Archives of Physiology and Biochemistry
ISSN: 1381-3455 (Print) 1744-4160 (Online) Journal homepage: http://www.tandfonline.com/loi/iarp20
Implementing diabetes self-management education (DSME) in a Nigerian population: perceptions of practice nurses and dieticians Clementina U. Nwankwo, Chidum E. Ezenwaka, Philip C. Onuoha & Nneka R. Agbakoba To cite this article: Clementina U. Nwankwo, Chidum E. Ezenwaka, Philip C. Onuoha & Nneka R. Agbakoba (2015) Implementing diabetes self-management education (DSME) in a Nigerian population: perceptions of practice nurses and dieticians, Archives of Physiology and Biochemistry, 121:3, 123-127, DOI: 10.3109/13813455.2015.1031140 To link to this article: http://dx.doi.org/10.3109/13813455.2015.1031140
Published online: 26 Jun 2015.
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Date: 09 November 2015, At: 03:05
http://informahealthcare.com/arp ISSN: 1381-3455 (print), 1744-4160 (electronic) Arch Physiol Biochem, 2015; 121(3): 123–127 ! 2015 Informa UK Ltd. DOI: 10.3109/13813455.2015.1031140
ORIGINAL ARTICLE
Implementing diabetes self-management education (DSME) in a Nigerian population: perceptions of practice nurses and dieticians Clementina U. Nwankwo1, Chidum E. Ezenwaka2, Philip C. Onuoha2, and Nneka R. Agbakoba1 Faculty of Health Sciences and Technology, Nnamdi Azikiwe University, Nnewi Campus, Nigeria, and 2Faculty of Medical Sciences, The University of the West Indies, St Augustine Campus, Trinidad and Tobago
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1
Abstract
Keywords
Hyperglycaemic complication is the most common cause of hospitalization amongst diabetes patients in Nigeria. Research showed that diabetes self-management education (DSME) assists in controlling hyperglycaemia in diabetes patients. We assessed the opinions of practice nurses and dieticians on implementing DSME in a Nigerian population. 517 nurses and dieticians completed a self-administered questionnaire tool. Results showed that the majority of the participants agreed that DSME in a Nigerian population will assist patients (88.3%) and assist to reduce diabetes complications (91.4%). While only 34% of all participants believed that their establishments were prepared to implement DSME, a large proportion of the participants agreed that their work places do not have enough qualified health personnel (62.4%), educational facilities (65.8%) and economic resources (65.6%) to embark on DSME. These constitute significant barriers for effective DSME and demand that strategic investment in human and material resources for DSME is needed in this population of a developing country.
Developing countries, diabetes complications, diabetes education, diabetes self-management
Introduction The International Diabetes Federation (IDF) current Diabetes Atlas report on the global prevalence rates of diabetes showed that 382 million people are currently living with diabetes with higher prevalence rates in low and middle-income countries of the world (IDF, 2013). Although there are many healthcare awareness campaigns in the developing countries which are geared towards reducing diabetes-related mortality and morbidity (IDF, 2004; IDF, 2006; WHO, 2000), there is still increasing prevalence of diabetes and diabetes-related mortality in the world’s less developed populations (IDF, 2013). For instance, while Africa has the highest mortality rate due to diabetes, one in four deaths due to diabetes occurs in southeast Asia and one in 11 deaths in south and central America (IDF, 2013). Indeed, there has been a call for intensification of diabetes self-management education in developing countries to prevent diabetes complications and diabetes-related deaths (Ezenwaka & Eckel, 2011). Although diabetes selfmanagement education (DSME) plays a key role in diabetes care (Funnell, 2009; Moriyama et al., 2009), most of the diabetes health education teachings during lifestyle disease clinics in Nigeria are basic non-structured diabetes knowledge. The healthcare philosophy in the management of Correspondence: Professor Chidum Ezenwaka, Department of ParaClinical Sciences, Faculty of Medical Sciences, The University of the West Indies, St Augustine Campus, Trinidad and Tobago. Tel: +1-868663-6668. Fax: +1-868-663-3797, E-mail: chidum.ezenwaka@sta. uwi.edu or [email protected]
History Received 9 January 2015 Revised 6 February 2015 Accepted 14 March 2015 Published online 26 June 2015
diabetes is essentially glucocentric, aimed particularly at optimizing the patient’s blood glucose levels to prevent micro- and macro-vascular complications (Stratton et al., 2000). In Nigeria, one research study showed that hyperglycaemia is the most common cause of emergency admission and hospitalization and accounted for about 46% of all deaths in one tertiary hospital in south-western Nigeria (Ogbera et al., 2007). The major factors for hyperglycaemic emergencies identified in this population include infections and inappropriate or inadequate use of anti-diabetic agents (Balogun & Adeleye, 2008). Other studies have also shown that hyperosomolar hyperglycaemic status carry a high case fatality with diabetic foot ulcer, hypokalaemia and being elderly, serving as predictive factors for patient admission (Ogbera et al., 2009). It is possible that Nigerian diabetes patients are using more medical services and prescription medications than their non-diabetes counterparts. For instance, a recent study in the four sub-Saharan African countries of Mali, Cameroon, Tanzania and South Africa showed that in comparison with non-diabetes patients, persons living with diabetes used 12.95 times more days of inpatient treatment, 7.54 times more outpatient visits and 5.61 times more prescription medication (Brown et al., 2014). However, in comparison with diabetes patients in North America (ADA, 2013), Europe (Koster et al., 2006) or China (Yang et al., 2012), sub-Saharan African patients use relatively lesser medical services and medicines (Brown et al., 2014). Interestingly, several other research studies have demonstrated that DSME is a useful tool for controlling
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plasma glycaemia in type 2 diabetes patients (Davies et al., 2008; Norris et al., 2002; Sone et al., 2002). Effective implementation of DSME would be required to facilitate the prevention of acute hyperglycaemic emergencies in Nigerian population. There are lifestyle behavioural changes and practices expected from the person living with diabetes. The knowledge of these lifestyle modifications are acquired through structured diabetes health education from a multidisciplinary healthcare team (Henrichs, 2009). Thus, DSME will be effective if all stakeholders and healthcare providers (nurses, dieticians, doctors, health educators, patients, healthcare institutions, etc) work collaboratively to implement this critical aspect of diabetes management. Therefore, this study sought to assess the opinion of practice nurses and dieticians on DSME and the preparedness of their work establishments in implementing diabetes self-care in south-eastern Nigerian population.
