Kiến thức thái độ hành vi về tự chăm sóc của người đái tháo đường

Objectives: The objectives of this cross-sectional descriptive study are to investigate, evaluate knowledge, attitude and behavior of people withdiabetes being treated in Binh Chanh Dist

Meiho University Graduate Institute of Health Care

Thesis

KNOWLEDGE, ATTITUDE AND BEHAVIOR OF DIABETIC PATIENTS ON SELF-CARE ABILITY

IN VIETNAM

Graduate student: Vo Thi Hong Phuong

Supervisor: Dr Pi-Li Lin

July 2015

KNOWLEDGE, ATTITUDE AND BEHAVIOR OF DIABETIC PATIENTS ON SELF-CARE ABILITY

IN VIETNAM

In partial fulfillment of the requirement for the degree of

Master of Health Care

July 2015 Acknowledgement

I am grateful to my advisor, Dr Pi-Li Lin, for his great effort andsupport for my study and research It is his guidance with patience,motivation, enthusiasm, and immense knowledge encouraged me to finish

my study

I’d like to give special thanks to Dr Ho Truc Le, First degreespecialist – Director of Binh Chanh hospital, Scientific and TechnicalCommittee and Board of Internal Medicine Department of Binh Chanhhospital, who are supportive of conducting this study

Many sincerely thank to the Board of Meiho University and theBoard of Nguyen Tat Thanh University for providing scholarship andsupporting me during my study period, and to all the staff of ForeignDepartment of Nguyen Tat Thanh, the staff of Meiho University helped

me during the study and stay in Meiho University, Taiwan

By the way, I would like to appreciate all of teachers and professors

of Meiho university, who kindly guided me on study methodology anddata analyses

Finally, I definitely cannot finish my study without support of myhusband and children Thank you for being beside me with essentialemotional supports during my study, my beloved ones

Background: Diabetes mellitus is an urgently topical question of public

health Up to now, many studies on diabetes have been conducted on thescope of the country, but there is not any research on this issue in BinhChanh District Hospital Moreover, in recent years, along with economicdevelopment, the living standards of residents in Binh Chanh district havebeen improved, the rate of diabetic patients in healthcare facilities areincreasingly increased The most effective method is applied to reduce thedisease progression and complications; the least expensive treatment cost

is having early detection and timely patient treatment However, earlydetection, timely treatment as well as knowledge, attitude, and behavior ofdiabetic patients are very limited Therefore, the results of this study can

be used as evidence if any improvement requirement of their knowledge,attitude and behaviors of people with diabetes

Objectives: The objectives of this cross-sectional descriptive study are to

investigate, evaluate knowledge, attitude and behavior of people withdiabetes being treated in Binh Chanh District Hospital on self-care

Simultaneously, I have learned and defined the people rate with diabeteshaving correct knowledge, attitude and behavior on self- care in BinhChanh District Hospital

Method: A cross-sectional descriptive study was adopted for this study,

with the subjects selected using the purposive sampling method.227patients being treated at internal medicine clinic and internal medicinedepartment of Binh Chanh hospital during December 2015 participated inthis study The data were designed in a questionnaire with 5 levels ofstructured answers, from which patients choose the best answers.Approximately 10-minute interviews using a structured questionnaireinclude 3 parts: knowledge, attitude and behavior of people with diabetesbeing treated at Binh Chanh hospital on self-care

Results: There were a total of 227 participants enrolled in the study Of

those, 150 (66.10%) patients were female The mean age of participantswas 60.57 ± 10.35 There were 93.39%patients got married, while widows

or widowers accounted for 4.81% Housewives, retired, and manual laborgained the highest proportions (66.05%) Regarding to level of education,57.26% patients had finished education from primary school to highschool

There were only 33.92% patients had admitted the hospital in emergencystatus Among them, a great portion of patients (61.04%) have been in thehospital less than 1 week

Age had a strong association with knowledge about self-care (p< 0.001),meanwhile education had an impact on both knowledge and behavior ofdiabetic patients (p< 0.05) Patients who had emergency status got lower

knowledge, attitude and behavior score than patients with non-emergencystatus, and the differences were statistically significant (p < 0.05) Finally,length of hospital stay not only had an association with attitude but alsobehavior (p < 0.05).

