1Faculty of Nursing, Universitas Sumatera Utara, Medan 20155, Indonesia 2Faculty of Medicine, Universitas Sumatera Utara, Medan 20155, Indonesia 3Sekolan Tinggi Ilmu Kesehatan Flora, Medan 20151, Indonesia
*Corresponding Author’s Email: evikarota@usu.ac.id
Keyword: Diabetes; Ethnonursing; Nursing Therapeutic; Patent's View
Diabetes is a chronic condition characterised by consequences that are the leading cause of mortality, particularly hypertension, heart failure, renal failure, neuropathy, and organ damage (Ali et al., 2022). A significant issue for diabetic patients is the awareness of self-care practices and lack of adherence to diabetic medication (Abdulrahman et al., 2020; Alzaben et al., 2023). Diabetes is a degenerative disease characterised by chronic conditions necessitating prolonged care intervention, which requires specialised management (Lega et al., 2020). Self-care management via culture-based nursing activities is crucial for enhancing the quality of life of patients with diabetes; nevertheless, individuals frequently neglect it. Previous research reported a crucial shift from generalised education to tailored self-management interventions for diabetics(Chen & Lin, 2025). Consequently, individuals with diabetes often encounter various hurdles, including physical, psychological, social, economic, and other issues that diminish the motivation for treatment and autonomy in diabetes self-management (Karota et al., 2020).
These challenges are intensified by the severe consequences of diabetes, which can result in considerable physical and psycho-social issues due to perilous advanced complications, often termed “silent killers,” which may culminate in mortality. Diabetes can impact the functionality of all body organs, affecting both the micro-vascular and macro vascular systems as a result of uncontrolled blood glucose levels. Interventions must be implemented to manage the condition of patients with diabetes through comprehensive treatment (Samson et al., 2023). This strategy was implemented to avert problems and sustain normal blood glucose levels in individuals with diabetes. Nonetheless, sustaining normal glucose levels is challenging in diabetic individuals (WHO, 2023). The challenges faced by patients and their families in sustaining health can be affected by various factors including insufficient information and self-awareness, medication compliance, inconsistent self-management, diabetes self-care practices, and cultural considerations (Alexandre et al., 2021). Consequently, it is imperative to prioritise diabetes treatment within disease-preventive initiatives at the primary, secondary, and tertiary levels facilitated by global policies in both urban and rural community contexts (Gore et al., 2020; Misra et al., 2019). Self-care behaviour of type 2 diabetes patients is poor; there are patient barriers in managing diabetes. In fact, early diagnosis, treatment, self-management care is very important for disease prevention and control (WHO, 2023).
Successful diabetes management also requires diabetes patients to adhere to self-management practices (Abdulsalam et al., 2025). Self-management is a process of developing knowledge and skills to manage the complex of diabetes (Adhikari, Devkota & Cesuroglu, 2021). Consequently, ethnonursing as a qualitative study methodology is essential for comprehending the cultural dynamics that affect the health behaviours of patients with diabetes. Ethnonursing uncovers the values and social interactions that influence patient adherence to medication and self-care, by examining cultural experiences, beliefs, and practices (Sari et al., 2022). Based on literature review study by showed that the effectiveness of culturally tailored Diabetes Self-Management Education and Support (DSMES) programme in improving health outcomes among ethnic minority groups. It suggests that more research is needed to explore these barriers and develop strategies to enhance the uptake of DSMES programmes among underserved populations (Abu & Llahana, 2025). Examining the dynamics among nurses, physicians, and patients is essential for reconciling clinical practice with cultural considerations. Nurses’ awareness of patients’ cultural origins can enhance the efficacy of therapeutic interventions and facilitate culturally sensitive care. Comprehensive patient perspectives help healthcare practitioners recognise obstacles to medication adherence and misconceptions regarding conventional therapeutic choices. Incorporating cultural values into clinical practice can enhance the quality of care and health outcomes (Wehbe-Alamah & McFarland, 2020). Consequently, it is essential to comprehend the perspectives of patients by qualitative analyses of self-care and the medical management of diabetes. culturally tailored DSMES programme significantly improve uptake among ethnic minorities.