Arch Physiol Biochem, 2015; 121(3): 123–127
with the explanatory letters and consent forms was distributed to all public hospitals and health centres as identified above. After reading the letter explaining the purpose of the study, nurses and dieticians that consented to participate in the study completed the questionnaire and returned it to the research assistant. Our institutional Ethics Committee reviewed and approved the study protocol. Statistics The Statistical Package for the Social Sciences (SPSS) was used for the statistical analysis. Of the 545 participants, the data of 28 subjects were excluded from analysis because of non-completion of sections III and IV of the research questionnaire. The views of the remaining 517 participants on DSME were analysed descriptively. The data were presented as absolute number and percentages (in parentheses).
Results Methods Recruitment of subjects The study was conducted in one south-eastern state (Anambra) of the Federal Republic of Nigeria, Africa. Anambra State has a population of 4.2 million people and a landmass of 4844 sq km with estimated population density of between 1500 and 2000 persons per sq km of the land area (National Population Commission of Nigeria, 2014). There are about 507 health centres, 33 general hospitals and two university teaching hospitals in the state. The Ministry of Health had about 550 registered nurses on record at the time of the study, excluding practice nurses that were not under the jurisdiction of the Ministry. The research questionnaire was non-selectively distributed to all practice nurses and dieticians at the health centres and general hospitals. The study was conducted between May and July 2014. At the end of the study, 516 nurses and 29 dieticians volunteered for the survey; representing about 93.8% of the estimated 550 nurses registered with the Ministry of Health in Anambra state. Study protocol The protocol for the study has been published previously (Ezenwaka et al., 2014a, b). Briefly, the research questionnaire consists of four sections: (i) Bio-data and human resource with six closed-ended item questions. (ii) Nurses and dieticians continuing professional education with eight open- and closed-ended questions. (iii) Views of nurses and dieticians on DSME with five closed-ended questions. (iv) Views of nurses and dieticians on barriers to diabetes education with six closed-ended questions. Since the nurses and dieticians were educated and capable of understanding the health-related questions items in the questionnaire, a self-administered research questionnaire was designed and was pre-tested on a cohort of student nurses who were studying for upgrade course to bachelor’s degrees (Ezenwaka et al., 2014a). To preserve the anonymity of the participants, the questionnaire did not contain any personal identifiers. Thus, during the study, the research questionnaire
The data of 517 participants (488 nurses, 29 dieticians, 57 males, 460 females, aged (standard deviation, SD) 33.3 (±9.7 yr) were analysed and included in this report. Figure 1 shows information on the practice nurses’ and dieticians’ continuing professional education. About 85.5% of the participants would like to participate in diabetes continuing professional education or specialize as diabetes nurses (75.7%). A significant percentage (69.6%) of the participants wants continuing professional education. The views of the participants on DSME are shown in Table 1. About 88.3% of all the study participants agreed that intensification of DSME amongst diabetes patients is a good idea for their establishments. Forty-four percent of the participants thought that there was adequate diabetes health education for their patients. However, 92.6% of all the nurses and dieticians agreed that a good adapted DSME will be helpful to the patients and also assist in reducing diabetes complications (91.4%). Interestingly, only 34% of the participants believed that their work places were prepared to implement DSME (Table 1). Table 2 shows the views of the participants on the preparedness of their work establishments for DSME. The majority (strongly agree/agree) of all the participants agreed that there were not enough qualified health personnel (62.5%), educational facilities (65.8%) and economic resources (65.6%) for DSME in their places of work (Table 2). While 57.1% of all the participants agreed that some cultural factors or practices could be a hindrance to DSME, 54.4% do not agree that religious practices will militate against DSME in south-eastern Nigerian populations (Table 2).
Discussion Five hundred and seventeen nurses and dieticians practising in south-eastern Nigeria (Anambra State) were interviewed on DSME and the preparedness of their healthcare institutions on implementing DSME. Analyses of the data showed that higher percentages of the nurses and the dieticians agreed that: (i) DSME would assist to reduce diabetes complications. (ii) There were not enough qualified health personnel, educational facilities, economic resources in their places of work.
