Knowledge, Attitudes, and Practices of Patients with type 2 Diabetes Mellitus with Regard to their Disease: A Cross-Sectional Study Among Palestinians of the West Bank

Background: In Palestine, type 2 diabetes mellitus (T2DM) is a rapidly growing health concern. This study was conducted to evaluate current knowledge, attitudes, and practices among Palestinian patients with T2DM in the West Bank and to assess association between knowledge, attitudes, and practices with sociodemographic and clinical characteristics of the patients. Methods: This cross-sectional observational study was conducted in primary healthcare facilities frequently visited by patients with T2DM across the West Bank of Palestine. A pre-validated interviewer administered questionnaire was used to determine knowledge, attitudes and practices of patients with T2DM with regard to their disease. Results: Data were collected from 220 patients with T2DM. Patients who were younger than 55 years old (p-value = 0.002), male (p-value = 0.038), never married (p-value = 0.001), employed (p-value = 0.003), had university degree (p-value <0.001), had higher income (p-value <0.001), diagnosed less than 7 years ago (p-value = 0.009), and had usual fasting plasma glucose of less than 140 mg/dL (p-value = 0.027) tended to score more than 50% in the knowledge items. Patients who had higher income tended to have higher positive attitudes (p-value = 0.041) toward their disease. Patients who were younger than 55 years old (p-value = 0.002), employed (p-value = 0.003), had university degree (p-value <0.001), diagnosed less than 7 years ago (p-value = 0.009), had usual fasting plasma glucose of less than 140 mg/dL (p-value = 0.027), had usual postprandial plasma glucose of less than 200 mg/dL (p-value = 0.027), had usual HbA 1c of less than 7% (p-value = 0.027) tended to score more than 80% in the practice items. Conclusions: The study established correlation between knowledge, attitude, and practice scores with sociodemographic and clinical characteristics of patients with T2DM in Palestine. Findings of this study highlighted the need for


Background
Type 2 diabetes mellitus (T2DM) is a major metabolic disease that is characterized by sustained high levels of blood glycemia which result from defective secretion of insulin, ineffective insulin action, or both [1,2].Globally, T2DM is considered a major public health epidemic with considerable number of premature deaths, disabilities, high morbidity, and mortality rates [3].According to recent estimates, about 462 million people were affected by T2DM in 2017 which corresponded to approximately 6.3% of the world's population [4].Today, T2DM is the 9th leading cause of mortality that claims 1 million human lives on an annual basis.In Palestine, T2DM is a rapidly growing health concern.The prevalence of T2DM in the general Palestinian population was estimated at 15.3%.The prevalence rate was forecasted to increase to 20.8% for 2020 and 23.4% for 2030 [5].
Complications of T2DM range from acute conditions such as hypoglycemia, hyperosmolar hyperglycemic state and diabetic ketoacidosis to chronic complications affecting multiple vital organs including eyes, kidneys, nerves, and heart [6,7].Moreover, T2DM is a major cause of and amputations of the lower limbs [8,9].However, complications associated with T2DM might be mitigated by adherence to proper management approaches of the disease [10,11].Such approaches aim to achieve optimal glycemic control which might eventually lead to decrease in both macro-and microvascular complications of T2DM [12].Management of T2DM involves both lifestyle modi cations, including healthy diet and regular exercise, and pharmacological therapy [13].To achieve this, high levels of knowledge of the disease, access to insulin and other oral hypoglycemic agents, and equipment to monitor blood glycemia are required [14].
Recent studies that were conducted to assess knowledge, attitudes, and practices of patients with T2DM highlighted the necessity of larger awareness among patients with regard to preventing, diagnosis, mitigating risk factors, and minimizing the complications of the disease [15][16][17][18].It has been argued that educating patients on their disease was an effective strategy to reduce complications of T2DM and achieve good control over blood glycemia by improving attitudes of patients and their practices [19,20].Previous studies showed that patients with better knowledge about T2DM and its associated complications were expected to adhere to proper treatment and care compared to patients with poor knowledge.It has been argued that patients with T2DM who are knowledgeable of their disease would achieve better control of their blood glycemia resulting in improvement in their health and quality of life [21].Additionally, unfavorable attitudes were associated with poor control over blood glycemia and incidence of complications [22].Previous studies have shown differences in knowledge, attitude, and practices among patients with T2DM in different settings [3,[15][16][17][18].
Although having good knowledge, attitudes and practices regarding T2DM would be helpful for better patient related outcomes, currently, little is known on the level of knowledge, attitudes and practices among patients with T2DM in Palestine with regard to their disease.Therefore, this study was conducted to evaluate current knowledge, attitudes, and practices among Palestinian patients with T2DM in the West Bank.The study also assessed association between knowledge, attitudes, and practices of patients with T2DM with their sociodemographic and clinical characteristics.Findings of this study could inform future decisions and interventions to improve control over blood glycemia, reduce the incidence of complications, improve care, and quality of life of Palestinians with T2DM.

