Influence of Perceived Social Support on Self Care Activities and Glycaemic Control in adults with Type 2 Diabetes Mellitus attending outpatient clinics, University College Hospital, Ibadan.

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Influence of Perceived Social Support on Self Care Activities and Glycaemic Control in adults with Type 2 Diabetes Mellitus attending outpatient clinics, University College Hospital, Ibadan.  

Summary

Background: Patients with type 2 diabetes mellitus can play a central role in blood glucose control and optimal care, through diabetes self-care activities. This may require a collaborative therapeutic alliance among the health care team, the patient and the social support available in achieving optimal control. There are limited studies on the role of social support on diabetes self-care activities and glycaemic control, as well as the role of each component of self-care activities on glycaemic control in Nigerian adults with type 2 diabetes mellitus. The ability of the family physician to understand and influence patient’s behaviour that enhances self-care may significantly influence the success of treatment.

Objectives: This study assessed the influence of perceived social support on the self-care activities and blood glucose control of adults with type 2 diabetes attending outpatients’ clinics in UCH, Ibadan. It also determined the relationship between components of self-care activities and glycaemic control in the study sample.

Method: The study used a non-experimental cross sectional design and recruited 240 consenting adult patients, aged between 18 and 64 years, diagnosed with type 2 diabetes mellitus. The patients who were attending the Endocrine and General outpatients’ clinics of UCH, Ibadan for at least one year, were recruited between March and June 2014. Interviewer administered questionnaire were used to obtain data on socio-demographic characteristics, selfcare activities, perceived social support, knowledge of diabetes self-care, diabetes selfefficacy and depression of the participants. Revised Summary of Diabetes Self-Care Activities and Social support scale for self-care in middle-aged patients with type 2 diabetes mellitus were used to assess self-care activities and perceived social support respectively. Glycaemic control was assessed with HbA1c, using the Clover A1cTM analyser. Significance level of analysis was set at p ≤ 0.05.

Summary

Results: Majority of the participants (79.6%) were in the 50-64 age group and were females (79.2%). The mean HbA1c was 7.6 ± 2%, and 50.4% of the participants had good glycaemic control (HbA1c <7%). Medication use was the most practised self-care activity, done on an average of 6.35 days per week. Dietary, physical activity, foot and self-blood glucose monitoring self-care were performed on 5.4, 3.7, 2.98, and 1.78 days per week respectively. Overall, 19.2% of the participants perceived good support for diabetes self-care, with females perceiving significantly less support for dietary(p=0.000) and physical activity (p=0.041) selfcare compared to male participants. In a linear regression model, perceived social support was a significant predictor of overall self-care activities (β=0.005, p=0.000), as well as for each components of self-care. Initial significant univariate association found between perceived social support and glycaemic control was no longer found in the regression model for glycaemic control. Performance of physical activity and self-blood glucose monitoring were the only components of self-care that significantly predicted glycaemic control in the regression model (β=-036, p=0.021, and β=-0.031, p=0.021). Other factors such as diabetes self-efficacy, income level, at least a secondary level of education, use of insulin and membership of diabetes association were found to also predict glycaemic control.

Conclusion: Perceived social support was a significant predictor of self-care activity, but not of glycaemic control. Physical activity and self-blood glucose monitoring components of selfcare activity were the significant predictors of glycaemic control. It appeared that while perceived social support had a direct influence on self-care activities, it rather had an indirect influence on glycaemic control, through self-care activity among the study participants. Family physicians should therefore explore the available social network of the patient to optimize diabetes care.

Table of Content

Title page……………………………………………………………………………………….i

Declaration.................................................................................................................................... ii 

Certification................................................................................................................................. iii 

Dedication.................................................................................................................................... iv 

Acknowledgement........................................................................................................................ v 

Table of Content......................................................................................................................... vii 

 

List of Tables ......................................................................................................................... viii

List of Figures ........................................................................................................................... ix

List of Abbreviations ................................................................................................................. x

List of Appendices .................................................................................................................... xi

Summary .................................................................................................................................. xii  Chapter 1: Introduction .............................................................................................................. 1  Chapter 2 : Literature Review .................................................................................................... 9

Chapter 3 : Materials and Methods .......................................................................................... 26

Chapter 4 : Result..................................................................................................................... 39

Chapter 5 : Discussion ............................................................................................................. 66

Chapter 6 : Conclusion and Recommendation ......................................................................... 79

References................................................................................................................................. 79

Appendices ............................................................................................................................... 99

Chapter 1  INTRODUCTION

1.1      Introduction

Diabetes mellitus (DM) is a group of metabolic diseases characterized by hyperglycaemia resulting from defect in insulin secretion, insulin action, or both.1 The resulting chronic hyperglycaemia causes characteristic symptoms, increases the risk of microvascular damage (retinopathy, nephropathy and neuropathy) and macrovascular complications (ischaemic heart disease, stroke and peripheral heart disease), which eventually diminishes quality of life, life expectancy and leading to premature death.2

