Knowledge, Attitude and Practices Regarding Chronic Complications of Diabetes among Patients with Diabetes in Northeastern Ethiopia, 2024

Abstract

Background: In 2021, diabetes claimed the lives of 6.7 million people and cost the healthcare system at least $966 billion. Diabetic individuals with a poor understanding of the condition had greater risks of hospitalization for diabetes.

Objective: To assess knowledge, attitude and practices regarding chronic complications of diabetes among patients with diabetes in northeastern Ethiopia in 2024.

Methods: A cross-sectional study design was conducted among 350 diabetic patients in northeastern Ethiopia from April 25 to May 25, 2024. A pretested, structured questionnaire was developed from published sources on the same subject area. SPSS version 22 for Windows was used and binary and multivariate logistic regressions were applied to assess the knowledge, attitude and practice of respondents about diabetic complications. P ≤ 0.05 was used to declare statistically significant variables.

Result: A total of 350 diabetes patients were enrolled, with a response rate of 95%. In this study, 184(58%) of the participants had good knowledge, 188 (59.1%) had a good attitude and 168 (53.4%) had good practice. Patients staying with the disease for more than 10 years were 2.05 times (AOR = 2.05, 95% CI = 1.03, 4.05) more likely to have a good attitude. Government workers were 3.17 times (AOR = 3.17, 95% CI = 1.17, 8.62) more likely to have a good attitude toward chronic complications of DM. Male patients were 1.71 times (AOR = 1.71, 95% CI = 1.10, 2.65) more likely to have good practice than their female counterparts. Patients with a monthly income of 500–1500 and 150–1500 ETB were 2.02 times and 1.97 times more likely to have good practice for chronic complications of DM as compared to patients with a monthly income of < 500 ETB.

Conclusion: Participants with better educational status and a family history of DM were more likely to have good knowledge about diabetic complications. Study subjects with disease duration of more than 10 years and government employees had a positive attitude. Male patients and those with a good monthly income had good practices towards the chronic complications of DM.

Keywords: Attitude, Diabetes mellitus, Knowledge, Practice,

1. Introduction

Diabetes mellitus (DM) is a severe chronic illness that develops when a patient's serum glucose levels are high due to either insufficient or no insulin production by their body or an inability to utilize the insulin that is produced¹. Diabetes mellitus is a complex disease resulting in issues such as population health decline and increased health-care expenses². Diabetes is one of the four non-communicable diseases (NCDs) that the World Health Organization has prioritized for prevention and control³.

According to the International Diabetes Federation (IDF) 2021 report, there is a continued global increase in diabetes prevalence, confirming diabetes as a significant global challenge to the health and well-being of individuals. Globally, 537 million adults are living with diabetes, which is predicted to rise to 643 million by 2030. Moreover, with an expected 1.5 million fatalities due to diabetes directly in 2019, diabetes ranked as the ninth most common cause of death¹.

It is estimated that 24 million adults in Africa are living with diabetes and over 1 in 2 people living with diabetes in Africa are not diagnosed. Furthermore, more than two-thirds of diabetes mellitus patients in Sub-Saharan Africa are untreated⁴. According to an IDF report, diabetes mellitus was present in 3.3% of Ethiopians⁵. Other evidence suggests that the prevalence of diabetes in Ethiopia ranges from 0.5 percent to 6.5 percent^6-9.

Diabetes is linked to significant financial burdens for individuals, families and the community. Patients with diabetes who experience both macro and microvascular complications can spend up to 2.5 times as much on care overall as those without problems^10,11. Treatment of comorbidities associated with diabetes is essential for the patients’ health related quality of life. Over the past few years, the expense of treating diabetes and associated complications has increased¹².

In addition to preserving an ideal blood glucose level, the aim of diabetes management is to avoid consequences from the condition, including retinopathy, neuropathy, nephropathy and cardio cerebrovascular disease¹³. Non-adherence, a negative attitude toward the illness and its complications and unhealthy diet are typical causes of poor diabetic control and hence diabetic complications. These complications can predispose the patient to different infections and death or disability as final outcome¹⁴. In a US sample of 12,379 participants, hospitalization for infection-related reasons was much more likely in those with diabetes mellitus (1.67 times higher) than in those without the condition¹⁵.

