Evaluation of Diabetes Understanding among Diabetic Patients in Miri General Hospital
Chieng Chew Ling1, Chin Huei Erh1, Lay Siew Ling1, Lee Mei Chi1, Evelyn Wong SzeHui1, Elizabeth Ma Lee Ching1, Kamarudin Ahmad1
1Miri Hospital Pharmacy Department
Corresponding author name and email: Kamarudin Ahmad (kamarudin_a @moh.gov.my) Introduction: Malaysians have labelled as one of the populations with high prevalence of diabetes.
Objectives: This study conducted to evaluate the knowledge of diabetic patients in Hospital Miri. Hopefully, the findings of this study can used to clarify the correlation between patient’s demographic background and the diabetic awareness. Besides, the population knowledge gap and their attitude toward diabetes can detected to help in tailoring effective educational programme for prevention and management of this chronic disease in Malaysia.
Methods: A cross-sectional study carried out to evaluate the diabetes understanding among diabetic patients in Miri General Hospital, Malaysia from August until October 2014. 150 questionnaires gave out with 94% response rate. There are 3 parts in the instrument, where part 1 is the consent form, part 2 is the patient’s socio-demographic data and part 3 is the questionnaire. The patient’s socio-demographic data includes gender, age, race, educational level, household income and year since diagnosis of diabetes. The questionnaire adapted from the Malaysian version of 14-item Michigan Diabetes Knowledge Test (MDKT).
Result: Result shows significant association between age and level of diabetes understanding (p<0.05). There are equal number of respondents who had attended primary school and
respondents earn less than a thousand. There is significance association between diabetes assessment scores and years since diagnosis (p=0.003). Most of the patients have their diabetes diagnosed two to five years ago, followed by patients who already have diabetes for more than a decade. The least number of respondents have this endocrine disease for 6-10 years.
Conclusion: This study carried out to evaluate the diabetes understanding among diabetes patients in Miri General Hospital. In this study, we found that diabetes knowledge among the subjects significantly associated with 4 variables which are age, educational level, household income and years since diagnosis. The findings from this study allow us to know the underlying factors that contribute to the lack of knowledge among diabetic patients.
Therefore, we can focus on this population and provide useful information to empower their knowledge and awareness on diabetes.
Introduction
In year 2000, 171 million people in the world diagnosed with diabetes and this figure expected to double in the coming thirty years (1). Malaysians labelled as one of the populations with high prevalence of diabetes (2). According to the International Diabetes Federation Diabetes Atlas, estimated 4 million adults estimated to be diabetic in Malaysia, and this number is large enough to put Malaysia as the top country in Asean for having the highest number of diabetics (3).
Diabetes is a chronic endocrine disorder that characterised by hyperglycaemia. This condition could be due either to autoimmune destruction of the pancreatic β-cells with consequent insulin deficiency, or abnormalities that lead to insulin resistance. Diabetes grouped according to the pathophysiology, namely type 1 or insulin-dependent diabetes, and type 2 or non-insulin dependent diabetes (4).
Polyuria, polydipsia and weight loss are the common symptoms of hyperglycemias. In extreme cases, acute and life-threatening ketoacidosis or non-ketotic hyperosmolar syndrome may occur. Diabetesoften called the “silent killer” because if it uncontrolled, it can result in long-term complications like retinopathy with potential sight loss, nephropathy with deteriorated renal function, and peripheral neuropathy with risk of amputations.
Cardiovascular risk will also increase in diabetic population because of the abnormal
lipoprotein metabolism (5). This supported by the National Diabetic Registry Report which pointed out that 70.1% of type 2 diabetic patients had hypertension and 55.1% of them had dyslipidemia (6). As well as the above-mentioned, episodes of hypoglycaemia, fear of hypoglycaemia or long-term complication, and change in lifestyle may lead to reduced health-related quality of life (7).
