|Year : 2016 | Volume
| Issue : 4 | Page : 847-852
Knowledge and self-care practices regarding diabetes among patients with Type 2 diabetes in Rural Sullia, Karnataka: A community-based, cross-sectional study
Peraje Vasu Dinesh1, Annarao Gunderao Kulkarni1, Namratha Kurunji Gangadhar2
1 Department of Community Medicine, KVG Medical College, Sullia, Karnataka, India
2 Department of Microbiology, KVG Medical College, Sullia, Karnataka, India
|Date of Web Publication||28-Feb-2017|
Peraje Vasu Dinesh
Department of Community Medicine, KVG Medical College, Sullia, Karnataka
Source of Support: None, Conflict of Interest: None
Introduction: Diabetes is a lifestyle disease which requires a multipronged approach for its management, wherein patient has an important role to play in terms of self-care practices, which can be taught to them by educational programs. To develop such an educational program, a baseline assessment of knowledge and self-care practices of patients, needs to be made. The two objectives of the study were to estimate 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: The study was conducted in rural Sullia, Karnataka, from January 2014 to May 2015. The sample size was calculated to be 400, and the sampling method was probability proportionate to sampling size. Result: Majority of them were married males of Hindu religion and belonged to upper middle class. Only 24.25% of them had good knowledge. Among the self-care practices, foot care was the most neglected area. Conclusion: Only one-fourth of the study population had a good knowledge toward diabetes. Adherence to some of the self-care practices was also poor. Government policies may help in creating guidelines on diabetes management, funding community programs for public awareness, availability of medicines, and diagnostic services to all sections of the community. Continuing education programs for health-care providers and utilization of mass media to the fullest potential may also help in creating awareness.
Keywords: Knowledge, self-care practices, Type 2 diabetes mellitus
|How to cite this article:|
Dinesh PV, Kulkarni AG, Gangadhar NK. Knowledge and self-care practices regarding diabetes among patients with Type 2 diabetes in Rural Sullia, Karnataka: A community-based, cross-sectional study. J Family Med Prim Care 2016;5:847-52
|How to cite this URL:|
Dinesh PV, Kulkarni AG, Gangadhar NK. Knowledge and self-care practices regarding diabetes among patients with Type 2 diabetes in Rural Sullia, Karnataka: A community-based, cross-sectional study. J Family Med Prim Care [serial online] 2016 [cited 2017 Oct 23];5:847-52. Available from: http://www.jfmpc.com/text.asp?2016/5/4/847/201176
| 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. As of 2013, India ranks second in the list of diabetes among people aged 20–79 years next only to China. India had 65.1 million diabetic people aged 20–79 years, while China had 98.4 million people. Probably because of a staggering rise in obesity, 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.
Diabetes is a chronic disease, requiring a multipronged approach for its management, wherein the patient has an important role to play. 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, daily foot care practice, compliance with treatment regimen, and tackling complications such as hypoglycemic episodes. Thus, the objective of this study was to assess the baseline knowledge and self-care behavioral practices regarding diabetes among the rural population so that it will serve as a benchmark for future comparisons to assess the effectiveness of any educational training program for the diabetic patients.
| Materials and Methods|| |
A community-based, cross-sectional study was done among patients with Type 2 diabetes mellitus in Sullia Taluk, Karnataka, to assess their knowledge regarding the disease and the self-care practices that were followed by them. Assuming that 50% of the diabetics had reasonable knowledge, and they followed self-care practices as advised and requiring a precision of 5%, the sample size was calculated using the formula, 4 pq/d2. Thus, the study was conducted among 400 patients with Type 2 diabetes mellitus who were 20 years of age and above and who had the disease for at least 1 year and residing in that locality for more than a year. The patients were selected from forty villages of Sullia by probability proportionate to sample size and then by a random sampling technique.
A pretested, semi-structured questionnaire was handed over to each participant to collect sociodemographic details, diabetes-specific information, knowledge regarding diabetes, and the self-care practices that were followed by them. The questionnaire was reviewed by three professionals before being used – a public health expert, a diabetologist, and a statistician and their suggestions were utilized for improving the questionnaire thus ensuring consensus validity of the instrument. The questionnaire originally made in English was translated and back translated to and from Kannada to ensure appropriateness of translation. The questionnaire was also pilot tested before the actual start of the study. Ethical clearance was obtained from the Institutional Ethical Committee before the actual start of the study.
