Factors Associated With Diabetes Self-Care Performance in Indonesians With Type 2 Diabetes: A Cross-Sectional Study

ABSTRACT Background In Indonesia, the number of Type 2 diabetes cases is increasing rapidly, making it the third leading cause of death and among the leading noncommunicable disease healthcare expenditures in the country. Thus, there is a critical need for Indonesians with Type 2 diabetes to perform better self-care to optimize their health and prevent the onset of comorbidities. Purpose This study was designed to investigate the influence of knowledge, depression, and perceived barriers on Type 2 diabetes self-care performance in Indonesia. Methods A cross-sectional study was conducted on 185 patients with Type 2 diabetes, with demographic, diabetes history, obesity status, diabetes knowledge, depression, perceived barriers, and self-care performance data collected. The Indonesian version of the Revised Diabetes Knowledge Test, Depression Anxiety Stress Scale, Perceived Barrier Questionnaire and Self-Care Inventory-Revised were used. Descriptive, bivariate, and multiple linear regression analyses were performed. Results Study participants were found to have moderate diabetes self-care performance scores. Annual eye checks, blood glucose self-monitoring, healthy diet selection, and regular exercise were the least common self-management techniques performed and were consistent with the perceived difficulties of the participants. Being illiterate or having an elementary school education (β = 4.59, p = .002), having a junior or senior high school education (β = 3.01, p = .006), having moderate depression (β = −0.92, p = .04), diabetes knowledge (β = 0.09, p = .006), and perceived barriers (β = 0.31, p < .001) were found to explain 40% of the variance in self-care performance. Educational level, depression, and perceived barriers were the strongest factors that impacted Type 2 diabetes self-care performance in this study. Conclusions/Implications for Practice Nurses should not only provide diabetes education but also identify barriers to diabetes self-care early, screen for the signs and symptoms of depression, and target patients with lower levels of education.


