Type 2 Diabetes Mellitus (T2DM) is one of the most significant global health challenges of the 21st century. It is characterized by insulin resistance, impaired insulin secretion, and chronic hyperglycemia leading to long-term microvascular and macrovascular complications (retinopathy, nephropathy, neuropathy, ischemic heart disease, stroke) [1]. According to the International Diabetes Federation (IDF), approximately 537 million adults were living with diabetes in 2021, and this number is projected to rise to 643 million by 2030 and 783 million by 2045 [2]. More than 90% of these cases are Type 2 diabetes, reflecting the massive burden of the disease globally.

India contributes significantly to the global diabetes burden and is often referred to as the “diabetes capital of the world.” IDF estimates indicate that India currently has over 77 million adults with diabetes, expected to exceed 134 million by 2045 [2]. Rapid urbanization, sedentary lifestyle, unhealthy diet, obesity, and genetic predisposition have all contributed to the rising incidence of T2DM in India [3]. Effective diabetes control requires not only medical treatment but also active patient participation.

Successful diabetes management largely depends on the patient’s Knowledge, Attitude, and Practice (KAP) toward the disease. Adequate knowledge about the nature of diabetes, its complications, diet, exercise, medication adherence, and glucose monitoring is essential for achieving good glycemic control [4]. Studies have shown that patients with higher knowledge levels demonstrate better glucose control and reduced complication rates [5].

Attitude refers to the patient’s feelings, beliefs, and perceptions regarding diabetes and its management. A positive attitude improves motivation and adherence to lifestyle modifications and treatment plans [6]. Practice includes the patient’s actual behaviors such as dietary compliance, regular exercise, blood glucose monitoring, medication adherence, and foot care. Poor practices despite good knowledge are a major challenge in diabetes self-management [7].

KAP studies among diabetic patients are vital for understanding the gaps between awareness and behavior. They help identify misconceptions, barriers to lifestyle change, and socio-demographic factors influencing diabetes care. Several studies in India and other developing countries have reported that although many patients possess adequate knowledge, their actual practices remain inadequate due to lack of motivation, cultural beliefs, financial constraints, or limited access to healthcare resources [8,9].

In tertiary care hospitals, where patients often seek continuous care for chronic illnesses, evaluating KAP levels allows clinicians to design targeted educational interventions tailored to the population’s needs. Hence, assessing KAP among Type 2 diabetic patients becomes crucial in improving disease control, preventing chronic complications, and reducing healthcare burden.

Therefore, the present study aims to assess the knowledge, attitude, and practice of Type 2 diabetic patients attending a tertiary care hospital and identify factors influencing poor KAP scores.

MATERIALS AND METHODS:

Study Design:

This was a hospital-based, descriptive, cross-sectional study conducted to assess the knowledge, attitude, and practice (KAP) of patients diagnosed with Type 2 Diabetes Mellitus (T2DM).

Study Setting:

The study was conducted in the dept. of SPM in collaboration with General Medicine Department at a tertiary care teaching hospital for a period of 6 months.

Study Population

All adult patients with Type 2 Diabetes Mellitus attending the outpatient department during the study period were considered for inclusion.

Inclusion Criteria

• Patients aged 18 years and above
• Diagnosed with Type 2 Diabetes Mellitus for at least 6 months
• On treatment (oral antidiabetic drugs or insulin)
• Willing to provide written informed consent

Exclusion Criteria

• Type 1 diabetes mellitus
• Gestational diabetes
• Patients with severe psychiatric illness or cognitive impairment
• Critically ill patients and those unwilling to participate

Sample Size Calculation

Sample size (n) was calculated using the formula for prevalence studies:

Where:

• Z = 1.96 (95% confidence interval)
• p = anticipated proportion with good KAP = 50% (0.5), used for maximum sample size
• d = precision = 6% (0.06)

Considering a 10% non-response rate, the final sample size was rounded to 300 participants.

Sampling Technique: A systematic random sampling method was used.

Study Tool: KAP Questionnaire

A structured, interviewer-administered questionnaire was used. It consisted of three sections:

1. Knowledge Section (15 items)

• Questions on nature of diabetes, complications, diet, exercise, hypoglycemia, foot care, and medication adherence.
• Responses: Correct = 1, Incorrect/Don’t Know = 0
• Score range: 0–15

2. Attitude Section (10 items)

• Assessed beliefs, motivation, self-confidence, and perception using a 5-point Likert scale:
  Strongly Agree, Agree, Neutral, Disagree, Strongly Disagree
• Score range: 10–50

3. Practice Section (10 items)

• Questions on diet, exercise, glucose monitoring, medication adherence, foot care, and follow-up visits.
• Responses: Always = 2, Sometimes = 1, Never = 0
• Score range: 0–20

Validation of the Questionnaire

• The questionnaire was adapted from previously validated KAP studies and modified for local context.
• It underwent expert validation by a panel of physicians, endocrinologists, and public health experts (n = 7).
• Content Validity Index (CVI): 0.86 (acceptable >0.8)
• A pilot study was conducted on 30 patients (not included in final study).
• Cronbach’s alpha:
• Knowledge: 0.79
• Attitude: 0.82
• Practice:0.76
  These values indicated good internal consistency.

