International Journal of Africa Nursing Sciences 18 (2023) 100548

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International Journal of Africa Nursing Sciences

journal homepage: www.elsevier.com/locate/ijans

Effects of Nurse-Led diabetes Self-Management education on Self-Care

knowledge and Self-Care behavior among adult patients with type 2
diabetes mellitus attending diabetes follow up clinic: A Quasi-Experimental
study design
Sanbato Tamiru a, *, Milkias Dugassa a, Bonsa Amsalu a, Kebebe Bidira a, Lemi Bacha a,
Dereje Tsegaye b
a
Department of Nursing, Mettu University, Mettu, Ethiopia
b
Department of Public Health, Mettu University, Mettu, Ethiopia

A R T I C L E I N F O A B S T R A C T

Keywords: Introduction: The prevalence of type II diabetes is growing globally. Nurse-led diabetes self-management edu­
Self-care cation (DSME) plays an important role in DM treatment because it enhances diabetic self-care knowledge and
Behavior practice, which in turn improves clinical outcomes.
Education
Purpose: To assess the effect of DSME on self-care knowledge and behavior among adult people with type II
Nurse-led
diabetes attending diabetic follow-up clinics in selected hospitals.
Methods: An institution-based quasi-experimental study design was used, and a systematic random sampling
technique was used to select 360 patients, out of whom 321 patients participated and 278 completed the study.
Participants were assigned to the interventional or control group, and DSME was delivered monthly for six
months for the interventional groups. The data was collected by trained nurses using structured interviews.
Results: An independent t-test showed that there was no significant difference in all of the outcomes before
intervention; however, there was a statistically significant higher mean score difference in self-care knowledge
and self-care behavior after the delivery of DSME (p < 0.05). Before the intervention, 96 (62.7%), 39 (25.5%),
and 18 (11.8%) of participants in the intervention group had low, medium, and high knowledge, respectively.
After the intervention, the level of participant knowledge in the low range for an interventional group decreased
from 62.7% to 20.6%, and the high range increased from 11.8% to 54%. In addition, 129 (84.3%) and 24
(15.7%) of participants from the intervention group before the intervention had poor and good self-care be­
haviors, respectively, while 30 (23.6%) and 97 (76.4%) of participants from the intervention group after the
intervention had poor and good self-care behaviors, respectively.
Conclusion: The study concluded that there was a significant improvement in the mean score of self-care
knowledge and self-care behavior after nurse-led DSME; hence, the implementation of DSME in health facil­
ities can improve diabetes self-care management.

1. Introduction
Diabetes mellitus (DM) is a metabolic disorder characterized by
chronically elevated blood glucose levels resulting from defects in in­
sulin discharge, insulin action, or both (Rossi, 2018). It is the most
common metabolic disorder and one of the world’s top four non-
communicable diseases (Organization, 2016). The two main types of
DM are Type I and Type II diabetes mellitus, with Type II being more
common than Type I, which accounts for 90–95% of all instances of
diabetes (Dabelea et al., 2014, CDC, 2017).

Abbreviations: AADE, American Association Diabetic Educator; ADA, American Diabetes Association; CDC, Communicable Disease Control; CDE, Certified Dia­
betic Educator; DM, Diabetic Mellitus; DSMES, Diabetes Self, Management Education and support; NIH, National Institute of Health; IDF, International diabetes
federation; LFTU, Left to follow-up; MKH, Mettu Karl Hospital; T1DM, Type 1 Diabetic Mellitus; T2DM, Type 2 Diabetic Mellitus; WHO, World Health Organization.
* Corresponding author.
E-mail address: tsanbato@yahoo.com (S. Tamiru).

