Awareness
Regarding Self Care among Diabetics in Rural India
.........................................................................................................................
1. Dr J P, Majra (Corresponding author)
MD (Community Medicine), MBA (Health Care Services),
Associate Professor,
Dept. of Community Medicine,
K.S.Hegde Medical Academy, Mangalore. India.
575018
Tel: 919480287990
e-mail: jpmajra@hotmail.com
2. Dr. Das Acharya,
MD (Community Medicine),
Professor & HOD, Dept. of Community Medicine,
K.S.Hegde Medical Academy, Mangalore. India.
575018
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ABSTRACT
One of the greatest
challenges faced by the modern world is
Diabetes mellitus (DM). The physical,
social and economic factors involved in
the management of diabetes are a continuous
strain for the health sector and the government
agencies. It is expected that approximately
366 million people will be affected by
Diabetes mellitus by the year 2030.
Diabetes mellitus is a group of metabolic
disorders with multiple etiologies characterized
by chronic hyperglycemia with disturbance
of carbohydrate and fat, resulting from
insulin defect in secretion or action.
The new classification of diabetes mellitus
given by The Report of the Expert Committee
on the Diagnosis and Classification of
Diabetes Mellitus in 1997 is universally
adopted. Type 1 diabetes appears as a
result of autoimmune destruction of beta
cells or may be idiopathic. The more common
type 2 DM, affecting mostly adults manifests
as a result of insulin resistance. The
other specific types are impaired fasting
glucose (IFG), impaired glucose tolerance
(IGT), gestational diabetes and some genetic
defects of Beta cells.
The high risk groups of diabetes are Blacks,
Hispanics, Indian Americans, people having
a BMI of > 27 kg/m2 ,high BP, high
cholesterol and having a first degree
relative with DM.
According to the 1998 WHO report normal
Fasting plasma glucose (FPG) should be
less than 6.1 mmol/l and 2 hour plasma
glucose less than 7.8 mmol/l . The FPG
above 7.8 mmol/l is diagnostic of Diabetes
mellitus. The Glycosylated hemoglobin
(A1C) is one of the best indicators of
diabetes.
Obesity and lack of exercise are the most
important factors in precipitating diabetes.
Regular screening at an early age of individuals
with high risk is strongly recommended.
Screening for Gestational diabetes should
be done at 24 -28 weeks.
General standards for diabetes management
and self management education are recommended.
Preventing diabetic complications is the
objective.
Diabetes poses a great economic burden
on government resources. The US alone
has spent 91.8 billion $ on Diabetes in
1992, while England spent 113 million
pounds the same year. The Middle East
region spent almost 5.2 billion ID in
2003 on diabetes alone. Pakistan, a developing
country spent 800 million ID. Saudi Arabia's
expenditure on diabetes is estimated to
be around 1142 ID. According to WHO records
almost one Saudi diabetic patient costs
$ 800 per month
Key words: Classification of Diabetes,
Criteria of Diabetes, Obesity, Diabetes
cast.
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Diabetes mellitus is a disease
associated with significant morbidity and mortality1,2.
Patients with diabetes have higher rates of
coronary artery disease, retinopathy, neuropathy
and nephropathy1. Many of these complications
can be prevented with appropriate medical care3,4.
This care, however, in addition to taking medications
by the patient, often requires significant alterations
in lifestyle, (increasing exercise and changing
the type of food one eats) and strict adherence
to self-care tasks, such as checking urine/blood
sugars, to obtain good control of the disease5.
The importance of self-management skills in
diabetes care has also been stressed by the
American Diabetes Association (ADA) and the
Veterans Health Administration (VHA). Patient
education has been proven to be an important
method of management of such a community health
problem6. This study was carried
out to assess the level of awareness about the
disease and self-care methods and to identify
any patient specific characteristics associated
with this knowledge. We hope it will form the
basis for further research in the future to
develop educational strategies to improve patients'
self-management skills and hence help to better
control the disease.
