Advertisement

Knowledge towards diabetes and its chronic complications and associated factors among diabetes patients in University of Gondar comprehensive and specialized hospital, Gondar, Northwest Ethiopia

Open AccessPublished:March 25, 2022DOI:https://doi.org/10.1016/j.cegh.2022.101033

      Abstract

      Background

      Diabetes mellitus (DM) is a complex disease that affects many organ systems, resulting in problems such as the deteriorating health of the population and rising health care costs. Awareness about diabetes and its complications is important to reduce diabetes-related morbidity and mortality. Thus, this study aimed to assess the knowledge of DM and its chronic complications and associated factors among diabetic patients in University of Gondar Compressive Specialized Hospital, Gondar (UoGCSH), Northwest Ethiopia.

      Method

      A cross-sectional study was employed at the diabetic care service of UoGCSH from August 1, 2021–September 10, 2021. Interview-guided self-administered questionnaire and a chart review were used for data collection. Univariate and multivariate logistic regression was computed to know the association between variables.

      Results

      The knowledge score regarding diabetes was 85.6% in this study whereas the knowledge score about the chronic complications of diabetes was 58.8%. Age being 26–45 years old (AOR = 0.333,95% CI:0.12–0.918), educational status being able to read and write (AOR = 0.253, 95% CI:0.094–0.683), duration of diabetes diagnosis greater than 10 years (AOR = 2.827, 95% CI:1.458–5.481), and occupational status of being a daily laborer (AOR = 2.531, 95% CI:1.030–6.221) were significantly associated with knowledge regarding chronic complications of DM.

      Conclusion

      This study demonstrated higher knowledge scores regarding DM and its chronic complications. Age, educational status, duration of diabetes diagnosis, and occupational status have a significant association with knowledge of subjects regarding chronic complications.

      Keywords

      1. Introduction

      Diabetes mellitus (DM), also known as diabetes, is a severe chronic illness that occurs when the serum glucose levels in these patients are high because their body does not produce insulin, or only inadequately, or cannot use the insulin it produces.
      • Federation I.D.
      IDF Diabetes Atlas Ninth.
      DM is a complex disease that affects many organ systems, resulting in problems such as the deteriorating health of the population and rising health care costs.
      • Kong H.
      • Yu F.
      • Zhang W.
      • Li X.
      Clinical and microbiological characteristics of pyogenic liver abscess in a tertiary hospital in East China.
      ,
      • Blaum C.S.
      • Cigolle C.T.
      • Boyd C.
      • et al.
      Clinical complexity in middle-aged and older adults with diabetes: the Health and Retirement Study.
      The global escalation of diabetes is being influenced by the aging population, sedentary lifestyles, and poor diet, which is expected to triple the weight of the disease in the next 25 years. In addition, inadequate diabetes education and self-care practices contribute to poor glycemic control and complications such as diabetic nephropathy, diabetic retinopathy, diabetic neuropathy, etc.
      • Shrestha N.
      • Yadav S.
      • Joshi A.
      • Patel B.
      • Shrestha J.
      • Bharkher D.
      Diabetes knowledge and associated factors among diabetes patients in central Nepal.
      Elevated blood sugar levels cause widespread risk of cardiovascular disease by more than one mechanism, along with insulin resistance, inflammation, and endothelial dysfunction. In addition, accelerated blood sugar levels have been linked to a not uncommon number of different underlying metabolic threats, along with hypertension, dyslipidemia, and significant obesity. The risk is also strongly influenced by smoking and little physical activity.
      • Federation I.D.
      IDF Diabetes Atlas Ninth.
      Diabetic patients with a poor understanding of the disease have shown higher hospitalization rates for unstable diabetes.
      • Abdullah L.
      • Margolis S.
      • Townsend T.
      Primary health care patients' knowledge about diabetes in the United Arab Emirates.
      In contrast, patients with excellent knowledge and understanding of diabetes can adhere to the principles of self-management and have documented better glycemic control along with better health outcomes.
      • McPherson M.L.
      • Smith S.W.
      • Powers A.
      • Zuckerman I.H.
      Association between diabetes patients' knowledge about medications and their blood glucose control.
      Regarding optimum management of the problem, it requires an individual to be aware and be familiar with the nature and consequence of the disease, its risk factors, management, and chronic complications.
      • Al Bshabshe A.
      • Ahmad M.T.
      • Assiri O.A.A.
      • et al.
      Diabetes-care practices and related awareness amongst type-2 diabetes patients attending diabetes OPD at a tertiary care hospital in southwestern Saudi Arabia.
      Therefore, awareness regarding DM and its chronic complications has a crucial impact on good diabetic control which plays a key role in preventing diabetic complications.
      DM is one of the most common conditions that healthcare professionals often face. Worldwide, the superiority rate among adults was predicted to be 4% due to DM in 1995 and is expected to rise to 5.4% by 2025.
      • King H.
      • Aubert R.E.
      • Herman W.H.
      Global burden of diabetes, 1995–2025: prevalence, numerical estimates, and projections.
      A silent disease: Many patients only recognize their diabetes when they develop one of these diseases, life-threatening complications.
      • Wee H.
      • Ho H.
      • Li S.
      Public awareness of diabetes mellitus in Singapore.
      An estimated 4.2 million adults and the elderly in the 20- to 79-year-old age group are projected to die from diabetes and its complications in 2019, the equivalent of one death every 8 s. Deaths Worldwide from all reasons in people in this age group almost half (46.2%) of diabetes-related deaths, some in the 20–79 age group, occur in people under 60, the current age group. This effect is characterized by premature mortality and diminished livelihoods from diabetes-related headaches. Diabetes also has a massive financial impact on countries, health structures and, while medical care needs to be financed “out of pocket”, for people with diabetes and their families.
      • Federation I.D.
      IDF Diabetes Atlas Ninth.
      Lower limb amputation in people with diabetes is 10–20 times greater now no longer unusual vicinity compared to people without diabetes. It has been predicted that, globally, a lower limb (or part of a lower limb), is misplaced to amputation every 30 s attributable to diabetes. 60 Foot ulcers and amputations are greater now no longer strange vicinity in low- and middle-income countries than in high-income countries.
      • Moxey P.
      • Gogalniceanu P.
      • Hinchliffe R.
      • et al.
      Lower extremity amputations—a review of global variability in incidence.
      ,
      • Mishra S.C.
      • Chhatbar K.C.
      • Kashikar A.
      • Mehndiratta A.
      Diabetic foot.
      People with diabetes who have foot ulcers bear fitness fees 5 incidences better than those without foot ulcers. Compared to humans with diabetes without foot ulcers, the value of care for humans with diabetes and foot ulcers is 5.4 incidences better within the 12 months of the primary episode and 2.6 incidences better within the 12 months of the second episode.
      • Driver V.
      • Fabbi M.
      • Lavery L.
      • Gibbons G.
      Erratum: the costs of diabetic foot: the economic case for the limb salvage team (Journal of Vascular Surgery.
      A study done in Addis Ababa reported that the overall mortality of hospitalized patients was 89 deaths (21.0%), and the main complications in the admission were diabetic foot ulcers and cardiovascular disease.
      • Gizaw M.
      • Harries A.
      • Ade S.
      • et al.
      Diabetes mellitus in Addis Ababa, Ethiopia: admissions, complications and outcomes in a large referral hospital.
      Knowledge of diabetes and its chronic complications can assist in early detection and reduction of the incidence of complications. The level of knowledge about chronic complications of diabetes among diabetics who visit UoGCSH has not been studied yet. A study that measures the baseline knowledge of the target population is the very first job to be performed for designing health education programs. Moreover, such a study is vital for the appropriate and efficient use of limited resources to address any health condition. Up to now, there are no studies that have been conducted regarding knowledge of chronic complications of diabetes among diabetes patients in UoGCSH. Thus, this study aimed to assess the level of knowledge of DM and its chronic complications and associated factors among diabetic patients in UoGCSH, Northwest Ethiopia.

