Patient-Perceived Challenges to Type 2 Diabetes Self-Management in Sub-Saharan Africa: A Qualitative Exploratory Study

Abstract

Purpose

The purpose of the study was to explore patient-reported challenges influencing type 2 diabetes self-management in a diabetes center in Ethiopia.

Methods

Exploratory qualitative interviews were conducted with purposively sampled patients with type 2 diabetes. Thematic data analysis was performed to identify challenges to diabetes self-management, and the themes were interpreted using Leininger’s sunrise model.

Results

Thirty patients with type 2 diabetes participated. Four themes were identified regarding challenges to type 2 diabetes self-management: (1) cultural values and beliefs, (2) kinship and social factors, (3) educational factors, and (4) economic conditions. Sociocultural factors and low income intersected to significantly impede effective diabetes self-management. Sociocultural contexts strongly influenced patient beliefs and interpretations related to diabetes self-care. Misconceptions and limited awareness of diabetes, reliance on herbal remedies, ritual fasting, and prioritization of family needs over individual needs also involved challenges for diabetes self-care. Poverty influenced access to diabetes care. Many patients faced difficulties in adhering to healthy diets for diabetes due to limited income and food costs, and some patients reduced medication doses, including insulin, to manage costs effectively.

Conclusion

The study highlighted the pressing need for comprehensive and culturally appropriate patient education and empowerment interventions involving various stakeholders to enhance knowledge, understanding, and self-efficacy in diabetes self-management. Urgent attention is needed to ensure patients have access to affordable and sustainable diabetes medications and healthy diets for diabetes through financial incentives. These findings can be considered in designing tailored strategies for improving self-management practice in diabetes care in Ethiopia.

Type 2 Diabetes is a major public health problem affecting about 6.2% (462 million) of the world’s population.¹ The International Diabetes Federation^2-5 predicts that the prevalence of type 2 diabetes will continue to rise, leading to substantial morbidity, mortality, and economic burden worldwide, particularly in developing regions like Sub-Saharan Africa (SSA). In Ethiopia, type 2 diabetes affects about 6.5% of the population ages 20 to 79 years and contributes to about 5% of all deaths in the country.^6-8

In SSA, including Ethiopia, type 2 diabetes care is suboptimal,⁹ with about two-thirds of patients having uncontrolled glucose levels (A1C > 7%).^10-14 A systematic review and meta-analysis¹⁵ examining blood glucose and lipid levels among type 2 diabetes patients in Ethiopia showed that over half of patients with type 2 diabetes have uncontrolled fasting blood glucose levels (exceeding 8 mmol/L). Furthermore, more than two-thirds demonstrated uncontrolled lipid levels (total cholesterol levels ≥200 mg/dL or low-density lipoprotein cholesterol levels ≥100 mg/dL).¹⁵ These findings suggest suboptimal diabetes care, including inadequate self-management practices, contributing significantly to these outcomes.¹⁶

Self-management of type 2 diabetes is an essential component of care.^4,17 It refers to activities undertaken by patients to manage their diabetes successfully.^4,18 It involves diet management, physical activity, glucose monitoring, medication adherence, and the prevention, detection, and treatment of acute and chronic complications.^4,17 Evidence in SSA indicates that effective self-management of type 2 diabetes improves metabolic control and quality of life and decreases diabetes-related complications and health care costs.^19-23 Despite its proven benefits, self-management practice is not adequately implemented by many patients in SSA, including Ethiopia.^19-23 Available studies in SSA, including in Ethiopia,^{9,11,12,24-26} show that over half of patients with type 2 diabetes do not regularly monitor their blood glucose, engage in physical exercise, or adhere to medication and healthy diets for diabetes. Additionally, a significant number of patients lack essential knowledge about diabetes management, such as understanding target blood glucose levels and recognizing symptoms of acute complications, such as hypoglycemia and hyperglycemia, which are essential skills for effective self-management.^9,10,27 Additionally, laboratory tests for diabetes monitoring, diabetes medications, and healthy diets for diabetes are often unaffordable for patients in SSA,^27-29 influencing diabetes self-management practices.^27-29

