Understanding the Impact of Literacy on Knowledge Gap and Behaviour Pattern among Diabetic Patients: A Cross-Sectional Study

doi:10.21203/rs.3.rs-4864039/v1

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Understanding the Impact of Literacy on Knowledge Gap and Behaviour Pattern among Diabetic Patients: A Cross-Sectional Study

https://doi.org/10.21203/rs.3.rs-4864039/v1

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Background

Diabetes mellitus is a growing health concern affecting more than 6.2% of the global population.This cross-sectional study aimed to investigate the association of knowledge, attitude, and practice (KAP) of patients diagnosed with type II diabetes mellitus (DM II) with demographic and clinical variables in Punjab, India, focusing on education to understanding knowledge gap and behavioral pattern of patients influencing prevention and control of disease.

Methods

The study was conducted from March 2022 to September 2023 at three outpatient clinics in Punjab.Data were collected through a modified questionnaire, covering demographic profiles and KAP variablesusing non-probability purposive sampling of 500 respondents with SPSS software.

Results

The study analyzed 500 patients (197 females, 303 males) aged 31–90 years. Key findings revealed that knowledge scores were higher in males (33.7%), married individuals (32.3%), degree holders (60.0%), and insured patients (40.9%). Attitude scores were better in males (50.2%), degree holders (75.3%), and insured patients (57.9%). Practice scores were higher among females (25.9%), unmarried (43.3%), and insured patients (23.2%). Significant predictors of high KAP scores included education, patient history, blood sugar levels, clinic visits, marital status, occupation, health insurance, and physical activity. Education status had a substantial impact on all KAP scores.

Conclusion

This study highlights disparities in knowledge, attitudes, and practices related to DM II management among patients in North India. Addressing these disparities through targeted interventions, community-based programs, and improved healthcare accessibility is crucial for promoting positive outcomes in diabetes mellitus.

Diabetes mellitus

type II diabetes mellitus

knowledge

attitude

practice

diabetes prevention and control

Diabetes mellitus, a chronic metabolic disorder, is characterized by sustained elevated blood glucose levels resulting from defective insulin secretion, ineffective insulin action, or both (1,2). Type II diabetes mellitus (DM II) poses substantial public health challenge, contributing significantly to morbidity and mortality (3,4). Globally, around 462 million people (6.2% of total population) were affected by DM II in 2017 (5), marking a surge in prevalence that burdens healthcare systems and communities. Effectively managing diabetes requires a comprehensive approach beyond medical interventions, with patients' knowledge, attitudes, and practices (KAP) playing a crucial role in prevention and control (6).

Recent studies have emphasized the importance of awareness among DM II patients for effective prevention and control of diabetes (7–9). Higher patient knowledge has been linked to favorable attitudes and practices regarding diabetes management (10). Demographic parameters, including age, gender, socioeconomic status, education, and cultural factors, significantly influence individuals' understanding and approach to diabetes management(11). Analyzing these parameters can reveal disparities in diabetes-related KAP among diverse demographic groups, guiding targeted educational interventions.

Identifying knowledge gaps and behavioral patterns is crucial for designing effective diabetes prevention and control strategies. Patients' misconceptions, lack of awareness and adherence to unhealthy lifestyles can hinder effective diabetes management. By pinpointing these gaps, healthcare professionals and policymakers can develop evidence-based interventions to bridge divides and promote accurate knowledge dissemination and positive behavioral changes.

Despite KAP contributing to improved quality of life and health outcomes in DM II patients, limited information is available on the association between demographic profiles and KAP in DM II patients from North India. This clinical study aims to unravel the complex relationship between demographic factors and diabetes prevention and control. Primary objectives are to analyze the influence of demographic parameters on the KAP of diabetes patients, identify knowledge gaps and behavioral patterns hindering prevention and control efforts, and establish a clear relationship between patients' KAP and actual control of DM II.

Establishing robust connection between patients' KAP and disease control is essential for evaluating effectiveness of existing diabetes management programs. Correlating these factors with clinical outcomes aims to elucidate impact of patients' beliefs and behaviors on the progression of DM II. This knowledge is pivotal for refining interventions to induce tangible improvements in disease control and overall well-being

Study setting and design

This cross-sectional study was carried out among patients diagnosed with DM II, receiving care at three outpatient clinics (Garg Hospital, Moga, Moga Medicity Hospital, and SD Thapar Hospital) in Punjab, India. The study was conducted from March 2022 to September 2023.

