Factors Affecting Diabetes Management


16 Apr 2018

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This chapter of review of literature helps focus on some of the recent literature related to diabetes. It helps throw light on the research articles relating to the knowledge, attitude and practices in diabetic patients. Further it also gives a brief account of studies related to the predictors of alternative approaches and the studies that are related to the sources that influence the usage of alternative approaches. The review is limited to the articles that were done between 1985-2014 of which some of them are quantitative and qualitative in nature. The databases through which the journals are referred include Pubmed, Springerlink, ScienceDirect, Sage, Wiley online library, Taylor & Francis, Plos one, Mary Ann Liebert, American Diabetes Association, BioMedCentral (BMC) and Oxford Journals. This review helps in identifying the gaps that exist in the present literature.

Knowledge, attitude and Practices amongst Diabetic adults

Awareness of diabetes and diabetes care is needed for successful disease management. Low level of awareness of diabetes and its complications among patients results in poor glycemic control in Indians with diabetes. Knowledge about diabetes mellitus, appropriate attitude and practices are vital to reduce the incidence and morbidity associated with it. Obtaining information about the level of awareness about diabetes in a population is the first step in formulating a prevention program for diabetes (Mohan, Raj, Shanthirani, Datta, Unwin, Kapur, & Mohan, 2005). A study from Pakistan highlighted the fact that proper education and awareness program can change the attitude of the public regarding diabetes (Badrudin, Basit, Hydrie, & Hakeem, 2002) as a large gap between knowledge and attitude among the diabetes patients was found (Sivagnanam, Namasivayam, Rajasekaran, Thirumalaikolundusubramanian, & Ravindranath, 2002) and proper knowledge regarding various aspects of health education program can improve the knowledge of patients and change their attitude (Mehta, Karki, & Sharma, 2006).

In a study that was conducted in Philippines to test the knowledge, attitude and practices among diabetic patients it was found that the overall knowledge scores are poor, with a percentage mean score of only 43%. The finding also reveal that only 1% of the 156 respondents believed that type 2 diabetes is a serious illness reflecting how most of the residents think of their condition as something to be taken lightly, this in turn had an effect on the participants practices where less than half of the respondents reported regular follow-up with their doctors (Ardeňa, Paz-Pacheco, Jimeno, Lantion-Ang, Paterno, & Juban, 2010). Adequate knowledge has been associated with more adequate behavioural outcomes.

In a cross-sectional study on knowledge, attitude and practices among diabetes patients about diabetes and its complications in Central Delhi, it was found that out of 170 patients 85.9% participants had the basic knowledge about the type of diabetes, about 87.6% of the participants revealed that they knew what they had to consume, while only 11.8% participants knew about normal blood sugar levels. The maximum knowledge that the participants had were about the eye problems (48.82%) and kidney problems (40%) while very little knowledge was noted for diabetic coma and stroke that results from diabetes. It was also found that the participants have a positive attitude (72.65%) that was not reflected in their practices (Singh, Khobragade, & Anil, 2013). Another study done in Bijapur, Karnataka revealed the same results as the above where the positive attitude was about 60-90% among the participants and it was also found that 59.9% had poor knowledge and 24.8% had good knowledge about diabetes. Further the study focused on the practices of the respondents where they took extra care in case they were injured and 40.7% were exercised regularly (Raj & Angadi, 2011).

A study that was conducted among 238 diabetes patients in Saurashtra region, Gujarat, Shah, Kamdar and Shah (2009) found despite being diagnosed with diabetes for eight years only 46% of them knew the pathophysiology of diabetes. The three main findings of the study revealed that low education about diabetes among the participants were because 40% of the participants belonged to the below poverty line, because of which they could not afford therapy or a minimum standard care. The second reason for having low knowledge was only 3% of the participants were being treated by an endocrinologist, the reason being Gujarat having very less number of endocrinologists with not even one in the Government hospital making it difficult for the poor to afford the private institutions. Third and the most important factor was the low level of education where only 10% of them were graduates and 37% of the participants were completely literate. The study also shows the attitude towards diabetes among the participants where it was found that the participants believed that they are completely responsible for their own health indicating that if motivated and given education about diabetes they would make necessary changes in their lifestyle.

