Download Type of manuscript: Original article Title: Profile and health seeking

Type of manuscript: Original article
Title: Profile and health seeking behaviour of registered diabetes cases at primary health
centres in North Sharqiya, Oman - a cross sectional study
Running title Diabetes in PHC of Oman
Abstract:
Background: For easy access, the diabetes control program is integrated to the primary
health care system in Oman. We present the health seeking behaviour, current status,
complications and risk factors of diabetes at three health institutions (HI) of the North
Sharqiya governorate of Oman.
Methods: This study was conducted in 2011. Participant’s past health information was noted
from the case records and diabetes registers. Glycaemic level, lipid levels, complications of
diabetes were assessed. To determine the health seeking behaviour, participants were
interviewed. The risk factors for diabetes and complications were associated.
Result: We studied 260 diabetics (103 males and mean age of 55.9 ±13.8 years). The health
seeking behaviour of 129 (49.6%) diabetics was satisfactory. Family history of diabetes
(64.2%), hypercholesterolemia (53.5%) and obesity (47%) were the main risk factors for
diabetes. Cardiac (46.9%) and renal complications (18.9%) of diabetes were high. The rate of
diabetic retinopathy was 4%. Two-thirds of cases were provided oral hypoglycaemic agents.
Aspirin and antihypertensive medicines were provided to 25% and 40% of diabetics
respectively. HbA1c level of <7 mmol/L was found in 73 (28.5%) of patients. The difference
in glycaemic control of patients with and without complications of diabetes was not
significant. [Odds Ratio = 0.7 (95% confidence intervals: 0.4 – 1.3)].
Conclusion: In spite of availability of services free of cost at nearby health institutions,
health-seeking behaviour of diabetics was less than desired. The rates of cardiac and renal
complications were high but diabetic retinopathy was low. Glycaemic control of patients was
good in one fourth of patients.
Key words: Diabetes, Health behaviour, Primary Health Institution, Oman.
Advances in Knowledge: The persons with diabetes in rural areas of Oman have poor health
seeking behaviour. Their glycaemic control and management of risk factors are less than
desired. In spite of primary health care initiative, free, accessible and high standard health
care available in Ministry of Health institutions, status of diabetes in the community is a
matter of concern. Health promotion at PHCs does not seem to have desired impact. Cardiac
complications of diabetes were of high proportions while prevalence of diabetic retinopathy
was low.
Application to Patient Care:
Judicious control of blood sugar and risk factors like hypercholesteromia, hypertension and
regular check-ups are recommended at PHCs of North Sharqiya. Institution based health
promotion activities could be complimented by community based initiatives to improve
health behaviour of persons with diabetes.
Introduction:
The world is facing a global epidemic of diabetes [1]. Primary prevention and standard
management of diabetes are recommended to reduce mortality and morbidity due to diabetes
[2, 3]
[4]
. The prevalence of diabetes was estimated at 12.3% in adults over 20 years old in Oman
. The diabetes control initiative in Oman includes primary prevention, screening and timely
management of diabetes and its complications through governmental health institutions. The
primary health institutions keep diabetes registers for the residents of the catchment areas.
Free medications are provided to those registered at the primary health centre (PHC). Annual
assessments to detect and address important complications are performed from these registers
since 1994 [4, 5]. Studies have revealed inadequacies in managing diabetes at the primary
levels [6].
Samad and Al Ayoon health centres and Mudaibi wilayat hospital at the North Sharqiya
governorate of Oman have a catchment area population of nearly 47, 237 individuals [7].
Fourteen medical doctors trained in standard care of diabetics, provide health services from
these health centres. Two health educators counsel patients with diabetes periodically to
increase their awareness of diabetes. At diagnosis, an individual with diabetes is examined by
an endocrinologist at the governorate hospital. Subsequently, they are schedule for annual
check-ups with an endocrinologist and an ophthalmologist. The medications are prescribed
by the endocrinologist for diabetics and they are dispensed free of cost at the Government
health institutions.
