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KNOWLEDGE AND ATTITUDE OF TYPE II DIABETIC PATIENTS AND THEIR UTILIZATION OF MANAGEMENT APPROACHES IN AKWA IBOM STATE.
Background of the Study
The high prevalence of diabetes mellitus has been reported worldwide and its related complications continue to be of great concern (Whiting, Guariginta, Weil and Shaw, 2011). Diabetes is one of the chronic diseases which are now the major causes of death and disability globally and mainly in low income countries. Regrettably these countries bear the dual burden brought about by infectious and chronic diseases. According to World Health Organization (2009), over 30 percent of our elite population including decision makers are diabetics and majority of the Nigerians who are affected cannot afford meaningful treatment with many being ignorant of the disease.
Diabetes is a metabolic disorder or chronic disease characterized by chronic hyperglycemia with disturbances of carbohydrates, fat and protein metabolism resulting from a quantitative deficiency of insulin, an abnormal insulin level resistance to its action or a combination of deficits. Insulin is a hormone that controls glucose, fat and amino acid metabolism and is produced by beta cells from the islet of langarhan in the pancreas. The disease is a public health concern and account for 3.8 million deaths per year (World Bank, 2012).
According to Orchard (1994) two major types of diabetes are recognized – type I diabetes formerly referred to insulin dependent diabetes which comprises about ten percent of all cases, and type 2 diabetes formerly referred to as non-insulin dependent diabetes which accounts for about ninety percents of the cases. Type two diabetes may occasionally occur as a result of other diseases such as acromegaly and cushingssyndrome.
Orchard (1994) also asserted that diabetes can be drug induced (for example by steroids and possibly by the thiazide discreticsand oral contraceptives) or induced by the disease affecting the pancreas such as cancer of chronic pancreatitis. Gestational diabetes also occurs during pregnancy but remits shortly after delivery. Impaired glucose tolerance (IGT) or impaired fasting glucose (IFG) which is prediabetes are conditions in which blood glucose is elevated but not high enough to be classified as diabetes but may carry increased risk of large vessel (Coronary heart) disease.
According to Park (2013)unfavourable modification of lifestyle and dietary habits that are associated with urbanization are believed to be the most important factors for the development of diabetes. He further postulated that a bulk of evidence from studies on migrants indicates that the ethnic, presumably genetic vulnerability of Asians manifests into diabetes when subjected to unfavourable lifestyles. His surveys indicated considerable increase in the prevalence rate of the disease in both urban and rural dwellers when compared to earlier result obtained. He still lamented on the inadequate awareness about the real dimension of the problem among the general public and the lack of awareness about the existing interventions for preventing diabetes and the management of complications.
Health knowledge is then necessary in curbing the menace of this diseases. According to Moronkola (2001), health knowledge is acquired from sources which directly or indirectly influence the individual’s health attitude and practice. Arogundade and Erakpotober (2005) affirmed that behaviour turns to attitude and then to habit. Ojo (2005) was of the opinion that health behaviour otherwise known as healthy life styles which help to increase an individual sense of wellbeing can act as a buffer against diseases like diabetes.
A person’s attitude therefore plays a significant role in effecting and determining his or her health. As asserted by Rennie (1999) attitude could be viewed as a way of thinking or feeling which could be positive or negative to people, objects or ideasin ones environment. Therefore a positive behaviour and attitude is favourable to health while a negative behaviour and attitude is detrimental to health. According toMullooly& Kermis (2005) an impact can only be made on behaviour when the patient has a good understanding of the disease process (informational approach) as well as disease management. Park (2013) also added that for a successful management of any disease condition affecting man an understanding of the behaviour of the individual is necessary.
Ikorok, Ekpu and Assian (2010) refer to disease as harmful departure from normal functioning of human system, and the desire to return to good health is the basic reason for seeking healthcare services. According to Achalu (1999) various reasons come into focus, this is probably due to the fact that health issues depend on many other factors not related to medical science only. In Nigeria like many sub-saharan African countries both traditional (non-scientific health care service provided by lay men) and modern health care services (healthcare based on scientific methods and technological knowledge are available (Ademulegun, 2002).
The utilization of either of the health services depend largely on many factors which determine health. Utilization according to Crowder (1998) is an act of making use of, find use for or being used effectively. One can only make use of something with an aim of receiving maximum benefit. Therefore utilization of management approaches in this study is based on approaches used in prevention and control of diabetes. Health care services are designed to provide benefits to patients. The utilization of modern health care system implies both accessibility of care, facility and the willingness of persons to use such care available.
Availability equally depends on the following factors – cost of services availability and planning effort of the health administration, Ademulegun (2002) asserted that the willingness to use depends not only on economic factors but various aspects of illness ignorance, level of education, attitude and behaviour including health knowledge. Behaviour change is of utmost importance if prevention or control of a disease is to be achieved (Achalu, 2008). Ekoja (2006) has asserted that overcoming ignorance is the key to achieving behavioural change which remains a major strategic option for control of a disease like diabetes.