Scoring and Classification

Knowledge

• Good: ≥75% (≥12 points)
• Moderate: 50–74% (8–11 points)
• Poor: <50% (<8 points)

Attitude

• Positive: ≥75% of total score
• Neutral: 50–74%
• Negative: <50%

Practice

• Good Practice: ≥75%
• Moderate: 50–74%
• Poor: <50%

Data Collection Procedure

• Data were collected using face-to-face interviews conducted in the OPD waiting area.
• Each interview took approximately 10–12 minutes.
• Investigators were trained beforehand to ensure uniformity.
• Blood glucose and treatment history were cross-checked using patient records when available.

Data Entry and Management

• Data were coded and entered into Microsoft Excel 2019.
• Regular data validation was done to minimize entry errors.
• Confidentiality was maintained; questionnaires were stored securely.

Statistical Analysis

Data were analyzed using SPSS version 20.0 (IBM Corp.)

• Descriptive Statistics:
  Means, standard deviation, frequencies, and percentages.
• Inferential Statistics:
• Chi-square test: association of KAP with demographic variables
• Independent t-test/ANOVA: mean KAP score comparison
• Pearson correlation: relationship between knowledge, attitude, and practice
• p < 0.05 was considered statistically significant.

RESULTS:

The mean age of participants was 54.7 ± 10.8 years, ranging from 30 to 82 years. Most patients (58%) belonged to the 40–60 year age group. Males constituted 56.7%, while females were 43.3%. Approximately 44% of participants had education up to high school, whereas 19% were illiterate. The majority (42%) had diabetes duration between 5–10 years, and 52% had coexisting hypertension as shown in Table 1

TABLE 1: Sociodemographic Characteristics of the Study Participants (n = 300)

Of the 300 patients, 62% demonstrated good knowledge regarding diabetes, 28% had moderate knowledge, and 10% had poor knowledge. High awareness was noted regarding the need for regular medications (92%) and dietary control (88%). However, only 47% correctly identified symptoms of hypoglycemia, and 39% were aware of recommended foot-care practices as shown in Table 2

Table 2: Distribution of Knowledge Scores Among Participants (n = 300)

The majority of participants (71%) exhibited a positive attitude toward diabetes management. About 23% had a neutral attitude, and 6% showed a negative attitude. Most patients agreed that diabetes requires lifelong care (94%) and supported lifestyle modification (87%). However, only 58% felt confident in managing their diabetes as shown in Table 3.

Table 3: Distribution of Attitude Scores Among Participants (n = 300)

Good practice was observed in only 39% of the patients, while 42% demonstrated moderate practice and 19% showed poor practice. Positive practices such as medication adherence were high (82%), but regular exercise was practiced by only 34%. Daily foot inspection was reported by 21%, and regular blood glucose monitoring by 46% as shown in Table 4

Table 4: Distribution of Practice Scores Among Participants (n = 300)

Poor practice was significantly associated with Age > 60 years (p = 0.03), Lower education level (p = 0.001) and Duration of diabetes > 10 years (p = 0.04). Gender (p = 0.28) and comorbidities (p = 0.19) did not show a significant association as shown in Table 5.

Table 5: Association of Sociodemographic Factors With Poor Practice

The correlation table shows that better knowledge leads to better practice, because the knowledge–practice correlation (r = 0.41) is positive and significant. Similarly, patients with better knowledge also have a more positive attitude (r = 0.39).

Although weaker, there is still a significant link between attitude and practice (r = 0.28), meaning a good attitude also improves self-care behavior as shown in Table 6

Table 6: Correlation Between Knowledge, Attitude, and Practice Scores

DISCUSSION:

In the present study, the majority of participants demonstrated good knowledge (62%) and a positive attitude (71%), but only 39% exhibited good self-care practices. This reflects a clear knowledge–practice gap, a pattern reported in multiple diabetes KAP studies across Asia and the Middle East.

The high proportion of patients with good knowledge is consistent with findings from Subish et al. in Nepal, who also observed that over half of their diabetic population possessed adequate knowledge about disease management [10]. Similar results were reported in Oman, where Al-Adawi et al. found that most patients were aware of the chronic nature of diabetes and the need for lifestyle modification [11]. The present study’s high knowledge scores may be attributed to regular follow-ups in tertiary care settings, where patients often receive repeated counseling.

Despite good knowledge, self-care practice remained poor, particularly with respect to exercise (34%), foot inspection (21%), and blood glucose monitoring (46%). These findings are in line with the recommendations of the American Diabetes Association and international guidelines, which emphasize that lifestyle modification is crucial but often inadequately followed by diabetic patients [12]. A systematic review by Chen et al. also highlighted that self-efficacy plays a major role in adopting diabetes self-care behavior; patients may know what to do but lack confidence or motivation to implement lifestyle changes [13].

