Attitude, practice and its associated factors towards Diabetes complications among type 2 diabetic patients at Addis Zemen District hospital, Northwest Ethiopia

We conducted an institution-based cross-sectional study from April 02, 2019 to June 02, 2019 at Addis Zemen District Hospital, South Gondar, northwest Ethiopia. Addis Zemen District Hospital is found in Addis Zemen town, which is a central town of Libo Kemkem District, South Gondar Zone, Amhara regional state. It is found 90 km (km) away from Bahir Dar (the capital city of Amhara Regional State) and 656 km northwest of Addis Ababa.

Type 2 diabetic patients who were present at the diabetic center during the study period were incorporated with the exception of those individuals who were in an extreme disease condition that restricts them to respond to questionnaires and the individuals who were health professionals.

An organized pretested interviewer-administered questionnaire was utilized to collect data regarding attitude, practice, and associated factors. The questionnaire was adapted from relevant literature [20‐23] and contains 9 attitudes and 13 practice-related questions towards diabetes complications It also incorporates main socio-demographic factors like sex, age, residence, occupation, marital status, educational status, income, duration since diagnosis as diabetic, and family history of DM. The questionnaire was prepared in English by language expert, and translated to local language (Amharic) and then translated back to English by another language expert to ensure its consistency and wording. Data were collected by five BSc nurses. From socio-demographic variables, educational level was categorized as follows; “cannot read and write”, “informal education and can read and write”, “primary school and can read and write”, and “secondary school and above”. The essential point here was to distinguish whether they can read and write not to miss the beneficial outcome of reading and writing on their attitude and practice. If the study participants attended primary school but couldn’t read and write we will put them under unable to read and write. In Ethiopia, some people attend informal and religious educations but not primary school and are able to read and write. Hence, we grouped such candidates under the category of read and write. Settling in the field outside of huge urban communities or towns in Ethiopia is alluded to as provincial inhabitants [24].

We had used 9 questions adapted from different literatures [25, 26] to assess the attitude of the patients. Each question had three choices of responses (agree, neither agree nor disagree, and disagree). A score of “1” was given for a favorable attitude (correct answer) and “0” for unfavorable attitude (incorrect answer) for each respective attitude questions [20]. All possible correct answers were summated out of 9. The diabetic patient’s attitude level towards diabetic complications was determined by adding the right answers and calculating the mean value as 5 with possible maximum correct answer of 9. Participants mentioning under the mean score of 5 correct answers grouped as having poor attitudes. The participants who mentioned five or more correct answers rated as a good attitude. Attitude questions and their respective response scores are presented in the attached Additional files.

There were 13 inquiries that survey the practice of the patients about diabetic complications, 10 inquiries had a “Yes”, or “No” responses, “Yes” demonstrates the practice of suggested action. A score “1” was given for “Yes”, and “0” for “No”. The remaining three measures of practice questions scored as follows: How often have you done physical work or exercise in the last week? Those who respond “Never” was given a score of “0” but the remaining recommended options (daily, almost daily, 2–3 times per day and once a week) were given a score of “1”. For questions on non-recommended activities/habits like “How often do you drink alcohol?” the response never was given a value of “1” which is a suggested practice for diabetic patients while the rest of the responses (rarely, nearly every day, 2–3 times/day, and weekly) given a score of “0”. Finally, since the recommended type water for foot care is warm water but not too hot or too cold, for the question “What type of water do you use to wash your feet?” the response of warm but not hot water was recorded as “1” and cold water recorded as “0”. Then, the patient’s practice level was calculated by adding their responses and the maximum possible score was 13. A score of 8 and above were categorized as good practice, while the remaining as a poor level of practice [20, 27, 28]. Practice questions and their respective response score are presented in the attached Additional files.

