Keywords awareness - diabetes mellitus - knowledge - undergraduate students
Introduction
Chronic noncommunicable diseases (NCDs) represent a significant threat to global public
health. They are the leading cause of mortality worldwide, responsible for approximately
41 million deaths annually, which constitutes 71% of all deaths. Among the various
NCDs, diabetes mellitus (DM) ranks fourth, resulting in approximately 1.6 million
deaths globally each year.[1 ]
DM, a prominent category of NCDs, is experiencing a troubling increase in prevalence.
Current estimates suggest that around 536.6 million individuals (10.5% of the global
population) are living with diabetes, a figure projected to rise to 783.2 million
(12.2%) by 2045.[2 ] According to the World Health Organization, Saudi Arabia has the second-highest
prevalence of diabetes in the Middle East and ranks seventh globally. Approximately
8.5% of the Saudi population is estimated to be living with diabetes, with prevalence
rates continuing to rise in recent years.[3 ] Type 2 DM (T2DM) affects individuals across all age groups; however, it is increasingly
prevalent among adolescents and young adults (ages 15–34).[4 ] Fortunately, T2DM is preventable if risk factors are identified early.[5 ] Enhancing awareness of these risk factors in the general population, particularly
among health care professionals who are often consulted for guidance, can help reduce
the burden of T2DM and its complications.
It is therefore essential that health sciences students, as future health care providers,
are adequately informed about the risk factors, preventive strategies, and management
of DM. The extent to which preprofessional health sciences students in Saudi Arabia
understand T2DM, however, remains unclear.
This study aimed to evaluate the knowledge and awareness of T2DM including risk factors,
treatment, and the reversibility of prediabetes among students at King Saud bin Abdulaziz
University for Health Sciences (KSAU-HS) in Riyadh, Saudi Arabia. The focus was on
their understanding of risk factors, clinical information, preventive measures, and
perceptions of the disease.
Methods
Ethical Approval
This study was approved by the Research Committee and the Institutional Review Board
(IRB) at King Abdullah Medical Research Center, Riyadh, Saudi Arabia (Reference No.
IRBC/0320/20). Informed consent was obtained from all participants during data collection.
Study Design and Participants
A descriptive cross-sectional survey design was employed using a self-administered
structured questionnaire. The study population comprised first- and second-year preprofessional
students (male and female) from the College of Science and Health Professions (COSHP)
at KSAU-HS, Riyadh campus, during the 2021 to 2022 academic year.
All first- and second-year COSHP students were invited to participate. They received
a briefing regarding the study's objectives and instructions for completing the questionnaire.
Participation was voluntary and anonymous. Questionnaires were distributed along with
a consent form outlining the purpose of the research, and participants were assured
of confidentiality.
Development of the Questionnaire
The structured questionnaire was developed following a comprehensive literature review,
drawing on studies conducted by Khan et al, Xu et al, and Amankwah-Poku.[5 ]
[6 ]
[7 ] Validity of the questionnaire was established through face and content validity
assessments. A panel of subject experts evaluated the questionnaire to ensure alignment
with the study objectives.
A pilot study was conducted with 35 university students to identify potential issues
with questions' design, flow, or interpretation. Based on feedback, minor modifications
were made. The finalized version was then translated into Arabic by a bilingual individual
with expertise in the subject area, and the translation was reviewed by a language
expert prior to distribution.
The finalized questionnaire consisted of two sections. The first collected demographic
data, including age, gender, year of study, and personal and familial health status.
The second assessed knowledge of diabetes through 47 questions covering symptoms,
risk factors, diagnosis, complications, treatment, and prevention.
Sample Size
The required sample size was calculated to be 317, based on a 95% confidence interval,
a 5% margin of error, and an estimated population proportion of 50%.
Data Analysis
Descriptive statistics were used to summarize demographic characteristics expressed
as frequencies and percentages or as means and standard deviations. Participants'
responses to the knowledge questions were also summarized as percentages. To evaluate
the influence of demographic variables on the participants' knowledge, the forward
backward with early dropping variable selection algorithm[8 ] was implemented in the R package MXM.[9 ] Given that knowledge questions offered only two response options (Yes/No), logistic
regression was employed.[10 ] The sign in parentheses accompanying each demographic variable indicates the direction
of its effect.
