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To Assess and Compare the Knowledge, Attitude and Practice of Patients with Diabetes in Control and Intervention Groups
Potha Amulya Reddy Kunchithapatham SaravananAkkala Madhukar
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2023 年 46 巻 4 号 p. 586-591

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Abstract

Diabetes is a combination of heterogeneous disorders presenting with episodes of hyperglycemia and glucose intolerance, as a result of lack of insulin, defective insulin action, or both. There are more than 387 million people with Diabetes Mellitus (DM) and the number is likely to reach 592 million by 2035. The prevalence of DM is 9.1% in India. With increasing incidence of diabetes worldwide, evaluation of diabetes knowledge, attitude and practice (KAP) has become crucial for guiding behavioral changes for persons with diabetes and individuals at risk. KAP-related studies are important in tailoring a health programme to help curb the threats caused by the disease. Adequate information helps the public understand the risks of diabetes and its complications, seeks treatment of existing disease, takes preventive measures and develops proactive attitude towards health. This was an interventional study where patients of either gender with ≥1-year history of DM were enrolled into the study after obtaining the consent. A total of 200 patients were included in this study. The p-value (<0.0001) showed that there was significant improvement in the KAP score of intervention group patients from baseline to follow up compared to that of control group. This study shows that improvement in knowledge of the disease has positive impact on Attitude and Practice of the subjects, thus improving their glycemic control.

INTRODUCTION

Diabetes is one of the most common chronic diseases worldwide.1) The number of people with type 2 diabetes began to rise globally in the 1990 s, and since 2000, the world has seen a dramatic increase.2) According to the International Diabetes Federation (IDF), 8.8% of the adult population have diabetes, with men having slightly higher rates (9.6%) than women (9.0%). Current global statistics shows that 463 million and 374 million individuals have diabetes and impaired glucose tolerance (IGT), a prediabetic condition. These numbers are estimated to increase to 700 million people with diabetes and 548 million people with IGT by 2045, which represents a 51% increase compared to 2019.3)

According to the IDF in 2019, the top three countries with the highest number of individuals with diabetes are China (116.4 million), India (77.0 million), and the U.S.A. (31.0 million). This trend is expected to continue in 2030 and 2045, with China (140.5 and 147.2 million) and India (101.0 and 134.2 million) continuing to have the highest burden of diabetes.4)

The prevalence of Diabetes is 9.1% in India. Life style management is the basis of management of diabetes mellitus (DM) and is recognized as being an essential part of diabetes and cardiovascular disease prevention.5) Uncontrolled blood glucose in the long term will lead to micro vascular and macro vascular complications with increased morbidity and mortality and negatively affects the QOL. In order to minimize the complications of Diabetes there is a requirement for comprehensive diabetes care which is a complex task that takes the entire team of healthcare professionals including the pharmacist to work together to provide, multidisciplinary care for patients.6)

With increasing incidence of diabetes worldwide, evaluation of diabetes knowledge, attitude and practice (KAP) has become crucial for guiding behavioral changes for persons with diabetes and individuals at risk. When treating patients with diabetes, it is essential to improve lifestyle habits before using medication.7) KAP-related studies are important in tailoring a health programme to help curb the threats caused by the disease. Adequate information helps the public understand the risks of diabetes and its complications, seeks treatment of existing disease, takes preventive measures and develops proactive attitude towards health.8)

Knowledge is a set of understandings. It is also one’s capacity to imagine, one’s way of perceiving. The degree of knowledge assessed helps to locate areas where information and education efforts remain to be exerted.9) Attitude is an intermediate variable between the situation and the response to the situation. Attitudes are not directly observable as are practices, thus it is a good idea to assess them. Practices or behaviors are the observable actions of an individual in response to a stimulus.10)

There are evidences that show patient education and awareness are effective in reducing the complications of diabetes.11)

There is a need to assess Knowledge, Attitude and Practice of patients with diabetes in order to aid in future development of control programs and techniques for effective health education and patients counselling. This helps in ensuring that each patient with diabetes has sufficient information and are motivated to lead a better life. Hence, this study was intended to evaluate the Knowledge, Attitude and Practice of patients with Diabetes.12)

MATERIALS AND METHODS

Study Design and Data Collection

This was an interventional study where male and female patients with ≥1-year history of Diabetes Mellitus were enrolled into the study after obtaining the consent. Patients who were not willing to give their consent were excluded.