Conclusion: Our study aimed at exploring the knowledge, attitude, and

behavior towards self-care among people with diabetes Results showedthat diabetic patients visiting Binh Chanh hospital had poor knowledge,attitude, and behaviors scores The possible factors could be lack ofawareness, unavailability of information and literacy level of the studypopulation We recommend that implementation of adequate awarenessprograms may enhance the knowledge, attitude, and behavior which inturn would improve the control of diabetes

Pages

Appendix 1: The detailed findings

Appendix 2: The questionnaire

Appendix 3: Informed consent

Appendix 4: Ethical certification for conducting study

Appendix 5: Consultant expert forms

LIST OF TABLES

Pages

ADA American Diabetes Association

BMI Body Mass Index

CDC Centers for Disease Control and Prevention

DDCT Diabetes Control and Complications Trial

HLA Human Leukocyte Antigen

IDF International Diabetes Federation

SD Standard Deviation

UK The United Kingdom

UKPDS The United Kingdom Prospective Diabetes StudyWHO World Health Organization

Chapter 1 Introduction

1.1. Significance of this research

Nowadays, diabetes is a globally public health problem, affectingthe health of many people, especially people in the working age over theworld According to the World Health Organization, in 2014 the globalprevalence of diabetes was estimated to be 9% among adults aged 18yearsand above (WHO, 2012) and more than 80% of diabetes deaths occur inlow- and middle-income countries (WHO, 2014) Therefore, diabetes is a

non-communicable diseases which WHO initially concerns in communityhealthcare strategy.

The complications caused by type 2 diabetes have significant impact

on the social and economic burden among patients and society morebroadly (van Dieren, Beulens, van der Schouw, Grobbee, & Neal, 2010)

A number of studies were implemented to investigate the economicimpact of type II diabetes worldwide The results were surprising to findnot only a large cost burden in high-income countries, but also in low andmiddle-income countries where people with diabetes and their familiesface high costs for treatment (Seuring, Archangelidi, & Suhrcke, 2015)

As WHO stated that there are about 30 million people with diabetes

in the world in 1985, and about 98.9 million people in 2004, and up tonow about 180 million people and that number will be doubled to 366million in the 2030s (Ta, 2006) This is one of three diseases with thefastest growing rate and one of the causes of death in developingcountries

The prevalence of diabetes is different between continents andregions There is 1.4% of the population suffered from diabetes in France;the rate of diabetics is 6.6% in America; Singapore is 8.6%; 3.5% ofdiabetes rate in Thailand; and the rate of diabetes is 3.01% in Malaysia(D S Nguyen, 2007); in Cambodia (2005) the age of 25 and over

suffered diabetes in Siemreap is 5% and 11% in Kampong Cham (Dean,King, & Keuky, 2005)

The prevalence of diabetes in Vietnamese adults was about 5.3% in

2014 (International Diabetes Federation Western Pacific, 2015) Totalcases of adults (20-79 years) with diabetes were about 3.3 million inwhich there were 54.106 deaths due to diabetes among adults(International Diabetes Federation Western Pacific, 2015) Cost perperson with diabetes is about USD 150 More importantly, the number ofcases of diabetes in adults that are undiagnosed is relatively high, with 1.7million cases (International Diabetes Federation Western Pacific, 2015).Diabetes is also a burden for socio-economic development becausethe late detection and treatment will leave serious complications inpatients According to the International Diabetes Federation, type2diabetes increasingly tends to appear in people in the working age andyounger ages; huge costs for diabetes treatment will be a burden to manydeveloping countries in the forthcoming future (American DiabetesAssociation, 2009; Bennett & Knowler, 2006) It is essential to detectearly and manage diabetes in the community A lot of medical documentshave proven that diabetes can be prevented completely and managed, ifpeople with diabetes have been provided management, media consultancyand timely treatment with medicine, reasonable regimen and exercise will

reduce the disease risk and slow down the appearance of complicationscaused by the disease (V M Tran, 2006).

In the recent years, the number of people with diabetes in BinhChanh District - Ho Chi Minh City in Vietnam is growing rapidly, it isessential to raise the resident’s understanding about the disease in generaland people being treated for diabetes in particular At the hospital in BinhChanh District, communication consultation as well as treatment bymedicine, regimen, and exercise for diabetics is concerned by the nurses,doctors However, there is not any research to measure knowledge,attitudes and behavior of people with diabetes about self-care Therefore,the purpose of this study is to investigate the knowledge, attitudes andbehavior on self-care of people with diabetes being treated in Binh ChanhDistrict Hospital, in Vietnam

1.2 Aim of this research

1.2.1 General objectives

The objective of this cross-sectional descriptive study is toinvestigate the levels of knowledge, attitud and behavior (KAB) ofdiabetic patients on self-care and their relationships with patient’scharacteristics

1.2.2 Specific objectives:

− To identify the prevalence of people with diabetes having knowledge

on self- care in Binh Chanh District Hospital

− To identify the prevalence of people with diabetes having attitude on

self- care in Binh Chanh District Hospital

− To identify the prevalence of people with diabetes having behavior

on self- care in Binh Chanh District Hospital

− To evaluate the relationship between knowledge, attitude andbehavior on self-care of people with diabetes being treated in Binh

Chanh District Hospital with demographic characteristics

− To evaluate the relationship between knowledge, attitudes andbehavior on self-care of people with diabetes being treated in BinhChanh District Hospital with physical status of patients at admissionand length of hospitalization

1.3 Research questions

1. Recently, how is the knowledge, attitude, and behavior of peoplewith diabetes being treated in Binh Chanh district hospital on self-

care?

