Assessing the knowledge , attitudes and practice of type 2 diabetes among patients of Saurashtra region , Gujarat

As India will ranks fi rst in diabetes now and will continue to do so in 2025, we must prevent the disease by various measures. Before setting the programmes, we should have ample data on the population’s knowledge, attitude and practice (KAP) of diabetes. There are some epidemiological studies from southern India, Mumbai and north India, but there is no KAP study from Gujarat. The study was conducted between the period of June 2007 to November 2007 at three centers of Saurashtra region. Out of 300 patients who were given questionnaire, 238 patients were included for the analysis, rest were excluded due to various reasons. 52% were male. Mean age of patients was 55.82±10.2 years (95% CI 54.5-57.1) with mean weight of 64.52±10.96 Kg (95% CI 62.8-66.2). Mean duration of diabetes was 8.2±6.8 years (95% CI 7.2-9.1). 46% of patients knew the pathophysiology of diabetes. Nearly 50% knew the complications of diabetes. Dietary modifi cations were relied more than exercises among the interviewed subjects. Most of the lacunae in knowledge prevailed in drug therapy of diabetes. Insulin was not favored by most of patients. An encouraging fi nding in our study was that most believed in self-care and ready to change. Consultation time given by their treating doctors was less than 5 minutes in nearly 50%. Foot care and education to prevent complications were least suggested by doctors.


Introduction
Prevalence of type 2 diabetes is increasing globally, [1] more so in developing countries like India due to rapid urbanization. [2,4]It is estimated that prevalence of diabetes will rise to 5.5% in 2025 as compared to 4% in year 1995. [3]The total direct cost for diabetes management has doubled from 1998 to 2005. [5]Therefore, prevention is important both on monetary and human matt ers.There is an increasing amount of evidence that the patient education is the most eff ective way to lessen the complications of diabetes and its management. [6]ducation is likely to be effective if we know the characteristic of the patients in terms of knowledge, their att itude and practices about diabetes.There are numerous studies with special emphasis on epidemiology mainly from South India, Delhi and Mumbai. [7,8]However, despite our extensive literature search we could not Þ nd any KAP study of diabetes mellitus especially from the Saurashtra region.

Aims
The aim of the study was to assess the knowledge, att itude and practice of patients with type 2 DM in Saurashtra region.

Materials and Methods
The study was conducted between the period of June 2007 to November 2007 at three centers 1) G.G.Hospital, Jamnagar 2) Sir Takhatsinhji Hospital, Bhavnagar 3) S. J. Eye Hospital, Gondal, Rajkot.All these places belong to Saurashtra region, Gujarat.First two are tertiary care hospitals with teaching facilities and third is private sector in rural area run by a Non Government Organization (NGO).The patients att ending out-door facility of these hospitals were included in the study and given predesigned proforma to Þ ll the questionnaire.To avoid bias, the patients who were not being treated by authors at the time of this study were only included.The questionnaire did not contain any questions which can reveal the identity of patients or their treating doctors.

Knowledge regarding diabetes
Despite 8 years of average duration of diabetes, about 46% of patients knew the pathophysiology of diabetes.Fewer (38.23%) still believed that diabetes can be cured.Many other aspects are covered in Table 3.Among the knowledge of complications of diabetes, renal complication was least known to patients.Most were afraid of heart related complications.Details of knowledge of complications depicted in Figure 1.Table 4 shows the responder knowledge regarding diet and exercises.Dietary modiÞ cations were relied more than exercises among the evaluated patients.Most of the lacunae in knowledge prevailed in drug therapy of diabetes.Insulin was disfavored by most of patients.Details of knowledge of drug therapy in diabetes are shown in Table 5.

Attitude and practices in diabetes
An encouraging part in our study was that most believed in self care in diabetes.Majority of the patients could not aff ord a blood glucose meter and hence, could not check their blood glucose level regularly.Practice of taking herbal drugs prevailed in approximately 40% of patients.Table 6 details the att itude and practices in our patients.

Appraisal of doctor by patients
Most patients were dissatisÞ ed with the consultation time given by their treating doctors.The time given was less than 5 mins in nearly 50%.Foot care and watch for complications were least suggested by doctors [Table 7].

Discussion
Most studies regarding epidemiology and prevalence of diabetes were conducted from south India [9][10][11][12] and very few studies from north India. [13]There is no study regarding KAP is available for Saurastra region and hence, this study is in att empt to gather the data regarding the same.
Since the study conducted among patients with type 2, average age was between 50-59 years (40.33%) and average duration of diabetes among patients was 8.2years.nearly 60% of patients were from low socio-economical status and 36% were illiterate.Since the majority of patients were recruited from government-run hospitals, there may be bias regarding these two factors.Both aff ordability and literacy may be the problem in diabetes education and management.Education of vulnerable communities can become a cost-eff ective public health strategy.It has been shown that self-care among individuals with type 2 diabetes improved glycemic control [14] and reduced complications. [15]erican Diabetic Association has defined self management education as the process of providing the person with diabetes the knowledge and skill that is needed to perform self care, manage crises and make life style changes.National standard for self care management in diabetes has been set by Mensing [16] et al.  complications and importance of life style modiÞ cation.
Three main findings of our study which may be responsible for low diabetes education among the patients were: 1) Nearly 40% of patients were below poverty line and hence could not aff ord even minimum standard care and therapy.2) Only 3% of patients were treated by endocrinologists.This is because very few endocrinologists are available in Gujarat.None of them are available in government run hospital and, patients can not aff ord the private care.No single institute in Gujarat had superspeciality course on diabetology or endocrinology.[19][20][21][22] 3) Most important factor is low level of education, only 10% were graduate and nearly 37% were completely illiterate.Therefore, illiteracy may be the most important obstacle in diabetes management of such patients.It is rightly said that education of vulnerable communities can become a cost-eff ective public health strategy. [23]r study showed that people in Saurashtra region wrongly believe that diabetes can be cured with bitt er substances and allopathic drugs are harmful to the body.They also have many misconceptions about insulin.
An encouraging part of the study is that although there was, quite low diabetes self education among patients, most of patients believed that they are responsible for their care and this implies that they were ready to change if motivated or educated properly.
Though it was not the aim of study, we studied the appraisal of doctors by their patients.The shocking fact was physicians could spare very limtied time for their patients and a search for complications was ignored by most.Foot care checking and self care motivation, the two main aspects of diabetes care were ignored by most of the treating practitioners.Though there are few studies regarding the cost analysis of diabetes in India, it is a proven fact that ignoring such vital aspects may increase cost steeply. [24]There are Indian standards set by Agrawal [25] and others on how to set up a diabetes clinic.There should be emphasized to strengthen the diabetic care.

Recommendations
• Emphasis on improving the literacy rate of the population.
• To increase the availability of endocrinologists.
• Diabetes education must be imparted by every clinician as per standard norms.• Generalist or primary care physician should be enriched with more knowledge by CME and other programmes.• Media and Non Government Organisation should be involved in the daunting task of removing misbelieves, ignorance and instituting diabetes preventive measures in the community.

Figure 1 :
Figure 1: Frequency distribution of knowledge regarding complications of diabetes

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Out of 300 patients who were given questionnaire, only 238 patients were included for the Þ nal analysis.Rest were excluded due to incomplete or irrelevant information and poor handwriting.Data were analyzed using Microsoft Excel 2006.

Table 6 : Frequency distribution of respondent's attitude and practice toward diabetes
Respondent's attitude and practice PercentageWho is responsible for DM care?

Table 7 : Frequency distribution of respondent's appraisal of their treating doctors How
much time your doctor devotes to you?