Gender Difference in Care of Type 2 Diabetes

Introduction: Biologically male and female have similar diabetes prevalence. Gender differences in the social structure bring differences in life style modifications and all other self care behaviors in type 2 diabetes. The primary purpose of this study was to assess the gender difference in care of type 2 diabetes in Western region, Nepal. Methods: Hundred men and hundred women respondents participated in a cross-sectional study conducted in two hospitals in Pokhara, Nepal. A pre-tested questionnaire was administered to each of the respondents. results: Dry mouth (χ2 = 3.977, P = 0.046) and abdominal pain (χ2 = 3.840, P = 0.050) were reported as symptoms of diabetes in 51% and 31% women compared to 37% and 19% men respectively. The study revealed that women had low self-efficacy with respect to their diabetes care (35%) in comparison to men (65%). There was significant association between gender and diet practices which showed men have 0.328 (95% CI: 0.184 0.585) times less chances of bad dietary practices compared to women. After adjusting for age, education, occupation and self-efficacy, men were less likely to have bad dietary practices (OR= 0.513, 95% CI: 0.266, 0.992). Conclusions: The result of this study provided evidence that there are gender differences in reporting of symptoms, mode of diagnosis and certain self-management behaviors. Therefore there is a need to design gender specific behavior change communication strategies for better management of type 2 diabetes. _______________________________________________________________________________________


INTrODUCTION
Diabetes mellitus is emerging as an epidemic of the 21 st century.About 366 million people around the world have diabetes and it is expected to increase to 552 million by 2030 in which more than 90% have type 2 diabetes.Three out of four people with diabetes live in low and middle-income countries where more than 80% of diabetes deaths occur. 1 South-East Asia region harbors approximately onefifth of all adults with diabetes in the world.Current estimate indicates, 71.4 million people, have diabetes in 2011, and it is expected to increase to 120.9 million by 2030. 2 Biologically male and female have similar diabetes prevalence. 1 Gender differences in the social structure, gender differentials in diagnosis, access to care, access to medications and follow up, adherence to medications, life style modifications and all other self care behaviors are likely to introduce a dramatic contrast in the experiences of women with diabetes.
Several studies in the developed countries have shown that women have worse survival, higher risk of cardiac, renal complications and blindness compared to men. 3 Limited studies have been conducted to explore gender differences in diabetes treatment and the situation is worse in developing countries.
Self management for people with chronic health problems is widely recognized as a necessary part of treatment.The patient is responsible for the day-to-day management of their illness. 4Self efficacy or confidence refers to the individual's belief in his or her capacity to perform self-management behaviors. 5The complex nature of diabetes self management makes it difficult for patients to practice. 6Self-management becomes more difficult for women in the developing countries where facts show that the position and status of women in society is worse and so is their health status as revealed by numerous health indices. 7e primary purpose of this study was to assess the gender differences in care, symptoms, mode of diagnosis and self-management of type 2 diabetes.There is shortage of such studies in Nepal where gender differences is highly rooted in social structure.So, it is important to explore differences between men and women in diagnosis, treatment and follow up, adherence to medications, life style modifications and self-management.

METHODS
A cross-sectional study was conducted at two super specialty hospitals, Western Regional Hospital and the Fishtail Hospital and Research Center located in Pokhara between the months of June and July 2012.The respondents were the diabetic patients visiting for the routine checkups in the outpatient department and diabetic education program conducted by the hospital weekly.Patient having severe conditions of disease and not able to speak, walk, and perform their daily routine were not included in the study.Those participants of age 20 years and above who had type 2 diabetes of at least one year history were included in the study.
As there was no data available regarding good selfmanagement behaviour 50% prevalence was assumed.Quota sapling technique was done calculating the sample size of 100 men and 100 women.They were administered a semi-structured questionnaire.The questionnaire was prepared in English language and Nepali language as well.It was pretested to 20 patients and necessary corrections were done.Pilot study participants were excluded from the main analysis.
The questionnaire consisted of two sections, the first section consisted of introduction and informed consent and the second section started with personal information, symptoms of diabetes, mode of diagnosis followed by date of diagnosis and treatment, selfmanagement and self-efficacy.Characteristics of the respondent were obtained from the first section with personal information age, gender, weight, height, marital status, education and occupation.There were dichotomous questions to assess if the respondent had symptoms of diabetes like increased thirst, dry mouth, decreased appetite, nausea or vomiting, abdominal pain, frequent urination at night and morning headaches.Mode of diagnosis was obtained by asking each of the respondents whether they were diagnosed during routine screening test, due to symptoms, or due to complications.Recent fasting blood sugar and post prandial blood sugar reports were recorded.
Diabetes self-care activities questions were asked for each of the five domains diet, exercise, blood-glucose testing, foot-care, and smoking status. 8All the eleven questions were rated on the scale of zero to seven where zero denotes not following for even a single day and one to seven for the number of days in a week that the behavior is followed.
Diabetes Self efficacy scale was administered. 9esponses were rated on a scale of one to ten where the increasing number denotes the maximum confidence level.The scale consisted of eight items about confidence to perform diabetes self management behaviors.Both the scales were translated into Nepali.In order to validate the translation in Nepali, the recommendations of a professional English and Nepali teacher was obtained.Data were processed using the Statistical Package for the Social Sciences (SPSS) version 17.Independent t-test was done to compare the overall self management scores between men and women.Chi square test was done to find the association between gender with diet and exercise.Multiple logistic regression analyses were performed for diet and exercise adjusting for age, education, occupation and self efficacy.
The study was clearly explained to the respondent and informed consent was taken from each of them before the personal interview.The study was also given expedited approval from the Institutional Review Board of School of Public Health, SRM University.

