Objective: To compare the knowledge, attitude and practice regarding diabetes mellitus among diabetics and non-diabetics.
Methods: The cross-sectional study was conducted at the Government College University, Faisalabad, Pakistan, from December 2017 to April 2018, and comprised subjects recruited randomly from different cities of Punjab, Pakistan. Data was collected using a predesigned structured questionnaire regarding socio-demographic characteristics, general knowledge about diabetes, perception regarding indication, risk factors, diagnosis, and complications, and practices followed for treatment and management of diabetes.
Results: Of the 2,000 subjects, 972(48.6%) had family history of diabetes, 1338(66.9%) were living in urban areas, 1068(53.4%) were university graduates, 804(40.2%) were employed and 1152(57.6%) belonged to socio-economically balanced families. Composite knowledge score was significantly associated with age and socio-economic status (p<0.05). A highly significant association was observed regarding family history (p<0.001), level of education (p<0.0001) and occupation (p<0.001) with composite knowledge score.
Conclusion: The knowledge level about diabetes was seen to be average.
Keywords: Complications of diabetes mellitus, Diabetes knowledge, Management of diabetes mellitus, Pakistani population, Questionnaire. (JPMA 71: 286; 2021)
According to the International Diabetes Federation (IDF) edition 8th, there were 451 million people living with diabetes mellitus (DM) globally in 2017 and this figure was expected to rise up to 693 million in 2045.1 Growing urbanisation, sedentary lifestyle, consumption of high caloric food and stressful lifestyle have led to an increase in the prevalence of metabolic disorder exclusively DM.2 Pakistan is the 6th most populous country in the world, with a population of 207.7 million according to the 6th census conducted in 2017. In South Asia, Pakistan is 2nd behind India with 74.05 million diabetics. Recently, diabetic prevalence survey of Pakistan, conducted by Hayatabad Medical Complex, Peshawar, estimated that about 35.5 million people were living with diabetes, which is approximately 17% of total population of Pakistan.3 About 63.6% of Pakistani population lives in rural areas and has relatively low knowledge about the treatment and management of DM.4
Good knowledge is a prerequisite for good health, early diagnosis, prevention and better management of diseases like DM.5
There is an immediate need to educate people for better control of DM in Pakistan.4,6,7 The current study was planned to investigate the knowledge, attitude and practice of general population regarding prevention, treatment and management of DM and its-associated completions.
Subjects and Methods
The cross-sectional study was conducted at the Government College University, Faisalabad (GCU-F), Pakistan, from December 2017 to April 2018, and comprised subjects from different cities of Punjab, Pakistan. Analysis was conducted at the GCU-F Department of Pharmaceutical Chemistry and the Department of Pharmacy at the University of Agriculture, Faisalabad.
After approval from the institutional ethics review committee, the sample size was calculated using Raosoft calculator8 while keeping margin of error 5% with 95% confidence interval for minimum population of 20,000. The outcome factor (response distribution) used for sample size estimation was 50%. The bulk of the sample was raised from four Lahore, Faisalabad, Gujranwala and Multan, while the rest were enrolled from Jhang, Nankana Sahib, Rahim Yar Khan, Shaikhupura, Sialkot, Toba Tek Singh and Vehari. The sample was raised using random sampling strategy to minimise any kind of bias from among both diabetics and non-diabetics in the community aged >18 of either gender. Those with severe behavioural, mental illness, cardiovascular, kidney and liver disorders were excluded, and so were those not willing to participate or not able to understand even local languages and those who had attended a diabetes awareness programme previously.
Literature was reviewed to develop a structured questionnaire for data collection.9 The questionnaire was in English language. Trained research assistants translated the questionnaire into the native language for those who were not able to understand the English language. The questionnaire was first tested on a small sample (n=10) and was reviewed subsequently.
The questionnaire was validated by a panel of health care professionals comprising diabetologist, physician, hospital pharmacists and community pharmacists. Content validation was done to make sure that there was no ambiguity in the questionnaire and all questions were appropriate for the study. On the basis of panel reviews, alterations were carried out with respect to structure and arrangement of questions. A pilot study was conducted by employing diabetics and non-diabetics (n=25). A test-retest method was used, and the same participants were asked to fill the same questionnaire after a 10-day interval.
The final questionnaire contained 86 questions divided into 6 sections. Research assistants were trained to interview the subjects. The questionnaire was filled up by the assistants, and the respondents were given sufficient time to answer the questions, with each interview lasting approximately 25-30 minutes.
General knowledge of the subjects was assessed in line with literature.9 Under the domain, 19 questions were asked (Annexure).