Knowledge was assessed using closed-ended questions, and the study subjects were classified as having poor, average, and good knowledge depending on the score obtained. Details regarding self-management activities were collected using the Summary Diabetes Self-care Activities Questionnaire after making minor changes to it to suit the local study population. The following variables were checked for: smoking habits, checking of feet daily and checking the inside of the footwear, checking blood sugars regularly and as advised by the health-care provider, regular drug intake, exercise for at least 5 days in a week, and adherence to a healthy eating plan. Since self-care practices cannot be scored collectively and given a single value, it was partitioned into different habits and then scored accordingly. Thus, participants were classified into either following self-care practices or not.
The data collected were entered in Microsoft Excel Office 2007 and SPSS statistics version 20 (IBM, New York, United States) was used for statistical analysis.
| Results|| |
Majority of the respondents were males (61.2%) and belonged to 40–49 years age group (31%). Majority of the study population belonged to Hindu religion (71%) and were married (91.2%). Only 9.5% of the participants were illiterates. Most of the study population were either agriculturists or self-employed and belonged to the upper middle class as per Modified BG Prasad Classification. Fifty-one percent of the respondents had diabetes for 1–5 years, 35% for 6–10 years, and 11% of them for 11–20 years. Only 4% had diabetes for more than 20 years. Regarding the treatment profile of the study group, it was evident that 50% were treated by doctors with MBBS qualification and <1% by specialists. Thirty-three percent were treated by an M.D. physician, and 15% by an AYUSH practitioner. The baseline characteristics of the respondents are shown in [Table 1].
Among the participants, almost half of them (49.5%) denied of having any comorbidity. Among those who knew of comorbidities in them, majority of them accepted to have hypertension (32%) followed by dyslipidemia (28.75%).
The study population was questioned about the general features of diabetes, its risk factors, symptoms, mode of diagnosis, and complications to estimate the knowledge about the disease. It was seen that only 24% of the participants had good knowledge about the disease, 59% of them had an average knowledge, and 17% had poor knowledge.
Among the general questions that were asked on diabetes, more than 50% had good knowledge on diabetes being hereditary (65.25%) and 52.5% felt that diabetes cannot be cured. More than 50% of the study population did not know that age, high cholesterol, and low physical activity were risk factors of diabetes. About 50% of them did not know that fatigue, hunger, and thirst could be a symptom of diabetes. More than 70% of them were not aware that neuropathy, skin infection, and ophthalmic problems could be a complication of diabetes [Table 2].
|Table 2: Frequency distribution of respondent's knowledge regarding diabetes mellitus|
Click here to view
More than 50% were aware that fatigue (77%), excessive sweating (67.5%), and blurred vision (55.75%) were signs of hypoglycemia. However, <50% of them were aware that a headache (35.25%) could be a symptom of hypoglycemia [Table 2].
The respondents had a good knowledge about the ideal way of detection of diabetes. More than 80% felt that diabetes can be detected by blood sugar estimation [Table 2].
Regarding misconceptions about diabetes, more than 50% of the respondents (56.5%) felt that drugs can be stopped once diabetes is controlled. About 28.25% felt that diabetes can be treated with all bitter substances.
It was noted that those participants who visited private establishments for their treatment were more knowledgeable than those who visited government facilities, and this was also found to be statistically significant (χ2 = 9.09, df = 1, P = 0.003). Participants who visited health-care providers of modern medicine background (allopathic practice) were found to be more knowledgeable than those who visited AYUSH practitioners, and this was also found to be statistically significant (χ2 = 12, df = 1, P = 0.001).
ANOVA was done to compare the mean knowledge score obtained against various age groups, religion, educational status, occupation, and socioeconomic status. Z-test was done to compare the knowledge score obtained between the two genders. It was noted that there was statistically significant difference in the knowledge among age groups (F = 4.041, P < 0.05), religion (F = 34.67, P < 0.05), occupation (F = 17.54, P < 0.05), socioeconomic status (F = 9.41, P < 0.05), and duration of diabetes (F = 7.33, P < 0.05).