A Cross-sectional study that used the knowledge, attitude and practice (KAP) questionnaire among the out patients in Nepal revealed that the knowledge, attitude and practice level of the participants were low (Gul, 2010; Upadhyay, Palaian, Shankar, Mishra, & Pokhara, 2008). Supporting this study another recent study involving young (31-40 years) diabetic Saudi women also reported poor KAP scores (Saadia, Rushdi, Alsheha, Saeed, & Rajab, 2010). Another study done in Malaysia reported that diabetic patients in a primary care centre had good knowledge and better attitude towards the care of their own disease (Ranjini, Subashini, Ling HM, 2003). Some research articles revealed that diabetic patients possess adequate knowledge and have positive attitude towards their condition and that there is no relation between the KAP and actual control of Diabetes Mellitus (Ng, Chan, Lian, Chuah, & Noora, 2012).

A study that was conducted by Kheir, Greer, Yousif, Geed and Okkah (2011) evaluated the knowledge, attitude, practice (KAP) and psychological status of adult Qatari patients with type 2 diabetes mellitus to study the role of these factors on the ability of the patients to manage their diabetes and to achieve desirable health outcomes. It was found that there were significant differences in the attitude and knowledge between educational levels. The study concluded that providing education and other support programs to diabetics could be more effective if the KAP of the patients are understood before conducting such programs.

A study which was done in United Arab Emirates to find out the KAP in diabetic patients revealed poor knowledge among the participants. It was found that the majority of patients (72%) had a negative attitude towards having diabetes. However, only 6% expressed a ‘negative attitude’ towards the importance of DM care. The results also showed marginally significant associations between the practice score and level of education, marital status, mode of diagnosis, duration of disease, insulin use and frequency of seeing diabetes educator (Al-Maskari El-Sadig, Al-Kaabi, Afandi, Nagelkerke, & Yeatts, 2013). Another research indicated that although the knowledge levels(56.14% of the respondents scored 100% in knowledge related questions) among our study participants are high, the levels of attitudes (17.5% scored above 50%) and practice (15.78% scored 100%) are lower than desirable (Saadia, Rushdi, Alsheha, Saeed, & Rajab, 2010).

Predictors of Alternative Approaches

Various predictors have been found to play a role in an individual's behaviour to engage in alternative approaches. The studies below throws light on the recent research that has been done in this area. The demographic factor was not found to be a significant predictor of CAM usage which included age ( Nilsson, Trehn, & Asplund, 2001; Singh, Raidoo, & Harries, 2004). A study conducted by Mehrotra, Bajaj and Kumar (2004) shows that age was not significantly associated (p>0.1) with usage of complementary and alternative medicine. Whereas, on the contrary age was related to the usage of alternative approaches (Chang, Wallis, & Tiralongo, 2007; Ogbera, Dada, Adeleye, & Jewo, 2010). Adding to this, research conducted by Hasan, Ahmed, Bukhari and Loon (2009) indicated that variables such as age groups (above 50 years ), those in the 25-44 year age group (Metcalfe, Williams, Mc Chesney, Patten, & Jetté, 2010), middle age (Bishop, & Lewith, 2010; Ernst, 2000; Pirotta, Cohen, Kotsirilos, & Farish, 2000) that is 46–60 years (Lee, Charn, Chew, & Ng, 2004) contributed to the usage of complementary and alternative medicines. Findings from the 2007 National Health Interview Survey women reveal that middle age men reported to use complementary and alternative medicine more than younger or older individuals. Higher levels of education were associated with higher rates of use. Prevalence rates of use for each type of complementary and alternative medicine significantly increased with an individual’s income (Upchurch, & Rainisch, 2013).

