Accepted Manuscript

Self-efficacy, Self-care and Glycemic control in Saudi Arabian patients with

type 2 Diabetes Mellitus: A Cross-sectional Survey

Ahmad M.J. Saad, Zeina M.H. Younes, Hafez Ahmed, Jason A. Brown, Rafat
M. Al Owesie, Ahmed A.K. Hassoun

PII: S0168-8227(17)31120-8
DOI: https://doi.org/10.1016/j.diabres.2017.12.014
Reference: DIAB 7170

To appear in: Diabetes Research and Clinical Practice

Received Date: 10 July 2017

Revised Date: 20 November 2017
Accepted Date: 18 December 2017

Please cite this article as: A.M.J. Saad, Z.M.H. Younes, H. Ahmed, J.A. Brown, R.M. Al Owesie, A.A.K. Hassoun,
Self-efficacy, Self-care and Glycemic control in Saudi Arabian patients with type 2 Diabetes Mellitus: A Cross-
sectional Survey, Diabetes Research and Clinical Practice (2017), doi: https://doi.org/10.1016/j.diabres.
2017.12.014

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Self-efficacy, Self-care and Glycemic control in Saudi Arabian patients with type
2 Diabetes Mellitus: A Cross-sectional Survey

Ahmad MJ. Saad, MSc a, Zeina MH. Younes, MSca, Hafez Ahmed, PhD b, Jason A
Brown PhD c , Rafat M. Al Owesie MD c, Ahmed AK. Hassoun MD a
a
Dubai Diabetes Center, Dubai Health Authority, Block C, Al Hudaiba Awards
Building, P.O.Box 215252, Dubai, United Arab Emirates
b
Dubai Medical College, Al Muhaisanah 1, Al Mizhar, P.O.Box 20170, Dubai,
United Arab Emirates
c
Sultan Bin AbdulAziz Humanitarian City, Bahban, Riyadh 13567, Kingdom of Saudi
Arabia

Correspondence to:

Ahmad MJ. Saad

Dubai Health Authority,
Dubai Diabetes Center,
PO Box 215252, Dubai, United Arab Emirates

Tel. +971 (4) 3819611

Fax. +971 (4) 3546669
Mobile: +971 522415234
Email: ahsaad@dha.gov.ae , ahmed-mjs@live.com

Word count: 4,893

Tables: 5

1
Abstract

Aims: To determine the prevalence of diabetes self-care activities among type 2

diabetes patients and examine the association between socio-demographic and clinical

parameters, diabetes self-care activities, and glycemic control among type 2 diabetes

patients.

Methods: A cross sectional study was conducted among patients with diabetes

(n=123) at the Sultan Bin Abdulaziz Humanitarian City (SBAHC). A regression

model was used to examine the variables that predicted glycemic control. Moreover, a

regression analysis examining the effect of each self-efficacy subscale on its

respective diabetes self -management (DSM) behavior was carried out.

Results: The most frequently reported DSM behaviors were foot care followed by

medication taking self-management behavior. The least frequently reported DSM

behaviors were exercise self-management behavior and blood sugar testing behavior.

Self-efficacy was associated with higher levels of diet, exercise, blood sugar testing,

and medication taking self-management behaviors. Diet self-management behaviors

and oral hypoglycemic agents (OHA) use were significantly independent predictors of

glycemic control HbA1c < 7% (53 mmol/mol).

Conclusions: The findings can serve to help clinicians have a better understanding on

the extent to which different self-efficacy parameters have an influence on self-

management behaviors, which will in turn lead to better glycemic control and thus

improved HbA1c levels.

Keywords: Patient self-management; Self-efficacy; HbA1c; Diet; Exercise.

2
 1. Introduction

Diabetes mellitus is a major global health problem that is increasing worldwide,

reaching pandemic proportions [1,2]. Recent estimates by the World Health

Organization (WHO) have shown that the number of patients diagnosed with diabetes

will reach 366 million people by the year 2030 [3]. According to the International

Diabetes Federation (IDF), the prevalence of diabetes mellitus by the year 2025 is

forecasted at 334 million people [4]. A recent study done in the Kingdom of Saudi

Arabia (KSA) found the prevalence of patients with diabetes to equal 30% and to be

increasing with age [5].

