Effect of Nutrition Education to Enhance Dietary Adherence Among Type II Diabetes Mellitus Patients Attending Diabetic follow-up Clinics in Addis Ababa: A Multi-center Quasi Experimental Study Based on the Health Belief Model

Effect of Nutrition Education to Enhance Dietary Adherence Among Type II Diabetes Mellitus Patients Attending Diabetic follow-up Clinics in Addis Ababa: A Multi-center Quasi Experimental Study Based on the Health Belief Model | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Effect of Nutrition Education to Enhance Dietary Adherence Among Type II Diabetes Mellitus Patients Attending Diabetic follow-up Clinics in Addis Ababa: A Multi-center Quasi Experimental Study Based on the Health Belief Model Chala Getaneh, Semre G/Mariam, Dawit Tsegaye, Oliyad Kuma, Mulgeta Taybele, and 2 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6706671/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract INTRODUCTION;Type 2 Diabetes Mellitus (T2D), is Aa Life-Threatening Condition Of Public Health Concern. it worsens acute and Chronic complications. However, lifestyle interventions reduce the risk of both acute and chronic complications, and nutrition education can empower individuals on the appropriate metabolic control, global lifestyle changes and optimize quality of life. OBJECTIVE; The study was to assess the effect of nutrtion educational intervention to enhance dietary adherence among type II diabetes mellitus patients. METHOD; A quasi- experimental study was conducted By Allocating Hospitals Into An Intervention that Was Receive Nutrition Education against Controls That Would Receive The Routine Service. Data was measured twice (baseline and end line survey after twelveweek.The data was collected using kobo toolbox.The collected data was exported to Spss version 25 Continuous variables was presented as the mean± standard deviation and categorical variables presented as percentages. Comparisons between groups was performed using paired-samples t tests to assess the Effect of educational intervention on Dietary Adherence. At 95% confidence level, value with p-values less than 0.05 was considered signifcant for all statistical tests. Result. The mean pre- and postintervention nutritional knowledge was 1.35 and 2.46 and Dietary Adherence was 2.8324 And 5.8002 in intervention group, respectively. The increase in mean nutritional knowledge and dietary adherence was statistically significant (P < 0.001). In control group, the pre- and postintervention mean nutritional knowledge was 1.40 and 1.40 and good dietary Adherence was,2.8567 and 2.9142 respectively. but the difference was not significant (P > 0.05) .There was significant (P < 0.001) improvement in the scores of HBM constructs in intervention group. Conclusion and Recommendations. Providing nutrition education based on Health Belief Model improves nutritional knowledge and dietary adherence of type II diabetes mellitus patients. Hence, governmental, nongovernmental organization, and health-care provider should include Health Belief Model construct into existing nutrition education programs. Moreover, government should incorporate HBM theory into national nutrition education guidelines. Ethiopia diabetes Mellitus dietary Adhrence Figures Figure 1 Figure 2 Figure 3 Introduction 1.1 Background Diabetes mellitus (DM) is a metabolic disorder characterized by chronically elevated blood glucose levels resulting from defects in insulin secretion, insulin action, or both(1). It has become one of the world biggest health concern affecting both developed and developing countries and world-wide it is ranked among one of the four priority non-communicable diseases(2,3). Diabetes Mellitus is increasing rapidly in the world. According to International Diabetes Federation (IDF) there were 463 million people aged 20-79 years living with diabetes globally. These numbers are predicted to rise to 642 million by 2045, with the highest increase occurring in low to middle income countries(4). In 2019 the International Diabetes Federation Africa Region (AFR) estimated that there were 19.4 million adults aged 20-79 years living with diabetes, with a regional prevalence of 3.9%(5). The prevalence of diabetes in Ethiopia, ranging from 2.0% to 6.5%(6). Overweight has been a major contributor of type 2 diabetes epidemic it accounts for about 90 of all diagnosed cases of diabetes in adult (7). Nearly 80% of type diabetic individuals are overweigh and Approximately 50% of new cases of type 2 diabetes can be controlled adequately by lifestyle changes (diet and exercise)(8). The management of diabetes mellitus (DM) includes both medical care and non-pharmacological care such as meal planning, changes in lifestyle, education, physical activity habits, self-care by the patient. Nutrition education intervention by professional is a key component of diabetes care and diabetes management(9).Non adherence to dietary practice advice is the main challenge among Type 2 diabetic patients(10). In order to achieve effective nutrition therapy each patient should adhere properly to Healthy eating habit and weight management combined with physical activity may help to improve glycaemic level(11).Nutrition therapy is important in preventing pre diabetes,managing existing diabetes and slow the rate of development of diabetes complications(12). A number of studies supports that type 2 diabetes is largely preventable through diet and life style adjustment. The incidence can be decreased by 25% by following lifestyle modification(13).Nutrition-related health issues have become more prevalent in the Middle East during the last two decades, causing changes that include increases in obesity and risk factors for chronic disease(14). In addition, excessive energy intake leads to overweight and obesity, which is linked with a range of health problems, including diabetes mellitus(15). FAO/WHO International Conference of Nutrition indicate that unhealthy eating patterns have been increasing around the world.fat intake has been rising rapidly in lower-middle-income countries since the 1980s(16).Evidence showed that nutrition education is a cost-effective method for controlling diabetes compared to treating patients in hospitals and has been shown to improve eating behaviour and clinical outcome(17,18).Previous studies have shown that nutrition education is significantly associated with adherence to recommended dietary habits among diabetes mellitus patients in different countries(15)(16)(17)(18)(19)(20). Poor nutritional knowledge and conflicting dietary recommendations On the other hand can lead to poor dietary adherence(21). Methods and materials Study area Addis Ababa the capital and largest city of Ethiopia. the city is divided in to 11sub-cities containing 117 woredas at which the City lies at an altitude of 7,546 feet (2,300metres). Its population of 2024 is estimated to be 5,703,628 million that resides in 11sub-cities and 117 woredas.The city has 06 public hospitals, 25 private hospitals, more than 97 health centers and about 500 clinics according to EDHS 2016. The Addis Ababa health bureau is responsible for managing Six hospitals including Gandhi Memorial Hospital, Yekatit 12 Hospital Medical College, Zewditu Memorial, Ras-Desta Damtew Memorial, Menelik II Referral, and Tirunesh Beijing General Hospital.The study will be done in ras desta hospital, Zewditu memorial hospital,Menlik II referal hospital and yekatit 12 hospital Addis Ababa, Ethiopia. Menlik II referal hospital, yekatit 12 Hospital, Zewditu memorial hospital and Ras Desta hospital are some of the hospitals that are capable in providing follow up service for diabetes mellitus patients. Study design& Study period Non equivalent Control Group Pretest-Posttest quasi-experimental study was employed from May 2024 to September 2024 Source Population The source populations was all adult patients with Type 2 diabetes mellitus attending diabetic follow-up clinics at public hospitals in Addis Ababa from May2024 to september 2024. Study Population All selected adult Type 2 diabetes mellitus who attended diabetic follow-up clinics at public hospitals in Addis Ababa from May2024 to september 2024 who the fulfill the iclusion Criteria. Inclusion Criteria - Those who are above the age of 18 years - Had a follow up in the hospital for at least 6 month Exclusion Criteria - those who are critically sick during the time of data collection period. Sample Size Determination. Sample size calculation was done using proportion (2 groups, two sided) driven by using OpenEpi (a web application used to perform statistical analysis) By assuming equal sample size number in each group, two sided 95% confidence interval (CI), and 80% power. Because of there is no previous prevalence we will take 50% and the assumption of 20% incensement after the intervention which will be 70%. Which make the Risk/Prevalence difference =20%.Hence, using the following formula, the final sample size included in this study will be 208 by adding 10% the total final 228(114 for intervention and 114 for control group) Type 2 diabetes mellitus patients. Two-sided significance level(1-alpha): 95 Power(1-beta, % chance of detecting): 80 Ratio of sample size, Unexposed/Exposed: 1 Percent of Unexposed with Outcome: 50 Percent of Exposed with Outcome: 70 Odds Ratio: 2.3 Risk/Prevalence Ratio: 1.4 Risk/Prevalence difference: 20 Kelsey Fleiss Fleiss with CC Sample Size - Exposed 95 94 104 Sample Size-Nonexposed 95 94 104 Total sample size: 190 188 208 By Adding 10% non response rate n= the final Sample size will be (n) =228 Epi info out put for Sample size calculation using proportion (2 groups, two sided) 4.8 Sampling technique A Multi stage sampling procedure was employed. There are available six hospitals from six Hospitals four hospitals was selected which are under Addis Ababa Health Bureau and from those four Hospitals twl hospitals was the intervention and two was the control group. Yekatit 12 Hospitals Medical College and Zewditu Memorial hospital,Ras desta Damtew memorial hospital, Menlik II referall hospital was selected by a Lottery Method. The total sample size of 228 was allocated to each hospital proportionally to the number of patients in each hospital. Data collection tool and technique Socioeconomic and demographic information was collected only at baseline. Health Belief Model constructs, nutrition knowledge, and dietary adhrence measured twice baseline and end line after nutrition education. Nutrition Knowledge was assessed using eight questions that were adopted from other literature and contextualized into the local context. Each question was answered using the “Yes”, “No” and “I don’t know” options. A correct answer (“Yes”) was assigned 1 point and an incorrect//unknown answer (“No” and “I don’t know”) were assigned 0 points. The total score for each patient on the eight questions was calculated and changed to percentage. After that the score of each participant was changed into a three-category response based on modified Bloom’s cut-off point, as adequate (if score was between 80 and 100%), moderate (if the score was between 60 and 79.9%), and inadequate (if the score was less than 60%) knowledge. Dietary data was collected by asking participants nine health questions based on the Perceived Dietary Adherence Questionnaire (PDAQ). Responses was recorded in days based on a 7-Likert scale. Higher values indicate higher compliance. Patients who reported 4 to 7 days was classified as practicing good eating habits, while, less than four days were classified as poor dietary practices(61). Items of Health Belief Model constructs was measured using five-point likert scale (strongly agree = 5; through strongly disagree =1). )Then, the value of each likert scale scored by participants for each question was summed and the average was calculated. Operational definition Diet : refers to the recommended diet for people with DM who should ate small meals spread throughout the day (at least 5/day), ate fruits and vegetables daily, and ate foods high in fibers and whole grain but low in fats, sugars and carbohydrates that have high glycemic index(69) Adherence : Participants were asked about how