AbstractSection Background

It’s crucial for individuals with diabetes to practice effective self-management to reach their treatment goals and to prevent complications.

AbstractSection Aim

This study aimed to explore needs and challenges in diabetes self-management for patients with type 2 diabetes (T2D) and healthcare providers in Addis Ababa, Ethiopia, between February and April 2023.

AbstractSection Methods

This study employed a mixed method approach, with an exploratory qualitative study, including in-depth interviews with 22 patients with diabetes and key informant interviews with 25 healthcare providers. Additionally, we conducted a quantitative assessment of 26 primary health care facilities to understand facility-related factors that impact diabetes self-management practices. Thematic analysis was performed using a deductive coding approach following the socioecological model, with the help of Open Code software.

AbstractSection Findings

This study revealed that poor diabetes self-management practices are a major risk factor for blood glucose control among patients with type 2 diabetes. Patients struggled with misconceptions, low health literacy, dietary preferences, a lack of glucometers, financial constraints, age-related issues, and comorbidities. Healthcare system factors included insufficient trained staff, the absence of health insurance coverage, inadequate diabetes education, the scarcity of educational resources, and limited access to affordable diagnostic facilities. At the community level, a lack of social support, self-stigma, religious fasting practices, and restricted access to diverse food options were prominent obstacles. Patients expressed preferences for accessible educational materials such as pamphlets, mobile messages, and localized TV programs. Healthcare providers emphasized the necessity for culturally appropriate guidelines tailored to local contexts, emphasizing patient understanding and personalized care.

AbstractSection Conclusions

This study found that inadequate diabetes self-management practices are the risk behaviours for poor blood glucose control in patients with T2D and these issues are associated with challenges at the patient, organizational, and community levels. This study highlights the need for tailored diabetes self-management programs in Ethiopian primary healthcare, considering local contexts, diabetes health literacy, participant demographics, and evolving patient needs.

Appropriate self-management practices are important for patients with diabetes to reach their treatment goals and prevent complications. According to the American Association of Diabetes care and Education Specialists (ADCES) [1], successful and effective management of diabetes involves seven key self-care actions, which include healthy eating, being physically active, blood glucose monitoring, taking medication, problem solving, healthy coping, and risk reduction.

The prevalence of diabetes in Ethiopia ranges from 1.9 to 14%, as reported by some studies conducted in different parts of the country [2,3,4,5,6,7,8,9]. A systematic review and meta-analysis on the level of self-care practice among diabetic patients in Ethiopia revealed that the overall pooled prevalence of good diabetes self-care behaviour was 49% (95% CI: 43, 56%) [10]. Another systematic review and meta-analysis reported a pooled estimate of overall good self-care practices of 51.12% (95% CI: 41.90–60.34) [11].

A qualitative study among peoples living with type two diabetes (T2D) in two public hospitals in Addis Ababa, Ethiopia, concluded that the overall self-care practices were not adequate [12]. The study reported that regular self-monitoring of blood glucose, dietary and physical exercise were inadequately practiced by most participants. Moreover, patients generally lacked proper information and knowledge regarding the importance of self-care and how it should be implemented.

Several risk factors, including comorbidities [13], no access to blood glucose monitoring kits [14,15,16], poor knowledge about diabetes [13, 14, 17, 18], never having diabetes health education [15, 17, 18], poor self-efficacy [16, 18], and not having social support [15, 16, 18, 19], have been found to be significantly associated with poor self-care practices in patients with diabetes. A facility-based cross-sectional study conducted to assess the quality of care provided to adult people living with T2D in southern Ethiopia described gaps in care and management, with public hospitals often lacking diabetes-specific evidence-based guidelines [20].

An exploratory qualitative study conducted in Eastern Ethiopia [21] revealed the healthcare system and provider-related barriers to diabetes peoples’ self-care practices, such as a lack of organized diabetes care services, limited collaborative care practices, a lack of multidisciplinary team care, a lack of training for healthcare providers (HCPs) on diabetes self-care practices, and a shortage of laboratory tests and diabetes medication. Another mixed-methods study conducted in Northeast Ethiopia [22] revealed that diabetes education was significantly associated with good diabetes self-care and revealed poor access to fruits and vegetables and a lack of social support as barriers to good diabetes self-care practices.

