Assessing the knowledge, attitudes and understanding of type 2 diabetes amongst ethnic groups in Glasgow, Scotland

Assessing the knowledge, attitudes and understanding of type 2 diabetes amongst ethnic groups in Glasgow, Scotland H Baradaran*, R Knill-Jones Introduction It has been shown that ethnicity is a risk factor or variable in public health. Therefore such research has often emphasised high rates of disease in minority ethnic groups, for example, diabetes. 1 3 The epidemiology of type 2 diabetes and its complications vary significantly between ethnic groups and their host communities. 4 8 The prevalence of type 2 diabetes has been rising around the world. 9,10 The increase in prevalence has accelerated due to ageing population structures in developed countries and increasing obesity globally. High prevalence occurs in the Caribbean 11 and among some communities in Britain, 11,12 for example, in individuals of Indian subcontinent origin. 13 Whether this occurs as a result of genetic or environmental factors remains unclear. 11,14 Studies in the United Kingdom have shown diabetes prevalence rates of 11 20% in Asian Indians, 15% in Afro-Caribbeans and 1 5% in White Caucasians. The age distribution of the disease also varies significantly, with type 2 diabetes presenting in Asians at a younger age than in Europeans. 15 17 Generally type 2 diabetes is up to four times more common in British South Asians than in the indigenous White population. 16,18 South Asians develop diabetes up to 10 years earlier 19 and are more likely to present with renal and cardiac complications. 20 22 In addition, it appears from some studies that health knowledge in minority ethnic community groups is poor. 23,24 It has also been ABSTRACT Type 2 diabetes is a growing public health problem amongst ethnic groups in developed countries. For example, people from the Indian subcontinent living in the UK have a higher rate of type 2 diabetes and a poorer prognosis than that of the host population, but there is a paucity of information about knowledge and attitudes concerning control, complications and the impact of diabetes among ethnic minority groups. We conducted a cross-sectional study in people with diagnosed type 2 diabetes in ethnic minority groups in Glasgow and a comparison group from the host population. We modified a questionnaire developed by the Diabetes Research and Training Center in Michigan, USA, and the Chinese University of Hong Kong. It was administered by the researcher (with translators when needed) to 145 type 2 diabetes patients, including British (n=27), Indian (n=33) and Pakistani (n=85) people living in Glasgow, UK. The mean age was 58.3 (SD=11.9), 51% were male. The mean duration of diabetes was 8.5 (SD=7.4) years. The mean knowledge scores (minimum 3, maximum 25) were 17.7 (95% CI 15.6, 19.6), 14.3 (95% CI 12.4, 16.2), and 13.8 (95% CI 12.8, 14.8) in the British, Indian and Pakistani groups respectively. There were significant differences between the British and each ethnic group (p=0.002). The mean attitude scores about seriousness of type 2 diabetes were similar at 9.8 (95% CI 8.9, 10.6), 8.2 (95% CI 8.0, 9.3), and 9.1 (95% CI 8.8, 9.5) respectively. The mean attitude scores about control and complications were 15.4 (95% CI 14.5, 16.2), 13.2 (95% CI 12.2, 14.1), and 13.9 (95% CI 13.5, 14.2) respectively, with significant differences between the British and each ethnic group (p=0.001). The results indicate that the knowledge of ethnic groups about diabetes is poor. Therefore an appropriate educational intervention is necessary for this group. Copyright 2004 John Wiley & Sons, Ltd. Practical Diabetes Int 2004; 21(4): 143 148 KEY WORDS epidemiology; diabetes; ethnicity; knowledge; attitudes; education; Scotland suggested that knowledge about delivery and access to health and social services is poor as well. 25,26 Therefore knowledge about this disease is a prerequisite for individuals and communities to take action to control the effect of this health problem. Peoples attitudes to health and their uptake of health services, including health education, are strongly affected by their knowledge, culture and beliefs. Yet research into health knowledge and beliefs around disease causation and prevention among ethnic minority groups in the UK in general, and in Scotland in particular, is sparse. Methods A cross-sectional study was carried out as the initial phase of evaluating an educational intervention for diabetic people in ethnic groups. A specially designed questionnaire was used to measure knowledge, attitudes and practice regarding type 2 diabetes amongst patients of Hamid Baradaran, MD, PhD Candidate Robin Knill-Jones, FRCP (London, Glasgow), FFPHM, MSc, DPH, Reader in Epidemiology Section of Public Health and Health Policy, University of Glasgow, UK *Correspondence to: Hamid Baradaran, MD, 1 Lilybank Gardens, Section of Public Health and Health Policy, Glasgow G12 8RZ, UK; e-mail: baradaran98@yahoo.com Received: 7 May 2003 Accepted in revised form: 22 October 2003 Pract Diab Int May 2004 Vol. 21 No. 4 Copyright 2004 John Wiley & Sons, Ltd. 143

