Executive Summary
Modernization, urbanization, increased availability of white-collar work, the perennial temptation of convenience food, and diminished physical activity have all proved to be mixed blessings for Malaysia, its Asian neighbors and trading partners in the West. The prevalence of obesity has risen and so has diabetes. Employing a robust questionnaire, a student-implemented survey looked for updated insights into knowledge and practice about diabetes in several urban centers. Within the confines of this short-format report, certain encouraging findings were drawn about widespread knowledge concerning the disease and its life-threatening complications. The population is largely prudent about seeing physicians when assailed by unexplained symptoms. More can be done, however, to leverage widespread Internet penetration and the variety of information channels Malaysian adults resort to as part of a preventive awareness-building and behavioral change intervention strategy.
Introduction and Background
Diabetes is a metabolic disorder affecting the way the body uses digested food for growth and energy. Genetic predisposition is considered the principal antecedent (Aschner et al., 1999) but for some reason not wholly understood, the pancreas progressively fails to produce the insulin needed to keep blood glucose levels balanced between meals.
Most of the food people eat – notably simple sugars, complex carbohydrates and starches – is broken down after digestion into glucose, the form of sugar in the blood. Blood glucose is the main source of energy for all metabolic and growth processes of cells in the human body. During the period immediately after meals or snacks, blood glucose levels tend to rise beyond the requirements of human metabolism, whether at work or rest. Without the biochemical monitoring and control exerted by insulin, excess glucose is excreted with urine and thus goes to waste. This is called the hyperglycaemic state. A few hours after the meal, in contrast, the just-ingested glucose is mostly gone and, absent intervention by insulin, the body goes into what is called the hypoglycaemic state (Porte, Sherwin, Baron, Ellenberg & Rifkin, 2003).
Both conditions have their perils. Severe hypoglycemia can make a patient fall into an irreversible coma while chronic (continuous, i.e. experienced over weeks, months and years) hyperglycemia interferes with the functioning of many organs. Complications induced by the latter include blindness (“diabetic retinopathy”), nerve dysfunction, cardiovascular disease and kidney failure.
There are three main types of diabetes. Type I is juvenile, presenting during adolescence and chronic because it persists for the rest of adult life. Type II is adult-onset diabetes, usually manifesting along with other degenerative syndromes in middle age. Type III is gestational, experienced by women during pregnancy and more often than not dissipating at birth (Aschner et al., 1999; World Health Organisation/ International Diabetes Federation, 2008; Van den Berghe et al., 2006).
The numbers of those afflicted by diabetes have become astounding and already impose a grave burden on primary and tertiary healthcare facilities. One estimate put the global population of diabetics at 171 million people globally as of 2000. At current trends, this is likely to increase to 366 million in just two more decades (Wild, Roglic, Green, Sicree & King, 2004). The healthcare burden is imposed by the wide range of complications associated with poorly-managed hyperglycemia: the aforementioned retinopathy, kidney problems, cardiovascular system failure, and neuropathy (nerve destruction). Heart disease and end-stage kidney failure are the main culprits for reduced life expectancy. In financial terms, the burden of diabetes in the United States, for example, has been estimated at $US 132 billion as of 2002; this is expected to rise significantly to $US 192 billion by 2020 (American Diabetes Association, 2003).
Around Southeast Asia, Fonseca (2006) reports, the diabetes prevalence rate ranged from two to five percent as of 1987. By 2007, the regional and comparative prevalence rates had risen to between 6.0 and 6.5 percent. In Malaysia itself, the incidence of diabetes, specifically type II, has risen continuously. Prevalence was insignificant at 0.65% in the 1960s but this rose to between two to four percent in the following decade and perhaps eight to 12 percent by the 1980s. More recently, between 1996 and 2006, prevalence reportedly increased by 80 percent (Fonseca, 2006; International Diabetes Federation, 2009).
According to Dr. Ismail, the director of healthcare in Malaysia, the increase is due to lifestyle-related changes in the country. The number of obese individuals had increased by 200 percent over the years and obesity remains the most significant risk factor for the development of diabetes. As of 2007, statistics show, the Malaysian population of diabetics was the fourth highest in Asia at 800,000 and was forecasted to increase to 1.3 million cases by 2008 (Mafauzy, 2006). Doctors say many young adults and children have been diagnosed with diabetes due to bad eating habits and have sedentary lifestyles.
