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| ORIGINAL ARTICLES |
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| Year : 2021 | Volume
: 12
| Issue : 2 | Page : 186-190 |
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Diabetes Educational intervention in Society to Improve (DESI) quality of life
Rishi Shukla1, Deepak Yagnik2, Neha Agarwal3, Manisha Gupta4, Bhasker Ganguli5, Sangeeta Shukla5, Anurag Bajpai6
1 Department of Endocrinology, Regency Health Care, Kanpur, India; Centre for Diabetes and Endocrine Disease, Kanpur, India; Society for Prevention and Awareness of Diabetes (SPAD), Delhi, India
2 Society for Prevention and Awareness of Diabetes (SPAD), Delhi, India; Yagnik’s Diabetes Center, Kanpur, India
3 Growth and Obesity Workforce, Kanpur, India; Department of Pediatrics, Himalayan Institute of Medical Sciences, Swami Rama Himalayan University, Dehradun, India
4 Society for Prevention and Awareness of Diabetes (SPAD), Delhi, India; Centre for Diabetes and Endocrine Disease, Kanpur, India
5 Society for Prevention and Awareness of Diabetes (SPAD), Delhi, India
6 Department of Endocrinology, Regency Health Care, Kanpur, India
| Date of Submission | 15-Aug-2020 |
| Date of Decision | 18-Oct-2020 |
| Date of Acceptance | 23-Oct-2020 |
| Date of Web Publication | 31-Mar-2021 |
Correspondence Address:
Dr. Neha Agarwal
Department of Pediatrics, Himalayan Institute of Medical Sciences, Swami Rama Himalayan University, Dehradun, Uttarakhand.
India
 Source of Support: None, Conflict of Interest: None
DOI: 10.4103/jod.jod_78_20
Background: Diabetes self-management education (DSME) is globally recognized as an integral part of diabetes management and in majority of the developed countries, it is delivered by trained diabetes educators. Unfortunately, in India, it is still not considered an essential part of diabetes management. Materials and Methods: A self-structured diabetes education program, of a 75-min duration, was developed over a period of six months. To assess the knowledge, before and after the implementation of the education program, a validated questionnaire, Diabetes Knowledge Questionnaire 24 (DKQ24) was used. Results: A total of 50 patients (34 males; 74%) were recruited in the study. The mean age of the study participants was 54.98 ± 12.02years, with a mean duration of diabetes 12.34 ± 8.76years and mean HbA1c 8.1 ± 1.49%. A statistically significant (P < 0.05) improvement in the proportion of correct responses (14 out of 24 questions; 58.3%) was seen after the implementation of the DSME program. Conclusion: There is limited research available in India on DSME. To meet the need of a structured diabetes education program in India, we have evolved one such program (duration of 75 min) within a period of six months. We anticipate this program to have enough potential in developing countries in the long run. Keywords: Diabetes education, India, structured
How to cite this article:
Shukla R, Yagnik D, Agarwal N, Gupta M, Ganguli B, Shukla S, Bajpai A. Diabetes Educational intervention in Society to Improve (DESI) quality of life. J Diabetol 2021;12:186-90 |
| Introduction | |  |
India is considered as the “Diabetes Capital” of the world, with a national prevalence of diabetes of more than 66 million in 2014.[1] The reported number of patients with diabetes is expected to reach 70 million by the year 2025.[1] Despite the high prevalence of type 2 diabetes, nearly half of the patients remain undetected, leading to complications at the time of diagnosis.[2] Diabetes and its related complications impose a huge economic threat, especially to the weaker sections of the society.[3] An effective diabetes management demands a continuum of care in terms of adherence to medications, lifestyle modifications, self-monitoring of blood glucose, balanced nutrition, regular physical activity, and foot care.[4] To attain optimal health outcomes, people with diabetes themselves need to become caregivers. Empowerment of the patients towards self-care is a key element in the overall management of diabetes.
