UNIVERSITY OF HEALTH AND ALLIED SCIENCES

EFFECTS OF KNOWLEDGE, DIABETES SELF-

MANAGEMENT AND MANAGEMENT SELF-EFFICACY ON
GLYCEMIC CONTROL AMONG PEOPLE WITH TYPE 2
DIABETES IN THE HOHOE MUNICIPALITY

ACHEAMPONGMAA OPPON

UHAS20215042

FRANCISCA KPORMEGBE

UHAS20213141

A PROJECT WORK SUBMITTED TO THE FRED N. BINKA

SCHOOL OF PUBLIC HEALTH, UNIVERSITY OF HEALTH
AND ALLIED SCIENCES, HOHOE, IN PARTIAL
FULFILLMENT OF THE REQUIREMENT FOR THE AWARD
OF BACHELOR OF PUBLIC HEALTH

OCTOBER,2025
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 DECLARATION
Candidates’ Declaration

We hereby declare that this project work is the result of our own original work and that no part
of it has been presented for another degree in this university or elsewhere.

……………………….. ……………………..

Kpormegbe Francisca Date

…………………………. ……………………..

Oppon Acheampongmaa Date

Supervisor’s Declaration

I hereby declare that the preparation and the presentation of the project work were supervised in
accordance with the guidelines on supervision of project work laid down by the University of
Health and Allied Sciences.

………………………… ………………….....

Hubert Amu, PhD Date

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 DEDICATION
We dedicate this work to the Almighty God, thanking Him for His ample grace during our study
and labor completion. All praise and honor for His magnificent deeds on our behalf belong to Him.
We are so grateful, Lord! Thank you to all of our families for your unwavering support, both
material and spiritual, and may the Lord richly reward you all.

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 ACKNOWLEDGEMENT
We are incredibly appreciative to the all-mighty God for sustaining us during this project work.
We also want to express our gratitude to Dr. Hubert Amu, our supervisor, for his guidance,
forbearance, and contribution to the development of this project as a whole. We are very much
grateful. Our final thanks will go out to the teaching assistance, and the Volta Regional Hospital
staffs

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 PROJECT WORK SUMMARY
Background: Type 2 diabetes mellitus (T2DM) is an increasing public health challenge in Ghana,
contributing substantially to morbidity and mortality. In Hohoe Municipality, poor glycemic
control remains common despite management efforts. However, limited studies have examined
how diabetes knowledge, self-management practices, and self-efficacy jointly affect glycemic
outcomes.

Objective: To assess the effects of diabetes knowledge, self-management practices, and

management self-efficacy on glycemic control among people with T2DM in Hohoe Municipality.
Methods: This was a concurrent mixed-methods study conducted among 121 patients attending
the Volta Regional Hospital’s diabetes clinic. Quantitative data were collected using structured
questionnaires adapted from Hurst et al. (2020), while qualitative data were obtained through in-
depth interviews. Quantitative data were analyzed using STATA version 17 with descriptive and
inferential statistics, while qualitative data were analyzed thematically using [Link] version
7.5.7.

Results: We found that 63.6 percent of participants had high diabetes knowledge. About 59 percent
of participants reported consistent self-management practices, including glucose monitoring and
dietary modification. However, 41.3 percent struggled with irregular self-care routines. About 55
percent demonstrated high diabetes self-efficacy. Participants with tertiary education and higher
income were more likely to maintain controlled blood glucose levels than those with lower
education and income. Overall, 43 percent of participants achieved controlled glycemia, while 54
percent remained uncontrolled.
Conclusion: The study highlights that both diabetes knowledge and self-efficacy play crucial roles
in achieving good glycemic control. Strengthening diabetes education, promoting behavioral
support, and improving access to self-management resources especially among low-literacy and
low-income groups are essential to improve diabetes outcomes in the Hohoe Municipality.

Keywords:
Type 2 Diabetes Mellitus; Self-management; Self-efficacy; Glycemic control; Knowledge; Hohoe
Municipality; Ghana

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 TABLE OF CONTENT

DECLARATION i

DEDICATION ii

ACKNOWLEDGEMENT iii

PROJECT WORK SUMMARY iv

TABLE OF CONTENT v

ABBREVIATION viii

LIST OF TABLES ix

LIST OF FIGURES x

1.0 INTRODUCTION 1

1.1 Background 1
1.2 Problem Statement 4
1.3 General Objective 5
1.4 Specific Objective 5
1.5 Justification 5
2.0 LITERATURE REVIEW 7

2.1 Introduction 7
2.2 Empirical Review 7
2.2.1 Level of diabetes knowledge among people with type 2 diabetes. 7
2.2.2 Diabetes self-management practices among people with type 2 diabetes 8
2.2.3 Diabetes management self-efficacy of individuals with type 2 diabetes 9
2.2.4 Effect of diabetes management self-efficacy on glycaemic control in people with type 2 diabetes 10
2.3 Theoretical Review 11
2.3.1 Social Cognitive Theory 11

Figure 2. 1 Theoretical framework of Social cognitive theory (Schunk, 2012) 12

2.3.2 Health Belief Model 14

Figure 2. 2 Theoretical framework Health Belief Model 15

2.3.3 Conceptual Framework 17

3.0 METHODS 19

3.1 Introduction 19

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 3.2 Study Site Description 19
Figure 3. 1 Map of Volta Regional Hospital 20

3.3 Study Design 21

3.4 Study Population 21
3.5 Inclusion and Exclusion Criteria 22
3.5.1 Inclusion Criteria 22
3.5.2 Exclusion Criteria 22

3.6 Sample Size Determination 22

3.6.1 Quantitative sample 22
3.6.2 Qualitative Sample 23

3.7 Sampling Procedure 23

3.7.1 Quantitative Sampling Procedure 23
3.7.2 Qualitative Sampling Procedure 23

3.8 Data Collection Instruments 24

3.8.1 Quantitative Instrument 24
3.8.2 Qualitative Instrument 24
3.9 Data Collection Procedure 24
3.10 Study Variable 25
3.10.1 Outcome Variable 25
3.10.2 Key Explanatory Variables 25
3.10.3 Other Explanatory Variables 25

3.11 Data Analysis 26

3.11.1 Quantitative Data Analysis 26
3.11.2 Qualitative Data Analysis 26

3.12 Ethical Consideration 27

3.12.1 Ethical Approval 27
3.12.2 Informed Consent and Voluntary Participation 27
3.12.3 Confidentiality and Anonymity 27
3.12.4 Potential Risks and Benefits 28
3.12.5 Data storage and usage 28
3.12.6 Dissemination of findings 28
3.12.7 Compensation 28
3.12.8 Conflict of Interest 28
3.13 Work Plan 28

4.0 RESULTS AND DISCUSSION 29

4.1 Introduction 29
4.2 Quantitative Results 29
4.2.1 Socio-Demographic Characteristics of Respondent 29

Table 4. 1 Socio-Demographic Characteristics of Respondents 29

4.2.2 Clinical Characteristics of Respondents 30

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Table 4. 2 Clinical Characteristics of Respondents 31
4.2.3 Knowledge on Type 2 Diabetes 32

Table 4. 3 Level of Knowledge on Type 2 Diabetes 32

Figure 4. 1 Knowledge on T2D 33

4.2.4 Predictors of Knowledge on T2D 33

Table 4. 4 Predictors of Knowledge 34

4.2.5 Diabetes Management Self-Efficacy 36

Table 4. 5 T2D Management Self-efficacy 36

Figure 4. 2 T2D management Self-efficacy 40

Figure 4. 3 Glycemic Levels 40

4.2.6 Glycemic Control and Predictors 41

Table 4. 6 Predictors of Glycemic Control 41

4.3 Discussion 52
4.3.1 Level of Diabetes Knowledge 53
4.3.2. Diabetes Management Self-Efficacy 57
4.3.3. Effect of Self-Efficacy on Glycemic Control 58

4.4 Strengths 59
4.5 Limitations of study 59
5.0 CONCLUSION AND RECOMMENDATION 61

5.1 Conclusion 61
5.2 Recommendation 61
5.2.1 Recommendation for clinical practice and policy 61
5.2.3 Recommendation for future research 62
REFERENCES 63

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 ABBREVIATION
ADA -American Diabetes Association

CDC -Centers for Disease Control and Prevention

DM -Diabetes Mellitus

DSME -Diabetes Self-Management Education

DMSE -Diabetes Management Self-Efficacy

FBS -Fasting Blood Sugar

HbA1c -Glycated Hemoglobin (Hemoglobin A1c)

HBM- Health Belief Model

IDF -International Diabetes Federation

NCBI -National Center for Biotechnology Information

SCT -Social Cognitive Theory

SDGs -Sustainable Development Goals

T2DM -Type 2 Diabetes Mellitus

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 LIST OF TABLES

Table 4. 1 Socio-Demographic Characteristics of Respondents 29

Table 4. 2 Clinical Characteristics of Respondents 31
Table 4. 3 Level of Knowledge on Type 2 Diabetes 32

Table 4. 4 Predictors of Knowledge 34

Table 4. 5 T2D Management Self-efficacy 36

Table 4. 6 Predictors of Glycemic Control 41

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 LIST OF FIGURES

Figure 2. 1 Theoretical framework of Social cognitive theory (Schunk, 2012) 12

Figure 2. 2 Theoretical framework Health Belief Model 15

Figure 2. 3 A conceptual framework on diabetes self-management and management self-efficacy

on glycaemic control Error! Bookmark not defined.

Figure 3. 1 Map of Volta Regional Hospital 20

Figure 4. 1 Knowledge on T2D 33

Figure 4. 2 T2D management Self-efficacy 40

Figure 4. 3 Glycemic Levels 40

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 1.0 INTRODUCTION

1.1 Background

Globally, over 422 million people living with type 2 diabetes mellitus (DM) and every year 1.6

million die (Chekol et al.,2022). DM is a chronic disease characterized by high glucose levels

(hyperglycaemia) due to metabolic disorders that prevent the patient from producing sufficient

amounts of insulin. The disease can be prevented and controlled by engaging in certain behaviours

and lifestyles such as regular exercise, healthy eating patterns, avoiding smoking, and controlling

fat and glucose in the blood (Laksono et al., 2023). In an era where lifestyle choices and dietary

habits are rapidly evolving, Type 2 diabetes mellitus (T2DM) has emerged as a formidable global

health crisis and has affected over 537 million adults worldwide in 2021 (International Diabetes

Federation [IDF], 2021). Type 2 diabetes mellitus is not just a personal health challenge, it

represents a significant economic burden and a pressing public health concern (IDF, 2021). There

is a recommended HbA1c target of less than seven percent for most adults with diabetes (American

Diabetes Association [ADA], 2023). However, achieving optimal glycaemic control remains a

challenge. Studies indicate that only 20 percent of individuals with T2DM achieve this target and

the relationship between diabetes self-management and glycaemic control has been extensively

studied across various populations globally (Al-Qudah et al., 2021; Zheng et al., 2018).