Several evidence-based Diabetes Self-Management Programs (DSMP), including the Self-Management Resource Centre’s Diabetes Self-Management Program (DSMP) [23], the Diabetes X-PERT Programme [24], and the DESMOND program [25] in the UK, have shown that DSMP improves diabetes self-management practices and glycaemic control in people living with T2D patients and could be considered as best practices to be adapted in developing countries [26]. Although DSMPs have shown efficacy and effectiveness in developed countries, it is not known whether these interventions are also effective in low-income countries including Ethiopia. Moreover, locally appropriate implementation strategies and related barriers and facilitators are not known. Structured, patient-centred, self-management education and support have been recommended as cornerstones for effective diabetes management by the Ethiopian Ministry of Health National Strategic Plan [27]. Despite this recommendation and a growing body of research on diabetes management globally, there is limited data focused on the Ethiopian context, particularly regarding challenges and needs in diabetes self-management in primary healthcare (PHC) settings. This formative study aims to fill the gap in understanding the specific needs and challenges faced by patients and HCPs in Addis Ababa, Ethiopia regarding diabetes self-management. By focusing on both patient and provider perspectives, the research aims to create a more holistic understanding of diabetes management needs, that may lead to the development of tailored interventions that can improve health outcomes and empower patients with T2D and HCPs in the PHC context in Ethiopia.

The study was conducted among patients with T2D in 26 PHC facilities (Health centres) in Addis Ababa, Ethiopia. Addis Ababa, the capital of Ethiopia, is selected as the study setting because of its high T2D prevalence (9%) [9], likely driven by urbanization, lifestyle changes, and more sedentary behaviour, which impact diabetes self-management. Additionally, there is a lack of research on the needs and challenges of diabetes self-management and support among patients and HCPs, especially at the city’s health centres. These health centres serve as the primary level of healthcare in urban areas. Diabetes care is offered by medical doctors and/or nurses at outpatient clinics, with some fees applicable if not covered by health insurance. Public health officers are HCPs with a bachelor’s degree in public health and medical practice, primarily responsible for the clinical management of patients, including those with diabetes, at health centres in Ethiopia. At the time of the study, there was no structured diabetes self-management program for managing diabetes. Instead, infrequent diabetes education at the clinic was offered individually to patients on the basis of their needs when they visited the clinic to refill medications, typically on a monthly basis.

The study was performed using a mixed method approach with an exploratory qualitative study to explore challenges and needs in diabetes self-management among individuals with T2D and HCPs. Additionally, a quantitative assessment of health facilities to understand facility-related factors that impact diabetes self-management practices were conducted. The study was conducted between February and April 2023. The study was reported according to the Standards for Reporting Qualitative Research (SRQR) [28], as detailed in Additional File 1. We used the socioecological model to guide the study [29]. The model assumes that individual health promotion is influenced by various factors, including personal beliefs and understanding, family and social support, and institutional and environmental factors. The model was used to develop interview questions and to guide the thematic analysis.

This study was conducted among people with T2D and HCPs in 26 primary health care facilities. Participants were selected via a purposive sampling method. People living with T2D who were on oral diabetes medication with no apparently seen mental health problems were enrolled from selected health centres with diabetic follow-up. Similarly, HCPs were selected if they had a minimum of six months of experience in managing non-communicable diseases (NCDs) at chronic outpatient departments. The number of participants was determined on the basis of the saturation level. The data collection process was considered saturated once successive interviews within each sample failed to uncover new information. Accordingly, we decided to conclude data collection after 22 in-depth interviews (IDIs) with patients with T2D and 25 key informant interviews (KIIs) with HCPs.

We conducted in-depth interviews with patients with T2D and key informant interviews (KIIs) with HCPs. Patients with T2DM were asked about their experiences with diabetes self-management practices and the related barriers, while HCPs were asked about their views on diabetes self-management programs, their clients’ living with T2D experiences, the barriers from both the providers’ and facilities’ perspectives, and their needs. All interviews were audio-recorded via a digital sound recorder. During the interviews, notes were recorded to capture both verbal and nonverbal expressions of emotions. A semi-structured interview guide, developed specifically for this study (Supplementary File 1), was used for both patients and HCPs. For the quantitative data, we conducted facility observations to assess and understand the availability of resources and diabetes services that affect diabetes self-management practices, discussed them with health center managers, and reviewed processes at 26 health centres pertaining to diabetes management via the World Health Organization (WHO) facility assessment checklist for NCD services (Supplementary File 1) [30]. The health centres for the site assessment were randomly selected from those that have a diabetes clinic in each subcity. The tool contains data elements pertaining to patient flow, patient care services, staff, equipment, medical laboratory services, medicine, records, reports, and referrals.

