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Table of Contents
Year : 2010  |  Volume : 14  |  Issue : 1  |  Page : 3-7

Health education intervention on diabetes in Sikkim

Department of Community Medicine, Sikkim-Manipal Institute of Medical Sciences and Central Referral Hospital, Gangtok, Sikkim, India

Date of Web Publication10-Jan-2011

Correspondence Address:
Ranabir Pal
Associate Professor, Department of Community Medicine, Sikkim-Mampal Institute of Medical Sciences and Central Referral Hospital, 5th Mile Tadong, Gangtok, Sikkim. 737 102
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Source of Support: None, Conflict of Interest: None

PMID: 21448407

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Introduction: In the present study, we have sought to determine the existing Knowledge, attitude & practice and impact of a structured health education intervention regarding diabetes in adults in Sikkim.
Materials and Methods: This was an experimental study of non-randomised trial done at the Central Referral Hospital of SMIMS, Sikkim, India on 189 adult individuals attending the 'Diabetes Awareness Camp'. A pre-tested closed ended questionnaire was used to assess the impact of health education intervention. The data was analysed by a computer programme, the Statistical Package for Social Sciences. Paired t-test was applied.
Results: A questionnaire specifically designed to find knowledge and attitude related to diabetes total of administered on 189 adults revealed that mean age of participants was 45.7 years (+14.8 yrs), majority were males (63.5%), 23.3% had positive family history, 55.6% were previously diagnosed. Knowledge of diabetes was suboptimal in pre-test. Significantly improved knowledge was after intervention regarding: (a) Risk factors, (b) Early symptoms, (c) Organs affected, (d) Warning signs of Hypoglycaemia, (e) Personal Precautions. Significantly improved positive attitude was among: (a) motivate all family members to get their blood sugar tested yearly after 40 yrs of age, (b) undergo regular check-up, continue medication and motivate family members. Majority of previously diagnosed diabetics (78.6%) were on regular medication. 82.8% were on insulin, 18.4% taking it themselves. 7.8% were carrying identification card with treatment regimen and 35.9% carrying sugar/chocolate.
Conclusions: This study highlighted the need for better health information to the patient through large scale awareness interventions regarding diabetes.

Keywords: Diabetes, adults, health education

How to cite this article:
Pal R, Pal S, Barua A, Ghosh M K. Health education intervention on diabetes in Sikkim. Indian J Endocr Metab 2010;14:3-7

How to cite this URL:
Pal R, Pal S, Barua A, Ghosh M K. Health education intervention on diabetes in Sikkim. Indian J Endocr Metab [serial online] 2010 [cited 2021 Jul 26];14:3-7. Available from: https://www.ijem.in/text.asp?2010/14/1/3/75070

  Introduction Top

Type 2 diabetes is a common and costly chronic metabolic disease associated with significant premature mortality and morbidity requiring medical diagnosis, treatment and lifestyle changes.

Since the first therapeutic use of insulin diabetes has been a treatable but chronic condition, and the main risks to health are its characteristic long-term complications. These include cardiovascular disease (doubled risk), chronic renal failure, retinal damage which can lead to blindness and is the most significant cause of adult blindness in the non-elderly in the developed world, nerve damage, erectile dysfunction (impotence), to gangrene with risk of amputation of toes, feet, and even legs. Research has shown that improved glycemic control reduces the rate and number of diabetes-related complications. Evidence suggests that patients who are more knowledgeable about diabetes self-care may be more likely to achieve better glycemic control. Although patient education is an integral component of diabetes care, there remain uncertainties regarding the effectiveness of different methods and modes of education [1],[2],[3],[4].

Training in self-management is integral to the treat­ment of diabetes. Proper management requires patients to be aware of the nature of the disease, its risk factors, its treatment and its complications. Therapeutic patient education is a patient-centred approach, focussed on patients' needs, resources, values and strategies. It allows patients to improve their knowledge and skills not only concerning their illness but also their treatment. It brings a better quality of life, a greater therapeutic compliance and a reduction in complica­tions [5]. University of Venda study revealed that the outcome of diabetes depends mainly on the patient's self-management. Health care professionals therefore have a major responsibility to assist patients to acquire the essential knowledge, skills and attitudes towards self-management [6].

