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Knowledge and practice on prevention of hypoglycemia among diabetic patients in South Gondar, Northwest Ethiopia: Institution based cross-sectional study

Girma Nega Gezie

Department of Applied Human nutrition, Faculty of chemical and Food Engineering, Bahir Dar Institute of technology, Bahir Dar University, Bahirdar, Ethiopia

E-mail : girma_nega@yahoo.com

Getahun Asres Alemie

Department of Epidemiology and Biostatistics, Institute of Public Health, University of Gondar, Ethiopia

Tadesse Awoke

Department of Epidemiology and Biostatistics, Institute of Public Health, University of Gondar, Ethiopia

DOI: 10.15761/IOD.1000113

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Abstract

Hypoglycemia is an emergency life threatening condition for diabetic patients who take their medication. Proper hypoglycemia prevention relies on knowledge and self care practice. The objective of this study was to assess knowledge and practice of hypoglycemia prevention and associated factors among diabetic patients in South Gondar, Northwest Ethiopia, 2012. Institution based cross-sectional study was conducted from June-October, 2012 at governmental health institutions in South Gondar. Four hundred sixteen diabetic patients were involved in the study. A pre-tested, structured and interview administered questionnaire was used to collect data and analysis was done using SPSS version 16. Logistic regression was fitted and 95% CI and odds ratio were presented to identify associated factors and to assess the strength of the association. For all statistical significance, the cut- off value was P ≤ 0.05. From the total study participants 105(25.5%) were found to have good knowledge about hypoglycemia prevention. Eighty nine (21.4%) had good practice in hypoglycemia prevention. Educational status and being a member of diabetic association were found to be positively associated with knowledge and practice. Respondents who attained primary education (AOR=2.14, 95%CI: 1.19, 3.84), secondary education (AOR 3.02, 95%CI: 1.53, 5.98), college and above (AOR=2.35, 95%CI: 1.08, 5.13) were found to be more likely to have good knowledge compared with respondents who did not have formal education. Those who were members of Ethiopian diabetic association were about four times more likely to be knowledgeable (AOR=3.91, 95%CI: 2.26, 6.77) and six times more likely to practice hypoglycemia prevention (AOR=6.08, 95%CI: 3.34, 11.05). Knowledge and practice on hypoglycemia prevention are poor. Members of Ethiopian Diabetic Association are very low in this study. Thus the association should design and provide information tailored to patient education level.

Key words

hypoglycemia, Ethiopia, diabetes

Introduction

Hypoglycemia is an acute medical situation that occurs when blood sugar falls below the recommended level. Individuals taking diabetic medications are at increased risk of experiencing low blood sugar [1,2]. An estimated 2-4% of people with type 1 diabetes mellitus die from hypoglycemia each year. It might explain the “dead in bed syndrome” unexplained death of a person with type 1 diabetes occurring during night time [3]. The symptoms of low blood sugar vary from person to person, and can change over time. During the early stages a person with low blood sugar level may have sweating, trembling, feeling hungry and feeling anxious. The symptoms can become more severe, and can include difficulty of walking, weakness, visual disturbance; bizarre behavior, personality changes, confusion and unconsciousness or seizure may be observed [4] .

Knowledge about these symptoms is an important step to self care practice, because informed people are more likely to have better self care practice [5]. It is important for patients with diabetes especially, those receiving insulin to learn about hypoglycemia, and to carry some form of simple sugar with them at all times. Self care practice in diabetes management  also includes dietary regulation, medication, physical activity and self monitoring of blood glucose (SMBG) [6]. Additionally, these patients should always wear an identification bracelet or tag [7,8].

Several retrospective studies indicate that risk factors for hypoglycemia in 1,418 type2 diabetes mellitus are of drug- induced and fasting as the major risk factors for sever hypoglycemia and require hospitalization [9]. Majority of hospitalized diabetic patients and their relatives had inadequate understanding  of diabetes and its consequences or complications, and they had lack of confidence in own ability to manage diabetes effectively [10]. Patients knowledge about various aspect of the disease together with the understanding of the aims and objectives of various treatment outcomes have tremendous impact on patients self care practice, skills necessary to control of self blood glucose (SMBG) [11,12].

