Analytical Data Review to Determine the Factors Impacting Risk of Diabetes in North Al-Batinah Region, Oman

Diabetes is one of the most widespread diseases resulting in an increase in mortality rate, and negatively affecting Oman’s economy. In 2019, an estimated 1.5 million deaths were directly caused by diabetes world health organization (WHO). The total number of diabetes cases among Omanis aged between 20 and 79 in 2015 is about 128,769, which increased in 2020 to 149,195. However, the total forecast number of diabetes cases will double in 2050 to 352,156. The healthcare spend on diabetes is 16.6%, which has triggered the need for the study. This research aims to review and analyze the prevailing situation around diabetes in Oman and its risk factors using multilinear regression tests, ANOVA, and descriptive analysis. Two hundred and fourteen samples were collected through a well-defined questionnaire using the purposive sampling technique. The study’s empirical results reveal that females, who were 79% of the respondents, have at least one of their family members as a diabetes patient; 41% of the respondents were affected by Type-2 (T2-DM) diabetes, and 38% were unaware of their type of diabetes. While, 91% of them were undergoing medication. The study indicates the risk factors that impact the diabetes number and type in North Oman, which include Aage with a rate of (0.595), followed by family history (0.560), smoking habits (0.530), and being overweight (0.435). Age plays an important role in the type of diabetes of the patients, and the types of diabetes impacts medication type. The type of diabetes has influenced the frequency of diabetes patients’ self-testing at home. Overall, 92% were rushed to the hospital or took medication immediately in case of a considerable variation in the readings; and 68% of the respondents complained that visiting the hospital is a costly affair and the health service is deteriorating.


Introduction
Improved health care facilities are important for the sustainable economic development of a country. Due to rapid changes in global lifestyle, governments and health care organizations must be on their toes all the time, able to gather real-time, on-demand information, and respond reactively. Towards this, the willingness and ability to adopt the latest technologies is key.
A chronic disease, also known as Non-Communicable Disease (NCDs), has been defined by the U.S. National Center for Health Statistics as a disease that lasts for three months or more [1]. It was reported that, in 2018, more people were admitted to hospitals in Oman for NCDs [2], particularly for heart diseases, hypertension (high blood pressure), stroke, cancer, chronic respiratory diseases, diabetes, arthritis, and asthma [3]. These diseases require sincere medical attention because they cause death and disability across the globe [4,5]. According to WHO report estimates that losses in gross domestic product (GDP) GDP worldwide [6], including both the direct and indirect costs of diabetes from 2011 to 2030, will reach a total of US 1.7 trillion, comprising both high-income countries with US 900 billion and low-income countries with US 800 billion. In 2019, an estimated 1.5 million deaths were directly caused by diabetes [7].
The total number of diabetes cases among Omanis aged between 20 and 79 years in 2015 is 128,769, which increased in 2020 to 149,195. However, the total forecast number of diabetes cases is expected to double in 2050 to reach 352,156, as shown in Figure 1. Though diabetic clinics function in PHCs, complications due to T2 DM need to be primarily addressed [8]. High blood pressure, high blood glucose, obesity, and physical inactivity are commonly related factors [9]. However, the focus of this study is restricted to the situation of diabetes in the Sultanate of Oman. The commonly known types of diabetes are Type 1 diabetes (T1 DM)-insulin-dependent, Type 2 diabetes (T2 DM)-noninsulin-dependent, and Gestational Diabetes Miletus (GDM) [10]. It was believed that chronic diseases, particularly T2 DM, construed a major workload for clinicians in Omani hospitals in the early nineties. Most outpatient attendance, admissions, and bed occupancy in regional hospitals were caused by diabetes [11]. Moreover, it is noted that 71.9% of the total Omani population had at least one of the other chronic diseases and 12.61% are have diabetes [12].
As diabetes leads to life-threatening complications, diabetes patients are usually advised of healthy lifestyle habits, such as exercising and diet control. The normal practice here in Oman is that these patients visit the diabetes clinics at the Public Health Centers (PHCs) as outpatients, daily or once in two days. In Oman, every PHC has an exclusive diabetes clinic. The Health care staff of this diabetes clinic do general checkupsheight/weight measurements, blood pressure, and glucose level, and provide medications for three months. However, patients are advised to keep track of their weight, blood pressure, and glucose levels daily. It is preferred that records are made of the health parameters at home and share them with the healthcare providers. However, during their visit to the clinic, most of them do not carry their recordings for references causing increased expenses in health care services.
Even though such follow up measures and preventive measures are being taken, it was reported that health care expenses have grown in Oman based on the ministry of health (MOH-Oman) reports from 148.9 million to 699.53 million from 2003 to 2015. In 2018, 16.6% of the healthcare budget was spent on diabetes, which has triggered the study's need.

Research Objectives
The aim of this paper is as follows:

•
To review the prevailing situation of diabetes in the North Al-Batinah Region, Sultanate of Oman, and • To analyze the risk factors of diabetes in the country using multilinear regression tests, ANOVA, and descriptive analysis.