Sub optimal glycemic management in clinical practice is linked to diabetes complications such as diabetic ketoacidosis, micro- and macro-vascular diabetic problems and their associated poor consequences¹⁶. Poor glycemic control and consequences such as diabetic nephropathy, diabetic retinopathy and diabetic neuropathy are linked to insufficient diabetes education and self-care behaviors¹⁷. Each 1% drop in mean glycated hemoglobin (HbA1c) has been linked to a 21% reduction in the risk of diabetes-related mortality, a 14% reduction in the risk of myocardial infarction and a 37% reduction in the risk of micro-vascular complications^18,19.

With an expected 1.5 million fatalities directly related to diabetes in 2019, diabetes ranked tenth among all causes of mortality¹. Furthermore, those with diabetes are two to three times more likely to die from any cause, including liver disease, cancer, heart disease, stroke and chronic renal illness^20,21. According to a Chinese study, 76.4% of diabetes patients reported experiencing at least one type of diabetes related complications^22,23. In sub-Saharan Africa, up to 48% of diabetics had neuropathy symptoms, while 14-18% of diabetics had ocular problems, 10% to 15% of diabetics have acquired diabetic foot ulcers at some point in their lives and in sub-Saharan Africa, diabetic foot issues account for over 50% of all DM-related hospitalizations²³. According to a prior study conducted in Ethiopia, 29.4% of diabetics suffer at least one chronic problem²⁴.

Individuals diagnosed with diabetes mellitus must keep an eye on their health, specifically on complications, treatment and prescription schedules. Along with exercise, diet and medication adjustment, therapeutic adherence is crucial for achieving glycemic control and preventing complications^25-28. Misconceptions stemming from a lack of awareness, when combined with insufficient knowledge, are significant obstacles to appropriate diabetes management²⁹.

Diabetes self-care routines are significantly influenced by perceptions of sickness and diabetes knowledge. Furthermore, decision-making about nutrition, exercise, medication use and health status monitoring which includes diabetic screening and foot care is influenced by knowledge about the disease³⁰. Diabetic individuals with a poor understanding of the condition had greater risks of hospitalization for diabetes, which is unstable³¹.

Glycemic control knowledge can assist people in comprehending the risks of diabetes and motivating them to seek appropriate therapy and care in order to keep the disease under control¹⁶. In order to effectively manage the condition, an individual must be aware of and knowledgeable about the disease's nature and consequences, as well as its risk factors, management and chronic complications. The aim of this study was to assess knowledge, attitude and practices regarding chronic complications of diabetes among patients with diabetes in a comprehensive specialized hospital in Woldia, Ethiopia in 2024.

2. Methods

2.1. Study design, period and area

A cross-sectional study design was conducted in Woldia comprehensive specialized hospital from April 25 to May 25, 2024, Woldia, northeast Ethiopia. Woldia Comprehensive Specialized Hospital, located in Woldia Town in Ethiopia, is a prominent healthcare institution dedicated to providing high-quality medical services. As a comprehensive specialized hospital, it serves as a critical healthcare provider for the region, offering a wide range of medical services and specialized treatments to the local population.

2.2. Population

2.2.1. Source population: All diabetes patients who visited to Woldia comprehensive specialized hospital diabetic clinic.

2.2.2. Study population: all diabetes patients who fulfill the eligibility criteria and visited woldia comprehensive specialized hospital during the data collection time.

2.3. Inclusion criteria

Diabetic patients who are on follow up or take regular medical checkups and services, at Woldia comprehensive specialized hospital diabetic clinic.

Diabetic patients whose age is greater than 18 years.

2.4. Exclusion criteria

Diabetics secondary to pregnancy (gestational DM). Those unable to respond because of dementia or psychiatric illness. Diabetes patients admitted to ward

2.5. Sample size and sampling technique

The convenience sampling technique was employed to select participants who visited the diabetic clinic of Woldia Comprehensive Specialized Hospital for routine appointment visits. So, using this sampling technique, 368 subjects were recruited. The sample size was calculated using a single population proportion formula and determined by taking 58.8% as the rate of prevalence (p) of knowledge toward diabetic complications among diabetics in Gondar, Ethiopia (32), a 95% confidence level (Zα/2 = 1.96) and a 5% margin of error.

Z_α/2 is the standard normal variable value at (1-α) % confidence level (α is 0.05 with 95% CI, Z_α/2 = 1.96), an estimate of the proportion (p) was considered as 58.8 % and margin of error (d) 5%.

