The impact of existing diabetes self-management education interventions on knowledge, attitudes and practices in public health care institutions in Harare, Zimbabwe

Figures & data

Figure 1: Sampling strategy for clinic selection.

Table 1: Knowledge, attitudes and practices questionnaire items

	Subscale	Items	Total number of items
Knowledge	Diet self-management	How should a healthy meal look like on a plate?	5
		Which of the following foods will raise blood sugar the most?
		Does eating unrefined wholegrains help control blood sugars?
		Which of the following foods has the highest starch (carbohydrate) content?
		Which of the following foods has the highest fat content?
	General self-management	If one is overweight, weight loss is a strategy to prevent diabetes?	6
		Eating less sugar is a strategy to prevent diabetes?
		Exercising regularly is a strategy to prevent diabetes?
		Which of the following foods can be eaten to treat low blood sugar?
		What effect does exercise have on blood sugar for a person with good blood sugar control?
		Low-fat foods reduce a person’s risk for which condition?
Attitudes	Diet self-management	Following a prescribed diet can help to keep my sugars under control	5
		I find it difficult to follow a prescribed diet that helps control my blood sugars
		Diet is just as important as medication in controlling blood sugar
		My diabetes and its treatment keep me from eating the foods that I like
		My diabetes and its treatment keep from eating as much as I like
	General self-management	I think it is important to keep good blood sugar control	8
		My health depends on taking my diabetes medication
		Regular exercise is not an important part of keeping good control of my blood sugars
		I feel I have the skills necessary to keep my blood sugar in control
		Traditional/herbal medicines are more effective than medicines prescribed by doctors in treating diabetes
		My diabetes and its treatment keep me from being as active as I want
		In general, I believe that most people can still enjoy life and keep tight blood sugar control
		I do not think that being overweight can make it harder for me to control my blood sugars
Practices	Diet self-care behaviours	How many days in the past seven days have you followed an eating plan or health professional advice to plan your meals?	5
		How many days in the past seven days have you controlled your portions of starch by measuring how much you eat at meals?
		How many days in the past seven days have you eaten unrefined whole grains?
		How many days in the past seven days have you eaten at least two fruits in a day?
		How many days in the past seven days have you eaten at least three portions of vegetables in a day?
	Physical activity self-care behaviours	How many days of the past seven days have you participated in at least 30 min of physical activity (emphasis on the total minutes of continuous activity)?	2
		How many days of the past seven days have you participated in a specific exercise session (such as walking, running, playing sport) other than what you do around the house or as part of your work?

Table 2: Demographic characteristics of participants.

		Tertiary outpatient clinics		Primary outpatient clinics		All groups
Variable		n	%	n	%	n	%
Gender (n = 154)	Male	26	33.8	25	32.5	51	33.1
	Female	51	66.2	52	67.5	103	66.9
Age (years), mean (SD±)(n = 154)*		59.2 ( ± 13.2)		64.4 ( ± 11.7)		61.8 ( ± 12.7)
Education level (n = 153)	Never went to school	4	5.2	3	3.9	7	4.6
	Completed some primary school	27	35.1	29	38.2	56	36.6
	Completed all primary school	13	16.9	14	18.4	27	17.8
	Completed some secondary	16	20.8	13	17.1	29	18.9
	Secondary O-level	15	19.4	13	17.1	28	18.3
	Post-secondary	2	2.6	4	5.3	6	3.9
Duration of diabetes (years), mean (±SD) (n = 154)**		8.5 (± 9.2)		7.6 (± 7.3)		8.1 (± 8.3)
Type of medication (n = 154)	Oral	54	70.1	66	85.7	120	77.9
	Oral/insulin	13	16.9	7	9.1	20	13.0
	Insulin	10	13.0	1	1.3	11	7.1
	Not on medication	0	0	3	3.9	3	1.9
Self-reported DSME (n = 154)	Yes	74	96.1	65	84.4	139	90.3
	No	3	3.9	11	14.3	14	9.1
	Do not know	0	0	1	1.3	1	0.6
Place/site for DSME (n = 130)	Tertiary outpatient clinics	72	97.3	51	91.1	123	94.6
	Primary outpatient clinics	0	0	4	7.1	4	3.1
	Other	2	2.7	1	1.8	3	2.3
Consultation with dietitian (n = 154)	Yes	48	62.3	28	36.4	76	49.4
	No	23	29.9	41	53.2	64	41.5
	Do not know	6	7.8	8	10.4	14	9.1
Consultation with a diabetes educator (n = 154)	Yes	50	64.9	30	39.0	80	52.0
	No	20	26	41	53.2	61	39.6
	Do not know	7	9.1	6	7.8	13	8.4
Primary diet information (n = 154)	Media (internet, TV, radio, newspapers)	5	6.5	10	13.0	15	9.8
	Dietitian	25	32.5	15	19.5	40	25.9
	Doctor	27	35.1	27	35.1	54	35.1
	Nurse	16	20.8	17	22.1	33	21.4
	Other (non-health professional)	3	3.9	5	6.5	8	5.2
	No information	1	1.3	3	3.9	4	2.6

*Age difference between tertiary hospital clinic attendees and primary clinic attendees (p = 0.02) by Mann–Whitney U-test.

**Difference between tertiary hospital clinics and primary clinics for duration of diabetes (p = 0.77) by Mann–Whitney U-test.

SD± = standard deviation.

Table 3: Mean diabetes knowledge scores, characteristics of diabetes education, clinic type and education level.

