This cross-sectional survey of adults residing in rural areas of Tamil Nadu shows low knowledge of diabetes among the population. Of particular concern, even those sub-groups of participants with higher wealth and education demonstrated a lack of knowledge of diabetes. Among those in the highest education category, over 40% had a knowledge score of zero, meaning they answered ‘no’ to the question, “Do you know what diabetes is?”. Such results indicate that even among the most educated individuals in the study population, general knowledge of diabetes is low. Although these findings are consistent with other studies [12, 14, 17, 19, 24, 25], this rural region of Tamil Nadu demonstrated one of the lowest levels of knowledge in India reported to date, with 66% of participants being unaware of diabetes altogether. A study conducted in another area of rural Tamil Nadu assessed knowledge and self-care practices among patients with diabetes and showed that even among those with diabetes, knowledge of the disease was low. One result from this study was that 49% of participants with diagnosed diabetes thought diabetes was curable [16]. A similar qualitative study looking deeper into themes regarding diabetes knowledge among individuals with diabetes, showed that 96% of participants answered, “I don’t know” when asked “what happens inside your body when you get sick with diabetes?” [26]. The low awareness of diabetes shown in these studies constitutes a serious public health concern in South India.
Although the trend of low diabetes knowledge levels is consistent across most studies in rural India, awareness appears to vary across regions in South Asia. A study conducted with adults from both urban and rural regions of Punjab, Pakistan, found that 86% of respondents had heard of diabetes [27]. The higher levels of education and SES of this population could be an explanation for the heightened knowledge scores as compared to the present study. Another study conducted on a lower-middle class urban population in Chennai, the capital of the state of Tamil Nadu, showed that over 90% of the general population knew of diabetes [13]. Such findings suggest that diabetes awareness and knowledge may be better in urban regions, where information, messaging, and resources for diabetes may be more accessible. The association between higher wealth, education, and lower rurality and diabetes knowledge is consistent with other studies in India [12, 13, 17], and other low- and middle-income countries, including Jordan [28], Bangladesh [29], Southeast Ethiopia [30], Oman [31], and Pakistan [27].
Doctor-patient interactions in healthcare settings are important opportunities for patient education, as shown by the strong association between frequency of healthcare visits and diabetes knowledge. This finding corresponds with previous research in the study region showing that patients with diabetes perceived doctors as the most important source of knowledge on diabetes [26]. However, this study adds to the body of evidence suggesting that healthcare professionals in rural regions of South India do not adequately educate patients on diabetes; indeed, previous research in the study site found that both public and private healthcare practitioners often failed to provide sufficient education and support to patients with NCDs [26].
An interesting result was the association between source of income and knowledge score. We found that individuals working as a merchant or shop owner were more knowledgeable about diabetes, perhaps due to increased income and SES status, allowing for more exposure and access to accurate health information when compared to farmers or labourers. Individuals of higher SES may also be at increased risk of cardiometabolic diseases such as diabetes, perhaps increasing the likelihood that a healthcare professional would educate them on such topics, or that they would have gained more information from peers of similar status and risk of diabetes [32]. The nature of being a merchant and/or shop owner also creates opportunities for interaction with community members. Social networking could therefore offer opportunities for exchanging information on diabetes for these individuals, perhaps more so than for farmers or labourers. Similarly, rurality is associated with a lower risk of diabetes [9], meaning those in a more rural setting are less likely to be exposed or have peers and community members with diabetes, which could be a plausible explanation for increased rurality being associated with lower diabetes knowledge.
Obtaining government funds as a source of income (MGNREGA and similar government schemes) was strongly associated with increased knowledge of diabetes. To our knowledge, this association has not yet been established in any previous studies. The MGNREGA provides employment security for adults (over age 18) who apply to the program and reside in rural households throughout all districts of India [33]. The main goal of the MGNREGA program is to provide employment opportunities to applicants within a radius of five kilometers of their home for at least 100 days in a year. Most jobs involve manual unskilled labour and pay minimum wage, however, some higher-skill jobs (e.g., project supervisor) are available with higher compensation [34]. MGNREGA creates work projects for members of rural communities involving different forms of labour, sometimes including the construction of permanent assets in participating communities, such as wells, roads, and bridges [33, 35]. While critiques of MGNREGA exist [34, 36, 37, 38, 39, 40], involvement in this program throughout rural communities has the potential to foster local economic and employment activity, improve household income security, as well as improve quality of life [34, 35, 41].
While this relationship between diabetes knowledge and MGNREGA involvement has not been previously explored, this finding begets a number of plausible hypotheses that bear further exploration. Household income security through MGNREGA participation has been associated with increased household expenditure on education and healthcare [34, 35, 42, 43, 44], possibly increasing healthcare access, and therefore exposure to diabetes knowledge. However, MGNREGA wages are often delayed and unpredictable, and may be insufficient on their own to sustain households [35, 36, 38, 40, 41, 43]. Additionally, involvement in government programs such as MGNREGA may improve participation in other government or social welfare programs, although research in this area is lacking. One study in particular found that women involved in MGNREGA had a high awareness of other existing government schemes, with some even expressing concern for over-dependency on government benefits and programs [35]. Engagement in several government or social welfare programs may have the potential to foster trust and improve uptake in other government services and sources of information. In our case, it is possible that those participants involved in MGNREGA may be more likely to trust and seek information regarding diabetes. Lastly, MGNREGA can improve community cohesion and bonding among those involved in the program [35, 41]. Involvement in MGNREGA work may provide a platform to discuss common issues and interests [35], possibly leading to community members discussing health issues of peers, such as diabetes. Overall, the relationship between MGNREGA and diabetes knowledge is unique and possible pathways of association must be explored further.