Review of Literature
Diabetes Miletus (DM) is considered a global cause of disability and a decisive risk factor for other diseases [13]. Alzaman stated that overweight, obesity, and Body Mass Index (BMI) increases the burden of diabetes in the Arab world [14]. There is a moderate risk of developing T2 DM among Omani adults within the next ten years if no preventive measures were taken [15]. There is a dire need for preventive measures from the future pandemic of diabetes in Oman as many people remain undiagnosed and others live without treatment [16]. Epidemiological changeover of diseases-CVDs, obesity, and diabetes in Oman are due to changes in the lifestyle of Omani society [17].
DM and obesity are more common in urban areas than in rural areas, and most of them are unaware that they have diabetes [18][19][20]. Most of the diabetes patients in Oman were of T2 DM type and not knowing physical activities, diet, blood glucose monitoring, etc., and there is a need for self-care education [21]. Self-maintenance and management of stable blood sugar levels among T2 DM patients are low with the education level and the higher the self-management of diabetes [22].
Due to deteriorating health services, people prefer private hospitals to public hospitals in Oman [23]. Hemoglobin A1c, Blood sugar (Random and fasting) levels for most diabetes patients seemed to be less within the safe range [24,25]. Diabetes leads to foot diseases, such as foot ulceration, infection, deformity, and lower limb amputation resulting in an increase in mortality rates in Oman [26]. A large number of diabetes patients in Oman have developed visual disabilities [27]. Diabetic retinopathy prevails mostly among those who have crossed 50 years [28]. There is a significant increase in the number of Omanis registered with DM and diabetic retinopathy in Oman in the past two decades [29]. Most of the Omani families have at least one of the parents with diabetes and having the risk of developing diabetes with at least one complication-high blood pressure, coronary artery disease, or retinopathy [30,31].
After thoroughly going through the above review of literature, the factors such as lifestyle-smoking habit, overweight, physical activity, family history, blood sugar level, family history of diabetes, knowledge of diabetes, self-care, medication were identified and taken into consideration for the research study. A theoretical framework is illustrated in Figure 2.

Material and Methods
A well-defined questionnaire was prepared to carry out the research study, including the factors mentioned above, then distributed to the selected participants. The participants in this questionnaire did not report their written acceptance regarding their participation in the research, but received the questionnaire by text message and voluntarily answered it. The collected data were filtered using a purposive sampling technique. Out of the 332 samples collected from the population, 214 samples were diabetes patients only considered for the research study [32]. Further, the data were compiled, tabulated, and tested for robustness before proceeding with other tests, such as multilinear regression tests (gender-wise), ANOVA, cross-tabulation relational analyses, descriptive analysis, etc. The cross-tabulation test between (Age, Type of diabetes, Medication type, the types of diabetes) and frequency of testing at the home of diabetes of the patients.
From the review of the literature, it can be summarized that the type of diabetes is an important factor, which influences the medication type of diabetes patients. It also influences the frequency of testing at home. Blood glucose status is also an important factor, which affects the frequency of testing at home.
Blood glucose status is a factor that influences the frequency of visiting diabetes clinic and the tests prescribed by doctors is an important factor, which affects the frequency of visiting diabetes Clinic.
Thus, the following hypotheses are drawn: Hypotheses 1a. Age plays an important role in the type of diabetes of the patients.  Table 1 shows the demographic details of the respondents. Age is an important factor, which influences the type of diabetes of the patients. It is claimed that age plays an important role in the type of diabetes of the patients.  Table 2 shows the cross-tabulation between the age and the type of diabetes, the medication type and the types of diabetes and frequency of testing at home and the types of diabetes of the patients.

Results and Discussion
It is evident from Table 2 that the p values are less than 0.05. Hence there is a relationship between the age of the patients and the type of diabetes and also a relationship between types of diabetes and the medication type undertaken. Therefore, Hypothesis 1a-c, i.e., age plays an important role in the type of diabetes; the types of diabetes play an important role in the medication type of diabetes patients, and the types of diabetes play an important role in the frequency of testing at home are proved.
It is evident from Table 3 that the p-value is less than 0.05. Hence, there is a relationship between blood glucose status and the frequency of testing at home. There is a relationship between blood glucose status and the frequency of visiting diabetes clinics. Therefore, Hypotheses 2a,b, that the blood glucose status plays an important role in the frequency of testing at home and the testing blood sugar at home plays an important role in monitoring blood sugar per day is proved.  It is evident from Table 4 that the p-value is less than 0.05 for the cross-tabulation between the kind of test prescribed and the frequency visiting diabetes clinic, whereas the p-value > 0.05 for the cross-tabulation between High/Low Blood sugar status. Hence there is a relationship between the kind of tests prescribed by Doctors and the frequency of visiting diabetes clinics, whereas there is NO relationship between blood glucose status and the frequency of visiting diabetes clinics. In other words, the kind of tests prescribed by Doctors plays an important role in the frequency of visiting diabetes clinics, whereas the blood glucose status plays an important role in the frequency of visiting diabetes clinics is disproved.

