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 Table of Contents  
ORIGINAL ARTICLE
Year : 2021  |  Volume : 12  |  Issue : 3  |  Page : 310-318

Knowledge, practice, and barriers regarding self-monitoring of blood glucose among patients with type 2 diabetes mellitus in Enugu State, Nigeria


Department of Clinical Pharmacy and Pharmacy Management, Faculty of Pharmaceutical Sciences, University of Nigeria, Nsukka, PMB 410001 Enugu State, Nigeria

Date of Submission23-Nov-2020
Date of Decision17-Jan-2021
Date of Acceptance10-Feb-2021
Date of Web Publication30-Sep-2021

Correspondence Address:
Adaobi Uchenna Mosanya
Department of Clinical Pharmacy and Pharmacy Management, Faculty of Pharmaceutical Sciences, University of Nigeria, Nsukka, PMB 410001 Enugu State.
Nigeria
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/JOD.JOD_99_20

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  Abstract 

Aims: Self-monitoring of blood glucose can improve treatment adherence and clinical outcomes. The aim of this study is to assess knowledge, practice, and barriers to self-monitoring of blood glucose (SMBG) among patients with type 2 diabetes mellitus (T2DM) in Enugu State, Nigeria. Settings and Design: This study was a cross-sectional survey of 340 patients with type 2 diabetes at the University of Nigeria Teaching Hospital (UNTH) and Enugu State University Teaching Hospital (Park Lane) in August 2017. Materials and Methods: The data collection tool was a 26-item, four-sectioned questionnaire: the socio-demographic and clinical characteristics, 11 items on knowledge, seven on practice, and eight on barriers regarding SMBG. The questionnaires were self-administered. Statistical Analysis Used: Data were analyzed using SPSS version 20. Descriptive, χ2, Spearman’s correlation, and logistics regression statistics were reported at P < 0.05. Results: Majority of the patients were 46–55 years old (27.9%). Female respondents were 53.5%. Patients with good knowledge and practice were 35.9% and 46.2%, respectively. Knowledge of SMBG was negatively correlated to barrier against SMBG (r = ‒0.178, P=0.001) and positively correlated with practice of SMBG (r = 0.138, P=0.011). Those who were not taught SMBG were less likely to have good practice of SMBG than those who were taught (adjusted odd ratio 0.122, 95% confidence interval: 0.044–0.338). Conclusions: Patients with T2DM in Enugu State have poor knowledge and practice SMBG.

Keywords: Glycemic control, Nigeria, self-care, SMBG, type 2 diabetes mellitus


How to cite this article:
Anene-Okeke CG, Mosanya AU, Osakwe O. Knowledge, practice, and barriers regarding self-monitoring of blood glucose among patients with type 2 diabetes mellitus in Enugu State, Nigeria. J Diabetol 2021;12:310-8

How to cite this URL:
Anene-Okeke CG, Mosanya AU, Osakwe O. Knowledge, practice, and barriers regarding self-monitoring of blood glucose among patients with type 2 diabetes mellitus in Enugu State, Nigeria. J Diabetol [serial online] 2021 [cited 2021 Nov 30];12:310-8. Available from: https://www.journalofdiabetology.org/text.asp?2021/12/3/310/327322




  Introduction Top


In 2018, WHO stated that about 1.5 million deaths were directly caused by diabetes.[1] An adequate and optimum glycemic control is achievable if patients adhere to their medications as indicated and to self-care habits such as following a healthy diet, reducing the risk factors, regular exercise, and blood glucose monitoring.[2],[3],[4] However, in Nigeria, very few studies such as those carried by Edah et al.,[5] Unachukwu et al.,[6] Eregie and Unadike,[7] and Nwankwo et al.[8] were done to assess the knowledge, practice, and barriers regarding self-monitoring of blood glucose (SMBG). Therefore, the study was aimed to assess knowledge, practice, and barriers regarding SMBG among patients with type 2 diabetes mellitus (T2DM) in Enugu State, Nigeria.


