Statement of Problems

A range of illnesses collectively referred to as diabetes are characterized by elevated blood

glucose levels. Protein and lipid metabolic diseases are the result of a shortage in the generation
or action of insulin, or both, which can happen for a variety of causes(1).

Type 1 diabetes means (T1D), their immune system targets the beta cells in their pancreas,
which are in charge of manufacturing insulin and the hormone needed to turn food into
energy(2). The country with the highest prevalence of type 1 diabetes in the world more than 40
cases per 100,000 people annually Finland, has seen the most notable increase(3) .The
prevalence of types 1(DM) numerous African nations surrounding the Mediterranean Sea and the
Middle East have access to reliable data. Between 1/100,000 per year Pakistan and 8/100,000 per
year (Egypt(3). The prevalence of type 1 DM in Ethiopia, account for 9.8% of patients attending
Diabetes clinic in Addis Abeba(4).

However control of type 1 diabetes has been shown to depend on adherence to diabetic self-
management. The body of evidence revealed that numerous trials had produced clinical
recommendations. These clinical recommendations call for adherence to the rules on exercise,
insulin administration management, food management, blood glucose testing, and hypoglycemia
management in order to control the disease on their own(5).

Despites of the fact that the prevalence of, poor adherence to diabetes self-management is the
most frequent cause of type 1 diabetes that is not under control. Poor adherence is present in
about 20% of high-income nations such as America(6). While the exposure to easily controllable
risks factors has a particularly negative impact on the population in low- and middle-income
countries. For instance, a study in Palestine found that, 66%, 89%, 79%, and 21% of T1D
teenagers do not comply to glucose monitoring, food control, exercise, or insulin administration
respectively(7). Researchers attempted to foresee variables that would improve or impede
adherence to diabetic self-management. Time since disease diagnosis, self-efficacy, social
support, awareness of disease, comorbidities, and sociodemographic variables were some of the
contributors3,21. Furthermore, the socioeconomic conditions and psychological
characteristics of adolescents are strongly associated with adherence to diabetes self-
management 22
Adolescents find it extremely challenging to follow a structured diabetes self-
management strategy and its domains. Access to insulin and self-management
resources, including formal diabetes education, is limited in many nations, particularly
for families who are economically poor. Due to the accumulation of dangerous
compounds known as "ketones" in the body, this could result in severe impairment and
early death23. Therefore, the only way to enhance health behaviors and health status is
by effective adherence to diabetic self-management through the creation of a trusting
and motivating connection between health care professionals and the teenager24.
Few studies have been undertaken to demonstrate the gap and scope of the problem,
despite the fact that the issue of adherence to diabetic self-management calls for
intense devotion and considerable attention. To the best of the researcher's knowledge,
no research has been published that examines factors related to diabetes self-
management compliance among teenagers with type 1 diabetes in the study area.
Therefore, the aim of this study will be to assess adherence to diabetes self-
management of adolescents with type1diabetes and associated factors in the study
area. Hence, such types of data would show the level of poor adherence and will be
essential for the care delivery services of the adolescents to fill the gaps.

2. Literature review
2.1 Adherence to Diabetes Self-management
Adherence to diabetes self-management follows and emphasizes a person-centered model of care
through the integration of tools and programs into routine care. This element of the chronic care
model is about how people could be empowered to take control and improve their self-
confidence to manage the disease(1).

According to a study done at Indiana University in the United States, teenagers with T1D should
have their ability to take care of themselves evaluated. This achievement has relevance for
adolescents' ability to control their diabetes, their psychosocial well-being, and their short- and
long-term health(2).

For most nations, the proportion of adolescents who do not comply with their diabetes self-
management practice is relatively high. In Iraq, for instance, a descriptive study revealed that, of
100 adolescents with T1D, about 46% have poor adherence to diabetic self-management(3).
Similarly, another study found in Palestine reveals that 60% of teenagers with T1D don't follow
their own diabetes self-management regimens(4).
Furthermore, a study conducted in Uganda and Cameroon shows that the prevalence of poor
adherence to diabetes self-management of adolescents are 63% and 67.4% respectively(5) (6).

Despite the fact that most scholars have focused on adherence to medication, adherence also
encompasses other health-related behaviors that extend beyond taking prescribed drugs. Studies
that determine overall adherence to diabetes self-management among adolescents are limited.
The need for active self-management practices to prevent diabetes-related morbidity and
mortality is substantial(7).

One study conducted in Addis Ababa public health hospitals, the prevalence of poor adherence
to diabetes self-management of adolescents with type 1 diabetes were about 53%(3).