https://doi.org/10.1016/j.ijans.2023.100548
Received 8 August 2022; Received in revised form 22 February 2023; Accepted 25 February 2023
Available online 28 February 2023
2214-1391/© 2023 The Author(s). Published by Elsevier Ltd. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-
nc-nd/4.0/).
S. Tamiru et al.
The management of diabetes mellitus (DM) includes both ongoing
medical care and continuing non-pharmacological self-care by the pa­
tient. Nurse-led Diabetes self-management education (DSME) is a key
component of diabetes care (Beck et al., 2017). It offers good glycemic
and metabolic control, which is essential for preventing long-term
complications, especially in low-resource settings where it is known to
have positive effects on knowledge of diabetes, glycemic control, and
behavioral outcomes (Dube, Van den Broucke, Housiaux, Dhoore, &
Rendall-Mkosi, 2015). Nurse-led diabetes self-management education
plays an important role in diabetes mellitus (DM) treatment because it
enhances diabetic self-care knowledge and practice which in turns im­
proves clinical and psychological outcomes and quality of life. In addi­
tion to medical care, the American Diabetes Association (ADA)
recommends that all patients with DM receive diabetes self-management
education at diagnosis and as needed thereafter (Association, 2018).
Facilitating appropriate diabetes self-management and improving
clinical outcomes, health status, and quality of life are key goals of
nurse-led DSMES to be measured and monitored as part of routine care
(Association, 2018). These goals could be achieved by providing pa­
tients with diabetes self-management education from diabetic educa­
tors, nurses, physicians, and pharmacists collaboratively, and diabetes
self-management support from lay health coaches, navigators, or com­
munity health workers when available (Powers et al., 2015). To
demonstrate the benefits of nurse-led DSMES, it is important for DSMES
providers to track relevant evidence-based DSMES outcomes such as, its
effect on self-care knowledge and self-care (Educators, 2009, Powers
et al., 2015, Beck et al., 2017).
Globally, diabetes mellitus is becoming a major public health prob­
lem due to the steadily increasing number of people with the disease
(Organization, 2016, Zhou et al., 2016, Cho et al., 2018). The World
Health Organization (WHO) reported that globally the number of people
with diabetes has increased from 108 million in 1980 to 422 million in
2014, and this number will rise to 592 million by 2025. The global
prevalence of diabetes has nearly doubled since 1980, rising from 4.7%
to 8.5% in the adult population (Organization, 2016). Recent estimates
also indicate that the people with diabetes has been rising more rapidly
in developing countries in which about 77% of people with diabetes live
in low- and middle-income countries (Organization, 2016, Cho et al.,
2018). According to the international diabetes federation (IDF), the
prevalence of diabetic mellitus in Ethiopia is steadily increasing with,
3.5% in 2011 (Atlas, 2015), 4.36% in 2013(CDC, 2017), and 5.2 % in
2015 making one of the top four countries with the highest adult dia­
betic populations in sub-Saharan Africa (Cho et al., 2018). According to
a recent systematic review, the prevalence of diabetes in Ethiopia ranges
from 0.3% to 7% (Abebe, Kebede, & Addise, 2017).
Diabetes mellitus is a major cause of mortality, morbidity, and
disability (Maffi & Secchi, 2017). Diabetes and its complications bring
substantial economic loss to people with diabetes and their families, as
well as to health systems and national economies through direct medical
costs and loss of work and wages (Association, 2013, Control, 2014,
Organization, 2016). Knowledge of self-care related to diet, exercise,
and medication, and its practice is a critical element of treatment for
diabetes to bring a positive outcome. Diabetes patients, on the other
hand, demonstrated poor knowledge and practice of diabetes care