2. Is there a relationship between knowledge, attitudes and behavior

on self-care of people with diabetes being treated in Binh ChanhDistrict Hospital with demographic characteristics and physicalstatus of patients at admission and length of hospitalization?

1.4 Study hypotheses

Hypothesis 1

There is a relationship between knowledge, attitude and behavior

on self-care of people with diabetes being treated in Binh Chanh DistrictHospital with demographic characteristics, including age, gender,occupation, marriage, and education level

Hypothesis 2

There is a relationship between knowledge, attitude and behavior

on self-care of people with diabetes being treated in Binh Chanh DistrictHospital with physical status of patients at admission

Hypothesis 3

There is a relationship between knowledge, attitude and behavior

on self-care of people with diabetes being treated in Binh Chanh DistrictHospital with length of hospitalization

1.5 Definition of terms

Diabetes Mellitus

Diabetes is a disease which is caused by the inadequate production ofinsulin by the body or by the body not being able to properly use theinsulin that is produced thereby resulting in hyperglycaemia (high bloodglucose levels) (Sabri, Qayyum, Saigol, Zafar, & Aslam, 2007)

Knowledge, attitude, and behavior (KAB)

Knowledge, attitude, and behavior can be used interchangeable inliterature as knowledge-attitude-practice (KAP) This is an importanttheoretical model of health education, which shows that change in

individual behavior is affected by knowledge and attitude(Schneider &Cheslock, 2003) Evidence suggests that compliance is improved ifpatients know what they have been prescribed, what it will do to theirbodies, what will happen if they fail to take medications according todoctor’s instruction, any factors which may alter drug efficacy, and anypossible side effects (Miller, 1997)

Knowledge of Diabetes

A review of the literature concerning different aspects of publicknowledge and perceptions towards diabetes identified potential items toinclude in the survey questionnaire used in this study (Kemple, Zlot, &Leman, 2005; Tessaro, Smith, & Rye, 2005) The final survey instrumentcontained 4 sections Knowledge regarding diabetes definition, glycemicindex, risk factors, signs and symptoms, and complications was included

in the second section with 20 items (see Appendix 2)

Attitude towards diabetes

In this study, attitude towards self-care and glycemic index wereincluded in the third part of the questionnaire with 25 items

Behavior of self-care

The assessment of behaviors towards self-care and glycemic index wasincluded in the last part of the questionnaire with 11 items regarding to

food rations, physical activity, blood sugar monitoring, foot self-care,treatment adherence, and good behavior practices

1.6 Chapter summary

Diabetes mellitus is an urgently topical question of public health

Up to now, many studies on diabetes have been conducted on the scope ofthe country, but there is not any research on this issue in Binh ChanhDistrict Hospital Moreover, in recent years, along with economicdevelopment, the living standards of residents in Binh Chanh district havebeen improved, the rate of diabetic patients in healthcare facilities areincreasingly increased The most effective method is applied to reduce thedisease progression and complications; the least expensive treatment cost

is having early detection and timely patient treatment However, earlydetection, timely treatment as well as knowledge, attitude, and behavior ofdiabetic patients are very limited Therefore, the results of this study can

be used as evidence if any improvement requirement of their knowledge,attitude and behaviors of people with diabetes

Chapter 2 Literature Review

2.1 A brief history of diabetes study

In metabolic diseases, diabetes is the most common pathology andhas a very long history in research, but the research achievements of thedisease has only been achieved in recent decades

First century AD, Aretaeus began having the description of peoplewith diabetes For the first time, Dobson (1775) understood that the sweettaste in urine of patients with diabetes is due to the presence of glucose(Ta, 2007)

In 1869, Langerhans found sub-cell organizations, including 2 types

of cells secreting insulin and glucagon are not connected to the pancreaspath In 1889, Minkowski and Von Mering made a diabetes experiment indogs which were removed their pancreas, set the basis for the theory ofdiabetes due to pancreas (Mc.Phee, 2002)

