ARTICLE IN PRESS
PCD-411; No. of Pages 7
p r i m a r y c a r e d i a b e t e s x x x ( 2 0 1 4 ) xxx–xxx
Contents lists available at ScienceDirect
Primary Care Diabetes journal homepage: http://www.elsevier.com/locate/pcd
Original Research
Evaluation of knowledge regarding gestational diabetes mellitus and its association with glycaemic level: A Malaysian study Zahid Hussain ∗ , Zuraidah Mohd Yusoff, Syed Azhar Syed Sulaiman Discipline of Clinical Pharmacy, School of Pharmaceutical Sciences, Universiti Sains Malaysia, Malaysia
a r t i c l e
i n f o
a b s t r a c t
Article history:
Aims: The aim of this study was to evaluate the knowledge about GDM and its corresponding
Received 17 May 2014
relation with glycaemic level in GDM patients.
Received in revised form 2 July 2014
Method: A cross-sectional study was conducted in antenatal clinic of Hospital Pulau Pinang,
Accepted 14 July 2014
Malaysia from June 2013 to December 2013 using Gestational Diabetes Mellitus Knowledge
Available online xxx
Questionnaire (GDMKQ) on the sample of 175 GDM patients. Three most recent fasting
Keywords:
calculated.
GDM
Results: A total of 166 patients were included in final analysis. A total mean knowledge score
Knowledge
of 166 patients was 10.01 ± 3.63 and total mean FPG value was 5.50 ± 1.13. Knowledge had a
plasma glucose (FPG) values (mmol/l) were taken from patients profiles and mean was
Glycaemic level
significant negative association with FPG (r = − 0.306, P < 0.01). Among different knowledge
Educational level
domains, highest mean score was seen for diet/food values domain and lowest for management of GDM. Educational level seems to be the most significant predictor of GDM knowledge and glycaemic control. Highest mean knowledge score and lowest mean glycaemic levels were recorded for patients aged 25–29 years, Malay ethnicity, working women and family history of DM. Conclusion: Higher Knowledge about GDM is related to better glycaemic control. New educational strategies should be developed to improve the lower health literacy. © 2014 Primary Care Diabetes Europe. Published by Elsevier Ltd. All rights reserved.
1.
Introduction
Several studies reported the prevalence of GDM in different countries depending upon the diagnostic criteria used locally. Incidence of GDM is higher in non white population as compared to Caucasian [1]. Prevalence of GDM is highest among Asians and especially among Indian Asians [2].
GDM prevalence ranges from 35 years, family history of diabetes, Asian ethnicity,
∗
Corresponding author. Tel.: +60 102742025; fax: +60 46570017. E-mail addresses: dr [email protected], zh12 [email protected] (Z. Hussain). http://dx.doi.org/10.1016/j.pcd.2014.07.007 1751-9918/© 2014 Primary Care Diabetes Europe. Published by Elsevier Ltd. All rights reserved.
Please cite this article in press as: Z. Hussain, et al., Evaluation of knowledge regarding gestational diabetes mellitus and its association with glycaemic level: A Malaysian study, Prim. Care Diab. (2014), http://dx.doi.org/10.1016/j.pcd.2014.07.007
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p r i m a r y c a r e d i a b e t e s x x x ( 2 0 1 4 ) xxx–xxx
history of caesarean section, macrocosmic baby and still birth [8,9]. A recent study indicated that sleep disturbances may also be associated with glucose intolerance which in turn increases the risk of GDM [10]. Women with GDM are also at increase risk of development of permanent diabetes in future [11,12]. Poorly managed GDM results in number of undesirable maternal–foetal events such as miscarriages, lengthened labour pain, caesarean section, macrosomia, shoulder dystocia, neonatal hypoglycaemia, still birth and neonatal death [7,13–18]. Well controlled GDM results in reduction of these unfavourable outcomes [19]. Proper management of GDM is the most important factor for better health outcomes [20,21]. Management of GDM is principally dependent on active care measures taken by women to keep their glycaemic levels normal [1]. It depends on the sufficient health literacy including patient’s knowledge about normal and abnormal glycaemic values, dietary values, food restraints and importance of physical activity [22–24]. Knowledge is considered as one of the important component of health literacy [25]. Inadequate health literacy is associated with limited knowledge about disease. It results in limited adherence to disease management strategies which in turn leads to unfavourable maternal and foetal outcomes [22,26,27]. Although, a number of studies reporting the knowledge evaluation among type 1 and type 2 DM patients but a literature related to knowledge evaluation among GDM patients is scarce. Therefore, present study aimed to evaluate knowledge of patients suffering from GDM about different aspects of disease including general knowledge about the disease, risk factors, diet, food, complications, prognosis and health outcomes. The secondary objective of this study was to access the association between extent of knowledge and glycaemic levels of study participants.