 Despite the abundance of studies on self-care practice and knowledge about hypoglycemia, there are no available studies done on knowledge and practice regarding hypoglycemia prevention among diabetic patients. But this study tried to identify determinants of knowledge and practice regarding hypoglycemia among diabetic patients.

Materials and methods

Institution based cross-sectional study was conducted on public health facilities which provide chronic illness follow-up for diabetic patients from June to October 2012 in South Gondar. There is only one zonal hospital and 90 health centers giving medical service for a total of 2,238,737 people in the zone. Diabetes patients aged 18 years and above who were attending government health institutions in south Gondar zone were included in the study. Study subjects were recruited with proportional allocation from 1 Hospital and 9 Health centers. Then final sample was taken by simple random sampling technique from their registration book.

    A structured questionnaire was developed and prepared originally in English and translated to Amharic and then translated to English to check consistency. For administering the interview, 10 diploma nurses and 4 trained BSC Nurses were recruited for data collection and supervision respectively. Training was given for data collectors and supervisors for two days about the objective, relevance, confidentiality, respondent’s right, informed consent and techniques of interview for the study.

    Data analysis was made by using SPSS version 16 statistical package. For all statistical significance tests, the cut- off value was p-value £ 0.05. Multivariate logistic regression was used to check the effect of each explanatory variable on the dependent variable. Odds ratio and 95% confidence interval were computed to assess the strength of the association and statistical significance.

   Knowledge on hypoglycemia is defined as good glycemic control when respondents answered equal to or above the mean score of knowledge questions. Practice on hypoglycemia is defined as good self care practice when respondents answered equal to or above the mean score of practice questions.

   Regular exercise means a 30 minute fast walk or riding bicycle daily. Member of Ethiopian diabetic association is diabetic patient who are voluntary to be member of the association and governed on the rule and the regulation of the association.

   Ethical clearance was obtained from University of Gondar and permission letter was taken from Amhara Regional Health Bureau and South Gondar zone health department.

Results

Socio demographic characteristics of participants

A total of 416 diabetes mellitus patients were included in the study with response rate of 98.6%. The mean age of the respondents was 39.1 with S.D of ± 1.4 years. One hundred ninety six (47.1%) of them were urban residents. One hundred fifty four (37%) participants did not have formal education; 307 (88.2%) respondents were Orthodox Christian in religion. One hundred forty four (34.6%) of the respondents were unemployed, 201 (53.1%) of respondents were married. From the total participants only 70(16.8%) were found to be members of the Ethiopian diabetic association (Table1).

Table 1. Socio demographic Characteristic of participants, South Gondar, Northwest- Ethiopia, October, 2012.

Variable

Frequency (n=416)            

Percent (%)

Age

18-34

208

50

35-64

196

47.1

≥65

12

2.9

Total

416

100

Sex

Male

259

62.3

Female

157

37.7

Total

416

100

Residence

Rural

220

52.9

Urban

196

47.1

Total

416

100

Religion

Orthodox

367

88.2

Muslim

49

11.8

Total

416

100

Ethnicity

Amhara

412

99.0

Tigrie

4

1.0

Total

416

100

Marital status

Single

114

27.4

Married

221

53.1

Divorced

81

19.5

Total

416

100

Educational status

No formal education

154

37.0

Primary

145

34.9

Secondary

69

16.6

College and above

48

11.5

Total

416

100

Occupation

Unemployed

144

34.6

Government

99

23.8

Private

173

41.6

Total

416

100

Economical  status

≤ 400 Eth birr

117

28.1

401-700

106

25.5

701-999

42

10.1

≥1000

151

36.3

Total

416

100

Membership of diabetic association

No

346

83.2

Yes

70

16.8

Total

416

100

Knowledge regarding hypoglycemia

From all knowledge questions, 105 (25.5%) respondents had good knowledge in hypoglycemia prevention; however in specific question 213 (51.2%) participants had poor knowledge in identifying symptoms of hypoglycemia. With regard to the effect of exercise, majority 365(87.7%) didn’t know that exercise aggravated hypoglycemia, 348 (83%) respondents knew that alcohol intake leads to hypoglycemia (Table 2).

