p r i m a r y c a r e d i a b e t e s 9 ( 2 0 1 5 ) 275–282
Contents lists available at ScienceDirect
Primary Care Diabetes journal homepage: http://www.elsevier.com/locate/pcd
Original research
A study exploring the association of attitude and treatment satisfaction with glycaemic level among gestational diabetes mellitus patients Zahid Hussain ∗ , Zuraidah Mohd Yusoff, Syed Azhar Syed Sulaiman Discipline of Clinical Pharmacy, School of Pharmaceutical Sciences, Universiti Sains Malaysia, Malaysia
a r t i c l e
i n f o
a b s t r a c t
Article history:
Aims: The aim of this study was to evaluate attitude and treatment satisfaction of women
Received 25 September 2014
suffering from GDM and their association with glycaemic level.
Received in revised form
Methods: A cross sectional study was conducted in antenatal clinic of Hospital Pulau Pinang,
11 October 2014
Malaysia from June to December 2013 on the sample of 175 patients. Data was collected
Accepted 13 October 2014
through modified version of Diabetes Integration Scale (ATT-19) and Diabetes Treatment Sat-
Available online 7 November 2014
isfaction Questionnaires (DSTQs). Glycaemic level was evaluated in terms of Fasting Plasma Glucose (FPG). Three most recent values of FPG (mmol/l) were taken from patients medical
Keywords:
profiles and their mean was calculated. Descriptive and inferential statistics were used for
GDM
data analysis.
Attitude
Results: A total of 166 patients were included in final analysis. Only 35 (21.1%) patients had
Treatment satisfaction
positive attitude and 122 (73.5%) of patients had adequate treatment satisfaction. There
Glycaemic level
was no significant association of total mean ATT-19 score with age, ethnicity, educational level, occupational status, family history and type of therapy. For treatment satisfaction statistically significant association was present only between total mean treatment satisfaction score and educational level. Patients with negative attitude and inadequate treatment satisfaction had higher mean glycaemic level. Conclusions: It is concluded that more than two folds of patients were satisfied with their ongoing treatment but majority of the patients were feeling difficulty in active coping measures for the management of GDM. © 2014 Primary Care Diabetes Europe. Published by Elsevier Ltd. All rights reserved.
1.
Introduction
Gestational Diabetes Mellitus (GDM) is defined as occurrence of glucose intolerance and is first recognized during pregnancy [1]. It is one of the most common pregnancy problems
∗
and complicates about 3–5% of pregnancies worldwide [2]. Highest prevalence of GDM was reported in Nepal 28% and lowest in Germany 70 depicts positive attitude towards disease. For evaluation of treatment satisfaction, Diabetes Treatment Satisfaction Questionnaire (DTSQs) status version was used. DSTQs is a well validated questionnaire used in number of studies to evaluate the satisfaction level of patients from diabetes specific treatment. Malaysian version of DSTQs was taken from Prof Clare Bradely. After a detailed discussion with Prof Clare Bradely this questionnaire was used without modifications because it does not contain specific words like “type 1 DM” or “type 2 DM”, rather a general term “diabetes” used in this questionnaire. However this instrument was used first time on GDM patients so pilot study was done to evaluate its reliability for this specific population. The Crobach’s alpha was 0.775 [26] exhibit good reliability. DTSQs is an 8 items questionnaire which include questions related to satisfaction with current treatment, treatment convenience, treatment flexibility, understanding of diabetes, satisfaction with treatment continuation and recommending treatment to other diabetic patients. Item no 2 and 3 related to perceived frequency of hyperglycaemia and hypoglycaemia and were treated separately in all analysis (score 0 for “none of the times” and 6 for “most of the times”). Response was measured by seven point Likert scale (score 0 for very dissatisfied and score 6 for very satisfied). For remaining 6 items total score varies from 0 to 36. Satisfaction was evaluated in terms of satisfied and unsatisfied. Higher score depict greater treatment satisfaction. Score > 21 indicate adequate treatment satisfaction.
2.4.