many of the last 7 days they participated in healthy diet eating habits.those who scored the mean and above the overall dietary recommendation score is Adherent to dietary recommendation and those who scored below the overall mean dietary recommendation score is Non Adherent to dietary recommendation(64,66). Nutritional knowledge : Knowledge was assessed using eight questions and the total response was classified in to three groups based on the modified Bloom’s cut-off point as adequate (80-100%), moderate (60-79.9%) and inadequate (<60%) knowledge(71,(72) Procedure of follow up and intervention After collecting relevant baseline data from both groups, education was given every 15 days for 3 month For intervention group, education was given by two nutritonist based on Health Belief Model theory: (1) susceptibility of the disease due to inappropriate dietary practices nutrient deficiency or over nutrient intake; (2) severity of the disease; (3) benefits of right eating or dietary practices to improve nutritional status and health, (4) barriers to practice appropriate good dietary practices; (5) self-confidence/efficacy to follow right dietary practices. The first and second intervention sessions focused on the overview and basic concepts of DM, including risk factors, diagnosis, symptoms, complications, and treatment of type II patients. The goal of this session was to create awareness of patient on how to take action. The 3rd and 4th sessions was adress management of type 2 diabetes mellitus according to national and international guidelines. The aim of this session was to encourage behaviour change the session was including a varied and balanced diet, how to reduce unhealthy eating habits, and how to replace foods not recommended for people with diabetes with recommended foods, healthy eating habits, how to prepare and cook healthy food(65,66, 67,68). The fifth session focused on adherence to recommended dietary recommendations, development of a healthy eating plan, and clinical monitoring The goal of this session on lifestyle change counselling and behavioural change(69,70,71,72). The education was provided using theoretical session, poster, flipchart, and whiteboard in a small group format (8 to 10 patients) every 15 days for one and a half hours for five consecutive months from May,2024 to september 30,2024. after they received their usual care. A control group did not receive any specifc Education intervention during follow-up. Control patients received usual care according to national guidelines for non-communicable diseases then a Three-month follow-up was done without providing any additional nutrition education. Data analysis The data were entered using the Kobo Toolbox and exported to SPSS version 25 for analysis. Continuous data was checked for normality using the Kolmogrov–Smirnov test.Descriptive statistics such as the mean±standard deviation and percentage was generated.Comparisons between groups was performed using paired-samples t tests to assess the Effect of educational intervention on Dietary Adherence. At 95% confidence level, value with p-values less than 0.05 was considered signifcant for all statistical tests. Results Sociodemographic and clinical characteristics of the study participants A total of 228 type II diabetes patients participated in the study.The majority of study participants in both groups were female 58 (50.9%) and 69( 60.5%),being married 69( 60.5%) and 89(78.1%),and aged 48 to 63 years respectively. Of the 228 participants 99(99.1%) in the intervention group and 80(70.2%) in the control group were from Urban area. Most of the study participants in both groups work as government employee. Moreover 36(31.6%)of the participants in the intervention group and 63(55.3%)participants in the control group were high school completed.The mean duration since diagnosis of DM was 5.31±3.4years and 4.41±2.7 years in intervention and control groups, respectively(Table 1) Nutritional Knowledge of type II diabetes mellitus patients before and after educational intervention. A total of 9(7.9%) patients had adequate knowledge regarding the recommended dietary practices for individuals with T2DM, 22(19.3%) had moderate knowledge, and the remaining 83 (72.8%) had inadequate knowledge from the intervention group before educational intervention (baseline). A total of 14(12.3%) patients had adequate knowledge regarding the recommended dietary practices for individuals with T2DM, 18(15.8%) had moderate knowledge, and the remaining 82 (71.9%) had inadequate knowledge from the control group before educational intervention (baseline). After the educational intervention (end-line) 65(57.0%) patients had adequate knowledge, 37(32.5%)had moderate knowledge,12(10.5%) had inadequate knowledge from the intervention group,while 23(20.2%)patients had adequate knowledge,8(7%) had moderate and 83(70.8%)had inadequate knowledge,respectively from the control group after educational intervention( end-line)(figure 5) Thus, the result of this study revealed that there was an improvement in the knowledge of participants after educational intervention in the intervention group when compared to the control group.Accordingly, there was no statistically significant mean score difference on the Nutritional Knowledge at baseline,between the two groups P=( 0. 116) but the difference was highly significant (P < 0.001) at the end of nutrition education. The paired t-test indicated that the mean nutritional knowledge score was highly significantly improved (P < 0.001) from 1.35 to 2.46 in intervention group(Table 2). Effect of nutritional expert led education on dietary adherence of type II diabetes mellitus patients before and after educational intervention. At baseline, there was no statistically signifcant diference in the mean score of dietary adherence between intervention and control group(2.8324 ± .54458 vs 2.8567± .1.75786) Afer the implementation of the educational intervention a paired t-test indicated a difference in mean score of adherence level in the intervention group signifcantly increased from the baseline (p=<0.001) from 2.8324 to 5.8002 (Table 3 ). Health belief model construct scores At baseline, there was no signifcant diference in the HBM construct scores between the intervention and control groups. The mean and standard deviation (SD) of Health Belief Model (HBM) constructs subscale are shown in (Table 4).Except perceiving barrier, which was decreased The meanscore of all Health Belief Model constructs were increased.The paired t-test indicated that there was highly significant difference (P < 0.001) between pre- and post nutrition education intervention mean of Health Belief Model constructs score in intervention group (Table 4) Discussion The finding supports the effectiveness of nutrition expert-led education to enhance dietary adherence based on Health Belief Model (HBM) to improve the nutrition knowledge and dietary Adhrence of type II DM patients through increasing perceived severity, susceptibility,benefits, self-efficacy, and decreasing perceived barriers. Accordingly the present study revealed that there was no statistically significant mean score difference on the nutrition knowledge at baseline between the intervention 1.35 and 1.40 control groups,respectively. But at the end line, the intervention group had a greater mean dietary knowledge score compared to that of the comparison group 2.46 ± .681(p < 0.01). This result is consistant with previous study in Jimma reveled that educational programm offer for T2DM patients improve dietary knowledge(73).Similar quasi expermental study conducted at public hospitals in the Ilu Aba Bor and Buno Bedelle zones of southwest Ethiopiaa significant improvement in the mean score of knowledge and s after nurse-led Diabetic self management education(57). an interventional study finding from south Africa add to the evidence that intervention improved the knowledge of diabetes significantly from baseline to post-intervention(74).Similarly,results are in agreement with india studies done in people with T2DM. These results add to the evidence that Nutrition education programme significantly improved knowledge of diet(75).Another similar result from malasia support the result of this study educational intervention was effective in improving knowledge(76). A possible explanation for these fndings is that to frequent education and follow-up during intervention period as human behavior can be changed by well-designed adequate nutritional education, which ultimately leads to improvements in nutritional status and better health. In this study, the nutrition expert education intervention program signifcantly increased the overall mean number of days adhering to a healthy diet. After the educational intervention, the mean days of adherence to a healthy diet increased in the intervention group compared to the control group, with a signifcant diference (p<0.0001). This fnding was supported by previous studie in Mekelle general Hospital and Adigrat General Hospital in Ethiopia where they suggested that Patient-centered nutrition education has resulted in positive adjustments in the eating behavior of people with type 2 diabetes(77). The finding was also in agreement with another Another quasi expermental study conducted in Ethiopia North shoa which suggest that a nutritional intervention program could signifcantly increase the overall mean number of days of adherence to a healthy diet(58)similar study also support the result of this study which conclude educational intervention have a significant impact on the patients' selfcare of dietary adherence following the training(78).on contrary a study from kenya support the result of this study by concluding nutrition education and other health education improve dietary adhrence of type II diabetes patients(54). the finding is consistant with previous study that support the efectiveness of educational intervention related to adherence to a diabetic diet on improved performance of patients with T2DM(79) .Similar evidence from iran support the result of this study educational programs based on the health belief model constructs over 3 and 6 months in adopting healthy dietary adherence behavior(80). For Health Belief Model the study revealed that except perceived barriers which were decreased, all the other mean Health Belief Model scores significantly increased after nutrition education in experimental group. The perceived barriers were decreased in this study This fnding is consistent with the fndings of other studies(78,79). Perceived barriers are ofen the most predictive constructs and are ofen more difcult to change than other constructs; therefore, more attention needs to be given to perceived barriers. Addressing perceived barriers ofen requires considering and addressing the broader context in which the behavior occurs. Perceived barriers are infuenced by various contextual factors, such as social, cultural, economic, and environmental factors. On the contrary, the higher improvement of dietary adherence in the intervention group might be explained by higher impact of Health Belief Models by increasing perceived susceptibility, severity, benefits, self-efficacy, and decreased perceived barriers to appropriate dietary adherence and improvement in nutritional knowledge. Patients ,who fear for severity of diabetes, understand the benefits of practicing good nutrition for improvement of there health, and have ability to act on good nutritional activities, were more likely to practice good nutrition and eating habits. Similarly, patients exposed to nutrition information could follow good nutrition practices since research evidence suggested that those who exposed to nutrition information were more likely to practice good dietary practices . Knowledge on severity and susceptibility of patient to diabetes mellitus and poor health outcomes as they are likely to be more sensitive to there health condition and follow appropriate dietary pattern. And the use of counseling technique, teaching aids such as leafets, and providing Nutrition expert -based nutrition education Strength of the study - since there is no similarly study in the study setup it makes a new study. - The study design that was used is strong and generate strong cause effect relationship so the result of the study is generalizeable to the general population. - The period of observation is long whene compared to other studies conducted in different region of Ethiopia . Limitation of the study - Findings were based on patient responses to assessments of dietary changes that contribute to information bias. - Whene people know as they are observed theye may change there practice from the routine so observer and social desirability bias may have infuenced the results Conclusion This study found that a nutritional intervention program could signifcantly increase the overall mean of adherence to a healthy diet . After the educational intervention, the mean of dietary knowledge in the intervention group (2.46± .681) compared to thecontrolgroup (1.40 ± .806) and adherence to a healthy diet increased in the intervention group (5.8002 ± .31813) compared to the control group (2.9142± 1.18533), with a signifcant diference (p<0.0001). Hence, delivering nutrition education based on Heath Belief Model can be appropriate tool to improve nutritional knowledge, and dietary adhrence of typeII diabetes patients. Recommendations In summary, policy makers and health car providers are focusing on the following key program areas: 1) The government include Health Belief Model constructs in national nutrition education guidelines and Nutritional health promotion programs should be integrated into existing systems as a common therapeutic service/treatment tool to bring change in nutritional knowledge and dietary Adhrence of type II diabetes patients.. 