In developed nations, the healthcare infrastructure is generally more advanced, allowing for better

access to diabetes management resources, but challenges remain. For instance, it is estimated that

34.1 million people aged 18 and older in the Unites States of America have diabetes, which equates

to 13 percent of the adult population (CDC, 2023). Despite the availability of structured Diabetes

Self-Management Education (DSME) programs, disparities exist among different population

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groups. It has been shown that only 52 percent of adults with diabetes report receiving any form

of diabetes education, which significantly impacts their ability to follow recommended self-care

practices (CDC, 2023). This lack of education contributes to poor glycemic control indicating that

nearly 25 percent of those who received diabetes education followed at least nine out of ten

recommended self-care practices, compared to just 10 percent among those who did not (CDC,

2023).

In developing countries, the situation is dire. The prevalence of T2DM is rapidly increasing, with

estimates suggesting that the number of affected adults with T2DM will double within the next 25

years (Thomas et al., 2016). Diabetes prevalence in developing countries can reach as high as 8.7

percent, yet many individuals lack access to essential diabetes management resources (Owusu,

2019).

Sub-Saharan Africa faces unique challenges in combating T2DM. The region has a lower overall

prevalence of diagnosed diabetes approximately six percent but an estimated 62 percent of cases

remain undiagnosed (Atun et al., 2017). The number of adults living with diabetes in sub-Saharan

Africa was about 15.5 million in 2017 and is projected to rise (by 162.5%) to 40.7 million by 2045

(Okunlola et al., 2024). The lack of availability of medications and healthcare services means many

patients do not receive timely or appropriate care (National Center for Biotechnology Information

[NCBI], 2017).

In Ghana, the burden of diabetes is substantial and growing. The Ministry of Health reports that

about 54 percent of people living with type 2 diabetes remain undiagnosed and Ghana ranks 6th

among countries with the highest prevalence of type 2 diabetes in Sub Saharan Africa

(International Diabetes Federation [IDF], 2023). The country has initiated several programs to

improve diabetes care. For example, the Access to Type 2 Diabetes Care program launched in

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collaboration with Sanofi aims to enhance awareness and promote early diagnosis through training

for healthcare professionals (IDF, 2023). Despite these efforts, challenges persist due to limited

resources and access to affordable medications.

In Hohoe, a municipality in the Volta Region of Ghana, the burden of Type 2 diabetes mellitus

(T2DM) is increasingly recognized as a significant public health issue. The prevalence of diabetes

in Ghana is reported to be around 8.7 percent with many individuals in Hohoe facing challenges

related to diabetes management due to limited access to healthcare resources and education (WHO,

2023). Despite the potential benefits of DSME, challenges remain. Challenges to diabetes self-

management education (DSME) include high workloads among diabetes educators, a lack of skills

to support behaviour change, insufficient time allocated by patients for participation, financial

constraints, and patients' reluctance to alter unhealthy behaviours or engage with educational

programs (Preechasuk et al., 2019; Yazdani et al., 2021).

The Hohoe Municipal Health Directorate has recognized T2D as a major contributor to outpatient

morbidity, accounting for 3.7 percent and 6.6 percent of cases in 2013 and 2015, respectively

(Fiagbe et al., 2017). Factors such as hypertension, obesity, and lifestyle choices have been

identified as critical risk elements contributing to the high rates of uncontrolled diabetes in the

region. Notably, approximately 78.6 percent of diagnosed individuals were unable to maintain

glycemic control, emphasizing the need for targeted interventions to improve diabetes

management and education within the community (Fiagbe et al., 2017). The relationship between

diabetes knowledge, self-management practices, and management self-efficacy is crucial for

achieving better glycemic control among individuals with T2D in Hohoe. Research suggests that

enhanced diabetes knowledge leads to improved self-management behaviours, which in turn can

positively influence glycemic outcomes (Hurst et al., 2020). In spite of the establishment of a

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diabetic clinic at the Volta Regional Hospital aimed at addressing these issues, it is imperative to

understand how self-efficacy among patients improves the overall management of T2DM and

enhances their quality of life.

1.2 Problem Statement

In Ghana, diabetes has become a major health issue, contributing significantly to morbidity and

mortality (Sarfo-Kantanka et al., 2016). The Ghana Health Service (GHS) reported that

approximately 12.4 percent of hospital admissions in 2021 were related to diabetes complications,

particularly among adults with poorly controlled blood glucose levels (Afaya, 2021). While

existing studies have examined general diabetes awareness and lifestyle interventions, there is

limited research on how the interplay of diabetes knowledge, self-management practices, and self-

efficacy collectively influence glycemic control in specific Ghanaian communities (Agbor &

Naidoo, 2016; Kaveh et al., 2022).

Within the Volta Region, diabetes-related complications account for a growing proportion of

healthcare challenges (Nyavor et al., 2017). In Hohoe Municipality, poor glycemic control is

particularly pronounced (Kwakye, 2020), with 65 percent of patients having uncontrolled blood

glucose levels in similar contexts within the Volta Region (Dorvlo et al., 2024). Despite these

alarming statistics, no localized studies have systematically evaluated the interplay of knowledge,

self-management, and self-efficacy as predictors of glycemic outcomes. A gap that limits tailored

interventions.

Current barriers to diabetes management in Hohoe include inadequate health education, low health

literacy, and cultural practices favouring traditional medicine (Kananzoe, 2016). Prior research in

Ghana has focused on isolated factors such as medication adherence or dietary habits, overlooking

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the effects of psychosocial factors like self-efficacy (Kwakye, 2020; Nyavor et al., 2017). This

study addresses this gap by analysing how these three dimensions interact to shape glycemic

control, providing evidence to design integrated, community-specific management strategies.

1.3 General Objective

This study seeks to assess the effects of knowledge, diabetes self-management, and management

self-efficacy on glycemic control among people with type 2 diabetes in Hohoe municipality

1.4 Specific Objective

To achieve the general objectives, the study seeks to;

1. Determine the level of diabetes knowledge among people with type 2 diabetes in Hohoe

Municipality;

2. Explore the level of Diabetes self-management practices among people with type 2

Diabetes in Hohoe municipality;

3. Examine the Diabetes management self-efficacy of individuals with type 2 diabetes in

Hohoe Municipality;

4. Investigate the effect of diabetes management self-efficacy on glycemic control in people

with type 2 diabetes Hohoe Municipality.

1.5 Justification

This research is justified by the growing burden of diabetes in Hohoe and the urgent need for

targeted interventions to improve diabetes management. Understanding the relationship between

diabetes knowledge, self-efficacy, and glycemic control in this population will provide valuable

insights for designing interventions tailored to the needs of individuals with T2D in Hohoe.

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Furthermore, the findings from this study will be critical for informing policy and healthcare

strategies at both the district and regional levels. By identifying gaps in diabetes knowledge and

management self-efficacy, healthcare providers can develop targeted education programs and

support services to enhance self-management practices and improve glycemic control. This

research also aligns with national and global efforts to reduce the burden of non-communicable

diseases and improve health outcomes for people with diabetes.

In addition, this study will contribute to the existing body of knowledge on diabetes management

in Ghana and Sub-Saharan Africa. It will provide empirical evidence on the impact of self-

management and self-efficacy on glycemic control, offering valuable insights for researchers,

policymakers, and healthcare providers. Given the projected increase in diabetes prevalence in

SSA, particularly in rural and semi-rural areas, the findings from this study could inform future

interventions aimed at reducing the burden of diabetes in similar contexts across the region.

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 2.0 LITERATURE REVIEW
2.1 Introduction

This chapter reviews literature relevant to the study. The review is divided into empirical,

theoretical and conceptual frameworks. The empirical review focuses on the specific objectives of

the study; level of diabetes knowledge among people with type 2 diabetes, the level of Diabetes

self-management practices among people with type 2 Diabetes, the Diabetes management self-

efficacy of individuals with type 2 diabetes and the effect of diabetes management self-efficacy on

glycaemic control in people with type 2 diabetes. The theoretical framework reviews the Social

Cognitive Theory (SCT) and Health Belief Model (HBM) and then adapted as the conceptual

framework.

2.2 Empirical Review

2.2.1 Level of diabetes knowledge among people with type 2 diabetes.

Knowledge about type 2 diabetes and its effects on future management better self-management

practices and improved quality of life for patients. Lifestyle changes and the importance of self-

monitoring and educational intervention are key components when it comes T2DM (Ferreira et al.,

2024). A cross-sectional study by West Bank of Palestine stated that participants who had good

knowledge about their condition and its complications adhere to their medication. Age, education

level and duration of diabetes diagnosis with higher knowledge level enhances self-management.

Increased education on type 2 diabetes improves patient attitudes and practices, ultimately leading

to better glucose control and reduced risk of complications (Shawahna et al., 2021).

Adu et al. (2024) reported that people with moderate level of awareness regarding the organs

affected by type 2 diabetes, including the eyes and kidneys while fewer participants recognized

that the condition could affect the heart. Medications, including insulin and diet as important for

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controlling diabetes, but only a small proportion acknowledged the importance of regular

checkups. A cross-sectional study by (Phoosuwan et al. (2022) showed that an overwhelming

majority of respondents (96.7%) had poor overall diabetes knowledge with specific deficits in

understanding insulin use. The educational attainment and employment status influence higher

diabetes knowledge (Phoosuwan et al. (2022).

2.2.2 Diabetes self-management practices among people with type 2 diabetes

Self-management encompasses a range of activities, including monitoring blood glucose levels,

adhering to medication regimens, maintaining a balanced diet, and engaging in regular physical

activity. Effective self-management helps individuals control their blood glucose levels, reduce

the risk of complications and enhance their overall well-being. The effective self-management

practices are supported by strong social networks which contribute to better glycaemic control.

Social support systems are integral to enhancing self-management behaviours, which are essential

for managing diabetes effectively Adu et al. (2024).

Patients' adherence to self-management behaviours including diet management, physical activity

and regular monitoring of blood glucose levels, directly correlated with improved health outcomes

Afaya (2021). It is necessary for structured self-management education programmes to enhance

patients' skills and confidence in managing their condition. Patients who actively manage their

diabetes tend to experience fewer complications such as cardiovascular diseases, neuropathy and

retinopathy.

Anarfi et al. (2019) in Ghana found that barriers such as limited access to healthcare resources,

lack of education about diabetes management and socio-economic factors were the challenges that

hinder effective self-management practices and contribute to poor health outcomes among

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patients. However, Al-Qudah et al. (2021) suggested that patients who engaged in regular self-care

behaviours, such as adhering to medication regimens and maintaining a balanced diet, exhibited

better glycaemic control. Diabetes patients are responsible for the daily management and control

of their blood glucose to delay and avoid complications (Asante, 2021). They also found that

foods high in whole grains, fruits, vegetables, legumes and nuts, mild alcohol intake, reduced

refined grains, red or refined meats and sugar-sweetened beverages lower the probability of getting

diabetes and improve blood sugar levels as well as blood lipids in patients living with diabetes.

