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Diabetes awareness in general population in Cameroon
diabetes research and clinical practice 90 (2010) 312–318
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Diabetes Research and Clinical Practice jou rna l hom ep ag e: w ww.e lse v ier .com/ loca te /d iab res
Diabetes awareness in general population in Cameroon Leopold Fezeu a,b,c,*, Emma Fointama a, George Ngufor a, George Mbeh a, Jean-Claude Mbanya a a
Health of Populations in Transition Research Group, Cameroon Inserm U780 – IFR69, Villejuif, France c Univ Paris XI, France b
article info
abstract
Article history:
Background: A good knowledge about diabetes could lead to early diagnosis and improved
Received 12 May 2010
management.
Accepted 28 June 2010
Objective: To evaluate the level of diabetes awareness in Cameroonians, and to identify
Published on line 8 October 2010
factors that influence this awareness. Methods: In subjects aged 25 years (n = 1000, 93.4% of response), details regarding risk
Keywords:
factors, symptoms, treatment and complications of type 2 diabetes were collected. One
Type II diabetes
mark was attributed to each true answer and a global diabetes awareness score was
Developing countries
computed. Influence of age, gender, educational level, occupational level, notion of a relative
Sub-Saharan Africa
having a chronic condition and presence of chronic disease were analyzed.
Diabetes awareness
Results: Eighty percent of subjects scored more than the total mean score. The highest score
Patient education
obtained by participants (0.10%) was 28/30. The mean total score was higher in men ( p < 0.02) and in subjects with a relative having a chronic condition ( p < 0.001). In multivariate analyses, age classes ( p < 0.01), educational level ( p < 0.001) and relatives with a chronic condition ( p < 0.001) were associated to the global diabetes awareness score. Conclusions: Diabetes awareness was generally good. This may be due to the fact that the study was conducted in an area where health promotion and health education on diabetes have been intensively delivered for the past 4 years. # 2010 Published by Elsevier Ireland Ltd.
1.
Introduction
Diabetes mellitus (DM) continues to be a major threat to global public health [1,2]. More than 170 million people worldwide have diabetes, and this burden is projected to more than double by the year 2030, if current trends continue [3]. The global increase in diabetes prevalence is mainly associated to the ageing of population, the unhealthy diets and sedentary lifestyles that increase the propensity of individuals towards obesity [4,5]. There is growing evidence that preventing and/or delaying the onset of diabetes can be achieved by adopting healthy lifestyles [6,7]. Increased
physical activity, modest weight reduction, and pharmacological interventions can decrease the incidence of diabetes complications significantly, even among high-risk groups. Simple lifestyle modifications, such as a healthy diet that includes reducing sugar intake, are considered to be essential for the prevention and control of incident diabetes mellitus [6–8]. Thus, increasing public awareness regarding modifiable diabetes risk factors and healthier lifestyles, and developing strategies to identify and manage at-risk populations, are among the various possible mechanisms being used to reduce the present epidemic of diabetes in many parts of the world.
* Corresponding author at: Nutritional epidemiology and research unit (UREN), U557 Inserm, U1125 Inra, Cnam, Universite´ Paris 13, CRNH Idf, SMBH, 74 rue Marcel Cachin, 93017 Bobigny, France. Tel.: +331 48 38 89 61. E-mail addresses: [email protected], [email protected] (L. Fezeu). 0168-8227/$ – see front matter # 2010 Published by Elsevier Ireland Ltd. doi:10.1016/j.diabres.2010.06.029
diabetes research and clinical practice 90 (2010) 312–318
The Cameroon Burden of Diabetes (CamBoD) Project, funded by the World Diabetes Foundation, was set up in Cameroon in order to improve the early detection, better management, and follow-up of the complications of type 2 diabetes, as well as to increase the knowledge of the general population on the risks factors, symptoms and complications of diabetes. During the initial phase of this project, the prevalence of diabetes in Cameroon in 2003 was 6.4%, compared with 0.9% in 1994, representing a very high increase over a single decade [9,10]. Considering the relative low cost of health promotion on diabetes compared to the management of its complications, and benefits of improved awareness, it is important to know the level of awareness of a community to help in the planning of a health promotion intervention. Exploring of barriers set up due to ignorance and wrong beliefs on diabetes, will aid in setting up a more adapted approach to increasing the level of awareness. This study was carried out to find out the level of awareness on diabetes in an adult Cameroonian population exposed to health promotion about diabetes.
2.
Methods
2.1.
Study site and study population
A cross-sectional community based study was conducted between August and September 2006 at the Bamenda health district, located in the North West province of Cameroon. The Bamenda health district is one of the five health districts of Mezam division. It is made up of 13 health areas with a total population of 210,799 inhabitants. The health areas of Azire, Ntamulung, Ntambag, and Nkwen Urban were selected for this study. Adults aged 25 years and above resident in Bamenda health district during the period of recruitment, constituted the target population. A two-stage recruitment procedure was used to obtain the sample. The first stage consisted of a census of all households in the Azire, Ntambag, Ntamulung and Nkwen Urban health areas with subjects aged 25 years or more. Each health area was divided into zones and every household numbered in that zone. For each household numbered a census form was filled indicating the phone number of the household head, the quarter, the number of persons in that household aged 25 years, and the best period to be visited for an interview. The census provided a database of 3058 households from which the sample of households was selected. A random sample of 582 households was selected after the census and all the subjects aged 25 years residing in the selected households were included in the study. In each selected household informed consent was sought from the head of the household for inclusion in the study. Thereafter an appointment was taken with him for the structured questionnaire to be administered. On the appointed date and time, a survey worker visited the household and each member of the household fulfilling the inclusion criteria was interviewed.
