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Table of Contents
Year : 2021  |  Volume : 20  |  Issue : 3  |  Page : 222-227  

Diabetes-related knowledge, attitude, and practice among outpatients of a tertiary hospital in North-western Nigeria

1 Department of Medicine, Mohammad Abdullahi Wase Teaching Hospital, Kano, Nigeria
2 Department of Medicine, College of Health Science, Bayero University, Kano, Nigeria
3 Department of Medicine, University of Medical Science Teaching Hospital Complex, Akure, Nigeria

Date of Submission29-May-2020
Date of Acceptance11-Mar-2021
Date of Web Publication17-Sep-2021

Correspondence Address:
Dr. Fakhraddeen Yahya Muhammad
Department of Medicine, Mohammad Abdullahi Wase Teaching Hospital, Kano
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/aam.aam_48_20

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Introduction: One of the challenges facing the management of diabetes is the misconception and inadequate knowledge about the disease. We assessed the level of diabetes-related knowledge, attitude, and practice (KAP) among patients with diabetes in North-western Nigeria. Materials and Methods: This was a hospital-based cross-sectional study. A total of 400 participants were recruited. A KAP questionnaire was used to assess the KAP of the patients. Glycated hemoglobin was used to measure the level of glucose control of the study participants. Results: The mean age of the patients was 51 years, majority being females 233 (58.3%). The mean knowledge score was 6.2 ± 3.1 points (out of 15), average attitude score was 2.5 ± 1.5 points (out of 5), and the mean practice score was 2.1 ± 1.3 points (out of 6). The level of KAP was found to be directly related to glycemic control (P < 0.01). The level of education (odds ratio [OR]: 5.0 and 95% confidence interval [CI]: 0.196–0.452) and monthly income (OR: 4.4 and 95% CI: 0.123–0.326) were found to be independent predictors of diabetes-related KAP. Conclusion: The study has demonstrated poor diabetes-related KAP. The patient's level of education and income plays a major role in the management of diabetes.

   Abstract in French 

Introduction: L'un des défis auxquels est confrontée la gestion du diabète est l'idée fausse et les connaissances insuffisantes sur la maladie. Nous avons évalué le niveau de connaissances, d'attitudes et de pratiques liées au diabète chez les patients atteints de diabète dans le nord-ouest du Nigéria. Matériel et méthodes: Il s'agissait d'une étude transversale en milieu hospitalier. Au total, 400 participants ont été recrutés. Un questionnaire CAP a été utilisé pour évaluer le KAP des patients. L'hémoglobine glyquée a été utilisée pour mesurer le niveau de contrôle du glucose des participants à l'étude. Résultats: L'âge moyen des patients était de 51 ans, la majorité étant des femmes 233 (58,3%). Le score de connaissance moyen était de 6,2 ± 3,1 points (horssur 15), le score d'attitude moyen était de 2,5 ± 1,5 points (sur 5) et le score moyen de pratique était de 2,1 ± 1,3 points (sur 6). Le niveau de KAP s'est avérée être directement liée au contrôle glycémique (P <0,01). Le niveau d'éducation (odds ratio [OR]: 5,0 et intervalle de confiance à 95% [IC]: 0,196 à 0,452) et le revenu mensuel (OR: 4,4 et IC à 95%: 0,123 à 0,326) se sont avérés être des prédicteurs indépendants de la KAP liée au diabète. Conclusion: L'étude a démontré une faible CAP liée au diabète. Le niveau d'éducation et le revenu du patient jouent un rôle majeur dans la gestion du diabète.