The interrelationships among the 47 knowledge questions were further analyzed using
a Bayesian network.[11 ] The PC Hill Climbing (PCHC) Bayesian network-learning algorithm,[12 ] as described in the literature, was employed for this analysis and implemented using
the R package pchc.[13 ]
Results
A total of 429 students participated in the survey. The majority of the participants
(92.10%) were aged 20 years or younger, with first-year students representing the
largest group (60.1%). Additionally, a significant proportion of the respondents (78.1%)
reported having family members or relatives with type 2 diabetes ([Table 1 ]).
Table 1
Descriptive statistics of the demographic variables
Categorical variable
Values
Frequency (%)
Age
20 years or younger
395 (92.10)
Older than 20 years
34 (7.90)
Gender
Female
156 (36.40)
Male
273 (63.60)
Year of study
1st
258 (60.10)
2nd
171 (39.90)
If you were a second-year student, then your group is:
PAMS
48 (28.07)
PDNT
20 (11.70)
PHIS
7 (4.09)
PMED
78 (45.61)
PPHR
18 (10.53)
Do you suffer from type 2 diabetes mellitus?
Don't know
21 (4.90)
No
401 (93.50)
Yes
7 (1.60)
Does any of your family member or relative has/had type 2 diabetes mellitus?
Don't know
17 (4.00)
No
77 (17.90)
Yes
335 (78.10)
Are you maintaining healthy diet?
Don't know
58 (13.50)
No
280 (65.30)
Yes
91 (21.20)
Are you engaged in any physical exercises?
Don't know
30 (7.00)
No
248 (57.80)
Yes
151 (35.20)
Abbreviations: PAMS, preapplied medical sciences; PDNT, predental; PHIS, prehealth
informatics; PMED, premedicine; PPHR, prepharmacy.
The participants' responses to diabetes-related questions are summarized in [Table 2 ]. Of the 47 questions, only 4 received a lower percentage of positive (“Yes”) responses.
The majority of participants responded positively to a large number of questions (n = 43).
Table 2
Distribution of responses to each diabetes-related question
No.
Full question
Answers
Yes %
No %
Q1
Diabetes is a medical condition characterized by elevated levels of glucose in the
blood
71.10
28.90
Q2
Type 2 diabetes is preventable and controllable
96.27
3.73
Q3
Excessive eating is a symptom of diabetes
27.74
72.26
Q4
Excessive thirst is a common symptom observed in individuals with diabetes
91.14
8.86
Q5
Diabetes can be treated
76.79
23.21
Q6
Unusual weight loss occurs in diabetic patients
83.68
16.32
Q7
Persistent fatigue is a common symptom among individuals with diabetes
90.44
9.56
Q8
Frequent urination occurs in diabetic patients
97.20
2.80
Q9
Blurry vision occurs in diabetic patients
92.07
7.93
Q10
Slow healing of cuts and wounds occurs in diabetic patient
95.80
4.20
Q11
Numbness of hands and feet occurs in diabetic patient
92.31
7.69
Q12
Excessive Sugar intake increases the chances of developing diabetes
88.81
11.19
Q13
Sedentary life styles increase the chances of developing diabetes
92.07
7.93
Q14
Fatty food intake increases the chances of developing diabetes
85.08
14.92
Q15
Obesity increases the chances of developing diabetes
97.44
2.56
Q16
High blood pressure increases the chances of developing diabetes
81.12
18.88
Q17
Family history of diabetes increases the chances of developing diabetes
94.87
5.13
Q18
Being above 45 years old, increases the chances of developing diabetes
90.91
9.09
Q19
Race/ethnicity increases the chances of developing diabetes
29.37
70.63
Q20
Uncontrolled diabetes may cause eye problems (retinopathy)
92.31
7.69
Q21
Uncontrolled diabetes may cause cardiovascular diseases
91.61
8.39
Q22
Uncontrolled diabetes may cause nerve damage (neuropathy)
88.81
11.19
Q23
Uncontrolled diabetes may cause kidney damage (nephropathy)
89.51
10.49
Q24
Uncontrolled diabetes may cause diabetic foot (gangrene)
92.54
7.46
Q25
Uncontrolled diabetes may increase the chances of recurrent infections
93.94
6.06
Q26
Uncontrolled diabetes may cause psychological problems
89.74
