Journal of Health Care Communications Open Access

Keywords

Knowledge; Attitude; Practice; Type 2 Diabetes (T2D); Chronic Kidney Disease (CKD); Islamabad, KAP questionnaire; Awareness

Introduction

Type 2 Diabetes (T2D) is a metabolic disorder that impairs the body’s ability to consume insulin, giving rise to a state of high blood sugar, if sustained for longer periods [1]. Chronic kidney disease is one of the most feared complications of T2D and is the 9th leading cause of death worldwide resulting in a huge economic burden on health systems [1]. T2D is, therefore, considered to be one of the significant health problems and cardinal causes of death globally [2]. According to a WHO estimation of 2014, 422 million people globally were affected by diabetes mellitus [1]. It is expected to become the 7th leading cause of death by 2030. This number is expected to rise by 592 million by 2035 [3].

If untreated, the complications arising from the disease can affect multiple organs. T2D doubles a person’s risk of cardiovascular events such as stroke or health attack [4], can impair vision (Retinopathy) and nerves (Neuropathy), and is the major cause of CKD [5]. However, an early diagnosis and proper treatment can reduce associated complications [6]. Early detection and proper intervention of this highly prevalent disease can be accomplished by proper awareness and knowledge of the disease. Behavioral modifications including a healthy diet, regular exercise, weight loss, and adherence to prescribed drug therapy can help to achieve optimal glycemic control [6].

In developing countries, a crucial challenge of CKD patients is the late presentation with most patients in an advanced stage. It is due to a poor level of knowledge and awareness of the disease [7,8]. The prevalence of T2D in Pakistan is 17% [9], giving the country a rank of number 4 on the list of top 10 countries having 19.4 million adults (20-79 years), Diabetes Mellitus (DM) in 2019, and this number will rise to 26.2 million in 2030 and will further jump to 37.1 million by 2045 bringing the rank one level up to number 3 by 2045 [10]. The prevalence is likely to rise further and it is projected that DM and hypertension will continue to increase in the emerging economies [11].

Diabetes, Knowledge, Attitude, and Practice (KAP) are vital in diabetes management. Several studies have used a KAP-based questionnaire to assess the knowledge, attitudes, and practices of individuals toward the DM disease [12], and supported the need for improved awareness of control of risk factors to prevent diabetes [13]. There is evidence that suggests that educated diabetic patients with good knowledge and health literacy achieve better disease control and management [14,15].

A low level of awareness, knowledge, and risk factors of CKD is found in previous epidemiological studies from developed countries. In the United States, only 24.3% of people with Glomerulus Filtration Rate (GFR) 15-60 ml/min were aware of CKD [16]. In Australia, hypertension and diabetes were cited as risk factors by only 2.8% and 8.6% of the population studied [17]. Among African Americans, few people (23.7%) had an idea of at least one laboratory test for kidney disease and few consider CKD a significant health condition [18]. A randomized controlled trial found a significant association between diabetes risk factors and motivation to make lifestyle changes with diet modifications and exercise habits. Also, it found a strong association between lifestyle modifications and reduction in waist circumference, body mass index, and Blood Glucose Level (BGL) [19,20].

People having an advanced CKD were aware of the disease though, but at this level, the kidney function had been already severely impaired [21]. The associated morbidity, mortality, economic and public health burden can be significantly reduced by early identification and treatment of CKD [22]. Owing to the health and economic benefits of preventive measures, it is critical to shift towards the implementation of preventive interventions from hospital-based interventions [23].

In Pakistan, disease management is generally decided by the Healthcare Provider (HCP) while patients act as the passive care recipient. Disease management strategies should be planned and guided in partnership with the HCP’s. It can be made possible by identifying the KAP of patients to help understand the factors hindering patient’s disease control. Knowing patient’s perspectives is an essential step towards employing innovative ideas to promote their health thus empowering them.

Aims

This study was aimed towards determining the level of KAP towards the causes, prevention, diagnosis, treatment, and management of T2D patients with CKD visiting General Patients (GPs) in Islamabad city of Pakistan from Dec 1st, 2020 to Feb 28th, 2021.

Methods

A cross-sectional, quantitative study is designed to identify the frequency of KAP in T2D patients with CKD at five private clinics of Islamabad based on convenience and willingness to participate in the study. Purposive sampling is done to identify the eligible participants.

