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ABSTRACT

OBJECTIVE: To find out the association between gender, socioeconomic status and health behaviors with diabetes management of Type II patients in Multan. STUDY DESIGN: A cross sectional study.

rd thPLACE AND DURATION: The study was conducted at Nishtar Hospital Multan, Pakistan from 3 April 2015 to 27 June 2015.METHODOLOGY: The data was collected through structured questionnaire from 310 Type II diabetic patients randomly who were visited diabetic outpatient department (OPD). The bivariate and multivariate logistic regression was applied with 95% confidence interval (CI).RESULTS: Of the 310 respondents, (48.7%) were males and (51.3%) were females. The overall respondents mean age was 41.36 years and (37.1%) belonged to 31-40 years age group. (94.2%) were married, Most of the respondents (57.7%) were living in urban areas, (58.7%) were poor and (42.9%) had middle education. Poor diabetes management was seen in (80%) while (20%) had better diabetes management. Highest portions of poor diabetes management were observed in female, (96.7%) in poor, (97.4%) in in female (96.2%), illiterate, (83.3%) in having duration of diabetes more than 3 years, (88.7%) in obese, (86.7%) in having more than one diabetes related complication, (97.1%) in having inadequate knowledge about diabetes, (91.2%) in doing irregular exercise, (95.2%) in having irregular doctor checkups and (91.4%) in poorly managed their diet. These all factors were significantly associated with diabetes management. CONCLUSIONS: Females, low socioeconomic status and risky health behaviors of Type II patient were poorly managed their diabetes. Type II patient's knowledge was important to improve diabetes management and changing health behaviors. KEY WORDS: Gender, Socioeconomic, Health Behavior, Type II Diabetes, Diabetes Management.

HOW TO CITE THIS:Siddique K, Malik R, Usman A, Ishfaq K. Gender, Socioeconomic Status and Health Behaviors of Type II Patients in Diabetes Management in Multan, Pakistan. Isra Med J. 2017; 9(3): 141-148.

This is an Open Access article distributed under the terms of the Creative Commons Attribution-Non Commercial 4.0 International License (http://creativecommons.org/licenses/by-nc/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

ORIGINAL ARTICLE ISRA MEDICAL JOURNAL | Volume 9 - Issue 3 | May - Jun 2017

INTRODUCTION

Diabetes management is major public health concern for health 1professionals. Diabetes mellitus (DM) is a progressive disease

requiring effective lifelong diabetes management for the prevention of diabetes related complications. Currently 215.2 million men and 199.5 million women worldwide have diabetes and about 75% are living in low and middle income countries. This situation is not different in Pakistan where 10.1 million

people are living with diabetes and it is expected that in 2040 2having 144 million diabetic patients.

DM occurs when patients have persistence high blood glucose level due to pancreas dysfunction or because their body do not

3response properly to insulin. Type II diabetes develops in association with various factors leading to decreased insulin secretion or insulin resistance amplified by health risk behaviors, such as uncontrolled diet, lack of exercise and

4resultant obesity. It is reported that the risk of diabetes complications like coronary artery disease, blindness, stroke, kidney failure, leg amputation and early death increases due to

5poor glycaemic control. For better diabetes management and prevention of diabetes related complications, health behavior plays a central role. Health behavior included behavior patterns, habits and actions that related to prevention or health

6improvement or management of disease. Health behaviors like physical activity, healthy dietary habits, and regularity in taking medication, doctor checkup and glucose monitoring had

7productive effects on better diabetes management. Socioeconomic status of the patient is also contributing in

8diabetes management. The relat ionship between socioeconomic positions, diabetes management and complications of diabetes are well established in developed countries. The low socioeconomic status is associated with unhealthy behaviors, irregular doctor checkups, poor diabetes

Gender, Socioeconomic Status and Health Behaviors of Patientsin Type II Diabetes Management in Multan, Pakistan