Table 2. Knowledge regarding hypoglycemia prevention, South Gondar, Northwest- Ethiopia, October, 2012 (n=416)

         Variable                         

Good knowledge n(%)        

Poor knowledge n(%)   

Symptom of hypoglycemia

203(48.8)

            213(51.2)

 DM diet

373(89.7)

             43(10.3)

Effect of exercise

51(12.3)

             365(87.7)

Effect of break fast

231(55.5)

             185(44.5)

Effect of alcohol on hypoglycemia

348(83.6)

             68(16.4)

Effect of bean on hypoglycemia

287(69.0)

             129(31.0)

Effect of wheat on blood sugar

377(90.6)

             39(9.4)

Practice regarding hypoglycemia

From the total respondents eighty nine (21.4%) study subjects had good practice in hypoglycemia prevention. Three hundred ninety three (94%) of participants take their medication at the right time; 244(58%) had good practice by taking snack and 151(36%) carrying table sugar to treat hypoglycemia (Table 3).

Table 3.  Practice regarding hypoglycemia prevention, South Gondar, Northwest- Ethiopia, October 2012 (n=416)

Variables

                                           Good practice n (%)

Poor practice n (%)

Self blood glucose monitoring at home

32(7.7)

384(92.3)

Taking medication at the right time

393(94.5)

23(5.5)

Taking snack

244(58.7)

172(41.3)

Taking carbohydrate diets irregularly

153(36.8)

263(63.2)

Carry table sugar to treat hypoglycemia

151(36.3 )

265(63.7)

Coming in regular appointments

388(93.3)

28(6.7)

Carrying diabetic identification card

56(13.5)

360(86.5)

Regular exercise

123(29.6)

293(70.4)

Duration of exercise

74(17.8)

342(82.2)

Adjustment of medication

193(46.4)

223(53.6)

Hypoglycemia treatment

245(58.9)

171(41.1)

Determinants of knowledge and practice on hypoglycemia prevention

Multivariate logistic regression showed that, being a member of the Ethiopian Diabetic association, completed their primary school, secondary school, college and above were significantly and independently associated with knowledge and practice of hypoglycemia prevention.

Diabetic patients who attained primary education were (AOR=2.14, 95%CI: 1.19, 3.84), secondary education (AOR 3.02, 95%CI: 1.53, 5.98) and completed college and above (AOR=2.35, 95%CI: 1.08, 5.13) were more likely to have good knowledge than respondents who had not formal education. Being the member of diabetic association has positively associated with knowledge (AOR= 3.91, 95%CI: 2.26, 6.77) (Table 4).

Table 4. Association of Selected demographic variables with Hypoglycemia Knowledge in South Gondar, Ethiopia, October 2012 (n=416)

Variable

Good 

Poor  

COR(95%CI)                      

AOR(95%CI)

Residence

Rural

47(21.4)

173(78.6)

1.00

Urban

58(29.6)

138(70.4)

1.55(0.99,2.41)

Age

18-34

57(27.4)

151(72.6)

1.00

35-64

47(24)

149(76)

0.84(0.53, 1.31)

≥65

1(8.3)

11(91.7)

0.24(0.03, 1.91)

Marital status

Single

29(25.4)

85(74.6)

1.00

Married

55(24.9)

166(75.1)

0.97(0.58, 1.63)

Divorced

21(25.9)

60(74.1)

1.03(0.54, 1.97)

Education

No formal education

23(14.9)

131(85.1)

1.00

1.00

Primary

41(28.3)

104(71.7)

2.25(1.27, 3.98)

2.14(1.19,3.84)

Secondary

26(37.7)

43(62.3)

3.44(1.78,6.65)

3.02(1.53,5.98)

College and above

15(31.3)

33(68.7)

2.59(1.22, 5.50)

2.35(1.08,5.13)

Occupation

Unemployed

37(25.7)

107(74.3)

1.00

Government

33(33.3)

66(66.7)

1.45(0.83, 2.53)

