Correlation between Glycated Hemoglobin Levels and Knowledge, Attitude, and Practice of Type 2 Diabetic Patients Attending Primary Health Care Centers in Dubai Health Authority

Diabetes mellitus (DM) is one of the fastest-growing health problems in the world that requires long-term care and treatment, placing a burden on individuals and the society. Globally, in 2019, according to the International Diabetes Federation (IDF), it was estimated that 463 million adults (20–79 years) suffered from diabetes; and this number is expected to rise to 700 million in 2045 (IDF 2019). The proportion of people with type 2 diabetes is increasing worldwide. The top five countries with higher number of diabetes in 2019 are China, India, USA, Pakistan, and Brazil, respectively. In the Middle East and North Africa (MENA), it was estimated in 2019 that 55 million people were affected by diabetes and this is expected to rise to 108 million in 2045, requiring immediate action. The top five countries with a higher number of diabetes in the MENA region 2019 are Pakistan, Egypt, Iran, Saudi Arabia, and Sudan [1].

According to the IDF, there were over 1,185,500 cases of diabetes in the UAE in 2017 with a prevalence of (15.6%) (IDF 2019). Type 2 DM prevalence in the UAE was ranked to be the 2nd highest in the world (19.5%) in 2007 and currently is ranked to be the 15th highest worldwide [1, 2]. Due to advances in medicine and research, glycated hemoglobin (HbA1c) was enrolled as a measurement and follow-up tool of glycemic control in diabetic patients. A report published in 2009 by an International Expert Committee on the role of HbA1c in the diagnosis of diabetes recommended that HbA1c can be used to diagnose diabetes and that the diagnosis can be made if the HbA1c level is 6.5% [3]. According to IDF 2019, most guidelines consider HbA1c less than 7% (53 mmol/mol) as the general target for glucose control [1].

Plausible reasons of the increasing prevalence of diabetes worldwide include an upsurge of type 2 diabetes and risk factors, which include unhealthy diet, physical inactivity, and rising levels of obesity. Furthermore, growing urbanization and changing lifestyle habits, for example, higher calorie intake, consumption of processed foods, and sedentary lifestyles, are contributing factors. The basis of diabetes treatment is increasing individuals’ motivation through their positive knowledge, attitude, and practice. It has been shown that increasing the level of knowledge of patients with diabetes contributes to developing a positive attitude and practice toward the disease. By having this positivity, their glycemic control is expected to improve [4, 6]. A study done in the USA [7] established that patients with negative attitude to diabetes have higher HbA1c levels [1]. Another study done in Turkey in 2015 concluded previous diabetic education had a positive effect, raising knowledge and attitude to diabetes, and lowering HbA1c levels [8].

Knowledge, attitude, and practice (KAP) are expected to significantly impact the outcome of self-management in patients with diabetes, yet the association between KAP of type 2 diabetes and the combined control of the HbA1c level to date remains uncertain due to lack in the number of studies. According to a study done in the UAE, there was only one study that was done in PHC to assess the knowledge, and it identified significant knowledge gaps in this population [9]. Therefore, this study aimed to evaluate the correlation between the KAP of type 2 diabetes and HbA1c levels in primary health care centers (PHCs) in Dubai and to investigate the factors associated with the HbA1c and KAP.

This cross-sectional study was conducted by a face-to-face survey in type 2 diabetic patients who visited ten PHCs with a diabetes clinic located in Dubai, UAE, between March 2019 and March 2020. The number of patients from each center is proportionate to the center size. The target population included patients with type 2 diabetes, 18 years old and above, and all nationalities that speak either Arabic or English who visited PHCs in Dubai Health Authority. We excluded patients with other types of diabetes. We used convenient sampling to get the total number of respondents (N = 292). At each clinic, patients who met the inclusion and exclusion criteria were interviewed during the study period.

A questionnaire was developed using the Michigan Diabetes Research Center (MDRC) instrument surveys [10]. The questionnaires are in both Arabic and English formats. We validated the Arabic version by translation and back translation. It was revised to meet our objectives by modifying some of the questions. The questionnaire was validated by conducting a pilot study. The questionnaire was administered and completed by the researchers after a face-to-face interview with the target population. It contained 50 questions and was divided into five parts that addressed participants’ sociodemographic characteristics (8 questions), clinical characteristics of their DM condition (3 questions), knowledge about type 2 DM and HbA1c (27 questions), attitude toward type 2 DM and HbA1c (5 questions), and practice of type 2 DM and HbA1c (7 questions).