Study settings and design
This study was conducted in different primary healthcare facilities frequently visited by patients with T2DM across the West Bank of Palestine.Patients were approached and invited to take part in the study by the eld researchers.The sample was collected in the period of October 2018 to January 2019.After obtaining their consent, patients with T2DM were interviewed to determine their knowledge, attitudes and practices toward T2DM.This study was conducted in a cross-sectional observational design using a validated and reliable study tool.The study tool was tested for reliability in a pilot before conducting the study.

Population, Inclusion, And Exclusion Criteria
The study population was patients with T2DM who visited primary healthcare facilities in the West Bank of Palestine.Patients of both genders who were at least 18 years old and diagnosed with T2DM at least 6 months ago were invited to take part in this study.Patients were included if they provided verbal consent and were able to respond to questions in a questionnaire.
Patients who were less than 18 years old and those who were unable to respond to questions in a questionnaire were excluded.

Sample Size And Sampling Method
According to the International Diabetes Federation, there were 174,300 patients with T2DM in Palestine [23].The sample size required for this study was calculated using an online sample size calculator (http://www.raosoft.com/samplesize.html).The sample size was estimated for a population of more than 20,000 with a 95% con dence interval and accepting a 5% margin of error.A convenience sampling method was followed to recruit participants in this study.Patients with T2DM were approached and recruited by eld researchers from different primary healthcare facilities in the West Bank of Palestine.

Study Tool
The study was conducted using a pre-validated and reliable questionnaire to collect data relevant to knowledge, attitudes, and practices of patients with T2DM with regard to their disease.The questions included in the questionnaire were informed by relevant literature [24][25][26].The study tool used in this study is shown in Additional File 1.The questionnaire collected sociodemographic characteristics of the patients like age, gender, body weight, height, marital status, employment, place of residence, educational level, and monthly income.The body weight and height were used to calculate the body mass index of the patient [27].Patient health records were used to obtain the time elapsed since they received their diagnosis with T2DM, if they had a health insurance, if they have had attended an educational program regarding diabetes, their usual fasting plasma glucose level, their usual postprandial plasma glucose level, and their usual glycated hemoglobin (HbA 1c ) level.Regarding knowledge, the patients were asked to answer the items regardless of their actual practice.The knowledge items included specifying the tests used to diagnose DM, what can be done to keep DM under control, how long patients should continue adherence to diet control/ treatment, and what organs would DM affect.Regarding attitudes, the patients were asked to answer the items regardless of their practice.
Attitude items included whether occasional eating of sweets was alright, forgetting to take insulin or antidiabetic medications on some says was alright, whether not practicing recommended exercise was alright, and whether the patient should go for regular checkups even if their blood glycemia was under control.Regarding practice, the patients were asked to answer items relevant to their actual practice.Practice items included whether the patients: took insulin and/or other antidiabetic medications as their caring physicians recommended, followed diet schedule as recommended by their caring healthcare providers, adhered to practicing regular exercise as recommended by their caring healthcare providers, whether their blood glycemia was under control, and whether they regularly go for follow ups with their caring healthcare professionals.
The data were collected into an interviewer administered questionnaire in face-to-face interviews.The interviewers were nal year Doctor of Medicine (MD) candidates who were trained to administer interviews.

Pilot Testing, Reliability And Internal Consistency
The study tool was pilot tested with 25 patients to assess if the questions were readable and understandable.To test the stability of the scores over a short period of time (30 min to 1 h), the test-retest method.The 25 patients were asked to answer the items twice.Scores obtained in the two rounds were correlated using Pearson's correlation.As used in previous studies, acceptable coe cients were set a priori as > 80% [28-32].Cronbach's alpha statistics were used to assess the internal consistency of the items used in the study tool.Acceptable coe cients were set a priori between 70% and 95%.