Objective of the study is to describe health seeking behaviour, current status of diabetic care,
complications and risk factors associated with diabetes among registered diabetic cases at
primary health centres in North Sharqiya, Oman
Methods
This cross sectional study was conducted between September 2011 and December 2011. The
research and ethical committee of the Directorate General of Health Services, North Sharqiya
region of Oman provided permission for conducting this study. The study population was
comprised of 1,300 individuals with diabetes registered at three Ministry of Health (MOH)
HI’s - Samad, Al Ayoom and Mudaibi. We assumed that the rate of healthy practices for
controlling diabetes among this study population was 25%. To calculate the representative
sample of registered diabetics with 95% confidence interval (CI) and 5% acceptable error
margin, we needed randomly selected at least 236 individuals with diabetes from the study
population. We further stratified the sample according to the percentage proportion of
registered diabetics in three HI’s. All registered cases were given serial number and a
systemic random sampling method was used to identify the study sample. Verbal consent for
participation was obtained from all study subjects. Data were collected on demographics, past
history of diabetes and management from patient charts and the diabetes register. All patients
were assessed to determine their current status of diabetes. They were interviewed to
determine their health seeking behaviour in relation to control of diabetes and their risk
factors.
Family physicians, nurses from the chronic diseases section of HI’s and epidemiologists of
the governorate were the field staff for this study. The information on risk factors of diabetes
were collected both through history taking and measurements during the last comprehensive
check up by an endocrinologist over the previous year. A positive family history was
classified as either parents or siblings also diagnosed with diabetes. Patients classified with a
positive risk factor for tobacco consumption were, current smokers (shisha or cigarettes) or
patients who reported oral consumption of tobacco. A body mass index (BMI) of 30 kg/m2 or
higher was classified as obese, a risk factor for diabetes. A history of regular alcohol
consumption was considered a risk factor for diabetes. Females with diabetes, who were
pregnant at the time of assessment for the study, were considered as having a risk factor for
diabetes. If any other known risk factor was mentioned in the case file it was classified as
“other” risk factor for diabetes.
Complications of diabetes were based on the diagnosis of an endocrinologist and/or
ophthalmologist and as per the standard operating procedures of Oman. Complications were
diabetic neuropathy, diabetic retinopathy (DR), diabetic nephropathy, diabetic foot and
cardiovascular complications of diabetes [5].
Health behaviour of diabetics was evaluated through data on HbA1c levels, serum cholesterol
levels, attendance for the annual diabetes assessment in the previous year, attendance for the
annual DR screening, attendance for regular monthly follow up visits at PHC and timely
collection of free diabetic medications. If at least four out of six parameters were judiciously
followed, the health behaviour was considered as satisfactory. If less than three parameters
were followed, the health behaviour was considered as poor.
The mode of management of diabetes was noted form the patient chart. These included, diet
and exercise only, oral hypoglycaemic, insulin, aspirin, anti-cholesterol, antihypertensive
medications or combinations of the above.
The data were collected on a pre-tested form and computed on Microsoft Excel® (Microsoft
Corp., Redmond, WA, USA). Statistical analysis was performed with statistical package for
social studies (SPSS, Version 16) (IBM Corp., New York, NY, USA). Frequencies,
percentage proportions and 95% CI using univariate analysis were calculated using with
OpenEPI software [8].
Results
The study population was comprised of 260 patients with diabetes registered at three HI’s.
There were 157 females. The demographic data are presented in table 1. The mean age of
study population was 55.9 ± 13.8 years. The mean duration of diabetes was 8.5 ± 4 years.
Of the entire study population, 129 (49.5%) participants visited the HI at least 10 times in a
year for follow up and to collect medicines. Two-thirds [173 (66.5%)] of the participants had
visited the governorate hospital for an annual diabetes assessment. DR screening was
performed in 209 (80.4%) of the study population. The overall health seeking behaviour of
129 (49.6%) participants was satisfactory.