Categorical responses were "yes" or "no", with each "yes" given a score of 1 and each "no" given a score of 0. The maximum score for general knowledge domain was 19. The Knowledge score (KS) had four grades; up to 25% "poor", 50% was considered "average", 75% "good" and 100% was considered "excellent".
Socio-demographic characteristics included age, gender, marital status, education, diabetes history, income status and occupation were also noted.
Socio-demographic characteristics were analysed using simple descriptive statistics in Microsoft Excel Sheet. Continuous data was expressed as mean ± standard deviation (SD) and continuous data as frequencies and percentages. Normality of data was tested using Kolmogorov-Smirnov test. Data were transferred to GraphPad Prism 5 software 5.01, and student t-test was performed. P<0.05 was considered statistically significant.
Of the 2000 subjects, 377(18.85%) each were enrolled from Lahore, Faisalabad, Gujranwala and Multan, while the remaining 492(24.6%) belonged to the other smaller cities. Also, 894(44.7%) were diabetics and 1106(55.3%) were non-diabetics, and 1014(50.7%) were males and 986(49.3%) were females. The overall mean age was 38.8±16.3 years; 1212(60.6%) were married; 972(48.6%) had family history of DM; 1338(66.9%) were living in urban areas; 1068(53.4%) were university graduates; 1608(80.4%) were non-smokers; 804(40.2%) were employed; and 1152(57.6%) belonged to socio-economically balanced families (Table-1).
Of the total, 1260(63%) participants knew the definition of DM, and 1560(78%) answered correctly about DM symptoms of DM. Among the male participants, 56(3%), 444(22%), 283(14%) and 202(10%) had poor, average, good and excellent composite KS respectively, while the corresponding numbers for female participants were 119(6%), 396(20%), 339(17%) and 161(8%). KS had highly significant association with family history (p<0.001), higher education (p<0.0001) and employment (p<0.001), while it had significant association with age and socio-economic status (p<0.05). Gender and marital status had no significant association (p>0.05) with KS (Table-2).
Participants belonging to the major cities had comparatively good KS compared to the smaller cities (Table-3).
Further, 96(11%) participants had poor knowledge about DM indications, 132(15%) had average, 270(30%) good and 342(38) had excellent (>75%) knowledge. Also, 270(30%) participants had excellent KS regarding indications of DM-associated kidney diseases, 342(38%) eye diseases, 288(32%) heart diseases and 336(38%) foot diseases. Likewise, 306(34%) participants had excellent KS about prevention of DM-associated kidney diseases, 372(42%) eye diseases, 552(62%) heart disease and 480(54%) foot diseases (Table-4).
Regarding perception about DM diagnosis, diabetics scored better than non-diabetics (Figure-1).
Likewise, the difference of knowledge among diabetic and non-diabetic participants about DM risk factors was statistically significant (Figure-2-A).
The participants were asked who should go for a DM diagnosis, and the difference in responses between diabetics and non-diabetics was not significant (Figure-2-B).
Of the total, 720(36%) subjects had visited the doctor once per month (frequently), 940(47%) had visited at least once in the preceding six months, and 300(15%) had never visited the doctor after DM diagnosis; 1700(85%) said their doctors had advised them to change lifestyle; and 1440(72%) of them acted upon doctor's advice (Figure-3).
Attitude towards various medicinal options were also explored (Figure-4),
and the same was the case with lifestyle modification options (Figure-5).
Difference between perception about DM management between diabetics and non-diabetics was statistically significant (p<0.05).
Better knowledge of DM leads to better treatment and management of DM. In Pakistan, very few reports have emphasised the need to organise educational programmes for better DM management.7,10 In the current study, 51% of participants had average general knowledge. Similarly, Islam et al. reported that 45.6%, 37.7% and 16.7% participants had shown good, average and poor knowledge of DM.11 Results of the current study are consistent with results reported elsewhere from different developing countries.7,12-14 Additionally, in a study, knowledge level was higher among diabetics than non-diabetics, because of regular visits to the doctor.15 It was found that participants mostly gained knowledge from friends, relatives and healthcare professionals.
Different studies have investigated that higher education, income and residence strongly affect knowledge.14-16 Better knowledge and self-care practices e.g., changing lifestyle, healthy diet and exercise, are associated with a healthy lifestyle.5,17 A survey conducted in West Bengal, India, showed that 80.9% diabetics and 76.1% non-diabetics thought that healthy and selected diet led to a healthy lifestyle.15
A study conducted in Karachi showed that 97.7% participants were using allopathic medicine and only 2.3% were using homoeopathic medicines for DM (18). A study conducted in Ethiopia, 57.3% participants responded that insulin can be used for DM treatment.14 A study from Bangladesh reported that the participants showed average attitude about prevention and management of DM. In several studies from developing countries, 56% in Ethiopia,14 31.8% in Oman,19 18% to 55.9% participants in Pakistan,6,20 62.1% in Saudi Arabia,21 and 72% participants in the United Arab Emirates (UAE)17 had poor attitude towards DM treatment, and our results are in line with literature.