Implementing DSME in a Nigerian population
DOI: 10.3109/13813455.2015.1031140
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Figure 1. Information on the nurses’ and dieticians’ continuing professional education. 383 (75.7%)
Number that would like to be specialist diabetes nurses (Validcases506;97.9%) Number that would like to parcipate in connuing professional educaon (Valid cases 502; 97.1%)
429 (85.5%)
245 (49.7%)
Number that have aended any connuing professional educaon (Valid cases 493; 95.4%)
348 (69.6%)
Number that have heard of connuing professional educaon (Valid cases 500; 96.7%) 0
100
200
300
400
500
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Number of Nurses & Dieans
Table 1. The views of nurses and dieticians on diabetes self-management education in a Nigerian population. Responses in relation to total valid cases Questionnaire questions
Yes
No
Don’t know
Have reservations
Do you think that the proposal to intensify self-management education amongst diabetes patients is a good idea in your establishment? (Valid cases ¼ 511, 98.8%) Do you think that there is adequate diabetes health education for patients with diabetes in the establishment that you work? (Valid cases ¼ 508, 98.3%) Do you believe that a good adapted diabetes self-management education will be helpful to diabetes patients in your establishment? (Valid cases ¼ 516, 99.8%) Do you believe that a well adapted diabetes self-management education will help to reduce diabetes complications in your establishment? (Valid cases ¼ 513, 99.2%) In your experience, do you think that the healthcare system in your establishment is prepared for diabetes self-management education? (Valid cases ¼ 512, 99.0%)
451 (88.3)
47 (9.2)
9 (1.8)
4 (0.8)
221 (43.5)
236 (46.5)
42 (8.3)
9 (1.8)
478 (92.6)
31 (6.0)
6 (1.2)
1 (0.2)
469 (91.4)
35 (6.8)
8 (1.6)
1 (0.2)
174 (34.0)
114 (22.3)
193 (37.7)
30 (5.9)
(iii) Their work places were not prepared to implement DSME. (iv) There were cultural factors or practices that could be hindrances to diabetes self-care education in southeastern Nigerian population. These findings are discussed in relation to the previous suggestion for increased DSME in the developing countries (Ezenwaka & Eckel, 2011) and the many challenges on implementing DSME in countries with limited economic resources (Debussche et al., 2009; Ezenwaka et al., 2013). The finding that the majority of Nigerian practice nurses and dieticians agreed that DSME would assist to reduce diabetes complications is a knowledge expected from experienced nursing practitioners in the field. Practice nurses are usually involved in individualized patients’ management and health promotion activities (Carey & Courtenay, 2007). The extent of individualized patient care given to patients in the public healthcare institutions in a developing country such as Nigeria is not clear. Nonetheless, the views expressed by the practice nurses and dieticians agreed with the suggestion that DSME should be an important health
policy in developing countries (Debussche et al., 2009). In this population, anecdotal reports showed that non-specialist diabetes educators conduct generalized diabetes health education in a non-structured format within a short time frame of the usually crowded clinics. The clinic education class is not usually tailored to meet individual patient’s needs/challenges or set goals for lifestyle modifications or made provision for feedback from the patients in the next clinic as required for effective DSME programme (Moriyama et al., 2009). The clinic scenario described above is not in conformity with the International Diabetes Federation (IDF) bench mark for diabetes health education (IDF, 2009) and does not meet the basic requirements for effective DSME (IDF, 2009; Moriyama et al., 2009). DSME has been demonstrated in several studies to assist in controlling plasma glycaemia and prevent diabetes complications (Davies et al., 2008; Norris et al., 2002; Sone et al., 2002) The absence of effective DSME in this population may, in part, be responsible for the several reports of hyperglycaemic emergencies and hospitalization amongst diabetes patients in Nigeria (Balogun & Adeleye, 2008; Ogbera et al., 2007; Ogbera et al., 2009).
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Arch Physiol Biochem, 2015; 121(3): 123–127
Table 2. The views of nurses and dieticians on the preparedness of healthcare system for diabetes self-management education in a Nigerian population. Responses in relation to total valid cases Questionnaire statements
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There are not enough qualified health personnel to deal with diabetes self-management education? (Valid cases ¼ 517, 100%) There are not enough economic resources for diabetes selfmanagement education in your establishment? (Valid cases ¼ 514, 99.4%) There are not enough educational facilities to assist with diabetes self-management education? (Valid cases ¼ 514, 99.4%) The country’s religious practices will militate against diabetes self-management education? (Valid cases ¼ 507, 98.1%) Some other cultural factors/practices are a hindrance to diabetes self-management education? (Valid cases ¼ 503, 97.3%)
Strongly agree
Agree
Not sure
Disagree
Strongly disagree
131 (25.3)
192 (37.1)
67 (13.0)
103 (19.9)
24 (4.6)
135 (26.3)
202 (39.3)
68 (13.2)
83 (16.1)
26 (5.1)
154 (30.0)
184 (35.8)
72 (14.0)
81 (15.8)
23 (4.5)
52 (10.3)
87 (17.2)
92 (18.1)
169 (33.3)
107 (21.1)
105 (20.9)
182 (36.2)
73 (14.5)
108 (21.5)
35 (7.0)