The data were collected by two experienced qualitative data collectors with master’s degree in public health and the principal investigator. Interviews were conducted in Amharic on-site during a single session. Patients were interviewed in-person in a private room at the health center during their follow-up visits with their HCPs. HCPs were interviewed either at the beginning or end of their clinic hours in the outpatient clinic. The interviews and facility assessments were carried out from February to April 2023.

Thematic analysis was carried out on the qualitative data. The recorded IDIs and KIIs were transcribed verbatim and translated into English by the two data collectors and the principal investigator (YSY). The transcripts were first read several times to obtain an overall picture, and then, via a deductive approach, we assigned codes to the data. Then, meaningful concepts related to the challenges of diabetes self-management were condensed and categorized into broad themes on the basis of the socioecological model [29]. Participant quotations were selected to illustrate the particular issues discussed. A code book was used for the consistent application of codes and themes to the data by two research team members (YSY and EGK). We followed an open coding approach where data is broken down into discrete parts, and each part is assigned a code based on its content. The coding of data was done using Open Code software. The quantitative data were presented using percentages and summary statistics, including the mean and standard deviation, and/or the median and interquartile range.

We tried to enhance the quality of our findings by adhering to the principles of trustworthiness in qualitative research, as outlined in [31]. The thick description of the study context, methods, and participant quotes enhanced trustworthiness, whereas dependability is evidenced by references to the literature that align with our results. Furthermore, credibility was established through triangulation, integrating data from patients, HCPs, and both qualitative and quantitative sources. We tried to ensure the rigor of the data through maintaining the researcher’s reflexivity, prolonged engagement, and member checking. The research team upheld reflexivity by recording, discussing, and challenging established assumptions. We engaged with the target population and setting for an extended period of three months, allowing us to gain a broader understanding of the challenges related to diabetes self-management through a diverse range of experiences. Additionally, we sought feedback on the transcripts from two participants—one HCPs and one diabetes patient—who confirmed the accuracy of our transcripts.

Ethical clearance was obtained from the Institutional Review Board (IRB) of the College of Health Sciences, Addis Ababa University (Protocol number: 104/22/SPH). The purpose of the study was explained to the study participants, and participation in the study was completely voluntary. The participants were informed of the potential benefits and zero risks associated with participation in this study. The confidentiality of the information was maintained, and on the basis of the needs of the participants, appropriate diabetes health information was provided. The right of study participants to refuse to respond to any question or to participate in the study was respected. Furthermore, anonymous participant identification codes were used during data collection and analysis.

We conducted twenty-two in-depth interviews (IDIs) with people living with T2D at 22 health centres and 25 key informant interviews (KIIs), with HCPs from 25 health centres. Among the 22 patients, nine were males. The average age of the patients was 50.8 years. Similarly, 25 HCPs, including general practitioners (n = 16), nurses (n = 5), and public health officers (n = 4), participated in this study. These interviews provided valuable insights into the risk behaviours and diabetes self-management needs of both patients and HCPs.

Most patients reported having uncontrolled blood glucose at the time of the interview. They attributed their poor blood sugar level to poor diabetes self-management tasks, specifically poor practice of dietary and physical exercise recommendations and poor adherence to medication. HCPs, who verified the higher level of uncontrolled blood glucose in their patients, reported that the level of self-management practice of patients was inadequate. The following quotations illustrate these findings:

“Regarding the level of diabetes self-care management of our patients, we can consider it poor. Some of them know nothing about diabetes except that they have this condition; others have some knowledge about their diabetes. Home-based blood glucose monitoring via a glucometer, results in almost zero glucose. Physical exercise and healthy dietary practices were also poor in our patients (R19, HCP).

A 64-year-old diabetes patient also reported a poor level of diabetes self-management, representing the majority of the participants.

“My self-management practice is poor; I am taking only the tablet; no exercise; no fruits and vegetables; no blood monitoring. Sometimes the tablet makes me ‘zero’. I was frequently affected by hypoglycaemia, and I have fainted several times.” (P19, Patient).