      2. Methods

      2.1 Study design, period, and area

      A cross-sectional study design was conducted in UoGCSH from August 1, 2021–September 10, 2021. The University of Gondar is one of the oldest and most well-established higher education institutions in the country and its hospital is found in Gondar town, Northwest Ethiopia, Amhara regional state; Gondar town is located at 738 km far from Addis Ababa to north and 180 km from Bahir Dar to north direction. UoGCSH is one of the oldest institutions in Ethiopia. UoGCSH contains the main referral hospital, in Keble 16. It has been producing several professionals since 1954. It is one of the centers of excellence in the country, especially concerning the health sector. According to the chronic outpatient department staff, it is estimated that 4000 diabetic patients come within three months. Diabetic patients in this hospital come for follow up especially on Tuesday and Friday to the chronic outpatient department.
      Source population: This includes all diabetes patients who came to UoGCSH within the past one month.
      Study population: This includes all diabetes patients who fulfill the eligibility criteria.
      Inclusion criteria.
      • Diabetic patients who are on follow up
      • Age older than 18 years
      • Includes all patients initially diagnosed with DM.
      Exclusion criteria.
      • The presence of gestational DM
      • Diabetes patients admitted to wards or critically ill patients
      • Those unable to answer the questionnaire because of dementia, psychosis or profound deafness were excluded from the study

      2.2 Sample size determination, and sampling technique

      Convenience sampling technique was employed to select participants who came to the chronic outpatient department of UoGCSH for routine medical checkups as well as a refill. So, using this sampling technique 320 subjects who came to the chronic outpatient department during the study period were recruited.
      n=N1+Ne2


      Were.
      • n-is a sample size
      • N-the total population size (it is estimated that 2700 DM patients visit the chronic outpatient department within the 3 months).
      • e−is the acceptable sampling error at a 95% Confidence interval.
      n=27001+2700(0.05)2=n=348 subjects


      Assuming a 5% non-response rate sample size will be 365.
      And using the correction formula as follows
      nf=nNn+N=nf=nNn+N=365×2700365+2700


      nf = 320 is the final sample size.
      Dependent variables: Dependent variables include; Knowledge towards DM and knowledge towards chronic complications of DM.
      Independent variables: Independent variables include; age, sex, residence, marital status, occupation, educational status, income, duration since diagnosis as diabetic, family history, use of herbal medication, smoking status, and type of DM.

