CHAPTER ONE
INTRODUCTION
Diabetes mellitus (DM) is increasingly becoming a global burden with compelling data of rising incidence and prevalence in Africa especially sub-saharan Africa (SSA) due to fast population growth, ageing and urbanisation leading altered lifestyle.
Diabetes mellitus is referred to as a metabolic disorder characterized by chronic hyperglycaemia resulting from defects in insulin secretion, insulin action or both.
It is broadly divided into Type 1, type 2, other specific types of diabetes and gestational diabetes mellitus.
Type 2 diabetes mellitus (T2DM) is defined as a heterogeneous group of disorders characterized by variable degrees of insulin resistance, impaired insulin secretion, and increased glucose production.
It constitutes about 90-95% of diabetes mellitus globally. 2, 3 In 2010, 55 million persons were estimated to have DM in Europe, 37 million persons in North America & Caribbean, 18 million persons in South & Central America, 59 million Persons in South-East Asia and 77 million in Western Pacific.
In 2014, about 387 million persons had DM globally and Africa accounted for more than 22 million persons and it was predicted to double by 2035.
The World Health Organisation (WHO) also in 2014 estimated global prevalence of diabetes mellitus as 9%.
In SSA, the estimated prevalence of T2DM ranged from 1% in rural Uganda to 12% in urban Kenya.
There were 3.747 million cases of DM in Nigeria with a prevalence of 4.6% among adults between ages 20 and 79 years in 2014.
In Lagos, South-Western Nigeria, the prevalence of DM was 4.2% in 2014.
The mortality from DM in 2010 according to International Diabetes Federation (IDF) was about 4 million, amounting to 6.8% of global deaths and most of the affected countries were in the SSA.
This high mortality rate was attributed to the complications of T2DM and more than 80% of diabetes deaths occurred in low- and middle-income countries.
In view of the high global mortality attributable to the complications of T2DM, global attention has been shifted to formulation of policies that will promote adequate funding of T2DM management and excellent service delivery.
There is also a global drive for the incorporation of psychosocial support and care in the management of people living with T2DM.
However, in developing regions like SSA, T2DM has received poor attention from government and non-governmental organisation in terms of appropriate policies and adequate funding. 7, 10 This has adversely affected the realisation of optimal glycaemic control in a sizeable number of people living with T2DM in Nigeria despite use of recommended guideline.
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Also, modern therapies for achieving optimal glycaemic control like food exchanges, home blood sugar monitoring and continuous ambulatory insulin infusion by pump routinely used in developed countries are largely beyond the reach of most diabetic patients in developing countries like Nigeria.
Furthermore, in an attempt to achieve an improved treatment outcome among T2DM patients, recent studies have recommended further research on factors affecting glycaemic control such as psychosocial factors.
Psychosocial factors like family support, patient-provider relationship, provider collaboration and psychological distress may be the complementing factors for enhancing glycaemic control in a bid to reduce the risk of developing diabetes-related macro-vascular and micro- vascular complications.
The second Diabetes Attitudes Wishes and Needs (DAWN-2) study also underscored the need to provide holistic care for people with T2DM.
The holistic care with regard to psychosocial and behavioural assessment could help to optimize glycaemic control in people with T2DM. According to American Diabetes Association, European Association for the Study of Diabetes, and International Diabetes Federation, the diagnosis of DM is made based on any of the recommended diagnostic criteria. 2, 3 The diagnostic criteria include symptoms of diabetes plus random blood glucose concentration of ≥11.1 mmol/L (≥200 mg/dL) or fasting
plasma glucose value of ≥7.0 mmol/L (≥126 mg/dL) or glycosylated haemoglobin (HbA1c) ≥ 6.5% or two-hour plasma glucose value of ≥11.1 mmol/L (≥200 mg/dL) during an oral glucose tolerance test. In order to ensure good clinical outcome among persons living with T2DM, ADA also recommended in its treatment guideline a glycaemic control target.
It is regarded as good glycaemic control or controlled T2DM when HbA1c is <7% or when pre-prandial capillary plasma glucose is within 3.9–7.2 mmol/L (70–130 mg/dL) or when Peak post-prandial capillary plasma glucose (1 – 2 hours) is < 10.0 mmol/L (<180 mg/dL).
