INTRODUCTION
Diabetes mellitus (DM) is an illness that occurs when there is a chronic increase in blood glucose concentration or hyperglycaemia (Ministry of Health Malaysia 2015). DM is a silent and progressive disease. During the initial phase of the disease, it could show no symptoms. Some may take many years to develop the symptoms and experience long-term DM complications, such as retinopathy, nephropathy, sexual dysfunction, and diabetic neuropathy (Fowler 2008). DM is also one of the key risk factors for cardiovascular diseases, which contributes to the leading causes of death in Malaysia (Aniza et al. 2016).
The prevalence of DM has increased globally. In 2000, more than 170 million individuals in the world were diagnosed with DM (Wild et al. 2004). The figure is estimated to increase to 366 million by the year 2030. In Malaysia, DM remains the most prevalent non-communicable disease affecting the public. The prevalence of DM increased from 11.2% in 2011, 13.4% in 2015, to 18.3% in 2019 for adults above 18 years old, based on the latest National Health and Morbidity Survey (Institute for Public Health 2020b). There was a considerable variation of DM prevalence rate between different states in Malaysia, with the second highest prevalence of DM was found in Perlis (32.6%) (Institute for Public Health 2020b). Perlis is the smallest state located in the north of Peninsular Malaysia. Up to 2015, a total of 33,090 diabetic patients was found in Perlis (Institute for Public Health 2015). The number of adults with DM in Perlis increased to 52,184 in 2019 (Institute for Public Health 2020b).
Conceivable reasons for the steady increment in the prevalence of DM in Asian countries may include poor nutritional habits, physical inactivity, urbanisation, low health literacy, and poor attitudes towards DM management among the overall population and diabetic patients (Bollu et al. 2015). Disease awareness, early diagnosis and patients’ active involvement in controlling blood glucose levels are associated with knowledge, attitudes, and self-practice towards DM. Patients with insufficient knowledge regarding their illness frequently have poor self-management skills (Perera et al. 2013). DM self-care activities involve following a diet plan with high fibre, low sugar, and fat intake, staying active, regular blood glucose monitoring, and foot care. These activities could improve glycaemic control, reduce DM complications, and subsequently improve the quality of life among DM patients (Glasgow & Strycker 2000).
The alarming rise of non-communicable diseases, including DM in Perlis, is of great concern. Although various health promotion programs have been done by health authorities to educate the public about DM through multiple platforms, the impact of these efforts has not been evaluated. Therefore, we have no information on how much the public knows regarding this disease. The objective of the current study was to investigate public knowledge, attitude and factors associated with self-practice towards DM among the public in Kangar, Perlis.
MATERIALS AND METHODS
This cross-sectional study was carried out in Kangar, Perlis, starting from June 2018 for three months. The study targeted the public aged 18 years old and above residing in Kangar. The sample size calculation for this study was based on the population proportion (Lemeshow et al. 1990). The prevalence of DM in Perlis was 0.206 (Institute for Public Health 2015), and the population size of Kangar residents was 97,700 (Department of Statistics Malaysia 2017). If the Type I error probability and precision were 0.05, respectively; we needed to study 252 samples. After taking into consideration of a 20% dropout rate, the final sample size was 315. The quota sampling method was used to collect samples from every administrative division in Kangar. There are nine administrative divisions in Kangar, namely Abi, Jejawi, Kechor, Kurong Batang, Seriab, Wang Bintong, Sena, Kuala Perlis, and Kayang. A total of 35 subjects were selected from each administrative division in public areas such as bus stops, jetty, and markets.
A questionnaire containing 51 questions was adapted from a previous study (Al-Naggar et al. 2017). This self-administered questionnaire was distributed to the public in Kangar who fulfilled the following criteria, i.e., i) Inclusion: Adults aged ≥18 years old residing in Kangar, Perlis; ii) Exclusion: Unable to read and write in Malay. The questionnaire was divided into four parts measuring sociodemographic characteristics, medical history, knowledge, attitudes, and self-practice towards DM. There were nine questions assessing sociodemographic and medical backgrounds, 13 questions measuring knowledge, nine questions for attitudes, and 20 questions on DM self-practice. Informed consent was obtained before participating in this survey. Then, respondents were given approximately 15 minutes to answer the questionnaire. All responses received from this survey remained confidential.
