Keywords
Diabetes mellitus - hypoglycemia - knowledge - primary care
Introduction
Diabetes mellitus is one of the most common noncommunicable chronic diseases and is a major public health problem worldwide.[[1]] Based on the recent statistics by the International Diabetes Federation, the estimated number of people with diabetes worldwide in 2015 was 415 million adults aged 20–79 years old, and by 2040, this will reach 642 million.[[2]] The number of adults who died from diabetes were 5 million in 2015.[[2]] In Saudi Arabia which is among the top 10 countries of the world with the highest prevalence of diabetes, the estimated number of patients with diabetes in 2015 was 3.4 million, with an associated mortality of 23,420 among adults aged 20 years old or older.[[2]]
One of the true medical emergencies associated with Type 1 diabetes (T1D) and Type 2 diabetes (T2D) is hypoglycemia. According to the American Diabetes Association, hypoglycemia is defined as blood glucose level fall below 3.9 mmol/L (70 mg/dL) and classified into symptomatic and asymptomatic hypoglycemia.[[3]] Hypoglycemia occurs about two to three times more frequently in T1D than in T2D. However, because T2D is more prevalent than T1D, most episodes of hypoglycemia, including severe hypoglycemia, occur in people with T2D.[[4]]
According to a systemic review that was published in 2015, episodes of hypoglycemia often occur because of patient inability to recognize symptoms of hypoglycemia and poor knowledge about how to respond appropriately.[[5]] Hypoglycemia has a significant impact on an individual's quality of life and has many risks, including taking place in dangerous situations such as driving or operating machinery in work.[[6]]
Hypoglycemia can also lead to major complications in the vital organs such as brain and kidneys which can lead to permanent neurological and renal damage.[[7]] Some principles of prevention of hypoglycemia had been published. These principles include education about diabetes self-management, self-monitoring of blood glucose levels, flexible and proper insulin and/or other drug regimens, personalized glycemic goals, and consideration of known risk factors of hypoglycemia.[[8]],[[9]]
Recognition of factors associated with the knowledge of hypoglycemic self-management and selection of appropriate educational programs for health-care professionals and patients with diabetes are the major issues to improve hypoglycemic attacks self-management and to minimize the long-term complications.[[10]],[[11]]
Data on knowledge of hypoglycemia and its management among Saudi patients attending diabetes clinics is limited. This study aimed to assess knowledge of hypoglycemia and its management and to determine the associated factors among adult patients with diabetes at the primary health-care centers of the National Guard Health Affairs, Jeddah, Saudi Arabia.Methods
This cross-sectional study was conducted from April to May 2017 among adult patients with DM attending chronic disease clinics at the primary health-care centers of the National Guard Health Affairs in Jeddah, Saudi Arabia. Patients included were adult aged 18 years or older with either T1D or T2D and on oral antihyperglycemic agents or insulin treatment.
Assuming knowledge prevalence of 50%, with margin of error as (5%), and confidence level of (95%), the required sample size was 385. Study participants were selected from the three primary health-care centers using stratified random sampling technique with equal allocation, 130 participants from each center.
A questionnaire was developed specifically for the purpose of this study. The questionnaire was self-administered with assistance provided to those with low educational level. The questionnaire included demographic information, duration of diabetes, current medication, self-monitoring practices, knowledge of the symptoms, and patients' responses to hypoglycemic symptoms, treatment, prevention, and complications in addition to the source of information (e.g., media, newspaper, mobile, friend, spouse, parents, school, or teacher).
The questionnaire was reviewed for face and content validity by three experts in the field of family and community medicine. The reliability of the questionnaire was assessed using the Cronbach's alpha coefficient which was 0.802, indicating high reliability.
Data were analyzed using Statistical Package for the Social Sciences software version 21 (IBM SPSS Statistics, Armonk, New York, 10504-1722 United States, USA). Descriptive statistics (proportion and frequency for categorical variables, mean and standard deviation for numeric variables) was used. Inferential statistics was performed in the form of Student's t-test and one-way ANOVA. Statistical significance was considered at P < 0.05 and confidence interval of (95%).
Regarding knowledge questions, a score of (1) was given to the right answer. The summation of scores was computed (the total score was 42). Knowledge scores were categorized into good (score above 31.5, the mean knowledge score), moderate (score from 21 to 31.5), and poor (score below 21).
Results
Of the 361 participants, 208 (57.6%) were women, and 153 (42.4%) were men, with the mean age of 56.8 ± 12.2. Majority (123; 34.1%) did not have formal education. A total of 117 (32.4%) were housewives, 105 (29.2%) were retired, and 55 (15.2%) were current employees. Also, 141 (39.1%) had monthly income 5000–10,000 Saudi Arabian riyal (SAR) followed by 127 (35.2%) had monthly income <5000 SAR. In addition, 15% of the sample were ever-smokers. Approximately 151 (41.8%) participants had other chronic illnesses where hypertension 113 (74.8%) was the most common. Regular exercise was reported by 52.3% of the patients, where 76.7% of them perform 150 min or less [[Table 1]].The results revealed that the mean knowledge score percentage was 32.0 (8.2). Majority of the participants had low knowledge scores (92.2%) [[Figure 1]].
Figure 1: Knowledge score classifications of participants
Table 1: Demographic data of the studied population
As shown in [[Table 2]], most patients (341; 94.5%) suffered from T2D. In terms of their current management, around 141 (39.1%) participants received insulin, while 312 (86.4%) received oral medications. Only 39 (10.8%) of the patients stated having DM complications, with vision-related problems being the most common (59%). More than third of the patients reported self-monitoring of blood glucose on daily basis (35.2%). Family history of diabetes was identified by 67.1% of the patients. Most of the information on diabetes were delivered by physicians (68.1%), followed by family members (33.5%) then internet websites (22.2%).
