Social Cultural and Economic Factors Affecting the Practice of Secondary Prevention among Patients with Type 2 Diabetes Mellitus at Consolata Nkubu and Meru Level Five Hospital in Meru County

Diabetes is chronic metabolic disorder characterized 
by states of hyperglycemia with disturbances of carbohydrates, fat and protein 
metabolism. Diabetes affects millions of people globally every day and the 
prevalence of the disease is on the rise due to unhealthy diet and lifestyle. 
The disorder usually results to chronic complications including cardiovascular 
diseases, diabetic nephropathy, diabetic neuropathy, foot ulcers and diabetic 
eye diseases that are all preventable through secondary preventive measures. 
Once an individual has been diagnosed with T2DM, secondary 
preventive approaches are essential in preventing the occurrence of chronic 
complications. However, lack of awareness of these measures has been cited as 
the common reasons for the development of complications. The study aimed to 
assess the effect of social cultural and economic factors on the practice of 
secondary diabetes prevention among patients with Type 2 Diabetes Mellitus 
(T2DM) at Consolata Hospital Nkubu and Meru Level Five Hospital between March 
and April 2019. A descriptive correlational 
study design was adopted to collect data from 357 purposively sampled participants with T2DM 
using questionnaires and Focus Group Discussion Guide. Quantitative data 
were analyzed using SPSS version 25 at 95% confidence interval and a 
significance level p ≤ 0.05. Most respondents attended Meru Teaching and Referral Hospital. 
Majority of the respondents were aged between 40 - 60 years. 
Most respondents 31.6% had secondary level 
of education and majority 67% was employed. Concerning secondary 
prevention, majority did foot examination on every visit 70.6% and BP 
monitoring 69.5% while 56.5% did annual eye screening. Level of income, affordability of 
services, health insurance cover of the patients, monthly cost of DM management 
and traditional beliefs in managing DM all significantly influenced DM 
secondary prevention at a p value ≤ 0.05. The 
factors need to be addressed to reduce the global burden posed by the disease.


Introduction
Diabetes mellitus (DM) is a chronic metabolic disorder of multiple etiologies characterized by chronic hyperglycemia with disturbances of carbohydrates, fat and protein metabolism resulting from defects in insulin secretion, insulin action or both [1]. The condition is one of the most significant public health challenges of the 21st century. Diabetes mellitus is among the chronic conditions taking a huge toll on human health and resources, and continue to be neglected by states, individuals, and communities [2]. There are two types of diabetes mellitus: Type1 Diabetes Mellitus (DM) and type 2 diabetes mellitus. Type 1 diabetes mellitus (also referred to as juvenile diabetes) accounts for 5% -10% of diabetes mellitus cases while type 2 DM (maturity-onset diabetes mellitus) accounts for 90% -95% of DM cases [3]. The current trends of DM indicate a disproportionate rise in the prevalence rate in developing nations due to changes in demographic transitions from the traditional to the westernized urban lifestyle. A decade ago, the disease was not considered as a significant public health threat in the developing countries like Kenya, but recently the situation has drastically changed [4]. Currently, Diabetes mellitus has become an epidemic globally that is associated with significant disability, premature deaths and enormous medical costs often resulting from the chronic complications [5].
Diabetes mellitus is characterized by elevated sugar levels in the blood and in urine. A fasting glucose level of 7.0-mmol/L or higher suggests presence of diabetes mellitus. As well random glucose levels of 11.0-mmol/L indicate the presence of DM [6]. Uncontrolled DM significantly increases risks of heart diseases, diabetic neuropathy, foot ulcers, kidney failures and diabetic eye diseases (glaucoma, cataract and retinopathy) which are chronic complications of DM. According to an observational research that involved 1746 respondents with type 1 DM and 272 respondents with type 2 DM with their onset being individuals who were younger than 20 years, it was evident from the findings that the prevalence of diabetic retinopathy, kidney disease, and neuropathy was significantly greater in patients with type 2 DM [7].
According to the current posting on the website of the WHO, the worldwide prevalence of diabetes mellitus among persons 18 years of age or older is 8.5% and increasing [3]. Most of those patients affected by type 2 diabetes have been epidemic for several decades and is associated with many complications, in-cluding premature macrovascular and microvascular diseases affecting the eyes, heart, kidneys, and the circulation. Diabetes is associated with major morbidity and mortality, with an estimated 1.5 million deaths in 2012 being directly due to diabetes [8].
Effective interventions are available for lowering the blood glucose levels for diabetic patients thus, delaying the onset of overt diabetes [9]. T2DM is associated with an array of serious health problems. It is a significant risk factor for the development of CVD such as coronary artery disease and stroke [10]. DM is also the leading cause of blindness due to diabetes retinopathy, kidney failure, as well as non-traumatic amputations of the lower limbs [11]. The prevention approaches for DM just like any other chronic disease can be categorized in four stages that are primordial prevention strategies, primary and secondary prevention and tertiary prevention strategies [12]. Secondary prevention refers to preventing complications in those who already have diabetes with the aim of delaying or preventing the development of long-term complications of the disease such as DR, diabetes neuropathy and cardiovascular complications [13].
The burden of T2DM complications and comorbidity is substantial among sub-Saharan Africans (SSA). Interventions to reduce T2DM morbidity and mortality in SSA need to prioritize early detection, the maintenance of healthy blood pressure, weight and lipid levels, as well as strengthen health care system capacities to provide treatment and care for neurological and ophthalmological complications of T2DM [14]. Chronic complications of diabetes mellitus can be effectively controlled through the diabetic secondary preventive measures that include eye examinations, cardiovascular care, kidney care and foot care. However, these services are underutilized due to inadequate knowledge by the patients coupled with other influencing factors that include social-cultural and economic factors [15]. Thus, the study aimed at assessing the social cultural and economic factors affecting the practice of secondary diabetes prevention among patients with Type 2 Diabetes Mellitus (T2DM) at Consolata Hospital Nkubu and Meru Level Five Hospitals. Informed consent was also obtained from the respondents where they were informed to fill an informed consent form as prove of their acceptance and availability to participate in the study. Names of subjects were kept anonymous by writing their unique codes on the questionnaire instead of their names. Data was cleaned, coded and analyzed at a significance p ≤ 0.05. Frequencies and percentages were used to describe the quantitative data. Chi squares was used to test the relationship between variables of association at 95% significance level.  Table 2. Table 2 shows that 70.6% (n = 250) of the respondents did foot examination during every visit to the clinic, 56.5% (n = 200) had their eyes examined annually, 26% (n = 92) had urine checks annually, 18.9% (n = 67) had body cholesterol level check-up regularly and 69.5% (n = 246) had regular blood pressure monitoring. The mean score was 48.3% and SD was 30. 1 Criterion on Level of practice of secondary preventive measures The level of practice was determined by the number of practice items that respondents adhered to as described on Table 2. Those respondents who adhered to at least three items were considered to have good secondary prevention practice while those who adhered to less than three were considered to have poor secondary prevention practice. Figure 1 shows that 45.5% (161) had good secondary prevention practice while 54.5% (193) had poor secondary prevention practice. The level of practice was the dependent variable in this study and all independent variables were cross-tabulated against it to check for any statistical significance.

