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

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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.

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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.

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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.

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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;

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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.

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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

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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

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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

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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

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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

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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

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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

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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

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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

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(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).

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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?

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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

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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.

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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.

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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.