Despite some evidence existing regarding the challenges to type 2 diabetes self-management in SSA, overall understanding of self-management in the region remains inadequate.^9,30-32 Although diabetes self-management is an essential element of care, in Ethiopia, experiences of patients in relation to type 2 diabetes self-management has not been comprehensively investigated. A deeper understanding and insight around the factors, including sociocultural and economic factors, preventing diabetes self-management practice is required to address these challenges for diabetes self-management in Ethiopia.^9,24,30,31 The evidence obtained would help to design tailored and patient-centered strategies for type 2 diabetes self-management in Ethiopia and elsewhere in SSA.^24,31 The purpose of this study was to explore patient-reported challenges influencing type 2 diabetes self-management in a diabetes center in Ethiopia.

Materials and Methods

Study Design and Participants

An exploratory qualitative study was undertaken through interviews. The study participants included patients with type 2 diabetes, ages 18 years and above, who received diabetes treatment for at least 1 year prior to recruitment at a diabetes center of a tertiary hospital (Tikur Anbessa Specialized Hospital [TASH]).^33,34 Pregnant women with type 2 diabetes were excluded from the study.

Study Setting

The study was undertaken at the diabetes center of TASH in Ethiopia. TASH is the country’s largest tertiary care hospital, with about 700 beds and around 200 physicians, 379 nurses, 85 pharmacists, and 950 administrative staff.^35,36 It serves nearly 400 000 patients annually. The diabetes center of the hospital is the only dedicated center for diabetes care in the country. It is staffed by endocrinologists, endocrinology fellows, nurses, and pharmacists. Internal medicine resident doctors also practice at the center as part of their academic training.³⁴ In 2020, more than 7000 patients with diabetes received care at the diabetes center.³⁷

Sampling and Recruitment of Participants

Authors used purposive sampling to access potential study participants. During diabetes clinic visits of patients at the diabetes center of TASH, the first author, who was trained in qualitative research and understood the study setting and the culture and language of the community, approached patients, verbally informed them about the study, and distributed information sheets about the study. Patients were then informed to contact the first author in person or via phone if they were interested in study participation. Once patients expressed interest in participating, they were screened for eligibility, and eligible consenting patients were recruited.

Data Collection

Data were collected through interviews conducted by the first author in the Amharic language, which all participants spoke. The first author was a native speaker of this language. In interviews, participants were asked about the things that prevented them from self-managing their diabetes at home. Interviews were undertaken face-to-face or by telephone. The interviewer initiated a discussion with the participants to determine their preferred mode of interview (face-to-face or via telephone). Participants who preferred face-to-face interviews were individually interviewed by the first author in a private room at the diabetes center of TASH.

An interview guide was used during the interviews. The interview guide was developed by reviewing the literature,^38-41 discussion with the research team, and consideration of the context of the hospital setting. The interview guide was developed in English, translated into Amharic, and back-translated into English.⁴² The translation and back-translation processes are described in Figure 1. Interviews were audio-recorded. The interviewer documented field notes during the interview. Before collecting data for the main study, pilot interviews were conducted to test the interview guides, identify any potential shortcomings that needed to be addressed, and refine participant recruitment strategies.⁴³ After the pilot interviews, only minor editorial amendments were undertaken to the interview guide. The pilot interviews were not included in the main study.

Figure 1.

Diagrammatic representation of interview guide translation and back-translation processes.