Table 2 presents the known risk factors for the development and progression of diabetes
among participants. A family history of diabetes (64.2%), hypercholesterolemia (S.
Chlestereol >=5.2 mmol/lt) (53.5) and obesity (47%) were the main risk factors for diabetes.
Diabetes related complications are presented in Table 3. Cardiac (46.9%) and renal
complications (18.9%) of diabetes were high. The rate of DR was 4%.
The current mode of management of diabetics is described in Table 4 and Two-thirds of cases
were given oral hypoglycaemic agents. Aspirin and antihypertensive medications were given
to 25% and 40% of the study population.
The HbA1c value of 249 patients was available. Seventy-four (28.5%) participants had a
HbA1c value <7 % whereas 71.5% patient found to be having poor glycaemic control. 71. Of
the 136 patients with at least one complication of diabetes, 98 (72.1%) had a HbA1c level
greater than 7 %. Of the 113 patients without complications of diabetes, 81 (72%) had a
HbA1c level greater than 7 % [Odds ratio (OR): 0.7) (95% CI: 0.4 – 1.3)]. The mean HbA1c
in the 20-39 years age group (n=29) was 9.1 ± 2.98 %. The mean HbA1c in the 40 to 59 years
age group (n= 122) was 8.58 ± 2.05 %. In 98 participants aged 60 years and older, the mean
HbA1c was 8.9 ± 2.96 %.
Discussion:
This review of diabetics and their related complications in a community where proactive
screening for identifying diabetics has been in place for five years, has provided unique
insights into healthcare delivery, health seeking behaviour of diabetics and challenges to
improve the health care of diabetics.[7]
The health seeking behaviour of our cohort was less than desired. Despite free healthcare
services, distances to the HI (within 10 km) and provision of health services by well trained
professionals, the low rate of seeking periodic assistance to actively treat diabetes suggests
the presence of other barriers. The gap between knowledge, preventive and healthcare
practices among diabetics noted by previous studies could explain the low rate of health
seeking behaviour in our study [8]. With half of the registered individuals not regularly
visiting the HI’s, counselling of diabetics could be community-based in addition to shifted
from institution-based.
Nearly one-sixth of the diabetic population in our study was using Insulin to manage their
diabetes. This is less than 22% reported by Elliott et al [9]. Reluctance to use an injectable
form of treatment among the rural community could explain this relatively low rate in our
study. However, poor glycaemic control among patients on oral diabetic medications should
prompt the caregivers to switch to insulin treatment.
The good glycaemic control among 28.5% of registered diabetics found in our study is
disconcerting. Among Omani diabetics this rate was 32% in a study in 2007 [10]. Interestingly,
there was no significant association of complications of diabetes to the glycaemic control in
our study. Good glycaemic control delays the progression of complications of diabetes [11].
Better glycaemic control may be possible through counselling at HI’s and an improved
commitment among diabetic patients after developing complications. Although HbA1c test is
considered the gold standard for assessing glycaemic control in a diabetes control program, it
is not uniformly available in all countries especially in rural areas of developing countries [12].
However, in the current study, 97% of the cohort had easy access to facilities for testing
HbA1c.
In the current study the major diabetic complications were, diabetic nephropathy and
cardiovascular complications. The rate of diabetic nephropathy was lower in the current study
(18.9%) compared to 42.5% reported in the Dhakhiliya governorate of Oman [13]. This
difference is likely due to the catchment area in the latter study [13] which was semi-urban and
the cases were from a polyclinic with a different subset of patients and health care providers
compared to HI’s in our study. The significant difference in the rate of nephropathy observed
in two studies should be investigated. Based on the data of end stage renal failure, it has been
suggested that the prevalence of diabetic nephropathy is unusually high in Gulf countries [14].