      2.3 Operational definitions

      • Cardiovascular diseases (CVD): Diseases and injuries of the circulatory system: the heart, blood vessels of the heart, and the system of blood vessels throughout the body and to (and in) the brain; generally, refers to conditions that involve narrowed or blocked blood vessels.
        • Moroz Y.
        How Do Cardiovascular Diseases Affect the Body?.
      • Diabetes complications: Acute and chronic conditions caused by diabetes.
        • Gizaw M.
        • Harries A.
        • Ade S.
        • et al.
        Diabetes mellitus in Addis Ababa, Ethiopia: admissions, complications and outcomes in a large referral hospital.
      • Diabetic foot: A foot that exhibits any disease that results directly from diabetes or a complication of diabetes.
        • Driver V.
        • Fabbi M.
        • Lavery L.
        • Gibbons G.
        Erratum: the costs of diabetic foot: the economic case for the limb salvage team (Journal of Vascular Surgery.
      • Hyperglycemia: A raised concentration of glucose in the blood. It occurs when the body does not have enough insulin or cannot use the insulin it does have to turn glucose into energy. Signs of hyperglycemia include great thirst, dry mouth, weight loss, and the need to urinate often.
        • Feleke S.A.
        • Alemayehu C.M.
        • Adane H.T.
        • Onigbinde A.
        • Akindoyi O.
        • Faremi F.
        Assessment of the level and associated factors with knowledge and practice of diabetes mellitus among diabetic patients attending at FelegeHiwot hospital, Northwest Ethiopia.
        ,
        • Rahaman K.S.
        • Majdzadeh R.
        • Naieni K.H.
        • Raza O.
        Knowledge, attitude and practices (KAP) regarding chronic complications of diabetes among patients with type 2 diabetes in Dhaka.
      • Hypoglycemia: A low concentration of glucose in the blood. This may occur when a person with diabetes has injected too much insulin, eaten too little food, or has exercised without extra food.
        • Feleke S.A.
        • Alemayehu C.M.
        • Adane H.T.
        • Onigbinde A.
        • Akindoyi O.
        • Faremi F.
        Assessment of the level and associated factors with knowledge and practice of diabetes mellitus among diabetic patients attending at FelegeHiwot hospital, Northwest Ethiopia.
      • Obesity: A condition in which a person carries excess weight or body fat that might affect their health (BMI ≥30 kg/m2).
        • Driver V.
        • Fabbi M.
        • Lavery L.
        • Gibbons G.
        Erratum: the costs of diabetic foot: the economic case for the limb salvage team (Journal of Vascular Surgery.
        ,
        • Gizaw M.
        • Harries A.
        • Ade S.
        • et al.
        Diabetes mellitus in Addis Ababa, Ethiopia: admissions, complications and outcomes in a large referral hospital.
      • Self-management: Management of or by oneself; the taking of responsibility for one's own behavior and well-being.
        • Ahola A.J.
        • Groop P.H.
        Barriers to self‐management of diabetes.
      • Knowledge scoring: Subjects who answer a question both in the general diabetes knowledge and knowledge regarding chronic complications get one if they answer it correctly and 0 if they did not get the correct answer.
        • Kassahun C.W.
        • Mekonen A.G.
        Knowledge, attitude, practices and their associated factors towards diabetes mellitus among non diabetes community members of Bale Zone administrative towns, South East Ethiopia. A cross-sectional study.
        • Daba A.
        • Yazew T.
        Associated factors with knowledge, attitude and practices of Type II diabetic patients in Ambo university referral hospital, Ethiopia.
        • Afaya R.A.
        • Bam V.
        • Azongo T.B.
        • Afaya A.
        Knowledge of chronic complications of diabetes among persons living with type 2 diabetes mellitus in northern Ghana.
        • Obirikorang Y.
        • Obirikorang C.
        • Anto E.O.
        • et al.
        Knowledge of complications of diabetes mellitus among patients visiting the diabetes clinic at Sampa Government Hospital, Ghana: a descriptive study.
      • Poor diabetes knowledge: A person who has a knowledge score of diabetes itself below the score of 13.5 is regarded to have poor diabetes knowledge.
        • Kassahun C.W.
        • Mekonen A.G.
        Knowledge, attitude, practices and their associated factors towards diabetes mellitus among non diabetes community members of Bale Zone administrative towns, South East Ethiopia. A cross-sectional study.
        • Daba A.
        • Yazew T.
        Associated factors with knowledge, attitude and practices of Type II diabetic patients in Ambo university referral hospital, Ethiopia.
        • Afaya R.A.
        • Bam V.
        • Azongo T.B.
        • Afaya A.
        Knowledge of chronic complications of diabetes among persons living with type 2 diabetes mellitus in northern Ghana.
        • Obirikorang Y.
        • Obirikorang C.
        • Anto E.O.
        • et al.
        Knowledge of complications of diabetes mellitus among patients visiting the diabetes clinic at Sampa Government Hospital, Ghana: a descriptive study.
      • Good diabetes knowledge: A person who has a knowledge score of diabetes itself above the score of 13.5 is regarded to have good diabetes knowledge.
        • Kassahun C.W.
        • Mekonen A.G.
        Knowledge, attitude, practices and their associated factors towards diabetes mellitus among non diabetes community members of Bale Zone administrative towns, South East Ethiopia. A cross-sectional study.
        • Daba A.
        • Yazew T.
        Associated factors with knowledge, attitude and practices of Type II diabetic patients in Ambo university referral hospital, Ethiopia.
        • Afaya R.A.
        • Bam V.
        • Azongo T.B.
        • Afaya A.
        Knowledge of chronic complications of diabetes among persons living with type 2 diabetes mellitus in northern Ghana.
        • Obirikorang Y.
        • Obirikorang C.
        • Anto E.O.
        • et al.
        Knowledge of complications of diabetes mellitus among patients visiting the diabetes clinic at Sampa Government Hospital, Ghana: a descriptive study.
      • Poor chronic complications of diabetes knowledge: A person who has a knowledge score of diabetes itself below the score of seven is regarded to have poor chronic complications of diabetes knowledge.
        • Driver V.
        • Fabbi M.
        • Lavery L.
        • Gibbons G.
        Erratum: the costs of diabetic foot: the economic case for the limb salvage team (Journal of Vascular Surgery.
        ,
        • Gizaw M.
        • Harries A.
        • Ade S.
        • et al.
        Diabetes mellitus in Addis Ababa, Ethiopia: admissions, complications and outcomes in a large referral hospital.
      • Good chronic complications of diabetes knowledge: A person who has a knowledge score of diabetes itself above the score of 7 is regarded to have good chronic complications of diabetes knowledge.
        • Gizaw M.
        • Harries A.
        • Ade S.
        • et al.
        Diabetes mellitus in Addis Ababa, Ethiopia: admissions, complications and outcomes in a large referral hospital.

      2.4 Data collection tool and data collection process

      The data collectors were appropriately skilled in the data collection tool before data collection. Several published articles were reviewed to prepare the data collection tool.
      • Kassahun C.W.
      • Mekonen A.G.
      Knowledge, attitude, practices and their associated factors towards diabetes mellitus among non diabetes community members of Bale Zone administrative towns, South East Ethiopia. A cross-sectional study.
      • Daba A.
      • Yazew T.
      Associated factors with knowledge, attitude and practices of Type II diabetic patients in Ambo university referral hospital, Ethiopia.
      • Afaya R.A.
      • Bam V.
      • Azongo T.B.
      • Afaya A.
      Knowledge of chronic complications of diabetes among persons living with type 2 diabetes mellitus in northern Ghana.
      • Obirikorang Y.
      • Obirikorang C.
      • Anto E.O.
      • et al.
      Knowledge of complications of diabetes mellitus among patients visiting the diabetes clinic at Sampa Government Hospital, Ghana: a descriptive study.
      Interview-directed self-administered questionnaires and a chart review were employed for data collection. Patients with diabetes mellitus who were unable to write and read were interviewed. The questionnaire was divided into 4 main sections including demographic information (age, marital status, gender, religion, and residence), socioeconomic information (educational status, work status, monthly income), diabetes history, and knowledge-related information. The collected data were checked and cleared every day for consistency and completeness before processing. During data gathering, three trained health professionals were recruited and supervised by two MSc graduate health professionals. Finally, the fulfillment and completeness of all questions were checked by the data collectors and principal investigator.

      2.5 Data processing and analysis

      The collected data was entered into Statistical package for social science (SPSS) version 20 and was analyzed. Descriptive statistics such as frequencies and percentages were used. A binary logistic regression was used to identify predictors of awareness of diabetes and its complications. On bivariable analysis, variables with a p-value < 0.25 were entered into a multivariable logistic regression model. p ≤ 0.05 were used to declare statistically significant variables in the final model.

      3. Results

      3.1 Socio-demographic characteristics of study subjects

      Out of 320 subjects, 52.8% were males and 44.1% of the subjects were in the age group of 46–65 which accounts for most of the subjects. Regarding religion, most of the subjects were Orthodox 69.4% followers and most of the subjects were married 65.9%. The majority (74.7%) of the subjects were from urban areas. Of all participants, 24.1% were above high school but did not reach campus and 28.8% of the participants were housewives (Table 1).
      Table 1Socio demographic characteristics of diabetes patients.
      VariableCategoriesFrequency%
      Age≤253811.9
      26–457623.8
      46–6514144.1
      >656520.3
      GenderMale16952.8
      Female15147.2
      ReligionOrthodox22269.4
      Muslim8225.6
      Protestant154.7
      Others10.3
      Marital statusMarried21165.9
      Unmarried5818.1
      Divorced/Widowed5115.9
      ResidenceUrban23974.7
      Rural8125.3
      Educational statusUnable to read and write7222.5
      Read and write5717.8
      Grade 1-84313.4
      Grade 9-127724.1
      College and above7122.2
      OccupationCivil servant7122.2
      Merchant6319.7
      Daily laborer3510.9
      House wife9228.8
      Farmer5918.4

