FACTORS AFFECTING TYPE 2 DIABETES

MANAGEMENT AMONGST OUT-PATIENT DIABETIC

WOMEN AGED 50 YEARS AND ABOVE AT KENYATTA
NATIONAL HOSPITAL, KENYA

ESTA MLALE MWALOMA

(Public Health)

JOMO KENYATTA UNIVERSITY OF AGRICULTURE

AND TECHNOLOGY

2016
Factors affecting Type 2 Diabetes management amongst out-patient
diabetic women aged 50 years and above at Kenyatta National
Hospital, Kenya

ESTA MLALE MWALOMA

A thesis submitted in partial fulfillment for a degree of master of

science in public health at Jomo Kenyatta University of Agriculture
and Technology

2016
 DECLARATION
This thesis is my original work and has not been presented for a degree or a diploma in
any other University.
Signature ………………………………………..Date ……………………….................
Esta Mwaloma

This thesis has been submitted for examination with our approval as University
supervisors:
Signature …………………………………….....Date ……………………......................
Professor Joseph Gikunju
JKUAT, Kenya

Signature………………………………………...Date ………………………………….
Dr Joseph Mutai
KEMRI, Kenya

ii
 DEDICATION
I dedicate this thesis to my wonderful family. I appreciate their support, understanding
and patience through the many years of study.

iii
 ACKNOWLEDGEMENT

I would like to thank all of those people who helped make this thesis possible.

First, I wish to thank my advisors, Professor Joseph Gikunju and Dr. Joseph Mutai for
their tireless guidance, encouragement, support and patience.

Secondly, I would like to acknowledge the administrative staff at the Institute of

Tropical Medicine and Infectious Diseases (ITROMID) Coordination Office at the
Kenya Medical Research Institute (KEMRI), Centre for Public Health Research
(CPHR) and The Board of Postgraduate studies (BPS) at the Jomo Kenyatta University
of Agriculture and Technology.

I am grateful to all the participants who voluntarily opened their hearts and minds to
me during the data collection. I also wish to thank the staff at Kenyatta National
Hospital and especially the Diabetic clinic for their cooperation.

Finally, I would like to acknowledge my fellow graduate students who provided

invaluable support and suggestions throughout this process.

iv
 TABLE OF CONTENTS

DECLARATION .........................................................................................................i

DEDICATION .......................................................................................................... iii

ACKNOWLEDGEMENT ........................................................................................iv

TABLE OF CONTENTS ........................................................................................... v

LIST OF TABLES .................................................................................................. viii

LIST OF FIGURES ...................................................................................................ix

LIST OF APPENDICES ............................................................................................ x

ABBREVIATIONS AND ACRONYMS..................................................................xi

DEFINITION OF TERMS .................................................................................... xiii

ABSTRACT..............................................................................................................xiv

CHAPTER ONE .........................................................................................................1

INTRODUCTION ......................................................................................................1

1.1 Background Information ......................................................................................... 1

1.2 Problem statement .................................................................................................. 3
1.3 Justification ............................................................................................................. 4
1.4 Research questions.................................................................................................. 4
1.5 Objectives ............................................................................................................... 5
1.5.1 General Objective ................................................................................................ 5
1.5.2 Specific Objectives .............................................................................................. 5

CHAPTER TWO ........................................................................................................6

v
LITERATURE REVIEW .......................................................................................... 6

2.1 Diabetes Mellitus .................................................................................................... 6

2.2 Regional and local situation of diabetes ................................................................. 7
2.3 Risk factors for type 2 diabetes .............................................................................. 9
2.4 Clinical manifestations and diagnosis of diabetes ................................................ 10
2.5 Diabetes complications......................................................................................... 11
2.6 Diabetes Management .......................................................................................... 13
2.7 Public health importance ...................................................................................... 13

CHAPTER THREE ................................................................................................. 15

MATERIALS AND METHODS ............................................................................. 15

3.1 Study Site ............................................................................................................. 15

3.2 Study Design ........................................................................................................ 15
3.3 Study Population .................................................................................................. 15
3.4 Inclusion criteria ................................................................................................... 15
3.5 Exclusion criteria .................................................................................................. 15
3.6 Sample size determination.................................................................................... 16
3.7 Sampling procedures ............................................................................................ 16
3.8 Data Collection ..................................................................................................... 16
3.9 Data Management and Analysis ........................................................................... 17
3.10 Ethical Considerations ........................................................................................ 17

CHAPTER FOUR .................................................................................................... 18

RESULTS .................................................................................................................. 18

4.1 Respondents Background ..................................................................................... 18

4.2 Level of awareness of diabetes management ....................................................... 20
4.3 Self Management Practices .................................................................................. 25
4.4 Social Factors ....................................................................................................... 29
vi
4.5 Economic factors .................................................................................................. 31
4.6 Bivariate Analysis ................................................................................................. 33
4.6.1 Influence of Demographic Characteristics on Awareness levels of Diabetes
Management ....................................................................................................33
4.6.2 Influence of Demographic Characteristics on Self Management Practices .......34
4.6.3 Influence of social economic and cultural factors on diabetes management .....37

CHAPTER FIVE: .....................................................................................................42

DISCUSSION, CONCLUSION AND RECOMMENDATIONS ......................... 42

5.1 Awareness levels of diabetes management ........................................................... 42

5.2 Self-management practices ................................................................................... 42
5.3 Socio- economic factors affecting diabetes management ..................................... 43
5.4 Limitations of the study ........................................................................................ 45
5.5 Conclusions........................................................................................................... 46
Recommendations....................................................................................................... 46

REFERENCES .........................................................................................................48

APPENDICES ...........................................................................................................54

vii
 LIST OF TABLES

Table 4.1: Demographic data ................................................................................... 19

Table 4.2: Awareness levels of respondents on diabetes cause, cure and management
............................................................................................................... 21
Table 4.3: Effect of fruit juice, exercise and other diseases on blood glucose ........ 23
Table 4.4: Knowledge of conditions arising from Diabetes .................................... 24
Table 4.5: Responses on self management practices............................................... 25
Table 4.6: Distribution of responses on self management practices of respondent 27
Table 4.7 Distribution of responses on self management practices of respondent . 28
Table 4.8 Distribution of responses on self management practices ........................ 29
Table 4.9: Distribution of responses on social factors of respondent...................... 30
Table 4.10: Distribution of responses on economic factors of respondent ............... 32
Table 4.11: Analysis of education level, occupation and duration with diabetes against
awareness levels of diabetic management............................................. 33
Table 4.12: Analysis of demographics against self management practices ........... 36
Table 4.13: Analysis of social economic and cultural factors on diabetes management
............................................................................................................... 38
Table 4.14: Analysis of social economic and cultural factors on diabetes
management .......................................................................................... 39
Table 4.:15 Analysis of social economic and cultural factors on diabetes management
.......................................................................................................... 40

viii
 LIST OF FIGURES
Figure 4.1: Benefits of smoking cessation..................................................... 43
Figure 4.2: Knowledge of the normal fasting range for blood glucose .........44
Figure 4.3: Frequency of visits to the KNH clinic ........................................46

ix
 LIST OF APPENDICES

Appendix 1: Consent form ....................................................................................... 70

Appendix 2: Questionnaire....................................................................................... 77
Appendix 3: Approval letters ................................................................................. 105

x
 ABBREVIATIONS AND ACRONYMS

AADE American Association of Diabetes Educators

ADA American Diabetes Association

BMI Body Mass Index

DLF Diabetes Leadership Forum

FPG Fasting Plasma Glucose

HIV Human Immunodeficiency Virus

IDF International Diabetes Federation

IIF International Insulin Foundation

KEHHEUS Kenya Household Health Expenditure and Utilization Survey

KEMRI Kenya Medical Research Institute

KNH Kenyatta National Hospital

KNCHR ` Kenya National Commission on Human Rights

KSPA Kenya Service Provision Assessment

MDGs Millennium Development Goals

MIPAA Madrid International Plan of Action on Ageing

MOMS Ministry of Medical Services

NHSSP National Health Sector Strategic Plan

NCDs Non Communicable Diseases

NGOs Non Governmental Organizations

OGTT Oral Glucose Tolerance Test

xi
SSA Sub Saharan Africa

T2DM Type 2 Diabetes Mellitus

UN United Nations

USD United States of America Dollars

WHO World Health Organization

xii
 DEFINITION OF TERMS
Blood glucose - This is the amount of glucose (sugar) present in the blood of a
human. Normally, in mammals the body maintains the fasting
blood glucose level at a reference range between about 3.9 and
5.6 mM (mmol/L). .

BMI - This is a measure of body fat that is the ratio of the weight of
the body in kilograms to the square of its height in meters.

Diabetes management - This is dealing with short term events such as high or low
blood sugar to controlling it over the long term by
understanding the condition.

Glucose - This is sugar that can be linked to form carbohydrates and that
serves as a primary source of energy in the body.

Glycaemic Control - This is a medical term referring to the typical levels of blood
sugar (glucose) in a person with diabetes mellitus.

Hyperglycaemia - This is the excess of sugar in the blood.

Hypertension - This is abnormally high arterial blood pressure that is usually

indicated by an adult systolic blood pressure of 140 mm Hg or
greater or a diastolic blood pressure of 90 mm Hg or greater.

Socioeconomic status – In this study socioeconomic status is the social standing of an

individual in terms of their income, education and occupation.

xiii
 ABSTRACT
Diabetes Mellitus has emerged as one of the most challenging public health problems
currently. It affects over 366 million people worldwide and this figure is likely to
double by 2030. The greatest burden of this condition is felt in low and middle-income
countries which account for about 80% of all cases of diabetes. Diabetes prevalence
increases sharply with age, and it is projected that by the year 2025, the majority of
persons with diabetes will be aged 65years or older with 55% of diabetes deaths
occurring in women. The limited availability of high quality data on health
disaggregated by sex and age has been a major obstacle to gender responsive planning
and policy-making therefore it is urgent to collect, analyze and publish data
disaggregated by sex and age. The study therefore aimed to address the gap in
knowledge by focusing on the factors that affected diabetic women over 50 years of
age which included awareness levels, self management practices and socio economic
factors. The study adopted a cross sectional, descriptive study design. Structured
questionnaires were used to collect data. 105 women were selected for the study. Most
of the patients were in the 65 - 69 age group (22%) with 82.7% of the respondents
having moderate awareness levels, 16.3%. 54.87% of the respondents had a moderate
score of self-management practices, 38.5% had a high score of self-management
practices and 6.7% had a low score of self-management practices. It was concluded
from the study that decisions to seek care were influenced by a number of factors
which included signs and symptoms, support from the community, availability of
resources to seek care and services available at the health care facilities. Majority of
the respondents had moderate awareness about diabetic management however this
awareness has not led to any changes in the disease management because patients are
not sufficiently equipped with knowledge to comprehensively manage their disease.
This study recommends that the hospital management should offer diabetes education
at no cost to the patients and provide additional training of the health care providers
working in the diabetes clinic with skills for delivering adequate health education
message tailored to knowledge needs of Type 2 diabetic patients.
xiv
 CHAPTER ONE

INTRODUCTION
1.1 Background Information
Diabetes Mellitus is a chronic condition that arises when the pancreas does not produce
enough insulin, or when the body cannot effectively use the insulin produced. Insulin is
a hormone made by the pancreas that helps „sugar‟ (glucose) to leave the blood and enter
the cells of the body to be used as „fuel‟. When a person has diabetes, either their
pancreas does not produce the insulin they need (Type 1 diabetes) or their body cannot
make effective use of the insulin they produce (Type 2 diabetes) (Alberti K. et al., 1998)

Diabetes Mellitus has emerged as one of the most challenging public health problems in
the 21st century. It currently affects over 366 million people worldwide and this figure is
likely to double by 2030. The greatest burden of this condition is felt in low and middle-
income countries, and these nations account for about 80% of all cases of diabetes. The
African continent counts approximately 13.6 million people with diabetes. The Africa
Region of the International Diabetes Federation (IDF), which mainly includes sub-
Saharan Africa, counts approximately 7 million people with diabetes. Estimates for the
region for 2025 are likely to double and reach 15 million. In Kenya for instance the
World Health Organization (WHO) estimates that the prevalence of diabetes in Kenya is
at 3.3% and predicts a rise to 4.5% by 2025 (WHO 2011).