1 2 3 4Kashif Siddique , Raana Malik , Ahmed Usman , Kamran Ishfaq

1. Lecturer of Gender Studies Bahauddin Zakariya University Multan, Pakistan2. Assistant Professor of Gender StudiesThe University of Punjab, Lahore3. Assistant Professor of Institute of Social and Cultural StudiesUniversity of the Punjab, Lahore, Pakistan4. Assistant Professor of SociologyBahauddin Zakariya University Multan, Pakistan

Correspondence to:Kashif SiddiqueLecturer of Gender Studies Bahauddin Zakariya University Multan, PakistanEmail: kashif.siddique@bzu.edu.pk

Received for Publication: 24-08-16Accepted for Publication: 20-03-17

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(HbA1c). Type II diabetic patients who had glycemic level (HbA1c < 7 mmol/dl) were called better diabetes management and glycemic level (HbA1c > 7 mmol/dl) were called poor diabetes management. The actual HbA1c value was included in the data. The continuous variable (HbA1c) was converted into two categories better diabetes management and poor diabetes management as defined above.The BMI of the Type II patients was measured through weight

2(kg) and height (m ) by the researcher with the help of duty nurse through digital weight machine and height chart hanged on the wall. Written permission was taken from the administrative head of the hospital to conduct the study. Before start of each interview, written informed consent was obtained from the participants, who were assured about the safety and confidentiality of the data. All Type II diabetic patients were interviewed in head nurse room. No financial compensation was provided to the interviewed Type II diabetic patients; however those who needed diabetes information and better management were referred to relevant sources for assistance. Both bivariate and multivariate logistic regression analyses were used to identify the association between socio-demographic, patient diabetic history, BMI, comorbidities, gender health behaviors and diabetes management. The results of which significance p-value was more than 0.2 were excluded from multivariate analysis. Multivariate logistic regression analysis was also performed to assess the association between different socio-demographic variables and diabetes management. SPSS version 19 was used for statistical analysis. P<0.05 was considered to be statistically significant.

RESULTS

Table-I showed that out of total 310 Type II diabetic patients 62 (20%) had better diabetes management and 248 (80%) had poor diabetes management. The mean age of respondents was 41.36 years and there was no significance relationship between age and diabetes management. Among 151 (48.7%) males, 56 (37.1%) respondents were having better diabetes management whereas 159 (51.3%) females, only 6 (3.6%) managed their diabetes and gender was significantly associated with diabetes management. Among the respondents, 179 (57.7%) and 132 (42.3%) respondents lived in urban and rural areas of South Punjab. Locality was not associated with diabetes management. The marital status was significantly associated with diabetes management and showed that among 18 (5.8%) single respondents, 8 (44.4%) had better diabetes management and married respondents 292 (94.2%) in which only 54 (18.5%) had managed their diabetes better. The monthly Income level showed the economic status of the respondents among which 182 (58.2%) respondents were found poor, 102 (32.9%) mediocre and 26 (8.4%) rich. They had a better diabetes management 6 (3.3%), 33 (32.4%) and 23 (88.5%) respectively and was significantly associated with diabetes management. The educational status of the respondents was 116 (37.4%) illiterate, 133 (42.9%) upto middle and 61 (19.7%) higher education respectively. The respondentsʹ educational status was significantly associated with diabetes management among

management and low health literacy. The patient's diabetic knowledge is also contributing in the management of diabetes.

But lack of diabetes knowledge is more common among Type II 9 diabetic patients in Pakistan. Various studies and survey

conducted nationally and internationally had shown that the level of awareness among patients regarding diabetes is inadequate and lead towards unhealthy behaviors and poor

10-12diabetes management.In this study, diabetes management is measured through the glycated hemoglobin level (HbA1c). The diabetic patients having better diabetes management (HbA1c < 7) is called 'controlled' and having poor diabetes management (HbA1c > 7) is called 'uncontrolled'. Most of the previous studies conducted in Pakistan focused on diabetes related complications and its prevalence. But this study has been carried out to understand how gender, socioeconomic determinants and health behaviors of Type II diabetic patients in the management of diabetes would help to focus problems related diabetes management. This would further help to plan exact strategies aimed at reducing gender socioeconomic inequalities, improving health behaviors and shed more light as to why diabetes management have failed in Type II diabetic patients. To find out the association between gender, socioeconomic status and health behaviors with diabetes management of Type II patients in Multan.