In 1921, Banting, Best and his colleagues succeeded in isolatinginsulin from the pancreas (Ta, 2007) In the 1936, 1976 and 1977 theauthors Himsworth, Gudworth and Jeytt classified diabetes into two typethat were type 1 and type 2 diabetes (Mc.Phee, 2002)

Research DDCT (Clinical trials Research on disease control anddiabetic complications, published in 1993) and the UKPDS study

(published in 1998) opened a new era for the treatment of diabetesmellitus, which is the era of medical intensive study and medicalredundancy, redundancy both the mergence and development limitation ofthe disease (Ta, 2007) It is noted that in the UKPDS study, up to 50% ofpatients being detected have some complications (Absetz & Oldenburg,

2009) This emphasizes the importance of the early detection andtreatment of diabetes

2.2 Definition of diabetes

According to the World Health Organization, "Diabetes is asyndrome characterizing by increasing in blood sugar as a result of thecomplete insulin loss or the degradation in insulin secretion or activities”(Ta, 2007)

In January 2003, experts under the United States Committee ondiagnosis and classification of diabetes gave a new definition of diabetes:

"Diabetes is a group of metabolic diseases characterized by increasingblood glucose as a result of the insulin secretion shortage; deficiencies ininsulin operations or both Chronic hyperglycemia is associated withdestruction, the dysfunction of multiple organs especially the eyes,kidneys, nerves, heart and blood vessels "(Department of InternalMedicine, 2005)

2.3 Diagnosis and classification of diabetes

2.3.1 Diagnosis

According to the ADA in 1997 and recognized by World HealthOrganization in 1998, informally applied in 1999, diabetes was diagnosed

as any one of the three following criteria:

− Criteria 1: Any blood glucose > 11.1 mmol/1 accompanied by thesymptoms drinking more, urinating more, and losing weight withoutcause

− Criteria 2: Blood glucose as hungry > 7.0 mmol/1, doing experimentafter patient abstained from the food about 6-8 hours

− Criteria 3: Blood glucose at 2 hours after increasing blood glucose

Type 1 diabetes mellitus depends on genetic factors and is usuallydetected before 40 years old Many patients, especially children andadolescents manifest ketoacidosis, the first symptoms of the disease Themajority of people diagnosed with type 1 diabetes are usually thin, but noexception for fat people People with type 1 diabetes will be dependentcompletely on insulin.

2.3.2.2 Type 2 diabetes

Type 2 Diabetes accounts for around 90% of diabetes worldwide,and is common in adults over 40 years old Disease risk increases withages However, due to rapid changes in lifestyle, eating habits, type 2diabetes at a young age tends to develop quickly

Characteristic of type 2 diabetes is insulin resistance associated withrelative deficiency of insulin secretion Type 2 Diabetes is usuallydiagnosed very late because the firstly hyperglycemia progresses quietlywithout symptoms When clinical manifestations are often accompanied

by other disorders of lipid metabolism, the pathological manifestations ofcardiovascular, neurological, renal ., sometimes complications wereserious level

The biggest feature in the pathophysiology of type 2 diabetes is theinteraction between genetic factors and environmental factors inpathophysiological mechanisms People with type 2 diabetes can betreated by changing habit connecting to medications to control blood

glucose; however, if this process is not suitable, the patient will be treated

by using insulin

2.3.2.3 Gestational Diabetes

Gestational Diabetes is common in pregnant women with a bloodglucose increase for the first time of pregnancy The progression ofgestational diabetes after postpartum may be three possibilities: diabetes,impaired glucose tolerance, normal (Department of Internal Medicine,

2005)

2.3.2.4 Other types of diabetes (rare)

Causes related to some diseases, drugs, and chemicals

− Defect in beta-cell function

− Genetic defects in insulin activities

− Exocrine pancreatic disease: pancreatitis, trauma, pancreaticcarcinoma

− Endocrine disease: Cushing's syndrome, overactive thyroid

− Drugs and chemicals

− Less common in mediated immunity

2.4 Diabetes complications

If diabetes is not detected early and treated timely, the disease willprogress rapidly and appear to acute and chronic complications Patientscan be died due to this complication

2.4.1 Acute complications

Acute complications are usually caused by late diagnosis, acuteinfection or inappropriate treatment by The Learning Resource Center-Thai Nguyen University Even when properly treated, ketoacidosis comaand coma increasing osmotic pressure can be two dangerouscomplications

Ketoacidosis is serious manifestations of metabolic disorders caused

by lack of insulin causing an increase in hyperglycemia, decomposition oflipids, ketones proliferation that cause acidification of the organization.Although modern medicine has made advances in equipment, treatmentand care, mortality remains highly about 5-10%