The questions intended to assess knowledge about type 2 DM included causes of type 2 diabetes, signs and symptoms, risk factors, complications of diabetes, and knowledge about HbA1c (repeat test and best reading value). In addition, questions on attitude intended to assess importance of HbA1c reading and attitude toward checking blood sugar levels. Questions intended to assess practice asked about patients’ practice toward type 2 diabetes and the frequency of checking blood sugar levels at home.

To validate the questionnaire, a pilot study was conducted among 10 patients with type 2 diabetes. The interview was conducted face to face with patients with type 2 diabetes who attended the clinic and met the inclusion criteria. Informed consent was obtained from patients at the time of their visit to the clinic. The recent levels of HbA1c were obtained from patients’ medical records. After completion, the questionnaires were sealed in envelopes to ensure participants’ confidentiality.

There are 27 knowledge questions. One point is given to each correct knowledge answer, while zero point is given to each incorrect knowledge answer. The points were added up to obtain the knowledge score. The knowledge percent score ranged from 0 to 100% and was calculated by dividing the total number of correct answers by 27 and multiplied by 100. The data obtained in the questionnaires were organized using Microsoft Excel and coded and analyzed using SPSS (version 24) (IBM Corp., released 2016; IBM SPSS Statistics for Windows, Version 24.0; Armonk, NY: IBM Corp.). The duration of diabetes was analyzed as categorical variables, whereas HbA1c was analyzed as a continuous variable. Numerical data were checked for the normality using the Shapiro-Wilk test.

Median (minimal-maximal) was used for age and HbA1c and count and percentages for categorical data. The HbA1c level was compared between the categories of the categorical variables using the Mann-Whitney test or Kruskal-Wallis test. Correlation between numerical variables was assessed using Pearson correlation coefficients. The χ² test or Fisher’s exact test was used to test the association between the categorical variables and the attitude categories (positive and negative) and between the categorical variables and the practice categories (correct and incorrect practice). All statistical tests were two-tailed tests, and a p value <0.05 indicates a statistical significant result. Factors analyzed in this study are age, gender, nationality, education, employment status, marital status, family history of diabetes, and the duration of diabetes categories.

Out of the 292 participants, 51.9% were males and 48.1% were females and 65.6% were UAE citizens. The median age of the sample was 55 (31–81) years, and the median HbA1c was 7 (4.8–14). Other patients’ sociodemographic and clinical characteristics are shown in (Table 1).

One of the factors that affected HbA1c was the level of education (p value = 0.029). The group with the highest HbA1c was the illiterate group (median: 7.5 [5.6–14]), while the university group had the lowest HbA1c (median: 6.75 [4.8–12.8]). The other factor that affected HbA1c was marital status (p value = 0.003). Those who were widowed had the highest HbA1c (median: 7.5 [6.5–14]), and those who were married had the lowest HbA1c (median: 6.9 [4.8–12.8]). Finally, duration of diabetes also affected HbA1c (p value = 0.006). Those who had a duration of diabetes more than 20 years had the highest HbA1c (median: 7.8 [5.8–14]), and those who had a duration of diabetes for 6–10 years and 1–5 years had the lowest HbA1c (median: 6.9 [5.1–13.1] and median: 6.9 [5.3–12.8]), respectively. This information is summarized in (Table 2). The relationship between HbA1c and the knowledge percent score is not statistically significant (p value = 0.628), and the correlation coefficient is 0.032 (95% CI [−0.096 to 0.159]).

For the causes of diabetes questions, (n = 247, 84.6%) know that infection is not a cause of diabetes, (n = 222, 76%) know that diabetes is caused by genetics, while only (n = 139, 47.6%) know that diabetes is caused when the body fails to respond to insulin (Table 3). About diabetes symptoms, (n = 256, 87.7%) know that flu is not a symptom of diabetes, (n = 239, 81.8%) know that frequency of urination is a symptom, while only (n = 115, 39.4%) know that recurrent infections is not a symptom of diabetes (Table 3).

About the risk factors of diabetes, (n = 260, 89%) know that sedentary lifestyle is a risk factor, (n = 255, 87.3%) and (n = 240, 82.2%) know that obesity and heredity are risk factors, respectively, while only (n = 113, 38.7%) know that high blood pressure is a risk factor (Table 3). Regarding the complications of diabetes knowledge questions, (n = 256, 87.7%) know that eye disease is one of the complications, (n = 242, 82.9%) know that foot disease is a complication, while only (n = 141, 48.3%) know that hearing impairment is a complication (Table 3).

