Social determinants of health and glycemic control in persons with type 2 diabetes mellitus attending a tertiary hospital in Nepal: A cross-sectional study


glycemic control
social determinants of health
type 2 diabetes mellitus

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Adhikari, P., Sriyuktasuth, A., & Phligbua, W. (2023). Social determinants of health and glycemic control in persons with type 2 diabetes mellitus attending a tertiary hospital in Nepal: A cross-sectional study. Belitung Nursing Journal, 9(5), 489–497.
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Accepted for publication: 2023-09-05
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Background: Diabetes mellitus (DM) is an emerging global public health challenge worldwide, including Nepal. Social determinants of health (SDOH) play a major role in glycemic control among persons with type 2 DM (T2DM). However, little is known about the association between SDOH and glycemic control among individuals with T2DM in Nepal.

Objective: This study aimed to identify the level of glycemic control and SDOH associated with glycemic control among Nepalese with T2DM.

Methods: This cross-sectional study was conducted at a tertiary hospital in Kathmandu, Nepal, among 135 Nepalese diagnosed with T2DM who attended follow-up appointments. Convenience sampling and inclusion criteria were utilized for participant selection. Data were collected from April to June 2021 using validated scales. Descriptive statistics, Chi-square test, and binary logistic regression were employed to analyze the data.

Results: The mean age of the participants in this study was 53.84 (SD = 11.78) years, and the average monthly household income was 567.64 (SD = 362.30) USD. The majority of the participants (77.8%) were literate and had no health insurance coverage (73.3%). Approximately 64.4% of the participants showed suboptimal glycemic control indicated by glycated hemoglobin (HbA1c) ≥7%. The significant determinants of good glycemic control included monthly household income of  >850 USD (odds ratio  [OR] = 12.20, 95% confident interval [CI] = 1.76–84.61, p = 0.011) and 341–600 USD (OR = 7.64, 95% CI 1.35–42.98, p = 0.021), being literate (OR = 6.37, 95% CI = 1.65–24.49, p = 0.007), having health insurance (OR = 5.82, 95% CI = 1.49–22.65, p = 0.011), sufficient health literacy (OR = 3.46, 95% CI = 1.10–10.83, p = 0.03), and high (OR = 16.17, 95% CI = 2.36–110.67, p = 0.005)  and moderate (OR = 7.02, 95% CI = 1.26–39.07, p = 0.026) food availability, respectively.

Conclusion: The study revealed suboptimal glycemic control in Nepalese with T2DM. This study presents essential social determinants of glycemic control in this population. Therefore, healthcare providers, particularly nurses, should pay more attention to assessing social determinants and provide targeted interventions to patients with T2DM who have low income, are illiterate, have no health insurance coverage, have insufficient health literacy, and have low resources for food availability.


Copyright (c) 2023 Prava Adhikari, Aurawamon Sriyuktasuth, Warunee Phligbua

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Declaration of Conflicting Interest

The authors have no conflict of interest to disclose.


The authors acknowledged the support of the Faculty of Nursing, Mahidol University, Thailand.

Authors’ Contributions

PA initiated the study, coordinated data collection, performed statistical analysis, and prepared the manuscript. AS contributed to the design of the study. AS and WP reviewed the data and contributed to the manuscript revision. All authors were accountable for the study processes and approved the final version of the manuscript.

Data Availability

The data presented in this study are available from the corresponding author upon reasonable request.

Declaration of Use of AI in Scientific Writing

Nothing to declare.


Acharya, D., Wagle, B. P., & Bhattarai, R. (2019). Illness, healthcare, and health insurance: Socio-economic perspective in Nepalese context. Nepalese Journal of Insurance and Social Security, 2(2), 1-9.

Al-Amin, M., Zannat, T., Uddin, M. N., Moniruzzaman, M., Habibullah, M., Kabir, A. K. M., & Karim, M. E. (2021). Relation between glycemic control among the patients with type 2 DM and level of blood pressure. Journal of Medicine, 22(1), 12-17.

Al-Rasheedi, A. A. S. (2014). The role of educational level in glycemic control among patients with type II diabetes mellitus. International Journal of Health Sciences, 8(2), 177-187.