      3.2 Health profile of study subjects

      Of all participants, 37.8% were diagnosed as diabetics within the past 5 years and most of the subjects (74.4%) did not have a family history of diabetes. Regarding counseling programs of DM, 43.4% of the subjects never attended these sessions. Half (49.7%) of the subjects were on oral agents and dietary modification as their treatment. Regarding herbal medicine use, most of the subjects (83.8%) did not use herbal medicine and most of the subjects (84.7%) have their blood glucose checked in Hospitals. Regarding comorbid chronic conditions, 66.3% of the subjects were free from comorbidities and 94.7% were nonsmokers. Concerning complications, 73.4% of the participants had no medically confirmed diabetic complications and 63.4% of the subjects were type II diabetes patients (Table 2).
      Table 2Health profile of diabetes patients.
      VariableCategoriesFrequency%
      Duration of DM, years<5 Yrs.12137.8
      5–10 Yrs.11034.4
      >10 Yrs.8927.8
      Family history of DMYes6520.3
      No23874.4
      Counseling sessionsAttended once5717.8
      Attended regularly12438.8
      Never attended13943.4
      Counseling duration, min<54112.8
      5–108325.9
      >106119.1
      TreatmentDiet + Oral agents15949.7
      Diet + Insulin13341.6
      Diet + Oral agents + Insulin278.4
      None1.3
      Use of herbal medicationYes5216.3
      No26883.8
      Monitoring of blood glucoseSelf-monitoringYes8526.6
      No23573.4
      Local pharmacyYes3210.0
      No28890.0
      HospitalYes27184.7
      No4915.3
      Other chronic illnessYes10833.8
      No21266.3
      Smoking statusYes175.3
      No30394.7
      Medically confirmed diabetic complicationsYes7021.9
      No23573.4
      Type of DMT1DM11736.6
      T2DM20363.4

      3.3 Knowledge about diabetes mellitus

      Most of the subjects (62.5%) did not know that diabetes can affect any part of the body. Most of the subjects (67.8%) knew family history as the leading risk factor of diabetes. Regarding symptoms of poorly controlled diabetes, tiredness was reported by 81.6% of the subjects and the leading health risk factor reported by most of the subjects was hyperlipidemia (79.1%). Regarding lifestyle modification, diet was reported by 95.3% of the subjects as an effective lifestyle modification strategy. The majority (95.9%) of study subjects think controlling blood glucose is crucial in their fight with diabetes and 48.1% think that blood pressure monitoring is essential (Table 3). Of all participants, 85.6% had a good awareness of diabetes mellitus (Fig. 1).
      Table 3Knowledge about diabetes among diabetic patients.
      VariableCategoriesFrequency (yes)%
      What is Diabetes?Diabetes is a raised blood sugar only12338.4
      Diabetes is a disease which affects any part of the body20062.5
      - I don't know206.3
      Risk factor for DMOver eating13943.4
      Family history21767.8
      Eating too much fat and sugar24175.3
      Alcohol12438.8
      Cigarette smoking11836.9
      No response113.4
      Symptom \of poorly controlled

      DM
      Passing lots of urine22670.6
      Loss of appetite18758.4
      Excess thirst23372.8
      Tiredness26181.6
      Weight loss11134.7
      Don't know61.9
      Health risk factors for DMHypertension24175.3
      Hyper-lipidemia25379.1
      Sedentary life style20965.3
      Obesity23974.7
      Don't know216.6
      Lifestyle modification throughExercise27786.6
      Dietary modification30595.3
      Weight reduction23974.7
      Don't know51.6
      Control of your blood glucose levels30795.9
      Diabetes patients should measure BP15448.1
      Fig. 1
      Fig. 1Knowledge score of diabetic patients on questions about diabetes.

      3.4 Knowledge about chronic complications of diabetes

      Most of the subjects (76.6%) know that nephropathy is a complication of diabetes, and 71.6% of them did know diabetic neuropathy and 92.5% of them reported diabetic retinopathy as a complication of diabetes. Heart diseases as a complication of diabetes were reported by 78.1% of the subjects and foot ulcer was reported as a complication by 91.3% of the participants. Hyposexual dysfunction was reported by 58.1% of the subjects as a chronic complication of diabetes and 87.5% of the subjects reported that hypertension can be caused by diabetes. More than half (66.6%) of the subjects reported numbness of the extremities and most of them (92.2%) contemplate that regular retinal examination is necessary. Most of the participants (95%) think foot care is essential and 93% of the subjects think wearing a tight shoe is not good. Half of the subjects think blood donation is not good for diabetics and 85.9% of the participants think that urinalysis is crucial (Table 4). Generally, 58.8% of the subjects had good knowledge of the chronic complications of DM (Fig. 2).
      Table 4Knowledge about chronic complications of DM.
      VariablesFrequency (correct)%
      Diabetes can bring kidney diseases24576.6
      Diabetes can bring Neuropathy22971.6
      Diabetes can bring Retinopathy (blurred vision)29692.5
      Diabetes can bring heart diseases25078.1
      Diabetes can bring Diabetic foot ulcers29291.3
      Diabetes can bring Hypo sexual dysfunction18658.1
      Diabetes can bring Hypertension28087.5
      Have you ever felt loss of sensation in arms and legs21366.6
      Diabetics should go for regular eye check-up29592.2
      Diabetics should care for their toes and feet30495.0
      Diabetics should not wear tight shoes29792.8
      Diabetics should make regular visits to the eye doctor27686.3
      Diabetics should not donate blood16050.0
      Diabetics should check their renal function (urinalysis27585.9
      Fig. 2
      Fig. 2Knowledge score of chronic complications of diabetes.

      3.5 Assessing whether or not patients are told by their physicians about risks and glucose-lowering methods of DM

      Most of the subjects (54.10%) said that their doctor always tells them to lower their cholesterol and 63.80% of the subjects were always told to follow a healthier diet. Regarding physical activity, 48.40% of subjects reported that their doctor always told them to be physically active and 70% were also always told to lower their blood glucose levels. More than half (54.10%) of the subjects were always told to quit smoking. Blood pressure-lowering was told to 46.90% of the subjects by their physicians and 47.80% of the subjects were sometimes counseled on the need of losing weight to avoid diabetic complications (Fig. 3).
      Fig. 3
      Fig. 3Assessing whether or not patients are told by their physician about risks and methods of glucose lowering methods of DM.

