|Year : 2021 | Volume
| Issue : 1 | Page : 80
Knowledge, attitudes and practice among primary care physicians in Sudan regarding prediabetes: A cross-sectional survey
Amel Mohamed Saleh1, Ahmed Omer Almobarak2, Safaa Badi3, Samar B Siddiq4, Hanan Tahir1, Mohamed Suliman5, Mohamed H Ahmed6
1 Public and Tropical Health Program, Dean of Graduate College, University of Medical Sciences and Technology, Khartoum, Sudan
2 Department of Pathology, Faculty of Medicine, University of Medical Sciences and Technology, Khartoum, Sudan
3 Department of Clinical Pharmacy, Faculty of Pharmacy, Omdurman Islamic University, Khartoum, Sudan
4 Department of Research and Training, Alsharg Ahlia University, Kassala, Sudan
5 Imperial College London Diabetes Centre, AL Ain, United Arab Emirates
6 Department of Medicine and HIV Metabolic Clinic, Milton Keynes University Hospital NHS Foundation Trust, Eagelstone, Milton Keynes, Buckinghamshire, UK
|Date of Submission||02-Apr-2020|
|Date of Acceptance||21-Jan-2021|
|Date of Web Publication||05-Jul-2021|
Mohamed H Ahmed
Department of Medicine and HIV Metabolic Clinic, Milton Keynes University Hospital NHS Foundation Trust, Eaglestone, Milton Keynes, Buckinghamshire
Source of Support: None, Conflict of Interest: None
Background: Prediabetes is an important stage before diabetes that can be treated with intensive lifestyle changes. The aim of this study was to assess knowledge, attitudes, and practice of primary care physician in Sudan about prediabetes. Methods: A cross-sectional questionnaire-based study was conducted among primary care physicians working at two family and primary health care centers in Khartoum. Data were analyzed using descriptive statistics and expressed as percentages. Results: Out of 200 primary care physicians, 189 completed the questionnaire. 60.8% of the participants had satisfactory knowledge about prediabetes and positive attitude towards prediabetes and their practice was relatively good. Knowledge score was significantly correlated with age (P = 0.000), duration of experience (P value = 0.000), the number of working hours per day (P value = 0.001), and the number patients seen per day (P value = 0.001). Logistic regression analysis showed that attending courses relevant to prediabetes revealed statistically significant result in knowledge, and attending such courses were likely to be associated with gaining sufficient knowledge than those who didn't by 2 times (P value 0.033, OR 2, CI. 1.063-4.079). Conclusions: Primary care physicians in Sudan have satisfactory knowledge, attitude, and practice about prediabetes. As they are in the front line in dealing with community, primary care physicians' efforts can help in slowing down the epidemic of diabetes in Sudan.
Keywords: Attitude, knowledge, practice, prediabetes, Sudan
|How to cite this article:|
Saleh AM, Almobarak AO, Badi S, Siddiq SB, Tahir H, Suliman M, Ahmed MH. Knowledge, attitudes and practice among primary care physicians in Sudan regarding prediabetes: A cross-sectional survey. Int J Prev Med 2021;12:80
|How to cite this URL:|
Saleh AM, Almobarak AO, Badi S, Siddiq SB, Tahir H, Suliman M, Ahmed MH. Knowledge, attitudes and practice among primary care physicians in Sudan regarding prediabetes: A cross-sectional survey. Int J Prev Med [serial online] 2021 [cited 2021 Nov 28];12:80. Available from: https://www.ijpvmjournal.net/text.asp?2021/12/1/80/320723
| Introduction|| |
Prediabetes is defined as an intermediate state of hyperglycemia with glucose levels above the normal state but below the diagnostic levels of diabetes. The latest estimates from the International Diabetes Federation (IDF) Diabetes Atlas published in 2019 indicate that the global prevalence of diabetes is 9.3% with an estimated 463 million people with diabetes across the world while the global prevalence of prediabetes is 7.5% i.e., 374 million people with prediabetes. Sudan has a very high prevalence of diabetes for instance the prevalence of diabetes in the eastern part of Sudan was estimated to be 20.8%%. The number of people with prediabetes in Sudan is expected to increase from 8.2% in 2017 to 9.4% in 2045 as part of the estimation of prediabetes in the Middle East (these figures applies to all countries in the region).