Africa is often referred to as the youngest continent in terms of age structure. This may
contribute to the current relatively low prioritization of ageing issues in national policies
(Naidoo et al., 2010). Yet the annual growth rate of older persons in Africa has been
estimated at 3.1% between 2007 and 2015, and 3.3% between 2015 and 2050, greater
than the global average. In this context, it is concerning that there will be approximately
64.5 million Africans aged ≥55 years in 2015, and more than 103 million and 205

1
million in 2030 and 2050, respectively (Guariguata et al., 2011). Indeed it has been
predicted that the diabetes peak in Africa is expected to be in the oldest individual by
2035 (Guariguata et al., 2013).

The population of sub-Saharan Africa is set to grow from around 860 million in 2010 to
more than 1.3 billion by 2030. For age groups above 40 years, the increases will double
the size of the population. People aged 45-59 years are 8.5 times more likely to develop
diabetes than those aged 15-29 years; and those above the age of 60 are 12.5 times more
likely to develop diabetes. Based on the present prevalence rates in sub-Saharan Africa,
the demographic changes alone will account for an increase of 9.5 million people with
diabetes between 2010 and 2030 (DLF, 2010). In 2013, the majority of individuals with
diabetes in Africa were reported to be under 60 years of age with the highest proportion
(43.2%) in people aged 40–59 years (Guariguata et al. 2013).

In many settings, ageing women do not have the same access to health care as men or
younger women. The barriers to primary health care faced by older people are often
worse for older women. These barriers include lack of transportation, low literacy levels
and a lack of money to pay for services and medications. Because women live longer
than men and are more likely to be alone in old age, policymakers and practitioners must
pay special attention to the gender implications of long term care policies and
programmes (WHO, 2007).

Treatment of diabetes in Kenya, as in other parts of sub-Saharan Africa, is fraught with

problems. Besides challenges related to diagnosis, care, and treatment, there is a lack of
understanding and knowledge about the disease among healthcare professionals and the
general population (McFerran,
2008). Because it is a chronic disease that lasts for many years, people diagnosed with
diabetes need continuing access to proper medical care. That includes medication
(insulin and other medicines), equipment (such as glucose measuring strips), and, most
2
importantly, healthcare professionals who have had adequate training in the diagnosis
and treatment of diabetes and its complications (DLF, 2010).

Information is a vital tool enabling the pursuit of gender equity in all areas including in
health. The limited availability of high quality data on health disaggregated by sex and
age has been a major obstacle to gender responsive planning and policy-making.
Without knowing whether and in what dimensions of health, and in which population
subgroups disadvantages exist, there is no way to begin redressing gender or other
inequities in health. The urgency of collection, analysis and publication of data
disaggregated by sex and age cannot be overemphasized (WHO, 2010).

Most research carried out in Kenya has focused on those affected by diabetes as a whole
regardless of their gender or age. The objective of this study therefore was to address
this gap by focusing specifically on women over 50 years of age with an aim of
generating findings that can be utilized to resolve some of the challenges they face in
their diabetes management. The age of 50 years is thought to incorporate the
chronological, functional and social definitions of "old" in Africa and has been adapted
by the World Health Organization (WHO) for its minimum data set project. This age
cut-off has also been used in other studies in Africa (WHO, 2006).

1.2 Problem statement

Diabetes is a chronic disease that requires patients to continue their treatment for the rest
of their lives. The emphasis is usually on the management of the condition through a
tight schedule of blood glucose and urine sugar monitoring, medication and adjustment
to dietary modification. Such a chronic condition requires competent self-care, which
can be developed from a thorough under-standing of the disease process by the patient
and pre-supposes a need for some form of diabetes education and counseling for the
patient. For people with diabetes, medical issues are not the only area that requires
management; lifestyle, family, psychosocial, cultural, and economic issues also need

3
attention. Diabetes affects women in uniquely gendered ways, many of which are related
to the underlying determinants of health and socioeconomic status.

The Kenyan constitution acknowledges that all age groups have the right of equal access
to health services. However significant health disparities continue to exist in diabetes.
Stopping the diabetes epidemic involves halting health disparities caused by age, sex and
socioeconomic factors. This study therefore aimed to address the gaps in knowledge by
focusing on the factors that affect outpatient Type 2 diabetic women over 50 years of
age attending Kenyatta National Hospital in the management of diabetes. The findings
will assist in generating policies that will ensure that there is prioritized allocation of
resources.

1.3 Justification
This study, carried out at Kenyatta National Hospital, aimed at providing findings that
will assist in diabetes management. Assessment of the women‟s awareness levels and
self management practices about diabetes is important in developing educational
material relevant to their age and sex. Assessing the socioeconomic and cultural factors
that affect their management is also important as strategies can be localized for
particular groups in terms of age and sex. Programs can be formulated specifically for
older women thereby reducing morbidity associated with diabetes and therefore improve
their quality of life. The findings will also assist in priority setting for
management of diabetes in older women by the Ministry of Health, Health insurers and
relevant Non Governmental Organizations.

1.4 Research questions

1. What is the level of awareness of diabetes management amongst Type 2

diabetic women over 50 years?

4
 2. What are the self diabetic management practices amongst Type 2 diabetic
women over 50 years?
3. What are socioeconomic factors that affect diabetes management amongst
Type 2 diabetic women over 50 years?

1.5 Objectives

1.5.1 General Objective

To determine factors affecting diabetes management amongst Type 2 diabetic women
aged 50 years and above at Kenyatta National Hospital

1.5.2 Specific Objectives

1. To determine the levels of awareness of diabetes management amongst Type

2 diabetic women over 50 years.
2. To determine the self diabetic management practices amongst Type 2
diabetic women over 50 years.
3. 3). To determine the socioeconomic factors that affect diabetes management
amongst Type 2 diabetic women over 50 years.

5
 CHAPTER TWO

LITERATURE REVIEW
2.1 Diabetes Mellitus
Diabetes is a chronic disease that occurs either when the pancreas does not produce
enough insulin or when the body cannot effectively use the insulin it produces. Insulin is
a hormone that regulates blood sugar. There are three main types of diabetes; Type 1
diabetes, Type 2 diabetes and gestational diabetes. Type 1 diabetes once known as
juvenile diabetes or insulin-dependent diabetes is a chronic condition in which the
pancreas produces little or no insulin; Gestational diabetes is a type of diabetes that
affects women during pregnancy. It is defined as any degree of glucose intolerance with
onset or first recognition during pregnancy. The definition applies whether insulin or
only diet modification is used for treatment and whether the condition persists after
pregnancy. It does not exclude the possibility that unrecognized glucose intolerance may
have antedated or begun concomitantly with the pregnancy (WHO, 2006).

Type 2 diabetes mellitus (T2DM) is the most common type of diabetes. The body is able
to produce insulin but either this is not sufficient or the body is unable to respond to its
effects (also known as insulin resistance), leading to a build-up of glucose in the blood.
Many people with T2DM remain unaware of their illness for a long time because
symptoms may take years to appear or be recognized, during which time the body is
being damaged by excess blood glucose. They are often diagnosed only when
complications of diabetes have already developed (Malecki, 2004).

Although the reasons for developing T2DM are still not known, there are several
important risk factors. These include; obesity, poor diet, physical inactivity, advancing
age, family history of diabetes and ethnicity The

6
majority of those with T2DM usually do not require daily doses of insulin to survive.
Many people are able to manage their condition through a healthy diet and increased
physical activity or oral medication. However, if they are unable to regulate their blood
glucose levels, they may be prescribed insulin. The number of people with T2DM is
growing rapidly worldwide. This rise is associated with economic development, ageing
populations, increasing urbanization, dietary changes, reduced physical activity, and
changes in other lifestyle patterns (Hu et al., 2001).

2.2 Regional and local situation of diabetes

In developing countries the number of people with diabetes will increase by 150% in the
next 25 years. The global increase in diabetes will occur because of population ageing
and growth, and because of increasing trends towards obesity, unhealthy diets and
sedentary lifestyles. In developed countries most people with diabetes are above the age
of retirement, whereas in developing countries those most frequently affected are aged
between 35 and 64 (Wild et al., 2004).

Regionally before the 1990s, diabetes was considered a rare medical condition.
Epidemiological studies carried out in that decade, however, provided evidence of a
trend toward increased incidence and prevalence of type 2 diabetes in African
populations (Sobngwi et al., 2001). Indeed, Africa is experiencing the most rapid
demographic and epidemiological transition in world history (Mosley et al., 1993). It is
characterized by a tremendous rise in the burden of non-communicable diseases
underlined by the increasing life expectancy and lifestyle changes resulting from the
reduction in infectious diseases and increased fertility, as well as Westernization

The prevalence of diabetes in Africa was approximately 3 million in 1994; but the
region is due to experience a two-to threefold increase by the year 2010 (Amos et
l.,1997). The highest prevalence is found in populations of Indian origin, followed by
black populations and Caucasians. Among the population of Indian origin in South
Africa and Tanzania, the prevalence is between 12 and 13 percent (Ramaiya et a1.,

7
1991). The prevalence in blacks follows a Westernization gradient, with that of rural
Africa generally below 1 percent but that of urban Africa between 1 and 6 percent. In
general the prevalence of type 2 diabetes is low in both rural and urban communities of
West Africa except in urban Ghana, where a high rate of 6.3 percent was recently
reported (Amoah, et a1., 2002). Moderate rates have been reported from South Africa:
4.8 percent in a semi-urban community in the Orange Free State, 6.0 percent in an urban
community of the Orange Free State, 5.5 percent in Durban (mostly occupied by the
Zulu tribe), and 8 percent in Cape Town (mostly occupied by the Xhosa tribe). Also,
moderate rates have been reported in studies from Tanzania.