METHODOLOGY

rd thA survey was conducted from 3 April 2015 to 27 June 2015 in Nishtar Hospital Multan, Pakistan. A total of 310 Type II diabetic patients were selected through random sampling method with odd slip number for male and even slip number for female. The inclusion criteria for selection of Type II diabetic patients was having diabetes from the last six months, age 20 year or more and visiting Diabetic OPD. The patients with Type I diabetes and gestational diabetes were excluded from the study. A structured questionnaire was developed and translated into Urdu language to collect the data. The questionnaire consisted of questions on demographic information like: age (years), gender (male/female), area (rural/urban), marital status (single/married), monthly income level (poor= less than 15000, middle= 15000-25000, rich= more than 25000) Pakistani rupees), education level (Illiterate= having no education, middle= having education upto 8 level and higher= more than 8 level) , duration of diabetes (less than or equal to 3 years/more

2than 3 years), BMI (underweight, BMI< 18.5 kg/m ; healthy, 2 2BMI< 18.5-24.9 kg/m ; overweight or obese, BMI> 25 kg/m ),

comorbidities (having no disease/ one or more diseases-retinopathy, neuropathy, nephropathy, heart disease, foot ulcer), gender health behavior: daily exercise 30 minutes (irregular/regular), pattern of taking medicine daily (irregular/regular), doctor checkup in last six months ( i r regular/ i rregular) and d iet management dai ly (irregular/regular) and diabetes knowledge (inadequate knowledge/adequate knowledge).The diabetes management was used as dependent variable. The diabetes management was measured through glycemic level

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which highly educated respondents 53 (86.9%) had better diabetes management. 112 (36.1%) respondents had duration of the diabetes less than three years among which 29 (25.9%) respondents had managed their diabetes better and 198 (63.9%) respondents had diabetes more than three years among which 33 (16.7%) better managed their diabetes. Duration of suffering from diabetes was significantly associated with diabetes management. The respondents body mass index showed that 31 (10%) were underweight, 75 (24.2%) were healthy and 204 (65.8%) were overweight or obese and BMI was significantly associated with diabetes management. The respondents had better diabetes management who were underweight 12 (38.7%), healthy 27 (36%) and overweight or obese 23 (11.3%) respectively. The results showed that 47 (15.2%) respondents had no disease with diabetes and among 27 (57.4%) respondents had better diabetes management and 263 (84.8%) respondents had one or more than one disease with diabetes among which only 35 (13.3%) respondents had better diabetes management. Awareness about diabetes was significantly associated with diabetes management. The respondents 240 (77.4%) were not aware about diabetes

among which 7 (2.9%) had better diabetes management and 70 (22.6%) respondents were well aware about diabetes among which 55 (78.6%) had better diabetes management. Sixty-one (19.7%) respondents were doing daily exercise for 30 minutes and 249 (80.3%) were not exercising daily among whom 40 (65.6%) and 22 (8.8%) respondents had managed better diabetes who exercised or did not exercise daily respectively. The pattern of medicine take daily was not significantly associated with diabetes management. 146 (47.1%) respondents were having irregular doctor checkup and 164 (52.9%) respondents were having regular doctor checkup in last six months. Doctor checkup in the last six months was significantly associated with diabetes management and only 7 (4.8%) and 55 (33.5%) respondents had better diabetes management who were irregular and regular doctor checkup respectively. 116 (37.4%) respondents did not manage their diet daily among which only 10 (8.6%) had better diabetes management and 194 (62.6%) respondents managed their diet and 52 (26.8%) respondents managed diabetes better. Manage diet daily was significantly associated with diabetes management.