Antidiabetic treatment has come a long way in the past decade, with new drugs and devices adding up to better lives for patients. Oral hypoglycaemic agents like metformin and rosiglitazone used to lessen peripheral insulin resistance. Sulfonylureas, repaglinide and dipeptidylpeptidase-4 inhibitors can stimulate insulin secretion. However, these anti-diabetic medications can only be effective if there are some residual functioning pancreatic islet cells, this makes them unfavourable for treating type 1 diabetes. Insulin is the recommended treatment for type 1 diabetes and it can considered in type 2 diabetes when other methods have failed to achieve desirable glycaemic control (4).
Besides pharmacological approaches, there are several other components of diabetes, including physical activity, blood glucose monitoring, foot care and dietary balance. With knowledge of these, the patient will become more aware of it and know what it takes and how to manage it.
Several studies (8-10) reported was significant association between diabetes family history and diabetes knowledge. Patients with family history of DM have a higher awareness on the disease. There was a positive association between duration of illness and awareness (9, 11). The reports also revealed positive effect of monthly income, occupation and education on understanding the disease (8, 11). This opposed to the studies conducted in 2009, where no correlation found between these factors and the diabetic understanding (12, 13). However, it could be due to the fact the participants enrolled in the latter two studies were mostly women, from urban areas, of low educational level and salary.
Diabetes knowledge further correlated with gender and age. A study found that women know better about diabetes than men (11) while the other found the otherwise (10). In term of age, it has reported that every 10 years increment of age associated with a 3%
decrement in the diabetes knowledge score (14). Yet, most recent studies revealed insignificant association between awareness of the disease and patients’ sex and age(8, 9).
Positive correlations found between knowledge, medical adherence and glycaemic control (14, 15). By delivering proper diabetes education and care management, improvement in patient results and quality of life can achieved (16).
This study conducted to evaluate the knowledge of diabetic patients in Hospital Miri.
Hopefully, the findings of this study can used to clarify the correlation between patient’s demographic background and the diabetic awareness. Besides, the population knowledge gap and their attitude toward diabetes can detected to help in tailoring effective educational programme for prevention and management of this chronic disease in Malaysia.
Methods
Ethical approval
The ethical approvals from the Ministry of Health Medical Research Ethics Committee (MREC) and Miri General Hospital received before carrying out the study. A written consent presented to each respondent before taking part into this survey.
Participants and Setting
A cross-sectional study carried out to evaluate the diabetes understanding among diabetic patients in Miri General Hospital, Malaysia. Miri General Hospital is the largest public hospital in Miri city of Sarawak state. This study conducted in wards and outpatient department of Miri General Hospital from August until October 2014.
We need 112 participants to achieve precision of 5% in estimating prevalence of diabetes mellitus which is 0.625% (data from Hospital Miri Record Office). This sample size calculated by using Sample Size Calculator for Prevalence Studies (17). A total of 150 questionnaires distributed out with 94% response rate. Subjects capture by purposive sampling. The inclusion criteria of this study includes [1] subjects have diagnosed with diabetes at least one year, [2] must be using anti-diabetic medications, [3] be greater than 15 years old and [4] be able to understand the instruction of the survey. The exclusion criteria of this study are subjects with cognitive impairment or severe health problem.
A written consent presented to each subject. We conducted face-to-face interview and we requested verbal consent for data collection if subject is illiterate. The verbal consent
contained all the elements stated in written consent. The consent form attached with the questionnaires.
Instrument
There are 3 parts in the instrument, where part 1 is the consent form, part 2 is the patient’s socio-demographic data and part 3 is the questionnaire. The patient’s socio- demographic data includes gender, age, race, educational level, household income and year since diagnosis of diabetes. The questionnaire adapted and adapted from the Malaysian version of 14-item Michigan Diabetes Knowledge Test (MDKT)(18). Permission to use MDKT questionnaire obtained from the corresponding author by email. The questionnaire consists of 14 items. Each item is a close-ended, multiple-choice question with 1 correct answer. The questionnaire is available in 2 languages: Malay and English. Subjects must answer all the 14 questions. The whole instrument needs 10-15 minutes to complete. One point given for each correct answer and zero point for each wrong answer. The total score of this questionnaire ranges from 0 to 14. The higher the score, the higher level of diabetes understanding of patient. The level of diabetes understanding classified into 3 groups based on patient’s total score: low (<7 points), moderate (7-10 points) and good (≥11 points).
