A Systematic Review on Knowledge-Attitude-Practice on diabetes: Assessment Process and Outcome Levels

 

Bilkis Banu^1,2, Farzana Yasmin¹, Mobarak Hossain Khan³, Liaquat Ali⁴,

Rainer Sauerborn¹, Aurélia Souares¹

¹Heidelberg Institute of Global Health, Heidelberg University Hospital, INF 130.3, 69120 Heidelberg, Germany.

²Northern University Bangladesh, Holding-13, Road-17, Banani C/A, Dhaka-1213, Bangladesh.

³East West University, Plot-A/2, Jahirul Islam Avenue, Jahirul Islam City, Aftabnagar, Dhaka-1212, Bangladesh.

⁴Pothikrit Institute of Health Studies, 1/ E, Paribag, Dhaka, Bangladesh.

 

ABSTRACT:  

This systematic review aimed to gather scientific evidence regarding the methods and indicators used to measure Knowledge Attitude and Practices (KAP) related to their disease among patient with diabetes and the level of KAP measured as outcome. 65 studies were included in this review following the defined inclusion and exclusion criteria and using the 7 electronic databases. Reviewed papers were categorized according to the assessment process of KAP in the studies. Articles were described and analyzed according to a list of criteria defined: the publication year; research location; study design; age of study subjects; addressed issues, process to measure and level of KAP in the article. Assessment of KAP on diabetes was expressed by mean, categories, percentage or in combined process. Majority of the reviewed studies were cross sectional (n=46, 71%), performed among adult patients (n=59, 91%), conducted in Asia (n=39, 60%) and used non- standardized questionnaire (65%). In most of the studies, level of knowledge and attitude on diabetes was found to be average (n=39, 60% & n=7, 11% respectively) and practices were found poor (n=12, 19%). The findings showed different types of indicators produced to measure KAP and the different dimensions being used either independently or together. There is a need for a standard validated questionnaire to be able to produce a measure of knowledge and behaviors of patients with diabetes that will be valid and comparable.

 

 

 

INTRODUCTION:

KAP (knowledge, attitude, practice) studies are widely used to gather information on a specific disease¹ and identify what people know (knowledge), how they feel (attitude) and what they do(practice).² Knowledge, attitude, and practice are not only correlated but also knowledge and attitude directly influence preventive practice.³KAP studies can be used for a large variety of themes and health-related subjects.²The attractive characteristics of KAP studies include: simple study design, quantifiable data, concise results with easy interpretation, generalization of small sample results to a wider population if properly implemented, cross cultural comparability and speed of implementation.¹KAP studies are helpful to plan and design appropriate, cost effective and specific intervention strategies. But, also to measure the impact of an intervention comparing the baseline with end line values to measure the effectiveness of health promotion and education activities or interventions which have the ability to change health-related behaviors.² Nevertheless, some social scientists have criticised the accuracy of information and applicability of KAP studies because there is limited scientific evidence regarding the appropriate indicators to measure KAP in the studies throughout the international health community.

 

Diabetes Mellitus (DM) is a major and increasing health problem which imposes huge economic burdens on patients, their families, society and national healthcare systems across the world. In 2015, the International Diabetes Federation (IDF) estimated that 415 million adults aged 20 to 79 years had diabetes and USD 673 billion was spent to treat diabetes and its related complications.⁴ If effective and sustainable actions are not taken, there will be 642 million people living with this disease and total health expenditure on diabetes are expected to increase by USD 802 billion by 2040.⁵ Patient’s own management is very important in controlling glycemic status adequately and in preventing complications, disability limitations and rehabilitation.⁶

 

Diabetes knowledge related in particular to necessary practices in prevention, management and control of the disease influence patients for their attitude, preconceived ideas about diabetes and its management. Appropriate knowledge and positive attitude help patients to maintain healthy lifestyles practices and to become adherent to physician’s advices.^{3, 7} Many effective interventions are available to reduce the economic burden of diabetes by improving management of the disease, to prevent or delay the apparition of the disease or of related complications.⁸ The aim of this review is to gather scientific evidence regarding the methods used to measure KAP on diabetes in different studies and the level of KAP on diabetes which was found as outcome in the different articles.

 

Material and methods:

Data sources and searches:

An extensive search was performed to identify relevant studies by using PubMed, Hinari, Web of Science, INASP PERII CONSORTIUM, Wiley Online Library, Research Gate, Google. The key terms used for all searches engines were – “KAP”, “knowledge”, “attitude”, “practice”, “measurement”, “assessment”, “diabetes”, “diabetes management”, “diabetes prevention”, “patients with diabetes”, “type 1 diabetes”, “type 2 diabetes”, “cross sectional study”, “survey”, “intervention”, “effectiveness”, “randomized control trial”, and “cluster randomized control trial”.