The Ministry of Health of Malaysia took the alarming prevalence of diabetes cases seriously and improved the care and management of diabetic patients in clinics and hospitals, aside from training more nurses and creating more awareness on the symptoms and causes of diabetes. Health education campaigns are key. The population remains largely unaware of the symptoms of “pre-diabetes”, when dysfunctional blood glucose control begins to make itself felt. As well, those at risk owing to genetic predisposition, obesity and unhealthy lifestyles may be unaware of the serious complications that ensue as the disease progresses. Physicians themselves may lack the training or inclination to conduct full-scale check-ups for this dread disease. The key factor underlying this study, however, is the unabated rise in domestic diabetes prevalence. This suggests a population that is either heedless of physician advice or prone to seek information from less authoritative sources.
Research Question and Objectives
In general, therefore, this research therefore aims to update the level of knowledge about diabetes in Malaysia, to determine the relationships of behavior and attitudes of the population and level of knowledge about the disease. Furthermore, it seeks to determine how the people are currently acquiring information about the disease. More specifically, the study aims to quantify:
- The penetration of, and level of trust reposed in, health information channels.
- The level of knowledge about diabetes, including symptoms, diagnostic signposts, and attendant complications.
- Incidence of being diagnosed as diabetic.
- Awareness of the lifestyle changes needed to manage and stabilize blood glucose levels among those who oscillate between hyper- and hypoglycemia.
- Attitudes about the role of government in diabetes social marketing or educational campaigns.
- The potential utility of the Internet as a health information channel and a dedicated portal for self-management of the disease.
- Whether there Is a relationship among consumer behavior, attitudes and knowledge about the inherent risk of contracting diabetes.
- The relationship between better knowledge or information gaps, on one hand, and socio-demographic factors, on the other, such as gender, age, education, occupation, income, ethnicity, locale and information-seeking propensity.
Owing to the limitations of this short report format, the “Analysis of Results” is limited to testing just two hypotheses.
Literature Review
Awareness and Level of Knowledge about Diabetes
Recently, the rate of diabetes prevalence in Malaysia has risen faster than expected, almost doubling between 1996 and 2006, owing to the lack of knowledge about the disease. In order to increase awareness about diabetes, medical practitioners and the public health service or care centers must devote more effort to working with stakeholders and other health groups to have better-quality educational programs.
Such programs concentrate on providing doctors and patients the additional help they will need in order to manage this growing chronic disease (National Diabetes Institute, 2010). Type II diabetes needs more and better attention in Malaysia, before the disease becomes endemic. Already, the number of children with juvenile diabetes has grown enough to become a matter of some concern, contributing as it does to the burden of healthcare devoted to a diabetic population (Kamaruddin, 2010).
A study carried out in Cheras, Kuala Lumpur, investigated how well diabetics adopted the recommended regimen of maintaining or embarking on physical activity. About 132 subjects aged 30 years and above (mean: 51.9 ±5.8) participated in the study. The research team found that “…physical activity levels of the patients were unsatisfactory and associated with poor glycaemic control, especially in the elderly. There is a need to encourage diabetic patients to undertake regular physical activity in order to achieve optimal glycaemic control” (Shazwani et al., 2010, p. 110).
Consistent with this finding, National Diabetes Institute spokesman Dzulkiflee asserts that it is very important that the public be made aware of the danger of the disease which has already struck close to 15% of Malaysians from the age of 30 onward. As well, it was considered vital to learn more about diabetes and educate the public on how to prevent the disease and its complications (National Diabetes Institute, 2010).
Information-Seeking Pattern
A study carried out by Bakar & Alhadri (2009) in Gombak suggested that respondent-housewives carried more than their fair share of searching for information about the diseases and degenerative conditions afflicting their families. This is consistent with greater concern, vis-à-vis husbands, for the well-being of their families. By locale, the researcher found that housewives in villages are keener on seeking health information than those in rural areas. This is presumably related to the greater incidence of lifestyle-linked degenerative diseases in cities and villages than in the countryside.