Data analyses were done in the Statistical Packages for Social Sciences (SPSS) Version 20.0 (IBM Corp., Armonk, NY, USA). Descriptive analyses on the sociodemographic characteristics, medical history, knowledge, attitudes, and self-practice towards DM were performed. The raw scores for knowledge, attitudes, and self-practice towards DM were summed up and transformed into percentage scores. An arbitrary cut-off point of 75% was used for knowledge, while 50% was used for attitudes and self-practice towards DM, respectively (Al-Naggar et al. 2017). Univariable analyses (Independent t-test and Spearman’s correlation) were performed to assess the association between each of the sociodemographic backgrounds, medical history, knowledge, and attitudes of the public in Kangar with their self-practice towards DM. All variables in univariable analysis (p<0.10) were included for the downstream analysis. These variables were tested for multicollinearity before entering multiple linear regression. All statistical tests were performed at a 5% significance level.
RESULTS
Out of the 346 questionnaires distributed during the study period, 319 member of the public responded to this study, providing a response rate of 91.9%. Approximately one-third of the respondents (32.6%) were aged between 18 to 28 years old. Most of our respondents were female (66.5%), Malay (94.0%), married (63.9%). Slightly more than half of them had tertiary education (51.7%), and 31.0% worked in the government sector. More than 80% of them were non-smokers and had no previous medical history of chronic illnesses (DM, hypertension, dyslipidaemia, and ischaemic heart disease). Only 13.8% of the respondents were known case of DM. More than half (57.4%) of the respondents reported they had a family history of DM. The sociodemographic characteristics and medical history of the respondents is shown in Table 1.
Respondents’ knowledge about the disease, symptoms, complication, prevention, and treatment of DM is shown in Table 2. Almost all of the respondents (99.1%) answered DM is a condition in which the blood glucose level is higher than normal. More than 90% of the respondents answered frequent urination, increased thirst, loss of weight, waking up at night to urinate and fatigue as symptoms of DM. Most respondents answered renal failure, retinopathy, diabetic foot disease and nerve damage as complications of DM. Only about 70% of respondents were aware of heart attack, and stroke were also the complications of DM. Most respondents answered DM is preventable via losing weight, maintaining a healthy and balanced diet, staying physically active, having good and sufficient sleep, controlling the blood pressure and cholesterol levels in the normal range, and following routine eye check-up. This study found that most respondents believed insulin is the first-line treatment for DM (73.4%). About 40% of the respondents believed traditional medicines are useful in the treatment of diabetes. Besides, 64.9% of the respondents believed there is no need for subsequent retinopathy treatment if they already had the treatment.
For attitudes towards DM (Table 3), most respondents (90.6%) agreed that diabetes is preventable. A total of 88.4% of respondents also agreed that DM is treatable. Besides, they also believed that regular exercise helps to control DM (88.4%). More than 90% of the respondents agreed that it is vital to keep in touch with their physician and take medications appropriately. About 67.1% of respondents agreed that smoking would increase the risk of vascular complications due to DM. Respondents’ self-practice towards DM is shown in Table 4. The percentage for those who never check their blood glucose level, cholesterol level, and blood pressure were 18.2%, 24.1%, and 12.9%, respectively. About 80.8% of the respondents reported they had physical exercise daily. Less than half of the respondents cycled to work or during free time. There were 78.7% of respondents consumed carbohydrates in their diet every day. Only 50.8% of the respondents had fibre and fruits intake daily. This study found an overall good knowledge, attitudes, and self-practice towards DM among the respondents, with the percentage of 80.3%, 98.4% and 97.2%, respectively (Table 5).
Table 6 shows the descriptive association between sociodemographic, medical backgrounds, knowledge and attitudes towards self-practice on DM among in this study. Univariate analyses revealed nine factors were significantly associated with self-practice on DM (p<0.05). The factors included age, marital status, education level, history of hypertension, DM, dyslipidaemia, family history of DM, as well as knowledge and attitudes towards DM. Only age (Adjusted β = 0.151), education level (Adjusted β = 2.445), and level of attitudes (Adjusted β = 0.150) were significantly associated with self-practice on DM (p<0.05) in multiple linear regression after accounting for other variables (Table 7).