Study population, sampling method, inclusion, and exclusion criteria

Total population of Moga is 995,746 (Directorate of Census Operations, 2011 Justice) out of which 28.7 % woman’s and 25 % men’s (above 15 years) are suffering from type II diabetes mellitus (National Family Health Survey 2019-21 (NFHS-5)). The sample size of the study was calculated by taking the mean of sample size calculated by software Statcal Epiinfo and Raosoft at 95% confidence interval. Mean sample size for study was found to be 388 (500 sample will be taken). A total of 500 respondents were included in the study using non-probability purposive sampling methods, based on the specified inclusion and exclusion criteria (Figure 1). The study recruited both male and female participants >18 years of age with DM II[HbA1c >5.7% (39 mmol/mol)], provided they did not have any mental illnesses and were willing to provide informed consent. Pregnant and lactating women were excluded from the study.

Pilot testing, face validity, reliability and internal consistency of study tool

The study tool was pilot tested with 25 patients to as if the questions were readable and understandable. To test the stability of the scores over a short period of time, the test-retest method was used. The 25 patients were asked to answer the items twice. A short time interval (1 week) was let between both rounds. Scores obtained in the two rounds were correlated using Pearson’s correlation. Excellent stability of scores was indicated by a Pearson’s correlation coefficient (knowledge 0.954, attitude 0.911 practice.835) with p <0.001.Reliability accessed via Cronbach's alpha yielded a value of 0.72, signifying acceptable internal consistency.

Ethical approval

The study was approved by Institutional Ethics Committee of ISF College of Pharmacy, Moga (ECR/296/PB/2022/ISFCP/10). Prior to their participation, all patients were thoroughly briefed about the study details, and their informed consent was duly obtained. It is essential to note that inclusion in the study had no impact on the patients' ongoing treatment processes. To ensure utmost confidentiality, all patient information was securely stored and kept confidential.

Data collection and analysis

Data was collected using a pre-validated questionnaire on DM II with some modifications (12). First part of the questionnaire obtained informed consent while the second gathered demographic information and KAP variables. Patients' disease knowledge, assessed through multiple-choice questions, generated scores (0-40) categorized as poor (0-12), fair (13-26), or good (27-40). Attitudes were measured with a Likert scale (1-5) across nine questions, categorized as poor (<15), fair (15-30), or good (31-45). Practices were assessed with five categorical questions, with scores categorized as poor (0-2), fair (3-5), and good (6-7). Data analysis utilized SPSS version 25, with a 95% confidence interval. Data analysis utilized SPSS version 25, with a 95% confidence interval.Demographic and clinical variables were presented by using descriptive statistics. The difference of continuous variables between groups was analyzed using the chi-square test. Multiple linear regressions were applied to identify significant predictors of diabetes knowledge. Statistical tests were considered significant at p<0.05.

Patient’s demographics

Table 1compiles the demographic characteristics of included patients.The clinical trial included 500 participants from our previous study, comprising 197 females and 303 males, aged 31 to 90 years and weighingbetween 41 to >101 kgs. Educational backgrounds varied, 17% had graduation and 5.8% had master's degree. Majority of the patients (males and females) included in the study were illiterate as shown in Figure 2. Occupationally, 44% were employed, 22% unemployed, 21.2% homemakers, 10.4% retired, and 2.4% in other occupations. 254 participants had health insurance, while 246 did not have coverage. Notably, 81.4% patients exhibited blood HbA1c levels >6.5% (48 mmol/mol). Furthermore, physical activity was highest in patients who completed masters degree (Figure 3).

Identification of knowledge gaps and behavioral patterns that may influence diabetes prevention and control

The study revealed statistically significant (p<0.05) effects of various demographic parameters on knowledge scores related to diabetes prevention and control. Notably, marital status, education status, occupation, health insurance, family history, patient history, blood sugar, FBS, HbA1c, clinic visit, and physical activitysignificantly (p<0.05) influenced knowledge scores. Male patients (33.7%), married individuals (32.3%), those with a degree (60.0%) or master's (69.0%), working patients (46.4%), and those with health insurance (40.9%) reported higher knowledge scores.

Conversely, factors associated with poor knowledge scores included age >101 (100%), females (34%), widowed individuals (52.6%), illiterates (55.9%), unemployed (45.5%), housewives (42.5%), lack of health insurance (45.5%), no family history of diabetes (43.8%), diabetes history of 10 years (38.6%), elevated blood sugar levels, HbA1c level <6.0% (42 mmol/mol), annual clinic visits (36.6%), and mild physical activity (40.4%) (Table 1). These findings emphasize the diverse impact of demographic factors on patients' knowledge regarding diabetes prevention and control.