Locally the International Diabetes Federation (IDF) estimated the prevalence of diabetes
to be about 3.3% in 2013. However, local studies have shown a prevalence of 4.2% in
the general population with a prevalence rate of 2.2% in the rural areas and as high as
12.2% in urban areas. Sadly, the majority of the people with diabetes are within the
productive age range of 45–64 years. These are the same individuals who are expected
to drive the economic engines of their countries in order to achieve the agreed
international development goals (Maina et al., 2011). In Kenya, Type 2 Diabetes
Mellitus is the more prevalent, and Kenyans are developing it younger than those in
developed countries. The age of onset of T2DM in Kenya is between 45 and 55,
compared with 64 years in developed countries. Kenyans are also at higher risk for
crippling or life-threatening complications, because they report to health centers when
the disease is advanced (Mwangi et al., 2011).

As in other parts of the World, in African countries, there are more elderly females than
males (UNSD, 2010). Indeed with increasing life expectancy, it should be expected that
there would be even more elderly females surviving.
Hence, elderly females will bear the bigger share of constraints caused by lack of
appropriate policies and plans aimed at improving the welfare of the population (Velkoff
and Kowal, 2007).

8
2.3 Risk factors for type 2 diabetes
There are controllable risk factors associated with diabetes, including obesity and an
inactive lifestyle. However, other uncontrollable risk factors, such as ethnicity and
genetics, also play a dramatic role.

Age and Ethnicity

Age and ethnicity are the two main non-modifiable risk factors of diabetes in Africa.
Glucose intolerance in Sub-Saharan Africa, as in other regions of the world, increases
with age in both men and women however, published studies lack uniformity on the age
range in which the prevalence of diabetes is observed. According to King et a1.,(1998),
in most developed communities the peak of occurrence falls in the age group of 65 years
or older, whereas in developing countries it is in the age group 45 to 64, and in Sub-
Saharan Africa it is in the age groups 20 to 44 and 45 to 64 years. Yet data from 12 other
studies from Sub-Saharan Africa indicate two peak age ranges of 45 to 64 and older than
65 years

Family History of Diabetes

A significant proportion of the offspring of Cameroonians with type 2 diabetes have

either type 2 diabetes (4 percent) or IGT (8 percent) (Mbanya et al., 2000). A positive
family history seems to be an independent risk

factor for diabetes, but this was not the case in the Cape Town study (Levitt et al., 1993),
in which family history was not an independent risk factor.

Measure of Adiposity

Several studies from Sub-Saharan Africa have confirmed the association between the
prevalence of diabetes and a surrogate of obesity, body mass index (BMI). Reports from

Mali (Fisch et al., 1987), Nigeria (Cooper et al., 1997) and Tanzania (McLarty et al.,
1989) have shown that the prevalence of diabetes increases with increasing BMI. BMI
and obesity seem to be independent risk factors for diabetes (Levitt et al., 1993).

9
Physical Activity
There seems to be a significant relationship between physical inactivity and diabetes and
obesity (Sobngwi et al., 2002). Physical activity is more common in rural than urban
regions of Africa because rural populations rely on walking for transport and often have
intense agricultural activities as their main occupation. In Sub-Saharan Africa, walking
time and pace is drastically reduced in an urban community as compared with a rural
community. The main difference in physical activity between the two types of
community, however, is the use of walking in rural areas as a means of transportation.
The reduction in physical activity associated with life in a city partly explains the excess
prevalence of obesity in urban areas. In a South African study, the prevalence of a
sedentary lifestyle in Cape Town in subjects age 30 years and over was 39 percent for
men and 44 percent for women (Omar et al., 1993). Low physical activity was normal
for 22 percent of men and 52 percent of women in urban Tanzania, whereas it was usual
for only 10 percent of men and 15 percent of women living in rural areas (Edwards et
al., 2000). Cross-sectional data from 1,417 women age 15 to 83 years in a rural
community and an urban community in Cameroon showed that in all age groups, fasting
blood glucose levels were inversely associated with energy expenditure from walking
(Sobngwi, et a1.,2003). Rural dwellers' higher level of physical activity and related
energy expenditure compared with urban subjects goes far to explain why obesity was

found to be at least four times higher in urban areas than rural (Aspray et al., 2000).
Thus, lack of physical activity appears to be a significant risk factor for diabetes in Sub-
Saharan Africa

2.4 Clinical manifestations and diagnosis of diabetes

Diabetes mellitus may present with characteristic symptoms such as thirst, polyuria,
blurring of vision, and weight loss. Often symptoms are not severe, or may be absent.
The diagnosis of diabetes mellitus is easily established when a patient presents the
classic symptoms of hyperglycaemia and has a random blood glucose value of 200
mg/dL (11.1 mmol/L) or higher, and confirmed on another occasion (Twillman, 2002).

10
The following tests are used for the basic diagnosis: fasting plasma glucose (FPG) test
measures blood glucose in a person who has not eaten anything for at least 8 hours. This
test is used to detect diabetes and prediabetes. An oral glucose tolerance test (OGTT)
measures blood glucose after a person fasts at least 8 hours and 2 hours after the person
drinks a glucose-containing beverage. This test can be used to diagnose diabetes and
prediabetes. The FPG test is the preferred test for diagnosing diabetes because of its
convenience and low cost. However, it may miss some diabetes or prediabetes that can
be found with the OGTT. The FPG test is most reliable when done in the morning.
Research has shown that the OGTT is more sensitive than the FPG test for diagnosing
prediabetes, but it is less convenient to administer (WHO,1999).

2.5 Diabetes complications

Complications due to diabetes are a major cause of disability, reduced quality of life,
and death. Diabetes complications can affect various parts of the body manifesting in
different ways for different people. Diabetes complications are divided into two major
categories: Acute complications such as hypoglycaemia and comas resulting either from
diabetic ketoacidosis

or hyperosmolar hyperglycemic nonketotic syndrome and chronic complications, either

microvascular (diabetic retinopathy, nephropathy, neuropathy) or macrovascular
(coronary artery disease, peripheral arterial disease, and stroke) (Aalto et al., 1997).

The most serious microvascular diabetes complications are the eye complications.
Diabetic patients are strongly advised to have an annual ophthalmic exam. Diabetic
retinopathy is the leading cause of blindness in the working population of the Western
world. The risk of developing diabetic retinopathy or other microvascular complications

11
26 of diabetes depends on both the duration and the severity of hyperglycaemia (Almdal
et al., 2004).

Diabetes increases the risk that an individual will develop cardiovascular disease.
Although the precise mechanisms through which diabetes increases the likelihood of
atherosclerotic plaque formation are not completely defined, the association between the
two is profound (Laing et al., 2003). Cardiovascular disease is a major complication and
the leading cause of premature death among diabetic patients (Merz et a.,l 2002).
Diabetic patients have a 2 to 6 times higher risk for developing complications such as
ischemic heart disease, cerebrovascular disease and peripheral vascular disease than the
general population.

With bacterial and fungal infections diabetics have increased risk of cystitis and, more
important, of serious upper urinary tract infection as well as ear, nose, and throat
infections, necrotizing otitis externa principally occurs. Skin and soft tissue infections
are common in DM and may spread to adjacent bone causing osteomyelitis infection (
Eron et al., 2003). Diabetic patients are also in greater risk of infections than healthy
individuals. The association
between diabetes and increased susceptibility to infection in general is not supported by
strong evidence. However, many specific infections are more
common in diabetic patients and some occur almost exclusively in them. Other
infections occur with increased severity and are associated with an increased risk of
complications. Several aspects of immunity are altered in patients with diabetes. There is
evidence that improving glycaemic control improves immune function. Fungal cystitis,
rhino-cerebral mucormycosis and community-acquired pneumonia are among the most
common infections the diabetic patients suffer from (Gu et al., 1998)

Peripheral vascular disease, are often seen in patients who have foot infections. Poorly
controlled DM lead to impaired circulation and slow healing from small cuts. The
12
untreated damage, or failing to heal or unnoticed minor trauma may result in an infection
especially in the lower- extremity, where the blood flow delays, and micro-angiopathic
lesions lead to cellulitis, osteomyelitis, or nonclostridial gangrene that end in
amputation. In 2004 about 60% of non-traumatic lower limb amputations occur in
people with diabetes in USA. The complications of diabetes are far less common and
less severe in people who have well-controlled blood sugar levels (IDF, 2008)

2.6 Diabetes Management

Diabetes mellitus is primarily a self-managed condition. The Institute of Medicine
defines self-management as the task that individuals must undertake to live with one or
more chronic conditions. These tasks include having the confidence to deal with
medical, behavioral, and emotional management of their conditions. Low awareness and
practices among diabetic patients are some of the important variables influencing the
progression of diabetes and its complications, which are largely preventable.

Depending on the parameter, blood sugar level, blood pressure and weight should be
checked on a regular basis (Hoy B, 2007). Doctor-patient relationship, such as trust and
communication (Zgibor and Songer, 2001). Socio-economic status and its constituent
elements are accepted as being determinants of health. For primary prevention of
diabetes complications to be effective, patients must have access to quality medical care,
the means to pay for services (either through insurance or self-pay), and the knowledge
and skills to manage their diabetes on a day-to-day basis. Because access and self-care
are critical contributors to outcomes in patients with diabetes, socioeconomic mediators
(education and/or income) may play a significant role in these processes (Connolly et
al., 2001)

2.7 Public health importance

Diabetes is undoubtedly a public health concern epidemiologically and economically. It
accounts for 3.8 million deaths worldwide per year, a number similar in magnitude to
the mortality attributed to HIV/AIDS (WHO Africa, 2007). Studies suggest that these
13
deaths can be prevented, especially in economically productive individuals between the
ages of 35 and 64 years of age (Roglic et al.,2005). Currently, however, statistics show
that, every 10 minutes, someone dies from a diabetes-related disease. Unfortunately, the
resources and responses to meet this epidemic have not kept pace with its demographic
spread and impact.

Therefore, Kenya, as well as other countries in the world, must redouble their efforts to
ensure follow-up of patients, whenever treatment has commenced and thus help reduce
and/or prevent the high death toll from this chronic and debilitating disease. The
adoption of a healthy diet and lifestyle requires not only individual behavioral changes,
but also changes in our food, built, and social environments. Public health strategies that
target the obesogenic environment are critical. Translating clinical and epidemiologic
findings into practice requires fundamental shifts in public policies and
health systems. To curb the diabetes epidemic, primary prevention through the
promotion of a healthy diet and lifestyle should be a global public policy priority (Zhang
et al., 2010).

