Diabetes decimates the lives of three people every two hours in Saudi Arabia, which is classified as having the world’s third-highest prevalence rate of the scourge, and the worst-hit country in the Middle East (Al-Daghri et al., 2011). Indeed, according to these authors, the prevalence of diabetes in the country is bound to increase, from 16.8% recorded in 2010 to 18.9% in 2030. The matter is further compounded by the fact that although Diabetes in Saudi Arabia characteristically affects adults and the elderly, recent figures show the disease is increasingly affecting other groups of the population, including overweight and obese children (Ng et al., 2011). The mounting level of type 2 diabetes in Saudi Arabia is threatening to increase the disease burden unless a comprehensive control program is rigorously implemented to promote healthy lifestyles.
Self-management is recognized as an essential component in the treatment of persons with diabetes and has a high potential to enhance the management of chronic disease and improve health outcomes. Indeed, self-management acts as the cornerstone in the pursuit of successful health-related outcomes for diabetic patients. There is growing evidence in the literature that self-management behaviors and self-efficacy can contribute to a range of positive health outcomes in the overall management of the scourge (Tol et al., 2012).
Previous studies undertaken in Saudi have been largely physician-directed, with no substantive contributions from nurses and other health professionals ever been noted. These studies, however, demonstrate a significant gap in knowledge, particularly with regard to the effective self-management initiatives of type 2 diabetes among the population. It is these gaps in knowledge that the proposed study aims to fill.
When the concept of self-management is investigated among the Saudi population, it will provide the basis for both a framework and theory that will greatly illuminate how the scourge can be managed more effectively. New knowledge will strengthen and build the science, and when this knowledge is discovered and tested, the science will be grounded on a more practical understanding of the health care provider’s perceptions of patient self-management. This in turn will assist in the evolution and development of nursing involvement within the spectrum of patient-centered management of their medical condition. The resulting outcome will produce nurses who are more aware of diabetes self-management initiatives and patients who will benefit from the concept of self-management.
Background and Significance
Chronic diseases form a serious health problem, not only in developing countries but also globally. However, healthcare experts, policymakers, and other relevant stakeholders do not pay serious attention to the prevalence of chronic diseases in developing countries because the conditions progress at a slower pace, not to mention that they are often invisible and essentially under-diagnosed (Nugent, 2008).
The recent globalization trends, along with the ensuing consumerism culture reinforced in global societies, have led to a pronounced shift in the human environment, behavior, and lifestyle, leading to an escalation of life-style dependent diseases such as diabetes (Schwarz et al., 2007). Recent diabetes prevalence figures released by the World Health Organization (WHO) and the International Diabetes Federation (IDF) unearth a grave situation, which is threatening to get out of control (Boutayeb et al., 2005). For instance, the WHO estimates show that in excess of 180 million people worldwide suffered from diabetes in 2008 and the number is likely to double by 2030 (Pan et al., 2010), while IDF puts the 2010 diabetes prevalence rate for Saudi Arabia at 16.8%, noting that the number is expected to rise to 18.9% by 2030 (IDF Diabetes Atlas, 2009).
The prevalence of type 2 diabetes, commonly referred to as diabetes mellitus, has increased dramatically in the Middle East over the last three decades, a trend that only parallels the rapid growth achieved by countries during the initialization of industrial development. Oil-rich resources found in huge quantities in many countries in the Arabian Gulf have not only triggered a shift towards improved living standards but also led to hastened urbanization, radical changes in feeding and nutrition, diminished level of physical activity among the population, as well as a greater dependence on mechanization and migrant workers (Badran & Laher, 2012).
Available figures released by the IDF (2011) capture the magnitude and scope of the problem by demonstrating that the prevalence rate for type 2 diabetes in sampled developing nations located in the Middle East and North Africa currently stands at 9.1% (32.8 million people) of the total population in the two regions, with projections reaching 60 million people by 2030. The sudden increase of type 2 diabetes in these regions (Middle East and North Africa), especially within the 20–79 age category, is directly to blame for over 280,000 yearly deaths, with fatalities being almost equal across gender (IDF, 2011).
Moreover, several factors have been proposed in the literature as influencing the high prevalence rate of diabetes in developing countries, including Saudi Arabia. (Badran et al, 2011). One such factor, according to these authors, is the proliferation of the more problematic diabetes mellitus in most Arab-speaking countries, in large part due to the rapid shift in lifestyle, feeding patterns, nutrition, and other socioeconomic predictors brought about by the rapid development that has occurred over the last three decades or so.