Data Analysis

Data analysis involved repeated listening and verbatim transcription of the audio records of interviews and field notes. Two individuals who were bilingual in Amharic and English were involved in forward or backward translations. First, the Amharic transcripts were translated into English by the first author. Second, the other bilingual person performed a back-translation of the English version to Amharic. Finally, the back-translated Amharic version of the transcripts was compared with the original Amharic transcripts and checked for accuracy and equivalence.⁴⁴ English versions of the interview transcripts were exported to NVivo 20,⁴⁵ which assisted in data management. Inductive thematic analysis was undertaken.^46,47 The first author read and reread the English transcripts several times to familiarize himself with the data and checked against the audio recordings at times of any lack of clarity. He then inductively developed coding frames and initial codes, subthemes, and themes. The initial codes, subthemes, and themes were iteratively reviewed and revised to ensure each theme contained a central concept related to the research questions, checked for validity, and final themes were refined and defined. The other 2 authors reviewed the codes, subthemes, and themes multiple times and provided feedback.^46,47

Conceptual Framework: Leininger’s Sunrise Model

The themes identified through inductive thematic analysis were mapped against the dimensions of Leininger’s⁴⁸ sunrise model to make sense of the meanings of participant experiences and aid a comprehensive understanding of contextual factors, such as social, cultural, and economic conditions that influenced diabetes self-management at the diabetes center of TASH in Ethiopia. Leininger’s^48,49 sunrise model offers a comprehensive framework for explaining and understanding the interplay of sociocultural and economic factors that impact the health and health care practices of individuals within a specific sociocultural context. This model facilitates the visualization and identification of important sociocultural and individual patient-related elements, such as patient values, beliefs, attitudes, and income, which significantly influence health care behaviors, including diabetes self-care.^48-50 Given Ethiopia’s rich cultural diversity and the myriad of patient-related factors shaping diabetes care, the application of Leininger’s^48,49 sunrise model to interpret the findings in this study proves useful.²⁵ The model has been effectively used to explore the sociocultural and economic factors influencing self-management of type 2 diabetes in developing countries, such as Kenya, and in South Asia, illustrating the usability and suitability of the model in the context of the study.^32,51 The model comprises cultural and social structure dimensions along with 7 key factors that significantly influence patterns and practices of self-care, including type 2 diabetes (Figure 2).^48,49 These factors include (1) cultural values and beliefs, (2) economic conditions, (3) education, (4) politics and law, (5) kinship and society, (6) religion and philosophy, and (7) technology, all of which have a profound impact on health care practices, particularly type 2 diabetes self-care practice. Notably, this model is versatile and can be effectively applied across various health care levels and areas of interest, providing valuable insights into perspectives and practices related to health care, including type 2 diabetes self-management.^32,48,49

Figure 2.

Cultural and social structure dimensions and the 7 factors that influence self-care patterns and practices in Leininger’s sunrise model.

Ethical Considerations

Dual ethics approval from Deakin University (HEAG-H 102_2019) and from the institutional review board of Addis Ababa University (092/19/SoP) was received to undertake the study in Ethiopia. All participants provided written informed consent before data collection.

Trustworthiness of the Study

Authors employed several strategies to ensure trustworthiness of this study. The first author had prolonged engagement in the study setting during participant recruitment and data collection and was familiar with the study setting and the culture, norms, and values of the setting and speaks the native language. This prior engagement and cultural and language knowledge enabled the researcher to mitigate personal biases and accurately interpret participant views and experiences during interviews.^52,53 Purposive sampling was employed, and a theoretical framework informed data analysis and reporting.^53-55 The research team had debriefing sessions and discussed participant recruitment, data collection, analysis, and manuscript writing biweekly. A pilot test of data collection tools was conducted before data collection. Six pilot interviews were conducted, transcribed, translated, and reviewed by the other authors, who provided feedback. Codes and themes were generated from each pilot interview and discussed among all authors. The pilot interviews allowed the researcher to practice interview techniques, receive feedback, and make necessary modifications to the interview questions and techniques. The results from pilot interviews were not included in the main study. Results of the study were reported using the Consolidated Criteria for Reporting Qualitative Studies checklist.⁵⁶

Results

Thirty participants were recruited and involved in the study. The mean age of the participants was 56.1 ± 12 years. Over half of the participants (53.3%) were men. The mean duration of diabetes treatment of participants was 11.1 ± 6.8 years. Over three-fourths of the participants lived in the capital city of Ethiopia, where the study was conducted (Table 1). Mean durations of interviews was 45.0 minutes.

Table 1.