The same study culled some insights about trusted healthcare information channels. More than 67 percent of respondents consider magazines a useful source to obtain information, followed by mass media and word of mouth (i.e., family and friends). No more than 10 percent use the Internet as a source of information about health. This stands to reason since personal computers and connections to the World Wide Web have comparatively poor penetration in rural areas.
Further, the researcher found that just under half (43 percent) of respondents reported no difficulty in gathering information about healthcare matters. After all, village residents do have access to mobile libraries and magazines. In contrast, Mafauzy (2006) had earlier concluded that the alarming rise in diabetes prevalence correlated with poor knowledge and awareness about the condition.
The Role of Education in Diabetes
Since diabetes has no known cure, patients constantly need information if they are not to deteriorate to the point of experiencing such deadly complications as cardiovascular disease and renal failure. According to the Worldwide Initiative for Diabetes Education, the aim of information campaigns for this syndrome are to change behavior and to become competent at self-management. In Malaysia, however, a study conducted on a sample of 110 adults (18+ years) patients seen at Kuala Lumpur care centers (Azimah, Radzniwan, Zuhra & Khairani, 2010) suggested that although patients had good general knowledge about diabetes, some entertained the misconception that liver failure is one of the complications of diabetes. The researchers believed that such a misunderstanding could get in the way of the treatment process. It was also discovered that patients with Type II diabetes entertained the misconception that they needed from 60 to 75 minutes of exercise daily in order to manage blood glucose levels.
An equally glaring healthcare gap is that, despite more than 90% of diabetics receiving care from primary care doctors, Ali (2009) pointed out that some patients were not even informed about the disease because physicians did not think the condition had advanced to a high-risk stage. This explains why patients in the early stages of Type II diabetes may receive little information and health education.
Attitudes and Behaviour of Target Populations Around Issues Related to Diabetes
Since studies have found that adult-onset diabetes can be delayed or even prevented outright given change in unhealthy lifestyles (National Institute of Diabetes and Digestive and Kidney Diseases, 2009), it is encouraging that those who believe they are at high risk for a particular illness are amenable to altering their habits and unhealthy behaviors. Healthier eating habits and engaging in physical exercise can be the most useful steps in guiding interventions for community practice. Regular physical activity plays a central role in the management of both juvenile and adult-onset diabetes, helping to delay the onset of such perilous complications as hypertension, amputation of the lower limbs, end-stage renal failure and coronary disease.
Physically active individuals tend to smoke less and have healthier diets (Paffenbarger, Hyde & Wing, 1987). In fact, Malaysian Health Ministry (2010) surveys suggest that adults with either juvenile or Type II diabetes appeared to meet current guidelines of 150 minutes a week for moderate physical activity. As in the West and other newly-industrialized nations, the rise of per-capita incomes and availability of convenience foods has made obesity and inactivity nearly endemic in Malaysia. Both happen to be implicated as risk factors for both diabetes and cardiovascular diseases.
Methodology and Research Design
The survey on knowledge and perceptions about diabetes was quantitative in nature, aimed at interviewing adults residing around the campus premises. The study employed convenience sampling, with quotas set for each age group from 18 to “over 65 years” so as to arrive at a respondent profile approximately reflective of age distribution in the urban Malaysian population. After data cleaning, a total of 452 qualified respondents entered the database.
The field procedure relied on face-to-face interviews, based on a structured questionnaire (see Appendix B). The study instrument comprised 26 items, chiefly closed-end and two open-ended items. The closed-end items were prompted with either checklist of prepared choices or Likert-type rating scales. The latter was constructed as five-point intervals of importance or agreement.
The plan of analysis was guided by the following null hypotheses:
- H1: There is no difference in knowledge of diabetes across signposts of socio-economic advantage and health.
- H2: There is no difference across age cohorts in preferred channels for information about diabetes.
Results
Channels of Information
The test of null hypothesis #2, “There is no difference across age cohorts in preferred channels for information about diabetes,” must be done within the context of all information generated by the study about media.
Confronted with unfamiliar symptoms of the bodily condition (question 1), the adults surveyed were more likely to consult a physician first (46.5 percent, Table 1 in Appendix B). On the other hand, close to one-fourth would look for information over the Internet while one in five relies on word-of-mouth, advice from family members, other relatives and friends. Comparatively few rely on the other prompted choices: books, pharmacists and mass media.