2.6. Variables

2.6.1. Dependent variables: knowledge, attitude and practice towards chronic complications of DM.

2.6.2. Independent variables: age, sex, residency, marital status, occupation, educational status, income, duration since diagnosis as diabetic, family history and type of DM.

2.7. Operational definitions

· Diabetes complications: Acute and chronic conditions caused by diabetes⁷.

· Positive attitude: if participants scored ≥ mean score of answered questions for attitude of diabetic complications

· Poor attitude: if participants scored < mean score of questions about diabetic complications

· Good knowledge: if participants scored ≥ mean score of the correctly answered questions for knowledge of diabetic complications

· Poor knowledge: participants scored <mean score of the correctly answered questions for knowledge of diabetic complications

· Good practice: if participants scored ≥ mean score for answers to practice questions about diabetic complications

· Poor practice: if participants scored < mean score for answers to practice questions about diabetic complications³³.

2.8. Data collection tool and data collection process

An organized, pretested interviewer-administered questionnaire was utilized to collect data regarding knowledge, attitude, practice and associated factors. A number of published articles were reviewed in order to build the tool for gathering data^34-36. The data collection survey was structured into four primary sections: Socio-demographic data, diabetes knowledge and history, attitude and practice-specific data. To ensure consistency in wording, the questionnaire was produced in English, translated into the local language (Amharic) and then translated back into English. To calculate the knowledge, attitude and practice (KAP) score, a scoring system was prepared. Each correct answer was coded as 1, while each incorrect answer was coded as 0. The data collectors were trained in the data collection tool before data collection. Each participant was interviewed face-to-face by a data collection team. The collected data was checked every day for consistency and completeness before processing. During data gathering, three trained health professionals were recruited and supervised by two MSc graduate health professionals.

2.8.1. Assessment of knowledge: The participants had two options for responses to questions testing their knowledge of diabetes complications: "Yes" or "No." A "0" point was given for no and a "1" point for yes. After calculating the mean knowledge score, knowledge was divided into two categories: good and poor. Participants were classified as having good knowledge if their answers scored higher than the mean (10.6) and as having poor knowledge if their answers scored lower than the mean (10.6).

2.8.2. Assessment of attitude: To assess the patients' attitudes, we had adapted questions from several articles. There were three options for each question: agree, neutral and disagree. For each attitude question, a score of "0" indicated an unfavorable attitude (disagree and indifferent), while a score of "1" indicated a favorable attitude (right answer). By adding up the correct responses and computing the mean value, the diabetic patient's attitude toward complications related to their diabetes was determined. Individuals who scored lower than the average (22.9) were classified as having negative attitudes. Those who scored higher than the average (22.9) was considered to have a positive attitude.

2.8.3. Assessment of practice

Patients were asked questions about diabetic complications and were asked to respond with a "Yes" or "No." "Yes" receives a score of 1, while "No" receives a score of 0. "Yes" indicates that the patient is adhering to the advised course of action. Subsequently, Then, the patient’s practice level was calculated by adding their responses and calculating the mean which is 7.9. Those with a mean score or higher were considered good practice while the remaining scores were classified as poor practice.

2.9. Data processing and analysis

The social science statistics package (SPSS) version 22 for Windows was used to enter the gathered data. The mean (± SD) was used to express all continuous data, while numbers and percentages were used to express categorical variables. Descriptive statistics and frequency distributions were used to describe participant characteristics. Based on bi-variable analysis, variables with a p-value < 0.25 were entered into a multivariable logistic regression model; P ≤ 0.05 was used to declare statistically significant variables in the final model. Descriptive statistics, such as frequencies and percentages, were used. A binary logistic regression was used to identify predictors of awareness of diabetes and its complications.

2.10. Data quality control

The principal investigator performed continuous oversight and follow-up to ensure the quality of the data. In addition, the data was checked on a daily basis for completeness and consistency and then corrections were made accordingly.

2.11. Ethical approval

Ethical approval was obtained from Woldia comprehensive specialized hospital ethical review committee with ethical clearance number ERC 016/2024. A permission letter was obtained from the medical director's office. Written consent was obtained from each respondent in the study to fulfill ethical considerations and confidentiality was maintained throughout the study process.

3. Result

A total of 350 diabetes patients were enrolled, with a response rate of 95%.