Statistical Analysis
Statistical Package for Social Science (SPSS) software version 20 used to enter and analyse the data. Descriptive statistics used to describe the demographic data of patients. The patient’s demographic data presented in percentages and frequencies since the data are categorical variables. The score of patient’s diabetes knowledge are numerical variables, therefore the data presented in 3 groups: low (<7 points), moderate (7-10 points) and good (≥11 points). Fisher exact test performed to analyse the relationship between the demographic data and patient’s diabetes understanding. The significance level of correlation between variables set at p-value <0.05.
Result
The result showed that, among the 141 patients with Type 2 Diabetes Mellitus, most of them are female.
Most of the subjects aged more than 50 years old, followed by the age group of 35-50 years old and 20-35 years old. Result shows significant association between age and level of diabetes understanding.
In this study, most of the respondents are Sarawak natives (Iban, Bidayuh, Bisayah, Kayan, Kenyah, Penan, Kelabit, and others). Result reveals insignificant association between races and level of understanding. Almost equal numbers of Malay and Chinese took part in this survey.
Most of the respondents not educated. Result shows significant association between age and level of diabetes understanding. There are equal number of respondents who had attended primary school and secondary school previously. Only a minority of the respondents had education level of diploma or degree. The result not expected because of high understanding in less educated group.
Fisher’s exact test shows significant association between diabetes knowledge according and income. Most of the respondents earn less than a thousand. Only a few of them earned more than RM3001.
The patients grouped based on the duration of having diabetes mellitus.Fisher’s Exact test shows significance association between diabetes assessment scores and years since diagnosis. Most of the patients have their diabetes diagnosed two to five years ago, followed by patients who already have diabetes for more than a decade. The least number of respondents have this endocrine disease for 6-10 years.
Table 1: Correlation between patients’ characteristics and their understanding about type 2 Diabetes Mellitus
Variable Frequency (%) Association with diabetes
understanding (p-value) Gender
Male Female
57 (40.4) 84 (59.6)
1.00
Age (years) 20-35 36-50
>50
10 (7.1) 43 (30.5) 88 (62.4)
0.021*
Race Others†
Malay Chinese Indian
78 (55.3) 30 (21.3) 32 (22.7) 1 (0.7)
0.625
Educational level None
Primary school Secondary school Diploma/Degree
45 (31.9) 40 (28.4) 40 (28.4) 16 (11.3)
0.000*
Household income
<RM1000 RM1000-2000 RM2001-3000
>RM3000
85 (61.0) 26 (18.4) 21 (14.9) 8 (5.7)
0.024*
Years since diagnosis of diabetes (years)
<2 2-5 6-10
>10
33 (23.4) 48 (34.0) 16 (11.3) 44 (31.2)
0.003*
Note: *indicates a p-value <0.05,†Sarawak natives (Iban, Bidayuh, Bisayah, Kayan, Kenyah, Penan, Kelabit, and others)
Discussion
There is no significant difference between genders regarding the level of diabetes knowledge in this study. This statement is supported by other studies done previously. Al- Qazaz et al. (2011) and Najib et al. (2014) stated that patient’s diabetes knowledge significantly related to age group and educational level instead of gender (14, 19).
In this study, respondents with higher age group showed better level of diabetes understanding compared with those in lower age group. Pongmesa et al. (2009) found that subjects who are more than 45 years old have higher score on knowledge of diabetes than younger respondents (20). Pongmesa et al. (2009) agreed with the positive relation between age and diabetes knowledge found in this study (20). The possible reasons that contribute to this positive correlation includes (1) most of the respondents are more than >50 years old (62.4%) and (2) frequent diabetes education carried out by health care professionals and focused on older population because of higher risk of diabetes complication. However, there are other studies showing that younger respondents have better diabetes knowledge compared with older respondents. Al-Qazaz et al. (2011) reported there is 3% decrease in diabetes knowledge score with every 10 years increase in patient’s age(14).