	Nutrition self-management knowledge	General self-management knowledge	Overall DSME knowledge
Variables	Mean (SD) (Max score = 5)	Mean (SD) (Max score = 6)	Mean (SD) (Max score = 11)
Final score	3.10 (1.40)	4.50 (1.50)	7.60 (2.50)
Clinic groups
Tertiary outpatient clinics	3.50 (1.30)	4.80 (1.20)	8.30 (2.20)
Primary outpatient clinics	2.80 (1.30)	4.20 (1.60)	6.90 (2.60)
p-value  Mann–Whitney U-test	< 0.001	0.02	< 0.001
Consultation with a diabetes educator
Yes	3.5 (1.4)	4.90 (1.10)	8.4 (2.00)
No	2.7 (1.4)	4.10 (1.80)	6.90 (2.50)
p-value Mann–Whitney U-test	< 0.001	< 0.001	< 0.001
Consultation with a dietitian
Yes	3.70 (1.10)	4.90 (1.20)	8.60 (2.00)
No	2.60 (1.20)	4.20 (1.60)	6.80 (2.30)
p-value Mann–Whitney U-test	< 0.001	0.01	< 0.001
Primary diet information
Media	3.30 (1.00)	5.07 (1.20)	8.30 (2.30)
Dietitian	4.00 (1.20)	5.10 (1.00)	9.10 (1.90)
Doctor	2.90 (1.30)	4.10 (1.60)	7.00 (2.60)
Nurse	2.80 (1.20)	4.50 (1.50)	7.20 (2.30)
No information received	1.80 (1.30)	3.30 (2.80)	5.00 (2.90)
Other	2.80 (1.40)	3.90 (1.4)	6.60 (2.40)
p-value Kruskal–Wallis test			< 0.01
Education level
Post-secondary	3.85 (1.70)	4.75 (1.40)	8.60 (2.75)
Secondary	4.17 (1.35)	5.30 (1.15)	9.47 (3.07)
Primary	2.80 (1.30)	4.30 (1.45)	7.10 (2.35)
None	2.40 (1.10)	4.30 (1.50)	6.70 (2.40)
p-value Kruskal–Wallis H-test			0.01

Table 4: Mean attitude scores, history of diabetes self-management education, clinic type and education level.

	Diet attitudes	General-self management attitudes	Total attitudes
Variables	Mean (SD)	Mean (SD)	Mean (SD)
Overall attitudes score	3.58 (0.60)	4.02 (0.49)	3.81 (0.44)
Clinic groups
Tertiary outpatient clinics	3.69 (0.66)	4.08 (0.52)	3.90 (0.47)
Primary outpatient clinics	3.47 (0.52)	3.97 (0.47)	3.73 (0.40)
p-value Mann–Whitney U-test	0.05	0.17	0.10
Consultation with a diabetes educator
Yes	3.67 (0.64)	4.07 (0.52)	3.89 (0.47)
No	3.47 (0.54)	4.00 (0.44)	3.74 (0.40)
p-value Mann–Whitney U-test	0.11	0.33	0.19
Consultation with a dietitian
Yes	3.67 (0.62)	4.06 (0.52)	3.88 (0.47)
No	3.52 (0.61)	4.00 (0.47)	3.77 (0.42)
p-value Mann–Whitney U-test	0.24	0.60	0.30
Primary diet information
Media	3.43 (0.21)	4.10 (0.26)	3.79 (0.19)
Dietitian	3.79 (0.55)	4.09 (0.55)	3.95 (0.45)
Doctor	3.50 (0.63)	4.00 (0.51)	3.76 (0.48)
Nurse	3.61 (0.69)	4.01 (0.48)	3.83 (0.46)
No information received	3.25 (0.40)	3.86 (0.25)	3.58 (0.26)
p-value Kruskal–Wallis H-test	0.15	0.34	0.13
Education level
Post-secondary	3.74 (0.29)	3.86 (0.46)	3.75 (0.29)
Secondary	3.90 (0.43)	4.02 (0.50)	3.93 (0.43)
Primary	3.54 (0.69)	3.94 (0.53)	3.76 (0.46)
None	3.50 (0.41)	3.95 (0.52)	3.75 (0.45)
p-value Kruskall–Wallis H-test	0.24	0.41	0.41

Table 5: Diet and physical activity practices.

Variables	Mean days of dietary adherence (SD)	Mean days of physical activity (SD)
Overall adherence	3.64 (1.82)	2.81 (2.15)
Clinic groups
Tertiary outpatient clinics	3.89 (1.90)	2.82 (2.22)
Primary outpatient clinics	3.39 (1.72)	2.82 (2.11)
p-value Mann–Whitney U-test	0.11	0.98
Consultation with a diabetes educator
Yes	3.83 (1.71)	3.03 (2.07)
No	3.42 (1.84)	2.64 (2.27)
p-value Mann–Whitney U-test	0.47	0.33
Consultation with a dietitian
Yes	4.45 (1.57)	3.03 (2.07)
No	2.93 (1.75)	2.64 (2.27)
p-value Mann–Whitney U-test	< 0.001	0.02
Primary diet information
Media	3.24 (0.99)	3.50 (2.44)
Dietitian	4.67 (1.44)	3.20 (1.85)
Doctor	3.36 (1.83)	2.51 (2.12)
Nurse	3.38 (1.84)	2.82 (2.30)
No information received	1.80 (1.30)	1.63 (1.49)
p-value Kruskal–Wallis H-test	< 0.001	0.50
Education level
Post-secondary	3.90 (1.05)	1.92 (1.97)
Secondary	4.67 (1.50)	3.31 (2.16)
Primary	3.60 (1.78)	2.74 (2.14)
None	2.53 (1.64)	2.00 (1.96)
p-value Kruskal–Wallis H-test	0.24	0.53