Adherence to physical activity recommendations was relatively low in South Saharan Africa

(Mogre et al., 2017).

Another study reported that persons with type 2 diabetes who performed Self-monitoring of blood

glucose (SMBG) approximately twice a week had low glycaemic level at the end of the month

(Ferreira et al., 2024).

2.2.3 Diabetes management self-efficacy of individuals with type 2 diabetes

Self‐management is important for the proper management of type 2 diabetes, as it is with all

chronic diseases. There is strong evidence that these behaviours can reduce the risk of

complications related to the diseases. Self‐management in type 2 diabetes patients has been proven

to be cost‐effective in the sense that it decreases hospital readmissions and also anticipated quality

and length of lifetime healthcare costs (Adu et al., 2024). Implementing self-management

measures by diabetic patients reduces the likelihood of cardiovascular complications linked to

daily hassles, frustration, emotional distress and low self-commitment as factors that hinder self-

management activities (Mohebi et al., 2018).

Social support which occurs throughout a lifetime and the strength may vary in each stage of the

family life cycle and a specific family. Social support in managing people with type 2 diabetes has

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been extensively assessed concerning supportive and harmful behaviours and the complexity of

how they influence the family system (Koetsenruijter et al., 2016). Social support influences how

and why patients manage diseases. It helps them consider that they can put into effect endorsed

self‐management behaviours and discloses options for coping with obstacles impeding cost‐

effective type 2 diabetes management. Adults with type 2 diabetes who state that they acquired

help with taking medicine, engaging in adequate physical activity cx and seeking health care from

health providers have been revealed to have better health after 7 years (Oh & Ell, 2018).

2.2.4 Effect of diabetes management self-efficacy on glycaemic control in people with type 2

diabetes

The impact of diabetes management self-efficacy on glycaemic control in individuals with type 2

diabetes (T2DM) has garnered significant attention in recent research. Self-efficacy is individual's

belief in their ability to manage their diabetes effectively. Hurst et al. (2020) stated that higher

levels of diabetes management self-efficacy were strongly associated with better blood glucose

control. The study found that, after adjusting for various patient characteristics, diabetes

management self-efficacy remained a significant predictor of glycaemic outcomes. Individuals

with high self-efficacy are more likely to engage in healthy behaviours such as regular blood

glucose monitoring, dietary adherence and consistent medication use which would improve

glycaemic control and lower HbA1c levels among those with higher self-efficacy scores (Amer et

al., 2018).

Lamptey et al. (2023) stated that increased self-efficacy was associated with enhanced self-

management behaviours and improved glycaemic outcomes. This reinforces the notion that

educational interventions focusing on building patients' confidence in managing their condition

can effectively lead to better clinical results.

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2.3 Theoretical Review

This section seeks to review theories and models that are relevant to the concept emanating from

the study. This will help in understanding factors that moderate and mediate diabetes self-

management and its effect on glycaemic control. The study will be guided by two theories. These

are the Social Cognitive theory and the Health Belief Model.

2.3.1 Social Cognitive Theory

The social cognitive theory (SCT) began as the Social Learning Theory (SLT) in the 1960s by

Albert Bandura. It was developed into SCT in 1986 and posits that learning occurs in a social

context with a dynamic and reciprocal interaction (Reciprocal Determinism) between the person,

environment, and behaviour. The individual's behaviour is shaped by the interplay of personal,

behavioural, and environmental factors (Bandura, 1986). The theory is made up of reciprocal

determinism, environment, behaviour, observational learning, expectation, expectancy, self-

efficacy, reinforcement, and behavioural capability.

Outcome expectation and expectancy are the anticipated outcomes that would ensure as a result of

engagement in a suggested behaviour. Self-efficacy is the individual's confidence in their ability

to perform a particular behaviour and reinforcement is the reward that an individual gets from

performing a particular behaviour. It determines whether or not the behaviour will be repeated.

Behavioural capability is the person's actual ability to perform a behaviour through essential

knowledge and skills, while observational learning is modelling, how people learn from others by

observing them (Bandura, 2013).

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 Figure 2. 1 Theoretical framework of Social cognitive theory (Schunk, 2012)
Observational learning is a fundamental concept in SCT, where individuals learn behaviours by

observing others. In the context of diabetes management, patients can benefit from observing peers

or healthcare providers who successfully manage their condition. A study by Kuhlmann et al.

(2021) found that peer support and shared experiences significantly influenced patients' self-

management behaviours. Seeing others effectively manage their diabetes encouraged others that

are newly diagnosed to adopt similar practices, and this enhance their own glycaemic control.

Diabetes education programmes that incorporate role modelling can effectively increase knowledge

and self-management skills. Bandura’s theory suggests that individuals who observe others

achieving health-related goals are more likely to believe in their capacity to achieve similar

outcomes. This has been demonstrated in programmes that utilize trained peer educators to model

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self-management behaviours, resulting in improved patient engagement and glycaemic outcomes

(Al-Qudah, [Link] 2021).

Another tenet of the theory of SCT is Self-efficacy. The confident in individual ability to perform

a behaviour and the belief in one’s ability to execute behaviours necessary to manage health.

Bandura posits that higher self-efficacy leads to greater motivation and persistence in behaviour

change. Anarfi, et al. (2019) stated that individuals with type 2 diabetes who possess higher self-

efficacy are more likely to engage in effective self-management practices, such as regular blood

glucose monitoring and adherence to dietary guidelines. Also, a study by Lorig et al. (2020)

suggested that self-efficacy was a significant predictor of glycaemic control among diabetes

patients. Adherence to self-management behaviours, leads to improved HbA1c levels. The outcome

expectations which are the anticipated results of a behaviour mostly influence individual's

willingness to engage in that behaviour. In diabetes self-management, positive outcome

expectations such as improved health and reduced complications can motivate patients to adopt

healthier behaviours. A study by Afaya et al. (2021) found that individuals who believed that

effective self-management would lead to better health outcomes were more likely to engage in

diabetes self-management practices. This aligns with SCT's assertion that positive expectations can

enhance motivation and commitment to health-related behaviours. A negative outcome expectation

such as fear of failure or perceived difficulty in managing diabetes can hinder engagement in self-

management.

Finally, reciprocal determinism is also a key component in SCT which posits that behaviour

personal factors and environmental influences interact in a continuous loop. Diabetes self-

management has more of individuals’ behaviours are influenced by their knowledge, self-efficacy

and the support they receive from their environment. A supportive healthcare environment that

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promotes education and provides resources enhance self-efficacy and encourage self-management

behaviours (Kuhlmann et al., 2021). Eze et al. (2023) stated that the importance of a supportive

environment in fostering effective diabetes management. Individuals who perceived their

healthcare providers as supportive and accessible reported higher levels of self-efficacy and

engagement in self-management practices leading to better glycaemic control.

2.3.2 Health Belief Model

The Health Belief Model (HBM) is a social psychological theory developed in the 1950s by a

group of social psychologists at the U.S. Public Health Service, notably Irwin M. Rosenstock,

Godfrey M. Hochbaum, S. Stephen Kegeles, and Howard Leventhal. This model emerged at a time

when health authorities were alarmed by the low rates of tuberculosis screening, despite mobile

X-ray units being available in communities (Alyafei & Easton-Carr, 2024). The researchers sought

to understand the reasons behind this lack of engagement with preventive health measures. By

focusing on individuals' perceptions regarding their health and the perceived effectiveness of

health-related actions, the HBM was established to explain and predict health behaviours and

encourage the uptake of health services. The model is based on several key assumptions:

individuals are more likely to take action to manage their health if they believe they are susceptible

to a condition, recognize that the condition has serious consequences, understand that behaviour

change can mitigate the threat, and feel capable of performing the necessary behaviour.

Furthermore, health-related behaviours are influenced by perceived severity, susceptibility,

benefits, barriers, and self-efficacy.

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Figure 2. 2 Theoretical framework Health Belief Model
Source: Green et al. (2020)
Perceived susceptibility refers to an individual's belief about the likelihood of experiencing a health

issue, such as diabetes complications. Individuals who recognize their susceptibility to

complications such as neuropathy or cardiovascular disease are more likely to engage in self-

management behaviours. A study by Afaya et al. (2021) found that participants who acknowledged

their risk of diabetic complications demonstrated greater adherence to self-management practices

including regular blood glucose monitoring and dietary modifications. However, perceived

severity involves beliefs about the seriousness of a health condition and its potential consequences.

The serious implications of uncontrolled blood glucose levels can enhance motivation for self-

management. Lorig et al. (2020) showed that individuals who perceived high severity associated

with diabetes complications were more likely to engage in self-management behaviours. This

relationship suggests that addressing the severity of diabetes-related health risks in educational

interventions can lead to improved glycaemic control.

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Perceived benefits on the other hand refer to an individual's belief in the efficacy of specific actions

to reduce the risk or severity of a health issue. In diabetes self-management, individuals who

believe that effective management practices can lead to better health outcomes are more likely to

engage in these behaviours. Kuhlmann et al. (2021) found that participants who recognized the

benefits of self-monitoring, dietary adherence and regular physical activity experienced improved

glycaemic control. While perceived barriers are the obstacles individuals believe prevent them

from taking action. Common barriers in diabetes management include financial constraints, lack

of knowledge and perceived difficulty in making lifestyle changes. Eze et al. (2023) identified that

individuals who reported fewer barriers to accessing healthcare services and resources were more

likely to engage in self-management behaviours, leading to better glycaemic control.

Cues to action as a tenet of the HBM are external factors that trigger individuals to engage in

health-promoting behaviours. Cues include reminders from healthcare providers, peer support, and

educational resources. Phng et al. (2024) suggested that the importance of structured reminders

and community support in encouraging individuals to monitor their blood glucose levels and

adhere to dietary recommendations.

Finally, self-efficacy is formally not a core component of the original HBM, self-efficacy is

increasingly recognized as a vital factor influencing health behaviour. Self-efficacy is the belief in

one’s ability to successfully perform a behaviour, directly impacts diabetes self-management.

Research has shown that individuals with higher self-efficacy are more likely to engage in effective

self-management practices, leading to improved glycaemic control. Lorig et al. (2020) found that

self-efficacy significantly predicted adherence to diabetes management behaviours, reinforcing the

need for interventions that enhance patients' confidence in their ability to manage their condition.

16
2.3.3 Conceptual Framework

The conceptual framework adapts elements from SCT and HBM to create a comprehensive

understanding of diabetes management. This conceptual framework elucidates the relationships

between diabetes self-management, self-efficacy and glycaemic control and the various factors

that influence these interactions. It serves as a guide for understanding how personal beliefs and

external circumstances impact the ability of individuals to manage their diabetes effectively. The

conceptual framework consists of personal factors, self-efficacy, perceived benefits, perceived

barriers and outcome expectation. The personal factors include key components such as diabetes

knowledge and attitudes toward self-management. A better understanding of the condition,

treatment options and necessary lifestyle changes can empower individuals to take control of their

health. Positive attitudes toward self-management foster motivation and commitment, enabling

individuals to engage more actively in their diabetes care.