 

Study selection:

All studies published between 2001 and 2015 and reporting the level of knowledge, attitude and practice of patients with diabetes were included. The inclusion criteria were: (1) level of KAP on diabetes was measured whether K or A or P were measured separately or jointly, (2) observational/ cross-sectional studies, intervention/ effectiveness studies, case control studies randomized-control trials (RCTs) focusing on diabetes, (3) articles published between 2001 and 2015, (4) publications in peer-reviewed journals and (5) publications written in English. Exclusion criteria were (1) qualitative studies on KAP focusing on diabetes, (2) KAP studies focusing on other issues such as heart disease, hypertension etc., (3) reviews, policy papers, feasibility studies, grey publications, reports, book/chapters, thesis/proposal, editorial letter focusing on diabetes, (4) publications not written in English, (5) publications in non-peer reviewed journals and (6) published articles were not accessed in the full text.

 

Figure 1: Review process of the articles

 

Data extraction:

The articles were searched by two of the authors (BB and FY) independently using the same search engines and the same key terms list. 407 potential articles (BB 268, FY 178, and among them 39 articles were common to the two reviewers) were identified after the initial individual search. The first author (BB) has then reviewed all the titles and abstracts following inclusion and exclusion criteria. Among the 407 articles, the full texts of 7 articles were non-accessible. 139 articles were measuring KAP among subjects without diabetes: health care professionals, students, teachers of different grade of education and many other professionals (physicians, nurses, pharmacists, dentists, diabetes educators, veterans, medical students, etc.) and ethnic population; 125 articles were measuring KAP focusing on patients with diabetes and eye diseases, heart diseases, oral health, smoking, insulin use, hypertension etc.; 10 articles were not written in English; 13 were qualitative studies; 9 were systematic reviews; 9 were reports; 4 theses and 26 other types of publications were excluded. At the end, 65 articles met the full inclusion criteria (Fig 1).

 

Data synthesis and analysis:

The researchers carefully checked in each paper which dimension were presented and the assessment indicators used to measure KAP on diabetes in different studies. The results of KAP were presented either showing the mean value of total score (in percentage), or in different types of category or as percentage or as combination. Characteristics of the included studies were analyzed: publication year, research location, study design, methodology and age category of study subjects. Continent (North America, South America, Europe, Africa, Antarctica, Asia and Australia) of the study area was considered as research location.⁹ Age of the study subjects of the included articles were dichotomized as children (age <18 years) and adult (age ≥18 years).¹⁰

 

To compare the outcome result between studies, the results of K/A/P/KA/KP/KAP were categorized. Results were expressed as ‘poor’, ‘average’ and ‘high’. Results expressed in mean, values and percentage were categorized into the three categories (poor =<50%, average 50% to 80% and high>80%). When, the mean values were not in percentage (100%), there were converted into 100% and afterwards these values were categorized into above mentioned three levels.

 

Level of K/A/P/KA/KP/KAP were categorized in many studies, but the categorized terms varied from study to study. Rephrasing was done such as ‘insufficient/highly insufficient/very poor/ strongly negative/ negative’ were rephrased as poor; ‘sufficient/good/positive/fair’ were rephrased as average and ‘highly sufficient/ strongly positive’ were rephrased as high.

 

Results:

Assessment process of KAP on diabetes:

From a total number of 407 potential research results, 400 full texts were selected for the review, as for the full texts were not accessible. Among them65 articles were included, following the inclusion criteria. Amongst the included 65 articles, in 36 articles mean was used to present the results, in 5 articles categories were used and in 10 articles percentage were used to express KAP. A combination of these three was used to express KAP result in 14 articles. Table 1 to 5 representing the scrutinize information of this review study.

 

Table 1: Major study results of KAP on Diabetes (expressed by mean) with study characteristics

Table 1 continued

 

Table 2: Major study results of KAP on Diabetes (expressed by categories) with study characteristics

 

Table 2 contiued

Level of K/A/P/KA/KP/KAP expressed by categories was rephrased. This was for ‘insufficient/highly insufficient/very poor/ strongly negative/ negative’ were rephrased as poor; ‘sufficient/good/positive/fair’ were rephrased as average and ‘highly sufficient/ strongly positive’ were rephrased as high.

 

Table 3:  Major study results of KAP on Diabetes (expressed by percentage) with study characteristics

 

Table 3 contiued

If the percentage of the respondents found for the total/ all components of diabetes, then the percentage value was considered to decide level of KAP. The percentage value was leveled as poor=<50%, average= (50% to 80%), high= >80%. If the percentage of the respondents found for the individual components of diabetes and each component showed separate result in one study, then to make the KAP result in one unified status, rephrasing was done. At first, identified the level i.e. poor=<50%, average= (50% to 80%), high= >80% for each individual component. Afterwards, whatever the categorized level we found for most of the components, we considered that category (‘poor’, ‘average’ and ‘high’) as the summarized KAP result of each specified study.

 

Table 4:  Major study results of KAP on Diabetes (combined expression) with study characteristics

 

Results of KAP were expressed any of the three measures or its combination i.e. mean followed the measures of Table 1, category followed the measures of Table 2 and percentage followed the measures of Table 3.

 

Characteristics of reviewed studies:

Year of publication

Most of the articles (n=42, 64%) included were published after the year 2010 and the highest number (n=12, 18%) were published in 2012.

 

Research location:

Most of the studies (n=39, 60%) were conducted in Asia, 11 (17%) in North America, 6 (9%) studies in Africa and 5(8%) in South America.

