INFLUENCE OF SOCIAL SUPPORT ON GLYCAEMIC CONTROL IN DIABETES MELLITUS PATIENTS ATTENDING THE OUTPATIENT CLINIC OF ECWA EVANGEL HOSPITAL , (NOW, BINGHAM UNIVERSITY TEACHING HOSPITAL), JOS.

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INFLUENCE OF SOCIAL SUPPORT ON  GLYCAEMIC CONTROL IN DIABETES  MELLITUS PATIENTS ATTENDING THE OUTPATIENT CLINIC OF ECWA EVANGEL HOSPITAL , (NOW, BINGHAM UNIVERSITY TEACHING HOSPITAL), JOS.

SUMMARY

Objectives: The main objective of this study was to determine the influence of social support on glycemic control in patients with diabetes mellitus (DM), attending the outpatient clinic of Bingham University Teaching Hospital (BhUTH), Jos; with a view to making recommendations to improve these support systems and thus promote adherence and ultimately, improve glycaemic control. The research determined the level of glycaemic control, social support and adherence, as well as factors affecting adherence in patients with DM. The study also determined the correlation between social support and adherence, between adherence and glycaemic control and between social support and glycaemic control in patients with DM. 

 

Methods:This was a Hospital based Cross Sectional study. Patients who met the inclusion criteria were selected using systematic random sampling technique. A physical examination was done to determine their BP, weight, height, and peripheral neuropathy. Visual acuity and fundoscopy were  also done to check the state of their eyes.  Questionnaires were then admistered to elicit their sociodemographic characteristics, Social support and adherence. Urinalysis, glycosylated  haemoglobin  and  full blood count  were carried out for these patients. The Data collected were then analysed with SPSS-15.0 version.  

Results: A total of 70 participants, made up of 29 males (41.4%) and 41 females (58.6%) were studied. The mean age of the patients was 53,61years ±12.57 with literacy rate of 64.3%.  74.8% of them were married and 58.6% of the patients were employed. However, 54.3% had a monthly earning of Twenty thousand naira and below as a household income with only 10% having a monthly household income of one hundred thousand naira and above.

The mean body mass index (BMI) was 27.33Kg/M2 and 55.7% of the participants were overweight, while 18.6% were obese. Majority (62.9%) of the participants had disease duration of 0-5years and 41.4% had positive family history of DM.

 

Only 32.9 of the participants had good glycaemic control (HbA 1C of 7.0% or less).  The adherence to DM management in this study was set at 80% of adherence scores and only 35.7% of the participants were adherent. Lack of finance (30.0%) was the commonest reason for poor or non adherence. This was followed by lack of symptoms (23.33%), feeling of having been cured

(16.67%), side effects of drugs (13.33%), perceived drug inefficacy (10.0 %) and forgetfulness

(6.67%). Furthermore majority (67.2%) of the patients had social support score of 51% and above. This study found functional and structural (practical or tangible) social support as the main forms of social support received by the study participants.   

 

There was a significant positive correlation between social support and adherence, between adherence and glycaemic control and between social support and glycaemic control in patients with DM.There was also a significant negative relationship between BMI and glycaemic control and between disease duration and glycaemic control.

 

Conclusion:  In spite of the limitations of the study, the results provide solid quantitative evidence that social support has significant influence on glycaemic control in patients with DM. It does not however prove a causal relationship nor does it try to show the link between the variables.

These are subjects for further studies.

TABLE OF CONTENTS

      Page

Title Page…………………………………………………………………….……..i

Declaration…………………………………………………………………………ii

Dedication………………………………………………………………………….iii

Acknowledgement………………………………………………………………..iv

Certification…………………………………………………………………….….v

Table of contents…………………………………………………………………vi

List of Tables………………………………………………………………………X

List of figures……………………………………………………………………..xi

List of Abbreviations………………………………………………………….…xii

Summary                                                                                                      1

 

CHAPTER ONE

INTRODUCTION

1.1       Background…………………………………………...................3

1.2       Statement of Problem and Problem analysis..........................5

1.3      General Objective................................................................... 7

1.4      Specific Objectives ……………………................................... 7

1.5       Justification for the study.............………………………………8

1.6    Hypothesis…………………………………………………..........9 CHAPTER TWO

LITERATURE REVIEW

2.1       Overview of Diabetes Mellitus………………........…………......10

2.2       Definition and classification of Diabetes Mellitusl....................12

2.3   Epidemiology of Diabetes Mellitus.............................................17

2.4       Pathophysiology of Diabetes Mellitus.........................................19

2.5       Management of Diabetes Mellitus...............................................21

2.6       Complications of Diabetes Mellitus.............................................29

2.7       Issues with Adherence to the Management of DM......................32

2.8       Role of Social Support in the Management of DM .....................36

 

