Evaluation of Knowledge, Awareness, and Factors Associated with Diabetes: A Cross-Sectional Community-Based Study

Methods A cross-sectional study was carried out for over 4 months from May to August 2020 using a self-administered, anonymous online questionnaire. All adults of both genders were invited to participate in the study. Individuals who are able to read and understand the English language were included in the study. Data were descriptively analyzed using a statistical package for social science version 26 (SPSS). Results A total of 427 subjects responded to the questionnaires. More than half of them were male 253 (59.3%), while 174 (40.7%) were female, approximately 49% had a university degree, and 196 (45.9%) were postgraduates. The mean age of the participants was 25.7 ± 6.2 (mean ± SD). Most of them were single 230 (53.9%). The majority of the respondents 367 (85.9%) had heard of hyperglycemia, while a comparable number of 366 (85.7%) were aware of it being a lifelong disease. About 305 (71.4%) of participants knew that genetic factors were associated with hyperglycemia, and more than half of 250 (58.5%) knew that diabetes causes foot problems. There was a significant association between the cause of diabetes with income and educational status (p < 0.05) and diabetic complications with age, education, and family income (p < 0.05). Conclusion In conclusion, there is a need for greater awareness and additional education regarding hyperglycemia among the general community in the state of Telangana, India, to reduce the incidence of diabetes and associated risk factors. Public health campaigns that encourage healthier lifestyles might help achieve this aim.


Introduction
Diabetes is a chronic disease, affecting people of both genders and across all age groups, and is currently considered a major public health challenge worldwide [1]. Globally, estimates suggest that nearly 425 million adults aged between 20 and 79 years are currently living with diabetes, and this number is expected to reach 629 million by 2045 [2]. According to the World Health Organization (WHO), approximately, 69.2 million people were living with diabetes in India in 2015, with this number expected to reach 98 million by 2030, making India a country with the highest diabetes incidence after China [2,3]. In India, the prevalence of diabetes in the capital city of the Telangana state has been estimated at 16.6%, which is higher than for comparable cities, such as Mumbai (7.5%), Chennai (13.5%), and Bangalore (11.7%) is followed by the capital of India at 11.06% [4,5]. More recently, a large community-based study from North India, using a sample of 5127 individuals aged between 25 and 44 years, reported an overall prevalence of diabetes at 8.3% [6].
Although raising awareness of risk factors and complications associated with diabetes has been a common strategy for controlling disease incidence. For example, Singla et al. measured diabetes awareness in a visiting outpatients in Dehradun over 6 months, revealing that 56% were aware of diabetes [7]. Similarly, a study by Muninarayana et al., assessing the prevalence and awareness of diabetes mellitus among 311 adults in rural areas of India, showed that 50% of participants were aware of diabetes [8]. Moreover, another study by Aljin et al., using a sample of 258 patients with type 2 diabetes in the Tamil Nadu state, showed that 63.1% of them had adequate knowledge regarding type 2 diabetes mellitus [9] However, a study by Mohan et al., assessing awareness and knowledge about diabetes among the general population, as well as among individuals with diabetes in 4 selected regions of India, revealed poor knowledge and awareness of diabetes, particularly in rural areas [10]. According to preliminary research, a gap or lack of knowledge of chronic diseases can increase morbidity and mortality rates [11]. Several studies, however, assessed knowledge, attitudes, and practice regarding other acute and chronic diseases such as malaria [12], intestinal parasitic infection [13], influenza [14], and corona virus [15]. Until now, there have been few studies that looked at communitywide knowledge and awareness in response to diabetes [16][17][18]. According to published studies, adequate knowledge and awareness and strict adherence and self-care measures would have a significant impact on morbidity and mortality rates, thereby aiding in disease control. To the best of our knowledge, there are currently limited data about knowledge and awareness of diabetes among the general population of the Telangana state, India. us, this study aimed to evaluate public knowledge and awareness regarding diabetes in the state of Telangana.

Methods
A cross-sectional study design was used to collect the data. An electronic survey was developed, using Google forms, and distributed among the general population in the state of Telangana, India, over 4 months, from May to August 2020 using social media as the platform to collect the data. Participants were recruited through the snowball technique (an individual who is recruited in the study will provide referrals). e study included individuals aged >18 years or more, of both genders, who can read and understand the English language, and are willing to provide informed consent. Others who do not match the inclusion criteria were excluded from the study. Data collection was completed using a structured, self-administered questionnaire.
To explore diabetes knowledge and awareness, we developed a questionnaire, following a thorough review of the relevant literature. e questionnaire was validated for content and ease of use, with the help of an advisor with experience in questionnaire development. A validated version of the questionnaire was used in this study [16]. e questionnaire included a series of closed-and openended questions. e first part of the questionnaire collected demographic details, such as age, gender, educational level attained, monthly income, employment, and marital status. e second part of the questionnaire collected information about diabetes knowledge and awareness through nine closed-ended questions, including questions about risk factors for diabetes. e questionnaire was tested in a pilot study, involving randomly selected 10 participants, to evaluate its design and content. Based on the results, minor modifications were made to the questionnaire. e study employed a simple random sampling approach. Data collection was carried out through social media (WhatsApp©, Facebook©, and Twitter©). Nonresponders were sent reminders and messages encouraging them to complete and return their questionnaires. All questionnaires were completed anonymously. Informed consent was obtained from each participant. All participants were assured of the confidentiality of the information that they provided.

