Introduction: According to an estimate of the World Health Organization, about 171 million people worldwide suffer from diabetes. But the incidence is increasing so rapidly that it is speculated that by 2030 this number will be almost doubled. Diabetes mellitus occurs all the way through the world, but it is becoming more common (especially type 2) in the developing countries. Due to rapid urbanization and changes of lifestyles, it is in the state of epidemiological shift. This study aimed to assess patients’ compliance to treatment and whether it reduces the complication of diabetes, and its impact on overall management of diabetes. Objectives: The study objectives were to assess the compliances of diabetic’s patients in terms of disease management & to assess the association of patients’ compliance with disease complexity. Methods: Mixed methods (qualitative & quantitative) were used to conduct this study in Manikgong and Dhaka city. A pre-tested questionnaire was used for both methods. Quantitative data were collected by a structured questionnaire from 1830 participants of both sexes, and for the qualitative data a semi-structured questionnaire was used to conduct in-depth interview from 25 respondents and informal discussion was also organized with 8 care providers, i.e. physicians. Results: Findings revealed that very significant relation exists with compliances and complication in managing diabetes. That compliances influence by various factors like gender, education, occupation, treatment facilitates etc. But who followed the proper compliances faced fewer complications. In addition, compliances to herbal medicine were also familiar to diabetic patients. Most compliance as respondents preferred are: diet, exercise, weight control than the medication. Conclusion: Largely a optimistic outcome blowing that the patients (type 2 diabetes) who maintained appropriate compliances faced less complication than who didn’t follow.
Diabetes mellitus is recognized as a group of metabolic diseases while a person having high blood sugar, either because the body does not produce enough insulin or the cells don’t respond to produced insulin [
Type 2 diabetes is the prevalent form disease from the very begining for its asymptomatic characteristic and remains undiagnosed for many years. A study found that approximately 5.4 million adults in the U.S. suffered from undiagnosed type 2 diabetes, who are under significant higher risk for coronary heart disease, stroke, and peripheral vascular disease than the non-diabetic people [
Considering this huge DALYs, Dr Mohammed Ibrahim, Professor of Medicine first thought of diabetic care in Bangladesh. He realized that diabetes is such a disease where not only doctors but patients should be involved in the process of diabetic care. Addressing the matter as socio-medical facts he established Bangladesh Institute of Research and Rehabilitation for Diabetes (BIRDEM). Presently BIRDEM, as the sister organization of Bangladesh Associassion of Diabetics Society (BADAS), efficiently and effectively provided services to the diabetic patients to reduce their complication, and to lower the prevalence rate one of the major non commu- nicable diseases. There exists two types of compliance to reduce the complication of diabetes, they are:
Diabetic patients do their own care (95%), where physicians only play a collaborative role in the management system [
This study was utilized a mixed study design both qualitative and quantitative methods to adherences the comprehensive approaches. For that face to face in-depth interviews and key informant interview were conducted as a part of qualitative study. Participants were stratified to ensure homogeneity within different sex group. For quantitative part we selected a cross sectional design to assess the dietary consumption patterns and diversity of the participants’ households. Data on socio-demographic variable and treatment option were also collected.
The study was conducted in two settings: urban and rural area to compare the situation comprehensively. For urban settings BIRDEM (Bangladesh Institute of Research and Rehabilitation for Diabetes, Endocrine and Metabolic Disorders) and one of its sister institution were selected. BIRDEM the largest 600-bedded multidisciplinary hospital complex of the Diabetic Association of Bangladesh, situated at 129 New Eskaton Road, Dhaka district was selected. For rural settings Shibaloy Upazila of Manikgonj district was selected, which area is 1378.99 km2, under Dhaka District and situated in the east of the country. Here below the map showed that under the Dhaka Division the selected areas for the study were Shibaloy under Manikgonj District and BIRDEM from Dhaka District (
A) Inclusion Criteria: Participants aged 25 - 60 years, suffering from diabetes for last six months.
B) Exclusion Criteria: Participants with mental disabilities, who are visibly ill and those who are unable to
A) Inclusion Criteria: between the ages of 25 - 60 years and serves the diabetic patients.
B) Exclusion Criteria: Service provider who refused to participate.
We conducted 25 semi-structured in-depth interviews with patients and 8 key informant interview with physicians’. For the quantitative part a pre-coded structured questionnaire was applied to collect information from 1830 respondents (selected randomly), where 930 from urban (BIRDEM) and 900 from rural. It is estimated that around 500,000 patients’ covered by BIRDEM where the daily turnover is around 2500 [
For qualitative analysis we used thematic analysis. The transcribed data were coded and analysis was performed using Microsoft Office Excel, 2007, for qualitative analysis. For quantitative analysis all completed questionnaires were checked for inconsistency and errors before sending for analysis. After coding and cleaning of data, final analysis was done by using the SPSS 17.0 software.
