Diabetes mellitus (DM) is a major health problem worldwide. In 2010, around 285 million adults were reported to be affected by DM globally; by 2030, it is estimated that there will be a 69% increase in the number of adults affected in developing countries (Shaw, Sicree, & Zimmet, 2010). The age affected in developing countries will be of working age (40–60 years; Jayawardena et al., 2012). In Nepal, a developing country, the prevalence of DM is around 26% in adults aged 60 and above (Chhetri & Chapman, 2009) and between 4.3% and 12% in adults aged 30 years and above (Aryal et al., 2014; Sharma et al., 2011). Factors like rapid urbanization, increasing elderly population, and lack of national health insurances in developing countries make diabetes an important health issue in Nepal, which necessitates the exploration of the diabetes self-care behaviors.
Nepal
Nepal is a small landlocked country located in south Asia and is one of the least developed countries with a gross domestic product per capita of USD 19.29 (Central Intelligence Agency, 2015). The main challenges to economic and healthcare reform are its geographical location (landlocked), difficult topography, and political instability. The number of healthcare workers available in the country is 7/10,000 population (World Health Organization threshold: 23/10,000 population; World Health Organization, 2016). The national expenditure on health is about 5.4% of the gross domestic product (Central Intelligence Agency, 2015). Community-based health insurance programs are being pilot tested in some districts of Nepal; however, it is still a long way from being implemented nationally. All visits to healthcare institutions have to be borne as out-of-pocket payment. Because of limited resources, communicable diseases and maternal and child health issues are a top priority for the government of Nepal. However, in recent years, rapid urbanization (urbanization rate = 3.62%) has led to an increase in the prevalence of noncommunicable diseases. Among the noncommunicable diseases, DM is reported to be the most common reasons for an emergency room visit (Sanjel, Mudbhari, Risal, & Khanal, 2012).
Self-Care Behaviors
The multidimensional, self-care regimen of DM includes, but is not limited to, diet control, exercise, blood glucose monitoring, foot care, management of stress, and intake of oral and/or injectable hypoglycemic agents (Funnell et al., 2011) and is influenced by various sociodemographic, psychological, and disease-related factors. Adherence to the multidimensional, self-care regimen is challenging (Zulman, Rosland, Choi, Langa, & Heisler, 2012) and places a significant burden on physical and mental well-being (Wang, Wu, & Hsu, 2011). Various external factors like availability of social support, psychological factors such as self-efficacy (Hunt, Grant, & Pritchard, 2012; Strom & Egede, 2012), socioeconomic factors (e.g., low income, employment status; Debussche, Balcou-Debussche, Besancon, & Traore, 2009), demographic factors (e.g., gender, religion, marital status, educational status, expectation regarding aging [ERA]; Kart, Kinney, Subedi, Basnyat, & Vadakkan, 2007; Karter et al., 2007; Kiberenge, Ndegwa, Njenga, & Muchemi, 2010; Shrestha, Kosalram, & Gopichandran, 2013), cultural factors (Nam, Chesla, Stotts, Kroon, & Janson, 2011; Shrestha et al., 2013), and disease-related factors (like presence of DM-related complications, presence of comorbidities; Song et al., 2012) have been identified to affect self-care behaviors of adults with DM.