      3.6 Assessment of patient perception toward diabetes mellitus complication

      Of all participants, 38% feel that they have no risk of stroke, 31.9% of the subjects feel that they have some risk of kidney problems, 32.5% of them feel that hyperlipidemia poses a great risk at them, 27.8% of the subjects think that they were at a greater risk of hypertension, 28.1% of the subjects feel that they were at some risk for a heart condition, 29.7% of the subjects feel that no risk of heart attack, 40.9% of the subjects feel a great deal of risk, 40.6% also feel that they have a great deal of risk, and 38.1% feared that they have a great risk of limb amputation (Fig. 4).
      Fig. 4
      Fig. 4Assessment of patient perception toward DM complication.

      3.7 Factors associated with awareness of diabetes and its chronic complications

      Age, educational status, residence, duration of DM, and work status were significant at 0.25 so they were entered into the final regression model. Age, educational status, duration of DM therapy, and occupational status showed a significant association with good knowledge at a 5% level of significance. So, people in the age group of 26–45 years were 66.7% (AOR = 0.333, 95% CI: 0.12–0.918) less likely to have good knowledge towards chronic complications of diabetes as compared to people less than the age of 25 years. People who can read and write were 74.7% (AOR = 0.253, 95% CI: 0.094–0.683) less likely to have good knowledge towards chronic complications of diabetes as compared to people who are unable to read and write. And people who are diagnosed with DM before 10 years were 2.827 times (AOR = 2.827, 95% CI:1.458–5.481) more likely to have good knowledge towards chronic complications of DM as compared to people whose first diabetes diagnosis did not reach 5 years. Finally, people who are daily laborers were 2.531 times (AOR = 2.531, 95% CI: 1.030–6.221) more likely to have good knowledge towards chronic complications of diabetes as compared to people who work as civil servants (Table 5).
      Table 5Factors associated with awareness of chronic complications of DM among diabetic patients.
      VariableKnowledge status (n = 320)OR (95% CI)
      Poor N (%)Good N (%)CORPAORP
      GenderMale68(40.2)101(59.8)1
      Female64(42.4)87(57.6)0.915(0.586–1.429)0.697
      Age0.083
      ≤2523(60.5)15(39.5)11
      26–4528(36.8)48(63.2)2.629(1.2–5.9)0.0180.333(0.12–0.9180.034
      46–6557(40.4)84(59.6)2.26(1.1–4.7)0.0291.042(0.466–2.33)0.919
      >6524(36.9)41(63.1)2.62(1.15–5.96)0.0220.909(0.459–1.799)0.783
      Education0.0220.052
      Unable to read and write40(55.6)32(44.4)11
      Read and write26(45.6)31(54.4)1.49(0.741–2.996)0.2630.253(0.094–0.683)0.007
      Grade 1-818(41.9)25(58.1)1.74(0.81–3.73)0.1570.505(0.192–1.328)0.166
      Grade 9-1227(35.1)50(64.1)2.32(1.2–4.5)0.0130.476(0.178–1.275)0.140
      Higher education and

      Above
      21(29.6)50(70.4)2.98(1.49–5.93)0.020.742(0.322–1.714)0.486
      Work status0.0040.350
      Civil servant22(31)49(69)11
      Merchant20(31.7)43(68.3)0.965(0.46–2)0.9251.688(0.610–4.669)0.313
      Daily laborer17(48.6)18(51.4)0.475(0.207–1.1)0.802.531(1.030–6.221)0.043
      House wife37(40.2)55(59.8)0.667(0.347–1.3)0.2251.754(0.618–4.979)0.291
      Farmer36(61)23(39)0.287(0.139–0.593)0.011.901(0.843–4.285)0.122
      Residence
      Urban88(36.8)151(63.12)11
      Rural44(54.3)37(45.7)0.49(0.294–0.816)0.0061.114(0.572–2.172)0.751
      Duration of DM0.0040.008
      <560(49.6)61(50.4)11
      5–1048(43.6)62(56.4)1.27(0.756–2.134)0.3661.331(0.752–2.355)0.327
      >1024(27)65(73)2.664(1.479–4.798)0.0012.827(1.458–5.481)0.001
      Family history of DM0.816
      Yes28(43.1)37(56.9)1
      No95(40)142(60)1.119(0.643–1.95)0.69
      Unknown8(47)9(53)0.851(0.292–2.486)0.768
      AOR (Adjusted odds ratio), COR (Crude odds ratio), N (Knowledge), CI (confidence interval) and P (Significance).
      The crude odds ratio for the independent variables affecting diabetes knowledge was calculated; gender, age, educational status, work status, residence, and duration of diabetes were possessing significance below 0.25 were entered into the final regression model. However, there was no significant association in the final regression model between the participants' knowledge score regarding diabetes itself and the associated factors (Table 6).
      Table 6Factors associated with awareness of DM among diabetic patients.
      VariableKnowledge status (n = 350)OR (95% CI)
      Poor N (%)Good N (%)CORPAORP
      GenderMale29(17.2)140(82.8)11
      Female17(11.3)134(88.7)1.633(0.858–3.108)0.1360.584(0.235–1.453)0.247
      Age0.090.114
      ≤2510(26.3)28(73.7)11
      26–4512(15.8)64(84.2)1.905(0.737–4.923)0.1830.430(0.121–1.533)0.193
      46–6514(9.9)127(90.1)3.24(1.306–8.039)0.0110.994(0.35–2.82)0.990
      >6510(15.3)55(84.7)1.964(0.732–5.274)0.181.636(0.638–4.196)0.306
      Education0.602
      Unable to read and write12(16.7)60(83.3)11
      Read and write10(17.5)47(82.5)0.940(0.374–2.363)0.8950.317(0.076–1.323)0.115
      Grade 1-87(16.3)36(83.7)1.029(0.371–2.851)0.9570.358(0.09–1.423)0.145
      Grade 9-1211(14.3)66(85.7)1.2(0.493–2.921)0.6880.384(0.095–1.547)0.178
      Higher education and

      Above
      6(8.4)65(91.6)2.167(0.765–6.136)0.1450.486(0.145–1.630)0.243
      Work status0.2470.564
      Civil servant8(11.3)63(88.7)11
      Merchant6(9.5)57(90.5)1.206(0.39–3.69)0.7421.268(0.344–4.676)0.721
      Daily laborer7(20)28(80)0.508(0.17–1.54)0.2312.704(0.802–9.118)0.109
      House wife12(13)80(87)0.847(0.33–2.2)0.7321.64(0.462–5.827)0.444
      Farmer13(22)46(78)0.449(0.17–1.17)0.1021.216(0.371–3.988)0.747
      Residence
      Urban30(12.6)209(87.4)11
      Rural16(19.8)65(80.2)0.58(0.3–1.14)0.1131.097(0.460–2.613)0.835
      Duration of DM0.1820.347
      <523(19)98(81)11
      5–1012(10.9)65(80.2)1.917(0.9–4)0.091.754(0.791–3.891)0.167
      >1011(12.4)78(87.6)1.66(0.77–3.62)0.1991.538(0.646–3.659)0.331
      Family history of DM0.553
      Yes9(13.8)56(86.2)1
      No33(13.9)205(86.1)0.998(0.45–2.21)0.997
      Unknown4(23.5)13(76.5)0.522(0.139–1.96)0.336
      Legend- AOR (Adjusted odds ratio), COR (Crude odds ratio), N (Knowledge), CI (confidence interval) and P (Significance).

