University of Ghana http://ugspace.ug.edu.gh UNIVERSITY OF GHANA, LEGON COLLEGE OF HEALTH SCIENCES SCHOOL OF PUBLIC HEALTH ADHERENCE TO DIET AND EXERCISE REGIMEN AMONG PATIENTS WITH TYPE 2 DIABETES MELLITUS AT THE TEMA GENERAL HOSPITAL, GREATER ACCRA, GHANA. BY GRACE DZIFA WORNYOH 10340214 THIS DISSERTATION IS SUBMITTED TO THE UNIVERSITY OF GHANA, LEGON IN PARTIAL FULFILMENT OF THE REQUIREMENTS FOR THE AWARD OF MASTER OF PUBLIC HEALTH DEGREE JULY, 2020 University of Ghana http://ugspace.ug.edu.gh DECLARATION I hereby do declare that except for references to other people‟s work which have been duly acknowledged, this piece of work is my own composition and neither in whole nor in part has this work been presented for the award of a degree in this university or elsewhere. SIGNATURE................................................. DATE……………………………………. (GRACE DZIFA WORNYOH) SIGNATURE........................................ DATE……………………… (DR. BENEDICT WEOBONG) i University of Ghana http://ugspace.ug.edu.gh DEDICATION I dedicate this dissertation to my parents, Mr. and Mrs. Wornyoh. To my siblings: Isaac Brown, Enoch, Jonathan, Richard, Joseph and Benjamin, I say thank you. Your support and love was in the end what made this research possible. ii University of Ghana http://ugspace.ug.edu.gh ACKNOWLEDGEMENTS I am grateful to the Almighty God who granted me the knowledge, wisdom and strength to complete this dissertation. My thanks and appreciation to Dr. Benedict Weobong for persevering with me as my supervisor throughout the time it took me to complete this dissertation. I was blessed to have you as my supervisor. A special thanks goes to Dr. Juliana Safowaa Appiah, whose feedback and assistance enabled me to successfully complete this research. My deepest gratitude goes to my forever loving and caring family for their support. Finally, I would like to thank the new family I made in the pursuance of this Master‟s degree including course-mates and staff, whose encouragement kept me going. Thank You. iii University of Ghana http://ugspace.ug.edu.gh ABSTRACT Background: Diabetes is not curable. Lifestyle changes such as diet and physical exercise are important factors in achieving good control of type-2 diabetes (T2D) thereby avoiding its long-term complications. However, knowledge on the factors that hinder the adherence to diet and physical exercise in diabetes management is limited. This study aimed to determine the adherence to dietary and exercise requirements among type 2 diabetics in the Tema General Hospital Method: A cross-sectional design was used in the study. Consecutive sampling was used to sample 275 patients who met criteria. A closed ended questionnaire was used to collect the data. Chi-square was used to assess relationships between variables. Simple logistic regression was used to test the study‟s hypothesis. Results were reported as odds ratios with 95% confidence intervals. Results: Adherence to dietary recommendations was 26.7%. Low socio-economic status of participants did not influence adherence to dietary and physical exercise recommendations. Participants on insulin only, (AOR=44.0; 95% CI=1.65- 1171; p=0.024). and those who were on drug and diet therapy, (AOR=55.3; 95%CI=5.59 – 547.6; p=0.001) were adherent to dietary recommendations. Participants who were not on herb therapy were less likely to be adherent to dietary recommendations (AOR= 0.002; 95%CI=0.001- 0.05; p<0.001). 67.8% of respondents were knowledgeable on the benefits of physical education and diet recommendations for diabetes management. Adherence to physical exercise recommendations was found to be 22%. Senior secondary school trained participants are less likely to adhere to exercise recommendations (AOR=0.01; 95%CI=0.001– 0.14; p= 0.004). Vocationally trained participants were less likely to be adherent to dietary recommendations (AOR=0.06; 95%CI=0.001-0.36; p<0.001). Participants who were knowledgeable about their iv University of Ghana http://ugspace.ug.edu.gh condition were likely to be adherent (AOR=38.8; 95%CI=3.01- 49.25; p=0.016). 96% of participants had the recommended 3 square meals a day. Conclusion: Adherence to diet and exercise was found to be relatively low. The type of treatment and being on herb therapy was found to influence adherence to dietary recommendations. Majority of participants were knowledgeable about their condition. v University of Ghana http://ugspace.ug.edu.gh TABLE OF CONTENT DECLARATION ............................................................................................................................. i DEDICATION ................................................................................................................................ ii ACKNOWLEDGEMENTS ........................................................................................................... iii ABSTRACT ................................................................................................................................... iv TABLE OF CONTENT ................................................................................................................. vi LIST OF FIGURES ........................................................................................................................ x LIST OF TABLES ......................................................................................................................... xi LIST OF ABBREVIATIONS ....................................................................................................... xii CHAPTER ONE ........................................................................................................................... 1 INTRODUCTION .......................................................................................................................... 1 1.1 Background to the Study .......................................................................................................1 1.2 Problem Statement ................................................................................................................3 1.3 Significance of the study .......................................................................................................5 1.4 Conceptual framework ...........................................................................................................6 1.5 Narrative .................................................................................................................................7 1.6 Research Questions ................................................................................................................8 1.7 Aim .........................................................................................................................................8 1.7.1 Specific objectives...............................................................................................................9 CHAPTER TWO ........................................................................................................................ 10 LITERATURE REVIEW ............................................................................................................. 10 2.0 Introduction ..........................................................................................................................10 2.1 Diabetes ............................................................................................................................10 2.1.1 Biological, Medical and Lifestyle Risk Factors ............................................................11 2.2 The Global Prevalence of Diabetes ......................................................................................12 2.2.1 Prevalence of Diabetes in Sub-Sahara Africa ................................................................14 2.3 Treatment and Management of Diabetes .............................................................................15 2.3.1 Diet therapy ...................................................................................................................16 2.4 Adherence among Diabetes Patients ....................................................................................17 2.4.1 Dietary and Exercise Adherence among Diabetes Patients ...........................................18 vi University of Ghana http://ugspace.ug.edu.gh 2.5 Prevalence and Factors associated with adherence to dietary and exercise regimen ...........19 Summary ....................................................................................................................................21 Knowledge Gap ..........................................................................................................................22 CHAPTER THREE .................................................................................................................... 23 METHODS ................................................................................................................................... 23 3.1 Introduction .........................................................................................................................23 3.2 Study Design ........................................................................................................................23 3.3 Study Area ............................................................................................................................23 3.3.1 Tema General Hospital ..................................................................................................25 3.3.1.1 The Diabetes Clinic..................................................................................................26 3.3.1.2 The Diet Therapy Unit ................................................................................................26 3.4 Study Population ..................................................................................................................26 3.4.1 Inclusion criteria ............................................................................................................26 3.4.2 Exclusion criteria ...........................................................................................................27 3.5 Study Variables ....................................................................................................................27 3.5.1 Independent Variables ...................................................................................................27 3.5.2 Dependent Variable .......................................................................................................28 Measurement ..............................................................................................................................29 3.6 Sample Size determination ...................................................................................................29 3.6.1 Sampling Method ..........................................................................................................30 3.7. Data Collection procedure ...................................................................................................30 3.8 Data Collection Tools...........................................................................................................31 3.8.1 Background Information form .......................................................................................31 3.8.2 Food consumption frequency questionnaire ..................................................................32 3.8.3 Knowledge measurement scale .....................................................................................32 3.9 Ethical Considerations..........................................................................................................32 3.9.1 Benefits ..........................................................................................................................33 3.9.2 Training of Interviewers ....................................................................................................33 3.9.3 Quality Assurance .............................................................................................................34 3.9.4 Pre-Test of Instruments .................................................................................................34 3.9.5 Data Analysis ....................................................................................................................34 CHAPTER FOUR ....................................................................................................................... 36 RESULTS ..................................................................................................................................... 36 vii University of Ghana http://ugspace.ug.edu.gh 4.1 Introduction ..........................................................................................................................36 4.2 Demographic profile of respondents ....................................................................................36 4.3 Clinical and personal lifestyle factors of respondents ..........................................................38 4.4 The level of knowledge on the role of dietary and exercise requirements among T2D ......41 4.4.1 Factors associated with knowledge level among respondents .......................................42 4.5 Level of non-adherence to physical exercise among type 2 diabetes patients .....................45 4.5.1 Adherence to physical exercise requirement and associated factors among participants..............................................................................................................................46 4.5.2 Logistic regression analysis of factors significantly associated with non-adherence to physical exercises requirement ...........................................................................................48 4.5.3 Adherence to dietary requirement and associated factors among participants ..............50 4.6 Adherence to dietary requirement among type 2 diabetes patients ......................................53 4.6.1 Dietary/food frequency patterns among participants .....................................................53 CHAPTER FIVE ........................................................................................................................ 56 DISCUSSION ............................................................................................................................... 56 5.1 Introduction ..........................................................................................................................56 5.2 Prevalence of participants who adhere to physical exercise recommendations ...................56 5.3 Factors that influence adherence to physical exercise recommendations ............................57 5.4 Level of patient‟s knowledge on importance of physical exercise and diet recommendations .......................................................................................................................58 5.5 Factors that influenced knowledge on importance of physical exercise and diet recommendations .......................................................................................................................58 5.6 Prevalence of participants who adhere to physical exercise recommendations ...................59 5.7 Factors that influence adherence to dietary recommendations ............................................59 5.8 Eating behaviour among participants ...................................................................................59 5.9 Consistency with Previous Research....................................................................................61 5.10 Strengths and Limitations of the Study ..............................................................................62 CHAPTER SIX ............................................................................................................................. 63 CONCLUSION AND RECOMMENDATIONS ......................................................................... 63 6.1 CONCLUSIONS ..................................................................................................................63 6.2 RECOMMENDATIONS .....................................................................................................65 For research ................................................................................................................................65 For public health.........................................................................................................................65 viii University of Ghana http://ugspace.ug.edu.gh For policy ...................................................................................................................................65 REFERENCES ...........................................................................................................................66 APPENDIX A: QUESTIONNAIRE............................................................................................... 1 APPENDIX B: INFORMATION SHEETS ................................................................................... 