Diabetes is a major cause of different comorbidities like stoke, ischeamic heart disease, and chronic kidney disease and high risk of mortality.,, The American Diabetes Association (ADA) has a cut-off value for impaired glucose tolerance (IGT) of 140-200 mg/dL and a cut-off value for impaired fasting glycaemia (IFG) of 100-125 mg/dL. In addition, HbA1c-based criterion for diagnosis of prediabetes is 5.7% to 6.4%. Despite different metabolic abnormalities that characterize IFG and IGT, both confer increased risk for future T2DM. Prospective epidemiologic studies have reported an approximate 5% annual conversion rate to T2DM for both isolated IFG and isolated IGT. Because of the increased risk for T2DM associated with IFG and IGT, they have been referred to as prediabetes. Clusters of features of the metabolic syndrome (high blood pressure, high triglyceride, low high-density lipoprotein and abdominal obesity) have also been associated with an increase in incidence of diabetes.
In order to reduce the progression from prediabetes to diabetes, maintenance of a healthy weight through exercise and healthy eating should be advised. Exercising for at least 150 minutes a week and losing about 7% of body weight has been shown in the Diabetes Prevention Program (DPP) to prevent or delay progression to type 2 diabetes. Metformin has also been shown to be effective in the treatment of prediabetes especially in patients less than 60 years of age and in women with a history of gestational diabetes. Many patients are keen and motivated to reverse prediabetes. Primary care physicians can play an important role in increasing patient awareness about pre-diabetes and guiding them to use behavioral weight loss programs. Primary care physicians in some developed countries were also reported to overlook the issue of prediabetes. For instance, in USA only slightly more than half of physicians surveyed reported following national guidelines for diabetes prevention and physicians perceive significant barriers to diabetes prevention. Mainous et al. reported that physicians who have a positive attitude towards prediabetes, were more likely to follow national guidelines for screening and recommend metformin to their patients for prediabetes. Creating awareness about diabetes risk and complications among stakeholders may be the key to promoting healthy behavior., Several studies showed that intensive life style changes and metformin can be used in prediabetes.,, As the burden of diabetes and prediabetes in Sudan is increasing rapidly, investment in the treatment of prediabetes can be one part in the management of diabetes epidemic in this poorly resourced country. Hence, this study aimed to assess knowledge, attitudes, and practice of primary care physicians in Sudan toward prediabetes management.
| Methods|| |
This was a descriptive, cross-sectional, health facility-based study. The study was conducted in Primary Health Care Centres at Khartoum and Karary localities in Khartoum State. Each center is served by an average of 5–10 doctors. The working days of each doctor are between 3 and 5 days a week with 5-7 working hours per day. The doctors in these centers provided their medical care services for 30–60 patients per day. The study was conducted during the period from May to December 2019. The study population were primary care physicians who were employed at primary care health centers at specified localities during the study period.
All primary care doctors in the study area who agreed to participate in the study were included.
The total number of primary care doctors in the targeted 2 health care centers was 200, with 133 doctors in the Khartoum center and 67 in the Karary center. The sampling method used was the total coverage. Totally, 189 doctors completed the questionnaire and this represents response rate of 94.5%.
Data were collected through a pretested, self-administered, online questionnaire. The questionnaire consisted of five sections: demographic characteristics of the participants, knowledge section, attitude, practice, and the perceived barriers section.
A correct answer was given 1 mark while no mark was given for each question that was wrongly answered or left blank. The total score ranged from 0 to 8 and the median score was found to be 4. Therefore, participants were divided into two categories, those who scored 4 (the median score of knowledge) or more were called as having sufficient knowledge and those who scored less than 4 were called as having insufficient knowledge.
Ethical clearance was obtained from SUMASRI Institutional Review Board (SIRB). Research purpose and objectives were explained to participants in clear simple words. Verbal consent was obtained from participants.
The collected data was analyzed by using Statistical Package for Social Science (SPSS) version 25 and excel version 16. The results obtained were presented in the form of descriptive statistics (tables and figures, means, median, and standard deviations) as well as inferential statistics (Chi-square test for cross tabulation at 0.05 margins of error (P value) and 95% confidence intervals.
| Results|| |
Demographic characteristics of the participants
There was a high response to the questionnaire as 189 primary care doctors out of 200 (94.5%) answered. Female doctors represented 79%. The median age of the participants was 34 years. The median duration of clinical experience was 7 years while the median working hours for each doctor per day was 7 hours. The average number of patients which the participants see per day was 40 (±15). The median number of patients with pre-diabetes per shift or working day was 2 patients. Fifty-two percent of the participants were family medicine MSc holders, 12% were general practitioners while only 1.6% had a family medicine MD. Forty-two percent of the participants worked abroad and nearly two thirds of them attended relevant courses about dealing with prediabetes either inside or outside the country [Table 1].