Introduction
Type 2 diabetes is a global health pandemic that threatens both public and national economic health because of the rapidly increasing number of cases and limited resources available for management (Ogurtsova et al., 2017).Indonesia, the world's fourth largest country, has a population of 272 million (Worldometer, 2019).Nearly four in every 100 (i.e., 10.7 million) Indonesians were living with a diabetes diagnosis in 2019 (International Diabetes Federation, 2019).Moreover, the prevalence of diabetes is expected to increase to 16.6 million people in 2045, with 90%-95% expected to have Type 2 diabetes (International Diabetes Federation, 2019).The high and rapidly increasing number of Type 2 diabetes cases aggregates the care burden and impacts the daily life of sufferers.Diabetes was the third leading cause of death in 2016, and about U.S. $576 million of the Indonesian health insurance (Jaminan Kesehatan Nasional) budget was spent treating this disease (Hidayat et al., 2022;Mboi et al., 2018), highlighting the importance of proper management to diabetes-related complication prevention and optimal health outcomes.
Proper self-care performance is key to preventing diabetesrelated complications (Gode et al., 2022;Letta et al., 2022).Upon their diabetes diagnosis, patients in Indonesia are enrolled automatically in the chronic disease management program Prolanis, which is a program paid for by Indonesian Health Insurance from the Social Security Administrator for Health and is free for patients to attend monthly (Mahendradhata et al., 2017).Despite the Indonesian government providing money and manpower for diabetes management, the care outcome for patients has been unsatisfactory.A recent large population-based study in Indonesia surveyed 1,976 patients with Type 2 diabetes, finding only 30.8% of participants achieved the American Diabetes Association's recommended long-term serum glucose levels target (HbA1C < 7.0%), more than half reported not adhering to doctors' or nurses' recommendations, and nearly one in every three reported having at least one diabetes-related comorbidity (e.g., eye complications, cardiovascular complications, renal complications; Cholil et al., 2019).This indicates the importance of investigating and identifying the significant factors contributing to poor diabetes self-care performance to improving diabetes care outcomes.
Many factors influence self-care performance.Low knowledge levels (Mikhael et al., 2018) and depression (Alexandre et al., 2021;Shrestha et al., 2021) have been found to be associated with poor diabetes self-care performance.In addition, Ajzen (1991) proposed self-perceived behavioral control as potentially affecting related behaviors.Perceived behavioral control is defined as the perceived ease or difficulty associated with performing a particular behavior because of the presence of internal and/or external factors that can act as either inhibitors or facilitators (Ajzen, 1991(Ajzen, , 2002)).Higher perceived barriers and lower perceived control (Alexandre et al., 2021) have been found to be significantly associated with low levels of diabetes self-care performance.
The population of Indonesia has a relatively low average level of literacy (Asril et al., 2019).This, together with indigenous cultural mores related to the meaning and preparation of food, makes it difficult for Indonesians with diabetes to choose a healthy diet (Widayanti et al., 2020).Maintaining physical activity is another big challenge in Indonesia, particularly among patients with diabetes, because of modern work patterns, urbanization, technological conveniences, and gender-related expectations.Nearly one in two (45%) people with diabetes in Indonesia rarely or never completes the recommended amount of exercise (Cholil et al., 2019).A sedentary lifestyle is more evident in women than men, as women are more likely to be housewives and to work at home than men (Nurwanti et al., 2018).Previous studies addressed how urbanization relates to a sedentary lifestyle and how conflicts between traditional and Western health beliefs (healthy eating and regular follow-ups) pose challenges to preventing and managing Type 2 diabetes in developing countries (Fanany & Fanany, 2015;Fong et al., 2019).Although all of these barriers should be considered as potential factors affecting diabetes self-care performance, little is known regarding their effects on Indonesians.
In addition to the barriers to preparing/choosing healthy food and exercise, psychological well-being also influences diabetes self-care performance.Depression decreases the ability of patients to solve their health problems and reduces their motivation, interest, and concentration, all of which lowers diabetes self-management ability (Shrestha et al., 2021).Ajuwon and Love (2020) reported that about 25% of African American patients with Type 2 diabetes reported having depressive symptoms (Ajuwon & Love, 2020).However, depressive symptom status is less reported and recognized in Indonesia because the assessment fee is not covered by insurance or Prolanis (Mahendradhata et al., 2017).
The cultural and psychological characteristics of the unique health practices employed by Indonesians present challenges to those with diabetes who attempt to achieve a good glycemic outcome.In addition, the theory of planned behavior (Ajzen, 2002) suggests all relevant factors should be considered together to obtain a more comprehensive understanding of self-care performance.However, previous studies conducted in Indonesia on patients with Type diabetes 2 only explored the relationship of each factor with self-care performance and did not consider how these factors may influence each other.Therefore, it is important to elucidate using a welldeveloped theoretical approach the influences of knowledge, perceived barriers, and depression on Indonesians with diabetes.In light of the above, this study was designed to address the influence the abovementioned factors have on the self-care performance of Indonesians with Type 2 diabetes.

Design, Participants, and Sample Size
This cross-sectional study was conducted at two hospitalaffiliated outpatient departments and four public health service centers in Makassar, Indonesia, from July to August 2017.Men and women aged 20 years and above (the legal age for signed informed consent in Indonesia) who had been diagnosed with Type 2 diabetes, had received medical treatment for at least 1 year, had managed their diabetes independently, and did not have a diagnosed cognitive impairment were eligible.The sample size was estimated using G*Power 3.0.10,with the alpha level set at .05, the power set at 0.8, and the effect size set at 0.15 (Cohen, 1988), and 14 predictors.The minimum sample size was estimated at 135.However, 20% was added to buffer the possibility of missing data, giving a final required sample size of 162.

Ethical Considerations
The study protocol and the informed consent form were approved by two university institutional review boards (N201706022 and 361/H4.8.4.5.31/PP36-KOMETIK/2017).A detailed introduction and explanation of the study were given to the participants, and written informed consent was obtained from each individual.The participants' understanding of the study and their voluntary participation were both confirmed before securing informed consent.

