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ORIGINAL ARTICLE
Year : 2018  |  Volume : 62  |  Issue : 2  |  Page : 104-110  

Diabetes self care activities among adults 20 years and above residing in a resettlement colony in East Delhi


1 Assistant Professor, Department of Community Medicine, Government Medical College, Kozhikode, Kerala, India
2 Professor, Department of Community Medicine, University College of Medical Sciences and GTB Hospital, New Delhi, India
3 Associate Professor, Department of Community Medicine, University College of Medical Sciences and GTB Hospital, New Delhi, India
4 Director Professor, Department of Medicine, UCMS and GTB Hospital, New Delhi, India

Date of Web Publication14-Jun-2018

Correspondence Address:
Anu Mohandas
AATHIRA, Sanmanas Road, Chemmad, Malappuram - 676 306, Kerala
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijph.IJPH_249_17

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   Abstract 


Background: Self-care activities are the cornerstone of diabetes care that ensures patients participation to achieve optimal glycemic control and to prevent complications. Objective: The aim of this study is to find the level of self-care activities among diabetics aged ≥20 years residing in a resettlement colony in East Delhi and its association with sociodemographic factors, disease, and treatment profile. Methods: Using cross-sectional survey, 168 known diabetic patients were selected from Nand Nagri, a resettlement colony in East Delhi. Data were collected using Hindi translation of revised version-Summary of Diabetic Self Care Activities along with a pretested semi-open-ended questionnaire. Self-care was assessed on six parameters as follows: (a) general diet, (b) specific diet, (c) exercise, (d) blood sugar testing, (e) foot-care, and (f) smoking. The study period was from November 2014 to April 2016. Results: Nearly 35.1% of respondents belonged to 60–69 years age group. About 52.4% of respondents were female. Fifty-two diabetics (31%) reported having practised diet control on all 7 days in the past 1 week. Nearly 39.3% of patients did not perform any physical activity. The blood test was not practised by 92.3% of respondents. Foot-care was practised by only 19% of patients. There was a significant association between general diet among diabetics with family support (P = 0.020), place of diagnosis (P = 0.033), and treatment funds (P = 0.017). The exercise score among diabetics who were below the poverty line was higher than those above poverty line (P = 0.029). Younger age (P = 0.005) and treatment with insulin (P = 0.008) were positively associated with blood glucose testing. The foot-care practice was better in patients aware of complications and foot-care practices (P < 0.001). Conclusion: Self-care activities among diabetic patients were very poor. Self-management educational programs at hospitals along with information, education, and communication activities at the community level and one-to-one counseling are recommended.

Keywords: Diabetes self-care, foot care, self-management of diabetes, self-monitoring of blood glucose


How to cite this article:
Mohandas A, Bhasin S K, Upadhyay M, Madhu S V. Diabetes self care activities among adults 20 years and above residing in a resettlement colony in East Delhi. Indian J Public Health 2018;62:104-10

How to cite this URL:
Mohandas A, Bhasin S K, Upadhyay M, Madhu S V. Diabetes self care activities among adults 20 years and above residing in a resettlement colony in East Delhi. Indian J Public Health [serial online] 2018 [cited 2019 Nov 12];62:104-10. Available from: http://www.ijph.in/text.asp?2018/62/2/104/234501




   Introduction Top


Diabetes is one of the global health emergencies of the 21st century with a prevalence of 9.1% and accounts for 5 million deaths annually. In 2015, India ranked second to China with 69.2 million diabetic patients,[1] and it is predicted that this figure will cross 100 million by 2030.[2]

The real burden of diabetes is caused by the long-term damage, dysfunction, and failure of various organs, leading to increased morbidity and mortality.[3] Self-care in diabetes is an evolutionary process of development of knowledge or awareness by learning to survive with the complex nature of diabetes in a social context.[4],[5] The various self-care practices that predict good outcome in diabetic patients include regular physical activity, appropriate dietary practices, daily foot examination, compliance with the treatment regimen and monitoring of blood sugar, etc.[6] Diabetes self-care requires patients to make lifestyle modifications supplemented with supportive role of health-care staff for maintaining a higher level of self-confidence leading to a successful behavior change.[6]