All data were entered and stored on password protected computer by the researcher. Only the primary investigator has access to this information. To ensure ambiguity of the participants, code was used to identify participants and groups in all stages of this research. Participants’ names and other personal information were never be linked to their responses. All identifying information were modified when case studies cited in written reports. Ethical clearance was approved by the respective institutions and a written consent taken from the participants before data collection.
The data was collected during the period from November, 2011 to January, 2012 and from proposal developed to report writing it takes around 6 months.
From the study finding data were presented below
Vast majority of them were married which is almost 87%. The percentages of widow, unmarried were pretty much higher among the rural area’s respondents’ comparing to the urban area. Both areas we found vast majority were Muslim. The second higher religion category was Hindu. According to the occupational category majority of female were housewife and male were service holders. The next occupational category belongs to business. Fewest people from the respondent were retired from their job.
Here
From the qualitative part of study we found that most of the respondents at first couldn’t identify their diabetes status because of their poor knowledge on signs and symptoms of the diseases. Whenever they noticed any symptoms of diabetes they simply ignored it until they developed complications when they go to doctor for
Study variables | Study areas % | ||
---|---|---|---|
Urban (n = 930) | Rural (n = 900) | All (n = 1830) | |
Age | |||
<31 | 2.4 | 4.2 | 6.6 |
32 - 46 | 15.1 | 18.2 | 33.3 |
47 - 61 | 28.8 | 20.4 | 49.2 |
62+ | 6.3 | 4.6 | 10.9 |
School education | |||
No education | 8.9 | 4.3 | 13.2 |
Pre-Primary (I-IV) | 3.2 | 2.3 | 5.5 |
Primary (VI-X) | 15.1 | 17.5 | 32.6 |
Secondary (XI-XII) | 12.9 | 10.1 | 23.0 |
Graduate and Above | 8.5 | 16.6 | 25.1 |
Madrasha education | 0.6 | 0 | 0.6 |
Marital status | |||
Unmarried | 1.1 | 2.8 | 3.9 |
Married | 48.7 | 37.8 | 86.5 |
Widow/witch | 1.9 | 3.5 | 5.4 |
Divorced/Separated | 1.5 | 2.7 | 4.2 |
Religion | |||
Islam | 53.3 | 34.1 | 87.4 |
Hindu | 2.3 | 4.7 | 7.0 |
others | 0 | 5.6 | 5.6 |
Occupation | |||
Sewing | 0.6 | 0.6 | 1.2 |
Labor | 1.8 | 1.2 | 3.0 |
Service holders | 11.9 | 11.3 | 23.2 |
Business | 6.1 | 7.6 | 13.7 |
Teacher | 1.2 | 1.2 | 2.4 |
Retire | 3.0 | 5.0 | 8.0 |
Housewife | 23.9 | 22.9 | 46.8 |
Unemployed | 1.7 | 0 | 1.7 |
Area | Sources of information on diabetes from any physicians | Total | ||
---|---|---|---|---|
Yes | No | Unknown | ||
Urban | 49.2% | 1.6% | 0.0% | 50.8% |
Rural | 48.1% | 0.0% | 1.1% | 49.2% |
Total | 97.3% | 1.6% | 1.1% | 100.0% |
treatment and then they knew about their diabetes.
One patient said that, “At first I simply ignored the physical problem like sweating, excessive urination and others. But when I had some more problems I went to nearest doctor and to tell my symptoms, the doctor suggested for some blood test and then I could know about my diabetes. But I couldn’t belief it at first, ignored to maintain doctor’s advices.”
Even after knowing about their diabetes some respondents didn’t take any treatment. So we analyzed the data according to the following pathways to see the compliances. Here we considered compliances according to patients’ perception of their health outcome and their practices of various treatment methods.