TABLE-I: FREQUENCIES AND PERCENTAGES OF DEMOGRAPHIC INFORMATION AND OTHER CHARACTERISTICS WITH SIMPLEBINARY LOGISTIC REGRESSION ANALYSIS FOR THE PREDICTOR ASSOCIATED WITH DIABETIC CONTROL (HBA ) AMONG TYPE II1C

DIABETIC PATIENTS AGED 20-78 YEARS (N= 310).

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abbreviations: BMI, body mass index; HbA1c, glycated hemoglobin level; Kg; kilogram; m; meter; Rs., Pakistani rupee. *p < 0.05, **p < 0.01, ***p < 0.001When binary logistic regression is applied, most of the male respondents were having better diabetes management (OR, 5.03; 95% CI, 4.23-6.08) as compared to female respondents.

TABLE-II: ADJUSTED ODD RATIO FOR MULTIVARIABLE LOGISTIC REGRESSION OF FACTORS INDEPENDENTLY ASSOCIATED WITH DIABETIC CONTROL (HBA ) AMONG TYPE II DIABETIC PATIENTS AGED 20-78 YEARS (N=310)1C

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3.99) respectively.

DISCUSSION

The results of the study showed that various factors like age, area, monthly Income level, education, health awareness, BMI, family history and health behaviors (exercise, diet management, medication) affected diabetes management. A national study conducted in Pakistan mentioned that younger Type II patients had better diabetes management and fewer

13chances of complications as compared to older patients. When the duration of Type II diabetic patient increased their

14diabetes management regarding glycemic control decrease 11,15and significantly higher HbA1c levels.

National and International studies results mentioned that males had relatively good diabetes management as compared

11,13 to females and had poor glycemic control. The findings of the study also mentioned that Type II patients in urban area had better diabetes management as compared to rural area patients. This result was persistence with a study that diabetic patients were living in urban areas had better opportunities of

16health literacy and management from different sources. The respondents with higher education and higher income level were significantly associated with good diabetes management as compared to less educated and belonging to lower income

12 level groups. The higher income status of Type II had offered better treatment facilities yet also had access to more accessories of life, hence there was a positive relationship

17 between income and diabetes management. A result of a study revealed that Type II patients who had lower family income never changed their diet and exercise pattern led toward bad

18health and poor diabetes management. Obesity was positively associated with poor glycemic control or

19 management among diabetic patients. Due to obesity the risk of other comorbidities had been enhanced in Type II diabetic patients. A study mentioned that there were multiple factors like obesity and diabetes related complications were associated

15 with poor glycemic control in diabetic patients. The sedentary lifestyle or non-exercise behaviors increased the glycemic level

20in diabetic patients. Due to regular exercise a significant 2 1improvement in blood glucose, weight reduction ,

22 hypertension and reduced the risk factors of cardiovascular 23 disease. This reduced the severity of the disease and patients

managed their diabetes better as compared to sedentary 24 lifestyle patients. Healthy diet and physical activity played an