There is continuing need to assess the level of self-care activities and factors influencing them because it facilitates the healthcare professionals in identifying patients with low adherence and thereby aiding them in planning interventions to improve medication and adherence to self-care activities.[7],[8] The present study was a community-based inquiry aimed at finding self-care activities and significant factors associated with these practices among adult diabetic patients, aged 20 years and above residing in a resettlement colony in East Delhi.


   Materials and Methods Top


A cross-sectional study was conducted in a resettlement colony, Nand Nagri in East Delhi from November 2014 to April 2016. Study participants were diabetic patients, 20 years and above residing in Nand Nagri for more than 6 months. Diabetics with the following characteristics, i.e. diabetics with lower limb or limbs amputated, those in wheelchair or bedridden state, inability to count fingers at 3 m, terminally ill patients, patients with gestational diabetes mellitus or who were mentally unfit to comprehend questions and respond, were excluded from the study.

On the basis of a published urban community-based study in India, good self-care activities among diabetics with respect to diet, exercise, blood sugar monitoring, and drug adherence [9] ranged from 20% to 80%. Taking prevalence of good self-care activities as 50% (to get the maximum sample size) at an absolute precision of 10% and at 95% confidence level, the sample size calculated was 100. A design effect of 1.5 was applied to make allowance for heterogeneity which gave the revised sample size of 150. For equal representation, eight diabetic patients were included from each of 21 sub-blocks. Thus, a final sample size of 168 was arrived at. Each sub-block of NandNagri has 500 houses numbered sequentially from 1 to 500. For each sub-block, a complete list of houses was prepared, and the first house was randomly selected using random number table. Subsequent houses were selected following the “nearest contiguous house from the last house to the right” criteria asking the head of the family for known diabetic/s in their house until 8 diabetics were found. In houses that had more than one diabetic patient, all of them were included in the study. Diabetic patients who were not available on the day of the visit were revisited, and patients who could not be contacted despite three consecutive visits were excluded from the study.

A revised version of the summary of diabetes self-care activities (SDSCA),[10] a standardized, validated questionnaire was used to assess self-care activities of diabetic patients. Translation validity was done in two parts. Initially, the questionnaire was translated into Hindi (forward translation) by two experts. Subsequently, the back translation was done in English by another expert unaware of the source document. All discrepancies were resolved by investigators and translators to get the final version. SDSCA is a brief 11 item questionnaire consisting of two items each of general diet, specific diet, physical activity, blood glucose testing, foot care, and one item for smoking measuring the number of days of the previous 7 days during which the patient has reported adequate adherence to self-care activities. A pretested, semi-open-ended questionnaire prepared by Investigator, containing information on socio-demographic profile, disease history, and treatment profile of the study participants was also used. Depression was assessed using two questions instrument,[11] i.e., (a) During the past month have you often been bothered by feeling down, depressed, or hopeless? (b) During the past month have you often been bothered by little interest or pleasure in doing things? A person was considered depressed if the patient answered in affirmative to any of these two questions. Diseases such as diabetes, hypertension, tuberculosis, hypothyroidism, coronary artery disease, and cancers were also inquired from the patients and were categorized as systemic illnesses. The person was considered substance abuser if he/she currently used any of (a) chewing tobacco, (b) smoking tobacco, and (c) consuming alcohol. Treatment support was categorized into two groups as follows: (i) “Own funds,” for those who used their own funds to procure treatment and (ii) “Others,” for those who used other sources (provided by Government employer, insurance, etc.). Family support was assessed using two questions, i.e., whether diabetic patients needed support in any domain of self-care and whether that need was fulfilled by the family.