2.
Method
2.1.
Ethical approval
This study was approved by local hospital Clinical Research Committee (CRC), National Institute of Health (NIH), Malaysia and Medical Research and Ethics Committee (MREC), Malaysia (Ethical approval number 13-612-16135). Patients were informed that participation is entirely voluntary and don’t involve any risk of harm to their health. Written consent was taken from patients prior to enrolment.
2.2.
Participants and setting
A cross sectional study design was used and the study was conducted in the antenatal clinic of Hospital Pulau Pinang, Malaysia. This is the largest tertiary care public hospital in Penang state [28]. The study was conducted from June to December 2013. A total 188 eligible patients were invited and out of which 175 agreed to take part in the study. Inclusion criteria were; patients diagnosed with diabetes during pregnancy, age above 18 years, can read and understand Malaysian Language (Bahasa Melayu) and diagnosed with GDM at least 4 weeks prior to enrolment. Patient information sheet was given to all the patients who met inclusion criteria.
2.3. Development of questionnaire and sampling procedure Data was collected by using self administered questionnaire by a pharmacist (principal investigator). Based on extensive literature review no questionnaire was found that specifically related to knowledge evaluation among GDM patients. Research team designed a questionnaire named Gestational Diabetes Mellitus Knowledge Questionnaire (GDMKQ). Basic theme of questionnaire was taken from Diabetes Knowledge Questionnaire (DKN), a well validated tool for knowledge assessment among type 1 and type 2 diabetes mellitus patients [29]. Some modifications were made and new questions particularly related to GDM were included after a detailed discussion with experts’ team from different healthcare professionals. Questionnaire was validated by experts’ panel including specialists and physicians from obstetrics and gynaecology department of Hospital Pulau Pinang (PH), lecturers of School of Pharmacy of Universiti Sains Malaysia (USM), registered pharmacists, and PhD scholars from pharmacy practice division. Questionnaire was translated and back translated into Bahasa Melayu (National language of Malaysia) to ensure that essential meaning of questionnaire remained preserved and translated version was validated in terms of its face and content validity. After validation and translation questionnaire was piloted on 30 patients to evaluate its reliability. Reliability analysis showed the Cronbach’s alpha of GDMKQ was 0.77. Final version of GDMKQ consists of 15 questions divided into five main categories which are basic knowledge about GDM (3 questions), risk factors (3 questions), food and diet values (3 questions), management (3 questions) and complications/outcomes (3 questions). All questions were in multiple choice format with one option was “I don’t know” to avoid unnecessary guess by the participants. Score 1 was given to every right answer and 0 to every wrong answer. Higher score indicate better knowledge about GDM. Thus the maximum score is 15 and minimum is 0. Glycaemic values were recorded in terms of fasting plasma glucose (FPG). Three most recent values of FPG were taken from patients medical profiles and mean was calculated. Though HbA1c is considered as an accurate marker for glycaemic measurement over a long period of time, but due to short lived nature of GDM, values of HbA1c could not be taken as a standard so as an alternative, values of FPG were taken. Research has shown that Plasma Glucose (PG) has a direct association with HbA1c [30]. As indicated by antenatal care, division of family health development, Ministry of Health, Malaysia, FPG values above ≥5.6 mmol/l indicative of poorly controlled GDM [31].
2.4.
Statistical method
All the statistical analysis was done by using Statistical Package for Social Sciences (SPSS Inc., Chicago, IL) version 20. Number and percentage were used for grouped variables whereas mean and standard deviation was used for continuous variables. Responses to all questions of GDMKQ were recorded in numbers and percentages. Association of demographic characteristics with knowledge score and glycaemic level of patients were represented by using Mann Whitney U
Please cite this article in press as: Z. Hussain, et al., Evaluation of knowledge regarding gestational diabetes mellitus and its association with glycaemic level: A Malaysian study, Prim. Care Diab. (2014), http://dx.doi.org/10.1016/j.pcd.2014.07.007
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Table 1 – Demographic characteristics (n = 166). Variable
Mean ± SD
Age of patients 3
41 (27.4) 78 (47.0) 47 (28.3)
Ethnicity Malay Chinese Indian Indonesian
118 (71.1) 21 (12.7) 19 (11.4) 8 (4.8)
Educational level Primary Secondary Diploma Degree
53 (31.9) 54 (32.5) 34 (20.5) 25 (15.1)
Occupational status Working woman Housewife
108 (65.1) 58 (34.9)
Family history of diabetes Family history of DM No family history of DM
91 (54.8) 75 (45.2)
Type of therapy Diet control Insulin OHA,s
145 (87.3) 21 (12.7) 0 (0)
test (for 2 group variable) and Kruskal Wallis test (for more than 2 group variables). Bonferroni post hoc adjustment was done if significant difference was found by using Kruskal Wallis test. Association between knowledge and FPG was identified by using Spearman rank correlation. For all the statistical analysis P value of >0.05 was considered as significant.