CHAPTER THREE

MATERIALS AND METHOD

3.1       Study Design ………………………………………………...........46

3.2       Study Area ……………………………………………...................46

3.3       Study Population .......................................................................46

3.4      Sample Size………………………………………………………...47

3.5       Sampling Method......................................................................47

3.6       Inclusion Criteria........................................................................48

3.7       Exclusion Criteria……………………………………………........48

3.8       Method and Instrument of Data Collection...............................48

3.9       Method of Data Analysis............................................................51

3.10 Ethical Consideration ………………….............……………......51

3.11 Funding  ...................................................................................51  CHAPTER FOUR 

RESULTS

4.1      Characteristics of study participants at enrolment……………………..53

4.2      Level of glycaemic control ………………………………………………..55

4.3       Level of adherence …………………………………...............................59

4.4       Level of social support .........................................................................62

4.5       Correlation between social support and adherence............................64

4.6       Correlation between adherence and glycaemic control......................64

4.7       Correlation between social support and glycaemic control ................64

 

CHAPTER FIVE

DISCUSSION 

5.1       Level of glycaemic control........................................................................66

5.2       Factors affecting glycaemic control ........................................................67

5.3       Level of adherence..................................................................................69

5.4       Level of social support ............................................................................70

5.5       Correlation between social support and adherence...............................71

5.6    Correlation between adherence and glycaemic control ........................72 5.7           Correlation between social support and glycaemic control  .................72

58     Demographic characteristics of the study participants……………........73 CHAPTER SIX

CONCLUSION AND RECOMMENDATIONS

6.1      Conclusion………………………………………………………………......78

6.2       Relevance to Family Medicine................................................................78

6.3   Recommendations………………………………………………………     .79

6.4      Limitations and constraints…………………………………………….      .81

6.7      Further research needs …………………………………………………     82

 

REFERENCES.........................................................................................................  ..83

APPENDICES

 

CHAPTER ONE

 

INTRODUCTION

 

1.1         BACK GROUND

The increasing trend of Diabetes Mellitus (DM) has become a problem of great magnitude

and a major public health concern worldwide.1-6    It is one of the most common endocrine diseases affecting people of all age groups. The world wide prevalence of DM is about 2% .7The incidence of DM is on the increase, with an annual incidence of 6% in the United States of America and more than that in the developing countries.8 The international Diabetic Federation (IDF) estimated that currently, more than 246 million people have diabetes worldwide. 9   This figure is estimated to reach 380 million people by 2030 and in 2005 an estimated 1.1 million people died from diabetes and almost 80% of diabetic deaths occurred in low and middle income countries.9 Diabetes mellitus

causes considerable human sufferings and enormous socio-economic costs.1-10

The prevalence of DM varies from country to country and even within the same country

from rural to urban centres. The prevalence rate in African countries ranges from 1-13% and type 2 diabetes accounts for 70-90% of cases.11-12   The Nigerian standardized national prevalence rate reported in 1997 by an expert committee set up by the Federal Ministry of Health (FMOH) was 2.2%.13,14  The prevalence rate of DM in Jos, Ife, Port Harcourt and Zaria were 3.3%, 4.76%, 6.8% and 2% respectively15-17 The IDF predicted an average prevalence rate of 3.2% and 3.9% for Africa and Nigeria respectively in 2010.18 Therefore, DM patients constitute a large percentage of patients attended to by Family Physicians in most of our hospitals on daily basis.

Diabetes Mellitus is defined by the World Health Organization (WHO) as a metabolic disorder of multiple aetiology characterized by chronic hyperglycaemia with disturbances of carbohydrate, fat and protein metabolism resulting from defects in insulin secretion, insulin action or both.19   WHO classified diabetes mellitus on the basis of aetiology and clinical presentation of the disorder into 4 major groups; type 1, type 2, other specific types of DM and gestational diabetes. The classification is very important for management purposes. The most common types of DM seen in sub-Saharan Africa are type 2 and type 1 diabetes mellitus.20 This study therefore, focused only on patients with type 1 and type 2 diabetes mellitus.   