(Hailu, Mariam, Belachew, & Birhanu, 2012, Mikhael, Hassali, Hussain,
& Shawky, 2019). In Ethiopia, 44.9% of participants had poor diabetes
knowledge, 49.1% had poor self-care behaviors, and 24.9% had poor
adherence to anti-diabetes medication (Kassahun, Gesesew, Mwanri, &
Eshetie, 2016), and only 87(39.2%) of diabetes patients followed the
recommended self-care practices (Ayele, Tesfa, Abebe, Tilahun, &
Girma, 2012), 318(75.9%) diabetes patients did not adhere to the rec­
ommended diet management, 228 (53.7%) adhered to physical exercise,
and 350(83.5%) did not adhere to self-monitoring of blood glucose level
(Bonger, Shiferaw, & Tariku, 2018).
Self-care knowledge and practice could be enhanced by providing
diabetes self-management education and support for patients. The
2
International Journal of Africa Nursing Sciences 18 (2023) 100548
American Diabetes Association, 2015 Standards for Care recognize
diabetes self-management education (DSME) as an integral aspect of
care for people with diabetes (Claborn, 2014, Association, 2015). The
2014 American Diabetes Association (ADA) Standards of Medical Care
recommended Nurse-led DSMES to be included in DM management
(Haas et al., 2014). AADE (Parkin et al., 2009), WHO, IDF, and CDC
(Control, 2014) also recommended the nurse-led DSMES service be
included in the management of DM. Facilitating appropriate diabetes
self-management and improving clinical outcomes, health status, and
quality of life are key goals of DSMES to be measured and monitored as
part of routine care (Duncan et al., 2011, Klein, Jackson, Street, &
Whitacre, 2013).
Studies on the effectiveness of nurse-led DSMES on self-care
knowledge and behaviors are still rare, even in developing countries.
Therefore, the present study aims to investigate the effect of diabetic
self-management education on diabetic self-care knowledge and
behavior among adult patients with type 2 DM. The main objective of
the study was to assess the effect of diabetes self-management education
on self-care knowledge and behavior among adult people with type 2
DM attending the diabetic follow up clinic at Ilu Ababor and Buno
Bedelle zone hospitals, southwest Ethiopia.
2. Materials and methods
2.1. Study area and study period
This institution-based quasi-experimental study was conducted in
selected hospitals (Mettu Karl referral hospital, Darimu general hospital,
Diddesa primary hospital, and Beddelle general hospital) in Ilu Abbabor
and Buno Bedelle Zones, southwest Ethiopia. Mettu Karl hospital and
Darimu hospitals are found in the Illubabor zone, while Beddle hospital
and Diddessa hospitals are found in the Buno Beddelle zone. Mettu Karl
referral Hospital serves as a training hospital for health science students,
medical interns, and masters of emergency surgery students from
different universities. The study was conducted from October 1, 2020, to
June 30, 2021.
2.2. Study design
A quasi-experimental study design was employed.
2.3. Population
2.3.1. Source population
The source populations were all adult patients with Type 2 diabetes
mellitus attending diabetic follow-up clinics at public hospitals in Ilu
Ababor and Buno Bedelle zones, southwest Ethiopia.
2.3.2. Study population
All adult patients with Type 2 diabetes mellitus who attended dia­
betic follow-up clinics at public hospitals in the Ilu Aba Bor and Buno
Bedelle zones of southwest Ethiopia were randomly selected for the
study.
2.4. Inclusion and exclusion criteria
2.4.1. Inclusion criteria
At the onset of the study, all registered patients aged 18 years and
older with Type 2 diabetes mellitus and attending diabetic follow-up
clinics at public hospitals in Ilu Aba Bor and Buno Bedelle zones,
southwest Ethiopia were involved.
2.4.2. Exclusion criteria
Patients with severe cognitive or physical impairment and terminally
ill people with serious diseases, such as severe cardiovascular and ce­
rebrovascular diseases, severe kidney disease, cancer, and visual
S. Tamiru et al. International Journal of Africa Nursing Sciences 18 (2023) 100548