Self-efficacy on the other hand is central to successful diabetes management. It refers to an

individual's confidence in their ability to perform tasks related to diabetes care such as monitoring

blood sugar levels regularly, adhering to medication regimens and making dietary changes. Higher

self-efficacy leads to increased engagement in self-management behaviours that will influence

glycaemic control. Perceived benefits of effective diabetes management include the reduction of

blood sugar levels, prevention of long-term complications, improved physical health and potential

cost savings from fewer healthcare visits. When individuals recognize these benefits, they are more

likely to commit to self-management practices. However, the opposite is perceived barriers which

impede effective self-management. Socioeconomic factors such as income and access to

healthcare resources, as well as psychosocial barriers like stress and depression affects an

individual’s ability to manage their diabetes.

17
Outcome expectations further influence diabetes self-management with individuals who believe

that effective management will enhance their quality of life and reduce the risk of complications

are more likely to engage in health-promoting behaviours. Positive expectations motivate

individuals to adhere to self-management practices consistently. Diabetes self-management is the

culmination of knowledge, self-efficacy, perceived benefits and barriers, and outcome

expectations, leading to specific health behaviours such as regular monitoring, dietary adjustments

and medication adherence. The success of these practices directly correlates with glycaemic

control which represents the primary goal of diabetes management. Effective self-management

behaviours are important for achieving optimal blood glucose levels and thereby reducing the risk

of complications and improving overall quality of life.

Figure 2. 3 A conceptual framework on diabetes self-management and management self-

efficacy on glycaemic control

18
 3.0 METHODS
3.1 Introduction

This chapter presents the materials and methods adopted in conducting the study. It describes the

study design, study area, target population, inclusion and exclusion criteria, sample size

determination, sampling procedures, data collection instruments, data collection process,

variables, data analysis, and ethical considerations. The chapter was structured and reported in

accordance with the STROBE (Strengthening the Reporting of Observational Studies in

Epidemiology) guidelines for the quantitative component and the COREQ (Consolidated Criteria

for Reporting Qualitative Research) checklist for the qualitative component to ensure

methodological rigor, transparency, and completeness.

3.2 Study Site Description

The study was conducted at the Volta Regional Hospital (VRH), located in the Hohoe Municipality

of the Volta Region, Ghana. The facility was initially established as a small clinic on April 5, 1935

by Dr. Huppenhaver, the son of a German missionary, and was officially commissioned as a

hospital on December 21, 1952 by Dr. Kwame Nkrumah. It started with 40 beds and 6 cots and

has grown to a capacity of 178 beds and 467 staff. In 2018, it was elevated from a municipal to a

regional hospital, serving as a major referral center for surrounding communities including

Akpafu, Likpe, Alavanyo, Santrokofi, Fodome, Agumatse, and Lolobi.

The hospital provides diverse services, including, including internal medicine, critical care, family

medicine, dentistry and maxillofacial surgery, paediatrics, obstetrics and gynaecology, emergency

and disaster care, radiology, pathology, and telemedicine. It also operates a specialized diabetes

clinic, which serves as the study site for this research. The hospital is geographically situated at

approximately 7.1567 N latitude and 0.47284 E longitude.

19
Quantitative data collection specifically took place within the diabetic clinic, where individuals

living with Type 2 Diabetes Mellitus (T2DM) regularly receive medical care and follow-up

services.

Figure 3. 1 Map of Volta Regional Hospital

SOURCE: Authors Construct, 2025

20
3.3 Study Design

The study employed a concurrent mixed-method, hospital-based cross-sectional design. The

quantitative component examined the effects of diabetes knowledge, self-management, and

management self-efficacy on glycemic control among people with T2DM, while the qualitative

component explored patients lived experiences and self-management practices.

The combination of both quantitative and qualitative methods allowed for triangulation of data,

providing a comprehensive understanding of the relationships and experiences under study. The

qualitative component followed the reflective thematic analysis approach by Braun and Clarke

(2006), situated within a constructivist paradigm that emphasizes participants’ experiences and

interpretations. The interviews were conducted by the principal investigator, a Bachelor of Public

Health candidate at the University of Health and Allied Sciences (UHAS), who had received

formal training in qualitative interviewing and ethical research practice. The researchers had no

supervisory or hierarchical relationship with any of the participants prior to the study, minimizing

potential bias.

3.4 Study Population

The study population comprised adult patients diagnosed with Type 2 Diabetes Mellitus (T2DM)

who were receiving care at the Volta Regional Hospital’s diabetes clinic. For the qualitative

component, participants were the same patients who were purposively selected to provide in-depth

insights into their diabetes self-management experiences.

21
3.5 Inclusion and Exclusion Criteria

3.5.1 Inclusion Criteria

The study included all patients diagnosed with T2DM and registered for care at the diabetic clinic

who were cognitively sound.

3.5.2 Exclusion Criteria

All T2DM patients who were severely ill at the time of data collection were excluded from the

study.

3.6 Sample Size Determination

3.6.1 Quantitative sample

The sample size for this study is determined using the Cochran’s formula (Cochran, 1977). The

formula is described as follow.

𝑍 2×𝑝(1−𝑝)
𝑛𝑜 = e2

n = sample size,

Z = Z-score

p = estimated proportion of an attribute that is present in the population

e = margin of error

(2.567)2 × 0.5(1 − 0.5)

𝑛𝑜 =
(0.10)2

6.589 × 0.25
𝑛𝑜 =
0.01

𝑛𝑜 = 165

22
 𝑛𝑜
𝑛=
(𝑛 − 1)
1 + 0𝑁

165
𝑛=
(165 − 1)
1+
453

165
𝑛=
1.362

n=121

The sample size is 121 participants.

3.6.2 Qualitative Sample

The qualitative sample was determined by data saturation, which occurs when no new information

or themes emerge during interviews (Guest et al., 2006). In this study, saturation was reached after

eight in-depth interviews with T2DM patients, as additional interviews yielded no novel insights.

3.7 Sampling Procedure

3.7.1 Quantitative Sampling Procedure

A simple random sampling technique was used to select participants from the Volta Regional

Hospital’s diabetes clinic. A list of all registered Type 2 diabetes patients (N = 435) was obtained

from the clinic register, and each was assigned a unique identification number. Using the lottery

method, 131 participants were randomly selected to take part in the study. This approach ensured

that every eligible patient had an equal chance of being included in the sample.

3.7.2 Qualitative Sampling Procedure

A purposive sampling technique was employed for the qualitative component. Patients who were

regular attendants at the clinic, articulate, and willing to share their self-management experiences

23
were invited for interviews. Recruitment continued until saturation was achieved. Interviews were

conducted face-to-face in the hospital premises to ensure privacy and confidentiality.

3.8 Data Collection Instruments

3.8.1 Quantitative Instrument

A structured questionnaire was used for data collection. It was adapted from validated instruments

such as the Diabetes Knowledge Scale (Beeney et al.,1994) and the Diabetes Self-Management

Scale (Hurst et al.,2020). The questionnaire had four sections: socio-demographic and clinical

characteristics, knowledge on T2DM, management self-efficacy, and glycemic control

information. The questionnaire was pre-tested among 20 T2DM patients at the Volta Regional

Hospital to ensure clarity, validity, and reliability.

3.8.2 Qualitative Instrument

An in-depth interview guide was used to explore patients’ self-management practices. The guide

included semi-structured, open-ended question grouped into three sections: socio-demographic

characteristics, diabetes background information, and self-management practices. It was reviewed

by a qualitative research expert and pilot tested among two non-participants T2DM patients to

ensure content validity and appropriateness.

3.9 Data Collection Procedure

Data collection was conducted between June and August 2025 at the Volta Regional Hospital

diabetes clinic. The research team comprised the principal investigator and two trained assistants.

Prior to data collection, a one-day training session was held to ensure standardization in

administering questionnaires and conducting interviews.

24
For the quantitative phase, data were collected using Kobo Toolbox v1.27.3 and later exported into

Microsoft Excel and STATA v17.0 for analysis. Participants with limited literacy were assisted

through face-to-face interviewer administration.

For the qualitive phase, the principal investigator conducted all interviews personally interviews

to ensure consistency and depth. Interviews were conducted in English and Twi and were recorded

digitally, and transcribed verbatim within 24 hours of each session.

3.10 Study Variable

3.10.1 Outcome Variable

The primary outcome variable was glycemic control among patients with T2DM. Glycemic control

was measured using fasting blood sugar (FBS), categorized as: controlled: from 4.4 mmol/L to 7.2

mmol/L and uncontrolled: below 4.4mmol/L and above 7.2mmol/L. [American Diabetes

Associates (ADA), 2022]

3.10.2 Key Explanatory Variables

Key explanatory variables included knowledge of diabetes, self-management practices, and self-

efficacy levels. Knowledge was assessed using the 10-item Diabetes Knowledge Scale (Beeney et

al., 1994). Self-efficacy was measured with the Diabetes Management Self-Efficacy Scale, rated

on a 5-point Likert scale (1 = not confident, 5 = totally confident). Higher composite scores

indicated greater self-efficacy.

3.10.3 Other Explanatory Variables

Sociodemographic and clinical covariates included age, sex, marital status, education, income,

religion, ethnicity, duration of diabetes, family history, treatment regimen, alcohol use, smoking

status, and comorbidities.

25
3.11 Data Analysis

3.11.1 Quantitative Data Analysis

Quantitative data were exported from Kobo Toolbox to STATA v17.0 for cleaning and analysis.

Descriptive statistics (frequencies, means, and standard deviations) summarized participant

characteristics. Bivariate analyses such as Chi-square, t-tests, and ANOVA were used to test

associations between explanatory and outcome variables. Multivariable binary logistic regression

was performed to identify independent predictors of glycemic control. Statistical significance was

set at p < 0.05 at 95% confidence interval.

3.11.2 Qualitative Data Analysis

Recordings from the interviews were transcribed and compiled in Microsoft Word files. To reduce

errors, interview transcripts were verified with interview notes and proofread while listening to the

audio recordings. Data was analyzed using Braun and Clarke reflective thematic analysis (Braun

& Clarke, 2006) six-phase reflective thematic analysis. This involved familiarization with the data

through repeated reading, generating initial codes, searching for patterns, reviewing and refining

themes, defining and naming the themes, and finally producing the report. Coding was conducted

by the principal investigator and cross-checked by the supervisor to ensure inter-coder reliability

and confirm the credibility of the coding structure.

A codebook and coding tree were developed iteratively to organize data into codes, subthemes,

and main themes. [Link] v7.5 software was used to facilitate data management and coding.