Islamabad city has a population of 116, 400,0. With a T2D prevalence rate of 17% [9], 98% confidence level, and 5% margin of error, the estimated sample size was 307, which became 338 with an addition of 10% subjects. However, during the three- month period (Dec 1st,2020 to Feb 28th, 2021), 422 patients visited the five participating clinics who met the inclusion criteria, 375 agreed to participate in the study, and this sample size was considered appropriate for the study.

Patients were recruited from five General Physician (GP) clinics in Islamabad from December 1st, 2020 through Feb 28th, 2021, with the permission from GP. The study was conducted at GP clinics because of the convenience of researcher access and the availability of population of interest for the study.

All patients who visited the clinics during the study period and satisfied the inclusion criteria were asked to participate in the study. After obtaining their informed consent, patients were included in the study if they satisfy the inclusion criteria and were regarded as eligible for the study. A total of 375 patients, finally participated in the study.

Informed consent was obtained from the participants and they were guaranteed confidentiality and anonymity of their identity. Participants were given the right to refuse participation as the study was voluntary.

Data collection tool

The self-reported questionnaire was originally developed by an extensive literature review of already published literature using CKD screening index questionnaires [24] and the KAP questionnaire [25]. A validated questionnaire used previously [26] is employed for the study. The questionnaire was translated into Urdu and was pilot tested among 30 patients for reliability. On average, the questionnaire took ~10-15 min to complete. The questionnaire was divided into four sections; first section included demographic information, while the later sections include questions related to KAP of T2D patients with CKD.

The knowledge component: The responses to knowledge related questions were: “yes”, “no”, or “don’t know”. Here, a correct response was given a score of “2”, “1” for “don’t know” and “0” for an incorrect answer. The total scoring range of this section of 9 questions was 0-18 for each participant. A “low level of knowledge” was given 0-6 score, a “medium level of knowledge” 7-12 and a “high level of knowledge” will score equal or above 13.

The attitude component: The responses to attitude related questions were: “agree”, “disagree” or “neutral”. For this component, a score of “2” is given for a positive attitude, “1” for neutral, and “0” for a negative attitude. The total scoring range for this section of 10 questions was 0-20 with 0-7 considered being “low level of attitude”, 8-14 as “medium level of attitude”, and those scoring equal to or above 15 were considered having a “high level of attitude”.

The practice component: The responses to practice related question were: “yes” or “no”. Each item in the practice component was given a score of "1" for a positive practice and "0" for negative practice. Thus, the total scoring range for this section of 7 questions was 0-7 for each participant. Those with a score of less than 3 were considered to have a "low level of practice" and those scoring 4 or over a "high level of practice".

Training of interviewers and data quality assurance: Two interviewers were trained by the Principal Investigator (PI) to collect the data and were described the purpose of the study and how to conduct face-to-face and telephonic interviews. Later, interviewer’s pilot tested the questionnaire and observed for their interviewing skills.

Data collection and analysis

Before administration, the questionnaire is pilot tested and modified based on the responses obtained. Participants were then asked to fill in the questionnaire (Urdu and English version). Verbal or written assistance is provided to those participants who were not able to fill and understand it. The information obtained is entered in Microsoft excel for cleaning and coding. After designing a data dictionary, data analysis was carried out on SPSS, version 25.

Sociodemographic characteristics are demonstrated using descriptive statistics from section A of the questionnaire. The frequency of responses to the KAP questions was expressed in total and percentages.

Results

Complete data of all participants is demonstrated in tables. The sample size comprised 375 people aged 27-95 years (55.4 ± 9.99). The majority of participants were aged 46-55 years (36.36%) followed by 66-75 years (25.06%) with almost an equal number of male (48%) and female (52%) participants. 45.9% were employed, while 54.1% were unemployed. The majority of the participants were married (77%), 11% single, 12% divorced, and widowed (Tables 1-5).

Table 1: Demographic characteristics of study participants (n=375).

Table 2: Frequency of response on knowledge related questions n=375.

Table 3: Frequency of response on attitude related questions n=375.

Table 4: Frequency of response on practice related questions n=375.

Table 5: Distribution of responses by level of KAP.

Distribution of responses by level of KAP

71.5% of the participants had a high level of knowledge regarding the function of the kidney and the causes, prevention, diagnosis, and treatment of T2D/CKD (Score of 13-18). Similarly, 73% had a high level of attitude regarding prevention, burden, impact, effect, awareness, and future implications of T2D/CKD (Score of 15-20). 89% had a high level of practice towards prevention, selfmanagement, behavior modification, medical consultation and health-seeking behavior (Score over 4).