Data analysis
For knowledge, attitudes, and practice items, the patients were given 1 point for each correct/positive answer and 0 for each incorrect/negative answer.As in previous studies, scoring more than 50% in the knowledge items was considered as having good knowledge (scores could range from 0-12), scoring more than 75% in the attitude items was considered as having positive attitude (scores could range from 0-4), and scoring more than 80% in the practice items was considered as having good practice with regard to T2DM (scores could range from 0-5).
The data obtained in this study were coded and entered into IBM SPSS for Windows v.21.0 0 (IBM Inc., Armonk, New York) for analysis.To determine whether the data were normally distributed or not, Shapiro-Wilk test was used.As determined by the test, the data were not normally distributed.Therefore, medians and their corresponding interquartile ranges (IQR) were used to express the data.Categorical data were compared using the Chi-square (χ 2 ) test.Spearman's rank correlation was used to assess correlations between variables.In this study, a p-value of < 0.05 was considered statistically signi cant.

Ethics Approval And Consent To Participate
Ethics approval was obtained from the Institutional Board Review (IRB) of An-Najah National University.Field researchers explained the study design and objectives to the potential participants and obtained their informed consent before they took part in the present study.

Results
When the scores of the patients in the two rounds were compared for the test-retest, the Pearson's correlation coe cient was 95% (95% CI = 91.2-98.7%)with a p-value of < 0.001.Internal consistency of the items used in the test was good as indicated by a Cronbach's alpha of 74.2%.

Characteristics Of The Patients
In this study, data were collected from 220 patients with T2DM.Of those, more 138 (62.7%) were 55 years of age and older, 118 (53.6%) were female in gender, 139 (63.2%) were unemployed, 149 (67.7%) resided in urban areas, 55 (25.0%) has university degrees, 135 (61.4%) had moderate or high income, 116 (52.7%) were diagnosed with T2DM 7 or more years ago, 45 (20.5%) did not have any health insurance, 198 (90.0%) did not attend any educational program regarding DM, 154 (70.0%) had their usual fasting plasma glucose level of more than 140 mg/dL, 177 (80.5%) had their usual postprandial plasma glucose level of more than 200 mg/dL, 167 (75.9%) had their HbA 1c level more than 7%, and 175 (79.5%) had a BMI of more than 25 kg/m 2 .Details of the sociodemographic and clinical variables of the patients who took part in this study are shown in Table 1.In this study, χ 2 and Spearman's correlations showed that patients who were younger than 55 years old (p-value = 0.002), male in gender (p-value = 0.038), never married (p-value = 0.001), employed (p-value = 0.003), having university degree (pvalue < 0.001), earning higher income (p-value < 0.001), diagnosed with T2DM since less than 7 years ago (p-value = 0.009), and having usual fasting plasma glucose level of less than 140 mg/dL (p-value = 0.027) tended to score more than 50% in the knowledge items.Details of association between knowledge and sociodemographic and clinical characteristics of the patients are shown in Table 4.

Attitudes With Regards To Diabetes
Attitudes of patients with regard to their DM were measured using attitude items.Of the patients, 129 (58.7%) scored more than 75% in the attitude items.The median score of the patient attitudes was 3 with an IQR of 2. Of the patients, about 36% of patients believed that eating sweets occasionally was alright, about 29% of the patients stated that it was alright if they forgot to take their medicines on some days, around 30% of the patients believed that it was not necessary to go for regular checkups if their sugar level was under control, and close to 44% believed that they got enough exercise when doing their daily activity.In this study, χ 2 and Spearman's correlations showed that patients who had higher income tended to have higher positive attitudes (p-value = 0.041) toward their DM.Details of association between attitudes and sociodemographic and clinical characteristics of the patients are shown in Table 5. Detailed distribution of patient answers on the attitude items are shown in Additional File 3.