Coma increasing osmotic pressure is a condition of serious glucosemetabolism disorders, high levels of blood sugar Coma increasingosmotic pressure accounts for 5-10% In old patients with type 2 diabetes,the mortality is from 30 to 50% (Mc.Phee, 2002)

For many comatose patients, the first sign of the disease ishyperglycemia This demonstrates that the understanding of diabetes hasnot been popular in the community

2.4.2 Chronic complications

2.4.2.1 Cardiovascular complications

Cardiopulmonary diseases in patients with diabetes are commoncomplications and dangerous Although there are many factors that may

cause coronary artery disease, but studies show that high blood glucoselevels increases the risk of coronary artery disease and othercardiovascular complications Patients with diabetes and cardiovasculardisease account for 45%, the risk of cardiovascular disease is 2-4 timeshigher than normal person The death cause of cardiovascular diseaseaccounts for about 75% of overall mortality in patients with diabetes,including myocardial ischemia and myocardial infarction as the greatestdeath cause A study conducted on 353 patients with type 2 diabetes whowere Mexican-American in 8 years stated that 67 patients died and 60%

of those were due to coronary artery disease (Ta, 2007)

Hypertension is common in patients with diabetes, the diseaseincidence of hypertension in patients with diabetes is double than normalpersons In type 2 diabetes, 50% people with diabetes is diagnosed withhypertension Hypertension in people with type 2 diabetes is oftenaccompanied by metabolic disorders and hyperlipidemia (Sam & Haffner,

2008; Ta, 2006)

In addition, the rate of cerebrovascular complications in patients withdiabetes is 1.5 to 2 times, arthritis in lower limb is 5-10 times than normalperson

In Vietnam, according to the research by Ta Van Binh, about 80% ofpatients with diabetes are infected additionally cardiovascular-relateddiseases (Ta, 2007)

2.4.2.2 Kidney complications

Kidney complication due to diabetes is one of the commoncomplications, complication rates increase over time Diabetes- relatednephropathy begins with proteinuria; then the kidney function will bereduced, urea and creatinine will be accumulated in the blood

Nephropathy caused by diabetes is the most common cause of stage renal failure For persons with type 1 diabetes, ten years after clearkidney manifestation, 50% of those progresses to end-stage renal failureand after 20 years about 75% of those patients need periodic dialysis Thecomplication capacity to end-stage renal failure patients with type 2diabetes patients is less than type 1 diabetes patients, but the number ofpatients with type 2 diabetes is very large, actually the patients with end-stage renal failure are mainly patients with type 2 diabetes

end-To follow nephropathy caused by diabetes by quantifying albuminuria, measuring glomerular filtration rate and quantifyingproteinuria /24 hours are required Today, many laboratories choosequantitative method of proteinuria in overnight urine samples

In Vietnam, according to a survey in 1998, the rate of positive albuminuria accounts for highly 71% of people with type 2 diabetes (Ta,

micro-2007)

2.4.2.3 Eye disease in patients with diabetes

Cataracts are common lesions in patients with diabetes, likely tocorrelate with disease duration and degree of prolonged hyperglycemia.Cataracts in old people with diabetes will progress faster than peoplewithout diabetes

Diabetic retinopathy is the leading cause of blindness in people from

20 to 60 years of age Slightly disease manifestation is increasingcapillary permeability; disease will progress to a blood vessel at a laterstage, vascular proliferation and weak blood vessel walls hemorrhageeasily cause blindness After 20 years of disease, most patients with type 1diabetes and 60% of patients with type 2 diabetes have diabeticretinopathy

According to research by Van Hai, Hoai Anh Pham in Thanh NhanHospital - Hanoi, the number of patients with eye diseases accounted for72.5%, including the diabetic retinopathy rate is 60.5%, glaucoma crystal

is 59% (To & Pham, 2006)

A research in Thai Nguyen National General Hospital showed thatthere were 52.94% patients with cataracts, 22.94% patients with diabeticretinopathy (Dang & Nguyen, 2007)

2.4.2.4 Diabetic neuropathy

Diabetic neuropathy is quite popular, it is estimated that 30% of patientswith diabetes has this complication People with type 2 diabetes oftenhave neurologic manifestations at the time of diagnosis

Diabetic neuropathy is usually divided into the following majorsyndromes: Acute polyneuropathy, single nerve disease, vegetativenervous disease, motor neurone disease

2.4.3 Other complications

2.4.3.1 Diabetic Foot Disease

Diabetic foot disease is increasingly concerned due to the popularity

of the disease Diabetic foot disease is the combination of vascularlesions, peripheral neuropathy and atopic infections caused by increasedblood glucose