  Subjects and Methods Top


Study design and settings

We used a cross-sectional survey method for this study among type 2 diabetic patients who receive health care at endocrine units of two tertiary hospitals: Enugu State University Teaching Hospital (Park Lane) and University of Nigeria Teaching Hospital, Enugu State, Nigeria.

The study was conducted at the University of Nigeria Teaching Hospital (UNTH), Ituku-Ozalla, a Federal government tertiary hospital. Diabetic patients visit the Endocrine Unit of the University of Nigeria Teaching Hospital (UNTH) on Wednesdays and of the Enugu State University Teaching Hospital (formerly known as Park Lane) on Wednesdays and Fridays.

Sample size and sampling technique

The registers were not available leading to lack of a sampling frame. As a result, probability sampling methods were ruled out. However, the minimum sample size estimation was calculated using this formula:

[INLINE 1]

where S is the sample size for unknown population;

z = z-score (determined based on the confidence level). We considered 95% confidence level. Therefore, the z-score is 1.96;

p = percentage of population probability (assumed to be 50% =0.5);

m = margin of error, which is 5%=0.05;

s = 384.

Participants

A convenient sampling method was utilized for all type 2 diabetic patients who visited the two clinics during the study period. The eligibility criteria were 18 years and above, ability to read and write, having been diagnosed of the disease for more than 6 months, and those who gave verbal consent after the pre-survey talk. The researchers explained to the prospective respondents the purpose of the survey; they were assured that no identifiable information will be collected from them and that participation in the survey was voluntary. Only 350 questionnaires were completed and returned.

Ethical consideration and patient consent

The ethical approval was obtained from the Medical Advisory Committee, Enugu State University Teaching Hospital Park Lane, Enugu with Registration number NHREC/05/01/2008B-FWA00002458-1RB00002323, and from the Board of Health Research and Ethics of the University of Nigeria Teaching Hospital (UNTH), Enugu State with Registration number ESUTHP/C-MAC/RA/034/203. Verbal and voluntary consent was obtained from each patient before administering the questionnaire.

Statistical methods

Data collection and analysis

A 26-item structured self-administered questionnaire was the instrument used for data collection. The questionnaire was adapted from a study by Nazmi et al.[9] and Ong et al.[10] and face validated by three experts. This was divided into four sections: the socio-demographic and clinical characteristics data; age, gender, marital status, educational status, yearly income, the length of diabetes mellitus illness, the type of treatment, and the presence of comorbidities; 11 questions on knowledge of SMBG, seven questions on practice, and eight questions regarding barriers against the practice of SMBG. The researchers distributed the questionnaires among the patients during the clinic days at the two study sites. Three hundred and forty consenting diabetic patients filled the questionnaires themselves. The questionnaires were collected on the spot after completion to avoid respondent sourcing for information on the internet. Data collection in both hospitals was in August 2017.

We used the software SPSS version 20 to code and analyze the collected data. With the descriptive statistics, namely, frequencies and percentages, we measured the level of knowledge of SMBG among the patients. The total knowledge score (TKS) was computed for each respondent. The median score was 7 (range: 3–11). Those who scored above the median score were categorized as having good knowledge, whereas those who had knowledge score of 7 and below were categorized as having poor knowledge. The median score for all the respondents’ total practice scores (TPSs) was 4 (range: 0–7). Those who got scores above the cutoff score of 4 were identified as having a good practice of SMBG, whereas those with scores of 4 and below had poor practice of SMBG. In order to identify any association of the sociodemographic data with the knowledge and practice of SMBG as well as barriers against it, we utilized the χ2 statistical analysis. All the associating factors that were significant at P <0.05 in the χ2 analysis were considered for further analysis using the binary logistic regression model to determine the predictors of good knowledge of SMBG among the participants. All the covariates that were significant at P <0.05 in the bivariate analysis were considered for further multivariate analysis. A multivariable logistic regression was used to identify the independent variables that were associated with good knowledge of SMBG. The level of statistical significance was at P <0.05.