One day training was given for data collectors and supervisors about the data collection procedure and ethical issues. The pretest was conducted on 60 type 2 DM patients at the University of Gondar specialized Hospital DM clinic. Data collection was closely supervised by two health officer supervisors and investigators. The collected data were checked for completeness at a daily meeting. The data were cleaned and checked before analysis.

Among of 404 participants 402 responded well, giving a response rate of 99.5%. Of all respondents, 225 (56%) were female and 243 (60.4%) were urban inhabitants. Most of the respondents (150 (37.3%)) were aged 45–70 years. The majority of (304 (75.6%)) of the participants were Orthodox Christians and 348 (86.6%) were from the Amhara ethnic group. Of all participants, 118(29.4%) had a family history of DM. Out of the total respondents, 242 (61.3%) were married, 110(27.4%) were unable to read and write, were urban residents 85 (21%) were farmers, and 156 (38.8%) had a monthly income below 500 Ethiopian birr (Table 1).

About two-thirds of respondents (65.2% (95% CI: 60.2, 69.4)) had good attitude levels. Most (74.1%) of the respondents agreed that diabetic complications could be prevented. Nearly three quarters (74.1%) of respondents thought they could lead a normal life if they take appropriate measures for diabetes. Over two-thirds of the participants 69(16.9%) believed that diabetic complications can be prevented by having good glycemic control. The majority (79.9%) of participants agreed that regular exercise can prevent complications of diabetes. Dietary modification and weight reduction were considered important to prevent diabetic complications by 91.8% (n = 369) and 46.3% (n = 186) respondents, respectively. One hundred thirty-five (33.6%) respondents believed that their diabetic diet spoils their social life. Furthermore, 214(53.2%) respondents thought diabetics were the worst thing that ever happened to them (Table 2).

The residence and educational status of the respondents had a significant influence on attitude. Subjects with educational level of informal school and can read and write were 2.3 times (AOR = 2.32, 95% CI (1.26, 4.27)) more likely to have a good attitude as compared to those who cannot read and write. Type 2 diabetic patients who attained primary school and can read and write were 4 times (AOR = 4.31, 95% CI (2.06, 9.02)) more likely to have a good attitude than those who cannot read and write. Similarly, those who conquered secondary school and above were 2.8 times (AOR = 2.79, 95% CI (1.41, 5.50)) more likely to have a good attitude than those who cannot read and write. Patients from urban areas were 1.8 times (AOR = 1.80, 95% CI (1.12, 2.91)) more likely to have a good attitude than those who live in a rural area (Table 3).

Almost half of the respondents (48.8% (95% CI: 44.0, 53.5)) had a good practice towards diabetic complications. More than two-thirds of the patients 280(69.7%) reported that they never forgot to take their medication. One hundred nine (27.1%) and 179(44.5%) respondents said that they stopped their medication when they felt better and felt worse, respectively. Only about 21(5%) respondents performed exercise daily. The majority (86.6%) of them change their diet according to the recommendations of their physician. Most (80.1%) of respondents monitor their blood glucose levels in the hospital. One hundred fifty-one (37.6%) of respondents monitor their blood glucose level monthly. Greater than 239 (59%) of respondents reported daily feet examination. Only 48(11.9%) of respondents use hot water to wash their foot and 45.5% take care when they cut their nails. Regular kidney and eye checkup was practiced by 29.9 and 7.7% of study participants, respectively. Nearly all (96.8%) of respondents do not smoke, and 188(46.8%) of the participants never drink alcohol (Table 4).

Educational status was the single independent factor associated with patient practice towards diabetic complications. The odds of good practice towards prevention of complications of diabetes were two times (AOR = 1.96, 95% CI (1.06, 3.61)) more likely among type 2 diabetic patients with educational level of informal school and can read and write, four times (AOR = 4.31, 95% CI (2.06, 9.02)) more likely among participants who attained primary school and can read and write and two-point six times (AOR = 2.57, 95% CI (1.32, 5.02)) more likely among those who attained secondary school and above than those who cannot read and write (Table 5).