3.
Results
The study included 175 patients of GDM in which 9 were excluded due to incomplete filling of questionnaire. A total of 166 patients were included in the final analysis. The demographic characteristics of patients are presented in Table 1 including the frequency distribution of study participants. Mean age of patients was 31.95 ± 5.35 years ranging from 19 to 44 years. With reference of parity 47.0% had 2nd or 3rd pregnancy. Ethnic distribution was 71.1% Malay, 12.7% Chinese, 11.4% Indian and 4.8% were Indonesian. Majority of patients had primary and secondary level education. A total of 65.1% of participants were working women and more than half (54.8%) had family history of diabetes mellitus. Response to all GDMKQ items is represented in Table 2. Knowledge was recorded in terms of right and wrong answers and is represented in numbers and percentage. Maximum number of right answers were recorded for question 7 (79.5%), 8 (83.1%) and 9 (82.5%) whereas maximum number of wrong answers were noted for question 5 (59.0%), 10 (54.8%) and 12 (44.0%).
3
Mean knowledge score for different knowledge categories is presented in Table 3.The highest mean knowledge score of 2.45 ± 0.77 was noted of diet/food values category, whereas lowest mean knowledge score of 1.62 ± 1.01 was recorded for management domain. Association between demographic variables of 166 study participants with mean knowledge score and mean FPG value is given in Table 4. With reference to total mean knowledge score (10.01 ± 3.63), statistically significant difference was found between age groups, ethnicity, educational level and occupational status (P < 0.05). Mean FPG value of 166 study participants was 5.50 ± 1.13 with 67 (40.4%) patients had glycaemic value above target range (≥5.6 mmol/l). Educational level was only significantly associated with FPG vales (P < 0.01). There was no significant association between glycaemic values and age, ethnicity, occupational status and family history of diabetes. Spearman rank correlation showed that FPG (mean) was significantly correlated with knowledge score (total mean) (r = − 0.306, P < 0.01). Patients with higher level of knowledge had lower glycaemic level. Further categorization of degree of knowledge shown in Table 5 revealed that 94 (54.4%) of patients had adequate knowledge about disease. Patients who had inadequate knowledge had higher mean glycaemic level as compared to patients with adequate knowledge. This association was statistically significant (P < 0.01).
4.
Discussion
The overall findings of this study indicate that patient’s showed the highest knowledge about diet and food values. The most probable reason for this finding is that majority of our study participants (87.3%) were on diet control therapy. Among all the knowledge categories, the lowest knowledge score was observed for the management of the disease. This may lead to difficulties for the patients in following selfmanagement plans, increases the incidence of complications and decreases the coping skills for diabetes and related conditions. A contradictory finding was reported by a study done in Malaysia on type 2 DM patients reported appropriate knowledge related to the management of diabetes [32]. There might be two possible reasons for this difference in the findings. Firstly, our study subjects were GDM patients and due to short lived nature of GDM our subjects were not very much familiar with self management strategies as compared with type 2 DM patients who would be suffering for a longer period. Second possible assumption is the availability of more specialist healthcare professionals in endocrinology including endocrinologists, diabetes educators, clinical pharmacist and nutritionist involved in the management of type 2 DM as compared to obstetrics and genecology department had limited number of diabetes related professionals involved in treatment and management of GDM in present study settings. In the present study significant difference in knowledge score was found in age groups, ethnicity, educational level and occupational status. Patients from age group 25–29 years had highest mean knowledge score among all age groups. This might be due to the reason that majority of patients from this
Please cite this article in press as: Z. Hussain, et al., Evaluation of knowledge regarding gestational diabetes mellitus and its association with glycaemic level: A Malaysian study, Prim. Care Diab. (2014), http://dx.doi.org/10.1016/j.pcd.2014.07.007
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Table 2 – Response of study participants to all GDMKQ items. Questions
Right no. (%)
Wrong no. (%)
Basic knowledge about GDM Q. 1 Gestational Diabetes Mellitus is the type of diabetes that occur: Q. 2 In uncontrolled Gestational Diabetes Mellitus the blood sugar level is: Q. 3 What is the best way for testing blood glucose level for Gestational Diabetes Mellitus patients?