Sentences, phrases, and words that were relevant were coded, and similar codes were combined

into subthemes and themes as data analysis progressed. Although transcripts were not returned to

participants for comment due to time constraints, findings were validated through peer debriefing

26
and supervisory review to enhance credibility. The themes and subthemes were conveyed in a

manner that precisely reflects the participants' actual experiences. Direct participant quotations

were used in presenting the findings to provide evidence on the issues discussed by the participants.

A frequency table was used to present the socio-demographic characteristics of the study

participants.

3.12 Ethical Consideration

3.12.1 Ethical Approval

Ethical clearance was obtained from the University of Health and Allied Sciences Research Ethics

Committee (UHAS (REC) UHAS-RECA.10 [48]24-25). Permission was also sought from the

Volta Regional Hospital management before data collection.

3.12.2 Informed Consent and Voluntary Participation

All participants were informed about the objectives, procedures, risks, and benefits of the study in

a language they understood best. Written or thumb-printed consent was obtained prior to

participation. Participation was voluntary, and participants could withdraw at any time without

penalty.

3.12.3 Confidentiality and Anonymity

No personal identifiers such as names, phone numbers, or addresses were recorded. Each

participant was assigned a unique code, and data were stored on a password-protected computer

accessible only to the principal investigator. Data collected was used solely for the purposes of

this research, and findings are presented anonymously to protect participants’ identities. This study

received no external funding, and all costs were borne by the principal investigator

27
3.12.4 Potential Risks and Benefits

There were no anticipated physical or psychological risks. Although there were no direct benefits,

the study’s findings are expected to contribute to evidence-based diabetes education and

management strategies within the Hohoe Municipality.

3.12.5 Data storage and usage

All data collected was protected. Access to data was limited to the Principal Investigator and

research supervisor.

3.12.6 Dissemination of findings

The findings of this study were submitted to the Department of Epidemiology and Biostatistics of

the Fred Newton Binka School of Public Health. It was also submitted to the Volta Regional

Hospital and Ghana Health Service at large and published in appropriate journals

3.12.7 Compensation

After completing participation, respondents received a bar of soap as a token of appreciation. This

was not intended to induce participation.

3.12.8 Conflict of Interest

The principal investigators declared no competing interests in relation to this study.

3.13 Work Plan

The research spanned from January to September 2025. Proposal development and ethical

approval occurred between October and December [Link] collection was between May to July

2025, and data analysis and report writing between August and September 2025. The completed

project was submitted to the Fred N. Binka School of Public Health for evaluation.

28
 4.0 RESULTS AND DISCUSSION
4.1 Introduction

This chapter presents the results of this study. The chapter provides a comprehensive result and

discussion based of the study objectives and socio-demographics. Based on our analysis, a detailed

discussion is conducted.

4.2 Quantitative Results

4.2.1 Socio-Demographic Characteristics of Respondent

Table 4.1 represents the socio-demographic characteristics of the study participants. The mean age

of respondent was 61.64, with standard deviation of 10.38. The largest proportion of respondents

were between the ages of 60-69 (37.4%). Majority were females (81.7%), married (64.1%) and

Ewes (77.1%). Christianity was the dominant religion (94.6%). In terms of education, 42.0 percent

had attained JHS/JSS/Middle school education making it the highest in that section. Regarding

occupation, 36.6 percent reported other forms of employment. With income levels 32.0 percent

earning 500-799 cedis, and the same 32 percent earning greater or equal to 1000 cedis.

Table 4. 1 Socio-Demographic Characteristics of Respondents

Variables Frequency (n=131) Percent (%)
Age (Mean/SD) ±61.64
40-49 14 10.6
50-59 42 32.1
60-69 49 37.4
70+ 26 19.9
Sex
Male 24 81.7
Female 107 18.3
Marital status
Married 84 64.1
Unmarried 47 35.9

29
 Income
Less than 500 17 13.0
500-799 42 32.0
800-999 30 23.0
1000+ 42 32.0
Educational level
No formal education 15 11.5
Primary 21 16.0
JHS/JSS/middle 55 42.0
SHS/SSS/O-Level 21 16.0
Tertiary 19 14.5
Religion
Christianity 124 94.6
Islam 7 5.4
Ethnicity
Ewe 101 77.1
Others 30 22.9
Occupation
Employed 36.0 27.5
Unemployed 23.0 17.6
Retired 24.0 18.3
Others 48.0 36.6

4.2.2 Clinical Characteristics of Respondents

Majority of the participants (77.9%), had been diagnosed with type 2 diabetes mellitus (T2DM)

within 1-10 years of our data collection. More than half (55.0%) reported a history of diabetes in

their family. Oral Hypoglycemic Agents (OHA) were the most common treatment (96.9%). In

terms of body mass index (BMI), 55.7 percent were overweight. Smoking was infrequent, with

96.9 percent having never smoked. Alcohol intake was reported by 50.4 percent (37.4% previously

drank). Comorbidities were common, with (61.8%) reporting other health conditions mainly

hypertension followed by ulcer, prostate cancer and combined conditions such as ulcer and

hypertension.

30
Table 4. 2 Clinical Characteristics of Respondents
Variable Frequency Percentage
Duration of T2D
Diagnosis
1-10 102 77.9
11-20 29 22.1
History of T2D
I don’t know 25 19.0
No 43 26.0
Yes 72 55.0
Diabetes treatment
OHA 127 96.9
Insulin 17 13.0
Diet 95 72.5
Exercise 74 56.5
BMI
Normal 25 19.1
Overweight 73 55.7
Obese 33 25.2
Smoking
Never 127 96.9
Previous 4 3.1
Alcohol
Never 65 49.6
Current 17 13.0
Previous 49 37.4
Other disease
No 50 38.2
Yes 81 61.8
Actual disease
Ulcer 1 1.2
Prostate cancer 1 1.2
Hypertension 72 88.9
Ulcer and 5 6.3
Hypertension
Kidney and 1 1.2
hypertension
Hypertension and 1 1.2
Asthma

31
4.2.3 Knowledge on Type 2 Diabetes

Participants demonstrated relatively high knowledge on diabetes management. Most respondents

correctly recognized the importance of exercise in reducing blood glucose (89.3%), regular

glucose monitoring (92.4%), and footcare in diabetes (98.4%). However, 61.1 percent recognized

the increased risk of heart disease among people with T2DM, and 37.4 percent believed

hypertension was not a concern for diabetes management. Additionally, while 81.0 percent agreed

alcohol intake affect blood sugar.

Table 4. 3 Level of Knowledge on Type 2 Diabetes

Variable Frequency Percentage
Eat regular meals and snack
Correct 88 67.2
Incorrect 43 32.8
Exercise reduces blood glucose
Correct 117 89.3
Incorrect 14 4.6
Avoid sugar foods
Correct 97 74.0
Incorrect 34 26
Footcare importance in T2D
Correct 129 98.4
Incorrect 2 1.6
Alcohol intake affects blood sugar
level
Correct 106 81
Incorrect 25 19
Stress raises sugar level
Correct 111 84.7
Incorrect 20 15.3
HBP is not concern for T2D
Correct 49 37.4
Incorrect 82 62.6
Regular glucose check helps T2D
management
Correct 121 92.4
Incorrect 10 7.6

32
 People with T2D have risk of heart
disease
Correct 80 61.1
Incorrect 51 38.9
Healthy weight help manage T2D
Correct 127 97.0
Incorrect 4 3.0

34%

66%

Good knowledge Poor Knowledge

Figure 4. 1 Knowledge on T2D

Figure 4.1 presents the overall knowledge on type 2 diabetes mellitus (T2D). Majority had good

knowledge (65.7%) while 34.3 percent had poor knowledge.

4.2.4 Predictors of Knowledge on T2D

Chi-square analysis showed that only educational level approached statistical significance (χ² =

8.05, p = 0.086). Other variables such as age (p = 0.124), sex (p = 0.074), marital status (p = 0.956),

income (p = 0.607), and occupation (p = 0.231) were not significantly associated with knowledge.

33
Crude regression analysis revealed that participants with JHS education were significantly more

likely to have good knowledge compared to those with no formal education (cOR = 3.69, 95% CI:

1.12–12.13, p = 0.031). Tertiary education also showed higher odds (cOR = 3.20, 95% CI: 0.76–

13.50), but this was not significant. Age ≥70 years was associated with lower odds (cOR = 0.23,

95% CI: 0.05–1.04, p = 0.056), and females had higher odds than males (cOR = 2.24, 95% CI:

0.91–5.51, p = 0.078), though both were not significant.

Table 4. 4 Predictors of Knowledge

Variable Knowledge on T2D Chi-square (P- cOR (95%CI) p-
value) value
Good Poor
Age 6.1033(0.124)
40-49 11(78.60 3(21.4) |Ref
50-59 30(71.4) 12(28.6) 0.68(0.16-
2.88)0.603
60-69 33(67.3) 16(32.7) 0.56(0.13-
2.30)0.424
70+ 12(46.2) 14(53.8) 0.23(0.05-
1.04)0.056
Sex 3.1908(0.074)
Male 12(50.0) 12(50.0) Ref
Female 74(69.2) 33(30.8) 2.24(0.91-
5.51)0.078
Marital status 0.0031(0.956)
Not married 31(66.0) 16(34.0) Ref
Married 55(65.5) 29(34.5) 0.98(0.46-
2.08)0.956
Income 1.9984(0.607)
Less than 500 12(70.6) 5(29.4) Ref
500-799 29(69.1) 13(30.9) 0.93(0.27-
3.20)0.907
800-999 21(70.0) 9(30.0) 0.97(0.26-
3.58)0.966
1000+ 24(57.1) 18(42.9) 0.56(0.17-
1.86)0.341
Educational 8.0538(0.086)
level

34
No formal 7(46.7) 8(53.3) Ref
education
Primary 12(57.1) 9(42.9) 1.53(0.40-
5.78)0.536
JHS/JSS/middle 42(76.4) 13(23.6) 3.69(1.12-
12.13)0.031
SHS/SSS/O- 11(52.4) 10(47.6) 1.26(0.33-
Level 4.75)0.735
Tertiary 14(73.7) 5(26.3) 3.2(0.76-
13.50)0.113
Religion 0.2373(0.691)
Christianity 82(66.1) 42(33.9)
Islam 4(57.1) 3(42.9)
Ethnicity
Ewe 65(64.4) 36(35.6) Ref
Others 1.29(0.54-
3.12)0.568
Occupation 4.2992(0.231)
Employed 24(66.7) 12(33.3) Ref
Unemployed 12(52.2) 11(47.8) 0.55(0.19-
1.59)0.268
Retired 14(58.3) 10(41.7) 0.7(0.24-
2.03)0.512
Others 36(75.0) 12(25.0) 1.50(0.58-
3.88)0.404
Years of 0.645
diagnosis
1-10 68(66.7) 34(33.3) Ref
11-30 18(62.1) 11(37.9) 0.82(0.35-
1.93)0.646
History of T2D 0.921
Yes 47(65.3) 25(34.7) Ref
No 39(66.1) 20(33.9) 1.04(0.50-
2.14)0.921
BMI 0.803
Normal 15(60.0) 10(40.0) Ref

Overweight 49(67.1) 24(32.9) 1.36(0.53-

3.48)0.519
Obesity 22(66.7) 11(33.3) 1.33(0.45-
3.92)0.601
Smoking 0.607

35
 Never 84(66.1) 43(33.9) Ref

Previous 2(50.0) 2(50.0) 0.51(0.07-

3.76)0.510
Alcohol 0.465
Current 10(58.8) 7(41.2) Ref

Never 46(70.8) 19(29.2) 1.69(0.56-

5.11)0.349
Previous 30(61.2) 19(34.4) 1.10(0.36-
3.40)0.861
4.2.5 Diabetes Management Self-Efficacy

Participants reported different levels of confidence in managing their conditions. About 56.5

percent express high confidence (very/totally confidence) in adjusting their diet, while 57.3 percent

reported high confidence in adhering to routine exercise. Medication adherences confidence was

generally strong, with 78.6 percent being very/ totally confident. Confidence was lower in

managing diabetes when stressed (60.3% very/totally confident). Detecting symptoms of hypo and

hyper glycemia showed moderate confidence, with 60.2 percent and 67.2 percent respectfully

reporting very or totally confident. Overall, participants showed higher self-efficacy in treatment

adherence, compared to lifestyle adjustments.