rESULTS
The average age of men and women were 57.76 (SD 12.24) and 55.26 (SD 11.18) years respectively.Majority of the men (91%) and women (78%) were married.The respondents were Hindu and Buddhist.They belonged to different ethnicity Brahmin, Chhettri, Janajati, Dalit, Madhesi and Newar.About 59% of the men and 27% of the women had education of 10 th grade and above, whereas 12% and 41% of men and women had no formal education.Nearly 70% of the women were home makers (Table 1).

___________________________________________________
Dry mouth (χ 2 = 3.977, P = 0.046) and abdominal pain (χ 2 = 3.840, P = 0.050) were reported as symptoms of diabetes in 51% of women and 37% of men and 31% of women and 19% of men respectively.Other symptoms like increased thirst, decreased appetite, nausea or vomiting, frequent urination and morning headache were not significantly different between men and women.While 37% of men were diagnosed with diabetes when testing for other illnesses, half of the women were diagnosed in that manner.About 45% men and 35% women were diagnosed as diabetic due to symptoms.This association was also statistically significant.Only 3% men and 1% women were diagnosed as diabetic during routine test.The average fasting blood sugar of the respondent was 121.51 (SD 42.7) among men and 138.59 (SD 70.89) among women and this difference was statistically significant applying the independent t-test (t = -2.05,P = 0.042).
There was no significant gender difference in the findings of seven days physical activity, fat consumption, foot care and inspection of shoes.Tobacco consumption percentage was higher in men including both smoked and chewed.The study revealed that women had low self-efficacy (35%) in comparison to men (65%) (χ 2 = 18.00 P = <0.05).
There was significant association between gender and diet practices which showed men have 0.328 times lesser chances of bad dietary practices compared to women (95% CI: 0.184 -0.585).Further stratifying by self efficacy, the association between gender and diet practices was observed more among those with high self efficacy (OR = 0.346, 95% CI: 0.145 -0.826) and was not observed among those with low self efficacy (OR = 0.483, 95% CI: 0.209 -1.118).Self-efficacy was found as a confounding factor in the association between gender and good dietary practices.
Multiple logistic regression analyses were constructed to assess the association of diet and exercise (Table 2).Gender was still associated with good dietary practices when adjusted for age, education, occupation and self-efficacy.After adjusting for age, education and occupation and self efficacy, self-efficacy was significantly associated with exercise practices (Table 3).

