Arslaan Javaeed  ( Department of Pathology, Poonch Medical College, Azad Kashmir, Pakistan )
Maria Shahid  ( Poonch Medical College, Azad Kashmir )
Sana Samad Khan  ( Poonch Medical College, Azad Kashmir )
Sanniya Khan Ghauri  ( Department of Emergency Medicine, Shifa International Hospital, Islamabad )
Shafqat Husnain Khan  ( Poonch Medical College, Azad Kashmir )
Zarghoona Wajid  ( ZiaUddin Hospital, Karachi, Pakistan. )

Objective: To determine the knowledge, attitudes and practices of type 2 diabetes mellitus patients.

Methods: The cross-sectonal study was conducted at Sheikh Khalifa Bin Zayed Al Nahyan Hospital, Rawalakot, Azad Kashmir, from March 26 to September 25, 2017, and comprised patients of type 2 diabetes mellitus who were enrolled using convenience sampling. Each participant completed a self-administered 35-item questionnaire. Data was analysed using SPSS 23 to determine the correlations among variables.

Results: Of the 116 patients, 74(63.8%) were females, and the largest group 58(50%) was aged 51-70 years. Of the total, 111(95.6%) had heard about type 2 diabetes mellitus, 112(96.6%) had sought treatment after diagnosis, and 115(99.1%) had blood sugar tested within the preceding year. There was a positive correlation between knowledge and attitude (p=0.005), knowledge and practice (p<0.001), and attitude and practice (p<0.001). Knowledge, attitude and practice improved with increase in education (p>0.05).

Conclusion: The subjects had fair knowledge and good attitude toward type 2 diabetes mellitus, and they appeared willing to improve diabetic control. However, diabetes-related practice was found to be poor.

Keywords: Diabetes mellitus, Knowledge, Attitude, Practice, Pakistan. (JPMA 70: 667; 2020)

https://doi.org/10.5455/JPMA.9502

 

Introduction

 

Type 2 Diabetes Mellitus (T2DM) is one of the most important and rapidly increasing non-communicable diseases (NCDs) in the world. In 1995, there were an estimated 135 million patients with DM, and by 2000 the number had increased to 151 million.^1,2 Current estimates indicate that, by 2025, there will be approximately 300 million DM patients worldwide; with more than 75% of them living in developing countries.^3,4 In 2007, the World Health Organisation (WHO), and the United Nations (UN) indicated that DM would likely evolve to be one of the most significant global public health issues. In South Asian countries, inadequate patient understanding of T2DM, underutilisation of medical services, and poor attitudes toward T2DM control may well worsen the current outlook.^5-8

Pakistan is a developing country in South Asia and has a population of approximately 207.77 million.⁶ A decade ago, DM was not included in the country's list of severe diseases. Around the end of 2015, there was an increased incidence of DM in both urban and rural Pakistan. According to Shera et al.,^7,9 12% of Pakistanis aged >25 years suffer from DM. Overall weighted prevalence of diabetes was 26.3%, of which 19.2% had known diabetes, and 7.1% were newly-diagnosed. Prevalence of diabetes in urban and rural areas was 28.3% and 25.3%, respectively. Prevalence of pre-diabetes was 14.4%.¹⁰ WHO estimates that Pakistan has the seventh highest prevalence of DM globally.^3,11 Thus, effective interventions, increased disease-related awareness, and innovative preventive measures are urgently needed.^8,11

The adequacy of DM-related knowledge among patients affects disease detection and control.¹² The relationship that exists among knowledge, attitude and practice (KAP) factors is vital for researchers. Increases in one KAP variable will directly increase the other two factors.^13,14 However, socio-demographic characteristics of the patients may also affect KAP variables.^15,16 KAP literature focuses on the importance of increasing disease knowledge and awareness that relates to prevention, risk factor control, and disease management. Hence, there is a need for KAP studies in developing countries because of the rising incidence of T2DM in these countries.^15,17

Although KAP studies have been conducted with patients living in Karachi,^17,18 there is limited research data available for the northern regions. Therefore, the current study was planned to measure KAP factors in T2DM patients with complications residing in a mountainous area.

 

Subjects and Methods

 

The cross-sectional study was conducted at Sheikh Khalifa Bin Zayed Al Nahyan Hospital, Rawalakot, Azad Kashmir, from March 26 to September 25, 2017, and comprised outpatients with T2DM and complications who were enrolled using convenience sampling. Patients were approached with the study questionnaire and those who furnished informed consent were included. Patients with type 1 DM and type 2DM without any known complication were excluded.

Data was collected using a questionnaire that was successfully used in an earlier study.¹² Written permission was obtained from the main author¹² and modified the questionnaire to reflect specific regional and cultural attributes of the study population. Additionally, it was pilot-tested with 20 respondents, and the questionnaire was accordingly amended considering the issues raised during the pilot testing. The questionnaire was validated by two epidemiology professors, and the self-administered questionnaire had 35 questions. Of these, 5 assessed demographic characteristics, 16 assessed knowledge, 5 assessed attitudes, and 9 assessed practices (Annexure).