It is obvious that lack of knowledge makes DM condition worse. A study from Dhaka, Bangladesh, reported that an overwhelming majority (70% and 72%) of participants responded that increasing physical activity and reduced carbohydrate intake is a good choice to control DM.22 Another study from Pakistan showed that study participants thought that DM can be managed by diet (3.3%), exercise (0.7%), medication (5.3%) and diet + exercise + medication (3.3%).23 A study conducted in Bangladesh revealed average knowledge that DM can be managed and prevented by controlling diet (77%), taking medicine (88%), regular exercise (73%), eating less (76%), planned diet (69%), weight reduction (43%) and physical activity (31%).15
Several studies had reported that knowledge about pathogenesis and risk factors of DM is poor among people in developing countries.11,13,18 Less than half of study participants believed that excessive intake of sweet foods causes DM and only 50% merely knew about nutrition and food.24 Another study revealed that the participants thought that lack of insulin (53.7%), impaired insulin production (6.9%), increased sugar consumption (43.5%), hereditary (51.5%), lack of physical activity (17.9%), mental stress (26.8%) and being overweight (18.25%) are risk factors for DM.15 Another study also reported very low perception of study participants regarding DM causes that were food habit (19.8%), genetic (18.6%), lack of physical activity (24.6%), obesity (9.1%), medication (2.7%) and high blood sugar (1.9%).11
It has been reported that rural inhabitants had poor knowledge of risk factors. The study participants had responded that obesity, being overweight (30.1%), eating more food (9.6%), hypertension (5.8%), family history of type 2 DM (3.2%) and reduced physical activity (2.6%) may be possible risk factors.25 A cross-sectional study in a north western Ethiopian town showed that less than half the participants had responded that DM-associated complications included brain disease (47.5%), hypertension (37.9%), blindness (35.3%), amputation of a limb (33.2%), and kidney diseases (29.3%).14 Koley et al. showed that the participants did not have adequate knowledge and thought that poor wound healing (48.1%), foot ulcer (23.1%), loss of vision (36%), kidney failure (31.6%), heart failure (16%), stroke (6.2%) and amputation (6.1%) were the complications associated with DM.15 In the current study, knowledge of the participants about the prevention of DM-associated complications was also poor. A population-based study from Bangladesh showed that more than half (53%) of the diabetic participants had never got their blood sugar level checked.13 In the current study, the participants had shown little knowledge regarding when and how to measure fasting blood glucose (FBG), random blood glucose (RBG), and oral glucose tolerance (OGT) tests.
The current study has some potential limitations. First, the sample size was not large enough, so the results cannot be generalised to the entire population of Punjab. Secondly, there was no follow-up as study participants were from different cities, and it was very difficult to get the information again over an extended period followed by an intervention of diabetic educational programme.
The knowledge level was found to be average or below-average about DM risk factors, causes and complications, indicating the need to improve knowledge levels. The possible reasons behind average knowledge and poor attitude were low literacy rate, rural residence and lack of interest in self-care practices like physical activity.
Conflict of Interest: None.
Source of Funding: The Higher Education Commission (HEC) of Pakistan (5661/Punjab/NRPU/R&D/HEC/2016 and 6429/Punjab/NRPU/R&D/HEC/2016).
1. Cho N, Shaw J, Karuranga S, Huang Y, da Rocha Fernandes J, Ohlrogge A, et al. IDF Diabetes Atlas: Global estimates of diabetes prevalence for 2017 and projections for 2045. Diabetes Res Clin Pract. 2018;138:271-81.
2. Hu FB. Globalization of diabetes: the role of diet, lifestyle, and genes. Diabetes care. 2011;34:1249-57.
3. Aamir AH, Ul-Haq Z, Mahar SA, Qureshi FM, Ahmad I, Jawa A, et al. Diabetes Prevalence Survey of Pakistan (DPS-PAK): prevalence of type 2 diabetes mellitus and prediabetes using HbA1c: a population-based survey from Pakistan. BMJ open. 2019;9:e025300.
4. Masood I, Saleem A, Hassan A, Zia A, Khan AT. Evaluation of diabetes awareness among general population of Bahawalpur, Pakistan. Primary care diabetes. 2016;10:3-9.
5. Saleh F, Mumu SJ, Ara F, Ali L, Hossain S, Ahmed KR. Knowledge, attitude and practice of type 2 diabetic patients regarding obesity: study in a tertiary care hospital in Bangladesh. J Public Health Africa. 2012;3.