Pakistani, Indian and British (White) origin in Glasgow, Scotland, UK. The questionnaire consisted of three subscales: knowledge, attitude and practice (KAP). The questions regarding knowledge and practice were derived from the DM- Questionnaire, and items on attitude adapted from the Diabetes Attitudes Scale (DAS-3). These instruments are designed to assess KAP in diabetic patients and were developed by the universities of Hong Kong and Michigan respectively. 27,28 The study questionnaire was translated from English into Urdu, Punjabi and Hindi by bilingual health professionals, and then piloted on 20 patients (10 from ethnic groups including some with Urdu, Punjabi and Hindi as their first language and 10 from White British residents) attending the diabetic clinic in the Victoria Infirmary, Glasgow, for face and content validity. The non-english versions were each translated back into English by different translators. Following this, very few words were changed in the non-english versions prior to the main study. Patients with type 2 diabetes mellitus attending three general practitioner-run diabetic miniclinics in primary care in south and west Glasgow, and four day care centres for elderly and ethnic groups in Glasgow, were asked to take part in a structured one-to-one questionnaire interview, administered by the researcher and a multilingual translator when it was necessary. These translators did not have formal health care training and were taught by the researcher to translate the participants answers word by word. Patients were given a consent form to read and sign, and an explanatory letter, written in English, Urdu, Punjabi and Hindi. Some patients gave verbal consent because they could not write (31 out of 145). The study was approved by the Greater Glasgow Community/Primary Care local Research Ethics Committee. Statistical analyses SPSS for Windows (SPSS, Chicago, IL) was used to analyse data collected. A χ 2 test was used for categorical data. For continuous data, when more than two groups were being compared, analysis of variance (ANOVA) was used. Where only two groups were being compared, Student s t-test was used. Results Demographic The characteristics of the enrolled patients are shown in Table 1. The study population comprised White (n=27), Indian (n=33) and Pakistani patients (n=85). Of the 145 patients who entered the survey, the mean age was 58 years (standard deviation=11.9). Men made up 51% of the subjects. There were significant differences among Whites, Indians and Pakistanis in reading ability (χ 2 =9.7, df=2, p=0.008), preferable language speaking at home (χ 2 =152.7, df=6, p<0.001) and marital status (χ 2 =6.9, df=2, p=0.03). The ethnic groups tended to be less literate and had more family members. Knowledge Table 2 gives a comparison of the mean KAP scores by gender, age, reading ability, duration of diabetes and ethnicity. Overall mean knowledge score was 14.6 (SD=5.1), and ranged from 3 to the maximum of 25. There was a statistically significant difference in the total mean knowledge about diabetes among the three groups, (ANOVA F=6.3, p=0.002). However, further analysis showed that there was no significant difference between the Indian and Pakistani groups (mean=14.3, SD=5.3, mean=13.8, SD=4.6 respectively, p=0.6) indicating that the White group scored significantly higher on knowledge about diabetes compared to both Indian and Pakistani groups. There was a statistically significant difference in the total mean knowledge score of diabetes between literate and illiterate patients (t=2.5, df=143, p=0.01). In other words, patients who could read and write had a higher score of knowledge about diabetes. The results also show that patients with longer duration of disease (eight or more years) were more knowledgeable regarding their disease. Attitudes Table 2 gives a comparison of two subscale scores on the DAS-3 by gender, age, reading ability, duration of diabetes and ethnicity. Overall, the mean score for attitudes about seriousness of type 2 diabetes was 9.2 (SD=1.8), ranging between 5 and 14 (n=142). Differences in the total mean attitude about seriousness of type 2 diabetes among the three groups approached significance (White higher than Indian), (F=2.8, p=0.06). Since obtaining a score of less than 9 was considered to indicate a negative attitude towards the seriousness of type 2 diabetes, the results indicate that the Indian group had on average a small negative attitude towards the seriousness of type 2 diabetes, unlike the White and Pakistani groups. Overall, the mean score for attitudes about the value of achieving tight glucose control in diabetes was 14 (SD=2.2), ranging from 8 to 20 (n=141). There was a significant difference in the total mean score of attitudes towards control and complications of type 2 diabetes among the three groups (F=8.2, p<0.001). However, further analysis showed that there was no significant difference between the Indian and Pakistani groups (mean=13.2, SD=2.7, mean=13.9, SD=1.7 respectively, p=0.12) indicating that the White group scored significantly higher for attitudes about the value of tight glucose control in diabetes, compared to the Indian and Pakistani groups. Practice The majority of patients (67%) did not practise diet control at home. Forty-five per cent of participants said that they ate at least one meal per week outside the home. Sixtyfive per cent of patients did not check their urine at home at least once a week and 39% did not check their blood sugar at home. Eight per cent (n=12) of patients used herbal medicines or food remedies. Four people used Karela and two people said they used homeopathy. The other six did not know the name of their herbal medicine. The overall mean practice score 144 Pract Diab Int May 2004 Vol. 21 No. 4 Copyright 2004 John Wiley & Sons, Ltd.

