Background
Diabetes Mellitus (DM) related clinical complications are most important causes of morbidity and mortality, and have considerable effect on the patients’ quality of life and productivity [
1,
2]. Globally, approximately half a billion people live with diabetes, and almost 80% of diabetes burden was shared by low and middle income countries including Ethiopia [
3,
4]. According to the International Diabetes Federation (IDF) report, there were 2,567,900 cases of diabetes in Ethiopia making the adult prevalence of 5.2% [
3]. Due to the rapid expansion of urbanization, unhealthy diets, and sedentary change of life style, the incidence of DM keeps increasing [
3,
5].. The chronic nature of DM causes significant personal suffering and economical difficulty in the families [
3,
4,
6,
7]. Moreover, DM have not impose only personal suffering; due to its continued needs and demands of individual effort, it was considered as a major challenge for health care workers as well [
8].
In order to reduce the burden posed to health systems and affected individuals, patients with diabetes need to adopt certain diabetes self-care behaviors. Diabetes self-care behavior is defined as an evolutionary process of development of knowledge or awareness by learning to survive with the complex nature of the diabetes in a social context [
4,
6,
9]. American Diabetes Association (ADA) has set a list of essential self-care activities, which used for monitoring blood glucose at recommended level, prevent diabetic complications and improving the quality of life of diabetic patients [
6,
7]. These diabetes self-care includes: self-monitoring of blood glucose (SMBG), nutrition, physical activity and diabetic foot care [
1,
6,
10]. Diabetes is a complex, chronic illness requiring continuous medical care with multifactorial risk-reduction strategies beyond glycemic control [
3]. Several studies reported that, ongoing patient self-care education and support are critical to preventing acute complications and reducing the risk of long-term complications [
3,
11,
12].
DM self-care activities are owned by patients and their families;, as a result, there should be consistent and effective measure for diabetes self-care through dietary and lifestyle modification complemented with supportive role of health care providers [
4,
13‐
15]. Self-monitoring of glycemic combined with regular physical activity are considered as a cornerstone of diabetes cares to ensure patient participation in achieving and maintaining at recommended level of blood glucose [
6,
16‐
19].
The majority of patients with diabetes can significantly reduce the chance of developing long-term complication by improving self–care activities. To date, the level of DM self- care practice have been reported in several studies in Ethiopia, which ranges from 22.5 to 76.8% [
1,
20‐
35]. However, most of these studies have offered district level information. As a result of variability of findings across previously existing studies, producing pooled proportion of DM self-care at the national level is needed. Moreover, comprehensive estimates of the extent of DM self-care levels are needed for the programmatic management of diabetes within the context of diabetes care. Therefore, this systematic review and meta-analysis was undertaken to produce pooled estimates of DM self-care levels in Ethiopia.
Methods
Data source and search strategy
Published and unpublished research articles that were conducted to assess a minimum of one variety of diabetic self-care (overall diabetic self-care, diet, physical activity, self-monitoring of glucose, foot care) in Ethiopia were included during this study. An intensive search was done from PubMed/MEDLINE, and EMBASE online databases to access articles done on the diabetes self-care practices. Moreover, Google Scholar and Science direct were accustomed to retrieve articles. Besides, reference lists of screened studies were checked. The search was administered by two authors (DBK and AA) independently. The term ‘diabetes’ was searched with all of the subsequent terms as a mix of free text and thesaurus terms in numerous variations: diabetes self-care, dietary care, foot care, physical activity, glycemic control, and Ethiopia. Moreover, the subsequent keywords were accustomed to retrieve studies from PubMed database; (((((Diabetes self-care) OR diabetes dietary care) OR diabetes foot care) OR diabetes physical activity) OR self-monitoring of blood glucose) AND Ethiopia. Studies that were relevant by title and abstract were assessed by full text to see those that provided adequate data to be included in our meta-analysis. This systematic review and meta-analysis was reported per preferred reporting items for Systematic Review and Meta-Analysis (PRISMA) guideline [
36].
Inclusion criteria
-
Study setting: Studies done in Ethiopia.
-
Study participants: Studies conducted among all Diabetes Mellitus patients.
-
Publication status: All published and unpublished articles.
-
Language: Only studies published in the English were included
-
Types of studies: Studies that employed observational study design.
-
Publication date: The authors included articles published until August 20,2019
Outcome measures
Diabetes self-care was defined as good self-care practice and poor self-care practice [
24,
25]. In this meta-analysis, we measure diabetes self-care practice using four domains: dietary practices, engagement in regular exercise, foot-care and blood glucose monitoring [
3,
6].
Dietary practice
Patients who scored above the mean value for the response were classified as having good dietary practice and poor dietary practice otherwise.
Glycemic control
The level of glycemic control was indicated as ‘good glycemic control’ when FBS results were between 70 and 130 mg/dL (i.e. an average of three measures at different visits).
Regular exercise
20–30 min of aerobic exercise such as walking or swimming 3–4 days per week [
37].
a total practice score of ≥50% of maximum score is categorized as good foot care practice, while a total practice less than a score of 50% categorized as poor foot care practice [
38].
Data extraction and quality assessment
Seven authors (DBK, AAA, GDK, AA, AAA, and CTL) done data abstraction using pre-piloted data extraction format prepared in Microsoft™ Excel spreadsheet. The seventh author (GMK) reconciled any disagreements among the six authors. From each study, we have extracted data on the study location, region, publication year, study design, sample size, and first author name for the overall diabetes self-care and for each domains of diabetes self-care practice (Supplementary File
1, Supplementary File
2, Supplementary File
3, Supplementary File
4, and Supplementary File
5).
