Diabetes mellitus (DM) is a group of metabolic disorders characterized by hyperglycemia. It is associated with abnormalities in carbohydrate, fat, and protein metabolism, which results in chronic complications, including microvascular, macrovascular, and neuropathic disorders [
Throughout the last twenty years, the incidence of diabetes has been raised intensively in many parts of the world [
In 2010, 12.1 million people were estimated to be living with diabetes in Africa, and this is projected to increase to 23.9 million by 2030 [
Regardless of the pathogenesis, uncontrolled diabetes or poor glycemic control is associated with chronic hyperglycemia, leading to the development of long-term microvascular, macrovascular, and neuropathic complications. According to the American Diabetes Association, the target for long-term glycemic control in patients with diabetes is glycated hemoglobin A1c (HbA1c) value of less than 7% [
Diabetic complications such as diabetic ketoacidosis, micro- and macrovascular diabetic complications, and their associated adverse outcomes are intimately related to suboptimal glycemic control in clinical practice. Each 1% reduction in the mean glycated hemoglobin (HbA1c) has been shown to be associated with a reduction in risk of 21% for deaths related to diabetes, 14% for myocardial infarction, and 37% for microvascular complications [
The management of DM largely depends on the patient’s ability to do self-care in their daily lives, and therefore, patient education is always considered an essential element of DM management. Studies have shown that patients, who are knowledgeable about the DM self-care, have better long-term glycemic control [
Many studies have shown that control of hyperglycemia in diabetic patients can prevent or reduce the risks of diabetic complications. Better glycemic management of DM requires not only the prescription of an appropriate nutritional and pharmacological regime by the physician but also intensive education of the patient. Most studies have used measurements such as blood glucose level and knowledge, attitude, and practice (KAP) as the index of diabetes management [
Nowadays, people in developing countries like Ethiopia are suffering from chronic diseases, of which diabetes is the major one having a significant contribution to mortality and morbidity. Diabetes is a self-managed condition; therefore, knowledge, attitudes, and practices about glycemic control in DM patients can influence the overall treatment outcomes and the complications of the disease. Identification of knowledge, attitudes, and practices towards glycemic control would provide better insight for the development of preventive and treatment strategies for the patients.
A cross-sectional study was conducted to determine the level of KAP towards glycemic control and its associated factors among DM patients at the University of Gondar Hospital from March to June 2018. The study population was all diabetic mellitus patients who visited the University of Gondar Hospital during the study period and fulfilled the inclusion criteria.
The dependent variables were knowledge, attitude, and practice, and the independent variables were sex, age, ethnicity, educational status, occupational status, religion, marital status, and duration of diabetes mellitus.
All DM patients who volunteered to give information about their knowledge, attitude, and practice towards glycemic control were included in the study. Patients with mental health problems and hearing impairments and those patients who were unable to provide the appropriate information were excluded.
The required sample size was determined by using a single population proportion formula. Therefore, the proportion was taken at 50%, and the sample size calculation was made as the following proportion of the study with 95% of confidence intervals (CI) and 5% of margin error.
Knowledge about glycemic control was assessed using 16 general questions which were considered to be known by diabetic patients like the importance of glycemic control, risk factors, and complications of poor glycemic control. Each response was scored as “1” for correct response and “0” for incorrect responses. Knowledge scores of individuals were calculated and summed up to give the total knowledge score. Participants who correctly responded to more than 50% of knowledge questions were considered as having adequate knowledge about glycemic control, whereas those who scored <50% were considered as having inadequate knowledge about glycemic control.
Similarly, 12 attitude- and 10 practice-related questions were asked, and the responses to each question were scored as “1” for correct response and “0” for incorrect responses. Participants who correctly responded more than 50% of attitude and practice assessing questions were considered as having good attitude and practice towards glycemic control, whereas those who scored ≤50% were considered as having a poor attitude towards glycemic control.
The data were collected by the structured questionnaire, which contains different items like sociodemographic and KAP towards glycemic controls
The questionnaire was prepared, first in English, and then, it was translated into local language, Amharic, to collect the data. The questionnaire was prepared by investigators based on the variables and objectives of the study.
After data collection, the response was coded and entered into the computer using EPI info data version 7 and the data was analyzed by using SPSS version 20. All independent variables with a
Ethical clearance was obtained from the research and ethics committee of the School of Biomedical and Laboratory Science, College of Medicine and Health Science, University of Gondar. The participants recruited to the study were informed about the objectives of the study, and their confidentiality was kept by using codes. Informed consent was obtained from each participant before the data collection.