Only gender and nationality are significant factors of the percent knowledge score. Females have a higher median percent knowledge score (81.5 [29.6–100]) than males (77.8 [22.2–96]) (p value = 0.028), and UAE nationals have a higher median score (81.5 [22.2–96.3]) than non-UAE nationals (74.1 [25.9–100]) (p value = 0.005).

The majority (n = 241, 82.5%) answered the best reading for HbA1c question correctly, whereas (n = 194, 66.4%) answered the question on frequency of repeating HbA1c in 1 year correctly.

There are 5 attitude questions. 93.7% of the participants answered correctly that HbA1c reading represents blood sugar control, and 22.9% believe diet and exercise not being important as a treatment in control of diabetes. The third question asked if a health care professional follows their DM care; 53.7% answered yes. The majority (90.9%) have a glucometer at home, and 98.6% of the participants reported that checking their blood sugar regularly is important for controlling diabetes.

Out of the attitude questions, only the attitude question “do you believe that checking your blood sugar regularly is important for controlling diabetes” was related to the percent knowledge score. The median percent knowledge score for the “yes” category was 81.5 (22.2–100) compared with 68.5 (33.3–74) for the “no” category.

The factor that affects the question of attitude that HbA1c represents blood sugar control was “marital status” (75% of divorced answered yes, 83.3% of single people answered yes, 94.6% married answered yes, and 100% widowed people answered yes; p value = 0.016). There is no association between any of the tested factors and the other attitude questions.

According to the frequency of self-monitoring of blood glucose (SMBG) in the practice section of the questionnaire, 25% of the participants chose to do SMBG once daily, 32.5% chose to do it twice daily, 9.2% once weekly, 13% twice weekly, 5.8% once in a month, and 8.9% do not practice SMBG. However, 78.1% of the participants checked their eyes regularly, 83.6% had their feet examined, 61.3% visited the dentist regularly, 61% followed up with the dietician, and 82.2% were compliant to their appointments with the diabetic clinic. Finally, 94% of the participants did the lab investigations that have been ordered as part of their clinic visit (Table 4).

The factors that affect the practice of health care providers checking the patients’ feet regularly were nationality (81.5% of UAE nationals answered yes, and 91.8% of non-UAE answered yes; p value = 0.02), marital status (50% of divorced answered yes, and 86.9% of married answered yes; p value = 0.006), and duration of diabetes (75.3% with a duration of 1–5 years answered yes, and 92.2% with a duration of 6–10 years answered yes; p value = 0.027). The factor affecting the practice of visiting the dentist was nationality (66.7% of UAE nationality answered yes, and 54.1% of non-UAE nationality answered yes; p value = 0.037). The factors that affect the practice of appointment compliance were nationality (88.9% of UAE nationality answered yes, and 74.2% of non-UAE nationality answered yes; p value = 0.01) and employment (90.6% who were unemployed answered yes, and 77.1% who were employed answered yes; p value = 0.02). The factors that affect the practice of frequency of blood sugar were nationality (with 39.6% of UAE nationality checking twice daily and 24.1% of UAE nationality checking once daily, 22.7% of non-UAE nationality checking twice daily and 31.8% of non-UAE nationality checking once daily; p value = 0.016), education (27.6% with university education checking twice daily and 25.5% checking once daily, 43.8% with elementary education checking twice daily and 27.1% checking once daily; p value = 0.033), and employment (36% who were unemployed checking twice daily and 27.9% checking once daily and 32.4% who were employed checking twice daily and 25% checking once daily; p value = 0.034). The factor that affects the practice of visiting the dietician was education (48.5% with university education answered yes, and 73.5% with high school education answered yes; p value = 0.003). The factors affecting doing the lab investigations were duration of diabetes (87.9% with a duration of diabetes more than 20 years answered yes, and 100% with a duration of diabetes both less than 1 year and more than 20 years answered yes; p value = 0.031).

There were only two practice factors associated with HbA1c: visiting the dentist and doing the lab investigation. The median HbA1c for those visiting the dentist 6.9 (5.1–12.8) was lower than those who do not visit the dentist (7.2 [4.8–14]) (p value = 0.01). The median HbA1c for those who were doing the lab investigations (7 [4.8–12.8]) was lower than those who did not do the lab investigation (7.95 [5.3–14]) (p value: 0.031). Even when the percent knowledge score was higher in the category of the “correct practice” (the “yes” category) than the “incorrect practice” category for all the practice questions, there was no statistically significant result in the percent knowledge score between the “correct practice” group and the “incorrect practice” group for any of the practice questions.

