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Evaluation of diabetes self-care with self-monitoring of blood glucose among type 2 diabetic patients and its impact on HbA1c

Evaluation of diabetes self-care with self-monitoring of blood glucose among type 2 diabetic patients and its impact on HbA1c
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  TAPI Journal Vol 4, lssue 3, September December 012 Bias and Barriers nfluencing patients' Attendance owardsDiabetes Education programme Sripriya Shaji, Satyavani Kumpaila, Vijay ViswanathanAbstractBackground: Despite several methods adaptedto improve diabetes education programme toempower patients' knowledge to takeresponsibility of their own health care,educational programmes have been underused bvthe patients.Objeetive: This study was designed tounderstand the- bias and bartiers influencingattendance of patients towaids diabeteseducation programme.Subjects and Methods: A total of Tb6 patientswith type 2 diabetes (M:F 44?:809; mean age54t11.5 years) who visited a tertiary carediabetes centre for both first visit and reviewafter long duration, more than 1 year, wereselected. The patients were fust exposed to aformal didactic lecture. All the subjects wereincluded for the study irrespective of theirattendance to diabetes education programme. Asurvey questionnaire consisting of both closed_and open-ended questions was used to gatherinformation about perceived barriers. Responsesto open-ended questions like ,,why don,t people get diabetes education', were recorded verbatimby trained research ofFcers.Results: Out of 786 patients, 2g..6vo hadattended and 7L.4Vo had not attended the formaldiabetes educational session. Majority of thenon-attenders (iB.BVo) reported lack of time or notime, 22.4Vo had no interest, and 2l.g%o ofattenders had trouble reading d.ue to eyesightproblems or pupil dilated for fundus examination.About 38.7Vo of non-attenders perceived that thecontent would te repetitive, and 20.5Vo perceivedtime consuming.Conclusion: Patient-centered efforrs canincrease the use of diabetes educationprogrammes. Health care providers have todesign effective interventions to address theidfitified barriers to improve patients'attendance towards the educational programmes.fntroductionDiabetes has emerged as one of the biggesthealth problems, and its prevalence is increasingat an alarming rate. people with diabetes whowant to lead a life without limitations have toknow more about their illness..Comprehensivepatient education is required to provide thepatient with self-management skills necessary toachieve good gylcemic control. Epidemiologic d.ataindicate that a large number of patients do notreceive the proper education necessary to developsuch self-management abilities. In order toconvey the importance of patient education, theAmerican Diabetic Association (ADA) has labeledself-manrigernent education as*the cornerstoneu therapy for'patients with diabet"rl. The NationalStandards of Diabetes Self-managementeducation defined patient education as uan. exchange of knowledge, tools, and practices thatwill address the client,s needs',2.  TAPI Journal Vol 4, lssue 3, September December 012According to Jarvells, diabetes education isas important as insulin, oral drugs and diet forpeople with diabetes. Education ensures that adiabetic patient can make decisions, learnpractical skills for _treatment and continuouslyinvolve in the day-to-day management ofdiabetes. There are a number of studies thathave demonstrated how diabetes education canpromote self-care, metabolic control andemotional well-beinga. The value of patienteducation is evident from research5demonstrating that the patients who neverreceived diabetes education showed a striking4-fold increased risk of major complication. Oneof the most significant advances in diabetes carehas been the recognition that the most importantperson in the diabetes care team is the patienthimself, who need to be empowered to take theresponsibility for his/her own healthcare ratherthan relying on otherss.Besides knowledge and self-care, educationcan bring about long-term cost benefits. Diabeteseducation results in more informed