Practices Of Patients With Regard To Their Diabetes
Practices of patients with regard to their DM were measured using practice items.Of the patients, 80 (36.4%) scored more than 80% in the practice items.The median score of the patient practices was 3 with an IQR of 3. Of the patients, about 71% stated that they regularly took their insulin and/or antidiabetic medications as advised by their physicians, about 39% followed the diet program as advised by their healthcare providers, approximately 37% stated that they adhered to regular exercises as advised by their healthcare providers, and around 65% stated that they regularly go for follow ups.In this study, χ 2 and Spearman's correlations showed that patients who were younger than 55 years old (pvalue = 0.002), employed (p-value = 0.003), having university degree (p-value < 0.001), diagnosed with T2DM since less than 7 years ago (p-value = 0.009), having usual fasting plasma glucose level of less than 140 mg/dL (p-value = 0.027), having usual postprandial plasma glucose level of less than 200 mg/dL (p-value = 0.027), having usual HbA 1c level of less than 7% (p-value = 0.027) tended to score more than 80% in the practice items.Details of association between practices and sociodemographic and clinical characteristics of the patients are shown in Table 6.Detailed distribution of patient answers on the practice items are shown in Additional File 4. HbA 1c : Glycated hemoglobin Spearman's correlations showed that knowledge scores correlated moderately with attitudes scores (Spearman's rho = 0.27, p-value < 0.001) and practice scores (Spearman's rho = 0.34, p-value < 0.001).Similarly, attitudes and practice scores correlated moderately (Spearman's rho = 0.29, p-value < 0.001).

Discussion
In this cross-sectional study, knowledge, attitudes, and practices of patients with T2DM with regard to their disease were assessed for the rst time among Palestinian patients.Patients who took part in this study were recruited from different primary healthcare facilities in the West Bank of Palestine.In this study, more than half (52.2%) had good knowledge and 58.7% has positive attitudes with regard to their disease.On the other hand, only 36.4% had good practices.
Findings of this study highlighted gaps in knowledge, attitudes, and practices with regard to T2DM among patients.In this study, correlations were established between knowledge, attitudes, and practices with the sociodemographic and clinical characteristics of the patients with T2DM.Additionally, knowledge, attitudes, and practices of patients who took part in this study correlated moderately.Findings of this study could be useful for policy makers, decision makers, healthcare providers, and patient advocacy groups who might need to design interventions to improve health outcomes of patients with T2DM.
In this study, the tool used to measure knowledge, attitudes, and practices was adopted from previous studies [24][25][26].
The tool was piloted for clarity and comprehension.Additional testing of stability of scores over a short period of time and internal consistency between the items included was performed.The test-retest method and Cronbach's alpha ensured that the tool used in this study was reliable and internally consistent [28][29][30][31][32].These measures might have added strength and rigor to methods used in this study.The data were collected using an interviewer administered questionnaire.Additionally, the interviewers in this study were nal year MD candidates who were familiar with conducting interviews and taking patient history.This should have minimized occasions of mis-or lack of understanding associated with self-administered questionnaires [33].
Our ndings indicated that almost half of the patients (52.2%) had good knowledge of T2DM and its associated complications.In a pilot study conducted in Sri Lanka, Hearth et al showed that 77% of patients with T2DM has moderate or above moderate knowledge of their disease [3].Studies in different settings have reported variable level of knowledge among patients with T2DM in Mongolia, Sri Lanka, Bangladesh, India, Jordan, and Lebanon [34][35][36][37][38][39][40].Not surprisingly, knowledge of T2DM was signi cantly higher among younger, male, never married, employed, educated, earning higher income, diagnosed with T2DM since less than 7 years ago, and having usual fasting plasma glucose level of less than 140 mg/dL.This could be explained simply because patients with higher education are expected to be more aware of their disease, its complications, and the ways to keep their blood glycemia under control.Additionally, it has been argued that younger patients are more interested in learning about their disease compared to older patients who could have other comorbidities and less interest in learning about their disease.Taken together, our ndings might suggest that older and less educated patients need greater motivation and support from their healthcare providers and families.Our ndings were consistent with those reported in some related studies that were conducted elsewhere.For example, Hearth et al showed that education was positively associated with higher knowledge of T2DM among patients in Sri Lanka [3].Similarly, Karaoui et al showed that higher level of education was positively correlated with higher knowledge of T2DM among patients in Lebanon [36].In Bangladesh, Fatema et al showed that male patients with T2DM had signi cantly higher knowledge of their disease compared to female patients [35].
Findings of this study showed that 58.7% of the patients had positive attitudes toward their disease.Our results were comparable to those reported by Belsti et al in Ethiopia in which [26].However, in this study attitude scores were not signi cantly associated with educational level of the patients as was shown in Belsti's study.Our ndings showed signi cant association between attitude scores and higher income.Our ndings were consistent with those reported among patients with T2DM in Bangladesh [35].Probably, patients with higher income could have better access to healthcare services, ability to go to regular checkups, and practice physical activity compared to patients with less income [25].
Regarding practice, our study showed that 36.4% of the patients with T2DM had good practices with regard to their disease.In Ethiopia, less than half of patients with T2DM had good practices regarding T2DM and its complications [26].Similarly, our ndings were consistent with those reported in Sri Lanka and Lebanon [3,36].Our ndings showed that younger, employed, educated, diagnosed since less than 7 years ago, and having controlled blood glycemia as indicated by fasting plasma glucose level, postprandial plasma glucose level, and HbA 1c level were signi cantly associated with good practices.Our results were consistent with those reported in different settings in Mongolia, Sri Lanka, Bangladesh, and Lebanon [34][35][36].