impairment due to complications of type II DM, were excluded.

2.4.3. Sample size determination

To come up with the final sample size, separate samples were
calculated for each of the two objectives, and the largest sample was
taken to enroll the study participants to increase power and precision.
All the sample sizes were determined by using G*Power 3.0.10. The
following assumptions were considered when estimating the required
minimum sample sizes for the objectives: a confidence level of 95%, a
power of 80%, and a margin of error of 5%. Finally, as this study is a
prospective study that needs a similar sample size, the maximum sample
size of 360 was taken (Table 1).

2.4.4. Sampling technique

For selecting study participants, a systematic random sampling
technique was used. First, Mettu Karl referral hospital and Darimu pri­
mary hospital were selected by the investigator as intervention hospitals
and the other two hospitals, Bedele General Hospital and Didesa Primary
hospitals were selected as control hospitals. The total sample size of 360
was allocated to each hospital proportionally to the number of patients
in each hospital. Individual patients in each of the hospitals were
selected by systematic random sampling, and the lists of patients in each
hospital were obtained from the hospital’s medical records (Fig. 1).
2.4.5. Data collection tool and technique
Data was collected using structured interviews. The Diabetes
Knowledge Test (DKT) was used to assess diabetes self-care knowledge.
The tool was developed and tested for reliability and validity by the
University of Michigan scholars and it consists of a 23-item multiple-
choice test designed to assess knowledge about diet, exercise, blood
glucose levels and testing and self-care activities (Fitzgerald et al.,
2016).
Self-care behavior was assessed using the Summary of Diabetes Self-
Care Activities (SDSCA. The SDSCA was originally developed from seven
studies carried out by scholars from Oregon Research Institute, United
States. It is designed to assess self-care activity in the last 7 days for the
following aspects of the diabetes regimen: general diet, foot-care, ex­
ercise and medication taking. (Toobert, Hampson, & Glasgow, 2000).
The tools was firstly designed in English and then translated in
Amharic and Afan Oromo (local languages), and again back translated
into English by experts who had similar experiences. A questionnaire
was pretested with diabetic patients in another nearby hospital at Jimma
and Based on the results of the pretest, changes were made to the
phrasing, phrases, and amount of time required to interview re­
spondents. Furthermore, instruments, questions, and instructions that
were unclear to respondents were adjusted and rebuilt. In addition,
cronbach’s alpha for each items were tested found >0.8.
2.4.6. Procedure of DSME
Nurse-led Diabetes Self-Management Education (DSME) was given in
a small group format (8 to 10 patients) every two weeks for one and a
half hours for six consecutive months from May 1, 2020 to October 30,
2021. The education was given after they received their usual care. The
topic of education includes the seven self-care behaviors that are iden­
tified by AADE as essential for successful and effective diabetes self-
management and are incorporated into the National Standards for Dia­
betes Self-Management Education. These topics include (1) healthy
Fig. 1. Schematic presentation of sampling technique.
eating; (2) physical activity; (3) monitoring; (4) medication adminis­
tration; (5) problem solving; (6) healthy coping; and (7) risk reduction.
Different methods of DSME delivery were used, including lecturing g,
demonstration, observance, role-playing, and problem-solving
scenarios.
2.4.7. Variables
Dependent Variables
• Diabetic self-care knowledge
• Diabetic self-care behaviors
Independent Variable
• Diabetic self-management education
• Operational definition
Diabetic self-care knowledge: Respondents who scored 75%,
74–60%, and 59% were labeled as having high, medium, and low
knowledge of diabetes, respectively (Fitzgerald et al., 2016).
Diabetic self-care behaviors:-Participants were asked about how
many of the last 7 days they participated in each of the self-care activ­
ities. Scores ranged from 0 to 7. For each question, a score of ≥3–7 were
considered as good self-care behaviors and 0–3 as poor self-care be­
haviors (Toobert et al., 2000).
2.5. Data processing and analysis
Data was entered into Epidata version 3.1 and then exported to SPSS
version 23 for analysis. The two entries were compared using the
questionnaire identification numbers and, the necessary corrections
were made to the error messages. The mean score differences for each
dependent variable at the baseline and end line for each group were
compared using an independent t-test.
2.6. Ethics approval and consent to participate
The study was conducted after getting ethical approval and clearance
from the institutional review board (IRB) of Mettu University. The
supportive letter was taken from Mettu University and submitted to each

Table 1
Summary of computed sample size for different variable from previous studies.
Variable Factor determining the outcome Proportion OR CI Power of the Total Sample size including References
variable study 10% NR

Diabetic Self-care related Residence 29.6% 3.37 95% 80% 156 Niguse et al.,
knowledge 2019
Diabetic self-care behavior Social support 43.4% 1.85 95% 80% 360 Chali et al., 2018

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S. Tamiru et al. International Journal of Africa Nursing Sciences 18 (2023) 100548

hospital, and permission was obtained from each hospital. Informed
consent was obtained from the study participants. Study participants
were provided with information about the objectives of the study and
had the right to respond fully or partially to the questionnaire, partici­
pate, or drop out at any time.
both at baseline and end line. Accordingly, there was no statistically
significant mean score difference on the DKT at baseline, between the
two groups. (P = 0.245). But at the end line, the intervention group had
a greater mean diabetes knowledge score (11.22 out of 23) compared to
that of the comparison group (8.21 out of 23) (p = 0.0001) (Table 3).