We combined the findings of interviews with patients and HCPs on the determinants of risk behaviour and presented them in fifteen subthemes (Table 1) that were categorized into three major themes on the basis of the socioecological model namely individual factors, health system factors and community factors, as presented in Fig. 1.

Logic model of the problem in diabetes self-management among type 2 diabetes patients and healthcare providers in Ethiopia

Full size image

Misconception

HCPs reported that patients with T2D held misunderstandings about the origins and management of diabetes. They noted that many diabetes patients believed that excessive sugar consumption caused diabetes, leading them to believe that avoiding sugar could effectively manage their condition. The other misconception is that some patients confuse curability with manageability and believe that diabetes is totally unmanageable. This misperception usually results in patients with diabetes seeking traditional medicine rather than Western medical care.

Health illiteracy

We found that the level of health literacy among the patients was low. Patients poorly understand self-management tasks, which has implications for diabetes self-management. HCPs noted that individuals with limited health literacy cannot easily understand information about diabetes.

Food preferences

One of the challenges that participants mentioned in relation to managing their diabetes was quitting favourite foods. We found that the participants had difficulty changing their food habits.

Lack of glucometer

Most of the participants did not have a personal glucometer. The blood glucose levels of the majority of the patients were monitored at the health center on a monthly basis. Few patients were able to monitor their blood glucose levels at home with a glucometer. Those who have glucometers find it difficult to either operate them or read and understand the results. In addition, they complain of a shortage of and/or incompatible test strips and glucometers.

Financial constraints

HCPs reported that financial constraints in the management of diabetes were the issues most frequently raised by their patients. This was related mostly to the necessity of buying medications and a range of foods advised for diabetes management. The problem was more pronounced among patients without medical insurance.

Age and comorbid illness

Both HCPs and patients explained that self-management tasks are difficult due to old age and the presence of other comorbid illnesses, such as asthma and musculoskeletal disorders. Doing physical exercise can often result in discomfort and pain for patients, especially in the back and legs, which are reported as barriers to maintaining daily exercise.

Work load

Some patients described how it was difficult for them to maintain certain aspects of self-management, such as exercising, eating a healthy diet, and taking their medications on time, because of their job schedule. Owing to their demanding job, the participants said that it was challenging to adhere to physical activity and regular medication.

Shortage of trained healthcare providers

A lack of trained HCPs was identified as a barrier to effective diabetes self-management. Patients with T2D expressed that HCPs were not adequately skilled in guiding them on proper self-management practices. HCPs themselves also acknowledged this issue, noting that they felt incompetent to support diabetes self-management due to the absence of a structured and locally relevant self-management program.

Lack of adequate health education or counselling

Patients mentioned a lack of sufficient health education or counseling as a reason for their poor diabetes self-management. The long waiting period at clinics was indicated to be one factor in not having adequate diabetes education and support. Moreover, patients are eager to return home quickly, as they often skip breakfast before arriving at the clinic to check their fasting blood sugar levels. Patients requested more time from HCPs to understand how and why they developed diabetes as well as to receive helpful advice on lifestyle change and self-management. Patients have little to no opportunity for involvement in provider‒patient communication since the provider takes on a dominant, expert role and sets the discussion point.

Lack of educational materials

The lack of educational materials was underscored by the HCPs; the only materials available in the majority of the health centres were the Ethiopian PHC Clinical Guidelines, which is not specific to non-communicable diseases and lacks detailed information on diabetes education and self-management. The participants stated that a lack of educational materials (such as patient brochures and handbooks) is among the barriers to diabetes self-management.

Lack of an affordable and accessible diagnostic facility

Both patients and HCPs raised challenges related to diagnostic services. A shortage of reagents or a test strip were common problems mentioned. HbA1c testing was not available at primary health facilities, as noted by HCPs.

The participants noted a wide range of community-level factors. Those included lack of social support, stigma and discrimination, religious fasting, and social gatherings.

Social support

Many patients said that they lack social support in any form. However, few patients mentioned how family members support them in medication administration and regular blood glucose testing. The participants reported no support from religious organizations, diabetes societies, non-governmental organizations (NGOs), or other organizations. However, at one health center, an organization focused on diagnostic services offered a week-long free random blood sugar (RBS) test in connection with Ethiopia’s 13 th month (Paugme) celebrations.

