Original Article

Knowledge, Attitude, and Practice Related to Diabetes Mellitus Among Diabetics and Nondiabetics Visiting Homeopathic Hospitals in West Bengal, India

Journal of Evidence-Based Complementary & Alternative Medicine 2016, Vol. 21(1) 39-47 ª The Author(s) 2015 Reprints and permission: sagepub.com/journalsPermissions.nav DOI: 10.1177/2156587215593656 cam.sagepub.com

Munmun Koley, BHMS, MSc1, Subhranil Saha, BHMS, MSc1, Jogendra Singh Arya, DHMS1, Gurudev Choubey, MD1, Shubhamoy Ghosh, MD2, Rajat Chattopadhyay, MD2, Kaushik Deb Das, MD3, Aloke Ghosh, MD3, Himangsu Hait, MD4, Rajarshi Mukherjee, BHMS4, and Tanapa Banerjee5

Abstract High prevalence of undiagnosed cases of diabetes mellitus and poor knowledge, awareness, and practice has increased premature death, costly complications, and financial burden. A cross-sectional survey was conducted in November 2014 on 273 diabetics and 355 nondiabetics in 3 government homeopathic hospitals in West Bengal, India. A self-administered questionnaire assessing knowledge, awareness, and practice related to diabetes was used. A total of 17.5% to 29.3% of the participants were aware of the normal blood sugar level. Lack of insulin, frequent urination, hypertension, and poor wound healing were identified most frequently as the cause, symptom, association, and complications. A total of 35.5% to 46.5% said that diabetes was preventable; 14.1% to 31.9% knew that diabetes was controllable rather than curable. Consumption of planned diet, avoiding sugar, and testing blood sugar were the most frequently identified components of healthy lifestyle, diabetic diet, and diagnostic domain. Diabetics had higher knowledge and awareness than nondiabetics (P < .0001); still the latter need to be made aware and knowledgeable to curtail the ever-increasing burden of diabetes. Keywords knowledge, attitude, practice, diabetes mellitus, diabetics, nondiabetics Received April 17, 2015. Accepted for publication June 4, 2015.

Diabetes mellitus is rapidly gaining a potential epidemic state all over the world. In 2014, about 387 million people (8.3% prevalence and 46.3% undiagnosed) were suffering from diabetes mellitus globally, of which 75 million people are from southeast Asia (prevalence 8.3% and undiagnosed 52.8%), and it is projected to be 592 million by 2035.1,2 Among the diabetic population, 77% are living in low- and middle-income countries.1 For every 12 people, one is diabetic; in every 2 diabetics one does not know that he or she has it; and every 7 seconds one person dies from diabetes mellitus, thereby amounting to 4.9 million deaths already in 2014.1,3 Globally, more than 21 million live births have been affected by diabetes mellitus during pregnancy in 2013.2 It not only poses a grave threat to the health of a mother and her child, but evidence shows that this can lead to an increased risk of type 2 diabetes mellitus later in life for the child.2 Among those 20 to 79 years of age, 66 846 million people have been diagnosed with diabetes mellitus3; 35 495 million people remained undiagnosed; 8.63 is the national prevalence; 9.11 is the diabetes comparative prevalence; and 1 039 980

million deaths have occurred, of which 54% are under the age of 60, and the per person cost is US$95.1 Very recent studies conducted among diabetics and the general population in India found meager levels of knowledge and



3 4


Clinical Research Unit (Homeopathy), Central Council for Research in Homeopathy, Siliguri, West Bengal, India Mahesh Bhattacharyya Homeopathic Medical College and Hospital, Howrah, West Bengal, India Midnapore Homoeopathic Medical College and Hospital, Midnapore, India The Calcutta Homoeopathic Medical College and Hospital, Kolkata, West Bengal, India Nitai Charan Chakroborty Homoeopathic Medical College and Hospital, Howrah, West Bengal, India

Corresponding Author: Munmun Koley, BHMS, MSc, Clinical Research Unit (Homeopathy), Central Council for Research in Homeopathy, Gokhel Road, Arabindapally, Siliguri 734006, Darjeeling, West Bengal, India. Email: [email protected]

