See discussions, stats, and author profiles for this publication at: https://www.researchgate.

net/publication/325738504

Inadequate Self-Care Behaviors among Malaysian Diabetic Patients: The Need

for Action by Hospital Pharmacists

Article · June 2018

DOI: 10.5530/jppcm.2018.2.14

CITATIONS READS

3 325

4 authors, including:

Doris George Huan-Keat Chan

Hospital Raja Permaisuri Bainun Hospital Sultanah Bahiyah
9 PUBLICATIONS   15 CITATIONS    53 PUBLICATIONS   226 CITATIONS   

SEE PROFILE SEE PROFILE

Some of the authors of this publication are also working on these related projects:

Satisfaction with traditional counter versus value-added services for prescription claims in a Malaysian Tertiary Hospital View project

Medication Error Reporting View project

All content following this page was uploaded by Doris George on 05 September 2018.

The user has requested enhancement of the downloaded file.

 RESEARCH ARTICLE OPEN ACCESS
Journal of Pharmacy Practice and Community Medicine.2018, 4(2):51-54• http://dx.doi.org/10.5530/jppcm.2018.2.14 e-ISSN: 2455-3255

Inadequate Self-Care Behaviors among Malaysian Diabetic Patients:

The Need for Action by Hospital Pharmacists
Ju-Ying Ang1*, Jie-Shi Leo2, Doris George2, Huan-Keat Chan3
1
Clinical Research Centre, Hospital Raja Permaisuri Bainun, Jalan Raja Asman Shah, 30450 Ipoh, Perak, MALAYSIA.
2
Department of Pharmacy, Hospital Raja Permaisuri Bainun, Jalan Raja Asman Shah, 30450 Ipoh, Perak, MALAYSIA.
3
Clinical Research Center, Sultanah Bahiyah Hospital, 05460 Alor Setar, Kedah, MALAYSIA.

Received: 23 February 2018; Abstract

Accepted: 11 May 2018
Background: Self-care behaviors have been confirmed to be strongly associated with clinical outcomes
*Correspondence to: of diabetes management. Objective: To determine the prevalence and risk factors of inadequate self-care
Ju-Ying Ang, B.Pharm, behaviors among the Malaysian patients with type two diabetes mellitus (T2DM) through screening by
Clinical Research Centre, Aras 4, Kompleks
Rawatan Harian, Hospital Raja Permaisuri hospital pharmacists. Methods: A cross-sectional study was undertaken over a nine-month period at a public
Bainun, Jalan Raja Asman Shah, 30450 Ipoh, tertiary care center in Northern Malaysia. Self-care behaviors of 103 patients with T2DM were evaluated
Perak, MALAYSIA. using the 16-item Diabetes Self-Management Questionnaire (DSMQ), and the scores were dichotomized
Email: angjy.crcperak@gmail.com
to represent “adequate” (≥6 out of 10) and “inadequate” (<6 out of 10) self-care behaviors. The risk
Copyright: © the author(s),publisher and
factors for inadequate self-care behaviors were identified using logistic regression analysis. Results: The
licensee Indian Academy of Pharmacists. This
is an open-access article distributed under the participants recorded a mean DSMQ score of 7.48±1.32, and 16 (15.5%) of them were found to have
terms of the Creative Commons Attribution inadequate self-care behaviors. Among the four subscales assessed, the “Health-Care Use” had the highest
Non-Commercial License, which permits
score (8.36±1.99), while the “Physical Activity” had the lowest score (6.82±2.56). Patients with a duration
unrestricted non-commercial use, distribution,
and reproduction in any medium, provided the of T2DM less than one year (OR: 12.00; 95%CI: 1.80, 80.05; p=0.010) and between six to ten years (OR:
original work is properly cited. 7.11; 95% CI: 1.36, 37.31; p=0.020) were found more likely to have inadequate self-care behaviors, as
compared with those with a disease duration greater than 10 years. Conclusion: A noticeable proportion
of patients with T2DM in Malaysia had inadequate self-care behaviors, and were found to be associated
with the disease duration. This study suggests a more active role for hospital pharmacists in monitoring
and improving the diabetes management of patients.
Key words: Malaysia, Tertiary care centers, Pharmaceutical services, Pharmacists, Self-care, Type 2
diabetes mellitus.