Operational definitions

Knowledge of SMBG: The number of knowledge questions was 11. Any correct answer for the knowledge items was given a score of “1,” whereas the incorrect answer was assigned “0.” The total score for each respondent was computed. A descriptive analysis was run to determine the measures of central tendency and dispersion. The scores were not normally distributed. Therefore, the median score was used as the cutoff score to categorize the patients into those with good knowledge or poor knowledge of SMBG. The same method was used for the practice of SMBG.


  Results Top


Demographic details of the patients

In [Table 1], about 28% of the respondents were between 46 and 55 years old; more than half of the respondents were female (53.5%); patients who had been living with diabetes from 1 to 6 years were 221 (65%). Two hundred and seventeen (63.2%) were being managed with oral hypoglycemic agents alone. Slightly higher than the average number of the participants (56.2%) had hypertension as a co-morbid condition.
Table 1: Association between sociodemographic and knowledge of SMBG

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Respondents’ knowledge of SMBG

[Table 1] shows that only about 36% of the respondents had good knowledge of SMBG. The χ2 analysis revealed that quite a number of factors were significantly associated with good knowledge of SMBG. Among them were the age of the respondents (P= 0.004), treatment type (P= 0.005), and hospital setting (P= 0.037). [Table 2] shows that almost all the patients think that a needle and lancet can be used more than once (n = 329, 96.8%). However, a good number of them think that a patient should regularly record the measured blood glucose level before consulting the physician (n = 271, 79.7%).
Table 2: Respondents knowledge of SMBG

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Respondents’ practice of SMBG

[Table 1] shows that less than half of the respondents had good practice of SMBG (46.2%). Factors associated with good practice of SMBG were age of the respondents (P=0.007), having been taught to do SMBG (P = 0.000). It was observed that more than 200 patients were taught by a pharmacist to use a glucometer (60%) while almost all of them usually measure their fasting blood glucose (93.5%). Also, 42.1% (143) reported that there were taught very much how to do SMBG.

Barriers to respondents’ SMBG

A greater percentage of the respondents (n = 230, 67.6%) lacked motivation for SMBG, whereas approximately 65% of them experienced inconvenience with SMBG. From [Table 1], two barriers were significantly associated with good knowledge and good practice of SMBG. Good knowledge of SMBG was significantly associated with inconvenience of SMBG (P =0.025) and lack of motivation for SMBG (P = 0.029). Good practice of SMBG was significantly associated with inconvenience of SMBG (P =0.001) and lack of motivation (P =0.003).

Spearman’s ρ correlation coefficient among TKS, TPS, and total barrier scores (TBS)

After the computation of the TKS, TPS, and TBS, descriptive analysis was run to determine the measures of central tendency and dispersion. The scores were not normally distributed. Therefore, a non-parametric correlation, Spearman’s ρ correlation analysis, was done. The results are presented in [Table 3]. Knowledge of SMBG was positively correlated with the practice of SMBG (r = 0.138, P = 0.011) and negatively correlated with the barriers against SMBG (r = ‒0.178, P = 0.001).
Table 3: Spearman’s ρ correlation coefficient among TKS, TPS, and TBS

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Association between covariates and good knowledge of SMBG

All the factors that were statistically associated with good knowledge using χ2 analysis at P < 0.05 were subjected to further analysis using logistic regression. Taking the last categories as the reference, binary logistics regression was done individually between categorized knowledge scores and age of respondents, treatment type, co-morbidities, hospital setting, taught to do SMBG, inconvenience of SMBG, and lack of motivation for SMBG. Then, they were all included in the multiple logistic model to control for their effects to get the adjusted odd ratios (AORs). [Table 4] shows that respondents who were between 18 and 25 years were more likely to have good knowledge of SMBG than those who were above 65 years old (AOR = 23.606; 95% confidence interval (CI) = 4.024–138.467). However, those who were taught a little about SMBG were less likely to have good knowledge of SMBG than those who were taught very much (AOR = 0.440; 95% CI = 0.201–0.960).
Table 4: Association between covariates and good knowledge of SMBG (n = 340)

