Knowledge, Attitude and Practices Related To Diabetes Among Community Members in Four Provinces in Kenya - A Cross-Sectional Study

3/11/2015
Knowledge, attitude and practices related to diabetes among community members in four provinces in Kenya: a cross-sectional study
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Tablesand
Figures
Table 1: Levels of
community
knowledge
on
different aspects of
diabetes
Table 2: Regional
differences in level
of knowledge of
diabetes
Table
3:
Relationship
betweencommunity
knowledge
diabetes
of
and
practices
Figure1:Levelof
educationandgood
knowledgeof
diabetesamong
community
membersinfour
provincesinKenya
Ratethisarticle
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3/11/2015
Research
Citethisarticle:
WilliamKiberengeMaina,ZacharyMuriukiNdegwa,EvaWangechi
Njenga,EvaWanguiMuchemi.Knowledge,attitudeandpractices
relatedtodiabetesamongcommunitymembersinfourprovincesin
Kenya:acrosssectionalstudy.
ThePanAfricanMedicalJournal.20107:2
Keywords:Diabetes,knowledge,attitude,practices,community,Kenya
Permanentlink:http://www.panafricanmed
journal.com/content/article/7/2/full
Received:13/07/2010Accepted:28/09/2010Published:06/10/2010
WilliamKiberengeMainaetal.ThePanAfricanMedicalJournal
ISSN19378688.ThisisanOpenAccessarticledistributedunderthe
termsoftheCreativeCommonsAttributionLicense
(http://creativecommons.org/licenses/by/2.0),whichpermits
unrestricteduse,distribution,andreproductioninanymedium,
providedtheoriginalworkisproperlycited.
Knowledge, attitude and practices related to

diabetes among community members in four
provincesinKenya:acrosssectionalstudy
William Kiberenge Maina1,&, Zachary Muriuki Ndegwa2, Eva Wangechi

Njenga3,EvaWanguiMuchemi4
1Ministry of Public Health and Sanitation Kenya, 2National Diabetes Control
Kenya, 3Diabetes Endocrinology Center Nairobi, 4Kenya Diabetes Management

andInformationCentre(DMI)
&Correspondingauthor
William Kiberenge Maina, Ministry of Public Health and Sanitation, P.O. Box
3001600100,phone:+254722334365/+254202717077,fax:+254202722599,
Nairobi,Kenya
Background
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The International Diabetes Federation estimated the prevalence of diabetes in

Kenya to be about 3.3% in 2007 [1]. However, local studies have shown
prevalenceof4.2%inthegeneralpopulationwithaprevalencerateof2.2%in
theruralareasandashighas12.2%inurbanareas.Theprevalenceofimpaired
glucosetoleranceisequallyhigh8.6%intheruralpopulation,and13.2%inthe
urbanpopulation[2].
Urbanization 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 grainbased
dietrichinvegetablesandfruits[2,3].Urbanorevenwesternlifestylesinrural
areas have resulted in overreliance on motorized transport and consumption
unhealthydietsrichincarbohydrates,fats,sugarsandsalts[4].
Theselifestyleshavecontributedtoariseinlevelsofobesityandoverweightin
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 [5]. Recent studies have shown even higher
figure of 60.3% and 19.5% for women and men respectively in urban areas as
comparedto22.6%and10%inwomenandmenrespectivelyinruralareas[6].
The rise of these determinants of chronic diseases reflects the major forces
driving social, economic and cultural change in the Kenyan society. These same
factorsaredrivingtheepidemiologicallandscapewithchronicnoncommunicable
diseasesbecomingmajorcontributorstothenationaldiseaseburden[3].
Diabetes is now emerging as an epidemic of the 21st Century. It threatens to

overwhelm the health care system in the near future [7].Sadly,themajorityof
the people with diabetes in developing countries are within the productive age
rangeof45to64years[3].Thesearethesameindividualswhoareexpectedto
drive the economic engines of these countries in order to achieve the agreed
international development goals. Besides their reduced productivity, diabetes
furtherimposesahigheconomicburdenintermsofhealthcareexpenditure,lost
productivityandforegoneeconomicgrowth[3].
To curb this scourge of diabetes, public health interventions are required to

preventdiabetesordelaytheonsetofitscomplications.Thiswillentailintensive
lifestyle modification for those at risk of diabetes and aggressive treatment for
those with the disease [8]. A high risk approach targeting individual at risk of
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diabetes and a population or public health approach aimed at reducing the risk
factorsfordiabetesatthecommunityarenecessary.
Knowledge is the greatest weapon in the fight against diabetes mellitus.