DSME is globally recognized as an integral part of the diabetes management and in majority of the developed countries, it is delivered by trained diabetes educators. The relationship between glycemic control and self-care has been documented extensively in the past.[5],[6] In the year 2012, Khunti et al. reported a program on Diabetes Education and Self-Management for Ongoing and Newly Diagnosed (DESMOND) patients.[7] This program involved 13 primary care centers in the United Kingdom and imparted diabetes education within 12 weeks of the diagnosis. In this study, a dramatic improvement in diabetes self-care was reported. Further, a meta-analysis of 31 studies showed that DSME enabled a reduction in HbA1c by 0.76%, at immediate follow-up.[8] Also, interventions delivered face to face have been shown to be more effective as compared with telecommunication in delivering diabetes self-management education (DSME) programs.[9]
In India, lack of diabetes-related knowledge and poor attitude toward the disease is responsible for medication noncompliance and limited self-care activities.[10],[11] Limited diabetes education programs have been conducted across the nation to overcome this drawback.[12] However, studies examining the impact of these interventions are lacking. Poor self-care practices among the Indian patients with type 2 diabetes highlight the need of a tailored and culturally acceptable diabetes education program in the country.
Unfortunately, there is a dearth of a structured diabetes education program in India that is easily accessible and simple to deliver. In this study, we analyzed the impact of a self-designed, structured diabetes education program on diabetes knowledge among the patients living with type 2 diabetes mellitus (T2DM), using a validated questionnaire (DKQ24).
| Materials and Methods | | |
A self-structured diabetes education program was developed over a period of six months. During this period, education leaflets were prepared and translated into Hindi. The total duration of the program was 75 min, which can easily be delivered in a single session. The key areas covered were: introduction to diabetes, diet and exercise, acute complications, chronic complications, screening investigations, self-monitoring of blood glucose, insulin delivery, and sick day rules, Appendix 1. After this, a qualified dietician, a trained insulin pump educator, a physiotherapist, two adults living with type 1 diabetes, and two representatives from a nongovernment organization were selected for logistic support. They were trained to implement this program, over a period of two months. This program has been running successfully for the past three months.
Data of patients pertaining to demographic details such as age, gender, duration of diabetes, education, socioeconomic status, medications, and presence of any comorbidities and complications were recorded. To assess the impact of DSME on their knowledge, a validated questionnaire (DKQ24) was used.[13] The questionnaire was first translated into the local vernacular language, internally validated, and linguistically adapted. This encompassed 24 basic questions to measure general diabetes knowledge. All answers were obtained in yes or no format. The total number of correct and incorrect scores were calculated, providing a total percentage score.
The study was approved by the Institute ethical committee, and informed consent was obtained from each participant.
Statistical analysis
The data was compiled by using Microsoft Excel, and statistical analysis was performed by using IBM Statistical Package for Social Sciences (SPSS version 25.0, SPSS, Inc., Chicago, IL, USA). Continuous variables were expressed as mean (SD); categorical variables were expressed as frequencies (percentages). Paired sample T-test was used to compare the proportion of correct responses for each DKQ24 question, before and after the implementation of DSME. A p-value of 0.05 was considered significant.
| Results | | |
A total of fifty patients (34 males; 74% and 16 females; 26%) were recruited in the study. The mean age of study participants was 54.9 ± 12.0years, with mean duration of diabetes 12.3 ± 8.8years and mean HbA1c 8.1 ± 1.5%. Nearly half of them had a postgraduate level of education [Figure 1].
Majority of the study participants (n = 31; 62%) were on various oral antidiabetic drugs. The remaining 19 patients were on insulin treatment (long-acting, short-acting, or mixed), with a mean daily insulin dose of 36.6 ± 15.0units. Almost half of the study participants (n = 29; 58%) were on antihypertensive treatment. Prevalence of the various micro- and macro-vascular complications is depicted in [Figure 2]. Nearly two-thirds of them (n = 33; 66%) were physically active, whereas 34% had a sedentary lifestyle. | Figure 2: Prevalence of microvascular and macrovascular complications among the study participants. PVD = peripheral vascular disease; CVD = cardiovascular disease
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A statistically significant (P < 0.05) improvement in the proportion of correct responses (14 out of 24 questions; 58.3%) was seen after the implementation of the DSME program [Table 1]. | Table 1: Diabetic questionnaire (DKQ24) responses before and after the implementation of DESI
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| Discussion | | |
The treatment of diabetes per se is not expensive (if done with basic medicines); however, treating complications is beyond the pockets for many Indians. We should, therefore, place more emphasis on diabetes self-care and make patients aware of its complications.[14]
In our study, we found that prevalence of diabetic retinopathy is 6% and that of nephropathy is 4%. This is much lower than the previously reported prevalence of diabetic retinopathy (17.6%) and nephropathy (26.9%).[15],[16] The difference could be attributed to the smaller sample size in our study. In a study by Mohan et al., coronary artery disease (CAD) was seen in 21.9% patients with diabetes.[17] The real problem with diabetes is that it is an asymptomatic disease, not only in the beginning, but a fair amount of microvascular complications are also asymptomatic. Lack of knowledge about the adverse outcomes of the uncontrolled diabetes is an important cause of the poor care of the disease.