10.26
Q27
Uncontrolled diabetes may cause erectile dysfunction/ low libido
93.01
6.99
Q28
A urine glucose test is helpful in diagnosis of type 2 diabetes
95.34
4.66
Q29
A blood sugar test is helpful in diagnosis of type 2 diabetes
96.74
3.26
Q30
HbA1c test is a better monitoring index of blood glucose fluctuations
96.27
3.73
Q31
Fasting blood sugar level above 125 mg/dL suggest diabetes
86.01
13.99
Q32
Random blood sugar level of 200 mg/dL or higher suggest diabetes
89.04
10.96
Q33
Balanced diet and exercise are the preferred treatment for type 2 diabetes
96.04
3.96
Q34
Oral hypoglycemic drugs are used for the treatment of type 2 diabetes
36.36
63.64
Q35
Insulin is used for the treatment of diabetes
93.01
6.99
Q36
Increased physical exercise decreases the chances of developing diabetes
96.04
3.96
Q37
Weight reduction in overweight individuals decreases the risk of developing diabetes
96.74
3.26
Q38
Quitting tobacco decreases the chances of developing diabetes
84.38
15.62
Q39
Quitting alcohol decreases the chances of developing diabetes
91.38
8.62
Q40
Increased intake of vegetable decreases the chances of developing diabetes
91.14
8.86
Q41
Reducing intake of sugary food decreases the chances of developing diabetes
92.31
7.69
Q42
Reduced carbohydrate intake decreases the chances of developing diabetes
91.61
8.39
Q43
Eating low fat food decreases the chances of developing diabetes
86.01
13.99
Q44
Reduced total calorie intake decreases the chances of developing diabetes
86.71
13.29
Q45
If one is going to be diabetic (prediabetic), there is not much he can do about it
13.29
86.71
Q46
People who make a good effort to control the risk of developing diabetes are less
likely to develop diabetes
92.31
7.69
Q47
If people don't change their lifestyle, such as diet and exercise, they are at a risk
of developing diabetes over the next 10 years
93.94
6.06
Note: Questions with a lower percentage of “Correct” answers are highlighted in bold.
Most participants recognized that diabetes is preventable (96.27%) but not curable
(76.79%). However, a large majority (86.71%) responded negatively (“No”) to the notion
that prediabetes is reversible or that no preventive measures can be taken for individuals
with prediabetes.
Participants correctly identified common symptoms of diabetes, including frequent
urination (97.2%), slow wound healing (95.8%), and excessive thirst (91.1%). Conversely,
only 27.74% of participants were aware that excessive eating is also frequently linked
to diabetes.
Participants demonstrate strong awareness of key risk factors for diabetes, including
obesity (97.44%), family history (94.87%), and age (90.91%). However, knowledge about
ethnicity as a contributing risk factor was notably lower, with only 29.37% recognizing
its relevance. Understanding of insulin as a treatment for diabetes was high (93.01%),
yet a significant portion of participants (63.64%) was unfamiliar with the role of
oral hypoglycemic medications in diabetes management.
Several variables were found to be associated with participant's responses to the
diabetes knowledge questions. For example, the determination of whether diabetes is
characterized by high blood glucose (Q1) was influenced by students' sources of information
and their eating habits. Those who had received education through targeted programs
and maintained healthy eating pattern were more likely to answer Q1 correctly.
Most students responded negatively to the question regarding excessive eating occurs
in patients with diabetes (Q3). Students who obtained information from books and magazines
were significantly more likely to respond affirmatively to the question than those
who did not consult these sources. Age also played a role. Students over 20 years
old were more likely to believe that diabetes could be treated compared with younger
students. .