Demographic Characteristics of Participants Involved in Interviews (N = 30)

Variable category		n	%
Age, y (M ± SD)	56.1 ± 12
Sex	Male	16	53.0
	Female	14	47.0
Residence	Capital city	26	87.0.
	Regional city	4	13.0
Marital status	Married	21	70.0
	Widowed	6	20.0
	Single	2	7.0
	Divorced	1	3.3
Level of education	Postsecondary education	17	57.0
	Secondary school education	8	27.0
	Elementary education	4	13.0
	Low education (illiterate or basic literacy)	1	3.0
Occupation	Pensioner	11	37.0
	House duties	7	23.0
	Private business	5	17.0
	Government employee	5	17.0
	Other	2	7.0
Duration of diabetes, y (M ± SD)	12.2 ± 7.5
Duration of diabetes treatment, y (M ± SD)	11.1 ± 6.8
Payment for medications	Government covered	15	50.0
	Out of pocket	10	33.0
	Employee covered	5	17.0
Diabetes comorbidity	Peripheral neuropathy	12	40.0
	Dyslipidemia	9	30.0
	Renal disorders	3	10.0
	Human immunodeficiency virus	3	10.0
Diabetes medications	Metformin	25	83.0
	Insulin	17	57.0
	Glibenclamide	2	7.0
Common concomitant medications and medication groups	Statins	24	80.0
	Enalapril	12	40.0
	Aspirin	9	30.0
	Diuretics	7	23.0

Four themes and 9 subthemes were identified through inductive thematic analysis regarding patient challenges to type 2 diabetes self-management (Table 2). The themes identified related to challenges to diabetes self-management aligned with 4 out of the 7 factors of Leininger’s⁴⁸ sunrise model: (1) cultural values and beliefs, (2) kinship and society, (3) educational factors, and (4) economic conditions. Consequently, we did not consider the remaining 3 dimensions of the model in discussing our findings.⁴⁸

Table 2.

Themes and Subthemes (N = 30)

Themes	Subthemes
1. Sociocultural factors	• Use of alternative therapies for diabetes treatment• Fear of adverse consequences of diabetes medications• Misconceptions about healthy diets for diabetes
2. Family and society	• Difficulty in managing diet at social events• Family factors and related busy schedules
3. Level of education and individual patient-related factors	• Patient knowledge and commitment to do self-care• Medication adherence
4. Income and financial constraints	• Poverty• Inadequate access to care (unaffordable care)

Cultural Values and Beliefs: Sociocultural Factors

The participants reported that their cultural practices and beliefs hindered their ability to engage in effective self-management of type 2 diabetes. This hindrance involved use of alternative therapies for diabetes treatment, fear of adverse consequences of diabetes medications, and misconceptions about healthy diets for diabetes.

Use of alternative therapies and remedies to treat type 2 diabetes was believed to hamper diabetes self-management. Many participants reported utilizing alternative therapies, such as herbal medicines, and religious interventions, such as holy water and prayer, due to strong cultural and religious beliefs in their curative properties for diabetes. These alternative therapies were believed to be more effective than diabetes medications, and several patients used them. According to participants, medical therapies were culturally believed to be unsuccessful in treating diabetes and were considered to aggravate diabetes. These thoughts created fear and stress in patients, and consequently, patients preferred alternative diabetes therapies, such as holy water or herbs. Some patients also explained they sometimes reduced their medication doses or completely stopped taking them and experienced side effects as a result.

It is culturally believed that diabetes medications are harmful to health. I was advised not to take diabetes medications and use holy water instead, and this advice mentally stressed and frustrated me, whether I had to take medical or traditional treatment. (Participant 10)

Deciding to take insulin was stressful and frustrating. My sugar was increasing . . . but I refused to take insulin. A lot has been talked about the negative health consequences of insulin and insulin needles, which scared me of insulin. Insulin is something I take lifelong . . . it is stressful. (Participant 10)

There were prevalent dietary misconceptions that compelled some patients to restrict their food intake by not consuming certain foods with sweetness and carbohydrates, including potatoes, sweet potatoes, bread, and maize. Myths surrounding these foods led to a belief that consuming these items would have adverse effects on diabetes health. Consequently, several patients avoided potatoes, including sweet potatoes and bread, from their meals. The impact of these misconceptions and meal avoidance was significant: Numerous participants reported feeling limited in their food choices and unable to consume what was available and affordable, and these contributed to a negative impact on their overall quality of life.