It is possible that the cases going to tertiary hospitals for renal dialysis and care for advanced
disease might not be visiting PHCs after previous registration and therefore are underrepresented in the present study.
The national prevalence of DR is 14.5% among diabetes cases [15]. In the present study it was
4%. Considering the poor glycaemic control and 8.5 years mean duration of DM, DR seems
to be under-represented.
There are some limitations to our study. The individuals with diabetes who reside in the
catchment areas but opt for health services from institutions other than HI’s (e.g. private
clinics, institutions in areas where their children are working in defence or at a university)
could have been missed. Some diabetics with severe incapacitating complications that
precluded any visits to PHCs may not have been included in this study.
Despite protocols for the standard management of diabetes that are available both
internationally and in Oman, the high levels of blood sugar strongly suggests the need
monitoring diabetic care at HI’s [16, 5]. The Ministry of Health performed an initial trial at
PHCs in the Muscat governorate (urban area) that involved screening the adult population for
chronic non-communicable diseases including diabetes. However, these initiatives should be
complemented with monitoring and periodic audit of registered diabetics as performed in this
study [17].
Conclusion: The health seeking behaviour of persons with diabetes was satisfactory level in
half of the participants. The good glycaemic control (HbA1c level was <7 %) was found in
28.5% of participants only. Family history of diabetes, hypercholesterolemia and obesity
were the main risk factors for diabetes. Cardiac and renal complications were of high
proportions among diabetics. The prevalence of Diabetic Retinopathy was unusually low in
the participants.
References:
1.
Herman WH, Zimmet P. Type 2 diabetes: an epidemic requiring global attention and
urgent action. Diabetes Care. 2012;35:943-4.
2.
Kahn R. Reducing the impact of diabetes: is prevention feasible today, or should we aim
for better treatment? Health Aff (Millwood). 2012;31:76-83.
3.
Ramachandran A, Snehalatha C, Shetty AS, Nanditha A. Trends in prevalence of
diabetes in Asian countries. World J Diabetes. 2012 15;3:110-7.
4.
Al Riyami A, Elaty MA, Morsi M, Al Kharusi H, Al Shukaily W, Jaju S. Oman world
health survey: part 1 - methodology, sociodemographic profile and epidemiology of noncommunicable diseases in Oman. Oman Med J. 2012;27:425-43.
5.
Ministry of health, Oman. Diabetes Mellitus. Management guidelines for Primary Health
Care. 2nd Edition 2003. http://www.moh.gov.om/en/mgl/Manual/diabetesmoh.pdf last
accessed on 23 June 2013.
6.
Sundquist K, Chaikiat A, León VR, Johansson SE, Sundquist J. Country of birth,
socioeconomic factors, and risk factor control in patients with type 2 diabetes: a Swedish
study from 25 primary health-care centres. Diabetes Metab Res Rev. 2011;27:244-54.
7.
Screening for diabetes in those visiting health institutions of North Sharqiya governorate
of Oman. Newsletter North Sharqiya.
8.
Dean AG, Sullivan KM, Soe MM. OpenEpi: Open Source Epidemiologic Statistics for
Public Health, Version. www.OpenEpi.com, updated 2013/04/06, accessed 2013/07/13.
9.
Rani PK, Raman R, Subramani S, Perumal G, Kumaramanickavel G, Sharma T.
Knowledge of diabetes and diabetic retinopathy among rural populations in India, and
the influence of knowledge of diabetic retinopathy on attitude and practice. Rural
Remote Health. 2008;8:838.
10. Elliott JA, Abdulhadi NN, Al-Maniri AA, Al-Shafaee MA, Wahlström R. Diabetes selfmanagement and education of people living with diabetes: a survey in primary health
care in Muscat Oman. PLoS One. 2013;8:e57400.