115 (69.3) 116 (69.9) 100 (60.2)
51 (30.7) 50 (30.1) 66 (39.8)
Knowledge about risk factors Q. 4 You are at increased risk of developing Gestational Diabetes Mellitus if you are: Q. 5 You have increased chances of developing Gestational Diabetes mellitus if: Q. 6 You are more likely to develop Gestational Diabetes Mellitus if you have:
124 (74.7) 68 (41.0) 123 (74.1)
42 (25.3) 98 (59.0) 43 (25.9)
132 (79.5) 138 (83.1) 137 (82.5)
34 (20.5) 28 (16.9) 29 (17.5)
75 (45.2) 101 (60.8) 93 (56.0)
91 (54.8) 65 (39.2) 73 (44.0)
119 (71.7) 109 (65.7) 112 (67.5)
47 (28.3) 57 (34.3) 54 (32.5)
Knowledge about diet/food values Q. 7 If you have Gestational Diabetes Mellitus, you should avoid food containing high content of: Q. 8 Which of the following food can be eaten without restriction during Gestational Diabetes Mellitus: Q. 9 What is the type of nutritional source mainly provided by rice? Knowledge about management of GDM Q. 10 The most common sign of hyperglycaemia (high blood sugar) is: Q. 11 The normal value of fasting plasma glucose (FPG) is: Q. 12 If you feel the onset of hypoglycaemic (low blood sugar) symptoms, you should: Knowledge about GDM complications/outcomes Q. 13 In uncontrolled Gestational Diabetes Mellitus your baby may be: Q. 14 If you have Gestational Diabetes Mellitus you have: Q. 15 Gestational Diabetes Mellitus is a condition that:
Score 1 was given to every right answer and score zero was given to every wrong answer. Maximum score is 15 and minimum is 0. Mean knowledge score study participants was 10.01 (SD = 3.63).
age group had university level education. While patients from other three age groups had almost similar knowledge status. Educational level was considered as strongest influencing factor for level of knowledge across all knowledge domains. Patients with primary education had least knowledge score whereas patients who had degree level education showed maximum knowledge score. Poor knowledge seemed to be associated with lower educational standards. Patients with higher educational level might have greater opportunity to get knowledge from health related literature, internet sources and books. Furthermore, they might have fewer barriers in communication with health care professionals. The findings from this study confirmed previous research outcomes showed that education had a strong impact on health literacy. Low educational level leads to low health literacy which results in limited knowledge about disease [33–36]. Patients with low health literacy had limited understanding of patient oriented health literature, clinical appointments cards and medication advices [37]. As for ethnicity, the results showed that Malay ethnic patients exhibited statistically significant highest knowledge about GDM. Chinese and Indian subjects exhibited moderate level of knowledge. Indonesian women had lowest knowledge about GDM and were identified as a group with highest risk of misunderstanding GDM and had difficulties to comply
with the management and treatment plans. Malay, Chinese and Indian participants being the native residents might be more familiar with the healthcare system and culture whereas Indonesian patients being the immigrants were less familiar with health services provided in Malaysia. Bradaran et al. (2008) evaluated the knowledge about diabetes mellitus among native residents and ethnic minorities living in Glasgow also reported that native Caucasian participants had higher knowledge level as compared to migrated Indian and Pakistani patients [38]. Carolan et al. (2010) investigated the knowledge of GDM among multiethnic population in Australia. This study concluded that participants from Indian ethnicity showed highest level of knowledge across all areas of disease as compared to patients from other ethnicity [36]. Another study concluded that ethnicity is an important factor in health information seeking behaviour and knowledge of patients [39]. Other key findings of this study revealed that women who had family history of diabetes and working women possessed higher knowledge. Study participants whose father or mother had diabetes mellitus had higher mean knowledge score. It is assumed that the patients whose family member was diabetic might performed a role of caretaker so they had better understanding and easy accessibility of diabetes related literature. As a result, their knowledge might have increased due to their
Table 3 – Knowledge score for all categories. Knowledge domains Basic Knowledge about GDM Knowledge about risk factors Knowledge about diet and food values Knowledge about management of GDM Knowledge about complications/outcomes Mean total score
Maximum possible score 3 3 3 3 3 15
Mean ± S.D 1.99 1.89 2.45 1.62 2.04 10.01
± ± ± ± ± ±
0.89 1.04 0.77 1.01 1.09 3.63
Please cite this article in press as: Z. Hussain, et al., Evaluation of knowledge regarding gestational diabetes mellitus and its association with glycaemic level: A Malaysian study, Prim. Care Diab. (2014), http://dx.doi.org/10.1016/j.pcd.2014.07.007
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Table 4 – Association between demographics and FPG values (n = 166). Variable
Knowledge (10.01 ± 3.63) Mean ± S.D
FPG (5.50 ± 1.13) Mean ± SD
P value
P value
Agea
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Contents lists available at ScienceDirect
Primary Care Diabetes journal homepage: http://www.elsevier.com/locate/pcd
Original Research
Evaluation of knowledge regarding gestational diabetes mellitus and its association with glycaemic level: A Malaysian study Zahid Hussain ∗ , Zuraidah Mohd Yusoff, Syed Azhar Syed Sulaiman Discipline of Clinical Pharmacy, School of Pharmaceutical Sciences, Universiti Sains Malaysia, Malaysia
a r t i c l e
i n f o
a b s t r a c t
Article history:
Aims: The aim of this study was to evaluate the knowledge about GDM and its corresponding
Received 17 May 2014
relation with glycaemic level in GDM patients.