AlHaidar, A. M., AlShehri, N. A., & AlHussaini, M. A. (2020). Family support and its association with glycemic control in adolescents with type 1 diabetes mellitus in Riyadh, Saudi Arabia. Journal of Diabetes Research, 2020, 5151604.

Alhariri, A., Daud, F., Almaiman, A., & Saghir, S. (2017). Factors associated with adherence to diet and exercise among type 2 diabetes patients in Hodeidah city, Yemen. Life, 7(3), 264-271.

American Diabetes Association. (2014). Diagnosis and classification of diabetes mellitus. Diabetes Care, 37(Supplement_1), S81-S90.

American Diabetes Association. (2016). Standards of medical care in diabetes—2016 abridged for primary care providers. Clinical Diabetes: A publication of the American Diabetes Association, 34(1), 3-21.

American Diabetes Association. (2020). 2. Classification and diagnosis of diabetes: Standards of medical care in diabetes—2020. Diabetes Care, 43(Supplement_1), S14-S31.

Auchincloss, A. H., Roux, A. V. D., Mujahid, M. S., Shen, M., Bertoni, A. G., & Carnethon, M. R. (2009). Neighborhood resources for physical activity and healthy foods and incidence of type 2 diabetes mellitus: The Multi-Ethnic study of Atherosclerosis. Archives of Internal Medicine, 169(18), 1698-1704.

Barrett, E. J., Liu, Z., Khamaisi, M., King, G. L., Klein, R., Klein, B. E. K., Hughes, T. M., Craft, S., Freedman, B. I., & Bowden, D. W. (2017). Diabetic microvascular disease: An endocrine society scientific statement. The Journal of Clinical Endocrinology & Metabolism, 102(12), 4343-4410.

Berkowitz, S. A., Karter, A. J., Corbie-Smith, G., Seligman, H. K., Ackroyd, S. A., Barnard, L. S., Atlas, S. J., & Wexler, D. J. (2018). Food insecurity, food “deserts,” and glycemic control in patients with diabetes: A longitudinal analysis. Diabetes Care, 41(6), 1188-1195.

Bohn, B., Herbst, A., Pfeifer, M., Krakow, D., Zimny, S., Kopp, F., Melmer, A., Steinacker, J. M., & Holl, R. W. (2015). Impact of physical activity on glycemic control and prevalence of cardiovascular risk factors in adults with type 1 diabetes: A cross-sectional multicenter study of 18,028 patients. Diabetes Care, 38(8), 1536-1543.

Borgharkar, S. S., & Das, S. S. (2019). Real-world evidence of glycemic control among patients with type 2 diabetes mellitus in India: The TIGHT study. BMJ Open Diabetes Research and Care, 7(1), e000654.

Brislin, R. W. (1970). Back-translation for cross-cultural research. Journal of Cross-Cultural Psychology, 1(3), 185-216.

Chen, R., Ji, L., Chen, L., Chen, L., Cai, D., Feng, B., Kuang, H., Li, H., Li, Y., & Liu, J. (2015). Glycemic control rate of T2DM outpatients in China: A multi-center survey. Medical Science Monitor: International Medical Journal of Experimental and Clinical Research, 21, 1440-1446.

Cho, N. H., Shaw, J. E., Karuranga, S., Huang, Y., da Rocha Fernandes, J. D., Ohlrogge, A. W., & Malanda, B. (2018). IDF Diabetes Atlas: Global estimates of diabetes prevalence for 2017 and projections for 2045. Diabetes Research and Clinical Practice, 138, 271-281.

Chrvala, C. A., Sherr, D., & Lipman, R. D. (2016). Diabetes self-management education for adults with type 2 diabetes mellitus: A systematic review of the effect on glycemic control. Patient Education and Counseling, 99(6), 926-943.

Dahal, G. P., Subedi, M., & Dahal, G. P. (2015). Social determinants of health in Nepal: A neglected paradigm. In A. P. Adhikari, G. P. Dahal, I. Mahat, B. Regmi, K. Subedi, & B. Shrestha (Eds.), Sustainable livelihood systems in Nepal: Principles, practices and prospects (1st ed., pp. 311-346). IUCN and CFFN.