Discussion

Despite having enough evidence to suggest that the risk of diabetes can be reduced by lifestyle changes [27], a dilemma of developing countries is the lack of awareness of the chronic complications of the disease and its early management. Also, it has been found that 30% of the population does not take up community services [28].

The results of this study are promising as a high level of Knowledge, Attitude and Practices (KAP) (71.5%, 72.8%, and 89% respectively) are observed. Awareness of the CKD was generally high apart from few areas in which low scores were attained, such as the relationship between diabetes and blood pressure and the need for transplant surgery in end-stage kidney disease.

Attitudes regarding disease prevention, outcome, and burden were high but the impact and management of renal disease were low. High practices of prevention, consultation, behavior, modification were seen but practices of disease self-management, usage of traditional herbal medicinal substitutes, and frequent clinical visits were low.

In previous studies on Pakistan’s general population, a low level of knowledge of diabetes risk factors, management, and care was found [29] in a study, while another found a lack of knowledge of diabetes especially in females and illiterates in another suburban town of a Pakistani city [30]. Various other studies such as BQ town and Gaddap study of Karachi towns [31] revealed poor knowledge, few positive attitudes, and bad practices of patients regarding disease management of the disease.

A possible explanation of the conflicting findings of our study to those of previous studies from Pakistan could be a high literacy rate (87%) of Islamabad residents [32] as compared to 59% literacy rate of the whole country [33], and a low sample size of past studies.

Various other global studies on T2D/CKD revealed a poor level of various aspects of knowledge such as definition, risk factors, diagnosis causes, symptoms, and treatment [18,34,35]. Thus, low-rate parameters of knowledge need to be evaluated and targeted in future interventions for diabetic awareness programs. Similarly, a range of attitudes from a high (97%) level of attitude regarding health concerns, economic and social impacts of kidney disease in Tanzania [36], to a poor (60%) attitude in Iranian participants [37] was identified.

The overall attitude was high in our study. Since behavior is influenced by attitude, our study predicts positive behavioural outcomes. Certain areas of low attitudes must be improved. Good practices towards disease are imperative to reduce associated morbidities and mortalities. In a Tanzanian study, patients were subjected to a high mortality rate due to the usage of traditional healing medicines as they lacked the knowledge of the disease and its effective management [36].

This study has shown that diabetics do visit physicians. It is the responsibility of the physician to educate the patient regarding the control of diabetes and its chronic complications. There is increasing evidence that diabetes can be managed in a community by increasing awareness and there is a dire need to start nationwide diabetic education programs to prevent this prevalent disease that is associated with multiple comorbidities and mortalities. Such programs proved to be a cost-effective preventive strategy in many countries [38-40].

Furthermore, diabetes-related KAP of family physicians also need to be improved while treating and educating patients. A study from Pakistan found that more than 90% of family physicians treated diabetics and found deficiencies in the KAP of GPs towards diabetes in rural and urban areas [41], so GP practices should be improved for treating and educating diabetics.

Diabetes management can be improved in South Asia by initiating diabetic programs that focus on improving communication with the healthcare provider, address misconceptions, and employ culture-specific strategies [42,43].

Conclusion

While most of the areas of our study indicated a high level of knowledge, attitude, and practices but for some in which low levels are obtained. These low-level areas should be the target of future interventions and public health programs for T2D and CKD. It will eventually lead to further improvement in the overall KAP scores. Moreover, there is a dire need to conduct similar studies for other population subgroups targeting those of low socioeconomic status, literacy levels, and ethnicities in other parts of the country. It will help to design tailored interventions for those populations and improve public health as a whole by preventing further marginalization of vulnerable communities.

Additionally, education material on the causes, prevention, and management of the disease catering to the needs and cognitive skills of the targeted populations should be made available. Behavioral change communication material for the targeted populations will be helpful to create awareness and provide education about the disease.

The effectiveness of the programs should be identified by large-scale studies and intervention studies to improve overall population health.

Strengths and Limitations

One of the main strengths of this study is probably that it is likely to be the first study of KAP of T2D and CKD among Islamabad residents visiting private clinics. However, it has some limitations which include small scope, sample size, and short time frame. The sample size is not representative of an entire population, of low socioeconomic status, literacy levels, and of those visiting public hospitals. There should be more research on those population groups.

Acknowledgment

I acknowledge the immense efforts and contribution of interviewers in data collection. Besides, I would also like to thank the clinical staff for their support and cooperation in the data collection.

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