A cross-sectional study
was carried out on the diabetic patients attending
the out patient clinic at three randomly selected
rural primary health centers i.e. PHC Natekal,
PHC Boliar, and PHC Amblamogaru in Dakshina
Kannada District of Karnataka state in India
in 2007. The following patients were excluded
from the study: 1) patients with disease duration
of less than two years; 2) patients below 18
years of age (still dependent on parents); and
3) patients above 80 years (as they could have
senile forgetfulness dementia, etc.). All diabetic
patients visiting these clinics except the above
were selected for the study. Patients were interviewed
by MBBS interns posted at the PHCs by the department
of community medicine. The data and responses
were recorded on a semi structured pre-tested
questionnaire. Patients' level of knowledge
was assessed by asking questions on symptoms
of hypoglycemia and chronic complications of
diabetes. Knowledge about hypoglycemia was considered
to be adequate if the patient could correctly
recall three of the following hypoglycemic symptoms:
sweating, palpitations, hunger, tremor or feeling
of impending disaster, each of which can be
relieved by taking some food or glucose. Knowledge
about chronic complications was assessed and
deemed adequate if patients could specify at
least three of the following: effect on vision
(retinopathy), kidneys (nephropathy), sensation
(neuropathy), potency (automatic neuropathy),
heart (ischemic heart disease) and on the legs
and feet (peripheral vasculopathy)7.
Patients' level of self- care was assessed by
asking about the following practices carried
out at home: 1) urine testing by the dipstick
method; 2) blood sugar testing by glucometer,
3) self-injection of insulin; 4) Diet control;
5) Abstinence from alcohol; 6) Abstinence from
smoking; 7) Eye care; 8) Foot care; 9) Skin
care; 10) Dental care; 11) Regular exercise;
12) Adherence to medication and 13) regular
follow up. The responses were recorded as "yes"
or "no." All the data were tabulated
and analyzed. Chi-squared test was used as a
test of significance.
A total of 342 diabetics were studied; 181
(53%) were men and 161 (43%) were women. The
majority, 63%, were Hindu, 26% were Christian
and 11% were Muslim by faith. The majority 128
(37%) of the respondents were in the age group
of 61-70 years, followed by 80 (24%), 68 (20%)
and 66 (19%) in the age group of 41-50 years,
51-60 years and >70 years respectively. One
hundred and twenty eight (37%) were high school
pass followed by 80 (24%) higher primary, 57
(17%) primary, 52 (15%) graduate and 23 (7%)
were illiterate. 73% had a per capita monthly
income of Rupee 3000 or more.
Table 1 shows that 191 (56%) of the respondents
had adequate knowledge about the symptoms of
hypoglycemia. Men were found to be more aware
than women and this difference was statistically
significant. Only 52 (15%) of the respondents
knew about the chronic complications of diabetes.
Here also men had better knowledge than women
but the difference was statistically non-significant.
Respondents with per capita income of rupee
two thousand or more and having ten or more
years of schooling were more aware regarding
the disease and its chronic complications. No
difference in the awareness was observed across
various religious groups.
Table 2 shows the awareness and practices regarding
self care among the diabetics. All the 342 respondents
were aware regarding diet control but only 148(43%)
followed the recommended diet schedules. It
was observed that more women (52%) than men
(32%) followed the recommended diet schedules.
Eighty two percent of the respondents were aware
that regular physical exercise is helpful but
only nine percent of the men and four percent
of the women followed this advice. One hundred
and forty one (41%) and 124 (36%) of the total
342 respondents had the knowledge that alcohol
and cigarette smoking are harmful for diabetics
but only 26 (19%) of the alcohol drinkers and
15 (14%) of the smokers stopped using these
products on the advice of their doctor after
being diagnosed as diabetics. One hundred percent
of the diabetics had knowledge regarding self
urine examination at regular intervals. Only
121 (35%) were monitoring their urine sugar
level regularly. 227 (66%) of respondents were
aware regarding self blood sugar examination
and just 11 (3%) were monitoring their blood
sugar level at home. Despite the fact all respondents
were aware that diabetes is not a curable disease
so regular follow up is very important, only
168 (48%) were showing compliance to this advice.
