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 Table of Contents  
Year : 2021  |  Volume : 12  |  Issue : 3  |  Page : 299-304

Knowledge on diabetes and its determinants among type 2 diabetic subjects in a low-resource setting: A cross-sectional study in a tertiary care hospital in Bangladesh

1 Center for International Health, Ludwig-Maximilians-Universität, Munich, Germany; Department of Health Promotion & Health Education, Bangladesh University of Health Sciences (BUHS), Dhaka, Bangladesh
2 Department of Health Promotion & Health Education, Bangladesh University of Health Sciences (BUHS), Dhaka, Bangladesh
3 Department of Statistics, University of Rajshahi, Rajshahi, Bangladesh
4 Diabetes Center, Medizinische Klinik IV, Ludwig-Maximilians-Universität, Munich, Germany
5 Pothikrit Institute of Health Studies

Date of Submission21-Sep-2020
Date of Decision21-Nov-2020
Date of Acceptance09-Dec-2020
Date of Web Publication30-Sep-2021

Correspondence Address:
Dr. Mohammad Wahiduzzaman
Department of Health Promotion & Health Education, Bangladesh University of Health Sciences (BUHS), Dhaka.
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/JOD.JOD_87_20

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Background: Knowledge about diabetes is the cornerstone of self-management, which is crucial for diabetes care. Improving patients’ knowledge and self-management toward their condition can achieve better control, delay complications, and improve their quality of life. However, there are great variations in the level of knowledge from population to population and this needs to be explored in different ethnic and sociocultural groups for designing appropriate preventive strategies. Due to lack of adequate studies in Bangladesh, this study aimed at assessing diabetes-related knowledge, its determinants and examined which subgroups of patients have the largest knowledge deficits. Materials and Methods: This cross-sectional study was carried out among 504 study participants with type 2 diabetes in the outpatient clinic of the Bangladesh Institute of Health Sciences (BIHS) hospital, a tertiary care center in Dhaka, Bangladesh. Sociodemographic information, anthropometric knowledge about diabetes were collected by semistructured, interviewer-administered questionnaires by the face-to-face interview technique. Respondents who achieved a 50% or higher score from a 16-item diabetic knowledge assessment questionnaire were considered to have good knowledge and their counterparts were considered as possessing poor knowledge about diabetes. Descriptive statistics was used to estimate the prevalence of knowledge. A univariate and multivariate logistic regression was carried out to identify significant factors associated with diabetic knowledge. Results: The participants’ mean age (±SD) was 52 ± 11years; among them, 57.3% were women, 17.1% were illiterate, and 31.5% belonged to a lower-income family. About one-third of them (29.2%) had good knowledge, and male participants were more educated and had higher diabetes knowledge compared with their counterparts. In particular, gender, education, occupation, monthly family income, and duration of diabetes showed a significant correlation with overall knowledge. On multivariate regression, age, education, duration of diabetes, and family members correlated independently with knowledge. Conclusions: On the basis of the current study, it is suggested that about two-third of the patients attending a tertiary care hospital had poor knowledge about diabetes. These results highlight the need for a coordinated educational program with a prioritized focus on older, newly diagnosed, and less educated groups, which reinforces the necessity for patient education.

Keywords: Bangladesh, diabetes knowledge, education, risk factors, training

How to cite this article:
Wahiduzzaman M, Hossain S, Islam S, Banning F, Ali L, Lechner A. Knowledge on diabetes and its determinants among type 2 diabetic subjects in a low-resource setting: A cross-sectional study in a tertiary care hospital in Bangladesh. J Diabetol 2021;12:299-304

How to cite this URL:
Wahiduzzaman M, Hossain S, Islam S, Banning F, Ali L, Lechner A. Knowledge on diabetes and its determinants among type 2 diabetic subjects in a low-resource setting: A cross-sectional study in a tertiary care hospital in Bangladesh. J Diabetol [serial online] 2021 [cited 2021 Nov 30];12:299-304. Available from: https://www.journalofdiabetology.org/text.asp?2021/12/3/299/327318

  Background Top

Diabetes mellitus (DM) is now one of the major epidemic noncommunicable diseases leading to mortality and morbidity worldwide. The International Diabetes Federation estimated that in 2019 there were 463 million (age 18–99 years) people with diabetes worldwide. These figures were expected to increase to 700 million by 2045 and almost half of all the people (50.1%) living with diabetes are undiagnosed.[1] People with diabetes mostly live in low- and middle-income countries (79.4%); the total number of deaths attributed to diabetes is 41.8%, and 58.2% of deaths due to diabetes occur in low- and middle-income countries.[1] The International Diabetes Federation estimated that in Bangladesh 8.4 million adults with DM, of whom an estimated 4.7 million are undiagnosed, and the number of Bangladeshis with DM will rise to 15 million in 2045.[2] Bangladesh was the 10th highest country of people living with diabetes in 2019 and it will be in the ninth position in 2045 (15 million).[2]