      4. Discussion

      This study was conducted to assess the level and associated factors with knowledge of diabetes and its chronic complications. Most of (85.6%) the study participants had good knowledge regarding diabetes. This displayed higher when compared to a previous similar study conducted in Mangalore (35%),
      • D'Souza AMP
      • Kundapur R.
      • Kiran N.U.
      A Cross sectional study to determine the prevalence of Diabetes Mellitus and its household awareness in the rural field practice areas of a medical college in Mangalore-A Pilot Study.
      Sudan (15%),
      • Balla S.A.
      • Ahmed H.A.
      • Awadelkareem M.A.
      Prevalence of diabetes, knowledge, and attitude of rural, population towards diabetes and hypoglycaemic event, Sudan 2013.
      Tarlai (43%),
      • Ulvi O.S.
      • Chaudhary R.Y.
      • Ali T.
      • et al.
      Investigating the awareness level about diabetes mellitus and associated factors in Tarlai (rural Islamabad).
      India (49.9%),
      • Rani P.K.
      • Raman R.
      • Subramani S.
      • Perumal G.
      • Kumaramanickavel G.
      • Sharma T.
      Knowledge of Diabetes and Diabetic Retinopathy Among Rural Populations in India, and the Influence of Knowledge of Diabetic Retinopathy on Attitude and Practice.
      Kenya (27%),
      • Maina W.K.
      • Ndegwa Z.M.
      • Njenga E.W.
      • Muchemi E.W.
      Knowledge, attitude and practices related to diabetes among community members in four provinces in Kenya: a cross-sectional study.
      Debre Tabor town, Ethiopia (49%),
      • Asmamaw A.
      • Asres G.
      • Negese D.
      • Fekadu A.
      • Assefa G.
      Knowledge and attitude about diabetes mellitus and its associated factors among people in Debre Tabor town, Northwest Ethiopia: cross sectional study.
      and Malaysia (41.9%).
      • Minhat H.
      • Hamedon T.
      Understanding towards diabetes mellitus among rural adult community in Malaysia.
      This difference can be explained by the studies done in Tarlai, Malaysia, Mangalore, and Sudan were only in rural societies while both rural and urban societies were included in the current study. The study showed that the mean (±SD) knowledge score of study subjects was 18.95(±4.50). This study had demonstrated a higher level of knowledge regarding diabetes as compared to studies done in Lebanon,
      • Karaoui L.R.
      • Deeb M.E.
      • Nasser L.
      • Hallit S.
      Knowledge and practice of patients with diabetes mellitus in Lebanon: a cross-sectional study.
      and Nepal,
      • Shrestha N.
      • Yadav S.
      • Joshi A.
      • Patel B.
      • Shrestha J.
      • Bharkher D.
      Diabetes knowledge and associated factors among diabetes patients in central Nepal.
      whose mean (±SD) knowledge scores were 2.34 ± 0.88 and 11.0 ± 3.32, respectively. The knowledge score of this study was also higher as compared to the study done in Bahirdar whose knowledge score was 12.71(±3.73).
      • Feleke S.A.
      • Alemayehu C.M.
      • Adane H.T.
      • Onigbinde A.
      • Akindoyi O.
      • Faremi F.
      Assessment of the level and associated factors with knowledge and practice of diabetes mellitus among diabetic patients attending at FelegeHiwot hospital, Northwest Ethiopia.
      The finding of this study is higher when compared to the others. This is may be due to most of the study's participants (75%) residing in an urban area where there are organized diabetic facilities and almost half of the subjects are above high school in their educational status which may explains their higher knowledge scores.
      In this study, more than half (55.6%) of the subjects thought that diabetes can affect any part of the body and is not characterized by raised blood sugar only. This is higher when compared to the study done in Bahirdar which was only 46.8%.
      • Feleke S.A.
      • Alemayehu C.M.
      • Adane H.T.
      • Onigbinde A.
      • Akindoyi O.
      • Faremi F.
      Assessment of the level and associated factors with knowledge and practice of diabetes mellitus among diabetic patients attending at FelegeHiwot hospital, Northwest Ethiopia.
      81.6% of the subjects of this study reported tiredness to be the leading symptom of poorly controlled diabetes which was only 27% in the study done in Bahirdar,
      • Feleke S.A.
      • Alemayehu C.M.
      • Adane H.T.
      • Onigbinde A.
      • Akindoyi O.
      • Faremi F.
      Assessment of the level and associated factors with knowledge and practice of diabetes mellitus among diabetic patients attending at FelegeHiwot hospital, Northwest Ethiopia.
      Which may be due to the fact that most of this study's participants are housewives and are prone to long and tiresome hours of household chores that they noticed being tired as a leading symptom. 79.1% of this study's subjects reported hyperlipidemia as a leading health risk factor of diabetes which was only reported by only 38.5% of the subjects of the Bahirdar study. This is due to the fact that 54.1% of this study's participants are always told to lower cholesterol by their doctors.
      Regarding lifestyle modification, most of the subjects (95.3%) reported diet as a preferable lifestyle measure. However, a study conducted in Bahir Dar revealed that only 47.6% of the subjects reported diet as a preferable lifestyle measure.
      • Feleke S.A.
      • Alemayehu C.M.
      • Adane H.T.
      • Onigbinde A.
      • Akindoyi O.
      • Faremi F.
      Assessment of the level and associated factors with knowledge and practice of diabetes mellitus among diabetic patients attending at FelegeHiwot hospital, Northwest Ethiopia.
      This difference may be due to the counseling of the participants to follow a healthier diet by their physicians in the current study. In this study, the majority of (75.3%) subjects believed that eating too much fat and sugar can lead to diabetes and this value was lower when compared to the study done in Nepal (78.8%).
      • Shrestha N.
      • Yadav S.
      • Joshi A.
      • Patel B.
      • Shrestha J.
      • Bharkher D.
      Diabetes knowledge and associated factors among diabetes patients in central Nepal.