Results
Economic and Social Cultural Factors Influencing DM Secondary Prevention The economic and socio-cultural factors under investigation included level of income, affordability of services, health insurance cover, and monthly cost of DM management, traditional beliefs and myths in the society.
Level of income and DM secondary prevention The level of income was categorized into three categories; this was done after  Figure 2 shows that 43.5% (n = 154) earned above 15,000, 27.4% (n = 97) earned between 5001 -15,000 shillings while 29.1% (n = 103) earned less than 5000 Kenya shillings per month.
The researcher further categorized the income as above Kshs 15,000 and below Kshs. 15,000. This was used to carry out binary regression analysis between level of income and practice of secondary preventive measures. The results are shown in Table 3. Table 3 shows that the level of monthly income significantly affected DM secondary prevention (χ 2 (1, N = 354) = 66.79, p ≤ 0.001, OR = 0.154) whereby,    whereby, those who reported that services were affordable were 16 times more likely to practice secondary prevention.
Health insurance cover and DM secondary prevention Some health insurance covers were catering for all the expenses for diabetic management while others were not. This made the researcher to identify and establish the health insurance cover each respondent had. The results are tabulated in Figure 3. However it emerged from the results that some patients had health insurance covers regardless of which while others never had the health insurance cover.
The researcher computed a Chi-squaire between having or not having a health insurance cover and practice of secondary preventive measures in diabetic management.   Table 5 shows that availability of health insurance cover influenced practice of DM secondary prevention (χ 2 (1, N = 354) = 46.51, p ≤ 0.001, OR = 10.17) whereby, those who had some form of health insurance cover were 10 more times likely to practice secondary prevention.
Monthly cost of DM management and secondary prevention Figure 4 shows that 68.6% (n = 243) spent less 5000 shillings in DM management, 29.4% (n = 104) spent 15,000 and below while 2% (n = 7) spent over 15,000 shillings. Table 6 shows that the estimated cost of DM management significantly influenced secondary prevention (χ 2 (1, N = 354) = 35.78, p ≤ 0.001, OR = 0.242) whereby, those who estimated the monthly costs to be 5000 or less were less likely to practice secondary prevention.   Diabetes etiology and management Some respondents 10.2% (n = 36) believed that diabetes was associated with curses and witchcraft and that one with DM ulcer was bewitched. As such, remedies such as prayers, witchcraft, traditional healers and herbal medicine could cure DM. When one had hyperglycemia, bitter herbs were very effective in lowering the blood sugars. DM patients should not eat sugary things because sugar levels would go high and easily accessible foods e.g. potatoes and cassava were restricted. There was no need of attempting to spend money to manage a lifelong disease whose management was too expensive. People did not die as a result of DM but rather from the harmful effects of the drugs they took. DM drugs made people grow fat and others ended up becoming obese. Women of childbearing age for instance should not take drugs, because these drugs ended up affecting their unborn children. During blood glucose monitoring, the pricking of fingers led to loss of too much blood and patients could die of anemia. Others believed that DM drugs should be taken for a short time because the disease was curable.
Diabetes epidemiology Diabetes is preserved only for fat people, the elderly and the rich; this was suggested by majority of the respondents 5.1% (n = 18). It affects more males than females; this was reported by 2.8% (n = 10). Therefore, the young and the slim could rest assured that whatever they might be suffering from could not in any way be diabetes.
The rights of women Women couldn't go anywhere unless accompanied by their husbands. Men had a big say in the family and major decisions especially those touching on the health of women came from men; this was indicated by 9% (n = 32). If the man was not in a position to accompany the wife to clinic, the wife would rather wait until it was convenient for the husband. Table 7 shows that cultural and traditional beliefs/myths significantly influenced DM secondary prevention practice (χ 2 (1, N = 354) = 14.14, p ≤ 0.001, OR = 0.387) whereby, those who reported the existence of traditional beliefs were less likely to practice secondary prevention.
The results from the research show that various social, economic and traditional beliefs had a statistically significant association with the practice of secondary preventive practices among T2DM patients.
Results as captured on Appendix I and Appendix II.