Knowledge of the respondents regarding eye,
foot and skin care was painfully low, only 52
(15%), 57 (17%) and 38 (11%) of respondents
respectively were aware of these and practice
was lower still. A minimum 23 (7%) of the diabetics
had knowledge regarding dental care and 11 (3%)
were visiting a dentist regularly. People across
religions had similar levels of knowledge and
practice. People with per capita income of less
than two thousand rupee and schooling less than
ten years had lower knowledge. It was further
observed that respondents with a longer duration
of disease had a wrong perception that they
knew more about the disease and its care, but
study found no such difference. No difference
was observed across PHCs under study.
|
Table
1 Level
of knowledge in diabetics about the disease |
Patient Data |
Hypoglycemic symptom awareness |
Chronic complications awareness |
|
Sex |
No. |
Yes (%) |
No (%) |
Yes (%) |
No (%) |
|
Men |
181 |
118 (65) |
63 (35) |
35 (19) |
146 (81) |
|
Women |
161 |
73 (45) |
88 (55) |
21 (13) |
140 (87) |
|
Total |
342 |
191 (56) |
151 (44) |
56 (16) |
286 (84) |
|
P value |
0.001 (significant) |
0.10 (non-significant) |
|
Table
2 Level
of self care among diabetics |
|
Activity |
Number of aware persons |
Number practicing |
Men
n= 181 |
Women n= 161 |
Total
n= 342 |
Men n= 181 |
Women n= 161 |
Total
n= 342 |
|
Diet control |
181(100) |
161(100) |
342(100) |
64(35) |
84(52) |
148(43) |
|
Regular exercise |
155(86) |
124(77) |
279(82) |
17(9) |
06(4) |
23(7) |
|
Abstinence from alcohol |
95(53) |
46(29) |
141(41) |
26( 19) |
NA● |
26*(19) |
|
Abstinence from smoking |
92(51) |
32(20) |
124(36) |
15(14) |
NA● |
15#(14) |
|
Self urine examination |
181(100) |
161(100) |
342(100) |
64(35) |
57(35) |
121(35) |
|
Self blood examination |
143(79) |
84(52) |
227(66) |
7(4) |
4(3) |
11(3) |
|
Adherence to medication |
181(100) |
161(100) |
342(100) |
169(93) |
150(93) |
319(93) |
|
Self administration of insulin |
3(100) |
NA● |
3(100) |
3(100) |
NA● |
3(100) |
|
Regular follow up |
181(100) |
161(100) |
342(100) |
87(48) |
76(47) |
163(48) |
|
Eye care |
33(18) |
19(12) |
52(15) |
14(8) |
9(6) |
23(7) |
|
Foot care |
35(19) |
22(14) |
57(17) |
16(9) |
19(12) |
46(14) |
|
Skin care |
28(16) |
16(10) |
38(11) |
18(10) |
16(10) |
34(10) |
|
Dental care |
14(8) |
9(6) |
23(7) |
7(4) |
4(3) |
11(32) |
- None among the female respondents were using
alcohol or tobacco and none was on insulin.
- Out of total 135 persons taking alcohol only
65 were aware and 26 quit after the disease.
- Out of total 104 smokers only 45 were aware
and 15 quit after the disease.
Diabetes is a disease
requiring many types of interventions to prevent
the associated morbidity and mortality, which
also involves self-care practices that the patient
can complete independently. The importance of
self-management skills in diabetes care has
been stressed by the American Diabetes Association
(ADA) and the Veterans Health Administration
(VHA). Self care is a crucial element in secondary
prevention of diabetes. It requires that the
diabetic should take a major responsibility
for his/her own care with medical guidance e.g.
adherence to diet and drug regimens, home monitoring
of urine and blood glucose, self administration
of insulin, maintenance of optimum weight, abstinence
from tobacco and alcohol, recognition of symptoms
associated with glycosuria and hypoglycemia
and attending periodic check ups. In order to
meet this requirement the diabetic has to make
very important and crucial decisions daily.
Therefore she/he must have a working knowledge
of the disease. The present study has shown
that diabetics in the area under study had a
poor level of knowledge about the disease and
self-care. Similar observations have been made
elsewhere also7,8,9. It was further
observed that the attitude of the diabetics
in the area under study, towards the disease,
was very casual and only a few of them had put
their knowledge into practice. Ruggiero et al,
in a nationwide survey of individuals with diabetes,
found that over 90% reported always or usually
taking their medication but only 64% always
or usually followed dietary recommendations
and less than half always or usually exercised10.