Measures
Eligible patients with Type 2 diabetes completed the selfreport questionnaires described below.The entire process took about 30-40 minutes.
The Journal of Nursing Research Participant characteristics Demographic (age, gender, marital status, educational level, and income), diabetes history (years with a diabetes diagnosis and their type of diabetes treatment), and obesity status data were collected from the participants.Diabetes treatment type was distinguished into three categories: oral medication, insulin, and both oral medication and insulin.Body mass index (BMI) and waist circumference were used to determine obesity status.BMI was categorized based on the World Health Organization's report for Asians, with BMI < 18.5 kg/m 2 identified as underweight, between 18.5 and 22.9 kg/m 2 identified as normal weight, between 23 and 24.9 kg/m 2 identified as overweight, and ≥ 25 kg/m 2 identified as obese (World Health Organization Western Pacific Region, 2000).On the basis of the same report, the waist circumference cutoff points of 90 cm for men and 80 cm for women were considered optimal to identify those with a BMI ≥ 25 kg/m 2 and for predicting metabolic syndromes and chronic diseases.Monthly family income was estimated based on Indonesia federal poverty guidelines (World Bank Group, 2021) and categorized into four categories: poor (monthly family income ≤ US $114), lower middle (monthly family income US $114-$196.2),middle (monthly family income US $196.2-$453), and upper middle (monthly family income > US $453).

The revised diabetes knowledge test
The Revised Diabetes Knowledge Test, which includes 14 items used to test general knowledge and nine items used to test insulin usage knowledge, has been used to evaluate diabetes knowledge levels (Fitzgerald et al., 2016).All of the participants were required to answer the 14 items on the general test, whereas only patients taking insulin were required to answer the nine items on the insulin usage test.Each multiple-choice question has one correct answer.Diabetes knowledge was treated as a standardized continuous variable (number of correct answers divided by the total number of questions) to minimize the effect of the number of questions that should be answered.Thus, a score of 1 indicates perfect diabetes knowledge, and higher scores indicate a higher level of knowledge.The authors conducted a forward and backward translation of this instrument into Indonesian from the original English.Both the general and insulin usage tests have shown good reliability (Cronbach's α = .77for the general test and .84 for the insulin usage test; Fitzgerald et al., 2016).In our pilot study, Cronbach's α values of .71 and .73 were obtained for the general and insulin usage tests, respectively.Five experts, including two endocrinologists and three diabetes care nurses, were invited to give their expert opinions.The content validity index was identified as .86 in this study.

Depression anxiety stress scale
The Indonesian version of the Depression Anxiety Stress Scale was translated from the original Lovibond and Lovibond (1995) Depression Anxiety Stress Scale and has shown good internal reliability for depression, anxiety, and stress level (Cronbach's α values of .91, .85, and .88, respectively;Damanik, 2011).In line with the purpose of this study, only 14 depressionlevel items were used.The participants were asked to rate their depressive symptoms for the past 2 weeks on a 4-point Likert-scale (0 = almost none, 1 = some of the time, 2 = a good part of the time, 3 = nearly all or most of the time).The total possible score range was 0-42, with higher scores indicating greater depressive symptom severity and normal = 0-9, mild = 10-13, moderate = 14-20, severe = 21-27, and extremely severe ≥ 28 (Damanik, 2011).

Perceived barrier questionnaire
The Perceived Barrier Questionnaire, previously modified from the Self-Care Inventory (Weinger et al., 2005), consists of 14 items that reflect the self-perceived level of difficulty regarding diabetes self-care and disease control.Each item was scored between 1 and 7, with 1 = extremely difficult and 7 = extremely easy.The total possible score ranged from 17 to 98, with higher scores indicating lower perceived barriers.In the pilot test for this study, the Cronbach's α of the questionnaire was identified as .72.

Self-care inventory-revised
The Self-Care Inventory-Revised (SCI-R) is used to evaluate diabetes self-care performance or capability to manage diabetes of the respondent (Weinger et al., 2005).The 12 items of the SCI-R are scored between 1 (never do this) and 5 (always do this as recommended without fail), with the aim being to show how often the respondent performs each behavior (e.g., choosing a healthy diet, self-monitoring blood glucose level, properly managing blood glucose, exercising regularly).The SCI-R total possible score ranges from 12 to 60, with higher scores indicating better self-care performance.The SCI-R has shown good reliability in a prior study (Cronbach's α = .87;Weinger et al., 2005) as well as in our pilot study (Cronbach's α = .72).