Multicollinearity Test Results
The results of the multicollinearity tests are presented in Table 5 as follows:  Table 5 shows that the tolerance value of all independent variables has a value >0.1 and has a Variance Inflation Factor value (VIF) <10. Therefore, it can be concluded that there is no multicollinearity between the independent variables in the regression model. Therefore, the obtained results of the multilinear regression tests are as shown in Tables 6-9.    From Table 9, it can be seen that the p-value for all the dependent variables (Sig.) is less than 0.05, which clearly shows that the types of diabetes are dependent on the independent variables viz. the gender, age, smoking habit, overweight, and family history. Thus, the obtained linear regression model can be written as in Equation (1)     From the above table (Table 13), it can be seen that the p-value for all the dependent variables (sig.) is less than 0.05, which clearly shows that the types of diabetes are dependent on the independent variables viz. Age, Overweight, and Family History. Thus, the obtained linear regression model can be written as in Equation (2). TD = −0.042 + 0.464 A + 0.435 OW + 0.437 FH (2) where TD-Types of Diabetes, A-Age, OW-overweight and FH-Family History. Based on observing the coefficients of the independent variables, we can say that age has the highest impact on the Types of diabetes (0.464), followed by Family History (0.437), and Overweight (0.435). Table 1 shows that most of the respondents (79%) are females, and it was also found that 70% of them were obese (Overweight), and most of them (58%) responded that at least one of their family members was a diabetes patient. Even though 80% of them did not have a Smoking habit, they reported diabetes. While, 41% of the respondents were affected by Type 2 (T2 DM) diabetes, and 38% were unaware of the type of diabetes. It was also found that 91% of them were undergoing medication of different types; 70% of them visiting the doctors continually and cared for their diabetes regularly; and 83% of the respondents reported that their blood glucose status varied often. Most of them (77%) suggested that they were prescribed to undergo general tests by the doctors during their visits; 94% said that they measured their blood glucose status daily; 78% reported that they measured their blood glucose status on their own at home; 88% of the respondents said that they kept a record of self-measured readings at home; and 59% reported recording their status in papers, while the rest reported maintaining records either in hospital files or in mobile phones.

Discussion
The comparison with other studies should undertake under the same conditions. Therefore, it is difficult to compare our results with other studies implemented in different environments. However, the literature review indicates some of the risk factors that impact the diabetes type and prevalence. These risk factors, include overweight and obesity [12], family history, blood sugar level, and age of those who have crossed 50 years [28]. These factors were identified and taken into consideration for the research study. The results of this study are in line with other studies that examine the risk factors, including age as the main factor followed by Family History, Smoking habit, and Overweight.

Conclusions
It is observed that age plays an important role in the type of diabetes of patients, and the types of diabetes impacts the medication type of diabetes patients. The type of diabetes also influenced the frequency of diabetes patients self-testing at home. Many patients rushed to the hospital or took medication immediately when they indicated considerable variations in the readings. One-third of the respondents worried and reported that they do not have any kind of access to their records and readings. While, 81% opined that using the related application in the mobile phones was helpful to save and retrieve their readings to communicate the same easily, and 66% reported that they were already using such applications through their mobile phones and tabs.
The primary investigation was to determine the risk factors that impact the types of diabetes and their speared rate. This study observed the following risk factors: 1.
Based on Equation (1) Based on Equation (2), it can say that age has the highest impact on the types of diabetes (0.464), followed by Family History (0.437) and Overweight (0.435).

3.
From the literature review, we can summarize that diabetes type is an important factor influencing the medication type of diabetes patients. It also affects the frequency of testing at home. This study also observed that age plays an essential role in the type of diabetes of patients and the types of diabetes impact the medication type of diabetes patients.
The study's limitations are the low number of participants, which impacts the generalization of all Oman results. Besides, a shortage of reliable data related to the exact number of patients with diabetes because we obtained different numbers based on WHO and MOH-Oman. This impact limits our analysis scope, which it considers a notable obstacle in finding a significant relationship.
From the above, as an implication of the study, the following suggestions were made: • The government should take initiatives to run awareness campaigns on Obesity and diabetes. • A database of diabetes patients need to be created so that regular advice, follow-up be made in an easy and smooth manner. • Facilities for their regular check up on their blood glucose sugar level can be made available, either by special camps or by providing them with self-measuring apparatuses. • Age-wise classification of diabetes patients should be made and special attention to be made to the age-old diabetes patients, and women in particular.

•
Records of such patients can be linked through online facilities so that they can upload their self-measured readings to retrieve them anytime, even during emergency situations. • Facilities for obtaining timely appointments can be made at every level starting from the roots-public health centers to the apex level-hospitals. • At the regional/Wilayat level, special camps can be established to curb and educate using increasing diabetes awareness campaigns, to be held on a periodic/regular interval. Informed Consent Statement: Informed consent was obtained from all subjects involved in the study.