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Association between covariates and good practice of SMBG

All the factors that were statistically associated with good practice using χ2 analysis at P < 0.05 were subjected to further analysis with logistic regression. Taking the last categories as the reference, binary logistics regressions were done individually between categorized knowledge scores and age of respondents, taught to do SMBG, inconvenience of SMBG, and lack of motivation for SMBG. Afterwards, they were included in the multiple logistic model to control for their effects, and their corresponding AORs were reported in [Table 5]. The respondents who were taught a little about SMBG were less likely to have good practice of SMBG than those who were taught very much (AOR = 0.231; 95% CI = 0.107–0.501). Similarly, the odds having good practice of SMBG are lower for those who were not taught at all to do SMBG than those who were taught very much to do SMBG (AOR = 0.122; 95% CI = 0.044–0.338).
Table 5: Association between covariates and good practice of SMBG (n = 340)

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  Discussion Top


This study was carried out to assess knowledge, practice, and barriers to SMBG among patients living with type 2 diabetes in Enugu State, Nigeria. There were more female respondents in this study. Comparable observations were made in other studies in Nigeria by Osuji et al., other African country, for example, in a study by Bonger et al., and in another continent by Guan et al. in China.[9],[11],[12],[13] More than 50% of the respondents were within the middle age range of 46–65 years. A recent study got similar findings.[12] A high proportion of the study participants has been living with T2DM between 1 and 6 years. The same can be said of a study by Afaya et al.[14] Not surprising is the fact that the mode of DM management among the respondents was oral hypoglycemic agents alone. This is because the therapy for T2DM rarely incorporates insulin. Hypertension is one of the common co-morbidities of patients living with T2DM. In this study, the prevalence of this disease condition was above average. The prevalence of the good knowledge of blood glucose self-monitoring was poor. This was much lower than a similar study in Norway carried out by Kjome et al.[15] This perhaps was caused by the fact that less than half of the respondents perceived that they were taught very much. This contrasts with another study by Al-Keilani et al.,[16] in which 55% of the participants reported that they had received adequate health education regarding how to use the SMBG meter. Nevertheless, there might not be any basis for the comparison of the results from this study with those from some developed countries because factors like literacy level and level of diabetes education of people living with diabetes may influence the knowledge of SMBG. In a systematic review by Mogre et al.,[17] it was noted too that SMBG is higher in high-income countries than in low-income countries. A high percentage of the patients did not know the symptoms of low blood glucose. This is comparable to the results from a study in South Africa by Moosa et al.,[18] which showed that 83.9% of the patients did not know the possible side effects of the prescribed antidiabetic agents. Before the patients can effectively do SMBG, it is required that they have the knowledge as stated by Austin in his study.[19] Edah et al.[5] observed that well-educated people are more likely to understand the process of SMBG, whereas those with no or low level of formal education will need to be taught through repetition and gentle guidance. We identified three factors that were associated with knowledge of SMBG: age, the treatment type, and the hospital setting. The prevalence of poor knowledge of SMBG among the patients >65 years old was high. Something similar was observed in Kenya by Wambui Charity et al.,[20] where age more than 30 years was associated with poor adherence to SMBG. Good SMBG practice among the patients who participated in this study was below average. This is much lower than the percentage of those who had good knowledge of SMBG. Perhaps, good knowledge does always lead to good practice. However, there was a positive Spearman correlation coefficient between total knowledge scores and total practice scores albeit, a weak one. Bezo et al.[21] in a study made a similar observation recently, in which diabetes knowledge correlated with increase in total self-management behavior and SMBG. Among the identified sociodemographic factors that were associated with good SMBG practice were age and thorough education regarding SMBG practice. Jibril et al.[22] showed in a study that a relationship exists among practice of SMBG, other self-care practices among patients living with diabetes mellitus, and age. In another study by Mutyambizi et al.,[23] the odds were less for patients more than 61 years than those between 21 and 40 years to practice SMBG. This is a problem because in Nigeria Olamoyegun et al.[24] have identified age among other factors to be associated with diabetic retinopathy and micro-angiopathy complications. Therefore, as observed by Shen et al.,[25] older people are more likely to suffer from the complications resulting from poor glycemic control such as retinopathy and obesity. It is interesting to note the role of pharmacists in the health education of patients living with diabetes with respect to SMBG. Three-fifths of the patients were taught by a pharmacist on how to use the glucometer. This proportion is much higher than that obtained from a comparable study by Mikhael et al.[2] Nevertheless, this role in the education of the patients regarding the use of glucometer was unequal in intensity. The disparity was seen as a determinant for both good knowledge and good practice of SMBG. In order words, those who reported that they were taught very much were more likely to practice good SMBG than those who perceived that they were taught very little as shown in the logistic regression analysis result. Supporting this observation is the conclusion from another study that respondents who never had diabetes health education were four times less likely to practice good self-care than those who had it regularly.[26] Getting education from health professionals was one of the predictors of self-care practices observed by Getie et al.[27] in their study. Moreover, some investigators of a recent study such as Owei et al.[28] opined that good communication between healthcare professionals and their patients regarding SMBG would improve their glycemic control. SMBG was also found by Sridharan et al.[29] to promote T2DM adherence to medication.