A notification from WHO in March 2005 showed that there were15% of people with diabetes-related foot pathology, 20% of peoplehospitalized due to foot ulcers Patients with diabetes amputated lowerlimb are 15 times more than people without diabetes, and account for 45-70% of total leg amputation cases (T D Dao & Nguyen, 2008)

The rate of leg amputation of people with diabetic foot complications

in Vietnam is also quite high, about 40% of people with diabetic footdisease (H T Nguyen & Dao, 2003)

2.4.3.2 Infection in patients with diabetes

Patients with diabetes are often sensitive to all kinds of infectionscaused by many favorable factors There are some infections in manyorgans, such as urinary tract infections, dental infections, osteomyelit is,cholecystitis, fungal infections (Department of Internal Medicine, 2005)

2.5 Main factors affecting to diabetes

2.5.1 Ages

Many studies showed that there are relationship between ages andtype 2 diabetes appearances The older age is, the higher the diabetesinfects

In Asia, the type 2 diabetes has a high proportion of people over 30years old In Europe, the disease usually occurs after the age of 50accounting for 85-90% of all diabetes cases (Ta, 2007) Over 65 years old,the rate of diabetes is up to 16%(T N Nguyen, 2006)

There are many factors involved increase in type 2 diabetes by age,the hydrate metabolic changes related to age, which explains why manypeople with diabetic genes without diabetes as being young, only infectthe disease as being older

However, with the growth speed of modern life, there are moreyoung people with diabetic type 2 Observing the appearance of type 2diabetes in families with clearly genetic factors, it is noted that the firstgeneration inflects the disease at the age of 60-70, at the age of 2nd

generation dropped by 40-50 years old, and today people diagnosed withtype 2 diabetic under the age of 20 is not rare (Mc.Phee, 2002).

2.5.2 Gender

The incidence of diabetes in both men and women depends on thedifferent residential areas The influence of gender on diabetes isirregular; it depends on race, age, living conditions, obesity level

In Pacific urban areas, the rate of women and men is 3/1, while inChina, Malaysia, India, the incidence of diabetes in both genders is equal

In Vietnam, according to the study by Hoang Kim Uoc and hiscoworkers, the incidence of diabetes in men was 3.5%; in women was5.3% (M C Hoang, 2007) Research on the status of diabetes and riskfactors conducted in the whole country in 2002 - 2003 showed that there

is no difference in incidence by gender (Ta, 2007)

2.5.3 Geography

The study of diabetic incidence showed that modern industriallifestyle affects the infection capacity of diabetes The incidence ofdiabetes increased by 2-3 times in the city compared to those living in thesuburbs according to the epidemiological studies published in Tunisia,Australia The results of some studies in Vietnam are also similar Astudy by Nguyen Huy Cuong in Hanoi showed that incidence of diabeteswas 1.4% in the inner city, the suburbs is 0.6% A research by Tran HuuDang in Quy Nhon stated that the incidence of the disease in the inner city

are 9.5% higher 2.1% than those in the suburbs which is statisticalsignificance with p <0.01 (H D Tran, 2007)

Geographic factors affecting the incidence of diabetic are essentiallylifestyle changes: sedentary, eating a lot leading to obesity

2.5.4 Obesity

"Obesity is a redundancy state of body fatness" (D T Nguyen &Hoang, 2006) According to experts from the WHO, obesity is thestrongest risk factor impacting the infection capacity of diabetes Thereare many methods of diagnosis and classification of obesity, in which thediagnosis of obesity by body mass index and waist-hip ratio are widelyapplied So far, the diagnostic standards for obesity were uniformed byWHO However, this standard is different between geographic regions,and continents

In obesity, fat accumulation occurs in a long time, so the decline initself protection against the steatosis may occur at some points andtriglycerides are gradually accumulated In obese people, clinical diabetesusually appears after 50-70% Langerhans cell hurt

Belly fat, known as trans fatty, is a term referring to those whose fatfocus on belly, visceral and upper body with significant proportion Bellyfat, even with whose weight are not really classified into overweight ormoderately fat, is an independent risk factor causing dyslipidemia,hypertension and glucose metabolism disorders

Many studies have concluded that obesity is the most importantreason leading to insulin resistance (Daniel, 1991; T N Tran & Tran,

2006) A research by Colditz GA et al concluded that obesity and suddenweight gain increases the risk of diabetes(Colditz, Willett, Rotnitzky, &Manson, 1995) The result of study by Hoang Kim Uoc showed thatpeople with a BMI> 23 have the risk of type 2 diabetes 2.89 times higherthan normal person (M C Hoang, 2007)

Today, obesity is increasing, leading to the rise of type 2 diabetes andcardiovascular disease

2.5.5 Cigarette and alcohol

Cigarette and alcohol are substances that harm the body, aggravatemetabolic disorders