The study employed a qualitative design utilising an ethnographic method and was conducted over a duration of eight months in 2023. Ethno-nursing was selected for its ability to investigate and assess cultural processes that affect health habits within particular community contexts (Wehbe-Alamah & McFarland, 2020). The researcher encompasses both ethical and emic dimensions in accordance with the ethno-nursing method used to comprehensively investigate the habits, values, beliefs, and cultural practices of diabetes patients from an ethnic perspective in Indonesia, referred to as the natives' viewpoint.
This research was conducted in Sumatera Utara Province, Indonesia, with participants from many ethnic groups including Batak Karo, Batak Toba, Batak Mandailing, Javanese and Malay.
The study included 25 informants, consisting of 25 diabetic patients. The informants were chosen using purposive and snowball sampling techniques to provide a comprehensive and varied data set. The following inclusion criteria were established to ensure the credibility and reliability of the collected data: willingness to participate in the study by providing informed consent, availability of multiple interviews, and active engagement in daily diabetes care practices within cultural and ethnic contexts (Creswell & Creswell, 2022).
Data were gathered through comprehensive interviews, observations, documents and field study reports. We conducted informant’s interviews in the patients’ residences, lasting 40 to 50 minutes each informant, within two to three times. This study included telephone calls to elucidate information and verify certain information from informants. The study utilised the following methodologies to guarantee reliability and validity: implementing data triangulation via interviews, observations, and field report analyses. Reliability: thoroughly documenting the complete research process to facilitate reprehensibility. Transfer-ability: Develop comprehensive and thorough descriptions of the study context to facilitate application in analogous environments. Confirm-ability: consistent peer debriefing to maintain objectivity in a comprehensive analysis. This study methodology framework guarantees that the findings are dependable and pertinent to the research objectives concerning diabetes care in ethical studies.
Accurate information was obtained through data analysis using the four phases of Leininger's ethno-nursing methodology. Thematic analysis was employed to identify themes that facilitated qualitative data interpretation (Wehbe-Alamah & McFarland, 2020).
Organise all data collection by arranging interviews, observations (body language, expressions, specific traditions, daily activities, etc.), video field documentation (clinical documents, medical history notes, traditional therapy records, etc.), and photographic recordings. The gathered data were catalogue and organised methodically. Phase Two: Generate coding summaries of the data collection, categorise the data according to the research question area using qualitative data tools, and rigorously finalize the results. Third Phase: Identification of the meanings of universal nursing and the diversity observed in field data. The similarities and contrasts among the research informants were analysed to extract the values, beliefs, and cultural practices of the community in relation to their everyday existence and environmental situations. Fourth Phase: Compile and synthesise the interpretation of findings presented in tables, images, document recordings, and other formats. Conduct follow-up interviews in person via telephone and WhatsApp to elucidate the interpretation and implications of the study results.
The researchers obtained ethical clearance by the National Ethics Committee of the Faculty of Nursing, Universitas Sumatera Utara, Indonesia with reference number 3014/IX/SP/2023 on 19th September 2023 and also obtained from the Medan Regional Research and Innovation Agency of Medan, Indonesia with reference number 0009/192 on 13th September 2023.
This section delineates the research findings pertaining to ethnic data and the demographic attributes of 25 informants from various tribes in the province of Sumatera Utara, Indonesia.
Table 1 presents the data of demographic and clinical characteristics of informant of 25 diabetic patients representing five ethnic groups in North Sumatra, including: Batak Karo, Batak Toba, Batak Mandailing, Javanese, and Malay. The participants ranged in age from 40 to 76 years old with a predominance of middle-aged and elderly individuals. There was a fairly equal gender distribution, with 13 females and 12 males. The patients’ blood glucose levels varied widely, ranging from 135 mg/dl to 401 mg/dl, indicating differing levels of glycaemic control. Then, several patients had severely elevated glucose levels above 300 mg/dl, particularly in the Batak Karo and Javanese groups. The highest glucose level recorded was 401 mg/dl in a 45- year-old Batak Karo male informant.