2) The governmental, nongovernmental organization should include Health Belief Model to Design diferent strategies in order to create health promotion programs to reach large communities in need using a wide range of learning strategies. 3) Assign health promoters to provide and design health education programs on nutritional advice recommended as routine care in hospitals and health centers diabetic follow-up clinics. 4) Focus on detailed analysis and understanding of the barrier faced by the patient and integrate them into their daily activities; additionally, providers should understand the basic nutritional needs of their patients. 5) Policy makers and planners Planner and policy maker need to address the high proportion inadequate gycemic control among type 2 diabetes patients through advocating and supporting dietary adherence which is fundamental for improving glycemic control through patients family centered model based diabetic education that consider educational status, gender and different age group and detailed written instruction like handouts/ leaflets and audio visuals as preferred by the patient 6) The Health care and professionals Health professionals should educate and empower patients to adhere to the recommended dietary and hospitals in general should improve the diabetic follow up service by making the follow up time more flexible and convenient for patients and devoting adequate time for consultation during each visit. 7)Researchers Furthermore investigation community based expermental study is needed to assess dietary adherence and Qualitative study is needed to understand reasons for non adherence inorder to enhance dietary adherence Abbreviations CI CONFIDENCE INTERVAL DM DIABETES MELLITUS EDHS ETHIOPIAN DEMOGRAPHIC HEALTH SURVEY FAO. FOOD AGRICULTURE ORGANIZATION IDF. INTERNATIONAL DIABETES FEDERATION NCD NON COMMUNICABLE DISEASES WHO. WORLD HEALTH ORGANIZATION HbA1c. HEMOGLOBIN A 1C T2DM. TYPE DIABETES MELLITUS HBM. HEALTH BELIEF MODEL PDAQ. PRECIVED DIETARY ADHERENCE QUESTIONNAIRE Declarations Ethical approval and consent to participate ; the ethical clearance was obtained from Institutional Review Board of menlik II Medical and Health Sciences college and official letters was submitted to each respective health facility.After explaining the objectives of the study, informed written consent was obtained from all mothers and caregivers, and anonymity and confidentiality of the data were kept. Respondents have the right not to participate or withdraw from the study at any stage, and all study methods were performed in accordance with the Declaration of Helsinki. Consent for publication ; Not applicable. Availability of data and materials; The data used to support the findings of this study are available from the corresponding author upon request Competing interests; The authors declare that they have no conflicts of interest Funding ; Not applicable. Author contributions; C.G; Conceptualization, Data curation, Formal analysis, Investigation, Methodology, Project administration, Resources, Software, Visualization, Writing – original draft S.G; Conceptualization, Formal analysis, Methodology, Resources, Software, Visualization, Writing and original draft D. T,Conceptualization, Formal analysis, Methodology, Software, Supervision, Writing, review & editing O.k; Conceptualization, Formal analysis, Methodology, Resources, Software, Visualization, Writing and original draft J.K,Conceptualization, Formal analysis, Methodology, Software, Supervision, Writing, review & editing M. T; Conceptualization, Formal analysis, Methodology, Software, Supervision, Writing, review & editing A.; L Conceptualization, Formal analysis, Methodology, Software, Supervision, Writing, review & editing Acknowledgements ; The authors would like to express their gratitude to respective health facility, data collectors, supervisors and study participants for their diligence and dedication in the collecting and inputting high quality data used in the study. References Diabetes DOF. DEFINITION AND DESCRIPTION OF DIABETES OTHER CATEGORIES OF GLUCOSE. 2010;33. Summary E. GLOBAL REPORT ON DIABETES EXECUTIVE SUMMARY. International Diabetes Federation 2015. IDF DIABETES ATLAS Seventh Edition 2015. Edition S, editor. 2015. IDF, 2015. DIABETES ATLAS Seventh Edition 2015. 2015. Atlas IDFD. Idf diabetes atlas. 2019. Zeru MA, Tesfa E, Mitiku AA, Seyoum A. Prevalence and risk factors of type ‑ 2 diabetes mellitus in Ethiopia : systematic review and meta ‑ analysis. 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Available from: https://doi.org/10.1038/s41598-020-71908-9 MINISTRY OF HEALTH E. Guidelines on Clinical and Programmatic Management of Major Non Communicable Diseases. 2016. Democratic F, Of R. FEDERAL DEMOCRATIC REPUBLIC OF ETHIOPIA NATIONAL NUTRITION PROGRAM 2016–2020. Ethiopian Diabetes Association. 2020; Reja A TM. taking on diabetes against all odds. Diabetes Voice. Ethiopian Diabetes Association. 2013;58(1):1–3. Tirfessa D, Abebe M, Darega J, Aboma M. Dietary practice and associated factors among type 2 diabetic patients attending chronic follow ‑ up in public hospitals , central. BMC Health Services Research [Internet]. 2023;1–13. Available from: https://doi.org/10.1186/s12913-023-10293-1 Dubale M, Gizaw K, Dessalegn D. Magnitude and predictors of poor glycemic control in patients with diabetes at Jimma Medical. Scientific Reports [Internet]. 2023;13:1–11. Available from: https://doi.org/10.1038/s41598-023-42774-y Sunuwar DR, Nayaju S, Dhungana R, Karki K, Singh M, Poudel P. Articles Effectiveness of a dietician-led intervention in reducing glycated haemoglobin among people with type 2 diabetes in Nepal : a single centre , open-label , randomised controlled trial. The Lancet Regional Health - Southeast Asia [Internet]. 2023;18:1–13. Available from: https://doi.org/10.1016/j.lansea.2023.100285 Gvozdanović Z, Farčić N, Placento H, Lovrić R, Dujmić Ž, Jurić A, et al. Diet education as a success factor of glycemia regulation in diabetes patients: A prospective study. International Journal of Environmental Research and Public Health. 2019;16(20):1–10. Luis G, Cañadas-gonz G, Romero-bejar JL, Suleiman-martos N, Arturo G, Fuente C, et al. Nursing-Intense Health Education Intervention for Persons with Type 2 Diabetes : A Quasi-Experimental Study. 2021;9:1–9. Study R, Study E. Effectiveness of A Multifactorial Intervention in Increasing Adherence to the Mediterranean Diet among Patients with Diabetes Mellitus Type 2 : A. nutrients. 2019;II:2–15. Whittemore R, Vilar-compte M, Cerda SD La, Delvy R, Jeon S, Burrola-méndez S, et al. ¡ Sí , Yo Puedo Vivir Sano con Diabetes ! A Self-Management Randomized Controlled Pilot Trial for Low-Income Adults with Type 2 Diabetes in Mexico City. Current Developments in Nutrition [Internet]. 4(5):1–8. Available from: https://doi.org/10.1093/cdn/nzaa074 Maryam Nikbina1, Mehdi Mameneh2, Mehdi Bakaeian3, Nayeb Fadaei Dehcheshmeh4 Ahmad Moradi5 , Habib Jalilian4 MJ. Effectiveness of nutrition education and counseling on metabolic control parameters of diabetes mellitus type 2 patients in primary health care centers. Clinical Diabetology. 2020;9(5):293–9. Afrasiabi F, Aeen FB, Jahromi MK. towards prevention of type 2 diabetes Applying the health belief model in identifying individual understanding towards prevention of type 2 diabetes. International Journal of Public Health Science. 2022;11(December):1267~1272. Varadaraj G, Sangeetha B, Nithiya DR, Dixit PK. Effectiveness of Medical Nutritional Therapy in the Management of Type 2 Diabetes Mellitus. 2021;69:36–9. Abdelsalam SE, Abdel M, Ismaail R, Sultan EA. The outcome of medical nutrition therapy on glycemic control among type 2 diabetic patients. Pan African Medical Journal. 2023;45:1–12. Taha NM. Impact of a health educational guidelines on the knowledge , self-management practice and self-efficacy of patients with type-2 diabetes. Journal ofNursing Education and Practice. 2016;6(9):47–55. Abbassi A. The Effect of A Therapeutic Education Program on the Feeling of Self-Efficacy , Self-Care Behaviors and Glycemic Control ( Hba1c ) in Type 2 Diabetic Patients. Journal of Advanced Practices in Nursing. 2022;7:1–5. Debussche X, Balcou-debussche M, Huiart L, Sidibe AT, Ferdynus C. Structured peer-led diabetes self- management and support in a low-income country : The ST2EP randomised controlled trial in Mali. PLOSONE. 2018;2:1–13. Muchiri JW, Gericke GJ, Rheeder P. Effect of a nutrition education programme on clinical status and dietary behaviours of adults with type 2 diabetes in a resource-limited setting in South Africa : a randomised contr ... Effect of a nutrition education programme on clinical status and diet. Public Health Nutrition ·. 2015;(June):1–14. Muchiri JW, Gericke GJ, Rheeder P. Effect of a nutrition education programme on clinical status and dietary behaviours of adults with type 2 diabetes in a resource- limited setting in South Africa : a randomised controlled trial. 2015;19(1):142–55. South-east M, Okafor CN, Onyenekwe CC, Okonkwo UP, Umunnah JO, Okoro CC, et al. Effect of Educational Intervention Program on Self-Efficacy of Individuals with Type 2 Diabetes. Nutrition and Metabolic Insights. 2023;16:1–8. Thuita AW, Kiage BN, Onyango AN, Makokha AO. Effect of a nutrition education programme on the metabolic syndrome in type 2 diabetes mellitus patients at a level 5 Hospital in Kenya : “ a randomized controlled trial .” 2020;1–14. Abdi H. ScholarWorks @ SeattleU Group-Based Diabetes Self-Management Education for Somali population with Type II Diabetes Mellitus. 2022;1–34. Syndrome M, Hailu FB, Moen A, Hjortdahl P. Diabetes Self-Management Education ( DSME ) – Effect on Knowledge , Self-Care Behavior , and Self- Ef fi cacy Among Type 2 Diabetes Patients in Ethiopia : A Controlled Clinical Trial. Diabetes, Metabolic Syndrome and Obesity. 2019;12:2489–2499. Tamiru S, Dugassa M, Amsalu B, Bidira K, Bacha L. International Journal of Africa Nursing Sciences Effects of Nurse-Led diabetes Self-Management education on Self-Care knowledge and Self-Care behavior among adult patients with type 2 diabetes mellitus attending diabetes follow up clinic : A Quasi-Experimental study design. International Journal of Africa Nursing Sciences [Internet]. 2023;18(February):100548. Available from: https://doi.org/10.1016/j.ijans.2023.100548 Eshete A, Lambebo A, Mohammed S, Shewasinad S, Assefa Y. Effect of nutritional promotion intervention on dietary adherence among type II diabetes patients in North Shoa Zone Amhara Region : quasi ‑ experimental study. Journal of Health, Population and Nutrition [Internet]. 