The study was conducted at Yashoda hospitals, Hyderabad from August 2019 to January 2021. Informed consent was obtained from all the patients involved in this study, and the study was notified and accepted by ethics committee, ECR/244/Indt/AP/2015/RR-18.

Every alternate patient was randomly grouped under Control and Intervention groups. Patients of both the groups were assessed for KAP at baseline as well as follow up, which was 90 d from baseline.

The KAP questionnaire consisted of 27 questions in both English and Telugu versions through which Knowledge, Attitude and Practice of patients were assessed.

Patient details were collected using the case report form, and KAP was assessed. A Patient data collection form was designed to collect the demographic and laboratory details. An informed consent form consisting of the study information was prepared in the regional language.

Patient counseling was given verbally and through Patient information leaflets only to the patients of Intervention group after collecting the baseline KAP at the hospital and twice telephonically during the period of 90 d. KAP of the patients who did not turn up for follow up visit was assessed telephonically. Patients of the control group also were counselled, however at follow up, after assessing the KAP. The counselling session lasted for 20–30 min for each patient and included information about Diabetes, its symptoms, etiology, complications, normal ranges of fasting blood sugar (FBS), postprandial blood sugar (PPBS). Also, importance of lifestyle modifications like planned diet, regular exercise was explained. Patients were also counselled to regularly monitor their body weight and blood glucose levels. Depending on the history of Diabetes and age, patients had different perceptions and knowledge of the disease, so accordingly the patients were counselled.

A total of 200 DM patients were included in the study of which 100 were of Intervention and 100 were of Control group.

After obtaining the consent from the patients through the informed consent form, information was gathered into patient data collection form that contained the socio demographic details of the patient like age, sex, educational qualification, occupation, family annual income, social and family history and also data on comorbid diseases. Data on Blood glucose levels (FBS, PPBS) and glicated hemoglobin (HbA1C) was also obtained and assessed.

The KAP questionnaire was closed ended consisting of 12 Knowledge, 8 Attitude and 7 Practice questions with only two Options-Yes or No, where option yes was considered correct and no was considered incorrect. Each correct answer was given a score 1 and incorrect answer was given a score 0. Total scores of Knowledge, Attitude and Practice were added together to yield the final KAP score, where 25 was the highest and 0 was the least KAP score a subject could get. The questionnaire was reviewed by Doctors and fellow pharmacists. Reliability of the questionnaire was calculated using “Kuder Richardson 21 (KR21)” method using a sample data of KAP score from 20 patients. Kuder Richardson method is a measure of internal consistency reliability for measures with dichotomous questions, which are ones that only offer two possible answers, which are typically presented to survey takers in the following format–Yes or No, True or False, Agree or Disagree and Fair or Unfair. KR-21 scores range from 0–1 (although it is possible to obtain a negative score); 0 indicates no reliability and 1 represents perfect test reliability. A KR-21 score above 0.70 is generally considered to represent a reasonable level of internal consistency reliability. After applying the formula, the scores obtained for Knowledge, Attitude, Practice and KAP were 0.71, 0.80, 0.71, and 0.75, respectively.

The questions on Knowledge covered definition, symptoms, etiology, risk factors, complications of diabetes, normal ranges of FBS and PPBS and symptoms of hypoglycemia with its immediate treatment. The questions on Attitude covered information that can assess the patients’ attitude towards regular monitoring of body weight, blood glucose level, exercise following a planned diet and taking medications regularly. The questions on Practice covered information on the patients’ contribution towards management of DM in terms of following a planned diet, exercise, regular monitoring of weight and glucose levels.