DISCUSSION
This cross-sectional study identified only a small proportion of respondents were diagnosed with DM. The prevalence of DM among the public in Kangar was lower than the prevalence of DM in Perlis’s population as reported in the National Health and Morbidity Survey in 2015 (Institute for Public Health 2015) and 2019 (Institute for Public Health 2020a). One possible explanation was that the settings in this study were mostly resided by well-educated respondents who were more aware of DM self-care. Additionally, most respondents reported a healthy lifestyle by eating a well-balanced diet, exercising regularly, and following routine check-ups.
Consistent with the findings from a previous study conducted in Selangor, Malaysia (Al-Naggar et al. 2017), most of the respondents in this study had good knowledge about DM. Nevertheless, there were some misconceptions about the knowledge of DM treatment. Like the previous study (Al-Naggar et al. 2017), some of the respondents believed that traditional medicines are effective in DM treatment. Studies showed a high prevalence of traditional medicine use among Malaysians (Siti et al. 2009), with this practice being closely related to our culture (Ikram & Abd Ghani 2015). Furthermore, in the current study, some respondents reported insulin was the first-line treatment for DM, and there is no need for retinopathy treatment afterwards if they already had the treatment. In most newly diagnosed DM cases, the patients will be started with oral anti-diabetic agents and suggested lifestyle modification (Ministry of Health Malaysia 2015). Insulin will be started later if the targeted glycaemic control is not achieved. Besides, every diabetic patient should have an eye examination annually and receive treatment accordingly (Paksin-Hall et al. 2013).
In the current study, most respondents had good attitudes towards DM, which was consistent with two other studies conducted earlier in Malaysia (Al-Naggar et al. 2017; Ng et al. 2012). These findings suggested that the satisfactory levels of attitudes towards DM were attributed to the implementation of current DM educational programs from the health authorities to the public. Another study conducted in Penang in 2009 showed that patients’ blood sugar level was significantly optimised after joining a structured DM educational program (Al-Haddad et al. 2009). Besides, the results from the current study were consistent with the findings from a previous study (Al-Naggar et al. 2017), which found that most respondents had good self-practice toward DM. Majority of the respondents in this study reported having routine check-ups, staying physically active, and following a healthy eating diet, which had contributed to good DM self-practice.
Additionally, the current study demonstrated a clear association between age, education level, and attitudes with self-practice towards DM. As the age of the respondent increases, they tend to have more self-practice towards DM. It was suggested in a study that older adults tend to be more aware of DM and its complications (Chavan et al. 2015). Those with higher education levels and good attitudes towards DM would tend to look for more information in this area and were more confident in DM self-care practice. In contrast, a study conducted in Northwest Ethiopia found education level did not influence DM’s self-practice (Feleke et al. 2013). Interestingly, knowledge levels were found to have no association with their self-practice towards DM in this study. The findings suggested that a good knowledge score does not always result in a positive self-practice.
There were a few limitations which should be noted in this study. The cross-sectional study design of this study measured all independent and dependent variables simultaneously. Therefore, the causality of the studied variables cannot be determined. However, the findings can still be useful as preliminary data for future studies, allowing further research to expand on the results. Moreover, this study’s results were limited only to the adults in public areas in Kangar; hence the prevalence rate of DM may be underestimated. Concerns on the generalizability of the results to the whole population may arise.
CONCLUSION
In conclusion, this study highlights most respondents had a good score for knowledge, attitudes, and self-practice towards DM in Kangar, Perlis. DM self-practice may vary by age, education level, and attitudes toward DM. Besides, several misconceptions about DM’s treatment were identified in this study. Therefore, more holistic educational programs that tackle the areas of weaknesses identified in this study are recommended, which can be started as early as in school to promote good self-practice towards DM.
ACKNOWLEDGEMENT
The authors would like to thank the Director General of Health for permission to publish this study. The authors would also like to thank Mr Ng Yit Han for his advice on data analysis for this study.