Exploring knowledge, attitudes and practices related to diabetes in Mongolia: a national population-based survey
© Demaio et al.; licensee BioMed Central Ltd. 2013
Received: 23 August 2012
Accepted: 11 March 2013
Published: 18 March 2013
Non-communicable diseases (NCDs) are now the leading causes of mortality in Mongolia, and diabetes, in particular, is a growing public health threat. Mongolia is a nation undergoing rapid and widespread epidemiological transition and urbanisation: a process that is expected to continue in coming decades and is likely to increase the diabetes burden. To better inform policy and public-health responses to the impact of the growth in NCDs, a national NCD Knowledge, Attitudes and Practices survey was implemented in Mongolia in 2010; a section of which focused on diabetes.
This survey was a nationally-representative, household-based questionnaire conducted by field-workers. Households were selected using a multi-stage, cluster sampling technique, with one participant (aged 15–64) selected from each of the 3540 households. Questions explored demographic and administrative parameters, as well as knowledge attitudes and practices around NCDs and their risk factors.
This research suggests low levels of diabetes-related health knowledge in Mongolia. Up to fifty percent of Mongolian sub-populations, and one in five of the total population, had never heard the term diabetes prior to surveying. This research also highlights a high level of misunderstanding around the symptomatology and natural progression of diabetes; for example, one-third of Mongolians were unaware that the disease could be prevented through lifestyle changes. Further, this study suggests that a low proportion of Mongolians have received counseling or health education about diabetes, with lowest access to such services for the urban poor and least educated sub-populations.
This research suggests a low prevalence of diabetes-related health-knowledge among Mongolians. In this light, health-education should be part of any national strategy on diabetes.
KeywordsDiabetes Epidemiology Gealth policy Mongolia Asia KAP Knowledge Population
Non-communicable diseases, including diabetes, cardiovascular diseases, respiratory diseases and cancers, are now the leading causes of mortality in Low and Middle Income Countries including Mongolia . Independent of the aging population process, this insidious rise in NCDs now poses a threat to economic and social development, as well as population health [1, 2].
In 2013, NCDs are no longer only diseases of the rich, the old, and the sedentary. More than 50% of NCD deaths occur in people under the age of 70 years and the majority of these deaths occur in the worlds’ poorest populations . Moreover, it is becoming evident that NCDs, including their risk factors, are reflections of wider social, economic and environmental determinants, rather than simply a result of poor lifestyle ‘choices’ [1, 3].
In Mongolia, diabetes mellitus represents a real and growing public health threat. Diabetes prevalence in 2009 was 9% in urban areas and 4% in rural regions. At the same time, pre-diabetes (IFG) was at 12% and 7.3% respectively [4, 5]. Mongolia is a nation undergoing rapid and widespread epidemiological transition and urbanisation: a process that is expected to continue in coming decades and is likely to drive the diabetes burden.
Given 80% of global diabetes is believed to be currently preventable, many in the health policy and public health communities call for greater focus, research and investment in known roads to reduce this burden. A crucial first step has been the implementation of national NCD surveillance programs, for example WHO STEPS . These surveys, now implemented in more than 40 nations worldwide, provide accurate, timely and comparable burden data using primarily anthropometric and biochemical parameters. One weakness of STEPS has been the limited focus on the social context of disease, or knowledge, attitudes and practices. This information can be crucial when building health promotion and public health responses . Whether for the appropriate structuring of healthcare systems or health promoting policies, nationally-representative KAPS data may provide governments and health planners more detailed epidemiological information than burden data alone, which could prove crucial for public health decision-making [8, 9].
With this in mind, in 2010, the national NCD KAPS survey was implemented in Mongolia designed to complement and triangulate information from the WHO STEPS surveys.
One in a series of publications reporting on the knowledge, attitudes and practices of Mongolians with regards to NCDs, this paper investigates key knowledge, attitudes and practices that may contribute to the national diabetes-related burden. It also aims to shed light on possible policy and prevention ramifications of these findings.
The 2010 NCD KAPS survey was a nationally-representative, mixed-methods survey. A full description of the methods has been published .
