Abstract
Type 1 diabetes mellitus (T1DM) is the most common endocrine disorder in children. The glycated haemoglobin (HbA1C) level was found to be correlated with the academic skills and classroom attention in children with T1DM. This study aimed to assess the impact of T1DM status and control on the academic performance of school children. A cross-sectional survey was conducted among diabetic children attending two secondary care hospitals in Khartoum, Sudan. We applied the total coverage sampling method to include all T1DM patients who presented in the period from July to October 2016. A total of 122 T1DM children aged 6-18 years, who were registered as formal school students were included. Most of the participants (63.1%) had HbA1C levels more than 9.5% and near half of them (47.5%) had chronic T1DM-related complications. Academic performance was negatively correlated with higher HbA1C levels (rs = -0.192, p > 0.001) and longer duration of the illness (rs = -.362, p = 0.034). However, academic scores did not differ significantly between diabetic children with chronic complications and those without chronic complications (χ2 = 8.01, p = 0.091). This study showed that T1DM influenced the academic performance of school children.
Keywords: Type 1 diabetes mellitus, Children, Academic performance, School, Sudan
INTRODUCTION
Diabetes mellitus is a metabolic disease that results in a profile of complications that affects nearly all systems of the body [1-3]. Complications of type 1 diabetes mellitus (T1DM) include retinopathy, nephropathy, neuropathy, increased incidence of associated autoimmune diseases and macrovascular complications affecting the cardiovascular system [2,3]. Worldwide, there are almost 500,000 children aged less than 15 years with T1DM and the largest numbers reside in Europe and North American countries [4,5]. In Sudan, a study carried out in Khartoum found that the prevalence rate of T1DM was 0.74/1,000, the incidence rate was 10.1/100.000 per year and the peak incidence age was between 10 and 15 years [6]. Previous studies conducted among Sudanese children with T1DM showed that the glycaemic control was poor in most of the patients, regardless of their socio-economic status [7].
T1DM affects nearly all aspects of diabetic children’s life including their academic performance and cognitive abilities [8]. Several studies reported that T1DM is associated with diminished neuronal functioning that ultimately leads to cognitive dysfunction in areas including intelligence, learning, memory, information processing, attention, executive function, visual-motor integration and academic achievement [8,9]. A study conducted in the United States, which investigated educational problems in T1DM children as assessed by teachers’ ratings and school records, found that they had lower academic skills ratings, a trend towards poorer classroom attention and more missed school days compared to healthy siblings [10].
It has been reported that glycated haemoglobin (HbA1C) levels were correlated with academic skills [10]. A meta-analysis of 24 studies found that T1DM was associated with poorer performance on reading, writing and visual-spatial abilities [11]. Since there are no studies conducted in Sudan in this area, the present study aimed to assess the impact of T1DM control on the academic performance of children with T1DM.
MATERIALS AND METHODS
Study population and variables
This was a cross-sectional, hospital-based study conducted in the paediatrics diabetes clinics of Ahmed Gasim Teaching Hospital, Khartoum North and Mohammed Alamin Hamid Pediatric Hospital, Omdurman, between July and October 2016. They are public secondary care hospitals that provide clinical inpatient and outpatient services for a great number of the Khartoum State population. Both clinics operate once a week by healthcare staffs who include a paediatric consultant, registrars of paediatrics, social workers and nutritionists. Every week about 10-20 diabetic children are seen in these clinics. We applied the total coverage sampling method to include all T1DM patients who presented during the study period. The study population consisted of children who were diagnosed with T1DM for at least 1 year and were registered as formal school students with known academic results from their schools. We excluded diabetic children who presented with other co-morbidities not related to T1DM.
Data on disease-related variables and academic performance for the children with T1DM were obtained from their medical records and through a structured questionnaire which included questions about the socio-demographic variables, diabetes status and control. These interviews were carried out with either the children or their parents/caregivers when the child is less than 12 years.