Available literature demonstrates that although the rapid economic development acts to stimulate infrastructural improvements, especially in critical areas of healthcare and education, it is also intrinsically associated with the burden of overreliance on mechanization, an explosion of Western-oriented unhealthy feeding patterns, access to inexpensive migrant labor and, as has been documented elsewhere, greater opportunities for inactive lifestyles, particularly among young children and adolescents (Badran et al., 2011). As acknowledged by these authors, it is the convergence of these environmental and lifestyle-related factors that continue to fuel the emerging epidemic of type 2 diabetes in the Middle East, not to mention that these same factors also continue to drive the current explosion in obesity in Arabic-speaking countries.
The rapid economic growth witnessed in Saudi Arabia during the last 4 decades has led to a remarkable increase in living standards and adoption of a ‘Westernized’ lifestyle, characterized by unhealthy dietary patterns and decreased physical activity. An increase in the prevalence of T2DM has also been observed during the same period, which is not only attributed to the dramatic shifts in lifestyle but also the genetic predisposition of Saudi people to diabetes, as well as a high prevalence of consanguineous marriages (Midhet et al., 2010).
From the ongoing, it is clear that the burden of diabetes in KSA is likely to increase to problematic levels unless a comprehensive epidemic control program is implemented rigorously, with the aim to promote a healthy diet, exercise, and active lifestyles, as well as curb obesity (Midhet et al., 2010).
Over the past three decades, self-management has received wide-ranging interest not only in diabetes care but also in managing other chronic diseases, in part due to its emphasis on how people may manage their behavior and promote healthier lifestyles through an integrative approach which demands active involvement of the patient, family, and healthcare professional. Indeed, the concept of self-management is recognized as an essential component in the treatment of persons with chronic illness because it has a high potential to enhance chronic disease management and improve outcomes (Fisher et al., 2005; Udlis, 2011).
A literature search on diabetes in Saudi Arabia shows a clear lack of published articles focused on patient self-management, implying that scholarly articles on self-management of diabetes in the Saudi Arabian context were almost absent. Therefore, the paucity of data dealing with self-management of diabetes in the country reveals a serious disconnect in the contribution of Saudi Arabian academics to the international body of knowledge (Aljohani, 2011).
Al-Nozha et al (2004) claim that the higher prevalence of diabetes in Saudi Arabia, especially in people over 30 years old, is likely to be between 20% and 30%, pointing to a fact that indeed many Saudis with the disease are currently unaware of their status and hence do not receive any primary healthcare for the condition.
The Saudi studies indicate a significant gap in the current T2DM health-care interventions, especially about self-management approaches. The majority of published Saudi studies are primarily concerned with disease prevalence rather than disease management. Most of these studies have been undertaken by physicians, pointing to a paucity of scientific contributions by nurses and other health professionals. Additionally, although several Saudi studies recommend improving healthcare interventions, no researchers seem to have responded to such a recommendation. More importantly, studies that have been conducted in Saudi fail to examine self-efficacy associated with diabetes self-management (Aljohani, 2010). Therefore, there is a need to investigate the level of confidence demonstrated by individuals in managing their diabetic conditions in Saudi Arabia.
Barlow et al (2001) propose that there is no universally acceptable definition of self-management; rather, the term is context-specific and can be used interchangeably with other terms based on the focus of discussion. In the proposed study, therefore, the concept of self-management will be employed to denote a set of approaches and strategies that people living with diabetes attempt to employ in the pursuit to manage chronic disease. Self-management, in a much broader sense, has been defined by Lorig (2003) as learning and practicing life skills that are fundamentally essential to carry on an active, vibrant and emotionally fulfilling, and rewarding life in the face of a persistent medical condition. This particular author further underlines that the concept of self-management is focused on assisting the individual to become an active independent person rather than an ‘entity’ that is entirely dependent on healthcare providers for survival.
Available literature demonstrates that self-management is also used about the individual’s capability to effectively manage the symptoms of the disease by aligning his life to available treatment alternatives and physical and psychosocial ramifications related to the disease, as well as internalizing an undertaking to make lifestyle changes with the view to manage and live with the chronic condition (Barlow et al., 2002). Successful and efficient self-management, therefore, encompasses the capacity for the individual patient not only to self-monitor his or her condition but also to employ cognitive, behavioral, and emotional responses essential to sustain an acceptable quality of life. Further, Barlow et al (2002) acknowledge that individuals with a high potential in self-management tend to cope with the disease and enhance their quality of life with fewer constraints to their current medical status.