I eat lentils and chickpeas because they are healthy for diabetes. I eat rice or pasta, perhaps once in 15 days and I do not eat eggs and peas at all because they are believed to be unhealthy for diabetes. (Participant 7)

Kinship and Society: Family and Society

The dynamics of relationships and roles within the family and societal factors significantly impacted the practice of diabetes self-management. These conditions involved diabetes diet management at social events and roles within the family and related busy schedules.

Attending social events was reported as a social obligation in Ethiopia. Several participants reported the negative influence of social events, such as weddings and holiday parties, on their dietary practices. They reported social practices of consuming excessive quantities of fried foods; meat, particularly fatty meat; and butter during holidays and weddings. These high-fat and fried foods were deemed unhealthy for patients with diabetes. The participants further explained that people at social events and festivals encouraged or pressured them to eat or overeat these foods. Although the participants did not report whether they refused food offers by their peers at the parties, several participants demonstrated that refusing such foods on social occasions was often impossible.

I go to parties . . . foods at parties are often unhealthy for diabetes, but I eat them because I have a social obligation. I eat any food available at the party . . . I do not choose because I have to comply with social values. My social life is highly affecting my diabetes management practice. (Participant 20)

Some participants reported the negative impact of society, including family, on their diabetes self-management activities. They elaborated on the cultural practice in Ethiopian society of sharing a communal plate during meals within the family. Consequently, it was not culturally acceptable for them to eat certain meals, such as vegetables, that were typically associated with a diabetes-specific diet. Instead, they were expected to share the same plate and consume whatever food was available regardless of its healthiness for their diabetes.

We Ethiopians eat together what is available at home and share a plate with all family members . . . we do not eat alone at home. So, I cannot stop eating a piece of any food, including those not considered healthy for diabetes. (Participant 20)

Several participants reported forgetfulness in taking diabetes medications at the right time. They explained that their busy schedules, stressful social and life events, and memory lapses due to the long intervals between follow-up appointments made it difficult for them to remember to take their medications at the right time and dose. Forgetfulness involved missing a dose, elapsed time of taking, or taking an underdose or overdose of medications.

I forget to take my medications on time . . . I cook food for my children and send them to school in the morning. I sleep after sending them to school as I feel tired and wake up late in the morning . . . this affected the schedule I take my medications. (Participant 22)

Self-Management Knowledge and Awareness: Level of Education and Individual Patient-Related Factors

Several participants reported that low levels of awareness and misperceptions about diabetes self-management negatively influenced their diabetes knowledge, related motivation and commitment to do self-care, and medication adherence, which consequently impeded diabetes self-management practices. Many participants reported inadequate knowledge about what diabetes self-management involves, including type and amount of food to eat, medication adherence, active lifestyle (exercise), proper foot care. They further elaborated on their lack of understanding of carbohydrate counts for locally available foods and how these foods affected their diabetes management. The foods that were locally available did not have clear labels showing the amount of carbohydrates, proteins, or fats in them, making it hard for participants to estimate what they were eating.

I do not eat anything sweet, I eat white teff [a grain most commonly grown in Ethiopia and key ingredient of Injera, a flatbread that is the staple food of Ethiopians], but the doctors have advised me to eat red teff and to avoid bread. It is these foods I commonly access to. (Participant 18)

Several participants reported that they struggled adhering to their diabetes treatment as prescribed. Some participants discontinued their diabetes medications or did not take the prescribed dose or frequency mainly because they had insufficient knowledge and awareness about the importance of medication adherence and the consequences related to medication nonadherence. Additionally, they admitted to not understanding the signs and symptoms of low blood sugar (hypoglycemia) and high blood sugar (hyperglycemia), which made it challenging for them to effectively manage these symptoms.