Received in revised form 2 July 2014
Method: A cross-sectional study was conducted in antenatal clinic of Hospital Pulau Pinang,
Accepted 14 July 2014
Malaysia from June 2013 to December 2013 using Gestational Diabetes Mellitus Knowledge
Available online xxx
Questionnaire (GDMKQ) on the sample of 175 GDM patients. Three most recent fasting
Keywords:
calculated.
GDM
Results: A total of 166 patients were included in final analysis. A total mean knowledge score
Knowledge
of 166 patients was 10.01 ± 3.63 and total mean FPG value was 5.50 ± 1.13. Knowledge had a
plasma glucose (FPG) values (mmol/l) were taken from patients profiles and mean was
Glycaemic level
significant negative association with FPG (r = − 0.306, P < 0.01). Among different knowledge
Educational level
domains, highest mean score was seen for diet/food values domain and lowest for management of GDM. Educational level seems to be the most significant predictor of GDM knowledge and glycaemic control. Highest mean knowledge score and lowest mean glycaemic levels were recorded for patients aged 25–29 years, Malay ethnicity, working women and family history of DM. Conclusion: Higher Knowledge about GDM is related to better glycaemic control. New educational strategies should be developed to improve the lower health literacy. © 2014 Primary Care Diabetes Europe. Published by Elsevier Ltd. All rights reserved.
1.
Introduction
Several studies reported the prevalence of GDM in different countries depending upon the diagnostic criteria used locally. Incidence of GDM is higher in non white population as compared to Caucasian [1]. Prevalence of GDM is highest among Asians and especially among Indian Asians [2].
GDM prevalence ranges from 35 years, family history of diabetes, Asian ethnicity,
∗
Corresponding author. Tel.: +60 102742025; fax: +60 46570017. E-mail addresses: dr [email protected], zh12 [email protected] (Z. Hussain). http://dx.doi.org/10.1016/j.pcd.2014.07.007 1751-9918/© 2014 Primary Care Diabetes Europe. Published by Elsevier Ltd. All rights reserved.
Please cite this article in press as: Z. Hussain, et al., Evaluation of knowledge regarding gestational diabetes mellitus and its association with glycaemic level: A Malaysian study, Prim. Care Diab. (2014), http://dx.doi.org/10.1016/j.pcd.2014.07.007
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p r i m a r y c a r e d i a b e t e s x x x ( 2 0 1 4 ) xxx–xxx
history of caesarean section, macrocosmic baby and still birth [8,9]. A recent study indicated that sleep disturbances may also be associated with glucose intolerance which in turn increases the risk of GDM [10]. Women with GDM are also at increase risk of development of permanent diabetes in future [11,12]. Poorly managed GDM results in number of undesirable maternal–foetal events such as miscarriages, lengthened labour pain, caesarean section, macrosomia, shoulder dystocia, neonatal hypoglycaemia, still birth and neonatal death [7,13–18]. Well controlled GDM results in reduction of these unfavourable outcomes [19]. Proper management of GDM is the most important factor for better health outcomes [20,21]. Management of GDM is principally dependent on active care measures taken by women to keep their glycaemic levels normal [1]. It depends on the sufficient health literacy including patient’s knowledge about normal and abnormal glycaemic values, dietary values, food restraints and importance of physical activity [22–24]. Knowledge is considered as one of the important component of health literacy [25]. Inadequate health literacy is associated with limited knowledge about disease. It results in limited adherence to disease management strategies which in turn leads to unfavourable maternal and foetal outcomes [22,26,27]. Although, a number of studies reporting the knowledge evaluation among type 1 and type 2 DM patients but a literature related to knowledge evaluation among GDM patients is scarce. Therefore, present study aimed to evaluate knowledge of patients suffering from GDM about different aspects of disease including general knowledge about the disease, risk factors, diet, food, complications, prognosis and health outcomes. The secondary objective of this study was to access the association between extent of knowledge and glycaemic levels of study participants.
2.
Method
2.1.
