|Year : 2021 | Volume
| Issue : 3 | Page : 293-298
Diabetes and its complications; Knowledge, attitude, and practices (KAP) and their determinants in Pakistani people with type 2 diabetes
Nazish Waris1, Anum Butt2, Saima Askari2, Asher Fawwad3, Abdul Basit4
1 Clinical Biochemistry and Psychopharmacology Research Unit, Department of Biochemistry, University of Karachi, Karachi, Pakistan; Research Department, Baqai Institute of Diabetology and Endocrinology, Baqai Medical University, Karachi, Pakistan
2 Research Department, Baqai Institute of Diabetology and Endocrinology, Baqai Medical University, Karachi, Pakistan
3 Research Department, Baqai Institute of Diabetology and Endocrinology, Baqai Medical University, Karachi, Pakistan; Biochemistry Department, Baqai Medical University, Karachi, Pakistan
4 Department of Medicine, Baqai Institute of Diabetology and Endocrinology, Baqai Medical University, Karachi, Pakistan
|Date of Submission||18-Aug-2020|
|Date of Acceptance||09-Dec-2020|
|Date of Web Publication||30-Sep-2021|
Dr. Asher Fawwad
Research Department, Baqai Institute of Diabetology and Endocrinology, Baqai Medical University, Plot No. 1-2, II-B, Nazimabad No. 2, Karachi.
Source of Support: None, Conflict of Interest: None
Objective: To assess the knowledge, attitude, and practices (KAP) regarding diabetes and its associated complications in people with type 2 diabetes. Materials and Methods: This prospective observational study was conducted at the Baqai Institute of Diabetology and Endocrinology (BIDE), Baqai Medical University (BMU), Karachi, Pakistan. The duration of the study was from January 2019 to June 2019. Ethical approval was obtained from the Institutional Review Board (IRB) of BIDE. People with type 2 diabetes aged older than 25 years, with more than two years’ duration of diabetes were included. A self-structured questionnaire was designed to assess KAP. Results: The mean age of the study participants was 53.14±11.62 years, and the mean duration of diabetes was 10.76±7.65 years. Knowledge and attitude showed higher mean percentage scores of 85.5% and 88.6% as compared with a practice score of 40.7%, which revealed good knowledge and attitude of the participants and poor practice. Education showed a significant association with knowledge and attitude, triglyceride level toward knowledge, LDL-C level toward practice, and HDL-C level toward knowledge and practice. Conclusion: A good knowledge and attitude score of the participants toward diabetes but a poor practice score was found. Individualized programs as well as group education programs still needed to be planned to enable better prevention and management techniques in diabetes. Behavioral therapy and counseling should be considered as a priority in subjects with low practice.
Keywords: Attitude, knowledge, practice, type 2 diabetes
|How to cite this article:|
Waris N, Butt A, Askari S, Fawwad A, Basit A. Diabetes and its complications; Knowledge, attitude, and practices (KAP) and their determinants in Pakistani people with type 2 diabetes. J Diabetol 2021;12:293-8
|How to cite this URL:|
Waris N, Butt A, Askari S, Fawwad A, Basit A. Diabetes and its complications; Knowledge, attitude, and practices (KAP) and their determinants in Pakistani people with type 2 diabetes. J Diabetol [serial online] 2021 [cited 2021 Nov 30];12:293-8. Available from: https://www.journalofdiabetology.org/text.asp?2021/12/3/293/327316
| Introduction|| |
Diabetes mellitus (DM) is a silent disease and it is identified as one of the fastest-growing threats to public health all around the world. The global prevalence of diabetes is estimated to be 9.3% in 2019, and it is expected to rise to 10% by 2030 and 10.9% by 2045, respectively.In lower-middle-income countries, the prevalence continues to rise irrespective of the income level.According to the second National Diabetes Survey of Pakistan (2016–2017), the prevalence of diabetes is estimated at 26.3%. This pandemic situation demands attention toward developing interventional strategies.
The American Diabetes Association states that diabetes self-management education and support (DSMES) is essential at the time of diagnosis of diabetes, to assess yearly education, nutrition, and emotional need; and during a transition in health status. There must be an instructor who trains nurses, dietitians, pharmacists, certified diabetes educators, or other credentialed health professionals regarding DSMES. This might be contributing significantly to the effective management of diabetes, in terms of not only appropriate antidiabetic medicine use but also patients’ knowledge about their medicines, healthy diet, exercise, and self-monitoring of blood glucose levels., However, improvement in behavior does not depend only on the knowledge of patients; besides that, the assessment of a patient’s knowledge of a disease shows a positive influence in health education interventions.