Access and Unaffordability of Care: Income and Financial Constraints

Low income rendered the costs of care unaffordable and hampered diabetes self-management. Most participants reflected that the financial hardships in affording diabetes medications and supplies, laboratory and diagnostic tests, and ensuring access to recommended foods and home diabetes monitoring devices (glucometer and glucose strips) hindered diabetes self-management activities. They further explained that medications were often out of stock at TASH, and they were supposed to buy the medications at private pharmacies. However, they could not afford medications from private pharmacies, which were much more expensive than at TASH. This caused them to discontinue medications. They also reported reducing doses of their diabetes medications to save and use them for an extended period, and this situation contributed to uncontrolled glucose, development of acute hyperglycemia, and hospitalizations.

I used to take diabetes, hypertension, and nerve medications. I discontinued the nerve medication as I could not afford it . . . I do not have money . . . I have to feed my children and the whole family. I bought insulin prescribed for 1 month but used it for 2 months because I took half the prescribed dose every day. Do you know what I did? I had to take 20 units of insulin in the morning and 10 units at night, but I took 10 units in the morning and 5 units at night for 2 months. (Participant 29)

A significant number of participants reported using insulin syringes for several days because they were not affordable to them. They explained that the reuse of insulin syringes made syringes blunt, which made insulin administration painful to them and caused infections at injection sites.

I reuse 1 insulin syringe 15 to 20 times because I have no money to buy it. The edges of the needle blunted, so I had to push the needle forcefully to administer insulin. This was a painful experience and caused me to have a broken heart. I often worry about this situation and have become irritable, hopeless, and stressed. (Participant 10)

Most participants reported not having home glucometers for glucose monitoring. Home glucometers were reported to be expensive to buy, and consequently, the participants often visited private labs for glucose monitoring. The price of glucose checkups at private labs was also high and unaffordable. As a result, most participants did not partake in glucose self-monitoring and checkups. This lack of glucose self-monitoring was a barrier to adjusting their lifestyle, such as a healthy diet or medications based on glucose readings. The participants stated that these conditions caused uncontrolled diabetes and acute complications, such as hyperglycemia and ketosis, which forced them to visit emergency clinics.

I check my sugar level at a private clinic probably once a month. I cannot do it more frequently because I do not have the machine for home glucose tests. It is expensive to do sugar tests at private clinics . . . it costs me more than 70 Ethiopian birr per test, which I cannot afford it. (Participant 06)

For several participants with low incomes, a healthy diet for diabetes was inaccessible and unaffordable. They expressed that they could not afford to buy healthy food options, such as fresh fruits and vegetables. As a result, they often ate whatever food was available and affordable, including wheat bread that may not be the healthiest option for managing diabetes.

It is hard for me to buy fruits and veggies because I do not have much money. I have kids, and I have to pay for their school fees. (Participant 05)

Discussion

The study explored the views of patients with type 2 diabetes regarding the challenges influencing type 2 diabetes self-management in SSA. It was found that sociocultural misconceptions and beliefs surrounding diabetes and its management, unaffordability of care, and insufficient knowledge of patients regarding diabetes self-care activities hampered type 2 diabetes self-management. Notably, sociocultural beliefs that diabetes medications were ineffective or harmful led patients to seek alternative therapies, such as herbal remedies, for their diabetes treatment. Engagement in social events posed challenges to adhering to diabetes diets because the available food options were often perceived as unhealthy for diabetes management. Poverty resulted in an inability to basic health care and nutritional needs and unaffordability of diabetes services further hindered self-management efforts for type 2 diabetes. Many patients with type 2 diabetes struggled to adhere to healthy diets due to their low income. In some cases, patients resorted to reducing medication doses, including insulin, to save costs because they could not afford the prescribed amount. Insufficient awareness regarding self-management practices also played a significant role in impeding diabetes self-management, including nonadherence to therapy.