was 5.3 (SD=2.7), ranging between 0 and the maximum of 11. There was no statistically significant difference in the total mean practice of diabetes Table 1. The characteristics of the study sample among the three groups, (F=1.9, p=0.16). However, patients who had diabetes for a longer period had higher practice scores (p=0.05). Discussion The ethnic minority population in Scotland comprises approximately 2.01% of the total population. The White (n=27) Indian (n=33) Pakistani (n=85) Total (n=145) p No. (%) No. (%) No. (%) No. (%) Gender 0.7 Male 13 (48) 19 (58) 42 (49) 74 (51) Female 14 (52) 14 (42) 43 (51) 71 (49) Age (years) 0.08 Mean (SD) 58 (13.8) 62.4 (12.8) 56.9 (10.6) 58.3 (11.9) Range 33 78 38 83 36 77 33 83 Duration of diabetes (years) 0.16 Mean (SD) 6.2 (5.7) 9.8 (7.4) 8.7 (7.7) 8.5 (7.4) Range 1 20 1 27 1 33 1 33 Years of education 0.17 Mean (SD) 8.6 (2.4) 6.9 (5.1) 6.7 (5.1) 7.0 (4.7) Range 5 14 0 16 0 18 0 18 Reading ability 0.008 None 7 (21) 24 (28) 31 (21) Any language 27 (100) 26 (79) 61 (72) 114 (79) Preferred language speaking 0.001 at home English 27 (100) 2 (6) 29 (20) Urdu 1 (3) 30 (35) 31 (21) Punjabi 28 (85) 55 (65) 83 (57) Hindi 2 (6) 2 (2) Marital status 0.03 Married 17 (63) 25 (76) 73 (86) 115 (79) Never married/separated/ 10 (37) 8 (24) 12 (14) 30 (21) divorced/widowed House ownership 0.02 Owned 27 (100) 26 (79) 77 (91) 129 (89) Rented or living with relative 7 (21) 8 (9) 16 (11) (family members) Number of family members 0.001 Live alone 8 (30) 3 (9) 4 (5) 15 (10) 1 3 other people 15 (56) 13 (39) 28 (33) 56 (39) 4 or more other people 4 (14) 17 (51) 53 (62) 74 (51) Employment status 0.16 Employed 8 (30) 12 (36) 15 (18) 35 (24) Unemployed 1 (3) 3 (4) 4 (3) Housewife 6 (22) 11 (33) 37 (43) 54 (37) Retired 13 (48) 9 (28) 30 (35) 52 (36) Preparing meal 0.15 Cook for self 13 (48) 8 (24) 31 (36) 52 (36) Cooked for by others 14 (52) 25 (76) 54 (64) 93 (64) Pract Diab Int May 2004 Vol. 21 No. 4 Copyright 2004 John Wiley & Sons, Ltd. 145

main ethnic minority communities in Scotland are of Pakistani, Indian, Bangladeshi, African, Asian, Afro- Caribbean and Chinese origin. Evidence shows that the majority of minority ethnic groups are resident in the four cities Aberdeen, Dundee, Edinburgh and Glasgow where they form 2.90%, 3.66%, 4.07% and 5.46% of the respective total populations. The Greater Glasgow Health Board Area has, however, proportionally more people from ethnic minority communities than any other part of Scotland (Office for Population Censuses and Surveys, 2001 Census). The ethnic minority population in Glasgow is 39 318. The Pakistani minority group is the largest, being almost three times the size of the Indian minority group, which is the second largest (2001 Census). This study provides evidence that the knowledge and understanding of Indian and Pakistani groups about diabetes in Glasgow are poor. Similar results have been found in the Pakistani community in Nottingham and the Indian community in Coventry. 