Knowledge of type 2 diabetes mellitus and adherence to management guidelines: a cross-sectional study in Juba, South Sudan

Author(s): Alexandre Ali M. Bili and Longying Zha

Department of Nutrition and Food Hygiene, School of Public Health, Southern Medical University, Guangzhou, China 

Correspondence:  Longying Zha [email protected]

Submitted: May 2018 Accepted: October 2018 Published: November 2018

Abstract

Introduction: In South Sudan, inadequate education and the lack of efficient diabetes care centres compounded by high costs are common barriers for diabetes care.

Objective: To assess the level of knowledge and adherence to guidelines for management of type 2 diabetes (T2D) and detected associations between knowledge scores and HbA1C levels.

Method: A cross-sectional study among 176 participants aged from 20 to 79 years with T2D randomly selected in Malakia Diabetic Clinic, Juba from July to September 2017.

Results: The proportions of “poor”, “average”, and “good” scores for knowledge were 58%, 18% and 24%, respectively.  Fewer than half of the patients had had retinal check-ups (46.6%), HbA1c tests (44.3%), lipid measurements (37.5%), dental examinations (20.5%) and renal function reviews (10.2%) in the last year.

Conclusion:  There was poor knowledge and low adherence to diabetes management guidelines. This study highlights the significance of educational intervention and implementation of diabetes management guidelines in South Sudan. 

Keywords: Type 2 diabetes; knowledge; adherence to guidelines; self-management; South Sudan

 

Introduction 

South Sudan is one of the world's youngest nations with extreme poverty and poor healthcare provision. Diabetes mellitus (DM) has steadily increased across the country in recent years and currently has a prevalence rate of 11.8% [1].

Diabetes is an expensive disease to treat because of the range of complications which exerts a tremendous economic burden on patients, families, health systems and society as a whole [2]. Knowledge of DM and adherence of physicians and patients to management guidelines are crucial for the reduction of complications and improved health outcomes. Management requires clear instruction from both doctors and nurses, and the patients making various  life style choices [3].

No studies in the country have specifically examined to what extent the diabetes management guidelines are being followed.  This small cross-sectional study evaluated the knowledge of, and adherence to, clinical guidelines of patients with type 2 diabetes (T2D), and detected associated factors.

Methodology

This descriptive cross-sectional study design used primary data that were collected from 176 adults with T2D in the Malakia Diabetic Control Centre of Juba City between July and September 2017. A three-part questionnaire was  used: Part I consisted of general characteristics of patients, Part II related to knowledge about different aspects of diabetes and general principles of disease care and Part III collected data on patients’ self-management of diabetes for annual follow-up criteria as reported in guidelines. The guidelines’ criteria were extracted from international guidelines [4-6]. The questionnaire about knowledge was developed and adopted from the Michigan Diabetes Training Centre Diabetes Knowledge Test (DKT) as a guide for primary data collection[7].

Data were analysed using Statistical Package for Social Sciences (SPSS) version 24. Descriptive statistics (frequencies and percentages) were used to describe the general characteristics. The level of adherence to criteria, i.e. the number of criteria achieved, was calculated for each criterion in percentage terms. The knowledge scores and HbA1C levels were compared with general information variables and management practices using an independent sample t-test and ANOVA. The means and standard deviations were calculated and a p-value of 0.05 or less was considered statistically significant.

Results 

Table 1 shows that the ages of patients ranged from 20 to 79 years, and that 91 (51.7%) were females and   85 (48.3%) were males.

Table 1. Characteristics of the study subjects (n = 176)

Characteristic 

n

  %

Age (years, mean±SD)

52.6±11.1

 

Age category

 

 

<40

19

10.7

  40 – 50

58

33.0

  51 – 60

61

34.7

>60

38

21.6

Gender

 

 

  Male

85

48.3

  Female

91

51.7

Education level

 

 

  No formal education

62

35.2

  Primary education

39

22.2

  Secondary education

50

28.4

Post-secondary education/degree

Employment status

  Employed

  Unemployed

25

 

114

62

14.2

 

64.8

35.2

Monthly income (South Sudanese Pounds)

 

 

<SSP 1000

102

58

  SSP 1001 – 2000

38

21.6

>SSP 2000

36

20.5

Duration of diabetes (years, mean±SD)

6.9±5.7

 

<2 years

30

17

  2 – 5 years

57

32.4

>5 years

89

50.7

Family history of DM

 

 

  Present

65

63.1

  Absent

111

36.9

Body Mass Index (BMI) (mean±SD)

  Underweight: BMI < 18.5

  Normal: BMI 18.5 - 25

  Overweight: BMI 25 - 30

  Obese: BMI ≥ 30

Smoking habit 

  Yes

  No                                       

25.6±5.1

10

70

67

29

 

27

149

 

5.7

39.8

38.1

16.5

 

15.3

84.7

DM=Diabetes Mellitus, 190 South Sudanese Pounds (SSP) = 1US$.

The level of adherence to criteria varied among the study participants. In the past year fewer than half of respondents had had eye examinations 46.6% (n=82), HbA1c tests 44.3% (n=78), lipid tests 37.5% (n=66), dental check-ups 20.5% (n=36) and renal check-ups 10.2% (n=18) (Figure 1.A). Almost 40% (n=69) were not using oral anti-diabetic medication or insulin (Figure 1.B). Only 1.7% (n=3) were following physical activity guidelines (Figure 1.C); 30.1% (n=53) were always following the dietary recommendations (Figure 1.D).

 

 

HbA1C = glycosylated haemoglobin

Figure 1. Level of adherence according to the criteria for type 2 diabetes follow-up (% of patients) (Credit Alexandre Ali M. Bili).