Private

35(20.2)

138(79.8)

0.73(0.43,1.24)

Member of DM association

No

69(11.3)

277(88.7)

1.00

1.00

Yes

36(50.7)

34(49.3)

4.25(2.48,7.28)

3.91(2.26,6.77)

With regard to practice, those who have primary, secondary and college and above education were (AOR=2.20, 95 %CI: 1.07, 4.52), (AOR=5.29, 95%CI: 2.43, 11.52), (AOR=8, 95%CI: 3.17, 17.51) more likely to have good practice than those were not formal education respectively. Being the members of diabetic association were 6 times (95%CI: 3.34, 11.05) more likely to have good practice than who were not member of diabetic association. However residence, occupation, income and sex of respondents were not significantly associated with hypoglycemia prevention knowledge and practice (Table 5).

Table 5. Association of Selected demographic variables with Hypoglycemia Practice in South Gondar, Ethiopia, October 2012

Variable

Good

poor

COR(95%CI)

COR(95%CI)

Address of respondent

Rural

28(12.7)

192(87.3)

1.00

Urban

61(31.1)

135(68.9)

3.10(1.88,5.10)

Religion

Orthodox

73(19.9)

294(80.1)

1.00

Muslim

16(32.7)

33(67.30

1.95(1.02, 3.74)

Education

Illiterate

14(9.1)

140(90.9)

1.00

1.00

Primary

28(19.3)

117(80.7)

2.39(1.20,4.76)

2.20(1.07,4.52)

Secondary

26(37.7)

43(62.3)

6.05(2.90,12.60)

5.29(2.43,11.52)

College and above

21(43.8)

27(56.2)

7.78(3.52,17.17)

8.1(3.53,18.95)

Occupation

Unemployed

30(20.8)

114(79.2)

1.00

Government

39(39.4)

60(60.6)

2.47(1.40, 4.37)

Private

20(11.6)

153(88.4)

0.50(0.27,0.92)

Income

≤ 400 birr

21(17.9)

96(82.1)

1.00

401-700

15(14.2)

91(85.8)

0.75(0.36, 1.55)

701-999

9(21.4)

33(78.6)

1.25(0.52, 2.99)

≥ 1000 birr

44(29.1)

107(70.9)

1.88(1.04, 3.38)

Member of  Dm association

No

53(15.3)

293(84.7)

1.00

1.00

Yes

36(51.4)

34(48.6)

5.85(3.37,10.17)

6.08(3.34,11.05)

Discussion

Knowledge about symptom of hypoglycemia is an important step to self care practice for diabetic patients, because informed people are more likely to have better self care practice [5].The goals in diabetes education consists in improving metabolic control, preventing acute and chronic complications and improving one’s quality of life at reasonable cost [13]. Self care practice in diabetic management includes dietary regulation, medication, physical activity self blood monitoring at home (SMBG) and always wearing an identification bracelet or tag (7, 8).

From all study subjects 105(25.5) participants had good knowledge in hypoglycemia prevention. Forty three (41%) female participants were knowledgeable in hypoglycemia prevention. This is relatively low when compared to study conducted in Kuwazulu Natal, South Africa were 66.9% had good knowledge [14]. This might be due to time variation and Sociodemographic differences.

Two hundred three (49.8%) of participants could identify symptom of hypoglycemia, but study conducted on type 2 diabetics in Kampala, Uganda showed that only 36% of study subjects could identify symptoms of hypoglycemia [15].

The higher knowledge in this study might be due to accessibility of health services recently giving chronic follow up for diabetic patients, so participants might get more information to hypoglycemia and diabetic complication.

Being a member of diabetic association create chance to get information about diabetic complication, and acquiring knowledge and practice on hypoglycemia prevention. Only 70(16.8%) patients were member of Ethiopian Diabetic Association. This is low compared to study conducted in Bangladesh 87.50% diabetes patients were member of diabetes association [16,17]. The reason of this higher difference might be Ethiopian diabetic association not still decentralized to far urban areas.

