Knowledge, attitude and practices
related to diabetes among community members in four provinces in Kenya: a
Kiberenge Maina1,&, Zachary Muriuki Ndegwa2, Eva
Wangechi Njenga3, Eva Wangui Muchemi4
of Public Health and Sanitation- Kenya, 2National Diabetes Control-
Kenya, 3Diabetes Endocrinology Center- Nairobi, 4Kenya
Diabetes Management and Information Centre (DMI)
Kiberenge Maina, Ministry of Public Health and Sanitation, P.O. Box
30016-00100, phone: +254722 334 365/+254 202717077, fax:+254 202722599,
International Diabetes Federation estimated the prevalence of diabetes in Kenya
to be about 3.3% in 2007 . However, local studies have
shown prevalence of 4.2% in the general population with a prevalence rate of
2.2% in the rural areas and as high as 12.2% in urban areas. The prevalence of
impaired glucose tolerance is equally high 8.6% in the rural population, and
13.2% in the urban population .
with adoption of “western lifestyles” has been incriminated in the abandonment
of the healthier “traditional lifestyles” by people in developing countries.
The traditional lifestyle was characterized by regular and vigorous physical
activity accompanied by subsistence on high fiber, whole grain-based diet rich
in vegetables and fruits [2,3]. Urban
or even “western lifestyles” in rural areas have resulted in overreliance on
motorized transport and consumption unhealthy diets rich in carbohydrates,
fats, sugars and salts .
lifestyles have contributed to a rise in levels of obesity and overweight in
the population increasing the risk for diabetes. For instance, the 2003 Kenya
Demographic and Health Survey about 20% of women and 7% of men in the country
were overweight or obese . Recent studies have shown
even higher figure of 60.3% and 19.5% for women and men respectively in urban
areas as compared to 22.6% and 10% in women and men respectively in rural areas
rise of these determinants of chronic diseases reflects the major forces
driving social, economic and cultural change in the Kenyan society. These same
factors are driving the epidemiological landscape with chronic non-communicable
diseases becoming major contributors to the national disease burden .
is now emerging as an epidemic of the 21st Century. It threatens to overwhelm
the health care system in the near future . Sadly, the
majority of the people with diabetes in developing countries are within the
productive age range of 45 to 64 years . These are the
same individuals who are expected to drive the economic engines of these
countries in order to achieve the agreed international development goals. Besides
their reduced productivity, diabetes further imposes a high economic burden in
terms of health care expenditure, lost productivity and foregone economic
curb this scourge of diabetes, public health interventions are required to
prevent diabetes or delay the onset of its complications. This will entail
intensive lifestyle modification for those at risk of diabetes and aggressive
treatment for those with the disease . A high risk approach
targeting individual at risk of diabetes and a population or public health
approach aimed at reducing the risk factors for diabetes at the community are
is the greatest weapon in the fight against diabetes mellitus. Information can
help people assess their risk of diabetes, motivate them to seek proper
treatment and care, and inspire them to take charge of their disease . It is therefore in the interest of the country to design
and develop a comprehensive health promotion strategy for diabetes mellitus and
its related risk factors. It is equally important to design and implement
suitable diagnostic, management and treatment protocols for people with
study therefore was conducted to assess the level of community awareness of
diabetes and how this knowledge influences their attitude and practices in
prevention and control of the disease. The findings will help in identifying
population knowledge gap and their behaviour towards diabetes which will guide
the development of prevention programmes in the country.
was a descriptive cross-sectional study involving 2000 people drawn from 8
districts in 4 provinces. The 4 provinces were selected from a total of 8 due
to their high burden of diabetes as reported in the health management and
information systems in the Ministry of Health. 2000 respondents were considered
adequate as similar studies done in the country have worked with nearly equal
number. The 4 provinces had a total of 23 districts, the districts were
stratified into rural and urban districts based on their geographical location.