Several studies in Europe showed that cigarette smoking rate inpatients with diabetes is quietly high, some areas is more than 50%(Manson, Ajani, Liu, & Nathan, 2000) The Lausanne University (UK)has conducted 25 studies on 1.2 million patients and found that those whosmoke have 44% infection risk of type 2 diabetes(Ta, 2007) Smokerstend to form other harmlesshabits, such as no exercise or eating foodsharmless for health

Alcohol may be harmful for human health, affecting all organs in thebody If people with diabetes drink a lot of alcohol, the consequences areoften more serious than the normal person According to research by Van

Hai, male diabetic patients with alcohol ratio are 22.3% and 16.8% withsmokers (To & Ngo, 2006).

2.6 The diabetes situation in the world and Vietnam

by the Learning Resource Center- Thai Nguyen University

In the United States, according to the Centers for Disease ControlCDC, diabetes increased by 14% in two years from 18.2 million (2003)

to 20.8 million (2005) (Ta, 2007)

According to a report by International Diabetes Association, in 2006

it was estimated there are 246 million people with diabetes, including thetype 2 diabetes accounts for about 85-95% of patients with diabetes indeveloping countries and even higher in developing countries (Pham,

2007)

Incidence of diabetic varies by countries with developed anddeveloping industry and varies from different geographic regions Inparticular, where the highest diabetes rate is in North America (7.8%), theMediterranean region and the Middle East (7.7%), Europe (4.9%) andAfrica (1.2%) (Ta, 2006)

The diabetes proportion in Asia also increased strongly, particularly

in Southeast Asia (5.3%) (Daniel, 1991; Ta, 2006) The rapid diseaseincreases is caused by the level of urbanization, migration from ruralareas to urban area, the rapid changes in industrial lifestyle, reduction inmanual activities, rapid economic growth and unbalanced diet with highfat

2.6.2 Diabetes in Vietnam

In 2002, according to a nationwide survey of people aging from 30

to 64, which was conducted by national Hospital of Endocrinology, theincidence of diabetes mellitus is 2.7% nationwide, 4.4% in the cities,2.2% in the coastal plain, and 2.1% in the mountainous region (Ta, 2007).One research was conducted on 2394 subjects aging from 30 to 64,who are living in four big cities (Hanoi, Hai Phong, Da Nang, Ho ChiMinh) It showed that the incidence of diabetes mellitus is from 4,6% to4,9% (Ta, 2006) The majority of patients having diabetes mellitus doesnot receive diagnosis and treatment

According to a research of Dang Thi Ngoc - Do Trung Quan at BachMai Hospital, the proportion of diabetes mellitus type 2 is 81,5%; theproportion of diabetes mellitus type 1 is 18,5%; the proportion of female

is 61,2%; the proportion of male is 38,8% [excerpt from Tran Thi Mai Ha,2004]

The researches of Le Minh Su in Thanh Hoa, Vu Huy Chien in ThaiBinh, and Ho Van Hieu in Nghe An showed the incidence of diabetesmellitus is 4%, 4,3% and 3% respectively (Ho & Nguyen, 2007; M S Le,

Le Canh Chien’s research in Tuyen Quang; and research of HoangThi Doi and Nguyen Kim Luong in Thai Nguyen, showed that theincidence is higher in female, and higher in people with less physicalexercises (Chau & Pham, 2006; C C Le & Do, 2007)

In BacKan, the number of patients having diabetes mellitus isincreasing Many people are only detected to have the disease when theyare in late stages of the disease and is having complications From March

2006, at the Department of Internal Medicine of the provincial GeneralHospital, there are many new inpatients The diabetes mellitus has the

proportion of 3,7% - 5,2% of the total patients having treatment at thedepartment in 2007 - 2008 (T H Hoang, 2007; Trieu & Trinh, 2008).However, there is not yet any comprehensive research conducted on theclinical and subclinical features of the disease.

Demographic characteristics

Age, gender, educational level, marital status, types of occupation

Admission status

Physical status, length of hospitalization

Knowledge about self-care ability Attitude about self-care ability Behavior about self-care ability

Chapter 3 Research Methodology

These variables included patient's socio-economic and demographiccharacteristics, patient's disease status at the time of admission, length ofhospitalization in days Patient characteristics are in part I of thequestionnaire (questions 1 to 8)

Age is a continuous variable

Gender is a variable with 2 values: 1 is male, 2 is female.