choices andbeneficial changes in behaviour, which, in turn,will improve clinical parameters and reduce therisk of secondary complications associated withdiabetes. Studies by Miller and Goldsteino,DavidsonT and Assal et al.8 have shown howeducation has helped in the reduction of footproblems, hospitalizations and amputations.There are a few studies from India that havehighlighted the effectiveness of patient education.One study done on patients withnoninsulin-dependent diabetes, who were diversein socioeconomic status, literacy and language,showed that there was not only a gain inknowledge but also improvement in HbAlc anddiet adherence on follow-up among the studysubjectse.There are specifrc challenges in patienteducation in the developing societieslo. High rateof illiteracy, low socio-economic status,multi-linguistic target group from pluralistbackgrounds and beliefs, social conditions andsuperstitions pose a distinct challenge indeveloping a single format of education contentand delivery. The problem is felt more in thedelivery aspect of educational programme.After analyzing these various aspects, theProf. M. Viswanathan Diabetes Research Centrehas set an aim that diabetes education shouldfulfill certain objectives and the diabetic patientshould be able to (a) Understand diabetes andits management, (b) Develop practical skills,analyze and relate facts, make decisions and takeappropriate action; for example, adjusting insulindosage or making the right food choices, (c)Develop a positive attitude and haveself-confidence, and (d) Live a healthy and activelife by reducing hospitalization due tocomplication of diabetesrl. Despite these efforts,patient education programme is underused, andit has been identified that the most crucialreason is patient not attending the educationpTogTamme.Therefore, the present study was designedto understand the bias and barriers influencingattendance of patients towards diabeteseducation programme. Socioeconomic and clinicalfactors that influence participation in diabeteseducation programmes were also assessed n thisstudy. Younger age, higher level of education,urban dwelling, insulin use, and the presence ofcomplications from diabetes have all been foundto be positively related to participating indiabetes education programmes.The health belief model has been used topredict and explain compliance with preventivehealth behaviours, as well as withdisease-specifrc health-promoting activities12,13.The model suggests that a health-relatedbehaviour is more likely to occur when anindividual perceives a high degree of severity ofthe disease and a high degree of susceptibilityto the disease or its consequences. Belief that thepotential barriers to performing a health-related  TAPI Journal Vol 4, lssue 3, September December 012behaviour do not outweigh the potential benefitsis also a critical degree of motivation and a cueto acti.on, either internal or external, should existto stimulate the health-rdlated behaviour.Subjects and MethodsA total of 756 (M:F 447:309) subjects withmean age of 54 x 1L.5 years with type 2 diabetesparticipated in the study. At the out-patientdepartment, the patients are first exposed to aformal didactic lecture. The family members of thediabetic subjects were also advised to attend thissession. This group education (multilingualsessions) has been-conducted on a daily basis forthe patients who are turning to the tertiary carecentres [M.V. Hospital for Diabetes at Royapuram(Chennai), M.V. Centre for Diabetes at Mylapore(Chennai), M.V. Centre for Diabetes atKoramangala (Bangalore)1 and was plannedaccordingly not to disturb the laboratoryinvestigations or consultation with their physicians.All the subjects with diabetes whopresented to our hospital for a non-acute visitwere eligible, regardless of type, irrespective oftheir gender, socio-economic status, education,occupation, family history of diabetes and obesity.A survey questionnaire was used to collect' information on demographics, clinical factorsassociated with diabetes, predictors of attendanceat diabetes education programme, and reasonsfor non-attendance at diabetes educationprogramme on their day of