HEALTH LITERACY REGARDING DIABETES AMONG DIABETIC AND NONDIABETIC SUBJECTS IN BANGLADESH Dr Natasha K Ex-Assistant Professor Department of Health Promotion and Health Education Division of Public Health Bangladesh University of Health Sciences, Dhaka, Bangladesh drnatasha1976@gmail.com

Background Bangladesh is still not practicing any standard rule to define or measure Health Literacy Knowledge-attitude-practice (KAP) is being used as a research tool and the principal markers of HL. The present study was undertaken to explore HL level in sense of KAP regarding diabetes mellitus (DM) among non-diabetic (non-DM) and Type 2 DM patients in Bangladesh.

Methods A cross-sectional study 18697 adults ≥18 years; 7796 male, 10901 female; 6780 nonDM and 11917 T2DM OPD of 19 healthcare centres in and around Dhaka and the northern part of Bangladesh. HL was defined as their KAP regarding DM, importance of drug-dose-schedule, discipline in life, complications, emergency conditions, visit physician and monitor biomedical parameters. Pre-structured, interviewer-administered 32 item questionnaire Uni, bi and Multivariate statistical analysis were done The questions relevant to KAP in the questionnaire were derived from the validated instruments, considering the fact that the people in Bangladesh and India are expected to follow a similar life style patterns: (i) Knowledge and Awareness of Diabetes Questionnaire developed for the Chennai Urban Rural Epidemiology Study [18], (ii) AusDiab Health Knowledge, Attitudes and Practices Questionnaire 99/00[19], and (iii) KAP construction guides[20]. selected purposively from the OPD of 19 healthcare centres in and around Dhaka and the northern part of Bangladesh. HL was defined as their KAP regarding DM, importance of drug-dose-schedule, discipline in life, complications, emergency conditions, visit physician and monitor biomedical parameters. HL-Level was assessed with a pre-structured, interviewer-administered 32 item questionnaire and measured using a predefined score-scale of poor (mean-1SD), average (mean±1SD) and good (mean+1SD). Uni, bi and Multivariate statistical analysis were done (as appropriate) to examine the association between diabetes related KAP and other different explanatory variables.

Method : Questionnaire Example Questions evaluating knowledge and attitude regarding diabetes What is diabetes? Do you know that diabetes is a genetic/hereditary disease? What is dyslipidemia/obesity/hypertension? What are the risk factors of diabetes/ dyslipidemia/ obesity/ hypertension? Do you know how to measure diabetes/ dyslipidemia/ obesity/ hypertension? Do you know the complications due to diabetes/dyslipidemia/ obesity/ hypertension? Do you know the effect of regular exercise on diabetes? Do you know the effect of healthy dietary habit (timing and food intake pattern, extra salt intake) on diabetes? Do you know the effect of sugar on diabetes? Do you know how active/passive smoking affects diabetes? Example Questions evaluated practice of diabetes control and management particularly for those who have been diagnosed with diabetes by asking: How often (daily/weekly/monthly) do you pay visit to physician How often you monitor blood glucose/ blood pressure? Do you control your weight? Do you take food timely? Do you add extra salt to your regular diet? How much time do you spend for exercise? Do you smoke? Do you have any exposure to passive smoking?

Method : Scoring For the ‘sixteen items knowledge question’, the maximum attainable score was '16' and the minimum score was '0'. Likewise, in the attitude section, a total of 8 items were included which consisted of respondents’ attitude towards diabetes. eight items in the practice category Each positive response (agree) was assigned as a score of '1', and each negative response as a score of '0'. The combined level of knowledge, attitude and practice (KAP) was classified according to each respondent’s score. Poor corresponded to a score of (<Mean – 1 SD); Average corresponded to a score between (Mean ± 1 SD); Good corresponded to a score of (>Mean + 1 SD). Informed written consent was obtained from all respondents after a full explanation of the nature, purpose, and procedures used for the study. Participants were informed about their right to withdraw from the study at any stage of the study. Ethical approval was obtained from the ‘Ethics and research review committees of the Diabetic Association of Bangladesh’.

Result The mean (±SD) age 46±14 (years). Most of them 36% had primary education The mean Knowledge 41±16, Attitude 85±12 Practice 57±30 The HL-level towards diabetes was found better among people living with diabetes compared to people without diabetes Males scored better knowledge and practice regarding diabetes Females showed better score of attitude compared to males Overall HL-level was found to be significantly higher (p<0.001) in middle aged (31-50 years) subjects in each group. Participants from urban residence, higher educational background and upper socio-economic class validated significantly greater score of HL in terms of KAP (p<0.001).