The ethnic composition in this study has closed estimate to the ethnic composition in Sarawak reported in 2008, consisting of non-Muslim indigenous groups (40%), Chinese (30%), Malays (25%) and others including Indians (5%) (21). A study conducted among indigenous groups in peninsular Malaysia revealed the knowledge of diabetes relied on the site of settlement (22). So far, there is no study has proven any knowledge gap between ethnic groups. Therefore, education on diabetes mellitus and its management should delivered to all patients regardless of their ethnicity.
Patient’s understanding on diabetes highly associated with educational level. Previous studies had consistently reported the relationship between education background and diabetes knowledge. Higher educated patients might have higher awareness of their diabetic condition.
This could be that they might have more opportunities to get knowledge from different sources e.g. internet and press and have less difficulty in understanding their physicians. The result of this study supported by the findings from Harith et al. (2011), which showed there was a significant association between education background and diabetes knowledge (14).
Another study conducted by Foma et al. (2013) in Gambia also showed that educational level was an important predictor of diabetes awareness (9). Berhe et al. (2014) also reported similar
result where illiterate patients have poorer knowledge compared with university level patients (8).
The findings of this study show that household income has a direct influence on the level of diabetes knowledge. This finding is congruent with the study carried out by Al- Shafaee et al. (2008) (23) which suggests that a higher household income found to positively associated with more knowledge. This further supported by the study of Al-Adsani et al.
(2009) (24) which stated that participants with limited family income had significantly lower knowledge scores. They concluded that limited family income is one of the predictors of knowledge deficits. Thus, household income is one of the factors associated with the levels of diabetes knowledge in diabetes patients. Household income reflects the socio-economic status of the family. Higher income group believed to have a greater access to gain knowledge from different media such as the press, books and internet.
The result revealed that diagnosis time has significant effect on individual’s knowledge on diabetes. However, it is difficult to determine the exact duration of diabetes, as the asymptomatic period may precede the diagnosis. Some of the patients might not know their diagnosis until few years later. A study conducted in 2012 reported that duration of diabetes inversely related to knowledge and attitudes of patients (25). In that sense, diagnosis time need to be considered when tailoring diabetes counselling and education programs to meet the patients; actual and potential needs.
Conclusion
This study carried out to evaluate the diabetes understanding among diabetes patients in Miri General Hospital. In this study, we found that diabetes knowledge among the subjects significantly associated with 4 variables which are age, educational level, household income and years since diagnosis. The findings from this study allow us to know the underlying factors that contribute to the lack of knowledge among diabetic patients. Hence, we can focus on this population and provide useful information to empower their knowledge and awareness regarding diabetes.
References
1. Wild S, Roglic G, Green A, Sicree R, King H. Global prevalence of diabetes estimates for the year 2000 and projections for 2030. Diabetes care. 2004;27(5):1047-53.
2. Lim T-O, Bakri R, Morad Z, Hamid MA. Bimodality in Blood Glucose Distribution Is it universal? Diabetes care. 2002;25(12):2212-7.
3. Atlas D. International Diabetes Federation. Hallado en: http://www idf org/diabetesatlas/5e/es/prologo. 2000.
4. Britain RPSoG, Association BM. British National Formulary. 64 ed. London: BMJ Publishing Group; 2012.
5. Association AD. Diagnosis and classification of diabetes mellitus. Diabetes care.
2010;33(Supplement 1):S62-S9.
6. Feisul MI As. National diabetic registry report. In: Health P, editor. Kuala Lumpur:
Ministry of Health; 2013.
7. Holmes J, McGill S, Kind P, Bottomley J, Gillam S, Murphy M. Health-related quality of life in type 2 diabetes (TARDIS-2). Value in health : the journal of the International Society for Pharmacoeconomics and Outcomes Research. 2000;3 Suppl 1:47-51.
