Knowledge and Awareness of Diabetes Mellitus Disease among High School Students in King Abdulaziz Military City, Tabuk, Saudi Arabia

Diabetes can lead to serious and lifelong complications that affect general health and worsen the quality of life. It is always considered to be a heavy burden for every medical institute [4,5]. Diabetes can cause damage to many organs and systems in the human body, including renal and nervous systems. The risks of stroke, cardiac disease, and limb problems are high as well [1,3]. Early detection of diabetes is effective for improving clinical outcomes and quality of life [6]. Therefore, increasing the awareness of diabetes is essential and important for the management, prevention, and control of the disease. Edited by: Sasho Stoleski Citation: Alenazi MA, Alenezi SH, Alhablani MN, Alanazi MAM, Alenazi WH, AlQahtani MS, Alenezi D, Mahzari QA. Knowledge and Awareness of Diabetes Mellitus Disease among High School Students in King Abdulaziz Military City, Tabuk, Saudi Arabia. Open Access Maced J Med Sci. 2020 Feb 05; 8(E):91-97. https://doi.org/10.3889/oamjms.2020.4194

https://www.id-press.eu/mjms/index Background In Saudi Arabia, data are lacking regarding knowledge and awareness about DM among school students. A study conducted at Tabuk University showed that 55% of the students were unaware of diabetes risk factors. This study included 200 subjects; among them, 103 were males and 97 were females. Their ages ranged from 18 to 24 years, and 16.5% of them were diabetic patients [7].
Another study was performed in the Al-Qassim region that evaluated more than 2000 citizens of Saudi nationality, which showed that most of the young population had a misconception that diabetes is a curable medical problem [8].
Another study was carried out in Oman among more than 500 students. It illustrated that knowledge of DM among high school students is suboptimal. In most cases, their knowledge deficiency was particularly in diabetes complications [9]. Therefore, the present study aimed to assess the level of knowledge and awareness of DM among high school students within the military city, Tabuk, Saudi Arabia. Identifying the lack of knowledge or misconception about DM might be a triggering point to increase the awareness by education campaign to ensure early detection and proper management of this chronic disease.

Objectives of the study
The objectives are as follows: • To assess the level of the awareness and knowledge regarding DM among high school students. • To explore if there is any significant association between the awareness and knowledge level of the high school students and their (i) gender, (ii) age, and (iii) level of education.

Study design
This was a cross-sectional study based on a questionnaire.

Study area/setting
This study was conducted at high school students in the military city, Tabuk, Saudi Arabia.

Inclusion criteria
Student, high school, and male and female in the military city in Tabuk were included in the study.

Exclusion criteria
Students with DM, students who were taking hypoglycemic agents, and the students who did not give written informed consent or refused to participate in the study were excluded from the study.

Sample size
Population size = 1000 Design effect = 1 We assumed confidence level = 95%, so accordingly, our sample size was 278 as calculated using OpenEpi, Version 3.

Sampling technique
This was a convenience sampling of the students who were attending high schools in the military city area in Tabuk, Saudi Arabia, and who fit the inclusion criteria.

Data collection methods, instruments used, and measurements
The questionnaire used in this study was adapted from P & T Journal, Medimedia USA, Inc., and was developed by Subish et al. [10]. It has been used in the previous KAP studies among diabetic patients and has been proven to be reliable [10,11]. The selfadministered questionnaire included demographic information (sex, age, education level, and diabetes status), knowledge questions about symptoms, causes, management and complication of DM, and questions about diet and physical activities. The questionnaires were distributed to the high school students (male and female) after official communication with the school's dean and taking permission. Each participant required 5-10 min to fill up the questionnaire. The level of knowledge and awareness was categorized into "adequate" (accurate response/answer) and "inadequate" (inaccurate response/answer, or partially know, or do not know) as per each topic/question and also as per each response/answer ( Table 1).