From a total of 403 participants, 216 (53.6%) were males. In the majority of the participants, 108 (26.8%) were farmers, 176 (43.7%) were illiterate, and 221 (54.8%) were within the age group of 46 years and above (Table
Sociodemographic characteristics of the study participants, at the University of Gondar Hospital, 2018.
Variables | Categories | Frequency | Percent (%) |
---|---|---|---|
Sex | Male | 216 | 53.6 |
Female | 187 | 46.4 | |
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Age | 18-25 years | 52 | 12.9 |
26-35 years | 66 | 16.4 | |
36-45 years | 64 | 15.9 | |
≥46 years | 221 | 54.8 | |
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Level of education | Unable to read and write | 176 | 43.7 |
Primary | 71 | 17.6 | |
High school | 73 | 18.1 | |
College/university and postgraduate | 83 | 20.6 | |
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Marital status | Married | 267 | 66.3 |
Divorced | 31 | 7.7 | |
Widowed | 43 | 10.7 | |
Single/never married | 62 | 15.4 | |
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Occupation | Government employed | 76 | 18.9 |
Unemployed | 84 | 20.8 | |
Merchant | 82 | 20.3 | |
Day laborers | 15 | 3.7 | |
Farmers | 108 | 26.8 | |
Others | 38 | 9.4 |
Of all participants, 250 (62%) had good knowledge towards glycemic control with the knowledge mean score of
Knowledge assessment towards glycemic controls among DM patients at the University of Gondar referral hospital 2018.
Knowledge assessment items | Correct response |
Incorrect response |
---|---|---|
Definition of DM | 251 (62.3) | 152 (37.7) |
What type of DM you had | 252 (62.5) | 151 (37.5) |
Causes of DM | 235 (58.3) | 168 (41.7) |
Type of medications used | 341 (84.6) | 62 (15.4) |
What to do when you become hypoglycemic | 337 (83.6) | 66 (16.4) |
How to inject insulin | 321 (79.7) | 82 (20.3) |
Is that DM hereditary? | 159 (39.5) | 244 (60.5) |
What does lipidemic/obesity/hypertension mean? | 277 (68.7) | 126 (31.3) |
Risk factors of DM | 241 (59.8) | 162 (40.2) |
How can DM be detected? | 184 (45.7) | 219 (54.3) |
Could DM affect other organs? | 134 (43.9) | 221 (56.1) |
Can complications occur due to DM? | 203 (50.4) | 200 (49.6) |
Effect of regular exercise on DM | 344 (85.4) | 59 (14.6) |
Effect of extra salt intake on DM | 362 (89.8) | 41 (10.2) |
Effect of extra sugar intake on DM | 253 (62.8) | 150 (37.2) |
Effect of smoking on DM | 275 (68.2) | 128 (31.8) |
Out of 403 participants, 271 (67.2%) had a good attitude towards glycemic control with an attitude mean score of
Attitude assessment towards glycemic controls among DM patients at the University of Gondar referral hospital 2018.
Attitude assessment | Correct response |
Incorrect response |
---|---|---|
Do you think glycemic control is necessary for DM? | 282 (94.8) | 21 (5.2) |
Do you think regular exercise can help to control DM? | 348 (86.4) | 55 (13.6) |
Do you think smoking causes poor glycemic control? | 288 (71.5) | 115 (28.5) |
Do you think blood pressure control is necessary for glycemic control? | 288 (71.5) | 115 (28.5) |
Do you think glycemic control prolonged life expectancy? | 263 (65.3) | 140 (34.7) |
Do you think that alternative treatments are good? | 111 (27.5) | 292 (72.5) |
Do you believe good blood sugar control is important for DM? | 360 (89.3) | 43 (10.7) |
Do you think diet alone glycemic control is better than medication with diet glycemic control? | 144 (35.7) | 259 (64.3) |
Do you believe fruits and vegetables are good for glycemic control? | 189 (46.9) | 214 (53.1) |
Do you think alcohol can increase the complication of DM? | 362 (89.8) | 41 (10.2) |
Do you think insulin (metformin) drug has harmful effects to the organs of the body? | 166 (41.2) | 237 (58.8) |
Do you think traditional treatments are better than modern medicines for DM? | 372 (92.3) | 31 (7.2) |
Out of the study population, 300 (74.4%) had good practices towards glycemic control with a practice mean score of
Practice assessments towards glycemic controls among DM patients at the University of Gondar referral hospital 2018.