2.1.1 Adherence to Insulin Administration

The prevalence of poor adherence to insulin administration in adolescents with T1D is generally
poor for most countries in the world. For instance, a study found in Pakistan revealed that 88.1%
of adolescents did not follow their prescribed insulin regimen(8). Another study conducted in the
Netherlands showed that adherence to the insulin administration self ‐ management domain in
adolescents declined with increasing age due to the switching over self ‐management from
parents to the adolescents themselves(9).

Furthermore, a study conducted in Uganda, revealed that out of 150 participants 32% did not
take their insulin medication as prescribed(10).

Similarly, study conducted in Addis Ababa public hospital, indicated that the prevalence of poor
adherence to insulin administration were about 57% of adolescents(3).

2.1.2 Adherence to Dietary Management

According to the American Diabetes Association (ADA), adolescents' poor adherence to dietary
control is a result of their behavioral issues and a lack of knowledge. As a result, many teenagers
with T1D struggle to stick to and don't follow the recommended diet for their condition (11).

For adolescents with type 1 diabetes, the challenge in adherence to dietary management is to
maintain good glycemic control while providing adequate energy for growth and development.
For instance, a study conducted in Australia revealed that modification in dietary advice for
adolescents was required, depending on their developmental stage(12).
Currently, adolescents' poor dietary management adherence is more prevalent and increasing
rapidly. For example, a study conducted in Pakistan revealed that out of 194 adolescents, 58.5%
of them were non-adherent to dietary recommendation (8). Nevertheless, a nationwide survey
conducted out in Brazil revealed that 45.8% of adolescents reported not adhering to dietary
management(13).

A study conducted in Addis Ababa public hospital, indicated that about 68% of adolescents with
T1D were poor adherence to dietary management(3).

2.1.3 Adherence to Management of Hypoglycemia

Adolescents' quality of life is negatively impacted by poor hypoglycemia management. For
instance, a study conducted in the United States found that inadequate management of
hypoglycemia worsens depression symptoms(14).

During the management of hypoglycemia attention should be given for prevention of

hyperglycemia. For instance, a study conducted in Australia found that the mothers who worry
most about hypoglycemia maintain their child’s blood glucose levels above recommended
levels(15).

In general, new and emerging technologies can help to regulate hypoglycemia even if it is a
concern for adolescents with T1D. For instance, a study in Switzerland found that flash
monitoring was a crucial strategy for enhancing adolescents with type 1 diabetes' adherence with
glucose monitoring and detecting hypoglycemia(16).

A study conducted in Addis Ababa public hospital respondents (31.4%) always keep something
handy in case their sugar gets too low and 40.3% of them sometimes check their low blood sugar
before treating it(3).

2.1.4 Adherence to Blood Glucose Testing

According to the American Diabetes Association, it was critical to regularly check blood sugar
levels before, during, and after exercise in order to prevent, detect, and treat abnormal blood
glucose levels(1).

According to a study in Brazil, poor glycemic control, which is prevalent in T1D, is also
associated with lower literacy, a self-perceived lack of diet adherence, and inadequate HbA1c
level monitoring. Certain measures, especially those aimed at enhancing adherence to diet and
insulin may help with the effective management of T1D(17).

Poor adherence to blood glucose testing among adolescents was reported from different countries
worldwide. For instance, a study conducted in Palestine revealed that approximately 66% of
patients reported significant non-adherence to blood glucose testing(4). Similarly, most of the
African adolescents with T1D poorly control their blood glucose level. For example, a study
conducted in Kenya identified that the median of adolescents participated in the study poorly
controlled their blood glucose(18).

Moreover, a study conducted in Addis Ababa public hospital, around half of respondents always
checked their blood sugar and 28% of them almost never did a blood glucose testing with 30
minutes before a meal. About 51% of respondents almost never did a blood glucose testing
within 2-3 hours after heavy exercise.in general the prevalence of , blood glucose testing
adherence were only 45% of them(3).

2.1.5 Adherence to Regulation of Exercise

Adolescents with T1D who don't exercise regularly have a variety of negative effects on
themselves, the healthcare system, and the public at large. For instance, according to the World
Health Organization (WHO), 3.2 million people die each year as a result of inactivity(19).
Similarly, a review of studies done in America revealed that Poor adherence to exercise in
adolescents with T1D decreases cardiorespiratory fitness, body composition, bone health, insulin
sensitivity, and psychosocial well‐being(20).

Furthermore, a study conducted in Britain revealed that there were strong correlations between
depressive symptoms and physical inactivity(21).