For Q4, both gender and source of information showed negative correlations. Students
whose primary source of information about type 2 diabetes was social education programs
were more likely to answer this question incorrectly. Similarly, male students were
more likely than females to respond incorrectly. Comparable patterns were observed
across many of the remaining 45 diabetes knowledge questions.
[Table 3 ] contains the results from the logistic regressions applied to each of the 47 questions,
the regression coefficients, their associated p -values, the odds ratio (OR), and the relevant 95% confidence interval for the OR.
Table 3
Demographic questions corresponding to each item assessing diabetes-related knowledge
Question
Demographic variables statistically associated to the question
Estimate
p -Value
OR
95% CI for OR
Q1
My main source of information about type 2 diabetes is from social awareness programs
0.556
0.012
1.743
1.132
2.684
Are you maintaining healthy diet?
0.616
0.034
1.852
1.049
3.268
Q2
Height
0.09
0.006
1.094
1.026
1.166
Does any of your family member or relative has/had diabetes mellitus?
1.449
0.007
4.26
1.495
12.14
Q3
Age:
0.992
0.007
2.697
1.304
5.577
My main source of information about type 2 diabetes are newspaper, books, and magazines
0.598
0.016
1.819
1.115
2.967
Q4
My main source of information about type 2 diabetes is from social awareness programs
–0.773
0.028
0.461
0.231
0.922
Gender: Male
–0.83
0.045
0.436
0.194
0.98
Q5
My main source of information about type 2 diabetes is from the awareness given in
the schools
–0.789
0.004
0.454
0.266
0.775
Age
1.288
0.084
3.627
0.841
15.636
My main source of information about type 2 diabetes are scientific lectures and seminars
0.565
0.054
1.759
0.99
3.123
Q6
Gender: Male
–0.811
0
0.444
0.284
0.695
Do you suffer from diabetes mellitus?
2.439
0.027
11.462
1.328
98.947
Year of study
0.499
0.028
1.646
1.056
2.568
My main source of information about type 2 diabetes is from social awareness programs
0.482
0.033
1.619
1.039
2.521
Q7[a ]
Q8
My main source of information about type 2 diabetes is from social awareness programs
–1.296
0.054
0.274
0.073
1.025
Q9
Gender: Male
–1.877
0.002
0.153
0.046
0.509
Q10[a ]
Q11[a ]
Q12
My main source of information about type 2 diabetes is social media
0.777
0.013
2.175
1.177
4.018
Gender: Male
0.623
0.045
1.865
1.015
3.429
Q13
Age
–1.67
0
0.188
0.078
0.455
Gender: Male
0.998
0.007
2.713
1.308
5.625
Q14
You are currently a:
–0.56
0.04
0.571
0.335
0.974
Q15
Age
–2.021
0.003
0.132
0.035
0.508
Do you suffer from diabetes mellitus?
–2.946
0.002
0.053
0.008
0.349
Q16[a ]
Q17[a ]
Q18
Age
–1.079
0.02
0.34
0.137
0.842
Q19
My main source of information about type 2 diabetes are scientific lectures and seminars
0.551
0.011
1.735
1.136
2.65
Q20
Does any of your family member or relative has/had diabetes mellitus?
0.916
0.02
2.5
1.157
5.402
Q21
Gender: Male
0.736
0.035
2.088
1.051
4.149
Q22
My main source of information about type 2 diabetes are my friends and relatives
1.624
0
5.073
2.653
9.699
My main source of information about type 2 diabetes is from the awareness given in
the schools
–1.044
0.002
0.352
0.184
0.674
You are currently a:
–0.674
0.038
0.51
0.27
0.963
Q23
You are currently a:
–0.712
0.025
0.491
0.263
0.915
Q24
My main source of information about type 2 diabetes are scientific lectures and seminars
–0.826
0.026
0.438
0.211
0.907
Q25
Weight
0.029
0.032
1.03
1.003
1.058
My main source of information about type 2 diabetes is from social awareness programs
–0.85
0.046
0.428
0.185
0.987
Q26[a ]
Q27
Does any of your family member or relative has/had diabetes mellitus?