      More than half (67.8%) of the subjects of the current study believed that family history plays a key role in diabetes but this figure was lower when compared to the study conducted in Nepal (78.8%).
      • Shrestha N.
      • Yadav S.
      • Joshi A.
      • Patel B.
      • Shrestha J.
      • Bharkher D.
      Diabetes knowledge and associated factors among diabetes patients in central Nepal.
      This is due to the fact that most of the participants of this study did not have a family history of diabetes.
      Concerning chronic complications, 58.8% of the current study subjects had good knowledge towards chronic complications of diabetes this figure is higher when compared to the study's done in Addis Zemen (48.5%) (30), Ghana (45.9%),
      • Afaya R.A.
      • Bam V.
      • Azongo T.B.
      • Afaya A.
      Knowledge of chronic complications of diabetes among persons living with type 2 diabetes mellitus in northern Ghana.
      and in line with the study done in Dhaka (57.9%).
      • Rahaman K.S.
      • Majdzadeh R.
      • Naieni K.H.
      • Raza O.
      Knowledge, attitude and practices (KAP) regarding chronic complications of diabetes among patients with type 2 diabetes in Dhaka.
      This is due to the fact that most of the subjects in this study were from urban areas and almost half of this study participants were above high school that explains their high scores. However, compared to the Irish study,
      • O'Sullivan E.
      • Bhargava A.
      • O'Callaghan M.
      • et al.
      Awareness of diabetes complications in an Irish population.
      whose score was 81.4% it was lower and this is clear that the Irish are mainly urban residents with higher educational status.
      In this study, nephropathy was reported as a chronic complication of diabetes by 76.6% of the subjects. This figure is lower than a study done in Dhaka (98.6%),
      • Rahaman K.S.
      • Majdzadeh R.
      • Naieni K.H.
      • Raza O.
      Knowledge, attitude and practices (KAP) regarding chronic complications of diabetes among patients with type 2 diabetes in Dhaka.
      and higher than a study conducted in Ghana (57.8%),
      • Afaya R.A.
      • Bam V.
      • Azongo T.B.
      • Afaya A.
      Knowledge of chronic complications of diabetes among persons living with type 2 diabetes mellitus in northern Ghana.
      the reason for the relatively higher values of this study was that most of the current study participants reported that they at least feel some risk of kidney problems. The majority (71.6%) of participants reported neuropathy as a chronic complication of diabetes which was higher than a study done in Dhaka,
      • Rahaman K.S.
      • Majdzadeh R.
      • Naieni K.H.
      • Raza O.
      Knowledge, attitude and practices (KAP) regarding chronic complications of diabetes among patients with type 2 diabetes in Dhaka.
      but lower than a study conducted in Ghana.
      • Afaya R.A.
      • Bam V.
      • Azongo T.B.
      • Afaya A.
      Knowledge of chronic complications of diabetes among persons living with type 2 diabetes mellitus in northern Ghana.
      This difference may be due to most of the current study subjects having some concerns regarding neurologic injury. Retinopathy was reported by almost 93% of the study subjects which was higher than studies done in Ghana (45.0%),
      • Afaya R.A.
      • Bam V.
      • Azongo T.B.
      • Afaya A.
      Knowledge of chronic complications of diabetes among persons living with type 2 diabetes mellitus in northern Ghana.
      and Dhaka (18.1%).
      • Rahaman K.S.
      • Majdzadeh R.
      • Naieni K.H.
      • Raza O.
      Knowledge, attitude and practices (KAP) regarding chronic complications of diabetes among patients with type 2 diabetes in Dhaka.
      Diabetic foot ulcer was reported to be a chronic complication of diabetes by 91.3% of the participants which was higher than the studies conducted in Ghana,
      • Afaya R.A.
      • Bam V.
      • Azongo T.B.
      • Afaya A.
      Knowledge of chronic complications of diabetes among persons living with type 2 diabetes mellitus in northern Ghana.
      and Dhaka.
      • Rahaman K.S.
      • Majdzadeh R.
      • Naieni K.H.
      • Raza O.
      Knowledge, attitude and practices (KAP) regarding chronic complications of diabetes among patients with type 2 diabetes in Dhaka.
      This difference may be due to the fact that most of the participants in this study had a great deal of risk and feel some risk of the diabetic foot so that, these high figures are expected.
      In the current study age, educational status, duration of DM therapy, and occupational status showed a significant association with good knowledge at a 5% level of significance. This finding is in line with the study conducted in Ghana.
      • Afaya R.A.
      • Bam V.
      • Azongo T.B.
      • Afaya A.
      Knowledge of chronic complications of diabetes among persons living with type 2 diabetes mellitus in northern Ghana.
      Participants in the age group of 26–45 years were 66.7% less likely to have good knowledge towards chronic complications of diabetes as compared to people less than the age of 25 years. This may be due to getting more counseling in this age group when compared to younger age groups and people in this age group can retain the information when compared to the elderly.
      Participants who were diagnosed with diabetes before 10 years were 2.827 times more likely to have good knowledge towards chronic complications of diabetes as compared to participants whose first diabetes diagnosis did not reach 5 years. This is probably due to the fact that these participants have lived a decade with diabetes and have heard better information regarding diabetes mellitus. Daily laborers participants were 2.531 times (AOR = 2.531, 95% CI: 1.030–6.221) more likely to have good knowledge towards chronic complications of diabetes as compared to participants who work as civil servants. This is probably due to the fact that most of the hypoglycemic episodes of diabetes were exhibited in individuals whose daily activities require strenuous physical activities.