Statistical Analysis

Descriptive and inferential statistical analysis was carried out in this study. Continuous data was analyzed by mean and standard deviation. Categorical data analyzed by counts and percentages. For calculating level of significance for two continuous variables, paired t-test was used and for more than two variables ANOVA was used.

Software like SAS 9.2 was used for the Statistical Analysis of the data, MS Word and XL Sheets were used to generate Tables and Graphs.

RESULTS

A total of 200 patients were included in this study. The majority of patients were recruited prior to the onset of the coronavirus disease 2019 (COVID-19) pandemic.

Majority of the patients were in the age group of 50–59 years in control (39%) and 60–69 years intervention group (41%), with least in 30–39 years in control (1%) and 70–79 years in the intervention group (7%).

Majority of them were males in both control (53%) and intervention groups (55%). Major part of control group patients was qualified for Intermediate (39%), while Primary in intervention group (36%). Most of the patients were private employees in both control (37%) and intervention (42%) groups. The demographic profile of control and intervention groups is depicted in Table 1.

Table 1. Demographic Profile of Patients in Control and Intervention Groups
ControlIntervention
Age (in years)%Age (in years)%
30–39130–390
40–491840–4919
50–593950–5933
60–693660–6941
70–79670–797
Gender%Gender%
F47F45
M53M55
Educational qualification%Educational qualification%
Graduate34Graduate12
High School7High School16
Illiterate9Illiterate16
Intermediate39Intermediate20
Primary11Primary36
Occupation%Occupation%
Farmer8Farmer8
Govt. employee5Govt. employee6
House wife34House wife34
Private employee37Private employee42
Retired16Retired10
Family annual income%Family annual income%
<2000008<20000019
>20000092>20000081
Smoker%Smoker%
1–2/d71–2/d7
5–6/d63–5/d2
Non-smoker87Non-smoker91
Alcohol use%Alcohol use%
Daily once2Daily once1
Daily more than once1Daily more than once0
Occasionally12Occasionally18
Weekly once8Weekly once9
Non-alcoholic77Non-alcoholic72
Family history%Family history%
DM4DM1
DM, HTN3DM and HTN5
HTN2HTN3
No family history89No family history91

Most of the patients had a 6–10 years’ history of DM in both control (49%) and intervention (59%) groups. The most common comorbidity was hypertension (HTN) with 19% in control and 16% in intervention groups. Only 36% from control and 4% from intervention groups had their FBS levels in the range of 75–104 mg/dL. None of the patients had their PPBS in normal ranges. None from intervention and only 12% from control had their HbA1C below 7% (refer Table 2).

Table 2. Clinical Profile of Patients in Control and Intervention Groups
ControlIntervention
History of DM (in years)%History of DM (in years)%
1–5461–532
6–10496–1059
11–15211–157
16–20316–202
Comorbidities%Comorbidities%
CAD7CAD4
Diabetic retinopathy2Diabetic retinopathy2
Foot ulcer2Foot ulcer1
HTN17HTN16
HTN, COPD1Nephropathy4
HTN, thyroid1Neuropathic pain8
Neuropathic pain7THYROID2
Thyroid2No comorbidity63
No comorbidity61
FBS%FBS%
75–1043675–1044
105–13415105–13427
135–16424135–16461
165–19425165–1948
PPBS%PPBS%
145–17419145–17427
175–20474175–20460
205–2347205–2348
235–2640235–2645
HbA1C%HbA1C%
6.5–7.5296.5–7.52
7.5–8.5417.5–8.526
8.5–9.5168.5–9.563
9.5–10.5149.5–10.59

Impact of Clinical Pharmacist Intervention (Patient Counselling) on KAP of Patients with Diabetes Mellitus

The mean KAP score in control group at baseline was 11.65 and at follow up was 11.61, while mean KAP score in intervention group at baseline was 9.42 and at follow up was 19.9, thus showing improvement of KAP in intervention group compared to control. The p-value (<0.0001) showed that there was significant improvement in the KAP score in intervention group (Table 3).