14
 CHAPTER THREE

MATERIALS AND METHODS

3.1 Study Site
The study was conducted at the Kenyatta National Hospital which is a National Referral
hospital situated about three kilometres away from Nairobi city. This study site was
suitable as it serves patients from all over the country thus expected to have patients
from diverse regions and socio economic statuses. The site had a daily mini diabetic
clinic from 0800hrs – 1300hrs and a main one on Friday from 0800hrs – 1300hrs.

3.2 Study Design

The study adopted a cross sectional descriptive design. A structured questionnaire was
used to assess awareness levels of diabetes management, self-management practices, and
socioeconomic factors amongst diabetic women aged 50years and above.

3.3 Study Population

The study population was women with Type 2 diabetes aged 50 years and above
attending the outpatient Diabetic clinic at Kenyatta National Hospital. This population
included all Type 2 diabetic cases regardless of how long they had lived with the
condition.

3.4 Inclusion criteria

(i) Women who were aged 50 years and above
(ii) Women who had been diagnosed with Type 2 Diabetes Mellitus
(iii) Women who consented to participate in the study

3.5 Exclusion criteria

(i) Women who didn‟t agree to participate in the study

15
 (ii) Women who were unable to speak due to illness or frailty.
3.6 Sample size determination
The minimum sample size was calculated using the following formula (Araoye, 2004)
N = Z2Pq /D2
Where:

N = minimum sample size required

Z =standard normal deviation set at 1.96
P = proportion (assumed) of diabetics that have awareness of self management
Q = 1-P
D= the absolute precision
N= 1.96*0.5*0.5/0.1*0.1= 96
The sample size was increased to 105 to allow for non-response.

3.7 Sampling procedures

In this study systematic random sampling was used. The first woman who met the
criteria was randomly selected and thereafter every alternate client who met the criteria
was recruited.

3.8 Data Collection

Data for this study was collected using a structured questionnaire (Appendix 2).The
content of the questionnaire were obtained from modifying sample diabetic patient
questionnaires from Stanford University School of Medicine, ICICE Baseline Interview
for Diabetes patients, Australian Diabetes Organisation and the International Diabetes
Federation. The questionnaire covered question on demographics, awareness levels of
diabetes management, self-management practices and socioeconomic factors affecting

16
the women. Informed consent was sort from the respondents before administration of the
questionnaire.

3.9 Data Management and Analysis

Collected data was kept confidential and was only utilized for purposes of this research.
Questionnaires were coded according to number of questionnaire and date of interview
for ease in traceability. Once questionnaires were filled, cleaning up was done prior to
entry on to Microsoft office excel (Ms Excel) spread sheets to form a database. Data was
then viewed to correct obvious errors and then exported/transferred to Statistical
Package for Social Scientists (SPSS, version 20).

Data was analysed using the techniques below;

Univariate analysis was used for descriptive statistics such as respondent‟s
demographics, type of treatment; years with T2DM were used to summarize frequencies
and percentages. Some of the findings were also presented by use of pie charts. Analysis
of variance (ANOVA) was used to assess the relationship between two variables for
example education level and awareness or time period with diabetes and self
management practices. The results were presented in tables.

3.10 Ethical Considerations

Scientific and ethical approvals for this study were sought from the KEMRI Scientific
Steering Committee (SSC), Kenyatta National Hospital Ethical Research Committee,
KEMRI Ethical Review Committee (ERC) and JKUAT Board of Post Graduate Studies.
The study provided no harm to the respondents and was entirely based on the principle
of voluntary participation. The participants were informed of their rights to privacy and
confidentiality. An informed consent form was issued to the respondents before
administration of questionnaires. No coercion or intimidation was
used to obtain any information. Data collected was filed and all files kept under lock and
key in a cabinet.

17
 CHAPTER FOUR

RESULTS

4.1 Respondents Background

The average age group of the patient population was 64 years. Most of the respondents
(45.7%) lived in the capital city while 37.1% lived in the countryside. Fifty nine percent
(59%) of the respondents had primary level of education while 15.2% had not gone to
school. A majority of the respondents were small scale farmers (34.6%), followed by
housewife‟s (26.9%) and self employed (19.2%). All the respondents were Christians
and 35.2% of the respondents got their first diabetes diagnosis at KNH, 26.7% were first
diagnosed at private clinics while 19% were first diagnosed at faith based hospitals. The
largest number (38.1%) of patients had lived with diabetes for more than 12 years while
21% of patients having been diagnosed with diabetes six to eight years earlier. Majority
of the respondents (81 %) said that the initial treatment prescribed was insulin tablets
(Table 4.1).

18
Table 4.1: Demographic data

Demographics Frequency Percent

Residence Capital city 48 45.7

Other city 1 1
Town 17 16.2
Country Side 39 37.1

Religion Christian 105 100

Highest education level No formal education 16 15.2

Primary 62 59
Secondary 17 16.2
College 9 8.6
University 1 1

Occupation House wife 28 26.7

Small scale farmer 37 35.2
Self employed 20 19
Formal employment 7 6.7
Retired 13 12.4

Duration of diagnosis 0-2 years 13 12.4

3-5 years 19 18.1
6-8 years 22 21

19
 9- 12 years 11 10.5
> 12 years 40 38.1

Where diagnosed Dispensary 1 1

Health Centre 13 12.4
Provincial Hospital 4 3.8
National Referral 38 36.2
Private Hospital 26 24.8
Faith based hospital 20 19
Pharmacy 1 1
Others( unemployed) 2 1.9

Initial treatment prescribed Insulin injections 17 16.1

Tablets 85 81
Both insulin & tablets 3 2.9

4.2 Level of awareness of diabetes management

The first objective of the study was to assess awareness levels of diabetes management
in Type 2 diabetic women over 50 years. Table 4.2 shows that majority of the
respondents (61%) knew that diabetes was hereditary. Slightly over half (50.5%) of the
respondents were of the opinion that diabetes could be cured if detected at early stages
while 75.2% reported that even if blood glucose had been controlled drugs should not
be stopped to avoid recurrence of the attack.

20
Table 4.2: Awareness levels of respondents on diabetes cause, cure and
management
Awareness levels on Diabetes Frequency Percent

Is diabetes hereditary No 38 36.2%

I don‟t know 3 2.9%

Yes 64 61.0%

53 50.5%
Can diabetes be cured No

I don‟t Know 15 14.3%

Yes 37 35.2%

Once blood glucose has been controlled

79 75.2%
should drugs be stopped No

I don‟t Know 12 11.4%

Yes 14 13.3%

Figure 4.1 illustrates that majority of the respondents (97%) reported that it was
important and beneficial to one‟s health if one stopped smoking or taking alcohol.

21
Figure 4.1: Benefits of smoking cessation

The respondents were asked to indicate their perceptions about fasting range for blood
glucose. Figure 4.2 revealed that 59% of the respondents indicated between 4.4 – 6.1
mmol.

Figure 4.2: Knowledge of the normal fasting range for blood glucose

The study further sought to establish the level of awareness of the respondents about the
effect of fruit juice, exercise and other diseases on blood glucose. Table 4.3 indicates

22
that 93.3% of the respondents reported that fruit juice raised the level of blood glucose,
97.1% of the respondents said exercise lowered the level of blood glucose while 55.2%
indicated that other diseases could cause an increase in blood glucose.

Table 4.3: Effect of fruit juice, exercise and other diseases on blood glucose

Effect of Fruit Juice and Exercise No. Percent

What effect does fruit juice have on

5 4.8
blood glucose Don‟t know
Lowers it 2 1.9
Raises it 98 93.3
Has no effect 0 0.0

What effect does exercise have on

blood glucose Don‟t know 1 1.0
Lowers it 102 97.1
Raises it 2 1.9
Has no effect 0 0.0

Don‟t know 25 23.8

Effect of other diseases on blood Increase blood

58 55.2
glucose glucose
Decrease blood
6 5.7
glucose
No change in blood
12 11.4
glucose
Either increases or
4 3.8
decreases

23
 Twenty five point seven percent (25.7%) of the respondents visited the clinic
after every three months, while 2.9 % visited once year (Figure 4.3).

Figure 4.3: Frequency of visits to the KNH Clinic

The respondents were asked to indicate if they had been informed by the doctor about
named conditions that they could get from having diabetes. Table 4.4 indicates that
majority of the respondents were not aware of the consequences of having diabetes.

Table 4.4: Knowledge of conditions arising from Diabetes

Conditions Frequency Percent

Heart Disease No 103 98.1%

Yes 2 1.9%

Blindness No 97 92.4%

24
 Yes 8 7.6%

Kidney Failure No 92 87.6%

Yes 13 12.4%

Amputation of limbs No 99 94.3%

Yes 6 5.7%

4.3 Self Management Practices

From the study 97% of the respondents used blood testing method for testing glucose
levels in their body, 66.7% of the respondents did not have a glucose meter to do the
tests at their work places or homes while 29 % of the respondents conducted self tests.
Most of the respondents (40%) checked their blood glucose every month. A majority of
the respondents (46.7%) indicated they controlled their diabetes using insulin injections
(Table 4.5)

Table 4.5: Responses on self management practices

Diabetes Control Management Frequency Percent

Testing Method for Glucose Don't know 3 2.9

Blood testing 102 97.1

70 66.7
Glucose Meter No

Yes 35 33.3

13 12.4
Place of Testing Dispensary

Health Centre 12 11.4

Provincial Hospital 1 1

25
 National Referral 17 16.2

Private Hospital 17 16.2

Faith based hospital 5 4.8

Pharmacy 7 6.7

I test Myself 31 29.5

Others 2 1.9

23 21.9
Frequency of Checking Blood Glucose Clinic Appointments

Once a day 6 5.7

Twice a day 4 3.8

Once a week 10 9.5

A few times a week 11 10.5

Every month 42 40

Other 9 8.6

49 46.7
Diabetes Control Inject insulin

Follow special diet 4 3.8

Exercise 1 1

Take tablet for diabetes 33 31.4

Both tablet and insulin 18 17.1

Majority of respondents (90.5%) checked for red sores on their feet every day. All the
respondents checked their weights at clinic appointments. 37.1% of the respondents
checked their eyes on a yearly basis with 22.9% checking every six month. Majority
(91.4%) had an idea of dealing with emergencies indicating that they ate some form of
sugar (Table 4.6).