Glycaemic level
Glycaemic values were recorded in terms of fasting plasma glucose (FPG). Three most recent values of FPG were taken from patients medical profiles and mean was calculated for every patient to evaluate their glycaemic levels. Though HbA1c is considered as most accurate test for glycaemic measurement over a long period of time, but due to short lived nature of GDM, values of HbA1c could not be taken as a standard so as alternative, values of FPG were taken. Research has shown
Table 1 – Characteristics of study respondents (n = 166). Variable
Mean ± SD
Age of patients 3
f (%) 13 (7.8) 45 (27.1) 57 (34.3) 51 (30.7)
41 (27.4) 78 (47.0) 47 (28.3)
Ethnicity Malay Chinese Indian Indonesian Educational level Primary Secondary Diploma Degree Occupational status Working woman Housewife Family history of DM Family history of DM No family history of DM Type of therapy Diet control Insulin OHAs
118 (71.1) 21 (12.7) 19 (11.4) 8 (4.8)
53 (31.9) 54 (32.5) 34 (20.5) 25 (15.1)
108 (65.1) 58 (34.9)
91 (54.8) 75 (45.2)
145 (87.3) 21 (12.7) 0 (0)
that Plasma Glucose (PG) has a direct association with HbA1c [27].
2.5.
Statistical method
All the statistical analysis was done by using Statistical Package for Social Sciences (SPSS Inc., Chicago, IL) version 20. P value of >0.05 was considered as significant. Frequency and percentage were used for grouped variables whereas mean and standard deviation were used for continuous variables. Association of demographic characteristics with attitude and treatment satisfaction scores of patients were represented by using Mann Whitney U test (for 2 group variable) and Kruskal–Wallis H test (for more than 2 group variables). Benferoni post hoc adjustment was done in case of significant P value of Kruskal Wallis H test. Relationship between type of attitude and level of treatment satisfaction with FPG was evaluated by using Mann Whitney U test.
3.
Results
In the present study 188 eligible patients were invited out of 175 agreed to take part in the study. Out of 175 enrolled patients 9 were excluded from the final analysis due to incompletely filled questionnaire and missing glycaemic values. The demographic characteristics of 166 patients presented in Table 1 including the frequency distribution
278
p r i m a r y c a r e d i a b e t e s 9 ( 2 0 1 5 ) 275–282
Table 2 – Distribution of response of diabetes integration scale (n = 166).
Table 3 – Distribution of responses of Diabetes Treatment Satisfaction Questionnaire (n = 166).
ATT-19
Mean ± SD
DSTQs
Mean ± SD
1. If I didn’t have Gestational diabetes mellitus I think that I would be quite a different person. 2. I dislike being referred to as “A DIABETIC”. 3. Gestational diabetes mellitus is the worst thing that has ever happened to me. 4. Most ladies would find it difficult to adjust to having gestational diabetes mellitus. 5. I often feel embarrassed about having gestational diabetes mellitus. 6. There is not much I seem to be able to do to control my diabetes. 7. There is a little hope of leading a normal life with gestational diabetes mellitus. 8. The proper control of diabetes involves a lot of sacrifice and inconvenience. 9. I try not to let people know about my diabetes. 10. Being told you have diabetes is like being sentenced to a life time of illness. 11. My diabetic diet does not really spoilt my social life. 12. In general doctors need to be a lot more sympathetic in their treatment of people with gestational diabetes mellitus. 13. Having gestational diabetes mellitus during pregnancy changes the personality. 14. I often find it difficult to decide whether I feel sick or well. 15. Gestational diabetes mellitus is not really a problem because it can be controlled. 16. There is really nothing you can do if you have gestational diabetes mellitus. 17. There is really no-one I feel I can talk to openly about my gestational diabetes mellitus. 18. I believe I have adjusted well to having gestational diabetes mellitus. 19. I often feel it is unfair that I should have gestational diabetes mellitus when other women are so healthy.