Examining the subsidiary null hypothesis H2B, “Having access to the Internet makes no difference in reliance on the Internet as the preferred information channel when experiencing unfamiliar physical symptoms”, one tests the cross-tabulation of questions 11 and 3. Since both items are categorical variables, the chi-square suits as a test of significance of differences. Unsurprisingly, the outcome of the cross-tabulation is that reliance on the Internet is completely and fully a function of access to the Web (Table 2). Only those who have access rely on the Internet for information about vague or newly-experienced physical symptoms. The result for the chi-square analysis (Table 3) is a value of 32.46; at five degrees of freedom, the associated significance is p <.001, far surpassing the standard social science threshold of α = 0.05. Since this suggests that the result in Table 2 could have occurred by random chance less than once in a thousand repetitions of the student survey, one rejects H2B and concludes that Internet access reliably explains preference for seeking health information over the Web when experiencing new physical symptoms.
The outcome for the backup question 2 series about the relative importance of the given information channels for health issues (Table 4) affirms the primacy of physicians. Doctors merited a mean likelihood rating of 4.3 on the five-point scale. As before, word of mouth ranked second (mean rating = 3.8) and the Internet third (mean rating = 3.42) though pharmacists ranked about the same (mean = 3.40) as Web sources.
The potential of the Internet as a health information channel is bolstered by the finding that the lion’s share of consumers did have access (85%, Table 13)and that it is convenient for mostly being available at home (Table 14). It follows then that usage is very frequent (daily for the majority, Table 15) and heavy (averaging nearly three hours daily, Table 17). Relevance and utility are significant since a majority report going on the Net to find answers for unfamiliar topics (67%, Table 19). At the same time, any thought of using the Net to promote healthier lifestyles should consider the fact that users go online more frequently to check email rather than catch up on the news (Tables 22 and 23), and much more than searching for medical information (26%, Table 25; 0.3%, Table 27).
Some Factors Relating to Knowledge About Diabetes
Null hypothesis H1 posits that a) those who already have the disease know more about it by now; and, b) better knowledge is directly related to the usual signposts of socio-economic advantage.
The findings indicate that having postgraduate education correlates best with knowing what the “normal” range of blood glucose level ought to be (Table 37). So do full-time employment status (Table 39), and annual family income in the RM100,000 or more range (truncated, not included in Appendix A). Postgraduate education and family income are also indicative where knowledge about the accuracy of blood testing is concerned and that diabetics are at risk of renal failure. However, the chi-square tests belie the statistical significance of the results. Irrespective of education and income, knowledge about the perilous complications of diabetes (heart attacks, blindness and kidney failure) is widespread.
Still, the extent of consumer knowledge is far from complete. Misconceptions abound as to whether, for example, weakness indicates hypoglycemia.
Conclusions and Recommendations
This exploratory, nationwide benchmarking study yields new insight into planning social marketing interventions for diabetes. The health ministry and worried non-government organizations have a firm foundation to build on in at least three respects. First, there exists a core of accurate knowledge about the constant battle to maintain a glycaemic balance that diabetics endure. Second, the population is generally aware of the three most ominous complications – cardiovascular disorders, blindness and kidney failure – following long periods of hyperglycemia. Thirdly, adult Malaysians are by and large predisposed to see physicians first when experiencing vague new symptoms.
Since modernization and the higher disposable incomes that an industrializing nation affords its people will continue to take a toll on healthy lifestyles, health education interventions must focus on a preventive strategy. As the “baby boom” generation goes into retirement, becomes more sedentary and approaches the 20% diabetes prevalence of countries like the U.S.A., the healthcare burden will become greater. Using incentives and “push” email campaigns leverages the Internet readiness of the population to encourage higher fiber intake, more exercise, and the consequent ability to maintain ideal body weight. Otherwise, diabetics will overload such tertiary care divisions as Ophthalmology, Cardiology, Orthopaedics, Endocrinology and Renal in the future.
Reference List
Ali, SM, 2009. Barriers to optimal control of type 2 diabetes in Malaysian Malay patients. Global Journal of Health Science, vol. 1, no. 2, pp. 106-118.