While this survey did not sample the same participants as the 2009 WHO STEPS survey, both methodologies were aligned and both nationally-representative samples were from the same broader population.
Households were selected using a multi-stage, cluster sampling technique, including Probability Proportional to Size sampling (PPS) and simple random sampling from government registries.
The questionnaire was field-worker implemented and administered on one household member from 3450 individual households across Mongolia, in each rural and urban area. Household members, aged 15 – 64 years, were chosen using a predefined algorithm. Questions explored demographic and administrative parameters, as well as knowledge, attitudes and practices around NCDs and their risk factors, and then a more vertical approach surveyed individual disease knowledge, attitudes and practices.
Quality assurance processes included back-translation, pre-testing, piloting and a modified Delphi process of international experts.
Knowledge was probed using a mix of open and closed questions, the first of which asked participants to rate their own level of diabetes knowledge. Participants were asked to volunteer one of four possible ordered responses, from no knowledge, to high knowledge. A series of questions then explored diabetes, the symptomatology and natural progression of the disease, the awareness of its preventable nature and common complications of diabetes. These were single questions posing a statement where the participant was asked to label the statement as true or false.
Prevention and barriers to prevention were then explored. Participants were posed an open-ended question and asked to volunteer prevention methods for diabetes. The most common five responses are reported in this paper. Then participants were asked another open-ended, unprompted question to volunteer main perceived barriers to the consumption of fresh fruits and vegetables. This question was to investigate issues of access as well as knowledge. Similarly, participants were questioned on the perceived barriers to physical activity.
With regards to body weight, in the context of a rapidly increasing prevalence of the overweight and obese in Mongolia, participants were asked to rank the perceived important of maintaining a ‘healthy’ body weight. ‘Healthy’ was left to the participant to define. The participant was asked to rank the importance on a four-level Likert scale, for which a mean and confidence interval were calculated.
Finally, investigating health practices regarding diabetes, participants were asked to report whether a health worker had ever counseled them about diabetes. This was to further assess higher-risk populations when triangulated with prevalence data. For this there was a yes/no response only.
This study was conducted according to the principles of the Helsinki declaration. The Mongolian National Ministry of Health’s Medical Ethical Committee approved the study on the 06 October 2010.
Data input and analysis was performed using the SPSS (IBM SPSS 20.0.0 Statistics) software package. Data was weighted (sample and population weighting coefficients applied) to correct for differences between the sampled population and Mongolian census data. Regression analyses were used to study the presence and strength of associations between populations and their knowledge, attitudes and practices. Major analysis indices included descriptive rates with associated confidence-intervals, as well as univariate and multivariate odds ratios. Covariates included gender, urbanicity, educational attainment and employment status. Age was not routinely included in analyses due to the even age distribution of the sample, and as both education and employment were found to be analogous with age. Significance was assumed at p < 0.05 for all tests (two-sided).
Descriptive information on sample population, disaggregated by age, sex, urbanicity, educational level and employment status; Mongolia, 2010
Education (n= 3450)
Primary or less
This national survey sampled 3450 participants from households across Mongolia. Using a pre-defined algorithm at the final stage of sampling, 42% of participants were male and 58% female. Disaggregated by age, the majority of participants were aged less than 45 years (Table 1). Half of the participants live in the national capital, Ulaanbaatar, in an urban setting. Almost two-thirds of participants achieved high school education only, while a further third attended university. Six percent completed only primary school education, a minority that is evenly spread throughout males and females. Two-fifths of all participants reported to be employed at the time of surveying, with a further one fifth identifying as students. Around 15% were unemployed and 20% reported to be retired or home-makers.