1 PARTICIPANT INFORMATION SHEET FOR PATIENTS WITH TYPE 2 DIABETES MELLITUS AT THE TEMA GENERAL HOSPITAL, GREATER ACCRA REGION ...........1 PROJECT TITLE: ADHERENCE TO DIET AND EXERCISE REGIMEN AMONG PATIENTS WITH TYPE 2 DIABETES AT THE TEMA GENERAL HOSPITAL, GREATER ACCRA .....................................................................................................................1 APPENDIX C: CONSENT FORM ................................................................................................ 1 CONSENT FORM FOR PATIENTS WITH TYPE 2 DIABETES AT THE TEMA GENERAL HOSPITAL, GREATER ACCRA REGION............................................................1 ETHICAL CLEARANCE ............................................................................................................1 ix University of Ghana http://ugspace.ug.edu.gh LIST OF FIGURES Figure 1: Conceptual Framework of factors influencing non-adherence of dietary and exercise regimen ............................................................................................................................. 6 Figure 2: Map of Tema Metropolis ............................................................................................... 24 Figure 3: Monthly income levels of Participants .......................................................................... 38 Figure 4: Personal lifestyle factors of respondents ....................................................................... 40 Figure 5: Fruit frequency patterns among participants ................................................................. 55 x University of Ghana http://ugspace.ug.edu.gh LIST OF TABLES Table 1: Definition of Independent Variables ......................................................................... 28 Table 2: Definition of Dependent Variables ............................................................................ 29 Table 3: Background Characteristics of Participants ............................................................... 37 Table 4: Clinical profile of participants/respondents ............................................................... 39 Table 5: Knowledge on the importance of diet and physical exercise .................................... 41 Table 6:Background factors associated with knowledge ........................................................ 43 Table 7 Binary logistic regression: background factors associated with knowledge .............. 44 Table 8: Adherence with physical exercises among T2D ........................................................ 45 Table 9: Background characteristics and non-adherence to exercise requirements ................ 47 Table 10: test of association of clinical/personal lifestyle factors and adherence ................... 48 Table 11: Multivariable analysis of factors associated with adherence to physical exercise .. 49 Table 13: Association between clinical factors and adherence to dietary recommendations .. 51 Table 12: Background characteristics and adherence to dietary requirements ........................ 51 Table 14: Logistic regression of factors associated with adherence to dietary recommendations ..................................................................................................................... 52 Table 15: Eating behavior among participants ........................................................................ 53 Table 16: Fish/meat and starch/carbohydrate food frequency ................................................. 54 xi University of Ghana http://ugspace.ug.edu.gh LIST OF ABBREVIATIONS ADA……American Diabetes Association DM…….Diabetes Mellitus GHS……Ghana Health Service IDF……. International Diabetes Federation HBAIC…Glycated Hemoglobin SES……Socio-Economic Status T2D…….Type 2 Diabetes TGH……Tema General Hospital WHO…. World Health Organization xii University of Ghana http://ugspace.ug.edu.gh CHAPTER ONE INTRODUCTION 1.1 Background to the Study Diabetes mellitus (DM) is one of the most common chronic diseases in both Western and developing countries. (King, Aubert & Herman, 1998; King & Rewers, 1993). Diabetes Mellitus has become a global health issue facing the world in this new millennium with its management and premature mortality affecting the total health care expenditure in several countries, especially in less developed and poor ones (Hu, 2011). The International Diabetes Federation (IDF) estimates that, 425 million individuals were living with diabetes worldwide in 2017 (IDF Atlas, 2017). This number is projected to be 438 million by the year 2030 (Wild, et al, 2004). The prevalence of diabetes ranges from 4.3% in Sub-Saharan Africa to 10.9% in the Middle East and North Africa (IDF, 2013). It is however projected that the number of individuals with diabetes in Sub-Saharan Africa will be more than double the 2017 estimates of 16 million by 2045 (IDF Atlas, 2017). This metabolic disorder is characterized by hyperglycemia and disturbances of carbohydrate, protein and fat metabolism secondary to an absolute or relative lack of the hormone insulin. Pre-diabetes mellitus is characterized by elevated blood glucose levels with fasting plasma glucose between 100 and 125 mg/dL or an oral glucose tolerance test between 140 and 200 mg/dL. Glucose levels greater than these values characterize DM (King, Aubert & Herman, 1998). This rapid increase in the number of individuals with diabetes will mainly be due to rapid nutritional and epidemiological transitions in rural and urban communities (Kandala & Stranges, 2014). Prolonged period of diabetes increases the risk for other complications. Diabetes Mellitus (DM) is the leading cause of end-stage renal disease (ESRD), traumatic 1 University of Ghana http://ugspace.ug.edu.gh lower extremity amputations, and adult blindness. It also predisposes patients to various cardiovascular diseases (Abejew, Belay, & Kerie, 2015). The frequency of diabetes is increasing many folds especially in South Asian population due to high genetic and non- genetic risk factors (Cheekurthy, et al., 2015). Diabetes has significant effect on adult population (Geiss, et al. 2000; Lee et al. 1995). The risk for death is twice in people with diabetes when compared to those without diabetes (CDC, 2011). Diabetes imposes a significant burden on health services and has become a global public health problem (Amod, Ascott-Evans & Berg, 2012; Zimmet, 2012). Although diabetes was considered a disease of the wealthy class, current shift in rural and semi-urban lifestyles shows populations from low socio-economic communities are affected (Inzucchi, Bergenstal & Buse, 2012). The occurrence of diabetes in individuals is associated with several factors including societal and biological factors (Gatimu, Milimo & Sebastian, 2016). Studies have shown an association between diabetes and socio-economic factors such as education, employment status, wealth and social class (Assari, Lankarani & Lankarani, 2014; Abubakari & Bhopal, 2008). Behavioural characteristics of the population such as physical inactivity, poor dietary intake, inadequate intake of fruits and vegetables, tobacco use and alcohol consumption are all factors associated with diabetes particularly type 2 diabetes mellitus (Motala, Esterhuizen, Gouws, Pirie & Omar, 2008). In Ghana, studies in the general population have estimated that, 3.3% to 6% of the population has diabetes with the prevalence increasing with age. Prevalence is also higher in urban than in rural areas (Saeed, Abdul-Aziz, Nguah & Zhao, 2013). Medication is not the sole method of treating type 2 diabetes mellitus; significant changes to the patient‟s lifestyle with respect to dietary habits and regular physical activity are also 2 University of Ghana http://ugspace.ug.edu.gh required (Franz, MacLeod, Evert, 2017). In fact, lifestyle change is the most challenging and difficult part of the treatment. Many patients tend to follow medical and dietary recommendations selectively (Ahola AJ, Groop, 2013). Non-adherence to treatment of diabetes mellitus is an issue known both in the national and international scene as it affects the physiological response to disease, doctor-patient relationship and increases direct and indirect costs of treatment (Parchman, Zeber & Palmer, 2010; Zhang, Zhang, Brown, Vistisen, Sicree & Shaw, 2010). Most studies focus on medication adherence and factors associated with it (Bubalo, Clark, Jiing, Johnson, Miller & Clemens, 2010). On the other hand, there is a need for studies that investigate dietary parameters and physical exercise. This study aimed to investigate the adherence to dietary and physical exercise treatment of type 2 diabetes mellitus and variables of metabolic control, clinic and socio-demographic. 1.2 Problem Statement Life-style changes such as balanced diet and physical exercise are important factors in achieving good control of type-2 diabetes (T2D) thereby avoiding its long-term complications (Shrivastava, Shrivastava & Ramasamy, 2013). Adherence is defined as the degree to which a person‟s behavior that is, taking medication, following a diet and or performing lifestyle changes correspond with agreed recommendations from a qualified health care provider (WHO, 2015). Dietary adherence and management by diabetes patients is one of the vital treatment components to be followed over the long term and it has been found to lower glycated hemoglobin (A1C) levels by 1% to 2% (4–6), this helps to prevent or delay micro-and macro vascular morbidities among patients (Raj et al., 2018). Again, healthy dietary habits such as minimizing the consumption of high glycemic foods, fats and carbohydrates is known to 3 University of Ghana http://ugspace.ug.edu.gh contribute in decreasing the level of blood glucose, which will lead to reducing the amount of needed insulin in the body (Hamdy, Laurie & Edward, 2001). Physical exercises especially among diabetes patients is recommended because it reduces blood glucose levels, thereby reducing the amount of insulin needed and increasing insulin sensitivity (Colberg, Sigal & Fernhall, 2010). Physical activity enhances glycemic control and insulin action, reduces cardiovascular risk and helps weight loss, which improves diabetes mellitus patients‟ general well-being. ADA recommends adults with diabetes to perform at least 150 minutes per week of moderate to intense aerobic physical activity (improves 50%–70% of maximum heart rate). It is to be spread over at least 3 days/week with no more than two consecutive days without exercise along with weight training exercises (ADA, 2013). Notwithstanding the development of full guidelines for realizing finest diabetes management, studies suggest that translation of dietary guidelines into daily routine of patients is a challenge for the majority of patients with diabetes (Monnier, Grimaldi, Charbonnel, et al. 2004). Additionally, it is noticed that most diabetics fail to include exercise in their daily schedules. It is further known that even in those who exercise the intensity of physical activity is low (Thomas, Alder & Leese, 2004). There is very limited knowledge on factors that facilitate or hinder the practice of physical activity in diabetics It is therefore feared that the burden of this disease may be increasing gradually. Nonetheless, there is rarity of empirical studies on adherence to lifestyle recommendations and patients‟ awareness in Ghana. In addition to that, T2D is preventable and rather affecting people in their later age. This is a major public health problem and could make people suffer premature death (Butt et al 2015). Therefore, this study is designed to investigate diet and exercise adherence and to determine the association between adherence to diet and physical exercises among T2D patients with demographic and clinical factors. It 4 University of Ghana http://ugspace.ug.edu.gh also aims to evaluate the knowledge level of the importance of diet and physical exercise on managing diabetes. 1.3 Significance of the study The prevalence of diabetes is increasing globally without equivalent increase in research and other resources to fight the disease. In Ghana, the increase is more rapid due to the changes in lifestyle and aging of the population. Healthy lifestyle practices such as adherence to diet and exercise protocols are known to help reverse this trend of burden. The nature of these lifestyle factors in Ghana and particularly Tema Metropolis is unkown. The Tema hospital has over the years reported increasing trend in this disease and the poor attitude of patients regarding treatment other than medication. It is hoped that the study will address this issue by establishing the reasons and factors associated with patients‟ adherence to diet and exercise recommendations. Knowing/profiling these lifestyle factors/practices with respect to adherence will form the basis for the design of culturally appropriate/personalized interventions. Again, a study on the adherence, reasons and lifestyle modification factors in diabetes management are essential for the formulation and implementation of appropriate measures to enhance care and support for patients with diabetes. 5 University of Ghana http://ugspace.ug.edu.gh 1.4 Conceptual framework Social Support: -Fam ily -Friends -Community Increase Complication and Non-adherence to diet Socio-Demographic Mortality. and exercise regimen Factors -Age -Sex -Marital status -Religion -Educational Level Clinical/provider Factors -Occupation -Income status Individual -Poor patient provider Factors communication -Knowledge le v el -Stage of the disease -Forgetfulness -Duration -Health see king -Inadequate co u nseling behaviors Figure 1: Conceptual Framework of factors influencing non-adherence of dietary and exercise regimen Source: Author‟s Construct 6 University of Ghana http://ugspace.ug.edu.gh 1.5 Narrative The framework attempts to explain the various factors influencing non-adherence to diet and exercise. These factors could be categorized into four main groups; social support, socio- demographic characteristics, individual factors and clinical or provider factors. To begin with, it can be argued that adherence to diet and exercise can be achieved when there is adequate counseling, good doctor-patient communication. In the case where there is inadequate counseling or poor doctor-patient communication, it can affect non-adherence to dietary and exercise recommendation hence increasing complications and resulting in mortality. However, constant development of confidentiality and trusting relationships with the patient may improve adherence remarkably (Kalyango et al., 2008). Furthermore, individual factors such as knowledge level, forgetfulness and health seeking behaviors can influence non-adherence to diet and exercise. It is very important, when individuals are aware or have knowledge on the need to exercise and diet (Freeman et al., 2012). Based on this, the patient will make a decision on whether to adhere or not. Also, health seeking behaviors are very crucial in assessing the effects of chronic diseases over time(Thapa, 2018). People with appropriate health-seeking behaviors are ready to recognize disease symptoms, particularly non-communicable chronic diseases, as quickly as possible to seek medical care, which is more likely to decrease disease complications and potential co- morbidities (Hjelm & Atwine, 2011). Worldwide, socio-demographic characteristics have been recognized to have an influence on non-adherence to diet and exercise. The model demonstrates how educational level of an individual could influence one‟s adherence to diet and exercise. It could be argued that individuals who are educated would have knowledge on the importance to adhere to diet and exercise to improve upon the condition as compared to those who are not educated or with low level of education. Nevertheless, Divya & Nadig (2015) in their research found that the 7 University of Ghana http://ugspace.ug.edu.gh risk of non-adherence is very high when patients cannot read and understand basic written provider‟s instructions. It could also as well be argued that those who are married are likely to adhere to exercise and diet compared to unmarried ones. According to Freeman et al., (2012), a higher proportion of non-adherence is among married women as compared to single (unmarried) women. More so, income status could affect one‟s non-adherence to diet and exercise. When one has a high income status it is possible that one could access health. Religion could also affect one‟s health seeking behavior and in turn have an impact on the individual‟s adherence to diet and exercise. Lastly, non-availability of social support can also influence non-adherence. When patient have friends and families who fail to support in diverse ways, it can cause patients to fail to adhere to dietary and exercise regimen. 1.6 Research Questions Based on the established need for this study, the following research questions were addressed. 1. What is the level of non-adherence to diet and physical exercise among T2D patients and associated clinical and socio-demographic predictors of non-adherence to physical exercise among type 2 diabetes patients? 2. What is the level of knowledge and associated factors on the role of dietary and exercise requirements in the management of T2D? 3. What is the eating habit and patterns of T2D patients? 