visit to the hospital.Both closed- and open-ended questions were usedto gather information about perceived barriers.Participants were asked to respond to structuralbarriers such as time, trouble reading, stress,hard of hearing, poor vision, interest, etc.Responses to open-ended question "why don,tpeople get diabetes ed.ucation" were recordedverbatim by the research assistants.AII data except the responses to theopen-ended question were entered in aspreadsheet and reviewed for accuracy beforeanalysis. Responses to the open-ended questionwere organized by consensus of the investigatorsinto categories representing common themes.Statistical analysisStatistical analysis was performed usingSPSS 16.0. In addition to descriptive analysis, wespecifrcally looked at differences in demographicand clinical variables, as well as differences inperceived barriers to education between patientswho attended or did not attend a diabeteseducation programme. We used chi-square testsfor categorical v4riables and the 't' distributionfor continuous variables. P value of 0.0b wasconsidered to be statistically significant.ResultsOut of 756 patients with diabetes, 216(28.6Vo) had attended the diabetes educationsession and 540 (7L.4Vo) had not attended theeducation session. There was no signifrcantdifference in the number of males and femalesattending or not attending the diabetes educationprogramme. Regarding the educationalqualifrcations, majority of the attenders (E6.gVo)were graduates compared to 27.gVo among thenon-attenders, and more than 60Vo ofnon-attenders had school education. Similarly,there was a difference in the employment statusof the individuals, 43Vo being unemployed amongthe non-attenders and, 28.2Vo unemployed amongthe attenders. However, the percentages ofemployed people were more or less similar amongthe two groups. Duration of diabetes did notseem to have any impact on attending thediabetes edication programme, except that l4.8Tobf the patients with more than 20 years ofdiabetes attended the education prograurme,compared to 7.2Vo n this category (Table 1).  fl-:. fi Mean age (years)54+1 .5 Gender Male 447 t59.12J 131 [60.6]316 [58.5]Female 30e [40.87]85 [3e"4]224 141.51 Educational qualificationllliterate 25 [3.3]7 [3.2J1B 3.3] School387 [51.2] 5s [27.3] 328 [60.7]Graduate 274 136.21123 56.e]151 127.e) Diploma 1e [2.5]7 [3.2112 12.2J Postgraduate 26 13.41 8 [3.7] r8 [3.3] Professional 25 [3.3] 12 [5.5] 13 12.41Employment tatus Employed 323 142.71104 l49.2l21e 40.5] Unemployed 2e3 [38.8]61 128.21232 [43] Retired140 18.5]51 [23.6] Be [16.5] Marital statusSingle 14 1.e] 4 t1.el 10 1.e] Married 725 es.e] 21O 197.21 515 [95.4]Divorced/separated 3 [0.4] 0 tol 3 10.51 Widowed 14 1 e] 2 [0.e] 12 [2.2] Duration of diabetes (years) 0-5242 l32l74 134.31 168 31.1]6-1 0 246 [32.5J56 [25.e] 190 [35.2] tt-tc 130 17.2) 36 [16.6] e4 117.41 1 6-2067 [8.9]1B [8.3] 4e [9.1] More than 2071 [9.4)32 [14.8) 3e [7.21 TAPI Journal Vol 4, lssue g, September December 2012 Table 1. Sociodemographic details of thestudy subjectsDiabetes management was a crucial aspectamong both attenders and non-attenders, asmajority of them were being treated with oralh;poglycemic agents (OIIAs), and more than 407oof the non-attenders were on a combination ofOHA + insulin. Regarding personal habits.majority of them did not have the habit oftobacco use and alcohol consumption in both thegroups (Table 2).Most of the attenders (4I.2Vo) andnon-attenders (5L.5Vo\ had no diabetes_relatedcomplications. Cardiovascular risk factors such ashypertension and high cholesterol levels wereobserved in 22.7Vo of attenders and 28.7% of non_attenders. Other complications viz., nephropathy,neuropathy, retinopathy, gastropathy, amputationand stroke were present in 7g.4% of attendersand 3.7Vo of non-attenders. presence of two ormore than 2 complications was observed in 16.67oof attenders and 2L.LVo of non-attenders (Table 2).