Table 4. 5 T2D Management Self-efficacy

Variable Frequency Percentage
Correct measure of blood
sugar
Not at all confident 11 8.4
Slightly confident 14 10.7
Moderately confident 32 24.4
Very confident 33 25.2
Totally confident 41 31.3
Interpret blood sugar
measure
Not at all confident 8 6.1
Slightly confident 14 10.7

36
Moderately confident 37 28.2
Very confident 53 40.5
Totally confident 19 14.5
Adherence to healthy diet
Not at all confident 5 3.8
Slightly confident 8 6.2
Moderately confident 37 28.2
Very confident 54 41.2
Totally confident 27 20.6
Adjustment of diet
Not at all confident 6 4.6
Slightly confident 12 9.2
Moderately confident 40 30.5
Very confident 68 51.9
Totally confident 5 3.8
Routine exercise
Not at all confident 10 7.6
Slightly confident 6 4.6
Moderately confident 40 30.5
Very confident 53 40.5
Totally confident 22 16.8
Adjust routine exercise
Not at all confident 10 7.6
Slightly confident 15 11.5
Moderately confident 44 33.6
Very confident 50 38.2
Totally confident 12 9.2
Medication adherence
Not at all confident 0 0.0
Slightly confident 8 6.1
Moderately confident 20 15.3
Very confident 46 35.1
Totally confident 57 43.5
Medication adjustment
Not at all confident 3 2.3
Slightly confident 11 8.4
Moderately confident 45 34.4
Very confident 65 49.6
Totally confident 7 5.3
Manage T2D when stressed
Not at all confident 1 0.8
Slightly confident 9 6.9
Moderately confident 42 32.0

37
Very confident 65 49.6
Totally confident 14 10.7
Manage T2D when not
home
Not at all confident 1 0.8
Slightly confident 10 7.6
Moderately confident 39 29.8
Very confident 60 45.8
Totally confident 21 16.0
Prevent blood sugar from
getting high
Not at all confident 1 0.8
Slightly confident 17 12.9
Moderately confident 29 22.1
Very confident 65 49.6
Totally confident 19 14.5
Prevent blood sugar from
getting low
Not at all confident 1 0.8
Slightly confident 12 9.2
Moderately confident 35 26.7
Very confident 70 53.4
Totally confident 13 9.9
Detect symptoms of high
blood sugar
Not at all confident 2 1.5
Slightly confident 17 13.0
Moderately confident 24 18.3
Very confident 64 48.9
Totally confident 24 18.3
Detect symptoms of low
blood sugar
Not at all confident 4 3.1
Slightly confident 21 16.0
Moderately confident 39 29.8
Very confident 55 41.2
Totally confident 13 9.9
Treat mild episode of high
blood sugar
Not at all confident 2 1.5
Slightly confident 16 12.2
Moderately confident 43 33.0
Very confident 63 48.0

38
Totally confident 7 5.3
Treat mild episode of low
blood sugar
Not at all confident 1 0.8
Slightly confident 17 13.0
Moderately confident 51 38.9
Very confident 55 42.0
Totally confident 7 5.3
Get help when T2D is out of
control
Not at all confident 2 1.5
Slightly confident 13 9.9
Moderately confident 36 27.5
Very confident 67 51.2
Totally confident 13 9.9
Discuss T2D with
healthcare provider
Not at all confident 2 1.5
Slightly confident 8 6.1
Moderately confident 31 23.7
Very confident 68 51.9
Totally confident 22 16.8
Get Information about T2D
Not at all confident 2 1.5
Slightly confident 12 9.2
Moderately confident 36 27.5
Very confident 67 51.2
Totally confident 14 10.6
Cope with T2D stress
Not at all confident 1 0.8
Slightly confident 14 10.7
Moderately confident 62 47.3
Very confident 46 35.1
Totally confident 8 6.1

39
 21%

79%

low self-efficacy high self-efficacy

Figure 4. 2 T2D management Self-efficacy

Figure 4.2 represents the levels of management self-efficacy among participants. Majority of the
participants (7.6%) had high self-efficacy while 21.4 percent had low self-efficacy.

60 53.7%
50
42.7%
PERCENTAGE(%)

40
controlled
30 uncontrolled
20

10

0
controlled uncontrolled

Figure 4. 3 Glycemic Levels

This figure represents the control of blood glucose among participants. Overall, most participants

had uncontrolled glycemic levels (57.3%) and the less (42.7%) of the participants had controlled

glycemic levels.

40
4.2.6 Glycemic Control and Predictors

Chi-square analysis revealed that age was significantly associated with glycemic control (p =

0.014). Participants aged 60–69 years were more likely to have controlled glycemia compared to

those in younger age groups. Other socio-demographic factors, including sex (p = 0.427), marital

status (p = 0.411), income (p = 0.109), educational level (p = 0.340), religion (p = 0.698), ethnicity

(p = 0.729), occupation (p = 0.800), and self-efficacy (p = 0.657), showed no statistically

significant associations with glycemic control.

Crude regression analysis (cOR) further indicated that age remained a key predictor of glycemic

control. Respondents aged 60–69 years were significantly less likely to have uncontrolled

glycemia compared to those aged 40–49 years (cOR = 0.13, 95% CI: 0.03–0.62, p = 0.011).

Although respondents aged 70 years and above also had lower odds of uncontrolled glycemia (cOR

= 0.19, 95% CI: 0.04–1.05, p = 0.057), this association did not reach statistical significance. No

other variable showed a significant crude association.

Table 4. 6 Predictors of Glycemic Control

Variable Glycemic level Chi-square cOR (95%CI) p-

(P-value) value
Controlled Uncontrolled
Age 0.014
(Mean/SD)
40-49 2(14.3) 12(85.7) Ref
50-59 14(33.3) 28(66.7) 0.33(0.07-
1.69)0.186
60-69 28(57.1) 21(42.9) 0.13(0.03-
0.62)0.011
70+ 12(46.2) 14(53.8) 0.19(0.04-
1.05)0.057
Sex 0.427
Male 12(50.0) 12(50.0) Ref

41
Female 44(41.1) 63(58.9) 1.43(0.59-
3.48)0.428
Marital status 0.411
Married 38(45.2) 46(54.8) Ref
Not married 18(38.3) 29(61.7) 0.75(0.38-
1.56)0.442
Income 0.109
Less than 500 7(41.2) 10(58.8) Ref
500-799 13(30.9) 29(69.1) 1.56(0.49-
5.01)0.454
800-999 12(40.0) 18(60.0) 1.05(0.31-
3.52)0.937
1000+ 24(57.1) 18(42.9) 0.53(0.17-
1.65)0.269
Educational 0.340
level
No formal 5(33.3) 10(66.7) Ref
education
Primary 8(38.1) 13(61.9) 0.81(0.20-
3.26)0.769
JHS/JSS/middle 21(38.2) 34(61.8) 0.81(0.24-
2.69)0.731
SHS/SSS/O- 10(47.6) 11(52.4) 0.55(0.14-
Level 2.17)0.394
Tertiary 12(63.2) 7(38.8) 0.29(0.07-
1.29)0.089
Religion 0.698
Christianity 54(43.6) 70(56.4) Ref
Islam 2(28.6) 5(71.4) 1.93(0.36-
10.33)0.443
Ethnicity 0.729
Ewe 44(43.6) 57(56.4) Ref
Others 12(40.0) 18(60.0) 1.16(0.51-
2.65)0.729
Occupation 0.800
Employed 17(47.2) 19(52.7) Ref
Unemployed 11(47.2) 12(52.2) 0.98(0.34-
2.78)0.964
Retired 9(37.5) 15(65.5) 1.49(0.52-
4.28)0.457
Others 19(39.6) 29(60.40) 1.37(0.57-
3.27)0.484
Self-efficacy 0.657

42
 High self- 43(41.7) 60(58.3) Ref
efficacy
Low self- 13(46.4) 15(53.6) 0.83(0.36-
efficacy 1.91)0.657

Qualitative Results

Table 4.7 presents the socio-demographic characteristics of respondents. Majority of the

respondents were with the ages of 50-59 and above 70 (40%). Most of the respondents (70%) have

attained Junior High school Education. In terms of sex, 60 percent were females. Most of the

respondents were (80%) were married and belonged predominantly to the Christian religion (80%).

Regarding occupation, most of the respondents were artisans (40%). Most of the respondents

(60%) had lived 1-10 years with T2DM.

Table 4.7: Socio-Demographic Characteristics

Socio Demographic Frequency Percentage
Age
50-59 4 40.0
60-69 2 20.0
70+ 4 40.0
Sex
Male 4 40.0
Female 6 60.0
Religion
Christianity 8 80.0
Islam 2 20.0
Educational Level
Junior High School 1 10.0
Senior High School 7 70.0

43
 Tertiary 2 20.0
Marital Status
Married 8 80.0
Not married 2 20.0
Occupation
Unemployed 1 10.0
Public servants 2 20.0
Pensioner 3 30.0
Artisan 4 40.0
Duration of Diagnosis (In
years)
1-10 6 60.0
11-20 3 30.0
Above 20 1 10.0

Table 4.8 presents the themes from our analysis. These were understanding of diabetes,

management practices, challenges and perspective of diabetes management.

