900 deaths in Africa were diabetes related and 75.1% of these deaths are diabetes patients under 60 years of age (Berhe et al., 2012).
Evidence of the dramatic costs of treating diabetes and its complications were found in the CODE-2 study (Massi-Benedetti, 2002), which reported the total direct costs of type 2 diabetes (T2D) to be 29 billion Euros in 1998. Ten million people with T2D were noted in eight European Union countries: representing up to 15 % of national health care spending. Nevertheless an European Union audit conducted in 2006 revealed the incompleteness of existing data regarding this problem, and moreover, the lack of specific programs to address it. The rise in diabetes was generally attributed to obesity, sedentary life style and unhealthy diets.
Finding by Shafer, (2000) on diabetes explained that itwas characterized by a disorder in metabolism of carbohydrate and subsequent derangement of fat and protein metabolism. Furthermore, disturbance in production and action of insulin, a hormone secreted by the islets of Langerhans in the pancreas wasalso implicated in the disease (Shafer, 2000). In addition to insulin, aging, over weight and several other hormones affect blood glucose level there-by preventing glucose from entering the cells (Clavell, 2005). This leads to hyperglycemia, which may result in acute and chronic complications such as diabetic keto-acidosis, coronary artery disease, cerebrovascular disease, kidney and eye diseases, disorders of the nerves and others (Iwueze, 2007).
The management of diabetes poses a challenge to the medical and nursing staff as well as to the patients themselves. Since diabetes is a chronic disease, most diabetic patients need to continue their treatment for the rest of their lives. The emphasis is usually therefore, on the control of the condition through a tight schedule of blood glucose and urine sugar monitoring, medication and adjustment to dietary modification (American Diabetes Association, 2006; Iwueze, 2007). Such a chronic condition requires competent self-care, which can be developed from a thorough understanding of the disease process and the management challenges by the patient and family members. This pre-supposes a need for some form of diabetes education and counseling for the patient and family members. According to Colbert (2007) educating and supporting diabetic patients in managing their daily lives were important goals of diabetic patients care.

Unfortunately, about a third of the people suffering from diabetes may not be aware of it early considering the insidious onset and development (Iwueze, 2007). Regrettably too, many who were diagnosed with the condition demonstrate fears about the future and a general distaste because of the predominant misconceptions about the disease and its management. This is heightened by the superstitious explanation of causation of diseases dominant in Africa where most diseases are caused by “poison” and/or “evil spirits”. Some of these problems highlighted could be taken care of if patients and indeed the general public were exposed to diabetes education (Iwueze, 2007).
The report concerning Ghana by the International Diabetes Federation (IDF) (2013) was much more serious. The report claimed that 440,000 adult populations in Ghana within the ages of 20-79 years had diabetes with a national prevalence of 3.35% (1 in every 30 adults), and that the total cost of diabetes per person was 148.4 USD. Eight thousand, five hundred and twenty eight deaths in Ghana are diabetes related, of which 72.4% are diabetes patients under 60 years. According to WHO (2014), NCDs were estimated to account for 43% of total deaths in Ghana of which diabetes contributed 2%. Diabetes is also said to be among the top 4 causes of mortality due to non-communicable diseases.

Problem Statement

While the Ghana Health Service (GHS) is highly focused on mitigating infectious diseases, NCDs currently contribute significantly to illness, disability and deaths in the country with diabetes, cardiovascular diseases, cancers, and chronic respiratory diseases on the lead. It is estimated by the National Diabetes Association that not less than 4 million Ghanaians suffer from diabetes, three out of every nine Ghanaian across the county. This has resulted in more than five thousand deaths every year (Kubi, &Okertchiri, 2016).Also, a study by Shaw, SicreeandZimmet(2010) further estimated a substantial increase in diabetic cases by 2030. The burden of diabetes and other NCDs are projected to increase owing to a myriad of factors; unwholesome lifestyles, ageing and rapid urbanization.
It was in response to this that the Ministry of Health (MOH) introduced the Regenerative Health and Nutrition Programme (RHNP) in 2006 and further developed a health policy which clearly prioritizes the promotion of healthy lifestyles and healthy environments.
It is indicated in the Ghana Health Sector 2013 Program of Work that there had been an increase in the incidence of non-communicable diseases in the country. To avert this and also prevent unwarranted deaths, a call was made to all and sundry to adopt a healthy lifestyle and routine check-ups. The document also provided some core programs that were to be undertaken to achieve the aims of the health sector of which was to scale up and improve management of diabetes and hypertension (MOH, 2013).
Moreover, various researchers had attempted to explore various dimensions of NCDs in the country, for instance whereas Aikins et al. (2012) focused on lay representations of chronic diseases among rural and urban Ghanaians, other such related studies channeled their focus on acceleration of control and prevention of non-communicable diseases in Ghana, spatial distribution of hypertension, pattern of cardiovascular disease mortality in Ghana (Owusu-Sekyere, Bonyah, &Ossei, 2013; Bonsu 2013; Sanuade, Anarfi, Aikins, de-Graft &Koram, 2014) without any targeting the Upper West Region.
Available records in the Upper West Region shows that diabetes cases were 397 in the year 2011, 552 in the year 2012, 681 in the year 2013 and 761 in the year 2014. These demonstrated continuous increase in cases since the year 2011. The record from January to December, 2014 also revealed that cases were widely recorded in almost all the municipal and district hospitals in the region as indicated;Waregional hospital=169, Lawra district hospital=82, Nadowli district hospital=71, Jirapa district hospital=34, Nandom district hospital=24 and Tumu district hospital=5 (Ghana Health Service (GHS), 2015). Despite the rising records of diabetes within the chosen study area, the inability of diabetes patients to keep their glycaemic levels within the normal range may be due to several factors including inadequate knowledge and poor attitude regarding self-care management and inappropriate application of already existing strategies to control diabetes by the care provider (World Health Organization and Department of Non-communicable Disease Surveillance, 1999). Nevertheless, not much is known regarding how the knowledge and attitude ondiabetes affect self-care management practices of diabetes patients among the citizens of Ghana.

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