Participants' knowledge toward prediabetes
[Table 2] showed that 82.5% and 56.5% recognized the fasting glucose and HbA1c cutoff indicative of prediabetes, respectively. Totally, 82% of them recognized that Family history of type 2 diabetes is a risk factor for prediabetes. Near to third the participants recognized that age 40–70 and overweight or obese is one of the USPSTF recommendations in screening adults for abnormal glucose. Overall, 60.8% of doctors had sufficient knowledge about prediabetes.
|Table 2: The distribution of study participants by knowledge towards prediabetes (n=189)|
Click here to view
Attitude of the participants
[Table 3] shows that 61% of the participants agreed that the national guidelines and recommendations for diabetes prevention focused on screening for prediabetes are useful in their practice. Near to half the participants agreed that diabetes prevention should be a focus for all patients, regardless of blood glucose levels. Only 13% of them agreed that diagnosing a patient with prediabetes can represent risks overtreatment while 45% agreed that current evidence supports the effectiveness of treating prediabetes.
|Table 3: The distribution of study participants by their attitude towards prediabetes (n=189)|
Click here to view
Management of prediabetes
[Table 4] shows that about 23% of the participants agreed that most health professionals do not consider screening for prediabetes to be a high priority in diabetes prevention while 28% of them reported that they give general lifestyle advice targeted toward reducing cardiovascular disease instead of advice specific to diabetes patients with abnormal blood glucose. More than one third the participants recommend metformin to most patients with prediabetes. More than half the participants follow the United States Preventive Services Task Force (USPSTF) current guideline.
|Table 4: The distribution of study participants by their management practice towards prediabetes (n=189)|
Click here to view
Perceived barriers to diabetes prevention
[Table 5] shows that medication compliance was a barrier to diabetes prevention for 51% of the participants, while patient acceptance of prediabetes diagnosis was a barrier for more than third the participants. Knowledge of treatment options for prediabetes was a barrier for 18% of the participants. Lack of sustaining patient motivation and lack of time for patient follow-up were the barriers for 15% and 25%, respectively.
|Table 5: The distribution of perceived barriers towards diabetes prevention to the study participants (n=189)|
Click here to view
When a independent T test was done to compare between means, we found that the mean score among males (5 ± 1.9) was more than that among females (4 ± 1.7) (p value 0.002). Moreover, the mean score of those who attended relevant courses about dealing with prediabetes (4.7 ± 1.7) was more than those who didn't (3.5 ± 1.5) (P value = 0.000).
When Chi-square test was performed to determine the associations between knowledge and categorical data, we found that: Knowledge had statistically significant association with attendance of courses related to prediabetes (P values 0.001). while it had statistically insignificant association with qualifications and the participants' marital status and working abroad for a while (P values = 0.153, 0.441,0.059), respectively.
Pearson correlation test
When Pearson correlation test was done to determine the correlation between variables, we found that the score of knowledge was correlated with age (p = 0.000), duration of experience (P value = 0.000), the number of working hours per day (P value = 0.001), and the number patients seen per day (P value = 0.001)
Logistic regression: showed that attending courses relevant to prediabetes revealed statistically significant result, those who attended courses were more likely to have sufficient knowledge than those who didn't by 2 times (P value 0.033, OR 2, CI. 1.063-4.079). Moreover, males were more likely to have a sufficient knowledge by 1.6 times than females (OR = 1.6, CI, 0.646-3.726, P value 0.326) [Table 6].
| Discussion|| |
Health authorities in Sudan should focus in treatment of prediabetes as one step to decrease the epidemic of diabetes in Sudan. The prevalence of diabetes in the north of Sudan can range between 19 and 22%,, while the prevalence in Eastern of Sudan was 20.8%. This likely due to high prevalence of obesity in Sudan, in association with decreased physical activity and excess sugar and carbohydrate intake.,, In this study, we have shown that primary care and family physician have excellent knowledge, good attitude and practice about prediabetes. Identification and screening for prediabetes is not only enough unless it was combined with health education and encouragement of individuals to engage in intensive lifestyles. This important for low resource country like Sudan, where diabetes was associated with high prevalence of complications. For instance, the prevalence of diabetes complications like retinopathy, nephropathy, ischaemic heart disease, heart failure, stroke, and diabetic foot were found to, respectively.,,,,, The high level of diabetes complications can be attributed to high prevalence of uncontrolled glycaemia., Prediabetes is also a condition that associated with an increase in different comorbidities like hypertension, fatty liver polycystic ovary syndrome, hyperlipideamia, metabolic syndrome, an increase risk of cardiovascular disease, decrease in chromium and an increase in oral lesions. Importantly, diabetes was significantly associated with high hospital mortality with COVID-19, but prediabetes was not statistically associated with high hospital mortality,,,,
Our study also showed that increasing educational courses about diabetes and increasing clinical experience have positive impact in increasing knowledge about prediabetes for primary care physicians. Therefore, Health authorities in Sudan need to invest in course related to diabetes education for health professionals.