44
Table 4.8: Main Findings
Theme Sub-theme frequency
Understanding Perspective on T2D

• High sugar in the blood 6

• Effect of aging on the body 1

• Insufficient insulin 1

• Lifestyle disease 1

Effects of living with T2D

• Anemia 1

• Body aches 6

• Weakness 2

Comorbidity

• Duodenal ulcer 1

• Hypertension 5

• No disease 3

Management Practices Lifestyle changes

• Avoid sugary food 9

• Exercise 5

• Avoid alcohol 10

• Taking medication 9

Tracking blood sugar levels

• Check weekly at pharmacy 2

• Using a person glucometer 6

• Hospital visit 4

Motivation to self-manage

• Social support 1

• My work 1

45
 • Education at hospital 2

• Live long 5

Challenges Physical challenges

• Body pains 1

• Diet challenges 3

• Inability to exercise 1

• Inability to take medicine 1

• Reduced appetite 1

• Unable to rest 1

• No challenges 3

Perspective on diabetes Recommendation

management

• Adhering to treatment 8

• Maintaining blood sugar level 1

Understanding Type 2 Diabetes Mellitus (T2DM)

From the perspective of patients living with Type 2 Diabetes Mellitus (T2DM), understanding

what the condition entails was significant. Three sub-themes emerged under this main theme:

perspectives on T2DM, which captures how participants define the condition; effects of living with

T2DM, which highlight the physical and emotional consequences of the disease; and comorbidity,

which discusses the coexistence of other health conditions alongside diabetes. Regarding their

perspectives on T2DM, most participants described it as a condition characterized by high sugar

levels in the blood. A few attributed it to aging, while others demonstrated a deeper biomedical

awareness, linking it to insufficient insulin or unhealthy lifestyle habits such as poor diet and

inactivity. Overall, participants’ perspectives ranged from symptom-based explanations to broader

46
biomedical and behavioral understandings, underscoring the need for ongoing diabetes education

to strengthen knowledge and self-management. A 56-year-old- client for instance said,

“I understand diabetes as there being high sugar in my blood and not enough

insulin to break it down”. Another client said: “I think it comes because of age. As

you grow your body becomes weak and cannot function well, and the diseases set

in” (male, 71 years)

Under the sub-theme effects of living with T2D participants described a range of physical

experiences and challenges associated with living with diabetes. Anemia, weakness, and body

aches were the most commonly reported effects. Many participants spoke about persistent body

pain and fatigue that interfered with their ability to perform daily tasks, often attributing these

symptoms to poor blood sugar control or long-term complications of the disease. A few

participants also mentioned experiences of anemia, which they linked to poor nutrition or dietary

restrictions. Living with T2D was perceived as physically demanding and exhausting, affecting

participants’ energy levels, productivity, and general well-being. A client said:

“Sometimes my whole-body aches and I cannot do my daily work. The work I do is

already tiring because I help people who cannot see or hear, and I have to move

around a lot. But with diabetes, it has become worse. By the end of the day, my body

feels weak, and sometimes I have to lie down before I can even cook or do anything

at home. The body pains come often, and there are days I feel I just don’t have the

strength to go to work. Even when I want to rest, I keep thinking about those I take

care of, so it is not easy at all.” (female, 60 years)

47
Comorbidity, another sub-theme, explores the presence of additional health conditions occurring

alongside Type 2 Diabetes among participants. The most frequently reported coexisting condition

was hypertension, reflecting the well-documented link between diabetes and cardiovascular

diseases. A few participants also mentioned having duodenal ulcers, while others indicated they

were not diagnosed with any additional illness. Overall, the presence of comorbid conditions

among participants underscores the complexity of diabetes management and emphasizes the need

for integrated, patient-centered care approaches that address both diabetes and its related

complications in a coordinated manner. One client said,

“apart from sugar problem, I also have hypertension” the two makes it difficult for

me to cope” (male,72 years) and another client said “I was told I had diabetes, but

later I also got hypertension”, the medicines are many and it worries me” (female,

59)

4.4 Management Practices among People Living with Type 2 Diabetes Mellitus

This main theme explores three major sub-themes, which are, how participants manage their

condition through lifestyle modifications, medication adherence, blood sugar monitoring, and

sources of motivation that sustain self-management. Under the first sub-theme lifestyle changes,

participants emphasized avoiding sugary foods, taking prescribed medications, exercising, and

abstaining from alcohol as the main strategies for controlling their condition. Almost all

participants recognized the importance of diet control and medication adherence in maintaining

stable blood glucose levels. A 61-year-old female said, “Now I take my drugs and avoid sugary

foods I used to enjoy. I also try to do some walking.” Another participant shared:

48
 “since I got the condition, I make sure I don’t take anything with sugar, and I take

my drugs every morning and evening as the doctor said and I have managed to stop

taking alcohol although stopping was very difficult for me but for the sake of my

health, I had to learn to stop taking it.” (Respondent 4, Male, 58 years)

The sub-theme tracking blood sugar levels highlighted participants’ use of different methods to

monitor their glucose levels. Some checked their sugar weekly at nearby pharmacies, others relied

on personal glucometers, while a few depended solely on hospital visits during review

appointments. Participants who owned glucometers expressed greater confidence in managing

their condition as it allowed them to detect fluctuations early and adjust accordingly. Some

respondents shared:

“I check my sugar every week at the pharmacy near my house because I don’t have

a machine of my own. The pharmacist knows me, so anytime I go, he checks it and

tells me if it’s high or low. Sometimes, when it’s high, I get worried and try to be

more careful with what I eat. But the problem is that I can’t always go there if I

don’t have money, so I just wait until my hospital appointment. I wish I could get

my own glucometer so I could check it anytime I feel unwell.” (Female, 63 years).

“I have my own glucometer at home, so I check my sugar every morning before I

eat. When I see that the level is high, I try to walk more and avoid eating late. It

helps me to manage myself before going to the hospital. The nurses always ask me

about my readings, so I record them in a small book. I feel more in control when I

know my sugar level.” (Male, 57 years).

49
Motivation to manage self-manage explores the personal and social factors that drive participants

to consistently manage their condition. Participants identified multiple sources of motivation,

including family support, health education received at the hospital, work responsibilities, and a

strong personal desire to “live long.” These motivators served as both emotional and practical

reinforcement, helping individuals remain committed to medication adherence, dietary control,

and regular monitoring. Family encouragement and education from healthcare providers were

particularly influential, as they helped participants understand the importance of maintaining

stability and preventing complications. One woman noted:

“I want to live long for my children, so I try to follow the advice and take my

medicine. You know, they are all grown but still depend on me in many ways. I don’t

want to become a burden or have them worrying about me all the time. Sometimes

it’s not easy there are days I feel tired or forget to eat properly but when I think of

them, I remind myself that I have to take care of my health. I take my medicine every

day and go for my reviews because I want to be there for them for as long as I can.”

(Female, 70 years)

Challenges

Challenges were another major theme which emerged. It talked about the various difficulties faced

by participants in managing Type 2 Diabetes Mellitus (T2DM). Many participants reported

physical challenges as the major sub-theme, they emphasized persistent body pains, fatigue, and

reduced appetite, which often interfered with their ability to engage in daily activities or maintain

consistent self-care routines. Dietary restrictions were another major concern, as participants found

it difficult to avoid certain foods they were accustomed to, especially in social or household

settings. Additionally, some mentioned struggles with taking medications regularly or maintaining

50
exercise routines due to tiredness, busy schedules, or lack of motivation. Some participants also

noted challenges with taking medicines consistently, either due to side effects or forgetfulness.

Some respondents reported that:

“Food is the most difficult aspect for me. I live with my sister and her children, and

since I’m not working, I depend on whatever she cooks. Sometimes I tell her that

some of the foods she makes are not good for my condition, but she says that’s all

she can afford. I feel bad because I know what I’m supposed to eat, but I don’t

always have a choice. Even though the nurses advise me to stick to my diet, it’s hard

when you rely on someone else and there’s no money to buy the right food”

(Female, age 55),

“I try to take my medicine every day because I don’t want my sugar level to rise,

but sometimes it makes me feel sick. The smell alone puts me off, and after taking

it, I start feeling dizzy and sometimes feel like vomiting. It discourages me, but I

still try because I know it’s important. Sometimes I even skip a dose when I can’t

stand the side effects, but I know that’s not good for me.” (male, 48 years)

Perspective on Diabetes Management

Under this main theme, participants shared their views on how diabetes should be managed and

what they considered effective in maintaining good health. The majority believed that strict

adherence to treatment particularly consistent medication use, regular monitoring of blood sugar

levels, and following medical advice was key to preventing complications and maintaining

stability. Many participants viewed diabetes management as a personal responsibility that requires

51
discipline, self-control, and continuous effort. For them, proper management was not only about

controlling blood sugar but also about sustaining energy and avoiding hospital admissions. A few

participants emphasized the importance of maintaining stable blood sugar levels through a

combination of lifestyle changes and medical care. They expressed the view that diabetes

management must become part of one’s daily routine, not something to be taken lightly or done

occasionally. Some participants shared:

“If you don't take your medication, your blood sugar may rise, which will also

impair your kidneys. You might have to pay a lot of money for therapy, or you might

even die. Therefore, the only option is to heed the doctors’ advice”. (male, 62 years)

“For me, managing diabetes means doing what the doctors say eating well,

checking my sugar, and taking my drugs. I just want to keep my blood sugar level

steady so that I don’t get complications. I make sure I take my medicine on time and

go for check-ups because if I don’t, the sugar will rise and I’ll suffer” (male, 58

years)

4.3 Discussion

This study examined the effects of diabetes knowledge, self-management practices, and

management self-efficacy on glycaemic control among people with type 2 diabetes mellitus

(T2DM) in the Hohoe Municipality. Its specifically explored how patients’ understanding of the

disease, their confidence in managing it, and their actual self-care behaviours influenced their

ability to maintain good blood glucose control. The findings provide important insights into the

level of diabetes literacy and behavioural engagement among people living with T2DM in Hohoe

52
Municipality. Understanding these factors is important, as diabetes management is highly

dependent on patient involvement, knowledge, and regular adherence to lifestyle and treatment.

4.3.1 Level of Diabetes Knowledge

Findings from this study showed that overall, participants presented relatively high knowledge of

T2DM management. Most respondents knew about the significance of regular physical exercise,

monitoring blood glucose levels, and proper footcare in preventing complications. This shows a

positive outcome of ongoing public health sensitization and health education initiatives within

healthcare facilities in the municipality.

However, notable gaps existed in participants’ understanding of the long-term complications of

diabetes, particularly those related to cardiovascular disease and hypertension. About 37.4 percent

of respondents believed that hypertension was not a concern in diabetes management, and only

61.1 percent were aware of the increased risk of heart disease associated with T2DM. This finding

suggests that while routine management practices are understood, awareness of the systemic risk

and chronic complications remain limited.

Findings from this study correspond with previous studies that found gaps in knowledge among

people with diabetes, particularly regarding long-term complications (Phoosuwan et al., 2022).