INTRODUCTION in Malaysia have long been involved in diabetes management, mainly through
Diabetes, notably type two diabetes mellitus (T2DM), is a major cause of the Diabetes Medication Therapy Adherence Clinic (DMTAC).[9-10]
mortality, morbidity and increasing healthcare cost worldwide.[1] The global
prevalence of diabetes has risen at an alarming rate, from 4.3% in 1980 to Nevertheless, to date, the information on the level of self-care behaviors
9% in 2014 in men, and from 5% in 1980 to 7.9% in 2014 in women.[2] A among the Malaysian diabetic patients is still limited. Additionally,
similar trend was also observed in Malaysia, as the prevalence of diabetes although education on medications, management of hypoglycemia and
increased steadily from 6.3% in 1986 to 14.9% in 2006, and the increasing hyperglycemia, diet and exercise has been incorporated into the pharmacist-
number of diabetic patients is expected to reach approximately 2.48 million operated DMTAC,[9] there is a lack of standardized tools to effectively and
by 2030.[3-4] The total healthcare cost of diabetes and its complications in systematically evaluate the self-care behaviors of patients. Therefore, this
Malaysia is estimated to be in the range of USD 1.07 to 1.83 million annually, hospital pharmacy-based study was designed to determine the prevalence
posing a burden, especially on the public healthcare system.[5] Hence, there of inadequate self-care behaviors among diabetic patients in Malaysia, and
is an urgent need for a population-based strategy that prevents diabetes and to determine the risk factors of inadequate self-care behaviors by using a
delays its progression in Malaysia. structured questionnaire.

When it comes to optimizing glycemic control in diabetes, one of the most METHODS
important factors is the self-care behaviors of patients.[6] Good self-care This cross-sectional study was undertaken at the Raja Permaisuri Bainun
management, including diet control, regular physical activity, self-monitoring Hospital, a public tertiary care center with 990-bed capacity in Northern
of blood glucose, and adherence to medications, enables patients to effectively Malaysia,[11] from December 2015 until August 2016. The study protocol
manage the disease on their own.[7] Within this context, pharmacists were was registered with the National Medical Research Register (NMRR-15-
confirmed to have a positive impact on health outcomes of diabetic patients 1193-24276) and was reviewed and approved by the Medical Research and
through their role in providing education on both medication and lifestyle Ethics Committee. A convenience sample of outpatients with T2DM, who
issues.[8] In fact, along with other health professionals, hospital pharmacists were aged 18 years or above, was recruited at the Medical Department of the

This is an open access article distributed under the terms of the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 License

Journal of Pharmacy Practice and Community Medicine  Vol. 4  ●  Issue 2  ●  Apr-Jun  2018 ● www.jppcm.org S51
 Ang, et al.: Study about Self-Care Behaviors among Diabetic Patients