Poor glycemic control has been found to lead to serious complications such as heart

attack, stroke, hypertension, kidney disease and leg amputations [6]. The high

prevalence of diabetes, the early morbidity and mortality and the massive load on the

interdisciplinary health care team makes diabetes a significant health concern [7].

Type 2 diabetes mellitus is described by the American Diabetes Association as being

the most common type of diabetes [8]. Effective diabetes self-management practices

have been shown to play an essential part in improving diabetes outcomes [9]. Access

to self-management is considered a key component to health care providers, with

many research supporting the need for diabetes self-management (DSM) skills to be

taught to all patients in order for them to become capable and responsible for their

own care [10-11]. Diabetes self-management is very challenging and it demands the

involvement of multiple treatment areas; including regular exercise, weight control,

continuous self-monitoring of blood glucose (SMBG), healthy diet behaviors and

incorporation of medications into the daily routine over their lifetime [12]. DSM

3
adopts healthy lifestyle behaviors, which have an effect on glycemic control for

patients with diabetes and will in turn help in preventing the micro-vascular and

macro-vascular complications that are consequential of the disease [10,13].

Diabetes is a disease that requires changes in behavior and in order to enable patients

with diabetes to perform self-care activities, they require education, skills building,

counseling and support by the diabetes health care team. Behavioral changes are

sophisticated processes that are affected by several factors such as knowledge, beliefs,

attitudes, skills, motivation, and social support.

One of the crucial factors in attaining behavioral goals is self-efficacy; defined as the

individual's beliefs about personal capabilities to perform specific behaviors that are

necessary to achieve their goals [14].

Self-efficacy concepts are based on social cognitive theory, which proposes that

patients’ confidence in their ability to perform health behaviors affects which

behaviors they will perform [14–16]. Diabetes Self Management (DSM) self-efficacy

therefore refers to the patient's confidence in his/her ability to perform several of the

DSM behaviors; and improving DSM is an ongoing challenge for health care teams

globally, including KSA. As a result, identifying DSM behaviors and diabetes

management self-efficacy and examining their effects on glycemic control, as well as

identifying which areas of diabetes management self-efficacy and DSM behaviors

patient need additional support in, can assist the health care team in achieving better

diabetes control [7]. In a recent study conducted in the United States, Melba et al. [28]

found diabetes-related psychosocial self-efficacy (diabetes empowerment) to be

significantly associated with increased effective self-care behaviors; diet (β = 0.09; p=

< 0.001), exercise (β= 0.10; p= < 0.001), blood sugar testing (β = 0.07; p= 0.016),

4
and foot care (β = 0.08; p= 0.001). Moreover, another study by Walker et al. [29]

reported a significant association between diabetes self-efficacy, glycemic control, the

mental health component of quality of life, medication adherence and most self-care

behaviors (diet, exercise and blood sugar testing) [29]. Another study conducted on

222 Chinese type 2 patients with diabetes found that higher self-efficacy was

associated with a higher performance of diabetes self-care behaviors (β= 0.32, p <

0.001); with these behaviors being linked to better glycemic control [30]. Delahanty

& Halford [31] found that among patients who followed specific diet related

behaviors, the average HbA1c was 0.25 to 1.0 lower than among patients who did not

follow these behaviors. The current study is aimed at determining the prevalence of

diabetes self-care activities among type 2 patients with diabetes and to examine the

association between socio-demographic and clinical parameters, diabetes self-care

activities, and glycemic control among type 2 patients with diabetes attending a

rehabilitation center.

2. Methods

2.1. Subjects

A cross sectional study was conducted between the 1st of September 2013 and the 1st

of December 2013 among patients with diabetes attending the Sultan Bin Abdulaziz

Humanitarian City (SBAHC) in Riyadh, Saudi Arabia.

All type 2 patients with diabetes admitted to SBAHC between the period of

September 1, 2013 and December 1, 2013 were reviewed for the study.