1.7 Aim To determine the level of adherence among patients regarding dietary and exercise requirements in the Tema General Hospital in the Greater Accra Region of Ghana. 8 University of Ghana http://ugspace.ug.edu.gh 1.7.1 Specific objectives 1. To estimate the level of adherence to diet and adherence to physical exercise recommendations among type 2 diabetes patients. 2. To estimate the association between knowledge, socio-demographic, clinical factors and the role of dietary and exercise requirements in the management of T2D. 3. To assess the eating habit and patterns of T2D patients 9 University of Ghana http://ugspace.ug.edu.gh CHAPTER TWO LITERATURE REVIEW 2.0 Introduction This chapter overviews various relevant literature on diabetes; its global, national and local prevalence as well as treatment methods. The literature review mainly focuses on areas captured by the research objectives. Again, areas such as etiology, types and risk factors are covered. 2.1 Diabetes Diabetes Mellitus is a complex, chronic disease and condition characterized by elevation of the level of glucose in the blood. Insulin, a hormone produced by the pancreas, controls the blood glucose level by regulating its production and storage. The condition may lead to decrease of the body‟s ability to respond to insulin or a decrease in the insulin produced by the pancreas which leads to abnormalities in the metabolism of carbohydrates, proteins and fats. The result may be hyperglycemia which may lead to acute metabolic complications including ketoacidosis and in the long term contribute to chronic microvascular complications (Smeltzer & Bare 1992). Diabetes can be classified as Type 1, Type 2 diabetes, and Gestational Diabetes Mellitus (GDM), where type 1 diabetes occurs due to beta-cell destruction, usually leading to absolute insulin deficiency. The pancreas produces insufficient amounts of the insulin therefore requiring insulin injections to control blood glucose. In Type 2 diabetes, due to a progressive defect in insulin secretion or decrease in sensitivity of the cells to insulin, it leads to insulin resistance. Lastly, GDM is diabetes diagnosed in the second or third trimester of pregnancy as a result of inhibition of insulin action by activity of hormones produced by the placenta. It occurs in about 2-5% of all pregnancies. About 30-40% of patients with Gestational Diabetes 10 University of Ghana http://ugspace.ug.edu.gh Mellitus will develop Type 2 diabetes (T2D) within 5-10 years, especially if obese. (Royle & Walsh 1992; Smeltzer & Bare 1992). The most prevalent type of diabetes is the T2D and affect people mostly in their later age. It is due to the combination of insulin resistance and defective secretion of insulin by pancreatic beta cells. The condition is a global burden and it is a common endocrine disease found in the world. According to Butt,et. al. (2015), people with diabetes mellitus suffer premature mortalities Furthermore, other specific types of diabetes may occur due to other causes. They include monogenic diabetes syndromes such as neonatal diabetes and maturity-onset diabetes of the young (MODY), diseases of the exocrine pancreas such as cystic fibrosis, and drug or chemical-induced diabetes such as in the treatment of HIV/AIDS or after organ transplantation, etc. For patients who do not clearly fit into a single category of classification, assigning a type of diabetes often depends on the circumstances present at the time of diagnosis (Diabetes Care, 2015). Complications of Diabetes Miletus (DM) include diabetic retinopathy, infection, nephropathy, ketoacidosis, diabetic foot ulcer (Holt, 2004). Foot ulcer as a result of diabetes can occur when there is ulceration and there is a neuropathic damage or complete loss of feeling in the foot or leg which often leads to ulceration in the limb amputation. In addition, skin disorders are also common in diabetes (Holt, 2004). 2.1.1 Biological, Medical and Lifestyle Risk Factors According to scientists, the exact mechanisms that lead to insulin resistance and impaired insulin secretion in Type 2 diabetes are unknown. Genetic factors are said to play a role in the development of insulin resistance. In addition, factors such as age, obesity, stress, depression, 11 University of Ghana http://ugspace.ug.edu.gh family history and ethnic group have been found as risk factors associated with the development of type 2 diabetes (Bain, 2001; Crowther & Van der Merwe 2001). A number of factors have been identified as increasing the risk of type 1 diabetes. Risk factors for type 1 diabetes mainly include family history, race and certain viral infections during childhood. Risk factors for type 2 diabetes (obesity, physical inactivity, high blood pressure, advance aging, etc) are more diverse, some are modifiable and others non- modifiable (Van der Merwe 2001). Additionally, modifiable or lifestyle risk factors include increased body mass index (BMI), physical inactivity, poor nutrition, hypertension, smoking, and alcohol use, among others. One of the strongest risk factors for development of diabetes is increased BMI. Lower levels of physical activity increase a person's risk for diabetes. Also, psychosocial factors such as depression, increased stress, low social support, and poor mental health status are also associated with an increased risk for the development of diabetes (Anjali et al, 2018). On the other hand, non-modifiable risk factors for type 2 diabetes include age, race or ethnicity, family history, that is, genetic predisposition, history of gestational diabetes, and low birth weight. The incidence and prevalence of diabetes increases with age (Anjali et. al, 2018). 2.2 The Global Prevalence of Diabetes There has been an increase in the prevalence of T2D during the last decades. The World Health Organization (WHO) estimation in 2014 put the figure at about 422 million adults (8.5% of the world‟s population) compared to 108 (4.7%) in 1980. It is projected to rise to 642 million by 2040 (WHO, 2014). According to Zhang et al., (2010), the estimated worldwide prevalence of diabetes among adults in 2010 was 285 million (6.4%) and this value is also predicted to rise to around 439 million (7.7%) by 2030. 12 University of Ghana http://ugspace.ug.edu.gh The International Diabetes Federation (IDF) also estimated that 425 million people suffer from diabetes worldwide (IDF, 2017). In the United States of America (USA), type 2 diabetes mellitus affects nearly 16 million people (Faria, Zanetti, & Damasceno, 2013). A study projected that the incidence of diabetes will tend to rise up 64% by 2025‚ meaning that an overwhelmingly 53.1 million citizens will be affected by the disease (May, 2013). The effects of diabetes mellitus on mortality and morbidity have drawn the attention of the healthcare community to the need for effective management. According to the World Health Organisation (WHO), there is an increase in the prevalence of diabetes especially in developing countries due to the epidemiological transition of health risks towards modern risks such as sedentary life style and unhealthy food rather than the health risks associated with communicable diseases (WHO, 2015). The increase in the prevalence of diabetes could also be caused by improved survival and aging of people and improved disease detection and diagnosis (WHO, 2015). Chronic non-communicable diseases, including diabetes, constitute the leading cause of death globally (WHO, 2013). WHO recent estimates showed that diabetes caused 1.5 million deaths in 2012, constituting 2.7% of total deaths. Majority of diabetes mortality occurred in low and middle-income countries (Eiman, Muna & Abdelmoneim, 2014). The greatest increase in prevalence is expected to occur in the Middle East Asia, sub-Saharan Africa, and India. It is found that the incidence of type 1 diabetes is increasing globally and especially among younger children (Beran & Yudkin, 2016). It is estimated that there are 300-350 new respondents of diabetes per year among children aged below the age of 15. The incidence has doubled during the last three decades (Seppanen et. al.,2009) Rapid socio-economic development and the consequent improvement in living standards and changes in lifestyle, have led to a dramatic increase in the prevalence of type 2 diabetes 13 University of Ghana http://ugspace.ug.edu.gh mellitus. Additionally, the negative tendency towards nutrition and decrease in physical activity have also contributed to the increase in prevalence (Akotey, 2012). 2.2.1 Prevalence of Diabetes in Sub-Sahara Africa The majority of people with diabetes in low resource nations are adults between the age of 45-64 years (King, Aubert & Herman, 2008), as against the majority of people in the developed world who have diabetes above the age 64 years. It is estimated that, by 2030, the number of people with diabetes below the age of 64 years will be more than 82 million in low resource countries and less than 48 million in developed countries (Wild et al., 2004). The largest increases in the diabetic populations are estimated to be in the most economically productive ages (Bjork et al., 2013). It is found that the prevalence of the disease in Africa is on the rise because of the ageing population and lifestyle changes that come with rapid urbanization. Recent reports show that traditional rural communities still maintain very low prevalence, which is at most 1-2% (WHO 2014). Type 2 diabetes is the most common form (70-90%), the rest being represented by typical type 1 patients and patients with atypical presentations. Due to modifiable risk factors such as the high urban growth rate, unhealthy dietary changes, reduction in physical activity and increasing obesity, it is projected that the prevalence of diabetes will triple in the next 25 years. Additionally, long-term complications occur early in the course of diabetes and affect many patients, and could be partly explicated by uncontrolled hypertension, poor glycemic control and possible ethnic predisposition (Bjork et al., 2013). The blend of the increasing prevalence of diabetes and the high rate of long-term complications of diabetes in Africans is expected to cause a drastic increase of the burden of diabetes on health care systems of the continent. It is therefore, a public health priority that, a 14 University of Ghana http://ugspace.ug.edu.gh design and implementation of an appropriate strategy for early diagnosis and treatment, and population-based primary prevention of diabetes in these high-risk populations is instituted (Sobngwi et al., 2011). The unidentified complications in diabetes in Africa are in the order of 60% to 80% in respondents diagnosed in Cameroon, Ghana and Tanzania (IDF, 2010). The rate of complication such as limb amputations varies from 1.4% to 6.7% of diabetic foot cases. Mortality associated with diabetes globally is estimated at more than one million (WHO, 2004). In some countries of sub-Sahara, the mortality rate is higher than 40 per 10 000 of the population (WHO, 2005). 2.3 Treatment and Management of Diabetes Diabetes has no permanent or definite cure; however, various treatments are given to patient to control and management their conditions so that they do not deteriorate. To effectively monitor patients, a thorough knowledge of the medications used to control hyperglycemia is needed. Diabetes mellitus management includes pharmacotherapy and non-pharmacotherapy such as dietary changes and lifestyle modifications. Pharmacotherapy of T2DM is with either insulin or oral anti-diabetic drugs (OADs), (Ozougwu, 2013). Primary failure with monotherapy has been studied and found to occur within 6 years of the condition. Combinations of two drug classes now are used to control blood glucose levels (Faria et al., 2013). The management at home also requires awareness of the mechanism of action of the different classes of hypoglycemic agents to monitor treatment. In a study conducted on effect of diabetes drug counseling by the pharmacist, and diabetic education, a total of 360 volunteers with type 2 DM patients were selected. Subjects were categorized into simple randomized 180 to control group and 180 to intervention group. One group received diabetes drug counseling; the other group received plus diabetic education. 15 University of Ghana http://ugspace.ug.edu.gh Both groups were monitored for fasting plasma glucose and HbAIc at 3-6 months. Glycemic levels in both groups were compared. The most favorable glycemic outcome was the group that received drug counseling and diabetes education. The results showed that drug counseling has little beneficial effect on diabetes management outcome compared to the diabetes management education and drug counseling. Thus, it was recommended that to improve glycemic control of type 2 diabetes mellitus, patients must integrate self- management in daily life, with wide a variety of education on drug taking behaviors by and health care providers. Available communication produces improvement in patient management and is somewhat better when used in combination with medication (Bjork, S., et al., 2013). A study suggested that dietary advice from health professionals can play a significant part in preventing and managing type 2 diabetes (Haynes, Taylor & Sackett, 2009). Overweight and obesity are strongly associated with this condition and individually tailored advice on weight loss and maintaining an appropriate weight are useful, together with encouragement to take appropriate exercise (Haynes, Taylor & Sackett, 2009). Current thinking about advantages of a healthy diet and lifestyle apply to people with type 2 diabetes. 2.3.1 Diet therapy Diet is considered an appropriate approach for patients with diabetes mellitus. Dietary modification is required to meet patients‟ needs and lifestyles. IDF (2006) recommends a conventional approach of diet composed of 60-65 percentage of carbohydrate, 25-35 percentage of fat, and 10-20 percent of protein with little or no drinking of alcohol. Vegetables serve as hypoglycemic agents and are among the numerous plant adjuncts. According to experiments, acupuncture is effective in treating diabetes and preventing future complications as a result of its active agents (Schmitt et al., 2013). Hypoglycemic agent acts 16 University of Ghana http://ugspace.ug.edu.gh as the pancreas to enhance insulin synthesis, increase the number of receptors on target cells. The acupuncture also increases the use of glucose ensuring lowering blood glucose. The agent has an anti-obesity effect which is a risk factor for type 2 diabetes. Additionally, it has a major therapeutic effect which acts on multiple organ systems in reducing the glucose level. Hot tub is recommended for T2D patients who are not able to exercise since it has effects on skeletal muscles and also aid in reduction in weight (Schmitt et al., 2013) 2.4 Adherence among Diabetes Patients This section of the chapter reviews literature on adherence among diabetes patients. Specifically, it focuses on adherence in terms of diet and exercise as part of diabetes management. Most health care providers instead of “compliance” use the term “adherence”, although these concepts are quite different. Adherence has been defined as “the extent to which a person's behavior coincides with medical advice (Haynes, Taylor & Sackett, 2009). Non-adherence then essentially means that patients disobey the advice of their health care providers. Patient non-adherence is attributed to personal qualities of the patients, such as forgetfulness, lack of will power or discipline, or low level of education (Gundala, Sastry, Manmohan, & Geeta, 2016). The concept of non-adherence not only assumes a negative attitude of health care providers toward patients, but also places patients in a passive, unequal role in relationship to their care providers. Adherence has been defined as the “active, voluntary, and collaborative involvement of the patient in a mutually acceptable course of behavior to produce a therapeutic result (Meichenbaum & Turk, 1987). Implicit in the concept of adherence is choice and mutuality in goal setting, treatment planning, and implementation of the regimen. Patients internalize treatment recommendations and then either adhere to these internal guidelines or do not adhere (Gundala et al., 2016). However, the concept of adherence has been criticized because 17 University of Ghana http://ugspace.ug.edu.gh of its focus on patients and because of the nature of the diabetes regimen itself, which is dynamic rather than static (Glasgow & Anderson, 1999). Furthermore, it is not useful to think of adherence as a unitary construct, but rather one which is multidimensional, because patients may adhere well to one aspect of the regimen but not to others. Non-adherence to prescribed drugs, exercise, diet schedule has been and continues to be a major problem the world over (Faria et al., 2013). Diabetes is considered to be one of the most psychologically and behaviorally demand of the chronic diseases. It requires frequent self-monitoring of blood glucose, dietary modifications, exercise, and administration of medication on schedule. Studies have emphasized the importance of achieving optimal glucose control through strict adherence to medications, diet, and exercise in order to minimize serious long-term complications (Gundala et al., 2016). These complications affect the patient's quality of life, increase mortality, morbidity and economic cost to society. It is imperative that patients adhere to their prescribed regimens to minimize the burden of the disease on the health systems. Non-adherence in chronic diseases has been described as taking less than 80% of the prescribed treatment (African Health Science, 2008). 