Ethical approval
This study was approved by local hospital Clinical Research Committee (CRC), National Institute of Health (NIH), Malaysia and Medical Research and Ethics Committee (MREC), Malaysia (Ethical approval number 13-612-16135). Patients were informed that participation is entirely voluntary and don’t involve any risk of harm to their health. Written consent was taken from patients prior to enrolment.
2.2.
Participants and setting
A cross sectional study design was used and the study was conducted in the antenatal clinic of Hospital Pulau Pinang, Malaysia. This is the largest tertiary care public hospital in Penang state [28]. The study was conducted from June to December 2013. A total 188 eligible patients were invited and out of which 175 agreed to take part in the study. Inclusion criteria were; patients diagnosed with diabetes during pregnancy, age above 18 years, can read and understand Malaysian Language (Bahasa Melayu) and diagnosed with GDM at least 4 weeks prior to enrolment. Patient information sheet was given to all the patients who met inclusion criteria.
2.3. Development of questionnaire and sampling procedure Data was collected by using self administered questionnaire by a pharmacist (principal investigator). Based on extensive literature review no questionnaire was found that specifically related to knowledge evaluation among GDM patients. Research team designed a questionnaire named Gestational Diabetes Mellitus Knowledge Questionnaire (GDMKQ). Basic theme of questionnaire was taken from Diabetes Knowledge Questionnaire (DKN), a well validated tool for knowledge assessment among type 1 and type 2 diabetes mellitus patients [29]. Some modifications were made and new questions particularly related to GDM were included after a detailed discussion with experts’ team from different healthcare professionals. Questionnaire was validated by experts’ panel including specialists and physicians from obstetrics and gynaecology department of Hospital Pulau Pinang (PH), lecturers of School of Pharmacy of Universiti Sains Malaysia (USM), registered pharmacists, and PhD scholars from pharmacy practice division. Questionnaire was translated and back translated into Bahasa Melayu (National language of Malaysia) to ensure that essential meaning of questionnaire remained preserved and translated version was validated in terms of its face and content validity. After validation and translation questionnaire was piloted on 30 patients to evaluate its reliability. Reliability analysis showed the Cronbach’s alpha of GDMKQ was 0.77. Final version of GDMKQ consists of 15 questions divided into five main categories which are basic knowledge about GDM (3 questions), risk factors (3 questions), food and diet values (3 questions), management (3 questions) and complications/outcomes (3 questions). All questions were in multiple choice format with one option was “I don’t know” to avoid unnecessary guess by the participants. Score 1 was given to every right answer and 0 to every wrong answer. Higher score indicate better knowledge about GDM. Thus the maximum score is 15 and minimum is 0. Glycaemic values were recorded in terms of fasting plasma glucose (FPG). Three most recent values of FPG were taken from patients medical profiles and mean was calculated. Though HbA1c is considered as an accurate marker for glycaemic measurement over a long period of time, but due to short lived nature of GDM, values of HbA1c could not be taken as a standard so as an alternative, values of FPG were taken. Research has shown that Plasma Glucose (PG) has a direct association with HbA1c [30]. As indicated by antenatal care, division of family health development, Ministry of Health, Malaysia, FPG values above ≥5.6 mmol/l indicative of poorly controlled GDM [31].
2.4.
Statistical method
All the statistical analysis was done by using Statistical Package for Social Sciences (SPSS Inc., Chicago, IL) version 20. Number and percentage were used for grouped variables whereas mean and standard deviation was used for continuous variables. Responses to all questions of GDMKQ were recorded in numbers and percentages. Association of demographic characteristics with knowledge score and glycaemic level of patients were represented by using Mann Whitney U
Please cite this article in press as: Z. Hussain, et al., Evaluation of knowledge regarding gestational diabetes mellitus and its association with glycaemic level: A Malaysian study, Prim. Care Diab. (2014), http://dx.doi.org/10.1016/j.pcd.2014.07.007
PCD-411; No. of Pages 7
ARTICLE IN PRESS p r i m a r y c a r e d i a b e t e s x x x ( 2 0 1 4 ) xxx–xxx
Table 1 – Demographic characteristics (n = 166). Variable
Mean ± SD
Age of patients 3
41 (27.4) 78 (47.0) 47 (28.3)
Ethnicity Malay Chinese Indian Indonesian
118 (71.1) 21 (12.7) 19 (11.4) 8 (4.8)
Educational level Primary Secondary Diploma Degree
53 (31.9) 54 (32.5) 34 (20.5) 25 (15.1)
Occupational status Working woman Housewife
108 (65.1) 58 (34.9)
Family history of diabetes Family history of DM No family history of DM
91 (54.8) 75 (45.2)
Type of therapy Diet control Insulin OHA,s
145 (87.3) 21 (12.7) 0 (0)
test (for 2 group variable) and Kruskal Wallis test (for more than 2 group variables). Bonferroni post hoc adjustment was done if significant difference was found by using Kruskal Wallis test. Association between knowledge and FPG was identified by using Spearman rank correlation. For all the statistical analysis P value of >0.05 was considered as significant.