Keywords: Diabetes mellitus, knowledge, attitude, practice, North-western Nigeria
Mots clés: diabète sucré, connaissances, attitude, pratique, nord-ouest du Nigéria

How to cite this article:
Muhammad FY, Iliyasu G, Uloko AE, Gezawa ID, Christiana EA. Diabetes-related knowledge, attitude, and practice among outpatients of a tertiary hospital in North-western Nigeria. Ann Afr Med 2021;20:222-7

How to cite this URL:
Muhammad FY, Iliyasu G, Uloko AE, Gezawa ID, Christiana EA. Diabetes-related knowledge, attitude, and practice among outpatients of a tertiary hospital in North-western Nigeria. Ann Afr Med [serial online] 2021 [cited 2023 Oct 2];20:222-7. Available from:

   Introduction Top

Diabetes mellitus is a chronic health condition which has a lifetime management needs as it affects vital organs in the body such as the eyes, heart, kidneys, brain, and the nerves.[1] The long-term effect of diabetes on these organs is the development of blindness, heart failure, kidney failure, stroke, and foot diseases, respectively.[2] These complications arise when the disease is not adequately managed. The effect of sustained elevation of blood sugar results in damage to the small and large blood vessels in the body. Injury to the small blood vessels is more common results in affectation of the eyes (diabetes retinopathy), kidneys (diabetes nephropathy), and limbs (from diabetes neuropathy). Damage to the large vessels causes heart attack (myocardial infarction) and stroke (cerebrovascular disease).[3] Diabetic complications could be prevented or delayed, which are the whole aim of managing the diabetes mellitus. It also saves cost and reduces mortality and morbidity associated with the health condition. However, management of diabetes requires a more significant commitment of the patients suffering from the condition in addition to the one provided by the health workers and caregivers.[4] One of the challenges facing the management of patients with this condition is the misconception and inadequate knowledge about the disease regarding its etiology and outcome from the patients' perspective.[5] Therefore, the prevention of these complications could not be achieved if diabetic patients do not play their role regarding managing their situation concerning lifestyle modification and use of medication.[6]

The aim of the study was therefore to assess the level of diabetes-related knowledge, attitude, and practice (KAP) and its relationship to glycemic control among patients with diabetes in a diabetic clinic in north-western Nigeria.

   Materials and Methods Top

The study was a hospital-based cross-sectional study among adult patients attending diabetic clinic of Muhammad Abdullahi Wase Specialist Hospital which is located in Kano city. The center is a tertiary health facility and receives referrals from secondary health centers in Kano city. The hospital has a bed capacity of two hundred and forty with four central departments, namely medicine, surgery, pediatrics, and obstetrics and gynecology. The diabetic clinic was the primary site of the study. The clinic runs on Mondays only and is managed by two consultant endocrinologists, two diabetic nurses, two nutritionists, and two record officers. The clinic receives an average of sixty diabetic patients per clinic day with an average doctor to patient ratio of 1:30. Ninety percent of the diabetic patients are type 2 diabetic. Most of the patients reside within Kano city with few from neighboring towns. Kano city is the capital of Kano state in North-western Nigeria. The region is located along latitude 12°N and longitude 8°31 iE. The city has an area of approximately 499 km2 with a population of 2,828,861 inhabitants making a population density of 14,000/km2.[7] Most of the activities in the town are sedentary which include trading, banking, and civil service. Feeding habit is mixed Western and Arab. The staple food of the inhabitants of Kano consists of meat, millet, flour, yogurt, and rice which are rich in fat and simple sugars and predispose to weight gain. This lifestyle contributes to the high prevalence of diabetes particularly type 2.[8]

The sample size was calculated using the formula for cross-sectional study n = z2pq/d.[9] The minimum sample size (n) was calculated using a constant (z) at 95% confidence interval (CI) (i.e., 1.96), the estimation of the prevalence of poor knowledge regarding type of diabetes from literature expressed as a fraction of 100 (4.0% = 0.04), complement probability of 0.96, and an absolute precision limit required of 2%.[10] The minimum number of participants required was found to be 368. However, 400 persons were recruited for the study to cover for nonresponse.

The research employed systematic random sampling techniques to choose the participants. The clinic register of the patients was used as a sampling frame. The sampling interval was calculated using the mean number of diabetic patients that are consulted in the clinic over 3 months (807). The 400 were selected out of the 807 patients giving a sampling interval of 807 ⁄ 400 = 2. Therefore, every 2nd diabetic patient was enrolled as part of the study group until the required sample size was obtained. All the 400 participants recruited participated in the study with no nonresponse.