In a longitudinal study among adults in the United States, participants reported that the most challenging aspect of self-care behavior was diet and exercise (Zulman et al., 2012). Similarly, in Jordan, adults older than 25 years with Type 2 DM reported that the least practiced behavior was self-monitoring of blood glucose and exercise (Al-Khawaldeh, Al-Hassan, & Froelicher, 2012). However, in developing countries, self-monitoring of blood glucose can be related to economic factors (Debussche et al., 2009). Multiple patient and provider factors have been identified as barriers in DM management. Use of insulin and polytherapy have been linked to low adherence and poor glycemic control; similarly, patient’s belief, attitudes, knowledge about the disease, cultural and socioeconomic factors, and availability of social support have been associated with self-care behaviors and disease outcome (Chlebowy, Hood, & LaJoie, 2010; Nam et al., 2011). Various physical and psychological factors such as self-efficacy and psychological distress (Zulman et al., 2012) and presence of comorbidities (Katon et al., 2010) have also been associated with self-care practices in DM. Higher self-care behaviors have been reported in older adults (Zulman et al., 2012). Highly self-efficacious adults are more likely to engage in self-care behaviors (King et al., 2010). Lack of or inadequate support from friends and family is recognized as a hindrance to self-care behaviors (Hunt et al., 2012; Rosland et al., 2008; Tang, Brown, Funnell, & Anderson, 2008). Adults with longer duration of diagnosis of diabetes are reported to have better self-care behaviors, whereas newly diagnosed adults may have overwhelmed feelings leading to distress while adhering to the prescribed self-care behaviors (Song et al., 2012). Cultural factors may influence adherence to self-care behaviors such as dietary regimen and lifestyle modifications (Nam et al., 2011).
ERA is a concept frequently associated with older adults and successful aging. However, in Nepal, where the life expectancy is around 68 years and the age for retirement starts as early as 58 years, it is expected that, as Nepalese adults enter their forties, they are prone to have anxieties secondary to role strain, family responsibilities, stress of advancing age, and impending retirement. Previous researches (Joshi, Malhotra, Lim, Østbye, & Wong, 2010; Sarkisian, Prohaska, Wong, Hirsch, & Mangione, 2005) have associated ERA with poor self-rated health and poor self-care behavior.
Literature review for the current study highlighted that most reported literatures are quantitative studies conducted in developed countries, the findings from which may not be generalizable to developing countries due to different sociodemographic factors and cultural differences. Specifically, in the context of Nepal, factors influencing self-care behavior are the social structure (where wide gender differences exists in self-care practices and health-seeking behaviors), religious practices and preferences, dietary pattern and timings, sedentary lifestyle, and unequal distribution of healthcare resources. In addition, socioeconomic factors such as low income, education, and employment status in Nepal, being a low-income developing country, have also been found to influence diabetes self-care.
Theoretical Framework
The revised health promotion model (HPM; Pender, Murdaugh, & Parsons, 2011) was used as a theoretical guide for this study. The HPM consists of three conceptual components: individual characteristics and experiences, behavior-specific cognitions, and affect and behavioral outcome. In the model, individual characteristics and experiences are composed of prior health-related behaviors and personal biological, psychological, and sociocultural factors. Individual characteristics are posited to influence the behavioral outcome directly or indirectly through the behavior-specific cognitions and affect. Perceived benefits, perceived barriers, perceived self-efficacy, activity-related affect, interpersonal influence, and situational influences are included in the HPM as behavior-specific cognitions and affect. In the current study, selected components of the HPM such as age, gender, educational status, employment status, ERA, DM duration, associated comorbidity, and type of treatment were included as individual characteristic variables; ERA was also included as individual characteristics in the current study because of sociodemographic characters specific to Nepal such as age of retirement (between 58 and 60 years) and an average lifespan (68 years), greater family role strains, etc. Perceived self-efficacy and perceived social support were measured as behavior-specific cognition and affect variables. The behavioral outcome targeted in this study was diabetes self-care behavior. In order to further explain the targeted behavioral outcome in Nepalese adults, an in-depth interview was collected as a supplementary part. It is expected that the findings of this study will enable healthcare providers to plan specific and effective interventions to promote self-care among Nepalese adults with DM.
Aims
The aims of this study were to (a) describe diabetes self-care, perceived social support, diabetes management self-efficacy (DMSE) and ERA; (b) develop an explanatory model for self-care; and (c) enhance model interpretation through qualitative input.
METHODS
Design
This study used a quantitatively driven, sequential, mixed method design where quantitative component was the core component; quantitative data collection and analysis were followed by subsequent collection and analysis of qualitative data (Morse & Niehaus, 2009). Using deductive theoretical drive, model testing was carried out for the quantitative part as a core component, and in order to enhance interpretation of the self-care behaviors used by Nepalese adults, a qualitative inductive approach was also undertaken.