hospital. All participants were briefed on the study objectives, and a written excluded from the analysis due to incomplete responses. The 103 participants
informed consent was obtained from each of them. included had a mean (SD) age of 62.2 (11.3) years. The majority of them
were male (26.2%), Chinese (36.9%), and with secondary education (61.2%).
The evaluation of self-care behaviors was conducted using the 16-item Besides, it is found that approximately half of them had been diagnosed with
Diabetes Self-Management Questionnaire (DSMQ), which consists of four T2DM for more than ten years, and most reported having at least one other
subscales: “Glucose Management” (five items), “Dietary Control” (four chronic illness (84.5%) and taking at least four prescription medications
items), “Physical Activity” (three items) and “Health-Care Use” (three items). (81.6%). It is also noted that nearly half of the patients had uncontrolled
[12]
Each item was designed for patients to self-describe their self-care activity T2DM, with a HbA1C level above 7.5% (Table 1).
over the past eight weeks by using a four-point scale (3 – “applies to me very
much”; 2 – “applies to me to a considerable degree”; 1 – “applies to me to The participants recorded a mean DSMQ score of 7.48±1.32, and 16 (15.5%)
some degree”; 0 – “does not apply to me”). of them were identified to have inadequate self-care behaviors. Among the
four subscales of self-care behaviors evaluated, the “Health-Care Use” had the
For the DSMQ to be used in the current study, its English version was highest score (8.36±1.99), followed by “Glucose Management” (7.61±2.56),
translated into Malay (M-DSMQ) and Simplified Chinese (SC-DSMQ) “Dietary Control” (7.49±1.89), and “Physical Activity” (6.82±2.56).
according to the methods recommended by Beaton et al,[13] including Moreover, in comparison with those with a duration of T2DM greater than
forward translation (by a bilingual pharmacists and a bilingual non-medical ten years, the patients with a duration of T2DM less than one year (OR:
personnel each), synthesis (discrepancies dissolved by consensus between 12.00; 95%CI: 1.80, 80.05; p=0.010) and between six to ten years (OR: 7.11;
two translators), backward translation (by two bilingual pharmacists each), 95% CI: 1.36, 37.31; p=0.020) were found more likely to have inadequate
and expert review (a panel of research officers to ensure that the translated self-care behaviors. Apart from that, no other baseline characteristics of the
versions were comprehensible and conceptually as close as possible to the participants were associated with self-care behaviors (Table 2).
original version). Subsequently, the finalized M-DSMQ and SC-DSMQ were
pilot-tested with 12 bilingual patients each, yielding Cronbach’s α coefficients DISCUSSION
of 0.91 and 0.82, respectively. To the best knowledge of the investigators, the current study is the first using
a validated self-administered questionnaire to evaluate the self-care behaviors
The self-reported demographic details of the participants, including age, of patients with T2DM in Malaysia. Different from a previous study that
gender, ethnicity, and educational level, were recorded using a data collection reported a number of poor self-care practices in Malaysian diabetic patients,[18]
form. On the other hand, the information on their disease and treatment, the different aspects of self-care behaviors of the patients were represented
including the most recent glycosylated hemoglobin (HbA1C) level, disease by a single score ranging from 0 to 10 in the current study. Therefore, by
duration, number of medications taken, and number of co-morbidity, was
providing an objective assessment for the level of self-care behaviors of the
obtained from the electronic medical records. Furthermore, the HbA1C
patients, the findings could be useful for the Malaysian pharmacists, who
levels were used to categorize the participants into “controlled” (≤7.5%) or
have been actively involved in designing, implementing, improving, and
“uncontrolled” (>7.5%) T2DM.[14]

Subsequently, the participants were given the option to use either the Table 1: Baseline characteristics of the participants
M-DSMQ or the SC-DSMQ. On average, each of them took 20 min to (n=103).
complete the questionnaire. Their responses were then transformed into Age, years, mean (SD*) 62.19 (11.30)
a total score (DSMQ score) and four subscale scores ranging from 0 to Gender, n (%)
10 such that a higher score was indicative of better self-care behaviors.[12] Male 71 (68.9)
Female 32 (31.3)
Subsequently, based on the recommendation of Schmitt et al. on the cut-off
value, the DMSQ scores of the participants were dichotomized to represent Ethnicity, n (%)
Malay 27 (26.2)
“adequate” (≥6) and “inadequate” (<6) self-care behaviors.[15] Chinese 38 (36.9)
Indian 38 (36.9)

Data were managed and analyzed using the Statistical Package for the Social Educational level, n (%)
Primary (6 years of elementary education) 27 (26.2)
Sciences 20.0 (IBM, New York). All the categorical variables were expressed
Secondary (pre-university) 63 (61.2)
as frequencies and percentages, whereas all the numerical variables, including Tertiary (university and college) 13 (12.6)
the subscale and DSMQ scores, were summarized as means and standard Duration of T2DM†, years, n (%)
deviations (SDs). Furthermore, the risk factors for inadequate self-care <1 7 (6.8)
1-5 32 (31.1)
behaviors were identified using logistic regression analysis, presented with 6-10 13 (12.6)
odds ratios (ORs) and 95% confidence intervals (CIs). All the statistical tests >10 51 (49.5)
were considered significant if p<0.05. Number of co-morbidity, n (%)
0 16 (15.5)
1 39 (37.9)
Sample size was calculated by using the formula for estimating the population 2 32 (31.1)
prevalence, with the level of confidence and precision fixed at 95% and 5%, ≥3 16 (15.5)
respectively.[16] The anticipated prevalence of inadequate self-care behaviors Number of medications taken, n (%)
was 6% based on a previous study reporting the self-management behaviors 1-3 19 (18.4)
4-6 56 (54.4)
of patients with T2DM in China.[17] To account for a 20% non-response rate, ≥7 28 (27.2)
the required sample size was determined to be 105. Most recent HbA1C level, %, n (%)
≤7.5 57 (55.3)
RESULTS >7.5 46 (44.7)

A total of 120 participants completed the survey, but 17 (14.2%) of them were SD*, standard deviation; T2DM†, type 2 diabetes mellitus.