Identification of attitude score and behavioral patterns that may influence diabetes prevention and control

The study identified significant influences of demographic parameters on attitude scores related to diabetes prevention and control. Weight, age, gender, marital status, education status, occupation, health insurance, family history, patient history, clinic visit, and physical activity had a statistically significant (p<0.05) impact, while FSL, RBS, and HbA1c did not affect attitude scores significantly (p>0.05). More male patients (50.2%) exhibited good attitudes compared to females (36.0%), and higher percentages of those with a degree (75.3%) and masters (86.2%), health insurance (57.9%), family history (51.0%), and high physical activity (61.0%) reported positive attitudes. Conversely, patients with specific characteristics such as weight range 41-50 and 91-100, age group 71-80, widowed or divorced status, primary education, housewives, unemployment, lack of health insurance, no family history, 5 years of diabetes history, clinic visits every 6 months or once a year, and mild physical activity were associated with poor attitude scores (Table 1). These findings underscore the intricate relationship between demographic factors and attitudes toward diabetes prevention and control.

Identification of practice score and behavioral patterns that may influence diabetes prevention and control

Practice scores for diabetes prevention and controlwere significantly (p<0.05) affected by various demographic parameters including age, gender, marital status, education status, occupation, health insurance, family history, patient history, FSL, RBS, clinic visit, and physical activity.No significant (p>0.05) effect of HbA1c and weight on practice scores was observed.

Female patients (25.9%), unmarried individuals (43.3%), retired patients (30.8%), those with health insurance (23.2%), and those visiting diabetes clinics every 3 months (27.3%) reported higher percentages of good practice scores. Conversely, factors associated with poor practice scores included age group 31-40 (77.8%), both males and females (31%), divorced (52.9%), widowed (43.9%), illiterates (43.5%), housewives (37.7%), absence of health insurance (39%), no family history of diabetes (36.9%), recent diabetes diagnosis (38%), elevated FSL and RBS levels, clinic visits every 6 months or first-time visits, and mild physical activity (Table 1). These findings underscore the varied impact of demographic factors on patients' practices related to diabetes prevention and control.

Relationship between education status and KAP score

All parameters of knowledge score varied significantly (p<0.05) among diabetes patients grouped as per education status (Table 2). Patients with higher education were able to give correct answers on the knowledge regarding diabetes. Thus, this study shows the importance of education for spreading the awareness regarding diabetes among the patients.

Similar results were observed regarding attitude score (Table 3) and practice scores (Table 4) where there was statistically significant differences in the responses of patients as per education status and patients with higher education status showed higher attitude and practice scores.

Relationship between KAP scores:

By using chi square test association of knowledge, attitude and practice scores among DM II patients was found statistically significant (p< 0.05) with each other. Most of the patients (72.7%) had good knowledge and attitude towards DMII; more than half of patients had (52.8%) fair knowledge and practice, 52.9 % had fair practice but poor attitude towards disease (Table 5).

Predictors of knowledge, attitude and practice

This study used a multiple linear regression model to identifypredictors of knowledge, attitude, and practice scores. The R²of the model for knowledge, attitude, and practice was found to be 0.418, 0.334, and 0.255, respectively. The model showed that education status, patient history of diabetes, blood sugar level (RBS), and how often the patient attended the clinic were significantly associated with the high knowledge score (p<0.001). Additionally, marital status (p=0.008), occupation of the patient (p=0.029), health insurance (p=0.001), and physical activity (p=0.004) were also associated with the knowledge score (Table 6).

Furthermore, the model showed that marital status and education status were strongly (p<0.001) related to attitude score. Additionally, gender (p=0.01), patient history (p=0.002), and physical activity (p=0.04) were also moderately associated with attitude score (Table 6).

The model showed that age group, gender, and education status were significantly (p<0.001) associated with practice score. Additionally, marital status (p=0.003), occupation of the patient (p=0.003), health insurance (p=0.002), blood sugar level (FSL) (p=0.007), and how often the patient visited the clinic (p=0.041) were also associated with practice score (Table 6).

The study findings offer valuable insights into the multifaceted dynamics influencing knowledge, attitudes, and practices (KAP) in prevention and control of diabetes. The intricate nature of diabetes management is underscored, emphasizing the diverse impact of socio-demographic and lifestyle factors.