Data Collection
Doctors and nurses, who first see potentially eligible patients during routine outpatient visits, asked potential participants regarding their willingness to be interviewed before referring them to the research team.One of the researchers or Indonesian research assistants approached each potential participant, introduced the study, answered research-related questions, explained the voluntary nature of participation, and obtained informed consent before providing the self-report questionnaire.If a participant had difficulty understanding or completing the questionnaires, the researcher (or research assistant) read and explained the questions and helped them complete the form.All other data, for example, weight, height, fasting blood glucose, and HbA1c, were collected via a medical record review.The entire process took approximately 30-40 minutes.

Statistical Analysis
The data set obtained during this study was evaluated using IBM Statistics SPSS 21.0 (IBM Inc., Armonk, NY, USA).
Descriptive analyses (frequency, percentage, mean, and SD) were used for demographic background information as well as for diabetes knowledge, depression, perceived behavioral control, and self-care performance.An independent t test and a one-way analysis of variance were used to investigate the differences in self-care performance scores among the various groups in terms of educational level and type of diabetes treatment.Pearson's r correlations were used for bivariate analysis to identify significant associations among the continuous variables.Statistically significant factors from the abovementioned inferential statistics were then entered into a regression analysis.Finally, a multiple linear regression analysis was conducted to determine the factors that were associated with self-care performance at a level of significance of .05 or higher.

Participant Characteristics
One hundred eighty-five patients with Type 2 diabetes were enrolled as participants in this study.The background data (demographics and diabetes history) of the participants are presented in Table 1.Most (n = 128, 69.2%) of the participants were women, the mean age was 59.5 (SD = 8.6) years, and 83.2% were married.Almost half were educated to the junior or senior high school level (n = 83, 40.9%), whereas slightly more than one third (n = 65, 35.1%) held baccalaureate or higher degrees.The median time since diabetes diagnosis was 8 (minimum = 1, maximum = 36) years.Oral hypoglycemic drugs were the most common form of medication (46.5%) prescribed, followed by insulin (36.7%) and a combination of the two (16.8%).Moreover, mean fasting blood glucose and HbA1c levels were 188.7 g/dl (SD = 71.7)and 8.1% (SD = 2.1), respectively.
Diabetes knowledge, perceived barriers, depressive symptoms, and self-care performance values are shown in Table 2.The mean score for diabetes knowledge was 0.4 (SD = 0.2), whereas the mean score for perceived barriers was 54.9 (SD = 10.2).Almost one in four of the participants (25.4%) were identified as experiencing depressive symptoms.The mean for self-care performance was 38.7 (SD = 6.9), which indicated moderate self-care performance.The poorest mean score for the self-care performance subscale was "keeping food records," followed by "recording blood glucose daily at home," "recording blood glucose level," and "reading food labels."The major self-perceived barriers included physical activity, self-monitoring blood glucose, and eye checks.

Factors Associated With Self-Care Performance
The relationship between different patient characteristics and diabetes self-care performance is presented in Table 3. Patients with higher levels of education (F = 13.1, p < .001)and with an upper middle level of income (F = 3.1, p = .02)had relatively higher self-care performance scores.Furthermore, diabetes knowledge (r = .2,p < .001)and perceived barriers (r = .6,p < .001)were shown to have statistically significant and positive relationships with self-care performance.In contrast, depression level (r = −.4,p < .001)shared a negative association with self-care performance.
The factors contributing to diabetes self-care performance is shown in Table 4. Educational level, income, depression, diabetes knowledge, and perceived barriers accounted for

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40% of the total variance in self-care performance.Having an elementary school or lower level of education (ß = 4.6, p = .002),having a junior or senior high school education (ß = 3.0, p = .006),and having moderate depression (ß = −0.9,p = .04)as well as level of diabetes knowledge (ß = 0.1, p = .006)and level of perceived barriers (ß = 0.3, p < .001)were all found to be significantly associated with self-care performance.

