Posted: March 23rd, 2023

Diabetes mellitus

Diabetes knowledge assessment among nurses working in primary health care centers in Riyadh

Introduction

Diabetes mellitus (DM) is one of the most common lifestyle diseases in Saudi Arabia and across the world. The condition is a metabolic disorder characterized by the deficiency of insulin in the body. The World Health Organization defines the illness as “a metabolic disorder of multiple aetiology characterized by chronic hyperglycaemia with disturbances of carbohydrate, fat and protein metabolism resulting from defects in insulin secretion, insulin action or both” (as cited by Alhaiti, Alotaibi, Jones, DaCosta, & Lenon, 2016, p. 1). The condition occurs in three main types: type 1 (T1DM), type 2 (T2DM), and gestational diabetes. The three disorders require effective management to achieve the quality of life for the affected persons. Therefore, nurses and other caregivers have a responsibility to support efficient treatment and management of the condition in collaboration with the patient. Health practitioners should develop an adequate understanding of the condition and therapeutic interventions.

Diabetes affects people of all ages, gender, and cultural backgrounds around the world. The International Diabetes Federation (2017) approximates that the illness affects approximately 8.8% of the worldwide population aged 20 years and above. However, some countries, such as the Middle Eastern and North African (MENA), have higher rates of the condition than others (9.6% in 2017) (International Diabetes Federation, 2017). The prevalence is expected to increase due to, among other factors, growth in urbanization process, increasing rate of obesity due to reduced physical activity, and a rise in the aging population (Majeed et al., 2014). Diabetes mellitus has become one of the most prevalent conditions in Saudi Arabia with a huge economic burden, creating the need for effective interventions. The International Diabetes Federation (2017) reveals that Saudi Arabia is leading in the MENA region in terms of diabetes mellitus, with a prevalence rate of 17.7%. Consequently, about 0.78 billion dollars of the overall health care budget in the country was used in the management of the disease in 2014 (Naeem, 2015). Therefore, considering the high rate of development of the condition and the resources required in its management, sufficient knowledge among nurses and other health care providers is critical to support promotion of public health interventions.

Significance of the Study

The high rate of diabetes mellitus in Saudi Arabia requires adequate levels of knowledge among nurses and other caregivers regarding the various aspects, such as the epidemiology, risk factors, effective management approaches, and proper medication administration. Nurse educators should develop evidence-based interventions for care providers according to their needs assessment and outcomes by applying reliable and valid measures (Francisco, 2013). Nurses should understand the necessary medication and lifestyle modifications to support treatment and management and reduce the high rates of the condition (Alwin Robert et al. 2017; Alanazi et al., 2018). Besides, health practitioners should improve their awareness to support self-care among patients to reduce the burden of the disease and the high cost for the country’s healthcare system (Naeem, 2015). Therefore, research is necessary to assess the current levels of knowledge and understand the essential interventions to increase awareness among nurses and other health care providers.

Purpose of the Study

The study aims to assess the current level of nurses’ knowledge about diabetes mellitus and its management, hence developing targeted interventions to create awareness among the caregivers in Riyadh and Saudi Arabia in general. The aim of the study will be achieved through the following objectives:

1. To assess the current level of nurses’ knowledge about diabetes mellitus using DKT (Michigan diabetes knowledge test).
2. To investigate the level of nurse’s knowledge about diabetes risk factors and epidemiology.
3. To establish the level of understanding among nurses about the risk factors for diabetes in Saudi Arabia.
4. To propose targeted interventions to increase the level of knowledge among nurses about diabetes mellitus.

Conceptual /Theoretical Framework

The section presents a conceptual framework to reveal the flow and impact of nurses’ knowledge about diabetes mellitus. The framework is developed following the problem identification, which will provide a better understanding of the issue. The graphical conceptual framework presents the relationship between different concepts in the study.

The hypothesis for the study is that adequate nurses’ knowledge about DM has a positive relationship with effective clinical care and patient self-care outcomes. The PICOT questions explored in the study are:

1. What level of knowledge about diabetes mellitus do the primary health care centers’ nurses have?
   2. Is there a relationship between demographic factors and the knowledge about diabetes among nurses working in primary health care settings?

Literature Review

The systematic review of the literature reveals the need for nurses’ knowledge about diabetes management and care. The analysis focuses on the current information to establish the level of understanding among caregivers regarding the disease to support patients to achieve self-care objectives and a better quality of life regardless of the illness. The review focuses on the studies conducted in Saudi Arabia and other parts of the world, including the United States, to examine the level of knowledge and design a useful tool to assess nurses’ knowledge.

Role of NURSES in Diabetes Management

Diabetes is an epidemic in various parts of the world, including Saudi Arabia. Many health care providers have a role in the management of diabetes. Therefore, nurses and other caregivers should have adequate knowledge to provide care to diabetic patients. Hollis, Glaster, and Lapsley (2014) suggest that some aspects of the knowledge should be on the proper diet for such patients. Hence, nurses should understand dietary advice, which is a critical part of diabetes care.