It is otherwise referred to as poor glycaemic control or uncontrolled T2DM when above targets are not met. The management goal of T2DM is aimed at achieving good glycaemic control in order to improve its overall prognosis. 2, 3 Evidence has shown that good glycaemic control reduces micro-vascular complications of DM and, if achieved and maintained soon after the diagnosis of DM, it is associated with long-term reduction in macro-vascular disease. 2, 3 Several non- Pharmacological factors have been extensively investigated and found to enhance glycaemic control such as medication adherence, diet and exercise.
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However, a number of other non- pharmacological factors are still less investigated and some of these are psychosocial factors like family support, patient-provider relationship, provider collaboration and psychological distress; which may play a pivotal role in achieving glycaemic control.
This study will focus on family support and psychological distress among T2DM patients. Family is defined as a social and intimate nurturing group of individuals connected to a patient biologically, legally, or by choice, from whom the patient can reasonably expect a measure of support in the form of food, shelter, finance and emotional nurturing; and also shares a past, a present and a future with the patient and includes all who contribute in one way or the other to the family culture.
Perceived family support which is one of the
psychosocial factors implicated in diabetes control is defined as the felt provision of different forms of emotional and instrumental services and assistance from family members along with negative or positive supportive forms of family interaction within past years.
The family support is largely considered as one of the most important social factors affecting how patients adapt to illness.
Vaccaro et al found in their study in South Florida in the United State among Cuban-, Haitian- and African Americans that family support for persons with T2DM may be beneficial to self-care, ultimately enhancing glycaemic control through diabetes self-management education (DSME) and diabetes self-management support (DSMS).
2, 19 Chinenye et al in Nigeria reviewed a variety of studies on patient-centred care and concluded that Family-centred and community-oriented therapy should be practised especially in the care of persons living with diabetes in order to improve their treatment outcome.
Also, Adetunji et al in Ibadan found in their study among T2DM patients attending General Outpatient Clinics that higher level of family support perception was significantly associated with better level of glycaemic control.
Psychological distress often referred to as diabetes distress in the context of T2DM is defined as patient’s concerns about disease management, support, emotional burden and access to care.
It is also defined as unique, often hidden emotional burdens and worries that are part of the spectrum of patient experience when managing a severe, demanding chronic disease like T2DM. 23, 24 DAWN – 2 study revealed a high level of distress among T2DM at diagnosis and later during follow-up, suggesting a possibility of an adverse treatment outcome due to often neglected psychological care in most persons living with DM. This distress often leads to poor drug adherence.
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The prevalence of diabetes distress among American patients was about 18 – 35% and it was found to worsen glycaemic control and increase the risk of DM in pre-diabetic patients. 25 - 29 In this regard, ADA has recommended
that special attention should be paid to diabetes-related distress in order to improve the outcome of diabetes care. 2, 30
STATEMENT OF PROBLEM There is a dramatic rise in diabetes – related morbidities and mortalities in Nigeria due to the challenge of poor glycaemic control among other factors. 31 - 33 It was reported that diabetes patients on minimum wage in Nigeria spent 29% of their salaries in procuring anti-diabetes drugs which made adherence with drugs somewhat unsustainable.
The challenge of poor glycaemic control is further compounded by the decaying infrastructures in most hospitals in Nigeria and inadequate man power.
It has been reported that only about 5 – 10 physicians are charged with the responsibility of caring for 100 to 200 patients across diabetes clinics in Nigeria.
Despite these inadequacies, the effort at harnessing patient-related factors to enhance glycaemic control is still very poor which requires a lot to be improved upon. The end product of this appalling state of diabetes management in Nigeria is the difficulty of achieving good glycaemic control target in over two – thirds of patients with T2DM. 32 – 35 A diabcare – study in Nigeria found that only 32.4% of diabetes patients had good glycaemic
Another diabcare – study in India found a much lower prevalence of good glycaemic control of 19.7% among Indian diabetes patients.