It was reported earlier that patients with diabetes with sound knowledge and who were self-motivated assisted in achieving better glycemic control.The effective treatment plan for DM is based on key components to improve interventions, which are the effectiveness of methods of health education and educational efforts accompanied by difference in opinion.Therefore, health education is essential in resource-poor settings, where DM poses excessive financial burden and calls for urgent input from clinicians at all levels, especially primary care physicians, and comes to be known as well as newly detected diabetes.A literature search on knowledge about diabetes in developing countries yields very few studies regarding the awareness of diabetes among people with the disease and as per our search, there are virtually no data on whole populations.To educate patients and influence their behavior, we need to know their current understanding and practices.This is more important in a country such as Pakistan, where patient literacy is low and the chances of misunderstanding regarding glycemic control guidelines are high. Hence, the aim of this study is to assess the KAP regarding diabetes and its associated complications in people with type 2 diabetes.
| Materials and Methods|| |
This prospective observational study was conducted at the BIDE, BMU, Karachi, Pakistan. The duration of the study was from January 2019 to June 2019. Ethical approval was obtained from the IRB of BIDE with IRB no: BIDE/IRB/NWARIS/08/10/19/0214. Subjects with type 2 diabetes aged older than 25 years, with more than two years’ duration of diabetes were included after obtaining informed verbal consent. The formula was used for sample size calculation by using a single population proportion formula considering P = 50%, 95% confidence interval, and 0.05 absolute precision.
where n = required sample size, Z = value from standard normal distribution corresponding to desired confidence level (Z = 1.96 for 95% CI), P = expected proportion of the population having correct knowledge about diabetes, 50%, and d = desired absolute precision (0.05). Hence, 378 participants were included.
A self-structured questionnaire was designed to collect data regarding KAP and it was divided into two sections: one for demographic data and a second section containing 45 items, 16 for knowledge, 15 for attitude, and 14 for practice, respectively. Cronbach’s alpha of the questionnaire =0.788 was used for validation, where a score of each answer was coded as Yes = 1, No = 0. After summing up the score of all items, it was transformed it into a scale from 0 to 10. A higher score represents better KAP.
The analysis was done by using a statistical package for social sciences (SPSS), version 20.0. The level of significance was shown at p-value <0.05. The KAP scores were converted to percentages by score/ total score *100. Continuous variables were presented as mean ± SD. The frequency of correct responses about KAP was presented as n (%). Associations between risk factors and KAP scores were assessed by using Student’s T-test and ANOVA. P-value<0.05 was considered statistically significant.
| Result|| |
Baseline and biochemical characteristics
A total number of 378 subjects with type 2 diabetes with a predominant 217 subjects (57.4%) were included. The mean age of the study participants was 53.14±11.62 years, and the mean duration of diabetes was 10.76±7.65 years. The majority of the participants were Urdu speaking: 137 (36.24%) and 84 (22.22%) study participants had secondary education [Table 1].
Knowledge of study participants
Of all participants, 270 (71.4%) had good knowledge of obesity as a risk factor of diabetes, 321 (84.9) unhealthy diet, 347 (91.8%) family history, and 382 (74.6) high blood cholesterol, respectively. The majority of the participants had good knowledge: 363 (96%) toward a healthy diet and healthy lifestyle; 356 (94.2) who were aware of diabetes complications, such as loss of vision and heart failure [Table 2].
|Table 2: Knowledge assessment toward glycemic controls among patients with DM|
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Attitude of study participants
Out of 378 participants, 361 (95.5%) had a good attitude toward glycemic control for diabetes management. In the majority of participants, 363 (96%) believed that green leafy vegetables and fruit intake were better and 373 (98.1%) of them had a good attitude toward avoiding excess salt and sugar in their diet. Further, most of the participants, 371 (98.7%), believed that people with diabetes should do extra foot care, avoid excessive cooking oil usage, and regularly screen their urine and blood glucose [Table 2].
Practices of study participants
Among a limited number of participants, 22 (5.8%) had a good practice on medication adherence. However, in the majority of the participants, 343 (90.7%) had a bad practice toward smoking cigarettes; 351 (92.9%) did not take treatment during hypoglycemia; 281 (74.3%) skipped their follow-up; 334 (88.4%) did not monitor their blood glucose level properly; and 327 (86.5%) avoided extra added salt and sugar [Table 2].