American Diabetes Association. 2003. Economic costs of diabetes in the US in 2002. Diabetes Care. vol. 26, pp. 917-32.
Aschner, P et al. 1999. Definition, diagnosis and classification of diabetes mellitus and its complications: report of a WHO Consultation. Geneva, World Health Organisation.
Azimah MN, Radzniwan R, Zuhra H, Khairani O. 2010. Have we done enough with diabetic education? A pilot study. Malaysian Family Physician. Vol. 5, no. 1, pp. 24-30.
Bakar ABA & Alhadri AYAL. 2009. Seeking access to health information: the dilemma of woman community in rural Malaysia. Proceedings of the World Library and Information Congress: 75th IFLA General Conference and Council. Milan, Italy, International Federation of Library Associations and Institutions, pp. 1-10.
Fonseca, VA. 2006. Clinical diabetes: translating research into practice. Philadelphia, PA, Elsevier Health Sciences.
International Diabetes Federation. 2009. Diabetes atlas: Southeast Asian region. Web.
Kamaruddin, NA, 2010. Diabetes: you’re in control. The Star Online. Web.
Mafauzy, M, 2006. Diabetes mellitus in Malaysia. Medical Journal of Malaysia, vol. 61, no. 4, pp. 397-8.
Ministry of Health Malaysia. 2010. CPG – endocrine disease. Web.
National Diabetes Institute. 2010. Managing diabetes and its complications. Web.
National Institute of Diabetes and Digestive and Kidney Diseases. 2009. National Diabetes Information Clearinghouse. [Internet], National Institutes of Health. Web.
Paffenbarger RS Jr, Hyde RT & Wing AL. 1987. Physical activity and incidence of cancer in diverse populations: a preliminary report. Am J Clin Nutr, vol. 45, pp. :312-7.
Porte D, Sherwin RS, Baron A, Ellenberg M & Rifkin, H, 2003. Ellenberg and Rifkin’s diabetes mellitus. New York, McGraw-Hill Professional.
Shazwani N, Suzana S, Hanis MY, Lim CJ, Teh SC, Mohd Fauzee MZ, Lim HC, Dahlia S & Norliza M. 2010. Assessment of physical activity level among individuals with type 2 diabetes mellitus at Cheras Health Clinic, Kuala Lumpur. Mal J Nutr, vol. 16, no. 1, pp. 101 – 12.
Van den Berghe G, Wilmer A, Hermans G, Meersseman W, Wouters PJ, Milants I, Van Wijngaerden E, Bobbaers H,Bouillon R. 2006. Intensive insulin therapy in the medical ICU. N.Engl.J.Med, vol. 354, pp. 449-61.
Wild S, Roglic G, Green A, Sicree R & King H. 2004. Global prevalence of diabetes: estimates for the year 2000 and projections for 2030. Diabetes Care. vol. 27, pp. 1047-53.
World Health Organisation/International Diabetes Federation. 2008. Definition and diagnosis of diabetes mellitus and intermediate hyperglycemia: report of a WHO/IDF consultation. Geneva, World Health Organisation.
Detail Tables and Statistical Analysis
Table 1
Table 2
Table 3
Table 4
Table 5
Table 6: Comparative Statistics for Likelihood of Use (Question 2)
Table 7
Table 8
Table 9
Table 10
Table 11
Table 12
Table 13
Table 14
Table 15
Table 16
Table 17
Table 18
Table 19
Table 20
Table 21
Table 22
Table 23
Table 24
Table 25
Table 26
Table 27
Table 28
Table 29
Table 30
Table 31
Table 32
Table 33
Table 34
Table 35: Summary Statistics for Internet Uses and Expertise (Part 1 of 2)
Table 36: Summary Statistics for Internet Uses and Claimed Expertise (Part 2 of 2)
Table 37: Awareness of Correct Blood Sugar Range, by Educational Attainment
Table 38: Result of Chi-Square Test for Table 37
Table 39: Knowledge About Normal Blood Glucose Range, by Employment Status
Table 40: Chi-Square Test of Significance for Table 39
a. 4 cells (25.0%) have expected count less than 5. The minimum expected count is.58.