2.2.
Data collection
To facilitate data collection 10 survey workers with at least a university degree were recruited and trained on the study
313
methodology, tested and certified to the survey methods. Eight survey workers fulfilled the certification criteria (administration of the questionnaire) and were retained to work. A pilot study was carried out to validate the questionnaire. This validation was mainly oriented on the comprehension of the questions by the study participants. It also sought to check the acceptability of the questionnaire, calculate the average time per interview and to revise poorly phrased questions. Data collection used structured interviews. The questionnaire requested information in the following sections: demographic information: the age, gender, marital status, level of education and profession, personal and family history of diabetes, hypertension and stroke, as well as current drug usage, knowledge on the risk factors of diabetes (nine items, maximum score: nine), Knowledge on the sign and symptoms of diabetes (seven items, maximum score: seven), knowledge of complications of diabetes (10 items, maximum score: 10), knowledge on the management and prevention of diabetes (three items, maximum score: four because one item had two true answers), various sources of information on diabetes. Each section on risks factors, signs and symptoms, complications and management of diabetes had true and wrong items, in order to avoid having a high score by chance. One mark was given to each true answer. The maximum global diabetes awareness score that a participant could obtain was 30. Thirty-three households selected refused to participate in the study, giving a non-response rate of 6.6%. The reasons advanced for the non-response were: refusal to participate: 75.7%; no longer interested in the study: 6.1%; participants of household traveled after the census, before the interview: 15.1%; hostility of the household residents when approached for the interview: 3.1%. All the questionnaires used for the analysis were valid and complete. The results below are thus based on 1000 validated questionnaires from 543 households. The number of adults per household ranged from one to five, with a mean of 1.8 subjects per household.
2.3.
Data management and data analysis
The subjects declaring having a personal history of diabetes, hypertension or stroke and under treatment were classified as having known chronic condition. Also, subjects with a close relative suffering from at least one of the three above cited condition were classified as having a relative with chronic condition. Three categories of educational level were constituted: primary or less (less than 7 years of education), secondary (between 7 and 14 years of education), and
314
diabetes research and clinical practice 90 (2010) 312–318
university (more than 14 years of education). Study participants were classified as married if they were married or lived together, and as single if otherwise. Three categories of occupational levels were constituted: employed (government and non-government employees), self-employed, and others (retired, student and housewives). Body mass Index (BMI) was computed using the declared weight (in kg) and the height (in meter) of the study participants and categorized using the WHO classification: underweight (BMI < 18.5 kg/m2), normal weight (18.5 BMI < 25), overweight (25 BMI < 30), obese (BMI 30 kg/m2). As only five subjects were underweight, the first two categories were merged. Data analyses used STATA 10.11, taking into account the sample technique. Results are expressed as means (standard error of the mean, SEM) or median (25th–75th percentiles) for quantitative variables and frequencies (percentages) for qualitative variables. Linear regression models in univariate and multivariate analyses with log transformed scores as dependent variables were used to study the associations between awareness about diabetes and age classes, gender, marital status, educational level, occupational level, having relatives with chronic condition, having a chronic condition, and BMI classes. All the tests were two-sided and significant level was set at p < 0.05.
2.4.
Ethical considerations
Approvals for this study were obtained from the National Ethical Committee of the Ministry of Health, the Minister of
Health and local administrative and traditional authorities prior to starting the study. Written informed consent was obtained from each study participant.
3.
Results
3.1.
General characteristics of the study population
Women represented 51% of the study population. The age ranged from 25 to 94 years. The mean age was 38.6 (SD: 12.9). The educational level of the study population was high, with 20.7% of them having university level. Although the prevalence of known diabetes was as low as 1.3%, 53.1% of the study participants knew a relative with type 2 diabetes, hypertension or stroke (Table 1). Men were almost 3 years older than women (40.0 years versus 37.3 years, p < 0.001). Also, they were more educated (university: 26.7% versus 15.0%, p < 0.001) and more often employed (72.5% versus 56.5%, p < 0.001). Women had higher self-reported BMI.
3.2.
Scores obtained by the study population
Table 2 displays the responses obtained from participants for each category of knowledge. The maximum diabetes awareness score was not obtained. The highest score was 28, obtained by one subject. As high as 80.3% of the study population obtained at least the average total score. However, 0.4% of study participants obtained the maximum
Table 1 – General characteristics of the study population stratified on gender:. Characteristics N Age, years (SD)
Women
Men
514 37.3 (12.2)
486 40.0 (13.5)
Age classes (%) 25–34 35–44 45–54 55+
52.1 22.2 15.8 9.9
44.0 24.3 16.1 15.6
Educational level (%) Primary or less Secondary University
38.9 46.1 15.0
28.2 45.1 26.7
Occupational level (%) Employed Auto-employed Others
21.7 34.8 43.5
30.3 42.2 27.5
Marital status (%) Single Married
35.2 64.8
37.0 63.0
BMI, kg/m2 (SD)
28.0 (5.0)
25.7 (3.2)
BMI classes (%) Normal weight Overweight Obese
30.0 41.2 29.8
41.8 49.4 8.8
Have relatives with chronic disease (%) Known diabetes (%) Known chronic diseases (%)
48.0 1.8 4.1
45.7 1.0 2.3
p 0.001 0.02
0.001
0.001
0.5
0.001 0.001
0.5 0.3 0.07
diabetes research and clinical practice 90 (2010) 312–318
Table 2 – Risk factors, symptoms, treatment and complications of diabetes (number of subjects prompting the items and relevant percentages) according to the study population. n
%
Risk factors of diabetes High intake of sugar Lack of physical activity Family history of diabetes Mosquito bites causes diabetes Excessive alcohol consumption Excess weight Sexual intercourse Inheritance Smoking
984 904 773 52 227 947 896 544 735
98.4 90.4 77.3 5.2 22.7 94.7 89.6 54.4 73.5
Symptoms of diabetes Frequent thirst Constant urination Weight loss Tiredness Dizziness Blurriness of vision Rapid breathing
708 854 608 855 823 726 626
70.8 85.4 60.8 85.5 82.3 72.6 62.6
Treatment of diabetes Diabetes treatment modality Medical treatment Medical and traditional treatment Traditional treatment Others Diabetes can be prevented Long term complications of diabetes can be prevented 657 Complications of diabetes Renal complications Liver cancer Neurologic complications Arthritis Diabetes foot Heart complications Stroke Eyes complications Asthma Sexual impotence
857 105 25 13 911 657
85.7 10.5 2.5 1.3 91.1 65.7
72.8 23.5 66.5 38.5 73.6 69.5 73.3 67.7 49.1 34.7
score for risks factors of diabetes, 39.5% for symptoms of diabetes, 56.3% for diabetes treatment and 1.3% for diabetes complications.