Behavioural change contribute to effective management of diabetes which includes self care, healthy diet, regular exercise and weight control, appropriate medication to achieve target lower blood sugar level, education and support should be developed. Clark, Berker and Janz (1991) review suggests self care to be a preventive strategy (ie tasks performed by healthy people at home). In contrast they maintain that self managementis interpreted as the day to day tasks an individual must undertake to control or reduce the impact of disease on physical health status. At home management tasks and strategies are undertaken with the collaboration and guidance of the individual’s physician and other healthcare providers (Clark et al, 1991).\
According to Vincent and Funham (2001) self care or self management approaches comprise of the complementary treatment advised by health care educators and traditional therapies, and they include regular exercise to aid weight management, improves insulin sensitivity and therefore blood glucose control; aids blood fat control and improves overall sense of wellbeing strengthen the heart muscle and improves circulation. Weight control - a ten percent reduction in body weight leads to an average fifty percent reduction in fasting blood sugar levels. Eating healthily maintenance and adherence to healthy diabetic diet and keeping eye on blood sugar levels also assist the diabetics.
The promotion of energy from each of the major groups of diets should be such that fifty-sixty percent energy should be derived from carbohydrate, twenty-five to thirty percent from fat and fifteen to twenty percent from protein. Dietary fibres/roughages increase intestinal transit time and retard nutrient absorption, vegetables and fruits to include green, spinach, bitter leaf, okro, melon, onions, tomatoes, garlic, garden eggs, vegetable or groundnut oil, green plantain and green pawpaw, apple, orange, banana (at least one of each daily. Drinks and snack to include soya bean milk, cucumber drink, fresh grapes, fruit juice (unsweetened) pure natural water and youghurts (WHO, 2013).
According to WHO (2013) oral medication for type 2 diabetes that exist work by lowering blood sugar, stimulating the pancreas to produce and release more insulin, inhibiting the production and release of glucose from the liver, blocking the action of stomach enzymes that breakdown carbohydrates and improving the sensitivity of cells to insulin, inhibiting the reabsorption of glucose in the kidney and slowing down the movement of food through the stomach.
Sulfonylureas-stimulate the release of insulin immediately with hypoglycemia, weight gain and skin rash as side effect e.gGibenclamide (Dionil) Gileiazide (Diamicron) and Tulbutamide.Biquanides help cells in the body to response more effectively to insulin i.e reduce insulin resistance e.g Metformin (Colucophage). It also promotes modest weight loss with nausea and diarrhea as side effect. Alphaglucosidaseinhibitors slow sugar absorption in the intestine, prevent sudden increase in blood glucose that occurs after eating e.gacorbose (Glycoham), miglitol. Meglitinides work by stimulating the release of insulin and reduce side effect ofhypoglycaemia, weight gain, neaseaand vomiting , headache.
Dipeptidyl-peptidase 4(DPP-4) inhibitors inhibit the release of glucose from the liver cause no weight gain and side effect include upper respiratory tract infection, sore throat, headache, Thiazolidiones – improve sensitivity to insulin, inhibit the release of glucose from the liver but has serious side effect like heart failure, heart attack, fracture losterpporousa and increase risk of bladder cancer.
The management of this disease is aimed at helping patients and their families to gain knowledge, skills, resources and support essential for optimal health (Funnel, 2009). It also helps them to gain confidence enabling them to take increasing control of their own condition and integrate effective self management into their daily life. The potential benefits of an effective patient education programme include improving knowledge health beliefs and lifestyles changes, improving patient outcome weight and reducing the need for potentially better targeting of medication.
Nembeko (2012) in his study of type 2 diabetes management asserted also that support is very important in chronic disease management as emotional support from family and friends will be needed including material support as socio-economic status makes it difficult to manage the disease and hinders access to and utilization of medical services, including hospital and nearby health care centres.
Wikby, Bjorn and Hjelm (2012) on their level and determinants of diabetes knowledge in patients with diabetes in Zimbabwe, a cross-sectional descriptive method using a standardized self report questionnaire. The sample consisted of 58 adult, 32 women and 26 men with diabetes obtained through convenience sampling. A standardized self reportquestionnaire was used to collect data on the respondents’ knowledge about diabetes, it treatment, their understanding, socio-demographic and diabetes related background data. Diabetes mellitus ranked fifth amongst the non communicable diseases recorded in most Zimbabwean public hospitals with a prevalence rate of 10 percent in the > 25 age group. The study has some areas of knowledge deficit with regard to diet,glycaemic control and insulin use. Low diabetes knowledge was significantly associated with female gender and could be a risk factor for development of diabetes related complications. The limited knowledge about DM affected self-care and health-seeking behaviours amongst Zimbabwean males and females, gender seemed to influence the riskawareness of the disease, with females being more information seeking and active in self care, limited diabetes knowledge and selfcare was indicated.