2023;1–10. Available from: https://doi.org/10.1186/s41043-023-00393-3 Theory at a Glance. Second Edi. 2005. 1–64 p. Health Belief Model,Theoretical Constructs,TheoreticalConcept. In 2003. Asaad G, Sadegian M, Lau R, Xu Y, Soria-contreras DC. The Reliability and Validity of the Perceived Dietary Adherence Questionnaire for People with Type 2 Diabetes. nutrients. 2015;7:5484–96. American Diabetes Association Standards of Medical Care in Diabetesd2019,Diabetes Care. 42(1). Standards of Medical Care in Diabetes — 2021 Abridged for Primary Care Providers. CLINICALDIABETES. 2021;39(1). Gericke G, Rheeder P, Muchiri JW. E LEMENTS OF EFFECTIVE NUTRITION EDUCATION FOR ADULTS WITH DIABETES MELLITUS IN RESOURCE - POOR SETTINGS : A REVIEW. Interdisciplinary Health Sciences Article. 2009;14(1):156–64. Mohammad Asif. The prevention and control the type-2 diabetes by changing lifestyle and dietary pattern. Education and Health Promotion. 2014;3(January):1–8. Greca AM La, Bearman KJ. The Diabetes Social Support Questionnaire-Family Version : Evaluating Adolescents ’ Diabetes-Specific Support From Family Members. Pediatric Psychology. 2002;27(8):665–76. Worku A, Abebe SM, Wassie MM. Dietary practice and associated factors among type 2 diabetic patients : a cross sectional hospital based study , Addis Ababa , Ethiopia. 2015;1–8. Muchiri JW, Gericke GJ, Rheeder P, Africa S, Africa S, Africa S. Adapting a diabetes nutrition education programme for adults with type 2 diabetes from a primary to tertiary healthcare setting. Clinical Nutrition. 2021;34(1):9–17. DEBALKE R. NON-ADHERENCE TO DIETARY AND PHYSICAL ACTIVITY RECOMMENDATIONS AND ASSOCIATED FACTORS AMONG TYPE 2 DIABETIC PATIENTS ON FOLLOW UP IN GOVERNMENT HOSPITALS OF ILU ABBA BORA ZONE, OROMIA REGION, ETHIOPIA. BY. 2018. DEBORAH J. TOOBERT, PHD SARAH E. HAMPSON, PHD RUSSELL E. GLASGOW P, OBJECTIVE—. The Summary of Diabetes Self-Care. Epidemiology/Health Services/Psychosocial Research ORIGINAL. 2000;23(7):943–50. Fa O, Ca A, Sa A, Osibogun A. COMMUNITY MEDICINE AND PRIMARY HEALTH CARE Nutritional Knowledge , Dietary Habits and Nutritional Status of Diabetic Patients Attending Teaching Hospitals in Lagos , Nigeria. 2019;31(2):90–103. Digssie A, Abebaw S, Achaw A, Getachew H, Achamyelew B. Level of glycemic control and its associated factors among type II diabetic patients in debre tabor general hospital , northwest Ethiopia. Metabolism Open [Internet]. 2020;8:100056. Available from: https://doi.org/10.1016/j.metop.2020.100056 Berhanu H, Feyissa GT, Geleta D, Morankar S. Diabetes mellitus self-management education at Jimma University Medical Diabetes mellitus self-management education at Jimma University Medical Center : evidence-based implementation project. researchgaTE. 2022;(November 2023). Muchiri JW, Gericke GJ, Rheeder P. Impact of nutrition education on diabetes knowledge and attitudes of adults with type 2 diabetes living in a resource-limited setting in South Africa : a randomised controlled trial Impact of nutrition education on diabetes knowledge and attitudes of adults with type 2 diabetes living in a resource-limited setting in South Africa : a randomised controlled trial. Journal of Endocrinology, Metabolism and Diabetes of South Africa [Internet]. 2016;21(2):26–34. Available from: http://dx.doi.org/10.1080/16089677.2016.1200324 Geetha K, Kanniammal C. Impact of Educational Intervention on Health Behavior towards Diabetes Mellitus – A Community based Interventional Study. 2023;6(9):332–8. Raman S, Ooi GS, Ong SC. Assessing the effectiveness of health belief model-based educational interventions on weight control intentions among Malaysians. 2024;1–7. Garduno-diaz SD, Gebreyesus HA, Abreha GF. Patient-centered nutrition education improved the eating behavior of persons with uncontrolled type 2 diabetes mellitus in North Ethiopia : a quasi-experimental study. 2024;(April). Sara M, Moghimi S, Payandeh A, Ranjbaran S. Effects of Educational Interventions on Dietary Adherence among Type 2 Diabetics in Zahedan : Using the Health Action Process Approach. (1). Salahshouri A, Alavijeh FZ, Mahaki B, Mostafavi F. Effectiveness of educational intervention based on psychological factors on achieving health outcomes in patients with type 2 diabetes. Diabetology & Metabolic Syndrome [Internet]. 2018;1–12. Available from: https://doi.org/10.1186/s13098-018-0368-8 Sarani M, Heydari A, Isfahani P. Research Paper Investigating the Effects of Educational Intervention Based on the Health Belief Model in Adopting Healthy Behaviors by Type 2 Diabetic Patients in 2021. 2023;13(6):417–26. Zareban I, Niknami S, Hidarnia A. The effect of education based on health belief model on reduction of HbA1c level in diabetes type 2. 2013; Tables Table 1:Baseline socio-demographic and clinical characteristics of type II diabetes mellitus patients in Adiss Ababa, 2024. Variable N=2 28 Categories Intervention(N=114,% Contron(N=1 14,% Age of the respondent 15-47 26(22.8%) 27( 23.7%) 48-63 42(36.8%) 67(58.8%) >64 46(40.4%) 20( 17.5%) Sex of the respondent Male 56 (49.1(%) 45(39.5%) Female 58 (50.9%) 69( 60.5%) Residance Urban 99(99.1%) 80(70.2%) Rular 1(9%) 34 (29.8%) Martial status Single 23( 20.2%) 14(12.3%) Married 69( 60.5%) 89(78.1%) Separated 3(2.6%) 8( 7%) Widowed 19(16.7%) 3(2.6%) Occupation Housewife 27(23.7%) 31(27.2%) Merchant 5(4.4%) 10(8.8%) Government employees 22(19.3%) 52(45.6%) Private 43 (37.7%) 21(18.4%) Other 17( 14.9%) Monthly income 6000 65(57%) Educational status Noformal education 9 ( 7.9%) 8(7 %) Elementary 21( 18.4%) 16( 14%) High school 36(31.6%) 63(55.3%) Higher institution completed 48(42.1) 27(23.7%) Duration since diagnosis of diabetes mellitus Mean±SD) 5.31 ± 3.4 4.4 1 ± 2.7 Duration since starting DM treatment Mean±SD) 4.8 1 ± 3.5 4.1 3 ± 2.7 Family history (yes) Yes 40( 35.1%) 78 (68.4%) Table 4 is available in the Supplementary Files section. Additional Declarations No competing interests reported. Supplementary Files Table4.docx Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-6706671","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":462528951,"identity":"06513c30-02c0-4281-9cc8-4756e8bd7390","order_by":0,"name":"Chala 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participants in the study\u003c/p\u003e","description":"","filename":"Fig2Getaneh.png","url":"https://assets-eu.researchsquare.com/files/rs-6706671/v1/ba3c5fa519bb6a1b94dbd02f.png"},{"id":90893621,"identity":"8b938059-bcda-432e-8475-c88d9f5557d6","added_by":"auto","created_at":"2025-09-09 11:24:45","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":14076,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eschematic presentation of Nutriton knowledge\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"3.png","url":"https://assets-eu.researchsquare.com/files/rs-6706671/v1/51ecc535bc165f7c02745663.png"},{"id":95619648,"identity":"9e94858a-4c3a-4de6-8f35-4b7d3822f48a","added_by":"auto","created_at":"2025-11-11 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Based on the Health Belief Model\u003c/p\u003e","fulltext":[{"header":"Introduction","content":"\u003ch2\u003e1.1 Background\u0026nbsp;\u003c/h2\u003e\n\u003cp\u003eDiabetes mellitus (DM) is a metabolic disorder characterized by chronically elevated blood glucose levels resulting from defects in insulin secretion, insulin action, or both(1). It has become one of the world biggest health concern affecting both developed and developing countries \u0026nbsp;and world-wide it is ranked among one of the \u0026nbsp;four priority non-communicable diseases(2,3).\u003c/p\u003e\n\u003cp\u003eDiabetes Mellitus is increasing rapidly in the world. According to International Diabetes Federation (IDF) there were 463 million people aged 20-79 years living with diabetes globally. These numbers are predicted to rise to 642 million by 2045, with the highest increase occurring in low to middle income countries(4). In 2019 the International Diabetes Federation Africa Region (AFR) estimated that there were 19.4 million adults aged 20-79 years living with diabetes, with a regional prevalence of 3.9%(5).\u003c/p\u003e\n\u003cp\u003eThe prevalence of diabetes in Ethiopia, ranging from 2.0% to 6.5%(6). Overweight has been a major contributor of type 2 diabetes epidemic it accounts for about 90 of all diagnosed cases of diabetes in adult (7). Nearly 80% of type diabetic individuals are overweigh and Approximately 50% of new cases of type 2 diabetes can be controlled adequately by lifestyle changes (diet and exercise)(8).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe management of diabetes mellitus (DM) includes both medical care and \u0026nbsp;non-pharmacological care \u0026nbsp;such as meal planning, changes in lifestyle, education, physical activity habits, self-care by the patient. Nutrition education intervention by professional is a key component of diabetes care and diabetes management(9).Non adherence to dietary practice advice is the main challenge among Type 2 diabetic patients(10).\u003c/p\u003e\n\u003cp\u003eIn order to achieve \u0026nbsp;effective nutrition therapy each patient should adhere properly to Healthy eating habit \u0026nbsp;and weight management combined with physical activity may help to improve glycaemic level(11).Nutrition therapy is important in preventing pre diabetes,managing existing diabetes and slow the rate of development of diabetes complications(12).\u003c/p\u003e\n\u003cp\u003eA number of studies supports that type 2 diabetes is largely preventable through diet and life style adjustment. The incidence can be decreased by 25% by following lifestyle modification(13).Nutrition-related health issues have become more prevalent in the Middle East during the last two decades, causing changes that include increases in obesity and risk factors for chronic disease(14).\u003c/p\u003e\n\u003cp\u003eIn addition, excessive energy intake leads to overweight and obesity, which is linked with a range of health problems, including diabetes mellitus(15).\u003c/p\u003e\n\u003cp\u003eFAO/WHO International Conference of Nutrition indicate that unhealthy eating patterns have been increasing around the world.fat intake has been rising rapidly in lower-middle-income countries since the 1980s(16).Evidence showed that nutrition education is a cost-effective method for controlling diabetes compared to treating patients in hospitals and has been shown to improve eating behaviour and clinical outcome(17,18).Previous studies have shown that nutrition education is significantly associated with adherence to recommended dietary habits among diabetes mellitus patients in different countries(15)(16)(17)(18)(19)(20).\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;Poor nutritional knowledge and conflicting dietary recommendations On the other hand can lead to poor dietary adherence(21).\u003c/p\u003e"},{"header":"Methods and materials","content":"\u003ch2\u003eStudy area\u003c/h2\u003e\n\u003cp\u003eAddis Ababa the capital and largest city of Ethiopia. the city is divided in to 11sub-cities containing 117 woredas at which the City lies at an altitude of 7,546 feet (2,300metres). Its population of 2024 is estimated to be 5,703,628 million that resides in 11sub-cities and 117 woredas.The city has \u0026nbsp;06 public hospitals, 25 private hospitals, more than 97 health centers and about 500 clinics according to EDHS 2016. The Addis Ababa health bureau\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003eis responsible for managing Six hospitals \u0026nbsp; including Gandhi Memorial Hospital, Yekatit 12 Hospital Medical College, Zewditu Memorial, Ras-Desta Damtew Memorial, Menelik II Referral, and Tirunesh Beijing General Hospital.The study will be done in ras desta hospital, Zewditu memorial hospital,Menlik II referal hospital and yekatit 12 hospital Addis Ababa, Ethiopia. Menlik II referal hospital, yekatit 12 \u0026nbsp;Hospital, Zewditu memorial hospital and Ras Desta hospital are some of the hospitals that are capable in providing follow up service for diabetes mellitus patients.