3.3.
Treatment of diabetes score Being a man, having a high educational level, having a chronic disease and BMI classes were associated with the knowledge about diabetes treatment. In multivariate analyses, having a chronic condition was no longer significant. Complications of diabetes score Knowledge about the complications of diabetes was associated with gender, age classes, educational level and having a relative with chronic disease. Gender was no more significant in multivariate analyses. Global diabetes awareness score All the study risk factors, except martial status, profession and personal history of chronic disease were associated with the global diabetes awareness score. In multivariate analyses, only age classes, educational level and having a relative with chronic disease remained significant (Table 4). Diabetes status, marital status and professional level were not associated to any knowledge score (data not shown).
3.4.
Factors influencing knowledge about diabetes
Risk factors of diabetes score In univariate (Table 3) and multivariate analyses, only gender (4.9 versus 5.2, p < 0.001) and educational level were positively associated with the risk factors of diabetes. Symptoms of diabetes score In univariate symptoms of diabetes score increased with educational level ( p < 0.001) and having a relative with chronic disease, and decreased as the BMI increased. When all these factors were included in the same model, educational level ( p < 0.001) and relatives with chronic disease ( p < 0.001) remained significant.
Main sources of information
The three most cited sources of information were health facilities (90.6%, Table 5), followed-up by TV/radios (88.7%) and health education material (poster/sticker/leaflet: 80.7%). Seventy-five percent of the study participants used more than four sources of information.
4. 728 235 665 385 736 695 733 677 491 347
315
Discussion
This is one of the rare studies in Africa evaluating population awareness regarding type II diabetes. This study showed that educational level, age and having a close relative suffering from type II diabetes, hypertension or stroke were associated with good knowledge on risk factors, symptoms, treatment and complications of type II diabetes. These findings have major implications concerning diabetes prevention and health promotion activities in Cameroon. We demonstrated that educational level have a direct influence on the extent of knowledge regarding the risk factors, symptoms, complications and management of diabetes. This finding is congruent with other studies [11,12] albeit with a few exceptions [13]. Main sources of information in Cameroon about diabetes are in French or in English, which are not the native language of the population. It seems therefore logical that the comprehension of that information and its translation in habitual lifestyle could be tributary to the level of education. The level of knowledge of less educated participants was not such low, as much of the time, their mean score was above the median. This is the result of efforts developed by broadcasting some health education session in native languages, and by using as much as possible, for health promotion activities, personnel able to speak native languages. To reduce the gap in diabetes awareness related to the level of education, this method of health promotion should be more generalised, and new health promotion methods thought out. Knowing a relative having hypertension, diabetes or stroke also appears to influence the level of knowledge on diabetes. Individuals with a positive family history of a disease may
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diabetes research and clinical practice 90 (2010) 312–318
Table 3 – Scores (mean and SD) associated with each factor potentially influencing the knowledge about diabetes in Cameroon. n
Risks factors
Maximum awareness score
9
7
4
Gender ( p) Women Men
514 486
0.001 4.9 (1.3) 5.2 (1.1)
0.2 5.1 (2.1) 5.3 (2.1)
0.001 3.3 (0.8) 3.5 (0.8)
0.01 5.5 (2.6) 5.9 (2.4)
0.02 18.8 (4.7) 19.8 (5.2)
Age classes ( p) 25–34 35–44 45–54 55+
482 232 159 127
0.3 5.0 4.9 5.1 5.2
0.4 5.1 5.2 5.3 5.4
0.2 3.3 3.5 3.4 3.4
(0.9) (0.8) (0.8) (0.7)
0.02 5.5 (2.5) 5.6 (2.6) 6.0 (2.4) 6.1 (2.2)
0.04 19.0 (4.9) 19.2 (5.2) 19.2 (5.2) 20.2 (4.5)
Educational level ( p) Primary or less Secondary University
337 456 207
0.001 4.8 (1.3) 5.0 (1.2) 5.5 (0.9)
0.001 4.9 (2.3) 5.2 (2.2) 5.7 (1.4)
0.001 3.3 (0.9) 3.4 (0.8) 3.5 (0.7)
0.001 5.1 (2.7) 5.7 (2.4) 6.6 (2.0)
0.001 18.1 (5.4) 19.3 (5.0) 21.3 (3.3)
Relative with chronic disease ( p) Yes No
469 531
0.9 5.0 (1.1) 5.1 (1.3)
0.001 5.5 (2.1) 4.9 (2.2)
0.001 3.5 (0.7) 3.3 (0.9)
0.001 6.1 (2.2) 5.3 (2.7)
0.001 20.1 (4.4) 18.6 (5.3)
Personal history chronic disease ( p) Yes No
32 968
0.7 5.0 (1.9) 5.1 (1.2)
0.1 5.8 (1.8) 5.2 (2.1)
0.001 3.4 (1.0) 2.8 (0.8)
0.4 5.7 (2.5) 5.3 (2.1)
0.6 18.9 (5.3) 19.3 (4.9)
BMI classes Normal weight (<25 kg/m2) Overweight (25–29.9 kg/m2) Obese (30 kg/m2)
352 452 196
0.09 5.0 (1.3) 5.1 (1.1) 4.9 (1.3)
0.01 5.1 (2.2) 5.4 (2.1) 4.9 (2.0)
0.03 3.4 (0.8) 3.5 (0.8) 3.3 (0.9)
0.09 5.7 (2.4) 5.8 (2.5) 5.4 (2.7)
0.005 19.2 (4.9) 19.8 (4.8) 18.5 (5.2)
(1.2) (1.3) (1.3) (1.1)
