Magnitude and factors associated with diabetic complication among diabetic patients attending Gurage Zone hospitals, South West Ethiopia.

Objective To assess the magnitude of diabetic complication and associated factors among diabetes mellitus patients attending in Gurage zone hospitals.Results According to this study the magnitude of diabetic complication among diabetic patients were 61% and the marital status; divorced [AOR: 0.252(0.11, 0.59); p=0.002], poor glycemic control [AOR: 1.88(1.04, 3.39); p=0.036], Body Mass Index >25 [AOR: 4.42(1.32, 14.86); p=0.016] and duration of illness > 6years [AOR:1.79 (1.02, 3.17) ; p=0.044] and 10years [AOR: 4.68(2.07, 10.61); p=<0.001] were signicantly associated with diabetic complication.Key


Introduction Background
Diabetes is a chronic disease marked by high level of blood glucose that occurs either when the pancreas does not produce enough insulin or when the body cannot effectively use the insulin that was produced. Complication of DM account for increased morbidity, disability and mortality and threats for the economies of all countries especially in the middle and low economic countries [(5)]. In 2016, an estimated 1.6 million deaths were directly caused by diabetes and 2.2 million deaths were attribute to high blood glucose in 2012 [(1) (2)]. Acute complication of DM consists diabetic ketoacidosis which is the most common acute complication and it mostly occur in type 1 diabetes mellitus (DM). Hyperglycemic hyperosmolar non ketosis syndrome mostly occurs in type 2 DM and hypoglycemia[(6) (7)]. The chronic complications are broadly classi ed in to macro vascular, micro vascular and other complication of DM.
Macro vascular complication of DM are primarily disease of coronary artery, cerebrovascular, and peripheral vascular. Microvascular complication of DM is those that affect small blood vessels typically include retinopathy, neuropathy and nephropathy. Other complication of DM is bacterial and fungal infection which occurs due to direct effects of hyperglycemia on cellular immunity[(1),(8)]. DM can result in an increased risk of sever sight impairment, end stage kidney disease, cardiovascular disease and in some cases early death [(9)]. Since there is limited study in the study area, this study nding addresses to determine the magnitude of DM complication with its associated factor in the study area.

General objective
To assess diabetic complications and its predictors among diabetic patients at Gurage zone hospitals, south west Ethiopia from April 1 -30, 2019.

Speci c objective
To assess prevalence of diabetic complications among diabetic patients attending Gurage Zone Hospitals.
To identify predictors of diabetic complication among diabetic patients attending Gurage Zone Hospitals.

Methodology Study area and period
This study was conducted at Gurage zone hospitals which is located in Southern Nations Nationalities and Peoples' Region state (SNNPRs) of Ethiopia. The "Gurage"zone has three primary Hospitals, one general hospital and 72 health centers. All hospitals have chronic follow up clinic especially for diabetes mellitus and hypertension. Those four hospitals were"Attat" (private hospital), "Gunchire", and "Bui" are primary hospitals and Butajira is the only General hospital in the zone. The study was conducted from April 1-30, 2019.

Study design
Were Institutional based cross sectional study.

Source population
Were all DM patients on follow up at Gurage Zone Hospitals.

Study population
All sampled diabetic patients attending "Butajira" general hospital, "Attat" and "Gunchire" primary hospitals follow up clinics during the study period.

Inclusion criteria
All diabetic patients who had follow up in sampled hospitals of Gurage zone having follow up during the study period.

Exclusion criteria
Were patients with less than three months durations and also who were unconscious and had mental illness during data collections were excluded.
Sample size and sampling technique (See Sample size and sampling technique in the Supplementary Files)

Sampling techniques
Strati ed sampling method was used to select the study sample from selected hospitals. First one general hospital was purposively selected and two primary hospitals were selected by simple random sampling using lottery method from three primary hospitals. Then strati ed sampling and proportional allocation was done for one general hospital (Butajira general hospital) and two primary hospital (Gunchire and Attat primary hospital) from the total diabetic patients of each hospitals by n = n/N * Nj equation. Number of study subjects in each stratum determined by proportion to population size from each hospital. This sampling procedure is presented schematically as follows. (Figure1).
Patients of each hospitals further selected by systematic sampling from follow-up registration books (sampling frame) after calculation of the sampling interval =N/n, 1540/338=5. The patient`s card were used to get other medical condition and laboratory results for additional information. The data were collected using structured questionnaire and by reviewing patients cards for laboratory results and other medical ndings (hypertension, kidney failure, heart failure and infection). The questionnaire had three parts. These includes socio-demographic data, medical related factors and management related factors Data collection process Three diploma nurses were selected for data collection for each hospital with two BSc nurses for supervisors. Training were given for both data collectors and supervisors for two days before the actual data collections about the study procedure and data collection techniques go through the questionnaires questions by questions, ways of data collection, supervision and nally clari cation was given for each doubt.
Operational de nition and de nition of terms DM complications: DM patients having both acute and chronic complications of type 1 and type 2 DM.
Diabetes ketoacidosis: ketonuria positive Hyperglycemic hyperosmolar state -it is mental change confusion, lethargy or coma associated with diabetes especially with recent history of dehydration of poor oral intake of uid associated with increased osmolality and blood glucose level.
Retinopathy-It is complication of diabetes which damages blood vessels in the retina due to leaking of blood and other uid as a result of long standing diabetes mellitus.
Nephropathy-It is the complication of diabetes in people who have had diabetes for 20 years or more present with albumin in the urine.
Neuropathy-It is diabetic effect of the nerve damage due to high blood glucose which mostly affects nerves of legs and feet. Yes: if the patients has one complication either acute(hypoglycemia, DKA and HHNS) or chronic complication (Macro vascular, micro vascular, neuropathy, nephropathy or diabetic foot ulcer) that rule out by laboratory investigation and physical examination during follow up.