Informationcanhelppeopleassesstheirriskofdiabetes,motivatethemtoseek
propertreatmentandcare,andinspirethemtotakechargeoftheirdisease[9].
It is therefore in the interest of the country to design and develop a
comprehensivehealthpromotionstrategyfordiabetesmellitusanditsrelatedrisk
factors. It is equally important to design and implement suitable diagnostic,
managementandtreatmentprotocolsforpeoplewithdiabetes.
Thisstudythereforewasconductedtoassessthelevelofcommunityawareness
of diabetes and how this knowledge influences their attitude and practices in
prevention and control of the disease. The findings will help in identifying
populationknowledgegapandtheirbehaviourtowardsdiabeteswhichwillguide
thedevelopmentofpreventionprogrammesinthecountry.
Methods
Thiswasadescriptivecrosssectionalstudyinvolving2000peopledrawnfrom8
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
informationsystemsintheMinistryofHealth.2000respondentswereconsidered
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
intoruralandurbandistrictsbasedontheirgeographicallocation.Twodistricts,
oneruralandoneurbanwererandomlyselectedfromeachprovince.Eachofthe
8 districts was assigned 500 respondents. The respondents were aged between
13 and 65 years. Only one respondent was interviewed for every household
visited.
Amediumsizedfourpartquestionnairewasdesignedbytheresearchers.Itwas
peer reviewed by 5 colleagues including a biostatistician for validation of the
questions. The questionnaire was then piloted on 10 respondents in Kajiado
districtwhichisaruraldistrictnexttoNairobi.Thiswasdoneinordertoassess
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
Englishlanguage,whichisthenationalofficiallanguage.
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The first part of the questionnaire covered the respondents demographic

information which included: name, age, sex, level of education, occupation and
averagemonthlyincome.
Part 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.Theoptionsgivenwere:lackofinsulin,failureofthebodytouseinsulin
andconsumptionoflotsofsugarordontknow.Forknowledgeaboutsignsand
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
dependingontheirresponsestotheknowledgeareasassessed.
Partthreeofthequestionnaireassessedtheattitudeoftherespondentstowards
lifestyle characteristics such as diet, physical activity and health seeking
behaviour.
Part four assessed what the respondents practiced in terms of adopting healthy
lifestylesthatpromotediabetesprevention.Thissectionlookedatconsumptionof
healthydiet,regularphysicalactivity,avoidanceofalcoholandtobaccouseand
regularmedicalcheckup.
The questionnaire was administered by interviewers who were people with

medical background knowledge of diabetes and included nurses, clinical officers
andnutritionists.Beforegoingtothefield,theinterviewersweretakenthrougha
onedaytrainingtoacquaintthemselveswiththedatacollectiontoolsandalsoto
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
theirabsencethenexthouseholdwasvisited.
All 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
thefielddata,analysiswasdoneunderthedomainofdescriptivestatisticsusing
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SPSSsoftware.
Results
Ofthetargeted2000respondents,1982(99.1%)wereinterviewedinthisstudy.
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
secondaryeducation,725(36.6%)hadprimaryeducationwhile162(8.2%)had
noeducationatall.
Only575(29%)ofrespondentshadgoodknowledgeofsignsandsymptomsof
diabeteswhile1407(71%)ofrespondentshadpoorknowledgeonwhatdiabetes
is.518(26.1%)couldcorrectlyidentifytheprobablecausesofdiabetesmellitus
while1464(73.9%)couldnot.Only523(26.4%)oftherespondentscouldidentify
complications of diabetes they knew while 1459(73.4%) had very little or no
knowledgeofcomplicationsofdiabetes(Table1).
Overall on average 539(27.2%) respondents had good knowledge of diabetes

while1443(72.8%)hadpoorknowledgeofthedisease.Therewasthereforeno
significant difference in knowledge levels between genders. The proportion of
femaleswhohadgoodknowledgewas26.8%comparedto27.7%inmales.
Regionaldifferencesinlevelofknowledge
Resultsrevealedasignificantisadisparityinthelevelofknowledgeindifferent
regions.Coastprovincehadthelowestknowledgelevelofdiabetes118(23.7%)
followedbyNairobi127(25.5%),Eastern140(28.9%)andCentral154(30.8%),
respectively. Nearly over 70% of all respondents from each of the four regions
hadpoorknowledgeofdiabetes(Table2).
Variationofknowledgeofdiabeteswithlevelofeducation
All the respondents with good knowledge were analyzed according to level of
education.Adirectrelationshipbetweenlevelofeducationandgoodknowledge
of diabetes was demonstrated. 52% of those who had good knowledge had
tertiary education, 25% had secondary education, and 14% had primary
educationwhile9%hadnoformaleducation(Figure1).
Communityattitudeandpracticestowardsdiabetes
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To assess the attitude of community towards diabetes, the attitude of people