Data management and analysis plan
Data entry and analysis were carried out using the Statistical Package for the Social Sciences. Frequencies and percentages were calculated for categorical variables, while mean, median, mode, maximum value, minimum value, and standard deviation were calculated for continuous variables. Pearson's Chi-square tests were performed to explore if there is any significant association between the knowledge and awareness level of the high school students and their (i) gender, (ii) age, and (iii) level of education. Table 2 shows the sociodemographic characteristics and diabetes status of high school students. Of 278 high school students, approximately two-thirds (66.9%) of the high school students belonged to the age group of 15-17 years, while the remaining 33.1% of them were adult, i.e., 18 years old or above. The mean age of the high school students who participated in the study (n = 278) was 17.15 ± 1.012 years ranging from a minimum age of 15 years to a maximum age of 22 years. Of 278 high school students, the majority (61.2%) were male, while the remaining 38.8% of the respondents were female. More than half (56.2%) of the respondents belonged to the second level of education in their school, approximately one-fourth (25.5%) belonged to the third level, and 18.3% belonged to the first level in their school. Of 278 high school students, the majority (79.5%) were non-diabetic, while only 2.5% were diabetic. However, the diabetes status of 18% of the respondents was unknown ( Table 2). Table 1 illustrates the knowledge and awareness level of high school students about DM. More than half of the high school students had an adequate level of knowledge and awareness about DM in terms of symptoms (67.3%), complications (56.5%), monitoring method (62.6%), lifestyle modifications (63.7%), frequency of routine eye check-up (63.3%), important factors for blood sugar control (79.1%), treatment (56.5%), and management of hypoglycemia symptoms (57.6%). On the contrary, a large number of the students showed an inadequate level of knowledge and awareness about the disease in terms of definition (80.6%), major causes (57.9%), effect of high blood pressure (51.8%), frequency of routine blood pressure check-up (55%), rationale of a regular urine test (58.3%), medication for DM (66.9%), and duration of medication (69.8%).

Results
Only 19.4% of 278 respondents knew the correct definition of the DM disease, while 22.3% of them did not know the definition of DM. However, more than half (58.3%) of the high school students had a wrong perception of the definition of DM. Of 278 respondents, 23.7% could not mention the major cause for occurring DM disease, while the maximum (42.1%) of them correctly knew that a decreased availability of insulin in the body is the major cause of DM. However, around one-third (34.2%) of the high school students had an incorrect perception of the major cause of DM (Table 1). Table 1 also shows that among 278 respondents, more than two-thirds (67.3%) knew the multiple symptoms of DM correctly, while 15.8% of the high school students mentioned "increased frequency of urination" as the only symptom of DM. However, 12.6% of the respondents did not have any concept about the symptoms of DM. Of 278 high school students, the majority (56.5%) were aware of the multiple complications of DM (e.g., eye problems, kidney problems, foot ulcers, and heart problems), while 19% of them knew at least one complication of this disease. Nevertheless, approximately one-fourth (24.5%) respondents did not have any idea about the complications of DM.
Regarding the most accurate method of monitoring DM, the majority (62.6%) of the respondents knew the correct method as "checking blood glucose level" (Table 1). Approximately 22% of them mentioned "checking urine sugar" as the most accurate method, which is actually not correct. However, 15.5% of the high school students did not have any idea about it. Of 278 high school students, the highest number (48.2%) were aware of the multiple effects of high blood pressure among the patients with DM (e.g., risk of heart attack, stroke, eye problems, and kidney problems), while 26.6% of them knew at least one type of such effects. However, approximately one-fourth (25.2%) respondents did not possess any knowledge about the effect of high blood pressure among diabetes patients. Of 278 high school students, the maximum number (45%) were aware that patients with DM should measure their blood pressure once every month, while 23.3% of them did not know the accurate frequency (Table 1). Moreover, 4.7% of respondents were not at all aware of the necessity of regular blood pressure check-up for diabetes patients, and more than one-fourth (27%) respondents did not have any idea about the frequency of regular blood pressure measurement.  Of 278 respondents, the majority (79.1%) had an appropriate concept about the multiple important factors (e.g., a controlled and planned diet, regular exercise, and medication) to control blood sugar, while remaining 20.9% of the respondents knew at least one of the important factors (Table 1). Of 278 respondents, the majority (56.5%) had the proper concept about the treatment of DM, while 15.8% of them had wrong ideas (e.g., antibiotic therapy, blood transfusion, and taking more bitter vegetables) about this issue. However, more than one-fourth (27.7%) of the high school students did not have any idea about the treatment of diabetes. Table 1 illustrates that among 278 respondents, approximately one-third (33.1%) knew correctly that antibiotics cannot be used for the treatment of diabetes. Remaining two-thirds (66.9%) did not have an appropriate idea about the medication for DM. Of 278 respondents, only 30.2% had the proper concept about the duration of medication for DM (i.e., medication should continue for life), while 29.1% of them had the wrong idea about this issue. However, 40.7% of the high school students did not have any idea about the duration of medication for DM. Table 1 also shows that among 278 respondents, the majority (57.6%) knew correctly that sugar can be used for the management of hypoglycemia symptoms, while 20.8% of high school students had an incorrect concept about this issue. However, 21.6% of the respondents did not know anything about the management of hypoglycemia symptoms. Table 3 shows that there were no significant associations between the awareness and knowledge level of the high school students about the definition of DM and their (i) gender (p = 0.06), (ii) age group (p = 0.97), and (iii) level of education (p = 0.37). Table 4 depicts that there were no significant associations between the awareness and knowledge level of the high school students about the major causes of DM and their (i) gender (p = 0.06), (ii) age group (p = 0.66), and (iii) level of education (p = 0.7).