3. Results 3.4. Level of self-care behavior before and after intervention

3.1. Participants Characteristics
Out of the 360 patients recruited, 321 (89.2%) were involved in the
study at baseline, of whom 153 (47.7%) and 168 (52.3%) were assigned
to an interventional and control group, respectively. From 321 partici­
pants, 43 (13.3%) were lost to follow-up, while 278 (86.7%) provided
data at the end of the study. From the total number of participants
involved at the end of the study, 126 (45.3%) and 152 (54.4%) were
involved in interventional and control groups, respectively (Table 2).
To assess self-care behavior, participants were asked how many of
the last 7 days they participated in each of the self-care activities (diet,
exercise, blood sugar testing, and foot care). The study found that 129
(84.3%) and 24 (15.7%) of intervention group participants before
intervention (baseline) had poor and good self-care behaviors, respec­
tively, while 97 (76.4%) and 30 (23.6%) of intervention group partici­
pants after intervention (end-line) had good and poor self-care
behaviors, respectively; however, the level of self-care activities for the
control group before and after intervention remained the same (Fig. 3).

3.2. Level of self-care knowledge before and after intervention 3.5. Effect of Nurse-led DSME on Self-Care behavior

The overall patient knowledge score was obtained by recoding every
correct answer as 1 and every incorrect answer as 0. Accordingly, 112
(66.7%), 39 (23%), and 17 (10.1%) of participants from the control
group before intervention (baseline) had low, medium, and high
knowledge, respectively, while 96 (62.7%), 39 (25.5%), and 18 (11.8%)
of participants from the intervention group before intervention (base­
line) had low, medium, and high knowledge, respectively. After the
intervention (end-line), 100 (65.7%), 33 (21.7%), and 19 (12.5%) of the
participants from the control group had low, medium, and high
knowledge, respectively, while 26 (20.6%), 32 (25.4%), and 68 (54%) of
participants from the intervention group had low, medium, and high
knowledge, respectively. Thus, the result of this study revealed that
there was an improvement in the knowledge of participants after DSME
(Fig. 2).
3.3. The effect of Nurse-led DSME on Self-Care knowledge
The following table shows the effect of DSME on self-care knowledge
for intervention and control before and after the intervention. An in­
dependent t-test was used to compare the mean scores of the two groups,
The general self-care behavior was computed by summing all com­
ponents of self-care activities (diet, exercise, blood sugar testing, and
foot care). Thus, the general mean of self-care activities for the inter­
vention group after the intervention was significantly higher than the
baseline (3.47 out of 7 days) compared to that of the comparison group
(2.45 out of 7 days), and the mean score significantly increased by 1.01
in the intervention group and decreased by 0.008 in the comparison
group from baseline to end line (Table 4).
4. Discussion
The present study was a quasi-experimental study design that eval­
uated the potential effect of Nurse-led diabetes self-management edu­
cation on knowledge and self-care behavior among type II DM patients.
The findings of the present study revealed that there was no statis­
tically significant mean score difference on the DKT at baseline between
the two groups (P = 0.245). But at the end line, the intervention group
had a greater mean diabetes knowledge score compared to that of the
comparison group (p < 0.01). This is in line with an RCT conducted in
Australia, which revealed a significant difference from the control group

Table 2
Characteristics of adult patients with type 2 diabetes attending diabetes follow-up clinics at the Ilu Aba Bor and Bunno Bedele zones hospitals in southwest Ethiopia in
2020/21 (n = 360).
Variables Categories Base line endline

Intervention Control Intervention Control

N (%) N (%) N (%) N (%)

Sex Male 97(30.2%) 104(32.4%) 79(28.4%) 92(33.1%)

Female 56(17.4%) 64(19.9%) 47(16.9%) 60(21.6%)
Age 18–29 23(7.2 39(12.1%) 20(7.2%) 34(12.2%)
30–39 37(11.5%) 39(12.1%) 31(11.2%) 36(12.9%)
40–49 49(15.3%) 48(15%) 38(13.7%) 47(16.9%)
50+ 44(13.7%) 42(25%) 37(13.3%) 35(12.6%)
Marital status Single 57(17.8%) 36 (11.2%) 47(16.9%) 33(11.9%)
Married 85(26%) 112(38%) 69(24.8%) 110(39.6%)
Other 11(3.4%) 10(3.1%) 10(3.6%) 9(3.2%)
Occupation Governmental 50(15.6%) 60(18.7%) 44(15.8%) 53(19.1%)
Farmer 86(26.8%) 82(25.5%) 69(24.8%) 78(28.1%)
Merchant 17(5.3%) 26(8.1%) 13(4.7%) 21(7.6%)
Level of education Primary school 67(20.9%) 93(29%) 56(20.1%) 85(30.6%)
Secondary school 52(16.2%) 47(14.6%) 42(15.1%) 43(15.5%)
Diploma 20(6.2%) 15(4.7%) 16(5.8%) 12(4.3%)
Degree and above 14(4.4%) 13(4%) 12(4.3%) 12(4.3%)
Residence Urban 90(28) 81(25.1) 73(26.3) 72(25.9)
Rural 63(19.6) 87(27.1) 53(19.1) 80(28.8)
Religion Orthodox 54(16.8%) 68(21.2%) 48(17.3%) 61(21.9%)
Muslim 80(24.9) 78(24.3) 63(22.7) 71(25.5)
Protestant 19(5.9%) 22(6.9%) 15(5.4%) 20(7.2%)