The majority of these individuals have poor metabolic control and are, therefore, prone to develop diabetic secondary complications.[3] Diabetes management largely depends on an individual’s self-care ability, which, in turn, is affected by a number of factors. One important factor is knowledge about the disease, its management, and its complications. Knowledge about diabetes among individuals affected by this disease is poor in many low- and middle-income countries.[4],[5],[6]

Several studies have shown that good knowledge about diabetes is required for adequate metabolic control and thus the prevention of diabetic secondary complications.[7],[8],[9],[10] On the other hand, poor knowledge is associated with a high rate of complications and higher healthcare costs.[11]

Some studies previously conducted in Bangladesh have shown that knowledge about diabetes is poor among the general population, as well as among the diabetic population especially those with newly detected DM.[6],[12],[13] Even in our recent study, knowledge is poor among patients with type 2 DM attending the outpatient department and receiving standard training by a qualified nurse, which is obviously insufficient for patient training.[11] None of the studies explore details pertaining to and knowledge about diabetes and its determinants as well as domain-specific deficits.

In consequence to our previous results, we have developed an optimized approach to patient training in resource-limited settings. To get a better understanding of the most urgent requirements for improved training sessions and material, we interviewed a second cohort of patients with diabetes at the same treatment center with a more detailed questionnaire. The objective was which knowledge areas have the biggest deficits and which subgroups of patients require the most attention in future training efforts.

  Materials and Methods Top

Study site, design, and population

A cross-sectional study was conducted at the BIHS hospital in Dhaka, Bangladesh between May 2017 and September 2017. BIHS hospital is a tertiary care hospital of the Bangladesh Diabetic Association (BADAS). Adults with type 2 diabetes who had registered at BIHS hospital and were attending the outpatient department for a routine visit were recruited consecutively. Patients with type 1 diabetes, severe physical illness (e.g., end-stage renal diseases, stroke, advanced cardiovascular diseases), or a mental disorder, as well as pregnant women, were excluded from the study.

Data collection

Two trained research assistants were recruited for data collection. A pretested questionnaire in Bangla, the local language, was developed after a review of the relevant literature and was used for data collection. The questionnaire was divided into three sections: Section 1 consisted of sociodemographic information, family history of the disease; section 2 consisted of anthropometric measurements (i.e., height, weight, and waist and hip circumferences) and clinical findings (systolic and diastolic blood pressure measurement); and section 3 consisted of issues related to knowledge and self-care practice and patients’ lifestyle. Multiple-choice diabetes knowledge questionnaires comprised 16 questionnaires, which were divided into nine components.

Knowledge scoring

To assess knowledge about diabetes, we asked a total of 16 multiple-choice questions covering nine areas: the meaning of diabetes, risk factors for diabetes, symptoms of diabetes, complications of diabetes, knowledge about adequate nutrition, physical activity requirements, diabetes management, hypoglycemia, and diabetic foot care. For questions with exactly one correct response, the correct response was assigned a score of 1 and each incorrect response got a score of 0. For questions with more than one correct response, each correct response was assigned the corresponding fraction of 1. Therefore, the maximum attainable total knowledge score was 16 and the minimum score was 0. “Poor knowledge” was defined as a score of <50% and “good knowledge” as a score of ≥50%.[14]

Statistical analysis

Metric variables are shown as mean ± standard deviation, and categorical variables are shown as absolute number and percentage. Bivariate analyses use ANOVA and t-test of each predictor variable. We also performed a multivariate logistic regression analysis with the dependent variable “poor knowledge” versus “good knowledge” and all significant variables (P < 0.05) from the univariate analyses as independent variables. A P-value of <0.05 was considered statistically significant. All analyses were performed with IBM SPSS, version 25, and R, version 3.4.1.

Ethical consideration

Informed written consent was obtained from all participants after a full explanation of the nature, purpose, and procedures of the study. Participants were informed about their right to withdraw from the study at any time. Ethical approval was obtained from the Ethics and Research Review Committee of BUHS in Dhaka, Bangladesh. The Ethics Committee of LMU in Munich, Germany, also consented to this study.