Result Level Knowledge Attitude Practice Diabetic (n=) Non Diabetic Unacceptable 63% 75% 3% 2% 17% 58% Fair 21% 13% 29% 26% Good 12% 8% 84% 85% 54% 16%

Result Regression analysis Knowledge associated with Education Income Residential area Diabetic state BMI Attitude associated with Age Sex Education Residence Practice associated with Age Diabetic State *[1= Unstandardized sample regression co- efficient; 2= Standardized sample regression co- efficient]; ** Adjusted Ra2 (a) for Knowledge - 19.9%, (b) for Attitude -0.00081%, (c) for Practice - 0.2%

Knowledge, attitude and practice score of the study subjects according to different variables (N=18697)   Variables NDM group (n=6780) DM group (n=11917) Knowledge Score (%) Attitude Score (%) Practice Score (%) Attitude Score (%) Sex Male 40.61±15.04 89.99±15.91 42.56±24.04 44.18±16.13 89.87±15.01 65.99±29.68 Female 38.65±15.11 91.25±12.95 43.62±25.13 40.88±15.62 90.41±14.35 64.21±31.79 t/p value1 5.362/0.001 -3.575/0.001 -1.766/0.078 11.004/0.001 -1.960/0.50 3.036/0.002 Age (years) 18 to 30 40.22±14.74 91.01±13.69 41.93±23.65 39.34±14.74 89.71±15.64 62.97±30.70 31 to 50 39.80±15.22 90.64±15.46 42.76±24.87 42.80±15.18 90.75±13.68 64.89±31.16 51 & above 38.25±15.38 89.94±14.51 45.80±25.30 41.70±16.65 89.72±15.34 65.06±30.94 F/p value1 7.579/0.001 2.322/0.098 11.107/0.001 16.859/0.001 7.402/0.001 1.299/0.273 Area Urban 43.15±16.01 90.62±14.24 46.53±25.14 44.38±17.02 89.58±16.09 64.72±30.99 Rural 36.75±13.68 90.63±14.73 40.29±23.77 40.02±14.47 90.78±13.06 65.01±31.08 17.766/0.001 -0.032/0.974 10.472/0.001 15.084/0.001 -4.491/0.001 -0.515/0.001 Education Illiterate 26.80±10.25 86.90±19.41 38.49±22.37 31.03±12.20 88.90±15.42 60.62±28.64 Primary to 8th grade 34.23±12.45 90.46±14.49 39.721±23.32 39.06±14.45 90.08±15.48 63.98±30.57 Secondary to higher secondary 40.41±13.27 92.09±12.92 42.38±24.38 45.46±14.76 91.44±12.80 65.13±33.07 Graduate & above 46.77±15.04 91.01±13.57 47.25±25.56 50.08±15.74 90.17±14.02 68.31±30.99 575.073/0.001 20.893/0.001 48.094/0.001 755.416/0.001 10.548/0.001 25.109/0.001 Monthly Family Income (in US$) Low income (≤905) 32.17±12.40 90.38±15.78 37.50±22.91 35.40±14.01 90.61±14.71 62.83±30.52 Lower-middle income (906 – 3595) 40.47±14.63 90.86±13.79 44.02±24.50 42.57±15.39 90.52±14.07 65.66±30.89 Upper-middle income (3596–11115) 45.75±15.50 90.47±14.84 47.58±25.26 46.82±16.29 89.28±15.47 64.97±31.66 High income ( ≥11116) 47.71±15.11 89.55±15.53 44.70±27.15 48.85±17.25 88.59±15.88 65.09±32.22 258.954/0.001 0.882/0.450 46.729/0.001 275.329/0.001 6.759/0.001 5.202/0.001 BMI Underweight 33.59±13.44 90.31±15.52 35.57±22.28 33.16±14.09 90.26±14.66 61.24±28.76 Normal 38.20±14.83± 90.46±14.90 41.64±24.43 40.96±15.68 90.15±14.61 65.08±30.86 Overweight 42.14±15.04 90.85±13.51 45.6±24.85 43.68±15.82 90.54±13.98 66.26±30.66 Obese 42.10±15.49 90.83±14.72 46.46±24.55 43.88±15.88 89.70±15.61 62.90±32.46 69.586/0.001 0.450/0.717 35.263/0.001 101.537/0.001 1.717/0.161 9.022/0.001 Result

Result Correlation coefficient of knowledge, attitude and practice score of the study subjects (N=18697) **Correlation is significant at the 0.01 level (2-tailed). Variables r/p Knowledge score vs attitude score (%) 0.038/0.000** Knowledge score vs practice score (%) 0.314/0.000** Attitude score vs practice score (%) 0.129/0.000**

Discussion HL is better in DM subjects (predicted) It is evident that the level of knowledge is directly related to the Level of Education Gender--Male Age--Middle Social-Economic status not self Income No significant relation with BMI & WHR Even after that the Health literacy level improved in each segment clearly and in combine from 27% to 80%. Baseline data showed that the GW had minimal knowledge about ‘Nu’ and ‘EOH’ but very poor at other three issues.

Conclusion HL vary greatly depending on socioeconomic conditions, cultural beliefs and habits. The overall HL-level concerning diabetes is mediocre But especially ‘Attitude’ alone is good There is an urgent need for coordinated educational campaigns, with a prioritized focus on poorer, rural and less educated groups improve overall health literacy.

Acknowledgments Co researchers -Kaniz Fatema, Sharmin Hossain, Hasina Akhter Chowdhury, Jesmin Akter, Tahmina Khan, Prof Liaquat Ali—BUHS. Research Place- Bangladesh University of Health Sciences, Health Care Development Project, Diabetic Association of Bangladesh Grateful to all Participants

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