develop a personal sense of vulnerability, which in turn may increase their awareness [14]. Risk perception is an essential concept in a number of theoretical models addressing healthprotective behaviours. Perceived risk is considered to be the primary motivation to change within the Health Belief Model, which assumes that, the higher the perceived risk related to the condition is, the more likely an individual will modify his or her behaviour to lower the risk [15]. A positive family history of a disease, and one’s gender, age and perceptions of disease seriousness may affect one’s level of perceived risk. In support of this view, Harwell et al. found that family history is the factor most significantly associated with the perceived risk of developing diabetes [16]. However, Pierce et al., in their randomized controlled trial, found that the family members of
Table 4 – Factors affecting the global score in multivariate analyses. Significant variables
b-Coefficient (95% CI)
p-Value
Age classes 25–34 35–44 45–54 55+
0 0.19 ( 0.58–0.96) 1.03 (0.14–1.93) 1.53 (0.49–2.57)
0.01 – 0.6 0.02 0.004
Educational level Primary or less Secondary University
0 1.37 (0.68–2.06) 2.95 (2.09–3.81)
0.001 – 0.001 0.001
Relatives with chronic disease No Yes
0 1.41 (0.81–2.01)
0.001 – 0.001
Symptoms
(2.1) (2.2) (2.1) (2.1)
Treatment
Complications 10
Global score 30
individuals with type II diabetes underestimate their own risk of developing the disease [17]. Factors influencing perceptions of family history may vary between individuals and between diseases. In the available literature and present findings, it has emerged that perceived risk might be important to motivate preventative health behaviours and control of disease [14]. Also, in Cameroon, family members actively participate in the care in the management of subjects with chronic conditions, particularly diabetes, by accompanying them to health care, by contributing financially for drugs and laboratory examinations. These surely increased the contact with health promotion activities regarding diabetes, and therefore their level of knowledge and awareness. In contrary to other studies [18], diabetes status was not associated to higher diabetes awareness. This could be due to a lack of power, as few study participants were diabetics. The high level of awareness of the study population, which make differences with the diabetic population difficult to demonstrate, could also explain it. Some limitations of this study should be highlighted. First, the findings of this study cannot be generalized to Cameroon, as the data were derived from a semi-urban area. Second, as the four sites yielding CamBoD pilot study, the population of Bamenda was exposed during 3 years to intensive health promotion activities using all conventional (mass media, health facilities, distribution of health education materials) and non-conventional (meetings in market places, in churches/mosques, health education activities in schools, drama on diabetes in TV/radios) methods. Therefore, the awareness about diabetes in Bamenda can be reasonably thought to be higher than in the rest of the country. However, these findings lay the groundwork for further similar studies
diabetes research and clinical practice 90 (2010) 312–318
Table 5 – Main sources of information about diabetes. n 906 887 807 667 509 397 389
90.6 88.7 80.7 66.7 50.9 39.7 38.9
Number of multiple sources No source cited One Two Three Four Five or more
24 28 60 141 207 540
2.4 2.8 6.0 14.1 20.7 54.0
in other parts of the country. To accommodate individuals who might be illiterate, the items were read to the subjects, rather than allowing them to self-administer the questionnaire. It is possible that this approach might have resulted in subject reluctance to reveal sensitive feelings that may have been more fully elicited in a self-administered questionnaire. Having said this, the questionnaire was specifically devised not to pry into people’s private lives; consequently, there is no explicit reason to suspect that subjects would be reluctant to respond honestly. There also tends to be culturally specific responses to questionnaires [19], a potential bias that was not explored in the present study, and which might have played a role, given that the study relied almost exclusively on selfreported, subjective data. These limitations and countless others that were not apparent, but are yet common in psychosocial studies, suggest that extrapolating the present findings to other populations should be viewed with caution. This study has demonstrated that significant numbers of Cameroonians have the knowledge and perceptions required to prevent and cope with the increasing prevalence of diabetes. It strongly implicates level of education as the most significant predictor of desirable knowledge and perceptions of diabetes risk factors, complications and prevention. This raises optimism that health education could be a powerful tool as we strive to develop strategies to fight against diabetes and other chronic conditions in Cameroon, health situations that often are amenable to lifestyle changes and, by implication, education. However, there is a great difference between acquiring knowledge about a disease and using this knowledge to prevent the occurrence of the disease or to better manage the disease when it has occurred. Studies are needed to investigate the translation of this knowledge in lifestyles and life attitudes benefit for health.
Acknowledgement This project was funded by a grant from the World Health Organisation.
