6.1 Need for study
Diabetes mellitus occupies a special place among non communicable diseases as it is one of the leading killers of the present time thus posing a considerable burden to the society in terms of public health. According to WHO ,India heads the world with over 32 million diabetic patients and this number is projected to increase to 79.4 million by the year 2030.1 World health statistics 2012, published by WHO reveals that, the prevalence of raised fasting blood sugar in those aged ≥25 years is 11.1% and 10.8 % among Indian males and Indian females against an overall global prevalence of 9.8% in males and 9.2% in females.2 Keeping in view the alarming rise in incidence and prevalence of diabetes in India, WHO declared India as “Diabetic Capital” of the world.3
Diabetes is a lifelong disease with a variety of complications. One can only achieve control over the blood sugars and complete cure is a distant reality. Thus it becomes the responsibility of the patient to acquire certain skills, and modify some of the behaviours to achieve a good glycemic control and thus prevent complications.
In the Indian socio-cultural scenario, it has been reported that the adherence to treatment regimens is very poor due to poor attitude towards the disease and poor health literacy thus in turn conveying that self care practices are very poor4. Adherence to treatment regimen is not the only self care practice but it also comprises the adherence to a healthy diet, being physically active, monitoring of blood sugars, and risk reduction behaviours on which patients usually tend to be reluctant. Thus if one adheres the self care practices, he can achieve a good glycemic control.
Health education can be given to improve the self care practices among diabetics. But education can be effective only if we first understand the knowledge and practices of the patient with regard to the disease, complications and its management. Presently there is very little data on the level of knowledge and self care practices among the diabetic patients in rural India and especially Karnataka. Thus this study was undertaken to study the knowledge and self care practices in rural area of Sullia, Dakshina Kannada district of Karnataka.
6.2 Review of Literature
In 2010, Padma K et al conducted a hospital based cross sectional study among type 2 diabetics to evaluate the knowledge and self care practices in diabetic patients and their role in disease management. 117 patients participated in the study and were given a semi structured questionnaire which had socio demographic information, diabetes specific information, knowledge regarding diabetes, and self care practices followed by the patient. Patients were then classified into those who had achieved glycemic control and those who did not. Self care practices were compared among these two groups. It was found that good number of patients had positive knowledge regarding diabetes. Almost 2/3rd patients were aware of importance of exercise, diet control and drug compliance. 64% of those who followed self care practices achieved glycemic control. Thus it was found that patients who were more self aware of the disease , having knowledge and regularly involved in self care practices achieved better glycemic control.5
In 2005, Gulabani M et al conducted a study on knowledge of diabetes, its treatment, and complications among diabetic patients in a tertiary care hospital in Ludhiana. 101 diabetic patients were included in the study. Mean score of women’s knowledge regarding the disease and complications was 2.84 points less than men .The study also indicated a significant lack of knowledge of primary and primordial prevention of diabetes in the population. Only 5.9% were actually aware of HbA1c. Only 60.4 % were aware of their target fasting and post prandial blood sugars, indicating an overdependence on physician and lack of empowerment of patient. Thus it was seen that patients knowledge regarding the disease and its complications showed serious deficiencies, more so among women even though they were diabetic for a long time.3
In 2005-2006, Priyanka C K et al conducted a hospital based KAP study on 730 diabetic patients in Bijapur, Karnataka. It was found that most patients in this study had fair or good knowledge regarding diabetes and they considered diabetes as a serious disease, with diet playing an important role in the control of the disease. It was also found that knowledge among the patients was more with increasing duration of diabetes. It was also found that even though the knowledge and attitude towards the disease was good, the same was not practised. Majority of them were not taking extra care if they were injured, or developed skin infection and were not involving in regular physical exercises. Thus this study reveals that knowledge of the disease and good attitude towards diabetes are not the only factors which will bring about glycemic control. Repeated reinforcement with motivation may be required.6
In 2007, Shah V N et al conducted a hospital based study to assess the knowledge, attitude and practise of type 2 diabetes among patients of Saurshtra region, Gujarat. 238 patients were included in the study. During evaluation of knowledge part, it was found that 63% patients did not know what diabetes is, and 60% did not know the complications of diabetes. They did not have knowledge on life style modifications as well. The concept that was prevalent among the patients was that, diabetes can be cured with bitter substances and allopathic drugs are harmful to the body. But people believed that, they are responsible for their care which implies that they were ready to change if motivated or educated properly. People also revealed that physicians spare very little time for the patient and search for complications was ignored by most.7
Muninarayana C et al conducted a community based study on prevalence and awareness regarding diabetes mellitus in the general population of rural Tamaka, Kolar, and is published in international journal of diabetes in developing countries. 311 adults were included in the study. This study showed that only 50.8% participants reported that they knew about a condition called diabetes. More than 75% of the interviewed population were not aware of long term complications of diabetes and diabetic care. About 48.4% of diabetic respondents were not aware of self care in diabetes.8
In March 2009, Nyunt S W et al conducted a study on self efficacy, self care behaviours,and glycemic control among type 2 diabetic patients attending two private clinics in Yangon. The prevalence of good glycemic control was 27.1% and was considered low. The low proportion of glycemic control was consistent with low proportion of good self care for diet (33.8%) and physical exercise (54.9%). Patients who were ≥60 years were 2.46 times better than <60 years in glycemic control. Patients with high self efficacy level were 5.29 times better than those with fair or low self efficacy level in glycemic control. Thus this study showed that patients with high self efficacy levels and good self care behaviour had better glycemic control.9
6.3 Objectives of the Study
1. To understand the knowledge of patients of type II diabetes mellitus regarding the disease and its complications.2. To estimate the knowledge and adherence to self care practices concerned with type II diabetes mellitus.