 

Study design:

Majority (n=48, 74%) of the reviewed studies were observational (cross-sectional= 47and exploratory= 1) and the rest (n=17, 26%) were analytical studies (intervention= 16; case control=1). Different types of intervention designs were found i.e. RCT (6 studies), prospective quasi experimental design (4 studies), different types of educational intervention (6 studies).

 

Table 5: Distribution of articles according to main characteristics of the studies (n=65)

n=number of included and reviewed studies

 

Study subjects:

A large number (n=59, 91%) of the included studies were conducted amongst adult subjects with diabetes. Only 3 studies were conducted among children and 3 studies among children and adult both. The mean sample size of the reviewed studies was 389 with a minimum number of 35 and a maximum number of 6,007 patients with diabetes included.

 

Level of KAP on Diabetes:

Addressed issues of KAP in the article:

Only K was addressed in more than half of the reviewed studies (n=37, 57%), KA in 5% (n=3), KP in 15% (n=10) and KAP in 23% (n=15).

Level of K

Level of K on diabetes found average in most of the studies (n=39, 60%), poor in few studies (n=16, 25%) and high in only few studies (n=10, 15%).

Level of A

Level of A on diabetes was measured in only 17 studies out of total 65 reviewed studies. Attitude level was found average in most of the studies (n=7, 41%), poor in 35% (n=6) and high in 24% (n=4).

Level of P

Level of P was assessed in 26 studies out of total 65 reviewed studies. Interestingly, P on diabetes was found poor in most of the studies (n=12, 46%), average for 38% (n=10) and high for 15% (n=4).

 

In this systematic review, we considered the baseline results in case of intervention studies to assess KAP on diabetes so that the results could be comparable. All studies showed improvement of KAP after the intervention.

 

Overview of questionnaire types and data collection methods:

Several types of questionnaire were used to measure KAP in the reviewed articles. Most of the studies (n=40.62%) mentioned that they have developed their own questionnaire based on the literature and following expert’s consultations (n=40, 62%). The other studies used validated scale: Diabetes Knowledge Test (DKT) was used in 9(15%) studies, Diabetes Knowledge Questionnaire (DKQ) was used in 7 (12%) studies, 4 (7%) studies mentioned that they used validated questionnaire without describing it. Four different types of questionnaire were used each one if one study: Diabetes Habits and Beliefs Questionnaire, KAP Questionnaire adopted from P&T Journal, Diabetes Knowledge Inventory/ DKI, Diabetes Self Care Knowledge/ DSCK-30.

 

An Overview of data collection methods of the reviewed studies:

In most of the reviewed studies (n=45.7%), data were collected by face to face interviewer administered questionnaire, while the rest (n=20.3%) were gathered by self-administered method.

 

DISCUSSION:

To our knowledge, this is the first published systematic review to identify different assessment process for measuring KAP on diabetes and to summarize the level of knowledge, attitudes and practices among patients with diabetes. Only one other systematic review was done on patients with diabetes and with the specific objective to identify the underlying causal mechanisms responsible for improved knowledge, attitude, preventive practice and outcomes. This study aimed to formulate a framework reflecting the relationships among knowledge, attitude, practice and outcomes (KAP-O), and investigating the factors which influenced in the variations of glycated hemoglobin, low-density lipoprotein, functional capacity, and poor perceived health.¹

 

A systematic review about KAP studies in general and not for a specific disease, stated that “no clear-cut methodology for a KAP survey is available”.⁷³ The same is observed in our study. KAP studies are very crucial to measure human behavior and behavior changes and are of particular importance to measure the impact of health interventions. To be able to compare the results between different sites and also enhance the validity of results, it would be important to have validated tools available that could be used in different settings.

 

Very few official guidelines were identified that are describing the study methods and questionnaire to be used for KAP studies. In the “Guideline for conducting a Knowledge, Attitude and Practice (KAP) study” stated by Kaliyaperumal K,⁷⁴ it is recommended to use a validated questionnaire and standardized methods to conduct the survey and analysis. In this review, some studies used validated questionnaire but most of the studies used self-produced and pre-tested questionnaire. In addition, types of validated questionnaire used differed from study to study. There would be a need for a standard validated questionnaire to measure KAP for diabetes and make the results more comparable. Variation analysis pattern create also barriers to comparability of KAP outcome. So, these elements should also be included in the validated guideline on KAP assessment. ^{59-60, 61, 62-64, 65, 66, 67, 68, 69-72}

 

KAP results were expressed as mean, category or percentage. In addition, some studies expressed a combined KAP status. ^{59-60, 61, 62-64, 65, 66, 67, 68, 69-72}  In KAP study usually K & P both are expressed as percentage of correct answers on a specific topic. Scores and percentages are then grouped into categories: for example, positive, middle and negative responses.⁷⁴

 

A good proportion of the KAP studies on diabetes and also most of the reviewed intervention studies were conducted in Asia where 60% of patients with diabetes live.^{74, 75} Surprisingly very few of the included studies were conducted in Europe and Oceania.