26
Table 4.6: Distribution of responses on self management practices of respondent
Self management practices
Frequency Percent
5.7
1.9
Checking feet for sores I don‟t check 6
Once a month 2 90.5
Everyday 95
Others 2 1.9

Frequency of checking weight At clinic appointments 105 100

Don‟t know 18.1

19
Every 6 month 22.9
24
Every year 37.1
Frequency of checking eyes 39
Every two years 13.3
14
Every 3 or more years 1.9
2
Other 6.7
7

Don‟t know 3 2.9

Lie down to rest 3 2.9
Dealing with emergencies
Eat some form of sugar 96 91.4
Other 3 2,9

Majority (88.6 %) of the respondents indicated that they exercised on a daily basis with
84.8% exercising at home. Only 13.3% indicated that they did not exercise because of
some medical condition (Table 4.7).

27
Table 4.7 Distribution of responses on self management practices of respondent
Self management
practices Frequency Percent
I don't exercise 9 8.6
Frequency of exercise
Three times a week 2 1.9
Daily 93 88.6
Other 1 1

Home 89 84.8
Place of exercise
Other 16 15.2
Lack of time 2 1.9
Lack of money 2 1.9
Fear of exercise 1 1
Reasons for not exercising
I exercise 85 81
Medical condition 14 13.3

Of those respondents who used insulin, 39% indicated that they stored insulin in a pot of
cold water and 23.8% kept in the refrigerators. 55% of the respondents had never lacked
prescribed treatment in the hospitals for the last three months with 62% of those who
missed opting for other alternatives such as buying their own medication (Table 4.8).

28
Table 4.8 Distribution of responses on self management practices

Self management practices Frequency Percent

Storage of insulin
37 35.2
25 23.8

I don‟t use insulin 41 39

Refrigeration
1 1
Pot of cold water
Others 1 1

55 52.4
Lack of prescribed treatment No 50 47.6
Yes

Frequency of lack of prescribed 50 47.6

treatment Never
9 8.6
Every month
Once or twice in 46 43.8
3 months

66
39 62.9
Alternative treatment Buying
Others 37.1

4.4 Social Factors

Many (65.7%) of the respondents had access to a health facility. Only 18.1% of the
respondents needed to stay with relatives when they had to visit the clinic as they lived
too far away to travel back and forth from their homes. The common means of transport
public reported by 95.2% of the respondents. Almost half of the respondents (48.6 %)

29
were accompanied by one person when they attended the clinic. 90.5% of the
respondents did not have a paid caretaker because they lived with family members.
93.3% stated that they did not believe herbalists or witchdoctors could cure their
condition while 2.9% were not sure (Table 4.9).

Table 4.9: Distribution of responses on social factors of respondent

Frequenc Percen
Social Factors y t

Do you believe herbalists or witch doctors

No 98 93.3%
can cure diabetes
Don‟t know 3 2.9%
Yes 4 3.8%

Distance of nearest health facility from

home < 1 km 69 65.7%
Between 1 &5
13 12.4%
km
>5 km 23 21.9%

Where do you stay when you come for

Home in Nairobi 86 81.9%
treatment at KNH
relatives 19 18.1%

Means of transport to access KNH walking 2 1.9%

Public transport 100 95.2%
Personal car 3 2.9%

0 ( none) 51 48.6%

30
How many people accompany you to KNH
1 person 51 48.6%
2 people 3 2.9%

Have you or your family hired someone to No 95 90.5%

take care of you due to ill health
Yes 10 9.5%

No 77 73.3%
Does someone from your family take care of
you because of your ill health without being
paid for it
Yes 28 26.7%
Total 105 100%

4.5 Economic factors

Most respondents (74.3%) reported spending more than Ksh 200 ($2.35) for a blood
glucose test. Almost half the respondents (45.7%) spent more than Ksh 1000 ($11.76)
monthly to manage their diabetes. Most respondents spent Ksh 200 – 499 ($2.35 – 5.87)
on transport costs for attending the. 33.3%, of the respondents also incurred other
medical costs such as medication for hypertension, kidney complications and other tests
amounting to Ksh 1000 – 1999 ($11.76 – 23.51). The major source of funds was from
family members (68.6%) Sixty eight point six percent of the respondents reported lack
of funds as the major challenge in meeting the costs required to manage their diabetes
(Table 4.10).

31
Table 4.10: Distribution of responses on economic factors of respondent

Frequenc Percen
Economic Factors y t
How much do you pay for a blood glucose
Kshs 0-99 1 1%
test
100- 199 26 24.8%
>200 4 74.3%

How much do you spend monthly on

Kshs 0 - 499 21 20%
insulin (+ syringes)/ tablets
500 - 999 36 34.3%
>1000 48 45.7%

How much does it cost to travel to and Kshs 0 – 199 6 5.7%

from KNH
200 -499 55 52.4%
500 – 799 27 25.7%
>800 17 16.2%
0 - 999 19 18.1%
How much do you spend per visit to KNH
(excluding transport)
Kshs 1000- 1999 35 33.3%
2000 -2999 30 28.6%
>3000 21 20%

How much do you pay the hired person Kshs

each month

32
 0 - 999 99 94.3%
1000- 1999 1 1%
2000 -2999 4 3.8%
>3000 1 1%
How do you pay for the diabetic treatment
and care Current income 32 30.5%
Family support 72 68.6%
From saved 1 1%
money

What prevents you from accessing

diabetic care Lack of funds 72 68.6%
I am able to
33 31.4%
access

4.6 Bivariate Analysis

4.6.1 Influence of Demographic Characteristics on Awareness levels of Diabetes

Management
ANOVA results of education level, occupation and duration in with diabetes against
awareness levels of diabetic management indicated that there was no significant
relationship between the variables. This was supported by an f statistic of 1.915
(p=0.114), f=1.815 (p=0.132) and f=1.965 (p=0.106) respectively (Table 4.11).

Table 4.11: Analysis of education level, occupation and duration with diabetes
against awareness levels of diabetic management
Std.
N Mean
Mean awareness Deviation f and p value

33
 Noformal
16 0.5938 0.19094
Education level education
Primary 62 0.6230 0.20805
Secondary 17 0.5221 0.16078
f=1.915;pvalue
College 9 0.4583 0.23385 =0.114

occupation House wife 28 0.5804 0. 19607

Farmer 37 0.6351 0.21323

Self employment 20 0.5938 0.17619
Formal
7 0.4286 0.23780
employment
Pensioner 13 0.5385 0.19355 f=1.815;pvalue
=0.13

0 – 2 years
13 0.7212 0. 19199
3-5 years
19 0.5921 0.24239
Duration with
6-8 years
22 0.5341 0.18168
Diabetes
9-11 years
11 0.6023 0.17216
12 years and f=1.965;pvalue
40 0.5656 0.19355
above =0.106

4.6.2 Influence of Demographic Characteristics on Self Management Practices

ANOVA results of level of education and duration with diabetes against self
management practices indicated that there was no significant relationship between the

34
variables and self management practices. This was supported by an f statistic of 1.868
(p=0.122) and 1.217 (p=0.308) respectively. However ANOVA results indicated that
there was significant relationship between places of residence, occupation with self
management practices. This was supported by an f statistic of 2.811 (p=0.043) and 5.264
(p=0.001) respectively. Table 4.12

35
Table 4.12: Analysis of demographics against self management practices
Std.
N Mean
Deviation f and p value

Education
16 1.7857 0.38244
level None
Primary 62 1.6993 0.35565
Secondary 17 1.8151 0.38800
College 9 2.0317 0.32363
University 1 1.9286 f=1.868;pvalue=0.1
22

48 1.8318 0. 36347
Residence Capital city
Other city 1 2.5000
Town 17 1.6681 0.31231 f=2.811;pvalue=0.0
43

Country side 39 1.6978 0.37276

Occupation House wife 28 1.8189 0. 31795

Farmer 37 1.6815 0.39684
Self
20 1.5714 0.30657
employment
Formal
7 1.9490 0.23224
employment

36
 Pensioner 13 2.064 0.31250 f=5.264;pvalue=0.0
01

Duration with
diabetes 0 – 2 years 13 1.6813 0. 52051
3 – 5 years 19 1.6654 0.38099
6 -8 years 22 1.7695 0.27614
9 – 11 years 11 1.6818 0.34011
12 years and f=1.217;pvalue=0.3
40 1.8518 0.35305
above 08

4.6.3 Influence of social economic and cultural factors on diabetes management

There was no significant relationship between use of herbal medicine, cost for testing
blood glucose and cost of insulin with management of diabetes This was supported by
an f statistic of 0.597 (p=0.553), 2.330 (p=0.102) and 0.848 (p=0.431) respectively.
ANOVA results also indicated that there was no significant relationship between
distance from the hospital and residential place with management practices. This was
supported by an f statistic of 0.219 (p=0.804) and 0.032 (p=0.858). Table 4.13

37
Table 4.13: Analysis of social economic and cultural factors on diabetes
management
Std.
N Mean
Deviation f and p value

Use of herbal
98 1.7675 0. 37647
medicine No
Don‟t know 4 1.5714 0.26726
f=0.597;pvalue=
Yes 3 1.8333 0.8248 0.553

Cost of testing 0 – 99
blood glucose in
Kshs 1 1.7143 0. 37647

100 – 199 26 1.8956 0.26726

f=2.330;pvalue=
78 1.7179 0.8248
>200 0.102

Cost of insulin in
21 1.6837 0. 37647
Kshs 0 - 499
500 - 999 36 1.7480 0.26726
f=0.848;pvalue=
48 1.8065 0.8248
>1000 0.431

Distance to nearest
facility <1 km 69 1.7723 0. 37647
Between1&5k
13 1.7857 0.26726
m
f=0.219;pvalue=
23 1.7174 0.8248
>5 km 0.804

38
Residence
occupied when
attending KNH Nairobi 86 1.7650 0. 35788

Relatives 19 1.7481 0.42483

f=0.032;pvalue=
105 1.7619 0.36872
Total 0.858

ANOVA results indicated that there was a significant relationship between means of
transport used, transport costs and hospital expenses with management practices. This Iis
supported by an f statistic of 4.582 (p=0.012), 3.128 (p=0.029) and 4.360 (p=0.006)
respectively. Table 4.14

Table 4.14: Analysis of social economic and cultural factors on diabetes

management
Std.
N Mean
Deviation f and p value

Means of transport Walking 2 2.5000 0. 10102

Public
100 1.7436 0.36167
transport
Personal car 3 1.8810 0.08248 f=4.582;pvalue
=0.012

Transport costs in
Kshs 0 - 199 6 1.3690 0.17738
200 - 499 55 1.8052 0.33261
500 - 799 27 1.7116 0.39397

39
 >800 17 1.8403 0.41614 f=3.128;pvalue
=0.029

Hospital expenses
in Kshs 0 - 999 19 1.5639 0.35785
1000- 1999 35 1.7020 0.34712
2000- 2999 30 1.9095 0.32160
>3000 21 1.8299 0.39479 f=4.360;pvalue
=0.006