Discussion
The participants in this study, Indonesians with Type 2 diabetes, were found to have an insufficient level of self-care performance (mean fasting blood glucose = 188.7 g/dl, mean HbA1C = 8.1%), indicating the importance of addressing patient needs/concerns to achieving optimal outcomes.Appropriate strategies are necessary to facilitate current management plans to improve Type 2 diabetes self-care performance.
The findings of this study indicate that, after controlling for other factors, educational level, depression, and perceived barriers are the most significant factors impacting self-care performance, which concurs with a previous study conducted in China (Hu et al., 2022).In addition, the participants faced higher difficulties in checking their eyes and blood glucose, conducting physical activity with sufficient length frequency, and avoiding food high in saturated fat.
In addition to barriers to diabetes self-care performance, the influence and high prevalence of depressive symptoms should be considered.Nearly one in four (25.4%) participants reported having experienced depressive symptoms, indicating a significant prevalence of depression among Indonesian patients with diabetes.The prevalence identified in this study is higher than in Decroli et al. (2019), which reported a depression prevalence as high as 11.7% among patients with diabetes in Padang, Indonesia (Decroli et al., 2019), and in Wang et al.'s (2016) population-based study in the United States, which reported depression in 10.7% of patients with Type 2 diabetes (Wang et al., 2016).Type 2 diabetes patients with depression tend to have higher blood glucose levels because of their impaired problem-solving ability and lower motivation to perform diabetes self-care compared with their peers without depression (Shin et al., 2017).The findings of this study support that patients with Type 2 diabetes may experience depressive symptoms before being diagnosed with depression, indicating the importance of identifying and properly managing depressive symptoms early in improving self-care performance and outcomes.
Mental illness assessments are uncommon in Indonesia because of lack of public awareness and low mental health literacy regarding the clinical manifestations, causes, and impacts of mental illnesses (Praharso et al., 2020).In the Prolanis program, depression screenings/evaluations are not part of standard management procedures and are not covered under the Indonesian Health Insurance (Mahendradhata et al., 2017).Therefore, healthcare providers are not trained to screen or manage depression under the Prolanis program.Praharso et al. (2020) found that healthcare providers with low knowledge of depression are likely to misrecognize depressive symptoms and thus recommended including mental healthcare providers under the Prolanis program (Praharso et al., 2020).In addition, because of their frontline care provider role, nurse managers/educators should also provide education and training