7,29 Table 2. The mean score of KAP by patient groups The study sample overall had inadequate knowledge about the cause of diabetes. For example, 63% of all patients did not know the connection between insulin and the cause of diabetes. Although they were knowledgeable regarding diet, control and monitoring, only 40 (28%) patients knew that blood sugar testing is more accurate than urine sugar testing. This raises a significant point for health care providers to take into account and also for any educational programme aimed at these groups. The majority of patients (>80%) had been told by their health care providers to follow a diet plan but only 33% of patients had a diet plan at home. This reflects the fact that compliance with the recommended diet is a major problem, particularly for South Asian diabetic people. The results show that the mean total score of knowledge of diabetes in illiterate patients was lower than it was for the literate. All illiterate patients were Indian and Pakistani (n=31). Although the proportion of males and females in the sample was almost equal, the predominance of females in the illiterate group was obvious. Amongst first generation immigrants in the Pakistani community it is quite common to find women who have never been to school and cannot read in any language. Culturally, women from this generation were never expected to go to school and learnt what they needed to know from their extended families. 29 Bansal 30 quotes a recent figure of 73% illiteracy in rural Indian women. This may also explain the lower score with regard to knowledge about diabetes in illiterate patients in this study. Our sample contained 25 women, and they made up 81% of the illiterate group. A long duration of diabetes, however, was found to be associated with an adequate knowledge score. This indicates that the patients who had had diabetes for a longer period were more knowledgeable about their disease. This might be the result of obtaining information from media, family members, friends or health care professionals. Knowledge p Attitude p Attitude p Practice p towards towards seriousness value of tight control Mean (SD) Mean (SD) Mean (SD) Mean (SD) Gender 0.59 0.89 0.29 0.31 Male 14.9 (5.0) 9.1 (1.6) 13.8 (2.2) 5.5 (2.8) Female 14.4 (5.1) 9.2 (1.9) 14.2 (2.1) 5.1 (2.6) Age group 0.76 0.29 0.08 0.70 <60 14.7 (5.1) 9.3 (1.8) 14.3 (2.2) 5.2 (2.5) 60 14.5 (5.1) 9.0 (1.6) 13.7 (2.0) 5.4 (2.8) Reading ability 0.01 0.68 0.17 0.15 Illiterate 12.6 (4.8) 9.3 (1.6) 13.5 (1.6) 4.7 (2.5) Literate 15.1 (5.0) 9.1 (1.8) 14.1 (2.2) 5.5 (2.7) Duration of diabetes 0.03 0.50 0.18 0.05 <8 13.8 (2.1) 9.1 (1.6) 13.8 (2.1) 4.9 (2.6) 8 15.7 (4.6) 9.3 (1.9) 14.3 (2.2) 5.8 (2.7) Ethnicity 0.002 0.06 0.001 0.16 White 17.7 (5.0) 9.8 (2.1) 15.4 (2.1) 4.5 (2.4) Indian 14.3 (5.3) 8.2 (1.8) 13.2 (2.6) 5.7 (2.9) Pakistani 13.8 (4.6) 9.1 (1.6) 13.9 (1.7) 5.4 (2.6) 146 Pract Diab Int May 2004 Vol. 21 No. 4 Copyright 2004 John Wiley & Sons, Ltd.