Nursing professionals play a critical role in educating patients about diabetes management because they spend more time with them. They can help them to improve their quality of life by working on the development and implementation of educational programs to support self-care in the management of the condition. Kaya and Karaca (2018) supported research on the importance of education for patients related to diabetic foot care. An effective education program can help in preventing or delaying the formation of health problems in diabetic patients.

Nurse education and knowledge can help in the identification of risk factors for the development of diabetes. A study by Daly, Arroll, Sheridan, Kenealy, and Scragg (2014) focusing on nurses in community health identified the potential of excess body weight as a significant risk for diabetes. Nurses needed to understand other factors that place people at risk, such as “cardiovascular risk factors (hypertension, dyslipidemia, smoking and lack of physical activity, and cardiovascular or macrovascular complications)” (p.7). The study revealed the need for training and education to help nurses to identify risk factors and implement behavior change interventions to minimize the risk.

Risk Factors for DM in Saudi Arabia

Further studies have investigated other risk factors for diabetes and the level of nurses’ knowledge in this aspect. Alanazi et al. (2018) revealed some critical risk factors that caregivers should understand to improve diabetes management. The study supports the role of obesity as a significant risk factor for the illness. Therefore, weight reduction is a necessary preventive measure that nurses should include in the education plan for the at-risk population.

While many studies focused on other countries outside Saudi Arabia, others have explored the risk factors for the disease in the country. Murad, Abdulmageed, Iftikhar, and Sagga (2014) are among the researchers who have examined the condition within the Saudi context. The risk factors for diabetes management are categorized into two groups: modifiable and non-modifiable. Some of the modifiable factors are low physical activity, diets rich in fat, high BMI, metabolic syndrome, high BP, and elevated plasma levels of triglycerides (Murad, Abdulmageed, Iftikhar, & Sagga, 2014). The non-modifiable risk factors include family history of diabetes and age (above 40 years).

Just like other studies that present obesity as the leading risk factor for diabetes in other countries, the same problem is evident in Saudi Arabia. High levels of obesity have caused a challenge in the country. For instance, urbanization has led to an increased rate of inactivity and more consumption of the western fat-rich diet. The lifestyle-related risk factors have posed a significant challenge for health care providers in terms of the management and care of diabetes due to the increasing prevalence (Murad, Abdulmageed, Iftikhar, & Sagga, 2014). The study revealed other risk factors, such as smoking, hypertension, and age. Alfadhli et al. (2015) discussed the role of high BMI, high blood pressure, and older maternal age in the development of diabetes, especially among Saudi women. Understanding the risk factors plays a vital role in effective management and care.

Assessment of Nurses’ Knowledge

Research supports the need for nurses’ knowledge about diabetes management. Therefore, nurse educators should assess the level of awareness among nurses (Kaya & Karaca, 2018). Nursing professionals develop and use tools to evaluate their level of knowledge about diabetes management. Tools are available that are tested and proven effective in identifying potential gaps in knowledge to implement education and training to improve the variable. One such approach includes DKT2 (Fitzgerald et al., 2016). Research has established the applicability of the instrument in various cultural settings. Alhaiti, Alotaibi, Jones, DaCostaand, and Lenon (2016) carried out a study to develop the usability of the DKT2 in the Arabian context through effective translation from English. The study focused on the translation of the tool from English into Arabic. The results revealed that the Arabic DKT2 questionnaire is usable in various cultural contexts. However, they revealed limitations in translating the instrument from English to Arabic. Although the tool can be used in multiple settings to establish the level of nurses’ knowledge about diabetes care and management, it should be translated to fit the cultural context in which it is applied.

Deficiency in Nurses’ Knowledge

Studies have revealed considerable flaws in nurses’ knowledge regarding the management of diabetes. In a review of 25 studies, Alotaibi, Al-Ganmi, Gholizadeh, and Perry (2016) revealed knowledge deficiencies across geographic locations in both developed and developing countries. Nurses show the limitation in various areas, including “insulin therapy, nutrition, oral diabetes medications, nutrition, BGM, diabetes complications and foot care, diabetes pathology, symptoms and management” (Perry, 2016, p.47). Modic et al. (2014) affirmed that the level of knowledge among bedside nurses was also considerably low. Another study conducted by Glaster and Lapsley (2014) revealed similar limitations in nurses’ knowledge regarding diabetes management. Notably, the study indicated a deficiency in the understanding of medication-related aspects of the condition. Gaps in nursing knowledge about drugs are common in research conducted in the United States and the United Kingdom.  Mogre, Ansah, Marfo, and Garti (2015) established that the nurses’ knowledge about diabetes management is inadequate when scored as a mean knowledge score of 12.13 (44% correct). The research raises critical questions about the knowledge of nurses concerning nutritional management for positive outcomes in patients.