Adherence is defined by WHO as the active, voluntary and collaborative involvement of the patient in a mutually acceptable course of behaviour in taking medications, following diet and for executing lifecycle changes which corresponds with the agreed recommendations from a health care provider. 21,22   While, compliance is the act of yielding, conforming or acquiescing to the instructions of a health care provider, depicting a lack of sharing in the decision made between provider and client. 22    Poor or non adherence to treatment is observed in all situations where self

administration of treatment is required, regardless of the type of disease.21

Social support in general, is broadly defined as assistance, encouragement and

interactions provided by family, friends and/or institutions to individuals with medical problems to help them cope better with the conditions. 23,24   Structural social support is quantification of the number of supportive relationships an individual has.23   Functional social support measures social support in terms of the functions it provides, including emotional and material support.23      Social support involves financial support ( payment for food, drugs, transport to hospital, etc); provision and or preparation of the right meals; reminders/encouragement to adhere to prescribed treatment and lifestyle modifications. It is positively associated with regimen adherence, better long-term management, health outcomes and glucose control in diabetes mellitus.24 It also serves to buffer stress on diabetes management. Lack of social support is considered a barrier to adherence

and self care in diabetes.24

Glycaemic control                The goal of contemporary diabetes treatment is to keep blood

glucose level as close to normal as possible through the use of medications, Insulin therapy, blood glucose monitoring, diet and or exercise.12,18,24   Considerable research (Diabetic Complication and Control Trial, (DCCT,1993) and United Kingdom Prospective Diabetes Study, (UKPDS, 1997)  demonstrated beyond doubt, that chronic hyperglycaemia is the single most important factor which

gives rise to the various complications of diabetes mellitus which patients usually die of. 1,12,18,19,24 

To prevent and minimize these complications, WHO, American Diabetes Association (2006), American College of Physician, Canadian Diabetic Association (2003) and other professional associations  recommend a haemoglobin (HbA1c) goal for patients in general of 7% or less, and maintaining blood glucose levels as close to normal as possible (4.5 – 6.7 mmol/l{80 – 120 mg/dl}) without causing hypoglycaemia.25,26   They also recommended HbA1c  value of7.0% or less, in patients who can achieve them without adverse effects such as hypoglycaemia and less stringent goals in those with limited life expectancies, co-morbid conditions and extremes of life.25,26 Based on above recommendations, this study  regarded HbA1c level of 7% or less as evidence of good glycaemic control, while, values above 7.0%  was  regarded as evidence of poor control.

 

1.2         STATEMENT OF PROBLEM AND PROBLEM ANALYSIS

Many countries in the Sub- Saharan Africa are plagued by political instability, internal factional hostilities, civil unrest, virtually no functional public infrastructure, agricultural production is severely inhibited by persistent drought and all experience economic problems.12 This is exacerbated by a massive burden of infectious diseases notably HIV/AIDS that alone has the potential to threaten the economic viability of the region.12   Sadly, HIV/AIDS is not the only health threat facing Africa, and many people who survive HIV/AIDS may die of diabetes and other

chronic diseases.12  

  Many countries in the Sub-Saharan Africa such as Nigeria have unacceptably high mortality rates and the consequences of poorly managed diabetes, such as kidney failure, coronary heart disease, blindness, diabetic foot problems, limb amputations and coma are also high.12   Directly or indirectly, everyone is affected by DM; that is , individuals, families communities, schools, churches, mosques, health professionals, politicians, all sectors of government, non - governmental organisations, business and industry.12 

Management of Diabetes Mellitus in sub-Saharan Africa faces a number of problems such as late presentations and diagnosis, poor understanding of the extent of the problem, lack of access to essential medications and services, early age of onset of the disease, low literacy level,  poverty, competing costs of education, housing,  infectious diseases such as HIV/AIDS, socio-economic setting that is poorly suited to maintaining a proper diabetic diet, limitations in infrastructure and personnel; cultural beliefs and patronage of traditional and faith healers.12,18,19   To worsen matters, patient adherence to treatment regimens in sub- Saharan Africa is very poor and for those living in abject poverty and facing hunger, social and educational  disadvantage, the management of DM

may be of low priority.3,7,27,28,29,30

The author observed in his training centre that 6 out of 10 patients with diabetes mellitus had poor social support and poor glycaemic control resulting in serious microvascular and macrovascular complications which lead to high cost burden, morbidity and mortality among these patients: despite the fact that in Nigeria the family structure is closely knit and the extended family system relatively strong. Several studies on prevalence of diabetes mellitus and factors affecting glycaemic control have been carried out in Nigeria. However, few studies have been carried out locally on the influence of social support on glycaemic control in patients with DM.