 

Sample size of the studies included in this review was very different from one to others and varied from35⁵³ to 6007⁶ which questioned the validity of some studies.

 

Moreover, the types of interventions presented in the study varied from educational or behavioral intervention to technology-based intervention etc. The intervention included in this review reflected improved outcome after the intervention. But the outcome was evaluated at short period of time where long term interval evaluation of intervention would allow better and stronger conclusion on the sustainability of the solution to the health problems. In addition, comprehensive intervention was absent among the studies review. These interventions would include combination of government support, standardized medical care and community involvement and are essential for the sustainable prevention and control of diseases or solution of any health problem.^{76, 77}

 

Level of knowledge and attitude on diabetes found was average but practices on diabetes were found poor in most of the studies in this systematic review. This is the so-called know-do gap, even if patients know what should be done to improve their health status they may not be able to do it. But, it is essential to have good level of practice for the improvement of health indicators of a nation.⁷⁸ This alarming scenario indicates that this is time to identify the causal predictors influencing patients with diabetes for their poor practices and poor health outcome although they have sufficient knowledge and attitude.⁷⁹ Research on the topic showed that socio-demographic factors (gender, occupation, residence, education level, social support), complications (nephropathy, neuropathy)^{80, 81} could lead patients with diabetes to adopt negative practice for their diabetes management although they have good knowledge and attitude related to diabetes.^82,83,84

 

The information collected through these reviewed studies i.e. summarized results of KAP on diabetes could facilitate the development of strategic plan for appropriate intervention to combat diabetes. In addition, level of KAP on diabetes among family members, health care service providers and health care authorities also need to be measured and taken into account for a better development of needed comprehensive and sustainable intervention to improve outcomes for patients with diabetes and prevent healthy or pre-diabetic people from diabetes.

 

Limitations:

Study subjects, study design, sample size, questionnaire, data collection method and analysis process differ from study to study in this review. This was a major limitation of this review to generalize and visualize the summary of the KAP result. New studies published during analysis and writing of this paper has also not been included.

 

Conclusion and recommendations:

Worldwide KAP studies on diabetes are considered as essential because this is the doorway to observe the situation of the scenario of prevention, management and control of diabetes. Lack of uniformity of KAP questionnaire (in the absence of a validated one), conduction of KAP study and assessment process of KAP study were identified in this review as limit for the validity and comparison of the data published. Four different types of assessment process (mean, categories, percentage and combination of these three) were identified in this reviewed study to assess KAP on diabetes. Level of knowledge and attitude on diabetes was identified average but level of good practices was estimated as poor among patients with diabetes. Comprehensive educational and behavioral program could be better generated to address the know-do gap. Level of KAP indicated the worldwide current scenario regarding KAP on diabetes and is also important to measure the impact of educational and behavioral intervention which will help to design appropriate, sustainable and cost-effective health promotional programs to combat diabetes in near future.

 

References:

1.      Marathe K R. Wan TTH. Marathe S. A systematic review on the KAP-O Framework for diabetes education and research. Medical Research Archives. KEI Journals. 2016; 4 (1): 2-21.

2.      du Monde M. The KAP survey model (knowledge, attitudes, & practices). 2016. The United States Agency for International Development (USAID). Available online at: http://www.medecinsdumonde.org/en/actualites/publications/2012/02/20/kap-survey-model-knowledge-attitude-and-practices. Accessed on March 08, 2015.

3.      International Diabetes Federation. IDF Diabetes Atlas. Seventh edition. Brussels, Belgium. Available online at: https://idf.org/e-library/epidemiology-research/diabetes-atlas/13-diabetes-atlas-seventh-edition.html. Accessed on March 09, 2015.

4.      M. Sujatha Kumari. M. Kiran Babu. Rehana Sulthana. M. Srinivas. Ch. Prasanthi. Diabetes Mellitus: Present status and Drug therapy Updates. Research J. Pharm. and Tech. 2014; 7(1): 84-94.

5.      International Diabetes Federation. Diabetes Voice. Volume 16, Issue 2. Brussels, Belgium. Available online at: https://issuu.com/int._diabetes_federation/docs/dv-0216-final. Accessed on April 12, 2016.

6.      Shin SA. Kim H. Lee K. et al. Effects of diabetic case management on knowledge, self-management abilities, health behaviors, and health service utilization for diabetes in Korea. Yonsei medical journal. 2015; 56(1):244-52. 10.3349/ymj.2015.56.1.244.

7.      S.V. Rupashri. Gheena. S. Recent Advances in Diabetes Research. Research J. Pharm. and Tech. 2016; 9(10):1806-1808. 10.5958/0974-360X.2016.00366.8.

8.      Suraj B. C D Tripathi. Krishna Biswas. B M Padhy. Tarun Arora. A Comparative evaluation of safety, efficacy and cost effectiveness of three add on treatment regimens in type 2 diabetics; not controlled by Metformin alone. Research J. Pharm. and Tech. 2015; 13 (1): 44-50. 10.5958/0974-360X.2015.00009.8.

