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 Table of Contents  
ORIGINAL ARTICLE
Year : 2022  |  Volume : 3  |  Issue : 1  |  Page : 8-13

Assessment of knowledge and practice trends about COVID-19 disease and vaccination among patients with type 2 diabetes mellitus attending an outpatient department of a tertiary care hospital


Department of Endocrinology, IMS and SUM Medical College and Hospital, Bhubaneswar, Odisha, India

Date of Submission05-Oct-2021
Date of Decision12-Dec-2021
Date of Acceptance19-Dec-2021
Date of Web Publication24-Mar-2022

Correspondence Address:
Dr. Jaspreet Singh
Department of Endocrinology, IMS and SUM Medical College and Hospital, Bhubaneswar, Odisha
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jascp.jascp_24_21

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  Abstract 


Background: COVID-19 pandemic has been the most challenging health-care crisis of modern times which has severely impacted the health-care and economic infrastructure of all affected nations. Diabetic people are at an increased risk of morbidity as well as mortality from COVID-19 infection. Efforts to stop the spread of any pandemic depend upon the people's knowledge regarding the preventive measures as well as their attitudes and healthy practices. The purpose of this study is to assess the knowledge, attitude, and healthy practices of the diabetic population in our part of the country toward COVID-19 pandemic as well as toward ongoing vaccination drive in our country. Materials and Methods: This is an observational study, face-to-face interview with the type 2 diabetes patients attending our endocrine outpatient department regarding the knowledge, attitude, and practice questionnaire. The knowledge questionnaire took into account the current knowledge regarding COVID-19 and its relationship with diabetes mellitus as well as healthy practices to be followed during pandemic. Results: Among our study population, around 78% of the participants had an average knowledge while 10% still had below-par knowledge. There was significant discordance between knowledge and healthy practices among the studied subjects. Even when patients had knowledge about the precautions to be taken, they were not following it strictly. In our study, nearly 54% of the subjects expressed confidence over the efficacy of the vaccine. Similarly, 53% of the subjects knew that they are supposed to follow social distancing norms and wear masks even after vaccination to prevent the spread of COVID-19. Conclusion: The knowledge of our diabetic population related to COVID-19 pandemic is still average. Even with average knowledge, there is a wide gap between knowledge and health practices. The attitude of the diabetic population toward vaccination is still below par which could have implications regarding vaccine acceptability.

Keywords: Attitude, COVID-19, diabetes mellitus, knowledge, knowledge, attitude, and practice, practice, vaccination


How to cite this article:
Swain J, Manglunia A, Mangaraj S, Singh J, Sravya S L, Jadhao P. Assessment of knowledge and practice trends about COVID-19 disease and vaccination among patients with type 2 diabetes mellitus attending an outpatient department of a tertiary care hospital. J Appl Sci Clin Pract 2022;3:8-13

How to cite this URL:
Swain J, Manglunia A, Mangaraj S, Singh J, Sravya S L, Jadhao P. Assessment of knowledge and practice trends about COVID-19 disease and vaccination among patients with type 2 diabetes mellitus attending an outpatient department of a tertiary care hospital. J Appl Sci Clin Pract [serial online] 2022 [cited 2022 May 17];3:8-13. Available from: http://www.jascp.com/text.asp?2022/3/1/8/340879




  Introduction Top


COVID-19 pandemic has been the biggest health-care challenge that mankind has faced in nearly a century. The disease continues to wreak havoc across the globe and has jeopardized the health-care as well as economic infrastructure of all the affected countries. Diabetes mellitus remains one of the major risk factors for developing severe disease as well as for having worse outcomes in COVID-19-infected individuals.[1],[2],[3] It is also now well known that poor glycemic control is an established risk factor for adverse outcomes in COVID-19 disease.[4],[5] Needless to say, the diabetic population remains one of the most susceptible at-risk populations for COVID-19 infection and subsequent adverse outcomes. Vaccination remains an invaluable public health intervention to mitigate and halt this devastating pandemic. COVID-19 appropriate measures such as regular handwashing with soap, following adequate social distancing norms, and mask usage must be strictly followed to avoid COVID-19 infection. Even people's knowledge and health practices regarding these simple measures are still lacking. Confidence of general population can be affected by various concerns which can lead to vaccine hesitancy causing delays and denials. It is feared that COVID-19 might take longer to keep under check if proper preventive measures are not followed.