Stigma

According to some HCPs, people living with T2D generally refrain from telling friends or relatives about their condition because they are afraid of facing stigma as a consequence. Diabetes patients also disclosed that they do not want to be called diabetes patients, and as a result, they withdraw themselves from the community to conceal their condition.

Holidays and religious fasting

Patients found it challenging to adhere to dietary restrictions during holy days and religious fasts. They were also required to eat the food that was served to them when they visited other people’s houses and were not given alternatives to make other food choices. They also raised how medication adherence is during social gatherings.

Access to a variety of foods

Patients reported that they ate whatever was available at home due to a lack of access to a variety of food options. Many of the patient participants acknowledged that, despite being given a dietary plan, they consumed whatever meals were prepared at home or any food available to them. Some patients with T2D mentioned that they eat meals from a common dish prepared for the whole family. They mentioned that separating meals for a diabetes patient in an Ethiopian family is difficult owing to economic and cultural problems.

Diabetes self-management needs

Patients were also asked about the type of tool for diabetes self-management they believed could be effective. Patients reported a number of unmet needs related to diabetes self-management support, diabetes self-management tool preferences, and self-management support.

Majority of the patients noted the usefulness of brochures. For individuals who are unable to read, assistance from family members or neighbours was suggested. They also suggested regular television programs, mobile phone messages, and workshops on diabetes self-management, noting that even patients with limited literacy engaged with movies and comprehended health-related messages. The participants emphasized the importance of brochures being written in local languages to enhance comprehension. The following quotations supported these findings:

“We don’t have structured guidelines on diabetes self-care management in hand. It could be better if we had brochures, regular television programs, mobile phone messages, and workshops on diabetes self-management.” (P19, Patient).

HCPs also emphasized the need for suitable teaching/learning materials for patients, noting,

“We need sufficient educational materials, like patient education booklets and locally applicable guidelines, to effectively implement diabetes education.” (P24, HCP).

To make informed decisions, patients require sufficient interaction with HCPs. Patients believe that HCPs should be aware of their unique circumstances, including age, physical condition, the psychological and emotional effects of type 2 diabetes, and the complexity of treatment. The majority of patients place high value on receiving personalized treatment, feeling understood, and receiving recommendations that are specific to their needs. Quotations in support of these findings included:

“…they (the doctors) told me nothing concerning diabetes self-management.” What they did was give me medicine (P07, Patient).

“I understand that the doctors are busy and that the next patient is waiting, but I wish they would provide more information.” (P17, Patient).

HCPs were requested to have locally appropriate, structured, pocket-size guidelines and recommendations on diabetes self-management tasks (meal planning methods, physical exercise, medication, and blood glucose monitoring). Furthermore, patients with T2D wish to have some economical and material support, a free laboratory test, and the provision of a glucometer and test strip. Quotations verifying these findings included:

“Giving all the necessary health education and counselling for at least one close family member of diabetes patients and scale-up of blood pressure corner experience for diabetes (establishing a diabetes corner that provides blood glucose testing)” (P23, HCP).

“Behavioural changes require ongoing counselling and community mobilization, along with awareness campaigns on events like World Diabetes Day. However, such efforts have been minimal so far.” (P17, HCP).

“The government should cover at least medical expenses and, if possible, should provide economic support to us.” (P2, Patient).

Status of the health facilities related to diabetes care and management

On average, 239 patients with T2D were registered and followed at each health center. The majority of patients (95%) were receiving drug treatment. The average number of people with T2D with HbA1c records over the previous three months of the visit was 163.6 across the 12 healthcare facilities. Half of the facilities had fewer than 40 people with T2D with uncontrolled blood pressure, while the other half had more than 40 people with T2D with uncontrolled blood pressure (median 40, IQR 94). All visited health facilities had at least one or at most four staff trained in diabetes diagnosis and treatment (Table 2).

All the health facilities visited had a separate NCD clinic, dedicated staff for NCD services, a glucometer and test strip, a weighing machine, height measuring tape, a blood pressure measuring apparatus, urine ketone and blood sugar tests, essential hypoglycaemic drugs (Metformin, Glibenclamide, and Glimepiride), and a separate NCD register.

The majority of the health centres (69.2%) had started national protocol-based management of NCDs. One-half of the health facilities had NCD treatment guidelines. Cholesterol testing was available in only 34% of facilities. HbA1 C was measured in 23.1% of the facilities, and insulin was measured in 30.8% of the facilities. Only 5 (19.2%) of the health centres had computerized patient records (Table 3).

