|ORIGINAL RESEARCH REPORT
|Year : 2016 | Volume
| Issue : 4 | Page : 193-198
Diabetes mellitus: Identifying the knowledge gaps and risk factors among adolescents attending a public school in Lagos State
Lovelyn Otammi Ubangha, Tinuola O Odugbemi, Abdulhakeem O Abiola
Department of Community Health and Primary Care, College of Medicine, University of Lagos, Lagos, Nigeria
|Date of Web Publication||14-Oct-2016|
Lovelyn Otammi Ubangha
Department of Community Health and Primary Care, College of Medicine, University of Lagos, Lagos
Source of Support: None, Conflict of Interest: None
Background: The prevalence of diabetes mellitus (DM), a noncommunicable disease (NCD) in adolescents, is on the rise worldwide; therefore, knowledge which facilitates prevention and early detection is important. The objective of this study was to determine the knowledge of DM and self-reported risk factors among adolescents in a senior secondary school, in Surulere, Lagos State. Methodology: This was a cross-sectional descriptive study of 144 male and 106 female senior secondary students with a mean age of 15.2 1.3 years. Respondents were selected through multistage sampling technique. A structured pretested questionnaire was used to collect data. Epi Info 7.1.5 was used for data analysis and the level of statistical significance was set at 5%. Results obtained were presented with the use of frequency tables. Results: Two out of three respondents had heard of DM. Among those who were aware of the condition, 64.9% knew it referred to abnormally high blood glucose. Only (10.9%) knew it was a lifelong condition and less than a third (26.7%) knew the measurement of blood glucose with a device for the screening test. Less than 30% considered obesity, family history, diet, and physical inactivity as risk factors. Their main source of information was the mass media. Overall, 46% of respondents had good knowledge of DM. As regards the presence of lifestyle behavior/risk factor for DM/NCDs in the respondents, 8.4% of the respondents had a family history of DM, had consumed alcohol (28.8%), smoked tobacco (4.8%), and were overweight/obese (5.2%). Conclusion: Two-thirds were aware of DM, of which over half had inadequate knowledge of DM despite the existence of some risk factors. There should, therefore, be an inclusion of NCD education in the curriculum of secondary school students.
Keywords: Adolescents, diabetes mellitus, knowledge, Nigeria, risk factors, schools
|How to cite this article:|
Ubangha LO, Odugbemi TO, Abiola AO. Diabetes mellitus: Identifying the knowledge gaps and risk factors among adolescents attending a public school in Lagos State. J Clin Sci 2016;13:193-8
|How to cite this URL:|
Ubangha LO, Odugbemi TO, Abiola AO. Diabetes mellitus: Identifying the knowledge gaps and risk factors among adolescents attending a public school in Lagos State. J Clin Sci [serial online] 2016 [cited 2019 Mar 20];13:193-8. Available from: http://www.jcsjournal.org/text.asp?2016/13/4/193/192302
| Introduction|| |
Diabetes Mellitus (DM) is a common chronic disease in almost all the countries of the world, and it is becoming a global health problem of alarming proportions. The prevalence of DM worldwide is rising with a projected increase of 8.3% in 2011-10% in 2030, if current trends continue.  This burden is also reflected in Nigeria, with a current estimated prevalence of 8%-10%.  Likewise, the prevalence of diabetes among children in Nigeria has increased from 0.1/1000 in 2009 to 10.1/1000 in 2013. ,
This rise in prevalence in the young has been attributed to obesity as a result of increasing urbanization with resultant reduced physical activity and increased caloric intake, as well as lack of information on healthy living. It is presumed that once knowledge is acquired, people are more likely to participate in prevention and control activities. ,
Most studies on DM in Nigeria have focused on adult populations. A recent search of existing literature showed a limited number of studies among adolescents mainly in the Southern parts, and no study existed on DM in the Southwest. The aim of this study was to determine the level of knowledge and identify lifestyle risk factors for noncommunicable diseases (NCDs) such as DM among in-school adolescents attending a Public Senior Secondary School in Surulere Local Government Area of Lagos State. The findings of this study are anticipated to identify gaps and form a background to aid in planning/implementing a health education curriculum/program for secondary school students on NCDs.
| Methodology|| |
This study was carried out in Surulere Local Government Area of Lagos state. Lagos state, one of the 36 states of the Federal Republic of Nigeria, is located in the Southwestern part of the country, on the narrow coastal flood plain of Bight of Benin. Basically, the position of the local government area is about 633N and 325E, while its distance from central Lagos is about 8 km with an area of about 27 km 2 and a population of 503,975 inhabitants as at the 2006 Census. Surulere has a population density of 21,864 inhabitants per square kilometer in its constituent nine wards. There are 52 public secondary schools in Surulere Local Government Area of Lagos State, of which 26 are Junior Secondary Schools and 26 are Senior Secondary Schools.