The concept of self-management for individuals with persistent medical challenges has been demonstrated in the literature as a fundamentally essential constituent in the management of diabetes (Tol et al., 2012). Under this concept, the individual is wholly accountable for the everyday management of their illness and associated symptoms (Lorig and Holman, 2000), implying that the person with the disease must acquire the requisite knowledge, skill, and confidence to manage the condition, as well as engage in specific behaviors such as testing blood glucose level and emotional management (Adams et al., 2004). Consequently, as reinforced in the literature, diabetes self-management is a particularly important concept because the adoption and internalization of healthy lifestyle behaviors tend to produce beneficial management outcomes of the chronic condition, thereby minimizing its complexity (Norris et al., 2001; Sousa et al., 2005).
The process of changing one’s behavior is particularly complex because it involves a multiplicity of intrinsic factors, such as scarce knowledge regarding the disease, health beliefs, personal attitudes and values, poor skills, and immediate social environment, that may adversely affect the realization of effective behavioral change (Tol et al., 2012). Yet, extant literature demonstrates that patients with Type 2 diabetes require to change their behavior through increasing their knowledge about diabetes, which can only be achieved through education, counseling, awareness creation, and seeking support through behavioral interventions programs offered by care providers to enable patients to perform self-care initiatives aimed at managing their condition (Al-Khawaldeh et al., 2012).
It is important to note that self-efficacy denotes the level of an individual’s confidence and conviction in his or her capacity to perform or undertake a specific behavior (Janz et al., 2002; Bandura, 1977). Kara et al (2006) indicate that an individual who experiences high self-efficacy allows for spending efforts toward achieving the optimum success regarding his or her situation and this depends on which behaviors the individual choose to enhance the quality of performance.
Nursing research in the field of self-management among diabetic patients in Saudi Arabia is almost absent. However, it is generally felt that identifying the behaviors related to diabetes self-management and examining the self-efficacy of individuals will play a significant role in the provision and implementation of the better intervention and support programs for optimum health outcomes (Aljohani, 2010). With regard to the importance of investigating the prevalence and complication of diabetes, the investigator will focus on providing continuous and optimal diabetic care and managing the symptoms in order to prevent or minimize the occurrence of diabetes complications. It is therefore plausible to develop effective self-management strategies and programs aimed at assisting Saudi diabetic patients to manage the disease and hence reduce overwhelming complications that undoubtedly result in decreased quality of life for the patients (Sukkarieh, 2011).
The increased rate of diabetes in Saudi Arabia has reinforced the importance of investigating this health problem through scientific research to build an evidence-based practice since the literature search suggests that the concept of self-management in Saudi Arabia is not well documented. However, diabetes self-management is a rather challenging area that requires adherence to complex protocol and integrated treatment strategies, encompassing a healthy diet, enhanced physical exercises aimed at controlling weight, blood glucose monitoring, and medication adjustments, if the individual is to achieve successful treatment and management outcomes (Montague et al., 2005).
Study Purpose & Research questions
Self-management has a high potential to enhance chronic disease management, not only of the core disease but also the underlying complications. Consequently, The purpose of this study is to examine the level of diabetes self-management and perceived self-efficacy among type 2 Saudi diabetic patients in Saudi Arabia. The proposed study will be guided by the following research questions:
- What is the relationship between the selected participants’ demographic characteristics and their self-management and Self-efficacy strategies?
- Does self-efficacy predict self-management behavior among Saudis with type 2 diabetes?
A cross-sectional research design will be used, whereby questionnaires will be distributed to the participants for purposes of collecting primary data.
Although probability sampling ensures the generalizability of study findings, a convenience sampling approach will be used due to the proximity/accessibility of the study subjects to the primary researcher. The study participants will be recruited using flyers, posters, and advertisements through Saudi daily newspapers. To obtain an adequate sample size, the researcher intends to sample participants from different diabetes centers located in the central city of Riyadh.
The literature review reveals no similar study for the appropriate sample size. In linear regression, the strength of the relationship is based on the interpretation of the correlation coefficient. Pearson’s r will convey information about the magnitude and nature of the relationship between variables. In involving Pearson’s r, the effect size of power analysis is the estimated value of population (ρ). In the absence of information required, estimation of population correlation ρ for the desired sample size recommends between small.10 to medium.20. For this research study, the effect size will be.30 with the power.80 and α =.05, resulting in the sampling of 85 participants for the study (Polit & Lake, 2010).
Inclusion and exclusion criteria
All males and females with type 2 diabetes between the ages of 24 and 45 will be included in the study. Newly diagnosed patients will be eligible for inclusion in the study. The participants should speak, write and read Arabic. Participants suffering from any cognitive impairment or cardiac complications will be excluded from the study.