\u003c/p\u003e\n\u003ch2 id=\"_Toc187873199\"\u003eStudy design\u0026amp; Study period\u003c/h2\u003e\n\u003cp\u003eNon equivalent Control Group Pretest-Posttest quasi-experimental study was employed from May 2024 to September 2024\u003c/p\u003e\n\u003ch2 id=\"_Toc187873200\"\u003eSource Population\u003c/h2\u003e\n\u003cp\u003eThe source populations was all adult patients with Type 2 diabetes mellitus attending diabetic follow-up clinics at public hospitals in Addis Ababa from May2024 to september 2024.\u0026nbsp;\u003c/p\u003e\n\u003ch2 id=\"_Toc187873201\"\u003e\u0026nbsp;Study Population\u003c/h2\u003e\n\u003cp\u003eAll selected adult Type 2 diabetes mellitus who attended diabetic follow-up clinics at public hospitals in Addis Ababa from May2024 to september 2024 who the fulfill the iclusion Criteria.\u0026nbsp;\u003c/p\u003e\n\u003ch2 id=\"_Toc187873204\"\u003eInclusion Criteria\u003c/h2\u003e\n\u003cp\u003e- Those who are above the \u0026nbsp;age of \u0026nbsp;18 years\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e- Had a follow up in the hospital for at least 6 month\u0026nbsp;\u003c/p\u003e\n\u003ch2 id=\"_Toc187873205\"\u003eExclusion Criteria\u003c/h2\u003e\n\u003cp\u003e- those who are critically sick during the time of \u0026nbsp;data collection period.\u003c/p\u003e\n\u003cp id=\"_Toc187873206\"\u003e\u003cstrong\u003e\u0026nbsp;Sample Size Determination.\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eSample size calculation was done \u0026nbsp;using proportion (2 groups, two sided) driven by using OpenEpi (a web application used to perform statistical analysis) By assuming equal sample size number in each group, two sided 95% confidence interval (CI), and 80% power. Because of there is no previous prevalence we will take 50% and the assumption of 20% incensement after the intervention which will be 70%. Which make the Risk/Prevalence difference =20%.Hence, using the following formula, the \u0026nbsp;final sample size included in this study will be 208 by adding 10% the total final 228(114 for intervention and 114 for control group) Type 2 diabetes mellitus patients.\u003c/p\u003e\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"3\"\u003e\n \u003cp\u003eTwo-sided significance level(1-alpha):\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e95\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"3\"\u003e\n \u003cp\u003ePower(1-beta, % chance of detecting):\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e80\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"3\"\u003e\n \u003cp\u003eRatio of sample size, Unexposed/Exposed:\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"3\"\u003e\n \u003cp\u003ePercent of Unexposed with Outcome:\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e50\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"3\"\u003e\n \u003cp\u003ePercent of Exposed with Outcome:\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e70\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"3\"\u003e\n \u003cp\u003eOdds Ratio:\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e2.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"3\"\u003e\n \u003cp\u003eRisk/Prevalence Ratio:\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e1.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"3\"\u003e\n \u003cp\u003eRisk/Prevalence difference:\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e20\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"4\"\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eKelsey\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eFleiss\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eFleiss with CC\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"4\"\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eSample Size - Exposed\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e95\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e94\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e104\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eSample Size-Nonexposed\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e95\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e94\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e104\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"4\"\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eTotal sample size:\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e190\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e188\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e208\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cstrong\u003eBy Adding 10% non response rate n= the final Sample size will be (n) =228\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eEpi info out put for Sample size calculation using proportion (2 groups, two sided)\u003c/p\u003e\n\u003ch2 id=\"_Toc187873207\"\u003e 4.8 Sampling technique \u003c/h2\u003e\n\u003cp\u003eA Multi stage sampling procedure was employed. There are available six hospitals from six Hospitals four hospitals was selected which are under Addis Ababa Health Bureau and from those four Hospitals twl hospitals was the intervention and two was the control group. Yekatit 12 Hospitals Medical College and Zewditu Memorial hospital,Ras desta Damtew memorial hospital, Menlik II referall hospital was selected by a Lottery Method. The total sample size of 228 was allocated to each hospital proportionally to the number of patients in each hospital.\u003c/p\u003e\n\u003ch2\u003e Data collection tool and technique \u003c/h2\u003e\n\u003cp\u003eSocioeconomic and demographic information was collected only at baseline. Health Belief Model constructs, nutrition knowledge, and dietary adhrence measured twice baseline and end line after nutrition education. \u003c/p\u003e\n\u003cp\u003eNutrition Knowledge was assessed using eight questions that were adopted from other literature and contextualized into the local context. Each question was answered using the “Yes”, “No” and “I don’t know” options. A correct answer (“Yes”) was assigned 1 point and an incorrect//unknown answer (“No” and “I don’t know”) were assigned 0 points. The total score for each patient on the eight questions was calculated and changed to percentage. After that the score of each participant was changed into a three-category response based on modified Bloom’s cut-off point, as adequate (if score was between 80 and 100%), moderate (if the score was between 60 and 79.9%), and inadequate (if the score was less than 60%) knowledge.\u003c/p\u003e\n\u003cp\u003eDietary data was collected by asking participants nine health questions based on the Perceived Dietary Adherence Questionnaire (PDAQ). Responses was recorded in days based on a 7-Likert scale. Higher values indicate higher compliance. Patients who reported 4 to 7 days was classified as practicing good eating habits, while, less than four days were classified as poor dietary practices(61).\u003c/p\u003e\n\u003cp\u003eItems of Health Belief Model constructs was measured using five-point likert scale (strongly agree = 5; through strongly disagree =1). )Then, the value of each likert scale scored by participants for each question was summed and the average was calculated.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eOperational definition \u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDiet : \u003c/strong\u003erefers to the recommended diet for people with DM who should ate small meals spread throughout the day (at least 5/day), ate fruits and vegetables daily, and ate foods high in fibers and whole grain but low in fats, sugars and carbohydrates that have high glycemic index(69)\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAdherence :\u003c/strong\u003e Participants were asked about how many of the last 7 days they participated in healthy diet eating habits.those who scored the mean and above the overall dietary recommendation score is Adherent to dietary recommendation and those who scored below the overall mean dietary recommendation score is Non Adherent to dietary recommendation(64,66).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eNutritional \u003c/strong\u003e\u003cstrong\u003eknowledge\u003c/strong\u003e: Knowledge was assessed using eight questions and the total response was classified in to three groups based on the modified Bloom’s cut-off point as adequate (80-100%), moderate (60-79.9%) and inadequate (\u0026lt;60%) knowledge(71,(72)\u003c/p\u003e\n\u003cp\u003eProcedure of follow up and intervention \u003c/p\u003e\n\u003cp\u003eAfter collecting relevant baseline data from both groups, education was given every 15 days for 3 month For intervention group, education was given by two nutritonist based on Health Belief Model theory:\u003c/p\u003e\n\u003cp\u003e(1) susceptibility of the disease due to inappropriate dietary practices nutrient deficiency or over nutrient intake; (2) severity of the disease; (3) benefits of right eating or dietary practices to improve nutritional status and health, (4) barriers to practice appropriate good dietary practices; (5) self-confidence/efficacy to follow right dietary practices. \u003c/p\u003e\n\u003cp\u003eThe first and second intervention sessions focused on the overview and basic concepts of DM, including risk factors, diagnosis, symptoms, complications, and treatment of type II patients. The goal of this session was to create awareness of patient on how to take action.\u003c/p\u003e\n\u003cp\u003eThe 3rd and 4th sessions was adress management of type 2 diabetes mellitus according to national and international guidelines. The aim of this session was to encourage behaviour change the session was including a varied and balanced diet, how to reduce unhealthy eating habits, and how to replace foods not recommended for people with diabetes with recommended foods, healthy eating habits, how to prepare and cook healthy food(65,66, 67,68).\u003c/p\u003e\n\u003cp\u003eThe fifth session focused on adherence to recommended dietary recommendations, development of a healthy eating plan, and clinical monitoring The goal of this session on lifestyle change counselling and behavioural change(69,70,71,72).\u003c/p\u003e\n\u003cp\u003eThe education was provided using theoretical session, poster, flipchart, and whiteboard in a small group format (8 to 10 patients) every 15 days for one and a half hours for five consecutive months from May,2024 to september 30,2024. after they received their usual care. \u003c/p\u003e\n\u003cp\u003eA control group did not receive any specifc Education intervention during follow-up. Control patients received usual care according to national guidelines for non-communicable diseases then a Three-month follow-up was done without providing any additional nutrition education.\u003c/p\u003e\n\u003ch2 id=\"_Toc187873225\"\u003e Data analysis\u003c/h2\u003e\n\u003cp\u003eThe data were entered using the Kobo Toolbox and exported to SPSS version 25 for analysis. Continuous data was checked for normality using the Kolmogrov–Smirnov test.Descriptive statistics such as the mean±standard deviation and percentage was generated.Comparisons between groups was performed using paired-samples t tests to assess the Effect of educational intervention on Dietary Adherence. At 95% confidence level, value with p-values less than 0.05 was considered signifcant for all statistical tests. \u003c/p\u003e\n"},{"header":"Results","content":"\u003cp\u003eSociodemographic and clinical characteristics of the study participants\u003c/p\u003e\n\u003cp id=\"_Toc187873230\"\u003eA total of 228 type II diabetes patients participated in the study.The majority of study participants in both groups were female 58 (50.9%) and 69( 60.5%),being married 69( 60.5%) and 89(78.1%),and aged 48 to 63 years respectively. Of the 228 participants 99(99.1%) in the intervention group and 80(70.2%) in the control group were from Urban area. Most of the study participants in both groups work as government employee. Moreover 36(31.6%)of the participants in the intervention group and 63(55.3%)participants in the control group were high school completed.The mean duration since diagnosis of DM was 5.31\u0026plusmn;3.4years and 4.41\u0026plusmn;2.7 years in intervention and control groups, respectively(Table 1)\u0026nbsp;\u003c/p\u003e\n\u003cp id=\"_Toc187873231\"\u003eNutritional Knowledge of type II diabetes mellitus patients before and after educational intervention.