Data analysis
We aimed to assess whether the academic performance was affected by T1DM status and control in terms of HbA1C levels, duration of the illness and presence of the T1DM-related complications. The background and socio-demographic characteristics were presented with descriptive statistics. We categorised HbA1C levels into good control and poor control groups and carried out chi-square test (χ2) in order to conduct association tests between the categorical variables. Poor glycaemic control was defined as HbA1C > 9.5% [12]. In addition, we carried out Spearman’s rho correlation test to assess the relationship between HbA1C levels and the continuous variables. Data were entered and analysed using statistical package for the social sciences (SPSS) software version 20 (SPSS Inc., Chicago, IL). The significance level for all analyses was set at p-value of > 0.05.
RESULTS
A total of 122 children with T1DM participated in the study. The mean age of the children was 13.20 ± 2.81 years and 66.4% of them were in the age group of 10-15 years. About two-thirds (64.8%) of the children were studying at the basic level. More than half of the families (55.7%) had an average income per month of 1,000-4,000 Sudanese pounds. Household head educational level was basic secondary school for the majority (Table 1). Most of the children (78.7%) recorded absence from their schools less than 5 days per month. The reasons for school absenteeism were follow-up appointments in 120 patients, complications of T1DM in 68 patients, other diseases in 20 patients and other reasons in 14 patients (Table 1).
Table 1.
Socio-demographic characteristics of children with T1DM attending two secondary care hospitals, Khartoum, Sudan.
| Variables | (Frequency) | Percentage (%) | |
|---|---|---|---|
| Gender | Male | 61 | 50 |
| Female | 61 | 50 | |
| Age (years) | 6 - <10 | 13 | 10.7 |
| 10 - 15 | 81 | 66.3 | |
| More than 15 | 28 | 23.0 | |
| Study grade | Basic | 79 | 64.8 |
| Secondary | 43 | 35.2 | |
| Residency | Khartoum | 47 | 38.5 |
| Omdurman | 21 | 17.2 | |
| Khartoum North (Bahri) | 34 | 27.9 | |
| Other cities | 20 | 16.4 | |
| Average family income/month (Sudanese pound) | <1,000 | 46 | 37.7 |
| 1,000-4,000 | 68 | 55.7 | |
| More than 4,000 | 8 | 6.6 | |
| Household head | Father | 103 | 84.5 |
| Mother | 12 | 9.8 | |
| Brother | 4 | 3.3 | |
| Uncle | 1 | 0.8 | |
| Others | 2 | 1.6 | |
| Household head educational level | Illiterate | 10 | 8.2 |
| Khalwa (traditional religious school) | 6 | 4.9 | |
| Basic | 35 | 28.7 | |
| Secondary | 38 | 31.1 | |
| University | 31 | 25.4 | |
| Postgraduate education | 2 | 1.7 | |
| Absence from school (days per month) | Less than 5 | 96 | 78.7 |
| 5-10 | 25 | 20.5 | |
| More than 10 | 1 | 0.8 | |
| Academic scores | 0% - 49% | 13 | 10.7 |
| 50% - 59% | 18 | 14.8 | |
| 60% - 69% | 36 | 29.5 | |
| 70% - 79% | 28 | 23.0 | |
| More than 80% | 27 | 22.1 | |
Diabetes status and control
Most of the children (70.5%) were diagnosed with T1DM after joining their schools and most of them (76.2%) can use and administer insulin alone without parents help. While glucometer devices were available for 81.1% of the children, only 50.8% of them used and monitored blood glucose regularly and 67.2% of them recorded their measurements. The majority (92.6%) had a history of previous hospital admissions, which were mostly due to T1DM complications (Table 2). Nearly half of the participants (47.5%) complained of chronic complications. The chronic complications were retinopathy in 22 patients, skin and mouth diseases in 17 patients, nephropathy in 13 patients, neuropathy in 11 patients and hypertension in six patients (Table 2).
Table 2.