Total 105 1.7619 0.36872

ANOVA results of home care costs against management practices indicate that there is
no significant relationship between home care cost and management practices. This is
supported by an f statistic of 0.720 (p=0.542). There was also no significant relationship
between family support, source of funds and management practices. This was supported
by an f statistic of

0.028 (p=0.977) and 0.579 (p=0.562) respectively. There was no significant

relationship between access to hospital challenges and management
practices. This was supported by an f statistic of 2.560 (p=0.113). Table 4.15

Table 4.15Analysis of social economic and cultural factors on diabetes management

Std.
N Mean
Deviation f and p value

Home care costs in

Kshs 0 - 999 99 1.7612 0.37383
1000- 1999 1 1.7857

40
 2000- 2999 4 1.8929 0.22208
>3000 1 1.2857 f=0.720;p
value=0.542

Family support No 77 1.7625 0.34068

Yes 28 1.7602
0.44383
f=-0.028,
pvalue=0.977

Current
32 1.7969 0.38018
Source of funds income
Family
72 1.7510 0.36579
support
Savings 1 1.4286 f=0.579;
pvalue=0.562

Challenges
experienced Lack of funds 72 1.7232 0.37008
Am able 33 1.8463 0.35675 f=2.560;
pvalue=0.113

41
 CHAPTER FIVE:

DISCUSSION, CONCLUSION AND RECOMMENDATIONS

5.1 Awareness levels of diabetes management

The first objective of this study was to assess the awareness levels of the patients with
regard to diabetes management. 82.7% of the respondents had moderate levels of
awareness and 1% had low awareness. These findings are consistent with similar studies
by Karam et al., (2012), Shah et al., (2009) and Priyanka et al., (2010) that found that
two thirds of patients were aware of diabetes management. Improving patient knowledge
on diabetes will allow them to better contribute to their care. Studies show that intensive
diabetes education and care management can improve patient outcome, glycaemic
control and quality of life of patient (Mc Murray et al., 2002). Training in self-
management is integral to the treatment of diabetes. Proper management requires
patients to be aware of the nature of the condition, its risk factors, its treatment and its
complications.

During the course of this study it was noted that diabetes education takes place weekly at
the mini clinic and it is self-sponsored. This is a barrier for those patients that do not
have the necessary funds. A shortage of nurses also hinders effective teaching of
diabetes self-management education to patients (Gross et al., 2010) and the diabetes
educators‟ cadre in Kenya is not officially recognized (MOPHS, 2010).These factors
may contribute to the study findings where majority of the patients having moderate
knowledge about diabetes self-management.

5.2 Self-management practices

In this study 54.87% of the respondents had a moderate score of self-management
practices. 38.5% had high self-management practices and 6.7% had low self-
management practices. Similar results were found in other studies for instance 30.8%

42
 had high self-care behavior in a study in Myanmar (Sandhi et al., 2010) and
39.2% in a study in Ethiopia (Ayele et al., 2012).

Knowledge is an important contributing factor for behaviour change but is

not sufficient one its own (Rosenstock et al., 1988). In this study awareness
of the respondents about self-management was moderate however; majority
of them did not follow the recommended self-care practices. This may be
associated to factors such as barriers of self-care, less perceived severity of
the disease and its complications, infrequent cues to action, low income and
educational status which is supported by the a study done in Nigeria (Adibe
2009).

5.3 Socio- economic factors affecting diabetes management

Geographic factors play an important role in access to and use of health
services (Snow et al. 1994). In Sub-Saharan Africa and other low-income
countries, distance contributes to the time required to access health services
(Hjorstberg and Mwikisa 2002), delays in decisions to seek treatment
(Amooti-Kaguna and Nuwaha 2000) and increases in household expenditure
on treatment and opportunity costs as a result of time spent away from
income generating activities (Ensor & Cooper 2004).

The two most significant barriers to entry in the Kenyan health system are
the cost of care, and the availability of suitable care within a reasonable
distance (i.e., geographic barriers). According to NHSSP II, “the health
infrastructure in some regions of the country has coverage of one facility per
50-200 km,” making the availability of health resources to those who are
sick virtually non-existent in certain cases (NHSSP II, 2005).Most health
care providers are located in urban areas and therefore persons who live in

43
rural areas face significant challenges in receiving timely, safe and quality diabetes care.
They often forgo important diabetes management (Landon et al., 2004). Travelling the
long distances necessary to access diabetes clinics hinders patients from rural areas from
receiving quality diabetes care from the clinics (Mutea and Baker, 2008; Rourke, 2010).

In this study, 70.2% the respondents reported spending Ksh 100 – 199 ($1.20 – 2.40) for
a blood glucose test and 24% spent less than Ksh 99 ($1.19) for the same. This was
comparable to a study carried out in Mali, Mozambique and Zambia that found that
patients spend $2.38 per test (IIF 2004). Also 45.2% the respondents spent more than
Ksh 1000 ($12.04) monthly to manage their diabetes while another 34.6% spent Ksh500
– 999 ($ 6.00 – 12.04) monthly. A similar study in Sudan found that patients spent
$22.49 monthly on diabetes drugs (Hind, 2007).

Studies have shown that the cost of care nevertheless remains a paramount issue in
Kenya. For those who were ill but did not seek treatment, the high cost of care was noted
as the primary reason by 44% of those surveyed in KHHEUS 2003. Funding by the
national government to the health sector has been inadequate for minimizing out of
pocket expenses on care. As a result, funding for the health sector is financed primarily
by the private sector, with 36% of it originating from households mainly through out of
pocket spending (MOPHS, 2008).

The major source of funds was from family members (68.3%) while 30.8% relied on
their personal income. 69.23% of the respondents reported facing challenges in meeting
the costs required to manage their diabetes. Low socio-economic status including low
education levels has been associated with development of diabetes mellitus (Ismail et
al., 1999). An association between increasing poverty levels and increasing prevalence
of diabetes has been shown among women (Walker et al., 2011 and Robbins et al.,
2000). According to Lester, (2011). Ksh 510 ($6 U.S) enabled a patient to monitor her or
his glucose at home for a month and ksh 2125 ($25) subsidized eight months of insulin

44
 therapy for a patient. But in a country where 60 percent of the population
lives on less than ksh 170 ($2) per day, these costs were often out of reach

Only 18.3% of the respondents needed to stay with relatives when they had
to visit the clinic as they lived too far away to travel back and forth from
their homes. The common means of transport used was public reported by
95.2% of the respondents. Almost half of the respondents (48.1%) are
accompanied by one person when they attend the clinic. 90.4% of the
respondents did not have a paid caretaker because they lived with family
members (26%) or were able to take care of themselves (74%). In this study
the utilization of herbal medicine was low as most of the respondents lived
in urban areas and their environs and were therefore more likely to make use
of conventional medicine. As seen 92.3% stated that they did not believe
herbalists or witchdoctors could cure their condition while 4.8% were not
sure. The frequency of utilization of alternative medicine is increasing
worldwide and is well documented in both African and global populations to
be between 20 to 80%. Cultural and economic reasons were largely
responsible for use of alternative medicine (Shappiro and Rapport 2009).

5.4 Limitations of the study

The small sample size and restricted research site limit the transferability of
the findings to the general population with T2DM. Data on medication
adherence, nutritional intake, and physical activity were obtained by self-
report and may be limited by recall and other biases. Due to its limited scope
of covering only the KNH, this study had limitation of not having access to
data from other health centres and medical centres. The area of health and
self management was also sensitive and therefore the respondents were not
willing to respond to some questions. However confidentiality and
protection of information was assured to the respondents. Information was
coded to avoid direct
45
reference to particular individuals. Also due to time and budgetary constraints the study
concentrated on the objectives stated.

5.5 Conclusions
We can conclude from the study management of diabetes requires knowledge, motiva-
tion, training, and support, which is mostly provided by health care workers. Decisions
to seek care were influenced by a number of factors for example, severity of signs and
symptoms of the disease, recognition of signs and symptoms, support from the
community, availability of resources to seek care and services available at the health
care facilities.

The decision to seek care at healthcare facilities for many patients appeared to be
hindered by a lack of financial resources to pay the transport costs to health care
facilities, medical tests and prescribed medication. Travel distances from patients‟
residences, coupled with inadequate and poor public transport infrastructure were
reported to negatively influence the decisions to seek health care.

Majority of the respondents had moderate awareness levels of diabetic management

however this awareness had not led to any changes in the disease management because
patients were not sufficiently equipped with the knowledge to comprehensively manage
their disease.

Recommendations
The hospital management should recast their communication strategy by revitalizing
their information, communication and education avenues in order to bolster information
on diabetic management.

The findings suggest that patients with type 2 diabetes require reinforcement of
knowledge through health communication to encourage them to understand their disease
management better, for more appropriate self-care.

46
The results of this study send a strong message to diabetes healthcare providers
and educators for the actual need for developing education and prevention
programs about diabetes targeting type 2 diabetes patients at outpatient clinics.

There is a deep need for an increase in the awareness of diabetes management

and its complications in the primary healthcare sector.

47
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APPENDICES
APPENDIX 1 CONSENT FORM

My name is Esta Mwaloma. I am Masters Student in Public Health from

JKUAT. You are invited to take part in research about diabetes in women.
You are a potential participant because you are a woman attending the
Diabetic clinic at the Kenyatta National Hospital. We ask that you read this
form before agreeing to be in the research. If you cannot read, you can
request the researcher or a member of hospital staff to read it to you.

Purpose

54
 The purpose of the research is to assess your level of awareness of diabetes
management, self management practices, socioeconomic and cultural factors
that affect your diabetes management.

Procedures
If you agree to be in this research, and sign this consent form, I or my
assistant will describe the questions you will be asked including their
purpose. The questions should take only 20 - 30 minutes of your time.

Risks and Benefits

There are no direct benefits to you of the study. The risk level of this
research is considered to be less than minimal.

Confidentiality
The records of this study will be kept private. Anything you tell us will
remain confidential. In any sort of report of the study, we will not include
any information that will make it possible to identify you. We are not asking
for your name, address, or phone number. Your name and other identifying
information will not be kept with this survey. The surveys will be kept in a

locked file; only the researchers for this study will have access to the records.

Voluntary nature of study

Your decision whether or not to participate will not prejudice your future relations with
Kenyatta National Hospital, Kenya Medical Research Institute, Jomo Kenyatta
University of Agriculture and Technology and staff helping with this study. If you do
not wish to take part or you do not want to answer some of the questions, you do not

55
have to give us a reason. Even if you sign the consent form, you are free to stop at any
time. You do not need to complete it if you feel uncomfortable doing it.

Contact
The researchers conducting this study are Esta Mwaloma and her assistant. You may
contact the researchers at anytime. Questions regarding the rights of research subjects
may be directed at the Ethical Committee at the Kenya Medical Research Institute.