The first author contacted study participants at their homes explained the purpose of the study and interviewed. Later, all patients were counseled and given a health education package incorporating standard self-care activities for diabetes. Patients requiring referral were directed to the Department of Endocrinology at GTB Hospital.

The data were analyzed using IBM SPSS Statistics for Windows, Version 20.0. (Armonk, NY: IBM Corp). All 6 items, i.e., general diet, specific diet, exercise, blood sugar test, foot care, and smoking were analyzed separately due to low inter-item correlation.[10] For all items except smoking, the frequency of respondents was calculated with regard to number of days per week they practised self-care activities on a scale of 0–7. The scoring and analysis was performed according to details provided along with SDSCA questionnaire by the authors.[10]

Mean scores were calculated for each of the following five items.

  1. General diet (by finding mean of items 1 and 2)
  2. Specific diet (by finding mean of items 3 and 4, after reversing the item 4)
  3. Exercise (by finding mean of items 5 and 6)
  4. Blood sugar test (by finding mean of items 7 and 8)
  5. Foot care (by finding mean of items 9 and 10).


The final sixth item pertained to smoking; it was dichotomized into smokers and non smokers and a score of 0 for nonsmokers and 1 for smokers was given.

During exploratory analysis, it was found that self-care scores of the patients were highly skewed. Therefore, median scores for general diet, specific diet, and exercise were used. Association between the self-care scores and sociodemographic factors, disease, and treatment profile was analyzed using the Mann–Whitney test. Blood test score was dichotomized into: (i) blood test score of 0 and (ii) score of ≥1. Foot care was dichotomized as (i) foot care score of 7 and (ii) score <7 days in the previous week for meaningful interpretation. For these two parameters and smoking, Chi-square test was applied to find the association with sociodemographic factors, disease, and treatment profile. For variables with expected cell count in each cell <5, Fisher's exact test was used.

Ethical clearance was obtained from the Institutional Ethics Committee-Human Research of UCMS and GTB Hospital. Informed written consent was obtained from the study participants before conducting the study.


   Results Top


As [Table 1] depicts, 35.1% of diabetic patients were in the age group of 60–69 years, 52.4% were female, 86.9% of Hindus, 41.7% illiterates, and 23.2% of patients were classified as below poverty line. Two most common complications were eye problems (111,66.1%) and feet problems (110,65.5%). Along with diabetes, 71 (42.3%) patients also had hypertension, 17 (10.1%) tuberculosis and 8.3% hypothyroidism which were categorized as “systemic illness.” Depression was present among 43.2% of the study participants. A total of 152 (90.5%) received family support in domains of self-care in which they needed help. Almost 57% of patients depended on own funds for treatment.
Table 1: Sociodemographic, disease and treatment profile of the study subjects (n=168)

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[Table 2] depicts that 30.9% of the study participants had a maximum score of 7 for a general diet and only 1.8% for a specific diet. Twenty-five percent of patients did not practise general diet self-care even for 1 day in the previous week. Only 9% of the study participants practised physical activity on all 7 days in last 1 week, while 39.3% of the study participants did not practise physical activity even for a single day. Out of all subjects, 155 patients (92.3%) did not practise blood sugar testing at all in the last 1 week. Out of the remaining 13 (7.7%) patients, 5 (3%) patients tested their blood sugar for 3 days while eight (4.7%) patients did so for one or 2 days only. About 80.4% of the study participants did not practise foot care for even a single day in the past 1 week. Maximum foot care score of 7 was present in only 19% respondents. For the sixth parameter smoking, 13.6% of patients reported as having smoked at least once in previous 1 week. Of these, six patients reported to be smoking >20 cigarettes/day.
Table 2: Self-care scores among the study subjects (n=168)