This study showed that informant’s occupation represented employment statuses including retirees, housewives, farmers, and self-employed individuals, some of them being unemployed, particularly among the Batak Mandailing. Regarding healthcare-seeking behaviour, most participants received treatment from community health centres, reflecting the accessibility and preference for primary care services. A smaller number accessed outpatient clinics or hospitals, suggesting potential barriers or preferences influenced by availability, affordability, or cultural perceptions of care. This table showed that cultural diversity provides different perspectives on the influence of cultural, socioeconomic, and healthcare system factors on diabetes self- management. The range of laboratory blood glucose levels and treatment choices varies, highlighting the need for diabetes health education that is culturally appropriate and widely accessible to the community through primary care.
Table 1: Informant Diabetics Patient’s Characteristics (N=25)
Information | Gender | Age(year s) | Blood Glucose Level (mg/dl) | Occupation | Place of Treatment |
Batak Karo (Batak people) (6) | |||||
IF1 | F | 54 | 270 | Lecturer | Medical Doctor |
IF2 | M | 65 | 305 | Retired | Medical Doctor |
IF3 | F | 66 | 248 | Farmer | Health centre |
IF4 | M | 63 | 265 | Self-employed | Health centre |
IF5 | M | 40 | 172 | Security | Health centre |
IF6 | M | 45 | 401 | Self-employed | Outpatient clinic |
Batak Toba (5) | |||||
IF8 | M | 76 | 190 | Self-employed | Health centre |
IF9 | M | 71 | 214 | Self-employed | Health centre |
IF10 | F | 66 | 231 | Retired | Health centre |
IF11 | F | 58 | 198 | Self-employed | Health centre |
IF32 | F | 55 | 280 | Unemployment | Health centre |
Batak Mandailing (5) | |||||
IF12 | F | 52 | 331 | Unemployment | Health centre |
IF13 | F | 53 | 211 | Self-employed | Health centre |
IF14 | F | 73 | 263 | Retired | Health centre |
IF15 | F | 53 | 308 | Unemployment | Health centre |
IF16 | M | 65 | 257 | Unemployment | Outpatient clinic |
Javanese (5) | |||||
IF17 | F | 50 | 189 | Self-employed | Outpatient clinic |
IF18 | F | 45 | 213 | Housewife | Outpatient clinic |
IF19 | M | 65 | 253 | Retired | Hospital |
IF20 | M | 64 | 350 | Unemployment | Health centre |
IF31 | F | 49 | 290 | Housewife | Health centre |
Malay (4) | |||||
IF21 | M | 54 | 135 | Official staff | Hospital |
IF22 | F | 45 | 196 | Farmer | Health centre |
IF23 | F | 61 | 295 | Housewife | Health centre |
IF24 | M | 52 | 320 | Retired | Health centre |
Table 2 shows the results of the study based on thematic analysis using ethnonursing on the experiences of diabetic patients in ethnic community groups in North Sumatra. There are six identified theme findings, consisting of several sub-themes that reflect the depth of the life experiences of diabetes informants.
Table 2: Themes and Sub-Themes
Themes | Sub-themes |
Disorders due to symptoms of diabetes |
|
Self-care behaviour diabetics patients |
|
| |
Value and beliefs of traditional therapy |
|
Stress of being diabetic | Resigned because diabetes interferes with activities
|
Skin problems and wounds that are difficult to heal |
|
Obstacles in diabetes treatment |
|
Diabetes symptom disorders, theme in this section informants generally experience several physical complications such as numbness, tingling, fatigue, and sleep disturbances. Blurred vision and drowsiness are often reported which affect their daily activities and work as well as their quality of life.
“The characteristics of diabetes symptoms that I often experience include urination, numbness, and sleep interference; I must buy medicine at the pharmacy to help me sleep. Feeling tired and almost napping, often urinating and starving, blurred eye vision, frequent urination that interferes with night sleep. These interfered with my activities and workday time. (IF2)”.
Diabetes patient self-care behaviour, in this theme it is known that there are several methods used in self-care actions. Meanwhile, some informants showed positive self-care health practices, for example: regular exercise, diet management, and adherence to recommended medication, while others admitted irregular use of medication, poor lifestyle habits, and difficulty maintaining a diabetes-friendly diet. Challenges in accessing comprehensive care and the lack of structured home visits also affect self-care routines.