The questionnaire was translated into the native language of the respondents for better understanding, and all the responses were back-translated into English.

Data was analysed at 95% confidence interval (CI) using SPSS 23. and it was expressed as frequencies and percentages. Normality tests for the number of correct responses were done using Shapiro Wilk test and Kolmogorov Smirnov test, which revealed the data was in non-normal distribution. Correlation between knowledge, attitude, and practice was evaluated with Spearman correlation test. KAP score was calculated by adding the number of correct responses to knowledge-related, attitude-related, practice-related questions. Mean KAP scores were compared between males and females by Mann Whitney U test. Mean KAP scores were compared across age groups, occupation and education levels by Kruskal Wallis H test.

 

Results

 

Of the 125 patients approached, 116(92.8%) responded positively. Of them, 74(63.8%) were females, and the largest group 58(50%) was aged 51-70 years (Table-1).

Of the total, 111(95.6%) had heard about T2DM, 112(96.6%) had sought treatment after diagnosis, 115(99.1%) had blood sugar tested within the preceding year, and 68(58.6%) were doing regular physical exercise (Figures-1-3).

There was a positive correlation between knowledge and attitude, knowledge and practice, and attitude and practice (Table-2).

KAP improved with increase in education level, but the improvement was not statistically significant (Table-3).

 

Discussion

 

There were statistically significant positive correlations among the knowledge of patients with T2DM and their attitudes and practices. However, despite their positive attitude toward practices and knowledge, the participants with limited knowledge of T2DM tended to exhibit negative practices. A similar descriptive study¹⁹ found that their participants had insufficient knowledge regarding T2DM. Most of the participants were >40 years, and there were almost twice as many females (64%) as males. The study¹⁹ showed that a small number of respondents had a good understanding of nutrition and risk factors, such as smoking and high blood pressure (BP), but were largely inactive. The findings of the present study showed a low awareness of the necessity of eye and renal failure testing which was in accordance with the earlier study¹⁹ which concluded that there was a need for improved education and awareness regarding T2DM, as evidenced by low KAP variable scores.

In another study,¹⁶ patients with and without T2DM in Bangladesh were compared to explore the effects of KAP variables on the two groups. Their population exhibited average levels of practices and knowledge, but both samples showed good attitudes. There is an urgent need to increase knowledge and coordinate appropriate practices to effectively treat DM in patients with T2DM and prevent the condition from materialising in non-diabetic patients. The findings of the present study also revealed an average outcome for the variables of knowledge and practices in comparison to the variable of attitudes.

Jabbar et al.²⁰ found increasing DM-related complications among Pakistanis, accompanied by poor awareness and inadequate education related to risk factors. The study recommendations included enhancing the relationships between patients and physicians, and the development of community initiatives for increasing knowledge and lifestyle habits of DM patients. Medical care standards are often poor in underprivileged areas of Pakistan, contributing to patients' low levels of awareness.^13,14 We found that female patients in Azad Kashmir had poorer levels of literacy. Lack of education was the primary reason for the lack of DM-related knowledge and for failure to adopt advantageous practices, including regular renal and eye check-ups, and diet control.

The popular assumption of significant associations among KAP variables were suggestive of the high control of T2DM.^16,17 Al-Maskari, et al.¹⁸ showed low levels of DM-related knowledge, but highly positive attitudes toward practices directed at controlling DM. Patients residing in the United Arab Emirates (UAE) had ready access to well-equipped healthcare facilities, which improved their collective ability to cope with DM. Similarly, in the present study, positive attitudes did not concur with levels of knowledge and practices because of the participants' low levels of education and awareness. The roles of physicians, educators, and medical facilities are critical in improving knowledge and encouraging appropriate practices.^7,8

A study revealed that the education level of diabetic patients significantly affects their KAP regarding disease management. Highly educated individuals had good knowledge about diabetes condition, positive attitude towards disease management, good compliance to diabetes treatment and better practice regarding planned diet and regular exercise habit.²¹ Another study identified positive attitude toward seeking healthcare for DM was strongly associated with having sufficient income for most of the time compared with an insufficient income for the whole year.²²

The limitations of the current study included its small sample size and single-centre design. The study only included outpatients while leaving out in-patients. No statistical method was used to calculate the sample size. Thus, there was a potential selection bias. Furthermore, the use of quantitative data limits the accuracy and detailed findings of the study. Future studies should use a more holistic sample and employ both quantitative and qualitative measures to collect data.

 

Conclusion

 

Although all variables were positively correlated, knowledge and attitude were better compared to practice regarding T2DM. Better knowledge, attitude and practice were observed among the participants with higher education. Health education may improve overall practice regarding DM.

 

Disclaimer: None.

Conflict of Interest: None.

Source of Funding: None.

 

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