In this study, we explored challenges and needs in diabetes self-management among individuals with T2D and HCPs and solicited strategies for improving the self-management of patients with T2D. The patients and HCP identified areas of support with regards to self-management practices, including a contextualized diabetes self-management guide, educational materials, and training on diabetes self-management. Meaningful concepts related to the challenges of diabetes self-management were condensed and categorized into broad themes on the basis of the socioecological model [29].

The research findings highlighting lack of good diabetes self-management practices as a key risk factor for blood glucose control among patients with T2D at the PHC level in Addis Ababa, Ethiopia, shed light on a critical area for intervention. This finding is supported by a qualitative study among patients with T2D in two public hospitals in Addis Ababa [12].

Misconceptions were found to be one of the barriers to diabetes self-management. Some common misconceptions include believing that diabetes is caused solely by consuming too much sugar and that people with diabetes cannot eat any carbohydrates. These misconceptions can result in individuals making poor dietary choices, neglecting necessary medication, or failing to monitor their blood sugar levels adequately. This can lead to uncontrolled blood sugar levels, an increased risk of complications, and overall poor diabetes management. The misunderstandings uncovered in this research align with similar findings in previous studies conducted in Ghana [32] and Pakistan [33], which highlighted these barriers to diabetes self-management.

This study revealed that individuals with diabetes had a basic understanding of general information related to their condition but lacked a detailed understanding of the specific tasks involved in managing diabetes. These findings are supported by other studies [13, 16, 18]. A mixed-method study conducted in Northeast Ethiopia [22] revealed that diabetes education was highly related to good diabetes self-management. Health illiteracy can make it difficult for individuals to understand important concepts related to diabetes, such as blood sugar monitoring, medication management, and dietary guidelines. This lack of understanding can hinder their ability to manage their condition effectively.

The study revealed personal food preferences as a serious challenge in diabetes self-management. Individuals struggling with food loving may find it challenging to adhere to a healthy diet and portion control, leading to frequent consumption of high-sugar and high-calorie foods that can exacerbate blood glucose levels. This finding is in line with studies conducted in Sub-Saharan Africa [34, 35].

We found that most participants lacked a glucometer for home blood glucose monitoring. Instead, they were only able to test their blood glucose levels during monthly follow-up appointments at the health center. This finding is also highlighted in other studies [13, 17, 18, 32]. The lack of a glucometer makes accurate tracking of blood sugar levels difficult. Regular monitoring is crucial for adjusting medication dosages, making dietary choices, and managing physical activity levels. Without this information, patients with T2D may struggle to make informed decisions about their diabetes management.

This study revealed that financial constraints prevented some patients with T2D from managing their condition effectively. For example, some struggled to afford healthy food, whereas others could not purchase essential blood glucose testing equipment and strips. These findings are supported by prior research by [36] highlighting how financial limitations affect various aspects of diabetes management, such as medication, supplies, and access to nutritious food.

Both HCPs and patients explained that self-management tasks are difficult due to old age and the presence of other comorbid conditions, such as asthma and musculoskeletal disorders. Physical exercise is critical for effectively controlling blood sugar levels [37]. Even though walking is a common mode of transportation for many Ethiopians, illness and advanced age can significantly reduce patients’ ability to walk as usual [38]. Older age and comorbid illness can lead to physical limitations, such as reduced mobility, causing difficulty in engaging in regular exercise or performing other self-care tasks.

Patients with T2D and HCPs underscored busy work schedules made it difficult for them to adhere to self-management tasks.; a similar finding has been reported elsewhere [33]. This may lead to limited time for physical activity, difficulty adhering to a healthy diet and medication, and challenges in monitoring blood sugar levels regularly.

Appropriate diabetes education was found to be helpful in improving the self-management practices of patients with T2D [39]. Without proper education, individuals may lack the necessary knowledge and skills to manage their diabetes effectively. This can lead to difficulties in monitoring blood sugar levels, understanding medication regimens, following a healthy diet, and engaging in regular physical activity.

Both patients and HCPs in this study reported a shortage of educational materials. This finding is supported by the contextual assessment, which revealed that only half of the health facilities had NCD treatment guidelines. Another study highlighted that local and national guidelines for diabetes management remain limited [40].Without the availability of such standardized documents, diabetes self-management is limited in content and consistency and is difficult to implement in real-world settings [41]. The lack of educational materials for diabetes self-management can have a negative impact on individuals’ ability to effectively manage their condition.