      4.1 Limitation of the study

      As the study is cross-sectional and depends on self-reported assessment, under-reporting is more likely to occur. Moreover, during assessment of knowledge of patients on DM chronic complications, even though the interviewers carried out it carefully, respondents may have replied socially acceptable responses which may cause an overestimation of awareness of study participants.

      5. Conclusion

      This study has demonstrated a higher level of awareness regarding diabetes and its chronic complications. Age, educational status, duration since diabetes diagnosis, and occupational status have a significant association with the patient's awareness of chronic complications of diabetes.

      5.1 Ethical consideration

      The school of Pharmacy on behalf of the University of Gondar institutional ethical review committee provided ethical clearance with a reference number of SOP/262/2013. Upon this clearance, additional written informed consent was taken with included study subjects before the interview. Confidentiality of information was maintained by avoiding the recording of patients’ names and keeping the data anonymous. Finally, personal identifiers were excluded during the data presentation.

      Availability of data and materials

      Most of the data is included in the manuscript. Additional can be found from the corresponding author based on reasonable request.

      Funding

      No funding to report.

      Declaration of competing interest

      The authors declares that they have no competing interests.

      Acknowledgment

      We would like to acknowledge University of Gondar for material supports.

      References

        • Federation I.D.
        IDF Diabetes Atlas Ninth.
        Dunia, 2019 (IDF)
        • Kong H.
        • Yu F.
        • Zhang W.
        • Li X.
        Clinical and microbiological characteristics of pyogenic liver abscess in a tertiary hospital in East China.
        Medicine. 2017; 96
        • Blaum C.S.
        • Cigolle C.T.
        • Boyd C.
        • et al.
        Clinical complexity in middle-aged and older adults with diabetes: the Health and Retirement Study.
        Med Care. 2010; 48: 327
        • Shrestha N.
        • Yadav S.
        • Joshi A.
        • Patel B.
        • Shrestha J.
        • Bharkher D.
        Diabetes knowledge and associated factors among diabetes patients in central Nepal.
        Int J Collab Res Intern Med Public Health. 2015; 7
        • Abdullah L.
        • Margolis S.
        • Townsend T.
        Primary health care patients' knowledge about diabetes in the United Arab Emirates.
        EMHJ-Eastern Mediterranean Health J. 2001; 7 (2001): 662-670
        • McPherson M.L.
        • Smith S.W.
        • Powers A.
        • Zuckerman I.H.
        Association between diabetes patients' knowledge about medications and their blood glucose control.
        Res Soc Adm Pharm. 2008; 4: 37-45
        • Al Bshabshe A.
        • Ahmad M.T.
        • Assiri O.A.A.
        • et al.
        Diabetes-care practices and related awareness amongst type-2 diabetes patients attending diabetes OPD at a tertiary care hospital in southwestern Saudi Arabia.
        J Fam Med Prim Care. 2020; 9: 2085
        • King H.
        • Aubert R.E.
        • Herman W.H.
        Global burden of diabetes, 1995–2025: prevalence, numerical estimates, and projections.
        Diabetes Care. 1998; 21: 1414-1431
        • Wee H.
        • Ho H.
        • Li S.
        Public awareness of diabetes mellitus in Singapore.
        Singap Med J. 2002; 43: 128-134
        • Moxey P.
        • Gogalniceanu P.
        • Hinchliffe R.
        • et al.
        Lower extremity amputations—a review of global variability in incidence.
        Diabet Med. 2011; 28: 1144-1153
        • Mishra S.C.
        • Chhatbar K.C.
        • Kashikar A.
        • Mehndiratta A.
        Diabetic foot.
        BMJ. 2017; 359
        • Driver V.
        • Fabbi M.
        • Lavery L.
        • Gibbons G.
        Erratum: the costs of diabetic foot: the economic case for the limb salvage team (Journal of Vascular Surgery.
        J Vasc Surg. 2010; 52 (52: 3 SUPPL.(17S-22S))) (2010)
        • Gizaw M.
        • Harries A.
        • Ade S.
        • et al.
        Diabetes mellitus in Addis Ababa, Ethiopia: admissions, complications and outcomes in a large referral hospital.
        Public Health Action. 2015; 5: 74-78
        • Moroz Y.
        How Do Cardiovascular Diseases Affect the Body?.
        2016
        • Feleke S.A.
        • Alemayehu C.M.
        • Adane H.T.
        • Onigbinde A.
        • Akindoyi O.
        • Faremi F.
        Assessment of the level and associated factors with knowledge and practice of diabetes mellitus among diabetic patients attending at FelegeHiwot hospital, Northwest Ethiopia.
        Clin Med Res. 2013; 2: 110
        • Rahaman K.S.
        • Majdzadeh R.
        • Naieni K.H.
        • Raza O.
        Knowledge, attitude and practices (KAP) regarding chronic complications of diabetes among patients with type 2 diabetes in Dhaka.
        Int J Endocrinol Metabol. 2017; 15
        • Ahola A.J.
        • Groop P.H.
        Barriers to self‐management of diabetes.
        Diabet Med. 2013; 30: 413-420
        • Kassahun C.W.
        • Mekonen A.G.
        Knowledge, attitude, practices and their associated factors towards diabetes mellitus among non diabetes community members of Bale Zone administrative towns, South East Ethiopia. A cross-sectional study.
        PLoS One. 2017; 12e0170040
        • Daba A.
        • Yazew T.
        Associated factors with knowledge, attitude and practices of Type II diabetic patients in Ambo university referral hospital, Ethiopia.
        Am J Lab Med. 2020; 5: 102-112
        • Afaya R.A.
        • Bam V.
        • Azongo T.B.
        • Afaya A.
        Knowledge of chronic complications of diabetes among persons living with type 2 diabetes mellitus in northern Ghana.
        PLoS One. 2020; 15e0241424
        • Obirikorang Y.
        • Obirikorang C.
        • Anto E.O.
        • et al.
        Knowledge of complications of diabetes mellitus among patients visiting the diabetes clinic at Sampa Government Hospital, Ghana: a descriptive study.
        BMC Publ Health. 2016; 16: 1-8
        • D'Souza AMP
        • Kundapur R.
        • Kiran N.U.
        A Cross sectional study to determine the prevalence of Diabetes Mellitus and its household awareness in the rural field practice areas of a medical college in Mangalore-A Pilot Study.
        J Health Allied Sci NU. 2015; 5: 43-46
        • Balla S.A.
        • Ahmed H.A.
        • Awadelkareem M.A.
        Prevalence of diabetes, knowledge, and attitude of rural, population towards diabetes and hypoglycaemic event, Sudan 2013.
        Am J Health Res. 2014; 2: 356-360
        • Ulvi O.S.
        • Chaudhary R.Y.
        • Ali T.
        • et al.
        Investigating the awareness level about diabetes mellitus and associated factors in Tarlai (rural Islamabad).
        JPMA (J Pak Med Assoc). 2009; 59: 798-801
        • Rani P.K.
        • Raman R.
        • Subramani S.
        • Perumal G.
        • Kumaramanickavel G.
        • Sharma T.
        Knowledge of Diabetes and Diabetic Retinopathy Among Rural Populations in India, and the Influence of Knowledge of Diabetic Retinopathy on Attitude and Practice.
        2008
        • Maina W.K.
        • Ndegwa Z.M.
        • Njenga E.W.
        • Muchemi E.W.
        Knowledge, attitude and practices related to diabetes among community members in four provinces in Kenya: a cross-sectional study.
        Pan African Med J. 2010; 7
        • Asmamaw A.
        • Asres G.
        • Negese D.
        • Fekadu A.
        • Assefa G.
        Knowledge and attitude about diabetes mellitus and its associated factors among people in Debre Tabor town, Northwest Ethiopia: cross sectional study.
        Science. 2015; 3: 199-209
        • Minhat H.
        • Hamedon T.
        Understanding towards diabetes mellitus among rural adult community in Malaysia.
        World J Med Sci. 2014; 11: 217-221
        • Karaoui L.R.
        • Deeb M.E.
        • Nasser L.
        • Hallit S.
        Knowledge and practice of patients with diabetes mellitus in Lebanon: a cross-sectional study.
        BMC Publ Health. 2018; 18: 1-9
        • O'Sullivan E.
        • Bhargava A.
        • O'Callaghan M.
        • et al.
        Awareness of diabetes complications in an Irish population.
        Ir J Med Sci. 2009; 178: 401-406