Sample Size.
e needed sample size was computed using the Rao soft sample size calculator (http://www.raosoft.com/samplesize.html.) with a 95% confidence level and a 5% margin of error. Because we were unaware of the possible results for each question, we assumed the response distribution for each question would equal 50%. e calculated sample size was 377 individuals. However, we opted to survey at least 430 individuals to increase the dependability of the results.

Data Analysis.
Descriptive statistics, including counts and percentages, were calculated for each variable. Statistical Package for Social Sciences version 26.0 (SPSS Inc., Chicago, IL, USA) was used for statistical calculations. Mean ages were calculated. e Chi-square test or Fisher's exact test was used, as appropriate, to assess the association between demographic characteristics and diabetes knowledge questionnaires. A p value of <0.05 was considered statistically significant.

Results
During the study period, a total of 427 subjects were responded to the survey. More than half of the respondents were male 253 (59.3%), while 174 (40.7%) were female, approximately 49% had a university degree and 196 (45.9%) were postgraduates. e mean age of the participants was 25.7 ± 6.2 (mean ± SD). About 33% were employed and 45.2% were students. Most of them were single 230(53.9%) ( Table 1).
ere was a significant association between the cause of diabetes concerning income and educational status (p < 0.05); similarly, there was a significant association among the respondents regarding the question about diabetes-associated complications with age, education, and family income (p < 0.05). Results also revealed that there was an association between male and female, educational levels concerning diabetes knowledge (p < 0.05).
e study parameters related to diabetes knowledge and demographics are given in Table 3.
When asked which organ was most commonly affected by high sugar levels, 202 (47.3%) of the respondents name kidneys and eyes as affected by diabetes, followed by 101 (23.6%) naming the foot, and 75 (17.5%) naming the heart (Figure 1). Regarding risk factors for diabetes, the majority of the respondents of 305 (72%) said genetic factors, 224 (52%) said lack of physical activity, and 296 (69%) said smoking were the main risk factors for diabetes, while 221 (51.7%), 251 (59%), and 206 (48.2%) named alcohol use, being overweight, and stressful mental work, respectively ( Figure 2).

Discussion
Previous studies have shown that the effective management of blood glucose levels was strongly connected to adequate awareness and knowledge of diabetes; in addition, previous reports have also shown a correlation between diabetes mellitus knowledge and hemoglobin A1C level [17][18][19]. e present study demonstrated acceptable levels of diabetes awareness and knowledge in the population resident in the state of Telangana, comparable to previous findings from international and national research [20,21].
is study highlighted several important observations. Overall, the majority (86%) of the study participants were aware of a condition called "diabetes," and a large percentage knew it to be a lifelong disease; nevertheless, associated complications and affected organs were known to few respondents. Previous studies have suggested that patients with diabetes or a family history of diabetes are likely to have a high level of knowledge about the disease through either their physician or other resources. In our study, the majority of participants correctly identified risk factors for diabetes.
is finding shows that regardless of the diabetes status or family history, our study participants had adequate knowledge regarding diabetes. is might be due to the nature of the study sample background of the participants and the type of study instrument used.
A previous study in India found that 90% of the general population was aware of diabetes and its complications [22], which was a considerably higher proportion than that in our study. is discrepancy might be explained by the previous     study using a large sample size as well as study design used, whereas our tool was a group of senior researchers-constructed. Similarly, a study by Saleh et al. reported that 82% of the participants were aware of diabetes, which was a smaller proportion than that in our study [20]. However, a study by Deepa et al. involving urban and rural areas of the regions of Chandigarh, Tamil Nadu, Jharkhand, and Maharashtra revealed that only 43.2% of 14,274 respondents had heard about diabetes. is study also reported that urban residents had higher awareness rates (58.4%) than did rural residents (36.8%). ese results were inconsistent with our study results. Concurrently, our study found that 61% of the participants were aware of diabetes affecting other organs, compared to 72.7% who reported as having this awareness in a previous study [10]. e prevalence of diabetes is high among the Indian population [23], surprisingly India has got the secondhighest position in the prevalence of high rates of diabetes after China [23][24][25][26][27]. Raising awareness of the disease, its causes, treatment, and associated complications is the first step toward disease prevention, which could be achieved through a patient education program, including education on a healthy lifestyle. Few limitations exist in our study. First, the design of the research was an onlinebased cross-sectional self-reported survey, potentially rendering our results as less reliable. However, because the survey was anonymous and completely voluntary, one can assume that diabetes clinical status was reliably captured. Second, the study was conducted on a single state of the individuals; hence, results cannot be generalized to all public in India. ird, despite assessing the knowledge and awareness of diabetes, the level of knowledge about types of diabetes was not evaluated among the individuals.

Conclusion
Diabetes poses the main health challenge from both a public perspective and economically all over the world. However, awareness of diabetes is vital for good health and healthy living of individuals. Our findings suggest that awareness and knowledge are inadequate of diabetes, concerning several items in the study including its complications and effects of diabetes on other organs. e need to raise the level of awareness of diabetes among the Indian population is essentially warranted.

Data Availability
e datasets used to support the findings of this study are available from the corresponding author on reasonable request (wali@ksu.edu.sa).

Conflicts of Interest
e authors declare that they have no conflicts of interest.  International Journal of Endocrinology 5