Significant knowledge disparities were uncovered among different demographic groups. Lower education levels, a longer history of diabetes, and engagement in mild or moderate physical activity were associated with notably lower knowledge levels. This aligns with research indicating that health education interventions significantly improve KAP scores in diabetes patients. For instance, Peyman and Anbarani's study (2015) demonstrated enhanced KAP in diabetes patients through health education, emphasizing the pivotal role of education in promoting effective management practices(13).

Education's critical role in health literacy is well-acknowledged, with higher educational attainment correlating with better knowledge about chronic disease prevention, including diabetes. The study emphasizes the need for continuous education and awareness campaigns targeting individuals with a longer diabetes history and those with lower physical activity, highlighting the importance of exercise in diabetes management(8).

Conversely, working individuals, retirees, those with health insurance, and regular clinic visitors exhibited higher knowledge levels. This aligns with the notion that healthcare accessibility and regular medical check-ups enhance awareness and knowledge about diabetes. Structured healthcare interventions positively impact patients' understanding, emphasizing the role of continuous medical guidance and regular check-ups(14,15).

The study delved into individuals' attitudes toward diabetes prevention and control, revealing that younger individuals, married individuals, and those with a family history of diabetes displayed more positive attitudes. These findings are consistent with prior research, suggesting that younger individuals may be more receptive to behaviour change. Having a family history can act as a motivator for positive attitudes, while marriage may provide social support for positive health behaviours.

Conversely, females, illiterates, and individuals with lower education levels and physical activity exhibited negative attitudes, emphasizing the need for targeted interventions and education programs. Gender disparities in attitudes may stem from cultural or societal factors, and lower education levels and physical inactivity contribute to less positive attitudes.

Variations in practices related to diabetes prevention and control were identified, influenced by factors such as gender, marital status, employment, and healthcare access. These findings align with research indicating that married individuals, those with healthcare access, and employed individuals have better practices in managing chronic conditions, emphasizing the impact of social and economic factors(16,17)However, in contrast to our findings, a population-based study reported that patients with diabetes>70 years showed positive attitude towards the disease(18).Having a family history of diabetes can serve as a motivator for adopting positive attitudes (19). Marriage may also provide social support and encouragement for positive health behaviours (20).

Furthermore, the current study shows that patients with higher education had higher KAP scores. This highlights the importance of education status in spreading the awareness regarding the disease among patients.

In summary, this research provides a comprehensive understanding of the interplay between demographic parameters, knowledge, attitudes, practices, and disease control among type IIdiabetes mellitus (DMII) patients. By shedding light on these interconnected factors, study aims to inform healthcare practitioners, policymakers, and researchers, facilitating the development of targeted interventions that bridge knowledge gaps, modify negative attitudes, and encourage positive practices. Ultimately, the research holds the potential to transform diabetes management strategies, leading to improved health outcomes and a higher quality of life for individuals affected by this pervasive chronic condition.

Limitations and Recommendations:

While this study provides valuable insights, it is essential to acknowledge its limitations. The cross-sectional nature of the study restricts the establishment of causality. Longitudinal studies could provide a deeper understanding of the changes in KAP variables over time. Additionally, the study's geographical focus on North India might limit the generalizability of the findings to other regions.

In conclusion, this study provides valuable insights into the complex interplay of demographic, lifestyle, and healthcare-related factors that influence knowledge, attitude, and practice in diabetes prevention and control. These findings highlight the importance of targeted interventions and educational programs to improve diabetes management, especially for vulnerable populations.

Acknowledgments:

We acknowledge the patients for sharing their details and thanks to I.K.G. P.T.U Jalandhar, ISF College of Pharmacy, Moga, Punjab, and SD Thappar, Moga, Garg Hospital, Moga Medicity Punjab Hospital staff for the continuous support provided.

Conflict of interest:

The authors declare that they do not have any conflicts of interest.

Ethical approval:

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional Ethics Committee of ISF College of Pharmacy, Moga (ECR/296/PB/2022/ISFCP/10).

Informed consent:

Informed consent was obtained from all participants

Funding: This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Author contributions:

Sandeep kaur: Major contributor in writing, drafting and editing of the manuscript, data collection, original draft preparation. Dr. G.D Gupta: Supervision and data analysis.

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Tables 1 to 6 are available in the Supplementary Files section.

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Understanding the Impact of Literacy on Knowledge Gap and Behaviour Pattern among Diabetic Patients: A Cross-Sectional Study

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