“I feel too lazy to take medications. I did not care about regular medication; I just maintained a diet, but did not measure it correctly, even though I feared kidney complications (IF1)”.
“I rarely go to the clinic, and I do not think it is important because it is the same and not much change for me; taking medication did not follow the doctor's (IF6)”.
“I did not undergo routine check-ups at clinics; if there were feeling worse such as an unhealthy body, I went to the pharmacy to buy the drug (IF13)”.
“I did not follow all the doctors’ advice, because if I followed the doctors’ advice, I felt worse and weakness, So I can’ t work a day (IF4)”.
“If I did a diet diabetes program and only ate a limited portion, I would feel weak. The diet program from the doctor was hard to do (IF12)”.
“I do not know why this leg turned black; it had been there for a long time. However, there was no feeling on this leg, so I just left it because it did not bother me. It was never cleaned, because we didn't have time because we were in the fields every day (IF3)”.
“On my feet, there were thick black calluses. I had a nurse at a foot spa, but it did not go away. It's not annoying but it looks like his feet are calloused (IF15)”.
“I often wake up at night due to itching. Perhaps because my skin is dry, it causes itching and ultimately disturbs my sleep at night. (IF5)”.
“Itching can occur in certain body parts. Itching always occurs on the hands, feet, eyes, ears, or even the gums of the teeth, and the location of the itch moves from time to time (IF15)”.
“I exercise regularly, and every morning I walk. (IF4)”.
“I exercise, although rarely, work at home, and clean the garden. (IF21)”.
“Since I have diabetes, I have limited my food consumption. I eat everything but limit it (IF18)”.
“I take diabetes medications regularly, as recommended by the doctor. I am overweight and have pain in my legs. I am following a diet program that limits prohibited foods, physiotherapy, and swimming” (IF18).
Values and beliefs regarding traditional therapy, this theme shows that cultural beliefs greatly influence and depend on traditional therapies, such as herbal therapy, they express it with the term "long-life leaves" and this healing practice comes from the Karo ethnic group. Spiritual activities such as praying and reading holy books or read the Qur'an are considered an integral part of healing. In general, informants expressed a stronger belief in traditional medicine than in medical care.
“I routinely use traditional medicine such as “cinnamon” herb with hot water to reduce blood glucose levels (IF9)”.
“I believe that traditional medicine is more effective than medicine alone. So, I stopped the doctor's medicines (IF18)”.
“We used to drink the traditional herbal spray which consists of various types of leaves that are dried, then boiled with hot water and the water drunk without sugar twice a day (IF3)”.
“It was common for people who lived around this village to make traditional ingredients for herbal medicine for diabetes in the form of boiled moringa leaf water; body pain was healed and feeling better (IF15)”.
Stress of Being a Diabetic, in this theme section it is explained that the emotional burden of living with diabetes is very high. Informants reported feelings of hopelessness, fear of the disease being difficult to cure, and having given up. The nature of the disease is a chronic condition, having to restrict diet, and the threat of complications such as amputation create psychological stress.
“Most of Karo people think that if they have diabetes, their life expectancy is low, so they immediately feel hopeless and their enthusiasm for life decreases (IF3)”.
“I have given up because the symptoms appear to interfere with my usual physical activity. There are many foods that I cannot eat anymore (IF2)”.
“I was afraid if I follow doctor advice. If I limit food, my body becomes weaker. (IF4)”.
“I think that this disease makes us stressed, so we have to be careful about taking care of our health, controlling our food, and not letting our minds feel stressed (IF22)”.
“I was hospitalized for surgery on the right leg. I was very stressed because I did not regret that my leg could not be cured and had to be operated upon and amputated”.
Skin problems and wounds that are difficult to heal, in this theme identifies that many informants expressed their struggles with persistent skin problems, including chronic wounds, black skin on the feet, and severe itching. These complications are considered burdensome and sometimes they are ignored due to lack of understanding about the diseases and access to wound care health services.