Sample
Sequential, mixed method sampling was used. A nonprobability sampling method was used to recruit participants for the quantitative study. In this study, a total of 230 participants were recruited from the outpatient department of private clinics and tertiary level (government) hospitals. The inclusion criteria were age of >40 years with a diagnosis of Type 2 DM (for >6 months). The rationale for including 40 years and above was because in developing countries the prevalence of DM is expected to be high among the working age (40–60 years; Shaw et al., 2010) and also because of multiple familial and societal roles common to Nepalese adults, which may hinder participation in diabetes self-care behavior (Nam et al., 2011).
The participants for the qualitative component were selected from the same quantitative sample subset using maximum variation sampling method guided by research aims. The criteria were based on general demographic characteristics, disease characteristics, and scores of self-care. Seventeen participants were initially selected. On approaching the participants, four refused to participate; hence, a total of 13 participants were interviewed.
Protection of Human Participants
Ethical approval was obtained from the university institution review board and from Nepal Health Research Council prior to data collection. Informed consent was obtained from all participants.
Data Collection
Data were collected between October and December 2013. The quantitative data collection was done face to face using survey questionnaires as the participants waited to see their doctor in the outpatient departments. Qualitative interviews were conducted by the first author in Nepali language at a location selected by the participants. The interview was guided by questions such as
- “What are some of the self-care activities that you carry out for DM?”
- “What motivates you to practice self-care for your disease?”
- “Have you encountered any problems in managing your disease?”
- “How do you think being a woman/(un)educated/(un)employed/young or old makes a difference in the self-care that you perform?”
- “What do you think are the barriers for you in practicing self-care for diabetes?”
The interview was carried out until the researcher was certain that all the dimensions of self-care strategies in relation to the context of Nepalese culture had been explored. All interviews were audio recorded and transcribed verbatim.
Measurement
Demographic and Disease Characteristics General demographic information and disease characteristics were collected using questionnaire developed by the researchers.
Self-Care Self-care is an individual’s capacity to act and make choices in order to stay physically, mentally, and spiritually fit and healthy and “to successfully manage the symptoms, treatment, physical, psychosocial, cultural and spiritual consequences and inherent lifestyle changes required for living with a long-term chronic disease” (Wilkinson & Whitehead, 2009). In this study, self-care was operationalized as a set of behaviors performed by individuals with DM in relation to diet, exercise, blood sugar testing, foot care, and intake of medicine/insulin and was defined as measures obtained from Summary of Diabetes Self-Care Activities (SDSCA; Toobert, Hampson, & Glasgow, 2000). Higher scores on the SDSCA referred to better self-care behaviors. Cronbach’s alpha was .68 in a Chinese study (Yin, Savage, Toobert, Wei, & Whitmer, 2008) and .69 in a Korean study (Choi et al., 2011). In the current study, the Cronbach’s alpha was .42, and the item-total correlation was between .3 and .9. Diabetes self-care encompasses multidimensional areas that can be independent of each other—which might contribute to the low reliability results.
Self-Efficacy Self-efficacy refers to an individual’s belief that he or she can exert control over their motivation, behavior, and social environment (Bandura, 1982). In our study, DMSE was conceptualized as the belief and confidence possessed by an individual with DM that he or she can adhere to and manage the prescribed diabetes management self-care behaviors and was measured with the DMSE scale (Bijl, Peolgeest-Eeltink, & Shortbridge-Baggett, 1999). Self-efficacy in areas of diet, exercise, blood sugar testing, foot care, and medical treatment (medication and insulin) were assessed on a 5-point Likert scale ranging from 1 = probably not to 5 = definitely, yes. Higher scores on the DMSE scale referred to better DMSE. Cronbach’s alpha was .81 in a study of European adults with Type 2 DM (Bijl et al., 1999); it was .86 in the current study.