3.05 ± 1.21
1. How satisfied are you with your current treatment? 4. How convenient have you been finding your treatment to be recently? 5. How satisfied are you with the extent to which your treatment fits in with your daily life? 6. How satisfied are you with your understanding of your diabetes? 7. Would you recommend this form of treatment to someone else with your kind of diabetes? 8. How satisfied would you be to continue with your present form of treatment?
4.51 ± 1.14
Total mean
3.74 ± 1.12 3.63 ± 1.04 3.63 ± 0.99 3.01 ± 1.05 2.85 ± 1.17 2.38 ± 1.10 3.32 ± 1.11 2.71 ± 1.03 2.59 ± 1.14 2.39 ± 1.03 3.46 ± 1.05
3.02 ± 1.15 3.09 ± 1.10 2.22 ± 0.86
3.88 ± 1.40
4.15 ± 1.46 4.22 ± 1.79
4.56 ± 1.34 25.16 ± 5.94 2.75 ± 1.60 2.46 ± 1.61
(2.22 ± 0.86), item 16 (2.25 ± 1.03) and item 17 (2.29 ± 1.04). Total mean attitude score (range 19–95) of 166 study respondents was 55.10 ± 11.41. A total of 131 (78.9%) patients fall within definition of negative attitude (score ≤70). Association of demographic features with mean attitude score is presented in Table 4. There was no significant association between total mean ATT-19 score with age, ethnicity, educational level, occupational status, family history and type of therapy.
2.25 ± 1.03
3.2.
2.29 ± 1.04
Mean treatment satisfaction score for individual item of DSTQ (range 0–6) is presented in Table 3. Higher mean treatment satisfaction score was observed for item 1 (4.51 ± 1.14) and item 8 (4.56 ± 1.34). Lower treatment satisfaction score was noted for item 4 (3.83 ± 1.42) and item 5 (3.88 ± 1.40). Total mean treatment satisfaction score (range 0–36) of 166 study participants was 25.16 ± 5.94. A total of 122 (73.5%) patients fall within the definition of satisfied (score >21) and 44 (26.5%) fall within the category of unsatisfied (score ≤21). Relationship between treatment satisfaction score and demographic characteristics of study participants is elaborated in Table 4. Non parametric analysis showed that statistically significant association was present only between total mean treatment satisfaction score and educational level. Benforroni post hoc adjustment revealed that patients with secondary school education had significantly higher score among all educational groups (p = 0.16). Other variables like age, ethnicity, occupational status, history of GDM, type of therapy were not significantly associated. Mean score for perceived frequency of hyperglycaemia and perceived frequency of hypoglycaemia were 2.75 ± 1.60 and 2.46 ± 1.61 respectively for all study participants.
2.69 ± 1.01 2.68 ± 1.17
55.10 ± 11.41
of study participants. Mean age of patients was 31.95 ± 5.35 years ranging from 19 to 44 years. Majority of them were aged more than 30 years and had more than 2nd parity. Malay ethnic patients constitute the largest portion of sample size and almost two third of participants had educational level less than or up to secondary school. A total of 65% patients were working women and more than half had family history of diabetes (father, mother or both). Majority of the patients were on diet management therapy with small number of patients on insulin and none of the patients was prescribed with oral hypoglycaemic agents (OHAs).
3.1.
Total Mean 2. How often have you felt that your blood sugar has been unacceptably high recently? 3. How often have you felt that your blood sugar has been unacceptably low recently?
3.83 ± 1.42
Attitude assessment
Mean attitude score for every item of ATT-19 (range 0–5) is presented in Table 2. Higher mean attitude score was observed for item 2 (3.74 ± 1.12), item 3 (3.63 ± 1.04) and item 4 (3.63 ± 0.99). Whereas, lower mean attitude score was noted for item 15
Treatment satisfaction assessment
3.3. Association of attitude and treatment satisfaction with glycaemic level Mean FPG of 166 study participants was 5.49 ± 1.06. Association between type of attitude and degree of treatment
279
p r i m a r y c a r e d i a b e t e s 9 ( 2 0 1 5 ) 275–282
Table 4 – Association of mean attitude and treatment satisfaction score with demographic characteristics of GDM patients (n = 166). Variable
f (%)
Age of patients (31.69 ± 5.35)
Contents lists available at ScienceDirect
Primary Care Diabetes journal homepage: http://www.elsevier.com/locate/pcd
Original research
A study exploring the association of attitude and treatment satisfaction with glycaemic level among gestational diabetes mellitus patients Zahid Hussain ∗ , Zuraidah Mohd Yusoff, Syed Azhar Syed Sulaiman Discipline of Clinical Pharmacy, School of Pharmaceutical Sciences, Universiti Sains Malaysia, Malaysia
a r t i c l e
i n f o
a b s t r a c t
Article history:
Aims: The aim of this study was to evaluate attitude and treatment satisfaction of women
Received 25 September 2014
suffering from GDM and their association with glycaemic level.