Two districts, one rural and one urban were randomly selected from each
province. Each of the 8 districts was assigned 500 respondents. The respondents
were aged between 13 and 65 years. Only one respondent was interviewed for
every household visited.
medium sized four part questionnaire was designed by the researchers. It was
peer reviewed by 5 colleagues including a biostatistician for validation of the
questions. The questionnaire was then piloted on 10 respondents in Kajiado
district which is a rural district next to Nairobi. This was done in order to
assess the suitability of the contents, clarity, sequence and flow of the
questionnaire. The questionnaire was then refined for final use. All
questionnaires were in the English language, which is the national official
first part of the questionnaire covered the respondent’s demographic
information which included: name, age, sex, level of education, occupation and
average monthly income.
two covered knowledge about diabetes. Knowledge on causes of diabetes was based
on responses to a question on what they knew was the cause of diabetes. The
options given were: lack of insulin, failure of the body to use insulin and
consumption of lots of sugar or don’t know. For knowledge about signs and
symptoms of diabetes, five options were given: frequent urination, excessive
thirst, excessive hunger, weight loss, and high blood sugar. Knowledge of
complications of diabetes was assessed by asking respondents to describe
complications of the disease they knew. Options listed included, loss of
vision, kidney failure, heart failure and stroke, poor healing wound and
amputation. Respondents’ knowledge of diabetes was categorized as either good
or poor depending on their responses to the knowledge areas assessed.
three of the questionnaire assessed the attitude of the respondents towards
lifestyle characteristics such as diet, physical activity and health seeking
four assessed what the respondents practiced in terms of adopting healthy
lifestyles that promote diabetes prevention. This section looked at consumption
of healthy diet, regular physical activity, avoidance of alcohol and tobacco
use and regular medical checkup.
questionnaire was administered by interviewers who were people with medical
background knowledge of diabetes and included nurses, clinical officers and
nutritionists. Before going to the field, the interviewers were taken through a
one day training to acquaint themselves with the data collection tools and also
to understand the whole concept. The interviewers then embarked on data
collection by moving from house to house within their allocated areas. The
first person to be encountered in the household meeting the age criteria was
interviewed. For those who declined, a second person was interviewed and in
their absence the next household was visited.
filled questionnaires were then submitted to the survey supervisors who checked
their completeness before the interviewer left that area. Where information was
missing the interviewer revisited the respondent for further information unless
they had initially declined to disclose. Upon processing of all the field data,
analysis was done under the domain of descriptive statistics using SPSS
the targeted 2000 respondents, 1982 (99.1%) were interviewed in this study.
There were more females 1151 (58.1%) than males 831 (41.9%) interviewed. 358
(18%) of the respondents had tertiary education, 737 (37.2%) had secondary
education, 725 (36.6%) had primary education while 162 (8.2%) had no education
575 (29%) of respondents had good knowledge of signs and symptoms of diabetes
while 1407(71%) of respondents had poor knowledge on what diabetes is. 518
(26.1%) could correctly identify the probable causes of diabetes mellitus while
1464(73.9%) could not. Only 523(26.4%) of the respondents could identify
complications of diabetes they knew while 1459(73.4%) had very little or no
knowledge of complications of diabetes (Table 1).
on average 539(27.2%) respondents had good knowledge of diabetes while 1443
(72.8%) had poor knowledge of the disease. There was therefore no significant
difference in knowledge levels between genders. The proportion of females who
had good knowledge was 26.8% compared to 27.7% in males.
differences in level of knowledge
revealed a significant is a disparity in the level of knowledge in different
regions. Coast province had the lowest knowledge level of diabetes 118 (23.7%)
followed by Nairobi 127 (25.5%), Eastern 140(28.9%) and Central 154 (30.8%),
respectively. Nearly over 70% of all respondents from each of the four regions
had poor knowledge of diabetes (Table 2).
