KNOWLEDGE, AWARENESS AND ATTITUDES TOWARDS THE MANAGEMENT OF DIABETES MELLITUS AMONG PATIENTS IN SRI LANKAN SUBURBAN COMMUNITY

Introduction: Due to the sedentary lifestyle and unhealthy eating habits, the prevalence of diabetes is increasing rapidly in urban Sri Lanka than the rural suburbs. Awareness of the disease is pivotal for the prevention and minimization of diabetes-related complications. No information on patient's knowledge is recorded for Sri Lanka, in a country where a comparably high literacy level is recorded. The objective of this study was to evaluate the awareness, knowledge and attitudes regarding their disease among patients with diabetes mellitus in a population of Colombo suburb.

Diabetes mellitus is a complex metabolic disorder that can adversely affect the normal human physiology. It is one of the commonest noncommunicable diseases that has escalated to an epidemic level worldwide. The modern sedentary lifestyle focused on comfort living and unhealthy eating habits have created a striking increase in the diabetes related deaths occur in low and middle-income countries. The World Health Organization projects diabetic deaths to rise by two third by 2030 and the incident of diabetes mellitus in developing countries to increase by 170% by 2025. It has been estimated that 228 million patients in these countries will account for 75 % of the world population of diabetes by 2025 (2). The prevalence of diabetes in Sri Lanka was 10.3 % in 2005 and during the last decade, there has been a prevalence of non-communicable health issues such as diabetes mellitus, obesity and cardiovascular disease. This is not restricted to developed countries but seen more frequently in developing countries such as Sri Lanka.
In 2011, 366 million people suffered from diabetes and 4.6 million people in the world died due to consequences of high blood sugar (1). The number is expected to reach 552 million by 2030. More than 80% of rapid rise in the prevalence of diabetes affecting urban population living in Colombo and suburbs compared to the rural community (3). Improvement of the disease awareness is the key to reduce the disease burden by early diagnosis and appropriate treatment that will minimise disease related complications of these patients (4).
Effective health education is directly influenced by the literacy level of the population (5). Sri Lanka is a country with a high literacy rate of 91.2 %, which is comparable to the literacy level of developed countries (6). Most of literate Sri Lankans are clustered in urban Colombo and its suburbs. Therefore, it can be expected that diabetic patients from these areas to have a better disease awareness. The existing research on awareness and knowledge in developing countries are from countries with low literacy levels (7,8,9,10) and there are no recorded data in the medical literature on the level of awareness of diabetes mellitus for our population. Establishing data on this is a national need to plan public health policies and to identify specific requirements to implement national diabetic control programs. This study was carried out to establish the current level of awareness, knowledge and attitudes on diabetes mellitus in a patient population attending a Colombo suburb hospital in Sri Lanka. achievable score. d) The knowledge level was rated based on the compo-site score as 0-24.9 very po-or, 25-49.9 poor, 50-74.9 good, 75-100 very good. e) The demonstrated knowledge level of patients was further analysed to determine if any significance existed based on gender, educational level, duration of diabetes and previous diabetes education.
Socio-demographic profile of study population is given in Table 1 The literacy levels of the participants were distributed as grade 10 completion (42%), studied up to advanced level (35.1%), undergraduate education (9.2%) and postgraduate completion (0.8%). This question was not responded by 17 patients (13.0%). Only 28.7% of the study group was employed and the rest of the group were unemployed (48.9%), retired (11.5%) or did not respond (13.0%). Answers to the setup questions based on 1) diagnosis, 2) treatment (life style changes and drug), 3) complications, 4) prevention and prognosis were analysed according to the following scoring system. a) Each correct answer was given score of 1. b) Questions of each assessed component were given a maximum score: diagnosis (12), lifestyle changes (15), drug therapy (10), complications (10) and prevention and prognosis (10). The components were analyzed separately. The final score was calculated by adding up of scores of each component and the maximum achievable score was 57. c) A composite score in percentage was determined separately for each component and for the total score by dividing individual scores by the maximum This cross-sectional descriptive study was carried out at Dr Neville Fernando Teaching hospital, Malabe, Sri Lanka, for a period of 6 months from October 2013. The data was collected using a self-administered questionnaire designed in English, which was validated after translating to Sinhalese. The questions included; patient's demography and set up questions on four clinical aspects of diabetes mellitus: 1) diagnosis 2) complications 3) treatment 4) prevention and prognosis.

RESULTS
Patients diagnosed with diabetes mellitus and attending the medical or  Polyuria, non-healing ulcers and weight loss were correctly recognised as presenting symptoms of diabetes by more than 50% of patients. The highest response (77.10%) was on polyuria while responses for nonhealing ulcers and weight loss were 68.70% and 53.40% respectively. Incorrect responses of presenting symptoms included chest pain (93.9%) and loss of appetite (90.8%) ( Figure 1B).
Patients were asked to identify the factors known to increase the risk of diabetes from a list.  Figure  1D). incorrect answers, kidney was selected by 25.95% and thyroid by 1.53% ( Figure 1A).