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S. Tamiru et al. International Journal of Africa Nursing Sciences 18 (2023) 100548

Fig. 2. Level of patient’s self-care knowledge before and after the deliverance of DSM among adult patients with type 2 diabetes mellitus attending diabetes follow-
up clinic at Ilu Ababor and Bunno Bedele zones hospitals, southwest Ethiopia, 2020/21 (n = 360).

after DSME (Atak, Gurkan, & Kose, 2008). It is also in line with the study
Table 3
on improvement in medication adherence and self-management of
Effect of DSME on self-care knowledge among adult patients with type 2 diabetes
diabetes with a clinical pharmacy program in Brazil, which revealed that
mellitus attending diabetes follow-up clinic at Ilu Aba Bor and Bunno Bedele
zones hospitals, southwest Ethiopia, 2020 (n = 360) (Table 3).
diabetes knowledge was significantly improved in the intervention
group but remained unchanged in the control group (Cani, Lopes,
Group Baseline End-line
Queiroz, & Nery, 2015). In addition, a Cochrane review of group-based
N Mean Std. error N Mean Std. error training for self-management strategies showed improved knowledge of
Intervention 153 7.64 0.25 126 11.22 0.31 diabetes after intervention (Steinsbekk, Rygg, Lisulo, Rise, & Fretheim,
Control 168 8.08 0.27 152 8.21 0.29 2012).
Difference − 0.44 0.37 3 0.43 The finding of the current study is also in line with the study on the
Significance 0.245
effect of DSME on self-care knowledge among Type 2 diabetes patients
0.00
in Jimma Medical Center, Ethiopia, which found a significant increase in
the mean diabetes knowledge score in the intervention group (Hailu,

Fig. 3. Level of self-care behavior among adult patients with type 2 diabetes mellitus attending diabetes follow-up clinic at Ilu Ababor and Bunno Bedele zones
hospitals, southwest Ethiopia, 2020/21 (n = 360).

5
S. Tamiru et al. International Journal of Africa Nursing Sciences 18 (2023) 100548

Table 4 5. Conclusion
Effect of DSME on Self-Care Behavior in Adult Patients with Type 2 Diabetes
Mellitus Attending Diabetes Follow-Up Clinic at Ilu Ababor and Bunno Bedele The study concluded that there was a significant improvement in the
Zone Hospitals, Southwest Ethiopia, 2020/21(n = 360). mean scores of self-care knowledge and self-care behavior after DSME;
Group Baseline End-line hence, the implementation of DSME in health facilities can improve
N Mean Std.err n mean Std.err diabetes self-care management. Therefore, different stakeholders like
FMHO, zonal departments, woreda health offices, and hospitals should
Diet
Intervention 153 2.72 0.08 126 3.48 0.09
work collaboratively in order to integrate DSME into the healthcare
Comparison 168 2.52 0.09 152 2.61 0.09 system.
Difference 0.2 0.12 0.87 0.13
significance 0.11 0.00 5.1. Recommendation
Exercise
Intervention 153 2.59 0.12 126 3.9 0.13
Comparison 168 2.22 0.09 152 2.4 0.10 Based on the findings of this study, the following recommendations
Difference 0.36 0.15 1.48 0.16 were made for policymakers, health institutions, higher education in­
Significance 0.018 0.00 stitutions, and future research. Health policymakers should set strategies
to incorporate nurse-led DSME into the healthcare system in order to
Blood sugar testing assure the quality of healthcare services provided to a patient with type
Intervention 153 2.15 0.12 126 2.13 0.13 II DM. Health institution managers should arrange training for con­
Comparison 168 2.28 0.11 152 2.28 0.12
cerned healthcare providers and establish a means to implement nurse-
Difference − 0.13 0.16 − 0.14 0.17
Significance 0.43 0.43 led DSME. Higher education institutions, particularly colleges of health
sciences, should incorporate nurse-led DSME into their curricula and
provide DSME to health science students in the form of lectures and
Foot care
Intervention 153 2.05 0.07 126 3.23 0.09 demonstrations. Future researchers need to investigate barriers to the
Comparison 168 2.21 0.08 152 2.33 0.075 implementation of DSME and put forward solutions. In addition, DSME
Difference − 0.16 0.10 0.89 0.12 should be tested in a new setting.
Significance 0.12 0.00