Efforts to mitigate the spread of any pandemic largely depend on the people's behavior and their knowledge regarding the preventive measures. Multiple studies have shown that knowledge, attitude, and practice (KAP) among the people are effective prevention and management strategy.[2] The “KAP theory” is a health behavior change theory wherein the change in human behavior is divided into three successive processes, namely acquisition of right knowledge, generation of attitudes, and adoption of behavior (or practice).[6] We carried out the KAP questionnaire study regarding COVID-19 disease and vaccination knowledge among the type 2 diabetes patients of our region. The study was planned to assess the knowledge, attitude, and healthy practices of our diabetic population toward COVID-19 disease as well as their understanding of vaccination outcome.


  Materials and Methods Top


This cross-sectional, observational study was conducted in the month of April–May 2021 at the endocrinology department of a tertiary care hospital. We conducted a face-to-face interview with the type 2 diabetes patients attending our endocrine outpatient department (OPD) with proper precautions of wearing masks, social distancing, and sanitization measures. The patients were asked regarding the basic demographic details such as age, sex, educational status, occupation, residence, and the designed KAP questionnaire shown in [Table 1]. The knowledge questionnaire took into account the current knowledge and awareness regarding COVID-19 and its relationship with diabetes mellitus. Along with it, the subjects were individually asked regarding the preventive measures and their vaccination knowledge. The knowledge-based question has three options “Yes/No/Don't know” whereas the attitude and practice questionnaire has only “Yes/No” as option. Inclusion criteria are type 2 diabetes patients with age more than 18 years with good mental health and able to understand and answer the questions. The questions were both in English and local (Odia) language. A total of 150 diabetic patients who participated in the study and completed the questionnaire were finally included. Institutional ethical committee approval was taken for conducting the study [Table 1].
Table 1: KAP questionnaire

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  Results Top


Out of 212 patients who attended the diabetic OPD during the study period, a total of 150 participants were recruited for the final analysis as 35 patients did not consent for the study and 27 patients did not complete the interview. The demographic profile of 150 participants is summarized in [Table 2]. Majority of the participants in our study were males (56%) and resided in the urban areas (61.3%). An overwhelming majority of the participants (93%) were in the age group of 35–70 years. Among our recruited cohort, around 90% of the subjects had completed formal high school education.
Table 2: Demographic profile summary

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The knowledge-based question had three options “Yes/No/Don't know” whereas the attitude and practice questionnaire had only “Yes/No” as option. We also calculated a knowledge score (KS) for each participant depending on the points scored by the concerned participant. A correct answer was assigned 1 point whereas an incorrect/Don't know answer was assigned 0 points. A correct answer to questions 1–18 was assigned 1 point and questions 19 and 20 had 6 parts; each correct response to 1 part was assigned 1 point. All the answers were added to generate a KS for each participant. The maximum points for KS were 30. Subjects scoring more than 27 in KAS were classified as having good knowledge. Those subjects with score between 24 and 27 points were classified as average whereas those scoring <24 were classified as having poor knowledge.

Analysis of our data suggested that around 78% of the participants had an average knowledge while 10% still had below-par knowledge. The summary of the responses of the study population to the KAP questionnaire regarding COVID-19 is presented in [Table 3]. Around 91.3% of the participants believed that diabetic patients are at increased risk to catch COVID-19 infection from others. Majority of the participants (64.67%) believed that COVID-19 will increase the risk of micro- as well as macrovascular complications.
Table 3: COVID-19 knowledge questionnaire: Result

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We tried to assess the knowledge of participants toward COVID-19 vaccination. Around 54% of the participants believed that vaccination will be helpful in limiting the spread of COVID-19. To our surprise, 40% of our study participants felt that vaccination will lead to serious complications among diabetic patients. One-fourth of the participants believed that vaccination might result in decline in their immunity levels. When enquired regarding COVID-19 appropriate behavior, around 50% of the individuals agreed that COVID-19 appropriate behaviors such as social distancing, wearing masks, frequent handwashing, and sanitization need to be followed even after vaccination. The knowledge status of our study group regarding symptoms of COVID-19 and various measures to reduce the spread of COVID-19 is shown in [Figure 1] and [Figure 2], respectively.
Figure 1: Clinical symptoms of COVID-19

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Figure 2: Measures to reduce the spread of COVID-19

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Assessment of the attitude domain of our questionnaire revealed that 66.7% of the patients believed that the presence of diabetes can result in serious infection or even death. However, many (around 90%) also believed that early symptomatic and supportive management can lead to recovery from COVID-19 infection. We also tried to access the practice knowledge of our cohort regarding COVID-19 and diabetes. Regarding regular and proper usage of masks, 61.3% of the participants concurred that they use mask appropriately each time they step out of home. Around 46% of individuals agreed that that their glycemic status deteriorated during COVID-19 times as compared to pre COVID times.