Among the self-care practices, it was seen that checking the feet daily and inspecting the inside of shoes/footwear daily were the two practices which were not followed by a majority of the study participants which accounted for 99.5%. The practices that were best followed were checking of blood sugars at least once in 3 months and as advised by the doctor which accounted for almost 65% and 73% of the respondents. Only 48% of the respondents were regular in taking drugs and 20.5% exercised for at least 5 days in a week for 20–30 min. The details of the adherence to self-care practices are given in [Table 3].
Logistic regression analysis of each self-care practice with blood sugars was done, and the results are shown in [Table 4]. It was seen that dietary practice is one of the important factors influencing the achievement of good blood sugars in the participants. The odd ratio was more than 1 and P < 0.05.
| Discussion|| |
The present study was done to assess the knowledge and practices regarding diabetes among the known diabetics residing in rural field practice area of a teaching hospital.
Most of the study participants were in the 40–49 years age group, which was slightly lower than that seen in studies done by Priyanka and Angadi  and Shah et al. 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., respectively, where the majority of the participants were in the age group of 30–45 and 30–49 years, respectively. In the present study, the duration of diabetes in the participants was mostly 1–5 years in contrast to study done by Hawal et al. where the majority of them had diabetes for more than 5 years. Regarding the literacy status of the study participants, it was found that only 9.5% were illiterates as compared to 36.64% as seen in the study done by Shah et al. The literacy rate in the Southern part of Karnataka is generally very good. 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.
One of the most important findings in this study is that only 24% of the respondents had an overall good knowledge regarding diabetes. This is a matter of concern because India has around 65.1 million diabetic people and poor knowledge about their own health status and disease may be one of the barriers for healthful living. Further knowledge can serve as an important resource base for improving their own health and that of the society.
The results of our study regarding knowledge of the participants are similar to Chennai Urban Rural Epidemiology Study (CURES-9) study  which also reflects the poor knowledge and awareness about diabetes among the Chennai population. There was a misconception among 72% of our study participants that all bitter substances can treat diabetes against 53% which was seen in a study done by Shah et al. in Saurashtra. Eighty-two percent knew the methods to diagnose diabetes mellitus which was slightly different from findings in a study done by Gupta et al. where 90% of the study population in the rural area knew about accurate methods to diagnose diabetes.
Again, knowledge regarding complications of diabetes was also poor, which was also similar to CURES study. Only 30% of the participants knew that diabetes can cause ophthalmic problems against 15% of the participants in CURES study. Even more, worse was their knowledge on diabetes causing neuropathy and skin infections. The results obtained in our study regarding the knowledge on complications were different from the results obtained by Mehta et al., who observed that 82% of his study subjects had knowledge about the disease and its complications.
It was observed that mean composite knowledge score was better in the 30–49 years age group, being a professional and belonging to upper class. This finding is similar to the one done by Adibe et al. with respect to the age group who also found that younger the age group, better the knowledge. It was also seen that those with <5 years of disease had a better knowledge score. This is probably because the younger generation is more educated, aware, and more exposed to the media which make them knowledgeable.
This poor knowledge indicates that most of them are not educated regarding their disease by their primary care physicians and field-level health workers. One of the reasons for the lack of providing education could be that field workers are themselves not aware or not motivated to educate the public. Physician's failure in this part may be due to the heavy load of patients that they see in their daily practice and thus the lack of time to educate. This emphasizes that the already existing field-level workers like ASHAs should be educated, trained, and motivated in this aspect. Education through mass media can also bring about a change.
Among the self-care practices, good dietary behavior was present only in 24% of the study participants. This was quite different from a study done by Rajasekharan et al. in an urban area where 46% of the participants followed a diet plan regularly. Emphasis should be given to good dietary practices as it is a determinant of both glycemic control and weight management. The World Health Organization recommends at least 400 g of fruits and vegetables per day  which was not followed by most of the study participants. Consumption of these minimum recommended levels of fruits and vegetables will also protect an individual from cardiovascular diseases, stroke, and gastrointestinal diseases. In our study, only 3% of the participants consumed the recommended fruits and vegetables for at least 5 days or more in a week. This is in contrast to a study done by Rajasekharan et al. where 26% of the participants included fruits and vegetables in their diet on all days of the week. However, it was interesting to see that only 4% of the study participants included high-fat diet on 5 or more days of the week. These findings are almost similar to those seen in studies done by Rajasekharan et al. and Gopichandran et al.
