Awareness and Knowledge about Diabetes Mellitus amongst Nursing Students in the Niger Delta Region of Nigeria

	Unadike B. C., Department of Internal Medicine, University of Uyo Teaching Hospital, Uyo, Akwa Ibom State Nigeria E-Mail: bernadike@yahoo.com
	bernadike@yahoo.com

ABSTRACT Objective: To assess the awareness and knowledge about diabetes mellitus (DM) amongst nursing students in the Niger Delta region of Nigeria. Methods: The study was a cross sectional, descriptive study. A structured questionnaire about the causes, symptoms and complications of DM was administered to the nursing students. Results: A total of 144 students were enrolled for the study. 85% of the respondents know that DM is a chronic disease and caused by insulin deficiency. Less than a half of the respondents could correctly identify the cut off point of ?7mmol/l fasting plasma glucose as being diagnostic for DM. Two-thirds of the respondents identified obesity as a cause of diabetes while only 42% know that weight reduction could help in the management of DM. Dietary therapy and insulin was identified as the most common method of management of diabetes and passage of excessive urine the most common symptom of diabetes identified by the respondents. Two-thirds of the respondents stated that Type I is the most common form of DM. The kidney was the most common organ identified as being affected by DM, with the nervous system being the least, while 92% agreed that urine sugar can be used to diagnose diabetes. Only 40% of the subjects were of the view that Type 2 DM can be seen in the adolescent. Conclusion: Knowledge and awareness of certain aspects of diabetes amongst nursing students is poor. More health education is needed to address these deficiencies in order to equip them with the knowledge to positively help their community to reduce the burden of DM on society. Keywords: Students, awareness, diabetes mellitus, Uyo.

INTRODUCTION

Diabetes Mellitus (DM) has emerged as one of the world's biggest health problems and its prevalence is increasing at an alarming rate. By the year 2010, it is projected that about 220 million people will have diabetes¹. Diabetes is the leading cause of kidney failure and blindness and also an important cause of non-traumatic lower extremity amputation and cardiovascular disease.^2-5
In Nigeria, the national prevalence is put at about 2.2% and this continues to be on the increase.⁶ Factors responsible for this include increasing obesity due to sedentary lifestyle and reduced physical activity in the population.⁷
It is important to know about the awareness level of a condition in a population, as knowledge is a critical component of behaviour change. Once awareness is created, people are more likely to participate in prevention and control activity. Knowledge about the disease plays a vital role in its further development and its early prevention and detection.^8,9 This study therefore set out to find the awareness and knowledge about DM amongst students in a Nursing School in the Niger Delta region in Nigeria.

MATERIALS AND PROCEDURES

This study was a cross sectional, descriptive study. It was carried out at the School of Nursing Anua, Uyo in the Oil rich Niger Delta region in Nigeria. The school is co-educational with the majority of the students being females as the nursing profession is mainly female oriented. Students spend four years in the school with the junior class, being the first two years and senior class the last two years. The students who took part in the study were from the junior class. Ethical approval for this study was obtained from the Ethics Committee of the University of Uyo Teaching Hospital, Uyo. A structured questionnaire about the cause, symptoms, treatment and complications of diabetes mellitus was administered to the students after informed consent was obtained from them. The instrument was pilot tested on fifteen student nurses before distribution, to participants in the study. The purpose of the pilot test was to identify any problem with the wording and for feedback for potential difficulties when answering the question. No potential problem was identified in the course of the pilot study. All consenting students formed the study sample. The questionnaire was administered to the students after their lecture in class and collected immediately to stop them consulting each other. Data obtained from the students included age, sex, family history of DM, amongst other items. After the questionnaire was filled out by the students, it was collected and then analyzed.

STATISTICAL ANALYSIS
Descriptive statistics such as means and standard deviation was used to summarize quantitative variables while qualitative variables were summarized using percentages. Data Analysis was done using statistical package for social science (SPSS) version 13.