  Result Top

Among the 504 patients in this study, the mean age of the subjects was 52.5 ± 11.1 years and female preponderance (n = 289; 57%) was observed. The mean duration of diabetes was 9.6 ± 7.0 years. Most of the study participants (n = 227; 45%) had received secondary education or below. Eighty-six participants (17.1%) were illiterate, whereas 191 (38%) had received higher secondary education or above. The complete baseline characteristics are shown in [Table 1].
Table 1: Sociodemographic characteristics of the study subjects

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The mean total knowledge score covering all nine areas of knowledge about diabetes was 6.8 ± 2.2 out of the maximum possible score of 16. One hundred forty-seven participants (29%) had good knowledge (a score of at least 8), whereas 357 participants (71%) had poor knowledge [a score of <8; [Figure 1]].
Figure 1: Proportion of study participants with good (green) versus poor (orange) knowledge about diabetes (overall and in the 9 different areas covered by the questionnaire)

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Regarding the individual knowledge areas, the proportion of subjects with good knowledge was lowest in the areas of diabetic symptoms (18%), risk factors for diabetes (20%), foot care (22%), hypoglycemia (27%), and complications (28%). It was highest in the areas of recommended physical activity (79%) and recommended diet (60%). All nine knowledge areas are depicted in [Figure 1].

Factors associated with good knowledge, in univariate logistic regression analyses, were male gender, a higher level of education, having learned an occupation, a higher family income, a duration of diabetes of 10 years or more, and a lower number of family members [Table 2]. The associations of the different factors with knowledge in the nine different knowledge areas are summarized in [Supplementary Table 1].
Table 2: Univariate associations between level of knowledge and different sociodemographic factors

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Supplementary Table 1: Association of different factors with the different areas of knowledge about diabetes

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In multiple linear regression analysis, age, education, and duration of diabetes have a positive increment effect and family members have a negative increment effect on overall diabetes [Table 3].
Table 3: Multiple linear regression analysis of factors associated with knowledge about diabetes

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  Discussion Top

The main findings of this study were that, among outpatients of a tertiary diabetes care center in Bangladesh, knowledge about diabetes is most insufficient among the older, the uneducated, those with larger families, and those with a shorter duration of diabetes. Illiterate subjects constitute a particularly uninformed group. Among the different knowledge areas, diabetic symptoms, risk factors for diabetes, foot care, hypoglycemia, and diabetic complications were the ones least known to the study participants.

An individual’s level of education is the factor most strongly linked to knowledge about diabetes in our study. This result is not unexpected, as it is in line with several other publications from different countries.[15],[16],[17],[18],[19] Illiterate subjects had particularly low knowledge about diabetes in our sample, which may be due to the fact that, currently, part of the information about diabetes is conveyed in writing. To also reach the illiterate and poorly educated, a more comprehensive approach to patient training, beyond the current booklet and 1-hour training session, seems necessary. This is particularly relevant, because it has been shown that a comprehensive diabetes support program can be disproportionally effective for illiterate individuals.[20] The independent association of a larger family size with poor knowledge about diabetes that we observed is probably a reflection of socioeconomic status, which has also been associated with poor knowledge about diabetes in other studies, for example, from Malaysia and Nigeria.[21],[22],[23],[24],[25] We can only speculate about the reasons for this association, which goes beyond the effect of education. One explanation may be that the more affluent have a higher exposure to health-related information through the media. Regardless of the underlying causes, however, this result emphasizes that any intervention to improve knowledge about diabetes has to take the economic situation of the targeted individuals into account. Any approach that costs the poor a relevant sum of money or that occupies time that would otherwise be used to generate income would not be suitable.

The observed higher knowledge about diabetes with a longer time since diagnosis has also been previously shown.[17],[23],[26] It is reassuring that individuals with diabetes learn more about their disease as time progresses. Nevertheless, more intense training early after diagnosis is warranted because this is the time when lifestyle measures and interventions to prevent diabetic complications are most effective.

Regarding the different areas of knowledge about diabetes, our first observation was that many study participants had poor knowledge in all the areas examined. Thus, an improved, broad training program seems necessary. Among the five areas least known to the study participants, symptoms and management of hypoglycemia, complications, as well as foot care, are the ones directly important to the individual with diabetes. The other two areas with the lowest scores, risk factors for and symptoms of diabetes are more relevant for the families of the patients, where risk is high and prevention is necessary.

The strengths of our study are its large, consecutively recruited cohort of individuals with diabetes from a broad spectrum of socioeconomic backgrounds and its setting in a tertiary care center with standardized training and treatment procedures. This last point can also be seen as a potential weakness of our approach, because the findings in this setting may not be transferable to other contexts in Bangladesh or in other low- and middle-income countries. However, one would expect that knowledge about diabetes would not be better in other contexts. If anything, it would probably be worse.

  Conclusion Top

Our study underscores the need for improved training of individuals with diabetes in resource-limited settings, such as the outpatient department where the study was conducted. In particular, training should be targeted to the older, uneducated, often illiterate, and newly detected diabetic patients. Therefore, written information is probably of little use and training should focus on the information with the highest practical value. Contemporary tools, such as training videos available online, should be explored for their usefulness in this setting. Finally, new approaches to patient training should be evaluated prospectively in randomized trials to generate evidence for their effectiveness.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

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  [Figure 1]

  [Table 1], [Table 2], [Table 3], [Table 4]


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