Regarding the physical activity, only 19% of the study participants followed the recommended 20–30 min exercise per day for at least 5 days a week. Similar findings were seen in a study done by Hailu et al. Exercising regularly will have many benefits ranging from reduced insulin resistance, blood pressure control, and cardioprotective role.
Sixty-five percent of the study participants checked their blood sugars at least once in 3 months. Almost similar findings were seen in studies done elsewhere.,, Emphasis should be laid on checking blood sugars as the effectiveness of the treatment regimen can be ascertained only by checking their blood sugars. A negligible amount of participants checked their blood sugars at home.
Forty-eight percent of the participants take the recommended hypoglycemic agents and insulin daily and regularly, which were lower than the study conducted elsewhere.,
Regarding foot care, only 0.5% of them checked their feet and inspected the inside of their shoes daily which is <9% and 12%, respectively, which was observed in a study done by Raithatha et al. None of them wore footwear inside their houses, which was in contrast to a study done in Mumbai by Chandalia et al. where 55% were wearing footwear inside.
Logistic regression of self-care practices against the blood sugar levels showed that dietary practice is one of the important factors influencing the maintenance of good blood sugar levels in the participants. These findings are slightly different from a study conducted by Wynn Nyunt et al. where following a healthy diet, following exercise for at least 5 days in a week, and compliant to drug therapy were all associated statistically with the achievement of glycemic control.
| Conclusion|| |
As evidenced by the study, it was noted that only about one-fourth of diabetics had a good knowledge. The respondents were very poor with regards to the daily checking of foot and inside of footwear and also in adherence to exercises.
Although the Indian urban population has access to reliable screening methods, antidiabetic medications, counseling services, and preventive services, such health benefits, are not often available to the rural patients. There is a disproportionate allocation of health resources between urban and rural areas and in addition, poverty in rural areas may be responsible for this poor knowledge and self-care practices.
Food insecurity, illiteracy, poor sanitation, and dominance of communicable diseases may also contribute which suggests that both policy makers and local governments may be undermining and underprioritizing the looming threat of diabetes.
Such inadequacies contribute to an infrastructure that may result in poor diabetes screening and preventive services, nonadherence to diabetic management guidelines, lack of available counseling, and long distance travel to health services.
Regular health education services which will make them knowledgeable about the disease and encouraging self-care management in those who are diagnosed as diabetic will reduce the health-care burden and help in achieving glycemic control and thus minimizing complications.
As this study is done to assess the knowledge and self-care practices among diabetic patients only, the results cannot be generalized to the whole community. One more limitation is that the blood sugar values that have been obtained for this study are not done by the author. The last blood sugar values done by the patient at different times have been taken for this study. And also the questionnaire that is used is closed ended, and they can sometimes be guessed by the respondents.
Thanks to all patients without whom this study would not be completed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Unwin N, Whiting D, Gan D, Jacqmain O, Ghyoot G. The global burden. In: IDF Diabetes Atlas. 4th
ed. Belgium: International Diabetes Federation; 2009. p. 21-37.
Guariguata L, Nolan T, Beagley J, Linnenkamp U, Jacqmain O. The global burden. In: IDF Diabetes Atlas. 6th
ed. Belgium: International Diabetes Federation; 2013. p. 29-48.
Misra P, Upadhyay RP, Misra A, Anand K. A review of the epidemiology of diabetes in rural India. Diabetes Res Clin Pract 2011;92:303-11.
Raithatha SJ, Shankar SU, Dinesh K. Self-care practices among diabetic patients in Anand district of Gujarat. ISRN Family Med 2014;2014:743791.
American Diabetes Association. Standards of medical care in diabetes-2013. Diabetes Care 2013;36 Suppl 1:S11-66.
Toobert DJ, Hampson SE, Glasgow RE. The summary of diabetes self-care activities measure: Results from 7 studies and a revised scale. Diabetes Care 2000;23:943-50.