Received in revised form
Methods: A cross sectional study was conducted in antenatal clinic of Hospital Pulau Pinang,
11 October 2014
Malaysia from June to December 2013 on the sample of 175 patients. Data was collected
Accepted 13 October 2014
through modified version of Diabetes Integration Scale (ATT-19) and Diabetes Treatment Sat-
Available online 7 November 2014
isfaction Questionnaires (DSTQs). Glycaemic level was evaluated in terms of Fasting Plasma Glucose (FPG). Three most recent values of FPG (mmol/l) were taken from patients medical
Keywords:
profiles and their mean was calculated. Descriptive and inferential statistics were used for
GDM
data analysis.
Attitude
Results: A total of 166 patients were included in final analysis. Only 35 (21.1%) patients had
Treatment satisfaction
positive attitude and 122 (73.5%) of patients had adequate treatment satisfaction. There
Glycaemic level
was no significant association of total mean ATT-19 score with age, ethnicity, educational level, occupational status, family history and type of therapy. For treatment satisfaction statistically significant association was present only between total mean treatment satisfaction score and educational level. Patients with negative attitude and inadequate treatment satisfaction had higher mean glycaemic level. Conclusions: It is concluded that more than two folds of patients were satisfied with their ongoing treatment but majority of the patients were feeling difficulty in active coping measures for the management of GDM. © 2014 Primary Care Diabetes Europe. Published by Elsevier Ltd. All rights reserved.
1.
Introduction
Gestational Diabetes Mellitus (GDM) is defined as occurrence of glucose intolerance and is first recognized during pregnancy [1]. It is one of the most common pregnancy problems
∗
and complicates about 3–5% of pregnancies worldwide [2]. Highest prevalence of GDM was reported in Nepal 28% and lowest in Germany 70 depicts positive attitude towards disease. For evaluation of treatment satisfaction, Diabetes Treatment Satisfaction Questionnaire (DTSQs) status version was used. DSTQs is a well validated questionnaire used in number of studies to evaluate the satisfaction level of patients from diabetes specific treatment. Malaysian version of DSTQs was taken from Prof Clare Bradely. After a detailed discussion with Prof Clare Bradely this questionnaire was used without modifications because it does not contain specific words like “type 1 DM” or “type 2 DM”, rather a general term “diabetes” used in this questionnaire. However this instrument was used first time on GDM patients so pilot study was done to evaluate its reliability for this specific population. The Crobach’s alpha was 0.775 [26] exhibit good reliability. DTSQs is an 8 items questionnaire which include questions related to satisfaction with current treatment, treatment convenience, treatment flexibility, understanding of diabetes, satisfaction with treatment continuation and recommending treatment to other diabetic patients. Item no 2 and 3 related to perceived frequency of hyperglycaemia and hypoglycaemia and were treated separately in all analysis (score 0 for “none of the times” and 6 for “most of the times”). Response was measured by seven point Likert scale (score 0 for very dissatisfied and score 6 for very satisfied). For remaining 6 items total score varies from 0 to 36. Satisfaction was evaluated in terms of satisfied and unsatisfied. Higher score depict greater treatment satisfaction. Score > 21 indicate adequate treatment satisfaction.
2.4.