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Journal of Evidence-Based Complementary & Alternative Medicine 21(1)

awareness related to diabetes mellitus and poor self-care practices.4-7 Similar community and hospital surveys in developing countries also unfolded unsatisfactory knowledge, awareness, and practices of the diabetic patients.8-12 Thus, the high prevalence of undiagnosed cases, and consequently poor knowledge, awareness, and practices, has directly increased premature deaths, costly complications, and financial burdens. The high cost of diabetes mellitus management and treatment indirectly provoke patients to choose complementary and alternative medicine therapies.13-18 Recent studies in India revealed that 1.5% of the diabetic population underwent homeopathic treatment for diabetes19 and a considerable number of diabetics report at homeopathy hospitals20,21; still the effectiveness of homeopathy has not yet rigorously been evaluated and the research evidence base has remained miniscule.22 Evidence has showed that increasing knowledge regarding diabetes and its complications has significant benefits in management and treatment.23,24 This study was intended, for the first time, to be conducted on the diabetic and nondiabetic patients visiting the homeopathic hospitals in West Bengal, India, to disclose their levels of knowledge and awareness of diabetes mellitus and practices of diabetics to manage and prevent complications. It would also reveal the differences between the responses and would identify the reasons for such differences.

Methods A cross-sectional survey was conducted in November 2014 on patients (diabetics and nondiabetics/control) visiting as outpatients in 3 government homeopathic medical colleges of West Bengal. The survey sample size was calculated to be 643 (margin of error 5%, confidence level 99%, population size 20 000, and response distribution unknown, estimated to be 50%). However, as we obtained 628 total responses (97.7% response rate), the confidence level was slightly reduced to 98.9%. The diabetics were selected by simple random method and nondiabetics by convenience sampling. The inclusion criteria were patients aged 18 to 70 years, both sexes, literate, and willing to participate in the survey. Those patients who were illiterate, unwilling to participate in the survey, or unwilling to stay after the doctor consultation were excluded from the study. Before participation in survey, an information sheet was provided in local vernacular Bengali and written informed consent was obtained from each participant. Following that, a self-administered questionnaire in Bengali was distributed. The questionnaire was divided into 4 sections (see supplementary material, available online at http://chp.sagepub.com/content/by/supplemental-data). Sections A, B, and C were for both diabetics and nondiabetics, and section D was for diabetics only. Section A sought data on sociodemographic details; questions were either open-ended or close-ended and provided options allowing to choose the appropriate ones. Section B consisted of 16 close-ended questions assessing the knowledge of diabetes. Section C had 4 questions gauging the awareness about diabetes. Section D contained 6 questions about self-care practices among diabetics. Patients were allowed to choose multiple alternatives, if they desired, among the options provided with regard to the knowledge and awareness questions. One mark was attributed to each selected option and finally summarized to calculate the total knowledge and awareness scores.

No universally accepted standardized questionnaire in local vernacular Bengali was available for the purpose. The questionnaire was developed by extracting items from previously validated questionnaires,4,7-10,12 along with little modifications as per patients’ perspective. It was translated and back-translated in standard procedure independently by 2 translators. The face and content validity of the study questionnaire was already established in earlier studies. The questionnaire was piloted on 5 patients in each setting before widespread distribution to check for the appropriateness of wording. After little modifications as per the feedback from the pilot sample, the questionnaire was finalized. It was easy and took only 5 to 10 minutes to complete. The questionnaire was explained verbally to the patients by research assistants. After completing the questionnaire, the sheets were collected and subjected to data analysis. Various computational websites were used for sample size calculation and statistical analysis. Descriptive statistics were presented through frequencies and percentages for categorical data and mean + standard deviation for continuous data. Independent t tests were used to analyze the difference between knowledge and awareness scores of diabetics and nondiabetics. Univariate (1-way analysis of variance and independent t tests) and multivariate analyses were conducted to examine the influence of different potential predictors on knowledge and awareness scores. P < .05 (2-tailed) was taken as statistically significant.