\u003c/p\u003e\n\u003cp\u003eA total of 9(7.9%) patients had adequate knowledge regarding the recommended dietary practices for individuals with T2DM, 22(19.3%) had moderate knowledge, and the remaining 83 (72.8%) had inadequate knowledge from the intervention group before educational intervention (baseline).\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;A total of 14(12.3%) patients had adequate knowledge regarding the recommended dietary practices for individuals with T2DM, 18(15.8%) had moderate knowledge, and the remaining 82 (71.9%) had inadequate knowledge from the control group before educational intervention (baseline).\u003c/p\u003e\n\u003cp\u003eAfter the educational intervention (end-line) 65(57.0%) patients had adequate knowledge, 37(32.5%)had moderate knowledge,12(10.5%) had inadequate knowledge from the intervention group,while 23(20.2%)patients had adequate knowledge,8(7%) had moderate and 83(70.8%)had inadequate knowledge,respectively from the control group after educational intervention( end-line)(figure 5)\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;Thus, the result of this study revealed that there was an improvement in the knowledge of participants after educational intervention in the intervention group when compared to the control group.Accordingly, there was no statistically \u0026nbsp;significant mean score difference on the Nutritional Knowledge at baseline,between the two groups P=( 0. 116) but the difference was highly significant (P \u0026lt; 0.001) at the end of nutrition education. The paired t-test indicated that the mean nutritional knowledge score was highly significantly improved (P \u0026lt; 0.001) from 1.35 to 2.46 in intervention group(Table 2).\u003c/p\u003e\n\u003cp id=\"_Toc187873232\"\u003eEffect of nutritional expert led education on dietary adherence of type II diabetes mellitus patients before and after educational intervention.\u003c/p\u003e\n\u003cp\u003eAt baseline, there was no statistically signifcant diference in the mean score of dietary adherence between intervention and control group(2.8324 \u0026plusmn; .54458 \u0026nbsp;vs 2.8567\u0026plusmn; .1.75786) Afer the implementation of the educational intervention a paired t-test indicated a \u0026nbsp;difference in mean score of \u0026nbsp;adherence level in the intervention group signifcantly increased from the baseline (p=\u0026lt;0.001) from 2.8324 to 5.8002 (Table 3 ).\u003c/p\u003e\n\u003cp id=\"_Toc187873233\"\u003eHealth belief model construct scores\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAt baseline, there was no signifcant diference in the HBM construct scores between the intervention and control groups.\u003c/p\u003e\n\u003cp\u003eThe mean and standard deviation (SD) of Health Belief Model (HBM) constructs subscale are shown in (Table 4).Except perceiving \u0026nbsp;barrier, which was decreased The meanscore of all Health Belief Model constructs were increased.The paired t-test indicated that there was highly significant difference (P \u0026lt; 0.001) between pre- and post nutrition education intervention mean of \u0026nbsp; Health Belief Model constructs score in intervention group (Table 4)\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThe finding supports the effectiveness of nutrition expert-led education to enhance dietary adherence based on Health Belief Model (HBM) to improve the nutrition knowledge and dietary Adhrence \u0026nbsp;of type II DM patients through increasing perceived severity, susceptibility,benefits, self-efficacy, and decreasing perceived barriers.\u003c/p\u003e\n\u003cp\u003eAccordingly the present study revealed that there was no statistically significant mean score difference on the nutrition knowledge at baseline between the intervention 1.35 and \u0026nbsp;1.40 control groups,respectively. But at the end line, the intervention group had a greater mean dietary knowledge score compared to that of the comparison group \u0026nbsp;2.46 \u0026plusmn; .681(p \u0026lt; 0.01).\u003c/p\u003e\n\u003cp\u003eThis result is consistant with previous study in Jimma reveled that educational programm offer for T2DM patients improve dietary knowledge(73).Similar quasi expermental study conducted at public hospitals in the Ilu Aba Bor and Buno Bedelle zones of southwest Ethiopiaa significant improvement in the mean score of knowledge and s after nurse-led Diabetic self management education(57).\u003c/p\u003e\n\u003cp\u003ean interventional study finding from south Africa \u0026nbsp;add to the evidence that intervention improved the knowledge of diabetes significantly from baseline to post-intervention(74).Similarly,results are in agreement with india studies done in people with T2DM. These results add to the evidence that Nutrition education programme significantly improved knowledge of diet(75).Another similar result from malasia support the result of this study educational intervention was effective in improving knowledge(76).\u003c/p\u003e\n\u003cp\u003eA possible explanation for these fndings is that to frequent education and follow-up during intervention period as human behavior can be changed by well-designed adequate nutritional education, which ultimately leads to improvements in nutritional status and better health.\u003c/p\u003e\n\u003cp\u003eIn this study, the nutrition expert education intervention program signifcantly increased the overall mean number of days adhering to a healthy diet. After the educational intervention, the mean days of adherence to a healthy diet increased in the intervention group compared to the control group, with a signifcant diference (p\u0026lt;0.0001).\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;This fnding was supported by previous studie in Mekelle general Hospital and Adigrat General Hospital in Ethiopia where they suggested that Patient-centered nutrition education has resulted in positive adjustments in the eating behavior of people with type 2 diabetes(77).\u003c/p\u003e\n\u003cp id=\"_Toc187873236\"\u003eThe finding was also in agreement with another Another quasi expermental study conducted in Ethiopia North shoa which suggest that a nutritional intervention program could signifcantly increase the overall mean number of days of adherence to a healthy diet(58)similar\u0026nbsp;study also support the result of this study which conclude educational intervention have a significant impact on the patients\u0026apos; selfcare of dietary adherence following the training(78).on contrary a study from kenya support the result of this study by concluding nutrition education and other health education improve dietary adhrence of type II diabetes patients(54).\u003c/p\u003e\n\u003cp\u003ethe finding is consistant with previous study that support the efectiveness of educational intervention related to adherence to a diabetic diet on improved performance of patients with T2DM(79)\u003cspan id=\"_Toc187873238\"\u003e.Similar\u0026nbsp;\u003c/span\u003eevidence from iran support the result of this study educational programs based on the health belief model constructs over 3 and 6 months in adopting healthy dietary adherence behavior(80).\u003c/p\u003e\n\u003cp id=\"_Toc187873239\"\u003eFor Health Belief Model the study revealed that except perceived barriers which were decreased, all the other mean Health Belief Model scores significantly increased after nutrition education in experimental group. The perceived barriers were decreased in this study This fnding is consistent with the fndings of other studies(78,79).\u003c/p\u003e\n\u003cp id=\"_Toc187873240\"\u003ePerceived barriers are ofen the most predictive constructs and are ofen more difcult to change than other constructs; therefore, more attention needs to be given to perceived barriers. Addressing perceived barriers ofen requires considering and addressing the broader context in which the behavior occurs. Perceived barriers are infuenced by various contextual factors, such as social, cultural, economic, and environmental factors.\u003c/p\u003e\n\u003cp\u003eOn the contrary, the higher improvement of dietary adherence in the intervention group might be explained by higher impact of Health Belief Models by increasing perceived susceptibility, severity, benefits, self-efficacy, and decreased perceived barriers to \u0026nbsp;appropriate dietary adherence \u0026nbsp;and improvement in nutritional knowledge. Patients ,who fear for severity of diabetes, understand the benefits of practicing good nutrition for improvement of there health, and have ability to act on good nutritional activities, were more likely to practice good nutrition and eating habits.\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;Similarly, patients exposed to nutrition information could follow good nutrition practices since research evidence suggested that those who exposed to nutrition information were more likely to practice good dietary practices .\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eKnowledge on severity and susceptibility of patient to diabetes mellitus and poor health outcomes as they are likely to be more sensitive to there health condition and follow appropriate dietary pattern. And \u0026nbsp;the use of \u0026nbsp;counseling technique, teaching aids such as leafets, \u0026nbsp;and providing Nutrition expert -based nutrition education\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003eStrength of the study\u003c/p\u003e\n\u003cp\u003e- since there is no similarly study in the study setup it makes \u0026nbsp;a new study.\u003c/p\u003e\n\u003cp\u003e- The study design that was used is strong and generate strong cause effect relationship so the result of the study is generalizeable to the general population.\u003c/p\u003e\n\u003cp\u003e- The period of observation is long whene compared to other studies conducted in different region of Ethiopia .\u003c/p\u003e\n\u003cp id=\"_Toc187873242\"\u003e\u0026nbsp;Limitation of the study\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e- Findings were based on patient responses to assessments of dietary changes that contribute to information bias.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e- Whene people know as they are observed theye may change there practice \u0026nbsp;from the routine so observer and \u0026nbsp;social desirability bias may have infuenced the results\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThis study found that a nutritional intervention program could signifcantly increase the overall mean of adherence to a healthy diet . After the educational intervention, the mean \u0026nbsp; of dietary knowledge in the intervention group (2.46\u0026plusmn; .681) compared to thecontrolgroup (1.40 \u0026plusmn; .806) and adherence to a healthy diet increased \u0026nbsp;in the intervention group (5.8002 \u0026nbsp;\u0026plusmn; .31813) compared to the \u0026nbsp;control group (2.9142\u0026plusmn; 1.18533), with a signifcant diference (p\u0026lt;0.0001). Hence, delivering nutrition education based on Heath Belief Model can be appropriate tool to improve nutritional knowledge, and dietary adhrence of typeII diabetes patients.\u003c/p\u003e\n\u003ch2 id=\"_Toc187873245\"\u003eRecommendations\u003c/h2\u003e\n\u003cp\u003eIn summary, policy makers and health car providers are focusing on the following key program areas:\u003c/p\u003e\n\u003cp\u003e1) The government \u0026nbsp;include Health Belief Model constructs in national nutrition education guidelines and Nutritional health promotion programs should be integrated into existing systems as a common therapeutic service/treatment tool to bring change in nutritional knowledge and dietary Adhrence of type II diabetes patients..\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e2) The governmental, nongovernmental organization should include Health Belief Model to Design diferent strategies in order to \u0026nbsp;create health promotion programs to reach large communities in need using a wide range of learning strategies.