RESULTS

A total of one hundred and forty-four students (111 females and 33 males) took part in the study. The mean age of the study subjects was 20±4 years. There was a family history of DM in 28 (19.4%) of the subjects, while 76 (52.7%) said they knew someone who had the disease.
Definition and Diagnosis
One hundred and twenty two (85.9%) of the respondents identified insulin deficiency as the cause of DM with 18 (12.6%) saying it was due to glucagon deficiency and 2 (1.4%) attributing it to growth hormone deficiency. Fifty-seven of the respondents (46.3%) agreed that the cut off value for diagnosis of diabetes is a fasting plasma glucose value >7mmol/l. Ninety-six (66.1%) of the respondents stated that obesity can lead to DM, while 133 (92.3%) know that urine sugar can be used to diagnose diabetes mellitus. Fifty-seven respondents (39.5%) know that type 2 DM can be seen in the adolescent age group, while 60.5% stated that it cannot be seen in adolescents. Type I DM was identified by eighty-three respondents, (63.3%) as most common type of DM while 31 thought that Type 2 DM is the most common. On the other hand 17 respondents thought that Gestational DM is the most common type of DM.

Clinical Features/ Management
In terms of symptomatology, 131 subjects (90.9%) identified excessive passage of urine as a symptom of diabetes; 50 of them identified weight loss as a symptom, 31 excessive thirst, while 16 identified recurrent infection as a symptom of DM. Fifty-two respondents could identify more than one symptom of DM.
Sixty respondents (41.9%) agreed that weight reduction could help in the management of DM. One hundred and twenty one respondents (84 %) know that DM is a chronic disease. Seventy-six respondents (52 %) agreed that diet is important in the management of diabetes, 39 (27%) stated that drugs could be used to treat the disease, while 86 (59%) accepted that insulin is a treatment. Forty respondents (27%) could identify more than one method of management of DM.

Complications
That the kidney is the most common organ that could be affected by DM was indentified by 93 (64 %) respondents, while 63 (43.7 %) identified the eye, and 17 said it could affect the nerves. Eighteen respondents (12.5%) agreed that DM could affect more than one organ.
The results by the respondents are shown in Table 1.