There are no conflicts of interest.
references
%
Sources of information Health facility TV/radio Poster/sticker/leaflet Friend/relative Newspaper Church/mosque School
Conflict of interest
317
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Contents lists available at ScienceDirect
Diabetes Research and Clinical Practice jou rna l hom ep ag e: w ww.e lse v ier .com/ loca te /d iab res
Diabetes awareness in general population in Cameroon Leopold Fezeu a,b,c,*, Emma Fointama a, George Ngufor a, George Mbeh a, Jean-Claude Mbanya a a
Health of Populations in Transition Research Group, Cameroon Inserm U780 – IFR69, Villejuif, France c Univ Paris XI, France b
article info
abstract
Article history:
Background: A good knowledge about diabetes could lead to early diagnosis and improved
Received 12 May 2010
management.
Accepted 28 June 2010
Objective: To evaluate the level of diabetes awareness in Cameroonians, and to identify
Published on line 8 October 2010
factors that influence this awareness. Methods: In subjects aged 25 years (n = 1000, 93.4% of response), details regarding risk
Keywords:
factors, symptoms, treatment and complications of type 2 diabetes were collected. One
Type II diabetes
mark was attributed to each true answer and a global diabetes awareness score was
Developing countries
computed. Influence of age, gender, educational level, occupational level, notion of a relative
Sub-Saharan Africa
having a chronic condition and presence of chronic disease were analyzed.
Diabetes awareness
Results: Eighty percent of subjects scored more than the total mean score. The highest score
Patient education
obtained by participants (0.10%) was 28/30. The mean total score was higher in men ( p < 0.02) and in subjects with a relative having a chronic condition ( p < 0.001). In multivariate analyses, age classes ( p < 0.01), educational level ( p < 0.001) and relatives with a chronic condition ( p < 0.001) were associated to the global diabetes awareness score. Conclusions: Diabetes awareness was generally good. This may be due to the fact that the study was conducted in an area where health promotion and health education on diabetes have been intensively delivered for the past 4 years. # 2010 Published by Elsevier Ireland Ltd.
1.
Introduction
Diabetes mellitus (DM) continues to be a major threat to global public health [1,2]. More than 170 million people worldwide have diabetes, and this burden is projected to more than double by the year 2030, if current trends continue [3]. The global increase in diabetes prevalence is mainly associated to the ageing of population, the unhealthy diets and sedentary lifestyles that increase the propensity of individuals towards obesity [4,5]. There is growing evidence that preventing and/or delaying the onset of diabetes can be achieved by adopting healthy lifestyles [6,7]. Increased
physical activity, modest weight reduction, and pharmacological interventions can decrease the incidence of diabetes complications significantly, even among high-risk groups. Simple lifestyle modifications, such as a healthy diet that includes reducing sugar intake, are considered to be essential for the prevention and control of incident diabetes mellitus [6–8]. Thus, increasing public awareness regarding modifiable diabetes risk factors and healthier lifestyles, and developing strategies to identify and manage at-risk populations, are among the various possible mechanisms being used to reduce the present epidemic of diabetes in many parts of the world.
* Corresponding author at: Nutritional epidemiology and research unit (UREN), U557 Inserm, U1125 Inra, Cnam, Universite´ Paris 13, CRNH Idf, SMBH, 74 rue Marcel Cachin, 93017 Bobigny, France. Tel.: +331 48 38 89 61. E-mail addresses: [email protected], [email protected] (L. Fezeu). 0168-8227/$ – see front matter # 2010 Published by Elsevier Ireland Ltd. doi:10.1016/j.diabres.2010.06.029
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The Cameroon Burden of Diabetes (CamBoD) Project, funded by the World Diabetes Foundation, was set up in Cameroon in order to improve the early detection, better management, and follow-up of the complications of type 2 diabetes, as well as to increase the knowledge of the general population on the risks factors, symptoms and complications of diabetes. During the initial phase of this project, the prevalence of diabetes in Cameroon in 2003 was 6.4%, compared with 0.9% in 1994, representing a very high increase over a single decade [9,10]. Considering the relative low cost of health promotion on diabetes compared to the management of its complications, and benefits of improved awareness, it is important to know the level of awareness of a community to help in the planning of a health promotion intervention. Exploring of barriers set up due to ignorance and wrong beliefs on diabetes, will aid in setting up a more adapted approach to increasing the level of awareness. This study was carried out to find out the level of awareness on diabetes in an adult Cameroonian population exposed to health promotion about diabetes.
2.
Methods
2.1.
Study site and study population
A cross-sectional community based study was conducted between August and September 2006 at the Bamenda health district, located in the North West province of Cameroon. The Bamenda health district is one of the five health districts of Mezam division. It is made up of 13 health areas with a total population of 210,799 inhabitants. The health areas of Azire, Ntamulung, Ntambag, and Nkwen Urban were selected for this study. Adults aged 25 years and above resident in Bamenda health district during the period of recruitment, constituted the target population. A two-stage recruitment procedure was used to obtain the sample. The first stage consisted of a census of all households in the Azire, Ntambag, Ntamulung and Nkwen Urban health areas with subjects aged 25 years or more. Each health area was divided into zones and every household numbered in that zone. For each household numbered a census form was filled indicating the phone number of the household head, the quarter, the number of persons in that household aged 25 years, and the best period to be visited for an interview. The census provided a database of 3058 households from which the sample of households was selected. A random sample of 582 households was selected after the census and all the subjects aged 25 years residing in the selected households were included in the study. In each selected household informed consent was sought from the head of the household for inclusion in the study. Thereafter an appointment was taken with him for the structured questionnaire to be administered. On the appointed date and time, a survey worker visited the household and each member of the household fulfilling the inclusion criteria was interviewed.