Table 3. Comparison of KAP, Knowledge, Attitude and Practice Scores in Control and Intervention Groups
KAPControl (Mean ± S.D.)p-ValueIntervention (Mean ± S.D.)p-Value
Baseline11.65 ± 2.620.78319.42 ± 2.76p < 0.0001
Follow up11.61 ± 2.2719.9 ± 3.22
Knowledge
Baseline5 ± 0.90.13133.32 ± 1.23p < 0.0001
Follow up4.92 ± 1.099.28 ± 1.39
Attitude
Baseline4.04 ± 1.080.77444.07 ± 1.2p < 0.0001
Follow up4.06 ± 1.056.43 ± 1.39
Practice
Baseline2.61 ± 0.860.78312.03 ± 0.93p < 0.0001
Follow up2.63 ± 0.764.19 ± 1.28

Assessment and Comparison of the Individual Knowledge, Attitude and Practice Scores at Baseline and Follow-Up

The mean Knowledge score in control group at baseline was 5 and at follow up was 4.92, while mean Knowledge score in intervention group at baseline was 3.23 and at follow up was 9.28, thus showing improvement in Knowledge in intervention group compared to control. The p-value (<0.0001) showed that there was significant improvement in the Knowledge score in intervention group (Table 3).

The mean Attitude score in control group at baseline was 4.04 and at follow up was 4.06, while mean Attitude score in intervention group at baseline was 4.07 and at follow up was 6.43, thus showing improvement in Attitude in intervention group compared to control. The p-value (<0.0001) showed that there was significant improvement in the Attitude score in intervention group (Table 3).

The mean Practice score in control group at baseline was 2.61 and at follow up was 2.63, while mean Practice score in intervention group at baseline was 2.03 and at follow up was 4.19, thus showing improvement in Practice in intervention group compared to control. The p-value (<0.0001) showed that there was significant improvement in the Practice score in intervention group (Table 3).

Assessment of the Comparative Distribution of Total KAP Score in Control and Intervention Groups According to Their Demographic and Clinical Profile

Age

The highest mean KAP score in control group at baseline was seen in the age group of 70–79 years (12.2 ± 2.49) and at follow up was seen in the age group of 60–69 years (11.78 ± 2.43), while the highest mean score in intervention group at baseline (11.14 ± 2.85) and follow up (20.14 ± 4.67) was seen in the age group of 70–79 years.

Gender

The highest mean KAP score in control group at baseline (11.68 ± 2.64) and follow up (11.72 ± 2.17) was seen in males, while in intervention group females had higher mean KAP score at both baseline (9.49 ± 2.75) and follow up (20.02 ± 3.35).

Educational Qualification

The highest mean KAP score in control group at baseline (12.68 ± 1.97) and follow up (12.44 ± 1.67) was seen in graduates, while in intervention group high school graduates had higher mean KAP score at baseline (11.25 ± 2.72) and graduates had higher mean KAP score in follow up (21.58 ± 3.53).

Occupation

The highest mean KAP score in control group at baseline (12.11 ± 2.57) and follow up (12.05 ± 2.04), and in intervention group at baseline (10.51 ± 8.80) and follow up (20.86 ± 2.70) was seen in private employees.

Family Annual Income

Patients with higher annual income had higher KAP score at baseline and follow up in both control and intervention groups.

Smoking History

Non-smokers had a better KAP score than smokers in both control and intervention groups at baseline and follow up visits.

Alcohol Use

Non-alcoholics had a better KAP score than alcoholics in both control and intervention groups at baseline and follow up visits.

History of Diabetes

Patients with a greater history of DM had better KAP scores in both control and intervention groups at baseline and follow up visits.