Inclusion criteria:

In order to be included in the study, patients must have been diagnosed with type 2

diabetes according to the American Diabetes Association (ADA), they had to be 25

years of age and above, mentally competent, and able to communicate verbally and

5
provide informed consent. Patients with type 1 diabetes, pregnant women, patients

experiencing cognitive impairment and any patient who did not agree to participate in

the study were excluded.

2.2. Setting:

The Sultan bin Abdulaziz Humanitarian City (SBAHC) was established in Riyadh, the

capital of KSA, on the 30th of October 2002. SBAHC was intended to be a

rehabilitation center and a provider of related healthcare services as well. The city

receives patients from throughout the country, either directly or through referrals from

other hospitals or medical centers and clinics in the kingdom.

For patients with diabetes in SBAHC, routine measurements of HbA1c, blood

glucose, blood pressure, weight, and micro albuminuria are taken. For those who are

not hospitalized, these parameters are measured every three months. The screenings

are carried out at each visit.

All adult type 2 patients who attended SBAHC and met the criteria for enrollment in

the study were invited to participate. Interviews took place in the visit room

individually and lasted approximately 15 minutes, Subject’s verbal agreement and

written consent was obtained. For patients who were illiterate, written consent was

obtained from their accompanying family member.

The data was collected after taking verbal approval from the patients themselves

to participate in the study and after they had signed the consent form. Approval from

the ethical committee at Sultan Bin Abdulaziz Humanitarian City was obtained.

Participants were assured of confidentiality of the information and that their names

would be kept confidential.

6
 2.3. Data collection:

The data were collected via:

Medical records; which were used to collect the following data:

A) Socio-demographic information

Age, gender, level of education, employment status, marital status, monthly income,

previous diabetes education, smoking status and DM duration were documented.

B) Anthropometric measurements

The participants’ height was measured without shoes, to the nearest 0.5 cm using a

stadiometer with shoulders in a relaxed position and the arms hanging freely. The

weight was measured with the patient wearing light clothing and no shoes and was

measured to the nearest 0.5 kg. BMI were computed by dividing the weight (in

kilograms) with the height squared (in meters). Normal weight was defined as BMI

18.5kg/m2 – 24.9kg/ m2, overweight was defined as BMI 25 – 29.9kg/m2 and obesity

were defined as BMI ≥30 kg/m2.

C) Clinical and Laboratory measurements

Glycated hemoglobin (HbA1c) was analyzed using high performance liquid

chromatography (HPLC) (Bio-Rad) (24), with the last result being taken, Patients

with HbA1c <7% (53 mmol/mol) were reported as having good DM control, while

patients with HbA1c >7% (53 mmol/mol) were reported as having poor DM control.

Structured questionnaire: A face-to-face structured questionnaire interview was

performed and taken by the author directly from the participants.

* The Diabetes Management Self-Efficacy Scale (DMSES)

7
The DMSES is a self-administered rating scale containing 20 items that assesses the

confidence of patients in managing their blood glucose level, foot care, medication,

diet, and level of physical activity. The Arabic version of the DMSES used by Al-

Khawaldeh et al. [7] in their study involving Jordanian patients with diabetes [7] was

used to measure diabetes management self-efficacy; the Cronbach's alpha coefficient

of internal consistency reliability of DMSE was 0.91 for the total scale [7]. The

DMSES asks the respondents to rate their confidence using a scale ranging from 0 (I

can't do at all) to 10 (certain I can do). Factor analysis of DMSES revealed that the 20

items were clustered into the following five subscales: diet or nutrition self-efficacy

representing the patients' confidence in carrying out tasks for determining meal plans;

exercise self-efficacy representing self-efficacy related to carrying out physical

exercise; blood sugar testing and control reflecting self-efficacy related to monitoring

and the control of blood sugar levels; foot care self-efficacy representing self-efficacy

to carry out tasks of examining and inspecting feet for any changes such as cuts; and

medical treatment self-efficacy—representing self-efficacy related to tasks like taking

medications and taking care of their health and these were mentioned in previous

studies [23,25,26] .