  Discussion Top


The present study was conducted during the second wave of COVID-19 pandemic when cases were increasing at an exponential rate. India ranks second in terms of population as well as prevalence of diabetes. Numerous studies have shown that diabetes mellitus is associated with increased morbidity and mortality in COVID-19.[1],[2],[3] Hence, combination of COVID-19 and diabetes may pose a significant challenge to health-care resources. In terms of severity, the diabetes patients affected with COVID-19 may have poor prognosis. Diabetes mellitus is an independent risk factor for admission to intensive care unit, invasive ventilation, and death.[3],[4],[5] Hence, awareness is the most important aspect in diabetes patients by which they can take precautions and adopt good healthy practices to minimize the risk of acquiring infection, limit its spread, and ultimately decrease the severity of the disease. Moreover, good glycemic control is another key aspect for better outcomes. Our study reveals that among our diabetic cohort, majority of our participants (78%) had an average knowledge as reflected by their KS score. Only 12% of the subjects had a good KS. In a similar study among T1DM patients during the first wave of COVID-19 pandemic, the authors reported that 74% of their type 1 DM cohort had average knowledge whereas around 12% of the participants had good knowledge, respectively.[7] In a similar study among people with hypertension and diabetes mellitus attending public health facilities in Ambo, Ethiopia, the prevalence of poor, good, and moderate knowledge was around 31%, 38%, and 31%, respectively.[8] This difference could be attributed to difference in the study population.

Assessment of subject's knowledge regarding COVID-19 symptomology and its preventive measures revealed that majority of them knew fever and cough as the only symptoms. Despite the fact that more than a year has elapsed since the pandemic started, in our studied population, approximately 50% were still unaware that sore throat, myalgia, smell disturbance, and rhinitis could also be a spectrum of COVID-19 complaints. Although almost all of them had good idea regarding the use of face masks, sanitization, and social distancing norms. Around 98% of the subjects agreed/believed that mask usage will prevent them from getting COVID-19 infection. However, knowledge regarding right types of masks and proper ways to wear mask was lacking in many. Majority of them used their handkerchief as mask, and even if correct masks were used, it did not cover their nose or mouth. Approximately 5% of the participants believed that death is inevitable if they acquire COVID-19 infection, further aggravating anxiety, stress, and depressive behavior among the population. Sixty-seven percent of the subjects had an idea that diabetic individuals with COVID-19 infection may become critical and have increased mortality. Majority agreed that there is no specific treatment, but timely intervention may control the disease and limit its severity and complications.

Vaccination is one of the most important health-care measures that can limit the spread of COVID-19. Hence, rapid implementation of mass scale vaccination has been seen across the world as a necessary measure to stop the further spread of COVID-19. Since our country is presently going through a large-scale mega vaccination drive, our study tried to assess the knowledge and attitude of our diabetic population toward COVID-19 vaccine. In our study, just 54% had the confidence in efficacy of the vaccine. There is currently paucity of data regarding the assessment of vaccination knowledge among diabetic patients. There are some studies in general population to access the KAP toward vaccine. In a study among general population in Bangladesh, 78% of the participants had positive attitudes toward COVID-19 vaccine.[9] Another study from the USA suggested that among normal population, 84.55% of the respondents believed that vaccination is effective in preventing COVID-19.[10] We found that 40% of the patients were not aware of postvaccination side effects and only 53% of the subjects knew that they are supposed to follow social distancing norms and wear masks even after vaccination. This suggests that the knowledge of the study population regarding vaccination is average and not optimal despite widespread advertisements in various multimedia. The evaluation of attitude regarding vaccination suggested that only 60% of the participants were willing for vaccination.