Took Medicine Area | Yes | No | Unknown | Total |
---|---|---|---|---|
Urban (% of Total) | 48.6% | 2.2% | 0% | 51% |
Rural (% of Total) | 44.8% | 3.8% | 0.5% | 49% |
Total | 93.4% | 6.0% | 0 .5% | 100% |
Cases | Urban area % | Rural area % |
---|---|---|
After knowing diabetes took diet regularly | 46.2 | 35.6 |
After knowing diabetes took exercise regularly | 34.4 | 27.8 |
After knowing diabetes took medicine regularly | 74.2 | 85.6 |
After knowing diabetes took initiation to control weight | 7.5 | 16.7 |
After knowing diabetes took insulin | 4.3 | 1.1 |
After knowing diabetes no method taken at all. | 4.3 | 5 |
Qualitative finings revealed that after knowing about diabetes most of the people preferred for physical exercise which cost nothing for them. Then they go for diet, weight control, and medication. For the poor country like Bangladesh to bear medication cost is not affordable to all. So people at first preferred for low cost medication. They also preferred exercise like walking, house-hold works, and physical activities. For medication they preferred for herbal drugs which is less expensive. So consumption of insulin found to be very rare in rural area.
On the other hand around 58% female and 95% male respondents followed more than one method of treatment. The number was high among male in rural than all other category. Mostly they preferred physical exercise like walking, regular diet, intake low fat, ruti (homemade bread) as two main meals, fruits and vegetables etc. Only 19% from total respondents following only single measure to control like either diet or exercise or weight control etc where regular exercise and diet got most priorities.
Treatment | Age | Total | |||
---|---|---|---|---|---|
>31 | 32 - 46 | 47 - 61 | 62+ | ||
yes | 5.46 | 33.88 | 43.72 | 10.38 | 93.44 |
no | 0.55 | 2.19 | 3.28 | 0 | 6.01 |
unknown | 0 | 0 | 0 | 0.55 | 0.55 |
Total | 6.01 | 36.07 | 46.99 | 1.09 | 100 |
Education | |||||||
---|---|---|---|---|---|---|---|
Illiterate | Pre primary | Primary | Secondary | Graduate | Madrasha | ||
Treatment | yes | 10.93 | 5.46 | 28.96 | 22.95 | 24.59 | 0.55 |
no | 1.64 | 0.55 | 2.73 | 0 | 1.09 | 0 | |
unknown | 0.55 | 0 | 0 | 0 | 0 | 0 |
Feel better than previous | Improved disease status | Better living | Can do normal work | No weakness & frequent urination | No Sweating |
---|---|---|---|---|---|
97.4 | 100% | 98.2 | 95% | 100 | 100 |
Changes due to follow following treatment (%) | |||||
Balance diet | Exercise | Weight control | Oral medicine | Insulin | Herbal therapy |
38.25 | 28.96 | 11.46 | 71.04 | 27.32 | 2.19 |
problem. They believe these positive changes occurred because of taking a balanced diet (38.25%) and doing other activities like physical and mental exercise suggested by physician’s (28.96%), regular exercise including yoga and some free hand exercise to weight control (11.46%), intake of oral medication (71.04%), intake of inject able medication (27.32%), intake of some herbal medication like dry seed (black berry), Noyontara flower (China rose), roots (2.19%), etc.
The qualitative finding of the study revealed that some patients who did not take any treatment faced some difficulties for controlling diabetes. Majority mentioned that they mainly faced eye problem. Others mentioned that their blood glucose is not stable and increases and they also noticed accumulation of fluid in the whole body. Though few of them said that they have no problems but they were not fairconfident about their remarks. Other complications respondent perceived on sweating, weakness, obesity, and fluctuation of blood glucose as previous etc.
Type 2 diabetes increases with age and nearly 27% of people in the United States older than 65 years have diabetes [
Management of Type 2 diabetes consists of a combination of diet, exercise, and weight loss, in any achievable combination depending on the patient to control type 2 diabetics. Obesity is very common in type 2 diabetes which contributes mostly for insulin resistance. Patients with poor diabetic control after lifestyle modifications are typically placed on oral hypoglycemics. Some type 2 diabetics eventually fail to respond to these and lead to insulin therapy. By weight reduction and exercise the tissue sensitivity can be improve to allow its proper use by target tissues [
Some studies showed that within three weeks with the rigorous diet and exercise can brought dramatic improvement for diabetics and pre-diabetics patients [
From our study we found that most people with type 2 diabetes mellitus are active, although they are not enought confident about that regular physical activity may prevent or postpone the onset of diabetes and the complications of diabetes. Almost 93% patients preferred exercise (mostly walking) as compliance to controlling diabetics which is incuring no extra cost for them. Other studies also revailed that by achieving and maintaining a healthy weight diabetes can be well controlled and reduces other complications of diabetes [
From this study it was found that weight control method for controlling diabetics was used by 43%, participants which was higher in urban area. According the urban area people were more aware about obesity and its effect and so they were more conscious on weight control in addition to diet and exercise. This finding may point to the strong association of type 2 diabetes with in appropriate compliances in the Bangladeshi population.