This was a descriptive cross-sectional study. The sample population consisted of students attending a senior secondary school in Surulere Local Government Area of Lagos State. The respondents were selected through multistage sampling technique. In the first stage, a list of public senior secondary schools in Surulere Local Government Area was obtained from the website of Lagos State Government, after which a public secondary school was picked using simple random sampling by balloting. The second stage involved allocating quotas to each class (SSS1 and SSS2), each class had 125 respondents. Thirty-one respondents were then got from each of the four arms of the classes. In the fourth stage, respondents were picked from the first seat until the sample frame was complete.
All male and female students in the school were eligible for recruitment. However, the SS3 students were excluded from the study as they were writing examinations over the course of data collection.
The sample size of 250 respondents was calculated using the Cochran's formula, with a prevalence value got from previous studies of 18%,  at 95% confidence, precision of 5%, and a nonresponse rate of 10%. A tested self-administered structured questionnaire (adapted from the WHO STEPS questionnaire and diabetes knowledge questionnaire) was used to assess the basic knowledge of and risk factors for DM among the respondents. The questionnaires were in English and were administered to participants by a researcher and six research assistants in their classrooms on a Wednesday, during the clubs and societies period. After filling the questionnaires, the respondents then proceeded to the section of the class where the tape rule and bathroom scale were set up to have their height and weight measurements taken by two research assistants.
The body mass index (BMI) percentiles of the respondents were also calculated using weight and height measurements.
Body weight was measured to the nearest 0.1 kg using a portable weighing scale with the respondents wearing their underclothing and school uniform only. Their pockets were emptied, and shoes, belts, and other accessories were removed. Height was measured to the nearest 0.1 cm using a tape rule taped to the wall with the respondents standing erect, barefoot, heels together, and looking straight ahead in the Frankfurt plane. The lower edge of the eye socket was in the same horizontal plane as the external auditory meatus, with the heels and back against the tape rule. 
The data were analyzed using Epi Info Version 7.1.5 by the Centers for Disease Control, Atlanta, Georgia. Using the individual height, weight, and age measurements of each respondent, the weight status of each respondent was categorized as follows: Obese (≥95 th percentile), overweight (85 th to <95 th percentile), normal weight (5 th to <85 th percentile), and underweight (<5 th percentile) using the BMI-for-age percentiles calculator by the US Centers for Disease Control and Prevention (CDC).  The BMI-for-age percentiles calculator which is more appropriate for adolescents was used in this study rather than the BMI for adults; as adolescents were the study respondents.
In the scoring of knowledge, for every correct answer, a mark was awarded, whereas no mark was awarded for incorrect answers. The total obtainable marks were 37, and respondents were classified into good/adequate knowledge (≥18) and poor/inadequate knowledge (<18). The results were presented by the use of frequency tables. Comparison of variables was done using the Chi-square and Fisher's probability tests. The level of statistical significance was set at 5%.
Ethical approval for this study was obtained from the Health Research and Ethics Committee of the Lagos University Teaching Hospital, Lagos, and informed consent was obtained from the school principal and the students before the study was conducted.
| Results|| |
Two hundred and fifty students aged between 11 and 19 years participated in the study. The mean age of the respondents was 15.2 ± 1.3 years, with majority 144 (57.6%) being males [Table 1]. Of the 250 respondents, only 165 (66.0%) had ever heard about DM. The sources of information in descending order for those who were aware of DM were mass media 52 (31.0%), friends/family 27 (16.6%), school 25 (15.3%), social media 22 (13.5%), print media 21 (12.7%), and religious bodies 18 (10.9%).
Most 107 (64.9%) of the respondents correctly defined DM as an abnormally high blood glucose level. Only 18 (10.9%) respondents gave the correct response that DM could not be cured as it is a lifelong disease, whereas 75 (45.5%) respondents believed DM could be cured by adopting a healthy lifestyle. Although 38 (59.4%) respondents correctly identified DM as occurring among all age groups, 54 (32.7%) respondents wrongly believed that the best method for diagnosing DM was by the use of urine glucose, whereas only 44 (26.7%) respondents correctly identified the use of blood glucose as the best method for diagnosing DM. Most of the respondents 115 (69.7%) erroneously believed eating too much sugar/sweet foods was a risk factor for DM.