9.      Kheir N. Greer W. Yousif A. et al. Knowledge, attitude and practices of Qatari patients with type 2 diabetes mellitus. The International journal of pharmacy practice. 2011;19 (3):185-91. 10.1111/j.2042-7174.2011.00118.x.

10.   Hussain Z. Yusoff ZM. Sulaiman SA. Evaluation of knowledge regarding gestational diabetes mellitus and its association with glycaemic level: A Malaysian study. Primary care diabetes. 2015; 9(3):184-90. 10.1016/j.pcd.2014.07.007.

11.   Vivian EM. Ejebe IH. Identifying knowledge deficits of food insecure patients with diabetes. Current diabetes reviews. 2014; 10 (6):402-6. 10.2174/1573399810666141124111453.

12.   Ruiz JG. Andrade AD. Anam R. et al. Computer-based programmed instruction did not improve the knowledge retention of medication instructions of individuals with type 2 diabetes mellitus. The Diabetes educator. 2014; 40(1):77-88. 10.1177/0145721713508825.

13.   Jasper US. Ogundunmade BG. Opara MC. et al. Determinants of diabetes knowledge in a cohort of Nigerian diabetics. Journal of diabetes and metabolic disorders. 2014; 13(1):39. 10.1186/2251-6581-13-39.

14.   Hui SS. Hui GP. Xie YJ. Association between Physical Activity Knowledge and Levels of Physical Activity in Chinese Adults with Type 2 Diabetes. PloS one. 2014; 9 (12): e115098. 10.1371/journal.pone.0115098. 

15.   Araszkiewicz A. Zozulinska-Ziolkiewicz D. Pilacinski S. et al. Baseline diabetic knowledge after 5-day teaching program is an independent predictor of subclinical macroangiopathy in patients with type 1 diabetes (Poznan Prospective Study). Advances in medical sciences. 2014; 59(2):240-4. 10.1016/j.advms.2013.12.005.

16.   Negarandeh R. Mahmoodi H. Noktehdan H. et al. Teach back and pictorial image educational strategies on knowledge about diabetes and medication/dietary adherence among low health literate patients with type 2 diabetes. Primary care diabetes. 2013; 7(2):111-8. 10.1016/j.pcd.2012.11.001.

17.   Mansour-Ghanaei R. Joukar F. Soati F. et al. Association between knowledge, locus of control and health belief with self-management, HbA1c level and number of attendances in type 1 diabetes mellitus patients. International journal of clinical and experimental medicine. 2013; 6 (6):470-7. PMC3703118.

18.   Hu J. Gruber KJ. Liu H. et al. Diabetes knowledge among older adults with diabetes in Beijing, China. Journal of clinical nursing. 2013; 22 (1-2):51-60. 10.1111/j.1365-2702.2012.04273.x.

19.   Fenwick EK. Xie J, Rees G. et al. Factors associated with knowledge of diabetes in patients with type 2 diabetes using the Diabetes Knowledge Test validated with Rasch analysis. PloS one. 2013;8(12): e80593. 10.1371/journal.pone.0080593.

20.   Ali HI. Jarrar AH. El Sadig M. et al. Diet and carbohydrate food knowledge of multi-ethnic women: a comparative analysis of pregnant women with and without Gestational Diabetes Mellitus. PloS one. 2013;8 (9): e73486. 10.1371/journal.pone.0073486.

21.   Rovner AJ. Nansel TR. Mehta SN. et al. Development and validation of the type 1 diabetes nutrition knowledge survey. Diabetes care. 2012; 35 (8):1643-7. 10.2337/dc11-2371.

22.   Pereira DA. Costa NM. Sousa AL. et al. The effect of educational intervention on the disease knowledge of diabetes mellitus patients. Revistalatino-americana de enfermagem. 2012; 20(3):478-85.

23.   Mufunda E. Wikby K. Bjorn A. et al. Level and determinants of diabetes knowledge in patients with diabetes in Zimbabwe: a cross-sectional study. The Pan African medical journal. 2012; 13:78. 23396799.

24.   Lai PS. Chua SS. Tan CH. et al. Validation of the diabetes, hypertension and hyperlipidemia (DHL) knowledge instrument in Malaysia. BMC medical research methodology. 2012; 12:18. 10.1186/1471-2288-12-18.

25.   Goodarzi M. Ebrahimzadeh I. Rabi A. et al. Impact of distance education via mobile phone text messaging on knowledge, attitude, practice and self-efficacy of patients with type 2 diabetes mellitus in Iran. Journal of diabetes and metabolic disorders. 2012; 11(1):10. 10.1186/2251-6581-11-10.

26.   Wysocki T. Lochrie A. Antal H. et al. Youth and parent knowledge and communication about major complications of type 1 diabetes: associations with diabetes outcomes. Diabetes care. 2011; 34(8):1701-5. 10.2337/dc11-0577.

27.   Malathy R. Narmadha M. Ramesh S. et al. Effect of a diabetes counseling programme on knowledge, attitude and practice among diabetic patients in Erode district of South India. Journal of young pharmacists: JYP. 2011; 3(1):65-72. 10.4103/0975-1483.76422.