Assaad Khalil et al. identified barriers that can hinder measures to manage prediabetes in North Africa and Middle East. Among them were lack of knowledge of the public about diabetes and obesity. They also identified that small budget for diabetes prevention resulted in decreasing intervention for prediabetes program and intensive life style changes. In this study we identified several barriers for prediabetes prevention like individual's acceptance of prediabetes, ability to implement life style changes, lack of motivations, knowledge about diabetes and lack of time for follow up for doctors for those with prediabetes. The attitude of the physician towards treatment of prediabetes is key factor in management of prediabetes. Therefore, local authorities in Sudan should provide opportunities for follow up for individuals with prediabetes. Importantly, Mainous et al. reported that Physicians who have a positive attitude towards prediabetes, were more likely to follow national guidelines for management of prediabetes. This also important in order to empower and increase self-awareness of individuals with prediabetes, doctors and stakeholders about diabetes risk and complications in order to promote healthy behavior.,
This study is not without limitations. For instance, the cross-sectional designs of the study may not allow for the temporal relationship. Furthermore, the study was conducted in the capital Khartoum. Therefore, it is not possible to generalize the conclusion of this study to the whole of Sudan. Despite these limitations, the study showed that primary care physicians have good knowledge, attitude, and practice about prediabetes management.
| Conclusions|| |
Primary care and family physicians in Sudan have good knowledge, attitude, and practice about prediabetes. As they are in the front line in dealing with community, primary care, and family physicians' efforts can help in decreasing the epidemic of diabetes in Sudan.
Declaration of patient consent
The authors certify that they have obtained all appropriate participants consent forms. In the form the participant(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The participants understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Saeedi P, Petersohn I, Salpea P, Malanda B, Karuranga S, Unwin N, et al.
Global and regional diabetes prevalence estimates for 2019 and projections for 2030 and 2045: Results from the International Diabetes Federation Diabetes Atlas, 9th
.ition. Diabetes Res Clin Pract 2019;157:107843. doi: 10.1016/j.diabres. 2019.107843.
Hostalek U. Global epidemiology of prediabetes-present and future perspectives. Clin Diabetes Endocrinol 2019;5:5.
Omar SM, Musa IR, ElSouli A, Adam I. Prevalence, risk factors, and glycaemic control of type 2 diabetes mellitus in eastern Sudan: A community-based study. Ther Adv Endocrinol Metab 2019;10:2042018819860071. doi: 10.1177/2042018819860071.
Bansal N. Prediabetes diagnosis and treatment: A review. World J Diabetes 2015;6:296-303.
Ferrannini E, Gastaldelli A, Iozzo P. Pathophysiology of prediabetes. Med Clin North Am 2011;95:327–39.
Tseng E, Greer RC, Rourke PO, Yeh H, Mcguire MM, Clark JM, et al
. Survey of primary care providers' knowledge of screening for, diagnosing and managing prediabetes. J Gen Intern Med 2017;32:1172–8.
Mainous AG, Tanner RJ, Scuderi CB, Porter M, Carek PJ. Prediabetes screening and treatment in diabetes prevention: The impact of physician attitudes. J Am Board Fam Med 2016;29:663–71.
Okosun IS, Lyn R. Prediabetes awareness, healthcare provider's advice, and lifestyle changes in American adults. Int J Diabetes Mellit 2015;3:11–8.
Lee M, Saver JL, Hong KS, Song S, Chang KH, Ovbiagele B. Effect of pre-diabetes on future risk of stroke: Meta-analysis. BMJ 2012;344:e3564.
Mainous AG, Tanner RJ, Baker R. Prediabetes diagnosis and treatment in primary care. J Am Board Fam Med 2016;29:283–5.
Tseng E, Greer RC, O'Rourke P, Yeh HC, McGuire MM, Clark JM, et al
. Survey of primary care providers' knowledge of screening for, diagnosing and managing prediabetes. J Gen Intern Med 2017;32:1172–8.
Eltom MA, Babiker Mohamed AH, Elrayah-Eliadarous H, Yassin K, Noor SK, Elmadhoun WM, et al
. Increasing prevalence of type 2 diabetes mellitus and impact of ethnicity in north Sudan. Diabetes Res Clin Pract 2018;136:93-9.