 Self care practice was early warning method for diabetes emergency conditions. In this study only 7.7% practiced self blood glucose test at home which is lower than study conducted in Qatar, where 60.5% of respondents reported that they were monitoring their blood glucose at home. This might be due to financial barrier to self monitoring of blood glucose test (SBGT) apparatus, fear of pain related to finger prick and health professionals focus only dietary advice than self blood monitoring [18].

Even though wearing an identification band is need for diabetic patient, only 13.5% had practice of carrying identification card in this study. It is lower with the study conducted in Pakistan (18%) [19]. The difference might be healthcare providers and patients were not giving attention for the benefit of carrying ID cards to prevent hypoglycemia and hyperglycemia related complication.

In conclusion, knowledge and practice of hypoglycemia prevention among diabetic patients were low as revealed by this study. At least primary education and being the member of diabetic association were associated significantly with both knowledge and practice of hypoglycemia prevention. Lack of knowledge in identification of symptoms of hypoglycemia and in carrying of identification band and self blood glucose monitoring at home, to treat and to prevent hypoglycemia was poor.  

Acknowledgments

We would like to acknowledge the University of Gondar Institution of Public Health, World Bank nutrition project and Department of Human Nutrition for their unlimited supports. We gave our great thanks for data collection facilitators for their genuine dedication and effort shown during the data collection. We also express our heartfelt gratitude for respondents giving their precious time during interview.

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Editorial Information

Editor-in-Chief

Masayoshi Yamaguchi
Emory University School of Medicine

Article Type

Research Article

Publication history

Received: April 15, 2015
Accepted: May 23, 2015
Published: May 25, 2015

Copyright

©2015 Gezie GN. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Citation

Gezie GN, Alemie GA, Awoke T (2015) Knowledge and practice on prevention of hypoglycemia among diabetic patients in South Gondar, Northwest Ethiopia: Institution based cross-sectional study. Integr Obesity Diabetes . 1: doi: 10.15761/IOD.1000113

Corresponding author

Girma Nega Gezie

Department of Applied Human nutrition, Faculty of chemical and Food Engineering, Bahir Dar Institute of technology, Bahir Dar University, Bahirdar, Ethiopia, Tel: +251-582-205925.

E-mail : girma_nega@yahoo.com

Table 1. Socio demographic Characteristic of participants, South Gondar, Northwest- Ethiopia, October, 2012.

Variable

Frequency (n=416)            

Percent (%)

Age

18-34

208

50

35-64

196

47.1

≥65

12

2.9

Total

416

100

Sex

Male

259

62.3

Female

157

37.7

Total

416

100

Residence

Rural

220

52.9

Urban

196

47.1

Total

416

100

Religion

Orthodox

367

88.2

Muslim

49

11.8

Total

416

100

Ethnicity

Amhara

412

99.0

Tigrie

4

1.0

Total

416

100

Marital status

Single

114

27.4

Married

221

53.1

Divorced

81

19.5

Total

416

100

Educational status

No formal education

154

37.0

Primary

145

34.9

Secondary

69

16.6

College and above

48

11.5

Total

416

100

Occupation

Unemployed

144

34.6

Government

99

23.8

Private

173

41.6

Total

416

100

Economical  status

≤ 400 Eth birr

117

28.1

401-700

106

25.5

701-999

42

10.1

≥1000

151

36.3

Total

416

100

Membership of diabetic association

No

346

83.2

Yes

70

16.8

Total

416

100

Table 2. Knowledge regarding hypoglycemia prevention, South Gondar, Northwest- Ethiopia, October, 2012 (n=416)

         Variable                         

Good knowledge n(%)        

Poor knowledge n(%)   

Symptom of hypoglycemia

203(48.8)

            213(51.2)

 DM diet

373(89.7)

             43(10.3)

Effect of exercise

51(12.3)

             365(87.7)

Effect of break fast

231(55.5)

             185(44.5)

Effect of alcohol on hypoglycemia

348(83.6)

             68(16.4)

Effect of bean on hypoglycemia

287(69.0)

             129(31.0)

Effect of wheat on blood sugar

377(90.6)

             39(9.4)

Table 3.  Practice regarding hypoglycemia prevention, South Gondar, Northwest- Ethiopia, October 2012 (n=416)