3.
Results
The study included 175 patients of GDM in which 9 were excluded due to incomplete filling of questionnaire. A total of 166 patients were included in the final analysis. The demographic characteristics of patients are presented in Table 1 including the frequency distribution of study participants. Mean age of patients was 31.95 ± 5.35 years ranging from 19 to 44 years. With reference of parity 47.0% had 2nd or 3rd pregnancy. Ethnic distribution was 71.1% Malay, 12.7% Chinese, 11.4% Indian and 4.8% were Indonesian. Majority of patients had primary and secondary level education. A total of 65.1% of participants were working women and more than half (54.8%) had family history of diabetes mellitus. Response to all GDMKQ items is represented in Table 2. Knowledge was recorded in terms of right and wrong answers and is represented in numbers and percentage. Maximum number of right answers were recorded for question 7 (79.5%), 8 (83.1%) and 9 (82.5%) whereas maximum number of wrong answers were noted for question 5 (59.0%), 10 (54.8%) and 12 (44.0%).
3
Mean knowledge score for different knowledge categories is presented in Table 3.The highest mean knowledge score of 2.45 ± 0.77 was noted of diet/food values category, whereas lowest mean knowledge score of 1.62 ± 1.01 was recorded for management domain. Association between demographic variables of 166 study participants with mean knowledge score and mean FPG value is given in Table 4. With reference to total mean knowledge score (10.01 ± 3.63), statistically significant difference was found between age groups, ethnicity, educational level and occupational status (P < 0.05). Mean FPG value of 166 study participants was 5.50 ± 1.13 with 67 (40.4%) patients had glycaemic value above target range (≥5.6 mmol/l). Educational level was only significantly associated with FPG vales (P < 0.01). There was no significant association between glycaemic values and age, ethnicity, occupational status and family history of diabetes. Spearman rank correlation showed that FPG (mean) was significantly correlated with knowledge score (total mean) (r = − 0.306, P < 0.01). Patients with higher level of knowledge had lower glycaemic level. Further categorization of degree of knowledge shown in Table 5 revealed that 94 (54.4%) of patients had adequate knowledge about disease. Patients who had inadequate knowledge had higher mean glycaemic level as compared to patients with adequate knowledge. This association was statistically significant (P < 0.01).
4.
Discussion
The overall findings of this study indicate that patient’s showed the highest knowledge about diet and food values. The most probable reason for this finding is that majority of our study participants (87.3%) were on diet control therapy. Among all the knowledge categories, the lowest knowledge score was observed for the management of the disease. This may lead to difficulties for the patients in following selfmanagement plans, increases the incidence of complications and decreases the coping skills for diabetes and related conditions. A contradictory finding was reported by a study done in Malaysia on type 2 DM patients reported appropriate knowledge related to the management of diabetes [32]. There might be two possible reasons for this difference in the findings. Firstly, our study subjects were GDM patients and due to short lived nature of GDM our subjects were not very much familiar with self management strategies as compared with type 2 DM patients who would be suffering for a longer period. Second possible assumption is the availability of more specialist healthcare professionals in endocrinology including endocrinologists, diabetes educators, clinical pharmacist and nutritionist involved in the management of type 2 DM as compared to obstetrics and genecology department had limited number of diabetes related professionals involved in treatment and management of GDM in present study settings. In the present study significant difference in knowledge score was found in age groups, ethnicity, educational level and occupational status. Patients from age group 25–29 years had highest mean knowledge score among all age groups. This might be due to the reason that majority of patients from this
Please cite this article in press as: Z. Hussain, et al., Evaluation of knowledge regarding gestational diabetes mellitus and its association with glycaemic level: A Malaysian study, Prim. Care Diab. (2014), http://dx.doi.org/10.1016/j.pcd.2014.07.007
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Table 2 – Response of study participants to all GDMKQ items. Questions
Right no. (%)
Wrong no. (%)
Basic knowledge about GDM Q. 1 Gestational Diabetes Mellitus is the type of diabetes that occur: Q. 2 In uncontrolled Gestational Diabetes Mellitus the blood sugar level is: Q. 3 What is the best way for testing blood glucose level for Gestational Diabetes Mellitus patients?