Elmadhoun WM, Noor SK, Ibrahim AA, Bushara SO, Ahmed MH. Prevalence of diabetes mellitus and its risk factors in urban communities of north Sudan: Population-based study. J Diabetes 2016;8:839-84.
Khalil S, Almobarak AO, Awadalla H, Elmadhoun WM, Noor SK, Sulaiman AA, et al.
Low levels of physical activity in Sudanese individuals with some features of metabolic syndrome: Population based study. Diabetes Metab Syndr 2017;11(Suppl 2):S551-4.
Ahmed MH, Ali YA, Awadalla H, Elmadhoun WM, Noor SK, Almobarak AO. Prevalence and trends of obesity among adult Sudanese individuals: Population based study. Diabetes Metab Syndr 2017;11(Suppl 2):S963-7.
Awadalla H, Elmak NE, El-Sayed EF, Almobarak AO, Elmadhoun WM, Osman M, et al.
Hypertension in Sudanese individuals and associated risk factors: The critical intersection between salt and sugar intake. Cardiovasc Diagn Ther 2018;8:432-8.
Awadalla H, Noor SK, Elmadhoun WM, Almobarak AO, Elmak NE, Abdelaziz SI, et al
. Diabetes complications in Sudanese individuals with type 2 diabetes: Overlooked problems in sub-Saharan Africa? Diabetes Metab Syndr 2017;11(Suppl 2):S1047-51.
Almobarak AO, Badi S, Elmadhoun WM, Tahir H, Ahmed MH. The prevalence and risk factors of stroke among Sudanese individuals with diabetes: Cross-sectional survey. Brain Circ 2020;6:26-30. [Full text]
Ahmed MH, Awadalla H, Elmadhoun WM, Osman M, Noor SK, Almobarak AO. Prevalence and risk factors for acute coronary syndrome among Sudanese individuals with diabetes: A population-based study. Cardiol Res 2017;8:184-9.
Almobarak AO, Awadalla H, Osman M, Ahmed MH. Prevalence of diabetic foot ulceration and associated risk factors: An old and still major public health problem in Khartoum, Sudan? Ann Transl Med 2017;5:340. doi: 10.21037/atm. 2017.07.01.
Almobarak AO, Noor SK, Elmadhoun WM, Bushara SO, Salim RS, Forawi SA, et al.
Metabolic control targets in Sudanese adults with type 1 diabetes: A population-based study. J Family Med Prim Care 2017;6:374-9.
] [Full text]
Noor SK, Elmadhoun WM, Bushara SO, Almobarak AO, Salim RS, Forawi SA, et al
. Glycaemic control in Sudanese individuals with type 2 diabetes: Population based study. Diabetes Metab Syndr 2017;11(Suppl 1):S147-51.
Anari AG, Hazar N, Sadrabad MJ, Kharazmi S, Kheirollahi K, Mohiti A, et al
. Comparing the frequency of some oral lesions in prediabetic and healthy individuals: Is there any difference? Int J Prev Med 2019;10:177. doi: 10.4103/ijpvm.IJPVM_520_17.
Banihani SA, Jaradat SA, Khader YS. Serum chromium level is increased in Jordanian smokers, decreased in Jordanians with prediabetes and type 2 diabetes, but not altered in Jordanians with hypertension, with obesity, or with family history of diabetes. Int J Prev Med 2019;10:145. doi: 10.4103/ijpvm.IJPVM_137_18.
] [Full text]
Hadi Alijanvand M, Aminorroaya A, Kazemi I, Amini M, Aminorroaya Yamini S, Mansourian M. Prevalence and predictors of prediabetes and its coexistence with high blood pressure in first-degree relatives of patients with type 2 diabetes: A 9-year cohort study. J Res Med Sci 2020;25:31. doi: 10.4103/jrms.JRMS_472_18. [Full text]
Sourij H, Aziz F, Bräuer A, Ciardi C, Clodi M, Fasching P, et al
. Covid-19 fatality prediction in people with diabetes and prediabetes using a simple score at hospital admission. Diabetes Obes Metab 2020. doi: 10.1111/dom. 14256.
Alateeq MA, Aljohani M, Kinani SS, Aljabr IA, Alduayji AA, Aloud A, et al
. The prediabetes outcome at National Guard Primary Health Care Centers in Riyadh, Saudi Arabia: Retrospective chart review. Cureus 2020;12:e10227.
Assaad Khalil SH, Abdelaziz SI, Al Shammary A, Al Zahrani A, Amir A, Elkafrawy N, et al.
Prediabetes management in the Middle East, Africa and Russia: Current status and call for action. Diab Vasc Dis Res 2019;16:213-26.
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]