Perceived social support Perceived social support involves an evaluation or appraisal of whether, and to what extent, an interaction, pattern of interactions—within social relationship—is helpful (Schaefer, Coyne, & Lazarus, 1981). In this study, perceived social support was operationalized as perception of adequacy of subjective social support from friends, family, and significant others and was defined as measures obtained from Multidimensional Scale of Perceived Social Support (Tonsing, Zimet, & Tse, 2012; Zimet, Dahlem, Zimet, & Farley, 1988). Higher scores referred to better perception of social support. In another study, Cronbach’s alpha for the Nepalese version was reported as .90 (Tonsing et al., 2012); for this study, it was .88.
Expectation Regarding Aging refers to the extent to which older adults evaluate their physical, mental, and cognitive functioning in relation to aging (Sarkisian, Hays, Berry, & Mangione, 2002). In this study ERA was operationalized as the extent to which adults with DM expect age-associated decline in their physical and mental health and cognitive functioning and was defined as measures obtained from a 12-item ERA scale (Sarkisian, Steers, Hays, & Mangione, 2005); higher scores refers to a positive view of one’s physical, mental, and cognitive functioning in relation to aging. Cronbach’s alpha for this scale is reported to be .89 from a study conducted among older adults (>65 years) in the United States (Sarkisian, Prohaska, et al., 2005); for the current study, Cronbach’s alpha was .80.
The first author, who is fluent in both Nepali and English, translated the instruments; back translation into English was done by another unrelated nonnursing bilingual person. A standard forward and backward translation method was used, and the instruments were pilot tested before being used for the main study.
Data Analysis
Path Model IBM SPSS & AMOS Statistics 21 was used to analyze the collected quantitative data with the level of significance set to .05 (two-tailed). Path analysis was used to identify direct and indirect effects of predictors on diabetes self-care behavior. Path coefficients were expressed in standardized form. Mediating effects of DMSE and perceived social support on the relation between individual characteristics and diabetes self-care was analyzed; mediation was decided based on significant Sobel’s z-value. Goodness of fit of the hypothesized model was tested using the χ2 test statistic, comparative fit index (CFI), normed fit index (NFI), and root mean square error of approximation (RMSEA). Acceptable model fit was indicated by a CFI and NFI value of .09 or greater, an RMSEA value of .06 or less, and a nonsignificant chi-square test (Hu & Bentler, 1999).
Thematic Analysis In order to identify, analyze, and describe patterns of self-care specific to the context and culture of Nepal, thematic analysis method was chosen for qualitative data analysis. Qualitative data analysis was carried out by the first author. Thematic analysis using six phases as illustrated by Braun and Clarke (2006) was used for this study.
- Data collected from one-on-one interviews were transcribed verbatim, checked against the audio for accuracy, read, and reread. Notes were taken as and when required.
- Initial codes from each data item were identified. This was done manually, ensuring that all varied patterns relevant to the research questions and the corresponding data extract are identified.
- Data were searched to identify candidate themes. This step was facilitated using visual representations (thematic maps).
- Candidate themes were reviewed and refined in accordance with the research aims. In order to ensure that the themes were accurately and coherently representing the qualitative data collected, data extract in relation to themes and themes in relation to the entire qualitative data were evaluated for fit and coherence.
- Themes were refined, defined, and named. Themes that were ambiguous in content and those that were redundant were removed and/or refined. A total of nine themes which described the self-care behaviors of Nepalese adults with DM were retained as final.
- Themes were checked again to see whether they represented the research questions to which answers were sought and the final report was produced.
RESULTS
Sample Characteristics
The age of the participants ranged from 40 to 88 years, the mean age was 56.9 years (SD = 10.8 years). The mean DM duration was 8.7 years (SD = 6.7 years). Sociodemographic and disease characteristics of participants are shown in Table 1.