According to Singh et al. (2004) level of education and income (Mehrotra et al., 2004) were shown not to influence the usage of Complementary and alternative medicine on the other hand in contrast to their findings education level (Bishop, & Lewith, 2010; Ernst, 2000; Foltz et al., 2005; Harris, & Rees, 2000; Hasan, Ahmed, Bukhari, & Loon, 2009; McFarland, Bigelow, Zani, Newsom, & Kaplan, 2002; Metcalfe et al., 2010; Millar, 2001; Nilsson et al., 2001; Ogbera et al., 2010; Park, 2005; Wiles, & Rosenberg, 2001) and Income (Foltz et al., 2005; Hasan et al., 2009; MacLennan, Myers, & Taylor, 2006; Metcalfe et al., 2010; Park, 2005., Singh et al., 2004, Thomas, Nicholl, & Coleman, 2001; Wiles, & Rosenberg, 2001) was found to influence the CAM usage. Research evidence also reveals that sex (Singh et al., 2004) predicts the usage of alternative therapies. Women were more likely to have used CAM services than men (Aziz, & Tey, 2008; Bishop, & Lewith, 2010; Ernst, 2000; Lim, Sadarangani, Chan, & Heng, 2005; McFarland et al., 2002; Metcalfe et al., 2010; Millar et al., 2001; Nilsson et al., 2001; Park, 2004; Roth, & Kobayashi, 2008; Vincent, Eric, Jean, Sui VL, & Sian, 2007; Wiles, & Rosenberg, 2001). The other predictors that were identified were the marital status (Singh et al., 2004), individuals who were currently not married or in a common law relationship (Metcalfe et al., 2010), medicine use, duration of diabetes, degree of complications and self-monitoring of blood glucose (Chang et al., 2007) and factors relating to an individual’s health status (Bishop, & Lewith, 2010).

In a health survey which was conducted in England the first independent predictors of 12 month Complementary and alternative medicine use were the presence of anxiety or depression, perceived low levels of social support, having a healthy diet, being female, and income that is above the national average (Hunt et al., 2010).

Factors that influence Alternative Approaches

People resort to alternative approached due to a number of reasons, it is important from both academic and applied perspectives to understand why such substantial numbers of people use CAM. In a study that was conducted among the Indian community in Chadsworth, South Africa, Singh et al. (2004) found that people chose Alternative medicine/ approaches because it was a natural and safe form of medical care (23.4%), secondly because modern medicine carried a risk of unwanted side effects or they had experienced side effects themselves (15.6%). They also found that more than half (51.9%) of people who use Alternative therapy did so upon advice from someone they knew or because they came across an advertisement in the local press. Similar results were found by Hasan et al. (2009) where friends were the main source of influence (32.5%) on patients with chronic diseases to use Complementary and Alternative Medicine, followed by health professionals (25.9%), family members (20.2%) advertisement (15.8%) and old folks or culture beliefs (4.4%). Family history (Hasan et al., 2009; Lee, Charn, Chew, & Ng, 2004), poor perceived health, being recommended by social contacts who are close, holding on to strong traditional health beliefs and the perceived satisfaction with care influence the use of alternative methods (Lee et al., 2004)

The way an individual perceives the illness/health influences the usage of Complementary and alternative medicine (Bishop et al., 2007; Hasan et al., 2009; Nilsson et al., 2001). People chose different treatment options depending on their perceptions of the kind, duration, cause and severity of their illness and the order in which they resort to these different options is dependent on the perceptions of illness. Perception of oneself in poor health leads to usage of alternative approaches (Bausell, Lee, & Berman, 2001; Pirotta et al., 2000). Individual’s perceptions about effectiveness or the outcome of the treatment option and the perceived harm from treatment options also plays an important role in deciding the form of treatment/management (Rao, 2006).

