Diabetes Knowledge and Associated Factors among Adult Diabetic Patients in Southwest Ethiopia

Background 

Diabetes Mellitus (DM) is a metabolic disorder characterized by hyperglycemia which leads to a number of complications, and imposes a significant burden on the health care system [1]. Diabetes is the most proliferated disease recognized across the world in the healthcare domain [2]. There has been persistent rise in prevalence of diabetes throughout the world [1]. According to the International Diabetes Federation, an estimated global burden of diabetes is 463 million in 2019 with the expected number of 578 million by the year 2030 [3]. Currently, Ethiopia has 2.6 million people living with diabetes [4]. 

Despite advancement in management options, diabetes prevalence continues to increase [5]. The global increment of diabetes is influenced by increasing ageing population, sedentary lifestyles, unhealthy diets, obesity, and urbanization [1,6]. The impact of diabetes includes social and economic outcomes, including costing millions of health care budgets of nations across the world [7]. Diabetes contributed to approximately 5 million deaths worldwide among adult population in 2017, with about 36.5% of these deaths occurring in people aged less than 60 years [8]. 

The management of DM is largely depends on patients’ ability to self-care in their daily lives [9]. Diabetic patients with poor understanding of the disease have shown increased rate of hospitalization, and those with excellent knowledge and understanding of diabetes are able to adhere to the principles of self-care and have documented better glycemic control [5,6]. Therefore, patient education is the cornerstone of care for patients with DM [10]. 

Differences in knowledge level have been described depending on level of education, gender and social classes [11]. A study conducted by Eva K. Fenwick et al. [12], reported that socio-demographic, clinical and service use factors were independently associated with diabetes knowledge. A study done in Nepal showed that diabetes knowledge was associated with age, marital status, education level, occupation, and patients with family history of diabetes [6]. A study conducted by Kalayou K Berhe et al. [13], in Ethiopia revealed that diabetes knowledge was significant association diabetes family history. Another study conducted in Ethiopia showed that being illiterate, underweight and duration of diabetes less than 5 years were significantly associated with low level of diabetes knowledge [7]. 

Obtaining knowledge level among diabetes patient population about diabetes is important to plan public-health polices with specific reference for implementation of national diabetes control programs [14]. Additionally, a study that measures the baseline knowledge of target population is important in designing health education programs [6]. Moreover, such study is essential for the appropriate and efficient use of limited resources to address any health condition. There was no study conducted regarding diabetes knowledge among diabetes patients at Mettu Karl Referral Hospital. Thus, this study aimed to assess the level of knowledge and associated factors about diabetes mellitus among diabetic patients at Mettu Karl Referral Hospital in Southwest Ethiopia.

Study Setting and Period 

The study was conducted from 15 April to 17 May 2019 at Mettu Karl Referral Hospital, Southwest Ethiopia. The hospital is located in Mettu town at 600 km to Southwest of Addis Ababa, the capital city of Ethiopia. It serves about 2.5 million people from Ilu Ababor Zone, Glabella Regional State and Southern People Region. The hospital health service covers outpatient department, inpatient department, critical care and emergency intervention unit. 

Study Design and Population 

Health facility based a prospective cross-sectional study design was used. The source population was all diabetic patients on follow up at Mettu Karl Referral Hospital. The study population was all adult diabetic patients who visited the hospital during the data collection period and fulfilled the inclusion criteria. Type 1 and type 2 diabetes patients whose ages were ≥18 years were included in the study. Diabetic patients who were not willing to participate in the study and patients who were critically ill or unable to participant due to mental problems were excluded from the study. 

Sample size and sampling technique 

This study was conducted alongside our recently published studies [15,16]. Originally, the study had glycemic control, diabetes complications and diabetes knowledge as primary outcomes. The sample size was calculated considering all outcomes and glycemic control yielded the maximum sample size. The single population proportion formula was used to estimate sample size using 59.4% proportion poor glycemic control [17], 95% Confidence Interval (CI), 5% margin of error, and 10% nonresponse rate. The total number of diabetic patients attending follow-up at Mettu Karl Referral Hospital was 1560. Therefore, the correction formula was considered and the required sample size obtained was 330. A consecutive sampling technique was used to collect data from patients who fulfilled the inclusion criteria. 

Study variables 

The dependent variable was diabetes knowledge. The independent variables included socio-demographic variables (age, gender, marital status, religion, educational status, occupation, and place of residence), family history diabetes, duration of diabetes, and attending diabetes-related educational sessions. 

Data collection 

The data collection was performed using a structured questionnaire. The questionnaire contains diabetes knowledge questions, socio-demographic and clinical characteristics. Face to face interview was performed to collect information from all the participants. The questionnaire was translated into Afan Oromo and Amharic languages to interview the patients. The data collection was done by healthcare professionals. 