The Prevalence of poor adherence to exercise in adolescents with type 1 diabetes is very high in
the world. For instance, a study conducted in Portugal revealed that 35% of adolescents with
T1D had poor involvement in physical activity(22). Another study conducted in Pakistan showed
that out of a total of 194 patients 42.3% are non-adherent to physical activity(8).

Furthermore, a study conducted in Addis Ababa public hospital revealed that more than half of
adolescents with T1D were non adherence to regulation of exercise(3).
2.2 Factors Associated with Adherence to Diabetes Self-Management

2.2.1 Socio Demographic Factors

According to an Oxford University study, older adolescents reported lower adherence scores to
diet, exercise, and glucose monitoring compared to preadolescents(23). Moreover, a study
carried out in Tanzania revealed that younger individuals had better adherence to diabetic self-
management than older adolescents(24).Moreover, Study in Addis Ababa shows that younger
adolescents more likely adherence to diabetic self-management than older adolescents(3).

An Australian systematic review revealed that among young people with type 1 diabetes, there
was no correlation between gender and adherence to diabetic self-management(25). However;
study conducted in London, found that female’s adolescents were more likely adherent to
diabetes self-management than males(26).

According to a study done in Cameroon, teenagers with tertiary-level education (college or

university) were 30% more likely to adhere to glycemic control than teenagers who couldn't read
or write(6).Similarly, study in Addis Ababa, Ethiopia indicated that adolescents with tertiary-
level education (college or university) were more likely to adhere to glycemic control than
teenagers who were secondary level education(3).

2.2.2 Medical factors

Time since Diagnosis

Those adolescents with a shorter history of T1D were found to adhere to their diabetes self-
management regimens better than adolescents with a longer history. For instance, a study
conducted in America found that adolescents with shorter durations of diabetes self-managed
their illness significantly more than those with longer durations of the illness(27). Similarly, a
study conducted in Tanzania illustrated that adolescent with shorter diabetes duration since
diagnosis had a better adherence to diabetes self-management than adolescents with longer
duration(24). Similarly, study in Addis Ababa, Ethiopia indicated that adolescents with less than
5 years diabetic duration more likely adherence to diabetes self-management than adolescents
with 6 and above years diabetic duration(3).
.Even though, a study conducted in Cameroon showed that adolescents with above 2 years’ time
since diagnosis had 93% better adherence to glycemic control than those with time since
diagnosis below 2years (6).

Co-morbidities

Comorbidity is one patient specific factor that affects T1D control in adolescents. Hypertension,
heart failure, cardiomyopathy, strokes, coronary artery disease, Peripheral vascular disease,
epilepsy, cancer, asthma, cognitive dysfunction and dementia are among comorbidities
associated with T1D (28-30).

According to a study done at Jimma University medical center in Ethiopia, type 1 diabetes is
strongly linked to retinopathy, peripheral neuropathy, hypertension, and nephropathy(31).

2.2.3 Knowledge about Type 1 Diabetes

Adolescents’ knowledge about type 1 diabetes is very important for management of the disease.
For instance, a study conducted in Jacksonville, America illustrated that, greater youth
knowledge predicted better treatment adherence (32).

According to a study done in Uganda, teenagers with poor knowledge of type 1 diabetes were
68% and adolescents with moderate knowledge were 51% less likely to adhere to diabetic self-
management than adolescents with good knowledge of the disease(5) . Moreover, study in Addis
Ababa, Ethiopia indicated that adolescents with good knowledge of type 1 diabetes were more
likely to adhere to diabetic self-management than adolescents with poor knowledge of the
disease(3).

2.2.4 Self-efficacy
A systematic review of studies conducted in Columbia illustrated that providing care and support
can improve adherence to diabetes self-management by increasing self-efficacy(33). Another
study conducted in Spain showed that 32% of patients were unable to follow the treatment
recommendations for the management of their disease due to lack of self-efficacy(34).
Furthermore, study conducted in Iran showed that self-efficacy is a significant determinant factor
for successful adherence to diabetes self-management(35). Similarly, study conducted in Addis
Ababa, Ethiopia showed that adolescents with good self-efficacy were strongly significant factor
for good adherence to diabetes self-management(3).
2.2.5 Social Support
Lack of Social support is significantly associated with low quality of life, poor adherence to
diabetes self-management and high level of HbA1c. For instance, a Denmark study found that
poor diabetes self-management and high diabetic distress were substantially correlated with a
lack of social support(36). Furthermore, study conducted in Uganda showed that adolescents
who had social support were more likely adherent to diabetes self-management than who had no
social support(5). Similarly, study conducted in Addis Ababa, Ethiopia revealed that adolescents
who had social support were more likely adherent to diabetes self-management than who had no
social support(3).

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