The quality of included studies has been assessed in accordance with the Newcastle-Ottawa Quality assessment scale [
39]. Two independent reviewers (DBK & GDK) done a full-text quality assessment. Disagreement between the two reviewers was found to be very low (1.5%) and they resolved this by discussion. Then, a combined quality score ranging from 0 to 10 was assigned to each included articles.
Heterogeneity and publication bias
The presence of statistical heterogeneity within the included articles was assessed using I-squared statistic. Accordingly, heterogeneity was classified as low, moderate, or high when the value of I-squared were 25, 50, and 75%, respectively [
40]. Begg and Egger weighted regression method were employed to detect evidence of publication bias.
P-value < 0.05 was considered as presence of significant publication bias [
41].
Statistical analysis
Relevant data from every primary study was extracted using a Microsoft Excel format. Data were then exported to STATA™ Version fourteen software package for analysis. The pooled estimate was computed using metan SATA command. Results were presented using tables and forest plots with 95% confidence intervals (CI). We have used Higgins and Egger’s test to identify publication bias. As a result of high level of heterogeneity among included studies, random-effects model was used to produce Der Simonian and Laird’s pooled estimate. Additional advanced statistical analyses like univariate meta-regression and sensitivity analysis were performed to identify the potential sources of heterogeneity and to assess the influence of a single study on the overall pooled estimate respectively.
Discussion
This systematic review and meta-analysis was conducted to assess the level of self-care practice among diabetic patients in Ethiopia (including major four domains: like food choices, physical activity, foot care, and blood glucose monitoring). Accordingly, almost half (49%) of diabetic patients in Ethiopia practice the recommended levels of diabetes self-care. This finding was much lower than a study in Nigeria (80%), Thailand (87%), and Iran (74%) [
55‐
57], and higher than the study reported in Kenya (41%) [
58]. The difference in culture and economical status, lifestyle difference, and difference in the access to health care facilities and level of education of the general public could be the reasons for the difference. Furthermore, varied methods applied to measure outcome-parameters among countries may be contribute the variation of findings. Diabetes self-care practice demands the involvements of individuals with diabetes and health care providers to increase the adherence of good practice through increasing the knowledge and understanding of the disease and predicting the long-term impacts of the disease. However, difference in the level of education among diabetic patients across the countries, the level of understanding of health care works on diabetes self-care should contribute for the variation diabetes self-care practice across the countries mentioned above.
In this meta-analysis, 50% (95% CI: 42, 58%) of participants have practicing the recommended diet (grains and starchy vegetables, Non-starchy vegetables etc). Similar finding was reported in India (46%) [
59]. However, the finding of the current study is higher than the figure reported in Yemen (21%) and Pakistan (17%) [
60,
61]. The discrepancy might be explained due to socio-cultural difference, difference in the types of foods available with different nutritional value, as well as level of education provided for diabetic patients. The importance of following a regular dietary plan in terms of both quantity and quality lies in the fact that adequate blood sugar control and proper weight management are linked to it. The World Health Organization (WHO) recommends a minimum of 400 g of fruit and vegetables per day [
62]. ADA also recommends 45 to 65% of daily total calorie for patients who are suffering with diabetes [
6].
This meta-analysis identify that self-monitoring of blood glucose was a least practice in Ethiopia with pooled prevalence of 28%. This finding was much lower than a report in Alexandria which 64.7% had good compliance of blood glucose control [
63]. This low adherence to SMBG practices could probably be attributed to relevant financial barriers to acquisition of glucometer or to undergo a check-up at a health facility [
64]. Most patients, who had access to a glucometer at home, checked their glucose level only once a month or at no regular interval [
65,
66].
In this meta-analysis almost half (49%) of diabetic patients were engaged in the recommended physical activity. Physical exercise has been considered a cornerstone of diabetes management, along with diet and medication [
67]. This finding was almost comparable with a report at USA (39%) [
68]. The discrepancy could be explained by the time difference of the research carried out. The evidence reported from USA was conducted in 2007. Whereas almost all included studies which measured physical activity practice of DM patients in this meta-analysis were conducted at the mean year of 2015. Since various initiatives nationally and internationally (Ethiopia Diabetic Associating (EDA), Ministry of Health (MOH)) have been instigated by several organizations between these motioned time period, the proportion of diabetic patients who were engaged in the recommended physical activity could be increased. Researches have shown that physical activity can lower bad cholesterol and raise good cholesterol, improve body’s ability to use insulin [
50,
67,
69]. Exercise have also beneficial effect for diabetic patients to reduce the development of cardiovascular complication with regard to glucose control [
70].
In this meta-analysis, more than half of diabetes patients have good foot-care practice with pooled prevalence of 58% (95% CI:41, 74%). This finding was comparable with findings from Siri Lanka (53%) and South Africa (69.2%) [
71]. However,the finding was much higher than the study reported in Nigeria (10%) [
72]. This discrepancy could be explained by diabetic foot care involves many different professionals and the patient presentations also diverse. Successful management of diabetic foot problem needs the expertise of multidisciplinary team with implementation of universal good care. This involves good attitude of healthcare professionals, patients and health-care system.
Limitation of the study
This systematic review and meta-analysis have certain limitations. First, methods applied to measure outcome-parameters varied among included studies. Second, included studies used self-report as a measure of outcomes, and this may have introduced bias. Multiple methods may be required to detect those who report good practice but who may in fact may have poor practice.
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