Diabetes knowledge determinations 

Patient’s diabetes knowledge was measured using the 24-item version of Diabetes Knowledge Questionnaire (DKQ-24). It has 24 diabetes related questions with yes, no or don’t know alternative answers. Each knowledge question was scored 1 point for the correct answer and zero point for an incorrect or unknown response. For each participant, a sum of score was calculated to define a knowledge variable. The possible value that the patient could score was 0 to 24. Then the mean knowledge score for the participants was calculated. The DKQ-24 is a reliable and valid measure of diabetes-related knowledge [18,19]. 

Data quality assurance

The data collectors were trained by principal investigator. The pretest was done on 17 diabetic patients attending follow at Jimma University Medical Center to check applicability, consistency, and understandability of the questionnaire. Unclear and misunderstood questions were modified before data collection. All completed data collection forms were checked for their completeness, consistency, clarity, and accuracy by the principal investigator on daily basis. 

Statistical analysis 

The data were entered into Epidata Manager Version 4.4.2 and then exported to Statistical Package for Social Science (SPSS) version 24.0 for analysis. Frequency, percentage, mean and Standard Deviation (SD) were used for descriptive statistics. The association between patients’ characteristics and diabetes knowledge was evaluated by the independent sample t-test and one-way analysis of variance (ANOVA) using means among groups of different variables. All significance tests were two-tailed, P < 0.05 was considered statistically significant.

Socio-demographic and clinical characteristics of the study participants

The study included a total of 330 participants of whom males were 60.0%. The mean age of respondents was 49.85±14.19 and 47.3% were 41 to 60 years old. The majority of the study participants were married which counted for 84.5%. In terms of religion, orthodox followers counted highest number (43.9%). The educational status showed that about 34.5% of participants had attained primary school education. About 34.2% of participants were farmers in terms of occupational status. More than half (53.6%) of study participants were urban residents. Family history of diabetes was identified in 28.8% of study participants. About 40.0% of participants had duration of diabetes 5-10 years. Participants who did not attended diabetes educational sessions at the hospital were 60.0% (Table 1). 

Table 1: Socio-demographic and clinical characteristics of diabetic patients attending Mettu Karl Referral Hospital, 2019.

DM: Diabetes Mellitus 

Diabetes knowledge of the study participants 

The mean±SD DKQ score of the participants was 11.5±4.6. Maximum number of participants (92.4%) believed that in untreated diabetes, the amount of sugar in the blood usually increases. Similarly, majority of the participants (90.6%) had correctly answered about cuts and abrasions on diabetes. About 82.4% participants knew that a fasting blood sugar level of 210 is too high. More than four-fifth of the participants were well acquainted that children have a higher chance of being diabetic if parents had diabetes, diabetes is incurable, diabetics should take extra care when cutting their toenails, the way of preparing their food is as important as the foods they eat and diabetes can cause loss of feelings in hands, fingers and feet. Almost two-third of study participants knew the types of diabetes and recognized the signs of hypoglycemia. However, only 45.8% of participants knew the signs of hyperglycemia.  More the half of the participants knew that the usual cause of diabetes is lack of effective insulin in the body, diabetes can damage the kidneys and tight elastic hose or socks are bad for diabetics. Furthermore, less than one-third of the patients had knowledge about the effect eating too much sugar and other sweet foods on diabetes, the role of kidney failure on diabetes, the way of testing diabetes, the roles of exercise, diet and medications, insulin production and reaction, impact of diabetes on circulation and diabetic wound care (Table 2). 

Table 2: DKQ-24 Results of diabetic patients attending Mettu Karl Referral Hospital, 2019. 

*-correctly answered.

Factors associated with diabetes knowledge 

The association between DKQ scores and different characteristics of the study participants was determined. A significant association was identified between DKQ score and gender, educational status, occupation, residence, attending diabetes educational sessions and family history of diabetes. However, no significant difference was observed in DKQ score and age, marital status, religion and duration of diabetes (Table 3). 

Table 3: Association between socio-demographic and clinical characteristic of study participants and DKQ score among study participants at Mettu Karl Referral Hospital, 2019. 

DKQ-24: Diabetes Knowledge Questionnaire 24-item version, SD- Standard Deviation.

The risks of developing diabetes complications can be influenced by the patient's knowledge about the disease [20]. Adequate diabetes knowledge is considered as a key component of diabetes management [11]. Poor diabetes knowledge has a negative impact on self-care behavior. Those with greater knowledge of diabetes are expected to maintain better glycemic control [21]. Therefore, patient’s knowledge of diabetes is important to minimize the occurrence of diabetes complications, and it has significant impact on the quality of life of the diabetic patient [22]. 

The present study observed that diabetes knowledge among study participants was inadequate. Similarly, a study conducted in central Nepal reported poor diabetes knowledge among diabetic patients [6]. A study conducted by Arora S et al. [23], showed poor diabetes knowledge among diabetic patients. There are also other studies that reported similar findings of the present study [11,21]. A previous study conducted in Ethiopia also reported similar result [13]. In inconsistent to the present study, a study conducted in Saudi Arabia showed that diabetes patients had adequate knowledge about the disease [2]. The discrepancy might be due to difference methods of assessing diabetes knowledge.  The difference in level of education might be also a reason for the discrepancy. 