* The revised Summary of Diabetes Self-Care Activities Scale (SDSCA)

The SDSCA scale is a self-report measure asking subjects to report the number of

days in the last 7 days (prior to the initiation of the study) in which they performed

each of the 13 diabetes self-care tasks and it consists of six subscales of DSM

behaviors; diet, exercise, blood glucose testing, medication taking, foot care, and

smoking behavior. If they were sick during the past 7 days, they were asked to reflect

on the 7 days before they became sick. The SDSCA has been used widely, and its

reliability and validity has been demonstrated [27].

8
 2.4. Statistical analysis

Statistical Program for Social Sciences software 16.0 was used to analyze the data

obtained. The mean for each self-efficacy subscale was calculated for the DMSES,

with higher scores indicating higher levels of self-efficacy. For the SDSCA scale, the

mean number of days for each subscale was calculated; with higher scores indicating

a higher level of DSM performance. Descriptive statistics were used to describe

socio-demographic and clinical characteristics of the sample. Multivariate logistic

regression analysis was used to estimate relationships between the subsets of socio-

demographic and clinical characteristics, self-efficacy subscales, DSM behaviors and

glycemic control. The predictors from each subset that were found to be significant

were included in the final regression model to examine the variables that predicted

glycemic control. Moreover, a regression analysis examining the effect of each self-

efficacy subscale on its respective DSM behavior was carried out. Statistical

significance was set at p <0.05 with all tests being 2-sided.

3. Results

Demographic and clinical characteristics of the study population are presented in

Table 1. The sample consisted of 123 participants; 72.4% were male and 27.6% were

female. The majority (93.3%) were married and 17.9% reported being employed.

More than half (54.5%) were aged 60 years and above, with mean age being 61.97

years (median 63, ± 11.53). With regard to level of education, 26.8% were illiterate

while 31.7% had high school degrees. As for smoking, 59.3% reported being non-

smokers, 27.6% were ex-smokers and 13% were current smokers. More than half of

the participants (59.3%) had a monthly income lower than 8000 Saudi riyals (2133

US dollars) [(median 6000 riyals (1600 US dollars) + 6429 riyals (1714 US dollars)]

and the average duration of diabetes was 13.34 years (median 15 ± 8.33), with 52%

9
living with diabetes for ≥ 10 years. From the 123 subjects 59.3% patient had not

received any past diabetes education. Only 27.6% were of normal weight, 29.3%

were overweight and 43.1% were obese. Current pharmacological treatment consisted

of oral hypoglycemic medications in 52.8% of the patients; insulin only as a treatment

was shown in 21.1% of the patients, and 26% used a combination of insulin and oral

hypoglycemic medications. The mean value for glycemic control as measured by

HbA1c was 7.637 (60 mmol/mol) ±1.7053; using a cut of point according to the

ADA, 43.1% had controlled DM, whereas 56.9% had a level of ≥7 (53 mmol/mol),

suggesting that their DM was not in control. The two most frequently present

comorbid conditions were hypertension (70.7%) and dyslipidemia (69.1%).

The highest self-efficacy score was for "efficacy to carry out prescribed medical

treatment" [mean=7.7, median = 8.3, S.D.=±1.77], and the lowest self-efficacy score

was for "efficacy to carry out diet control" (mean=5.07, median = 4.8, S.D.=±2.63).

Table 2.1 illustrates the mean (±S.D.) for each item of the DMSE scale. The item “I

am confident that I am able to take my medications as prescribed” scored the highest

(mean = 9.4, median = 10, S.D.= ±1.57), followed by “I am confident that I am able

to visit my doctor according to treatment plan to monitor my DM” (mean = 7.6,

median = 9, S.D.= ±3.021). The lowest-scored items were “I am confident that I am

able to keep my weight under control” (mean = 4.42, median = 5, S.D. = ±3.4) and “I

am confident that I am able to follow a healthy eating pattern when I am on holiday”

(mean = 4.51, median = 5, S.D. = ±3.43).