DISCUSSION
This study, to our knowledge is the first one to compare the gender differences in the clinical presentation, diagnosis, treatment and self management practices of type 2 diabetes in Nepal, a developing country.Previous studies have shown that biologically there is no difference between men and women in the prevalence and characteristics of type 2 diabetes.The difference is likely to be much wider in developing countries where the position of women in the society is still poor.In this context the gender differences in the care of type 2 diabetes becomes very important.This study looked at symptoms of diabetes, mode of diagnosis, blood sugar control levels and self management behaviors.
Women compared to men reported a higher incidence of dry mouth and abdominal pain as symptoms of diabetes.Other symptoms like increased thirst, decreased appetite, nausea or vomiting, frequent urination and morning headache did not show significant differences.It is not clear if this represents a biological phenomenon or whether it is a social phenomenon.Some studies have shown that women tend to present more with depressive somatic symptoms associated with diabetes while men were more likely to present with fatigue, muscle aches and sexual dysfunction. 10There have also been reports of abdominal pain being one of the common somatic manifestations of depression. 11This could be a possible explanation of abdominal pain being a common symptom in women with diabetes in this study.Studies with bigger sample sizes are required to assess the patterns of presentation of diabetes among women and men.
Men were likely to be diagnosed because of testing after onset of symptoms whereas women were more likely to be diagnosed when being tested for some other illness.This again highlights the gender differences in social structure in developing countries.Women attribute low priority to health and symptoms and present late for screening or diagnosis compared to men. 12 This gender difference becomes very important in the setting of chronic non-communicable diseases as screening of asymptomatic individuals is very important for early diagnosis.Only 3% men and 1% women were diagnosed as diabetic during routine screening test.This highlights the need for better coverage of routine diabetes screening and preventive health check up in developing countries like Nepal.
The average of fasting blood sugar of women was higher in comparison to male indicating poorer levels of glycemic control.This is again attributable to the low emphasis placed on health of women.Previous studies have not shown major differences in the glycemic control between men and women. 13There could be some potential reasons for this disparity between studies in developed and developing countries.The most important being the social status of women in developing countries which is still poor.The parameter used to measure glycemic status in the previous studies was glycosylated hemoglobin which is a measure of blood sugar control over three months and is less susceptible to day to day variability in sugar levels.Whereas in the present study, the blood sugar level was assessed and is likely to reflect day to day variability.The third reason for this could be that the gender differences in care, support and self management reflects the difference in glycemic controls between men and women.In a study among Mexican Americans with type 2 diabetes it was observed that men had higher blood sugar levels compared to women. 14This is contrary to the findings of our study.A more robust measurement of glycemic levels and adjustment for other confounders could give a better picture of the gender differences in diabetes control.Similar to the French population based study, this study revealed that both men and women follow similar trend of drug adherence. 15The analyses for healthful eating plan, average monthly eating plan and consumption of five servings of fruit and vegetables daily revealed that significantly lesser women were following these recommended healthy diet practices. 16Also women were straggling behind men in the recommended exercise for at least five days a week. 17n were 0.328 times protected from bad dietary practices compared to women.Further stratified analysis revealed that self efficacy was an important confounder in the association between gender and dietary practices.Whereas men who had higher self efficacy had a better dietary practice, women with lower self efficacy couldn't follow good diet.The social dynamics of why women who have the control over the kitchen and food distribution in the household have poor self-efficacy when it comes to their own diabetes care is important to understand.In developing countries like Nepal women often play a dual role in the house.As much as they are home makers and intra-familiar food distributors, they are also bread winners in several families.But culturally women have a secondary position in the household where the men and children hold the primary position in terms of food distribution.This often leaves the healthy, which often is the more expensive foods, to the men and the left over less expensive foods for the women.The fatalistic attitudes attributed to women's health are another major reason for this unhealthy diet distribution in the family.This is the picture of the developing world where women neglect their own health. 18Social roles prevent women from practicing exercise.They have no time from their work.In addition customs and values bring upon hesitation and feeling of shyness to participate in physical exercise on par with men. 19Thus social structures and cultural beliefs play a huge role in restricting women from practicing self care behaviors.
The study shows low educational status of women similar with the national educational status of Nepal. 20 previous study showed that even in the lack of formal education when women are provided with short term disease specific education it results in improvements in self-management behaviour. 21In a similar study in the Malawi where GPs' gender sensitivity was stimulated by the training program and the supporting visits definite efficacy was demonstrated.Ideally, structural attention could be realized by embedding gender issues in existing organizational structures of general practices. 22herefore despite these compelling social factors that can influence self-management behaviors there is scope for improving the diabetes self care situation of women through targeted health education and empowerment of women which according to the UN Secretary General Kofi Annan is the most effective tool for development.

CONCLUSIONS
The results of this study urge for the need of gender sensitive health education for women.Health promotion cannot be done in a 'one size fits all' model.There need to be gender specific and gender sensitive health promotion for diabetes prevention.It is evident from this study and from the socio-cultural milieu of the developing countries that the gender sensitive health promotion strategies are all the more important.Focus should be laid on improving the self efficacy of women.
Based on these findings there is a need to design gender specific and gender sensitive diabetes health education campaigns in the study area.