2.4.1 Dietary and Exercise Adherence among Diabetes Patients It has been generally acknowledged for years that non-adherence rates for chronic illness regimen and for lifestyle changes are 50% (Haynes, Taylor & Sackett, 2009). Patients with diabetes are prone to substantial regimen adherence problems (Kurtz, 1990). Research has shown that the diabetes regimen is multidimensional, and adherence to one regimen component may be unrelated to adherence in other regimen areas (Kravitz, 1993). For instance, studies have shown better adherence for medication use than for lifestyle change 18 University of Ghana http://ugspace.ug.edu.gh such as diet and exercise (Anderson, Fitzgerald & Oh, 1993). In other studies, adherence rates of 65% were reported for diet but only 19% for exercise (Haynes, Taylor & Sackett, 2009). 2.5 Prevalence and Factors associated with adherence to dietary and exercise regimen Adherence or non-adherence to prescribed diabetes management procedures is affected by numerous factors some of which could be patient‟s reluctance, forgetfulness, environmental or household factors, availability and accessibility to required procedures among other things. Various studies on adherence particularly on dietary and exercises have been reviewed here. In a study carried out in Yemen, Hodeidah city, it was found that only 21.0% of patients adhered to the recommended diet and 15.0% adhered to regular exercise. These rates were consistent with the findings of similar studies in neighboring countries such as Jordan, and Kuwait, where the rate of adherence to diet varied between 10.7% and 36.5% (Shokair, 2007; Serour, Alqhenaei & Al–Saqabi, 2007). However, the rates of adherence to physical exercise found in these studies varied between 9.5% and 35.6% (Shokair, 2007; El-Abbassy, 2015). Reasons reported from these studies as contributing to adherence in Yemen was that most people eat together in groups with the family members and friends. Thus, in societies where communal living is common or where families do things together, it may be difficult for such patients to follow their special diet regimen that is different from the rest of the family. The study also showed that urban residents adhered to diet almost twice higher than rural residents (Alhariri, Daud, Almaiman, Ayesh, & Saghir, 2017). This finding is in contrast to that reported among diabetics from Bangladesh (Mumu, Saleh & Ara, 2015), where rural patients were three times more likely to adhere to prescribed diet than urban patients. This difference may be due to the lack of DM health care services and education in rural areas or the rate at which people do things together in the urban areas, may be lower than the rural areas. Demographic factors such as low level of education and the type of occupation have 19 University of Ghana http://ugspace.ug.edu.gh been found to be associated with lowered adherence and greater diabetes related morbidity (Delamater, 2001). For example, lower rates of adherence have been observed among minority African-American and Mexican-American patients (Harris, 1999). In another study, a report on the analysis done according to groups showed employed patients and housewives were four times more likely to adhere to diet than the unemployed ones (Gundala et al., 2016). This finding is consistent with a previous study in Bangladesh (Mumu, Saleh & Ara, 2015), where employees were more adherent to diet than unemployed patients. This may be due to differences in knowledge level and economic status, which are usually better among employees. In addition, it is also supported by a study conducted in Oman (Al– Sinani, Min & Ghebremeskel, 2010), which revealed that women were more amenable to changing their diet than men. Several other studies, have found gender difference in terms of adherence to diet and exercises. Where women are found to be more adherent to diet, men are also found to be more adherent to exercises. Consistent with other studies (El–Abbassy, 2015), patients with DM duration of ≤5 years in the study were more adherent to diet than those who had a duration of >5 years. This may imply that more years of the condition may lead to apathy and negligence on the part of some patients. The age distribution of patients has also been found to have a significant influence on adherence. Studies have indicated that younger age was significantly associated with adherence to physical exercise (Mumu, Saleh & Ara, 2015; Alrahbi, 2014). In fact, with increasing age, a decline in motor abilities and comorbid disease can occur, that makes it difficult to perform routine physical exercises. Patients who were treated with oral hypoglycemic medications were more engaged in physical exercise than those who were treated with insulin. A similar study in Saudi Arabia (Khan, Al–Abdul Lateef & Al Aithan, 2012), rather found that using insulin was significantly associated with adherence to diet. The various studies provide the evidence that there are multiple factors contributing to these 20 University of Ghana http://ugspace.ug.edu.gh findings, which require a further investigation in the subject matter, particularly in the sub- Sahara Africa. Findings related to metabolic control such as HbA1c showed a significant association with the rate of adherence to healthy diet and physical exercise (Serour, Alqhenaei, Al–& Saqabi, 2007; Shamsi, Shehab & AlNahash, 2013), indicating that good diabetes control is significantly higher in those following a diet and taking regular exercise. The low rate of adherence to both diet and exercise found in this study reflect the lack of glycemic control among patients. Summary Diabetes is found to have three broad categories which are type 1, type 2 and gestational diabetes. The classification is based on the nature and the occurrence of the condition. The prevalence of diabetes is growing with higher prevalence in low resource countries due to changing lifestyles and the adoption of western lifestyles. Several risk factors contribute to diabetes and these are modifiable risk factors such as lifestyle, example diet, alcohol and physical inability; non-modifiable risk factors include family history, genetics, hereditary among others. There is no permanent cure to the condition but several medications exist to manage the condition. In addition to medications are recommended exercise and diet for diabetics. Adherence to dietary and exercise regimen among diabetics are found to be influenced by a number of factors. Several studies reviewed found socio-demographic characteristics such as age, employment, sex. Other studies also reported duration of the diseases as a significant factor of adherence to exercise and diet. 21 University of Ghana http://ugspace.ug.edu.gh Knowledge Gap The literature review provided above shows that there has been extensive work done by various scholars on diabetes globally. To this extent, knowledge on diabetes in terms of risk factors, etiology, medication is well documented. It must also be acknowledged that in terms of adherence, a lot of studies have been done on medication adherence in international, regional and local contexts. However, it must be noted that literature on effectiveness to diet and exercise as methods of diabetes management is poorly understood. In terms of dietary and exercise adherence among patients, very few works have been done especially in sub- Sahara Africa. Various literature found were on studies mostly done in Asia and America. 22 University of Ghana http://ugspace.ug.edu.gh CHAPTER THREE METHODS 3.1 Introduction This chapter discusses the methods that were used to carry out the study. The chapter includes the study design, study area and population. Methods and procedures for data collection and sampling are also outlined here. In addition, data analysis and management as well as ethical consideration are also described. 3.2 Study Design The study employed a cross-sectional study design to examine diet and exercise treatment adherence among diabetes patients in the Tema General Hospital (TGH) of the Tema Metropolitan Assembly (TMA), Greater Accra Region of Ghana. Cross-sectional design was considered as appropriate for the study because the study seeks to provide an estimate of the prevalence of non-adherence and non-causal relationship between patient‟s demographic and clinical characteristics and non-adherence. 3.3 Study Area The study was conducted at the Tema General Hospital (TGH) of the Tema Metropolitan Assembly, Greater Accra Region of Ghana. Location / Physical features The study was carried out at the Tema General Hospital (TGH), located in the Tema Metropolis (Figure 3.1). Tema metropolis is one of the 16 districts in Greater Accra Region and is a vibrant commercial and industrial city. The population of Tema metropolis was estimated at 403,934 projection from 2010 population census (GSS PHC., 2012), making it the second largest populated district in the Greater Accra Region. The estimated 2016 population of Tema Metropolis is 351,616 as projected from the 2010 Census, making it the 23 University of Ghana http://ugspace.ug.edu.gh second largest-population of the ten districts in the Greater Accra Region, after Accra Metropolis. TGH was constructed in 1954 by J.W Harrow and Sons Ltd and later handed over to the government of Ghana in 1965. Tema Metropolis is a coastal district situated about 30 kilometers East of Accra, the Capital City of Ghana. Its unions boundaries in the northeast with the Dangme West District, south- west by Ledzokuku Krowor Municipal, north-west by Adentan Municipal and Ga East Municipal, north by the Akuapim South District and south by the Gulf of Guinea. The Metropolis covers an area of about 87.8 km with Tema as its capital. The metropolis lies in the coastal savannah zone. Figure 2: Map of Tema Metropolis Source: GSS, 2010 24 University of Ghana http://ugspace.ug.edu.gh 3.3.1 Tema General Hospital The Tema General Hospital is the largest public health institution in the Tema Metropolis, which promotes, protects and ensures good health and well-being of its clients and the community at large. The geographical location of the Hospital is surrounded by road networks, making the hospital the major referral points for all other clinics/ hospitals, public and private in and around the Metropolis. The catchment area includes the whole of Tema metropolis, its satellite town and villages. The Tema General Hospital has ten (10) wards and between 280 and 300 bed capacity, (District Analytical Report, 2014). There are several departments at the TGH of which the diet therapy unit is included. Other departments include surgical, dental, physiotherapy and eye (Tema metropolitan, 2013). The hospital delivers medical services to both in-patients and out-patients. Diabetes mellitus appears to be among the top (10) commonest conditions at the TGH. For the past 3 years there has been increase in hospital attendance of diabetes mellitus patients at the diabetic clinic and the diet therapy unit at the Tema General Hospital (GHS-Report, 2013). The study area was selected due to the high patients‟ attendance at the diet therapy unit and its wide catchment area. The diversity of the population would be helpful for the external validity of findings of the study. This was because of the opportunity to make selection from different group of persons having the condition. The facility renders services to all the communities within the Tema metropolis such as Nungua, Teshie, Spintex, Sakumono, Tema New town, Manhean, Ashaiman and Afienya, among others. 25 University of Ghana http://ugspace.ug.edu.gh 3.3.1.1 The Diabetes Clinic The diabetes clinic at the TGH serves over thousand patients in a year. However, it has clients of other private hospital who attending the clinic because of the fact the TGH is the main referral center. The client population has also grown steadily over the years. The diabetic clinic has six (6) staff comprising of four (4) nurses, a doctor and one record officer. Clients from the diabetes clinic are mostly referred to the diet therapy unit to see the dietitian. 3.3.1.2 The Diet Therapy Unit The diet therapy unit of the TGH also serves clients being referred within and out of the hospital. The diet therapy unit clinic has four (4) staff comprising a dietitian, two (2) nurses, and one record officer. The diet therapy unit has been able to capture information on diabetics with comorbidities such as hypertension, number of amputations, new diabetes patients, and people living with diabetes less than 40 years and mortalities but unfortunately, information has not been captured on non-adherence to dietary and physical exercise recommendations among diabetes patients. However, there is the need to identify the prevalence of adherence among clients with T2DM at TGH. 3.4 Study Population The target population was all patients with type 2 diabetes attending the diet therapy of the Tema General Hospital (TGH). The study population were patients diagnosed with type 2 diabetes, who have been seeing the dietitian for more than 2 months and have been given meal plans to follow. 3.4.1 Inclusion criteria  Age greater than or equal to 18 years,  Have sound cognitive and hearing capacities preserved  Male and female with type 2 diabetes mellitus 26 University of Ghana http://ugspace.ug.edu.gh  Patients who had complete clinical records in the hospital.  Being regularly monitored in the hospital selected for the study.  Patients who attended the diet therapy unit for at least 2 months.  Patients who would consent to be part of the study. 3.4.2 Exclusion criteria  Patients with type 1 diabetes  Patients with incomplete records or missing information 3.5 Study Variables The study variables consist of independent and dependent variables that were used to satisfy the research questions. 3.5.1 Independent Variables The effects of certain factors, which may influence non-adherence to treatment regimen (diet and exercise), were explored in this study. Socio-demographic factors, knowledge about treatment regimen and clinical factors were the explanatory variables under consideration in this study, and these are aligned with the study‟s conceptual framework. The socio-economic status of the participant is categorized as poor or rich using the national poverty line of ₵1314. A participant is considered poor if the average income is less than the National poverty line (GSS, 2018). 