Impact of Gender on Care of Type-2 Diabetes in Varkala, Kerala Mini P. Mani Dissertation submitted in partial fulfilment of the requirements for the award of the degree of Master of Public Health Achutha Menon Centre for Health Science Studies Sree Chitra Tirunal Institute for Medical Sciences and Technology, Thiruvananthapuram, Kerala, India 2008 Declaration I hereby declare that this dissertation work titled “IMPACT OF GENDER ON CARE OF TYPE-2 DIABETES IN VARKALA, KERALA” is the result of original research and it has not been submitted for the award of any degree in any other university or institution. Thiruvananthapuram October 2008 Mini P. Mani ii Certificate I hereby certify that the work in this dissertation titled “IMPACT OF GENDER ON CARE OF TYPE-2 DIABETES IN VARKALA, KERALA” is a certified record of original research work undertaken by Dr Mini P.Mani in partial fulfillment of requirement for the purpose of award of Master of Public Health Degree under my guidance and supervision. Dr. Mala Ramanathan Additional Professor Achutha Menon Centre for Health Science Studies Sree Chitra Tirunal Institute for Medical Sciences and Technology Thiruvananthapuram 695011, Kerala, India iii Acknowledgements This work would not have been materialised without the contributions of the individuals who are gratefully acknowledged here. Though the crude idea of doing this study resulted from my personal and professional experiences, it was my guide Dr. Mala Ramanathan, Additional Professor, AMCHSS who was with me at each step of developing every component of the study, patiently listening to me, correcting the mistakes, clearing the doubts, teaching me the right language to speak and write the subject, in short holding my hand and making me walk through every step till now, with so much care and affection. With a brimming heart I acknowledge my gratitude to her. It was Dr. V. Raman Kutty, Professor, AMCHSS who suggested the possibility of doing the study in Varkala, with the help of Health Action by People (HAP). I acknowledge my sincere thanks to him. I got valuable advice and directions from Dr. T.K Sundari Ravindran, Honorary Professor, AMCHSS during the initial stages of the study when I was preparing the questionnaire and Dr. Manju R Nair, Scientist, AMCHSS who asked me the gender questions that set me thinking. I am thankful to both of them for their contributions. Maths and statistics were nightmares till I met Dr. P. Sankara Sarma, Additional Professor, AMCHSS- the best maths teacher I have come across. He helped me move ahead in the right path, all through my study, from sample size calculation till the final analysis phase. I take this opportunity to thank him for all the help he did. I consider myself fortunate to have been able do my work in association with Dr.CR Soman and his organisation Health Action by People (HAP). He was so supportive and encouraging from the very beginning, and offered all help from his team, which I received till the last day. A few unforgettable persons are Mr. Ajayan, the Sr. Project Officer [Research], Mr. Sajikumar, the Sr.Project Officer [Clinical] and Ms. Tessy who is in charge of the field activities in Varkala. Had these persons not been there, the work would not have run so easy and smooth. The gratitude I have for them is beyond words. Becoming a student again, after a gap of ten years was not a cakewalk. My classmates were my informal teachers who spent hours in hostel helping me, especially with the modules which contained numbers more than words. I am thankful to each of them for tolerating my ignorance never showing an unpleasant face, and sparing their valuable time for me. It would be improper if I do not mention Mr. Shyam and family and Ms. Tessy and family, who were like my second homes, all through this study period. No words can explain how valuable their presence was for me in completing this study. Two years would not have been so easy without the immense support the two wonderful persons in my family extended to me. The lady who asks “how many pages finished” or “how many more slides to make”, every time we talk over the phone, so she can roughly estimate the next day I will be with her again- that is my daughter who behaves more mature than her seven years of age, understanding and coping up with my absence, the greatest support for me. Her dad, adjusting with the life without me beyond all ‘gender roles and norms’, extends his support every moment, across the miles. It will not be enough if I only thank them. So I just say “It is because of you, I am.” Last but not the least, I remember each and every participant of my study with heartfelt thanks. The people who took me into trust and opened their hearts out, many inviting me for tea and lunch, a few women who broke into tears during the interview – I am deeply indebted to each of them for the