Pattern, knowledge and practices of HbA1C testing among diabetic patients in a Kenyan tertiary referral hospital

Methods

One hundred and ninety eight diabetic patients (59 male and 139 female) attending the outpatient diabetes clinic at the Kenyatta National Hospital were interviewed on their level of knowledge and use of the HbA1C test, as well as their last HbA1C level. The respondent answers were tabulated, analyzed and summarized. The sample mean, standard deviation and percentages were calculated.

Results

Of the 198 patients interviewed, 11 (5.6%) had type I diabetes mellitus (DM) while 187 (94.4%) had type II DM. One hundred and thirty four patients (67.7%) had heard of the HbA1C test while 64 patients (32.3%) had never heard of the test. Forty patients (20.2%) had at one point done the test while 158 (79.8%) had never done the test. The mean HbA1C level of the 40 patients who had at any one time done the test was 8.5 ± 1.7%, with more than 90% having HbA1C > 8%.

Conclusion

Using self-reported accounts, the current study indicates inadequate knowledge and infrequent testing of HbA1C among diabetic outpatients in Kenya. This lack of knowledge and awareness may lead to increased susceptibility to the development of diabetic complications, and potentially higher healthcare costs among these patients. It is our recommendation that policy makers focus on strategies that address HbA1C test accessibility in Kenya, including financial coverage by the national insurance to access the test in public facilities, so as to effectively monitor and combat DM.

Background

Diabetes mellitus (DM) is a chronic debilitating non-communicable disease (NCD). In 2011, 366 million individuals had DM, a number that is projected to rise to 552 million by 2030, unless preventive interventions are put in place [1]. Approximately 80% of the burden of DM is in the low-and middle-income countries, and it is growing [1]. In one such country (Kenya), the prevalence of DM has risen from 3.3% in 2007 to 4.2% in 2009, with prevalence rates of up to 10% in some regions [1, 2].

The HbA1C test is an indicator of average blood glucose concentrations over the preceding three months. It is a well-established biomarker of long-term glucose control and was approved by the World Health Organization (WHO) for the diagnosis of DM and monitoring glycemic control in people with diabetes [3, 4]. Higher HbA1C levels (recommended levels should be maintained at <7%) are associated with the development of diabetic complications, and such an association is not apparent with usual blood glucose tests [5, 6].

Despite its value, the HbA1C test is not widely available in Kenya due to its high cost. Although HbA1C test is one of the recommended tests in the Kenyan national clinical guidelines [7], most hospitals have no HbA1C guidelines in place. Moreover, it is not offered in most rural facilities. For these reasons, the required testing of 2 to 4 times a year may be impossible for most diabetic patients in Kenya; hence, there is a need to assess patients’ knowledge and frequency of its use [8].

Health literacy among diabetic patients has been associated with better glycemic control, optimal medication and enhanced individual participation in diabetes self-care [9, 10]. Heisler et al. [9] reported that respondents who knew their HbA1C values had better understanding of diabetes care and assessment of their glycemic control than those who did not. Moreover, the lack of awareness may hinder health promotion strategies currently being implemented in Kenya, including screening and media campaigns that assume minimal awareness of such tests.

The current study therefore aimed to establish the state of awareness of the HbA1C test as well as its use among a subset of patients attending the outpatient diabetes clinic at the Kenyatta National Hospital (KNH), a major referral and teaching hospital in Kenya.

Methods

A cross-sectional descriptive study was conducted between October and November 2012 at the outpatient diabetes clinic of KNH. The hospital has a daily outpatient diabetes clinic with a daily turnover of approximately 20-30 patients, except on Fridays, when there is a major diabetes clinic with a larger turnover. Data were collected on three days of each week (Monday, Tuesday, and Thursday) and patients present on the three days were randomly selected to participate in the study.

One hundred and ninety eight adult type I and II diabetic patients (59 male and 139 female) agreed to participate in the study (response rate: 100%). All participants attended regular follow-up sessions at the diabetes outpatient clinic over the study’s two-month period; and were randomly interviewed before their clinic visit by one of the 3 interviewers (the authors) using a researcher-filled questionnaire. Caution was also taken to ensure that a respondent was not interviewed more than once over the two-month study period. Ethical approval was obtained from the Kenyatta National Hospital-Ethics and Research Committee (KNH-ERC/UA/66). The study protocol was explained to each of the patients, and consenting participants were asked to sign a consent form prior to their interview.

Information was gathered on the patients’ demographic details, level of literacy, type of DM, duration and control of their DM. The patients were also interviewed on their level of knowledge and their practices as appertained to the HbA1C test, as well as their last HbA1C level. This was through a series of short and simple self-reported questions that included: “1. Have you ever heard about HbA1C? (Yes, No, Unknown) 2. Have you ever done an HbA1C test? (Yes, No, Unknown) 3. What was your last HbA1C level?” No previous article known to the authors had utilized such an assessment or questions. The respondent answers offered after the above key questions were tabulated, analyzed and summarized using SPSS version 16. The sample mean, standard deviation and percentages were calculated.

Results

The age of the participants ranged from 20 to 82 years with a mean age of 53.1 ± 0.92 years. Fifty-two patients (26.3%) lived in rural Kenya, while 146 (73.7%) resided in urban areas. Twenty-seven patients (13.6%) had a tertiary level of education, 79 (39.9%) had attained secondary level of education, and 80 (40.4%) had schooled up to primary school level, while 12 (6.1%) had no formal education. The duration of DM ranged from 6 months to 30 years, with 50% of the patients having less than 6 years since diagnosis of their DM. Twenty-five percent of the patients had DM for more than 11 years. Of the patients interviewed, 11 (5.6%) had type I DM, while 187 (94.4%) had type II DM. However, of these patients, only 115 (58.1%) were aware of the type of DM they had been diagnosed with. Of these 115 patients, 11 (9.6%) had type I DM, while 104 (90.4%) had type II DM.

Of all the patients, 134 (67.7%) had heard of the HbA1C test while 64 patients (32.3%) had never heard of the test. Forty patients (20.2%) had at one point done the test while 158 (79.8%) had never done the test. All 40 patients who had done the test were type II DM patients, with 20 (50%) being male and 20 (50%) female. These 40 patients had a mean age of 55.8 years, and an average of 7.7 years after DM diagnosis. The overall mean HbA1C among those who had done the test was 8.5 ± 1.7%, with more than 90% having HbA1C > 8%.

Discussion