Practice assessment | Yes |
No |
---|---|---|
Eat vegetables daily | 183 (45.4) | 220 (54.6) |
Daily physical exercise | 197 (48.9) | 260 (51.1) |
Medication/treatment adherence | 399 (99) | 4 (1) |
Control/maintain body weight | 228 (56.6) | 175 (43.4) |
Regular blood sugar checkup | 393 (97.5) | 10 (2.5) |
Cigarette smoking | 45 (11.2) | 358 (88.8) |
Extra sugar/salt on your regular diet | 74 (18.3) | 325 (80.6) |
Do you drink alcohol? | 199 (49.4) | 204 (50.6) |
Do you eat food on time? | 390 (96.8) | 13 (3.2) |
Eye/foot care | 176 (43.7) | 227 (56.3) |
In addition, we have tried to assess the correlation between knowledge, attitude, and practices of the study participants based on the Spearman correlation. Knowledge and attitude scores of the participants achieved a significant positive correlation (
The level of KAP towards glycemic control by sex of DM patients at the University of Gondar Hospital, 2018.
In multivariate logistic regression, marital status and occupational status were significantly associated with knowledge towards glycemic control of diabetes (Table
Bivariant and multivariable analysis of factors associated with knowledge towards glycemic controls on DM patients at the University of Gondar referral hospital, 2018.
Variables | Knowledgeable | COR 95% CI | AOR 95% CI |
| |
---|---|---|---|---|---|
Good | Poor | ||||
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Male | 142 (56.8%) | 74 (48.4%) | 1.00 | 1.00 | |
Female | 108 (43.2%) | 79 (51.6%) | 0.712 (0.476, 1.067) | 0.95 (0.59, 1.53) | 0.86# |
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18-25 | 34 (13.6%) | 18 (11.8%) | 1.00 | 1.00 | |
26-35 | 43 (17.2%) | 23 (15.0%) | 0.990 (0.461, 2.124) | 0.91 (0.34, 2.4) | 0.85# |
36-45 | 43 (17.2%) | 21 (13.7%) | 1.084 (0.500, 2.350) | 1.16 (0.42, 3.2) | 0.76# |
≥46 | 130 (52.0%) | 91 (59.5%) | 0.756 (0.402, 1.421) | 0.92 (0.36, 2.36) | 0.87# |
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Married | 176 (43.7%) | 91 (59.5%) | 1.00 | 1.00 | |
Divorced | 14 (5.6%) | 17 (11.1%) | 0.426 (0.20, 1.903) | 0.485 (0.216, 1.087) | 0.079# |
Single | 45 (18%) | 17 (11.1%) | 1.369 (0.742, 2.526) | 1.628 (0.840, 3.15) | 0.015 |
Widowed | 15 (6%) | 28 (18.3%) | 0.277 (0.141, 0.545) | 0.257 (0.112, 0.590) | 0.001 |
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Unemployed | 48 (19.2%) | 36 (23.5%) | 1.00 | ||
Merchant | 49 (19.6%) | 33 (21.6%) | 1.114 (0.600, 2.065) | 0.707 (0.341, 1.464) | 0.35# |
Government employed | 73 (29.2%) | 3 (2.0%) | 18.250 (5.319, 62.614) | 9.772 (2.650, 36.0) | 0.001 |
Day laborers | 7 (2.8%) | 8 (5.2%) | 0.656 (0.218, 1.977) | 0.366 (0.112, 1.199) | 0.097# |
Farmer | 49 (19.6%) | 59 (38.6%) | 0.623 (0.351, 1.107) | 0.352 (0.176, 0.707) | 0.003 |
In multivariable logistic analysis, marital status, occupational status, and educational status were significantly associated with the attitude of participants towards glycemic controls of diabetes (Table
Bivariable and multivariable analysis of factors associated with attitude towards glycemic controls on DM patients at the University of Gondar referral hospital, 2018.