More research has revealed knowledge deficiency. Alanazi et al. (2018) conducted a systematic review to establish the current level of knowledge on diabetes management, the risk factors for the disease, and its complications. Unlike other studies reviewed in this section, the study focused on the Saudi Arabian population specifically, providing a targeted analysis of the topic. According to the authors, the most significant proportion of the reviewed literature supports the findings that nurses have a generally low level of knowledge regarding diabetes management. They have posted low to moderate knowledge scores in various parts of the country, including “Riyadh, Jeddah, Al Hasa, Al-Khobar, and Mecca” (p. 983). According to Daly, Arroll, and Scragg (2019), although notable changes are evident in nurses’ knowledge, gaps still exist concerning cardiovascular outcomes and related medication management. Just like in other parts of the world, nurses and health professionals in Saudi Arabia post relatively low knowledge scores regarding diabetes management. Nurses, physicians, and medical students have the lowest scores for the knowledge regarding various aspects of the disease, including epidemiology (Alanazi et al., 2018). They also lack sufficient understanding of the correct angle for the administration of insulin, which is the primary medication in diabetes treatment.

Importance of DM Education in Saudi Arabia

The reviewed literature revealed a significant knowledge gap in diabetes management in various countries around the world, including Saudi Arabia. The challenge affects healthcare providers (such as nurses), medical students, and even patients (Al-Alawi, Al-Hassan, Chauhan, Al-Futais, and Khandekar, 2016; Al-Aboudi, Hassali, and Shafie, 2016). The gaps in knowledge reveal the need for more research to increase the level of understanding and awareness in the country, especially relating to epidemiology, risk factors, and approaches to management. Research in other countries, such as the United States and the United Kingdom, has revealed the critical role that health education following a comprehensive assessment of knowledge level plays in improving diabetes management (Alanazi et al., 2018). Educated nurses and other caregivers help to train patients on the mechanisms to control the condition, leading to positive patient outcomes, minimal complications, and improved quality of life.

Gaps in the Current Literature

The current literature reveals considerable deficiencies in the level of knowledge regarding diabetes management. However, the reviewed studies experience methodological limitations that should be addressed in the current research. Some of the studies have a relatively small sample size, which affects their findings and the applicability in practical settings to inform the knowledge about diabetes management and care. For instance, Al-Alawi, Al-Hassan, Chauhan, Al-Futais, and Khandekar (2016) and Al-Aboudi, Hassali, and Shafie (2016) included 75 and 45 participants, respectively. Another limitation in the reviewed studies is the focus on different aspects of knowledge on diabetes management, creating a problem for the analysis. For example, while some researchers concentrated on food care, other studies focused on eye care and cardiovascular management. On the other hand, different approaches focused on risk factors and other medication administration. Therefore, it was hard to create a comprehensive illustration of the level of knowledge about diabetes management in general.

Methods

Research Design

The study will be a cross-sectional analysis, which is a type of observational study in a health care setting. The approach will help to analyze data from the population of nurses regarding their level of knowledge of diabetes.

Study Setting and Sample

The study will be conducted in primary health care centers in Riyadh. The population for the study will include nurses in the setting. All nurses in the five health centers in Riyadh will be included in the survey to provide a sufficient sample. The recruitment process will involve a site visit and emails sent to the nurses requesting their participation in the research. A purposive sampling method will be used to have a sufficient number of participants. Data will be collected from 130 nurses drawn from the five health centers in Riyadh.

Data Collection Procedure

Data for the study will be collected using the DKT (Michigan diabetes knowledge test) (see appendix 1 for the copy of the research instrument). The study will use an Arabic version of the DKT, which is already translated and validated. Each of the participants will complete the tool for data analysis. Research assistants will collect the completed tools and organize the data appropriately for analysis.

Measurements

The DKT2 tool contains 23 items (Haugstvedt, Aarflot, Igland, Landbakk, & Graue, 2016). The Arabic version of DKT has already been translated and validated for use. The tool has been tested for validity and reliability because it is already the standard instrument for the assessment of diabetes knowledge among nurses in the Arabic context. Each of the items in the tool has three or four categories of responses (only one is right). A pilot study will be conducted to test the applicability of the translated tool in the Saudi context.

Ethical Consideration

Ethics committee approval will be obtained before conducting the study. The authorization will be obtained from the ethical review board of the hospital from where the data will be collected. Besides, the research will be conducted according to the guidelines for research ethics in Saudi Arabia. The participants will give their signed consent upon their agreement to participate in the study. The study process will not cause harm to nurses or patients and will adhere to the principles of beneficence and human dignity. The participants will be debriefed after giving their consent and informed about the confidentiality of the information they provide.

Data Analysis

The data collected using the DKT tool will be analyzed to present the study findings. Since the data is numerical, the analysis will use SPSS Version 26, which is the most recent data analysis tool. The study will report descriptive statistics as counts, means, proportions, and standard deviation (SD). The process will help to characterize the number of participants and the DKT subscales scores. The standardized Cronbach’s alpha will be used to measure the subscale scores’ internal consistency reliability.