In search for a strategy to improve the clinical outcome of T2DM, clinical guideline has recommended emphasis on appropriate choice of pharmacological agents as well as non- pharmacological factors like drug adherence, diet and exercise but treatment outcome still remains poor in Nigeria. 2, 3, 33
Recently, few studies have been conducted on psychosocial factors like family support, provider collaboration, patient-provider relationship, psychological distress etc. in developed countries but with little attention being paid to these psychosocial factors in developing
countries like Nigeria. 19, 27, 30, 34 It is evident that these important psychosocial factors were contributory to the glycaemic control of T2DM in developed countries and it is gradually being incorporated into their diabetes management guidelines such as the ADA guideline. 2, 30, 35 However, in the developing countries like Nigeria, not much has been done in this regard. In view of the increasing evidence of poor treatment outcome among T2DM patients despite current treatment methods and stringent measures at achieving good glycaemic control, It is therefore important to investigate alternative methods to help improve control of T2DM.
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This study hopes to investigate the role of perceived family support and psychological distress in the glycaemic control of T2DM patients.
JUSTIFICATION FOR THE STUDY The management of T2DM has witnessed unrelenting emphasis on appropriate choice of Pharmacological agents and relevance of non – pharmacological measures such as drug adherence, medical nutrition therapy and exercise but treatment outcome still remains poor in Nigeria. With the unacceptably high level of uncontrolled DM despite stringent measures by Family Physicians and Endocrinologists in achieving glycaemic control among diabetic patients globally especially, SSA, the attention of researchers is needed to be paid on this ugly trend. 13, 33 It is imperative to focus research on under-studied psychosocial factors such as family support and psychological distress in order to determine their influence on glycaemic control as these factors could be the driver of change needed for achieving good glycaemic control. This study expects that assessment of perceived family support at diagnosis and follow-up and structured family intervention when indicated may improve glycaemic control. It is also
expected that assessment of diabetes distress among T2DM patients and ensuring appropriate intervention when necessary may improve glycaemic control. The Family Physicians who are charged with the responsibility of providing well-co- ordinated and comprehensive care in a holistic manner to their patients especially those with chronic diseases such as T2DM are better positioned to fill the gap in knowledge as regard the roles of psychosocial factors in glycaemic control. There have been several studies on the various interventions to improve the glycaemic control of T2DM patients such as methods to improve drug adherence, appropriate choice of drugs and exercise. However, there is paucity of data on the role of family support and psychological distress on glycaemic control in Nigeria and this could potentially contribute to improving T2DM control in Nigeria. This study shall then serve as a template for further interventions in the care of T2DM patients. It is also expected to form the basis for further studies in Family Medicine and in other clinical specialties that are involved in the management of people with T2DM
RESEARCH QUESTIONS 1. What is the difference in the levels of perceived family support among the controlled and uncontrolled T2DM patients? 2. What is the difference in the levels of psychological distress among the controlled and uncontrolled T2DM patients? 3. What is the association between perceived family support and glycaemic control of T2DM patients? 4. What is the association between perceived family support and glycaemic control of T2DM patients?
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STUDY HYPOTHESES 1. Participants with stronger family support have better glycaemic control than participants with weaker family support. 2. Participants with lower level of psychological distress have better glycaemic control than participants with higher level of psychological distress. 3. There is an association between the perceived family support and glycaemic control of T2DM participants. 4. There is an association between psychological distress and glycaemic control of T2DM participants.
AIM To compare the perceived family support and psychological distress among controlled and uncontrolled T2DM patients attending the General Outpatient (GOP) Clinic of Lagos University Teaching Hospital (LUTH) in order to recommend early psychosocial intervention in the management of persons living with T2DM.
OBJECTIVES 1. To compare the level of perceived family support among controlled and uncontrolled T2DM patients attending GOP Clinic of LUTH using Perceived Social Support – Family Scale. 2. To compare the level of psychological distress among controlled and uncontrolled T2DM patients attending GOP Clinic of LUTH using Diabetes Distress Scale. 3. To determine the association between perceived family support and glycaemic control among respondents. 4. To determine the association between psychological distress and glycaemic control among respondents.
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