Table 4 shows the comparison of correct responses to questionnaire in Control and Intervention groups at Baseline and Follow up. All the patients except 1 knew that diabetes is a condition of high level of sugar in the blood than normal, and all the patients from both the groups was aware that frequent hunger, thirst and urination are symptoms of diabetes. None from control and only 11% from intervention group was aware of the complications of diabetes. Eleven percent in control and 3% in intervention was aware that obesity and hereditary were the causes of diabetes. Only 30% from control and 19% from intervention group knew the symptoms of hypoglycemia, while only 10% from control and 11% from intervention knew the immediate treatment for hypoglycemia. None of the patients from both the groups knew the normal ranges for fasting and post prandial blood glucose levels at baseline.

Table 4. Comparison of Correct Responses to Questionnaire in Control and Intervention Groups at Baseline and Follow up
QuestionsControlIntervention
KnowledgeBaselineFollow upBaselineFollow up
1. Do you know that diabetes is a condition of high level of sugar in the blood than normal?10099100100
2. Do you know that frequent hunger, thirst and urination are symptoms of diabetes?100100100100
3. Do you know that diabetes is associated with certain complications like retinopathy, neuropathy, nephropathy and cardiovascular complications?0011100
4. Do you know that people of age 40years old are at higher risk of getting diabetes?4947870
5. Do you know that the major causes of diabetes are hereditary and obesity?11113100
6. Do you know the symptoms of hypoglycemia?30281990
7. Do you know the immediate treatment of hypoglycemia?10101180
8. Do you know the normal value of fasting blood sugar level?69661070
9. Do you know the normal value of post-prandial blood sugar level?010019
10. Do you know that pancreatic β-cells are affected when a person suffers with diabetes?00018
11. Do you know that there is low healing of cuts and wounds in patients with diabetes?3130091
12. Do you know that diabetes is incurable and requires a lifelong administration of medication?100917090
Attitude
1. Do you think that following a controlled (low sugar) and planned diet will help improve diabetes?8492100100
2. Do you think that regular exercise can help improve diabetes?919490100
3. Do you think missing doses of your diabetic medication will have a negative effect on your disease control?992091
4. Do you think you should keep in touch with your physician?19102139
5. Do you think that keeping the blood sugar close to normal can help to prevent the complications of diabetes?53621871
6. Do you think that once diabetes is controlled, eating restrictions are still required?30212871
7. Do you think that people with diabetes should control their weight?676180100
8. Do you think that diabetics should not skip their medication even when the blood glucose is not too high?5157971
Practice
1. Do you exercise regularly?12124151
2. Do you check your feet regularly and go for regular eye check-up?00067
3. Do you follow a controlled (low sugar) and planned diet?67607989
4. Do you keep in touch with your physician?00028
5. Do you regularly monitor your body weight?1111021
6. Do you regularly monitor your blood glucose levels?8571067
7. Do you take your medicines regularly?86838396

When Attitude and Practice scores at baseline were compared, it showed that though majority of them thought that they should follow a controlled, planned diet, only 67% in control and 79% in intervention groups made it a practice to follow a planned diet. Also, most of them believed that regular exercise improves condition of Diabetes, however only 12% in control and 41% in intervention groups made it a Practice to regularly exercise. Majority of them thought that patients with Diabetes should control their body weight, yet only 11% in control and none from intervention group had a Practice of regularly monitoring their body weight at home. Though many of the patients had good practice of taking medications regularly and following a planned diet, their HbA1C levels were higher than the acceptable range.

The mean FBS at baseline was 131.59 in control and 138.59 in intervention groups, while mean PPBS at baseline was 183.94 in control and 185.9 in intervention groups, HbA1C at baseline was 8 in control and 8.56 in intervention groups. There was significant reduction in FBS, PPBS, and HbA1C values from baseline in the intervention group at follow up compared to control group. Table 5 shows the FBS, PPBS, and HbA1C values at baseline and follow up in control and intervention groups. There was significant improvement in the glycemic control of patients of the intervention group when compared from baseline to follow up for FBS (p-value <0.0001), PPBS (p value <0.0001) and HbA1C (p-value <0.0001).