successful completion of my study. iv Abstract Background and objective: India contains the largest number of diabetic patients in the world and Kerala, the state within it despite being applauded for its achievements in health indicators, has the highest proportion of non-communicable diseases, especially diabetes. Many studies elsewhere have revealed the vulnerability of women to poor NCD management and outcome, but few have examined the gendered dimensions of diabetes management. The key objective of this study is to explore the disease management outcome among the cases of Type 2 Diabetes Mellitus in a selected population, with special focus on the gender mediated factors that affect the ability to manage the disease. Methodology: The sample of 200 diabetic patients selected from a sample frame of 504 diagnosed diabetics in two Panchayats of Varkala ICDS block of Trivandrum district, Kerala, contained equal number of male and female participants. A structured pretested interview schedule in Malayalam was administered after obtaining informed consent. The socio-demographic, disease and gender related variables were analysed to capture the gender mediated factors which determine the management outcome of diabetes mellitus. Results: Good diabetes management outcome of the study population was 23.5 percent (29 percent of men and 18 percent of women) with a statistically significant difference between men and women (Chi-square p value 0.045, OR=1.330). This sex difference was found to be mediated in terms of women’s roles at homes as caregivers, values that prevent woman from prioritising their health and inequitable access to resources that prevent woman from early diagnosis. Conclusion: The study establishes the linkages of gender roles, norms and values that exert significant influences on all phases of diabetes management, which in turn results in poor management of DM among women. There is a need for developing NCD control programmes, incorporating these gendered factors. v CHAPTER 1 INTRODUCTION Non Insulin Dependent Diabetes Mellitus- NIDDM is a disease that affects the endocrine system but infiltrates almost all the vital organs of the body. For decades, Diabetes has been a ‘rich man’s problem’ – a burden of industrialised countries to solve. But as the sugar disease, as it is often called, has penetrated the United States and other developed nations, it has also made inroads deep into the far more populous developing world. According to the UN, the world has now reached the point, where more people are overweight than undernourished. The prevalence of type 2 diabetes was as high as 50% among the offspring of conjugal type 2 diabetic parents in India, which is the highest prevalence rate reported until now. Throughout the world, Type 2 diabetes, once predominantly a disease of the old, has been striking younger people. Because Indians have such a pronounced genetic vulnerability to the disease, they tend to contract it ten years earlier than people in developed countries. It is because India is so youthful — half the population is under 25 - that the future of diabetes here is so chilling. Prevalence among adults in India is estimated at about six percent, two-thirds of that in the United States, but the illness is spreading faster, particularly in the country’s large cities. The risk factors for the increasing prevalence among Asian Indians included high racial susceptibility, central obesity and insulin resistance even with a low Body Mass Index. The so called “Asian Indian Phenotype” refers to certain unique clinical and biochemical abnormalities in Indians which include increased insulin resistance, greater abdominal adiposity i.e., higher waist circumference 1 despite lower body mass index, lower adiponectin and higher high sensitive C- reactive protein levels. Epidemiology of diabetes in India has a long history. Charaka Samhita, the ancient Indian medical treatise, describes this condition and suggests that being obese was a major risk factor. It was commented that fat asymmetry impairs strength and shortens lifespan; this may have been an indication of increased incidence of diabetes among the asymmetrically obese. The prevalence of DM in Kerala ranges from six percent in rural areas to nearly 20 percent in the cities. Reported prevalence of known diabetes mellitus was 9.0%. Women have made many strides in promoting equity in their social status; nevertheless, there are entrenched values and structures in our society that continue to negatively affect the health of women in general. Research has shown that many risk factors for diabetes (weight gain, obesity, lack of physical activity) are more common among women than men in all population subgroups. Mainstreaming gender into analysis, formulation and monitoring of policies to minimise inequalities, were seen in the health sector too.