Table 2.2. shows the means and medians for the five DSM subscales behaviors. The

most frequently reported DSM behaviors were foot care (mean = 4.4, median = 4.5,

S.D. = ±1.83) followed by medication taking self-management behavior (mean =

4.15, median = 3.5, S.D. = ±1.68). The least frequently reported DSM behaviors were

10
exercise self-management behavior (mean = 1.4, median = 0, S.D. = ±2.14) and blood

sugar testing behavior (mean = 3.73, median = 4, S.D. = ±2.63). Table 2.2. also shows

means and medians for the 15 items of the SDSCA calculated for the whole sample

per week. The most frequently reported DSM behaviors were "washes feet" (mean =

6.46, median = 7, S.D. = ±1.3) and "taking oral hypoglycemic agents" (mean = 5.25,

median = 7, S.D. = ±2.97). The lowest frequently reported DSM behaviors were

participation in specific exercise sessions (mean = 1.29, median = 0, S.D. = ±2.14)

and participating in at least 30 mint of physical activity (mean = 1.5, median = 0, S.D.

= ±2.27).

Table 3 shows four out of five self-efficacy subscales to be statistically significant

predictors of their respective DSM behaviors. The significant subscales were diet,

exercise, blood sugar testing and foot care; the self-efficacy of each significantly

predicted their respective behaviors. Self-efficacy was associated with higher levels of

diet, exercise, blood sugar testing, and medication taking self-management behaviors.

Medical treatment self-efficacy subscale was not found to predict medical treatment

self-management behavior (p= 0.369).

Do socio-demographic and clinical characteristics, self-efficacy beliefs for diabetes

management, and DSM behaviors predict glycemic control in patients with type 2

diabetes?

A separate logistic regression analysis that estimated each of the three subsets of

variables with glycemic control was conducted (Table 4). The significant predictors of

glycemic control from each subset of variables were included in a logistic regression

model to estimate their independent effects on HbA1c. The variables that were found

to have a significantly independent effect on HbA1c were duration of diabetes, OHA

use, insulin use, BMI, diet and exercise self-efficacy, blood sugar testing self-efficacy,

11
diet self-management behavior, exercise self-management behavior and blood sugar

testing self-management behavior. Forest plot graph showed that the variables age,

household income, education, marital status, employment, diabetes education,

medical treatment self-efficacy, foot care self-efficacy, medication taking self-

management behavior and foot care self-management behavior had no effect on

glycemic control with p >0.05. Predictors of good glycemic control were OHA use

(OR = 0.181; p= 0.000), high diet self-efficacy (OR =0.115; p=0.000), high exercise

self-efficacy (OR = 0275; p= 0.003), high blood sugar testing self-efficacy (OR =

0.321; p= 0.003), high diet self-management behavior (OR = 0.087; p=0.000), high

exercise self-management behavior (OR = 0.308; p= 0.004), and high blood sugar

testing self-management (OR = 0.219; p= 0.000). The second regression analysis

found diet to be the only self-efficacy subscale to be a statistically significant

predictor of glycemic control HbA1c <7% (53 mmol/mol) (Table 4).

Table 5 shows results of a final parsimonious regression model that included all of the

statistically significant predictors from the subset analysis shown in Table 5. This

model showed that diet self-management behavior and OHA use were significantly

independent predictors of glycemic control HbA1c < 7 (53 mmol/mol) (p<0.05).

4. Discussion

We found that 56.9% of the study participants had uncontrolled HbA1c, suggesting

poor diabetes control. Similar to our findings, a study from Jordan found 56.5% of

their study participants to have poor diabetes control [7,17]. A possible reason for the

comparable findings may be due to cultural similarities that are present among the

two sets of patients. Similarly to what was observed by Al-Khawaldeh et al. [7] in

their sample of Jordanian diabetes patients, our sample of patients exhibited low

levels of self-management behaviors that could have contributed to their higher A1c

12
values [7, 29]. The low levels of DSM behaviors may be due to factors not measured

in this study such as socioeconomic status; whereby self-efficacy has been reported in

the literature to be lower in individuals from disadvantaged populations [29].