3.1. Socio-demographic characteristics of respondents

Out of 350 diabetic respondents, 178 (50.9%) were male and 172 (49.1%) were female. The majority of participants were Orthodox Christian followers (66%). Concerning to educational status, 156(44.5%) study participants were Secondary school and above. Approximately 30% of the population earned more than 2500 ETB a month. About 60.6% of participants were urban dwellers and 48.9% had had diabetes for one to five years (Table 1). Around half of participants 171(48.9%) were under oral hypoglycemic treatment.

Table 1: Socio-medical characteristics of study participants in WCSH, 2024.

3.2. Knowledge, attitude and practice

In this study, 184 (58%) of the participants had good knowledge, 188 (59.1%) had a good attitude and 168 (53.4%) had good practice (Figure 1).

Figure 1: KAP regarding chronic complication of diabetes among patients with diabete in WCSH, 2024.

3.3. Factors associated with good knowledge

In multivariable analysis, education status, religion and family history of DM were significantly associated with good knowledge of chronic complications of diabetes. Patients who had primary education were 56% (AOR = 0.44, 95% CI = 0.23, 0.85) less likely to have good knowledge as compared to those who attended secondary education and above. Regarding religion, protestant patients were 82% (AOR = 0.18, 95% CI = 0.06, 0.55) less likely to have good knowledge (Table 2). Those with a family history of DM were 1.86 times (AOR = 1.86, 95% CI = 1.16, 3.00), more likely to have good knowledge as compared to their counterparts.

Table 2: Factors associated with knowledge towards chronic diabetic complications of study participants in WCSH, 2024.

3.4. Factors associated with attitude

Factors such as residence, duration of diseases, occupational status and level of knowledge were significantly associated with the attitude of respondents.

Regarding the duration of diseases, those patients staying with the disease for more than 10 years were 2.05 times (AOR = 2.05, 95% CI = 1.03-4.05) more likely to have a good attitude towards chronic complications of diabetes as compared to the counterparts, while the effect of other variables kept constant. The other significant predictor was occupation and patients who are government workers were 3.17 times (AOR = 3.17, 95% CI = 1.17, 8.62) more likely to have a good attitude toward chronic complications of DM (Table 3).

Table 3: Factors associated with attitude towards chronic diabetic complications of study participants in WCSH, 2024.

3.5. Determinants of good practice towards chronic complications of DM

In multivariable analysis, sex and income of patients were significantly associated with practice toward chronic complications of DM. As compared to female patients, male patients were 1.7 times more likely to have good practice (AOR = 1.71, 95% CI = 1.10, 2.65) (Table 4). Those patients with a monthly income of 500-1500 and 150-1500 were 2.02 times (AOR = 2.02, 95% CI = 1.05-3.88) and 1.97 times (AOR = 1.97, 95% CI = 1.02-3.81) more likely to have good practice for chronic complications of DM as compared to patients with a monthly income of < 500 birr.

Table 4: Factors associated with practice towards chronic diabetic complications of study participants in WCSH, 2024

4. Discussion

Worldwide, diabetes is one of the leading causes of death³⁶. It is a chronic illness with a variety of complications that require in-depth understanding and care. Adequate knowledge of DM and its complications is necessary for diabetes self-management³⁷.

In this study, 184 (58%) of the participants had good knowledge. This is in line with results from Ethiopia (59%)³⁸, Malaysia (58.1%)³⁹, Tarlai 57%⁴⁰, India (50.1%)⁴¹, Debre Tabor (Ethiopia) (51%). And this finding is higher than reports from a study in Ghana, which reported 45.9 % of participants had good knowledge of diabetes complications⁴². However, the findings of our study are incomparable with those of a Saudi Arabian study, which reported that 80% of participants knew the complications associated with diabetes and a study from Nigeria, where 90.5% of type 2 DM patients had adequate knowledge of diabetes complications⁴³. Variations in socioeconomic conditions, cultural beliefs and behaviors may account for the discrepancy, as they have an effect on the pattern of awareness regarding diabetic consequences⁴⁴.

The results of this study showed a favorable association between participants' knowledge of diabetic complications and their educational status. This is supported by other study findings that reported a positive relationship between the level of education and the degree of knowledge about diabetic complications^42,45-48. The knowledge of diabetics about maintaining appropriate blood glucose levels was greatly influenced by education⁴⁹. Knowledge is one of the predictors of behavior in many ways⁵⁰. This might be due to increased opportunity of learning about DM complications from various sources as they become more knowledgeable. Furthermore, educated people have access to a variety of medical literatures⁴⁴.