Research assistants who are community health extension workers assisted in the recruitment after been trained by the lead researcher on data collection and ethics. Patients that came to the weekly diabetic clinic were informed about the study, and those that were willing to participate were recruited after a written informed consent. A well-structured questionnaire was used to collect the demographic details of the patients which include age, gender, tribe, religion, educational status, employment status, monthly income, etc., Data on KAP related to diabetes were obtained using a KAP questionnaire adopted and modified from Subish and Leelavathy.[11] The tool has been previously validated. (11) The questionnaire had a total of 25 questions (14 – knowledge, 5 – attitude, and 6 – practice) aside from the section on biodata and diabetes history. In the knowledge section, the questionnaire inquires about the definition, presentation, and management of diabetes. The attitude section, mainly dwelled on self-management, while the practice part highlighted on monitoring the disease and its complications. A correct response was given a mark of “one,” and each wrong answer was given a score of “zero.” The median scores of the respondents for each of knowledge (5), attitude (2), and practice (2) were used as the yardstick to assess good KAP versus poor KAP, respectively. The overall KAP score for each participant was derived by adding the individual KAP scores. The median of the overall KAP (9) score was used as a yardstick to assess good versus poor overall KAP score. The consent form and questionnaire were translated to the local language (Hausa) as needed. The questionnaire was piloted among twenty patients who were not part of the study group and were recruited outside the study site. The piloting was done to test the appropriateness and clarity of the questionnaire.

Laboratory procedures: After counseling the patients on the laboratory protocols, a trained phlebotomist took 5 ml of whole blood sample under aseptic measures into an ethylenediaminetetraacetic acid container. The blood was used for the quantitative assay of glycated hemoglobin (HbA1C) using Cobas-e411 automated autoanalyzer Roche-Hitachi.[12] A HbA1C of <7% was taken as good long-term control for diabetes while 7% and above was deemed as poor control.[2]

The data were coded, and a password-protected Microsoft Excel software was used to store all the information. The analysis of the data collected was done using the software package SPSS (Statistical Package for the Social Sciences) for Windows version 16.0. International Business Machine Corporation (IBM), Chicago, Illinois, USA. Chi-square test was employed to do descriptive statistics with differences in the KAP variables and also their association with outcome (HbA1C). P value estimate of <0.05 was taken as statistically significant. Univariate and multivariate analyses were used to explore determinants and predictors of good KAP.[13] The analyzed data were presented using tables.[14]

Approvals were obtained from the research ethics committee of the University of Roehampton and the health authorities of Kano State. The provision of Helsinki declaration guided the study.[15]

   Results Top

The results of all the 400 participants that were administered the questionnaire were obtained with no nonresponse. The mean age of the patients' was 51 years (±7.3) with majority (195 [48.8%]) belonging to the bracket of 45–59 years. Participants (109 [27.3%]) above 65 years made up a little above a quarter of the patients. Majority of the patients were females, 233 (58.3%), and 333 (83.2%) had attained at least secondary level of education. More than half 209 (52.3%) had positive family history of diabetes mellitus among first-degree relatives [Table 1].
Table 1: Baseline characteristics of study participants

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The mean knowledge score was 6.2 ± 3.1 points (out of 15). Only 5 patients out of the 400 (1.3%) knew the meaning of diabetes mellitus. Majority of the patients did not know the accurate method of monitoring diabetes 348 (87%). Only 133 (33.6%) knew what a balanced diet comprised. The average score of the patients' attitude was 2.5 ± 1.5 points out of a score of 5 points. Most of the participants 242 (60.5%) lack the awareness of drug-induced hypoglycemia. The mean of the patients' practice toward diabetes was 2.1 ± 1.3 points (out of 6) [Table 2]. Most of the patients' reported keeping up with their physician appointment on regular basis 351 (88%), regular blood sugar check 335 (83.8%), and blood pressure monitoring 317 (79.3%). However, only a small percentage reported having their eyes 41 (10.3%), urine 112 (28%), and lipids 21 (5.3%) check as requested by the guideline.
Table 2: Distribution of study participants' according to their scores on knowledge, attitude, and practice and overall knowledge, attitude, practice