Data quality management
To assure the quality of data, properly designed data collection tool (structured questionnaire) was prepared in English and translated to Amharic language and then back to English to check the consistency. The questionnaire was pre tested. Training was also given for both data collectors and supervisors before actual data collection on the data collection process.

Data processing and analysis
After data collection, responses were entered into EPI data Version 3.1 and exported to SPSS version 23 for clearing, coding and analysis. In descriptive statics both frequency and proportion were calculated and in analytic logistic regression were made by considering diabetic complication as binary outcome variable (yes/no). Those explanatory variable with p-value 0.2 at 95% CI in bivariate were eligible for multivariate and those variables with p value0.05 were found to be signi cant Ethical consideration Before data collection, Ethical clearance letter was obtained from Wolkite University College of medicine and health science department of nursing and dispatch to each selected hospitals and Gurage zonal health o ce. The respondents were informed and their oral consent was obtained. The respondents had the right to refuse or with draw from participating were also maintained in addition to keep their response con dentially

Dissemination of nding
The result of the study was communicated to Wolkite University College of medicine and health science, department of nursing, "Butajira" general hospital, "Attat" primary hospital and "Gunchire" primary hospitals.

Discussion
This study showed that the magnitude of DM complication among diabetic patients in Gurage zone hospitals was60.65% and it wasrelatively similar with study done in Northeast Ethiopia (59.7%) and Bahirdar (53.5%) in Ethiopia[(13), (14)].So, designing strategy for early diagnose and management of DM should be crucial.
In this study nding; DM patients who live with DM between 6-10 years and above 10 years were1.79 and 4.68 times more likely to develop diabetes complication respectively when compared with patients who had live with DM less than 5 years duration. Thisstudy was similar with study conducted in "Felegehiwot" referral hospital, Bahirdar, Arbaminch and Jimma[(15),(16)]. So, patients should be clinical managed properly by initiatingearly diagnose and treatment.
Regarding Body mass index in our study; those diabetes mellitus patients who had higher BMI (>25kg/cm2) had 4 times more likely to develop diabetic complication when compared with patients who had BMI <18kg/cm2. It was similar with study done in China[ (17)] and Paci c Islands [(18)]. This will imply that having recommended dietary practice and exercising physical activity regularly will be strengthened.
This study nding suggest that those patients who had poor glycemic control were 2 times more likely to develop diabetic complication when compared with patients who had good glycemic control .This study nding was similar with study done in Arbaminch and Jimma[(16),(8)]. So, continuous follow up and checking patients FBS should be taken thoroughly.

Conclusion
The overall prevalence of diabetic complications among the Gurage zone hospitals was 60.65%. Being widowed, long duration of illness, having BMI greater than 25 kg/cm2 and having poor glycemic control were found to be signi cantly associated with DM complication.

Recommendations
Based on the ndings of this study; provision of health education, self-care practice and early diagnose and proper management of patient condition should be strengthened.

Limitation of the study
The study design was cross sectional nature of the study so it is snap shot and could not con rm cause and effect relationship.

Declarations
Ethics approval and consent to participate The study was conducted after approval of the proposal by Ethical Review Committee of wolikite university ethical review board. Written informed consent was obtained from each study participant by assuring privacy and con dentiality throughout the data collection period in the hospitals. There was no risk or hazardous procedures putting the participants at harm..

Consent to publish
The consent to publish was reached with authors.

Availability of data and materials
The data supporting the nding had attached to editorial o ce if necessarily

Competing interests
There is no competing interest.   Figure 1 Schematic presentation of sampling procedure, Gurage zone hospitals in 2019.

Supplementary Files
This is a list of supplementary les associated with this preprint. Click to download.