28.   Bains SS. Egede LE. Associations between health literacy, diabetes knowledge, self-care behaviors, and glycemic control in a low-income population with type 2 diabetes. Diabetes technology & therapeutics. 2011; 13 (3):335-41. 10.1089/dia.2010.0160.

29.   Ardena GJ. Paz-Pacheco E. Jimeno CA. et al. Knowledge, attitudes and practices of persons with type 2 diabetes in a rural community: phase I of the community-based Diabetes Self-Management Education (DSME) Program in San Juan, Batangas, Philippines. Diabetes research and clinical practice. 2010; 90 (2):160-6. 10.1016/j.diabres.2010.08.003.

30.   Al-Adsani AM. Moussa MA. Al-Jasem LI. et al. The level and determinants of diabetes knowledge in Kuwaiti adults with type 2 diabetes. Diabetes & metabolism. 2009; 35 (2):121-8. 10.1016/j.diabet.2008.09.005.

31.   McPherson ML. Smith SW. Powers A. et al. Association between diabetes patients' knowledge about medications and their blood glucose control. Research in social & administrative pharmacy: RSAP. 2008; 4(1):37-45. 10.1016/j.sapharm.2007.01.002.

32.   Koves IH. Boucher A. Ismail D. et al. Satisfaction of care in a tertiary level diabetes clinic: correlations with diabetes knowledge, clinical outcome and health-related quality of life. Journal of paediatrics and child health. 2008; 44(7-8):432-7. 10.1111/j.1440-1754.2008.01317.x

33.   Fitzgerald N. Damio G. Segura-Perez S. et al. Nutrition knowledge, food label use, and food intake patterns among Latinas with and without type 2 diabetes. Journal of the American Dietetic Association. 2008; 108(6):960-7. 10.1016/j.jada.2008.03.016.

34.   Yun LS. Hassan Y. Aziz NA. et al. A comparison of knowledge of diabetes mellitus between patients with diabetes and healthy adults: a survey from north Malaysia. Patient education and counseling. 2007; 69(1-3):47-54. 10.1016/j.pec.2007.06.017.

35.   Sabri AA. Qayyum MA. Saigol NU. et al. Comparing knowledge of diabetes mellitus among rural and urban diabetics. McGill journal of medicine: MJM: an international forum for the advancement of medical sciences by students. 2007; 10 (2):87-9. 10.26443/mjm.v10i2.741.

36.   He X. Wharrad HJ. Diabetes knowledge and glycemic control among Chinese people with type 2 diabetes. International nursing review. 2007; 54 (3):280-7. 10.1111/j.1466-7657.2007.00570.x.

37.   Ding CH. Teng CL. Koh CN. Knowledge of diabetes mellitus among diabetic and non-diabetic patients in KlinikKesihatan Seremban. The Medical journal of Malaysia. 2006; 61(4):399-404.

38.   Rothman RL. Malone R. Bryant B. et al. The Spoken Knowledge in Low Literacy in Diabetes scale: a diabetes knowledge scale for vulnerable patients. The Diabetes educator. 2005; 31(2):215-24. 10.1177/0145721705275002.

39.   Garrett N. Hageman CM. Sibley SD. et al. The effectiveness of an interactive small group diabetes intervention in improving knowledge, feeling of control, and behavior. Health promotion practice. 2005; 6(3):320-8. 10.1177/1524839903260846.

40.   Chapman-Novakofski K. Karduck J. Improvement in knowledge, social cognitive theory variables, and movement through stages of change after a community-based diabetes education program. Journal of the American Dietetic Association. 2005; 105(10):1613-6. 10.1016/j.jada.2005.07.010.

41.   NP Hawal. Shivaswamy M.S. S Kambar. et al. Knowledge, attitude and behaviour regarding self-care practices among type 2 diabetes mellitus patients residing in an urban area of South India. International Multidisciplinary Research Journal. 2012; 2(12):31-35.

42.   T Aklilu. D Hiko. MA. Mohammed. et al. Diabetic Patients' Knowledge of Their Disease, Therapeutic Goals, and Self-management: Association with Goal Attainment at Dessie Referral Hospital, Ethiopia.  Therapeutic Innovation & Regulatory Science. 2014. DOI: 10.1177/2168479014524960. 10.1177/2168479014524960.

43.   SH Ng. KH Chan. ZY Lian. et al. Reality vs Illusion: Knowledge, Attitude and Practice among Diabetic Patients. International Journal of Collaborative Research on Internal Medicine & Public Health. 2012; 4 (5): 709-718.

44.   Gautam A. Bhatta DN. Aryal UR. Diabetes related health knowledge, attitude and practice among diabetic patients in Nepal. BMC endocrine disorders. 2015; 15:25. 10.1186/s12902-015-0021-6.

45.   de Oliveira KC. Zanetti ML. Knowledge and attitudes of patients with diabetes mellitus in a primary health care system. Revista da Escola de Enfermagem da U S P. 2011; 45(4):862-8. 10.1590/s0080-62342011000400010.

46.   Rodrigues FF. Zanetti ML. dos Santos MA. et al. Knowledge and attitude: important components in diabetes education. Revistalatino-americana de enfermagem. 2009; 17(4):468-73. 10.1590/S0104-11692009000400006.