The 1989 Declaration of St. Vincent was the result of international efforts to improve the care accorded to those with diabetes. Several countries established more and less successful national diabetes programmes to improve treatment of the disease [7].

WHO has projected that diabetes as a major public health concern worldwide, will become the leading cause of global disease burden in the new millennium both in the developed and developing countries. In the developed world, the estimated increase is approximately 46%, from 55 million in 2000 to 83 million in 2030; whereas, among developing nations, the estimated increase is approximately 150%, from 30 million in 2000, to 80 million in 2030 [8],[9].

The lack of positive attitude could be an important barrier for long term management of diabetes. This study was conducted to assess the level of awareness and perception regarding diabetes mellitus among the general population of Sikkim attending a diabetic education programme and the associations between the elements of knowledge and perception, and socio-demographic factors before and after health education intervention. So far there has been no study done in this field in the state of Sikkim in India.

  Methods Top

Study Design

An experimental study of Non-Randomised Trial. Study period: 19th September 2004 (one day activity). Setting: Central Referral Hospital (CRH) of SMIMS, Tadong in Sikkim of India. Study Population: 189 adult individuals in the age group 18 years and above from East Sikkim, who attended the "Diabetes Awareness Camp" at Central Referral Hospital, Tadong, Sikkim, India.

Sampling Technique

Non-probability purposive Sampling method was applied using Snowball Technique for selecting the respon­dents. Main outcome measures: awareness and perception regarding diabetes mellitus among the general population. Content validity & reliability of study instruments: The Health Education module on Diabetes was developed on information provided in the WHO TRS. The experts of Community Medicine assessed the content validity of the Health Education Module by pre-testing on randomly selected sample of 20 adult visitors of Central Referral Hospital (CRH) prior to the study for ensuring feasibility acceptability time management and reliability following which some of the questions from the interview schedule were modified. By initial translation, back-translation, re-translation followed by pilot study the questionnaire was custom-made for the study. In addition to demographic information, the questionnaire contained questions on knowledge related to diabetes viz., early symptoms, risk factors, body organs affected, personal precautions, diabetic foot care, self injection of insulin and warning signs of hypoglycaemia as well as questions attitude on diabetes viz., willing to get blood sugar tested after 40 years of age, if diagnosed of Diabetes anytime in life, whether the person was willing to visit doctor for regular check-up and continue taking medications for adequate control of Diabetes, if any family member becomes Diabetic anytime in life, whether the person was willing to motivate him/her to visit doctor for regular check-up and continuing prescribed medications.

Data collection procedure

The ethical permission to conduct the study in Central Referral Hospital was taken. All the participants were explained about the purpose of the study and were ensured strict confidentiality and then verbal informed consent was taken from each of them before the interview. The partici­pants were given the options not to participate in the study if they wanted. Then by interview technique we collected the pre-test and post-test data. Details of the questionnaire can be provided, if required. To increase the participatory response, this health education intervention programme was followed by clinical examination and estimation of blood glucose level. Referral services and medication were provided free of cost to the needy patients.

Statistical Analysis

The data collected were thoroughly cleaned and entered into Excel spread sheets and analysis was carried out using SPSS, version 11 software. The procedures involved were transcription, preliminary data inspection, content analysis and interpretation. The pre-tested closed ended questionnaire was used to assess the impact of health education intervention, where a score of "1" was given to incorrect knowledge & negative attitude while score of "2" was given to correct knowledge and positive attitude. Proportions were used to derive information on baseline characteristics and practice aspect of diabetic patients. Paired t-test was applied to the pre-test and post-test results of Knowledge and Attitude on diabetes to assess the impact of health education intervention on diabetes. p value <0.05 was considered as statistically significant.

  Results Top

The mean age of the participants was 45.7 years (+ 14.8yrs). Majority were males (63.5%) and belonged to Hindu community (66.7%). Majority of them were literate (69.3%), married (83.6%) and belonged to middle/high socio-economic status (88.9%). Only 14.8% were on regular alcohol intake and 3.7% had habits of both smoking and alcohol intake at least three times a week.

Among the study population, 23.3% gave positive family history of diabetes. While 39.7% of respondents belonged to unemployed/housewife group, 36.0% were engaged in skilled/or professional occupations.