MATERIALS AND METHODS
7.1 Source of data
Place of study: Rural areas of Sullia, Dakshina Kannada, Karnataka. Sullia Taluk comprises of 40 villages. People with type II diabetes mellitus residing in these 40 villages will be considered as a source of data and will form the sample frame for my study.
Study period : June 2012 to May 2014
Sample size estimation:
Assuming that 50% of the diabetics had reasonable knowledge3,4 and they followed self care practices associated with the disease and that we require a precision of 5%, the sample size is calculated as:
n = Z2p(1–p)
d2
Where, n = sample size,
Z = Z statistic for a level of confidence,
P = expected prevalence or proportion
d = precision rate
Here by taking, Z = 1.96 (Approx.=2, for the level of confidence of 95%)
p = 50% (=0.5)
d = 0.05
n = (2)2(0.5)(1–0.5)
(0.05)2
n = 400
7.2 Method of collection of data (including sampling procedure)
A community based cross sectional study in which 400 diabetic adults, with atleast one year of the disease, will be selected from rural population of Sullia taluk using modified cluster sampling method.
Rural area of Sullia consists of 40 villages out of which all the villages will be selected for study purpose. 10 patients of type II diabetes mellitus from each village will be selected.
In the selected clusters, streets/lanes/direction will be randomly selected using random numbers and all consecutive houses on the selected street will be visited till required numbers (10 from each village) of study subjects are obtained. All adults fitting into the study criteria will be examined and interviewed using a structured questionnaire.
Operational definition of diabetic patients :
Adults ≥20 years ,who possessed a medical record or self reported to have Type 2 diabetes mellitus .4
Self care in diabetes mellitus :
These are behaviours undertaken by people with diabetes in order to successfully manage the disease like healthy eating, being physically active, monitoring of blood sugars, taking regular medications, and risk reduction behaviours.13
Inclusion criteria
1. Patients ≥ 20 years of age, who have a medical record or self reported cases of type 2 diabetes mellitus ,with a duration of disease ,of atleast one year residing in the study area.
Exclusion Criteria
1. Patients of diabetes mellitus <20 years will not be included in the study.
2. Patients of type II diabetes mellitus who are not willing to participate in the study.
3. If the patient is not available for atleast three times during the visit.
Study instrument
A structured questionnaire containing questions regarding age, sex, occupation, education, income, marital status, hypertension, diet, smoking, alcohol, duration of diabetes, blood sugar testing, foot care, exercise, medications, about the disease, and its complications.
It is planned to pilot test the questionnaire before the actual start of the study.
Consent
Informed consent will be taken from all the study subjects in the local language Kannada, copy of which is enclosed.
Time line chart
Copy is enclosed.
7.3 Does the study require any investigation or interventions to be conducted on patients/humans/animals? If so, please describe briefly.
No.
7.4 Has ethical clearance been obtained from your institution in case of 7.3?
Yes (copy is enclosed)
REFERENCES
1. 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.J Assoc Physicians India.2005; 53:283–7.
2. World Health Organisation. “World health statistics 2012”.
3. Gulabani M, John M, Isaac R. Knowledge of diabetes, its treatment and complications amongst diabetic patients in a tertiary care hospital. Indian J Community Med .2008; 33:204-6.
4. Gopichandran V, Lyndon S, Angel M K, Manayalil B P ,Blessy K R, Alex R G et al. Diabetes self care activities: A community-based survey in urban southern India. Natl Med J India.2012; 25:14-17.
5. Padma K, Bele S D, Bodhare N T , and Valsangkar S. Evaluation of knowledge and self care practices in diabetic patients and their role in disease management. National Journal of Community Medicine 2012; 3(1):3-6.
6. Priyanka C K, Angadi M M . Hospital based KAP study on diabetes in Bijapur, Karnataka. Indian Journal of Medical Specialities 2010; 1:80-83.
7. Shah V N, Kamdar P K , Shah N . Assessing the knowledge, attitudes, and practice of type 2 diabetes among patients of Saurashtra region, Gujarat. Int J Diab Dev Ctries 2009; 29:118-22.
8. Muninarayana C, Balachandra G, Hiremath S G, Iyengar K, Anil N S. Prevalence and awareness regarding diabetes mellitus in rural Tamaka, Kolar. Int J Diab Dev Ctries2010; 30:18-21.
9. Nyunt S W, Howteerakul N, Suwannapong N and Rajatanun T.Self efficacy, self care behaviours, and glycemic control among Type -2diabetes patients attending two private clinics in Yangon, Myanmar. SouthEast Asian J Trop Med Public Health; 41:943-951.
10. Mohan D, Raj D, Shanthirani C S, Datta M, Unwin N C, Kapur A et al. Awareness and knowledge od diabetes in Chennai-The Chennai Urban Rural Epidemiology Study
(CURES-9).Japi; 53:283-287.
11. Desalu O O, Salawu F K, Jimoh A K , Adekoya A O, Busari O A, Olokoba A B.Diabetic foot care:Self reported knowledge and practice among patients attending three tertiary hospital in Nigeria. Ghana Medical Journal; 45:60-65.
12. Tham K Y, Ong J J Y, Tan D K L, How K Y. How much do diabetic patients know about diabetes mellitus and its complications? Annals Academy of Medicine; 33:503-09.
13. American Association of Diabetes Educators.AADE7 Self-Care Behaviors. Diabetes Educ 2008; 34:445-9.