Type 2 diabetes mellitus (T2DM) is the most prevalent of the four clinical classes of DM, characterised by hyperglycaemia and progressive insulin secretory defect on the background of insulin resistance. Its insidious onset and late recognition contributes to its high morbidity and mortality.3

Control of hyperglycaemia is fundamental to the management of diabetes, and studies have shown its benefit in significantly reducing the development of complications.1, 4 Glycaemic goal of fasting plasma glucose of 70-130 mg/dL and glycosylated haemoglobin (HbA1c) of

≤7% are therefore aimed, to reduce acute illnesses and complications.1 However, in clinical practice, optimal diabetes control remains difficult to achieve, and studies have documented suboptimal blood glucose control in people with diabetes mellitus.5, 6

Diabetes care is complex, requiring major lifestyle changes and self-care management from patients, thus, imposing great demands on them and their families.1, 7 Typically, they are required to carry out various self-care activities which include adjustment of food intake, regular physical activity, medication administration, home self-blood glucose monitoring, foot care, regular clinic visits and other health behaviours.8 Adherence to these recommendations can be challenging and often overwhelming. Each patient with diabetes mellitus therefore plays a central and active role in optimal care. They need to have a common understanding with the care providers on each aspect of care and goals of treatment.1 In addition, collaborative therapeutic alliance among the health care team, the patient and their family are important in achieving optimal control.1

Blood glucose control through patient self-care is an essential component of overall diabetes mellitus management to forestall complications.1 Studies have shown that the performance of diabetes self-care activities is associated with improved glycaemic control, and prevents complications and mortality.1, 4, 5 Thus, the ability to understand and influence individual behaviours that enhance self-care may significantly influence the success of treatment for persons with diabetes.

Despite the well-known benefits of these self-care activities, it has been reported that compliance has been low and often inadequate.6, 9 Health related behaviour such as self-care behaviour, is often influenced by personal factors (beliefs, self-efficacy and other cognitions) and environmental factors (physical and social).10 Also, being well informed about a disease and possessing self-efficacy (an individual’s confidence in his or her ability to undertake specific self-care behaviours) have been highlighted to have significant influence on successful self-care.10

However, such behaviour does not occur in a vacuum but rather in a context that includes the informal social network members, the formal health care providers, and the physical environment.10 All of these contextual factors have the potential to significantly influence selfcare behaviour.10 Essentially, one who is well informed, personally motivated (selfefficacy), and socially motivated (social support), is likely to enact the necessary health behaviour and ultimately reap greater health benefits.11 Hence, an understanding of the social context of diabetes self-care has important implications for the design of interventions that can enhance self-care behaviour and for the health and well-being of individuals with diabetes mellitus.

Health-related social support refers to efforts by social network members to provide assistance and positive feedback aimed at promoting health enhancing behaviour.10 Diabetes specific social support may positively affect self-care behaviours and glycaemic control of individuals with T2DM.12, 13 This support may come from family, friends and significant others, and exert its influence on self-care behaviour through provision of informational, emotional, appraisal and tangible support. Tangible support may be indirectly facilitating self-management (e.g. shopping for healthy diet), or more directly assisting with diabetes management activities (e.g. administering insulin or managing medication).

Family members are the primary source of social support, especially the spouse in married individuals.12 Non supportive family behaviour has been associated with less adherence to medication regimen (a component of self-care behaviour) and worse glycaemic control.14 The availability and quality of social support may directly affect an individual’s ability to adapt to changes of self-care.15 However, some investigators found no relationship between social support and diabetes self-care behaviour, while some others noted unintentional negative influence on self-care behaviour.10

This study therefore sought to assess role of social support (social motivation) on diabetes selfcare behaviour and blood glucose control in a Nigerian tertiary hospital. It hypothesized that the presence of social support (social motivation) would be associated with the performance of diabetes self-care activities, and that such performance would be associated with improved glycaemic control and related clinical outcomes.

1.2        Statement of the problem

Diabetes Mellitus is one of the commonest non-communicable diseases in the world, affecting approximately 366 million people in 2011.16 With the present rapidly increasing incidence, the number of people with diabetes mellitus is projected to rise to 552 million by the year 2030.16 The greatest burden of this disease is in the low and middle-income countries, where 80% of people with diabetes live, and where about half of the people with this disease remain undiagnosed.16 This trend is fast becoming an epidemic in some countries, especially due to an increasing ageing global population. The burden diabetes will pose on the already weak health care delivery system of low and middle income countries, is likely going to be a great challenge in the nearest future.3 As most of these countries are still grappling with communicable diseases, a transition to non-communicable disease will result in a double burden of disease. Diabetes is undoubtedly one of the most challenging health problems in the 21st century.16

Nigeria, the largest country in the sub-Saharan Africa, is not excluded from the rising prevalence of diabetes mellitus among her populace. Akinkugbe in 1997 found a prevalence of 2.2%, while more recent estimates varies between 4.76% and 10.5%, depending on the area of the country that was surveyed.17-21 However, the International Diabetes Federation puts the prevalence of diabetes mellitus in Nigeria to be 3.9% in 2010.22

Adeleye et al., noted the rising prevalence of diabetes mellitus in Nigeria and the expected burden on the health system, and thus advocated for urgent need to revise the care delivery process for persons with diabetes in the country.23 This increasing prevalence of diabetes mellitus is associated with lifestyle changes, overweight and obesity, physical inactivity, alcohol consumption, poor dietary habit and cigarette smoking. These can be attributed to the urbanisation and progressive westernisation of the country.