towardslifestylecharacteristicssuchasdiet,physicalactivityandhealthseeking
behaviorwasassessed.Only28%ofrespondentsagreedwithstatementsrelating
to willingness to engage in physical activity, changing eating habits and
maintaininggoodbodyweights.Asignificant813(41%),oftherespondentsdid
not indicate any willingness to adopt these healthier lifestyles. 41% of all
respondentshadgoodpracticeswhiletherest59%hadbadpracticesinrelation
todiabetesprevention.75%ofthepeopleinterviewedhadpoordietarypractices,
72% did not participate in regular exercise and over 80% did not monitor their
bodyweights.
Relationshipbetweenpracticesandknowledge
Furtheranalysisoftherelationshipbetweencommunityknowledgeandpractices
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%ofthosewithgoodknowledgehadbadpracticescomparedto
62.6%ofthosewithoutknowledge(Table3).
Discussion
Moststudiesontheknowledge,attitudeandpracticesofdiabetesdoneinAfrica
andelsewheretargetpatientswithdiabetes.Unlikethese,thisstudytargetedthe
generalpopulation.Wethereforelackadequatecomparativedataforcommunity
and our discussions are based on knowledge, attitude and practices of people
withdiabeteswhoinmostcaseshavebetterexposuretodiabeteseducation.
The findings of this study reveal a serious deficiency in knowledge of diabetes

amongcommunitymembersinKenya.Only27.2%ofthepeopleinterviewedhad
goodknowledgeofdiabetes.Puepetetal.,foundasimilarlevelofknowledgeof
diabetes,30.2%,amongpatientswithdiabetesinJosState,Nigeria[10].Dinesh
etal.,inastudyinwesternNepal,notedalackofawarenessofdiabetesevenin
patients who had had the disease for a long time [11]. Even in a developed
country set up, Baradaran and Jones also found that knowledge about diabetes
amongstethnicgroupsinGlasgowwasverylow[12].
Thesefindingsunderscoreveryimportantaspectsofeducationtothecommunity
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asfarasdiabetesisconcerned.Firstlythereishistoricaldeficiencyinknowledge
aboutdiabetesandinequalitiesinthequalityofeducationreachingeachregionin
the country. Similar findings were documented by Hawthorne and Tomlinson
regarding Pakistani Moslems attending the Manchester Diabetic Centre [8,13].
Secondlythelowlevelofcommunityknowledgeofdiabetesreflectsontheextent
of health promotion for most chronic noncommunicable diseases. At the
moment, there are no comprehensive primary care programmes for diabetes in
thecountryanddiabeteshealtheducationisdonewithinhealthfacilitiesthrough
microteachingandonlytargetsthosewithdiabetes.Thisthereforeleavestherest
thepublicignorantofthedisease.Mostofthediabeteshealthpromotionefforts
by different stakeholders are uncoordinated and the messages are not
standardized due to lack of clear guidelines regarding diabetes education [12].
Lastly,thereisevenlowknowledgeofdiabetesamonghealthcareworkerswho
areexpectedtodeliverhealtheducationtothecommunity[14,15].
Community knowledge, culture and beliefs about diabetes is a prerequisite for

individualsandcommunitiestotakeactiontocontrolthedisease.Thisknowledge
affects their attitude and uptake of health services, including health education
[12]. Yet research into health knowledge and beliefs around diabetes causation
andpreventionamongthegeneralcommunityinKenyaislacking.
Diabetespreventioninterventionsneedtotargethealtheducationdirectedtothe
communityandthehealthcareproviders.Goodknowledgeofdiabetesamongst
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
favorabletreatmentoutcomes.Thisisduetothedirectinfluenceofknowledgeon
theattitudeandpracticesofboththecaregiverandthepatients[16].
Over49.3%ofthosewithgoodknowledgehadpoorpracticesasfarasdiabetes
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
goodknowledgeofthedisease.AltamimiandPetersondemonstratedthatwomen
continued to consume sweetened foods, even though they knew about the
deleteriousimpactofsugaronoralanddentaltissues[17].Knowledgedoesnot
alwaysresultinbehaviorchangeandneedtobereinforced[18].
Sincetheknowledgereferredtointhisstudywastheconventionalformobtained
from the formal information, communication and education systems, the reason
forgoodpracticeamong37.4%ofpeoplewithnoknowledgewasassociatedwith
theirindigenousknowledge.Itisthereforeimportanttoidentifyinterventionsthat
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reinforce peoples attitudes despite their levels of knowledge of a particular