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on communications and interactions, problem identification, psychosocial screening, intervention services, and referral processes to nurses based on the American Diabetes Association's position statement on the psychosocial care for people with diabetes (Young-Hyman et al., 2016).
In general, sedentary behavior is a health issue among Indonesians.The national Indonesian Basic Health Research 2013 survey showed that more than 80% of 471,240 adults aged 19-55 years exhibited a sedentary lifestyle (physical activity time < 5 hours/day) and that this problem affected all age groups (Nurwanti et al., 2018).Society-wide sedentary lifestyle trends, limited information about and access to tailored exercise services, resistance to behavioral change, and a perceived lack of enjoyment, motivation, time, knowledge, and confidence have been commonly reported by Indonesians as barriers to exercise (Arovah et al., 2019).In addition to the difficulty of performing regular exercise, the participants in this study reported poor performance in terms of choosing and eating a healthy diet.Study participants reported barriers to avoiding food high in saturated fat because it is impolite to choose otherwise (Widayanti et al., 2020).Indonesians with diabetes should learn and use ways to choose healthy food in their daily life and during social gatherings.
Diabetes is a chronic disease with complex conditions.From time of diagnosis, patients with diabetes receive care from a wide spectrum of social and healthcare professionals.The United Kingdom National Health Service ( 2013) posted an integrated diabetes care model to help ensure effective delivery, clarify roles and responsibilities to support self-management and preferred outcomes in a structured way, and provide equal access (Diabetes UK, 2013).Evidence supports the effectiveness of providing group-based and person-centered diabetes selfcare education focusing on helping patients acquire the knowledge, information, self-care practices, coping skills, and attitudes necessary to manage their dietary and exercise regimens.This approach achieved a statistically significant long-term impact (> 12 months) on behavioral changes and positive outcomes such as knowledge, coping, losing weight, and improving diet and exercise habits, medication adherence, and blood glucose monitoring and control (Smith et al., 2019;Stenov et al., 2019).Because the Prolanis program is available on a monthly basis for people with Type 2 diabetes, it is an ideal platform for diabetes experts to provide integrated services with multidisciplinary care professionals in a one-stop and group-based person-centered program to facilitate lifestyle changes and minimize the barriers to self-care performance in Indonesia.
Nurses may apply cultural brokerage strategies to bridge or mediate between the patient's culture and the healthcare system and thus promote behavioral change in patients using culturally appropriate methods.These strategies have been widely used to effectively help minority populations manage chronic diseases (Mortier et al., 2020).Cultural brokerage requires that nurses are aware of and understand their patients' cultural characteristics and the ways that culture impacts their patients' health practices, develop strategies to en-gage their patients in diabetes management programs, and build a system capable of responding to the needs of their patients.Indonesian nurses are already familiar with the cultural background of their patients and understand their challenges.Thus, they are able to work with patients, help them make healthy food choices, and minimize their intake of food high in saturated fat in a culturally appropriate way without offending others during social gatherings.Patients in Prolanis can discuss these strategies together and support each other to overcome barriers and sustain positive changes.
Annual eye checkups and proper blood glucose self-monitoring were the two most difficult barriers reported in this study.The high cost of monitoring strips and the uncertainty/frustration associated with having abnormal glucose levels are two reasons previously reported for not regularly self-monitoring glucose levels (Ong et al., 2014).Sasongko et al. (2021) reported that fewer than 25% of Indonesian patients with diabetes attend their annual eye checkup for diabetic retinopathy because of a lack of knowledge about the related need for eye care and financial concerns.Therefore, nurses and clinicians should not only educate patients with diabetes on the benefits of self-management but also assess and address their physical, psychological, and financial capabilities.Government and health insurance agencies should also consider offering reimbursement for glucometer strips and annual eye checkups to help close the gap between knowledge and positive management actions.

Limitations
Multiple factors affect self-care performance in Indonesians with Type 2 diabetes.The evidence provided in this study increased the number of known perceived barriers and examined their influence while considering the effects of diabetes knowledge and depression.Diabetes care outcomes should be improved by resolving the perceived barriers of individual patients and providing appropriate diabetes self-management education.In addition, because this study was conducted by Indonesian researchers, scholarly understanding of current diabetes care and cultural influences was improved, and new strategies to improve diabetes care were suggested.In this study, only the perceived barriers included in Ajzen's (1991) planned behavior model were considered.Future studies should explore the influences of individual attitudes and subjective norms on diabetes self-care performance.Furthermore, qualitative studies should be conducted to further explore the meaning of having Type 2 diabetes, the difficulties faced in performing self-management, and the strategies currently used or proposed to overcome these challenges from the patient perspective.The participants in this study were recruited from only a single area (Makassar, Indonesia), and the beta coefficients were relatively small in the regression model, which limit the generalizability of the results and conclusions.In addition, the data were collected before the COVID-19 pandemic and thus may not adequately represent the situation in the current postpandemic era.However, the study's findings highlight the need for clinicians to be aware of and assess the psychosocial conditions of patients with Type 2 diabetes.The findings of this study should be interpreted with appropriate caution.

Conclusions
The findings indicate patients with Type 2 diabetes in Makassar, Indonesia, exhibit moderate self-care performance, suggesting that self-care performance improvement is needed.Educational level, depression, and perceived barriers were identified as the strongest factors impacting Type 2 diabetes self-care performance.Nurses should not only provide diabetes education but also identify barriers to diabetes self-care early, screen for the signs and symptoms of depression, and target patients with lower levels of education to improve self-care outcomes.

Table 1
Demographics, Diabetes History, and Obesity Status of the Participants (N = 185)

Table 2
a Indonesian version of Depression Anxiety Stress Scale.b The Revised Diabetes Knowledge Test.c Perceived Barrier Questionnaire.d Self-Care Inventory-Revised.

Table 4
Regression Analysis of the Patients' Characteristics and Their Self-Care Performance The higher the score of perceived barriers, the less barriers perceived.