The finding that 43.5% of all the nurses and dieticians think that there was adequate diabetes health education in their places of work (Table 2) appears similar to previous reports from other developing countries (Ezenwaka et al., 2014a). The perception of inadequate diabetes health education needs urgent strategic intervention especially as the participants indicated that there were not enough qualified healthcare personnel, educational facilities and economic resources in their work places to facilitate DSME. Although Nigeria is ranked as a low-middle income economy (The World Bank, 2014), a report similar to the current finding has been documented in a high-income developing country (Ezenwaka et al., 2014a). Thus, one is tempted to classify inadequate infrastructural facilities for DSME as a common challenge of the developing countries. It is common knowledge that the quality of a healthcare system is largely dependent on economic resources, healthcare personnel and infrastructural facilities and diabetes self-management depends on these factors. Furthermore, the finding that the health care establishments in the population studied were not prepared for DSME is similar to a previous report in another developing country (Ezenwaka et al., 2014a). This perception may be linked to the often poor budgetary financial allocation to the healthcare sector in most developing countries. For instance, the current IDF diabetes atlas report showed that while China and India have the highest number of people currently living with diabetes (163.5 million), more money was spent on healthcare for diabetes in the region of North America than any other region of the world (IDF, 2013). Thus, the practice nurses and dieticians rightly observed that for effective DSME implementation, there should be adequate economic resources and infrastructural facilities in the public healthcare institutions. The finding that more than one half of the participants agreed (strongly agree/agree) that there were cultural factors or practices that could constitute barriers to effective DSME in population studied appeared interesting. This opinion warrants further investigation given that the design of the current study did not require the participants to enumerate such factors or practices. It is possible that factors such as patients’ unwillingness to accept that diabetes is a chronic
disorder that cannot be cured, delinquency in attending clinic health education classes as part of the diabetes management plan and inadequate lifestyle modifications, may be some cultural factors that could affect DSME in this population. Perhaps, these factors could differ in several ethnic nationalities and would warrant further studies to identify specific cultural practices for different ethnic populations. Indeed, a previous report on the DSME programme in developing countries suggested cultural tailoring of interventions to conform to the cultural aspects of the target population (Dube et al., 2015). There are a few limitations to the present study. First, we interviewed a significantly lower number of dieticians compared with nurses. This was not a deliberate omission as there is paucity of dieticians in most populations of the developing countries (Ezenwaka et al., 2014a). Secondly, we did not ascertain the number of participants that had higher educational qualifications in addition to certification in nursing and dietitics. Although it is possible that subjects’ opinion might be related to their educational background, the opinions expressed were based on the respondents’ experience in practising nursing and nutritional care for patients within the healthcare system. In conclusion, effective DSME may assist to stem the tide of hyperglycaemic complications in Nigerian population but the absence of adequate qualified healthcare personnel, economic resources and educational facilities constitute significant barriers for DSME. We recommend that health authorities and governments in developing countries should invest in human and material resources for effective DSME.
Acknowledgements This study was supported by the Publication and Research Fund from the University of the West Indies, St Augustine Campus and the Faculty of Health Sciences and Technology, Nnamdi Azikiwe University, Nigeria. We thank the Research Assistant Ms Chioma Linda for her assistance in the distribution and collection of the research questionnaires. We appreciate the cooperation of the relevant Health Authorities.
DOI: 10.3109/13813455.2015.1031140
Declaration of interest The authors report no declarations of interest.
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References American Diabetes Association (ADA). (2013). Economic costs of diabetes in the US in 2012. Diabetes Care, 36(4):1033–46. Balogun W, Adeleye J. (2008). Strategies for prevention of hyperglycaemic emergencies in Nigeria. Ann Ib Postgrad Med, 6(2):27–30. Brown JB, Ramaiya K, Besancon S, et al. (2014). Use of medical services and medicines attributable to diabetes in sub-saharan Africa. PLoS ONE, 9(9):e106716. Carey N, Courtenay M. (2007). A review of the activity and effects of nurse-led care in diabetes. J Clin Nurs, 16:296–304. Davies MJ, Heller S, Skinner TC, et al. (2008). Effectiveness of the diabetes education and self-management for ongoing and newly diagnosed (DESMOND) programme for people with newly diagnosed type 2 diabetes: Cluster randomised controlled trial. BMJ, 336:491–5. Debussche X, Balcou-Debussche M, Besancon S, Traore SA. (2009). Challenges of diabetes self-management in developing countries. DiabetesVoice, 54:12–14. Dube L, Van den Broucke S, Housiaux M, et al. (2015). Type 2 diabetes self-management education programs in high and low mortality developing countries: A systematic review. Diabetes Educ, 41(1):69–85. Ezenwaka C, Eckel J. (2011). Prevention of diabetes complications in developing countries: Time to intensify self-management education. Arch Physiol Biochem, 117(5):251–3. Ezenwaka C, Onuoha P, Olukoga A. (2013). Challenges of selfmonitoring of blood glucose in Caribbean type-2 diabetes patients. Int J Diabetes Dev Countries, 33(3):178–80. Ezenwaka C, Onuoha P, Sandy D, Israel-Richardson D. (2014a). Diabetes self-management education in a high-income developing country: Survey of the opinion of nurses and dietitians. Int J Diabetes Dev Countries, 34(3):163–8. Ezenwaka CE, Nwankwo CU, Onuoha PC, Agbakoba NR. (2014b). The opinion of practice nurses and dietitians on implementing diabetes self-management education (DSME) in Africa and the Caribbean. Int J Diabetes Res, 3(5):71–7. Funnell M. (2009). Diabetes self-management education and support: The key to diabetes care. Diabetes Voice, 54:20–3. Henrichs HR. (2009). The need for knowledge of self. Diabetes Voice, 54:3. International Diabetes Federation (IDF). (2004). World Health Organization. Diabetes Action Now, the Initiatives of World Health