Additionally, medical regimens used to treat
chronic disease are complicated. Patients may
not fully understand the medical rationale behind
particular recommendations such as exercise
and diet. Furthermore, exercise and diet may
not result in immediate improvement in symptoms
and often cause initial discomfort or feelings
of deprivation, thereby providing little positive
feedback and reinforcement. Information provided
by home monitoring of blood glucose and urine
testing for glucose is a powerful motivating
factor11, encouraging self management
of the diabetes by allowing the patient to measure
directly the impact of their behaviour, such
as the effect of eating on postprandial glucose,
or glucose lowering effect of exercise. Some
studies have shown that even in patients treated
with diet alone, those who measure their blood
glucose more often have better outcomes and
those who are highly motivated are likely to
do well in the long term12,13. Under
such circumstances health education is an area
which needs to be addressed immediately14.
Diabetes mellitus has been cited as a model
disease in which patient education makes a big
difference15. Regular assessment
of patients' skills and knowledge is critical16,17.
The American Diabetes Association (ADA) recommends
that patients' knowledge of the self-care responsibility
be assessed annually and the Veterans Health
Administration (VHA) recommends reassessing
patient knowledge about diabetes at least three
months after an educational intervention18,19.
This assessment can be easily made by administering
a written or oral evaluation with each outpatient
visit. Improving patients' knowledge of diabetes
self-care practices will allow them to better
contribute to their care thereby postponing,
if not avoiding, long-term complications. It
will be a small investment with a large benefit.
Self care is a crucial
element in secondary prevention of diabetes.
Diabetics had a poor level of knowledge about
the disease and self-care and hence a very casual
attitude towards the disease. This predisposes
them to the risk of development of complications
in later life. Health education is an area which
needs to be addressed immediately to improve
patients' knowledge and skills of diabetes self-care
practices so that they can better contribute
towards the management of their disease.
- National Diabetes Data Group. Diabetes in
America. 2nd edition. Bethesda, National Institutes
of Health, National Institute of Diabetes
and Digestive and Kidney Diseases; 1995.
- Saydah SH, Eberhardt MS, Loria CM, Brancati
FL. Age and the burden of death attributable
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2002;156:714-719. doi: 10.1093/aje/kwf111.
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macrovascular and microvascular complications
in type 2 diabetes: UKPDS 38. UK Prospective
Diabetes Study Group. Bmj. 1998;317:703-713.
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doi: 10.1016/S0140-6736(98)07019-6. [PubMed].
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- Hassan TA. The centrality of the patient's
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- Elzubier AG, Al-Amri ADA, Al-Haraka EA,
Abu-Samara IO. Self-care, self-reliance and
knowledge of diabetes among diabetics in Al-Qassim
region, Saudi Arabia. Saudi Med J 1996;17:598-603.
- Hsing-Yi Chang, Chii-Jun Chiou, Ming-Chu
Lin, Shu-Hui Lin, Tong-Yuan Tai. A population
study of the self-care behaviors and their
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- Binhemd TA. Diabetes mellitus. Knowledge,
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- Ruggiero L, Glasgow R, Dryfoos JM, Rossi
JS, Prochaska JO, Orleans CT, Prokhorov AV,
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- Alberti KG, Gries FA, Jervell J, Krans
HM. A desktop guide for the management of
non-insulin-dependent diabetes mellitis: an
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Med 1994;11:899-909.
- Karter AJ, Ackerson LM, Darbinian JA, D'Agostino
RB, Jr., Ferrara A, Liu j, et al. Self-monitoring
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- Martin S, Schneider B, Heiemann L, Lodwing
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- El-Hazmi MAF, Al-Swailem AR, Warsy AS,
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- American Diabetes Association. Clinical
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- Diabetes Mellitus Working Group. Veterans
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- Brown SA. Studies of educational interventions
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- Padgett D, Mumford E, Hynes M et al. Meta-analysis
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