Conclusions Knowledge about diabetes is a powerful predictor of the perceptions of people with diabetes concerning their illness and the quality of services they receive. Significant numbers of patients, particularly from ethnic minority groups, are poorly informed about key elements of diabetes care and are not receiving appropriate or significant education about it. Type 2 diabetes is a serious disease, and tight glucose control reduces morbidity and mortality associated with diabetes. Consequently, the negative attitudes toward the seriousness of type 2 diabetes by the Indian group in this study are important findings. However, ethnic groups have different heath beliefs and perceptions of seriousness compared to the host community that may explain this difference. The White group also scored significantly higher for attitudes toward the value of tight control of diabetes care than did the Indian and Pakistani groups. The results of this study show that there is a need for a change in the attitudes of patients from ethnic minority groups regarding the seriousness of the condition and the value of tight control of type 2 diabetes. Acknowledgements The authors wish to thank Dr Kesson, Dr Madhok, Dr Apiliga, Sister Buchan, Sister Brown and Ms Aitken for their assistance, and give special thanks to the staff in day care centres and to all of the patients who enthusiastically participated in this study. References 1. Bhopal R. Is research into ethnicity and health racist, unsound, or important science? BMJ 1997; 314(7096): 1751. 2. Zimmet P. Challenges in diabetes epidemiology from West to the Rest. Diabetes Care 1992; 15: 232 252. 3. Hamman RF. Genetic and environmental determinants of non-insulin dependent diabetes mellitus (NIDDM). Diabetes/Metabolism Reviews 1993; 8: 287 338. 4. Chaturverdi N, Jarrett J, Morrish N, et al. 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behaviour of the Asian community in Glasgow. Health Bulletin 1990; 48: 73 80. 25.Smith NJ, McCulloch JW. Immigrants knowledge and experience of social work services. Mental Health Soc 1977; 4: 190 197. 26. Ahmed T. The Asian Experience. In Assessing Health Needs. Rawaf S, Diabetes Vignette Bahl W (eds). London: Royal College of Physicians, 1998; 319 328. 27. Anderson RM, Fitzgerald J, Funnel MM. The Third Version of the Diabetes Attitudes Scale. Diabetes Care 1998; 21(9); 1403 1407. 28. T ang J, Chan C, Chan NF, et al. A survey of elderly diabetic patients attending a community clinic in Hong Kong. Patient Education & Counseling 1999; 36: 259 270. 29. Hawthorne K. Asian diabetics attending a British hospital clinic: a pilot study to evaluate their care. Br J Gen Prac 1990; 40: 243 247. 30.Bansal RK. Elementary education and its impact on health. BMJ 1999; 318: 141. Make sure that you watch your feet No. 34 in a regular educational series of brief illustrated descriptions of interesting or unusual diabetes-related cases and conditions A 62-year-old man with a seven-year history of type 2 diabetes was discovered at the time of diagnosis to have peripheral neuropathy. At his routine diabetes appointment he mentioned an incident whereby he had lost his wristwatch for a day before discovering he had unknowingly been walking on it in his shoe. The watch and strap made a permanent impression on his shoe (see Figure 1), but thankfully caused no harm to his foot. The consultation ended with banter from the patient about how he Figure 1. The patient s shoe was now retired and usually had time on his hands rather than his feet. The clinician resisted the temptation to recommend that he continue to keep a close watch on his feet. Dr Eric S Kilpatrick Consultant in Chemical Pathology Mrs Rosemary Short Podiatrist Dr David A Hepburn Consultant Physician Diabetes Centre Hull Royal Infirmary Anlaby Road Hull HU3 2JZ Practical Diabetes International invites you to submit your favourite slide with clinical details for possible publication in this series. JDRF News Column Put your best foot forward for diabetes research JDRF s biggest fundraising drive of the year kicks off this month as preparations for the annual Walks to Cure Diabetes get into full swing. Walks will be held in Bristol, London, Southampton, Birmingham, Liverpool and, for the second year, Aberdeen. Family walk teams are the Walks fastest growing group of supporters, with whole families, from grandparents to young children turning out to support JDRF. Gary Appleton, Family Chairman for the Southampton Walk said: When a child is diagnosed with diabetes, it affects their whole family. We get groups of relations and close friends all taking part in the walk, supporting the search for a cure that will directly affect their loved one. It s also a great opportunity to meet other families living with diabetes, swap stories and get valuable support. As well as gentle exercise, walkers take part in a warm-up to music and can enjoy refreshments during and after the walk. It s a fun day out for all the family and JDRF would like you to get involved! Invite patients, colleagues, friends and family along and put your best foot forward for diabetes research. Last year s Walks were a great success, said Ann Ramsdale, Associate Director, Walk to Cure Diabetes at JDRF. We raised nearly 800 000 which was used to support the most promising and groundbreaking UK research into a cure for type 1 diabetes. This year we hope to do even better and want to get lots of new people involved! Contact your local office for further information and publicity materials, or visit www.jdrf.org.uk. Contact telephone numbers for the Regional Offices are: Aberdeen: 01224 582 777; Birmingham: 0121 685 7102; Bristol: 0117 945 2491; Liverpool 0151 236 3939; London: 020 7713 2030; Southampton 023 80 58 62 69. Juvenile Diabetes Research Foundation For further information about JDRF please telephone 020 7713 2030, or look on our website www.jdrf.org.uk 148 Pract Diab Int May 2004 Vol. 21 No. 4 Copyright 2004 John Wiley & Sons, Ltd.