of knowledge of diabetes with level of education
the respondents with good knowledge were analyzed according to level of
education. A direct relationship between level of education and good knowledge of
diabetes was demonstrated. 52% of those who had good knowledge had tertiary
education, 25% had secondary education, and 14% had primary education while 9%
had no formal education (Figure 1).
attitude and practices towards diabetes
assess the attitude of community towards diabetes, the attitude of people
towards lifestyle characteristics such as diet, physical activity and health
seeking behavior was assessed. Only 28% of respondents agreed with statements
relating to willingness to engage in physical activity, changing eating habits
and maintaining “good” body weights. A significant 813 (41%), of the
respondents did not indicate any willingness to adopt these healthier
lifestyles. 41% of all respondents had good practices while the rest 59% had
bad practices in relation to diabetes prevention. 75% of the people interviewed
had poor dietary practices, 72% did not participate in regular exercise and
over 80% did not monitor their body weights.
between practices and knowledge
analysis of the relationship between community knowledge and practices provided
valuable insights in the assessment of community attitude. 50.7% of people with
good knowledge of diabetes had good practices as compared to 37.4% of people
with poor knowledge of diabetes had good practices. Conversely, 49.3% of those
with good knowledge had bad practices compared to 62.6% of those without
knowledge (Table 3).
studies on the knowledge, attitude and practices of diabetes done in Africa and
elsewhere target patients with diabetes. Unlike these, this study targeted the
general population. We therefore lack adequate comparative data for community
and our discussions are based on knowledge, attitude and practices of people
with diabetes who in most cases have better exposure to diabetes education.
findings of this study reveal a serious deficiency in knowledge of diabetes
among community members in Kenya. Only 27.2% of the people interviewed had good
knowledge of diabetes. Puepet et al., found a similar level of knowledge of
diabetes, 30.2%, among patients with diabetes in Jos State, Nigeria . Dinesh et al., in a study in western Nepal, noted a lack
of awareness of diabetes even in patients who had had the disease for a long
time . Even in a developed country set up, Baradaran
and Jones also found that knowledge about diabetes amongst ethnic groups in
Glasgow was very low .
findings underscore very important aspects of education to the community as far
as diabetes is concerned. Firstly there is historical deficiency in knowledge
about diabetes and inequalities in the quality of education reaching each
region in the country. Similar findings were documented by Hawthorne and
Tomlinson regarding Pakistani Moslems attending the Manchester Diabetic Centre
[8,13]. Secondly the low level of
community knowledge of diabetes reflects on the extent of health promotion for
most chronic non-communicable diseases. At the moment, there are no comprehensive
primary care programmes for diabetes in the country and diabetes health
education is done within health facilities through microteaching and only
targets those with diabetes. This therefore leaves the rest the public ignorant
of the disease. Most of the diabetes health promotion efforts by different
stakeholders are uncoordinated and the messages are not standardized due to
lack of clear guidelines regarding diabetes education .
Lastly, there is even low knowledge of diabetes among health care workers who
are expected to deliver health education to the community [14,15].
knowledge, culture and beliefs about diabetes is a prerequisite for individuals
and communities to take action to control the disease. This knowledge affects
their attitude and uptake of health services, including health education . Yet research into health knowledge and beliefs around
diabetes causation and prevention among the general community in Kenya is
prevention interventions need to target health education directed to the
community and the health care providers. Good knowledge of diabetes amongst
care givers is directly related to the quality of care given by such providers.
Education of patients, likewise, improves compliance to treatments and leads to
favorable treatment outcomes. This is due to the direct influence of knowledge
on the attitude and practices of both the care giver and the patients .
49.3 % of those with good knowledge had poor practices as far as diabetes is
concerned. Low knowledge of diabetes in the community may result in poor
attitude however; this does not explain the poor practices even in people with
good knowledge of the disease. Altamimi and Peterson demonstrated that women
continued to consume sweetened foods, even though they knew about the
deleterious impact of sugar on oral and dental tissues .