The participants in the study noted that a major concern was a lack of resources in the implementation of diabetes education at the PHC level. A related finding from the contextual assessment revealed that only one-fifth of the facilities offered the HbA1c test. Several other studies [13, 17, 18] also reported no access to blood glucose monitoring kits or diagnostic facilities as a barrier to diabetes self-management. When diagnostic tests such as HbA1c are not affordable and accessible, inadequate monitoring of blood sugar levels and difficulties in assessing the effectiveness of treatment can occur. Without regular access to diagnostic facilities, patients with T2D may struggle to make informed decisions about their diabetes management and may not receive timely interventions or adjustments to their treatment plans.

Social support improves self-management practices through diverse means, such as supporting medication recognition, administering medications, conducting blood glucose tests, and managing low blood glucose. It can significantly enhance an individual’s ability to effectively manage diabetes effectively. However, several participants in this study noted a lack of adequate social support. The importance of family support in enhancing medication adherence and blood glucose testing among individuals with diabetes has been highlighted in several studies [15, 16, 18].

Stigma was one of the barriers to diabetes self-management raised by the participants in this study. When individuals with diabetes experience stigma and discrimination, it can lead to negative emotional and psychological effects, such as feelings of shame, embarrassment, and low self-esteem [16, 18]. These negative emotions can hinder their motivation and confidence in managing their diabetes effectively. Stigma and discrimination can also create barriers to accessing healthcare services and support. Furthermore, it can limit opportunities for social support; patients may feel reluctant to disclose their condition to others, which is crucial for diabetes self-management.

The participants often mentioned holy days, religious fasting, and social gatherings as barriers to managing diabetes effectively. Our results align with those of previous studies [33, 35, 37], which underscore how food intertwined with sociocultural customs can impede effective diabetes management. During holidays and religious fasts, individuals may struggle to adhere to their usual dietary regimens due to the unsuitability of the food served. Religious fasting can also present challenges in adhering to medication adherence.

Exploration of availability of diverse foods options for patients with T2D revealed difficulty in regularly obtaining the range of foods necessary to fulfil their dietary requirements. Consistent with our findings, research conducted in Ethiopia [35] highlighted the challenge related to the availability of diverse food items as a barrier impeding dietary self-care practices among diabetes patients. A lack of food variety can make it difficult to follow dietary recommendations, such as consuming a balanced diet. In addition, not having access to a variety of foods can impact meal planning, potentially affecting adherence to dietary guidelines.

ADCES:

American Association of Diabetes Care and Education Specialists

DSM:

Diabetes Self-Management

DSMP:

Diabetes Self-Management Programs

FBS:

Fasting Blood Sugar

HbA1 C:

Glycated Hemoglobin. HCP: Healthcare Providers

IRB:

Institutional Review Board

KII:

Key Informant Interview

MPH:

Master of Public Health

NCDs:

Non-Communicable Diseases

NGO:

Non-Governmental Organization

P:

Participant

PEN:

Package of Essential NCDs

PHC:

Primary Healthcare

SRQR:

Standards for Reporting Qualitative Research

T2D:

Type 2 Diabetes

WHO:

World Health Organization

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YSY designed the study and participated in data collection and supervision. YSY analysed the data and wrote the first draft of the manuscript. YSY, AAA, AA, EGK, AR, and AAA contributed to the interpretation of the data. AAA, AA, EGK, AR, and AAA read and edited the first draft of the manuscript. All the authors read and approved the final manuscript.

Correspondence to Yimer Seid Yimer.

Ethical clearance was obtained from the Institutional Review Board (IRB) of the College of Health Sciences, Addis Ababa University (Protocol number: 104/22/SPH). The purpose of the study was explained to the study participants, and participation in the study was completely voluntary. The participants were informed of the potential benefits and zero risks associated with participation in this study. The confidentiality of the information was maintained, and on the basis of the needs of the participants, appropriate diabetes health information was provided. The right of study participants to refuse to respond to any question or to participate in the study was respected. Furthermore, anonymous participant identification codes were used during data collection and analysis. Informed oral consent was obtained from each study participant.

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The authors declare no competing interests.

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