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A better mean KAP was observed among educated versus noneducated (mean KAP 11.5 ± 5.3 vs. 7.0 ± 3.4; P < 0.01), employed versus unemployed (133 [33.3%] vs. 19 [4.8%]; P < 0.01), and those with good income (monthly income >50 dollars) versus low income (>50$ vs. ≤ 50$; P < 0.01) [Table 3]. The mean duration of diabetes was not found to be associated with the mean KAP score (7.8 ± 6.4 years vs. 7.8 ± 7.1 years, P = 0.441).
Table 3: Comparison of study participants' sociodemographic and clinical characteristics with their mean knowledge, attitude, practice score

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The mean HbA1C of the respondents was 8.5 ± 2.3 percent. Two hundred and forty-eight (62%) participants have poor glycemic control. There was a statistically significant relationship between the diabetes-related knowledge and attitude of the participants (P < 0.01). Furthermore, diabetes-related knowledge and practice affected each other significantly (P < 0.01). Similar relationship was also observed between diabetes-related attitude and practice (P < 0.01) [Table 4]. Participants with good KAP 75 (18.7%) were found to have a good control of diabetes as demonstrated by HbA1C < 7% and vice versa (P < 0.01) [Table 5].
Table 4: Analysis of participant's attitude and practice scores in relation to knowledge as well as participant's practice scores in relation to attitude

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Table 5: Association between study participants' diabetes-knowledge, attitude, practice and their glycated hemoglobin

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In a multivariate analysis, only education (odds ratio [OR]: 5.0 and 95% CI: 0.196–0.452) and monthly income earning (OR: 4.4 and 95% CI: 0.123–0.326) were found to be independent predictors of diabetes-related KAP, after subjecting all the significant variables to logistic (binary) regression [Table 6].
Table 6: Independent predictors of diabetes-related knowledge, attitude, practice

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   Discussion Top

The KAP scores of the study participants toward diabetes mellitus were generally poor. Majority of the respondents do not know the meaning of diabetes mellitus. Some attributed it to a curse by rivals. This superstitious belief is a common misconception among Africans regarding chronic diseases, and this is the reason why most of them resort to traditional ways of management such as prayers, use of herbs, and incantations.[16] A cohort study carried out at an Urban Health Centre in Ariyankuppam, Pondicherry, India, concluded that most of the participants believe that diabetes could be cured through prayers and use of “Bitter foods” which reduce blood sugar levels.[17] However, the drawback of the survey is the inclusion of nondiabetics as one study cohort, as this group of participants would not have the motivation of knowing what diabetes is since they are not affected by the illness. Similarly, in Pakistan, another cross-sectional community-based investigation revealed poor knowledge among the respondents after using a cutoff score of 6 and above in a scale of 9 to assess for the level of diabetes-related knowledge among the participants.[18] The conclusions from our study and those of the Indian and Pakistan cast doubt on how these patients have being managed for years without knowing what they are being treated for over this period. The poor knowledge may be one of the reasons why these patients do not comply with their medication because they assume that diabetes is an acute illness and one need not take medication for long. Most of them stop their medication when they feel no symptom. The consequence of this poor compliance is the accelerated development of complications which have a financial and social burden on the patients and their families.

A community-based cross-sectional study in Bangladesh demonstrated mean scores of 41 ± 16, 85 ± 12, and 57 ± 30 for KAP, respectively, among the participants with attitude having a better score compared to knowledge and practice.[19] Similarly, our study also demonstrated attitude and practice to be better than knowledge. Al-Maskari et al. found a lack of adequate diabetes-related knowledge among diabetic patients in the United Arab Emirates (UAE) which caused a poor outcome of their disease using HbA1C even though their attitude and practice toward the disease were satisfactory.[20]