6. Gul N. Knowledge, attitudes and practices of type 2 diabetic patients. J Ayub Med Coll Abbottabad. 2010;22:128-31.
7. Badruddin N, Basit A, Hydrie MZI, Hakeem R. Knowledge, attitude and practices of patients visiting a diabetes care unit. Pak J Nutrition. 2002;1:99-102.
8. Raosoft. [cited 2019 March 1]. http://www.raosoft.com/samplesize.html.
9. Saleh F, Ara F, Afnan F. Assessment of Gap between Knowledge and Practices among Type 2 Diabetes Mellitus Patients at a Tertiary-Care Hospital in Bangladesh. Adv Public Health. 2016;2016.
10. Shera A, Jawad F, Basit A. Diabetes related knowledge, attitude and practices of family physicians in Pakistan. J Pak Med Assoc. 2002;52:465-70
11. Islam SMS, Niessen LW, Seissler J, Ferrari U, Biswas T, Islam A, et al. Diabetes knowledge and glycemic control among patients with type 2 diabetes in Bangladesh. Springerplus. 2015;4:284.
12. Saeed H, Saleem Z, Naeem R, Shahzadi I, Islam M. Impact of health literacy on diabetes outcomes: a cross-sectional study from Lahore, Pakistan. Public health. 2018;156:8-14.
13. Islam FMA, Chakrabarti R, Dirani M, Islam MT, Ormsby G, Wahab M, et al. Knowledge, attitudes and practice of diabetes in rural Bangladesh: the Bangladesh Population based Diabetes and Eye Study (BPDES). PLoS One. 2014;9:e110368.
14. Asmamaw A, Asres G, Negese D, Fekadu A, Assefa G. Knowledge and attitude about diabetes mellitus and its associated factors among people in Debre Tabor town, Northwest Ethiopia: cross sectional study. Science. 2015;3:199-209.
15. Koley M, Saha S, Arya JS, Choubey G, Ghosh S, Chattopadhyay R, et al. Knowledge, Attitude, and Practice Related to Diabetes Mellitus Among Diabetics and Nondiabetics Visiting Homeopathic Hospitals in West Bengal, India. J Evidence-based Complement Altern Med 2016;21:39-47.
16. Al Bimani ZS, Khan SA, David P. Evaluation of T2DM related knowledge and practices of Omani patients. Saudi Pharmaceutical J. 2015;23:22-7.
17. Al-Maskari F, El-Sadig M, Al-Kaabi JM, Afandi B, Nagelkerke N, Yeatts KB. Knowledge, attitude and practices of diabetic patients in the United Arab Emirates. PloS one. 2013;8:e52857.
18. Anwer I, Shahzad A, Nanji K, Haider F, Ahmad MM. Diabetes mellitus-knowledge, management and complications: survey report from Faisalabad-Pakistan. Middle East J Fam Med. 2017;15:7-12.
19. Khandekar R, Al Harby S, Al Harthy H, Al Lawatti J. Knowledge, attitude and practice regarding eye complications and care among Omani persons with diabetes-A cross sectional study. Oman J Ophthalmol. 2010;3:60.
20. Memon MS, Shaikh SA, Shaikh AR, Fahim MF, Mumtaz SN, Ahmed N. An assessment of knowledge, attitude and practices (KAP) towards diabetes and diabetic retinopathy in a suburban town of Karachi. Pak J Med Sci. 2015;31:183.
21. Al-Mulla AH, Al-Thafar AK, Hussain MAA-S, Ali SI, Al-Dossary SK. Knowledge, attitude and practice toward diabetic retinopathy and retinal examination among diabetic population in Al-Hasa Region, Saudi Arabia: A cross-sectional study. Age. 2017;35:24.2.
22. Siddique MKB, Islam SMS, Banik PC, Rawal LB. Diabetes knowledge and utilization of healthcare services among patients with type 2 diabetes mellitus in Dhaka, Bangladesh. BMC Health Serv Res. 2017;17:586.
23. Ulvi O, Chaudhary RY, Ali T, Alvi RA, Khan M, Khan M, et al. Investigating the awareness level about diabetes mellitus and associated factors in Tarlai (rural Islamabad). J Pak Med Assoc. 2009;59:798-801.
24. Jabbar A, Ebrahim M, Mahmood K. Standard of knowledge about their disease among patients with diabetes in Karachi, Pakistan. J Pak Med Assoc.. 2001;51:216.
25. Binh T, Phuong P, Nhung B. Knowledge and associated factors towards type 2 diabetes among a rural population in the Red River Delta region, Vietnam. Rural Remote Health. 2015;15:3275.