Knowledge and attitudes among Mongolians, aged 15–64 years, towards diabetes; Mongolia, 2010
Self-Rated knowledge as “Never heard term diabetes before”
Aware of possible asymptomatic nature of diabetes
Aware that even with diabetes, a normal life can be possible
Aware of main health complications of diabetes (heart disease, vision loss)
Aware that diabetes is preventable
Able to name a diabetes prevention or treatment method
n (% of Total)
n (% of Total)
n (% of Total)
n (% of Total)
n (% of Total)
n (% of Total)
Total (n = 3450)
Less than Primary
Barriers to prevention methods were then explored. Regarding fruit and vegetable intake, almost two thirds of participants felt that ‘price’ was the main constraint hindering consumption, while one in five felt ‘physical access’ was the main limiter. One in three responded that they did not trust imported foods and that this hindered their fruit and vegetable consumption – a response significantly associated with urban living. For rural populations almost forty percent responded that a lack of access was the main deterring factor to a healthier diet. Perceived barriers to exercise were also studied. Around one third of participants felt that a ‘lack of time’, ‘knowledge’ or ‘interest’ were the main deterrents for Mongolians engaging in more exercise as a means of improving health. There are small differences between men and women; where men were more likely to blame a ‘lack of interest’ and women a ‘lack of time’ or ‘knowledge’.
Coverage of diabetes-related health counseling services among Mongolians aged 15–64 years; Mongolia 2010
Received diabetes counselling from a health worker
n (% of Total)
Total (n = 3450)
Less than Primary
This research suggests a correlation between populations with higher burdens of diabetes and lower levels of health knowledge. Rural, unemployed, less-educated and male populations are found to hold lower levels of knowledge on diabetes and are the same groups found to experience higher burdens of disease .
Findings also suggest that as many as one in five Mongolians has never heard the term ‘diabetes‘. Comparing this finding with other nations in the region, similar studies find analogous results in India where 20% - 25% of citizens are also unaware [8, 9, 11]. This health-knowledge gap represents a very different public health paradigm for policies and interventions from that in countries such as the USA or Australia where awareness of diabetes is much higher . A precursor for health literacy, this lack of awareness may hinder health promotion strategies currently being implemented in Mongolia, including screening and media campaigns which assume minimum awareness of the disease’s existence [13, 14]. This knowledge gap is particularly pronounced among rural participants, both nomadic and small regional town populations. Therefore one could surmise that as the nation continues to experience rapid epidemiological transition and rural to urban migration, a lack of knowledge coupled with changing diets and lifestyle patterns expected, may result in higher burdens of diabetes for future populations [15–17].
Investigating the public’s understanding of diabetes further, this research highlights a high level of misunderstanding around the symptomatology and natural progression of diabetes. On average, just one in two Mongolians are aware than diabetes can be asymptomatic in the early stages of disease. Further, one third of Mongolians are unaware that the disease can be prevented through lifestyle changes and simple medications. While this figure is higher than similar studies in India, this may go some way to explaining the reason 85% of Mongolians have never undertaken screening . These misunderstandings are more prevalent in the male population, of which 90% have never been screened .
Finally, this study suggests that a low proportion of Mongolians have received health education regarding diabetes. Those with least access to such services were the urban poor and least educated sub-populations, supporting findings from other research in the Asian region . A recommendation may be the targeted provision of preventative-focused primary care services in areas such as the urban ger districts. Housing the poorest and newly urbanised populations, these districts currently have primary care services though these have a limited role in chronic disease screening and management, which could be expanded .
In conclusion, this research suggests a low level of diabetes-related health-knowledge among Mongolians, with as many as one in two Mongolians having never heard the term ‘diabetes’. This low baseline of health knowledge, crucial to developing population health literacy, may hinder public health interventions particularly as the efficacy of such interventions relies on the pre-existence of basic health-information among target populations .
This study is funded by the Millennium Challenge Account - Mongolia Health Project. The authors of this paper would like to acknowledge Kyra-Bae Snell for her editorial support in drafting.