Lack of higher level of education has been shown to be one of the factors that caused poor diabetes-related KAP among most of the participants. This is because improved education provides more access to literature and increase overall better understanding of someone's health condition. However, the participants' educational level was demonstrated to be significantly related and a predictor to a better KAP. This finding is similar to what was found among Nepalese diabetic patients in an institutional-based cross-sectional study where KAP score was seventeen times higher among graduates compared to less educated participants.[21] Another study by Salem et al., in Riyadh, between diabetic and nondiabetic participants demonstrated educational level to correlate positively with KAP scores among the two groups of participants.[22]

One of the reasons for poor diabetes-related knowledge among our patients with diabetes is the lack of an adequately trained workforce to handle their condition. Our study area has a population of ten million people, with only six trained endocrinologist with no diabetic nurse or a nutritionist.[23] The number of patients with the disease condition is enormous for these doctors to handle and hence has little or no time to educate these patients on their disease condition. Patient's education on diabetes has been shown to play a vital role in the management of the disease condition. This has been proved by Shrivastava et al.[24] A case–control study done in a tertiary hospital in India also emphasizes the need for health professionals to inculcate diabetic education as part of care for patients with diabetes.[25]

We also found level of income as a predictor of good KAP. This finding is similar to what was obtained among diabetic patients in a hospital-based cross-sectional study in Tigray, Northern Ethiopia, where earning higher income was a determinant of proper knowledge, attitude, and self-care practice of the participants.[26]

The poor KAP scores observed in this study was related to the large number of participants with high HbA1C. HbA1C >7 mmol/l is a sign of poorly controlled diabetes which accelerates the development of complications and increased the mortality rate.[27] A similar cross-sectional study in Shanghai, China, among patients with type 2 diabetes demonstrated that patients having a higher knowledge score were more likely to achieve control of their blood glucose.[28] Another interventional study done in Port Said, Egypt, showed a marked decrease in HbA1C following the introduction of diabetic education among the participants.[29] A survey done among type 2 diabetic patients in Gujarat, India, found a strong positive correlation between KAP and glycemic control level.[30] These findings further strengthened the fact that patients play an essential role in the management of their disease condition and they have to have adequate knowledge regarding their disease for them to make this contribution. On the contrary, a survey done among type 2 diabetic patients with end-stage kidney disease and are on dialysis found a negative correlation between the level of KAP and HbA1C.[31] However, other factors such as inadequate metabolism of insulin and glucose may affect HbA1C in patients with chronic kidney disease.

Poor KAP significantly affects the outcome of diabetes which leads to increase morbidity and mortality associated with the health condition. Nigeria like other developing countries is still battling with managing infectious diseases using limited resources. The additional burden of noncommunicable long-term diseases such as stroke, kidney, and heart failure will further deplete the little resources directly from both direct and nondirect medical cost of illness and indirectly through the loss of workforce. These complications reduce the life span of those affected, and this leads to many individuals dying at their productive age which affects the economy of the country.[32] This effect poses a challenge on public health practitioners in third world countries to give more emphasis on enlightenment and prevention of noncommunicable diseases such as diabetes, hypertension, and cancers. Most of the public health practitioners in Nigeria are specialist in preventing infectious diseases, maternal, and child health. The finding from this study and other similar ones in the country will pose a challenge for these health workers to seek a specialization on the prevention of noncommunicable diseases such as diabetes, hypertension, and cancers.

The study is limited by being a hospital-based study and only seeks information from diabetic patients with positive health-seeking behavior. Therefore, community-based research needs to be carried out to explore the level of understanding on diabetes among people living with diabetes and those without the disease in the community. Our study should also form a basis for a before and after diabetes-related health education intervention study to compare the change in KAP and glycemic control.

   Conclusion Top

The study has demonstrated poor diabetes-related KAP among patients living with diabetes mellitus in a resource-limited setting. The study has also highlighted the significant role; a patient's level of education and income plays in the management of diabetes. The study has further emphasized that the poor KAP was associated with poor long-term glycemic control which could lead to the unfortunate outcome of diabetes regarding complications.

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Conflicts of interest

There are no conflicts of interest.

   References Top

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  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]


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