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TABLE 1: Participant Characteristics
The most frequently performed diabetes self-care was medication taking (M = 6.77, SD = 1.14); self-monitoring of blood glucose level was the least performed behavior (M = 0.61, SD = 0.93). The levels of self-care behavior, DMSE, perceived social support, and ERA are also shown in Table 1. Differences in study variables based on sociodemographic (Table 2) and disease characteristics (Table 3) were analyzed using t-test and ANOVA with Tukey’s post hoc analysis. The results showed that perceived social support was significantly lower in women (M = 5.55, SD = 0.97). DMSE was lowest among the 40–50 year age group. Significant differences in DMSE was seen based on age, educational level (lowest DMSE was seen among the illiterate), working status (lowest among the unemployed), treatment type (lower in the OHA [oral hypoglycemic agents] only group), duration since DM diagnosis (longer duration of DM diagnosis was associated with better DMSE), and hemoglobin A1c status (HbA1c; higher HbA1c was associated with lower DMSE). Differences in perceived social support were seen based on gender, educational level, and working status. Male gender and having a college education or more was associated with higher levels of perceived social support. Participants with higher education and higher income had significantly high expectations regarding aging. Similarly, significant differences in diabetes self-care were seen based on educational level, treatment type, and HbA1c status.
TABLE 2: Participant Characteristics and Diabetes-Related Variables
TABLE 3: Disease Characteristics and Diabetes-Related Variables
Path Model Testing
Correlations Correlations among variables used in the path modeling are shown in Table 4. Variables with the highest correlations with diabetes self-care were perceived social support (r = .28, p < .01) and diabetes self-efficacy (r = .42, p < .01).
TABLE 4: Correlations: Variables Used in Path Model
Model Specification The path model was specified following an extensive review of available evidence. Directional hypothesis were formulated to test the relationships among the endogenous and exogenous variables.
Model Fit The fit of the path model was assessed. The indices indicated good fit for the hypothesized path model (χ2 = .81, p = .36, CFI = 1, NFI = .99, RMSEA [PCLOSE] = <.001 [.49]).
Direct, Indirect, and Total Effects Age, educational status, working status, perceived social support, and DMSE had a significant direct effect on diabetes self-care behavior; DM duration had a significant indirect effect through DMSE. Using standardized path coefficients, DMSE had the strongest influence on diabetes self-care (b* = .42, p < .001), followed by perceived social support (b* = .26, p < .001) and educational status (b* = −.22, p = .01). The results are displayed in Table 5 and Figure 1. On the basis of significant correlation, it was tested whether DMSE mediated the relationship between DM duration and diabetes self-care and between ERA and diabetes self-care; mediating role of perceived social support between educational status and diabetes self-care was also analyzed. DMSE significantly and partially mediated the relationship between DM duration and diabetes self-care (Sobel’s z = 2.65, p < .001) and between ERA and diabetes self-care (Sobel’s z = 3.03, p < .001). Perceived social support significantly and partially mediated the relation between educational status and diabetes self-care (Sobel’s z = −2.81, p < .001).
TABLE 5: Direct, Indirect, and Total Effects on Diabetes Self-Care Behaviors
FIGURE 1: Path model of diabetes self-care in Nepalese adults. Standardized coefficients are shown. DM = diabetes mellitus. Categorical variables were coded as follows: gender: 0 = female, 1 = male; educational status: 0 = some formal education, 1 = illiterate; working status: 0 = working, 1 = unemployed; comorbidity: 0 = present, 1 = no comorbidity; treatment type: 0 = single method treatment, 1 = both oral hypoglycemic agents and insulin. *p < .05. **p < .01.
Qualitative Results
Using the verbatim transcripts, a total of 120 initial codes were identified and grouped. A total of 22 potential candidate themes with up to four subthemes were identified. The themes were grouped under self-care strategies, self-care boosters, and barriers to self-care. A total of nine themes describing the self-care behaviors of Nepalese adults with DM were retained as final.