We found foot care and complying with medication regimen to be the most frequently

performed self-care behaviors seen among our study participants, whereas the least

performed self-care behaviors were exercise and SMBG. A likely explanation as to

why foot care was among the most frequently performed self-care behaviors can be

linked to the Islamic practice of ablution; which includes the washing of parts of the

body including the feet in preparation for prayer. Another reason may be due to the

population’s cultural dress code, whereby in Saudi Arabia the cultural dress code

includes wearing open shoes with feet and toes exposed- placing high importance on

foot care. This factor may lead the population to place more attention and care of their

feet since they are publicly exposed. In addition, compliance to medication is also the

most frequently performed self care behavior because patients receiving treatment at

the hospital are insured, and thus receive their medication at no cost, making access

to, and in turn, adherence to medications less challenging [32-33].

Barriers to adherence to diet, exercise and BG testing scored low on self-management

behaviors – possibility related to the lack of team-focused education on the

importance of each in diabetes management in the hospital.

We found the most statistically significant predictors of glycemic control to be diet

self-management behavior and OHA use. These results coincide with the statements

by the ADA which indicate that achieving near normal or normal levels of blood

glucose requires education in self-management as well as intensive treatment

13
programs which among others, includes MNT, regular exercise and frequent self-

monitoring of blood glucose [17].

Furthermore, we found that subjects who exhibited greater diet self-management

behavior, who had previously received diabetes management education, and who

were taking OHAs had lower HbA1c levels. This finding is consistent with previous

studies indicating that greater diet self-management behavior is associated with better

glycemic control [7,18,19,20].

The use of OHAs was also found to be a significant predictor of good glycemic

control whereas use of insulin therapy was significantly greater among patients who

showed worsening glycemic control (>7%). A possible reason for this finding may be

that OHAs are usually prescribed as the primary treatment therapy in patients with

DM 2; whereas insulin is introduced into the therapy as a result of worsening

glycemic control [7].

We found self-efficacy to significantly predict self-management of certain behaviors;

whereby patients who had a stronger perception/belief of self-efficacy in following a

diet, performing exercise, blood sugar testing and care for feet were found to be more

likely to exhibit self-management behaviors in them. These findings are consistent

with the literature that has shown specific self-efficacy ratings to be significant

predictors of DSM behaviors [21-23]. Self-efficacy is a “social cognitive” concept

that has behavioral foundations; among which is the motivation for the individual to

initiate and persist on a certain a behavior even when faced with difficulties,

depending on the magnitude of the efficacy expectations. Self-efficacy is driven by

the subject’s expectations that following a specific behavior will result in benefits and

reduce risk of future difficulties [34].

14
The findings also support the theory by Bandura et al. [16], which states that people

tend to avoid tasks, and situations that they believe exceed their capabilities, while

pursuing those that they feel competent to perform.

Moreover, diet self-management behavior was found to be an independent predictor

of better glycemic control (p<0.05). Self-efficacy is driven by the subject’s

expectations that following a specific behavior will result in benefits and reduce risk

of future difficulties [34]. Since self-efficacy predicts self-management behaviors,

belief that diet control can in a certain component drive self-management behavior in

that component, patients that perceived self-efficacy in diet control are more likely to

practice it. A greater glycemic control is anticipated following dietary self-

management behavior and this is supported by literature which has found that patients

who followed specific diet-related behaviors had significantly lower A1cs compared

to those that did not follow these behaviors [31]. As a result, clinicians should

emphasize meal plan counseling for their patients as part of their diabetes

management education and treatment.

Several limitations are to be considered in this study. First, the fact that

recruitment of patients was performed in only one clinical setting raises questions

concerning the generalizability of our findings. Sultan bin Abdulaziz Humanitarian

City in Riyadh however, receives its patients from throughout the city either from

hospitals or other medical centers and clinics, thus increasing representativeness of

the sample. Second, the cross sectional nature of the study limits the definitive causal

interpretations between self-efficacy beliefs and DSM behaviors and glycemic

control. In order to be able to show causality, future longitudinal prospective studies

are needed. Third, the possibility of a recall bias cannot be ruled out in self-reports of

self-management, making the findings of this study reliant upon the accuracy of the

15
subject’s self-evaluation. Nevertheless, the findings of this study have succeeded in

confirming previous findings from other studies as well as provide new insights.