Variables | Attitude | COR 95% CI | AOR 95% CI |
| |
---|---|---|---|---|---|
Good | Poor | ||||
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18-25 | 35 (12.9%) | 17 (12.9%) | 1.00 | 1.00 | |
26-35 | 45 (16.6%) | 21 (15.9%) | 1.041 (0.478, 2.264) | 0.701 (0.24, 2.01) | 0.508# |
36-45 | 44 (16.2%) | 20 (15.2%) | 1.069 (0.488, 2.341) | 0.813 (0.27, 2.36) | 0.704# |
≥46 | 147 (54.2%) | 74 (56.1%) | 0.965 (0.507, 1.836) | 0.64 (2.34, 1.75) | 0.38# |
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Married | 193 (71.2%) | 74 (56.1%) | 1.00 | 1.00 | 1 |
Divorced | 17 (6.3%) | 14 (10.6%) | 0.466 (0.21, 0.992) | 0.588 (0.249, 1.386) | 0.225# |
Single | 40 (14.8%) | 22 (16.7%) | 0.697 (0.388, 1.252) | 0.339 (159, 0.721) | 0.005 |
Widowed | 21 (7.7%) | 22 (16.7%) | 0.366 (0.190, 0.705) | 3.287 (1.725, 6.262) | 0.002 |
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Unemployed | 52 (19.2%) | 32 (24.2%) | 1.00 | 1.00 | 1 |
Merchant | 55 (20.3%) | 27 (20.5%) | 1.254 (0.663, 2.371) | 0.46 (0.2, 1.05) | 0.083# |
Government employed | 73 (26.9%) | 3 (2.3%) | 14.974 (4.352, 51.525) | 0.86 (0.177, 4.209) | 0.001 |
Day laborers | 8 (3.0%) | 7 (5.3%) | 0.703 (0.233, 2.125) | 0.39 (0.107, 1.47) | 0.242# |
Farmer | 60 (22.1%) | 48 (36.4%) | 0.769 (0.430, 1.376) | 0.325 (0.15, 0.698) | 0.004 |
Others | 23 (8.5%) | 15 (11.4%) | 0.944 (0.430, 2.070) | 0.25 (0.09, 0.7) | 0.008 |
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Unable to read/write | 78 (28.8%) | 98 (74.2%) | 1.00 | 1.00 | |
Primary school | 49 (18.1%) | 22 (16.7%) | 2.798 (1.560, 5.020) | 3.287 (1.725, 6.262) | 0.001 |
High school | 66 (24.4%) | 7 (5.3%) | 11.846 (5.145, 27.274) | 13.562 (5.414, 33.97) | 0.001 |
College and above | 78 (28.8%) | 5 (3.8%) | 19.600 (7.56, 50.773) | 20.615 (5.901, 72.02) | 0.001 |
In multivariate logistic regression, occupational status, educational status, and marital status of the participants were significantly associated with practices towards glycemic controls (Table
Bivariable and multivariable analysis of factors associated with practices towards glycemic controls on DM patients at the University referral hospital of Gondar, 2018.
Variables | Category | Practice | COR 95% CI | AOR 95% CI |
| |
---|---|---|---|---|---|---|
Good | Poor | |||||
Sex | Male | 160 (53.3%) | 56 (54.4%) | 1.00 | 1.00 | |
Female | 140 (46.7%) | 47 (45.6%) | 1.043 (0.665, 1.634) | 1.23 (0.47, 1.23) | 0.114# | |
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Age | 18-25 | 43 (14.3%) | 9 (8.7%) | 1.00 | 100 | |
26-35 | 49 (16.3%) | 17 (16.5%) | 0.603 (0.2441, 0.493) | 0.45 (0.32, 4.1) | 0.42 | |
36-45 | 48 (16.0%) | 16 (15.5%) | 0.628 (0.252, 1.567) | 0.78 (0.35, 1.68) | 0.46 | |
≥46 | 160 (53.3%) | 61 (59.2%) | 0.549 (0.253, 1.194) | 0.85 (0.35, 1.78) | 0.22 | |
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Marital status | Married | 204 (68.0%) | 63 (61.2%) | 1.00 | 1.00 | |
Divorced | 22 (7.3%) | 9 (8.7%) | 0.755 (0.331, 1.723) | 2.121 (0.853, 5.275) | 0.331# | |
Single | 47 (15.7%) | 15 (14.6%) | 0.968 (0.507, 1.847) | 1.410 (0.450, 4.419) | 0.322# | |
Widowed | 27 (9.0%) | 16 (15.5%) | 0.521 (0.264, 1.028) | 0.735 (0.219, 2.469) | 0.066# | |
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Occupational status | Unemployed | 63 (21.0%) | 21 (20.4%) | 1.00 | 1.00 | |
Merchant | 69 (23.0%) | 13 (12.6%) | 1.769 (0.818, 3.827) | 0.861 (0.344, 2.157) | 0.894# | |
Government employed | 69 (23.0%) | 7 (6.8%) | 3.286 (1.308, 8.254) | 0.478 (0.121, 1.885) | 0.00 |
|
Day laborers | 11 (3.7%) | 4 (3.9%) | 0.917 (0.264, 3.188) | 0.476 (0.115, 1.973) | 0.69# | |
Farmer | 64 (21.3%) | 44 (48.7%) | 0.485 (0.259, 0.906) | 0.228 (0.102, 0.510) | 0.001 |
|
Others | 24 (8%) | 14 (13.5%) | 0.571 (0.251, 1.302) | 0.164 (0.057, 0.474) | 0.003 |
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Educational status | Unable to read/write | 107 (35.7%) | 69 (67.0%) | 1.00 | 1.00 | |