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Organization and International Diabetes Federation. Geneva: World Health Organization and International Diabetes Federation, 1–24. International Diabetes Federation (IDF). (2009). IDF International Standards for Diabetes Education. 3rd edn. Brussels, Belgium: International Diabetes Federation. International Diabetes Federation (IDF). (2013). Online version of IDF Diabetes Atlas, 6th edn, chapter 3, Regional Overviews, 51–68. Available from: www.idf.org/diabetesatlas [last accessed 6 Oct 2014]. International Diabetes Federation and World Health Organization. (2006). The diabetes declaration and strategy for Africa; a call to action and plan of action to prevent and control diabetes and related chronic diseases. International Diabetes Federation, World Health Organization-AFRO and the African Union, 1–94. Koster I, von Ferber I, Ihle P, et al. (2006). The cost burden of diabetes mellitus: The evidence from Germany the CoDiM study. Diabetologia, 49(7):1498–504. Moriyama M, Nakano M, Kuroe Y, et al. (2009). Efficacy of a selfmanagement education program for people with type 2 diabetes: Results of a 12 month trial. Jpn J Nurs Sci, 6(1):51–63. National Population Commission of Nigeria. Available from: http:// www.population.gov.ng [last accessed 2 May 2014]. Norris SL, Lau J, Smith SJ, et al. (2002). Self-management education for adults with type 2 diabetes: A meta-analysis of the effect on glycemic control. Diabetes Care, 25(7):1159–71. Ogbera AO, Awobusuyi J, Unachukwu C, Fasanmade O. (2009). Clinical features, predictive factors and outcome of hyperglycaemic emergencies in a developing country. BMC Endocr Disorder, 9:9. Ogbera AO, Chinenye S, Onyekwere A, Fasanmade O. (2007). Prognostic indices of diabetes mortality. Ethn Dis, 14(4):721–5. Sone H, Ito H, Saito Y, et al. (2002). The long-term effects of selfmanagement education for patients with type 2 diabetes on glycemic control: Response to Norris et al. Diabetes Care, 25(11):2115–16. Stratton IM, Adler AI, Neil HA, et al. (2000). Association of glycaemia with macrovascular and microvascular complications of type 2 diabetes (UKPDS 35): Prospective observational study. BMJ, 321(7258):405–12. The World Bank. Countries and Economies. Available from: http:// data.worldbank.org/news/2015-country-classifications [last accessed 6 Oct 2014]. World Health Organization (WHO). (2000). International Diabetes Federation. The Western Pacific Declaration on Diabetes. Kuala Lumpur: WHO, Western Pacific Regional Office; IDF Western Pacific Region; Secretariat of the Pacific Community and Western Pacific Diabetes Declaration, 1–23. Yang W, Zhao W, Xiao J, et al. (2012). Medical care and payment for diabetes in China: Enormous threat and great opportunity. PLoS ONE, 7(9):e39513.
ISSN: 1381-3455 (Print) 1744-4160 (Online) Journal homepage: http://www.tandfonline.com/loi/iarp20
Implementing diabetes self-management education (DSME) in a Nigerian population: perceptions of practice nurses and dieticians Clementina U. Nwankwo, Chidum E. Ezenwaka, Philip C. Onuoha & Nneka R. Agbakoba To cite this article: Clementina U. Nwankwo, Chidum E. Ezenwaka, Philip C. Onuoha & Nneka R. Agbakoba (2015) Implementing diabetes self-management education (DSME) in a Nigerian population: perceptions of practice nurses and dieticians, Archives of Physiology and Biochemistry, 121:3, 123-127, DOI: 10.3109/13813455.2015.1031140 To link to this article: http://dx.doi.org/10.3109/13813455.2015.1031140
Published online: 26 Jun 2015.
Submit your article to this journal
Article views: 12
View related articles
View Crossmark data
Full Terms & Conditions of access and use can be found at http://www.tandfonline.com/action/journalInformation?journalCode=iarp20 Download by: [University of Wisconsin Oshkosh]
Date: 09 November 2015, At: 03:05
http://informahealthcare.com/arp ISSN: 1381-3455 (print), 1744-4160 (electronic) Arch Physiol Biochem, 2015; 121(3): 123–127 ! 2015 Informa UK Ltd. DOI: 10.3109/13813455.2015.1031140
ORIGINAL ARTICLE
Implementing diabetes self-management education (DSME) in a Nigerian population: perceptions of practice nurses and dieticians Clementina U. Nwankwo1, Chidum E. Ezenwaka2, Philip C. Onuoha2, and Nneka R. Agbakoba1 Faculty of Health Sciences and Technology, Nnamdi Azikiwe University, Nnewi Campus, Nigeria, and 2Faculty of Medical Sciences, The University of the West Indies, St Augustine Campus, Trinidad and Tobago
Downloaded by [University of Wisconsin Oshkosh] at 03:05 09 November 2015
1
Abstract
Keywords
Hyperglycaemic complication is the most common cause of hospitalization amongst diabetes patients in Nigeria. Research showed that diabetes self-management education (DSME) assists in controlling hyperglycaemia in diabetes patients. We assessed the opinions of practice nurses and dieticians on implementing DSME in a Nigerian population. 517 nurses and dieticians completed a self-administered questionnaire tool. Results showed that the majority of the participants agreed that DSME in a Nigerian population will assist patients (88.3%) and assist to reduce diabetes complications (91.4%). While only 34% of all participants believed that their establishments were prepared to implement DSME, a large proportion of the participants agreed that their work places do not have enough qualified health personnel (62.4%), educational facilities (65.8%) and economic resources (65.6%) to embark on DSME. These constitute significant barriers for effective DSME and demand that strategic investment in human and material resources for DSME is needed in this population of a developing country.