27 University of Ghana http://ugspace.ug.edu.gh Table 1: Definition of Independent Variables Variables Definition Type of data Age Age at last birthday Ordered categorical BMI Quotient of body mass and height squared Ordered categorical Marital status Whether married or single Unordered categorical Educational status Last education attained Unordered categorical Socio-economic status Measured using the average income against the Binary National Poverty line estimate of ₵1314 per day. Duration of disease how long participant was diagnosed of diabetes Categorical Family history Any family member diagnosed with diabetes Binary Comorbidities Participant diagnosed of other conditions Categorical Glycemic level Amount of glucose in blood Continuous Blood pressure Sphygmomanometer reading of blood pressure Continuous Smoking status Whether the participant smokes or not Binary Alcohol consumption Whether the participants take alcohol Binary Food frequency Item of food lists with response categories to Unordered categorical indicate how often the food is consumed in a month 3.5.2 Dependent Variable The dependent variable was the outcome of interest to the study which were adherence or non-adherence to exercise and dietary recommendation. These were measured using treatment adherence scale described in detail below. Adherence to physical exercise recommendation is an item composite variable measuring whether the participant is engaged in some form of exercise, whether the participant is committed to the exercise, whether the participant has ample time to do the exercise, whether the exercise schedule is recommended by a professional and whether the exercise is routine. Responses from these items are scored as a summation of responses from the 15 items and the highest response of 45 and a minimum score of 15 could be obtained for a participant. A 28 University of Ghana http://ugspace.ug.edu.gh participant is adherent to physical exercise recommendation if the participant scored above 30. Adherence to dietary recommendation is a 5 item composite variable measured as the number of times a participant eats in a day, the interval of eating in a day, whether the participant takes some snacks between meals. Correct responses to each item are coded as 1 while wrong responses are scored 0. The maximum score a participant can obtain is 5 while the minimum score is 0. A participant is considered adherent if the participant scored more than 2 for the responses to dietary recommendations. Table 2: Definition of Dependent Variables Variables Definition Measurement Adherence to physical 15 item composite variable measuring how often a Binary recommendation participant exercises in a day, Adherence to dietary 5 item variable measuring how often a participant Binary recommendation eats in a day, Knowledge on Diabetes 5 item composite variable on diabetes Binary condition 3.6 Sample Size determination Assumptions Based on data available at the diabetes clinic and the diet therapy unit of the TGH, this study had a closed cohort of 275 participants with T2DM. Looking at the inclusion criteria and the time for completion, new admissions could not be included in the study. Since this study was interested in assessing predictors of increased risk of non-adherence to exercise and meal plans, there was the decision to conduct a power calculation instead of a sample size calculation given the closed cohort. In line with the literature on increased risk for non- adherence, the primary hypothesis was that patients from a low socio-economic status are more likely to report low adherence to exercise or meal plans, compared to those with high socio-economic status. The study also had secondary hypothesis in terms of the relationship 29 University of Ghana http://ugspace.ug.edu.gh between other predictors (clinical, metabolic) and non-adherence but the decision was to use the minimum prevalence approach to ensure that models have adequate power to detect differences in the other predictors. Based on previous literature, this study assumed a „control‟ (patients with high socio-economic status) prevalence of 45% non-adherence and a „comparison group‟ (patients with low socio-economic status) prevalence of 65% non- adherence. Based on these assumptions and using the Stata command; power two proportions 0.65 0.45, n (275), the sample size of 275 was sufficient to detect a prevalence difference of 20% with a power of 92%. 3.6.1 Sampling Method Consecutive sampling was used to select the study participants for the study until the sample size of 275 was met. The sampling consisted of diabetes patients with records with the hospital. The selected records were matched with patients when they visited the center for their routine check-ups for additional data to be collected. Patients were recruited as and when they visited the clinic and interviewed by answering questions on the questionnaire as they queued and waited for the clinic to commence or as they waited to see the doctor/dietitian. Further information was also taken from their records at the hospital as discussed. Administering of the questionnaire continued until the total number of sampled patients‟ records at the diet therapy unit was achieved 3.7. Data Collection procedure Data collection was conducted in July, 2019 by trained field research assistants. Period for data collection lasted 2 weeks; from the second week through to the third week of July. Each day it was expected to have an average of 20 respondents. Therefore, for 275 sample size, data collection was estimated to take up to approximately 14 days. 30 University of Ghana http://ugspace.ug.edu.gh The data collection took place at the hospital where patient records were obtained. The following data were collected: blood pressure, body weight and height (which were used to calculate BMI) and laboratory tests from history or records. Primary data such as blood pressure and weight were collected on the day of interview. Laboratory tests such as fasting blood sugar, random blood sugar, glycated hemoglobin (HBA1C), and lipid profile among others were obtained from history or records. The next step consisted of conducting structured interviews with the patients when they visited the diet therapy unit. Information obtained included their adherence to exercise and dietary recommendation and any data that were not obtained from the records. Each participant was interviewed by either the researcher or assistants who explained the contents of the questionnaire to their understanding. Questionnaires were self-administered. However, research assistants administered the questionnaires to the respondents who were not able to read and write. Respondents were requested to consent either verbally, signing or thumb printing. Before and during the interview, respondents who did not understand any item on the questionnaire were allowed the freedom to ask questions for clarification. Respondents who felt uncomfortable to continue with the interview for whatever reason were free to opt out. 3.8 Data Collection Tools The instruments that were used for the data collection were background information form, food consumption frequency and exercise adherence rating scale. 3.8.1 Background Information form The questionnaire contained socio-demographic variables (sex, age, education and family income (used to estimate socio-economic status), clinical variables (time since diagnosis, 31 University of Ghana http://ugspace.ug.edu.gh comorbidities, and chronic complications) and metabolic control variables (Body Mass Index – BMI, blood pressure and laboratory tests). 3.8.2 Food consumption frequency questionnaire This tool assessed the food consumption patterns and behavior among diabetes patients in order to determine their adherence to diet regime. This tool was modified as a Likert scale. The responses were ordered categorical. The categories are 3. Never was coded “0” Sometimes was coded “1” and always was coded “2”. The food frequency questionnaire was made up of 45 food items categorized under fish, starches, soup, stew, fruits, porridge, vegetables milk products and spreads 3.8.3 Knowledge measurement scale Knowledge was measured as a composite variable made up of 5 items. A correct response to an item was coded 1 while a wrong response was coded 0. Where participant obtained a score less than 3, the participant was considered less knowledgeable while a score above 2 was considered knowledgeable. 3.9 Ethical Considerations The study followed national and international standards of ethics in research involving human beings. Ethical clearance was sought from the Ghana Health Service Ethics Review Board. Consents were also sought from the appropriate authorities of the hospital and the Tema Metropolitan Assembly (TMA). Consent of the participants was sought before data was collected. Voluntary participation was indicated by signing or thumb printing a written informed consent form by each study participant. The purpose of the study, the benefits and rights of the subjects and the procedure involved were explained to all participants. All information provided by the respondents was 32 University of Ghana http://ugspace.ug.edu.gh kept confidential and data locked in a safe place and softcopy store and protected on computers. Electronic data files were secured by a password known by only the principal investigator. Research assistants could only access them when they had been given permission Participants were given the right to refuse to answer questions that they were not comfortable with. They also had the right to withdraw from the study at any time they do not feel comfortable to continue. They were assured of confidentiality with regard to all information they provided and were encouraged to fully participate. All responses obtained were kept private and confidential. Respondents were not paid for their direct involvement in the research. This was done to avoid biases in their response. 3.9.1 Benefits Patients who participated in the study had the opportunity to be educated on the importance and benefits of exercises and balanced diet in the management of type 2 diabetes. Also, respondents who needed special attention in the course of the study in terms of diet or exercise management were referred appropriately. 3.9.2 Training of Interviewers Training was organized for three research assistants who could speak some of the local languages to administer the questionnaires to participants at the Tema Metropolitan Assembly. The research assistants were trained on the interpretation of questions and how to administer the questionnaire. The training was for a period of two working days with the second day used on the field for practical experience during the pretesting. This was to ensure that the interviewers understood the questions and be able to provide the same interpretation to the questions. It also helped them to learn how to administer the questionnaires and how to examine them for inconsistencies and completeness. 33 University of Ghana http://ugspace.ug.edu.gh 3.9.3 Quality Assurance 3.9.4 Pre-Test of Instruments The study tools were the background information form and the adherence rating scales. The questions were both open-ended and close-ended. The tools were pre-tested at the Tema poly clinic on patients with similar characteristics. The selected participants for the pre-testing of the instruments were not part of the main study. Corrections and modifications were made and the final questionnaire and other tools prepared. 3.9.5 Data Analysis All completed questionnaires were cross-checked before they were included in the valid responses. Data was coded and entered into Microsoft Excel. The entered questionnaire was marked, numbered and put into labeled envelopes and stored safely. All statistical analyses were performed using STATA version 15 (StataCorp.2007. Stata Statistical Software. Release 15. StataCorp LP, College Station, TX, USA). Microsoft Excel 2016 was used to enter the data. For data analysis, descriptive statistics were used in order to determine the prevalence of adherence to treatment (with 95% CI) and characterization of the sample regarding socio- demographic and clinical variables. For the analysis of values obtained from the 5 item composite for adherence to dietary recommendation, which is measured as the number of times a participant eats in a day, the interval of eating in a day and whether the participant takes some snacks between meals, a participant is considered adherent if the participant scored more than 2 for the responses. For the analysis of values obtained from the 15 items on adherence to physical exercise recommendation, which measured whether the participant is engaged in some form of exercise, whether the participant is committed to the exercise, whether the participant has 34 University of Ghana http://ugspace.ug.edu.gh ample time to do the exercise, whether the exercise schedule is recommended by a professional and whether the exercise is routine, a participant is considered adherent to physical exercise recommendation if the participant scored above 30. To investigate the relationship between adherence to treatment and socio-demographic, clinical and metabolic control variables, the data was analyzed using chi-square test. The quantification of this association was measured by logistic regression models, because outcomes were regrouped into binary outcome which make logistic regression the more preferred option. The crude Odds Ratio (OR) and the Adjusted Odds Ratio (AOR) were calculated with its respective confidence interval of 95% for each variable in relation to adherence. Values of p < 0.05 were considered significant. 35 University of Ghana http://ugspace.ug.edu.gh CHAPTER FOUR RESULTS 4.1 Introduction This chapter presents the results from the study. The results presentation follows the order of the study objectives with the demographics and the clinical profile of the respondents preceding the chapter. Analysis done followed the three stages of analysis which are the descriptive, bivariate and logistic regression. In all, 275 participants‟ data were used in the analysis. 4.2 Demographic profile of respondents The average age of respondents was 45 years +14.36 and ranges from 18 to 78 years old. The age group categories of the respondents were below 30 years old (14.3%), 30 to 40 years (24.2%), 41 to 50 years (24.5%) and above 50 years (37.0%) (Table 3). Compared to all the other age groups, respondents who were above the age of 50 years were the majority. Males constituted more than half of the total sample (54.6%) whilst females were 45.4%. Furthermore, the marital status of respondents shows married respondents as the majority (56.8%) followed by widowed (27.1%). Those who were single and those divorced or separated were less than 14%. As shown in Table 3, the major educational levels recorded were basic to JSS, and vocational/technical schools (35.9 and 32.2% respectively). In terms of occupation, most of the respondents were self-employed (52.7%) followed by those on retirement (26.7%). Akan and Hausa were the major group (little above 28%) and Christians form the dominant religion (69.6%). 36 University of Ghana http://ugspace.ug.edu.gh Table 3: Background Characteristics of Participants Variables Frequency Percentage Age group Below 30 39 14.3 30-40 66 24.2 41-50 67 24.5 Above 50 101 37.0 Sex Female 124 45.4 Male 149 54.6 Marital Status Married 155 56.8 Single 33 12.1 Divorced/Separated 11 4.0 Widowed 74 27.1 Education status No formal 20 7.3 Basic/Primary/JSS 98 35.9 Vocational/Tech 88 32.2 Secondary/ High school 33 12.1 Tertiary 34 12.5 Socio-economic status Poor 161 58.97 Rich 112 41.03 Place of residence Rural 4 1.5 Urban 269 98.5 Employment status Public sector work 14 5.1 Private employee 18 6.6 Self-employed 144 52.7 Unemployed 12 4.4 Student 12 4.4 Retired 73 26.7 Ethnicity Akan 78 28.6 Ga/Adangbe 3 1.1 Krobo 38 13.9 Ewe 19 7.0 Hausa 79 28.9 Others 56 20.5 Religion Christian 190 69.6 Muslim 83 30.4 37 University of Ghana http://ugspace.ug.edu.gh 6% 7% 10% 16% 61% Income groups Below 500 Ghc 500-999 Ghc 1000-1499 Ghc 1500 and above No income Figure 3: Monthly income levels of Participants Figure 3 shows the monthly income of participants and as shown, those with income below Ghc 500.00 were the majority (61%), which was followed by those with income group of between 500 and 1000 Ghc and between 1000 and Ghc 1,500. 4.3 Clinical and personal lifestyle factors of respondents This section presents the results on clinical factors as well as personal life style factors of participants. This has been descriptively analyzed and presented in tables and graphs. 38 University of Ghana http://ugspace.ug.edu.gh Table 4: Clinical profile of participants/respondents Variable Frequency Percentage Duration of disease Less than 6 months 18 6.6 6 months- 11 months 24 8.7 1-2 years 21 7.8 3-5 years 165 60.4 6-9 years 22 8.1 10 years and above 23 8.4 Family history of diabetes Yes 173 63.4 No 100 36.6 BMI ˂18.5 (underweight) 22 8.1 18.5-24.9 (normal/healthy weight) 144 52.8 25-29.9 (overweight) 76 27.8 ˃30 (obese) 31 11.4 HbA1c <6.5 40 14.7 6.5 above 222 81.3 Missing 11 4.0 Regular blood glucose check-up Yes 263 96.3 No 10 3.7 First knowledge of diabetes Before coming to clinic 30 11.0 During routine medical checkup 243 89.0 Type of treatment Drug only 243 89.0 Insulin only 3 1.1 Drug and insulin 13 4.8 Drug and diet therapy 14 5.1 On herbs therapy Yes 56 20.5 No 217 79.5 Table 4 provides the detailed results on the clinical factors to the respondents studied. It is observed that the majority have had the condition (Type 2 diabetes) between 3-5 years (60.4%). Those less than 3 years were 15.3% whereas those with the condition more than 5 years formed 16.5%. Those who had family history of T2D constituted 63.4% whilst 36.6% had no family history of diabetes. In term of their BMI, more than half (52.9%) had between 18.5-24.9 (normal weight) followed by those overweight (27.8%). The underweight group and those obese were 8.1% 39 University of Ghana http://ugspace.ug.edu.gh and 11.4% respectively. Additionally, high proportion of the respondents had their HbAlc level greater than 6.5 (81.3%). 100 96 95 90 83 80 70 60 50 40 30 20 17 10 4 5 0 Yes No Yes No Yes No Smoking Consume alcohol Follow diet without treatment Lifestyle factors Figure 4: Personal lifestyle factors of respondents As shown in Figure 4, presents the lifestyle of participant while with diabetic condition. The proportion of respondents who are non-smokers was high. Almost all the respondents (96%) were non-smokers except 4%. Alcohol consumption was also low (5%) and about 83% indicated following diets. 