Discussion
Our study findings are similar to a number of previous study results that showed an inadequate level of knowledge and awareness of DM among the respondents in Saudi Arabia [12]. Al-Aboudi et al. [13] reported that 15% of the study participants in Riyadh had inadequate knowledge of DM, while 72% had moderate knowledge. In a study by Binhemd [14], the respondents in Dammam were found to obtain low scores regarding knowledge and attitudes toward DM. In another survey by Al Malki et al. [15], the percentage of correct answers to questions about DM was 49%, indicating a gap in DM knowledge among the Saudi population. A study was conducted among medical students that also reported that the medical students achieved low scores regarding knowledge about DM, and 90% of the students were not aware of the correct procedure for administering insulin injections [16]. Another study was carried out exclusively among secondary school students in Riyadh by Al-Mutairi et al. [17]. This study revealed that the awareness about the role of body weight in DM was lower in males (p = 0.037); males were less likely to recognize the risks for the disease than females, including obesity (p = 0.030), heredity (p = 0.013), and high-fat intake (p = 0.001). In our study, the high school students showed both adequate and inadequate levels of knowledge and awareness about DM (Table 1). More than half of the high school students had an adequate level of knowledge and awareness of the disease in terms of symptoms, complications, monitoring technique, lifestyle modification, routine eye check-up, blood sugar control, treatment, and management of hypoglycemia. On the other hand, a considerable number of the students showed an inadequate level of knowledge and awareness about DM in terms of definition, causes, the effect of high blood pressure, routine blood pressure check-up, urine test, medication, and duration of medication.
Our study is limited by the fact that we employed a non-probability convenient sampling method instead of a random sampling method. Therefore, our study participants should not be considered as a representative sample for generalization of the study findings, and caution should be taken in interpreting the results given that it was a convenience sample. In the present study, the use of a unique sample only from Tabuk may limit the generalizability of the study findings to other provinces in Saudi Arabia. Another limitation of the study was the severe time constraint faced by the researcher to complete the assignment within a strict deadline.

Conclusion
Our study concluded that the level of awareness and knowledge of a considerable number of high school students regarding DM was inadequate, and some of them possessed various misconceptions about this particular chronic disease. However, no significant associations were found between the knowledge and awareness level of the high school students about the definition or major causes of DM and the (i) gender, (ii) age group, and (iii) level of education of the students.
Health authorities and school authorities in the region should offer special efforts to improve the level of knowledge and awareness through regular health education campaigns about DM, particularly for school students, school teachers, and parents of the school students. Simultaneously, incorporation of health education messages about major chronic diseases into textbooks and school curriculum will provide opportunities for increasing awareness of school students regarding DM.