–1.92
0.061
0.147
0.02
1.093
Q28
Weight
0.027
0.074
1.028
0.997
1.059
Q29
Does any of your family member or relative has/had diabetes mellitus?
1.355
0.016
3.876
1.287
11.674
Height
0.066
0.045
1.068
1.002
1.139
Q30
My main source of information about type 2 diabetes are scientific lectures and seminars
–1.062
0.044
0.346
0.123
0.97
Q31[a ]
Q32
Does any of your family member or relative has/had diabetes mellitus?
–1.26
0.039
0.284
0.086
0.939
Q33[a ]
Q34
Gender: Male
–1.212
0
0.298
0.186
0.477
My main source of information about type 2 diabetes are scientific lectures and seminars
0.661
0.002
1.937
1.274
2.946
Weight
0.013
0.023
1.013
1.002
1.024
Q35
Are you engaged in any physical exercises (150 min/week)?
1.083
0.031
2.953
1.103
7.905
Gender: Male
–0.906
0.054
0.404
0.161
1.016
Q36[a ]
Q37
Weight
0.055
0.016
1.057
1.01
1.105
Q38
My main source of information about type 2 diabetes are scientific lectures and seminars
–0.573
0.032
0.564
0.333
0.953
Q39
You are currently a:
–0.712
0.042
0.491
0.247
0.974
My main source of information about type 2 diabetes is social media
0.726
0.039
2.067
1.039
4.11
Q40
Weight
–0.018
0.015
0.983
0.969
0.997
Q41[a ]
Q42
Age
16.266
0.988
Inf
0
Inf
Q43
Age
1.681
0.102
5.373
0.718
40.196
My main source of information about type 2 diabetes are newspaper, books and magazines
0.729
0.056
2.072
0.981
4.375
Q44
Age
1.696
0.098
5.451
0.731
40.661
Q45
My main source of information about type 2 diabetes are newspaper, books and magazines
1.137
0
3.119
1.709
5.691
My main source of information about type 2 diabetes is from social awareness programs
1.101
0.001
3.006
1.614
5.599
Are you engaged in any physical exercises?
–1.01
0.007
0.364
0.174
0.763
Are you maintaining healthy eating?
0.89
0.015
2.434
1.186
4.996
Q46
Weight
0.031
0.012
1.032
1.007
1.057
Q47[a ]
Abbreviations: CI, confidence interval; OR, odds ratio.
a No demographic variable was found to be statistically significantly associated with
it.
Several knowledge questions were found to be interrelated. [Fig. 1 ] shows the network analysis of these questions, where each question is represented
by an ellipse within the diagram. For example, questions 7 and 24 are linked to question
11, which in turn is connected to questions 21. In contrast, questions 1, 5, 10, 18,
and 35 are not connected to any other questions and thus appear isolated within the
network.
Fig. 1 Bayesian network of the 48 questions of interest.
The arrows indicate the direction of the relationships; however, these should be interpreted
with caution, as the analysis is exploratory and not based on expert knowledge. At
this stage, it is more meaningful to focus on the presence of relationships between
questions rather than the direction of those relationships.
Discussion
To address the global type 2 diabetes epidemic,[14 ] this study assessed preprofessional health science students' (premedical, predental,
prepharmacy, and preapplied medical science) knowledge of the disease. A total of
429 students participated, where majority of whom were aged 20 years or younger. Overall,
the findings revealed a satisfactory level of general knowledge about type 2 diabetes.
.
Questions related to diabetes prevention and the potential for a cure received the
highest percentage of accurate responses, with prevention scoring slightly higher.
Although most students responded accurately, a few minor gaps in knowledge were identified.
Specifically, students exhibited limited awareness regarding the association between
diabetes and eating disorders, the influence of ethnicity on diabetes prevalence,
and the role of oral hypoglycemic agents in diabetes management. Students' sources
of information, as well as their dietary habits and physical activity, appeared to
influence the quality and accuracy of their diabetes knowledge.
It is commonly assumed that students of health sciences possess substantial knowledge
about health-related matters, leading others to seek their advice, even though these
students are still in training.