Priyanka CK, Angadi MM. Hospital-based KAP study on diabetes in Bijapur, Karnataka. Indian J Med Specialities 2010;1:80-3.
Shah VN, Kamdar PK, Shah N. Assessing the knowledge, attitudes and practice of type 2 diabetes among patients of Saurashtra region, Gujarat. Int J Diabetes Dev Ctries 2009;29:118-22.
Muninarayana C, Balachandra G, Hiremath SG, Iyengar K, Anil NS. Prevalence and awareness regarding diabetes mellitus in rural Tamaka, Kolar. Int J Diabetes Dev Ctries 2010;30:18-21.
Patil PS, Dixit UR, Hiralal BD. Study of diabetes in Dharwad – An urban area in India. Indian J Sci Technol 2011;4:1481-3.
Hawal NP, Shiwaswamy MS, Kambar S, Patil S, Hiremath MB. Knowledge, attitude and behaviour regarding self-care practices among type 2 diabetes mellitus patients residing in an urban area of South India. Int Multidiscip Res J 2012;2:31-5.
Mohan D, Raj D, Shanthirani CS, Datta M, Unwin NC, Kapur A, et al
. Awareness and knowledge of diabetes in Chennai – The Chennai Urban Rural Epidemiology Study (CURES-9). J Assoc Physicians India 2005;53:283-7.
Gupta RK, Shora TN, Jan R, Raina SK, Mengi V, Khajuria V. Knowledge, attitude and practices in type 2 diabetes mellitus patients in rural Northern India. Indian J Community Health 2015;27:327-33.
Mehta RS, Karki P, Sharma SK. Risk factors, associated health problems, reasons for admission and knowledge profile of diabetes patients admitted in BPKIHS. Kathmandu Univ Med J (KUMJ) 2006;4:11-3.
Adibe MO, Aguwa CN, Ukwe CV, Okonta JM, Udeogaranya OP. Diabetes self care knowledge among type 2 diabetic outpatients in South-Eastern Nigeria. Int J Drug Dev Res 2009;1:85-104.
Rajasekharan D, Kulkarni V, Unnikrishnan B, Kumar N, Holla R, Thapar R. Self-care activities among patients with diabetes attending a tertiary care hospital in mangalore karnataka, India. Ann Med Health Sci Res 2015;5:59-64.
Lock K, Pomerleau J, Causer L, Altmann DR, McKee M. The global burden of disease attributable to low consumption of fruit and vegetables: Implications for the global strategy on diet. Bull World Health Organ 2005;83:100-8.
Gopichandran V, Lyndon S, Angel MK, Manayalil BP, Blessy KR, Alex RG, et al.
Diabetes self-care activities: A community-based survey in urban southern India. Natl Med J India 2012;25:14-7.
Hailu E, Wudineh HM, Belachew T, Birhanu Z. Self-care practice and glycaemic control amongst adults with diabetes at the Jimma university specialized hospital in South-West Ethiopia: A cross-sectional study. Afr J Prim Health Care Fam Med 2012;4:34-9.
Cayley WE. The role of exercise in patients with type 2 diabetes. Am Fam Physician 2007;75:335-6.
Ayele K, Tesfa B, Abebe L, Tilahun T, Girma E. Self care behavior among patients with diabetes in Harari, Eastern Ethiopia: The health belief model perspective. PLoS One 2012;7:e35515.
Guo XH, Yuan L, Lou QQ, Shen L, Sun ZL, Zhao F, et al.
A nationwide survey of diabetes education, self-management and glycemic control in patients with type 2 diabetes in China. Chin Med J (Engl) 2012;125:4175-80.
Chandalia HB, Singh D, Kapoor V, Chandalia SH, Lamba PS. Footwear and foot care knowledge as risk factors for foot problems in Indian diabetics. Int J Diabetes Dev Ctries 2008;28:109-13.
Wynn Nyunt S, Howteerakul N, Suwannapong N, Rajatanun T. Self-efficacy, self-care behaviors and glycemic control among type-2 diabetes patients attending two private clinics in Yangon, Myanmar. Southeast Asian J Trop Med Public Health 2010;41:943-51.
[Table 1], [Table 2], [Table 3], [Table 4]