Many studies highlight understandings and perceptions of diabetes among Indian populations that occasionally conflict with biomedical models of diabetes. A common perception in India is that consuming excess sugar is a direct cause of diabetes [14, 16, 17, 19, 24]. Additionally, ‘tension’ or mental stress are often also cited as direct causes of diabetes [14, 17], and herbal or religious remedies are often recognized as effective treatments for diabetes [12, 14]. Such patterns are consistent with the present study, as the most common perceived risk factor of diabetes was consuming sweets (16.5% of the study population). Correspondingly, the local colloquial term for diabetes was translated as ‘sugar disease’ [26]. Mental stress was also reported as a risk factor by 5% of those who knew of diabetes, the same proportion who reported obesity as a risk factor. This exemplifies how cultural and local understandings of health and disease (such as ‘tension') may influence perceptions of diabetes causation [14, 26]. Evidence also indicates that for many individuals in South Asia, family and friends are a main source of information on diabetes [45, 46]. This further perpetuates localized understandings of diabetes, grounded in experiences of individuals within social networks rather than information from health authorities.
The low number of individuals in this study who reported obesity as a risk factor to diabetes (1.7% of the total population) is particularly concerning, considering obesity is one of the strongest predictors of type 2 diabetes [4, 8, 9, 10]. Such findings correspond with a similar study investigating diabetes knowledge in a rural northeast Indian population, which found that only 40% of those who were overweight knew they had an increased risk of diabetes [15]. The views and information held by this population and other rural Indian populations may be influenced by a variety of societal and systemic factors. Some studies suggest that overweight and obesity are perceived as ‘healthy’ in some sub-populations in rural India, especially among low-SES individuals, since overweight can be a sign of wealth and food security [45].
Further, the fragmented healthcare system that is currently in place in India, along with poor investments in public health initiatives and health education, limit access to reputable and relevant information regarding health and disease, especially for rural populations. Many studies highlight the difficulty of receiving care for simple health issues, often citing the unavailability of doctors, long wait times, high costs, and lack of healthcare coordination [47, 48]. More specifically, a previous study within the study site described barriers to accessing both public and private healthcare – for example, corruption and poor quality of care in public services and prohibitively high costs in private services [48]. Despite the greater expense, private healthcare was preferred over public healthcare for major health problems such as diabetes [48]. Regardless, both public and private healthcare facilities are likely inadequate in appropriately disseminating important information regarding diabetes. Along with poor infrastructure, accessing healthcare in rural India is affected by broader issues associated with poverty. Healthcare centres are often located in urban cities (thus requiring transportation), are focused on tertiary care, and only affordable to the urban affluent, with rural poor individuals being faced with limited healthcare options [49]. Many individuals in rural areas face financial hardships and use their income to sustain daily living, often avoiding seeking healthcare unless for life-threatening conditions [47].
India is currently grappling with an epidemiological transition that is driving an increasing burden of NCDs such as diabetes [2]. As of yet, efforts towards diabetes prevention have been found to be unsatisfactory in India, especially in rural areas [49, 50]. It is therefore crucial and timely to improve efforts and allocate resources to alleviate the burden of diabetes. The associations of sociodemographic factors with diabetes knowledge in this study highlight priority areas for targeting initial public health efforts in Tamil Nadu. Specifically, efforts should emphasize the dissemination of accurate knowledge of diabetes signs, symptoms, prevention, and treatment to rural and isolated regions where high proportions of the population lack formal education and seldomly interact with healthcare systems. Importantly, improved knowledge on diabetes has been associated with positive attitudes and better self-care practices towards diabetes treatment and prevention [16, 28, 30, 31]. Thus, investing in stronger public health efforts to improve healthcare access, quality, and focus on non-communicable disease prevention and treatment, presents a crucial tool for lessening the severity and impacts of the diabetes epidemic in India. However, it should be noted that structural factors grounded in economic and political realities – for example, food environments, access to sustainable livelihoods, and availability of recreational opportunities – are also crucial components to preventing and managing non-communicable diseases and must be incorporated into any regional or national strategy to prevent burdens of diabetes [51, 52].
The use of systematic random sampling and the polytomous outcome used in modelling are strengths of this study. This study also examined rurality on a continuous scale instead of using a binary outcome to assess urban and rural residence, allowing for increased granularity in examining the relationship between rurality and diabetes knowledge. Using a culturally appropriate index to examine SES that takes into account many common assets for a rural Indian population, the wealth index allowed for a nuanced and accurate assessment of the relationship between SES and knowledge. Despite these strengths, this study had some limitations. Importantly, cross-sectional surveys are unable to establish causation. Since most sociodemographic data and knowledge on diabetes was self-reported, some data may be influenced by misreporting or social desirability bias. The weaknesses of the diabetes knowledge questionnaire have been well documented [19], and include open-ended questions being inhibited by memory and recall bias, and close-ended questions possibly encouraging respondents to provide guesses instead of informed answers.