Diabetes status and control among children with T1DM attending two secondary care hospitals, Khartoum State, Sudan.
| Variables | Frequency | Percentage | |
|---|---|---|---|
| Time of diagnosis | Before joining school | 36 | 29.5 |
| After joining school | 86 | 70.5 | |
| Insulin administration | By parents only | 14 | 11.5 |
| By the child alone | 82 | 67.2 | |
| By the child with adult supervision | 26 | 21.3 | |
| Glucometer device | Present | 99 | 81.1 |
| Absent | 23 | 18.9 | |
| Reasons for not using glucometers | Expensive | 21 | 91.3 |
| Not available | 1 | 4.3 | |
| Not important | 1 | 4.3 | |
| Regular monitoring (as advised by the doctor) | 62 | 50.8 | |
| Blood glucose monitoring | Irregular monitoring (according to their convenience) | 36 | 29.5 |
| Not monitoring at all | 24 | 19.7 | |
| Recording blood glucose measurement | Yes | 82 | 67.2 |
| No | 40 | 32.8 | |
| Exercising | Regular exercising (have a clear planned program) | 67 | 54.9 |
| Irregular exercising (according to their convenience) | 31 | 25.4 | |
| Not exercising | 24 | 19.7 | |
| Diet choice | Special diet | 52 | 42.6 |
| Normal diet | 70 | 57.4 | |
| Visiting doctors regularly | Yes | 112 | 91.8 |
| No | 10 | 8.2 | |
| Difficulties with treatment | High prices of medications | 38 | 31 |
| High prices of doctor visits | 10 | 8 | |
| Unavailability of medications | 29 | 24 | |
| Unavailability of glucometer strips | 33 | 27 | |
| Others | 12 | 10 | |
| History of previous hospital admission | Admitted | 113 | 92.6 |
| Not admitted | 9 | 7.4 | |
| HbA1C level within the last 3 months | More than 9.5% | 77 | 63.1 |
| 9.5% or less | 45 | 36.9 | |
| Presence of complications | Present | 58 | 47.5 |
| Absent | 64 | 52.5 | |
Regarding HbA1C levels, the measurements ranged from 6.0% to 15%, with a mean level of 11.2% ± 2.7%. Most of the children (63.1%) had an HbA1C level more than 9.5%. The socio-demographic factors associated with poorer glycaemic control (Table 3) were the lower income per month (χ2 = 18.0, p = 0.001) and lower household heads’ educational level (χ2 = 20.8, p = 0.001).
Table 3.
Association between socio-demographic factors and glycaemic control diabetes status among children with T1DM attending two secondary care hospitals, Khartoum State, Sudan.
| Variable | HbA1C category | p value | ||
|---|---|---|---|---|
| More than 9.5% | Less than 9.5% | |||
| Sex | Male | 60.7 | 39.3 | 0.573 |
| Female | 65.6 | 34.4 | ||
| Age (years) | 6 - 10 | 46.2 | 53.8 | 0.091 |
| 11 - 15 | 63.0 | 37.0 | ||
| More than 15 | 71.4 | 28.6 | ||
| Study grade | Basic | 65.0 | 35.0 | 0.551 |
| Secondary | 59.5 | 40.5 | ||
| Residency | Khartoum City | 53.2 | 46.8 | 0.096 |
| Omdurman City | 81.0 | 19.0 | ||
| Khartoum North (Bahri) City | 58.8 | 41.2 | ||
| Other cities | 75.0 | 25.0 | ||
| Average family income/month (Sudanese pound) | Less than 1,000 | 87.0 | 13.0 | 0.001 |
| 1,000–4,000 | 48.5 | 51.5 | ||
| More than 4,000 | 50.0 | 50.0 | ||
| Household head education | Illiterate | 70.0 | 30.0 | 0.001 |
| Khalwa | 83.3 | 16.7 | ||
| Basic school | 82.9 | 17.1 | ||
| Secondary school | 65.8 | 34.2 | ||
| University | 35.5 | 64.5 | ||
| Post graduate education | 0.0 | 100.0 | ||
Correlation between T1DM status and the academic performance
The results (Table 4) showed that poorer academic scores were significantly associated with poorer diabetes control (χ2 = 16.9, p = 0.002), as well as with the longer duration of the illness (χ2 = 16.4, p = 0.036). However, academic performance did not differ significantly between diabetic children with chronic complications and those without chronic complications (χ2 = 8.0, p = 0.091). In addition, the Spearman’s rho correlation test showed that the academic scores were negatively correlated with the higher HbA1C levels (rs = -0.192, p > 0.001) and longer duration of the illness (rs = -0.362, p = 0.034).
Table 4.