Primary | 53 (17.7%) | 18 (17.5%) | 1.899 (1.027, 3.510) | 1.929 (0.975, 3.815) | 0.049 |
|
High school | 66 (22.0%) | 7 (6.8%) | 6.080 (2.636, 14.02) | 7.07 (2.792, 17.93) | 0.00 |
|
College/university | 74 (24.7%) | 9 (8.7%) | 5.302 (2.492, 11.28) | 5.78 (1.890, 17.71) | 0.002 |
Out of 403 participants, 250 (62%) had a good knowledge. This finding was higher than the study done in Bale Town, Ethiopia (52.5%) [
In this finding, more than half of participants, 58.3%, know the cause of DM; this finding was lower than the study done in rural Bangladesh (93%) [
Of the participants, 62.3% were knowledgeable about the meaning of DM and 59.8% about the risk factors of DM. This study was higher than the study done in Bale, Ethiopia, in which 54.5% knew what DM means and 48% were able to identify the risk factors of DM [
The current study showed that 271 (67.2%) had a good attitude about glycemic controls. This finding was higher than the study done in Bangladesh (18%) [
Of all participants, 144 (35.7%) of them believed that the necessity was medication for controlling glucose with diet rather than diet alone. This finding was lower than the studies conducted in Pakistan (68%) [
Among 403 participants, 74.4% showed good practice towards glycemic control. This finding was lower compared to the studies conducted in South Africa (99%) [
A total of 99% of participants had medication adherence, and 11.2% had a history of smoking. This finding was inconsistent with studies done in Addis Ababa, Ethiopia, where 97% adhered to prescribed medication and 12% of all respondents have the habit of smoking [
The majority of participants, 393 (97.5%), had their blood sugar level checked for the last 3 months. This finding was higher than the study done in rural Bangladesh (47.5%) [
Less than half of participants, 176 (43.7), had a good eye/foot care practice. This study result was higher than the studies done in Iran, in which 33% [
In this study, occupation and marital status were significantly associated with knowledge of participants using multivariate logistic regression. This finding was similar to the study done in Mekelle, Ethiopia [
More than half of the participants had good knowledge, attitude, and practice towards glycemic controls. Occupational and educational status was the variable which remained to be significantly associated with knowledge towards glycemic control. In addition, occupation, education, and marital status were significantly associated with attitude and practice towards glycemic control.
A hospital-based intervention program should be implemented in order to improve the KAP of patients regarding glycemic control.
The KAP question response of participants might be affected by both interviewers and recall bias. In addition, the result of this study cannot be inferred to other populations in the country because KAP might be greatly influenced by sociodemographic factors of the population.
Adjusted odds ratio
Crude odds ratio
Confidence interval
Diabetes mellitus
Glycated hemoglobin A1c
World Health Organization
Knowledge, attitude, and practice.
The data generated or analyzed during this study were included in this published article.
The study was approved by the ethical clearance committee of the Biomedical and Laboratory Science of the University of Gondar. Each participant was informed in detail, and his/her consent was obtained before the data collection.
All participants provided a written informed consent to publish this study.
The authors declare that they have no competing interests.
DA was responsible for the conception of research idea and study design. DA, NA, ST, HB, and CD were responsible for the supervision, data collection, analysis, interpretation, and the drafting of the manuscript. All authors read and approved the final manuscript.
We would like to thank the study participants for volunteering to participate in the study and the University of Gondar Hospital for allowing us to use the laboratory facilities.