subject [19]. Proper education and awareness programs have previously been
shown to change the attitude of the public regarding diabetes. Improving
knowledgeofthepeoplecanimprovetheirattitudetowardsdiabetesandinthe
long run change their practices to embrace healthier lifestyles such as eating
healthyfoods,andengaginginphysicalactivity[20].Suchpracticeswillminimize
therisksfordiabetesinthegeneralpublicanddelaytheonsetofcomplicationsin
thosealreadydiabetic.
Thereisneedforfurtherindepthstudiestoinvestigatethesocialculturalbeliefs
of health in Kenyan communities. These perceptions have reinforced unhealthy
dietary habits even though people are aware of the relationship between these
practicesandchronicdiseasessuchasdiabetes[21].
TherewasmarkedregionaldiscrepanciesinthelevelofknowledgewithCentral
province having relatively higher level of 30.8% and Coast province having the
lowestat23.7%.Thedifferencesinthelevelofknowledgeorthelowlevelsdo
notimplyinanywaythatthereisdeficiencyinintelligenceinthevariousgroups
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
healthcareservicesandalsolowliteracylevelsinsomeareas.Thishaspreviously
been noted among patients with diabetes in a primary health care setting in
SouthAfrica[9]andamongPakistaniMoslemswithtype2diabetesinManchester
[13].
Preventing 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
gapwhichrequiresaconcertedeffortbythoseinvolvedindiabetesmanagement
and education. A systematic education curriculum for diabetes education is
essentialforalllevelsofhealthcare,fromthecommunitytothehighestreferral
level. The community health education interventions for diabetes need to take
into account the disparity and uniqueness which exist between gender, age
groupsandregions.
Studylimitations
This survey did not identify those with diabetes among the respondents. Such
peoplewouldhavehigherknowledgeduetothepatienteducationprovidedatthe
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clinic. The questionnaires were in English and their administration depended on

thetranslationofinterviewersfortherespondentstounderstand.Theresponses
depended on the memory and truthfulness of the respondents which was
assumedtobereliable.Theentryofresponsesintothequestionnairedepended
on the interviewers interpretation of the response and was subject to
misrepresentation.Thiswashoweverreducedduetotrainingofinterviewersand
useofpeoplewithmedicalbackground.
In this study, we did not ask the community about their sources of health
information.Knowledgeofthesesourcesofinformationwouldhavebeenuseful
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
throughsuchmedia.
Conclusion
Knowledge about diabetes mellitus is a prerequisite for individuals and

communities to take action to control the disease. However, research to assess
knowledgedeficienciesandtheirrelationtohealthseekingbehaviorislackingin
most developing countries. Diabetes education, with consequent improvements
inknowledge,attitudesandskills,willleadtobettercontrolofthedisease,andis
widelyacceptedtobeanintegralpartofcomprehensivediabetescare.
Competinginterests
Theauthorsdeclarenoconflictofinterest.
Authorscontribution
MWK 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
manuscriptandMEparticipatedinreviewofthedataandthemanuscript.
Tablesandfigures
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Table1:Levelsofcommunityknowledgeondifferentaspectsofdiabetes
Table2:Regionaldifferencesinlevelofknowledgeofdiabetes
Table3:Relationshipbetweencommunityknowledgeofdiabetesandpractices
Figure1:Levelofeducationandgoodknowledgeofdiabetes
Acknowledgements
TheauthorswouldliketoacknowledgetheWorldDiabetesFoundation(WDF)for
their financial support to carry out this study. We particularly appreciate the
contribution of Scholastica Mwende, Onesmus Mwaura and Edward Ndungu for
assistinginsupervisingthedatacollectors.WealsoappreciateMr.BensonMaina
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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Knowledge, attitude and practices related to

William Kiberenge Maina1,&, Zachary Muriuki Ndegwa2, Eva Wangechi

1Ministry of Public Health and Sanitation Kenya, 2National Diabetes Control

Kenya, 3Diabetes Endocrinology Center Nairobi, 4Kenya Diabetes Management

The International Diabetes Federation estimated the prevalence of diabetes in

Urbanization with adoption of western lifestyles has been incriminated in the

Diabetes is now emerging as an epidemic of the 21st Century. It threatens to

To curb this scourge of diabetes, public health interventions are required to

Knowledge is the greatest weapon in the fight against diabetes mellitus.

The first part of the questionnaire covered the respondents demographic

Part two covered knowledge about diabetes. Knowledge on causes of diabetes

The questionnaire was administered by interviewers who were people with

Overall on average 539(27.2%) respondents had good knowledge of diabetes

To assess the attitude of community towards diabetes, the attitude of people

The findings of this study reveal a serious deficiency in knowledge of diabetes

Community knowledge, culture and beliefs about diabetes is a prerequisite for

reinforce peoples attitudes despite their levels of knowledge of a particular

clinic. The questionnaires were in English and their administration depended on

Knowledge about diabetes mellitus is a prerequisite for individuals and

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