40 Percentage (%) University of Ghana http://ugspace.ug.edu.gh 4.4 The level of knowledge on the role of dietary and exercise requirements among T2D Diet and exercise play an important role in the management of T2D. In this study, participants were examined to describe their knowledge on dietary and exercise requirements. Table 4.3 provides the details. Table 5: Knowledge on the importance of diet and physical exercise Variables Yes No Not sure Conditions of diabetic patients can be 210 (76.9) 10 (3.7) 53 (19.4) improved by adhering to exercise and physical Skipping prescribed dietary regimen may 253 (92.7) 8 (2.9) 12 (4.4) not help to improve condition Eating food in large quantity that should 253 (92.7) 8 (2.9) 12 (4.4) be taken in little quantity is harmful to you Eating foods that one should avoid/limit is 187 (68.5) 8 (2.9) 78 (28.6) harmful to your condition Good general knowledge of dietary and 200 (73.3) 17 (6.2) 56 (20.5) exercise regimen could lead to consistent modification and awareness for the patient From Table 5, participants showed considerably good knowledge on the role diet and physical exercise on the management of T2D. That is 76.9% indicated in agreement that conditions of diabetic patients could be improved by adhering with exercise and exercise recommendations. However, 19% of these respondents indicated they had no knowledge conditions of diabetic may improve with exercise. In addition, majority of respondents indicated that skipping prescribed dietary regimen might not help to improve their condition. Similarly, 68.5% also agreed to the statement that eating foods that one should avoid is harmful to their conditions. 41 University of Ghana http://ugspace.ug.edu.gh 4.4.1 Factors associated with knowledge level among respondents Responses from participants were classified into good and low knowledge and the test of association was determined using socio-demographic characteristics. The score of those who responded correctly as well as wrongly were computed. The results showed that the majority of 68.1% had good knowledge of the role of diet and exercise on T2D managements whereas 32.9% had low knowledge. Table 6 shows the results on the test of relationship between demographic factors and knowledge level among participants. Age group was significant (p=<0.001), gender was found statistically significant (p=<0.001), marital status was associated with knowledge (p=<0.001) and educational status of participant was associated too (p=<0.001). Similarly, employment status, ethnicity, religion, income levels were also statistically significant at p<0.05.Among all the socio-demographic variables, only place of residence was found to be not significant with a p-value of 0.097. 42 University of Ghana http://ugspace.ug.edu.gh Table 6:Background factors associated with knowledge Variables Knowledge level P-value Poor (N=87) Good (N=186) Age group Below 30 18 (20.69) 21 (11.29) <0.001* 30-40 21 (24.14) 4 (2.15) 41-50 7 (8.04) 60 (32.26) Above 50 41 (47.13) 60 (32.26) Sex Female 72 (82.76) 52 (27.96) <0.001* Male 15 (17.24) 134 (72.04) Marital Status Married 52 (59.77) 103 (55.38) 0.009* Single 16 (18.39) 17 (9.14) Divorced/Separated 0 (0.0) 11 (5.91) Widowed 19 (21.84) 55 (29.57) Education status No formal 19 (21.84) 1 (0.54) <0.001* Basic/Primary/JSS 15 (17.24) 82 (44.09) Vocational/Tech 46 (52.87) 42 (22.58) Secondary/ High school 0 (0.0) 33 (17.74) Tertiary 7 (8.04) 27 (14.52) Socio-economic status Poor 50 (57.47) 111 (59.68) 0.730 Rich 37 (42.53) 75 (40.32) Place of residence Rural 3 (3.45) 1 (0.54) 0.097 Urban 84 (96.55) 185 (99.46) Employment status Working 68 (78.16) 108 (58.06) 0.001* Not working 19 (21.84) 78 (41.94) Ethnicity Akan 16 (18.39) 62 (33.33) <0.001* Ga/Adangbe/Krobo 0 (0.0) 41 (22.04) Ewe 15 (17.24) 4 (2.15) Hausa 0 (0.0) 79 (42.47) Others 56 (64.37) 0 (0.0) Religion Christian 87 (100.00) 103 (55.38) <0.001* Muslim 0 (0.0) 83 (44.62) Monthly Income Below 500 Ghc 60 (68.96) 107 (57.53) <0.001* 500-999 Ghc 8 (9.19) 35 (18.82) 1000-1499 Ghc 1 (1.15) 26 (13.98) 1500 and above 1 (1.15) 18 (9.68) No income 17 (19.54) 0 (0.0) Duration of disease 2 years and below 0 (0.0) 63 (33.87) <0.001* 3-5 years 32 (36.78) 12 (6.45) Above 5 years 55 (63.22) 110 (59.14) Note: *-Measured association is significant; test of association using Fisher‟s Exact correction 43 University of Ghana http://ugspace.ug.edu.gh Table 7 Binary logistic regression: background factors associated with knowledge Variable COR P-Value AOR P-value Age group Below 30 1 1 30-40 1.57 (0.71-3.44) 0.264 3.50 (0.66-18.62) 0.141 41-50 5.39 (2.09-13.88) <0.001 4.77 (0.95-23.94) 0.057 Above 50 1.00 (0.49-2.06) 0.990 1.57 (0.43-5.74) 0.492 Marital Status Married 1 1 Single 1.22 (0.54-2.75) 0.636 1.50 (0.25-8.87) 0.656 Divorced/Separated 5.53 (0.69-44.33) 0.107 5.02 (0.25-102.56) 0.294 Widowed 1.33 (0.72-2.45) 0.365 0.04 (0.65-1.91) 0.226 Sex Female 1 1 Male 5.67(3.2-10.03) <0.001 4.25 (1.36-13.35) 0.013* Employment status Working 1 1 Not working 0.03 (0.003-0.32) 0.001 0.46 (0.05-4.39) 0.501 Ethnicity Akan 1 1 Ga/Adangbe/Krobo 0.67 (0.06-7.73) 0.746 0.32 (0.01-17.14) 0.572 Ewe 5.67 (1.25-25.63) 0.024 4.07 (0.60-27.78) 0.152 Hausa 0.11 (0.04-0.34) <0.001 0.03 (0.01- 0.29) 0.002* Others 3.23 (1.29-8.14) 0.012 1.22 (0.28-5.38) 0.792 Religion Christian 1 1 Muslim 17.00(5.17-55.85) <0.001 2.89 (0.56-14.93) 0.204 Monthly Income Below 500 Ghc 1 1 500-999 Ghc 1.27 (0.65-2.47) 0.488 0.37 (0.09-1.49) 0.163 1000-1499 Ghc 3.38 (0.96-11.91) 0.058 2.86 (0.05-158.02 0608 1500 and above 10.13 (1.32-77.69) 0.026 11.83 (0.66-211.78) 0.093 Duration of disease 2 years and below 1 1 3-5 years 1.76 (0.65-4.75) 0.263 2.82 (0.22-36.42) 0.427 Above 5 years 0.95 (0.33-2.68) 0.926 1.06 (0.48-4.39) 0.954 44 University of Ghana http://ugspace.ug.edu.gh 4.5 Level of non-adherence to physical exercise among type 2 diabetes patients As part of the objective of this study, participants were examined to determine their levels of adherence to physical exercises. Results contain the descriptive presentation of findings as well as test of association and multivariable logistic regression of non-adherence. Table 8 presents adherence to physical exercise recommendation. Table 8: Adherence with physical exercises among T2D No Items Never Sometimes Always (1-3x a (≥4x a week) week) 1 I do my exercises as often as recommended 9 (3.3) 174 (63.7) 90 (33.0) 2 I adjust the way I do my exercises to suit myself 11 (4.0) 249 (91.2) 13 (4.8) 3 I don‟t get around to doing my exercises 44 (16.1) 226 (82.8) 3 (1.1) 4 Other commitments prevent me from doing my 77 (28.2) 196 (71.8) 0 (0.0) exercises 5 I feel confident about doing my exercises 12 (4.4) 194 (71.1) 67 (24.5) 6 I don‟t have time to do my exercises 41 (15.0) 186 (68.1) 46 (16.9) 7 I‟m not sure how to do my exercises 197 (72.2) 76 (27.8) 0 (0.0) 8 I do some, but not all, of my exercises 48 (17.6) 217 (79.5) 8 (2.9) 9 I don‟t do my exercises when I am tired 18 (6.6) 71 (26.0) 184 (67.4) 10 I do less exercise than recommended by my 20 (7.3) 206 (75.5) 47 (17.2) healthcare professional 11 I fit my exercises into my regular routine 24 (8.8) 177 (64.8) 72 (26.4) 12 I do my exercises because I enjoy them 23 (8.4) 238 (87.2) 12 (4.4) 13 I stop doing my exercises when my pain is worse 31 (11.4) 239 (87.6) 3 (1.1) 14 I forget to do my exercises 81 (29.7) 76 (27.8) 116 (42.5) 15 I continue doing my exercises when my pain is 11 (4.0) 244 (89.4) 18 (6.6) better As shown in Table 8, most of the participants indicated that they sometimes do their exercises as often as recommended (63.7%) and 33.0% always do their exercises as often as 45 University of Ghana http://ugspace.ug.edu.gh recommended. Also, almost all of the participants (91.2%) indicated that they sometimes adjust the way they do exercises to suit themselves; 4.0% never did whereas 4.8% always adjust the way they do their exercises. In terms of having time to do exercises, 16.9% indicated they always don‟t have time to do exercise and 68.1% were also of the view that they sometimes do have time to do exercises. Additionally, 75.5% also indicated that they sometimes do less of the exercise than recommended by their health care professional; 17.2% always do less whilst only 7.2% never do less. Lastly, 42.5% always forgets to do their exercise whilst 29.7% never forgot to do their exercises. 4.5.1 Adherence to physical exercise requirement and associated factors among participants The result showed that only 22.0% were adherent to physical exercise recommendations whereas the majority of 78.0% achieved low adherence. In the interest of this study, 78% of non-adherence was recorded. Test of association was further performed to determine the socio-demographic factors, clinical and personal style factors associated with non-adherence to physical exercise requirement among T2D patients. Table 9 shows the results on socio-demographic factors and non-adherence to exercise requirements. 46 University of Ghana http://ugspace.ug.edu.gh Table 9: Background characteristics and non-adherence to exercise requirements Variables Adherence to exercise requirement P-value No (N=213) Yes (N=60) Age group Below 30 35 (16.44) 4 (6.67) 0.012* 30-40 43 (20.18) 23 (38.33) 41-50 51 (23.94) 16 (26.67) Above 50 84 (39.44) 17 (28.33) Sex Female 100 (46.95) 24 (40.00) 0.380 Male 113 (53.05) 36 (60.00) Marital Status Married 104 (48.83) 51 (85.00) <0.001* Single 28 (13.14) 5 (8.33) Divorced/Separated/Widowed 81 (38.03) 4 (6.67) Education status No formal 20 (9.39) 0 (0.0) <0.001* Basic/Primary/JSS 66 (30.98) 32 (36.67) Vocational/Tech 84 (39.44) 4 (6.67) Secondary/ High school 30 (14.08) 2 (3.33) Tertiary 13 (6.11) 21 (35.00) Socio-economic status Poor 124 (58.22) 37 (61.67) 0.631 Rich 89 (41.78) 23 (38.33) Place of residence Rural 3 (1.41) 1 (1.67) <0.632 Urban 210 (98.59) 59 (98.33) Employment status Working 119 (55.87) 57 (95.00) <0.001 Not working 94 (44.13) 3 (5.00) Ethnicity Akan 28 (13.14) 50 (83.33) <0.001 Ga/Adangbe/Krobo 35 (16.43) 6 (10.00 Ewe 17 (7.98) 2 (3.33) Hausa 77 (36.15) 2 (3.33) Others 56 (26.29) 0 (0.0) Religion Christian 134 (62.91) 56 (93.33) <0.001* Muslim 79 (37.09) 4 (6.67) Monthly Income Below 500 Ghc 132 (61.97) 35 (58.33) <0.001* 500-999 Ghc 39 (18.31) 4 (6.67) 1000-1499 Ghc 19 (8.92) 8 (13.33 1500 and above 6 (2.82) 13 (21.67) No income 17 (7.98) 0 (0.0) Note: *Measured associated is significant; Table 10 shows the results on clinical and personal lifestyle factors and non-adherence to exercise requirements. 47 University of Ghana http://ugspace.ug.edu.gh Table 10: test of association of clinical/personal lifestyle factors and adherence Variables Adherence to exercise requirement P-value No (N=213) Yes (N=60) Duration of disease 2 years and below 38 (17.84) 25 (41.67) <0.001* 3-5 years 42 (19.72) 2 (3.33) Above 5 years 133 (62.44) 32 (53.33) Family history of diabetes Yes 129 (60.56) 44 (73.33) 0.095* No 84 (39.44) 16 (26.67) Regular blood glucose check-up Yes 208 (97.65) 55 (91.67) 0.045* No 5 (2.35) 5 (8.33) First knowledge of diabetes Before coming to clinic 17 (7.98) 13 (21.67) 0.005* During routine medical checkup 196 (92.02) 47 (78.33) Type of treatment Drug only 200 (93.90) 43 (71.67) <0.001* Drug and insulin 11 (5.16) 5 (8.33) Drug and diet therapy 2 (0.94) 12 (20.00) Smoking Yes 9 (4.22) 2 (3.33) 0.551 No 204 (95.78) 58 (96.67) Consume alcohol Yes 12 (92.9) 1 (1.67) 0.317 No 200 (77.2) 59 (98.33) On herbs therapy Yes 55 (98.2) 1 (1.67) <0.001* No 158 (72.8) 59 (98.33) Knowledge level Poor 86 (40.37) 1 (1.67) <0.001* Good 127 (59.63) 59 (98.33) Note: *Measured associated is significant; 4.5.2 Logistic regression analysis of factors significantly associated with non-adherence to physical exercises requirement A binary logistic regression model was fitted to demonstrate the odds of association of factors with adherence to physical exercise. 48 University of Ghana http://ugspace.ug.edu.gh Table 11: Multivariable analysis of factors associated with adherence to physical exercise Variables P-value COR (95%CI) P-Value AOR (95% CI) Age group Below 30 1 1 30-40 0.0056* 4.68 (1.41-15.58) 0.850 1.27 (0.11-14.67) 41-50 0.0853 2.75 (0.83-9.11) 0.683 0.61 (0.06-6.32) Above 50 0.3304 1.77 (0.55-5.69) 0.459 0.44 (0.049-3.89) Marital Status Married 1 1 Single 0.0435 0.36 (0.13-1.01) 0.884 0.71 (0.01-71.17) Divorced/Separated <0.001* 0.10 (0.03-0.31) 0.706 0.50 (0.01-18.53) Education Basic/Primary/JSS 1 1 status Vocational/Tech <0.001 0.13 (0.04-0.40) <0.001* 0.06 (0.01-0.36) Secondary/ High school 0.0306 0.27 (0.07-0.97) 0.004* 0.01 (0.00-0.14) Tertiary 0.0002 4.34 (1.87-10.09) 0.175 0.22 (0.02-1.96) Employment Not working 1 1 status Working <0.001* 15.00(4.22-53.40) 0.258 2.96(0.57-15.37) Religion Christianity 1 1 Islam <0.001* 0.12 (0.04-0.36) <0.001* 0.01 (0.001-0.10) Duration of 2 years and below 1 1 disease 3-5 years 0.0016* 0.37 (0.19-0.70) 0.479 1.95 (0.31-12.38) Above 5 years 0.0001* 0.11 (0.03-0.43) 0.712 2.98 (0.10-88.85) First knowledge During routine checkup 1 1 of diabetes Before coming to clinic 0.0028* 3.19 (1.43-7.13) 0.11 3.69 (0.56-24.32) Type of Drug only 1 1 treatment Drug and insulin 1.774 2.11 (0.69-6.44) 0.091 1.65 (0.83-3.30) Drug and diet therapy <0.001* 27.90 (5.32-43) 0.242 6.21 (0.71- 54.25) On herbs No 1 1 therapy Yes <0.001 0.05 (0.01-0.39) 0.141 3.38 (0.15-76.16) Knowledge Poor 1 1 level Good <0.001 29.95(4.75-35.85) 0.016* 38.80 (3.01- 49.25) Note: *Measured associated is significant; COR-Crude Odds Ratio; AOR-Adjusted Odds Ratio; CI: Confidence Interval. 49 University of Ghana http://ugspace.ug.edu.gh 4.5.3 Adherence to dietary requirement and associated factors among participants The result showed that only 26.7% were adherent to dietary requirement whereas the majority of 73.3% achieved low adherence. From the table, participant‟s sex, marital status, educational level, ethnicity and religion were found to be associated to adherence to dietary requirements. Table 12: Background characteristics and adherence to dietary requirements Variables Adherence to dietary requirement P-value No (N=200) Yes (N=73) Age group Below 30 35 (17.59) 10 (13.51) 0.703 30-40 47 (23.62) 19 (25.68) 41-50 46 (23.12) 21 (28.38) Above 50 71 (35.68) 24 (32.43) Sex Female 115 (58.38) 14 (19.18) <0.001* Male 82 (41.62) 59 (80.82) Marital Status Married 142 (71.72) 18 (24.66) <0.001* Single 26 (13.13) 6 (8.22) Divorced/Separated 3 (1.52) 8 (10.96) Widowed 27 (13.64) 41 (56.16) Education status No formal 15(7.54) 3 (4.05) <0.001* Basic/Primary/JSS 51(25.63) 41 (55.41) Vocational/Tech 87(43.72) 16 (21.62) Secondary/ High school 25(12.56) 5 (6.76) Tertiary 21 (10.55) 9 (12.16) Socio-economic status Poor 114 (57.29) 47 (63.51) 0.352 Rich 85 (42.71) 27 (36.49) Place of residence Rural 12 (6.03) 1 (1.35) 0.197 Urban 187 (93.97) 73 (98.65) Ethnicity Akan 69 (34.67) 15 (20.27) <0.001* Ga/Adangbe/Krobo 32 (16.08) 7 (9.46) Ewe 16 (8.04) 4 (5.41) Hausa 31 (15.58) 44 (59.46) Others 51 (25.63) 4 (5.41) Religion Christian 170 (85.43) 30 (40.54) <0.001* Muslim 29 (14.57) 44 (59.46) Monthly Income Below 500 Ghc 114 (61.29) 47 (66.20) 0.160 500-999 Ghc 45 (24.19) 9 (12.68) 1000-1499 Ghc 15 (8.06) 7 (9.86) 1500 and above 12 (6.45) 8 (11.27) 50 University of Ghana http://ugspace.ug.edu.gh Table 13: Association between clinical factors and adherence to dietary recommendations Variables Adherence to dietary requirement P-value No (N=200) Yes (N=73) Duration of disease 2 years and below 41 (20.60) 12 (16.22) 0.212 3-5 years 139 (69.85) 59 (79.73) Above 5 years 19 (9.55) 3 (4.05) Family history of diabetes Yes 156 (79.59) 16 (21.92) <0.001* No 40 (20.41) 57 (78.08) Regular blood glucose check-up Yes 191 (96.95) 71 (97.26) 0.827 No 6 (3.05) 2 (2.74) First knowledge of diabetes Before coming to clinic 17 (8.63) 12 (16.22) 0.168 During routine medical checkup 180 (91.37) 62 (83.78) Type of treatment Drug only 182 (91.92) 60 (81.08) 0.002 Insulin only 2 (1.01) 1 (1.35) Drug and insulin 10 (5.05) 3 (4.05) Drug and diet therapy 4 (2.02) 10 (13.51) Smoking Yes 2 (1.01) 9 (12.16) <0.001* No 196 (98.99) 65 (87.84) Consume alcohol Yes 10 (5.05) 3 (4.05) 0.732 No 188 (94.95) 71 (95.95) On herbs therapy Yes 2 (1.01) 54 (72.97) <0.001* No 196 (98.99) 20 (27.03) Similarly, testing for the association between clinical factors and adherence to dietary recommendations, participants with a family history of diabetes, those who smoke and those on herbs therapy were also associated with adherence to exercise recommendations. A multivariable analysis was done to test for the strength of the association with the significant variables. It was revealed that types of treatment; insulin only (AOR=44.0, 9 5%CI= 1.65 – 1171), drug and diet therapy (AOR=55.3, 95%CI= 5.59 – 547.6) and on herbs; No (AOR=0.002 95%CI=0.00 – 00.05) were associated with adherence to dietary recommendations. 