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Self-care behaviors in Nepalese adults with diabetes mellitus: a mixed method approach
ABSTRACT: The aim of this mixed method study was first to construct a path model based on existing literatures and test the direct and indirect influence of diabetes self -efficacy, social support, expectation regarding aging, social-demographic factors (age, gender, education and employment status) and disease specific characteristics (diabetes duration, associated comorbidity, type of treatment) on diabetes self-care behaviors, the second aim was to enhance description of self-care behaviors of Nepalese adults with DM by exploring self-care strategies and context and culture specific motivating factors and/or barriers. Understanding the interrelated path among variables influencing diabetes self-care and gaining an in-depth understanding about the self-care strategies, barriers and boosters will provide evidence for planning specific and holistic nursing interventions. The participants in this study were Nepalese adults (40 years and above), who were diagnosed to have diabetes mellitus (DM) for over 6 month. A total of 230 sample were included in this study. Quantitative data was analyzed using SPSS and AMOS version 21. For the qualitative component, using maximum variant sampling based on general demographic characteristics (age, gender, religion, education level and marital status) and disease characteristics (Treatment type, DM duration and Comorbidity) thirteen samples were recruited from the same subset. Qualitative data was analyzed using thematic analysis technique. The results are as follows: 1. The mean age of the participants was 56.9 years (ranger 40-88 years). The mean duration since diagnosis of DM was 8.7±6.7 years. Majority of the participants (74.3%) were on oral hypoglycemic agents for treatment of DM. 2. The total score of DM self-care was 3.6±.9. Medication/insulin intake was the most frequently performed behavior (6.7±1.1) and self-monitoring of blood glucose was the least performed behavior (.61±.93). 3. The DM self-efficacy score was 3.16±.75, expectation regarding aging was 25.4±18.8 and perceived social support was 5.65±.96. 4. Significant differences in DM self-care was seen based on the education level (F= 3.27, p=.01), treatment type (Welch F= 5.05, p=.05) and HbAlc values (t= 3.52, p=.001). Similarly, significant differences in DM self-efficacy was seen based on age (F = .10, p=.004), education level (F= 7.11, p<.001), employment status (F = 4.95, p<.001), treatment type (F =5.14, p<.002), duration since DM diagnosis (F =4.67, p<.003) and HbAlc value (t =2.51, p=.01). Differences in perceived social support was seen based on gender (t=2.09, p=.03), education level (F = 5.20, p=.001) and employment status (Welch F =3.05, p=.01). 5. The direct and indirect effects of selected study variables on DM self-care was examined using path analysis. DM self-efficacy had strongest influence on DM self-care (ᵦ=.42, p<.001), followed by perceived social support (ᵦ=.26, p<.001) and education status (ᵦ=-.22, p=.01). 6. Self -efficacy partially mediated the relationship between DM duration and DM self-care (Sobel's z= 2.65, p<.001) and between ERA and DM self-care (Sobel's z = 3.03, p<.001). 7. Perceived social support partially mediated the relationship between education status and DM self-care (Sobel's z =-2.81, p<.001). The qualitative data was analyzed using thematic analysis technique focusing on three major areas namely self-care strategies used, motivating factors for self-care and barriers for self-care. Thirteen themes, which described the self-care of Nepalese adults with DM, were identified which are as follows: 1. The themes representing self-care strategies used were a) adhering to recommended diet and related struggles, b) walking, c) having greater trust in medicine, d) cultivating networks for self-support and e) accepting the disease and finding normalcy. 2. The themes under boosters for self-care were a) responsibilities towards family, b) meeting other DM patients, c) believing that God will cure and d) fear of suffering. 3. The themes under barriers for self-care were a) economic burden, b) manifestation of physical and psychological symptoms, c) constraints due to nature of work. The results from this study highlighted the importance of incorporating DM self-efficacy and social support in interventions for Nepalese adults with DM; the interventions must be tailored according to the gender, education level and the employment status of patients. Specific to Nepalese culture, patients should also be given information about recommended diet intake, food exchanges and fasting for religious ceremonies. As highlighted from the qual component, acceptance of the disease and trying to find normalcy living with DM was mainly done using processes which were self-directed like positive thinking, self-encouragement, self-control etc. and this was not dependent on the availability of social support. Hence individualized interventions to promote self-care may benefit Nepalese adults with DM.