Strengths And Limitations
Results of this study might be carefully interpreted taking into consideration the following strengths and limitations.
First, this pilot study was the rst to assess knowledge, attitudes, and practices of Palestinians with T2DM with regard to their disease.Second, this study was also to establish association between knowledge, attitudes, and practices with various sociodemographic and clinical characteristics of the patients.Third, the study tool used in this study was piloted and evaluated for reliability and internal consistency.Fourth, the study tool was administered by interviewers who were nal year MD candidates who were familiar with interviewing patients and taking medical history.This should have reduced the occasions of mis-or lack of understanding that could be associated with self-administered questionnaires.
On the other hand, this study has a number of limitations.First, this study was a cross-sectional observational study.An interventional design should have permitted enhancing knowledge, improved positive attitudes, and promoted good practices among patients with T2DM with regard to their disease.Second, the sample size used in this study was relatively small.However, the sample size used in this study was comparable to those used in other studies [3,36].Third, a convenience sampling method was followed to recruit the sample needed for this study.It is noteworthy mentioning that the sample recruited was diversi ed by inclusion of patients from both genders, different educational levels, income levels, and geographic locations.Finally, the number of items relevant to knowledge, attitudes, and practices was relatively small.Despite the small number of items, we were able to expose the level of knowledge, attitudes, and practices of patients with T2DM with regard to their disease.

Conclusion
In conclusion, this study provided insights into current knowledge, attitudes, and practices of Palestinians with T2DM.
The study established correlation between knowledge, attitude, and practice scores with sociodemographic and clinical characteristics of patients with T2DM in Palestine.Findings of this study highlighted the need for appropriately designed interventions to increase knowledge of T2DM and its complications, address the negative attitudes toward the disease, and promote healthy practices with regard to the disease.
AbbreviationsT2DM Type 2 diabetes mellitus HbA 1c Glycated hemoglobin IQR Interquartile ranges IRB Institutional Board Review MD Doctor of Medicine χ 2 Chi-square

Table 1
Detailed sociodemographic and clinical characteristics of the patients who took part in this study (n = 220) Knowledge of the patients with regard to their DM was measured using the knowledge items.The median score of the patients in the knowledge items was 6 with an IQR of 3. Of the patients, 115 (52.2%) scored more than 50% in the knowledge items.When asked to identify the organs affected by DM, 129 (58.6%) could identify that DM could affect the eyes and 124 (56.4%) could identify that DM could affect the kidneys.Of the patients, only 82 (37.3%) could identify that DM could affect the heart.Details of the answers of the study patients with regard to the damaging effects of DM on the body organs are shown in

Table 2 .
Detailed distribution of patient answers on the knowledge items are shown in When asked about how diabetes could be kept under control, the vast majority (90.9%) of the patients could identify medications including insulin.Diet was identi ed by 174 (79.1%) patients.However, going for regular checkups was identi ed by only 25 (11.4%)patients.Details of the answers of the patients with regards to ways to control DM are shown in Table3.

Table 4
Association between knowledge and sociodemographic and clinical characteristics of the patients

Table 5
Association between attitudes and sociodemographic and clinical characteristics of the patients

Table 6
Association between practices and sociodemographic and clinical characteristics of the patients