In case of any queries or concerns, please contact the Principal investigator or KEMRI
on:
Esta Mwaloma
P.O. Box 55916-00200; Nairobi
Cell phone Number: +254 720 954 660
Email: [email protected]
OR
The Director;
Institute of Tropical Medicine and Infectious Diseases
Jomo Kenyatta University of Agriculture and Technology
P.O. Box 62200-00200; Nairobi
Tel: 067-52711
Email: [email protected]
OR
The Chairperson;
KEMRI National Ethical Review Committee
P.O. Box 54840-00200; Nairobi
Tel: 2722541-2713349-0722-205901

Consent

56
I have read the above information and understand that this survey is
voluntary and I may stop at any time. I consent to participate in the study.

_________________________________
Signature of participant Date

__________________________________
Signature of researcher/ research assistant Date

57
 FOMU YA KIBALI

ANWANI:

Jina langu ni Esta Mwaloma. Mimi ni mwanafunzi kutoka chuo kikuuu la JKUAT.
Nakualika uwe mmoja wa wanawake ambao watuulizwa maswahili kuhusu ugonjywa
wa kisukari. Umechaguliwa kwa kuwa wewe ni mwanamke anayepokea matibabu ya
ugonjwa wa kisukari katika hospitali ya Kenyatta. Nakuoomba tafadhali usome fomu hii
kabla ya kukubali kujibu maswali. Kama huwezi kusoma naweza kukusomea ama
uniulize nikusomme ama mtu yeyote ambae ameeandikwa katika hospitali hii.

Mada
Utafiti huu unanuia kugundua kama wagonjwa wa Diabetis wanajua jinsi ya kuitawala,
jinsi wanvyo itawala na shida za fedha na kijamii ambazo zinawakumba.

` Utaratibu wa utafiti

Ukikubali kuhusika na utafuti huu na utie sahihi fomu hii, mimi ama msaidizi wangu
atakuekezea maswahili utakayoulizwa na umuhimu wao. Maswali yatachukua dakika
ishirini ama thelathini.

Manufaa na hatari
Utafiti huu ni kwa ajili ya masomo tu. Hakuna faida au manufaa kwa mhusika yeyote
kabla au baada ya utafiti. Hakuna madhara yoyote kwa wale wote watakaohusika katika
utafiti huu.

Usiri
Matokeo na maneno yote yatakayotokana na utafiti huu yatawekwa kwa usiri wa hali
ya juu. Hakuna jina la mhusika litatumiwa; ilhali nambari

58
 maalumu tu ndizo zitakazotumika. Hoji zote zitawekwa ndani ya kabati na
kufungwa ndipo ziwe salama. Watafiti tu ndio wataweza kuona matokeo
haya.

Kutojihusisha
Kila mhusika, una uhuru wa kukataa kuhusishwa katika utafiti huu wala
hakuna hatari, machungu ama vitisho vyovyote vitakavyoambatana na
uamuzi wako. Hata ukikubali kuitkia kutia sahihi wakati wowote ule
unaweza kukatta kuendelea.

Mawasiliano
Watafiti ni Esta Mwaloma na msaidizi wake. Unaweza kuwasilian nao
wakati wowote. Ukiwa na maswali mengine kuhusu utafiti huu unaweza
kuwasiliana na KEMRI.

Esta Mwaloma
S.L.P: 55916-00200; Nairobi
Simu ya rununu: +254 720 954 660
Barua pepe: [email protected]

AU Msimamizi;
Institute of Tropical Medicine and Infectious Diseases
Jomo Kenyatta University of Agriculture and Technology
S.L.P: 62200-00200; Nairobi
Simu: 067-52711
Barua pepe: [email protected]

AU Mwenyekiti;
KEMRI National Ethical Review Committee
S.L.P: 54840-00200; Nairobi
59
Simu: 2722541-2713349-0722-205901
Kujitolea
Nimeesoma ama nimeelezwa fomu hii na naelewa ya kuwa sijalazimishwa
na wakati wowote naweza kusimamisha mahijiano haya. Nakubali kuwa
katika utafiti huu.

__________________________________
Sahihi ya mhusika Tarehe

________________________________
Sahihi ya mtafiti au msaidizi wake Tarehe

60
 APPENDIX 2: QUESTIONNAIRE

Form serial number

Research assistant’s name

Date of interview

Part 1: Background
1. How old are you/ When were you born?
Year of Birth

Age

2. What is your education level?

0 No formal education

1Primary

2Secondary

3College

4University

3. Where is your home?

1 Capital city

2 Other city

3 Town

4 Country side

61
 5 Other

4. What is your employment status?

1 I work only around the home stead

2 I am a small scale farmer

3 I am self-employed but not as a farmer

4 I am on formal employment

5 I am retired or a pensioner

5. What is your religion?

1 Christian

2 Muslim

3 Traditional

4 Other (specify)

6. How long have you had Diabetes?

1 0 – 2 years

2 3 - 5 years

3 6 - 8 years

4 9 – 11 years

5 12 years and above

62
 7. Which facility gave you this diagnosis?
1 Dispensary

2 Health Centre

3 Provincial Hospital

4 Referral Hospital

5 Private Hospital

6 Faith based Hospital

7 Pharmacy

8 Other

8. When you were first diagnosed what advice or treatment were you given?
0 None

1 Insulin injections

2 Tablets

3 Change diet and exercise

4 Lose weight

5 Both insulin and tablets

Part 2: Awareness of Diabetes management

9. Is diabetes hereditary?
63
 0 No

1Yes

2 I don‟t know

10. Can diabetes be cured?

0 No

1Yes

2 I don‟t know

11. If you are a smoker or you take alcohol is it beneficial to stop?

0 No

1Yes

12. What is the normal fasting range for blood glucose?

0 I don‟t know

1 3.9 – 5.6 mmol/l

2 4.4 - 6.1mmol/l

64
 3 7.0 – 10.0 mmol/l

4 Other

13. Once blood glucose has been controlled should drugs be stopped?
0 No

1Yes

2 I don‟t know

14. What effect does fruit juice have on blood glucose?

0 Don‟t know

1 Lowers it

2 Raises it

3 Has no effect

15. What effect does exercise have on blood glucose?

0 Don‟t know

1 Lowers it

2 Raises it

3 Has no effect

65
16. What effect does any other sickness have on blood glucose?
0 Don‟t know

1 An increase in blood glucose

2 A decrease in blood glucose

3No change in blood glucose

4 Either increases or decreases

17. How often do you visit the KNH Diabetes mini clinic in a year?
1 Once a year

2 Twice a year

3 Three times a year

4 Every month

5 Every 3 months

6 Every 2 months

7 Other

18. Please tell me which conditions I have listed a doctor has EVER said you may
get from having Diabetes. 0 No 1 Yes
Diabetes complications Response

66
 Heart Disease/Hypertension

Blindness

Kidney disease

Amputation of toe, foot, or leg

Part 3: Self management practices

19. Which is the best method for testing glucose?
0 Don‟t know

1 Urine testing

2 Blood testing

3 Both are equally high

4 Other

20. Do you have a blood glucose meter?

0 No

1Yes

21. If not where do you regularly measure your blood glucose?

1 Dispensary

2 Health Centre

3 Provincial Hospital

67
 4 Referral Hospital

5 Private Hospital

6 Faith based Hospital

7 Pharmacy

8 I test myself

9 Other

22. How often do you check your blood glucose?

0 I don‟t check/ At clinic appointments

1 Once a day

2 Twice a day

3 Once a week

4 A few times a week

5 Every month

6 Other

68
23. What do you do to keep your diabetes under control?
0 Nothing

1 Inject insulin

2 Follow a special diet

3 Exercise

4 Take tablets for diabetes

5 Both tablets and insulin

24. How often do you check your feet for sores or red spots?
0 I don‟t check

1 Once a week

2 Once a month

3 Everyday

4 Other

25. How often do you measure your weight?

0 At clinic appointments

69
 1 Once a week

2 Once a month

3 Every six months

4 Other

26. How often do you measure your blood pressure?

0 At clinic appointments

1 Once a week

2 Once a month

3 Everyday

4 Other

27. If you suddenly feel shaky, nervous or hungry, what should you do?
0 Don‟t know

1 Lie down and rest

2 Eat some form of sugar

3 Take more insulin or diabetes pills

4 Other

70
28. How often do you get your eyes checked?
0 Don‟t know

1 Every 6 months or sooner

2 Every year

3 Every two years

4 Every three or more years

5 Other

29. How often do you exercise?

0 I don‟t exercise (go to Q 30)

1Three times a week (go to Q31)

2 Daily (go to Q31)

3 Other

30. If you do, where do you exercise?

1At home

2 In a gym

3 Other

71
31. If you don‟t, what prevents you from exercising?
1 I don‟t have time

2 I don‟t have money to go to the gym

3 My family/ society does not encourage me

to exercise

4 I don‟t know which exercises to do

5 I exercise

6 I fear exercising

7 I have a medical condition that prevents

me

8 Other

32. How do you store your insulin?

0 I don‟t use insulin

72
 1 Refrigerator

2 Pot of cold water

3 Room temperature

4 Other

33. In the last 3 months, have you ever missed getting your prescribed insulin or
diabetic pills from the hospital?
0 No

1 Yes

2 Don‟t use Insulin/ diabetic pills

34. If yes, how frequently have you missed your supplies?

0 Never

1 Every month

2 Once or twice in 3 months

35. When you miss your supplies of insulin or diabetic pills, what do you usually do?
1 Buy your own

2 Wait till supplies are available from the hospital

73
 3 Other

Part 4: Socioeconomic and cultural factors

36. Do you believe herbalists or witchdoctors can cure diabetes?
0 No

1Yes

2 Don‟t know

37. If you do not have a blood glucose meter how much do you usually pay for the
test?
1 0 - 99

2 100 - 199

3 > 200

38. If you use insulin/tablets to manage your diabetes, how much do you spend on it
monthly (plus syringes)?
1 0 - 499

2 500 - 999

3 > 1000

74
39. How far is the nearest health facility from your home?
1 < 1km

2 Between 1 and 5 km

3 > 5 km

40. Where do you stay when you come for treatment at KNH?
1 Home is in Nairobi/Environs

2 Relatives

3 Hotel

41. Which means of transport do you use to access KNH?

1 Walking

2 Public transport

3 Personal car

42. How much does it cost to travel to and from KNH?

1 0 - 199

2 200 - 499

3 500 - 799

4 > 800

75
43 How many people accompany you when you are visiting KNH?
1 0

2 1

3 2

4 >2

43. How much do you spend per visit to KNH (excluding transport)?
1 0 - 999

2 1000 - 1999

3 2000 - 2999

4 > 3000

44. Have you or your family hired someone to take care of you
because of your ill health?
0 No

1 Yes

|_
45. IF YES, How much do you pay this person each month?
1 0 - 999

76
 2 1000 - 1999

3 2000 - 2999

4 > 3000

46. Does someone from your family take care of you because of
your ill health without being paid for it?
0 No

1 Yes

47. During the past 12 months, how did you pay for or get the
medical services, care-givers, medicines, and medical supplies
that you, yourself, used?
1 By spending out of your current income/pension