 

1.3                                             GENERAL OBJECTIVE

To determine the influence of social support on glycemic control in patients with DM, attending the outpatient clinic of Bingham University Teaching Hospital (BhUTH), Jos; with a view to making recommendations to improve these support systems and thus promote adherence and ultimately, improve glycaemic control.

 

1.4          SPECIFIC OBJECTIVES

  1. To determine the level of glycaemic control over a three month period in patients with

DM, attending the outpatient clinic of Bingham University Teaching Hospital Jos. ii. To determine the level of adherence and factors that influence adherence to agreed management guidelines in patients with DM, attending the outpatient clinic of Bingham University Teaching Hospital( BhUTH), Jos in three months period.

  • To determine the level of social support in patients with DM, attending the outpatient clinic of Bingham University Teaching Hospital, Jos in three months period.
  1. To determine the correlation between social support and adherence to treatment in patients with DM, attending the outpatient clinic of BhUTH, Jos.
  2. To determine the correlation between adherence to treatment and glycaemic control in patients with DM, attending the outpatient clinic of BhUTH, Hospital Jos.
  3. To determine the correlation between social support and glycaemic control in patients with

DM, attending the outpatient clinic of BhUTH, Jos.

1.5                                 JUSTIFICATION FOR THE STUDY

Sub-Saharan Africa is suffering the double impact of communicable and non communicable diseases and on the brink of an epidemic of DM in which the toll already devastating may worsen unless urgent action is taken.12 The greatest increases and greatest numbers of people to develop DM by the year 2025, in Sub- Saharan Africa are projected to be in the younger age groups (20-24 years and 45-64 years ).  This early age of  onset leads to a greater opportunity for developing complications and as a consequence greater financial costs.12  For many health systems already struggling to cope with infectious diseases, the additional burden of DM and related chronic diseases may prove disastrous.12 In Africa, the prevalence and incidence of diabetes mellitus is increasing with its associated complications leading to high morbidity and mortality.19 In many countries low literacy and poverty impact heavily on the potential of the individuals to understand and self manage their DM.12

Directly or indirectly, everyone is affected by DM; that is , individuals, families communities, schools, churches, mosques, health professionals, politicians, all sectors of government, non - governmental organisations, business and industry.12   Therefore, everyone must be involved in taking responsibility for combating DM.

 Like in the management of other chronic diseases where self administration of treatment is required; poor or non adherence to diabetes   treatment regimen is an increasing worldwide problem of striking magnitude.3,7   DM and its devastating complications are largely preventable and treated successfully through relatively simple interventions.12,18  Appropriate care systems, educational and psychosocial support are required for effective management of DM in the subSaharan Africa.12,18 

This is of great interest to Family Physicians because effective monitoring and control can reduce morbidity and mortality and it’s almost impossible for Family Physicians to provide high quality and cost effective patient care when patients do not adhere to treatment regimen.

Furthermore, Nigeria like other African countries has closely knit family structure and relatively strong extended family system. This strong family ties makes everyone his brother’s keeper and it’s common for family members to rally round any of the members who are sick or in need. This family structure can be positively explored and utilized by Family Physicians to foster social support and thus promote glycaemic control. By exploring the existing social support systems in these patients with DM, useful data could be obtained that will further lead to recommendations to improve these support systems, promote adherence and ultimately improve

glycaemic control.

 

1.6          HYPOTHESIS

Glycaemic control would generally be low in the study population but those with better social support would have better glycaemic control when compared with diabetes mellitus patients with poor social support. The null hypothesis (Ho) says that there is no relationship between social support and glycaemic control in patients with DM in Jos, Nigeria. While, the alternative hypothesis (H1), says that there is a relationship between social support and glycaemic control in patients with DM in Jos, Nigeria

 

INFLUENCE OF SOCIAL SUPPORT ON  GLYCAEMIC CONTROL IN DIABETES  MELLITUS PATIENTS ATTENDING THE OUTPATIENT CLINIC OF ECWA EVANGEL HOSPITAL , (NOW, BINGHAM UNIVERSITY TEACHING HOSPITAL), JOS.

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