Glycaemic level
Glycaemic values were recorded in terms of fasting plasma glucose (FPG). Three most recent values of FPG were taken from patients medical profiles and mean was calculated for every patient to evaluate their glycaemic levels. Though HbA1c is considered as most accurate test for glycaemic measurement over a long period of time, but due to short lived nature of GDM, values of HbA1c could not be taken as a standard so as alternative, values of FPG were taken. Research has shown
Table 1 – Characteristics of study respondents (n = 166). Variable
Mean ± SD
Age of patients 3
f (%) 13 (7.8) 45 (27.1) 57 (34.3) 51 (30.7)
41 (27.4) 78 (47.0) 47 (28.3)
Ethnicity Malay Chinese Indian Indonesian Educational level Primary Secondary Diploma Degree Occupational status Working woman Housewife Family history of DM Family history of DM No family history of DM Type of therapy Diet control Insulin OHAs
118 (71.1) 21 (12.7) 19 (11.4) 8 (4.8)
53 (31.9) 54 (32.5) 34 (20.5) 25 (15.1)
108 (65.1) 58 (34.9)
91 (54.8) 75 (45.2)
145 (87.3) 21 (12.7) 0 (0)
that Plasma Glucose (PG) has a direct association with HbA1c [27].
2.5.
Statistical method
All the statistical analysis was done by using Statistical Package for Social Sciences (SPSS Inc., Chicago, IL) version 20. P value of >0.05 was considered as significant. Frequency and percentage were used for grouped variables whereas mean and standard deviation were used for continuous variables. Association of demographic characteristics with attitude and treatment satisfaction scores of patients were represented by using Mann Whitney U test (for 2 group variable) and Kruskal–Wallis H test (for more than 2 group variables). Benferoni post hoc adjustment was done in case of significant P value of Kruskal Wallis H test. Relationship between type of attitude and level of treatment satisfaction with FPG was evaluated by using Mann Whitney U test.
3.
Results
In the present study 188 eligible patients were invited out of 175 agreed to take part in the study. Out of 175 enrolled patients 9 were excluded from the final analysis due to incompletely filled questionnaire and missing glycaemic values. The demographic characteristics of 166 patients presented in Table 1 including the frequency distribution
278
p r i m a r y c a r e d i a b e t e s 9 ( 2 0 1 5 ) 275–282
Table 2 – Distribution of response of diabetes integration scale (n = 166).
Table 3 – Distribution of responses of Diabetes Treatment Satisfaction Questionnaire (n = 166).
ATT-19
Mean ± SD
DSTQs
Mean ± SD
1. If I didn’t have Gestational diabetes mellitus I think that I would be quite a different person. 2. I dislike being referred to as “A DIABETIC”. 3. Gestational diabetes mellitus is the worst thing that has ever happened to me. 4. Most ladies would find it difficult to adjust to having gestational diabetes mellitus. 5. I often feel embarrassed about having gestational diabetes mellitus. 6. There is not much I seem to be able to do to control my diabetes. 7. There is a little hope of leading a normal life with gestational diabetes mellitus. 8. The proper control of diabetes involves a lot of sacrifice and inconvenience. 9. I try not to let people know about my diabetes. 10. Being told you have diabetes is like being sentenced to a life time of illness. 11. My diabetic diet does not really spoilt my social life. 12. In general doctors need to be a lot more sympathetic in their treatment of people with gestational diabetes mellitus. 13. Having gestational diabetes mellitus during pregnancy changes the personality. 14. I often find it difficult to decide whether I feel sick or well. 15. Gestational diabetes mellitus is not really a problem because it can be controlled. 16. There is really nothing you can do if you have gestational diabetes mellitus. 17. There is really no-one I feel I can talk to openly about my gestational diabetes mellitus. 18. I believe I have adjusted well to having gestational diabetes mellitus. 19. I often feel it is unfair that I should have gestational diabetes mellitus when other women are so healthy.
3.05 ± 1.21
1. How satisfied are you with your current treatment? 4. How convenient have you been finding your treatment to be recently? 5. How satisfied are you with the extent to which your treatment fits in with your daily life? 6. How satisfied are you with your understanding of your diabetes? 7. Would you recommend this form of treatment to someone else with your kind of diabetes? 8. How satisfied would you be to continue with your present form of treatment?