Developing countries, diabetes complications, diabetes education, diabetes self-management
Introduction The International Diabetes Federation (IDF) current Diabetes Atlas report on the global prevalence rates of diabetes showed that 382 million people are currently living with diabetes with higher prevalence rates in low and middle-income countries of the world (IDF, 2013). Although there are many healthcare awareness campaigns in the developing countries which are geared towards reducing diabetes-related mortality and morbidity (IDF, 2004; IDF, 2006; WHO, 2000), there is still increasing prevalence of diabetes and diabetes-related mortality in the world’s less developed populations (IDF, 2013). For instance, while Africa has the highest mortality rate due to diabetes, one in four deaths due to diabetes occurs in southeast Asia and one in 11 deaths in south and central America (IDF, 2013). Indeed, there has been a call for intensification of diabetes self-management education in developing countries to prevent diabetes complications and diabetes-related deaths (Ezenwaka & Eckel, 2011). Although diabetes selfmanagement education (DSME) plays a key role in diabetes care (Funnell, 2009; Moriyama et al., 2009), most of the diabetes health education teachings during lifestyle disease clinics in Nigeria are basic non-structured diabetes knowledge. The healthcare philosophy in the management of Correspondence: Professor Chidum Ezenwaka, Department of ParaClinical Sciences, Faculty of Medical Sciences, The University of the West Indies, St Augustine Campus, Trinidad and Tobago. Tel: +1-868663-6668. Fax: +1-868-663-3797, E-mail: chidum.ezenwaka@sta. uwi.edu or [email protected]
History Received 9 January 2015 Revised 6 February 2015 Accepted 14 March 2015 Published online 26 June 2015
diabetes is essentially glucocentric, aimed particularly at optimizing the patient’s blood glucose levels to prevent micro- and macro-vascular complications (Stratton et al., 2000). In Nigeria, one research study showed that hyperglycaemia is the most common cause of emergency admission and hospitalization and accounted for about 46% of all deaths in one tertiary hospital in south-western Nigeria (Ogbera et al., 2007). The major factors for hyperglycaemic emergencies identified in this population include infections and inappropriate or inadequate use of anti-diabetic agents (Balogun & Adeleye, 2008). Other studies have also shown that hyperosomolar hyperglycaemic status carry a high case fatality with diabetic foot ulcer, hypokalaemia and being elderly, serving as predictive factors for patient admission (Ogbera et al., 2009). It is possible that Nigerian diabetes patients are using more medical services and prescription medications than their non-diabetes counterparts. For instance, a recent study in the four sub-Saharan African countries of Mali, Cameroon, Tanzania and South Africa showed that in comparison with non-diabetes patients, persons living with diabetes used 12.95 times more days of inpatient treatment, 7.54 times more outpatient visits and 5.61 times more prescription medication (Brown et al., 2014). However, in comparison with diabetes patients in North America (ADA, 2013), Europe (Koster et al., 2006) or China (Yang et al., 2012), sub-Saharan African patients use relatively lesser medical services and medicines (Brown et al., 2014). Interestingly, several other research studies have demonstrated that DSME is a useful tool for controlling
Downloaded by [University of Wisconsin Oshkosh] at 03:05 09 November 2015
124
C. U. Nwankwo et al.
plasma glycaemia in type 2 diabetes patients (Davies et al., 2008; Norris et al., 2002; Sone et al., 2002). Effective implementation of DSME would be required to facilitate the prevention of acute hyperglycaemic emergencies in Nigerian population. There are lifestyle behavioural changes and practices expected from the person living with diabetes. The knowledge of these lifestyle modifications are acquired through structured diabetes health education from a multidisciplinary healthcare team (Henrichs, 2009). Thus, DSME will be effective if all stakeholders and healthcare providers (nurses, dieticians, doctors, health educators, patients, healthcare institutions, etc) work collaboratively to implement this critical aspect of diabetes management. Therefore, this study sought to assess the opinion of practice nurses and dieticians on DSME and the preparedness of their work establishments in implementing diabetes self-care in south-eastern Nigerian population.
Arch Physiol Biochem, 2015; 121(3): 123–127
with the explanatory letters and consent forms was distributed to all public hospitals and health centres as identified above. After reading the letter explaining the purpose of the study, nurses and dieticians that consented to participate in the study completed the questionnaire and returned it to the research assistant. Our institutional Ethics Committee reviewed and approved the study protocol. Statistics The Statistical Package for the Social Sciences (SPSS) was used for the statistical analysis. Of the 545 participants, the data of 28 subjects were excluded from analysis because of non-completion of sections III and IV of the research questionnaire. The views of the remaining 517 participants on DSME were analysed descriptively. The data were presented as absolute number and percentages (in parentheses).