Only 105 (55.6%) of the participants were previously diagnosed of diabetes and the average duration of diabetes among them was 4.9 years (+ 5.4 yrs).

Significant improvement in Knowledge & Positive Attitude between pre-test and post-test results was observed regarding the following aspects [Table 1] and [Table 2].
Table 1: Correct and apporpriate respose of respondents on knowledge of Diabetes Mellitus

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Table 2: Correct & apporpriate respose of respondents on attitude of Diabetes Mellitus

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  1. Significant Improvement in Knowledge on Diabetes was observed regarding following aspects: (a) Risk factors of diabetes, (b) Early symptoms of diabetes, (c) Organs affected by diabetes, (d) Warning signs of hypoglycaemia and (e) Personal precautions in diabetes.
  2. Significant Improvement in Positive Attitude was observed in following aspects: (a) Willing to motivate all family members to get their blood sugar tested once a year after 40 yrs of age, (b) Willing to undergo regular check-up & continue medication once diabetes is detected & motivate other family members to do the same.
  3. There were 105 individuals previously diagnosed of diabetes. Majority of them (78.6%) of them were on regular allopathic medication. Though 92.4% of the diabetics were on insulin, but only 18.4% were taking it themselves. Sons & other family members assisted others in injecting insulin. Only 7.8% of them were carrying ID card with treatment regimen mentioned and 35.9% were carrying sugar/chocolate in their pocket to prevent hypoglycaemic episode.

  Discussions Top

In Sikkim health care services are provided by the government health services network even in the remotest corner. There is no private nursing home in the state. Sikkim Manipal Institute of Medical Sciences with Central referral hospital has been started in the state as the only medical college in this state of Sikkim as public-private partnership. This study highlighted the need for better health information to the patient through large scale awareness interventions regarding diabetes.

Since majority attended the programme without fasting, Oral Glucose Tolerance Test could be performed on only a few participants, who were never diagnosed of diabetes previously. None of the participants were newly diagnosed of diabetes in this programme. Majority participants had poor knowledge about diabetes and negative attitude towards the disease before the health education intervention and improved after the intervention.

The study in Tamilnadu suggested that literacy, language and religion are interdependent factors associated with knowledge of diabetes and diabetic retinopathy. One useful approach may be to initiate literacy campaigns with a focus on creating awareness of health-related topics for rural populations [10].

Cochrane study to assess the effectiveness of culturally appropriate diabetes health education on important outcome measures in type 2 diabetes concluded that this appears to have short term effects on glycaemic control and knowledge of diabetes and healthy lifestyles(l 1).

Maryland study to determine the relationship between patients' knowledge about their diabetes medications and their blood glucose control observed that patients with greater understanding and knowledge of their diabetes medications demonstrated better glycemic control [4].

The study results in Chennai, India to determine the effectiveness of a large scale multipronged diabetes awareness program provided through community involvement conducted between 2004-2007 at various locations of Chennai as part of the Prevention, Awareness, Counselling and Evaluation [PACE] Diabetes Project were compared to a similar survey carried out, as part of the Chennai Urban Rural Epidemiology Study [CURES] in 2001-2002, which served as a measure of baseline diabetes awareness. Results showed that awareness of a condition called "diabetes" increased significantly from 75.5% in 2001-2002 (CURES) to 81% (p < 0.001) in 2007 (PACE). Significantly more people felt that diabetes could be prevented (p < 0.001), and that a combination of diet and exercise were needed to do so (p< 0.001). Respondents reporting obesity family history of diabetes, hypertension and mental stress as risk factors increased significantly after PACE (p < 0.001). More people were able to correctly identify the eyes (PACE 38.1% compared to CURES-16.1%, p < 0.001), kidney (PACE 42.3% compared to CURES 16.10%, p < 0.001), heart (PACE 4.6% compared to CURES 5.8%, p < 0.001) and feet (PACE 35.0% vs. CURES 21.9%, p < 0.001) as the main organs affected by diabetes. The study concluded that through direct public education and mass media campaigns, awareness about diabetes and its complications can be improved even in a whole city. If similar efforts are implemented state-wise and nationally, prevention and control of non-communicable diseases, specifically diabetes and cardiovascular disease, is an achievable goal in India [12].

Mass awareness and screening programs are feasible and, through community empowerment, can help in prevention and control of non-commuincable diseases such as diabetes and its complications on a large scale [13].

