1. 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

2. 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.

3. Methods A cross-sectional study
18697 adults ≥18 years; 7796 male, female;
6780 nonDM and 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.

4. 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?

5. 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’.

6. Result The mean (±SD) age 46±14 (years).
Most of them 36% had primary education
The mean Knowledge 41±16,
Attitude ±12
Practice ±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).

7. 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%

8. 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 %, (b) for Attitude %, (c) for Practice - 0.2%

9. 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
/0.001
20.893/0.001
48.094/0.001
/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
/0.001
0.882/0.450
46.729/0.001
/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
/0.001
1.717/0.161
9.022/0.001
Result

10. 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**

11. 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.

12. 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.

13. 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

14. THANK YOU ধন্যবাদ