This study observed that male participants had higher diabetes knowledge score than females. In consistent with this finding, a study conducted in King Hussein Medical Center of Jordan reported that men achieved significantly higher in knowledge score than women [11]. Similarly, a study done by Bukhsh et al. [5], in Pakistan showed that male gender had higher diabetes knowledge score. This might be because of women were less aware than men mostly due to low literacy rates. A study showed that there was a low literacy rate among women throughout the world [24]. In contradictory to this finding, other studies identified that female patients had better diabetes knowledge [25,26]. The discrepancy might be due to the differences of the patients’ populations. 

The present study revealed that diabetes knowledge significantly associated with educational status. It was observed that participants who never attended school scored lowest and those with tertiary education got highest score of diabetes knowledge. This result was correlate with a study done in central Nepal which observed better diabetes knowledge with higher level of education [6]. Similarly, a study conducted in Australia showed that higher education level was associated with better diabetes knowledge [12]. A previous study done in Ethiopia also reported that being illiterate was significantly associated with low level of diabetic knowledge [7]. A better educated people may be more curious while being counseled on diabetes [27]. Besides, it is possible that educated patients could gather more information about the disease from different sources like internet, magazine, etc. 

Occupation was significantly associated with diabetes knowledge in present study, with employees scored higher than others. This was in line with a study done by Shrestha et al. [6], which reported that government and private employee had better diabetes knowledge score than others. The possible reason is that employees are better educated and have higher chance of accessing educational resources to get information about their disease. House wives obtained the lowest diabetes knowledge scores in this study. This was supported by a study conducted in Bangladesh which reported that the mean knowledge of diabetes scores were the lowest among housewives [28]. 

The present study showed that the family history of diabetes was positively associated with better knowledge of patient. This finding was in accordance with the results of other studies [9,29,30]. A previous studies conducted in Ethiopia also demonstrated that participants with a family history of diabetes had better diabetes knowledge [7,31]. A study done in Pakistan observed that 65% of adults with a family history of diabetes were aware of diabetes. However, only 32% of people with a negative family history were aware of the disease [32]. A study showed that family member with chronic disease may be a source of information about the disease [33]. 

The urban resident diabetic patients were found to be more knowledgeable about diabetes when compared with the rural residents in this study. It was in line with study done by Sabri et al. [34], which reported that the rural diabetic patients were far less knowledgeable about diabetes. A study in India also showed that rural residents had poorer knowledge about diabetes compared to urban residents [35]. This might be because of the urban area is a place where education may be more readily accessible to people which affect patients ability to get diabetes related information. 

This study identified that participants who attended diabetes educational sessions at the hospital had better diabetes knowledge. This finding was supported by a study conducted by Ulvi et al. [32], in Pakistan. The finding was also consistent with a previous study done in Ethiopia [31]. A study revealed that educational sessions on diabetes have been shown to improve patients’ diabetes knowledge [30]. It is also identified that people who obtained information about diabetes from different sources were more likely to have a good level of knowledge about diabetes [30]. 

In this study there was no association between diabetes knowledge and age, marital status and duration of diabetes. In consistent with this finding, a study conducted in Lebanon reported that there was no significant association between  age and diabetes knowledge [36]. However, a study done in Peru and Kuwaiti indicated that age was associated with diabetes knowledge [29,30].  A study conducted by Al-Adsani et al. [19], found difference in diabetes knowledge by duration of diabetes. They reported that diabetes knowledge score was lower among those had shorter duration of diabetes. One of the limitations of this study was the possibility of self-reporting bias. Since this study was conducted on ambulatory diabetes patient population, the results may not be truly generalized to all diabetic patients in the country. There was also a possibility of selection bias.

The present study observed that diabetes knowledge was inadequate among diabetic patients at Mettu Karl Referral Hospital. The study identified that patients with male gender, higher educational level, being employed, urban residents, attending diabetes educational sessions and having positive family history of diabetes were associated with better diabetes knowledge. Knowledge related to diabetes can help patients to overcome diabetes related the problem through performing a good self-care practices and other important safety measures. Continuing education on diabetes for people living with the disease is crucial and this should be accompanied by a regular evaluation of their diabetic knowledge.

The author would like to thank the study participants, and data collectors for their cooperation.

The study was approved by the institutional review board of Jimma University. Written informed consent was obtained from all study participates.

The author declares that there are no competing interests.

No funding received for this study.

All authors made substantial contributions to conception and design, acquisition of data, or analysis and interpretation of data. TSH took part in writing up the manuscript. All authors involved in revising the manuscript critically for important intellectual content. All authors agreed to submit to the current journal; gave final approval of the version to be published; and agree to be accountable for all aspects of the work.

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