2.2.
Data collection
To facilitate data collection 10 survey workers with at least a university degree were recruited and trained on the study
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methodology, tested and certified to the survey methods. Eight survey workers fulfilled the certification criteria (administration of the questionnaire) and were retained to work. A pilot study was carried out to validate the questionnaire. This validation was mainly oriented on the comprehension of the questions by the study participants. It also sought to check the acceptability of the questionnaire, calculate the average time per interview and to revise poorly phrased questions. Data collection used structured interviews. The questionnaire requested information in the following sections: demographic information: the age, gender, marital status, level of education and profession, personal and family history of diabetes, hypertension and stroke, as well as current drug usage, knowledge on the risk factors of diabetes (nine items, maximum score: nine), Knowledge on the sign and symptoms of diabetes (seven items, maximum score: seven), knowledge of complications of diabetes (10 items, maximum score: 10), knowledge on the management and prevention of diabetes (three items, maximum score: four because one item had two true answers), various sources of information on diabetes. Each section on risks factors, signs and symptoms, complications and management of diabetes had true and wrong items, in order to avoid having a high score by chance. One mark was given to each true answer. The maximum global diabetes awareness score that a participant could obtain was 30. Thirty-three households selected refused to participate in the study, giving a non-response rate of 6.6%. The reasons advanced for the non-response were: refusal to participate: 75.7%; no longer interested in the study: 6.1%; participants of household traveled after the census, before the interview: 15.1%; hostility of the household residents when approached for the interview: 3.1%. All the questionnaires used for the analysis were valid and complete. The results below are thus based on 1000 validated questionnaires from 543 households. The number of adults per household ranged from one to five, with a mean of 1.8 subjects per household.
2.3.
Data management and data analysis
The subjects declaring having a personal history of diabetes, hypertension or stroke and under treatment were classified as having known chronic condition. Also, subjects with a close relative suffering from at least one of the three above cited condition were classified as having a relative with chronic condition. Three categories of educational level were constituted: primary or less (less than 7 years of education), secondary (between 7 and 14 years of education), and
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university (more than 14 years of education). Study participants were classified as married if they were married or lived together, and as single if otherwise. Three categories of occupational levels were constituted: employed (government and non-government employees), self-employed, and others (retired, student and housewives). Body mass Index (BMI) was computed using the declared weight (in kg) and the height (in meter) of the study participants and categorized using the WHO classification: underweight (BMI < 18.5 kg/m2), normal weight (18.5 BMI < 25), overweight (25 BMI < 30), obese (BMI 30 kg/m2). As only five subjects were underweight, the first two categories were merged. Data analyses used STATA 10.11, taking into account the sample technique. Results are expressed as means (standard error of the mean, SEM) or median (25th–75th percentiles) for quantitative variables and frequencies (percentages) for qualitative variables. Linear regression models in univariate and multivariate analyses with log transformed scores as dependent variables were used to study the associations between awareness about diabetes and age classes, gender, marital status, educational level, occupational level, having relatives with chronic condition, having a chronic condition, and BMI classes. All the tests were two-sided and significant level was set at p < 0.05.
2.4.
Ethical considerations
Approvals for this study were obtained from the National Ethical Committee of the Ministry of Health, the Minister of
Health and local administrative and traditional authorities prior to starting the study. Written informed consent was obtained from each study participant.
3.
Results
3.1.
General characteristics of the study population
Women represented 51% of the study population. The age ranged from 25 to 94 years. The mean age was 38.6 (SD: 12.9). The educational level of the study population was high, with 20.7% of them having university level. Although the prevalence of known diabetes was as low as 1.3%, 53.1% of the study participants knew a relative with type 2 diabetes, hypertension or stroke (Table 1). Men were almost 3 years older than women (40.0 years versus 37.3 years, p < 0.001). Also, they were more educated (university: 26.7% versus 15.0%, p < 0.001) and more often employed (72.5% versus 56.5%, p < 0.001). Women had higher self-reported BMI.
3.2.
Scores obtained by the study population
Table 2 displays the responses obtained from participants for each category of knowledge. The maximum diabetes awareness score was not obtained. The highest score was 28, obtained by one subject. As high as 80.3% of the study population obtained at least the average total score. However, 0.4% of study participants obtained the maximum
Table 1 – General characteristics of the study population stratified on gender:. Characteristics N Age, years (SD)
Women
Men
514 37.3 (12.2)
486 40.0 (13.5)
Age classes (%) 25–34 35–44 45–54 55+
52.1 22.2 15.8 9.9
44.0 24.3 16.1 15.6
Educational level (%) Primary or less Secondary University
38.9 46.1 15.0
28.2 45.1 26.7
Occupational level (%) Employed Auto-employed Others
21.7 34.8 43.5
30.3 42.2 27.5
Marital status (%) Single Married
35.2 64.8
37.0 63.0
BMI, kg/m2 (SD)
28.0 (5.0)
25.7 (3.2)
BMI classes (%) Normal weight Overweight Obese
30.0 41.2 29.8
41.8 49.4 8.8
Have relatives with chronic disease (%) Known diabetes (%) Known chronic diseases (%)
48.0 1.8 4.1
45.7 1.0 2.3
p 0.001 0.02
0.001
0.001
0.5
0.001 0.001
0.5 0.3 0.07
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Table 2 – Risk factors, symptoms, treatment and complications of diabetes (number of subjects prompting the items and relevant percentages) according to the study population. n
%
Risk factors of diabetes High intake of sugar Lack of physical activity Family history of diabetes Mosquito bites causes diabetes Excessive alcohol consumption Excess weight Sexual intercourse Inheritance Smoking
984 904 773 52 227 947 896 544 735
98.4 90.4 77.3 5.2 22.7 94.7 89.6 54.4 73.5
Symptoms of diabetes Frequent thirst Constant urination Weight loss Tiredness Dizziness Blurriness of vision Rapid breathing
708 854 608 855 823 726 626
70.8 85.4 60.8 85.5 82.3 72.6 62.6
Treatment of diabetes Diabetes treatment modality Medical treatment Medical and traditional treatment Traditional treatment Others Diabetes can be prevented Long term complications of diabetes can be prevented 657 Complications of diabetes Renal complications Liver cancer Neurologic complications Arthritis Diabetes foot Heart complications Stroke Eyes complications Asthma Sexual impotence
857 105 25 13 911 657
85.7 10.5 2.5 1.3 91.1 65.7
72.8 23.5 66.5 38.5 73.6 69.5 73.3 67.7 49.1 34.7
score for risks factors of diabetes, 39.5% for symptoms of diabetes, 56.3% for diabetes treatment and 1.3% for diabetes complications.
