Perceived barriers to lifestyle modification, motivation, knowledge and service needs of diabetic adults and their health care providers in Chennai, Tamil Nadu, India.

Abstract

Introduction: Over 415 million people worldwide live with diabetes mellitus, of which 50% live in five countries: China, India, the United States of America, Brazil and Indonesia. The number of people with diabetes is predicted to rise to 552 million by 2030 and may affect up to 79.4 million individuals in India. Diabetes mellitus is a chronic, non-communicable disease resulting in increased blood glucose levels. Poor control of diabetes leads to the development of complications that affect quality of life and health, and may even lead to death. Diabetics face many barriers such as time constraints, lack of knowledge, fear or depression, lack of self-motivation and lack of support from family and medical personnel. Barriers faced by health care providers (HCPs) are inadequate knowledge on treatment and management of diabetes, focusing on acute management rather than the preventive care, delay in clinical response to poor control and competing care demands. Given the fact that a large percentage of the world’s diabetics live in India, more research is needed to investigate the barriers that diabetics and their HCPs face in this unique region. Aim: This study aimed to evaluate the barriers to lifestyle modification, motivation, knowledge and service needs of diabetic adults and their HCPs in Chennai, Tamil Nadu, India. Location: The study was conducted in Apollo Specialty Hospital, Vanagaram, Chennai, India. Objectives: (i) To identify the barriers to lifestyle modification as perceived by South Indian Type 2 diabetic adults. (ii) To identify the barriers to motivation, knowledge and service needs as perceived by South Indian Type 2 diabetic adults. (iii) To identify the challenges as perceived by HCPs in providing education, motivation and services to their diabetic patients. Method: A sample of 50 male and female adults with type 2 diabetes from a private specialty hospital in Chennai were randomly selected to participate in this study. Participants had to be type 2 diabetic, aged between 18 to 70 years; diagnosed for more than one year; with not more than two other co-morbidities, excluding pre-renal or renal failure; latest glycosylated haemoglobin (HbA1c) available and previously been seen by a dietician. For HCPs (n=25) comprising of nurses, doctors and dieticians, the inclusion criteria were that they had to have been practicing for more than a year. Separate questionnaires were developed for the diabetic patients and for the HCPs. The patient questionnaires were conducted in an interview format and in the language (English or Tamil), preferred by the patients. The HCPs completed the questionnaires on their own. Results: The diabetic patients in this study ranged in age between 41 to 68 years and had a mean body mass index (BMI) of 26.8 kg/m2. The mean HbA1c was 8.05% and most patients had hypertension alone, as a comorbidity. In general, patients felt that they had no barriers to glucose monitoring, although 28% indicated that being busy with family was a barrier. Common barriers to exercise were being busy with work or family (72%) as well as fear and pain (44%). The most common barriers to healthy eating were eating away from home (52%; n=26), cost or expense of healthy foods (52%; n=26) and taste of food (46%; n=23). Extrinsic motivation significantly influenced the decision to take medication (p=0.001), check blood glucose levels (p=0.001) and keep health care appointments (p<0.05). Exercise was the only habit this sample followed regularly due to intrinsic motivation (p=0.030). Significantly, 82% of patients indicated that they understood their disease condition (p<0.05), whilst a significant small number reported that they would benefit from a workshop that provided knowledge and skills to help manage their diabetes (p=0.001). Most patients had confidence in treatment and advice obtained from health care providers (p=0.001), and their own skills and knowledge to prepare healthy meals (p<0.05). Most patients understood their disease condition and complications (p<0.05). A higher income (p=0.031) and consuming a mixed diet (p<0.05) was associated with higher HbA1c levels amongst patients. A significant positive correlation was found between BMI and HbA1c, as well as between BMI and income. Patients following a vegetarian diet were found to have a lower HbA1c. Health care providers (HCPs) felt that they had sufficient skills for lifestyle counselling (p=0.001), but also reported that their biggest barrier to counselling was time constraints (p=0.026). Health care providers indicated that patients found following an eating plan the most difficult to maintain (88%), followed by exercise (48%). Health care providers all agreed that patients should be assigned responsibility for self-care (p<0.05), even though healthcare providers indicated that important barriers to lifestyle changes were unwillingness to change (p<0.05), insufficient knowledge on complications (p=0.008) and lack of support from co-workers or bosses (p=0.005). There was a significant positive correlation between the experience level of the healthcare providers and the frequency with which they motivated and supported lifestyle changes (rho = 0.547, p =0.005) and how confident they were that they had the knowledge or skills needed to teach their patients (rho =0.406, p=0.004). The experience level of the HCPs and the frequency with which they referred patients to other team members (rho = 0.767, p <0.05) and how confident they were that they had the skills for lifestyle counselling (rho = 0.577, p =0.003), were also significantly positively correlated. Conclusion: For patients, being busy with family, work or other tasks was a common barrier to glucose monitoring and exercise, while a diet plan was not commonly used to control blood glucose levels. Overall, patients were satisfied with the services provided by their HCPs and were keen to participate in online medical support from health care providers. According to HCPs, patients found following an eating plan and exercise the most difficult to adhere to, while glucose monitoring and taking medication were the least difficult to adhere to. All healthcare providers agreed that patients should be assigned responsibility of self-care. According to HCPs, unwillingness to change, insufficient knowledge on complications and lack of support from co-workers or bosses, were the most important barriers to lifestyle counselling. Time constraints also prevented HCPs from counselling their patients adequately. In general, the more experienced HCPs were more likely to motivate and support lifestyle changes, more confident in their knowledge or skills and more likely to refer patients to other health care team members. It is evident that this sample need to place greater emphasis on dietary management of diabetes. They could benefit from regular information updates on how to effectively manage their diabetes.