\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;3) Assign health promoters to provide and design health education programs on nutritional advice recommended as routine care in hospitals and health centers diabetic follow-up clinics.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e4) Focus on detailed analysis and understanding of the barrier faced by the patient and integrate them into their daily activities; additionally, providers should understand the basic nutritional needs of their patients.\u003c/p\u003e\n\u003cp\u003e5) Policy makers and planners\u0026nbsp;\u003c/p\u003e\n\u003cp\u003ePlanner and policy maker need to address the high proportion inadequate gycemic control among type 2 diabetes patients through advocating and supporting dietary adherence which is fundamental for improving glycemic control through patients family centered model based diabetic education that consider educational status, gender and different age group and detailed written instruction like handouts/ leaflets and audio visuals as preferred by the patient\u003c/p\u003e\n\u003cp\u003e6) The Health care and professionals\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eHealth professionals should educate and empower patients to adhere to the recommended dietary and hospitals in general should improve the diabetic follow up service by making the follow up time more flexible and convenient for patients and devoting adequate time for consultation during each visit.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e7)Researchers Furthermore investigation community based expermental study is needed to assess dietary adherence and Qualitative study is needed to understand reasons for non adherence inorder to enhance dietary adherence \u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eCI CONFIDENCE INTERVAL \u003c/p\u003e\n\n\u003cp\u003eDM DIABETES MELLITUS\u003c/p\u003e\n\n\u003cp\u003eEDHS ETHIOPIAN DEMOGRAPHIC HEALTH SURVEY \u003c/p\u003e\n\n\u003cp\u003eFAO. FOOD AGRICULTURE ORGANIZATION \u003c/p\u003e\n\n\u003cp\u003eIDF. INTERNATIONAL DIABETES FEDERATION \u003c/p\u003e\n\n\u003cp\u003eNCD NON COMMUNICABLE DISEASES \u003c/p\u003e\n\n\u003cp\u003eWHO. WORLD HEALTH ORGANIZATION\u003c/p\u003e\n\n\u003cp\u003eHbA1c. HEMOGLOBIN A 1C \u003c/p\u003e\n\n\u003cp\u003eT2DM. TYPE DIABETES MELLITUS \u003c/p\u003e\n\n\u003cp\u003eHBM. HEALTH BELIEF MODEL \u003c/p\u003e\n\n\u003cp\u003ePDAQ. PRECIVED DIETARY ADHERENCE QUESTIONNAIRE\u003c/p\u003e\n"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthical\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003eapproval and consent to participate\u003c/strong\u003e\u003cstrong\u003e;\u0026nbsp;\u003c/strong\u003ethe ethical \u0026nbsp; clearance was obtained from Institutional Review Board of menlik II Medical and Health Sciences college and official letters was submitted to each respective health facility.After explaining the objectives of the study, informed written consent was obtained from all mothers and caregivers, and anonymity and confidentiality of the data were kept. Respondents have the right not to participate or withdraw from the study at any stage, and all study methods were performed in accordance with the Declaration of Helsinki.\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003cstrong\u003eConsent for publication\u003c/strong\u003e; Not applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials;\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003eThe data used to support the findings of this study are available from the corresponding author upon request\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests;\u003c/strong\u003e The authors declare that they have no conflicts of interest\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e; Not applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor contributions;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eC.G; Conceptualization, Data curation, Formal analysis, Investigation, Methodology, Project administration, Resources, Software, Visualization, Writing \u0026ndash; original draft\u003c/p\u003e\n\u003cp\u003eS.G; Conceptualization, Formal analysis, Methodology, Resources, Software, Visualization, Writing and original draft\u003c/p\u003e\n\u003cp\u003eD. T,Conceptualization, Formal analysis, Methodology, Software, Supervision, Writing, review \u0026amp; editing\u003c/p\u003e\n\u003cp\u003eO.k; Conceptualization, Formal analysis, Methodology, Resources, Software, Visualization, Writing and original draft\u003c/p\u003e\n\u003cp\u003eJ.K,Conceptualization, Formal analysis, Methodology, Software, Supervision, Writing, review \u0026amp; editing\u003c/p\u003e\n\u003cp\u003eM. T; Conceptualization, Formal analysis, Methodology, Software, Supervision, Writing, review \u0026amp; editing\u003c/p\u003e\n\u003cp\u003eA.; L Conceptualization, Formal analysis, Methodology, Software, Supervision, Writing, review \u0026amp; editing\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003cstrong\u003e;\u003c/strong\u003eThe authors would like to express their gratitude to respective health facility, data collectors, supervisors and study participants for their diligence and dedication in the collecting and inputting high quality data used in the study.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eDiabetes DOF. DEFINITION AND DESCRIPTION OF DIABETES OTHER CATEGORIES OF GLUCOSE. 2010;33. \u003c/li\u003e\n\u003cli\u003eSummary E. GLOBAL REPORT ON DIABETES EXECUTIVE SUMMARY. \u003c/li\u003e\n\u003cli\u003eInternational Diabetes Federation 2015. IDF DIABETES ATLAS Seventh Edition 2015. 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The Reliability and Validity of the Perceived Dietary Adherence Questionnaire for People with Type 2 Diabetes. nutrients. 2015;7:5484\u0026ndash;96. \u003c/li\u003e\n\u003cli\u003eAmerican Diabetes Association Standards of Medical Care in Diabetesd2019,Diabetes Care. 42(1). \u003c/li\u003e\n\u003cli\u003eStandards of Medical Care in Diabetes \u0026mdash; 2021 Abridged for Primary Care Providers. CLINICALDIABETES. 2021;39(1). \u003c/li\u003e\n\u003cli\u003eGericke G, Rheeder P, Muchiri JW. E LEMENTS OF EFFECTIVE NUTRITION EDUCATION FOR ADULTS WITH DIABETES MELLITUS IN RESOURCE - POOR SETTINGS : A REVIEW. Interdisciplinary Health Sciences Article. 2009;14(1):156\u0026ndash;64. \u003c/li\u003e\n\u003cli\u003eMohammad Asif. The prevention and control the type-2 diabetes by changing lifestyle and dietary pattern. Education and Health Promotion. 2014;3(January):1\u0026ndash;8. \u003c/li\u003e\n\u003cli\u003eGreca AM La, Bearman KJ. The Diabetes Social Support Questionnaire-Family Version : Evaluating Adolescents \u0026rsquo; Diabetes-Specific Support From Family Members. Pediatric Psychology. 2002;27(8):665\u0026ndash;76. \u003c/li\u003e\n\u003cli\u003eWorku A, Abebe SM, Wassie MM. Dietary practice and associated factors among type 2 diabetic patients : a cross sectional hospital based study , Addis Ababa , Ethiopia. 2015;1\u0026ndash;8. \u003c/li\u003e\n\u003cli\u003eMuchiri JW, Gericke GJ, Rheeder P, Africa S, Africa S, Africa S. Adapting a diabetes nutrition education programme for adults with type 2 diabetes from a primary to tertiary healthcare setting. Clinical Nutrition. 2021;34(1):9\u0026ndash;17. \u003c/li\u003e\n\u003cli\u003eDEBALKE R. NON-ADHERENCE TO DIETARY AND PHYSICAL ACTIVITY RECOMMENDATIONS AND ASSOCIATED FACTORS AMONG TYPE 2 DIABETIC PATIENTS ON FOLLOW UP IN GOVERNMENT HOSPITALS OF ILU ABBA BORA ZONE, OROMIA REGION, ETHIOPIA. BY. 2018. \u003c/li\u003e\n\u003cli\u003eDEBORAH J. TOOBERT, PHD SARAH E. HAMPSON, PHD RUSSELL E. GLASGOW P, OBJECTIVE\u0026mdash;. The Summary of Diabetes Self-Care. Epidemiology/Health Services/Psychosocial Research ORIGINAL. 2000;23(7):943\u0026ndash;50. \u003c/li\u003e\n\u003cli\u003eFa O, Ca A, Sa A, Osibogun A. COMMUNITY MEDICINE AND PRIMARY HEALTH CARE Nutritional Knowledge , Dietary Habits and Nutritional Status of Diabetic Patients Attending Teaching Hospitals in Lagos , Nigeria. 2019;31(2):90\u0026ndash;103. \u003c/li\u003e\n\u003cli\u003eDigssie A, Abebaw S, Achaw A, Getachew H, Achamyelew B. Level of glycemic control and its associated factors among type II diabetic patients in debre tabor general hospital , northwest Ethiopia. Metabolism Open [Internet]. 2020;8:100056. Available from: https://doi.org/10.1016/j.metop.2020.100056\u003c/li\u003e\n\u003cli\u003eBerhanu H, Feyissa GT, Geleta D, Morankar S. Diabetes mellitus self-management education at Jimma University Medical Diabetes mellitus self-management education at Jimma University Medical Center : evidence-based implementation project. researchgaTE. 2022;(November 2023). \u003c/li\u003e\n\u003cli\u003eMuchiri JW, Gericke GJ, Rheeder P. Impact of nutrition education on diabetes knowledge and attitudes of adults with type 2 diabetes living in a resource-limited setting in South Africa : a randomised controlled trial Impact of nutrition education on diabetes knowledge and attitudes of adults with type 2 diabetes living in a resource-limited setting in South Africa : a randomised controlled trial. Journal of Endocrinology, Metabolism and Diabetes of South Africa [Internet]. 2016;21(2):26\u0026ndash;34. Available from: http://dx.doi.org/10.1080/16089677.2016.1200324\u003c/li\u003e\n\u003cli\u003eGeetha K, Kanniammal C. Impact of Educational Intervention on Health Behavior towards Diabetes Mellitus \u0026ndash; A Community based Interventional Study. 2023;6(9):332\u0026ndash;8. \u003c/li\u003e\n\u003cli\u003eRaman S, Ooi GS, Ong SC. Assessing the effectiveness of health belief model-based educational interventions on weight control intentions among Malaysians. 2024;1\u0026ndash;7. \u003c/li\u003e\n\u003cli\u003eGarduno-diaz SD, Gebreyesus HA, Abreha GF. Patient-centered nutrition education improved the eating behavior of persons with uncontrolled type 2 diabetes mellitus in North Ethiopia : a quasi-experimental study. 2024;(April). \u003c/li\u003e\n\u003cli\u003eSara M, Moghimi S, Payandeh A, Ranjbaran S. Effects of Educational Interventions on Dietary Adherence among Type 2 Diabetics in Zahedan : Using the Health Action Process Approach. (1). \u003c/li\u003e\n\u003cli\u003eSalahshouri A, Alavijeh FZ, Mahaki B, Mostafavi F. Effectiveness of educational intervention based on psychological factors on achieving health outcomes in patients with type 2 diabetes. Diabetology \u0026amp; Metabolic Syndrome [Internet]. 2018;1\u0026ndash;12. Available from: https://doi.org/10.1186/s13098-018-0368-8\u003c/li\u003e\n\u003cli\u003eSarani M, Heydari A, Isfahani P. Research Paper Investigating the Effects of Educational Intervention Based on the Health Belief Model in Adopting Healthy Behaviors by Type 2 Diabetic Patients in 2021. 2023;13(6):417\u0026ndash;26. \u003c/li\u003e\n\u003cli\u003eZareban I, Niknami S, Hidarnia A. The effect of education based on health belief model on reduction of HbA1c level in diabetes type 2. 2013; \u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003eTable 1:Baseline\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;socio-demographic and clinical characteristics of type II diabetes mellitus patients in Adiss Ababa, 2024.\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"660\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 159px;\"\u003e\n \u003cp\u003eVariable N=2 28\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003eCategories\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 149px;\"\u003e\n \u003cp\u003eIntervention(N=114,%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 139px;\"\u003e\n \u003cp\u003eContron(N=1 14,%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 159px;\"\u003e\n \u003cp\u003eAge of the respondent\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003e15-47\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 149px;\"\u003e\n \u003cp\u003e26(22.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 139px;\"\u003e\n \u003cp\u003e27( 23.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 159px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003e48-63\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 149px;\"\u003e\n \u003cp\u003e42(36.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 139px;\"\u003e\n \u003cp\u003e67(58.