In India, given the physician-to-patient ratio of 1:1800, expecting the caregiver to be the sole provider of diabetes education would be unrealistic.[18] The evidence has consistently proved that the people with T2DM with more knowledge and motivated self-care achieve better glycemic control.[19],[20],[21],[22] Self-care in diabetes is a key element in the overall management of diabetes.[23] An organized diabetes education program plays a central role in this context.[24] Lack of general awareness about diabetes is a huge challenge in India.[25] India is a growing economy with lots of diversity. We have rich people for whom world-class health facilities are available, and unaffordable people with T2DM where minimum is also a challenge. DSME is one thing that is required by everyone and it becomes more important for the lower socioeconomic group. To our understanding, this program (DESI study) is not only the need of patients with diabetes, but other family members also need to be involved.
While this article is being written, the whole of India is locked down due to COVID-19 infection, where the need of DSME is tremendously essential as people with diabetes take longer time to recover and susceptibility is also more.[26] DSME plays a vital role in the management of both T1DM[27],[28] or T2DM. It becomes even more important, as we have limited resources in India. India needs a structured program for diabetes education to cater to the needs of the country.[12]
We found a significant improvement in the various DKQ24 questions. Similar to the findings reported by Chawla et al., we too found improvement in diabetes knowledge, particularly with regards to lifestyle modifications and dietary management.[29] Group sessions have shown a better role in improving lifestyle, psychological outcomes, better HbA1c, fasting blood glucose, diabetes knowledge, empowerment, self-management, and self-efficacy.[9] Group education can be cost-effective; a person-centric approach and provision of interactive learning will enhance quality of life.
Small sample size and unavailability of data pertaining to glycemic control (HbA1c) is the limitation of our study. Given the state of lockdown imposed due to COVID-19 crisis, the study could be conducted over a short period of 45 days and therefore, repeat HbA1c was not done. Also, the main purpose of the current study was to look at the impact of the education program on the knowledge level and hence, details regarding glycemic control were not recorded. Long-term studies, with increased sample size looking into the metabolic control, could help enhance our understanding regarding the effectiveness of the educational intervention programs.
| Conclusion | | |
To our understanding, this is the first organized Diabetes Education program (DESI study) in the country. We tried to cover all the relevant and useful aspects to deal with diabetes. It was, in fact, very challenging to prepare a comprehensive structured education program that can be delivered in a single session. We anticipate to spread this module across nations, and to empower diabetic educators, allied health-care workers, and diabetic volunteers to educate patients with diabetes. The program could be conducted either on an individual level or in groups. The module prepared and used in the DESI study is cost-effective and would be readily available in the form of a weblink and a portable document file.
Acknowledgment
The authors are thankful to Mr. Praveen Sachdeva, Mrs. Meena Srivastava, Mr. Manish Kumar, Mrs. Ranjana Saxena, Mrs. Sudha Srivastava, Miss Garima Sahney, and Mr. Sumit Gupta for their contributions as the educators to run the program. They are also thankful to a nongovernment organization, Society for Prevention and Awareness of Diabetes (SPAD) for unrestricted support to run the program. They offer special thanks to Dr. Arvind Gupta MD, FRCP, FACE, director and consultant, Jaipur Diabetes and Research Centre, Jaipur for his valuable guidance.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
Consent
Informed consent was obtained from the participants.
Availability of data and material
Yes.
Author contribution
RS and DY conceptualized and planned the study. MG and NA were involved in data collection. RS and NA conducted the literature review, did the statistical analysis, and drafted the initial manuscript. RS and DY critically reviewed the manuscript and would act as guarantors of the article.
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[Figure 1], [Figure 2]
[Table 1]
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