Table 2: Diabetes mellitus-related data among the studied participants
A total of 111 (30.8%) participants had previous experience with hypoglycemic attacks, where the main symptoms they experienced were dizziness (36%), fatigue (36%), sweating (27%), and shakiness (27%). Almost 50% had experience of hypoglycemia within the last month preceding the survey. Among the 111 hypoglycemia cases, only 9 (8.2%) needed hospital admission [[Table 3]].
Table 3: Hypoglycemia experience among the participants
Regarding the knowledge of hypoglycemia management, the majority (66.8%) chose “eating 15 g of fast-acting carbohydrate” as their preferred management option, while 26.3% reported lack of knowledge. In addition, 183 (50.7%) identified correctly the definition of hypoglycemia “plasma glucose concentration falling below 70 mg/dl.” The main symptoms of hypoglycemia as identified by the patients were fatigue 251 (69.5%), followed by shakiness 170 (47.1%), then sweating 160 (44.3%), heart palpitations 149 (41.3%), blurred vision 142 (39.3%), and lastly was nervousness 51 (14.1%) [[Table 4]].
Table 4: Knowledge on treatment, diagnosis, and symptoms of hypoglycemia
The main reasons for hypoglycemia reported by the participants were skipping meals (216; 59.8%), followed by overdose medications (135; 37.4%). Almost two-thirds 229 (63.4%) reported lack of knowledge on how to prevent hypoglycemic attacks, whereas 111 (30.7%) believed that eating balance meals is an optimal strategy [[Table 5]]. The most common complications regarding hypoglycemia identified by almost half of the participants were coma 171 (47.4%), followed by Glaucoma 156 (43.2%).
Table 5: Knowledge on reasons, prevention, and complications of hypoglycemia
Two thirds 266 (73.6%) answered hemoglobin A1c on the question “How doctor know if the sugar is control?” Regarding the best diet, 208 (57.7%) reported “low fat, high fiber, and low added sugar,” and 75 (21.1%) reported “Sugar-free diet.” More than half 208 (57.7%) reported consuming slow carbohydrates to keep blood sugar balance. Two-third said that they were aware of hypoglycemia [[Table 6]].
Table 6: Information of the studied participants on identification of hypoglycemia by physicians, diet, balance, and perception of awareness
[[Table 7]] shows a significant difference in knowledge level regarding demographic data, where male, younger patients, those with university degree, being single, being student, those with high monthly income, T1D patients and having previous hypoglycemia experience had a higher level of knowledge than others.
Table 7: Comparing level of knowledge according to demographic data
Discussion
In the last decades, diabetes has become one of the major public health problems due to its growing prevalence. Hypoglycemia is one of the main complications of diabetes management. The tendency among clinicians to keep blood sugar under control to decrease the long-term complications of diabetes may play an important role in the increasing frequency of hypoglycemia.[[12]]
The current study aimed to assess the knowledge of adult patients with diabetes regarding hypoglycemic self-management and the factors associated with their level of knowledge. Around 92% of the participants showed poor knowledge of hypoglycemia. Similar result was reported in another study in Saudi Arabia where 93.9% of the participants had poor knowledge.[[13]] In comparison, another study that was conducted in Najran City showed that around 56% have adequate knowledge on hypoglycemia.[[14]] The difference might be attributed to the methodological differences as the latter study considered the adequacy of knowledge if the patient identified correctly three symptoms associated with hypoglycemia, in comparison to our comprehensive assessment. Another possible explanation of the poor level of knowledge of hypoglycemia among our participants is that most of our sample did not complete the formal education which has been suggested as a barrier to effective physician-patient communication, and hence, education about the disease management and complications.[[15]],[[16]]
In the current study, (68.1%) reported that physicians were the main source of information, which is consistent with another study in India Tamil Nadu, India, who identified that (53.3%) of the patients reported doctors as the source of information.[[17]] This fact might be utilized to design special educational classes regarding hypoglycemia to patients with diabetes which was proven successful in previous studies.[[12]] Furthermore, these classes may pay special attention to social background, as unemployed patients achieved lower knowledge scores, and to the areas of weaknesses like the proper diet where only 21.1% out of the respondents identified that correctly.
We found also that participants' knowledge scores regarding hypoglycemia were significantly among participants who had experienced hypoglycemic attacks before. In addition, knowledge scores were higher among participants with younger age. This is consistent with other studies where knowledge of hypoglycemia was shown to decrease as age increased, which sheds the light on the importance of periodic education about hypoglycemia for the elderly patients.[[17]],[[18]],[[19]]
In contrast to Elzubier's study which was carried out on Saudi patients, male patients were more aware of hypoglycemia.[[13]] A possible explanation is the prevalence of male participants among their sample (67%) compared to ours (42.4%). Other studies found no link between sex and knowledge level of hypoglycemia.[[18]]
This study has some limitations. First, we followed the cross-sectional design. Second, we surveyed only patients in one city, and thus the results cannot be generalized to the whole population of Saudi Arabia.
Conclusion
The majority of participants showed poor knowledge regarding hypoglycemia, while less than one-tenth of them had moderate or good knowledge. Health-care providers in contact with patients with diabetes are demanded to provide the necessary health education about hypoglycemia signs for all diabetic patients during their regular visits. Educational classes regarding hypoglycemia might be tailored to enhance the awareness about hypoglycemic attacks to patients with DM and their caregivers.
Authors' contributions
All authors contributed adequately to the conception and conduct of the study and to drafting and revision of the manuscript. They all reviewed and approved the final version of the article.
Compliance with ethical principles
Institutional Review Board approval was obtained from King Abdullah International Medical Research Center. Informed consent from all participants was also obtained with strict maintenance of confidentiality of participants' dentities.