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[Table 3] depicts the univariate analysis of general diet and physical activity self-care with significant variables. It was seen that the general diet score among diabetic patients who received family support was much higher as compared to those who lacked family support (P = 0.020). There was a statistically significant association between general diet score with the place of diagnosis and treatment support received by the study participants (P < 0.05). There was no significant variable found on univariate analysis of specific diet self-care with sociodemographic factors, disease, and treatment profile of the study participants. This and the subsequent tables do not depict the variables that were not statistically significant because of the brevity of space.
Table 3: Association of general diet and exercise self-care practices with sociodemographic, disease and treatment factors among diabetic subjects

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Regarding the practice of physical activity, there was a statistically significant association between exercise score and income of diabetic patients. It was seen that exercise score among study participants who were below the poverty line was much higher (i.e., they had better self-care activities for physical activity) than those diabetic patients who were above poverty line (P = 0.029).

[Table 4] depicts that patients who were younger(<50 years) and those who were treated with insulin were more likely to do blood sugar testing compared to those who were ≥50 years (P = 0.005) and patients on treatment with oral hypoglycemic agents (P = 0.008), respectively. Foot care score was significantly better in those who had received advice about the complications and about the foot care practices to be followed (P < 0.001) as compared to those who were not aware of the same. There was a statistically significant association between smoking status with gender, marital and occupation status, i.e., the smoking status was found higher in males, in those who were married and those who were employed as compared to females, unmarried/widows and unemployed, respectively (P < 0.05).
Table 4: Association of blood sugar testing, foot care practices and smoking with sociodemographic, disease and treatment factors among diabetic subjects

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   Discussion Top


Self-care activities regarding both general and specific diet were poor in our study. Similar results have been described in a community-based study using the SDSCA questionnaire in urban Vellore which noted good dietary behavior present in only 29% of patients.[9] Even lower level of self-care activity regarding specific diet (2.8%) have been reported in a community-based study in Pune.[12] Much better self-care practices regarding general diet though, have been noted from two facility-based studies conducted at Vijayawada (41%)[13] and Mangalore (45.9%).[14] Most families in our study followed only twice a day meal schedule coventionally and adding 2–three extra meals for diabetic patients was considered a difficult cultural choice for them. In some families, “desi ghee” (saturated fat) was culturally more preferred instead of poly saturated or monosaturated fats. The prohibitive cost of seasonal fruits and vegetables may also have resulted in a poor intake of these food items in some patients. Adequate physical activity among our study participants was quite low (9%). Like our study, only 19.5% of study participants in the Vellore study [9] had good exercise behavior. Much better physical activity was reported in a study from Pune (47%),[12] Bangalore (45.5%),[15] and Gujarat (40%).[16] These differences may be due to varying awareness levels and cultural diversities among these population groups. We noted that females in Nand Nagri generally felt shy going for exercise if they were alone or their husbands did not permit them to go for exercise. Male diabetic patients attributed to lack of time as the main reason for not doing exercise.

Blood sugar testing was the most deficient self-care activity among diabetic patients in our study. Similar results have been reported in other community-based studies in Maharashtra,[12] Gujarat,[16] and Andhra Pradesh [17] with self-monitoring of blood glucose level lacking in 70%, 84%, and 93.3% of the study participants, respectively. Many patients reported poverty as the main reason as they could not afford a glucometer and its strips for self-monitoring. There was also apprehension toward needle prick, and some lacked the training of self-injection. Contrasting results have been shown by other studies from Vellore,[9] Bengaluru,[15] and Mangalore [14] with the very high prevalence of regular monitoring of blood sugar (70%, 76.6%, and 73% respectively). However, their criteria for regular blood sugar monitoring was different (i.e., once monthly or once 3 monthly).

Foot care practices were also lacking grossly among the study participants. In the Pune study,[12] it was found that foot care practices were lacking in 56.5% of the study participants and only 10.1% of the study participants practised optimum foot care regularly. Gujarat study [16] reported only 9% patients checking their feet on a routine basis for any damage to the skin. Studies from the various facility-based settings using SDSCA Questionnaire showed the varying prevalence of foot care, i.e., 4% (Bengaluru [15]), 16.7% (Puducherry [8]), 28.3% (Mangalore [14]), and 31% (Vijayawada [13]) among diabetic patients.