It has been shown that adopting self-management skills by patients with diabetes is

crucial to help them in managing their diabetes [35]. In a report on therapeutic patient

education by the World Health Organization, patient-centered education has been

shown to be important in the effective management of chronic disease [39]. The

findings from this study can serve to help clinicians have a better understanding on

the extent to which different self-efficacy parameters have an influence on self-

management behaviors, which will in turn lead to better glycemic control and thus

improved A1c levels. Further prospective studies are needed to further understand the

effect of self-efficacy on self-management behaviors and what that means in terms of

obtaining good glycemic control.

Conflict of interest

The authors declare that they have no conflict of interests that could affect their

objectivity.

Acknowledgments

16
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Table 1. Socio-demographic and clinical characteristics of the study participants.

Variable N (%)*

Sex Male 89 (72.4%)

Female 34 (27.6%)

Age <60 years 56 (45.5%)

≥60 years 67 (54.5%)

Education level Illiterate 33 (26.8%)

Intermediate 40 (32.5%)

High School 11 (8.9%)

University 39 (31.7%)

Smoking Non smoker 73 (59.3%)

Ex-Smoker 34 (27.6%)

Current Smoker 16 (13.0%)

DM Duration <10 years 59 (48.0%)

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 ≥10 years 64 (52.0%)

Pre-diabetes education No 73 (59.3%)

Yes 50 (40.7%)

Marital status Single 8 (6.5%)

Married 115 (93.5%)

Employment status No 101 (82.1%)

Yes 22 (17.9%)

Monthly Income <8000 riyals (<1233 73 (59.3%)

US dollars)

≥8000 riyals (>1233 46 (37.4%)

US dollars)

BMI <25 (normal) 34 (27.6%)

25-29.9 (overweight) 36 (29.3%)

≥30 (obese) 53 (43.1%)

Retinopathy No 62 (50.4%)

Yes 61 (49.6%)

Hypertension No 36 (29.3%)

Yes 87 (70.7%)

Dyslipidemia No 38 (30.9%)

Yes 85 (69.1%)

Heart diseases No 97 (78.9%)

Yes 26 (21.1%)

Lung diseases No 117 (95.1%)

Yes 6 (4.9%)

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 Kidney diseases No 108 (87.8%)

Yes 15 (12.2%)

Stroke No 56 (45.5%)

Yes 67 (54.5%)

OHA treatment only No 58 (47.2%)

Yes 65 (52.8%)

Insulin treatment only No 97 (78.9%)

Yes 26 (21.1%)

OHA+Insulin treatment No 91 (74%)

Yes 32 (26%)

HbA1c <7 (53 mmol/mol) 53 (43.1%)

≥7 (53 mmol/mol) 70 (56.9%)

*Values in this table represent n and % for the categorical variables

Table 2. The Diabetes Management Self-Efficacy Scale and Diabetes self-care

activities of the study participants.

2.1. The Diabetes Management Self-Efficacy Scale (n=123)

Subscale Items (scale 0=cannot do, 10=can do) Mean Median

I am confident that I am able to:

Diet 5.07
4.8
Choose the correct foods 5.71 5

Choose different foods and stick to a healthy eating pattern 5.62 5

Keep my weight under control 4.42 5

Adjust my eating plan when ill 5.09 5

Follow a healthy eating pattern most of the time 5.65 5

Follow a healthy eating pattern when I am away from home. 4.55 5

Adjust my eating plan when I am away from home 5.83 5

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 Follow a healthy eating pattern when I am on holiday 4.51 5