The questions on diabetes prevention received the highest proportion of affirmative
responses, closely followed by those concerning the potential for curing diabetes.
The results of this study align with previous findings. A study conducted in the United
Arab Emirates reported that college students had a good knowledge of diabetes prevention,[5 ] while a study in China similarly showed high correct responses rates on prevention-related
questions.[6 ]
The prevalence of diabetes among the adolescent population in Saudi Arabia has increased
significantly over the past two decades.[15 ] One way to reduce this prevalence is through education about risk factors and prevention
strategies. Over the past decade, various public health campaigns have been launched
in Saudi Arabia to counter the diabetes epidemic.[15 ]
[16 ] Although this study did not directly evaluate the impact of these initiatives, it
is possible that they contributed to students' awareness of diabetes prevention.
In this study, deficiencies in knowledge about type 2 diabetes were identified in
the study population. First, students did not recognize ethnicity as a significant
factor influencing diabetes occurrence. Lifestyle and environmental factors are likely
the main drivers of this trend. However, published literature indicates that diabetes
risk varies by ethnicity.[17 ] Arab populations, particularly in Middle Eastern countries, show some of the highest
projected increases in diabetes worldwide, with prevalence expected to rise by more
than 90%.[18 ] It is therefore important to incorporate information on the role of ethnicity into
diabetes educational programs in Saudi Arabia, both to improve students understanding
and to reduce the risk of diabetes in the population.
Students also reported a lack of knowledge about diabetes treatment. While most were
aware of insulin therapy, they showed insufficient understanding of oral antidiabetic
medications. This may arise from difficulty differentiating between type 1 and type
2 diabetes and their respective treatment strategies. This finding is concerning given
that students had received introductory lectures on diabetes as part of their preprofessional
education. Our findings suggest that the material was not covered in sufficient depth,
or students did not engage adequately with the content. Both possibilities highlight
the need for curricular reinforcement to ensure students acquire a solid understanding
of diabetes management. One of the most important findings of this study is that the
source of information significantly influences both the level of knowledge and the
accuracy of information regarding diabetes. For example, students who relied primarily
on social education programs were more likely to give incorrect answers. While social
education programs can be effective if based on sound evidence, many campaigns particularly
those shared online contain unverified or outdated content. Such programs may fail
to achieve their objectives and, in some cases, may disseminate misinformation.
To address this, there is a clear need for expert-driven, evidences-based health campaigns.
In Saudi Arabia, health care professionals are highly trusted source of medical advice,[19 ] and their involvement in educational initiatives could improve campaign effectiveness
and credibility.[20 ]
Limitations
The findings of this study should be interpreted in light of some limitations. First,
the sample was restricted to students from a single college, which may limit the generalizability
of results. Second, the relatively large number of knowledge questions compared to
other studies,[5 ]
[6 ]
[7 ] which may have increased the students' cognitive load. Third, because the questionnaire
was self-administered, it is unclear whether all participants fully comprehended or
correctly interpreted the questions. Finally, the correlations between knowledge questions
identified through Bayesian network analysis should be considered exploratory and
do not imply a causal relationship.
Conclusion
This study shows that health science students generally possess a satisfactory level
of knowledge regarding type 2 diabetes, particularly in relation to its prevention.
However, notable gaps remain, especially regarding the role of ethnicity in diabetes
risk, the use of oral medications in diabetes treatment, and the association between
diabetes and eating disorder. These findings point to areas where curricular enhancement
is needed to ensure that students are adequately informed about the nature of diabetes
management. The study also highlights the influence of information sources on student
knowledge, with those relying on unregulated social educational programs more likely
to provide inaccurate responses, emphasizing the importance of expert-led, evidence-based
public health initiatives, especially in the era of social media. .
Given the rising prevalence of diabetes in Saudi Arabia, and the high level of public
trust in health care professionals, it is crucial to equip future health care professionals
with comprehensive and accurate knowledge of the disease. While this study offers
valuable insights, the limitations noted should be kept in mind when interpreting
the results.