Results Table 1 shows he sociodemographic details of the survey respondents. Mean age of the study participants was 53.8 (standard deviation [SD] 11.5) and 39.3 (SD 15.6), and body mass index was 23.6 (SD 5.3) and 22.2 (SD 3.7), for diabetics and nondiabetics, respectively. Majority of diabetics belonged to the age group of 46 to 60 years (49.8%), male gender (58.9%), resided at rural areas (38.8%), had education of 10th standard or less (44.3%), were married (89.4%), were dependent (42.1%), and had a monthly family income of less than INR 10 000 (49.1%). Majority of the nondiabetics belonged to the age group of 18 to 45 years (67.6%), male gender (57.2%), resided at urban areas (43.4%), had education of 10th standard or less (38.3%), were married (63.1%), were dependent (34.4%), and had a monthly family income of less than INR 10 000 (60.6%). A total of 98.9% diabetic participants and 92.1% nondiabetic participants had heard about diabetes. Among diabetics, 67.8% participants were suffering from diabetes for past 5 years or less and 29.3% were suffering from diabetes for more than 5 years. Source of diabetic education among diabetics were doctor (79.1%), friend (34.4%), and family member (31.5%), and among nondiabetics it was family member (56.0%), friend (51.3%), and doctor (50.2%). Table 2 shows the percentages of correct knowledge responses, which were significantly higher (w2 tests; P < .05 two-tailed) for diabetics than nondiabetics in most of the occasions. A total of 84.9% of diabetics and 91.8% of nondiabetics identified diabetes correctly as a noninfectious disease; 76.2% of diabetics and 58.0% of nondiabetics recognized diabetes as a chronic disease. Although suffering from diabetes, only 29.3% of diabetics knew the normal blood sugar level; and in nondiabetics, it was only 17.5%. The most frequently

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Koley et al


Table 1. Sociodemographics of The study Population: Diabetics (n ¼ 273) and Nondiabetics (n ¼ 355). Sociodemographic Features Age (years)a Age groups (years)b 18-45 46-60 Above 60 Genderb Male Female Height (cm)a Weight (kg)a Body mass indexa Residenceb Urban Semiurban Rural Educationb 10th standard or less 12th standard Graduate or above Marital statusb Married Single Divorced/widowed, etc Occupationb Student Dependent Self-employed Service Monthly income (INR)b Less than 10 000 10 000-30 000 More than 30 000 Heard about DMb Duration of suffering from DMb 5 years or less More than 5 years Source of diabetic educationb Television Newspaper Radio Family member Friend Doctor Book


95% CI


95% CI

53.8 + 11.5


39.3 + 15.6


59 (21.6) 136 (49.8) 78 (28.6)

16.9-27.1 43.8-55.9 23.4-34.4

240 (67.6) 71 (20) 44 (12.4)

62.4-72.4 16.0-24.6 9.2-16.4

161 (58.9) 112 (41.0) 161.8 + 9.3 61.2 + 13.1 23.6 + 5.3

52.9-64.8 35.2-47.1 143.6-180.0 35.5-86.9 13.2-33.9

203 152 168.8 58.1 22.2

(57.2) (42.8) + 8.5 + 9.8 + 3.7

51.8-62.4 37.6-48.2 152.1-185.5 38.9-77.3 14.9-29.5

102 (37.4) 65 (23.8) 106 (38.8)

31.7-43.4 18.9-29.4 33.1-44.9

154 (43.4) 79 (22.3) 122 (34.4)

38.2-48.7 18.1-27.0 29.5-39.6

121 (44.3) 77 (28.2) 75 (27.5)

38.4-50.4 23.0-34.0 22.4-33.2

136 (38.3) 122 (34.4) 97 (27.3)

33.3-43.6 29.5-39.6 22.8-32.3

244 (89.4) 22 (8.1) 7 (2.6)

84.9-92.7 5.2-12.1 1.1-5.4

224 (63.1) 126 (35.5) 5 (1.4)

57.8-68.1 30.6-40.7 0.5-3.5

5 (1.8) 115 (42.1) 100 (36.6) 53 (19.4)

0.7-4.5 36.2-48.2 30.9-42.7 14.9-24.7

83 122 82 68

(23.4) (34.4) (23.1) (19.2)

19.2-28.2 29.5-39.6 18.9-27.9 15.3-23.7

134 (49.1) 87 (31.9) 52 (19.0) 270 (98.9)