3.3.
Treatment of diabetes score Being a man, having a high educational level, having a chronic disease and BMI classes were associated with the knowledge about diabetes treatment. In multivariate analyses, having a chronic condition was no longer significant. Complications of diabetes score Knowledge about the complications of diabetes was associated with gender, age classes, educational level and having a relative with chronic disease. Gender was no more significant in multivariate analyses. Global diabetes awareness score All the study risk factors, except martial status, profession and personal history of chronic disease were associated with the global diabetes awareness score. In multivariate analyses, only age classes, educational level and having a relative with chronic disease remained significant (Table 4). Diabetes status, marital status and professional level were not associated to any knowledge score (data not shown).
3.4.
Factors influencing knowledge about diabetes
Risk factors of diabetes score In univariate (Table 3) and multivariate analyses, only gender (4.9 versus 5.2, p < 0.001) and educational level were positively associated with the risk factors of diabetes. Symptoms of diabetes score In univariate symptoms of diabetes score increased with educational level ( p < 0.001) and having a relative with chronic disease, and decreased as the BMI increased. When all these factors were included in the same model, educational level ( p < 0.001) and relatives with chronic disease ( p < 0.001) remained significant.
Main sources of information
The three most cited sources of information were health facilities (90.6%, Table 5), followed-up by TV/radios (88.7%) and health education material (poster/sticker/leaflet: 80.7%). Seventy-five percent of the study participants used more than four sources of information.
4. 728 235 665 385 736 695 733 677 491 347
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Discussion
This is one of the rare studies in Africa evaluating population awareness regarding type II diabetes. This study showed that educational level, age and having a close relative suffering from type II diabetes, hypertension or stroke were associated with good knowledge on risk factors, symptoms, treatment and complications of type II diabetes. These findings have major implications concerning diabetes prevention and health promotion activities in Cameroon. We demonstrated that educational level have a direct influence on the extent of knowledge regarding the risk factors, symptoms, complications and management of diabetes. This finding is congruent with other studies [11,12] albeit with a few exceptions [13]. Main sources of information in Cameroon about diabetes are in French or in English, which are not the native language of the population. It seems therefore logical that the comprehension of that information and its translation in habitual lifestyle could be tributary to the level of education. The level of knowledge of less educated participants was not such low, as much of the time, their mean score was above the median. This is the result of efforts developed by broadcasting some health education session in native languages, and by using as much as possible, for health promotion activities, personnel able to speak native languages. To reduce the gap in diabetes awareness related to the level of education, this method of health promotion should be more generalised, and new health promotion methods thought out. Knowing a relative having hypertension, diabetes or stroke also appears to influence the level of knowledge on diabetes. Individuals with a positive family history of a disease may
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Table 3 – Scores (mean and SD) associated with each factor potentially influencing the knowledge about diabetes in Cameroon. n
Risks factors
Maximum awareness score
9
7
4
Gender ( p) Women Men
514 486
0.001 4.9 (1.3) 5.2 (1.1)
0.2 5.1 (2.1) 5.3 (2.1)
0.001 3.3 (0.8) 3.5 (0.8)
0.01 5.5 (2.6) 5.9 (2.4)
0.02 18.8 (4.7) 19.8 (5.2)
Age classes ( p) 25–34 35–44 45–54 55+
482 232 159 127
0.3 5.0 4.9 5.1 5.2
0.4 5.1 5.2 5.3 5.4
0.2 3.3 3.5 3.4 3.4
(0.9) (0.8) (0.8) (0.7)
0.02 5.5 (2.5) 5.6 (2.6) 6.0 (2.4) 6.1 (2.2)
0.04 19.0 (4.9) 19.2 (5.2) 19.2 (5.2) 20.2 (4.5)
Educational level ( p) Primary or less Secondary University
337 456 207
0.001 4.8 (1.3) 5.0 (1.2) 5.5 (0.9)
0.001 4.9 (2.3) 5.2 (2.2) 5.7 (1.4)
0.001 3.3 (0.9) 3.4 (0.8) 3.5 (0.7)
0.001 5.1 (2.7) 5.7 (2.4) 6.6 (2.0)
0.001 18.1 (5.4) 19.3 (5.0) 21.3 (3.3)
Relative with chronic disease ( p) Yes No
469 531
0.9 5.0 (1.1) 5.1 (1.3)
0.001 5.5 (2.1) 4.9 (2.2)
0.001 3.5 (0.7) 3.3 (0.9)
0.001 6.1 (2.2) 5.3 (2.7)
0.001 20.1 (4.4) 18.6 (5.3)
Personal history chronic disease ( p) Yes No
32 968
0.7 5.0 (1.9) 5.1 (1.2)
0.1 5.8 (1.8) 5.2 (2.1)
0.001 3.4 (1.0) 2.8 (0.8)
0.4 5.7 (2.5) 5.3 (2.1)
0.6 18.9 (5.3) 19.3 (4.9)
BMI classes Normal weight (<25 kg/m2) Overweight (25–29.9 kg/m2) Obese (30 kg/m2)
352 452 196
0.09 5.0 (1.3) 5.1 (1.1) 4.9 (1.3)
0.01 5.1 (2.2) 5.4 (2.1) 4.9 (2.0)
0.03 3.4 (0.8) 3.5 (0.8) 3.3 (0.9)
0.09 5.7 (2.4) 5.8 (2.5) 5.4 (2.7)
0.005 19.2 (4.9) 19.8 (4.8) 18.5 (5.2)
(1.2) (1.3) (1.3) (1.1)