4.51 ± 1.14
Total mean
3.74 ± 1.12 3.63 ± 1.04 3.63 ± 0.99 3.01 ± 1.05 2.85 ± 1.17 2.38 ± 1.10 3.32 ± 1.11 2.71 ± 1.03 2.59 ± 1.14 2.39 ± 1.03 3.46 ± 1.05
3.02 ± 1.15 3.09 ± 1.10 2.22 ± 0.86
3.88 ± 1.40
4.15 ± 1.46 4.22 ± 1.79
4.56 ± 1.34 25.16 ± 5.94 2.75 ± 1.60 2.46 ± 1.61
(2.22 ± 0.86), item 16 (2.25 ± 1.03) and item 17 (2.29 ± 1.04). Total mean attitude score (range 19–95) of 166 study respondents was 55.10 ± 11.41. A total of 131 (78.9%) patients fall within definition of negative attitude (score ≤70). Association of demographic features with mean attitude score is presented in Table 4. There was no significant association between total mean ATT-19 score with age, ethnicity, educational level, occupational status, family history and type of therapy.
2.25 ± 1.03
3.2.
2.29 ± 1.04
Mean treatment satisfaction score for individual item of DSTQ (range 0–6) is presented in Table 3. Higher mean treatment satisfaction score was observed for item 1 (4.51 ± 1.14) and item 8 (4.56 ± 1.34). Lower treatment satisfaction score was noted for item 4 (3.83 ± 1.42) and item 5 (3.88 ± 1.40). Total mean treatment satisfaction score (range 0–36) of 166 study participants was 25.16 ± 5.94. A total of 122 (73.5%) patients fall within the definition of satisfied (score >21) and 44 (26.5%) fall within the category of unsatisfied (score ≤21). Relationship between treatment satisfaction score and demographic characteristics of study participants is elaborated in Table 4. Non parametric analysis showed that statistically significant association was present only between total mean treatment satisfaction score and educational level. Benforroni post hoc adjustment revealed that patients with secondary school education had significantly higher score among all educational groups (p = 0.16). Other variables like age, ethnicity, occupational status, history of GDM, type of therapy were not significantly associated. Mean score for perceived frequency of hyperglycaemia and perceived frequency of hypoglycaemia were 2.75 ± 1.60 and 2.46 ± 1.61 respectively for all study participants.
2.69 ± 1.01 2.68 ± 1.17
55.10 ± 11.41
of study participants. Mean age of patients was 31.95 ± 5.35 years ranging from 19 to 44 years. Majority of them were aged more than 30 years and had more than 2nd parity. Malay ethnic patients constitute the largest portion of sample size and almost two third of participants had educational level less than or up to secondary school. A total of 65% patients were working women and more than half had family history of diabetes (father, mother or both). Majority of the patients were on diet management therapy with small number of patients on insulin and none of the patients was prescribed with oral hypoglycaemic agents (OHAs).
3.1.
Total Mean 2. How often have you felt that your blood sugar has been unacceptably high recently? 3. How often have you felt that your blood sugar has been unacceptably low recently?
3.83 ± 1.42
Attitude assessment
Mean attitude score for every item of ATT-19 (range 0–5) is presented in Table 2. Higher mean attitude score was observed for item 2 (3.74 ± 1.12), item 3 (3.63 ± 1.04) and item 4 (3.63 ± 0.99). Whereas, lower mean attitude score was noted for item 15
Treatment satisfaction assessment
3.3. Association of attitude and treatment satisfaction with glycaemic level Mean FPG of 166 study participants was 5.49 ± 1.06. Association between type of attitude and degree of treatment
279
p r i m a r y c a r e d i a b e t e s 9 ( 2 0 1 5 ) 275–282
Table 4 – Association of mean attitude and treatment satisfaction score with demographic characteristics of GDM patients (n = 166). Variable
f (%)
Age of patients (31.69 ± 5.35)