Discussion
The income of the respondents was significantly affecting the practice of secondary preventive measures for diabetic complications. Those who earned more were found to practice the secondary preventive measures than those who earned less, or were poor. These results are in agreement with those reported in the city of Isfahan. In Isfahan, the patients' economic status was found to determine the services the patients received in the hospital. Those patients who were economically stable received all screening tests for diabetic complications [18].
In another study, patients who belonged to low social economic status were linked to have more T2DM complications [19]. Similar findings were shown in a study in Thailand, where patients with low socio economic status were associated with complications of diabetes mellitus [20]. However, the patient individual income was found not to determine the diabetic complications in China where there was no association between patient's economic status and development of diabetic complications [21].
Affordability was a key indicator of the practices; those patients who were affording the cost of screening tests were more often screened compared to those who were unable to afford the screening tests. These results concur with those revealed in Korea on socioeconomic status of patients on their health behaviors, metabolic control, and chronic complications in T2DM. It was revealed that women with lower income were associated with higher stress level. This increased the chances of developing diabetic retinopathy [22] [23]. In the United Kingdom, low social and economic status were linked with high rates of death and morbidity as a result of diabetic related complications [24].
The patients who had the National Health Insurance Fund (NHIF) cover were more likely to receive the screening test compared to those who had other insurance covers. In this study the insurance cover that a patient had, was associated with the practice of secondary preventive measures. In China, it was also found that different respondents had different insurance covers; each cover had limited range of services to cover. This was associated with management of diabetes type 2 [11]. Another research done in Germany revealed that the cost of diabetes management differed between age groups and insurance cover for all that helped cut the costs [25].
The management cost for screening tests was high. Those patients whose screening tests cost was covered by the insurance scheme, were more likely to practice secondary preventive measures than those whose insurance scheme was not covering the screening tests. Patients from low socioeconomic status need to be catered for in terms of drug costs, this helps in the maintenance of glycemic levels within normal ranges. They should be screened for stress and depression. This was found to be associated with preventive measures for diabetes complications [26].
There were some patients who believed in traditional healing methods for diabetes. Others had myths about the diabetes disease; some believed it was a curse and others believed it was witchcraft. Those patients who believed in the medical pathology of diabetes, and that diabetes can be modified were more likely to practice secondary preventive measures for diabetic complications. In Chicago, diabetic patients had a negative perception about insulin use in management of the disease. Inaccurate information about complications of insulin in Diabetes management led to the negative perceptions [27]. Some religious beliefs, especially on fasting occasions affect both positively and negatively on management of diabetes. In Lamu town, ritual obligations observed especially while attending wedding ceremonies which last for weeks affect the management of diabetes. These occasions affected dietary restrictions of the diabetic patients [28]. The results in this study revealed that in this era, some patients still belief in herbal remedies for treatment and management of diabetes, these results concur with those found in a study in South Asia. In South Asia, patients with diabetic and cardiovascular diseases were found to prefer use of home remedies and poorly sought health care services from the hospital [29].

Conclusion
The main socio-economic factors that affected secondary prevention were: level of income, patients' type of insurance cover, management cost per for diabetes, traditional beliefs about the cause and management of diabetes and affordability of services.

Study Limitations
The limitations in this study was the large sample size involved in the study where there was a none-response of 3 respondents from the set sample size of 357 study participants. There was also a language barrier when administering the questionnaire as some respondents could only understand the local native language of "Kimeru".

Recommendations
1) The government of Kenya, through the county government to champion for campaigns on educating the public on secondary preventive measures for diabetic complications. These will include; retinopathy screening, kidney care and screening, cardiovascular care and screening, as well as foot care and ensuring medical services availability among the diabetic patients.
2) All the nurses in all facilities in Meru County, to champion for screening tests for both microvascular and macrovascular complications among patients in each clinic that diabetic patients attend.
3) Make services free or cheaper and encourage patient's enrollment in insurance covers to reduce T2DM management cost. 4) Health-educate and remind patients on preventive practices, organize grass root campaigns and seminars for all to promote secondary prevention and dismiss associated beliefs.