Asides the rising prevalence, a number of studies had observed suboptimal diabetes management and outcome in Nigeria, which is attributable to non-compliance with global guidelines and consequently leading to high morbidity and mortality.6, 24 Ogbera et al., observed a high diabetes related hospitalization rate of 10.3% over an 11 year period in a Nigerian hospital, with an equally high fatality rate of 22.6%.25

Studies on diabetes self-management, which is regarded as cornerstone of diabetes mellitus management, are not many in Nigeria. However, the few available indicates that self-care practise may be low in Nigeria. Nwankwo et al., found a low proportion of respondents (19.1%) in their study having ever engaged in self-glucose measurement.24 While Adisa et al., noted that about 81.8% of respondents never monitored their blood glucose themselves.26 They also noted poor basic knowledge of diabetes care, attitude and diabetes selfmanagement practice among respondents in Ibadan.27

While it is true that the knowledge and practice of diabetes self-care behaviour in Nigeria is low; there are few studies that examined the role of social support on diabetes self-care. The few available observed that perceived support from family and friends might not be adequate. Adetunji et al., in a study of the perceived family support and blood glucose control in T2DM patients at University College Hospital, Ibadan, found that only 39% of respondents have a positive family support perception.28

This study, therefore, examined the influence of perceived social support on the self-care activities and blood glucose control of adults with type 2 diabetes attending the General and

Medical outpatients’ clinics in UCH, Ibadan.

 

1.3        Aim and objectives

1.3.1  General objective: 

To assess the influence of perceived social support on the self-care activities and blood glucose control of adults with type 2 diabetes attending the General and Medical outpatients’ clinics in UCH, Ibadan, with a view to providing guidance in the design, implementation and evaluation of diabetes self-care management protocol.

1.3.2  Specific objectives: 

  1. Describe the pattern of diabetes self-care activities in the study participants.
  2. Assess the influence of socio-demographic variables on diabetes self-care activities.
  3. Determine the relationship between diabetes self-care activities and blood glucose control of study participants.
  4. Determine the relationship between diabetes self-care activities and related clinical

outcomes such as body mass index (BMI) and waist hip ratio (WHR) of study participants.

  1. Determine the influence of perceived social support on diabetes self-care activities and

blood glucose control of study participants.

 

1.4        Relevance and justification

The purpose of this study is to gain a better understanding of how diabetes specific social support affects self-care behaviour and blood glucose control in T2DM patients in this local environment. Most of the social support is believed to come from the family environment, health care provider, health system and the community, and an understanding of this will contribute to the overall diabetes care. By having a better understanding of these relationships in the local environment, relevant interventions can be designed to improve diabetes outcome.

Adetunji et al., assessed the role of perceived family support on blood glucose control, using the mean fasting plasma glucose as a measure of blood glucose control in Ibadan.28 This study aimed improving on that study, by assessing the influence of the available social support which included family support on blood glucose control through self-care behaviour. It also improved on that study, by using serum glycosylated haemoglobin (HbA1c), which is a better measure of blood glucose control over a period of 3 months, instead of mean fasting plasma glucose.

Self-care management is regarded as one of the cornerstone of management of diabetes.

Despite numerous studies on this topic in high income countries, there are few studies in Nigeria on the self-care activities of patients and its effects on the level of blood glucose control in T2DM patients. Also, studies on the influence of social support on the practise of self-care behaviour among T2DM patient in Nigeria are equally scarce.

As self-care behaviour is a social construct, the social context of the patient plays a big role in carrying out self-care behaviour. An understanding of how these factors determine the extent of these activities among T2DM patient in our environment will be a useful tool for the family physician to ensure the presence or absence of these factors are assessed and addressed during clinic consultation.

The peculiarity of the age of sampled patient is also significant. Given the higher prevalence of diabetes mellitus among older adults, the influence of family and friends on self-care activities, and the roles that social network play, may be different for older adults than for young or middle-aged adults. A chronic illness affecting a young or middle-aged adult may not be given as high a priority among family members, given other competing priorities such as child rearing or career development. This study examined the effect of social support in young and middle aged adults between 18 and 64 years.

This study therefore aim to contribute knowledge on the influence of perceived social support on the practice of self-care and glycaemic control in Nigeria, by examining the adults with T2DM attending two outpatients’ clinic at the University College Hospital, Ibadan.

 

Influence of Perceived Social Support on Self Care Activities and Glycaemic Control in adults with Type 2 Diabetes Mellitus attending outpatient clinics, University College Hospital, Ibadan.

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