The various other reasons why people might be attracted to and use complementary and alternative medicines are because they hold beliefs that are congruent with Complementary and alternative medicine which include beliefs related to the amount of personal control/autonomy over their health (Bishop et al., 2007; Pal, 2002). Hence pro-beliefs about complementary and alternative approaches play a major role in influencing an individual to use them. Ineffectiveness (Menniti-Ippolito, Gargiulo, Bologna, Forcella, & Raschetti, 2002; Sirois, 2008), having side-effects or dissatisfaction (Menniti-Ippolito et al., 2002) with allopathic/conventional medicine has led to people looking at other alternatives methods (Pal, 2002; Rao, 2006). It was also found that people value natural treatments/ holistic approaches (Sirois, 2008) which are non-toxic and hold ‘postmodern belief systems’ where the participants believe that psychological and lifestyle factors are important in the development of illness (Bishop et al., 2007). Individuals who are more likely to select healthy lifestyle choices are also likely to engage proactively in other self-care (Sirois, 2008) behaviours which includes the usage of complementary and alternative approaches (Hunt et al., 2010, Nahin et al., 2007).Research evidence also shows that cost plays an important role in determining which different alternatives to choose for treating an illness (Pal, 2002; Rao, 2006). Studies have also focused on how general philosophies of life predict the usage of alternative approaches. Alternative therapies are attractive because they are seen as more compatible with patient’s values, world-view, spiritual/religious philosophy or beliefs regarding the nature and meaning of health and illness (Bishop et al., 2007; Pal, 2002; Weaver, Flannelly, Stone, & Dossey, 2002).

Further research has suggested that people use alternative approaches because they suffer from chronic conditions (Al-Windi, 2004; Astin, Pelletier, Marie, & Haskell, 2000; Bausell et al., 2001; Menniti-Ippolito et al., 2002) which might not have been treated by conventional medicine effectively or satisfactorily or also use them as they experience psychological distress as a result of the life - threatening disease and would try anything that would reduce or might offer a cure for such a condition (Bishop, & Lewith, 2010; Ernst, 2000; Nilsson et al., 2001) to preserve their own health status (Furnham, & Vincent, 2000, Goldstein, 2000). Mehrotra, Bajaj and Kumar (2004) found that out of 493 participants 290 (86.8%) resort to complementary and alternative medicine because they desire for the maximum and early benefit. Several specific chronic disorders such as arthritis (95%) other musculoskeletal disorders (95%) and stroke (95%) were significantly associated with CAM use (Lee et al., 2004).

In a research that was conducted with type 2 diabetes it was found that complementary and alternative medicine use was influenced by people's beliefs, experience and their positive attitude towards the alternative approach, history of its use, having stronger health beliefs about diabetes, longer duration of diabetes, the outcome of complementary and alternative medicine in treating diabetes. It also associates the use to the person's behaviour (such as a higher degree of self-care activities by the individual) towards disease management rather than their demographic characteristics (Chang, Wallis & Tiralongo, 2012). It was also found that diabetic patients used complementary and alternative approaches to improve their general well-being rather than treating diabetes itself (Arcury, 2006; Bell, 2006; Lind, Lafferty, Grembowski, & Diehr, 2006).

Summary of the review

The review of literature highlights the level of knowledge, attitude and practices among diabetic patients indicating the importance of knowledge which affects the individual’s attitude and practices regarding management of their lifestyle and diet. Further the research evidence has also revealed a number of demographic factors that might have an effect in the usage of alternative approaches such as age, education level, socio-economic status (income) and marital status. A large number of reasons were found to influence people to use alternative approaches such as dissatisfaction or ineffectiveness of allopathic medication; friends and family members, advertisements that the individual encounters, individual’s attitude, holistic and cultural beliefs, cause, severity and duration and one’s perception of the illness, the cost of the treatment and having a chronic disease. The studies that have been done so far focus on the knowledge, attitude and practices in relation to managing the illness specifically with respect to diet and lifestyle modifications and it also shows the predictors and influencers of usage of complementary and alternative approaches. However, not much of research has been done integrating knowledge, attitude and practices with the usage of alternative approaches in Indian Context. Since India is a diverse country having high cultural diversity it is important to understand the influence it has on the level of knowledge, attitude and practices of the population with respect to the usage of the various other approaches that people indulge in other than allopathic medication so as to understand and provide the country with a culturally acceptable diabetes education programme.


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