“Since I was diagnosed with diabetes, the wounds on my feet have taken a very long time to heal, often occurring in the lower legs for up to 2 months which ultimately leave scars (IF16)”. “I have had diabetes for 4 years, I urinate frequently, get thirsty quickly, feel weak, if I have a wound, it itches, and other things take a long time to heal (IF17)”.
“If my blood sugar is high, when I get bitten by a mosquito, it causes a wound that is very difficult to heal, which is why I know my blood sugar is high (IF14)”.
“I often wake up at night disturbs my sleep because of itching. If I scratch it, I can get injured, and I feel afraid of the infection (IF5)”.
“Itching occurs in certain parts of the body; however, it occasionally occurs. Sometimes, on the hands, feet, eyes, ears, and even on the gums of the teeth, itching always occurs, and the location of the itch moves from time to time (IF15)”.
Obstacles in diabetes care, in this theme, structural and personal obstacles were found from the informants themselves that affected diabetes management. These were high laboratory costs, physical limitations (eg. pain, numbness in the extremities), and lack of motivation for informants to recover which were often mentioned. These challenges caused delays in care and reduced care capacity.
Lazy Work and Lack of Self-Care
“This diabetes disease seems to be healthy, but in fact, we feel weak. so we are lazy to work. taking a shower is sometimes postponed, not caring about personal hygiene (IF15)”
Laboratory Tests are Expensive
“I do not do routine blood sugar checks because I have to pay for it; yes, it's expensive for me, too. Therefore, I have checked it sparingly. I do it If I feel it is necessary (IF17)”.
“I have had diabetes for 13 years. I go to the health centre regularly for treatment, take medicine every month, and never stay away. However, yesterday, I still had problems with my legs, it hurt, and I could not walk more than 10 meters (IF19)”.
“Problems and obstacles are also encountered. I use assistive devices to walk because my legs feel numb and it is not easy to walk. (IF17)”.
Based on this study, patients with diabetes usually encounter their condition incidentally and are unable to detect it through clinical evaluation. Patients who disregarded any symptoms of diabetes required in-depth interviews to gather information. The negative behaviours of patients in self-care are an important aspect of diabetes care; they reported several reasons, including that their health condition was good and that they did not experience feel sickness. Diabetes patients experience psychosocial problems related to their disease, this requires considering nursing intervention through a holistic approach (Yilmaz, Gun, & Yaman, 2019). This study mention that methods of embedding diabetes self-management programme into routine care is needed (Davies et al., 2024). However, when they followed the advice of doctors and nurses regarding their diet and exercise, they felt physically weak and had no energy. Therefore, they did not comprehensively follow diabetes care guidelines. They ignore treatment because they feel that their condition is good without serious problems or misconceptions regarding diabetic treatment programs (Sari et al., 2022).
This study shows the importance of DSMES and the efforts to provide culturally sensitive care to diabetic patients (Goff et al., 2020). The patient's experience showed that patients still did not understand the importance of diabetes care and treatment as an effort to control themselves to prevent the risk of diabetes complications such as cardiovascular disease, kidney failure, hypertension and neuropathy (Kumar & Mohammadnezhad, 2022). They complained of several symptoms of diabetes that interfered with their daily activities. They stooped some activities because they felt unsafe and some of them did retire from work. However, they might not be doing the medical doctor's treatment or nursing intervention for a diabetes programme. Educational programmes for patients with diabetes can increase their knowledge and provide self-care competencies to help prevent the risk of diabetes (Alzaben et al., 2023). Patients view that they have skin problems: itching and scars and also wounds on the lower extremities that are difficult to heal. This should be a concern that patients need to control their disease (Kumar & Mohammadnezhad, 2022). Furthermore, positive behaviour toward diabetes care was also found in this study, which shows that self-care behaviour can be accepted by patients with diabetes through nursing and medical interventions. Research studies have shown that positive behaviour in diabetic patients can occur because of the development of health services and a model interventions of care practices in primary healthcare units that recommends doctors’ and health specialists' expertise so that they can handle complex diabetes care well (Chen & Lin, 2025).