Dong, Q., Huang, J., Liu, S., Yang, L., Li, J., Li, B., Zhao, X., Li, Z., & Wu, L. (2019). A survey on glycemic control rate of type 2 diabetes mellitus with different therapies and patients’ satisfaction in China. Patient Preference and Adherence, 1303-1310.

Echeverria, S. E., Diez-Roux, A. V., & Link, B. G. (2004). Reliability of self-reported neighborhood characteristics. Journal of Urban Health, 81(4), 682-701.

Faul, F., Erdfelder, E., Buchner, A., & Lang, A.-G. (2009). Statistical power analyses using G* Power 3.1: Tests for correlation and regression analyses. Behavior Research Methods, 41(4), 1149-1160.

Gariepy, G., Badawi, G., Page, V., & Schmitz, N. (2013). Response to Kawada: Self-rated health and depression of patients with diabetes: how to handle with wide range of ageing and diabetic status? Diabetic Medicine: a Journal of the British Diabetic Association, 30(6), 755-756.

Glasgow, R. E., & Toobert, D. J. (1988). Social environment and regimen adherence among type II diabetic patients. Diabetes Care, 11(5), 377-386.

Gomes, M. B., Muniz, L. H., Melo, L. G. N., Pizarro, M. H., Barros, B. S. V., Santos, D. C., & Negrato, C. A. (2020). Health literacy and glycemic control in patients with diabetes: A tertiary care center study in Brazil. Diabetology & Metabolic Syndrome, 12, 1-8.

Gyawali, B., Ferrario, A., van Teijlingen, E., & Kallestrup, P. (2016). Challenges in diabetes mellitus type 2 management in Nepal: A literature review. Global Health Action, 9(1), 31704.

Gyawali, B., Sharma, R., Neupane, D., Mishra, S. R., van Teijlingen, E., & Kallestrup, P. (2015). Prevalence of type 2 diabetes in Nepal: A systematic review and meta-analysis from 2000 to 2014. Global Health Action, 8(1), 29088.

Herndon, M. B., Gladders, B., Welch, G., Mehta, S., Belnap, T., & Morden, N. E. (2020). Visit frequency for patients with type-2 diabetes varies more by organization than by glucose control: A retrospective cohort study. Journal of General Internal Medicine, 35, 599-602.

Khanal, M. K., Bhandari, P., Dhungana, R. R., Gurung, Y., Rawal, L. B., Pandey, G., Bhandari, M., Devkota, S., Courten, M. d., & Courten, B. d. (2022). Poor glycemic control, cardiovascular disease risk factors and their clustering among patients with type 2 diabetes mellitus: A cross-sectional study from Nepal. PloS One, 17(7), e0271888.

Liese, A. D., Ma, X., Reid, L., Sutherland, M. W., Bell, B. A., Eberth, J. M., Probst, J. C., Turley, C. B., & Mayer‐Davis, E. J. (2019). Health care access and glycemic control in youth and young adults with type 1 and type 2 diabetes in South Carolina. Pediatric Diabetes, 20(3), 321-329.

Marciano, L., Camerini, A.-L., & Schulz, P. J. (2019). The role of health literacy in diabetes knowledge, self-care, and glycemic control: A meta-analysis. Journal of General Internal Medicine, 34, 1007-1017.

Mohebi, S., Parham, M., Sharifirad, G., Gharlipour, Z., Mohammadbeigi, A., & Rajati, F. (2018). Relationship between perceived social support and self-care behavior in type 2 diabetics: A cross-sectional study. Journal of Education and Health Promotion, 7, 48.

Office of Disease Prevention and Health Promotion. (n.d.). Social determinants of health. U.S. Department of Health and Human Services, Office of Disease Prevention and Health Promotion.

Olesen, K., Reynheim, A. L. F., Joensen, L., Ridderstråle, M., Kayser, L., Maindal, H. T., Osborne, R. H., Skinner, T., & Willaing, I. (2017). Higher health literacy is associated with better glycemic control in adults with type 1 diabetes: A cohort study among 1399 Danes. BMJ Open Diabetes Research and Care, 5(1), e000437.