Self-Care Strategies The four self-care strategies were (a) adhering to recommended diet and struggling to maintain a balance, (b) having greater trust in medicine, (c) cultivating networks for self-support, and (d) finding normalcy by integrating the disease as a part of life. Adhering to recommended diet and struggling to maintain a balance were challenges. Diet control was the commonly reported self-care behavior. Participants mostly avoided high carbohydrate food sources like potatoes, rice, and sweets. Eating whole wheat bread instead of rice, consuming green leafy vegetables in large quantities, and limiting the intake of fatty foods were other ways by which they adhered to a recommended diet. However, adhering to a recommended diet plan involved difficulties and struggles. Social gathering was an area where most participants struggled to maintain a balance between following the recommended dietary plan and being embarrassed. Also, there was a constant struggle between desire to “eat more” because the “stomach was always empty” and sticking to what was advised. This struggle was mostly reported among female participants.
…I cannot stop myself from wanting to eat, so I think anyway these things are eatables; I don’t think it is going to make much difference if I eat in this amount, but I know I should be controlling… (P10)
Participants said they had greater trust in medicine than other diabetes management approaches. Even though there was a tendency to equate self-care behavior with mostly diet control, there was a pattern of greater trust in medicines that were prescribed. Although dietary control and exercises like walking were reported as an inner struggle and a means to feel “better,” participants believed that, ultimately, it is the medicine prescribed by the doctors that will control their blood glucose. Cultivating networks for self-support was a frequently observed pattern seen among middle-aged participants. Networks provided them with a sense of hope, thinking that they were not alone. Morning walks, especially to religious temples, were the most commonly reported time where networks were built. The participants described the benefit of walking in terms of physical benefit and opportunity to socialize with “like” people with whom they felt motivated. Participants aimed for finding normalcy by integrating the disease as a part of life. Diabetes self-care was reported as something that causes “difficulties in everyday living” (P6) and something that “restricted you and limited your freedom” (P12). However, the participants tried to find normalcy by including the disease and required self-care as a part of their everyday lives. This was done by using coping strategies like positive thinking and self-encouragement:
Disease is something which everyone gets, so I make myself strong by thinking that I am fine…and I carry on with my life. (P2)
Self-Care Boosters Two themes related to self-care boosters emerged: (a) responsibilities toward family and (b) believing that God will cure. Fulfilling responsibilities toward family and successfully enacting family roles brought mental peace and motivated them to further practice better self-care. Responsibility to provide for the family, especially their sons and daughters, by working (job) or doing house work motivated them to “be in good health.” Specific to Nepalese culture, respondents verbalized that they still had sons and daughters who are yet to be married; hence, they should practice better self-care and be strong “for them.” This theme also included responsibilities of caring for the older adults in the family, which positively boosted them. A participant said,
I have a father-in-law who is 106 years old, I take care of him as there is no one else…and I feel good about it…I feel that service is my duty, my religion. (P2)
There were some exceptions in viewing responsibilities toward family solely as booster. Some participants had an ambivalent attitude and viewed their roles and responsibilities as barrier for self-care in terms of time and money constraints:
There is always tension at home because of expenses incurred due to my medicines…24 hours I have to listen to scolding (from husband)…so, I am fed up…I want to discontinue taking medicines so no one will be “allergic” about it. (P12)
Believing that God will cure was the second theme related to boosters for self-care. God as the ultimate strength was described by most of the participants. Religious activities, mainly focused on external activities rather than inner spirituality, were ways in which this belief was demonstrated. Doing puja (worship), listening to devotional songs or chanting stothra (devotional choruses), and visiting dhams (religious places) were some of the activities that were reported. Irrespective of the differences in religion, God as supreme was acknowledged by all participants, who had the power to help them with the disease:
I was supposed to go on the 19th, but I was worried what if I have to eat rice for both meals? I cannot carry biscuits for many days from home…but my sugars were so controlled during my stay…I was amazed…and I know it is the grace of God because I asked for God’s help. (P5)
Barriers for Self-Care The three themes related to barriers for self-care were (a) economic burden, restraint due to physical and psychological symptoms, and constraints due to the nature of work. Economic burden figured significantly in the participant experience. Participants felt that living with DM was very expensive, which required them to make adjustments in many things or give up certain options, as said by a participant:
It was said that health is wealth, but when you have this “sugar problem” you have to periodically do blood tests, go for checkups…take medicines…which are all very expensive…without money, it is impossible to care for myself. (P11)
Restraint due to physical and psychological symptoms was also identified. Fatigue, weight loss, internal weakness, and erectile dysfunction were some of the physical symptoms that acted as barriers to self-care by causing further mental stress, feelings of inadequacy, and anxiety:
I find myself weak because I can no longer enjoy sex…now this blood sugar has made my nerves weak…and I have no (sexual) satisfaction…. (P11)
Constraints due to nature of work were important. Work-related factors caused a tension between striving to follow prescribed self-care behaviors and trying to meet the demands of work. Work demands were given priority and adjustments made to the self-care practices:
I need to go out early to the fields, so I cannot prepare and take proper diet; I just take some flat rice and some vegetables. Vegetables are with potato, but I remove them before eating. (P6)
DISCUSSION
Factors Influencing Diabetes Self-Care
This study explored self-care behaviors of adults with DM. It was seen that medication taking was the most performed self-care behavior followed by dietary control. It was interesting to note that, despite perceiving DM as economically burdening disease, medication taking was still the most practiced self-care activity. This could be due to the influence of Nepalese culture where physicians are looked upon as figures of trust and respect. Education had both direct and indirect (through perceived social support) effect on diabetes self-care. Education promotes knowledge, awareness, and health-seeking behavior, which may have accounted for this effect (Karter et al., 2007; Kiberenge et al., 2010). Karter et al. (2007), through their large multicenter study, have shown that adults with less education had lesser probability of engaging in DM health-seeking behavior. Hence, DM education must be tailored based on a patient’s educational level. Education materials on self-care must be designed so that irrespective of the literacy level the information can be disseminated clearly, for instance, using pictures and diagrams.
Similarly, being employed was associated with better self-care. Also, being employed positively promoted self-efficacy, thus indirectly influencing diabetes self-care. However, as illuminated through thematic analysis, nature of work was looked upon as a barrier for self-care, mainly in areas of dietary regulations and exercise. It was seen that work demands were given priority over self-care. It is imperative for nurses to consider the working status and the type of job while planning care for patients with DM. Future studies could be directed to assessing direct and indirect effect of various work types on diabetes self-care.
DM duration only had an indirect influence on diabetes self-care through DMSE, meaning patients became more self-efficacious over the years, which positively facilitated diabetes self-care. Because DM duration influenced self-care through DMSE, it can be implied that promoting self-efficacy among patients newly diagnosed with DM will facilitate better self-care.
ERA had an indirect influence on diabetes self-care through DMSE. ERA measures expectation of age-related decline in three domains: physical health, mental health, and cognitive function. ERA is under researched in relation to DM; however, studies conducted among general older adults (Kim, 2009) and middle-aged adults (Joshi et al., 2010) have shown positive correlation with perceived health. Low ERA was significantly associated with low DMSE, which is consistent with previously reported findings (Joshi et al., 2010; Kim, 2009). Assessment of ERA will help identify patients for whom interventions to promote self-efficacy can be directed.
Perceived social support directly influenced diabetes self-care and also indirectly through DMSE. Consistent with previously reported findings (Chlebowy et al., 2010), we found that social support played an important role in the lives of adults with DM. However, even though family was viewed upon as a source of support and strength, the control imposed by family, mainly in the area of dietary restriction, was looked upon negatively (i.e., depriving their bodies of essential nutrients). On the other side, being connected to a network had a beneficial effect of adhering to diabetes self-care. The qualitative component also highlighted that middle-aged women had a need to feel connected to a network of people with DM, which also acted as a booster for their self-care. Lack of support from their spouses was a barrier for self-care in women. In line with a previous quantitative study (Tang et al., 2008), decreased support from spouses was associated with failure to adhere to medical treatment. Nepalese society is predominantly patriarchal, where women are less qualified and mostly involved in housekeeping work; hence, it is likely that their unmet needs for social support is higher (Song et al., 2012)—which may have contributed to differences in perception of social support. Assessing the unmet needs for social support, which is the difference between perceived social support need and the amount of social support actually received, might contribute in planning gender and literacy status-sensitive interventions. This highlights the need for nurses to act as facilitators to develop formal and informal support groups and networks among DM patients, which currently is lacking in Nepal.