115 (69.3) 116 (69.9) 100 (60.2)
51 (30.7) 50 (30.1) 66 (39.8)
Knowledge about risk factors Q. 4 You are at increased risk of developing Gestational Diabetes Mellitus if you are: Q. 5 You have increased chances of developing Gestational Diabetes mellitus if: Q. 6 You are more likely to develop Gestational Diabetes Mellitus if you have:
124 (74.7) 68 (41.0) 123 (74.1)
42 (25.3) 98 (59.0) 43 (25.9)
132 (79.5) 138 (83.1) 137 (82.5)
34 (20.5) 28 (16.9) 29 (17.5)
75 (45.2) 101 (60.8) 93 (56.0)
91 (54.8) 65 (39.2) 73 (44.0)
119 (71.7) 109 (65.7) 112 (67.5)
47 (28.3) 57 (34.3) 54 (32.5)
Knowledge about diet/food values Q. 7 If you have Gestational Diabetes Mellitus, you should avoid food containing high content of: Q. 8 Which of the following food can be eaten without restriction during Gestational Diabetes Mellitus: Q. 9 What is the type of nutritional source mainly provided by rice? Knowledge about management of GDM Q. 10 The most common sign of hyperglycaemia (high blood sugar) is: Q. 11 The normal value of fasting plasma glucose (FPG) is: Q. 12 If you feel the onset of hypoglycaemic (low blood sugar) symptoms, you should: Knowledge about GDM complications/outcomes Q. 13 In uncontrolled Gestational Diabetes Mellitus your baby may be: Q. 14 If you have Gestational Diabetes Mellitus you have: Q. 15 Gestational Diabetes Mellitus is a condition that:
Score 1 was given to every right answer and score zero was given to every wrong answer. Maximum score is 15 and minimum is 0. Mean knowledge score study participants was 10.01 (SD = 3.63).
age group had university level education. While patients from other three age groups had almost similar knowledge status. Educational level was considered as strongest influencing factor for level of knowledge across all knowledge domains. Patients with primary education had least knowledge score whereas patients who had degree level education showed maximum knowledge score. Poor knowledge seemed to be associated with lower educational standards. Patients with higher educational level might have greater opportunity to get knowledge from health related literature, internet sources and books. Furthermore, they might have fewer barriers in communication with health care professionals. The findings from this study confirmed previous research outcomes showed that education had a strong impact on health literacy. Low educational level leads to low health literacy which results in limited knowledge about disease [33–36]. Patients with low health literacy had limited understanding of patient oriented health literature, clinical appointments cards and medication advices [37]. As for ethnicity, the results showed that Malay ethnic patients exhibited statistically significant highest knowledge about GDM. Chinese and Indian subjects exhibited moderate level of knowledge. Indonesian women had lowest knowledge about GDM and were identified as a group with highest risk of misunderstanding GDM and had difficulties to comply
with the management and treatment plans. Malay, Chinese and Indian participants being the native residents might be more familiar with the healthcare system and culture whereas Indonesian patients being the immigrants were less familiar with health services provided in Malaysia. Bradaran et al. (2008) evaluated the knowledge about diabetes mellitus among native residents and ethnic minorities living in Glasgow also reported that native Caucasian participants had higher knowledge level as compared to migrated Indian and Pakistani patients [38]. Carolan et al. (2010) investigated the knowledge of GDM among multiethnic population in Australia. This study concluded that participants from Indian ethnicity showed highest level of knowledge across all areas of disease as compared to patients from other ethnicity [36]. Another study concluded that ethnicity is an important factor in health information seeking behaviour and knowledge of patients [39]. Other key findings of this study revealed that women who had family history of diabetes and working women possessed higher knowledge. Study participants whose father or mother had diabetes mellitus had higher mean knowledge score. It is assumed that the patients whose family member was diabetic might performed a role of caretaker so they had better understanding and easy accessibility of diabetes related literature. As a result, their knowledge might have increased due to their
Table 3 – Knowledge score for all categories. Knowledge domains Basic Knowledge about GDM Knowledge about risk factors Knowledge about diet and food values Knowledge about management of GDM Knowledge about complications/outcomes Mean total score
Maximum possible score 3 3 3 3 3 15
Mean ± S.D 1.99 1.89 2.45 1.62 2.04 10.01
± ± ± ± ± ±
0.89 1.04 0.77 1.01 1.09 3.63
Please cite this article in press as: Z. Hussain, et al., Evaluation of knowledge regarding gestational diabetes mellitus and its association with glycaemic level: A Malaysian study, Prim. Care Diab. (2014), http://dx.doi.org/10.1016/j.pcd.2014.07.007
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Table 4 – Association between demographics and FPG values (n = 166). Variable
Knowledge (10.01 ± 3.63) Mean ± S.D
FPG (5.50 ± 1.13) Mean ± SD
P value
P value
Agea