5.2. Strengths of the study

General self-care behavior
Intervention 153 2.34 0.05 126 3.47 0.08
The study covers a large random sample. Since study subjects were
Comparison 168 2.35 0.06 152 2.45 0.06
Difference − 0.008 0.08 1.01 0.09 grouped on a cluster basis, there was a minimal chance of information
Significance 0.92 0.00 contamination between the interventional and control groups. To ensure
high-quality education, the program was delivered by a professional and
trained facilitator. The approach greatly increases the generalizability of
Moen, & Hjortdahl, 2019). In contrast to this, structured peer-led dia­ the findings, and therefore the possibility of implementing this program
betes self-management and support in Mali found statistically no sig­ for use in other resource-limited settings is high. Although it has limi­
nificant difference in knowledge score after intervention (P = 0.17) tations and was conducted with limited resources in a less-controlled
(Debussche et al., 2018). The discrepancy in the findings of these studies environment, it demonstrates that a DSME can significantly improve
might be due to differences in the educational material, the literacy diabetes knowledge and self-care behavior.
status of participants, the delivery approach, their duration, the gap
between consecutive sessions, and the provider’s professional 5.3. Limitations of the study
backgrounds.
The findings of the present study revealed that the general mean of The fact that no study has been conducted on this topic in Ethiopia so
self-care activities for the interventional group after the intervention far, and that there is insufficient literature to discuss it in a national
was significantly higher than the baseline (p = 0.00). This is consistent context. COVID-19 pandemic was one of the challenges to effectively
with the findings of a multinational observation study on diabetes pa­ deliver the education, and there was the highest LTFU among the
tients in Middle Eastern countries, which found that patients who interventional group. Patient transfers to other health institutions were
received diabetes self-management education were more likely to also among the challenges we faced.
practice diabetes self-management than those who did not (OR: 2.51, P
0.005) (Gagliardino et al., 2019). The result is also in line with a single-
Declaration of Competing Interest
blinded RCT conducted in China, which indicated that self-management
skills were significantly improved in the experimental group compared
The authors declare the following financial interests/personal re­
with those in the control group (P < 0.01) (Luan et al., 2017). It is also in
lationships which may be considered as potential competing interests:
line with the Community-based peer support RCT study in Cameroon,
Sanbato Tamiru Dingata reports financial support, administrative
which reported that diabetes self-care behavior in the intervention
support, equipment, drugs, or supplies, and travel were provided by
group improved significantly over the course of six months of peer
Mettu University. Sanbaro Tamiru Dingta reports a relationship with
support (Assah, Atanga, Enoru, Sobngwi, & Mbanya, 2015).
Mettu University that includes: employment. Sanbato tamiru has patent
The finding of this study found that there was a higher mean score on
no pending to no. i have been working as lecture and researcher in Mettu
exercise after intervention for an interventional group, which is similar
university for the seven years. i have also been sercing as a reviewer for
to a pilot study of a community health agent-led type 2 diabetes self-
differnt journals like PLOs One.
management program in Brazil that reported increases in physical ac­
The remaining authors declare that they have no known competing
tivity (p = 0.001) (do Valle Nascimento et al., 2017). However, the study
financial interests or personal relationships that could have appeared to
on the effect of DSME on self-care behavior in Jimma Medical Center
influence the work reported in this paper.
found no significant difference between the interventional and control
groups before and after intervention (Hailu et al., 2019). The difference
Acknowledgements
might be due to differences in the mode of education and educational
materials.
We thank Mettu University for financial support with grant number

6
S. Tamiru et al.
of CHS/705/12. Again, our sincere appreciation goes to our re­
spondents, data collectors, and supervisors.
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