-> 30 morbidly bese; -long-term other omplications ncluderetinopathy, ephropathy, europathy, mputation, astropathy,stroke, and coronary rtery disease. Cardiac isk factorsinclude ypertension, igh cholesterol nd other isk actorsTable 2. Clinical details of the study subjects *"* ,: Mean Body MassIndex (kg/m2)27.04 + 4.7181 123.9o/") ad BMt above 30. Treatment Diet and Exercise 20 [2.6] B [3.7] 12 [2.21 OHA'S .tt'Y [51 5l 134 [62]255 [47.21Insulin48 [6.3] 7 13.2141 17.61 OHA's & Insulin 2ee 3e.6] 67 [31]232 [42.91 Self-reported long-term complications3.26 + 4.3x*ComplicationNo complication367 [48.5] 8S 141.21 278 [51.5]Cardiac factors 177 123.41 4e 122.71 128 123.71 Other complications 62 {8.2142 l1s.4J20 13.71 2 or more than 2complications 150 1e.8] 36 [16.6] 114 121.11 Tobacco usage Current obacco se '16 [21l 3 [1.4] 13 12.41 Previous obacco use8 l11l 2 [0.s] 6 [1.1]Non tobacco users732 [96.8] 211 197.71521 [ Alcohol consumptionAlcoholic 25 [3.3]e [4.16] 16 sl Ex-Alcoholic 7 [0.e]0 10 [1 9]Non-alcoholic 724 ss.8) 207 e5.8] c t4 [e5.2]  TAPI Journal Vol 4, lssue 3, September December 2012 Table 3 shows details regarding structuralbarriers in attending diabetes educationprogramme. 'Time' was ?eported as an importantbarrier by a majority-of non-attenders (SB.BVo),compared to 37Vo of attenders. .Not interested,in attending the programme was also equallyreported by both groups. The next barrier was'trouble reading', due to eyesight problems orpupil dilated for fundus examination, which wasreported by 27.8Vo of the attenders and I2.4Vo ofnon-attenders. The other barriers such as ,stress','hard of hearing', 'poor vision,, etc. were alsoreported by both groups in less numbers.Table 3. Structural barriers to diabeteseducationTable shows responses to the question, ,lMhichof the following might prevent you fromattending a diabetes education program?"lClosed-ended responses]Table 4 shows the response to theopen-ended question, ,lVhy don't people getdiabetes education?" 'Repetition of content, wasreported as a major patient-perceived barrier byboth attenderc (72.2Vo) and non-attenders (gB.TVd.Non-attenders also reported .ti ne, and ,nointeresUdon't care' barriers in getting diabeteseducation. Other barriers such as .low perceivedseriousness of the disease', ,deniaVfear,, ,nobenefits/don't need it', laziness,, and ,unaware ofresources' were also answered by both theattenders and non-attenders in less numbers. Table 4. Patient-perceived barriers todiabetes education*Table shows responses to the question, .Whydon't people get diabetes education?,, open-endedresponses) ttrrui, ii::"1 rltl p: :..:ih'fxi:" "r Low perceivedseriousness fthe disease24 [3.2)6 12.7118 [3.3] Denial/fear13 [1.7] 2 [0.e] 11 t21 Time131 [17.3] 20 [e.3] 111 [20.5]No perceivedbenefits/don'tneed it 37 14.91B [3.7] 2s 15.41 Repetition ofContent365 [48.3] 156 172.2120e [38.7] No interesVdon'tcare 112 114.Bl13 [6.0]ee [18.3] Lazy 17 [2.2]017 [3.2] Unaware ofresources57 [7.5]11 [5.1]46 [8.5]*Percentages are based on n. lssues related to educationclasses, hopelessness, oncompliance, mbarrassment, ndother miscellaneous esponses were mentioned bv less than10o/" of respondents. DiscussionMisperception about diabetes educationregarding time involved and the content ofeducation was reported frequently in this study.An earlier research showing that patients do notconsider or manage type 2 diabetes as a seriousproblem suggests that this attitude (i.e.. lack ofperceived seriousness) is a major barrier tooptimal "ar"14. In our study, low perceivedseriousness of diabetes and fear and denial ofdiabetes were not inhibitors. ,,Repetition of theclass content" and "Time consumption,' were themost frequently cited inhibitors to attend aneducation programme identified using theopen-ended question.In a study by Hissia insulin administration,a behaviour that creates sense of seriousness ofdisease, was positively associated withattendance, with a similar proportion of bothattenders and non-attenders reporting it as oneof the barriers.. But our study reportedBarrier lllanr{orc Non-attBnders,N=540 nffi #f ' Time 368 [48.7] 80 [37.0]288 [53.3] Trouble reading114 15.1] 47 121.81 67 [12.4] Stress40 [5.3] 17 [7.5] 23 [4.3] Hard of hearing 25 [3.3]7 [3.2]18 [3.3] Not interested174 t23l 5s [24.s]121 122.41 Poor vision11 [1.5] 4 [1.e]7 [1.3] Combination of above 24 13.21 8 [3"7]16 [3]
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