Table 5. Comparison of FBS, PPBS and HbA1C in Control and Intervention Groups
ParameterControl mean ± S.D.Intervention mean ± S.D.
BaselineFollow upBaselineFollow up
FBS
 Normal: 70–100 mg/dL
131.59 ± 34.94136.88 ± 31.34138.59 ± 18.21113.01 ± 8.94
PPBS
 Normal: <180 mg/dL
183.94 ± 14.55193.38 ± 15.81185.9 ± 19.41156.79 ± 14.40
HbA1C
 Normal: < 7.0%
8.01 ± 0.948.26 ± 0.888.56 ± 0.627.61 ± 0.57

DISCUSSION

The aim of the study was to assess the impact of pharmacist counselling on KAP of patients with Diabetes. Diabetic patients develop complications due to lack of mindfulness of the disease and insufficient glycemic control. Hence, patient counselling of diabetics on improving their KAP will have impact on their disease management. The American Diabetic Association has advised that education on self-management is essential to provide diabetic patients with the knowledge and ability that is needed to perform self-care, manage crises, and make lifestyle changes.

Patient counselling was provided to diabetic patients and their KAP was assessed to evaluate the impact of the same on their diabetes management.

Males had a higher KAP score at baseline compared to females. This was in contrary to the findings in studies conducted in India, China and Qatar that showed greater diabetes awareness among women than men, however was similar to the findings in countries like Pakistan, Bangladesh and Saudi Arabia, where men were reported to have a higher diabetes knowledge than women.8,12,13) Patients with a greater history of Diabetes had better KAP score in both control and intervention groups.

In a study, 94% believed in controlled and planned diet, which was closer to the findings in this study with 84% in control and 100% in intervention groups at baseline.14) When Attitude results from this study were compared with other such similar studies, variations were observed. In this study, 91% of the patients in control and 90% in intervention groups at baseline had good attitude towards regular exercise, while only 50, 36, and 73.68% had good attitude towards regular exercise in Tejaswi et al., Bollu et al., and Rathod et al. studies, respectively.1416) In another study, 70.16% monitored their blood glucose levels regularly which was very much alike to the results of the study done by Tejaswi et al., where 72% of the patients regularly monitored their blood glucose levels. These results were in contrary to the results of this study where none from intervention and 85% from control group monitored their blood glucose levels regularly. In the present study, neither a single patient monitored their feet regularly nor did they go for regular eye check-up which was not at all a satisfactory finding and when compared to other study 55% monitored their feet regularly and 41% went for regular eye check-up.14)

Though there was poor knowledge, attitude and practice at baseline, there was improvement at follow up in the intervention group and this can be attributed to patient counselling provided to the intervention group. The p-value (<0.0001) showed that there was significant improvement in the KAP score of intervention group patients from baseline to follow up compared to that of control group.

CONCLUSION

This study shows that clinical pharmacist intervention through patient counselling improved KAP scores. The study also showed that patients’ attitude towards pharmacist as a counsellor has also increased, showing positive results. Thus, suggesting that pharmacist counseling may have an impact in improving the perception about disease, diet, and lifestyle changes and thereby on glycemic control and the complications of diabetes. Limitations of the study were short term follow up, small sample size and confounding factors like patient counselling and knowledge attained by other sources was not considered. Also, attitude and practice scores were assessed based on patient interview and not by observing the patient’s actual practice for disease management. India has many skilled and talented pharmacists, who have the ability to show enormous effect on the profession of pharmacy, and aiding in the management of patients.

Conflict of Interest

The authors declare no conflict of interest.

Supplementary Materials

This article contains supplementary materials.

REFERENCES
 
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