In this face-to-face interview, we found that even if the patients had knowledge about the necessary precautions to be taken, many were not following it strictly. This can be seen from the fact that around 98% of the patients believed that face masks will prevent COVID-19, but only 61.33% of the subjects wore mask each time they stepped outside their homes. This underscores the point that there are still gaps between knowledge and actual adoption of self-protective measures. There is also change in dietary patterns of patients during COVID-19 pandemic. This is due to lockdown as more and more people stay at home for long times and resorted to intermittent snacking. In our study, only 66.67% of the patients properly follow their routine dietary advice since COVID-19 pandemic. During the first COVID-19 pandemic lockdown, 30% of the patients discontinued their treatment due to nonavailability of medicines nearby and lack of contact with their primary treating physician. Forty-six percent of the patients are having deranged glycemic status in the COVID-19 pandemic as compared to pre-COVID times. This was due to lack of physical activity, change in dietary pattern, and discontinuation of medications.

Our study provides key insights to ground realties pertaining to knowledge, safe health practices, and concerns regarding vaccination among the type 2 diabetes patients. Previous studies assessed the knowledge and attitudes of diabetic patients by telephonic interviews and customized applications on smartphones. Although the telephonic and apps-based collecting information is safer in the scenario of COVID-19, face-to-face interview has extra value and telephone-based interview is generally considered inferior to in-person interview.

Our study shows that the knowledge of our diabetic population related to COVID-19 pandemic is still average. There is a wide gap between knowledge and actual adopted health practices in our population. The attitude of the population toward vaccination is still below par regarding safety and efficacy with many myths leading to unwillingness for the vaccine. Efforts should be directed to educate our patients regarding the vaccination safety and efficacy. This will promote vaccine acceptance and increase our chance of containing the spread of COVID-19.

Financial support and sponsorship

All authors have no financial relationship related to this article to disclose.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Fang L, Karakiulakis G, Roth M. Are patients with hypertension and diabetes mellitus at increased risk for COVID-19 infection? Lancet Respir Med 2020;8:e21.  Back to cited text no. 1
    
2.
Singh AK, Gupta R, Ghosh A, Misra A. Diabetes in COVID-19: Prevalence, pathophysiology, prognosis and practical considerations. Diabetes Metab Syndr Clin Res Rev 2020;14:303-10.  Back to cited text no. 2
    
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Targher G, Mantovani A, Wang XB, Yan HD, Sun QF, Pan KH, et al. Patients with diabetes are at higher risk for severe illness from COVID-19. Diabetes Metab 2020;46:335-7.  Back to cited text no. 3
    
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Selvin E, Juraschek SP. Diabetes epidemiology in the COVID-19 pandemic. Diabetes Care 2020;43:1690-4.  Back to cited text no. 4
    
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Cariou B, Hadjadj S, Wargny M, Pichelin M, Al-Salameh A, Allix I, et al. Phenotypic characteristics and prognosis of inpatients with COVID-19 and diabetes: The CORONADO study. Diabetologia 2020;63:1500-15.  Back to cited text no. 5
    
6.
Kim T, Ross J, Smith D. KOREA: Trends in four national KAP surveys, 1964-67. Stud Fam Plann 1969;1:6-11.  Back to cited text no. 6
    
7.
Pal R, Yadav U, Grover S, Saboo B, Verma A, Bhadada SK. Knowledge, attitudes and practices towards COVID-19 among young adults with Type 1 Diabetes Mellitus amid the nationwide lockdown in India: A cross-sectional survey. Diabetes Res Clin Pract 2020;166:108344.  Back to cited text no. 7
    
8.
Melesie Taye G, Bose L, Beressa TB, Tefera GM, Mosisa B, Dinsa H, et al. COVID-19 knowledge, attitudes, and prevention practices among people with hypertension and diabetes mellitus attending public health facilities in Ambo, Ethiopia. Infect Drug Resist 2020;13:4203-14.  Back to cited text no. 8
    
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slam MS, Siddique AB, Akter R, Tasnim R, Sujan MSH, Ward PR, Sikder MT. Knowledge, attitudes and perceptions towards COVID-19 vaccinations: a cross-sectional community survey in Bangladesh. BMC Public Health. 2021 Oct 13;21(1):1851. doi: 10.1186/s12889-021-11880-9. PMID: 34645399; PMCID: PMC8513387.  Back to cited text no. 9
    
10.
Callaghan T, Moghtaderi A, Lueck JA, Hotez P, Strych U, Dor A, et al. Correlates and disparities of intention to vaccinate against COVID-19. Soc Sci Med. 2021 Mar;272:113638. doi: 10.1016/j.socscimed.2020.113638. Epub 2021 Jan 4. PMID: 33414032; PMCID: PMC7834845. [doi: 10.2139/ssrn. 3667971].  Back to cited text no. 10
    


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