51 University of Ghana http://ugspace.ug.edu.gh Table 14: Logistic regression of factors associated with adherence to dietary recommendations Variables P- COR (95%CI) P-Value AOR (95% CI) value Sex Female 1 1 Male <0.001 5.91 (3.09 – 11.30) 0.114 3.61 (0.74 – 17.72) Marital Status Married 1 1 Single 0.247 1.82 (0.66 – 5.02) 0.971 0.96 (0.10 – 8.85 ) Divorced/Separate <0.001 21.04 (5.11 - 86.57) 0.632 2.74 (0.04 – 169.9) d <0.001 11.98 (6.01 – 23.89) 0.267 2.55 (0.49 – 13.37) Widowed Educational status No formal 1 1 Basic/Primary/JSS 0.037 4.02 (1.09 – 14.84) 0.511 2.41 (0.18 – 33.09) Vocational/Tech 0.903 0.92 (0.24 – 3.54) 0.988 1.02 (0.06 – 16.15) Secondary/ High 1.000 1.00 (0.21 – 4.80) 0.972 1.05 (0.06 – 18.37) Tertiary 2.142 2.14 (0.50 – 9.27) 0.785 1.53 (0.71 – 32.94) Ethnicity Akan 1 1 Ga/Adangbe/Krob 0.990 1.01 (0.37 – 2.71) 0.875 0.86 (0.13 – 5.86) o 0.824 1.15 (0.34 – 3.93) 0.286 3.06 (0.39 – 23.85) Ewe <0.001 6.53 (3.17 – 13.46) 0.762 0.74 (0.10 – 5.37) Hausa 0.085 0.36 (0.11 – 1.15) 0.676 0.60 (0.06 – 6.49) Others Religion Christian 1 1 Muslim <0.001 8.60 (4.68 – 15.80) 0.141 2.97 (0.70 – 12.70) Family history of Yes 1 1 diabetes No <0.001 13.89 (7.22 – 26.72) 0.833 0.78 (0.08 – 8.00) Type of treatment Drug only 1 1 Insulin only 0.736 1.52 (0.14 – 17.02) 0.024 44.0 (1.65 – 1171) Drug and insulin 0.889 0.91 (0.24 – 3.42) 0.094 7.32 (0.71 – 75.50) Drug and diet 0.001 7.58 (2.29 – 25.07) 0.001 55.3 (5.59 – 547.6) therapy Smoking Yes 1 1 No 0.001 0.07 (0.02 – 0.35) 0.332 4.68 (0.21 – 105.39) On herbs therapy Yes 1 1 No <0.001 .004 (0.001 – 110.7) <0.001 0.002 (0.00 – 00.05) Note: *Measured associated is significant; COR-Crude Odds Ratio; AOR-Adjusted Odds Ratio 52 University of Ghana http://ugspace.ug.edu.gh 4.6 Adherence to dietary requirement among type 2 diabetes patients The final part of the study looked at the level of adherence to dietary requirement among T2D patients. The results are presented in table and charts where frequencies and percentages are provided. Table 15 shows the general eating behavior among participants. Table 15: Eating behavior among participants Variables Frequency Percentage Number of meals usually eaten during the day 1 meal 3 1.1 2 meals 8 2.9 3 meals 262 96.0 Usually eat meals at the same times Yes 130 47.6 No 146 52.4 The most frequent time intervals between meals 2 hours 16 5.9 3-4 hours 188 68.9 5–6 hours 69 25.3 Eat snacks in between your meals during the day Yes 32 11.7 No 210 76.9 Sometimes 31 11.4 4.6.1 Dietary/food frequency patterns among participants Participants were examined to determine their eating patterns and frequency across the various food groups. 53 University of Ghana http://ugspace.ug.edu.gh The results are presented in table 16 and Figure 5 Table 16: Fish/meat and starch/carbohydrate food frequency Food frequency Never Sometimes Always (1-3x a month) (≥ 4x a month) Fish/meat/seafood Beef meat 39 (14.3) 229 (82.8) 8 (2.9) Goat meat 83 (30.40) 7 (2.6) 7 (2.6) Pork 202 (74.0) 63 (23.1) 8 (2.9) Chicken 33 (12.1) 172 (63.0) 68 (24.9) Game (bushmeat) 39 (14.3) 223 (81.7) 11 (4.0) Fish (tuna , mackerel, tilapia, 6 (2.2) 183 (67.0) 84 (30.8) cassava fish, etc) Eggs 13 (4.8) 200 (73.3) 60 (22.0) Seafood (shrimps, oyster, 16 (5.9) 241 (88.3) 16 (5.9) crab, snails, etc) Starches Rice 2 (0.7) 197 (72.2) 74 (27.1) Rice and beans 3 (1.1) 187 (68.5) 83 (30.4) Banku/ kenkey 6 (2.2) 186 (68.1) 81 (29.7) Fufu/ kokonte 6 (2.2) 188 (68.9) 79 (28.9) Yam/plantain/cocoyam/potat 2 (0.7) 201 (73.6) 70 (25.6) o Spaghetti/macaroni/noodles 189 (69.2) 83 (30.4) 1 (0.4) 54 University of Ghana http://ugspace.ug.edu.gh 90 80 84 83 70 76 67 60 65 63 50 52 50 51 49 40 43 41 41 30 35 31 28 20 21 20 17 17 17 10 10 10 7 0 8 7 0 8 0 0 Apples Pawpaw Mango Citrus fruits Banana Watermelon Berries Avocado Grapes Coconut tangerine, pear orange, lemon Fruits Never Sometimes (1-3x amonth) Always (≥ 4x a month) Figure 5: Fruit frequency patterns among participants 55 Percentage (%) University of Ghana http://ugspace.ug.edu.gh CHAPTER FIVE DISCUSSION 5.1 Introduction This chapter discusses the results presented in the previous chapter. The discussion consists of the summary of the findings and comparison of the findings from the study with previous studies. Also, the chapter deals with the implications of the study as well as strengths and limitations of the study. The purpose of this study was to determine whether low Socio- economic status of the participants influenced their adherence to dietary and physical exercise recommendations. In addition, the research is to assess the level of knowledge and associated factors on the role of dietary and exercise requirements in the management of T2D patients, to identify the level of non-adherence to physical exercise among T2D patients, to assess the socio-demographics and clinical predictors of non-adherence to physical exercise among T2D patients and lastly to identify the level of non-adherence to diet among T2D patients. 5.2 Prevalence of participants who adhere to physical exercise recommendations From the results, approximately 22.0% of the patients reported to adhere to physical exercise whereas majority, 78.0% do not adhere to physical exercise. In addition, patients showed good knowledge on the role of physical exercise and diet in the improvement of T2D. About 76.9% indicated in agreement that adhering to exercise recommendations could improve one‟s diabetic condition. In addition to the above, patients indicated their level of non- adherence to exercise. About 63.7% of the patients said that they sometimes do exercise and 33.0% of the patients always do their exercises as often as recommended. More so, 68.1% of the participants said they sometimes do have time to do exercise, however, 16.9% of the participants said they always don‟t have time to do exercise. 56 University of Ghana http://ugspace.ug.edu.gh 5.3 Factors that influence adherence to physical exercise recommendations The primary hypothesis of this study was to assess the influence of Socio-economic status of patients on their adherence to physical exercise recommendations. From the findings of this study, Socio-economic status of the participants did not influence their adherence to physical exercise recommendations. To determine the factors that would influence patient‟s adherence to physical exercise, the study found that participants who had vocational education had a 99% reduced odds of adhering to physical exercise recommendations compared to participants with basic education. The study found that participants who had „good knowledge‟ were 38 times more likely to adhere with physical exercise recommendations compared to participants with low knowledge. Where persons are educated and well informed on the management of their conditions, they are well placed to adhere to recommended plans of management. This finding is consistent with Lascar et al where the study established that education to improve on patient knowledge improves on adherence to physical exercise. In this study he observed that educating participants on the need to exercise and the impact of exercise at reducing the glycemic levels in blood, goes a long way to improve participants adherence to physical exercise It is hypothesized that a higher training frequency (at least 3 days/week) may be necessary to maintain its effects on daily glucose control. For this reason, it seems plausible to recommend that exercise should be performed on most days of the week. However, it is also essential to consider the higher risk of overtraining or injury in the habitually sedentary T2DM patients. These concerns can be addressed by careful exercise planning that adequately alternates intensity, duration and mode of exertion on different training sessions. 57 University of Ghana http://ugspace.ug.edu.gh 5.4 Level of patient’s knowledge on importance of physical exercise and diet recommendations From this study, the proportion of participants that are knowledgeable on the importance of diet and physical exercise recommendation for the management of diabetes was 67.8%. That indicates that 185 of the total respondents had sufficient knowledge on the importance of diet and physical exercise recommendation for the management of diabetes. This is inconsistent with a study by Sami et al (2017) where he realised that there was low level of knowledge on the importance of diet and physical exercise recommendation for the management of diabetes. This finding of high level of knowledge amongst diabetic patients at the Tema General Hospital is attributed to the frequent education they receive at the hospital during the diabetic clinic days. This has made them more knowledgeable. Knowledge is a requirement to achieve better adherence with lifestyle modification therapy. Where participants have come to appreciate the importance of engaging in exercise and dietary modifications to help regulate hyperglycemia, they may not complain of the processes as been rigorous. 5.5 Factors that influenced knowledge on importance of physical exercise and diet recommendations This sought to identify factors that may influence the knowledge of participants on the importance of physical exercise and dietary recommendations. From the study, it was realised that males were 4.3 times more likely to be knowledgeable compared to females. It is seen that males tend to be more inclined to engage in physical activities to improve their health compared to females. Where they are morbid, they would seek enough knowledge about their medical conditions and ways to improve their health. Also, ethnicity was identified to influence the level of knowledge of the participants. It was realised that Hausas less likely to be knowledgeable about the importance of physical exercise and dietary recommendations in the management of diabetes conditions. There was about 97% reduced chance that Hausas would be knowledgeable on the importance of 58 University of Ghana http://ugspace.ug.edu.gh physical exercise compared to the Akans. Thus, more education should go to the Hausas to improve on adherence to physical exercise and diet modification. 5.6 Prevalence of participants who adhere to physical exercise recommendations The prevalence of participants who adhered to dietary recommendations was 26.7%. This findings indicates that a lower proportion of the participants adhere to dietary recommendations presented to them by their dietician. This finding is very worrying considering the fact that diabetes can be best managed with a combination of drugs and lifestyle modifications especially dietary modifications. Due to the risk of nephrotoxicity, diabetics are advised by dieticians to reduce their protein intake 5.7 Factors that influence adherence to dietary recommendations The findings of this study did not support the primary hypothesis. Results indicate that the Socio-economic status of the participants did not influence their adherence to dietary recommendations. The study also established that participants who are on insulin only were 44 times more likely to adhere to dietary recommendations compared to participants who were on drugs only. This is because most often for T2D patients, they are placed on insulin when it is quite challenging to achieve adequate glycemic control. Most often the diabetic condition may be worse. Such participants are willing to adhere to medical advice to help manage their conditions. Also participants who were on drug and dietary therapy were 55times more likely to adhere to dietary recommendations compared to participants who are on drugs only. 5.8 Eating behaviour among participants The eating behaviour of diabetic patients is of great importance to the management of hyperglycemia. Constantly diabetics are advised to maintain three meals daily since the drugs given them is to reduce the blood sugar. Once there is a reduced number of times meals are 59 University of Ghana http://ugspace.ug.edu.gh taken, there is an increased risk of hypoglycemia. From this study, 96% of the respondents took 3meals a day. This proportion was very encouraging, as majority of participants were not skipping meals in order to control their blood sugar. Regularization of eating time helps with digestion and proper planning of frequency for drug administration. Most diabetic drugs are administered either pre-prandial or post-prandial. Most diabetics are advised to eat at scheduled tines so as to help with glucose metabolism. This study established that 52% of the respondents ate on time and this is very encouraging. However, more patients should be encouraged to regularize their eating times. This would go a long way to help with glycemic control Patients with T2D are advised to eat adequate amounts of food required for daily activities. They are also advised to have snacks in between meals when there is symptom of hypoglycemia. This is because they are often more susceptible to reduced blood sugar after drug administration However, barring incidence of hypoglycemia which may require eating snacks in between meals, diabetics are required not to eat snacks in between meals as it could increase their blood glucose level. Majority of participants, that is 76%, responded that they do not eat snacks in between meals. Overall, the eating behaviour of participants was encouraging. Diabetics are advised to reduce their protein intake due to the potential of increasing the risk of kidney failure. Sadly, most of them may resort to avoiding protein intake completely. This situation may be harmful to their health. Since protein is essential for growth and cell formation. a stop in its intake may trigger the body to utilize protein from human muscle. Metabolism of the human muscle leads to production of more nitrogenous waste that may be even more nephrotoxic, hence rapid deterioration of the patient‟s kidney. From table 4.10, it 60 University of Ghana http://ugspace.ug.edu.gh was observed that majority of the participants take proteins in moderation. This would go a long way to prevent damage to the kidneys Dietitians advise patients with diabetes to increase their intake of fruits especially those with less glycemic index such as avocado pear, watermelon etc. Studies have found out that most of these fruits contain antioxidants which increase the secretion of insulin to help with glucose regulation. From figure 4.3, most participants sometimes take fruits. The study observed that majority of the participants do not take fruits especially the berries, apples that have been known to manage oxidative stress in diabetics. While dieticians recommend intake of fruits, it is noted that frequent intake of fruits with high glycemic index such as pineapple, banana may add on to the blood glucose of patients with diabetes and this may worsen their condition. 5.9 Consistency with Previous Research Diabetes as a condition has been identified to have no permanent cure. However, combinations of pharmacotherapy and non-pharmacotherapy such as dietary changes and lifestyle modifications have proven to control and manage the condition so it does not get worse. From the current study, participants revealed that physical exercise and diet adherence could help to control and manage diabetes. This is almost in line with studies done in Yemen, Hodeidah city. In that study, about 21.0% and 15.0% complied with diet and regular exercise respectively in managing diabetes. Similar studies in Jordan and Kuwait by Shokair N.F (2007), revealed similar results. Participants indicated that, diet and physical exercise recommended, could help in managing diabetes. Furthermore, it was revealed in this study that, socio-demographics: education and religion were the only factors associated with adherence to physical exercise. For example, 61 University of Ghana http://ugspace.ug.edu.gh participants who had secondary/technical education were 99% reduced odds to adhere with physical exercise compared to those who have had basic or primary education. This was not consistent with other studies. Mumu et al, 2015 and Alrahbi, 2014 which revealed otherwise. In their study they found that age distribution of the patients significantly influenced adherence to physical exercise. Another study in Saudi Arabia also found the use of insulin to be significantly associated with diet that contradicts the current study. One reported solution to the non-adherence of an exercise recommendation could be improved empowerment of patients regarding their care. In so much as patient self-efficacy (self-reliance) results in improved adherence to provider recommendations, it seems crucial that health care providers promote a “take responsibility for your diabetes care” mind-set in their patients and formulate an alliance with their patients in their care. 5.10 Strengths and Limitations of the Study This study helped to identify the overall adherence among patients regarding dietary and exercise requirements in the Tema General Hospital in the Greater Accra region of Ghana. The study like most researches is not without limitation. Some participants might have also given false information about themselves to look good. Also, where participants are to recall events of the past, the responses may have been biased. This led to recall bias. 62 University of Ghana http://ugspace.ug.edu.gh CHAPTER SIX CONCLUSION AND RECOMMENDATIONS The chapter gives the conclusions as well as the recommendations. 6.1 CONCLUSIONS The study set out to provide essential empirical data on adherence to diet and exercise regimen among patients with type 2 diabetes, and to test the hypothesis that patients with low SES are at an increased odds of poor adherence at the Tema General Hospital. To achieve this objective, an institutionally based cross-sectional study was conducted among 275 participants. The results from the current study showed that, a lower proportion, that is 22%, of diabetic patients adhere with physical exercise recommendations. However, factors such as educational status and religion of participants were found to influence the chance to adhere with physical exercise recommendations. Vocational trainee had about 99%-reduced odds to adhere with physical exercise recommendations compared to participants with Basic Education. Assessing the proportion of respondents who had sufficient knowledge on the importance of physical exercise and dietary recommendations, this study realized that, 67.8% of the respondents were knowledgeable on the benefits of physical exercise and dietary recommendations in the management of diabetes. Factors that were found to influence the knowledge were gender and ethnicity. The study established that males had 4.3 times increased odds to be knowledgeable on the benefits of exercise and dietary recommendations compared to females. In addition, Hausas were found less likely to be knowledgeable on the benefits associated with physical exercise and dietary modifications in diabetes management. 