Association of KAP with various factors
Out of 378 participants, 161 males had a mean knowledge score of 86.22±13.46, a mean attitude score of 88.78±10.01, and a mean practice score of 40.89±8.27; whereas 217 females had a mean knowledge score of 84.91±15.63, a mean attitude score of 88.42±9.03, and a mean practice 40.51±6.78, respectively. According to the table, depending on the participant’s age (≤55 years vs >55 years), the mean knowledge score was 85.04±15 vs 86.02±14.43, the mean attitude score was 88.92±7.82 vs 88.12±11.22, and the mean practice score was 40.89±6.47 vs 40.39±8.55. Based on the duration of diabetes (≤10 years vs>10 years), the mean knowledge score was 84.75±15.41 vs 86.46±13.82, the mean attitude score was 87.98±9.22 vs 89.41±9.71, and the mean practice score was 40.87±7.49 vs 40.39±7.41. A significant relationship existed between KAP score and cholesterol levels. Education showed a significant association with knowledge and attitude, triglyceride level toward knowledge, LDL level toward practice, and HDL level toward knowledge and practice [Table 3].
Mean percentage score of KAP
We also assessed the mean percentage score between KAP of the study participants.
Knowledge and attitude showed higher mean percentage scores of 85.5% and 88.6% as compared with practice scores of 40.7%, which revealed good knowledge and attitude of participants and poor practice as shown in [Figure 1].
| Discussion|| |
Overall, participants with better knowledge had a better attitude score toward diabetes whereas only 40.7% were in the good practice category. This may be because the study participants were hospital-based and they have better health education access. Previous studies from Iran and Tehran also reported that the KAP score of patients with diabetes was good where most of the educational programs had been held.
In this study, nearly 85.5% of respondents had good knowledge about risk factors (family history, obesity, high blood cholesterol), complications of diabetes (loss of vision, heart failure, kidney failure, foot ulcer) and they knew that diabetes could cause certain complications if it remained uncontrolled, similar to a recent study from Dhaka. Low knowledge score was seen in several studies from low-income countries,,, as compared with the current study. This difference may be explainable due to lack of accessibility of health education intervention programs in the community, limited sources of information, inadequate involvement of media, and other concerned bodies on raising knowledge toward glycemic control. In our study, most of the participants, 88.6%, had also a good attitude toward glycemic control and this was higher than the study done in Bangladesh, Kenya, and India. This difference might be that studies were conducted in rural communities in India and Kenya; on the other hand, the current study was performed in a tertiary care center with better access to a health education program.
The most interesting finding of this study was the gap between knowledge and practice toward diabetes and its management. Knowledge and attitude scores were higher in the majority of the participants but the practice was half of them. However, among participants, only 40.7% showed good practice toward glycemic control. This indicates that improving the implementation of dietary patterns and physical activities of the diabetics in our society will not be an easy task. In our study, 58.2% were doing physical exercise and only 32.8% were taking a healthy diet. The response to regular exercise and healthy diet was consistent with the studies conducted by Bruce et al. and Sangra et al. However, still great efforts are required by the health team to enhance education and its implementation in patients with diabetes to promote compliance with a recommendation regarding diet and exercise. For tertiary care diabetes centers, it also highlights the needs related to how our dieticians and educators alongside consultant diabetologists educate the patient to implement diet and exercise in their daily routine. The current study found that a lower number of participants had adherence to medication. Most of the participants were cigarette smokers, have irregular checkup for blood glucose level, eye and foot practices inconsistent with earlier studies. This might be due to difference in health beliefs, demographic characteristics, and diabetes education programs. We found no significant association in glycemic control and duration of diabetes toward KAP as compared with other studies. In the current study, a positive association was found between the KAP score and lipids that acknowledged previous study results. Education was significantly associated with knowledge and attitude but not with practice. Asmelash D et al. found a significant association between educational status and practice toward glycemic control.
Thus, in this modernized era where our population has been adopted, the westernized lifestyle, education, and counseling about diabetes in all aspects are needed. Individualized programs, as well as group education programs, should be planned for better prevention and management techniques related to diabetes. Our findings lend support to tailoring diabetes educational programs for subjects with diabetes in Pakistan. So, culturally sensitive and patient-tailored educational interventions by health-care providers are likely to be more effective at achieving desired clinical outcomes.
Further large-scale studies involving multiple centers are required. Consideration of other confounding factors is entailed to validate the findings of this study.
| Conclusion|| |
A good knowledge and attitude score of the participants toward diabetes but a poor practice score was found. Individualized programs as well as group education programs still need to be planned for better prevention and management techniques in diabetes. Behavioral therapy and counseling should be considered as a priority in subjects with low practice.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3]