Assessment of the level of knowledge about diabetes mellitus among diabetic patients: A cross-sectional study from Nepal

Introduction

Diabetes mellitus is a preventable, chronic metabolic, non-communicable disease characterized by hyperglycemia that results from defects in insulin secretion, insulin action, or both.¹ In 2019, P Saeedi et al. estimated the global prevalence to be 9.3% and projected it would be 10.2% by 2030 and 10.9% by 2045.² Recent meta-analysis in Nepal by N Shrestha et al. taking published data dated up to 2020, showed the pooled prevalence of diabetes to be 8.5%.³ So, under the same lifestyle, with an aging population, and unhealthy diet, the prevalence would likely be more unless necessary steps are taken. In addition to this, the meta-analysis also showed that less than half of known diabetic patients were treated with anti-diabetic drugs and only one-third had their blood glucose controlled.³

Proper management to control blood glucose can delay the progression of a disease with a significant reduction in diabetes-related complications.⁴ One of these management methods includes, patient education with appropriate and adequate knowledge of diabetes, which is a key to behavioral change for good glycemic control.^5–7 It is imperative for clinicians to know the knowledge status of the patient and counsel them properly, suggest them good educational programs which in turn would assist in the holistic care of the patient. In addition to this, concerned authorities should be aware of the knowledge status of the diabetic patient to change or add policies and programs to meet their needs.

Thus, this study aims to understand the knowledge related to diabetes in a diabetic patient using the Revised Michigan Diabetic Assessment tool, which consists of 20 true/false statements that assess a patient’s diabetes related knowledge, including items on diet, blood glucose control, exercise, medication taking, complications and insulin use.⁸ We also explore the socio-demographic and clinical characteristics of diabetic patients, and assess their relationship with their level of diabetic knowledge.

Methods

Results

Of the 360 participants, the mean (±SD) age was 58.23±11.83 years (range 24-88 years). A majority of the participants were male (n=217, 60.3%) and had no family history of diabetes mellitus (n=244, 67.8%). Approximately, one-third of the participants were illiterate (n=115, 31.9%) and had diabetes for at least 5 years (n=129, 35.8%). Most of the participants (n=191, 53.1%) were using a combination of oral hypoglycemic agents (OHA) for medical treatment, with 123 (34.2%) patients having complications with neuropathy (n=57,15.8%) being the most common complication.

Other socio-demographic and clinical characteristics of patients are shown in Tables 1 and 2. The full dataset can be found under Underlying data.

Knowledge status on diabetes and its correlate

The highest percentage of correct answers (93.9%), (91.7%) and (90.8%) respectively belonged to these questions: “Having regular check-ups with your doctor can help spot the early signs of diabetes complications”, “Exercising regularly can help reduce high blood pressure”, “Eating foods lower in fat decreases your risk for heart disease”. However, the lowest percentage of correct answers (14.7%), (22.2%), (26.9%) were for these questions respectively: “Attending your diabetes appointments stops you from getting diabetes complications”, “Lung problems are usually associated with having diabetes”, “Glycosylated hemoglobin (HbA1c) is a test that measures your average blood glucose level in the past week” as shown in Table 3. Among 30 patients taking insulin, 70% gave the right response to “High blood glucose level can be caused by too much insulin” as shown in Table 3.

Table 3. Frequency distribution of correct response.

