Awareness regarding self care among diabetics in urban slum of Kolkata: a community-based, cross-sectional study

INTRODUCTION

Diabetes mellitus is a common noncommunicable disease in India, as well as the rest of the world. It has emerged as a major public health problem, with low- and middle-income countries facing the greatest burden.¹ India ranks second in the list of diabetes among people aged 20-79 years next only to China. Diabetes currently affects more than 62 million Indians, which is more than 7.2% of the adult population. The average age on onset is 42.5 years. Nearly 1 million Indians die due to diabetes every year.²

Probably because of changes in lifestyle obesity and diabetes has manifested as a global epidemic. The change in life expectancy and lack of improvement in healthcare are in part responsible for the astounding rise in the incidence of this disease. Even in the rural Indian, population is undergoing lifestyle transition due to socioeconomic growth which can also be cited as a reason for increasing incidence of diabetes in rural areas.³

Diabetes is a chronic disease, requiring a multipronged approach for its management, wherein the patient has an important role to play.⁴ They are required to follow certain self-care practices to achieve an optimal glycemic control and prevent complications. These practices include regular physical activity, appropriate dietary practices, foot care practice, compliance with treatment regimen, and tackling complications such as hypoglycemic episodes.⁵ Self-care in the form of adherence to diet and drug regimens, blood glucose monitoring, self-administration of insulin, maintenance of optimum weight, blood pressure, recognition of symptoms associated with glycosuria and hypoglycemia etc. are crucial elements in secondary prevention.⁶ Thus, the objective of this study was to assess the knowledge of diabetic patients regarding the disease and its complications, and to estimate the knowledge and adherence to self-care practices concerned with Type 2 diabetes mellitus.

METHODS

Diabetes is a growing challenge in India with estimated 8.7% diabetic population in the age group of 20 and 70 years. This community based cross sectional study was conducted in ward no 58 of Tangra area of Kolkata, West Bengal. The ward has many slum areas. Total population is 88465 as per current census. Total male population is 46207 and female population is 42258. The study was conducted from July 2018 to December 2018. A house to house survey was conducted to identify the known diabetics in the community with the help of local NGO working in the field of diabetes and awareness in different health topics. Data of 362 patients were recorded on a semi structured pretested questionnaire. Patients’ level of knowledge was assessed by asking questions on symptoms of hypoglycemia and chronic complications of diabetes.

The demographic variables studied were age, gender, religion, marital status, educational status, occupation, socioeconomic status, duration of diabetes. Knowledge about hypoglycemia, family history, history of addiction was considered to be adequate if 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) blood sugar testing by glucometer, 2) self-injection of insulin; 3) Diet control; 4) Abstinence from alcohol; 5) Abstinence from smoking; 6) Eye care; 7) Foot care; 8) Skin care; 9) Dental care; 10) Regular exercise; 11) Adherence to medication and 12) 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.

Inclusion criteria

• • Those who agreed to participate in the study.

Exclusion criteria

• • Those who not willing to participate in the study and severely ill.
• • patients below 18 years of age (still dependent on parents).

Statistical analysis

The data were tabulated in Microsoft Excel 2007 and analyzed by using Statistical Package for the Social Sciences (SPSS) version 20.0 software for proportions and chi-square tests as test of significance.

RESULTS

A total of 362 diabetics were studied, majority 96(26.52%) among the respondents were in the age group of 50-59 years, followed by 75(20.72%), 69(19.06%) in the age group of 60-69 years, 40-49 years respectively. Male were 191(52.76%) and 171(47.24%) were females. Hindu, Muslims and Christians were 186(51.38%), 134(37.02%) and 42(11.06%) respectively. Majority 306(84.53%) were married. Only 28(7.73%) of the participants were illiterates.

Most of the study population were either homemaker or daily wage worker and belonged to the upper middle class as per Modified BG Prasad Classification. Thirty nine percent of the respondents had diabetes for 1-5 years, 28% for 6-10 years, and 22% of them for 11-20 years. Only 11% had diabetes for more than 20 years. The baseline characteristics of the respondents are shown in (Table 1).

Table 2 shows that 201(55.52%) of the respondents were having adequate knowledge about the symptoms of hypoglycemia and males were found to be more aware (33.98%) than females (21.55%) and this difference was statistically significant.

Only 66(18.23%) of the respondents know about the chronic complications of diabetes males (11.05%) were having better knowledge than females (7.18%) but the difference was statistically non-significant. Respondents with upper middle-income group and having high school education were more aware regarding the disease and its chronic complications. No difference in the awareness was observed across various religious groups.