In another study to assess knowledge, attitude of patients with type 2 diabetes and its complications, selfcare, practices to recognize and manage diabetes crisis, as well as self monitoring of blood glucose with a view to identify the areas to focus for diabetes self management education and to improve diabetes care conducted by Adisa, Fakeye and Okorie (2010) in Ibadan, a cross sectional study was conducted at Adeoyo General Hospital. Pretested questionnaire was administered to 200 randomly selected type 2 diabetes patients between 2nd March and 31st May 2009. Of these, 175 (87.5% properly filled questionnaires were subsequently analysed and descriptive strategies were used to summarize data. Chi-square was used for test of proportions, while students test and ANOVA were used to compare continuous variables, with P < 0.05 considered significant. Only 18 (19.3%) knew the most probable cause of diabetes, more than three fourth (77.7%) were not aware that poor control of blood glucose levels could result in complications. Only 24.1% could mention at least a symptom to recognize hypoglycemic episode, while (75.9%) were not aware of the self care approach to manage such crisis. Polyuria, 65 (37.4%) was the most commonly cited signal to recognize hyperglycemic episode. Only 3.4% practice self monitoring of blood glucose. Overall, 47 (26.9%) had a good knowledge and attitude about diabetes. Knowledge, attitude and self management practices among type II diabetic patients was low. It was then suggested that there was need for an institutionalized and effective standard for diabetes self management education so as to ensure improved diabetes care for the patient.
In a study conducted by Mshungane, Stewart and Rothberg (2012) in south Africa, to determine the knowledge that patients with type 2 diabetes have about the management of their disease, as well as the perceptions of the health care team about the service given to patients.
Qualitative data were collected using two focus groups and in-depth interviews. Patient focus group (n=10) explored patients’ knowledge about management of type 2 diabetes. Patients were recruited from Dr. George Makham Hospital outpatients’ diabetes clinic. Professional focus group (n=8) explored the health care teams experiences, barriers and facilitators in managing the disease. Professional focus group participants were recruited because of their expertise in chronic disease management, working in the community (public health) or working directly with patients with type 2 diabetes. Five health care professionals were interviewed using the same guide of questions as for the focusgroup. It was concluded that management of type II diabetes may be enhanced by reinforcing patients knowledge, encouraging behaviour change whilst taking into consideration patients backgrounds. The health care team needs to utilize a pertinent-centered approach.
In a study by pharmacists during Ramadan in Doha, Qatar, the study aimed to describe Qaterphamarcists’ practice, knowledge and attitudes towards guiding diabetes medication management. A cross sectional descriptive study was performed among a convenience sample of 580 Qutar pharmacists. A web-based questionnaire was systematically developed following comprehensive literature review and structured according to 4 main domains subject demographics, diabetes care experiences, knowledge of appropriate patient care during Ramadan fasting and attitude towards potential alpharmacist responsibilities in this regard. Results showed that in the 3 months prior to Ramadan (July 2013), 178 (31%) pharmacists responded to the survey. Ambulatory (103,58%) and inpatient practices (72,41%) were similarly represented. On-third of pharamacists reported at least weekly interactionwith diabetes patients during Ramadan. The most popular resources for management advice were the internet (94,53%) and practice guidelines (80,45%), however only 20% were aware of and had read the American Diabetes Association Ramadan consensus documents. Pharmacist knowledge scores of appropriate care was overall fair (99,57%). Pharmacist identified several barriers to participating in diabetes management including workload and lack of private counselling areas, but expressed attitudes consistent with a desire to assume greater roles in advising fasting diabetic patients. In conclusion Qutar pharmacists face several practical barriers to guiding diabetes patient self management during Ramadan, but are motivated to assume a greater role in such care. Educational programmes are necessary to improve pharmacist knowledge in the provision of accurate patient advice.
A study in South Africa by Nombeko, Stewart and Rothberg (2012) determined the knowledge that patients with type 2 diabetes have about the management of their disease, as well as the perceptions of the health care team about the services given to patients. Qualitative data were collected using two focus groups and indepth interviews. Patient focus group (n=10) explored patients’ knowledge about management of type 2 diabetes. Professional focus group (n-8) explored the health care teams experiences, barriers and facilitators in managing the disease. Professional focus group participants recruited because of their expertise in chronic disease management, working in the community (Public health) or working directly with patients with type 2 diabetes. Five health care professionals were interviewed using the same guide of questions as for the focus group. In the result, participants identified type II diabetes as a chronic disease that needs behaviour change for good control. Five major themes were identified patients’ knowledge; education programmes, behaviour change, support and a patient centredapproach.\