Results Methods Recruitment of subjects The study was conducted in one south-eastern state (Anambra) of the Federal Republic of Nigeria, Africa. Anambra State has a population of 4.2 million people and a landmass of 4844 sq km with estimated population density of between 1500 and 2000 persons per sq km of the land area (National Population Commission of Nigeria, 2014). There are about 507 health centres, 33 general hospitals and two university teaching hospitals in the state. The Ministry of Health had about 550 registered nurses on record at the time of the study, excluding practice nurses that were not under the jurisdiction of the Ministry. The research questionnaire was non-selectively distributed to all practice nurses and dieticians at the health centres and general hospitals. The study was conducted between May and July 2014. At the end of the study, 516 nurses and 29 dieticians volunteered for the survey; representing about 93.8% of the estimated 550 nurses registered with the Ministry of Health in Anambra state. Study protocol The protocol for the study has been published previously (Ezenwaka et al., 2014a, b). Briefly, the research questionnaire consists of four sections: (i) Bio-data and human resource with six closed-ended item questions. (ii) Nurses and dieticians continuing professional education with eight open- and closed-ended questions. (iii) Views of nurses and dieticians on DSME with five closed-ended questions. (iv) Views of nurses and dieticians on barriers to diabetes education with six closed-ended questions. Since the nurses and dieticians were educated and capable of understanding the health-related questions items in the questionnaire, a self-administered research questionnaire was designed and was pre-tested on a cohort of student nurses who were studying for upgrade course to bachelor’s degrees (Ezenwaka et al., 2014a). To preserve the anonymity of the participants, the questionnaire did not contain any personal identifiers. Thus, during the study, the research questionnaire
The data of 517 participants (488 nurses, 29 dieticians, 57 males, 460 females, aged (standard deviation, SD) 33.3 (±9.7 yr) were analysed and included in this report. Figure 1 shows information on the practice nurses’ and dieticians’ continuing professional education. About 85.5% of the participants would like to participate in diabetes continuing professional education or specialize as diabetes nurses (75.7%). A significant percentage (69.6%) of the participants wants continuing professional education. The views of the participants on DSME are shown in Table 1. About 88.3% of all the study participants agreed that intensification of DSME amongst diabetes patients is a good idea for their establishments. Forty-four percent of the participants thought that there was adequate diabetes health education for their patients. However, 92.6% of all the nurses and dieticians agreed that a good adapted DSME will be helpful to the patients and also assist in reducing diabetes complications (91.4%). Interestingly, only 34% of the participants believed that their work places were prepared to implement DSME (Table 1). Table 2 shows the views of the participants on the preparedness of their work establishments for DSME. The majority (strongly agree/agree) of all the participants agreed that there were not enough qualified health personnel (62.5%), educational facilities (65.8%) and economic resources (65.6%) for DSME in their places of work (Table 2). While 57.1% of all the participants agreed that some cultural factors or practices could be a hindrance to DSME, 54.4% do not agree that religious practices will militate against DSME in south-eastern Nigerian populations (Table 2).
Discussion Five hundred and seventeen nurses and dieticians practising in south-eastern Nigeria (Anambra State) were interviewed on DSME and the preparedness of their healthcare institutions on implementing DSME. Analyses of the data showed that higher percentages of the nurses and the dieticians agreed that: (i) DSME would assist to reduce diabetes complications. (ii) There were not enough qualified health personnel, educational facilities, economic resources in their places of work.
Implementing DSME in a Nigerian population
DOI: 10.3109/13813455.2015.1031140
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Figure 1. Information on the nurses’ and dieticians’ continuing professional education. 383 (75.7%)
Number that would like to be specialist diabetes nurses (Validcases506;97.9%) Number that would like to parcipate in connuing professional educaon (Valid cases 502; 97.1%)
429 (85.5%)
245 (49.7%)
Number that have aended any connuing professional educaon (Valid cases 493; 95.4%)
348 (69.6%)
Number that have heard of connuing professional educaon (Valid cases 500; 96.7%) 0
100
200
300
400
500
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Number of Nurses & Dieans
Table 1. The views of nurses and dieticians on diabetes self-management education in a Nigerian population. Responses in relation to total valid cases Questionnaire questions
Yes
No
Don’t know
Have reservations
Do you think that the proposal to intensify self-management education amongst diabetes patients is a good idea in your establishment? (Valid cases ¼ 511, 98.8%) Do you think that there is adequate diabetes health education for patients with diabetes in the establishment that you work? (Valid cases ¼ 508, 98.3%) Do you believe that a good adapted diabetes self-management education will be helpful to diabetes patients in your establishment? (Valid cases ¼ 516, 99.8%) Do you believe that a well adapted diabetes self-management education will help to reduce diabetes complications in your establishment? (Valid cases ¼ 513, 99.2%) In your experience, do you think that the healthcare system in your establishment is prepared for diabetes self-management education? (Valid cases ¼ 512, 99.0%)
451 (88.3)
47 (9.2)
9 (1.8)
4 (0.8)
221 (43.5)
236 (46.5)
42 (8.3)
9 (1.8)
478 (92.6)
31 (6.0)
6 (1.2)
1 (0.2)
469 (91.4)
35 (6.8)
8 (1.6)
1 (0.2)
174 (34.0)
114 (22.3)
193 (37.7)
30 (5.9)
(iii) Their work places were not prepared to implement DSME. (iv) There were cultural factors or practices that could be hindrances to diabetes self-care education in southeastern Nigerian population. These findings are discussed in relation to the previous suggestion for increased DSME in the developing countries (Ezenwaka & Eckel, 2011) and the many challenges on implementing DSME in countries with limited economic resources (Debussche et al., 2009; Ezenwaka et al., 2013). The finding that the majority of Nigerian practice nurses and dieticians agreed that DSME would assist to reduce diabetes complications is a knowledge expected from experienced nursing practitioners in the field. Practice nurses are usually involved in individualized patients’ management and health promotion activities (Carey & Courtenay, 2007). The extent of individualized patient care given to patients in the public healthcare institutions in a developing country such as Nigeria is not clear. Nonetheless, the views expressed by the practice nurses and dieticians agreed with the suggestion that DSME should be an important health
policy in developing countries (Debussche et al., 2009). In this population, anecdotal reports showed that non-specialist diabetes educators conduct generalized diabetes health education in a non-structured format within a short time frame of the usually crowded clinics. The clinic education class is not usually tailored to meet individual patient’s needs/challenges or set goals for lifestyle modifications or made provision for feedback from the patients in the next clinic as required for effective DSME programme (Moriyama et al., 2009). The clinic scenario described above is not in conformity with the International Diabetes Federation (IDF) bench mark for diabetes health education (IDF, 2009) and does not meet the basic requirements for effective DSME (IDF, 2009; Moriyama et al., 2009). DSME has been demonstrated in several studies to assist in controlling plasma glycaemia and prevent diabetes complications (Davies et al., 2008; Norris et al., 2002; Sone et al., 2002) The absence of effective DSME in this population may, in part, be responsible for the several reports of hyperglycaemic emergencies and hospitalization amongst diabetes patients in Nigeria (Balogun & Adeleye, 2008; Ogbera et al., 2007; Ogbera et al., 2009).