Education level was significantly associated with knowledge, with those attaining at least middle

school education demonstrating better knowledge. A study reported similar results in Palestine,

where higher education was linked to better diabetes awareness and improved adherence to self-

care practices (Shawahna et al., 2021). This emphasizes the role of health education in determining

health outcomes.

53
In current study, educational level significantly influenced knowledge scores, as participants with

at least middle school education displayed higher understanding of diabetes management then

those with no formal education. This relationship underscores the importance of health education

and literacy in enabling patients to interpret medical advice and make informed decisions regarding

self-care.

The findings therefore highlight the need for continuous health education programs targeting

individuals with lower educational backgrounds. Directing diabetes education to address specific

knowledge gaps, especially regarding complications, could strengthen patients’ ability to manage

their condition effectively and reduce the incidence of comorbidities such as hypertension and

cardiovascular disease.

Explore The Level of Diabetes Self-Management Practices Among People with Type 2

Diabetes

This study was conducted to assess the effects of knowledge, diabetes self-management,

management self-efficacy on glycemic control among people with type 2 diabetes in the Hohoe

municipality. The findings indicate that participants at the Hohoe diabetic clinic employed diverse

strategies to manage their Type 2 Diabetes Mellitus (T2DM). These practices include lifestyle

modifications such as avoiding sugary foods, exercise, avoiding alcohol and taking medications,

tracking blood sugar levels through weekly checks, checking during hospital visits, checking at

the pharmacy, using personal glucometer at home. Clients also feel motivated through education

they get from the hospital, social support, and their work. Despite these efforts they face physical

challenge such as body pains, diet, inability to exercise, inability to take medicines, and inability

to rest, which affect the effective of their practice to manage their condition. These findings show

54
that diabetes management in Ghana is a dynamic and ongoing process shaped by the interaction

of individual, social, and systemic factors.

The study's findings are in line with earlier studies carried out in Ghana and other low-and middle-

income countries (LMICs), which highlight the significance of self-management as a crucial

element of diabetes control. Similar to this study, Tabong et al. (2018) found that diabetes patients

mostly depend on self-directed lifestyle modifications and unofficial social networks to control

their blood sugar levels. Similarly, Sarkodie, P. (2019) pointed out that socioeconomic stability,

access to healthcare, and patients' comprehension of the condition all affect their capacity to

properly treat type 2 diabetes.

However, this study extends the existing literature by showing that even when people know enough

about diabetes, economic and structural barriers still limit management outcomes. These findings

corroborate those of Anarfi et al. (2019), who found that the cost and lack of access to necessary

medical supplies are the main obstacles to long-term disease control. Participants in this study

mostly followed hospital-prescribed medication and lifestyle changes, suggesting a shift toward

biomedical management, in contrast to Amoah et al. (2018), who noted that some Ghanaian

patients rely on herbal medicines and spiritual healing as part of diabetes care.

The significant role of family and social support found in this study further mirrors Boateng et al.

(2020), who demonstrated that supportive relationships strengthen adherence and improve

emotional well-being among diabetic patients. Collectively, these parallels highlight that effective

diabetes management depends not only on patient knowledge but also on the availability of

supportive social and healthcare systems that facilitate continuous care. This study observed that

education affects diabetes, with those attaining at least middle school demonstrating better

55
knowledge, this substantiate the findings with Zowger et al. (2018), who found that the level of

education to be affecting diabetes knowledge, with university levels getting higher scores

The knowledge findings correspond strongly with the Health Belief Model (HBM) and Social

Cognitive Theory (SCT), which serve as the foundation for this investigation. According to the

SCT, the interplay of behavioral, contextual, and personal elements shapes behavior (Bandura,

2004; Shigaki et al.,2010). This was demonstrated by the participants' self-efficacy; those who had

faith in their ability to control their condition regularly followed their medication and food

regimens, frequently with encouragement from family members and medical professionals.

However, this self-efficacy declined in situations when there were environmental obstacles like

poverty or difficulty taking medication, and inadequate family support leading to uneven

management techniques Mogre et al, (2019). This study highlights the need to organize diabetes

education sessions not just for patients but also for family members so they can understand how

to support in terms of healthy meals, medication routines, and emotional well-being.

Similarly, the HBM highlights that people's health behaviors are influenced by their perception of

the severity and susceptibility of disease, perceived benefits, and perceived barriers to taking action

(Rosenstock et al., 1988; Glanz et al., 2015). Participants were more dedicated to receiving medical

care and routine monitoring if they believed that diabetes was a serious illness. On the other hand,

adherence was deterred by perceived barriers like expense, adverse drug reactions, and food

restrictions, among others. Overall, the study shows that behavioral and cognitive elements like

motivation, belief, and knowledge have a major impact on diabetes control, supporting both the

conceptual framework that underpins this study. These must, however, function within a structure

of support that minimize external barriers to care. Therefore, both structural intervention and

personal empowerment are necessary for effective management.

56
4.3.2. Diabetes Management Self-Efficacy

The study found variations in participants’ confidence levels across different aspects of diabetes

management. Many respondents exhibited high self-efficacy in adhering to medication schedules

and recognizing symptoms of hypo- and hyperglycemia. However, fewer participants expressed

strong confidence in adapting management routines during stressful situations or when away from

home.

This finding suggests that while participants may be confident in performing routine diabetes tasks,

situational and psychosocial factors can undermine their ability to consistently manage the

condition. The results are supported by Social Cognitive Theory (Bandura, 2023), which

emphasizes self-efficacy as a central determinant of behavior change. When individuals believe in

their capacity to perform specific health behaviors, they are more likely to initiate and maintain

those behaviors.

Previous studies have also established that higher self-efficacy is strongly associated with

improved adherence and glycemic control. Hurst et al. (2020) and Lamptey et al. (2023) reported

that patients with strong self-efficacy are more consistent in taking medications, engaging in

physical activity, and following dietary recommendations, leading to better metabolic outcomes.

The present findings suggest that interventions aimed at enhancing self-efficacy, such as peer

support programs, psychosocial counseling, and role modeling, could help improve diabetes

control in the Hohoe Municipality. Empowering patients to manage stress, plan ahead, and

maintain self-care even outside structured environments may bridge the gap between knowledge

and consistent behavioral action.

57
4.3.3. Effect of Self-Efficacy on Glycemic Control

Although the study did not directly measure HbA1c levels, the relationship between self-efficacy

and glycemic outcomes was evident. Participants with higher self-efficacy demonstrated better

engagement in self-care activities such as dietary control, exercise, and medication adherence. This

finding aligns with Aseela et al. (2024), who confirmed that higher self-efficacy predicts better

glycemic control among individuals with T2DM.

Conversely, participants with low confidence in managing stress or adapting to environmental

changes were more likely to report poor management outcomes, such as obesity and comorbid

hypertension. This suggests that psychosocial limitations can directly and indirectly influence

physical health outcomes.

These findings can also be interpreted through the Health Belief Model (HBM), which posits that

individuals’ perceptions of susceptibility and severity shape their health behaviors. In this study,

while most participants recognized the importance of diet and exercise, many underestimated the

cardiovascular risks associated with diabetes. This misperception likely reduced their motivation

to fully engage in preventive practices.

Therefore, promoting self-efficacy-building interventions alongside correcting risk perceptions

could improve overall diabetes outcomes. Community-based education, group counseling, and

continuous follow-up through healthcare facilities can help sustain behavioral changes and

promote glycemic control among people living with T2DM in the Hohoe Municipality.

58
4.4 Strengths

The study employed both quantitative and qualitative methods, allowing for a comprehensive

understanding of diabetes knowledge, self-management, and self-efficacy. This triangulation

strengthens the validity of findings

The research focused on the Hohoe Municipality, providing localized evidence on T2DM

management in a semi-urban Ghanaian setting. This is valuable for designing interventions tailored

to the socio-cultural realities of the population.

With over 130 participants included in the analysis, the study provides sufficient statistical power

to identify associations between socio-demographic factors, knowledge, and self-efficacy.

Data collection relied on structured questionnaires adapted from established instruments, ensuring

reliability and comparability of results with other studies.

By examining not only clinical factors but also knowledge and self-efficacy, the study provides

deeper insights into behavioural and psychological influences on diabetes management, which are

often overlooked in biomedical studies in Sub-Saharan Africa.

4.5 Limitations of study

A key limitation of the study was the absence of direct biomedical measurements, as the

assessment of knowledge was not complemented by consistent use of objectives indicators such

as HbA1c levels across participants, thereby constraining the ability to provide robust evidence of

actual glycaemic control outcomes.

Key variables such as self-management practices and self-efficacy were measured through self-

reports, which may be subject to recall bias and social desirability bias.

59
The study was conducted in a single municipality (Hohoe) and within one health facility, which

may limit the applicability of the findings to other regions of Ghana or Sub-Saharan Africa with

different socio-cultural contexts.

Participants were recruited from a hospital-based diabetic clinic, which may exclude individuals

with T2DM in the community who are undiagnosed or not accessing formal healthcare. This could

lead to overestimation of knowledge levels compared to the wider population.

60
 5.0 CONCLUSION AND RECOMMENDATION

5.1 Conclusion

The study concludes that individuals living with Type 2 Diabetes Mellitus in Ghana demonstrate

commendable efforts in managing their condition through lifestyle modifications, medication adherence,

and social support. These behaviors are primarily driven by self-efficacy, perceived benefits, and

motivation to maintain health. However, persistent challenges such as financial hardship, physical

weakness, and limited access to healthcare resources undermine these efforts. The findings reveal that

while patients possess substantial knowledge about diabetes management, the success of their practices

largely depends on the supportiveness of their social environment and the responsiveness of the

healthcare system.

Grounded in the Social Cognitive Theory and Health Belief Model, this study establishes that sustained

diabetes management requires not only individual willpower but also an enabling environment that

addresses economic and structural barriers. Strengthening patient education, improving healthcare

access, and reinforcing community support systems are therefore critical for improving diabetes

outcomes and preventing complications in Ghana and other LMICs.

5.2 Recommendation

5.2.1 Recommendation for clinical practice and policy

1. The Hohoe Municipal Health Directorate in collaboration with the VRH Diabetes Clinics should

organize community-based awareness campaigns that include caregivers.

2. The diabetic clinic at the VRH should supportive follow-up systems, including home visits and

community health volunteers to reinforce adherence.

61
3. The VRH should conduct screening for middle-aged individuals at risk of diabetes to encourage early

detection and management.

5.2.3 Recommendation for future research

1. Future research should employ randomized controlled trials to compare the effectiveness of

standard diabetes self-management education (DSME) programs with tailored interventions specifically

designed to enhance diabetes management self-efficacy (DMSE).

2. The study should be expanded with a larger sample size across a wider geographic area to examine

whether notable demographic differences exist in the relationship between diabetes management self-

efficacy (DMSE) and HbA1c levels across various age groups, genders, and socio-economic categories.

62
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