52 Journal of Pharmacy Practice and Community Medicine  Vol. 4  ●  Issue 2  ●  Apr-Jun  2018 ● www.jppcm.org
 Ang, et al.: Study about Self-Care Behaviors among Diabetic Patients

Table 2: Risk Factors for inadequate self-care behavior.

Factors Adequate Inadequate OR* (95% CI†) p-value
Age, years, mean (SD‡) 58.25 (9.10) 62.92 (11.58) 0.97 (0.92, 1.01) 0.133

Gender, n (%)
Female 29 (90.6) 3 (9.4) 1 -
Male 58 (81.7) 13 (18.3) 2.17 (0.57, 8.21) 0.255

Ethnicity, n (%)
Indian 33 (86.8) 5 (13.2) 1 -
Chinese 33 (86.8) 5 (13.2) 1.00 (0.26, 3.78) >0.95
Malay 21 (77.8) 6 (22.2) 1.89 (0.51, 6.97) 0.341

Educational level, n (%)

Primary 25 (92.6) 2 (7.4) 1 -
Secondary 51 (81.0) 12 (19.0) 2.94 (0.61, 14.16) 0.178
Tertiary 11 (84.6) 2 (15.4) 2.27 (0.28, 18.27) 0.440

Duration of T2DM§, years, n (%)

>10 48 (94.1) 3 (5.9) 1 -
6-10 9 (69.2) 4 (30.8) 7.11 (1.36, 37.31) 0.020
1-5 26 (81.2) 6 (18.8) 3.69 (0.85, 15.99) 0.081
<1 4 (57.1) 3 (42.9) 12.00 (1.80, 80.05) 0.010

Number of co-morbidity, n (%)

≥3 15 (93.8) 1 (6.2) 1 -
2 26 (81.2) 6 (18.8) 3.46 (0.38, 31.57) 0.271
1 35 (89.7) 4 (10.3) 1.71 (0.18, 16.65) 0.642
0 11 (68.8) 5 (31.2) 6.82 (0.70, 66.90) 0.099

Number of medications taken, n (%)

≥7
4-6 25 (89.3) 3 (10.7) 1 -
1-3 47 (83.9) 9 (16.1) 1.60 (0.40, 6.43) 0.511
15 (78.9) 4 (21.1) 2.22 (0.44, 11.32) 0.336

Most recent HbA1C level, %, n (%)

>7.5 39 (84.8) 7 (15.2) 1 -
≤7.5 48 (84.2) 9 (15.8) 1.05 (0.36, 3.06) 0.936

OR*, odds ratio; CI†, confidence interval; SD‡, standard deviation; T2DM§, type 2 diabetes mellitus.