Table 3 shows the awareness and practices regarding self-care among the diabetics, 332(91.71 and) respondents were aware regarding diet control but only 170(46.96%) were practicing the recommended diet schedules. It was observed that more of the females (54.97%) than males (39.79%) were following the recommended diet schedules. More than 76% of the respondents were aware that regular physical exercise is helpful but only 24(12.57%) of the males and 28(16.37%) of the females were following this advice, 143(39.5%) and 232(64.09%) of the respondents had the knowledge that alcohol and cigarette smoking are more harming for the diabetics but only 34(17.8%) and 18(9.42%) of the aware persons stopped using alcohol and smoking respectively.

More than 76% of the respondents were aware that regular physical exercise is helpful but only 24(12.57%) of the males and 28(16.37%) of the females were following this advice, 143(39.5%) and 232(64.09%) of the respondents had the knowledge that alcohol and cigarette smoking are more harming for the diabetics but only 34(17.8%) and 18(9.42%) of the aware persons stopped using alcohol and smoking respectively.

About 208(57.46%) of respondents were aware regarding self-blood sugar examination and only 64(17.68%) 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 165(45.58%) were showing compliance to this advice. Knowledge of the respondents regarding eye, foot, skin and dental care was painfully low, only 67(18.51%), 102(28.18%), 62(17.13%) and 46(12.71%) respondents were aware respectively and practices were still very low i.e. 37(10.22%), 68(1.78%), 36(9.94%) and 16(4.42%) respectively. People across religions were having similar level of knowledge and practices. People with low income group and lower-class schooling were having lower knowledge. It was further observed that respondents with longer duration of disease were having a wrong perception that they know more about the disease and its care, but study found no such difference.

DISCUSSION

Diabetes is a disease requiring many types of interventions to prevent the associated morbidity and mortality which also involve 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 own care with medical guidance e.g. adherence to diet and drugs 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 checkups.

Most of the study participants were in the 50-59 years age group, which was slightly lower than that seen in studies done by Priyanka and Angadi and Shah et al.^7,8 The age group is higher when compared to studies conducted in two places of Karnataka, namely Kolar and Dharwad, by Muninarayana et al, and Patil et al.^9,10

In the present study, the duration of diabetes in the participants was mostly 1-5 years (39%) in contrast to study done by Hawal et al, where the majority of them had diabetes for more than 5 years (30.95%).¹¹ Regarding the literacy status of the study participants, it was found that only 28(7.73%) were illiterates as compared to 36.64% as seen in the study done by Shah et al.⁸

It is generally thought that the duration of diabetes and a literacy rate of the participants have some influence on the knowledge regarding the disease. In our study, higher the education of the participant better was the knowledge on the disease but lesser the duration of the disease, higher the knowledge. The present study has shown that diabetics in area under study had a poor level of knowledge about the disease and self-care. Similar observations have been made in the other studies.^12-14 It was further observed that the attitude of the diabetics in area under study towards the disease was very casual and only a few of them had put their knowledge in practice. In the present study 75.41% of the study population took the mediation regularly, diet control was practiced by 46.96% but only 14.36% exercised regularly. In the study conducted by Ruggiero et al, found that over 90% usually took their medication regularly but only 64% usually followed dietary recommendations and less than half usually exercised.¹⁵

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 factor, encouraging self-management of the diabetes by allowing patient to measure directly the impact of their behavior, 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 term.^16-18

To achieve the goal to diabetes awareness health education is an area which needs to be addressed immediately.¹⁹ Diabetes mellitus has been cited as a model disease in which patient education makes a big difference.²⁰ Regular assessment of patients' skills and knowledge is critical.^21,22 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 intervention.^23,24 This assessment can be easily made by administering a written or oral evaluation with patient. 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.

CONCLUSION

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 at latter 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.

Considering the disease burden of diabetes in India involvement of the ASHA, ANM, NGOs should be sought in the comprehensive management of diabetics particularly by positive behaviour modifications regarding self-care, treatment compliance, and encouraging patients to go the sub-centre for regular check-up of BP / blood glucose.

ACKNOWLEDGEMENTS

Authors would like to acknowledge all the patients who participated in this research study.

Funding: No funding sources

Conflict of interest: None declared

Ethical approval: The study was approved by the Institutional Ethics Committee

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