47.   Rafique G. Azam SI. White F. Diabetes knowledge, beliefs and practices among people with diabetes attending a university hospital in Karachi, Pakistan. Eastern Mediterranean Health Journal. 2006 ; 12(5): 590-8.

48.   HI Okonta. JB Ikombele. GA Ogunbanjo. Knowledge, attitude and practice regarding lifestyle modification in type 2 diabetic patients. African Journal of Primary Health Care & Family Medicine. 2014; 6(1): 655-660. 10.4102/phcfm.v6i1.655.

49.   Pena-Purcell NC. Boggess MM. An application of a diabetes knowledge scale for low-literate Hispanic/Latinos. Health promotion practice. 2014; 15(2):252-62. 10.1177/1524839912474006.

50.   Guler N. Oguz S. The spoken knowledge of low literacy in patients with diabetes. Diabetes research and clinical practice. 2011; 92(2):238-43. 10.1177/0145721705275002.

51.   Shah VN. Kamdar PK. Shah N. Assessing the knowledge, attitudes and practice of type 2 diabetes among patients of Saurashtra region, Gujarat. International Journal of Diabetes in Developing Countries. 2009; 29(3):118-22. 10.4103/0973-3930.54288.

52.   Kandula NR. Nsiah-Kumi PA. Makoul G. et al. The relationship between health literacy and knowledge improvement after a multimedia type 2 diabetes education program. Patient education and counseling. 2009; 75(3):321-7. 10.1016/j.pec.2009.04.001.

53.   Mehta RS. Karki P. Sharma SK. Risk factors, associated health problems, reasons for admission and knowledge profile of diabetes patients admitted in BPKIHS. Kathmandu University medical journal. 2006; 4(1):11-3. 10.4103/0973-3930.22775.

54.   N Badruddin. A Basit, MZI Hydrie. et al. Knowledge, Attitude and Practices of Patients visiting a diabetes care unit. Pakistan Journal of Nutrition. 2002; 1 (2): 99-102. 10.3923/pjn.2002.99.102.

55.   DK Upadhyay. MIzham MI. VM Alurkar. et al. Evaluation of knowledge, attitude and practice of newly diagnosed diabetes patients-a baseline study from Nepal.  International Journal of Pharmacy Teaching & Practices. 2012; 3(2): 245-252.

56.   Gul N. Knowledge, attitudes and practices of type 2 diabetic patients. Journal of Ayub Medical College Abbottabad. 2010; 22(3): 128-131. PMID: 22338437.

57.   Singh R P. Khobragade M. Kumar A. A cross-sectional study on knowledge, attitude and practices among diabetic patients about diabetes and its complications in Central Delhi. MRIMS Journal of Health Sciences. 2013; 1 (2): 44-47. 10.11648/j.sjph.20150304.20.

58.   Mangaiarkkarasi A. Nitya S. Mehar Ali R. et al. Study to Assess the Knowledge, Attitude and Practice about Diabetes among Diabetic Patients in Pondicherry. Research Journal of Pharmaceutical, Biological and Chemical Sciences. 2012; 3 (4): 1185-1196. 10.7860/JCDR/2016/19568.7862.

59.   Ku GM. Kegels G. Knowledge, attitudes and perceptions of people with type 2 diabetes as related to self-management practices: Results of a cross-sectional study conducted in Luzon, Philippines. Chronic illness. 2015; 11(2):93-107. 10.1177/1742395314538291.

60.   Quandt SA. Ip EH. Kirk JK. et al. Assessment of a short diabetes knowledge instrument for older and minority adults. The Diabetes educator. 2014; 40(1):68-76. 10.1177/0145721713508824.

61.   Ku GM. Kegels G. Effects of the First Line Diabetes Care (FiLDCare) self-management education and support project on knowledge, attitudes, perceptions, self-management practices and glycaemic control: a quasi-experimental study conducted in the Northern Philippines. BMJ open. 2014; 4(8): e005317. 10.1136/bmjopen-2014-005317.

62.   Jackson IL. Adibe MO. Okonta MJ. et al. Knowledge of self-care among type 2 diabetes patients in two states of Nigeria. Pharmacy practice. 2014; 12 (3):404. 10.4321/s1886-36552014000300001.

63.   Perera DP. De Silva RE. Perera WL. Knowledge of diabetes among type 2 diabetes patients attending a primary health care clinic in Sri Lanka. Eastern Mediterranean health journal. 2013; 19 (7):644-8. PMID: 24975310.

64.   Saleh F. Mumu SJ. Ara F. et al. Knowledge and self-care practices regarding diabetes among newly diagnosed type 2 diabetics in Bangladesh: a cross-sectional study. BMC public health. 2012; 12: 1112. 10.1186/1471-2458-12-1112.

65.   Hartayu TS. Mi MI. Suryawati S. Improving of type 2 diabetic patients' knowledge, attitude and practice towards diabetes self-care by implementing Community-Based Interactive Approach-diabetes mellitus strategy. BMC research notes. 2012; 5:315. 10.1186/1756-0500-5-315.