Pai, L.-W., Li, T.-C., Hwu, Y.-J., Chang, S.-C., Chen, L.-L., & Chang, P.-Y. (2016). The effectiveness of regular leisure-time physical activities on long-term glycemic control in people with type 2 diabetes: A systematic review and meta-analysis. Diabetes Research and Clinical Practice, 113, 77-85.

Pelikan, J. M., Röthlin, F., & Ganahl, K. (2014). Measuring comprehensive health literacy in general populations: validation of instrument, indices and scales of the HLS-EU study. The 6th Annual Health Literacy Research Conference, Bethesda, Maryland.

Pokhrel, S., Shrestha, S., Timilsina, A., Sapkota, M., Bhatt, M. P., & Pardhe, B. D. (2019). Self-care adherence and barriers to good glycaemic control in Nepalese type 2 diabetes mellitus patients: A hospital-based cross-sectional study. Journal of Multidisciplinary Healthcare, 12, 817-826.

Rutte, A., Rauh, S. P., Schram, M. T., Nijpels, G., DeVries, J. H., Holleman, F., Pijl, H., Dekkers, O. M., Özcan, B., & Sijbrands, E. J. G. (2017). Individual and partner's level of occupation and the association with HbA1c levels in people with Type 2 diabetes mellitus: The Dutch Diabetes Pearl cohort. Diabetic Medicine, 34(11), 1623-1628.

Sadiya, A., & Mnla, R. (2019). Impact of food pattern on glycemic control among type 2 diabetic patients: A cross-sectional study in the United Arab Emirates. Diabetes, Metabolic Syndrome and Obesity: Targets and Therapy, 1143-1150.

Saeed, H., Saleem, Z., Naeem, R., Shahzadi, I., & Islam, M. (2018). Impact of health literacy on diabetes outcomes: A cross-sectional study from Lahore, Pakistan. Public Health, 156, 8-14.

Shrestha, A., Singh, S. B., Khanal, V. K., Bhattarai, S., Maskey, R., & Pokharel, P. K. (2018). Health literacy and knowledge of chronic diseases in Nepal. HLRP: Health Literacy Research and Practice, 2(4), e221-e230.

Shrestha, S. S., Palanchoke, S., Shrestha, R., & Bhatta, R. D. (2019). Study of prescription pattern and factors associated with clinical outcomes in type 2 diabetes mellitus with reference to short term glycemic control. Kathmandu University Medical Journal, 68(4), 279-286.

Siripitayakunkit, A., Hanucharurnkul, S., Melkus, G. D. E., Vorapongsathorn, T., Rattarasarn, C., & Arpanantikul, M. (2008). Factors contributing to integrating lifestyle in Thai women with type 2 diabetes. Pacific Rim International Journal of Nursing Research, 12(3), 166-178.

Sørensen, K., Pelikan, J. M., Röthlin, F., Ganahl, K., Slonska, Z., Doyle, G., Fullam, J., Kondilis, B., Agrafiotis, D., Uiters, E., Falcon, M., Mensing, M., Tchamov, K., Broucke, S. v. d., Brand, H., & Consortium, o. b. o. t. H.-E. (2015). Health literacy in Europe: Comparative results of the European health literacy survey (HLS-EU). European Journal of Public Health, 25(6), 1053-1058.

Tefera, Y. G., Gebresillassie, B. M., Emiru, Y. K., Yilma, R., Hafiz, F., Akalu, H., & Ayele, A. A. (2020). Diabetic health literacy and its association with glycemic control among adult patients with type 2 diabetes mellitus attending the outpatient clinic of a university hospital in Ethiopia. PloS One, 15(4), e0231291.

World Health Organization. (2021). Social determinants of health.

Zhang, H., Xu, W., Dahl, A. K., Xu, Z., Wang, H. X., & Qi, X. (2013). Relation of socio‐economic status to impaired fasting glucose and Type 2 diabetes: Findings based on a large population‐based cross‐sectional study in Tianjin, China. Diabetic Medicine, 30(5), e157-e162.

Zhang, X., Bullard, K. M., Gregg, E. W., Beckles, G. L., Williams, D. E., Barker, L. E., Albright, A. L., & Imperatore, G. (2012). Access to health care and control of ABCs of diabetes. Diabetes Care, 35(7), 1566-1571.

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