In a systematic review to examine the clinical effective­ness of patient education models for adults with Type 2 diabetes, however, the researchers found that studies of focused educational interventions did not yield consistent results. Some effects were shown on measures of diabetic control in studies that focused on diet or exercise alone. Although the effects shown were generally small, those that were present did appear to be relatively long-lasting. Based on the evidence, it would seem that education delivered by a team of educators, with some degree of reinforcement of that education made at additional points of contact, may provide the best opportunity for improvements in patient outcomes. Educators need to have time and resources to fulfill the needs of any structured educational programme. There is also a need for education to have a clear programme at the outset. From the evidence reported it is unclear what resources would need to be directed at the educators themselves to ensure that they can deliver programmes successfully [14]. The health education module on diabetes was well accepted by the general community. The participatory response was more due to the fact that this health education intervention programme was followed by clinical examina­tion and estimation of blood glucose level. This kind of health education intervention activity coupled with clinical investigations is much accepted by the general community than health education or screening programme alone.

  Conclusion Top

In summary, our structured group education programme encapsulates a patient centred approach to augment awareness on the diabetes care at a time when the global realization has reached a consensus on the aggressively medical therapies to reach glycaemic targets, This study highlighted the need for better health information to the patient through large scale awareness programmes so as to change the attitude and practices of public regarding diabetes. It has also explored several aspects of diabetes related awareness and identified the need for improvement in their practices for treating and educating diabetics. The findings also indicated that there lies an ocean of difference between the fact on diabetes and that of true life practice among general mass of the capital of this north-eastern hilly state of India. We should also have to spend some extra time in case of counselling of close associates and relatives of the diabetic patients separately to motivate them in a socio-cultural setting both inside hospital as well as in the community. Additional studies are needed to delineate these findings further.

Strengths and limitations of the study

The limitations and difficulties of doing pragmatic intervention trials in a tertiary care setting are well recog­nised. The lack of difference in observation may result from a lack of sensitivity in the tool used as the sample size was not large enough.

The study has several strengths. The programme module was intended as the first step in an ongoing general health education programme. We applied the benefits of providing structured education. As this intervention is offered as primary prevention, it has to be developed and followed up later to understand the reason further.


Diabetes mellitus is a major public health problem and along with its complications contribute a significant amount of burden on the society. Lack of awareness has resulted in an increased number of diabetics over the years. It would be of immense impact if this activity could be replicated at other government and private health care organizations to generate awareness among people about diabetes prevention and how to live optimum quality life with the disease. Awareness and health education programmes are recommended to update the family physicians on early detection and management of diabetes.

Any future research should consider patient education within the context of overall diabetes care and as such follow guidelines for the development and evaluation of complex interventions. Good-quality, longer-term studies would be desirable, but these would require careful consideration around the nature of any control group. Information is needed to clarify the sensitivity of diabetes education programmes to the performance of the diabetes educators, in order to ensure success and cost-effectiveness of education programmes. Health education is by far the best vaccine to prevent and it needs to be strengthened. Thus, the study of understanding the various factors that could change the perception and awareness about diabetes among the general population may come out to be useful for the successful implementation of diabetes control program in the state. So far there has been no study done in this field in the state and to the horizon of our knowledge this was one of the first studies from North East part of India. India is a multi-cultural multi­lingual and geographically uneven country. Any short term solution will not help us to reach the goal of diabetes control in India in near future. The health professionals alone will not be able to meet this mammoth task.

We have to evaluate the effectiveness of the education programmes on biomedical, psychosocial, and lifestyle measures in people to generate awareness about slow epidemic of Diabetes and positive change in attitude of health planners for optimum quality life for our future generations.

Given the findings in the present study, the following recommendations are made.

Health education

Health education system needs to improve knowledge about Diabetes among the people with lesser educational level. It could be done by means of improving educational tools preferably based on audiovisual techniques to create wider awareness about the importance of Diabetes.

Removal of myths and misconceptions

The information education and communication system must have some productive advertisements to motivate the general public for Diabetes. The advertisements need to address the risk factor, which is of great concern to all the Diabetics. It also must focus on clearing the myths and misconceptions about Diabetes and keep the people well informed about the importance of prolonging life with good quality of life of Diabetics.