important role in the control of glycemic level as well as weight

Table-II showed a multivariable logistic regression analysis in which adjusted odd ratio (AOR) was obtained by controlling respondentsʹ age (continuous variable), education and economic status. The respondentsʹ ages (20-30 years) were more likely to have better diabetes management (OR, 1.76; 95% CI, 1.43-3.12) than older age respondents. The respondents who were single had better diabetes management (OR, 3.52; 95% CI, 1.32-4.35) than the married. The monthly Income level of respondents (middle and rich) had better diabetes management than the poor (OR, 2.03; 95% CI, 1.62-3.97) and (OR, 3.89; 95% CI, 2.22-6.07) respectively. The highly educated respondents were more likely to have better diabetes management (OR, 5.54; 95% CI, 3.64-8.54) than the illiterate. Duration of diabetes less than three years, BMI < 24.9 kg/m2 and having no other disease with diabetes were more likely to have better diabetes management (OR, 1.75; 95% CI, 1.01-3.07), (OR, 4.97; 95% CI, 2.33-6.40) and (OR, 6.79; 95% CI, 2.33-6.40) respectively. The respondents who had adequate knowledge about diabetes had better diabetes management (AOR, 12.05; 95% CI, 9.48-13.70) than respondents with inadequate diabetes knowledge. The respondents who exercised daily, had regular doctor checkup and regularly managed diet plan daily were found to have better diabetes management (OR, 9.65; 95% CI, 6.89-12.02), (OR, 10.02; 95% CI, 4.39-12.88) and (OR, 3.88; 95% CI, 1.89-4.99) respectively. The respondent's pattern of compliance with medication was not associated with diabetes management. A Multivariable logistic regression analysis was carried out to obtain the AOR after controlling for respondentsʹ age (continuous variable), respondentsʹ education and monthly income level.Table-III showed a multivariable logistic regression analysis in which adjusted odd ratio (AOR) was obtained by controlling respondentsʹ age (continuous variable), education and economic status. Male respondents living in urban areas had better diabetes management (AOR, 2.48; 95% CI, 1.67-4.21) and (AOR, 1.44; 95% CI, 1.51-4.08) respectively. The duration of diabetes less than three years, BMI (underweight< 18.5 kg/m2) and no disease with diabetes were more likely to better diabetes management (AOR, 1.50; 95% CI, 1.15-2.33), (AOR, 2.44; 95% CI, 1.79-4.44) and (AOR, 2.90; 95% CI, 1.12-3.64) respectively. The respondents health behaviors- regular exercise daily, regular take of medicine daily, regular doctor checkup last six month and regular managed diet plan had better diabetes management (AOR, 2.61; 95% CI, 1.97-4.02), (AOR, 1.64; 95% CI, 1.00-3.37) and (AOR, 1.56; 95% CI, 1.09-

abbreviations: 1, reference category; AOR, adjusted odd ratio; CI, confidence interval; BMI, body mass index; HbA1c, glycated hemoglobin level; Kg; kilogram; m; meter. All these variables were adjusted for respondentsʹ age (continuous variable), respondentsʹ education and monthly income level to perform multivariable logistic regression analysis to obtain adjusted odds ratio. *p < 0.05, **p < 0.01, ***p < 0.001

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25,26reduction. Limited or irregular health care access led toward 27 poor glycemic control due to irregular doctor checkup. The

results of the study showed that patients who took medicine and doctor checkup regularly were more likely to manage their diabetes as compared to patients taking medicine and doctor

11checkup irregularly. Diabetes education and awareness had been considers the

28 corner stone for the management of diabetes. Different studies conducted in Pakistan showed that level of diabetes awareness among men and women were low and diabetic population did not have enough knowledge about better diabetes management, use of medications, behavior

29,30modifications and dietary plans. Therefore, patient glycemic level was persistently elevated due to inadequate diabetes knowledge and they suffered more from diabetes related complications.

CONCLUSION

Females, low socioeconomic status and risky health behaviors of Type II patient were poorly managed their diabetes. Type II patient's knowledge was important to improve diabetes management and changing health behaviors.

RECOMMENDATIONS

Poor diabetes management was still a major issue in Type II patients. A special attention in this regard was needed by government, health professionals and health educators. For good diabetes management, quality of life and prevention of diabetes related complications- free medical camps, awareness campaigns, dieticians, public hospitals and diabetic centers would play a vital role. More attention should be given to provide information to diabetic patients how health risk behaviors like unhealthy diet, irregular (exercise, blood screening, doctor checkups, taking medicine) and obesity led towards poor diabetes management. The health risk behaviors threats would help to change behaviors in Type II patients and improve their health status and quality of life.

Contributions of AuthorsSiddique K: Designed research, Literature review, questionnaire designing and data collection.Malik R: Designed research, Literature reviewUsman A: Report writingIshfaq K: Data Analysis and Discussion.

Disclaimer: None.Conflict of Interest: None.Source of Funding: None.

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