Variables

                                           Good practice n (%)

Poor practice n (%)

Self blood glucose monitoring at home

32(7.7)

384(92.3)

Taking medication at the right time

393(94.5)

23(5.5)

Taking snack

244(58.7)

172(41.3)

Taking carbohydrate diets irregularly

153(36.8)

263(63.2)

Carry table sugar to treat hypoglycemia

151(36.3 )

265(63.7)

Coming in regular appointments

388(93.3)

28(6.7)

Carrying diabetic identification card

56(13.5)

360(86.5)

Regular exercise

123(29.6)

293(70.4)

Duration of exercise

74(17.8)

342(82.2)

Adjustment of medication

193(46.4)

223(53.6)

Hypoglycemia treatment

245(58.9)

171(41.1)

Table 4. Association of Selected demographic variables with Hypoglycemia Knowledge in South Gondar, Ethiopia, October 2012 (n=416)

Variable

Good 

Poor  

COR(95%CI)                      

AOR(95%CI)

Residence

Rural

47(21.4)

173(78.6)

1.00

Urban

58(29.6)

138(70.4)

1.55(0.99,2.41)

Age

18-34

57(27.4)

151(72.6)

1.00

35-64

47(24)

149(76)

0.84(0.53, 1.31)

≥65

1(8.3)

11(91.7)

0.24(0.03, 1.91)

Marital status

Single

29(25.4)

85(74.6)

1.00

Married

55(24.9)

166(75.1)

0.97(0.58, 1.63)

Divorced

21(25.9)

60(74.1)

1.03(0.54, 1.97)

Education

No formal education

23(14.9)

131(85.1)

1.00

1.00

Primary

41(28.3)

104(71.7)

2.25(1.27, 3.98)

2.14(1.19,3.84)

Secondary

26(37.7)

43(62.3)

3.44(1.78,6.65)

3.02(1.53,5.98)

College and above

15(31.3)

33(68.7)

2.59(1.22, 5.50)

2.35(1.08,5.13)

Occupation

Unemployed

37(25.7)

107(74.3)

1.00

Government

33(33.3)

66(66.7)

1.45(0.83, 2.53)

Private

35(20.2)

138(79.8)

0.73(0.43,1.24)

Member of DM association

No

69(11.3)

277(88.7)

1.00

1.00

Yes

36(50.7)

34(49.3)

4.25(2.48,7.28)

3.91(2.26,6.77)

Table 5. Association of Selected demographic variables with Hypoglycemia Practice in South Gondar, Ethiopia, October 2012

Variable

Good

poor

COR(95%CI)

COR(95%CI)

Address of respondent

Rural

28(12.7)

192(87.3)

1.00

Urban

61(31.1)

135(68.9)

3.10(1.88,5.10)

Religion

Orthodox

73(19.9)

294(80.1)

1.00

Muslim

16(32.7)

33(67.30

1.95(1.02, 3.74)

Education

Illiterate

14(9.1)

140(90.9)

1.00

1.00

Primary

28(19.3)

117(80.7)

2.39(1.20,4.76)

2.20(1.07,4.52)

Secondary

26(37.7)

43(62.3)

6.05(2.90,12.60)

5.29(2.43,11.52)

College and above

21(43.8)

27(56.2)

7.78(3.52,17.17)

8.1(3.53,18.95)

Occupation

Unemployed

30(20.8)

114(79.2)

1.00

Government

39(39.4)

60(60.6)

2.47(1.40, 4.37)

Private

20(11.6)

153(88.4)

0.50(0.27,0.92)

Income

≤ 400 birr

21(17.9)

96(82.1)

1.00

401-700

15(14.2)

91(85.8)

0.75(0.36, 1.55)

701-999

9(21.4)

33(78.6)

1.25(0.52, 2.99)

≥ 1000 birr

44(29.1)

107(70.9)

1.88(1.04, 3.38)

Member of  Dm association

No

53(15.3)

293(84.7)

1.00

1.00

Yes

36(51.4)

34(48.6)

5.85(3.37,10.17)

6.08(3.34,11.05)