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C. U. Nwankwo et al.
Arch Physiol Biochem, 2015; 121(3): 123–127
Table 2. The views of nurses and dieticians on the preparedness of healthcare system for diabetes self-management education in a Nigerian population. Responses in relation to total valid cases Questionnaire statements
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There are not enough qualified health personnel to deal with diabetes self-management education? (Valid cases ¼ 517, 100%) There are not enough economic resources for diabetes selfmanagement education in your establishment? (Valid cases ¼ 514, 99.4%) There are not enough educational facilities to assist with diabetes self-management education? (Valid cases ¼ 514, 99.4%) The country’s religious practices will militate against diabetes self-management education? (Valid cases ¼ 507, 98.1%) Some other cultural factors/practices are a hindrance to diabetes self-management education? (Valid cases ¼ 503, 97.3%)
Strongly agree
Agree
Not sure
Disagree
Strongly disagree
131 (25.3)
192 (37.1)
67 (13.0)
103 (19.9)
24 (4.6)
135 (26.3)
202 (39.3)
68 (13.2)
83 (16.1)
26 (5.1)
154 (30.0)
184 (35.8)
72 (14.0)
81 (15.8)
23 (4.5)
52 (10.3)
87 (17.2)
92 (18.1)
169 (33.3)
107 (21.1)
105 (20.9)
182 (36.2)
73 (14.5)
108 (21.5)
35 (7.0)
The finding that 43.5% of all the nurses and dieticians think that there was adequate diabetes health education in their places of work (Table 2) appears similar to previous reports from other developing countries (Ezenwaka et al., 2014a). The perception of inadequate diabetes health education needs urgent strategic intervention especially as the participants indicated that there were not enough qualified healthcare personnel, educational facilities and economic resources in their work places to facilitate DSME. Although Nigeria is ranked as a low-middle income economy (The World Bank, 2014), a report similar to the current finding has been documented in a high-income developing country (Ezenwaka et al., 2014a). Thus, one is tempted to classify inadequate infrastructural facilities for DSME as a common challenge of the developing countries. It is common knowledge that the quality of a healthcare system is largely dependent on economic resources, healthcare personnel and infrastructural facilities and diabetes self-management depends on these factors. Furthermore, the finding that the health care establishments in the population studied were not prepared for DSME is similar to a previous report in another developing country (Ezenwaka et al., 2014a). This perception may be linked to the often poor budgetary financial allocation to the healthcare sector in most developing countries. For instance, the current IDF diabetes atlas report showed that while China and India have the highest number of people currently living with diabetes (163.5 million), more money was spent on healthcare for diabetes in the region of North America than any other region of the world (IDF, 2013). Thus, the practice nurses and dieticians rightly observed that for effective DSME implementation, there should be adequate economic resources and infrastructural facilities in the public healthcare institutions. The finding that more than one half of the participants agreed (strongly agree/agree) that there were cultural factors or practices that could constitute barriers to effective DSME in population studied appeared interesting. This opinion warrants further investigation given that the design of the current study did not require the participants to enumerate such factors or practices. It is possible that factors such as patients’ unwillingness to accept that diabetes is a chronic
disorder that cannot be cured, delinquency in attending clinic health education classes as part of the diabetes management plan and inadequate lifestyle modifications, may be some cultural factors that could affect DSME in this population. Perhaps, these factors could differ in several ethnic nationalities and would warrant further studies to identify specific cultural practices for different ethnic populations. Indeed, a previous report on the DSME programme in developing countries suggested cultural tailoring of interventions to conform to the cultural aspects of the target population (Dube et al., 2015). There are a few limitations to the present study. First, we interviewed a significantly lower number of dieticians compared with nurses. This was not a deliberate omission as there is paucity of dieticians in most populations of the developing countries (Ezenwaka et al., 2014a). Secondly, we did not ascertain the number of participants that had higher educational qualifications in addition to certification in nursing and dietitics. Although it is possible that subjects’ opinion might be related to their educational background, the opinions expressed were based on the respondents’ experience in practising nursing and nutritional care for patients within the healthcare system. In conclusion, effective DSME may assist to stem the tide of hyperglycaemic complications in Nigerian population but the absence of adequate qualified healthcare personnel, economic resources and educational facilities constitute significant barriers for DSME. We recommend that health authorities and governments in developing countries should invest in human and material resources for effective DSME.
Acknowledgements This study was supported by the Publication and Research Fund from the University of the West Indies, St Augustine Campus and the Faculty of Health Sciences and Technology, Nnamdi Azikiwe University, Nigeria. We thank the Research Assistant Ms Chioma Linda for her assistance in the distribution and collection of the research questionnaires. We appreciate the cooperation of the relevant Health Authorities.
DOI: 10.3109/13813455.2015.1031140
Declaration of interest The authors report no declarations of interest.
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