Follow a healthy eating pattern when I am eating out or at a party 4.67 5

Adjust my eating plan when I am feeling stressed or anxious 4.69 5

Exercise 5.53 6

Do enough exercise 4.93 5

Do more exercise if the doctor advises me to 6.23 7

When taking more exercise, I am able to adjust my eating plan 5.45 5

Blood sugar testing and 6.49 6.66

control Check my blood sugar if necessary 6.59 8

Correct blood sugar when the sugar level is too high 6.16 7

Correct my blood sugar when the blood sugar level is too low 6.73 7

Medical treatment 7.73 8.33

Visit my doctor according to treatment plan to monitor my

7.60 9
diabetes

Take my medication as prescribed 9.40 10

Adjust my medication when I am ill 6.20 5

Foot care 7.27 9

Examine my feet for cuts 7.27 9

2.2. Diabetes self-care activities of the study participants (n=123)

Subscale mean Subscale items Mean Median

Diet 3.75 3.8

Follows a healthy eating plan 3.81 3

Follows eating plan over the past month 2.60 3

Eats 2 to 3 servings of fruits 4.43 4

Eats 5 or more servings of vegetables 5.08 7

Eats high-fat foods 2.83 2

Exercise 1.4 0.0

Participates in at least 30 min of

1.51 0.0
physical activity

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 Participates in specific exercise session 1.29 0.0

Blood sugar testing 3.73 4

Tests for blood sugar 4.05 4

Tests blood sugar as recommended by health care provider 3.42 4

Foot Care 4.4 4.5

Checks feet 4.97 7

Inspects the inside of shoes 2.57 0.0

Washes feet 6.46 7

Dries between toes after washing 3.62 4

Taking medication 4.15 3.5

Takes insulin 3.06 0.0

Takes oral hypoglycemic 5.25 7

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Table 3. Spearman regression analysis assessing the association between self-

efficacy and self-management behavior in relation to the five listed parameters.

Independent variables R Adjusted R2 P value

Diet 0.390 0.145 0.000

Exercise 0.505 0.248 0.000

Blood sugar testing and control 0.318 0.094 0.000

Medical treatment 0.082 0.002 0.369

Foot care 0.439 0.186 0.000

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 Table 4. Logistic regression between the socio-demographic and clinical

characteristics, diabetes self-efficacy subscales, self-management behavior and

glycemic control.

Variable OR 95% CI P-value

Gender 2.243 0.962 - 5.232 0.069

Age 0.983 0.480 - 2.012 1.000
Income 0.879 0.418 - 1.847 0.850
Education 0.872 0.645 - 1.177 0.370
Marital status 0.418 0.081 - 2.161 0.464
Employment 0.712 0.282 - 1.795 0.486
Duration of Diabetes 2.114 1.023 - 4.369 0.047
Oral hypoglycemic agents 0.181 0.082 - 0.399 0.000
Insulin 4.114 1.435 - 11.797 0.007
Diabetes Education 0.819 0.396 - 1.692 0.711
BMI 1.829 1.169 - 2.864 0.008
Self-Efficacy variables
Diet 0.115 0.046 - 0.287 0.000
Exercise 0.275 0.115 - 0.656 0.003
Blood sugar testing and control 0.321 0.153 - 0.675 0.003
Medical treatment 1.641 0.770 - 3.495 0.247
Foot care 1.992 0.965 - 4.111 0.070
Self-management variables
Diet 0.087 0.036 - 0.206 0.000
Exercise 0.308 0.142 - 0.668 0.004
Blood sugar testing and control 0.219 0.101 - 0.475 0.000
Taking Medication 2.241 0.932 - 5.385 0.093
Foot Care 0.843 0.413 - 1.723 0.717

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Table 5. Multivariate logistic regression of the seven variables and glycemic

control.

Variable Wald P-value

Oral hypoglycemic agents 10.3 0.001

Diet self-efficacy 2.9 0.084
Exercise self-efficacy 0.007 0.933
BS testing self-efficacy 0.730 0.393
Diet self-management 17.7 0.000
Exercise self-management 1.2 0.273
BS testing self-management 3.4 0.065

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Highlights

 We found foot care and complying with medication regimen to be the most frequently

performed self-care behaviors seen among our study participants.

 We found self-efficacy to significantly predict self-management of certain behaviors;

whereby patients who had a stronger perception/belief of self-efficacy in following a

diet, performing exercise, blood sugar testing and care for feet were found to be more

likely to exhibit self-management behaviors in them

 We found the most statistically significant predictors of glycemic control to be diet

self-management behavior and OHA use

27