 

Only 78 (44.3%) patients had been tested for HbA1C within last four months and only their results were used to compare their adherence to DM management guidelines. The mean HbA1C differed significantly according to whether respondents were taking neither oral anti-diabetic medication nor insulin, not undertaking vigorous physical activity and habitually not following diet recommendations. Insulin, ≥150 minutes/week of exercise and always following diet recommendations for diabetes were significantly associated with lower or normal HbA1C values (p < 0.01) (Table 2).

 

Table 2. HbA1C level in patients with different medication, diet and exercise (78 patients)

Characteristic

           Category

 HbA1C level

(mean±SD)

        P

Diabetes medication

Oral anti-diabetic (n=22)

Insulin (n=4)

Neither oral nor insulin (52)

 

   6.47±2.89b

   5.90±3.14c

   12.22±3.14a

<0.01

Following diet recommendations

Always (n=22)

Sometimes (n=15)

   6.20±2.82c

   8.87±2.87b

<0.01

 

Never (n=41)

 

   10.93±2.69a

 

Exercise duration/week

No exercise (n=69)

90-120 min./wk. (n=8)

   10.42±2.88a

   9.67±2.40a

<0.01

 

≥150 min./wk. (n=1)

   5.20±0.00b

 

⃰ Note: different letters (a, b or c) indicate statistical significance (P<0.05) among groups. SD=standard deviation.

 

More than 50% of patients showed poor knowledge (58%, n=102), 24% (n=42) expressed good knowledge and 18% (n=32) exhibited moderate knowledge (Figure.2).

Figure 2.  Distribution of participants according to their levels of knowledge of diabetes

The knowledge score was unaffected by the duration of diabetes and family history of diabetes. However, subjects younger than 40 years had significantly higher knowledge scores than those older than 60 years (P =.022). Similarly, subjects with post-secondary education or degrees had significantly higher knowledge scores than those with secondary education or less (P=<0.001). Participants with normal HbA1C (≤6.5) had significantly higher knowledge scores than subjects with HBA1C results >6.5 (P=<0.001) (Table 3).

 

Table 3. Knowledge scores of the study participants according to different variables

Characteristic

       Category

    Knowledge score

       (mean±SD)

   P

Age

<40 years (n=19)

40 – 50 years (n=58)

51 – 60 years (n=61)

>60 years (n=38)

 

         8.47±3.72a

         3.72±3.59c

         4.84±3.63b

         3.84±3.71c

.022

HbA1C

≤6.5

         9.43±3.86a

<0.01

 

>6.5

 

         4.30±3.54b

 

Education level

No formal (n=62)

         1.68±2.25d

<0.01

 

Primary (n=39)

         3.23±3.09c

 

 

Secondary (n=50)

         6.38±30b

 

 

Post-sec./degree (n=25)

 

         9.24±.53a

 

Duration of diabetes

<2 years (n=30)

         4.70±3.89

.911

 

2–5 years (n=57)

         4.37± 3.71

 

 

>5 years (n=89)

 

         4.38±3.75

 

Family history of diabetes

Present (n=65)

Absent (n=111)

         4.77±3.78

         4.23±3.70

.358

 

 

 

 

⃰ Note: different letters (a, b, c or d) indicate statistical significance (P<0.05) among groups. SD= standard deviation.

 

Discussion

Diabetes is a demanding disease requiring much patient self-management. This study highlights a critical situation in South Sudan, a country without official guidelines for the management of diabetes. Evidence suggests that knowing the facts about diabetes and adherence of patients to guidelines have a significant effect on control of the disease. One of the objectives of this study was to assess the level of knowledge among T2D patient: 58% of whom showed poor knowledge. This was associated with a low level of education among participants. Our study observed that higher educational backgrounds were associated with gradually increasing knowledge scores - a finding similar to that from Bangladesh [8].  However this is in contrast to a Kenyan report which found very low levels of knowledge (27%) [9]. Our study discovered that knowledge was associated with age:  age under 40 years was significantly associated with better knowledge regarding diabetes compared to those aged over 40 years. This matches findings from Ethiopia [10]. This indicates that older people are at a higher risk and may need targeted programmes for their care.

Concerning the adherence to recognised guidelines we found 28%, 27%, 46.6%, 10.2% and 20.5% of the patients had had at least one  HbA1C test, lipid profile, retinal, renal and dental check-up respectively in the last year which agree with previous Sudanese data in 2015: 22.9%, 17%, 9.2% and 14.1% [11].

Recommendations for the frequency of HbA1C measurement range from twice to four times annually [6]. This study found a strong inverse association between knowledge scores and HbA1C levels; the HbA1C level was lower with each one-unit increase in knowledge score.

Almost 50% of respondents were not following diet recommendations. Also, the finding of a statistically significant association between HbA1C levels and diet for T2D is as predicted.

This study found that patients who undertook vigorous activity had normal HbA1C levels compared to patients who undertook no physical activity, which was inconsistent with Bouléet et al [12].  Physical activity has the greatest effect to minimize diabetes complications and reducing weight. Our study suggested some barriers to exercise adherence such as lack of motivation and convenience and weather. Another barrier is that South Sudanese adult population are less inclined to engage in physical activity. 

Conclusion

Knowledge about diabetes mellitus and adherence to guidelines and recommendations are important drivers for controlling the disease and reducing risks of complications and death. Thus, this study emphasises the importance of implementation of guidelines in South Sudan and education of communities and physicians, with a view to to improved management of the disease. 

Acknowledgement We are grateful to the participants and data collectors.

Funding source Ministry of Commence of the People’s Republic of China through the Southern Medical University.

Conflict of interest  The authors declare that there is no conflict of interest.

 

References

 

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