- World Health Organization: Global Status Report on Noncommunicable Diseases 2010. 2011, Geneva: World Health OrganizationGoogle Scholar
- World Economic Forum: Global Risks Report. A Global Risk Network Report. 2010, Geneva: World Economic Forum, 24-26.Google Scholar
- World Health Organization: Reducing risks, promoting healthy life. World Health Report. 2002, Geneva: World Health OrganizationGoogle Scholar
- World Health Organization: STEPS Survey Report. Edited by: World Health Organization. 2009, Ulaanbaatar, Mongolia: World Health OrganizationGoogle Scholar
- Otgontuya D, Oum S, Palam E, Rani M, Buckley BS: Individual-based primary prevention of cardiovascular disease in Cambodia and Mongolia: early identification and management of hypertension and diabetes mellitus. BMC Publ Health. 2012, 12: 254-10.1186/1471-2458-12-254.View ArticleGoogle Scholar
- World Health Organization: STEPwise Approach to Surveillance (STEPS) Manual. 2008, Geneva: World Health Organization, 1Google Scholar
- Brewer NT, Chapman GB, Gibbons F, Gerrard M, McCaul KD, Weinstein ND: Meta-analysis of the relationship between risk perception and health behavior: The example of vaccination. Heal Psychol. 2007, 26 (2): 136-145.View ArticleGoogle Scholar
- Mohan D, Raj D, Shanthirani C, Datta M, Unwin N, Kapur A, Mohan V: Awareness and knowledge of diabetes in Chennai–the Chennai urban rural epidemiology study. J Assoc Physicians India. 2005, 53: 283-287.PubMedGoogle Scholar
- Raj CP, Angadi M: Hospital-based KAP study on Diabetes in Bijapur, Karnataka. Indian J Med Specialities. 2010, 1 (2): 80-83.View ArticleGoogle Scholar
- Demaio AR, Otgontuya D, Amgalan G, Maximenco E, Munkhtaivan A, Graeser S, Kryger T, Oyunbileg J, Jousilahti P, Courten M: Protocol for a national, mixed-methods knowledge, attitudes and practices survey on non-communicable diseases. BMC Publ Health. 2011, 11: 961-10.1186/1471-2458-11-961.View ArticleGoogle Scholar
- Shah VN, Kamdar PK, Shah N: Assessing the knowledge, attitudes and practice of type 2 diabetes among patients of Saurashtra region, Gujarat. Int J Diabetes Dev Countries. 2009, 29 (3): 118-122. 10.4103/0973-3930.54288.View ArticleGoogle Scholar
- Coulson F, Ypinazar V, Margolis S: Awareness of risks of overweight among rural Australians. Rural Remote Heal. 2006, 6 (2): 514-Google Scholar
- Edwards M, Wood F, Davies M, Edwards A: The development of health literacy in patients with a long-term health condition: the health literacy pathway model. BMC Publ Health. 2012, 12: 130-10.1186/1471-2458-12-130.View ArticleGoogle Scholar
- Nutbeam D: Health literacy as a public health goal: a challenge for contemporary health education and communication strategies into the 21st century. Heal Promot Int. 2006, 15 (3): 259-267.View ArticleGoogle Scholar
- Foggin PM, Farkas O, Shirev-Adiya S, Chinbat B: Health status and risk factors of seminomadic pastoralists in mongolia: a geographical approach. Soc Sci Med. 1997, 44 (11): 1623-1647. 10.1016/S0277-9536(96)00273-0.View ArticlePubMedGoogle Scholar
- Manaseki S: Mongolia: a health system in transition. Br Med J. 1993, 307 (6919): 1609-1611. 10.1136/bmj.307.6919.1609.View ArticleGoogle Scholar
- Dore G, Nagpal T: Urban transition in mongolia: pursuing sustainability in a unique environment, environment. Sci Policy Sustainable Dev. 2006, 48 (6): 10-24. 10.3200/ENVT.48.6.10-24.View ArticleGoogle Scholar
- Rani P, 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. Rural Remote Heal. 2008, 8 (3): 838-Google Scholar
- Enkhtuya B, Badamusuren T, Dondog N, Khandsuren L, Elbegtuya N, Jargal G, Surenchimeg V, Grundy J: Reaching every district – development and testing of a health micro-planning strategy for reaching difficult to reach populations in Mongolia. J Rural Remote Health. 2009, 9: 1045-Google Scholar
- Matthaei S, Munro N, Zinman B: Raising diabetes awareness in the public domain. Int J Clin Pract. 2007, 61 (s157): 31-37.View ArticleGoogle Scholar
- The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1471-2458/13/236/prepub