Respondents with family history of DM were 1.86 times more likely to have good knowledge about diabetic complications as compared to their counterparts. This is consistent with findings from the study done in India^44,47 and Ethiopia⁴⁴. Receiving information from the family with chronic disease might influence the patient’s attitude and daily practice, which can be a good source of information⁵¹. This is as a result of their learning from family experiences.

In this study, about 59.1% of study participants had a good attitude. This is in contrast to the results of a study done in Ethiopia, in which over 65.2% of the study participants had a good attitude level³⁵. Differences in culture and socioeconomic status could be the explanation. Our study findings revealed that, regarding the duration of diseases, those patients staying with the diseases for more than 10 years were 2.05 times more likely to have a good attitude towards chronic complications of diabetes as compared to the counterparts when the effect of other variables kept constant. This is supported by findings from a recent study conducted in Iran, which reported a substantial positive link between attitude level and the length of the disease⁵¹.

The other significant predictor in this study was occupation. Patients who are government workers were 3.17 times more likely to have a good attitude toward chronic complications of DM. This is supported by a study from southeast Ethiopia which reported that employment in the public or private sector was three times more likely to result in a favorable attitude toward DM³³. This might be due to patients with greater education and employment status may find it easier to obtain and read various resources and they may also be able to speak with medical staffs without difficulty. This aids in their knowledge gathering and helps them adopt a more positive outlook regarding DM complications^35,52.

Regarding practice, as compared to female patients, male patients were 1.71 times more likely to have good practice. This is in line with a study from Bangladesh which reported higher level of practice among males than females³⁶. Those patients with a monthly income of 500-2500 birr were 2.02 times more likely to have good practice for chronic complications of DM as compared to patients with a monthly income of < 500 birr. Low income is associated with poor access to educational opportunities regarding methods of preventions of diabetes. This could also be because people with lower incomes would have to wait longer to get health care⁵³.

5. Limitation

Since the information about the attitudes and practices related to DM problems was self-reported, recall bias might have existed. The study was conducted on all diabetic patients regardless of their diabetic complication history status during the data collection period which could possibly affect knowledge, attitude and practice levels. And being cross-sectional study, this study did not show the conditions of cause-and-effect relationships.

6. Conclusion

A higher percentage of diabetes patients had generally positive attitude, knowledge and practice towards preventing diabetic complications in this study. Participants with better educational status and having family history of DM were more likely to have good knowledge about diabetic complications. Study subjects with disease duration more than 10 years with diabetes and government employees were more likely to have positive attitude towards chronic complications of diabetes. Male patients and those with a monthly income of 500 -2500 ETB had good practice to prevent chronic complication of DM as compared to patients with monthly income of < 500 ETB. Based on the above information, increasing health education about diabetic complication will help to maintain the good KAP of the population and fills gaps in prevention.

7. Abbreviations and Acronyms

AOR- adjusted odds ratio

CI- confidence interval

CVD- cardiovascular diseases

DM- diabetes mellitus

ETB- Ethiopian birr

NCDS- Non communicable diseases

IDF- International diabets federation

SPSS- statstical packages for social sciences

WSCH- woldia specialized comprehensive hospital
 

8. Declarations

8.1. Ethical approval

Ethical approval was obtained from Woldia comprehensive specialized hospital ethical review committee with ethical clearance number ERC 016/2024. Written consent was obtained from each respondent in the study to fulfill ethical considerations and confidentiality was maintained throughout the study process.

8.2. Consent for publication

Not applicable.

8.3. Data availability

The data used in this study are included and available in the whole manuscript. The dataset can be available at the hand of the corresponding author and can be accessed upon reasonable request.

8.4. Competing interest

All authors declared that there is no competing interest.

8.5. Authors' contributions

All authors have contributed equally for the manuscript.

8.6. Funding

Not applicable.

8.7. Acknowledgment

We thank all participants and facilitators from for their support in accomplishment of this study.

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Appendix

Tool for assessing KAP towards chronic complications of diabetes among diabetic patients at northeast Ethiopia, 2023.

Questions for assessing socio demographic conditions

Questions for assessing Knowledge towards chronic complications of diabetes

 
Questions for assessing attitude towards chronic complications of diabetes

Questions for assessing practice towards chronic complications of diabetes