The importance of management of type 2 diabetes with pharmacologic and non-pharmacologic therapies varies in cost and risk [
Many physicians appear unwilling or cautious about prescribing exercise to individuals with type 2 diabetes for a variety of reasons; such as excessive body weight or the presence of health-related complications [
Education of patients and compliance with treatment is very important in managing the disease. Improper use of medications and insulin can be very dangerous causing hypo- or hyper-glycemic episodes which also in- fluenced by lack of knowledge about excersise, diet and weight loss [
Barriers found to follow the compliances among the respondents were the financial problem to follow treatment regimen. Culture is often defined as a learned set of values, beliefs, norms, and patterns of behavior. Diabetes is often believed to be caused by eating excess sweets (particularly sugar), brought on by stress and worry, or a form of punishment for immoral behavior. Often patients who do not practice healthy behaviors and don’t care about their health mostly suffered from diabetes. The second set of barriers: those of the health care system include issues of service availability, accessibility, and acceptability. Issues of availability traditionally include service/facility location, the number and type of providers in the facilities, and whether services are known to the disadvantage populations.
Special attention in terms of preventive strategies with abnormal glucose tolerance was needed for the patients, as this state was the most prominent for type 2 diabetes. Exercise, diet and weight loss can provide tremendous benefits to both body and soul at any age. It is therefore important to ensure that it is done properly and safely. Type 2 diabetes usually appears in people over the age of 45, but it is also increasingly becoming more common in children, adolescents and young people. So it is a prime need to build awareness on proper compliances and that should be maintained from the very beginning after accurate diagnosis of diabetes
The authors declare that they have no conflicts of interest.
All authors were equally involved in the conceptualization and design of the study. Umme Salma Mukta (USM) led data collection, analysis and interpretation with substantive inputs from Umme Sayka (US) and Pradip Sen Gupta (PSG). The paper developed with substantive input from US and PSG.
At first our thanks goes to Almighty Allah by whose blessing we are all right to did the job successfully. The authors place gratefulness to the Dean of Arts and Social Sciences Faculty (MPH programme) Prof. MdTazul Islam for his kind support. Then our warm regards goes to all the staff and the local implementing partners of Diabetes Association of Bangladesh (DAB) to arrange the voluntary participation for this study. We also appreciate the assistance provided by AIUB colleague and Office team. The authors heartily appreciate the assistance provided by research assistants for their good work and help me in data collection: Al Mamun, Rahima Akter, Saida Khan, Sayema Akter, Bithi Nandi, Bijoy Shangkar Barua and Sukanto Paul. Our warm thanks go to my colleague of BRAC for their advice, thoughtful suggestions and cooperation. Finally, the authors thank the entire respondent who actively participated in the interviews and expressed their views. Funding was provided by own sources of the Principle Investigator.
Umme Salma Mukta,Umme Sayka,Pradip Sen Gupta, (2015) How Does the Type 2 Diabetes Mellitus Patients’ Compliance to Managing Diabetics in Bangladesh. Open Access Library Journal,02,1-12. doi: 10.4236/oalib.1101176
ACOG: American College of Obstetricians and Gynecologists
ADA: American Diabetes Association
AIUB: American University of Bangladesh
AICR: The American Institute for Cancer Research
ACSM: American College of Sports Medicine
BADAS: Bangladesh Association of Diabetes Society
BMRG: Biomedical Research Group
BIRDEM: Bangladesh Institute of Research and Rehabilitation for Diabetes
CDC: Center for Diseases Control
CDA: Canadian Diabetes Association
DBP: Diastolic Blood Pressure
DALY: Disability Adjustment Life Year
DAB: Diabetes Association of Bangladesh
DM: Diabetes Mellitus
FPG: Fasting Plasma Glucose
FBG: Fasting Blood Glucose
GCT: Glucose Challenge Test
GDM: Gestational Diabetes Mellitus
HTN: Hypertension
MCH: Maternal and Child Health
MPH: Masters of Public Health
NPV: Negative Predictive Value
NHANES: National Health and Nutrition Examination Survey
NZGG: New Zealand Guidelines Group
OGTT: Oral Glucose Tolerance Test
PCAs: Priority Change Areas
PI: Principle investigator
ROC Curve: Receiver Operator Characteristics Curve
SBP: Systolic Blood Pressure
SPSS: Statistical Packages for Social Science
TG: Triglycerides
WHO: World Health Organization
US: United States