Technology and information can positively contribute to self-care among patients with diabetes (Zeh et al., 2024). This study showed that culture influences the self-care behaviour of patients with diabetes; they are more likely to believe in and select traditional therapy over medical treatment. The informant stated this in the TCM theme of beliefs and values in traditional medicine. They believe in traditional and complementary therapies that they know from family and cultural care from others. Previous studies have shown in-depth interviews; patients believe that traditional medicine provides guidance on healthy behaviour (Wehbe-Alamah & McFarland, 2020). In this case, patient care concentrates on the patient's physiological needs and family desires based on cultural beliefs that impact the health of diabetics. Understanding culturally inherited diabetes is important for improving the health and quality of life of diabetic patients. When people believe diabetes comes from spiritual power, culturally sensitive knowledge and understanding are needed to promote self-care with people's beliefs in mind. A model of care that accommodates cultural and psychosocial aspects and diseases can be a healthcare framework in which healthcare professionals assist in providing culturally appropriate diabetes care (Alexandre et al., 2021; Korsah, Dyson & Anthony, 2022). Health workers have made various efforts, although other appropriate methods are still required to optimise diabetes intervention programs. Therapeutic education for patients with diabetes needs to be implemented consistently and comprehensively because diabetes is a chronic condition that requires long-term treatment and specific care to reduce the risk of serious complications and high risk of death (Karota et al., 2020). Successful diabetes management also requires diabetes patients to adhere to self-management practices (Abdulsalam et al., 2025). Self-management diabetics is a process of developing knowledge and skills to manage the complex of diabetes (Adhikari, Devkota & Cesuroglu, 2021; Pal et al., 2018).
Healthy behaviours of patients with diabetes must be consistent to improve glycaemic control, diet, exercise, use of diabetes medications, perception, self-awareness, and culture. Thus, culturally based therapeutic nursing activities can be used to strengthen the effectiveness of health service programs using a specific approach (Alshammari et al., 2021). Based on the behaviour of patients who still believe in healing with traditional medicine and the cultural customs of the surrounding community which are contrary to diabetes health efforts. This requires strengthening education for patients to improve competence in health self-care decisions (Numsang et al., 2023). From the in-depth interviews, patients with diabetes had the perception that social media can be their reference in doing treatment without visiting a doctor, and that they do not select the information.
This study was conducted in a specific cultural and geographical context, with a focus on exploring community-based therapeutic interventions in a group of diabetic patients. Although this study provides valuable local insights, the application of the results to other cultural contexts requires further investigation.
This study is a qualitative research method with an ethnonursing approach that aims to explore in depth the perspectives of patients on health services about culturally informed therapeutic interventions through diabetes care management in Indonesian communities. The results of this study have found six themes that show nurses' views of cultural values and beliefs influencing self-care behaviours, treatment adherence, and patient decisions in therapy choices. They practice traditional medicine and medical care together and sometimes do not follow medical treatment and practice traditional medicine. Nurses play a role in providing culturally sensitive health education and promoting health by involving patients through community-based diabetes care programs. The results of this study focus on the need to integrate the principles of medical treatment and combine them with diabetes care through an ethnonursing approach into nursing practice to suit their culture. Cultural care values and beliefs based on nursing therapeutic intervention including medical treatment and nursing intervention are important to improve self-care behaviour in patients with diabetes.
The implication for nursing practice is to integrate ethnonursing methods into primary care and community nursing to improve self-care behaviours of patients with diabetes based on cultural values. The views of patients with diabetes can inform the development of nursing interventions to change health behaviours based on culturally specific programs. Future research should focus on developing culturally adaptive diabetes education models that incorporate ethnonursing principles. Further research is needed to explore how cultural values, traditional practices, and family involvement can be systematically integrated into intervention frameworks to improve long-term glycaemic control and reduce complications in diverse community settings.
The authors declare no conflict of interest associated with this publication.
The authors gratefully acknowledge the financial support and material resources provided by the institution, which were essential to the successful completion of this research project. This study was funded by the Universitas Sumatera Utara, Indonesia, under the grant number 256/UN5.2.31/PPM/KP-TALENTA/R/2023.
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