Findings of the study aligned with 4 out of the 7 factors of Leininger’s⁴⁸ sunrise model—(1) cultural values and beliefs, (2) kinship and society, (3) educational factors, and (4) economic conditions—that influenced diabetes self-management in Ethiopia, which resembled a similar report in Kenya.³² The themes identified in the study did not correlate with 3 factors of the Leininger⁴⁸ sunrise model, that is, politics and law, religion and philosophy, and technology; the interviews from this study did not identify information or themes related to the influence of these factors on diabetes self-management. Use of the Leininger⁴⁸ sunrise model to interpret the findings of this study enabled a comprehensive and structured description, understanding and discussion of various patient-related sociocultural values and practices and experiences, income levels, and education and awareness, all of which deeply influenced diabetes self-care practices in Ethiopia.^25,48,49 Use of the Leininger⁴⁸ sunrise model underscored the importance of recognizing and addressing cultural and socioeconomic aspects when designing self-management strategies for patients. It revealed how cultural needs and practices of patients are intertwined with self-management, emphasizing the need for tailored strategies aligned with the cultural and socioeconomic context of patients with type 2 diabetes management.^32,48,49

The findings of the study suggested that insufficient type 2 diabetes self-management practices among individuals with type 2 diabetes was substantially attributed to sociocultural misconceptions and inadequate knowledge and awareness regarding diabetes self-management. These conditions may negatively influence self-management practices in several ways.⁹ Patients with misconceptions about diabetes often attribute their disease to external factors, such as God, and place greater trust in alternative therapies, such as holy water, rather than medical treatments. For example, patients may neglect the advice provided by health care professionals and struggle to adhere to diabetes medications and healthy diets for diabetes.⁹ These circumstances emphasize the importance of culturally tailored patient empowerment and self-efficacy programs, such as diabetes self-management education, aimed at enhancing patient knowledge, promoting awareness about diabetes, and dispelling misconceptions related to its management. These programs may be particularly important in SSA, including Ethiopia.^9,57,58 In SSA, health care resources and access to specialist care are limited, with limited timely patient monitoring and support, and patient knowledge and understanding of diabetes and its management remain low.^21,59 In such contexts, cost-effective and targeted approaches to type 2 diabetes care, in particular, patient self-management, emerge as crucial and effective alternatives to extensive medical care.^21,27,59 Culturally tailored patient empowerment interventions that enable individuals to take charge of their diabetes care and self-management have been shown to dispel misconceptions around diabetes and its management and improve self-efficacy, knowledge, and awareness of type 2 diabetes self-management, representing feasible and cost-effective strategies.^9,21,27 Given the existing evidence supporting the efficacy of patient empowerment in improving diabetes self-management, it is evident that tailored diabetes self-management education services and patient empowerment programs are needed in SSA, including Ethiopia, to avoid embedded patient sociocultural misconceptions around diabetes and to improve knowledge and awareness of patients about diabetes self-management. These approaches could equip patients with personal responsibility, problem-solving skills, and the ability to set personalized goals for type 2 diabetes self-management.^9,58,60-63

This study indicated that a significant number of patients rely on alternative therapies, such as herbal medicines, holy water, or prayer, for the treatment of type 2 diabetes. This practice of using alternative therapies is prevalent in SSA,^32,57 where approximately 80% of the population employs complementary and alternative therapies to address their health issues, including type 2 diabetes.^64,65 In SSA, around 65% of patients with type 2 diabetes use complementary and alternative therapies, such as herbal drugs, as a means of self-treatment. This use of complementary and alternative therapies in SSA is likely attributable to patients’ lack of knowledge and awareness and embedded sociocultural beliefs regarding type 2 diabetes and its treatment. It is common in SSA for individuals to believe that type 2 diabetes is associated with witchcraft or fate, curable through herbal or spiritual remedies. Furthermore, cultural and societal perspectives often portray conventional therapies as harmful to health.^9,32,57,66 For instance, patients with type 2 diabetes in SSA hold the belief that insulin causes organ damage and eventual death, leading them to opt for herbal drugs because they are perceived as safe and effective treatments.^32,57,66,67 Given the prevalent use of alternative therapies in type 2 diabetes self-management identified in this study, there is a clear need for educational and awareness creation interventions targeting patients and other stakeholders, including faith-based organizations, religious leaders, traditional healers, and peer support groups in Ethiopia.^68,69