8. Berhe K, Gebru H, Kahsay H, Kahsay A. Assessment of Diabetes Knowledge and its Associated Factors among Type 2 Diabetic Patients in Mekelle and Ayder Referral Hospitals, Ethiopia. J Diabetes Metab 5: 378. doi: 10.4172/2155-6156.1000378 Page 2 of 7 J Diabetes Metab ISSN: 2155-6156 JDM, an open access journal Volume 5•
Issue 5• 1000378. study participants. 2014;171(57):3.
9. Foma MA, Saidu Y, Omoleke SA, Jafali J. Awareness of diabetes mellitus among diabetic patients in the Gambia: a strong case for health education and promotion.
BMC public health. 2013;13(1):1124.
10. Murugesan N, Snehalatha C, Shobhana R, Roglic G, Ramachandran A. Awareness about diabetes and its complications in the general and diabetic population in a city in southern India. Diabetes research and clinical practice. 2007;77(3):433-7.
11. Moodley L, Rambiritch V. An assessment of the level of knowledge about diabetes mellitus among diabetic patients in a primary healthcare setting. South African Family Practice. 2007;49(10):16-d.
12. Ulvi OS, Chaudhary RY, Ali T, Alvi R, Khan M, Khan M, et al. Investigating the awareness level about Diabetes Mellitus and associated factors in Tarlai (Rural Islamabad). J Pak Med Assoc. 2009;59:798-801.
13. Hoque MA, Islam MS, Khan MAM, Ahasan HN. Knowledge of diabetic complications in a diabetic population. Journal of Medicine. 2009;10(2):90-3.
14. Al-Qazaz HK, Sulaiman SA, Hassali MA, Shafie AA, Sundram S, Al-Nuri R, et al.
Diabetes knowledge, medication adherence and glycemic control among patients with type 2 diabetes. International journal of clinical pharmacy. 2011;33(6):1028-35.
15. Heisler M, Piette JD, Spencer M, Kieffer E, Vijan S. The relationship between knowledge of recent HbA1c values and diabetes care understanding and self- management. Diabetes care. 2005;28(4):816-22.
16. Al Bimani ZS, Khan SA, David P. Evaluation of T2DM related knowledge and practices of Omani patients. Saudi Pharmaceutical Journal. 2013.
17. Naing L, Than W, Rusli B. Practical issues in calculating the sample size for prevalence studies. 2006.
18. Al‐Qazaz H, Hassali M, Shafie A, Sulaiman S, Sundram S. The 14‐item Michigan Diabetes Knowledge Test: translation and validation study of the Malaysian version.
Practical Diabetes International. 2010;27(6):238-41a.
19. Najid MNM, Dali AF, Ahmad A, Sulaiman S, Hussin SN, Mokhtar NA. Knowledge and attitude on diabetes among public in Kota Bharu Kelantan, Malaysia
International Journal of Education and Research. 2014;2(2):2201-6333.
20. Pongmesa T, Li SC, Wee HL. A survey of knowledge on diabetes in the central region of Thailand. Value in Health. 2009;12(3):S110-3.
21. World directory of minorities and indigenous peoples - Malaysia: Indians2008 30 Disember 2014. Available from:http://www.refworld.org/docid/49749ce92b.html 22. Ahmad B, Khalid B, Quek KF, Zaini A, Phipps ME. Knowledge of diabetes and
lifestyle behaviour amongst indigenous population in Peninsular Malaysia. Med J Malaysia. 2013;68(4):309.
23. Al Shafaee MA, Al-Shukaili S, Rizvi SG, Al Farsi Y, Khan MA, Ganguly SS, et al.
Knowledge and perceptions of diabetes in a semi-urban Omani population. BMC Public Health. 2008;8(1):249.
24. Al-Adsani A, Moussa M, Al-Jasem L, Abdella N, Al-Hamad N. The level and determinants of diabetes knowledge in Kuwaiti adults with type 2 diabetes. Diabetes
& metabolism. 2009;35(2):121-8.
25. Rodrigues FFL, Santos MAd, Teixeira CRdS, Gonela JT, Zanetti ML. Relationship