66.   Al-Qazaz HK. Hassali MA. Shafie AA. et al. Perception and knowledge of patients with type 2 diabetes in Malaysia about their disease and medication: a qualitative study. Research in social & administrative pharmacy: RSAP. 2011; 7(2):180-91. 10.1016/j.sapharm.2010.04.005.

67.   Pongmesa T. Li SC. Wee HL. A survey of knowledge on diabetes in the central region of Thailand. Value in health: the journal of the International Society for Pharmacoeconomics and Outcomes Research. 2009; 12 Suppl 3: S110-3. 10.1111/j.1524-4733.2009.00641.x.

68.   Huang JP. Chen HH. Yeh ML. A comparison of diabetes learning with and without interactive multimedia to improve knowledge, control, and self-care among people with diabetes in Taiwan. Public health nursing. 2009; 26 (4):317-28. 10.1111/j.1525-1446.2009.00786.x.

69.   SA Feleke. CM Alemayehu. HT Adane. Assessment of the level and associated factors with knowledge and practice of Diabetes Mellitus among Diabetic Patients attending at FelegeHiwot Hospital, Northwest Ethiopia. Clinical Medicine Research; 2013: 2(6): 110-120. 10.11648/j.cmr.20130206.11.

70.   DK Upadhyay. S Palaian. PR Shankar. P Mishra. Knowledge, Attitude and Practice about Diabetes among Diabetes Patients in Western Nepal. Rawal Medical Journal. 2008; 33(1): 8-11.

71.   Z Saadia. S Rushdi. M Alsheha. et al. A Study of Knowledge Attitude and Practices of Saudi Women towards Diabetes Mellitus. A (KAP) Study in Al-Qassim Region. The Internet Journal of Health. 2009. 11 (2). 10.4236/jdm.2015.52014

72.   Al-Maskari F. El-Sadig M. Al-Kaabi JM. et al. Knowledge, Attitude and Practices of Diabetic Patients in the United Arab Emirates. PLoS ONE. 2013. 8(1): e52857. 10.1371/journal.pone.0052857.

73.   Vandamme E. Concepts and challenges in the use of knowledge-attitude-practice surveys: Literature review. Department of Animal Health. Institute of Tropical Medicine. 2009; 1:1-7. 74002477.

74.   Kaliyaperumal K. Guideline for Conducting a Knowledge, Attitude and Practice (KAP) Study. AECS Illumination. 2004; 4 (1): 7-9.

75.   Facts and Figures. Asian Diabetes Prevention Initiative. 2015. Available online at:  https://asiandiabetesprevention.org/what-is-diabetes/facts-and-figures. Accessed on January 25, 2020.

76.   Chao J. Song L. Zhang H. et al. Effects of comprehensive intervention on health-related quality of life in patients with chronic hepatitis B in China. BMC health services research. 2013; 13(1): 386. 10.1186/1472-6963-13-386.

77.   Samidha Kamtekar. Vrushali Keer. Management of Diabetes: A Review. Research J. Pharm. and Tech. 2014; 7(9): 1065-1072.

78.   Beauchamp A. Batterham RW. Dodson S. et al. Systematic development and implementation of interventions to OPtimise Health Literacy and Access (Ophelia). BMC public health. 2017 Dec 1; 17(1):230. 10.1186/s12889-017-4147-5.

79.   Li Z. Jin H. Chen W. et al. Influencing Factors of Knowledge, Attitude, and Practice regarding Medical Nutrition Therapy in Patients with Diabetes: A National Cross-Sectional Study in Urban China. Journal of diabetes research. 2017. 10.1155/2017/8948452.

80.   Hisham A. Abbas. Mona A. El-Sayed. Laila M. Al-Kadi. Amany I. Gad. Diabetic foot infections in Zagazig University Hospital: bacterial etiology, antimicrobial resistance and biofilm formation. Research J. Pharm. and Tech. 2014; 7(7): 783-788.

81.   Sajel S. Saranya P. Quality of Life in patients experiencing Diabetic Foot Ulcer: A cross sectional study in a Clinical Pharmacist’s Perspective. Research J. Pharm. and Tech. 2017; 10 (1): 219-222. 10.5958/0974-360X.2017.00046.4.

82.   Li Z. Jin H. Chen W. et al. Influencing Factors of Knowledge, Attitude, and Practice regarding Medical Nutrition Therapy in Patients with Diabetes: A National Cross-Sectional Study in Urban China. Journal of diabetes research. 2017; 2017. 10.1155/2017/8948452.

83.   Knight J. Nigam Y. Andrade M. Diabetes management 2: long-term complications due to poor control. Nursing times. 2017; 113(4):45-8.

84.   Pun SP. Coates V. Benzie IF. Barriers to the self‐care of type 2 diabetes from both patients’ and providers’ perspectives: literature review. Journal of Nursing and Healthcare of Chronic Illness. 2009; 1(1): 4-19. 10.1111/j.1365-2702.2008.01000.x.

 

 

Accepted on 14.07.2021           © RJPT All right reserved

Research J. Pharm. and Tech 2021; 14(11):6125-6138.