Education level showed a significant association with practice (p = 0.001), supporting the findings of Rani et al., who noted that literacy plays an important role in shaping health-related behavior among chronic disease patients in India [14]. Elderly patients (>60 years) in this study had poorer practice scores, which is comparable to findings by Abdelmoneim et al., who reported decreased adherence with increasing age due to physical limitations, comorbidities, and treatment fatigue [15].

A significant positive correlation was observed between knowledge and practice (r = 0.41), indicating that improved knowledge leads to better lifestyle behavior. This is consistent with studies by Berhe et al. and others in Ethiopia and Bangladesh, which emphasized the role of diabetes education programs in improving both practice and glycemic control [16]. Furthermore, structured diabetes self-management education has been shown to lead to reductions in HbA1c and long-term complications, as highlighted in a meta-analysis by Norris et al. [17].

Overall, the findings of this study reinforce the importance of continuous diabetes education, individualized counseling, and reinforcement of lifestyle modifications. Despite good knowledge and attitude, consistent practice remains a challenge, indicating the need for behavior-focused interventions rather than information alone.

CONCLUSION:

The study found that while most Type 2 diabetic patients possess adequate knowledge and generally positive attitudes, their actual self-care practices—especially exercise, foot care, and glucose monitoring—remain insufficient. Poorer practice was more common among older adults, those with limited education, and patients with longer disease duration. These findings highlight the need for continuous, patient-focused diabetes education that not only improves awareness but also strengthens motivation and confidence to adopt daily self-care behaviors.

Declaration:

Conflicts of interests: The authors declare no conflicts of interest.

Author contribution: All authors have contributed in the manuscript.

Author funding: Nill

REFERNCES:

1. American Diabetes Association. Diagnosis and classification of diabetes mellitus. Diabetes Care. 2022;45(Suppl 1):S17-38.
2. International Diabetes Federation. IDF Diabetes Atlas, 10th Edition. Brussels: IDF; 2021.
3. Anjana RM, Deepa M, Pradeepa R, et al. Prevalence of diabetes and prediabetes in 15 states of India: Results from the ICMR-INDIAB study. Lancet Diabetes Endocrinol. 2017;5(8):585-96.
4. Shrivastava SR, Shrivastava PS, Ramasamy J. Role of self-care in management of diabetes mellitus. J Diabetes Metab Disord. 2013;12:14.
5. Al-Maskari F, El-Sadig M. Knowledge, attitude and practices of diabetic patients in the United Arab Emirates. PLoS One. 2007;2(12):e828.
6. Kassahun CW, Mekonen AG. Knowledge, attitude, practices and their associated factors towards diabetes mellitus among non-diabetic community members. PloS One. 2017;12(2):e0170040.
7. Mumu SJ, Saleh F, Ara F, et al. Assessment of knowledge regarding diabetes mellitus among Type 2 diabetic patients in Bangladesh. BMC Res Notes. 2014;7:599.
8. Dinesh PV, Kulkarni AG, Gangadhar NK. Knowledge and self-care practices regarding diabetes among patients with Type 2 diabetes in rural Karnataka. Int J Community Med Public Health. 2016;3(1):52-6.
9. Mohan D, Raj D, Shanthirani CS, et al. Awareness and knowledge of diabetes in Chennai—The Chennai Urban Rural Epidemiology Study. J Assoc Physicians India. 2005;53:283-7.

1. Subish P, Kotian MS, Prabhu MM. Knowledge, attitude and practice (KAP) among diabetic patients in Nepal. Australas Med J. 2012;5(1):23–28.
2. Al-Adawi S, Al-Nabhani Y, Al-Ismaili M. Diabetes knowledge, attitude, and self-practice among patients in Oman. Oman Med J. 2016;31(1):52–58.
3. Colberg SR, Sigal RJ, Yardley JE, et al. Physical activity and diabetes: A joint position statement. Diabetes Care. 2016;39(11):2065–2079.
4. Chen L, Pei J, Kuang J, et al. Self-efficacy and diabetes self-management: A systematic review. Int J Nurs Sci. 2019;6(2):193–201.
5. Rani PK, Raman R, Subramani S, et al. Awareness of diabetes and diabetic retinopathy among rural and urban populations in India. Indian J Ophthalmol. 2008;56:383–387.
6. Abdelmoneim A, Al Ayoubi RA, Abdallah MS. Adherence to diabetes self-care activities among the elderly. Clin Med Insights Endocrinol Diabetes. 2021;14:1–8.
7. Berhe KK, Gebru HB, Kahsay HB. Diabetes self-care knowledge and associated factors among diabetic patients in Ethiopia. BMC Public Health. 2014;14:130.
8. Norris SL, Lau J, Smith SJ, et al. Self-management education for adults with Type 2 diabetes. Diabetes Care. 2002;25(7):1159–1171.