11. Al-Lawati JA, Barakat MN, Al-Maskari M, Elsayed MK, Al-Lawati AM, Mohammed
AJ. HbA1c Levels among Primary Healthcare Patients with Type 2 Diabetes Mellitus in
Oman. Oman Med J. 2012;27:465-70.
12. Lal B. R, Robyn J. T, Emily D. W, Carina C, Shajahan Y, Brian O. Prevention of Type 2
Diabetes and Its Complications in Developing Countries: A Review. Int J Behav Med.
2012; 19: 121–133.
13. International Expert Committee International Expert Committee report on the role of the
A1C assay in the diagnosis of diabetes. Diabetes Care 2009;32:1327–1334.
14. Alrawahi AH, Rizvi SG, Al-Riyami D, Al-Anqoodi Z. Prevalence and risk factors of
diabetic nephropathy in Omani type 2 diabetics in Al-dakhiliyah region. Oman Med J.
2012;27:212-6.
15. Farag YM, Al Wakeel JS. Diabetic nephropathy in the Arab Gulf countries. Nephron
Clin Pract. 2011;119:c317-22.
16. Khandekar R, Al Lawatii J, Mohammed AJ, Al Raisi A. Diabetic retinopathy in Oman: a
hospital based study. Br J Ophthalmol. 2003;87:1061-4.
17. Yung CW, Boyer MM, Marrero DG, Gavin TC. Patterns of diabetic eye care by primary
care physicians in the state of Indiana. Ophthalmic Epidemiol. 1995;2:85-91.
18. Al –Shereiqi S. Non-communicable diseases screening: Starts in Oman. Community
Health & Disease Surveillance Newsletter. 2008;13:1-5. Last accessed on 7th July 2013.
http://www.moh.gov.om/en/reports/publications/Newsletter17-3.pdf
Table: 1. Profile of registered diabetic cases included in study at three Primary Health
Centres of Oman (N=260)
Gender
PHC
Age group
Number
Percentage
Male
103
39.6
Female
157
60.4
Samad
136
52.3
Al Ayoon
44
16.9
Mudaibi
80
30.8
20 to 29
6
2.3
30 to 39
25
9.6
40 to 49
49
18.8
50 to 59
77
29.6
60 to 69
59
22.7
70 and more
44
16.9
Table: 2. Risk factors of diabetes among persons with diabetes at three Primary Health
Centres of Oman
(n = 260)
Number Percentage
95% confidence
interval
Family history of diabetes
167
64.2
58.4 -70.1
<5 years
74
28.5
23.0 - 33.9
5 to 9 years
69
26.5
21.2 -31.9
10 to 14 years
68
26.2
20.8 -31.5
49
18.8
14.1 -23.6
Tobacco consumption
5
1.9
0.3- 3.6
Alcohol consumption
1
0.4
-0.4- 1.1
Pregnancy (n = 157)
12
4.6
3.5- 11.8
Obesity (BMI ≥30Kg/M2)
122
46.9
40.7 - 53.0
Hypercholesterolemia (≥ 5.2 mmol/L)
139
53.5
47.4 - 59.5
Duration of diabetes
15 years and more
Table: 3 Complications among registered diabetics at three Primary Health Centres of Oman
(n= 260)
Number
Percentage
95% Confidence Interval
Diabetic neuropathy
4
1.5
0.04 - 3.03
Diabetic retinopathy
10
3.8
1.5 - 6.2
Diabetic nephropathy
48
18.5
13.8 - 23.2
1
0.4
-0.4 - 1.2
Cardiac complications
122
46.9
40.9 - 53.0
Any one complication
141
54.2
48.1- 60.3
Diabetic foot
Table: 4 Management of registered diabetics at three Primary health centres of Oman
Management mode of diabetes
#
%
Diet and exercise
38
14.6
Oral
176
67.7
Insulin
46
17.7
Other medicines for preventing complications
Aspirin
65
25.0
Statin
41
15.8
Antihypertensive
104
40.0