Less than a third of the respondents correctly identified eating an unbalanced diet 47 (28.5%), high blood pressure 45 (27.4%), obesity 29 (17.5%), family history of diabetes 26 (15.8%), and physical inactivity 16 (9.7%) as risk factors for DM [Table 2]. Symptoms of poorly controlled diabetes known by respondents were poor wound healing 32 (19.4%), affectation of the nerves 17 (10.3%), eyes 15 (9.1%), and leg ulcers 16 (9.7%) [Table 3]. While 84 (50.9%) respondents correctly identified the kidneys as an organ which could be affected by DM. As management modalities for DM, 85 (51.5%) respondents were aware of the use of insulin/oral medications, 86 (52.1%) correctly identified eating lots of fruits and vegetables, whereas only 33 (20%) considered exercise.
|Table 2: Respondents' knowledge of the risk factors for diabetes mellitus|
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|Table 3: Respondents' knowledge of the symptoms and organs that may be affected by diabetes mellitus|
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Considering their self-reported lifestyle/behavioral risks for NCDs [Table 4], majority of the respondents had never consumed alcohol 178 (71.2%) or smoked tobacco 238 (95.2%), with a few having behavioral risks regarding alcohol consumption 72 (28.8%) and tobacco smoking 12 (4.8%). One hundred and seventy-six (71.3%) respondents ate fruits <5 days a week, 188 (75.2%) ate vegetables <5 days a week, 197 (78.8%) exercised <5 days a week, of which 95 (38) exercised for <20 min for each day of exercise. Majority 191 (76.4%) of the respondents had body mass indices within the reference range, whereas only 10 (4.0%) and 3 (1.2%) were overweight and obese, respectively. Of the 8.4% of respondents with a positive family history of DM, 13 (5.2%) of them had extended family members with DM, whereas 8 (3.2%) had members of their nuclear family with DM.
|Table 4: Lifestyle risk factors for noncommunicable diseases among respondents (self-report)|
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The highest percentage (73.68%) of the respondents with good knowledge of DM was seen among those with a family history of DM [Table 5]. This association was statistically significant with P = 0.023.
|Table 5: Relationship between some sociodemographic characteristics of respondents and their overall knowledge|
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| Discussion|| |
The prevalence of DM is on the rise worldwide.  With this rise in prevalence, there is an expected associated rise in awareness of the disease entity, its risk factors, and prevention practices. However, among the study population, when asked about awareness of DM, only 66% of the respondents had heard about it. These values were lower than those got in similar studies in Port-Harcourt  and Oman,  where 90% of the respondents, respectively, were aware of diabetes. This disparity in figures may be due to the fact that an enlightenment program on DM exists in public schools in both Port-Harcourt and Oman, but not in Lagos. On the respondents' sources of information on diabetes, the main source of information was the mass media, as 43.0% of the respondents indicated this as their source of information. A similar figure was got in Oman  where 48% of the respondents got their information about DM from the mass media, but the values obtained in this study were higher than those obtained in a study carried out in Port-Harcourt  where only 25% of the respondents obtained their diabetic information from the mass media. This may be due to easier access to the mass media by adolescents in the more technologically advanced Oman and Lagos when compared to Port-Harcourt. This study showed that social institutions such as schools and religious institutions were not prominent sources of DM information. Information provided via these means, and mass media need to be correct, appropriate, and also directed at young ones and not more mainly focused on adults.
DM refers to a state of abnormally high blood glucose levels.  This was correctly defined by 64.9% of the respondents in this study, which was higher than findings of previous studies where only about a third in Port-Harcourt South-South zone of Nigeria at 33% and about 50% in Oman. , The higher percentage of respondents who correctly defined DM in this study as compared to those in Port-Harcourt maybe due to the fact that the respondents were in higher classes of the study than those in the Port-Harcourt study which also included students in junior secondary classes.
DM is a lifelong disease that can only be managed, but not cured.  Only a tenth of the respondents knew this fact and alarming about two-thirds (67.3%) of the respondents erroneously believed DM could be cured. Similar figures were got from Uyo and Oman, where 72%and 63% of the respondents, respectively, believed DM could be cured. ,
There is a common belief that diabetes only occurs in adults.  DM affects both young and old populations. In this study, 65.45% of the respondents said DM could be found in children and adolescents, similar to figures got from studies in Uyo,  Port-Harcourt,  and Oghara  where 73%, 87%, and 78% of the respondents correctly identified this.