Provision of better research facilities

The results point to find out the areas which need more attention in terms of resources and planning. Making people aware of recent findings, like strict control of risk factors is associated with a lower risk of cardiovascular events in Diabetics is our responsibility.

  References Top

1.Duke SA, Colagiuri S, Colagiuri R. Individual patient education for people with type 2 diabetes mellitus Cochrane Database Syst Rev 2009;(1):CD005268.  Back to cited text no. 1
2.Nathan DM, Cleary PA, Backlund JY, Genuth SM, Lachin JM, Orchard TJ, Raskin P, Zinman B. Diabetes Control and Complications Trial/Epidemiology of Diabetes Interventions and Complications (DCCT/EDIC) Study Research Group. Intensive diabetes treatment and cardiovascular disease in patients with type 1 diabetes. N Engl J Med 2005;353: 2643-53.  Back to cited text no. 2
3.Palma Gamiz JL, Hernandez Madrid A, Bertomeu Martinez V Gonzalez-Juanatey JR, Lopez Garcia-Aranda V, Calderon Montero A, Alegria Ezquerra E, Cadierno Carpintero M. Diabetes mellitus in clinical cardiology in Spain. Survey by the working group on the heart and diabetes regarding the importance of diabetes mellitus in relation with other cardiovascular diseases. Rev Esp Cardiol 2004;57(7): 661-6.  Back to cited text no. 3
4.McPherson ML, Smith SW, Powers A, Zuckerman IH Association between diabetes patients' knowledge about medications and their blood glucose control. Res Social Adm Pharm 2008, 4(1): 37-45.  Back to cited text no. 4
5.Golay A, Lagger G, Chambouleyron M, Carrard I, Lasserre-Moutet A. Therapeutic education of diabetic patients. Diabetes Metab Res Rev. 2008; 24(2): 192-6.  Back to cited text no. 5
6.Shilubane HN, Potgieter E. Patients' and family members' knowledge and views regarding diabetes mellitus and its treatment. Curationis. 2007;30(2): 58-65.  Back to cited text no. 6
7.Dubois H F W, Bankauskaite V Type 2 diabetes programmes in Europe. Euro Observer. 2005;792(2): 5-6.  Back to cited text no. 7
8.The World Health Organization. World Health Report: Mental Health: New understanding New Hope. Geneva: The institute; 2001.  Back to cited text no. 8
9.Wild S, Roglic G, Green A, Sicree R, King H. Global prevalence of diabetes: estimates for the year 2000 and projections for 2030. Diabetes Care 2004;27:1047-1053.  Back to cited text no. 9
10.Rani PK, Raman R, Subramani S, Perumal G, Kumaramanickavel G Sharma T Knowledge of diabetes and diabetic retinopathy among rural populations in India, and the influence of knowledge of diabetic retinopathy on attitude and practice. Rural Remote Health 2008;8(3): 838.  Back to cited text no. 10
11.Hawthorne K, Robles Y, Cannings-John R, Edwards AG. Culturally appropriate health education for type 2 diabetes mellitus in ethnic minority groups. Cochrane Database Syst Rev. 2008; (3): CD006424. Commentin:EvidBasedNurs.2009;12(l):15.  Back to cited text no. 11
12.Somannavar S, Lanthorn H, Deepa M, Pradeepa R, Rema M, Mohan V Increased awareness about diabetes and its complications in a whole city: effectiveness of the "prevention, awareness, counselling and evaluation" [PACE] Diabetes Project [PACE-6]. J Assoc Physicians India. 2008; 56: 497-502. Comment in: J Assoc Physicians India. 2008;56:493-4.  Back to cited text no. 12
13.Somannavar S, Lanthorn H, Pradeepa R, Narayanan V, Rema M, Mohan V. Prevention awareness counselling and evaluation (PACE) diabetes project: a mega multi-pronged program for diabetes awareness and prevention in South India (PACE- 5). J Assoc Physicians India 2008, 56:429-35.  Back to cited text no. 13
14.Loveman E, Frampton GK, Clegg AJ The clinical effectiveness of diabetes education models for Type 2 diabetes: a systematic review. Health TechnolAssess2008;12(9): 1-116.  Back to cited text no. 14


  [Table 1], [Table 2]


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