DMSE had the strongest association with diabetes self-care as seen from the path coefficient of .42. As reported previously (Al-Khawaldeh et al., 2012), this study substantiates the importance of self-efficacy on diabetes self-care. However, DMSE was the lowest among the 40–50 years age group, which could have been due to social and familial roles and responsibilities. These factors were interrelated, which negatively impacted the participants’ lives. Self-efficacy interventions for adults with DM must target these factors.
In this study, both perceived social support and self-efficacy were independently associated with diabetes self-care behavior; however, the availability of social support did not enhance the strength of the relationship between DMSE and diabetes self-care. This result can be explained from the result of qualitative component. Thematic analysis revealed that one of the strategies used for diabetes self-care was trying to find normalcy by integrating the disease and required self-care as a part of their everyday lives. This was mainly done through internal processes like positive thinking, self-encouragement, self-control, etc. Although social support was perceived either as a booster or barrier for practicing self-care, the actual momentum to exert control over their disease was derived internally. This result differs from prior studies that have documented social support as moderating variable for various aspects on diabetes self-care (Osborn, Bains, & Egede, 2010; Piette, Resnicow, Choi, & Heisler, 2013). Psychosocial interventions to promote DMSE may benefit Nepalese adults with DM; however, selection of individualized versus group-based interventions must be tailored for each patient.
Belief in God was a motivating factor for self-care behavior, and this led to participation in religious activities that were mostly focused on external activities rather than inner spirituality. The activities included visiting religious places, chanting devotional mantras, doing pujas, etc. However, in the quantitative analysis, no significant correlation was observed between study variables and religion. Prior studies have shown association of spirituality to DM, but no specific mechanism has been explained (Newlin, Melkus, Tappen, Chyun, & Koenig, 2008). The correlation of religion to self-care and glycemic control can be explored further in future studies along with identification of mediators that might explain this mechanism. Furthermore, in Nepalese context, this highlights the need for nurses to be aware of common religious ceremonies/activities practiced in Nepal and tailor DM education based on requirements for these religious festivals.
Limitations
This study was subject to some limitations. First, even though path analysis examines hypothesized causal processes, not all the variables explaining self-care were included in this study. However, the mixed method nature of the study, which included open-ended face-to-face interviews, compensated for this limitation to some extent. Second, the study sample was predominantly from urban areas; generalizability to rural Nepalese sample might be limited. Third, the reliability of the SDSCA scale was low for the translated Nepalese version. This could have been due to the multidimensional nature of self-care and also due to less number of items for each subscale. Other forms of psychometric testing were carried out to establish validity and reliability—the results of which were satisfactory. Fourth, the SDSCA only examines the frequency of self-care activities performed (days/week) and does not take into account the intensity and quality of these activities; hence, over- or underestimation may have been possible. Criterion validity testing was carried out (with HbA1c status checked within the last 3 months) to compensate for this limitation.
Conclusions
This mixed method study is the first of its kind in Nepal, which comprehensively assessed and illuminated important factors affecting self-care in Nepalese adults with DM. The results from this study highlighted the importance of incorporating self-efficacy and perceived social support in planning interventions for adults with DM; the interventions must be tailored according to gender and literacy status of patients. Involvement of family members in care must be done with caution as participants had ambivalent attitude toward family. As elucidated from the qualitative component, religious activities, belief in God, and network of friends acted as boosters for self-care; hence, it can be deduced that both individual- and group-based, tailored psychosocial interventions to promote self-care may benefit Nepalese adults with DM.
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