The level of blood sugar control in patients with type 2 diabetes is influenced by the patients’ knowledge about the disease. However, KAP vary greatly depending on sociodemographic conditions, personal habits, and from country to country. Understanding these variables is important in further improving the level of management and prevention provided to diabetic patients.

We found out that participants know 75.6% of the information about type 2 DM that matches perfectly with a similar study done in PHCs in Dubai Health Authority (Abdulrahman, Mahera et al.) with a knowledge score of 76%, respectively [10]. Both our studies revealed that our knowledge results are higher than those of studies conducted in Jordan (66%) [9], Saudi Arabia (48%) [9], Al Ain (15.7%) [9], Oman (4.92%) [11], and Iran (9.5%) [12]. The differences in the results of studies could be due to the sample size and the educational level of type 2 diabetic patients. When it comes to attitude, our research showed the majority of participants (93.7%) are aware that HbA1c reading represents blood sugar control. This could be due to proper health education provided by health care professionals and increased diabetes awareness campaigns done in the primary health care clinics in DHA.

With regard to the attitudes of patients toward diet and exercise, our study shows that the majority of participants (77.1%) answered that it is important in the control of diabetes. In comparison with a study done In Iran, it shows that attitude toward dietary modification was favorable in 74% of diabetics, but for exercise, it was 48% [12]. However, the study done in Dubai [13] showed that 71% of participants are aware that physical activity can prevent risk of diabetes and 77% are aware that maintaining a healthy weight is important in the management of diabetes. The factors associated with this positive awareness is due to the presence of diabetic education provided by the health educators and that patients are more educated due to the presence of widely accessible educational resources. In addition, the glucometer is widely used by the patients (99.9%). In our opinion, this could be because they believe that checking their blood sugar regularly is important for controlling diabetes.

When it comes to practice, most of the participants were compliant to visiting the diabetes clinic (82.2%). This finding was higher than the study done in India (78.8%) [14], Dubai (23%) [13], and rural Bangladesh (47.5%) [15]. In addition, our study revealed that 55.9% of participants visited the ophthalmologist and 99.6% had their feet checked. This finding is higher than the studies done in Dubai and Iran (43.7% and 33%, respectively). The diabetes educators in the clinics should emphasize this practice more to the patients. For example, they could explain more to the patients regarding the long-term effects of type 2 DM on the different organs of the body, and this in turn will increase their awareness.

Health professionals involved in the care of type 2 diabetic patients attending the primary health centers should be enriched with knowledge by keeping up to date on the latest guidelines and attending continuous medical education sessions. This will in turn improve the knowledge of patients with type 2 diabetes regarding their disease and eliminate misbeliefs and wrong information that they may have. Hopefully, this will lead to better control and disease outcome of type 2 diabetes among patients attending primary health care centers.

We faced several limitations in this study. One of them was during data collection; some patients did not cooperate with us in answering the questionnaire. This in turn led to missing data during analysis of the information gathered. Our study focused on type 2 diabetic patients attending the government primary health centers in Dubai; therefore, it did not include patients attending other sectors, which might have led to bias in our results. Finally, we could have used a random sample which is stronger than the convenience sample.

The study assessed the correlation between HbA1c levels and KAP of type 2 diabetic patients attending primary health centers in Dubai. Although the study shows that type 2 diabetic patients attending primary health centers in Dubai had relatively adequate scores in knowledge, this could be further improved by implementing continuous awareness programs of type 2 DM to improve their understanding, compliance, and management, thereby reducing the severity of disease.

This study was approved by the Dubai Health Authority Scientific Research Ethics Committee <DSREC/RRP/2019/01> on January 17, 2019, and performed in accordance with the ethical standards of the World Medical Association Declaration of Helsinki. Written informed consent was obtained from all participants by the researchers to participate in the study.

The authors have no conflict of interest to declare.

The authors have not received any funding to conduct this study. There was no compensation given as the participants were volunteered.

H.A.R., B.A.N., E.A.S., and K.I.J. conceived and designed the study. H.A.R., B.A.N., E.A.S., and K.I.J. contributed to the data collection. M.Z. contributed to data analysis, statistical analysis section, and editing the results section. H.A.N. and K.I.J. interpreted and analyzed the knowledge part of the study. B.A.N. interpreted and analyzed the attitude part, and finally, E.A.S. interpreted and analyzed the practice part. H.A.R. wrote the rest of the paper and drafted and revised the study for important intellectual content. W.M.S. and H.H.K. supervised and reviewed the study and approved the final version for publication. All the authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

All data generated or analyzed during this study are included in this article and the tables. Further inquiries can be directed to the corresponding author.