develop a personal sense of vulnerability, which in turn may increase their awareness [14]. Risk perception is an essential concept in a number of theoretical models addressing healthprotective behaviours. Perceived risk is considered to be the primary motivation to change within the Health Belief Model, which assumes that, the higher the perceived risk related to the condition is, the more likely an individual will modify his or her behaviour to lower the risk [15]. A positive family history of a disease, and one’s gender, age and perceptions of disease seriousness may affect one’s level of perceived risk. In support of this view, Harwell et al. found that family history is the factor most significantly associated with the perceived risk of developing diabetes [16]. However, Pierce et al., in their randomized controlled trial, found that the family members of
Table 4 – Factors affecting the global score in multivariate analyses. Significant variables
b-Coefficient (95% CI)
p-Value
Age classes 25–34 35–44 45–54 55+
0 0.19 ( 0.58–0.96) 1.03 (0.14–1.93) 1.53 (0.49–2.57)
0.01 – 0.6 0.02 0.004
Educational level Primary or less Secondary University
0 1.37 (0.68–2.06) 2.95 (2.09–3.81)
0.001 – 0.001 0.001
Relatives with chronic disease No Yes
0 1.41 (0.81–2.01)
0.001 – 0.001
Symptoms
(2.1) (2.2) (2.1) (2.1)
Treatment
Complications 10
Global score 30
individuals with type II diabetes underestimate their own risk of developing the disease [17]. Factors influencing perceptions of family history may vary between individuals and between diseases. In the available literature and present findings, it has emerged that perceived risk might be important to motivate preventative health behaviours and control of disease [14]. Also, in Cameroon, family members actively participate in the care in the management of subjects with chronic conditions, particularly diabetes, by accompanying them to health care, by contributing financially for drugs and laboratory examinations. These surely increased the contact with health promotion activities regarding diabetes, and therefore their level of knowledge and awareness. In contrary to other studies [18], diabetes status was not associated to higher diabetes awareness. This could be due to a lack of power, as few study participants were diabetics. The high level of awareness of the study population, which make differences with the diabetic population difficult to demonstrate, could also explain it. Some limitations of this study should be highlighted. First, the findings of this study cannot be generalized to Cameroon, as the data were derived from a semi-urban area. Second, as the four sites yielding CamBoD pilot study, the population of Bamenda was exposed during 3 years to intensive health promotion activities using all conventional (mass media, health facilities, distribution of health education materials) and non-conventional (meetings in market places, in churches/mosques, health education activities in schools, drama on diabetes in TV/radios) methods. Therefore, the awareness about diabetes in Bamenda can be reasonably thought to be higher than in the rest of the country. However, these findings lay the groundwork for further similar studies
diabetes research and clinical practice 90 (2010) 312–318
Table 5 – Main sources of information about diabetes. n 906 887 807 667 509 397 389
90.6 88.7 80.7 66.7 50.9 39.7 38.9
Number of multiple sources No source cited One Two Three Four Five or more
24 28 60 141 207 540
2.4 2.8 6.0 14.1 20.7 54.0
in other parts of the country. To accommodate individuals who might be illiterate, the items were read to the subjects, rather than allowing them to self-administer the questionnaire. It is possible that this approach might have resulted in subject reluctance to reveal sensitive feelings that may have been more fully elicited in a self-administered questionnaire. Having said this, the questionnaire was specifically devised not to pry into people’s private lives; consequently, there is no explicit reason to suspect that subjects would be reluctant to respond honestly. There also tends to be culturally specific responses to questionnaires [19], a potential bias that was not explored in the present study, and which might have played a role, given that the study relied almost exclusively on selfreported, subjective data. These limitations and countless others that were not apparent, but are yet common in psychosocial studies, suggest that extrapolating the present findings to other populations should be viewed with caution. This study has demonstrated that significant numbers of Cameroonians have the knowledge and perceptions required to prevent and cope with the increasing prevalence of diabetes. It strongly implicates level of education as the most significant predictor of desirable knowledge and perceptions of diabetes risk factors, complications and prevention. This raises optimism that health education could be a powerful tool as we strive to develop strategies to fight against diabetes and other chronic conditions in Cameroon, health situations that often are amenable to lifestyle changes and, by implication, education. However, there is a great difference between acquiring knowledge about a disease and using this knowledge to prevent the occurrence of the disease or to better manage the disease when it has occurred. Studies are needed to investigate the translation of this knowledge in lifestyles and life attitudes benefit for health.
Acknowledgement This project was funded by a grant from the World Health Organisation.
There are no conflicts of interest.
references
%
Sources of information Health facility TV/radio Poster/sticker/leaflet Friend/relative Newspaper Church/mosque School
Conflict of interest
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