43.0-55.2 26.5-37.8 14.7-24.3 96.6-99.7

215 109 31 327

(60.6) (30.7) (8.7) (92.1)

55.3-65.6 26.0-35.8 6.1-12.3 88.7-94.6

185 (67.8) 80 (29.3)

61.8-73.2 24.1-35.2

63 (23.1) 62 (22.7) 17 (6.2) 86 (31.5) 94 (34.4) 216 (79.1) 8 (2.9)

18.3-28.6 17.9-28.2 3.8-9.9 26.1-37.4 28.9-40.4 73.7-83.7 1.4-5.9

— — 38 78 48 153 140 137 8

(10.7) (21.9) (13.5) (56.0) (51.3) (50.2) (2.3)

— — 7.8-14.5 17.9-26.7 10.2-17.6 37.9-48.4 34.4-44.8 33.5-43.9 1.1-4.6

Abbreviations: CI, confidence interval; DM, diabetes mellitus. a Continuous data presented as mean + standard deviation. b Categorical data presented as n (%).

identified causes of diabetes were lack of insulin (47.6% diabetics and 59.7% nondiabetics), lots of sugar consumption (46.9% diabetics, 40% nondiabetics), heredity (59.3% diabetics, 43.7% nondiabetics), and mental stress (31.1% diabetics, 22.5% nondiabetics). Frequent urination was the most frequently identified symptom of diabetes (75.8% diabetics, 77.5% nondiabetics). A total of 47.3% diabetics and 40.6% nondiabetics recognized hypertension as the most frequently associated disease with hypertension. Among complications of diabetes mellitus, the respondents most frequently

made out poor wound healing (52.4% diabetics, 43.7% nondiabetics), loss of vision (44.7% diabetics, 27.3% nondiabetics), and kidney failure (36.6% diabetics, 26.5% nondiabetics); 46.5% of diabetics and 35.5% of nondiabetics believed that diabetes was preventable; 31.9% of diabetics and 14.1% of nondiabetics knew that diabetes could be controlled rather than cured; 35.9% of diabetics and 49.3% of nondiabetics were unaware of hypoglycemic symptoms; and 42.5% of diabetics and 25.4% of nondiabetics knew how to manage this lifethreatening condition.

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Journal of Evidence-Based Complementary & Alternative Medicine 21(1)

Table 2. Comparison of Correct Responses of Knowledge Questions Between Diabetics and Nondiabetics. Knowledge Questions DM is not infectious Diabetes Acute disease Chronic disease Don’t know Know normal blood sugar level Causes of diabetes Lack of insulin in blood Failure of the body to use insulin Lots of sugar consumption Heredity High blood pressure Lack of physical activity Mental stress Overweight Don’t know Signs and symptoms of DM Frequent urination Excessive thirst Excessive hunger Weight loss Tiredness Slow healing of wound Don’t know Associated disease Hypertension Hypercholesterolemia Obesity Don’t know Complications of DM Poor wound healing Foot ulcer Loss of vision Kidney failure Heart failure Stroke Amputation Don’t know DM is preventable Prevention of DM Eating less sugar Planned diet Weight reduction Physical activity Don’t know DM management Diet Medicine Exercise Don’t know DM cannot be cured Hypoglycemic symptoms Weakness Confusion Visual disturbances Don’t know Hypoglycemic management Taking sugar Medicine Insulin Don’t know

Diabetics; n (%)

95% CI

Nondiabetics; n (%)

95% CI

P Value

232 (84.9)


326 (91.8)



13 208 49 80

(4.8) (76.2) (17.9) (29.3)

2.7-8.2 70.6-81.0 13.7-23.1 24.1-35.2

16 206 133 62

(4.5) (58.0) (37.5) (17.5)

2.4-7.4 52.7-63.2 32.5-42.8 13.7-21.9


Knowledge, Attitude, and Practice Related to Diabetes Mellitus Among Diabetics and Nondiabetics Visiting Homeopathic Hospitals in West Bengal, India.

High prevalence of undiagnosed cases of diabetes mellitus and poor knowledge, awareness, and practice has increased premature death, costly complicati...
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