About 13.6% patients reported as having smoked at least once in previous 1 week. Much higher prevalence of smoking among diabetic patients as compared to our study has been observed in studies conducted in Pune [12] and Bengaluru [15] with the prevalence of 43.4% and 37.6%, respectively. There may be a strong possibility of patients hiding their smoking status which may be a reason for the low prevalence of smoking found in our study compared to other studies. Some patients might have quit smoking after being diagnosed with diabetics or on the development of complications.

The absence of family support had a negative effect on self-care activity for general diet. It is well known that family members can interfere with or facilitate self-care activities (e.g., by buying groceries) and thereby contributing to diabetes control among patients.[18] Many of our study participants responded that their diet depended on meals cooked in the family. Dependence on own funds and being diagnosed from a private hospital also negatively affected general diet self-care in diabetic patients. Diabetes being a chronic disease, its lifelong treatment and diet entail a substantial expenditure. Thus if patients had to use their own funds for treatment, they generally found it difficult to purchase such food items as were recommended for good dietary practices, for example, fruits and vegetables whose costs at times could be pretty high. It has been commonly observed that physicians in private practice and in private hospitals lay more emphasis on curative rather than on preventive aspects of management. This might be a reason for the reduced general diet self-care practices observed in our study participants.

Study participants belonging to families below the poverty line were found to have better exercise score. Although seemingly surprising, it was observed that some patients below the poverty line were involved in manual labor (nearly 20%). The physical activity they had as part of their work may be accounting for this relationship.

Diabetic patients who were put on insulin in our study were generally more aware of the need to carry out blood sugar testing because of advice received from doctors while they were taught self-injections with insulin and their own experience of hypoglycemic episodes. Similarly, many younger diabetics had a fear of debilitating long-term complications which made them responsible for carrying out blood sugar testing to prevent complications. Similar findings of diabetic patients belonging to younger age group (<50 years) performing blood sugar testing more frequently compared to the older age group (≥50 years), have been published in studies conducted in India [14] and abroad.[19],[20]

Diabetic patients who received advice regarding foot care and complications were found to have better foot self-care practices. The general awareness regarding recommended foot care practices and complications were very low, and misconceptions/myths were widely prevalent in our patients that may have led to poor foot care practices. Many patients believed that soaking feet in water would reduce their blood sugar and did not care either to inspect their feet or shoes properly. Moreover, wearing footwear inside the house was also rare in our study. Another study [21] also identified lack of foot care advice as a risk factor for poor foot care.

Smoking was found significantly higher in males and those who were employed. Smoking as a habit was present more among the married diabetics. The separation from family-of-origin and financial independence that happen after marriage may have made some patients start smoking and also accept their smoking status more frequently. The stress related to both occupational and personal life present in married individuals may also be a contributing factor to increased smoking. A similar result was found in a Delhi study in which smoking beedis/chuttas was more common in married and older people.[22] However, contrasting finding that single, widowed, and being separated led to significantly lesser self-management behavior, was reported from other Indian study.[9]

The limitation of our study is that it was conducted in NandNagri and therefore, the findings of our study are generalizable only to this area and may not be applicable to the whole of East Delhi. Therefore external validity may be lacking. Since SDSCA is a self-report questionnaire, the estimates for diet, exercise, etc., as reported by diabetic patients may be subject to some social desirability bias. Since ours was a cross-sectional inquiry, there are inherent issues of temporality and thus, cause and effect relationships may not be very clear in our study.


   Conclusion Top


Overall the level of self-care activities among diabetic patients in our study was quite low. There is a need for ongoing self-management education programs in all hospitals, for patients and caregivers. Peripheral level health functionaries should conduct regular information, education, and communication activities and one-to-one counseling sessions for diabetic patients.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

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