monitoring the effectiveness of diabetes management in collaboration in order to delay the disease progression, it is imperative for pharmacists
with other healthcare providers. to intensify education on self-care, particularly among those who are newly
diagnosed with T2DM.
As patient education programs, including the DMTAC and pharmacy-based
counseling, have long been implemented in the public health centers across Besides, notwithstanding that the majority of the participants had adequate
Malaysia to support patient participation in diseases management since the self-care behaviors, approximately 45% of them were still found to
last decade, the majority of the participants in the current study were found perpetuate suboptimal glycemic control, indicated by a HbA1C level above
to have adequate self-care behaviors. Nonetheless, it is noteworthy that the 7.5%. A similar trend was also observed in a UK study, in which many
prevalence of inadequate self-behaviors is still relatively high as compared diabetic patients were shown to have persistent HbA1C elevations despite
with a similar study, which reported a 6% prevalence in western urban standard diabetes management.[23] Aside from that, numerous studies have
China.[17] In particular, among the four subscales assessed in the current confirmed that increased HbA1C levels, especially above 7.5%, are strongly
study, the mean scores for the “Physical Activity” and “Diet Control” associated with increased risks of cardiovascular complications and
were lower than those of the other two subscales. This is consistent with all-cause death.[24] Accordingly, further investigation into the factors
the previous findings,[18,19] suggesting that the lack of physical activity associated with persistent poorly-controlled T2DM in Malaysia is
and poor diet control in patients still remain the major challenges in the warranted.
management of T2DM in Malaysia. Hence, besides ensuring medication
adherence among diabetic patients, continuous efforts should be made by The current study had several limitations. First, it was a single-center
pharmacists to determine specifically how an individual would meet the study, which only included diabetic patients actively followed up at a
recommended lifestyle modification. public tertiary care center. Therefore, the prevalence of inadequate self-
care behaviors might be underestimated, as the participants were likely to
Furthermore, in parallel with the findings of a number of studies,[20-22] it have better awareness of their health conditions and treatment in general.
is noted that disease duration of the patients was a significant predictor Apart from that, the assessment of self-care behaviors was based solely
of the level of self-care behaviors. Generally, the patients with disease on self-reporting by the participants, and the data could be affected by
duration less than ten years were found more likely to have inadequate self- bias arising from social desirability or selective recall.[25]
care behaviors. Within this context, Jackson et al. suggested that a longer
disease duration provides more opportunities for patients to be exposed CONCLUSION
to diabetes-related information, which is essential to strengthen their The findings imply that a noticeable proportion of patients with T2DM in
disease management skills.[21] Additionally, they might have experienced Malaysia had inadequate self-care behaviors. In addition, increased disease
complications, which propelled them to better self-care behaviors. Thus, duration was confirmed to be significantly associated with improved self-

Journal of Pharmacy Practice and Community Medicine  Vol. 4  ●  Issue 2  ●  Apr-Jun  2018 ● www.jppcm.org 53
 Ang, et al.: Study about Self-Care Behaviors among Diabetic Patients

care behaviors. As efforts have been made to broaden the scope of pharmacy 11. Raja Permaisuri Bainun H. Hospital’s profile. 2017. [cited 2017 31 May]. Available
practice, especially in the public health sector across Malaysia, the current from: http://hrpb.moh.gov.my/v2/index.php/en/mengenai-kami/profil-hospital.
study suggests a more active role for hospital pharmacists in improving the 12. Schmitt A, Gahr A, Hermanns N, Kulzer B, Huber J, Haak T. The diabetes
management of patients with T2DM. self-management questionnaire (DSMQ): Dvelopment and evaluation of an
instrument to assess diabetes self-care activities associated with glycaemic
control. Health and Quality of Life Outcomes. 2013;11(138):1-14.
ACKNOWLEDGEMENT 13. Beaton DE, Bombardier C, Guillemin F, Ferraz MB. Guidelines for the process
We would like to thank the Director General of Health, Malaysia, for his of cross-cultural adaptation of self-report measures. Spine (Phila Pa 1976).
permission to publish the findings from this study. We also acknowledge 2000;25(24):3186-91.
the guidance and support given by Dr. Arvinder Singh HS and Wei-Yin 14. Pfeiffer AF, Klein HH. The treatment of type 2 diabetes. Deutsches Arzteblatt
Lim (Pharmacist), research officers from Clinical Research Centre, Raja international. 2014;111(5):69-81.
Permaisuri Bainun Hospital, Malaysia. We wish to thank Dr. Andreas Schmitt 15. Schmitt A, Hermanns N, Kulzer B, Reimer A, Schall S, Haak T. The diabetes self-
for the permission to translate and use the DSMQ in the current study. management questionnaire (DSMQ) can detect inadequate self-care behaviour
and help identify patients at risk of a negative diabetes prognosis. 50th EASD
CONFLICT OF INTEREST Annual Meeting; 15-19 September 2014; Vienna Austria. 2014.
16. Naing L, Winn T, Rusli BN. Practical issues in calculating the sample size for
The authors declare no conflict of interest.
prevalence studies. Arch Orofacial Sci. 2006;1:9-14.
17. Huang M, Zhao R, Li S, Jiang X. Self-management behavior in patients with
REFERENCES type 2 diabetes: a cross-sectional survey in western urban China. PloS one.
1. Seuring T, Archangelidi O, Suhrcke M. The Economic Costs of Type 2 Diabetes:
2014;9(4):e95138.
A Global Systematic Review. PharmacoEconomics. 2015;33(8):811-31.
18. Tan M, Magarey J. Self-care practices of Malaysian adults with diabetes and sub-
2. NCD-RisC. Worldwide trends in diabetes since 1980: A pooled analysis
optimal glycaemic control. Patient education and counseling. 2008;72(2):252-67.
of 751 population-based studies with 4·4 million participants. Lancet.
19. Zaki NF, Sulaiman AS, Gillani WS. Clinical evaluation of Dyslipidemia among
2016;387(10027):1513-30.
type II diabetic patients at Public hospital Penang, Malaysia. Int Archi Med.
3. Wan Nazaimoon WM, Md Isa SH, Wan Mohamad WB, Khir AS, Kamaruddin NA,
2010;3(1):34.
Kamarul IM, et al. Prevalence of diabetes in Malaysia and usefulness of HbA1c
as a diagnostic criterion. Diabetic Med. 2013;30(7):825-8. 20. Tol A, Shojaeezadeh D, Eslami A, Alhani F, Mohajeritehrani M, Baghbanian A,
et al. Evaluation of self-care practices and relative components among type 2
4. World Health Organization. Country and regional data on diabetes. 2016.
Available from: http://www.who.int/diabetes/facts/world_figures/en/index6.html. diabetic patients. J Edu and Health Promotion. 2012;1:19.