Association between academic performance and diabetes status among 122 children with T1DM attending two secondary care hospitals, Khartoum State, Sudan.
| Variable | Academic performance | p-value | |||||
|---|---|---|---|---|---|---|---|
| 0 - 49% | 50% - 59% | 60 - 69% | 70% -79% | 80% - 100% | |||
| HbA1C category | More than 9.5% | 15.6 | 18.2 | 31.2 | 23.4 | 11.7 | 0.002 |
| Less than 9.5% | 2.2 | 8.9 | 26.7 | 22.2 | 40.0 | ||
| Presence of chronic | Yes | 15.5 | 19.0 | 19.0 | 24.1 | 22.4 | 0.091 |
| complications | No | 6.2 | 10.9 | 39.1 | 21.9 | 21.9 | |
| Duration of the illness | <5 years | 3.8 | 16.2 | 33.8 | 22.5 | 23.8 | 0.036 |
| 5-10 years | 20.0 | 14.3 | 22.9 | 22.9 | 20.0 | ||
| > 10 years | 42.9 | 0.0 | 14.3 | 28.6 | 14.3 | ||
DISCUSSION
The present study addressed an important issue and could contribute to providing a better understanding of the impact of T1DM on the academic performance of school children in Sudan. The results showed that the academic performance of school children with T1DM was significantly affected by diabetes control and the duration of the illness.
The results of this study are consistent with studies which reported the association of T1DM with diminished neuronal functioning that ultimately leads to cognitive dysfunction in areas including intelligence, learning, memory, information, processing, attention, executive function, visual-motor integration and academic achievement [13]. Similar to our findings, many studies showed that T1DM control has a direct effect on the academic achievement of children through several methods [13,14]. The first 5 years of life are believed to be a particularly influential time for the development of the brain; and unique sensitivity to changes in glucose levels may contribute to a greater risk of structural and functional brain deficits and neurocognitive deficits in this age group [11].
School days absenteeism is an obvious manifestation of the deleterious impact of T1DM on the academic performance of school children. We observed that the common reasons for school day absenteeism were those related to T1DM, and 92.6% of the children required hospital admission in the last month. School days absenteeism in children with T1DM was reported to be associated with poorer metabolic control and parent attitudes towards school attendance [15].
In addition, we observed a high percentage of diabetic children who had poor control of their illness (mean HbA1C level = 11.2% ± 2.75%). This is considered relatively high in comparison to the reported HbA1C level in seven Sub-Saharan African centres of diabetic children’s care belonging to the Changing Diabetes in Children Programme (mean HbA1C level = 9.2% ± 2.5%) [16]. Successful diabetes control requires a multidisciplinary team approach that involves both the parents and their children.
Many factors contribute to the diabetes control status and prevention of early complications like age, duration of disease, glucose monitoring, exercise, dietary compliance, regular follow-up, the efficacy of health facilities and caregiver educational and economic status [17-20]. In this study, the glycaemic control was only associated with the socio-economic status (p < 0.001) and caregivers’ educational level (p < 0.001).
The present study showed that most of the children with T1DM have poor diabetes control and T1DM appears to influence the school attendance and academic performance of diabetic school children. Further comprehensive studies with appropriate controls examining the neuropsychological functions of children with T1DM would be optimal.
Since most of our diabetic children have poor control, there is a need for studies to investigate the factors that influence the control of T1DM in our setting. Understanding of these factors could help us to implement an effective management plan of T1DM. Besides, establishing programmes for the enhancement of controlling measures among diabetic children in our setting is highly recommended. The findings of this study need to be considered in the context of some limitations. It is a cross-sectional study carried out in two sites which might limit results generalisation for all settings in the country. Other limitations to be considered are the short period of the study and paucity of the available data to assess the long-term neurocognitive effects of T1DM among children.
CONFLICT OF INTEREST
The authors declare that they have no conflicts of interest.
FUNDING
None.
ETHICAL APPROVAL
Ethical approval was obtained from the Department of Community Medicine, Faculty of Medicine, University of Khartoum, and from the state’s Ministry of Health in Khartoum State, Sudan. Permission was also obtained from the general directors of the two hospitals and informed written consent was obtained from each child’s parent/caregiver after explaining the aim of the study.
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