General Self-Efficacy Scale
The proposed study purposes to use the German version of the General Self-Efficacy (GSE) scale, which was initially developed by Jerusalem & Schwarzer (1979) as a measurement instrument for self-efficacy consisting of 20 items. In 1981, the items were streamlined into 10, not to mention that the scale was also translated into 28 languages, including Arabic, to attain validity and effectiveness in measuring the beliefs people have in their own abilities to exhibit the desired behaviors when exposed to diverse situations. Extant literature demonstrates that the scale has been employed by researchers on numerous occasions, where it characteristically generated internal consistencies between alpha =.75 and.91 (Scholz et al., 2002), not mentioning that its stability has been assessed in several longitudinal studies and found to be valid. The scale utilizes a 4-point Lickert-type scale, whereby responses are summed up to generate the final composite score ranging from 10 to 40. Certainly, the scale is unidimensional, as demonstrated in a series of confirmatory factor analyses (Scholz et al., 2002; Al-Eisa et al., 2012).
The Arabic Summary of Diabetes Self-Care Activities Scale-A (A-SDSCA)
Utilized widely in diabetes-related studies in most Arab-speaking countries across the world, the original Summary of Diabetes Self-care Activities (SDSCA) instrument was developed by Toobert et al (1994) and revised by the same group of researchers in 2000. It is important to note that the translation of the SDSCA was guided by the World Health Organization (2008), and was attained through specific stages of professional translation, expert panel reviews, and psychometric evaluations. While very similar to the steps suggested by WHO (2008), the present translation differs from the original in that the stage of cognition involves an expert panel establishing the content validity of the instrument, and is normally undertaken prior to, rather than as part of, pretesting.
The Arabic Summary of Diabetes Self-care Activities (ASDSCA) instrument has already proved to possess very acceptable psychometric properties: split-half reliability (.90); test-retest (.912, p = <.001); and Cronbach’s alpha (.76). The internal consistency of the instrument’s sub-scales is good for diet (.89), exercise (.83), blood glucose testing (.92), and foot care (.77). Factor analysis has revealed the presence of four components explaining 34.4%, 16%, 15.4%, and 11.2% of the variance of daily self-management practices for these items, respectively (accumulated total of 77.1%). Content validity reviewed by two panels of experts shows that the instrument representativeness score (R-CVI) is around 95.3 (95.3%) while the clarity score (C-CVI) is around 94.8 (94.8%), not only indicating acceptable levels but also guaranteeing that the current version of A-SDCA can measure self-management practices among Arab-speaking populations (Aljohani,2010).
Data will be collected at one point in time from the sampled participants. Data collectors will be trained to enter data, confirm their quality, and test their validity and reliability. The primary researcher will be available to double-check entry and ensure that the data are accurate and consistent.
The descriptive statistic will be used to analyze the participants’ demographic data. To determine the relationship between participants’ demographic variables, self-management, and self-efficacy, Chi analyses of frequency (chi-square tests) will be used as they are known to effectively show the relationship between categorical variables. To answer the second question, linear regression will be used to see if self-efficacy is the fundamental predictor of self-management behavior among diabetic patients.
The primary investigator will ensure that the collected data is stored in a secure location such as a locked cabinet, which will be accessible only to authorized members of the research team. A unique subject/participant identity will be used to protect the privacy and confidentiality of participants since these identifiers have no meaning other than that of enabling the researcher to handle data effectively and efficiently without compromising the identity of participants (Hulley et al., 2006).
The missing data will be managed according to its patterns, especially by employing random and systematic characteristic patterns for missing data. Missing data should be assessed carefully and treated seriously because they affect generalizability. Creating a dummy coding system for missing data and testing it against non-respondents to examine the differences in any variables will be used as a way to deal with missing data. Approaches such as mean substitution can be used as a single imputation for the missing data, especially if it is identified as completely missing at random. Using the subject’s means to impute it into the missing items is yet another approach that will be used for purposes of data management (Howell, 2007; Munro, 2001)
The project’s approval will be obtained from the Human Subjects Review Board at Kent State University and the School of Nursing at King Saud University in Saudi Arabia. Research participation is voluntary, and participants will be anonymous and will be instructed not to write any personal information on the instrument itself. The primary researcher will answer all underlying questions from participants before seeking their informed consent to undertake the study.
IRB approval timeline varies depending on the type of the study and the participants involved in the research. The complexity involved as well as the missing information means that approval may take a longer time to process. Overall, the proposed study will be conducted in Saudi Arabia in a time frame of not more than 18 months according to the dissertation period.
The expected challenge in the proposed study emanates from the instruments. Although the instruments are available in Arabic, the primary researcher will make sure that they are reliable and valid by undertaking an extensive literature review.