5. Zhang P, Zhang X, Brown J, Vistisen D, Sicree R, Shaw J, et al. Global 21. Jackson IL, Adibe MO, Okonta MJ, Ukwe CV. Knowledge of self-care among type
healthcare expenditure on diabetes for 2010 and 2030. Diabetes Res Clini 2 diabetes patients in two states of Nigeria. Pharmacy Practice. 2014;12(3):404.
Pract. 2010;87(3):293-301. 22. T’ang J, Chan C, Chan N, Ng C, Tse K, Lau L. A survey of elderly diabetic
6. Smith KJ, Rabasa-Lhoret R, Strychar I, Karelis AD, Clyde M, Levasseur J, et al. patients attending a community clinic in Hong Kong. Patient Edu Counseling.
Good vs. Poor self-rated diabetes control: Differences in cardiovascular risk and 1999;36(3):259-70.
self-care activities. Exp clini Endo Diabetes. 2014;122(4):236-9. 23. Crowley MJ, Holleman R, Klamerus ML, Bosworth HB, Edelman D, Heisler M.
7. Shrivastava SR, Shrivastava PS, Ramasamy J. Role of self-care in management Factors associated with persistent poorly controlled diabetes mellitus: clues to
of diabetes mellitus. J Diabetes Metab Disord. 2013;12(1):14. improving management in patients with resistant poor control. Chronic illness.
8. Smith M. Pharmacist’s role in improving diabetes medication management. J 2014;10(4):291-302.
Diabetes Sci and Technol. 2009;3(1):175-9. 24. Chen YY, Lin YJ, Chong E, Chen PC, Chao TF, Chen SA, et al. The impact
9. Lim P, Lim K. Evaluation of a pharmacist-managed diabetes medication therapy of diabetes mellitus and corresponding HbA1c levels on the future risks of
adherenece clinic. Pharmacy Practice (Granada). 2010;8(4):250-4. cardiovascular disease and mortality: a representative cohort study in Taiwan.
10. Bakar ZA, Fahrni ML, Khan TM. Patient satisfaction and medication adherence PloS one. 2015;10(4):e0123116.
assessment amongst patients at the diabetes medication therapy adherence 25. Althubaiti A. Information bias in health research: Definition, pitfalls, and
clinic. Diabetes and metabolic syndrome. 2016;10(2):S139-43. adjustment methods. J Multidiscip Healt. 2016;9:211-7.

Cite this article as: Ang JY, Leo JS, George D, Chan HK. Inadequate Self-Care Behaviors among Malaysian Diabetic Patients: The Need
for Action by Hospital Pharmacists. J Pharm Pract Community Med. 2018;4(2):51-4.

54 Journal of Pharmacy Practice and Community Medicine  Vol. 4  ●  Issue 2  ●  Apr-Jun  2018 ● www.jppcm.org

View publication stats