DISCUSSION

Diabetes Mellitus (DM) is the most common endocrine disorder. The prevalence worldwide ranges between 2 and 6% and has been increasing in Africa in the last 20 years.¹⁰ Despite this increasing rate and the various complications associated with the condition, knowledge of the disease by the public, patients, and health care providers is still very poor.¹¹ One major challenge for health care providers is how to increase public', patients' and health carers' awareness about the disease. This will help in early diagnosis, appropriate treatment and adequate follow-up strategies. Research has shown that education about diabetes to a population, resulted in a significant increase in knowledge as seen in a Singaporean study.¹²
Diabetes mellitus is caused by relative or absolute lack of insulin, which is produced by the islet cells of Langerhans. The majority of the respondents (85.9%) were able to identify lack of insulin as being the cause of the disorder. This finding is similar. This high level of awareness contrasts sharply with a study done in Tripoli, Libya among staff nurses as 95% of them were able to identify DM as secondary to insulin deficiency.¹³ A fasting plasma glucose of ?7mmol/l is the recommended cut off point for the diagnosis of diabetes.¹⁴ However, less than half of the respondents identified this cut off point. This is rather poor considering that only a blood sugar test and usually a fasting plasma glucose is used to diagnose diabetes. In the Tripoli study 96% of the respondents identified the cut off point for diagnosis of diabetes.¹³ Continuous nursing education is advocated to bridge these deficiencies in knowledge.
Weight reduction is an important aspect of management especially in Type 2 DM. Weight reduction reduces obesity and hence insulin resistance in these patients, who constitute about 80- 90% of the cases of diabetes worldwide.¹⁴ Less than half of the students agreed that weight reduction is important in diabetes mellitus, however, in the Tripoli study, 87% of the nurses agreed that weight reduction is important in the management of diabetes.¹³
Diabetes is a chronic medical disorder and treatment must be lifelong if patients are to avoid the complications of the disease. The majority of the students agreed that the disease is lifelong. This is encouraging considering that these students who will in the future become trained nurses will be in a vantage position to influence their patients positively in this aspect in terms of adequate health education as ward nurses are the patients' most frequent contacts.¹⁵
Management of diabetes involves dietherapy, medications including oral hypoglycaemic agents and insulin, amongst others. Many of the respondents identified dietherapy and use of insulin as modes of treatment of diabetes, however knowledge about oral hypoglycaemic drugs was poor. This knowledge about oral medications is poor considering that most persons with diabetes mellitus are taking oral hypoglycaemic drugs. A similar study in the United Kingdom documented this poor knowledge of management of type 2 DM.¹⁶
In terms of symptomatology, many of the respondents agreed that passage of excessive urine is a symptom of diabetes. Hyperglycemia by causing osmotic diuresis leads to excessive passage of urine with glycosuria in urine. This is not surprising because most people in our society associate passage of excessive urine with diabetes.
Few of the respondents identified weight loss, polydypsia and recurrent infections as symptoms of diabetes, with recurrent infection being the least identified symptom. In the study done in Tripoli 27% of the nurses did not recognize weight loss as a feature of diabetes.15 Possible explanation could be the association of diabetes and obesity in the adult population.
The increasing incidence and prevalence of diabetes is attributed to the epidemic of Type 2 DM, which is the commonest form of diabetes and is responsible for 80 - 90% of the cases of DM.¹⁴ However, less than a quarter of the nursing students agreed it was the most common type of diabetes with 63.3% of the respondents saying Type 1 DM was the most common type. Improved nursing education to correct this wrong perception is advocated.
Diabetes can lead to microvascular and macrovascular complications. Macrovascular disease is responsible for most of the deaths in persons with diabetes. Microvascular complications can affect the kidney, eye and nerves. Diabetes is the leading cause of end stage renal disease and blindness.^2,3 It is also an important cause of lower extremity non-traumatic amputation4. The majority of the subjects identified the kidney and eyes as the organs most affected by diabetes, similar to the Tripoli study.¹³
Nearly two thirds of the subjects (67.6%) agreed that obesity can cause diabetes. This is encouraging as the increasing incidence of Type 2 DM is clearly related to the increasing incidence of obesity as a result of sedentary lifestyle, reduced physical activity and unhealthy diets. Studies have shown that overweight and obesity significantly increase the risk of developing Type 2 Diabetes.^17,18
The majority (92.3%) of the respondents agreed that urine sugar can be used to diagnose diabetes. This is likely due to the fact that in our society, many people associate diabetes with sugar in urine and hence erroneously believe that diabetes can be diagnosed using urine sugar. This calls for continuous nursing education to correct this erroneous impression amongst the students.
Only 39.5% of the subjects agreed that Type 2 DM can be seen in adolescents. The majority of adolescents have Type 1 DM, but these days, we are seeing an epidemic of Type 2 DM amongst adolescents.¹⁹ This is as a result of unhealthy lifestyle of our youths with many youths living a sedentary lifestyle, not exercising adequately and have an intake of excessive calories which leads to obesity, a risk factor for Type 2 DM. Similar deficiencies in diabetes knowledge has also been documented amongst student nurses elsewhere by Fisher and Joshi et al.^20,21
Without the right knowledge about diabetes, student nurses who will be future nurses cannot positively affect their patients, families and the larger society and with the increasing incidence and prevalence of diabetes, continuous nursing education on diabetes is advocated to correct this poor knowledge.

CONCLUSSION

Knowledge and awareness of certain aspects of diabetes amongst nursing students in the Niger - Delta region is poor. More health education is needed to address this poor knowledge in order to equip them with the right information to positively affect their society in order to reduce the burden imposed by the disease.

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