Blood glucose measurement is, therefore, the most effective method used to check the level of body glucose.  In this study, 32.73% of the respondents wrongly believed testing urine sugar with a device was the most effective method of diagnosing DM. The findings were similar to those got in the Uyo study,  where 31% of the respondents agreed that urine sugar could be used to diagnose DM but was much lower than findings got from the Oghara study,  where 89% of the respondents believed urine sugar could be used to diagnose DM. This huge difference could be because the Oghara study used both junior and senior secondary classes, whereas this study used only senior classes; and a previous study  showed that senior classes have better knowledge as regards diagnosing of DM than their junior counterparts.
There is an increasing incidence of type 2 diabetes in the young as a result of obesity.  In this study, only 29% of the respondents identified obesity as a risk factor which was similar to the findings from Oghara  where 22% identified obesity as a risk factor, but in a similar study carried out in Uyo,  a much higher number (73%) agreed that obesity may lead to DM. This variation in knowledge could partly be explained by the different family and sociocultural environments of the respondents which could have had an influence on the preconceived perception of obesity-related diabetes.
There exist a myriad of diabetic symptoms. In this study, the most frequently (39.39%) identified a correct symptom of DM was excessive passage of urine. This is, however, higher than the 13% reported in Oghara  and the 29% in Uyo.  The higher values obtained in this study could be attributed to better educational facilities and possible better enlightenment in Lagos, as compared to Oghara, which is a semi-rural community.
There exists a myriad of long-term effects of type 2 DM.  Only 50.91% of the respondents correctly identified the kidney as an organ that could be affected by DM. This was significantly higher than the 24% observed in the Oghara study,  but lower than the 75% observed in the Uyo study.  Alarmingly, low knowledge of diabetic retinopathy as a complication of diabetes was observed in this study, as only 9.09% of the respondents agreed that diabetes could affect the eyes. Similarly, low values of 8% and 17% were obtained in similar studies. , Only 10.30% of the respondents in this study identified the nerves as organs that could be affected by DM. This was similar to a study carried out in Uyo  where 9% of the respondents identified the nerves as organs affected by DM.
Knowledge about the management of DM in this study was not satisfactory, as only 20% of respondents agreed that exercise played an important role in the management of DM. Higher values were got in a study carried out in Oman  where 60% of the respondents reported that exercise could help control blood sugar levels and lower blood pressure and cholesterol levels. In this study, 52.12% of the respondents knew that eating fruits and vegetables were essential in the management of DM, but higher values were got in Oman  where 86% of the respondents knew that diabetics needed a special diet to manage their condition. This huge discrepancy is most likely due to the low levels of education on healthy eating habits in this study population as compared to the Omani population.
As regards, the lifestyle risk factors for DM, 8.4% of the respondents had a family history of DM. In a similar study carried out in Port-Harcourt  and Oghara,  11.25% and 15% of the respondents, respectively, were aware of a family member with DM. This result was different from that of a similar study carried out in Brazil and Oman, where 51% and 62% of the respondents, respectively, had positive family histories of DM. , This huge discrepancy in Nigerian and International studies could be attributed to the fact that the overall prevalence of DM in Nigeria is lower than that found in countries in other continents.
Tobacco and alcohol intake pose a risk for the development of DM, whereas regular exercise and intake of fruits and vegetables offer protection against the development of the disease.  In this study, 72% and 4.80% of the respondents had a positive history of alcohol and tobacco intake, respectively, whereas 29.60%, 24.80%, and 24.09% of respondents ate fruits, vegetables, and exercised more than five times a week. These results indicate the need for an urgent reorientation on optimal feeding and exercise practices.
The CDC in 2008 reported that children and adolescents are at risk if they are obese, insulin-resistant, and have a family history of this disease.  In this study, 5.20% of the respondents were overweight and obese, lower than figures got from studies in Port-Harcourt,  Brazil,  and the United States of America , where 14.1%, 24%, 9%, and 49.3% of the respondents, respectively, were overweight and obese.
Limitations to the study
Glucose screening was not done among respondents. This would have given a better picture of the true state of glucose regulation among them. These were in-school adolescents with possible better access to information and therefore findings may be an overestimate for knowledge among adolescents in this area. Further studies should put this into consideration.
| Recommendations and conclusion|| |
There was poor knowledge of DM among the respondents, despite the existence of risk factors. Family history was found to influence knowledge scores as lower scores were seen among those without family histories of DM. There should, therefore, be an inclusion of NCD education in general, and DM education specifically in the curriculum of secondary school students; as this would go a long way in educating them about these disease entities which in turn will help in the prevention of modifiable risk factors.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]