2 Donations of medicines or supplies

3 With financial support from friends or family

4 From saved money

5 By borrowing money

6 By selling possessions like furniture, animals or

property

48. Please tell me which one of the following has prevented you
from getting medicines or medical care, over the last 12
months:

77
 1 Lack of funds to pay for the care

2 Lack of transportation

3 No one to help me get there/ Too sick to make

the trip
4 Would have taken too long to go there/too far
away

5 Would have had to wait too long once I was there

6 No doctor or other professional was available

7 I am able

8 Other

MASWALI

Nambari ya Fomu

Jina la msaidizi wa utafiti

Tarehe ya mahojiano

Part 1: Background
1. Una miaka mingapi/ Ulizaliwa mwaka gani?
Mwaka wa kuzaliwa

Miaka

2. Umesoma mpaka kiwango kipi?

0 Sijasoma

78
 1 Shule ya msingi

2 Shule ya upili

3 Chuo cha kadri

4 Chuo kikuu

3. Je, waishi wapi?

1 Mji mkuu

2 Mji mwingine

3 Mji mdogo

4 Mashambani

4. Hali yako ya ajira ni gani?

1 Nafanya kazi ya nyumbani

2 Mimi ni mkulima

3 Nimejiajiri lakini si kama mkulima

4 Nimeajiriwa

5 Nimestaafu

79
5. Dini yako ni gani?
1 Mkristo

2 Muislamu

3 Dini ya Kiasili

4 Nyingine (fafanua)

6. Umekuwa ukiuugua Diabetis kwa muda gani?

1 miezi - miaka miwili

2 miaka tatu - miaka tano

3 miaka sita - miaka nane

4 miaka tisa -miaka kumi na moja

5 miaka kuma na miwili - zaidi

80
 7. Hospitali gani ilikuambia kuwa una diabetis?
1 Zahanati

2 Hospitali ndogo

3 Hospitali ya mkoa

4 Hospitali kuu

5 Hospitali ya kibinafsi

6 Hospitali ya kidini

7 Duka la dawa

8. Ulipoambiwa kuwa una Diabetis uliambiwa nini kuhusu kuitawala?

0 Hakuna

1 Kudungwa insulin

2 Tembe

3 Kula kwenye afya na mazoezi ya mwili

4 Kupunguza kipimo

5 Tembe na kudunga insulin

Part 2: Awareness of Diabetes management

9. Je, diabetis ni ugonjwa wa kijamii?
0 La

81
 1Ndio

2 Sijui

10. Je, diabetis yaweza kutibiwa?

0 La

1Ndio

2 Sijui

11. Je, kuwacha kuvuta sigara ama kunywa pombe kuna manufaa?
0 La

1Ndio

12. Wakati hujakula chochote,kiwango cha sukari katika mwili ni ngapi?

0 Sijui

1 3.9 – 5.6 mmol/l

2 4.4 - 6.1mmol/l

3 7.0 – 10.0 mmol/l

4 Nyingine

13. Kiwango kinachotakikana cha sukari kinakapotimia, unafaa kuacha kunywa

dawa?
0 La

82
 1Ndio

2 Sijui

14. Juisi ya matunda inabadilisha vipi kiwango cha sukari chako?

0 Sijui

1 Inaongeza
2 Inapunguza
3 Haibadilishi

15. Je, mazoezi yanafanya nini kwa kiwango cha sukari yako?
0 Sijui

1 Inaongeza
2 Inapunguza
3 Haibadilishi

16. Magonjwa yanafanya nini kwa kiwango cha sukari yako?

0 Sijui

1 Inaongeza
2 Inapunguza
3 Haibadilishi
4 Saa zingine inapanda, saa zingine inashuka

17. Je, unamwona daktari wa klinkiki ndogo ya Daibetis ya KNH mara ngapi kwa
mwaka kwa uangalizi?
1 Mara moja kwa mwaka

83
 2 Mara mbili kwa mwaka

3 Mara tatu kwa mwaka

4 Kila mwezi

5 Kila baada ya miezi tatu

6 Kila baada ya miezi miwili

7 Nyingine

18. Tafadhali niambie magonjwa yale daktari amekuelezea kuwa unawea pata
kuotkana na Diabetis. 0 La 1 Ndio
Magonjwa Ndio au LA

Ugonjwa wa moyo/ Presha

Upofu

Ugonjwa wa figo

Kukatwa mguu au jino la mguu

Part 3: Self management practices

19. Je, kipi ni kipimo bora cha sukari chako?
0 Sijui

1 Kipimo cha mkojo

2 Kipimo cha damu
3 Vyote viko sawa

20. Je, una kifaa cha kupima sukari yako?

84
 0 La

1Ndio

21. Kama huna kifaa cha kupima glukos, unapimwa wapi kawaida?
1 Zahanati

2 Hospitali ndogo

3 Hospitali ya mkoa

4 Hospitali kuu

5 Hospitali ya kibinafsi

6 Hospitali ya kidini

7 Duka la dawa

8 Najipima

22. Umejipima au umepimwa kiwango cha sukari mara ngapi?

0 Sipimi/ Napimwa nikija kwa clinic
1 Kila siku
2 Mara 1-2 kwa siku
3 Mara moja kwa wiki
4 Mara kadhaa kwa wiki
5 Kila nwezi
6 Nyingine

23. Je, wafanya nini ili sukari yako iwe katika kiwango kinachotakikana?

85
 0 Hakuna

1 Natumia insulin

2 Nakula chakula maalum

3 Mazoezi

4 Nanywa dawa za diabetis

5 Nanywa dawa na kudunga insulin

24. Je, wakagua miguu yako mara ngapi kuangalia vidonda?

0 Sikagui

1 kila wiki

2 kila mwezi

3 kila siku

4 Nyingine

25. Je, wajipima mara ngapi kwa mwaka?

0 Nikija kwa clinic

1 Kila wiki

2 Kila mwezi

3 Kila miezi sita

4 Nyingine

86
26. Je, wapia pressure mare ngapi?
0 Nikija kwa clinic

1 Kila wiki

2 Kila mwezi

3 Kila siku

4 Nyingine

27. Ukihisi njaa, kutetemeka ama kutoa jasho, unafaa kufanya nini?
0 Sijui

1 Kulala na kupumzika

2 Kula kitu chenye sukari

3 Kunywa tembe za diabetis ama

kuongeza insulin

4 Nyingine

28. Je, unakaguliwa macho mara ngapi?

0 Sijui

1 kila miezi sita

2 Kila mwaka

3 Kila miaka miwili

4 Kila miaka tatu ama zaidi

87
 5 Nyingine

29. Je, wafanya mazoezi?

0 La (enda Q 30)

1 Mara tatu kwa wiki (enda Q31)

2 Kila siku (enda Q31)

3 Nyingine

30. Kama unfanya, wafanyia wapi?

1 Nyumbani

2 Kwa gym

3 Nyingine

31. Kama hufanyi,ni kwa nini?

1 Sina wakati

2 Sina pesa ya kenda kwa gym

3 Famila/ jamii hainiruhusu kufanya mazoezi

4 Sijui nifanye mazoezi yapi

5 Nafanya mazoezi

6 Naogopa kufanya mazoezi

7 Hali yangu ya afya hainiruhusu kufanya

88
 mazoezi

8 Nyingine

32. Unahifadhi vipi insulin?

0 Situmii insulin
1 Jokofu/friji
2 Chungu cha maji baridi
3 Joto la kawaida chumbani
4 Nyingine

33. Katika miezi 3 iliyopita, umewahi kukosa insulin/ tembe za diabetis yako
hospitalini?
0 Ndiyo
1 Hapana
2 Situmii insulin ama tembe

34. Kama jibu la swali iliyopita ni Ndiyo, Je umekosa mara ngapi?

1 Kila mwezi
2 Mara moja au mbili katika miezi 3

35. Ukikosa insulin au sindano huwa unafanya nini?

1 Nanunua mwenyewe
2 Nasubiri mpaka nipate kutoka hospitali

Part 4: Socioeconomic and cultural factors

89
36. Je, waamini kuwa waganga ama madaktari wa mitshamba wanaweza kutibu
diabetis?
0 La

1Ndio

2Sijui

37. Kama huna, walipa pesa ngapi kupimwa?

1 0 - 99

2 100 - 199

4 > 200

38. Kama watumia insulin watumia pesa nagpi kila mwezi kuinunua (pamoja na
sindano)?
1 0 - 499

2 500 - 999

3> 1000

39. Umbali wa zahanati iliyo karibu zaidi ni gani?

1 < 1km

2 Between 1 and 5 km

3> 5 km

40. Ukija wa matibabu Kenyatta wakaa wapi?

90
 1 Natoka Nairobi ama karibu

2 Kwa familia

3 Kwa hoteli

41. Watumia mbinu gani kufika Kenyatta?

1 Natembea

2 Matatu au Basi

3 Gari langu

42. Watumia pesa ngapi kusafiri toka nyumbani na kurudi toka Kenyatta?
1 0 - 199

2 200 - 499

3 500 - 799

4> 800

43. Waletwa na watu wangapi Kenyatta?

10

21

32

4> 2

91
44. Watumia pesa ngapi ukija Kenyatta (toa nauli)?
1 0 - 999

2 1000 - 1999

3 2000 - 2999

4 > 3000

45. Je, wewe ama familia yako imeajiri mtu wa kukuangalia juu ya
ugonjwa wako?
0 La

1 Ndio

46. Kama ndio, wampipa pesa ngapi kila mwezi?

1 0 - 999

2 1000 - 1999

3 2000 - 2999

4 > 3000

47. Kuna mtu anakuangalia kwa ajili ya ugonjwa wako bila

malipo?
0 La

1 Ndio

48. Kwa mwaka uliopita umetumia pesa toka wapi kulipia madawa
92
 unayoutumia?
1 Pesa nazozoipata kwa mwezi/ pensheni

2 Wapaji wa madawa

3 Familia na marafiki
4 Akiba

5 Kuomba

6
uuza wanyama au shamba

Tafadhali niambie kama sababu yeyote imekufanya usipate

matibabu katika mwaka moja:
1 Kukosa fedha za hospitali

2 Kukosa mbinu ya kesafiri

3 Hakuna mtu wa kunipeleka/ Mgonjwa sana kuenda

4 Ningechukua mud asana kuenda/ Iko mbali sana

5 Ningengoja sana kama ningeenda

6 Daktari ama msaidizi wake hakuwa

7 Sina shida yeyote

8 Nyingine

93
APPENDIX 3: APPROVAL LETTERS

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