Cost of test strips and needles, unconducive workplace, stigma, lack of knowledge and self-efficacy, fear of needles and pain, and frustration related to high blood glucose reading were the barriers surveyed in this study. However, only inconvenience and lack of motivation were statistically significant barriers identified as determinants for good knowledge and good practice of SMBG. Inconvenience may be linked to the cumbersome procedure associated with SMBG and travel. Other causes of inconvenience may include cost of needle. More than half of the respondents singly experienced the two. In a study, it was noted that less than 50% of the participants did not experience stress related to SMBG.[2] In this study, lack of motivation is the second significant barrier against SMBG. This is in consonance with the results of a systematic review by Al-Sahouri et al.[30] which identified SMBG as the least performed behavior among people living with DM in Jordan while low motivation was one of the barriers.

It is pertinent to note a few strengths of the study. One is that being a cross-sectional survey could be a springboard for further research. Secondly, a 26 structured self-administered questionnaire was utilized for data collection. Finally, it is interesting to note that three-fifths of the patients were taught by pharmacists.

Limitation of the study

The study was conducted only among type 2 diabetics outpatients. Also, the survey was done among 350 patients from a single region. Another limitation to the study was that convenient sampling was employed. Thus, this prevents the generalization of the results to the whole population of diabetic patients in Enugu State. Therefore, for such generalization to be possible, it is necessary to use a larger sample size in future studies. Another limitation to the study was that we could assess any possible correlation between HbA1c and good practice of SMBG because the scope of this study did not cover the measurement of HbA1c.


  Conclusion Top


The prevalence of good knowledge and good practice of blood glucose self-monitoring was poor. Patient’s education is the best way to achieve the desired therapeutic goals in which pharmacists must play a major role. This education should be geared toward ensuring that the patients acquire operational as well as interpretive skills regarding SMBG. Also there is need for more investment by the Federal Ministry of Health in SMBG programs as a way to achieve an effective management of patients with diabetes and to enhance their medication adherence. Ideally, newly initiated SMBG practice would be integrated as a teaching tool into a health education program soon after the diagnosis of diabetes. Healthcare providers also need to be trained on approaches to teaching SMBG to their patients.

Acknowledgement

We are grateful to the patients who consented to participate in the study.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]



 

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