63 University of Ghana http://ugspace.ug.edu.gh The prevalence of participants who adhered to dietary recommendations was 26.7%. The study also established that participants who are on insulin only were 44timess more likely to adhere to dietary recommendations compared to participants who were on drugs only. Also [articipants who were on drug and dietary therapy were 55times more likely to adhere to dietary recommendations compared to participants who are on drugs only. On participants‟ dietary habits and patterns, this study found that majority of diabetics, that is 96%, had the recommended 3 square meal a day. 52% of these persons had regularized eating times to ensure proper glycemic control in the body. However, most participants did not consume fruits. In conclusion, adherence to diet and exercise was found to differ for each person and it is a combination of several factors. However, it was strongly influenced by the individual‟s views, current circumstance and what they deemed right for themselves. 64 University of Ghana http://ugspace.ug.edu.gh 6.2 RECOMMENDATIONS From the findings gathered from the current study the following recommendations have been drawn. For research Given the limitations of a cross-sectional design this study is only able to generate important hypotheses about factors that could be associated with poor adherence to exercise and dietary regimens among T2D patients; future efforts should employ more rigorous study designs such as prospective cohort or case-control studies to help establish causality. In addition, future studies should be conducted to ascertain the impact of physical exercise and dietary modifications on the long-term management of diabetes. For public health For public health impact there should be an increased awareness campaign to sensitize the public especially patients with diabetes on the need for lifestyle modifications to help reduce the risk of developing diabetes. For policy Pending the completion of studies that use improved study designs, the study has produced some useful data that could potentially influence policy direction regarding management of diabetic patients in Tema. For example, based on the relatively low prevalence of adherence recorded in this study, a diabetes policy could be formulated to ensure that in the management of diabetic patients there is an integration of physical exercise and dietary modifications to ensure adequate management. There could be an inclusion of a diet card and exercise monitoring card to enhance adherence. 65 University of Ghana http://ugspace.ug.edu.gh REFERENCES Abejew, A. A., Belay, A. Z., & Kerie, M. W. (2015). 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Diabetes Research and Clinical Practice, 87(3), 293–301 69 University of Ghana http://ugspace.ug.edu.gh APPENDIX A: QUESTIONNAIRE ADHERENCE TO DIET AND EXERCISE REGIMEN AMONG PATIENTS WITH TYPE 2 DIABETES My name is GRACE DZIFA WORNYOH, a student of the School of Public Health, University of Ghana. I am conducting a research on adherence to diet and exercise regimen among patients with Type 2 diabetes. This forms part of the requirement for the award of a Master of Public Health degree. If you agree to be a part of this study, I would ask you a few questions which require answers. Your participation is voluntary and you are free to end the interview at any time. But I would be very grateful if you participated in the study to contribute to existing knowledge on Type 2 diabetes. Form No…………………. Date ………./……../….. Section 1: Demographic characteristics (Kindly check the appropriate box that corresponds to your answer. Provide response where options are not given) No. Characteristics Category Code 1 Age (in years) ……………………. 2 Height (mm) 3 Weight (kg) 4 Duration of diabetes 1. 1-2 [ ] 2. 3-5 [ ] 3. 6-9 [ ] 4. 10 and above [ ] 5 Sex 1. Female [ ] 2. Male [ ] 6 Marital status 1. Married [ ] 2. Single [ ] 3. Divorced/Separated [ ] 4. Widowed [ ] 7 Education 1. No formal [ ] 2. Basic/Primary/JSS [ ] 3. Vocational/Tech [ ] 4. Secondary/ High school [ ] 5. Tertiary [ ] 8 Place of residence 1. Rural area [ ] 1 University of Ghana http://ugspace.ug.edu.gh 2. Ural area [ ] 9 Employment status 1. Public sector work [ ] 2. Private employee [ ] 3. Self-employed [ ] 4. Unemployed [ ] 5. Student [ ] 6. 6 Retired [ ] Ethnicity 1. Akan [ ] 2. Ga/Adangbe [ ] 1 3. Krobo [ ] 0 4. Ewe [ ] 5. Hausa [ ] 6. Others, specify……. 11 Estimated monthly income 1. Below 500 Ghc [ ] 2. 500-999 Ghc [ ] 3. 1000-1499 Ghc [ ] 4. 1500 and above [ ] Section 2: Medical history of the respondents No. Variables Categories Code 1 Family history of diabetes 1. Yes [ ] 2. No [ ] 2 Other diseases apart from diabetes 1. Hypertension [ ] 2. Heart failure [ ] 3. Kidney problem [ ] 4. Visual problem [ ] 5. Leg ulcer [ ] 3 Duration of illness 1. <1yrs [ ] 2. 1-5 yrs [ ] 3. 6-10 yrs [ ] 4. Above 10 yrs [ ] 4 Glycemic control: HbA1c ………………… 5 Regular blood glucose check-up 1. Yes [ ] 2. No [ ] 2 University of Ghana http://ugspace.ug.edu.gh 6 First knowledge of diabetes 1. Before coming to clinic [ ] 2. During routing medical [ ] 3. checkup During treatment of a disease [ ] 7 Type of treatment 1. Drug only [ ] 2. Drug and diet therapy [ ] 7 Smoking 1. Yes [ ] 2. No [ ] 8 Consume alcohol 1. Yes [ ] 2. No [ ] 9 Follow diet without treatment 1. Yes [ ] 2. No [ ] 10 On tablets 1. Yes [ ] 2. No [ ] 11 On insulin 1. Yes [ ] 2. No [ ] 12 On herbs therapy 1. Yes [ ] 2. No [ ] Section 3: Physical activities adherence No. Items Never Sometimes Always 1 I do my exercises as often as recommended 2 I adjust the way I do my exercises to suit myself 3 I don‟t get around to doing my exercises 4 Other commitments prevent me from doing my exercises 5 I feel confident about doing my exercises 3 University of Ghana http://ugspace.ug.edu.gh 6 I don‟t have time to do my exercises 7 I‟m not sure how to do my exercises 8 I do some, but not all, of my exercises 9 I don‟t do my exercises when I am tired 10 I do less exercise than recommended by my healthcare professional 11 I fit my exercises into my regular routine 12 I do my exercises because I enjoy them 13 I stop doing my exercises when my pain is worse 14 I forget to do my exercises 15 I continue doing my exercises when my pain is better 4 University of Ghana http://ugspace.ug.edu.gh Section 4: Dietary Adherence Instructions: please complete the following questions to reflect your opinions as accurately as possible and to answer factual questions to the best of your knowledge. Please select only one answer for each question. 1 How many meals do you usually eat 1. 1-2 meal [ ] during the day? 2. 3-4 meals [ ] 3. 5-6 meals [ ] 4. Above 6meals [ ] 2 Do you usually eat meals at the same 1. Yes [ ] times? 2. No [ ] 3 What are the most frequent time 1. 3 hours [ ] intervals between meals? 2. 5–6 hours [ ] 3. 3–4 hours [ ] 4. 6 hours [ ] 4 Do you add sugar to hot drinks, such 1. Yes [ ] as tea, cocoa, or coffee? 2. No [ ] 5 What kind of bread do you usually 1. Rye bread, whole grain [ eat? ] 2. White bread, Vienna roll [] 3. I do not eat bread [ ] 5 University of Ghana http://ugspace.ug.edu.gh Dietary Adherence: Food frequency questionnaire for diabetic patients Food frequency questionnaire Never Sometimes Always Protein Beef meat 210g Boneless Chicken 210g Boneless Fish 210g Eggs 50gm Milk all kinds 100ml Grains Rice 120g Bread or loaf (wheat 120g) Bread or loaf (Flour120g) Fruits Apples 120g medium-sized Banana 120g medium-sized Orange 120g medium-sized Mango 120 medium-sized gm Food frequency items Never Sometimes Always Vegetables Tomato (One serving is 250g) Cucumber (One serving is 250g) Eggplant (One serving is 250g) Onions (50 grams per meal) Cabbage (One serving is 250g) Fat Animal fat (fat free) spoon cup 5ml Olive oil cup 5ml Palm oil cup 5ml 6 University of Ghana http://ugspace.ug.edu.gh Section 5: knowledge on the role of diet and exercise in the management of T2D No. Characteristics Category Code 1 Conditions of diabetic patients can be 1. Yes improved by adhering to exercise 2. No 3. Don‟t know 2 Skipping dietary regimen of prescribed 1. Yes may mot help to improve condition 2. No 3. Don‟t know 3 Eating food in large quantity that 1. Yes should be taken in little quantity is 2. No harmful to you 3. Don‟t know 4 Eating foods that one should stop taking 1. Yes because of the disease is harmful to 2. No your condition 3. Don‟t know 5 better general knowledge of dietary and 1. Yes exercise could lead to consistent 2. No modification and awareness for the 3. Don‟t know patient 7 University of Ghana http://ugspace.ug.edu.gh APPENDIX B: INFORMATION SHEETS PARTICIPANT INFORMATION SHEET FOR PATIENTS WITH TYPE 2 DIABETES MELLITUS AT THE TEMA GENERAL HOSPITAL, GREATER ACCRA REGION PROJECT TITLE: ADHERENCE TO DIET AND EXERCISE REGIMEN AMONG PATIENTS WITH TYPE 2 DIABETES AT THE TEMA GENERAL HOSPITAL, GREATER ACCRA INTRODUCTION I am Grace Dzifa Wornyoh, a student of the School of Public Health, University of Ghana. Legon. I am a postgraduate Student of the University of Ghana (UG) reading Masters of Public Health (MPH). I am the principal investigator of this study. BACKGROUND AND PURPOSE OF RESEARCH Diabetes mellitus (DM) is one of the most common chronic diseases in both Western and developing countries. Medication is not the sole method of treating type 2 diabetes mellitus; significant changes to the patient‟s lifestyle with respect to dietary habits and regular physical activity are also required. In fact, lifestyle change is the most challenging and difficult part of the treatment. A study on the adherence, reasons and lifestyle modification factors in diabetes management are essential for the formulation and implementation of appropriate measures to enhance care and support for patients with diabetes. I am here with my research assistants to carry out a study to find the adherence of type 2 diabetes patients to dietary and exercise recommendation. NATURE OF RESEARCH You are being invited to partake in this study. I am interested in finding the adherence among patients with type 2 diabetes regarding dietary and exercise requirements in the Tema General Hospital in the Greater Accra Region of Ghana. 1 University of Ghana http://ugspace.ug.edu.gh PARTICIPANTS’ INVOLVEMENT DURATION /WHAT IS INVOLVED This study will involve taking your clinical information and answering questions on socio- demographic factors and treatment adherence. Should you agree to participate, about 20-30 minutes would be used to ask you some few questions relating to the study. The information you provide will add to knowledge about the treatment behaviors among patients of diabetes. POTENTIAL RISKS Taking part in the study would not affect the quality of care you receive in any way. This research has no risks to you apart from feeling uncomfortable about answering some questions. Any possible risk that may occur in the form of any distress will lead to the respondent‟s participation in the study being ended. Respondents will be given free psychosocial support where the researcher will bear the cost if the need arises. BENEFITS Patients who will participate in the study will have the opportunity to be educated on the importance and benefits of exercises and balance diet in the management of type 2 diabetes. Also, respondents who will need special attention in the course of the study in terms of diet or exercise management will be referred appropriately. The results of the study will help formulate policies that will help improve and support patients living with diabetes to live healthier lives with less risk of complications at Tema General Hospital and the general public. ADDITIONAL COSTS AND COMPENSATION You will not have to spend money in partaking in this study and you will not be compensated for participating. If you agree to participate in the study, you will be asked to fill the questionnaires before or after your medical appointment and in a place at the hospital that is convenient for you. You will only have to spare 20-30 minutes of your time to answer the questions I will ask. 2 University of Ghana http://ugspace.ug.edu.gh CONFIDENTIALITY No name will be recorded. Your name and identity are not needed in the study. However, the information you are going to provide will be coded and will be treated strictly confidential. You are assured of total confidentiality to the information you will give. Apart from the researcher and supervisor of this research, no one else will have access to information provided whether in part or whole. The information that I will collect from this study will be used only for academic purposes. VOLUNTARY PARTICIPATION/WITHDRAWAL Participation in this study is voluntary. You are free to answer part or the entire questionnaire. You can choose to withdraw from the study or stop the interview at any time you want. You can also choose not to answer any question(s) you find uncomfortable about. No one will be coerced to obtain response from you, and you are at liberty to withdraw from the study at any time and it will not affect you in any way. Taking part in the study would not affect the quality of care you receive in any way. OUTCOME AND FEEDBACK Data collected will be stored under lock and key then destroyed after a minimum of three years as per research protocol. No feedback would be given to you. FUNDING INFORMATION This study is a self-sponsored study. SHARING OF PARTICIPANTS INFORMATION/DATA Data from this study solely belong to the principal investigator. Data taken from you would not be shared with anyone. PROVISION OF INFORMATION SHEET AND CONSENT FORMS A copy of the information sheet will be given to you after you have read, understood and 3 University of Ghana http://ugspace.ug.edu.gh signed or thumb printed to take home. WHO TO CONTACT FOR FURTHER CLARIFICATION/QUESTIONS If you have any question(s) or further clarification concerning this study and/or the conduct of the researcher and research assistants, please do not hesitate to contact the following; 1. Miss Grace Dzifa Wornyoh (Principal Investigation): Tel: 0243512963 Email: dzifawornyoh@gmail.com Or 2. Dr Benedict Weobong (Supervisor): Tel: 0200827195 Email: bweobong@ug.edu.gh If you have any concerns or need clarifications regarding ethical issues, please contact Mrs. Hannah Frimpong (Administrator) Ghana Health Service, Ethics Review Committee Secretariat, Accra Tel: 0507041223/0243235 4 University of Ghana http://ugspace.ug.edu.gh APPENDIX C: CONSENT FORM CONSENT FORM FOR PATIENTS WITH TYPE 2 DIABETES AT THE TEMA GENERAL HOSPITAL, GREATER ACCRA REGION. PROJECT TITLE: ADHERENCE TO DIET AND EXERCISE REGIMEN AMONG PATIENTS WITH TYPE 2 DIABETES AT THE TEMA GENERAL HOSPITAL, GREATER ACCRA REGION. PARTICIPANTS‟ STATEMENT I acknowledge that I have read or have had the purpose and contents of the Participants‟ Information Sheet read and that all questions have been satisfactorily explained to me in a language I understand (English /Ewe /GA/ TWI ). I fully understand the contents and any potential implications as well as my right to change my mind (ie withdraw from the research) even after I have signed this form. I voluntarily agree to be part of this research. Name or Initials of Participant……………… ID Code …………………………….. Participants‟ Signature …OR Thumb Print…… OR Mark (Please specify)…………. Date:………………………………… INTERPRETERS‟ STATEMENT I interpreted the purpose and contents of the Participants‟ Information Sheet to the afore named participant to the best of my ability in the (English /Ewe /GA/ TWI ). language to his/her proper understanding. All questions, appropriate clarifications sort by the participant and answers were also duly interpreted to his/her satisfaction. Name of Interpreter…………………………… Signature of Interpreter………………… Date:…………………… Contact Details…………………………… STATEMENT OF WITNESS 1 University of Ghana http://ugspace.ug.edu.gh I was present when the purpose and contents of the Participant Information Sheet was read and explained satisfactorily to the participant in the language he/she understood (English /Ewe /GA/ TWI ). I confirm that he/she was given the opportunity to ask questions/seek clarifications and same were duly answered to his/her satisfaction before voluntarily agreeing to be part of the research. Name:………………………… Signature………. OR Thumb Print …….... OR Mark (please specify)……………….. Date:…………………………… INVESTIGATOR STATEMENT AND SIGNATURE : I certify that the participant has been given ample time to read and learn about the study. All questions and clarifications raised by the participant have been addressed. Researcher‟s name………………………………………. Signature …………………………………………………. Date…………………………………………………………. 2 University of Ghana http://ugspace.ug.edu.gh ETHICAL CLEARANCE 1 University of Ghana http://ugspace.ug.edu.gh 1