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 159px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003e\u0026gt;64\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 149px;\"\u003e\n \u003cp\u003e46(40.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 139px;\"\u003e\n \u003cp\u003e20( 17.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 159px;\"\u003e\n \u003cp\u003eSex of the respondent\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; Male\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 149px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;56 (49.1(%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 139px;\"\u003e\n \u003cp\u003e45(39.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 159px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; Female\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 149px;\"\u003e\n \u003cp\u003e58 (50.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 139px;\"\u003e\n \u003cp\u003e69( 60.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 159px;\"\u003e\n \u003cp\u003eResidance\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; Urban\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 149px;\"\u003e\n \u003cp\u003e99(99.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 139px;\"\u003e\n \u003cp\u003e80(70.2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 159px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; Rular\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 149px;\"\u003e\n \u003cp\u003e1(9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 139px;\"\u003e\n \u003cp\u003e34 (29.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 159px;\"\u003e\n \u003cp\u003eMartial status\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;Single\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 149px;\"\u003e\n \u003cp\u003e23( 20.2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 139px;\"\u003e\n \u003cp\u003e14(12.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 159px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;Married\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 149px;\"\u003e\n \u003cp\u003e69( 60.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 139px;\"\u003e\n \u003cp\u003e89(78.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 159px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;Separated\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 149px;\"\u003e\n \u003cp\u003e3(2.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 139px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; 8( 7%)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 159px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;Widowed\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 149px;\"\u003e\n \u003cp\u003e19(16.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 139px;\"\u003e\n \u003cp\u003e\u0026nbsp; 3(2.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 159px;\"\u003e\n \u003cp\u003eOccupation\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; Housewife\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 149px;\"\u003e\n \u003cp\u003e27(23.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 139px;\"\u003e\n \u003cp\u003e31(27.2%)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 159px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; Merchant\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 149px;\"\u003e\n \u003cp\u003e5(4.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 139px;\"\u003e\n \u003cp\u003e10(8.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 159px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; Government employees\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 149px;\"\u003e\n \u003cp\u003e22(19.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 139px;\"\u003e\n \u003cp\u003e52(45.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 159px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003ePrivate\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 149px;\"\u003e\n \u003cp\u003e\u0026nbsp; 43 (37.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 139px;\"\u003e\n \u003cp\u003e21(18.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 57px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 159px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003eOther\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 149px;\"\u003e\n \u003cp\u003e17( 14.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 139px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 57px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 159px;\"\u003e\n \u003cp\u003eMonthly income\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003e\u0026lt;1500\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 149px;\"\u003e\n \u003cp\u003e4(3.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 139px;\"\u003e\n \u003cp\u003e66(57.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 57px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 159px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003e1501- 6000\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 149px;\"\u003e\n \u003cp\u003e45(39.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 139px;\"\u003e\n \u003cp\u003e48(42.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 57px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 159px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003e\u0026gt;6000\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 149px;\"\u003e\n \u003cp\u003e65(57%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 139px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 57px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 159px;\"\u003e\n \u003cp\u003eEducational status\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003eNoformal education\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 149px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;9 ( 7.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 139px;\"\u003e\n \u003cp\u003e8(7 %)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 57px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 159px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003eElementary\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 149px;\"\u003e\n \u003cp\u003e21( 18.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 139px;\"\u003e\n \u003cp\u003e16( 14%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 57px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 159px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003eHigh school\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 149px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;36(31.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 139px;\"\u003e\n \u003cp\u003e63(55.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 57px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 159px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003eHigher institution completed\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 149px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; 48(42.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 139px;\"\u003e\n \u003cp\u003e27(23.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 57px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 159px;\"\u003e\n \u003cp\u003eDuration since diagnosis of diabetes mellitus Mean\u0026plusmn;SD)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 149px;\"\u003e\n \u003cp\u003e5.31\u0026nbsp;\u0026plusmn;\u0026nbsp;3.4\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 139px;\"\u003e\n \u003cp\u003e4.4 1 \u0026plusmn; 2.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 57px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 159px;\"\u003e\n \u003cp\u003eDuration since starting DM treatment Mean\u0026plusmn;SD)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 149px;\"\u003e\n \u003cp\u003e4.8 1 \u0026plusmn; 3.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 139px;\"\u003e\n \u003cp\u003e4.1 3 \u0026plusmn; 2.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 57px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 159px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eFamily history (yes)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 149px;\"\u003e\n \u003cp\u003e40( 35.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 139px;\"\u003e\n \u003cp\u003e78 (68.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 57px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u0026nbsp;\u003cimg src=\"data:image/png;base64,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\"\u003e\u003c/p\u003e\n\u003cp\u003eTable 4 is available in the Supplementary Files section.\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Ethiopia, diabetes Mellitus, dietary Adhrence","lastPublishedDoi":"10.21203/rs.3.rs-6706671/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6706671/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eINTRODUCTION;Type 2 Diabetes Mellitus (T2D), is Aa Life-Threatening Condition Of Public Health Concern. it worsens acute and Chronic complications. However, lifestyle interventions reduce the risk of both acute and chronic complications, and nutrition education can empower individuals on the appropriate metabolic control, global lifestyle changes and optimize quality of life.\u003c/p\u003e\n\u003cp\u003eOBJECTIVE; The study was to assess the effect of nutrtion educational intervention to enhance dietary adherence among type II diabetes mellitus patients.\u003c/p\u003e\n\u003cp\u003eMETHOD; A quasi- experimental study was conducted By Allocating Hospitals Into An Intervention that Was Receive Nutrition Education against Controls That Would Receive The Routine Service. Data was measured twice (baseline and end line survey after twelveweek.The data was collected using kobo toolbox.The collected data was exported to Spss version 25 Continuous variables was presented as the mean± standard deviation and categorical variables presented as percentages. Comparisons between groups was performed using paired-samples t tests to assess the Effect of educational intervention on Dietary Adherence. At 95% confidence level, value with p-values less than 0.05 was considered signifcant for all statistical tests.\u003c/p\u003e\n\u003cp\u003eResult. The mean pre- and postintervention nutritional knowledge was 1.35 and 2.46 and Dietary Adherence was 2.8324 And 5.8002 in intervention group, respectively. The increase in mean nutritional knowledge and dietary adherence was statistically significant (P \u0026lt; 0.001). In control group, the pre- and postintervention mean nutritional knowledge was 1.40 and 1.40 and good dietary Adherence was,2.8567 and 2.9142 respectively. but the difference was not significant (P \u0026gt; 0.05) .There was significant (P \u0026lt; 0.001) improvement in the scores of HBM constructs in intervention group.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eConclusion and Recommendations. Providing nutrition education based on Health Belief Model improves nutritional knowledge and dietary adherence of type II diabetes mellitus patients. Hence, governmental, nongovernmental organization, and health-care provider should include Health Belief Model construct into existing nutrition education programs. Moreover, government should incorporate HBM theory into national nutrition education guidelines.\u003c/p\u003e","manuscriptTitle":"Effect of Nutrition Education to Enhance Dietary Adherence Among Type II Diabetes Mellitus Patients Attending Diabetic follow-up Clinics in Addis Ababa: A Multi-center Quasi Experimental Study Based on the Health Belief Model","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-09-09 11:24:40","doi":"10.21203/rs.3.rs-6706671/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"bd29b658-5134-42da-87a7-3cad0a249d5b","owner":[],"postedDate":"September 9th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2025-11-11T09:24:29+00:00","versionOfRecord":[],"versionCreatedAt":"2025-09-09 11:24:40","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-6706671","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6706671","identity":"rs-6706671","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}