Obstacles to the psychosocial management of diabetes in Pakistan

Sir,

Psychosocial issues are known to be associated with diabetes both as a cause and effect of the disease.[1] They lead to negative effects on the glycemic control and the natural course of the disease. Chronic diseases, such as diabetes, require the patients to play a more pro-active role in managing their own health by employing self-care.[2] Psychosocial factors can affect the disease itself, patient's self-care, outcome, and management.[2] Depression, anxiety, and anger are common findings in diabetics which may influence their glycemic control.[3] As a result of the prevalence of several psychosocial problems in diabetics, their quality of life is also negatively affected.

Medical therapy for diabetes is at its peak today, with more knowledge, better drugs and improved treatment strategies; however a large portion of the diabetics still fail to achieve a good glycemic control. The absence of better glycemic control despite improved medical therapy reflects the room for improvement in the psychosocial care offered to diabetics.[4] The recommendations for addressing psychosocial issues as a part of management of diabetics come from various organizations, including American Diabetes Association (ADA).[5] ADA recommends regular screening for various psychosocial problems. Due to the inherent differences in the various societies, it is not possible to apply the guidelines from ADA in their entirety in Pakistan. Therefore the specific psychosocial factors relevant to diabetes in Pakistan need to be evaluated.

The prevalence of diabetes and impaired glucose tolerance in Pakistan ranges from 17% to 22%.[6] The situation in Pakistan is dismal when it comes to addressing the psychosocial aspects of diabetes. Pakistan, being a low-income developing country, is likely to have additional stressors which may negatively impact the psychosocial aspects of diabetes even further. Therefore the need of addressing these aspects is even greater in Pakistan than elsewhere. However the basic issue in Pakistan here is not the lack of applicability of psychosocial care to diabetics but the lack of evidence regarding the psychosocial factors affecting diabetes in Pakistan.

Pakistan has diverse ethnic groups, each of which may possibly have different psychosocial factors affecting their glycemic control. Research into the various psychosocial factors affecting diabetes in a specific subgroup of the Pakistani population or the Pakistani population as a whole is nonexistent. Without adequate knowledge of the various factors influencing the diabetics, it is not possible to design interventions addressing these issues. The studies conducted elsewhere would not be truly representative of the Pakistani society and would need to be validated for the Pakistani population separately.

In Pakistan, the lack of psychosocial support to diabetics may be attributed to several factors in addition to the lack of scientific research into the subject. Due to the political, economic, and social problems in Pakistan, the magnitude of mental health diseases has risen exponentially; with a very limited number of psychiatrists available in the country.[7] The lack of social care hampers the physician's ability to control external factors negatively affecting the psychosocial factors relevant to diabetes. The low literacy level is responsible for the reduced capability of Pakistani patients to effectively employ self-care. Apart from that, culinary cruelty proves to be very disturbing for a number of diabetics. During social gatherings, where other people can enjoy the tempting food items rich in carbohydrates and fats, diabetics cannot even touch them. This gives birth to frustration. Likewise, negative peer pressure while dealing with day-to-day issues affects their mental health. Furthermore, ignorance on diabetes treatment can worsen the medical status of the patient. It is usual for the patients to not to take medication on time or skip the dose.

Despite the seemingly never ending issues, the actions taken by the government and the NGOs to educate people about diabetes are worth mentioning. Several institutions have been established in the recent years to spread the awareness about diabetes. Moreover, department of endocrinology is now present in certain tertiary care hospitals, which is something that we did not see in the past. NGOs like National Association for Diabetes Educators of Pakistan (NADEP)[8] are playing tremendous role in creating awareness about the disease. It is quite surprising to know that a cross-sectional survey conducted in a rural area of Pakistan revealed that 43% of the adults had awareness about diabetes, even though 34.3% people of the area were illiterate.[9] Education is a strong factor impacting the knowledge about diabetes and its various aspects. Thus urban population, with a higher literacy rate, is expected to have much better awareness about diabetes. This appears to be a ray of hope for managing psychosocial aspect of diabetes in Pakistan.

The people of Pakistan demonstrated exemplary solidarity and persistence while helping the affected population of Pakistan Floods of 2010. It is due to their conscious effort that many areas recovered the loss to a great extent, within a short period. They acted as a family, under a platform, focusing on a goal that paved the path to success. Now the burning question is: Why don′t they show such unity when it comes to combating with diabetes? The answer is simple, yet disappointing: it is because no one has given it a thought. With proper direction and plan, we can bring a positive change and improve the diabetic care in the country by several folds.

In conclusion, there is an urgent need to employ psychosocial care as a routine part of diabetes care in Pakistan. The factors impeding this task are multifactorial and, in the current scenario, some are even impossible to control. However the factors that can be controlled need to be addressed. The key steps in moving toward improved psychosocial care for diabetics is to generate data from Pakistan regarding the specific psychosocial factors affecting diabetics, spreading the awareness about the subject and making proper strategy to execute the plan in the right manner.

• References

• 1 Rubin RR, Peyrot M. Psychosocial problems and interventions in diabetes. Diabetes Care 1992; 15: 1640-1657
• 2 Rane K, Wajngot A, Wändell PE, Gåfvels C. Psychosocial problems in patients with newly diagnosed diabetes: Number and characteristics. Diabetes Res Clin Pract 2011; 93: 371-378
• 3 Penckofer S, Ferrans CE, Velsor-Friedrich B, Savoy S. The psychological impact of living with diabetes women's day-to-day experiences. Diabetes Educ 2007; 33: 680-690
• 4 Barnard KD, Peyrot M, Holt RI. Psychosocial support for people with diabetes: Past, present and future. Diabet Med 2012; 29: 1358-1360
• 5 American Diabetes Association. Executive Summary: Standards of Medical Care in Diabetes—2012. Diabetes Care 2012; 35: S4-S10
• 6 Shera AS, Jawad F, Maqsood A. Prevalence of diabetes in Pakistan. Diabetes Res Clin Pract 2007; 76: 219-222
• 7 Gadit MA. Mental Health in Pakistan: Where do we stand?. J Pak Med Assoc 2006; 56: 198-199
• 8 National Association of Diabetes Educators of Pakistan (NADEP). Available from: http://www.nadep.org.pk/Default.aspx [Last accessed on 2010 Feb 27].
• 9 Ulvi OS, Chaudhary RY, Ali T, Alvi RA, Khan MF, Khan M. et al. Investigating the awareness level about diabetes mellitus associated factors in Tarlai (Rural Islamabad). J Pak Med Assoc 2009; 59: 798-801