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patient from a given food list. Avoidance of jaggery (a concentrated sugary product) was recognised by 98.5% of respondents.  Awareness of healthy diabetic diet was assessed by asking study participants to select food items that could be freely taken by a diabetic by 82.4%. 96.2% of respondents failed to recognise consumption of extra vegetables as healthy.
Pharmacological treatment of diabetes ( Figure 2C and 2D): Dizziness was recognised as a symptom of hypoglycaemia by 42.7% and this was the best knowledge reported on oral drug use. Only 31.3% knew that some oral medications can enhance the insulin level in the body. The weight reducing benefit of metformin was only known to 11.5%. More 42.7% and this was the best knowledge reported on oral drug use.. More than 90% had false believes that oral drugs damage the pancreas (90.8 %) and increase appetite (93.9%).
The best response regarding insulin was for its storage requirements and 45.80% were aware that refrigerator facility was not compulsory to keep insulin at home. The overall awareness of insulin was poor and 94.70% considered insulin was used only in the treatment of type 1 diabetes mellitus. Insulin was falsely considered as a risk for infections

Figure 2D
By 92.40%. Administration of insulin was incorrectly recognized as oral by 87% while only 20.60% knew insulin is measured in units.
A list of specified organ dysfunctions and disease conditions were used to assess general awareness of complications of diabetes. The highest awareness was of chronic ulcers    occupations have a greater risk. 66.4% were aware that fastfood/take-away meals may worsen the blood sugar control. Data also revealed that 64.9% incorrectly believed that consumption of imported food increases the risks of diabetes.
The necessity of life-long therapy for diabetes was identified by 72.5% while 57.7% identified the relationship of poor glycaemic control and risk of limb amputations. The importance of annual screening to monitor disease progression was only identified by 32.1%. 82.4% believed that diabetesrelated complications will occur despite good glycaemic control and 89.3% believed intermittent drug treatment was adequate to control diabetes satisfactorily.
The mean percentage score on awareness and knowledge of diabetes mellitus was 37.7% with a minimum score of 5.3% and a maximum score of 73.7%. of a population, established misbelieves in the community and the level of effective communication by the health care provider (11). In spite of having a good literacy level, the majority of the patients in our study had a 'poor' or 'very poor' knowledge regarding diagnosis, treatment, prevention and prognosis of diabetes However, majority showed 'good' or 'very good' knowledge level for complications. The study also failed to establish statistically significant relationships between the level of understanding they have regarding their disease and the gender, literacy level, duration of diabetes or past participation in diabetes education.
10% of the current Sri Lankan population is diagnosed as having diabetes and it has been predicted to rise rapidly. Despite having a good literacy level, the general awareness and knowledge of the participants regarding their disease was 'poor' or 'very poor', which is a matter of concern. This study has been conducted in a Colombo suburb where healthcare facilities are of a higher standard and freely available for the diabetic patients. The results of this study represent a cross section of the diabetes population of the Western province of Sri Lanka and highlights accessibility, effectiveness and outcomes of the currently available public health education facilities for diabetic DISCUSSION Volume 6, No. 2, August 2016 28 Patients' knowledge and awareness of diabetes determine the successful management of the disease (1, 2) and their commitment to self-management determine the outcome of their disease. This is significantly influenced by correct information they receive from healthcare providers and other information sources such as media, health bulletins and the internet. The process is also influenced by the accuracy of the information they receive, literacy level  The study results indicated that the awareness and knowledge level of diabetes in this population was not affected by gender, educational level, duration of diabetes and previous formal education on diabetes. It seems that repetition of the same information is needed to establish better awareness among patients and there is a need for regular public health education programs with island wide coverage that could educate the public on basic facts such as diagnosis, treatment, prevention and prognosis of diabetes mellitus.
There are few limitations noted in this study. The questionnaire with closeended questions to assess knowledge would have affected the final results of the study as respondents had the choice of guessing and answer. However, using this type of questionnaire is the most feasible method of collecting data for a population-based study carried out in a busy clinic setting. Certain areas assessed in the study could have carried more questions in the questionnaire to gather additional information to establish further relationships of the knowledge level of the study population. Information to establish the type of diabetes, past exposure to a dietician or a physical trainer, current treatment modalities and the complications patient had developed could have been established by further questions. This study was carried out in a private hospital setting that may render a patient selection bias. However, it is noteworthy that the study population in this study is from an open public follow-up clinic run without financial benefits.

CONCLUSIONS AND RECOMMENDATIONS
Awareness and knowledge of diabetes mellitus are poor among patient of Colombo suburbs, a region with country's highest diabetes prevalence and good health care facilities. The current health education programs should be modified and free accessibility to these programs should be ensured to the patients and public. Further research covering the entire country is needed to assess the exact situation of the country and to find better ways to improve the awareness and knowledge regarding their disease among patients with diabetes.