Marital status is a nominal variable including the value of: 1 is

Single, 2 is Married, 3 is Widow, and 4 is Divorced/Separated

Level of education is a nominal variable including the value of: 1 is

Illiteracy, 2 is Literacy but no schooling, 3 is Primary school, 4 isSecondary school, 5 is High school, 6 is Vocational school, and 7 isUniversity or Higher

Occupation is a nominal variable including the value of: 1 is

Agriculture, 2 is Street vendor, 3 is Labor wager, 4 is Government service,

5 is Private firm, and 6 is Other specify

Length of hospitalization: This was the total number of days the

patients stayed in the hospital (from the day of admission to the day of theinterview): discontinuous quantitative variables

Patient's disease status at the time of admission: a variable with 2

values: 0 is emergency (inpatient), 1 is elective (outpatient) This was aquestion asking the patient about her or his disease status (emergency orelective) at the time of admission

3.2.2.2 Knowledge, attitude and behavior of people with diabetes being treated on self-care

This measure consisted of 3 groups of independent variables referred.Three categories consist of:

+ The people with diabetes having knowledge

+ The people with diabetes having attitude

+ The people with diabetes having behavior

3.3 Sampling issues

3.3.1 Study area

Binh Chanh District Hospital with 340 beds is the highest treatmentline, which is responsible for health care, examination for approximatelyone million and four hundred thousand people The Hospital has a staff of

243 official employees, including 220 officers, physicians and doctorswith university qualification and higher (60 doctors) in variousspecializations The hospital has been also built relatively completely withquite adequate and modern medical equipment

3.3.2 Study population

All outpatients and inpatients patients with diabetes being treated inBinh Chanh District Hospital from 01 to 31 December, 2014 wereincluded in the study

The inclusion criteria consisted of patients who were conscious andable to answer the questions, patients who were willing to participate inthe study, and patients who were aged of 20 and over years.

3.4 Data management and data analysis strategy

3.4.1 Research instrument

The research instrument consisted of structured questionnaire, based

on literature The questionnaire was prepared in English and translatedback into Vietnamese

The questionnaire included four parts The first part presentedpatient’s characteristics including 7 items (age, sex, marital status, level ofeducation, current occupation, length of hospital stay and admissionstatus)

The second part consisted of 20 items related to knowledge aboutself-care of patients with diabetes For each item, patients got 0 point forwrong answers and 1 point for right answers The knowledge of self-careamong patients was calculated by sum of scores of items Therefore amaximum of 17 point could be drawn if patients answered correctly all 20items

The third part consisted of 25 items related to attitude about self-care

of participants For each item, a five-point scale from “completely nocomplying” to “complying extremely well” was used Patients got 0 pointfor “completely no complying” and 4 point for “complying extremely

well” The attitude of self-care among patients was calculated by average

of scores of 25 items

The fourth part consisted of 11 items related to behavior of self-care

of participants For each item, a five-point scale from “not ever” to

“continuously” was used Patients got 0 point for “not ever” and 4 pointfor “continuously” The behavior of self-care among patients wascalculated by average of scores of 11 items

3.4.2 Examining the validity and Reliability

The Vietnamese questionnaire was evaluated by three medicalexperts who have experience in diabetes fields to check the contentvalidity of the questionnaire Each expert will check the fitnessess of eachitem on a 5-point scale (very, somewhat, average, low, not agree) and giveopinions to the whole questionaire The results showed that all experts hadhigh agreement on questionnaire’s items

In order to improve the consistency, readiability and compresion ofthe questionnaires, 10 patients with diabetes (those excluded from thestudy sample) would answer the questionnaires Ten items with confusedwords were reported and the investigators revised those items with moreunderstandable words

3.4.3 Pilot study

A sample of thirty patients with diabetes who admitted the hospitalfor examination (those excluded from the study sample) was used as apilot sample The main purpose of pilot study was to test the reliabilities

of the questionnaires The Cronbach’s alpha was calculated for each ofsubscale to check the reliability of the questionnaire Table 3.1 presentedthe values of Cronbach’s alpha for each subscale

Table 1 Cronbach’s alpha of subcale in the questionnaire

Subscale Cronbach’s alpha

Knowledge subscale 0.72

Attitude subscale 0.80

Behavior subscale 0.75

3.4.4 Training interviewers

Three nurses working in Binh Chanh District Hospital were chosen

as interviewers in this study Prior to data collection a two-day trainingcourse was established to instruct interviewers how to perform datacollection and skills of data mining During the training, the interviewershad interviews with five random patients with diabetes in the hospital toevaluate their inter-rater values The inter-rater reliability amonginterviewers was 0.81

3.4.5 Data collection

Firstly, the investigator contacted Director Board of Binh ChanhDistrict Hospital with an official letter from the MEIHO University -Taiwan to get permissions and arrange in advance a data collection plan