S.N.	Questions about diabetes knowledge	N	%
1.	The diabetes diet is a healthy diet for most people.	230	63.9%
2.	Glycosylated hemoglobin (HbA1c) is a test that measures your average blood glucose level in the past week.	97	26.9%
3.	A pound of chicken has more carbohydrate in it than a pound of potatoes.	225	62.5%
4.	Orange juice has more fat in it than low fat milk.	302	83.9%
5.	Urine testing and blood testing are both equally as good as testing the level of blood glucose.	113	31.4%
6.	Unsweetened fruit juice raises blood glucose levels.	226	62.8%
7.	A can of diet soft drink can be used for treating low blood glucose levels.	198	55.0%
8.	Using olive oil in cooking can help prevent raised cholesterol in the blood.	179	49.7%
9.	Exercising regularly can help reduce high blood pressure.	330	91.7%
10.	For a person in good control exercising has no effect on blood sugar levels.	137	38.1%
11.	Infection is likely to cause an increase in blood sugar levels.	168	46.7%
12.	Wearing shoes, a size bigger than usual helps prevent foot ulcers.	99	27.5%
13.	Eating foods lower in fat decreases your risk for heart disease.	327	90.8%
14.	Numbness and tingling may be symptoms of nerve disease.	312	86.7%
15.	Lung problems are usually associated with having diabetes.	80	22.2%
16.	When you are sick with the flu you should test for glucose more often.	146	40.6%
17.	Having regular check-ups with your doctor can help spot the early signs of diabetes complications.	338	93.9%
18.	Attending your diabetes appointments stops you getting diabetes complications.	53	14.7%
Among 30 patients using insulin
19.	High blood glucose levels may be caused by too much insulin.	21	70.0%
20.	If you take your morning insulin but skip breakfast your blood glucose level will usually decrease.	18	60.0%

98 patients (27.2%) possessed good knowledge about diabetes. Patients with good knowledge of diabetes had a mean age of 53.70±11.81, while patients with poor knowledge of diabetes had a mean age of 59.92±11.41 (p-value < 0.001). 30.45% of males had good knowledge compared to 22.4% of females with a non-significant p-value of 0.094 as shown in Figure 1. Patients living with the disease for more than ten years had poor knowledge of diabetes with a p-value of 0.005.

Figure 1. Gender and knowledge status.

According to this study, poor knowledge increased with age, and decreased with the level of education. Being a farmer, housewife and unemployed was associated with having poor knowledge on diabetes. Having a family member with diabetes was associated with having good knowledge of diabetes. Other variables like duration since diagnosis, co-morbidities, complications and BMI were significantly associated with knowledge status as shown in Table 4.

Table 4. Frequency distribution of the patient characteristics according to knowledge status.

Variables		Poor knowledge		Good knowledge		P value
		N	%	N	%
Age group	≤39.00	8	47.1%	9	52.9%	<0.001
	40.00-49.00	39	55.7%	31	44.3%
	50.00-59.00	81	71.7%	32	28.3%
	60.00-69.00	76	83.5%	15	16.5%
	70.00+	58	84.1%	11	15.9%
Gender	Male	151	69.6%	66	30.4%	0.094
	Female	111	77.6%	32	22.4%
Marital status	Married	225	71.4%	90	28.6%	0.290
	Unmarried	1	100.0%	0	0.0%
	Widow	36	81.8%	8	18.2%
	Divorced	0	0.0%	0	0.0%
Religion	Hindu	241	74.6%	82	25.4%	0.062
	Buddhist	11	55.0%	9	45.0%
	Muslim	8	53.3%	7	46.7%
	Christian	2	100.0%	0	0.0%
	Others	0	0.0%	0	0.0%
Education level	Illiterate	109	94.8%	6	5.2%	<0.001
	Literate	95	78.5%	26	21.5%
	School level	47	50.0%	47	50.0%
	Higher education	11	36.7%	19	63.3%
Occupation	Farmer	95	83.3%	19	16.7%	<0.001
	Housewife	62	91.2%	6	8.8%
	Business	19	48.7%	20	51.3%
	Government	9	36.0%	16	64.0%
	Unemployed	41	83.7%	8	16.3%
	Others	36	55.4%	29	44.6%
Family history	Yes	60	51.7%	56	48.3%	<0.001
	No	202	82.8%	42	17.2%
Duration	One year or less	41	82.0%	9	18.0%	0.005
	1 to 5 years	117	64.6%	64	35.4%
	5 to 10 years	75	78.9%	20	21.1%
	More than 10 years	29	85.3%	5	14.7%
Medication	Single OHA	89	66.9%	44	33.1%	0.141
	Combination OHA	145	75.9%	46	24.1%
	Insulin alone	2	50.0%	2	50.0%
	OHA plus insulin	26	81.3%	6	18.8%
Co-morbidities	Present	165	78.6%	45	21.4%	0.003
	Not present	97	64.7%	53	35.3%
BMI of patients	Underweight	1	100.0%	0	0.0%	<0.001
	Normal	110	82.7%	23	17.3%
	Overweight	134	72.0%	52	28.0%
	Obese	17	42.5%	23	57.5%
Complications	Present	98	79.7%	25	20.3%	0.034
	Not present	164	69.2%	73	30.8%