This study indicated that social factors, such as peer pressure during social events and family gatherings, posed challenges to diabetes self-management in terms of dietary choices. Many participants expressed difficulty in resisting unhealthy food options during weddings, feasts, and communal meals with their families.⁷¹ These social and familial influences on dietary choices of patients may be attributed to the limited knowledge and awareness within the community and families regarding healthy diets.32,70 In SSA, health literacy is low, and modifying healthy lifestyle behaviors appears challenging due to the entrenched and intricate nature of sociocultural beliefs and perceptions concerning health and diseases, such as type 2 diabetes.^9,27,32 Addressing the lack of health literacy and awareness within the community and families regarding diabetes diets necessitates interventions that are community- and family-oriented.^71-73 Educating and raising awareness among the community and families about supporting individuals with type 2 diabetes in adhering to appropriate dietary choices are needed because these forms of support significantly influence diabetes outcomes, including glucose control. Moreover, involving family members in diabetes self-management by consulting them alongside patients can address the dietary needs, values, and preferences of both patients and their families.^9,27,32 These educational and awareness creation programs need to be culturally tailored, accessible, comprehensible to the general population, and targeted at various levels: individual patients, the community, and families. These interventions need to be disseminated through media platforms, such as community radio, to reach a broader audience.^20,57

Limitations

The study was conducted at 1 diabetes center in a tertiary care setting located in a capital city in Ethiopia, and participants largely resided in the capital city. Therefore, the views and perceptions may not be transferable to patients in regional areas of Ethiopia or whose management is predominantly based in primary care. This study did not include family members of patients with type 2 diabetes, and therefore, views and experiences of family members on factors affecting type 2 diabetes self-management were not explored.

Conclusions

Findings of the study underscore the complex interplay of sociocultural, economic, and individual factors that impeded self-management practices for type 2 diabetes in a resource-limited setting in SSA. There was wide use of alternative therapies, such as herbal remedies, for self-treatment of type 2 diabetes, attributed to sociocultural beliefs, lack of knowledge and awareness of patients about the negative consequences of herbal therapy, and low income to access and afford medical care. Addressing these challenges hindering diabetes self-management requires comprehensive interventions that tackle misconceptions, enhance knowledge and motivation, and improve accessibility and affordability of diabetes care and services. A holistic approach that incorporates educational and training interventions targeting various stakeholders, including patients, their family members, religious leaders, and the broader community, is needed to bring about behavioral change in patients and enhance type 2 diabetes self-management practices within the hospital setting. Study findings provide important insights to develop a culturally tailored and community-based type 2 diabetes self-management education and support programs in Ethiopia.

Supplemental Material

sj-pdf-1-tde-10.1177_26350106241279809 – Supplemental material for Patient-Perceived Challenges to Type 2 Diabetes Self-Management in Sub-Saharan Africa: A Qualitative Exploratory Study

Supplemental material, sj-pdf-1-tde-10.1177_26350106241279809 for Patient-Perceived Challenges to Type 2 Diabetes Self-Management in Sub-Saharan Africa: A Qualitative Exploratory Study by Tigestu Alemu Desse, Kevin Mc. Namara and Elizabeth Manias in The Science of Diabetes Self-Management and Care

Footnotes

Acknowledgements

The authors would like to acknowledge all patients with type 2 diabetes who participated in the interviews and volunteered and took part in pilot interviews.

Authors Contributions

TAD, KMCN, and EM designed the study. TAD performed data collection, data management and analysis, and wrote the original draft of the manuscript. KMCN and EM were involved in the data analysis. TAD, KMCN, and EM supervised the project. All authors read and approved the manuscript.

Disclosure

The authors reported no conflicts of interest in this work.

ORCID iD

Tigestu Alemu Desse

Supplemental Material

Supplemental material for this article is available online.

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