Knowledge does not always result in behavior change and need to be reinforced .
the knowledge referred to in this study was the conventional form obtained from
the formal information, communication and education systems, the reason for
good practice among 37.4% of people with no knowledge was associated with their
indigenous knowledge. It is therefore important to identify interventions that
reinforce peoples’ attitudes despite their levels of knowledge of a particular
subject . Proper education and awareness programs have
previously been shown to change the attitude of the public regarding diabetes.
Improving knowledge of the people can improve their attitude towards diabetes
and in the long run change their practices to embrace healthier lifestyles such
as eating healthy foods, and engaging in physical activity .
Such practices will minimize the risks for diabetes in the general public and
delay the onset of complications in those already diabetic.
is need for further in-depth studies to investigate the social cultural beliefs
of health in Kenyan communities. These perceptions have reinforced unhealthy
dietary habits even though people are aware of the relationship between these
practices and chronic diseases such as diabetes .
was marked regional discrepancies in the level of knowledge with Central
province having relatively higher level of 30.8% and Coast province having the
lowest at 23.7%. The differences in the level of knowledge or the low levels do
not imply in any way that there is deficiency in intelligence in the various
groups and communities in the different regions. It only implies a lack of
exposure to knowledge about diabetes due to poor health education,
inaccessibility of good health care services and also low literacy levels in
some areas. This has previously been noted among patients with diabetes in a
primary health care setting in South Africa  and among
Pakistani Moslems with type 2 diabetes in Manchester .
disease potentially avoids and certainly postpones suffering and may have many
other benefits that are difficult to quantify (e.g. impact on families), which
may make it preferable to treatment. This study forms a baseline for the
national diabetes awareness campaigns and demonstrates the wide knowledge gap
which requires a concerted effort by those involved in diabetes management and
education. A systematic education curriculum for diabetes education is
essential for all levels of health care, from the community to the highest
referral level. The community health education interventions for diabetes need
to take into account the disparity and uniqueness which exist between gender,
age groups and regions.
survey did not identify those with diabetes among the respondents. Such people
would have higher knowledge due to the patient education provided at the
clinic. The questionnaires were in English and their administration depended on
the translation of interviewers for the respondents to understand. The
responses depended on the memory and truthfulness of the respondents which was
assumed to be reliable. The entry of responses into the questionnaire depended
on the interviewers’ interpretation of the response and was subject to misrepresentation.
This was however reduced due to training of interviewers and use of people with
this study, we did not ask the community about their sources of health
information. Knowledge of these sources of information would have been useful
in identifying the appropriate media for delivery of health promotion
interventions. There is therefore need for further community surveys to
identify sources of health information and the validity of the information
delivered through such media.
about diabetes mellitus is a prerequisite for individuals and communities to
take action to control the disease. However, research to assess knowledge
deficiencies and their relation to health-seeking behavior is lacking in most
developing countries. Diabetes education, with consequent improvements in
knowledge, attitudes and skills, will lead to better control of the disease,
and is widely accepted to be an integral part of comprehensive diabetes care.
authors declare no conflict of interest.
participated in obtaining the ethical approval, study design, data analysis and
in drafting the manuscript. NZ participated in study design, supervision of data
collection and literature review. NE participated in the review of the
manuscript and ME participated in review of the data and the manuscript.
Table 1: Levels of community knowledge on different
aspects of diabetes
Table 2: Regional differences in level of
knowledge of diabetes
Table 3: Relationship between community knowledge
of diabetes and practices
Figure 1: Level of education and
good knowledge of diabetes
authors would like to acknowledge the World Diabetes Foundation (WDF) for their
financial support to carry out this study. We particularly appreciate the
contribution of Scholastica Mwende, Onesmus Mwaura and Edward Ndungu for
assisting in supervising the data collectors. We also appreciate Mr. Benson
Maina and Retasi Strategic Solutions for assisting us in data entry and
analysis. We appreciate the contribution of Dr. Kathreen Karekezi in the peer
review of the manuscript.
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