Discussion

Knowledge of a disease in a patient is a first ladder towards change in behavior. Patient education is of utmost importance in the management of a disease especially when it is a chronic illness like diabetes mellitus.⁵ This could lead to the empowerment of a patient and thus limit their dependence on clinicians.

This study showed that 27.2% of patients possessed good knowledge about diabetes. As of investigators’ extensive literature review, two studies done using the same assessment tools were found. One of this study done in a hospital with specialist facility in Saudi Arabia by Almalki et al. showed 21.6% of diabetic patients had good knowledge about diabetes.¹¹ However, another study done in Al-Zahraa Teaching Hospital by Taher et al. showed 78.91% had good knowledge about diabetes.¹² Although different studies done at different times in Nepal, the United Arab Emirates and Pakistan had shown poor knowledge status, we cannot compare their findings to this study because of differences in assessment tools and ethnic groups.^13–16

This study showed that there was poor knowledge of diabetes among patients with a low level of education. However, this is in contrast with findings by Taher et al. which showed no significant association between education level and knowledge status.¹² This difference in finding could be because the study by Taher et al. was done in the teaching hospital where the participants got advice and treatment from specialists who could give individualized education.¹² The fact that this study was conducted at a government hospital where there was a high patient load and a lack of diabetic specialists and trained staff might have contributed to less time for effective individualized counselling and ultimately low knowledge status among the patients. This study also found that being a housewife, and unemployed, was significantly associated with poor knowledge. However, Taher et al. found that there was no significant association between employment and knowledge status.¹² This suggests that physicians, while counseling, should focus more on patients with poor education, housewives, and unemployed patients.

A study by Taher et al. showed a significant association between type of medication used and good knowledge, but this study showed no significant association between type of medication used with knowledge status. Younger patients and patients diagnosed with diabetes mellitus recently had good knowledge of diabetes. Similar findings were reported from Almalki et al.¹¹ This may be due to the curiousness about the diagnosis among these patient groups.

The three most common right responses in this study were similar to that of Taher et al.¹² and this might have occurred because these questionnaires are also related to other common chronic diseases like hypertension and obesity. The fact that the complications, co-morbidities, and BMI were associated with poor knowledge suggest that physicians had difficulties in providing the patients with the sufficient information about diabetes mellitus. Clinicians should be aware of the patient’s level of knowledge related to diabetes, and educate them accordingly. In addition to it, different levels of government should go hand in hand to raise awareness regarding diabetes through integration of diabetic programs with other health programs, by implementing dedicated diabetic awareness programs, and diabetes self-management education and support (DSMES) programs. Also, patient knowledge of diabetes mellitus may be increased through government-launched programs for information dissemination about diabetes mellitus using various social media platforms, continuing medical education for doctors on diabetes mellitus, and training female community health volunteers to provide diabetes-related knowledge.

The findings of this study represents the people with diabetes mellitus in Nawalparasi district and might be generalized to people in other districts in Nepal with similar characteristics. As our study was conducted in a single government hospital, we recommend collective inclusion of primary health care centers, government hospitals and private hospitals for further similar studies.

Conclusion

The majority of the patients with diabetes mellitus had poor knowledge about diabetes, and the level of knowledge was affected by these factors; age, level of education, occupation, family history, duration of diabetes mellitus, presence of co-morbidities, complications and BMI. This study shows that there is a need to implement and/or strengthen diabetes awareness and DSMES programs at the Madhyabindu Hospital and targeted communities.