Knowledge, Attitude, practice, and their associated factor towards Diabetes Mellitus among peoples live in Debre Markos Town, North West Ethiopia, Amhara Regional State, Ethiopia 2020 GC

Background: Diabetes mellitus is a group of metabolic disease in which there is high blood glucose level over a prolonged period of time, chronic multi system disease related to abnormal insulin production, impaired insulin utilization and both. Risk of diabetes are obesity, being young or old age, family history of diabetes, history gestational diabetes, impaired, glucose metabolism, physical inactivity and ethnicity/race respectively. In type one diabetes mellitus insulin injection is needed to control the blood glucose level where as in type two diabetes mellitus the rst line treatment is life style modication like diet management, exercise, and weight reduction then if uncontrolled use oral hypoglycemic agent. Objective: The main aim of the study was to assess Knowledge, Attitude, practice and their associated factor towards diabetes mellitus in Debre Markos town, northwest , Amhara Regional state, Ethiopia 2020 GC. Methodology: a community based cross-sectional study was conduct from June to July for 403 respondents using systematic random sampling technique to select the household after select the rst household by lottery method. Data collected through self administered questions, the collected data process and analysis manually using pen, pencil, tally sheet and present in tables, graphs and charts respectively. Result: based on our study 138 (34.6%) of the respondents were classied as having inadequate knowledge, whereas 261(65.4%) of the respondents were deemed to be knowledgeable. from the participant 186(46.6%) had unfavorable attitude while 213(53.4%) had favorable attitude towards diabetes mellitus. Overall practice of the participant was 37.8% good practice and 62.2% poor practice. Single individuals 5.133 times (AOR=5.133, CI=1.737, 15.051) more likely knowledgeable than those divorced. Family history of diabetes mellitus 5.019 times (AOR=5.02- CI=1.59-15.76) more likely had favorable attitude than those who had no family history of DM. secondary educational level were 2.34 times (AOR=2.34, CI=1.14- 0.78) more likely good practice than those with able to read and write and persons in primary educational level. DM patients 2.811


Background
Diabetes mellitus is a group of metabolic disease in which there is high blood glucose level over a prolonged period of time, chronic multi system disease related to abnormal insulin production, impaired insulin utilization and both. Diabetes mellitus is a serious Health problem throughout the world and its prevalence is increase rapidly. Currently in the united states an estimated 25.8 million people or 8.3% of total population have diabetes mellitus and 79 million more people are pre-diabetes. Diabetes is commonly classi ed as type one and type two diabetes mellitus which contains 5-10% and 90-95%of all diabetes [1].
In 2014 the international diabetes federation (IDF) reported that 387 million and 22 million adults had diabetes world and Africa respectively. While according to 2015 international diabetes federation 415 million people worldwide or 8.8% of adult aged 20-79 years, if this trend continue by 2040 some 460 million people (one in ten) will have diabetes worldwide( [2,3]. In 2015 IDF estimates that in the Africa region 14.2 million adult aged from 20-79 years had diabetes representing a prevalence of 3.2%. The region has also the highest proportion of previously undiagnosed diabetes over two thirds of people with diabetes being unaware they have the disease. Ethiopia is among the top four countries with the highest adult diabetic population in sub-Saharan Africa [3]. In this study we were investigated the knowledge, attitude, practice and their associated factor towards diabetes mellitus. the main problems of this study was poor knowledge, attitude and practice regarding to diabetes management, symptoms, complication, risk factors prevention and control modalities of diabetes mellitus. Considerable limited knowledge, attitude, and practice and practice about diabetes particularly diabetes symptom and risk factor this is related to awareness towards diabetes is low [4]. The factors that affect the knowledge, attitude and practices towards diabetes mellitus like socioeconomic characteristic, socio-demographic characteristics educational status and DM status. The global prevalence of diabetes greater than18year was 4.7% in 2014 [5].
Many studies generate deferent results related to associate factor with KAP about DM, but still there are gaps KAP related to DM and the factor in uences the prevention, therapy and control of diabetes mellitus among Ethiopia country. Now a day's chronic non communicable disease like diabetes mellitus became a common problem in developing country like Ethiopia. Educational status, family income, and family history of DM are the factor associated with knowledge, attitude, and practice. In our study we would study about knowledge, attitude, practice and their associated factor towards diabetes mellitus in Debre Markos Town to know the level of knowledge, attitude, practice and the factors that affect DM prevention and management.
This study shows that the awareness and knowledge about diabetes mellitus can have a positive in uence to attitude and practice of peoples toward diabetes mellitus, so this will be lead to good management and control of diabetes mellitus. while there is a gap in attitude, knowledge and practice towards DM management, prevention, control, sign and symptom, complication and also the risk factor , this cannot allow DM patient and care giver to implement the intervention and also those none Diabetic patients cannot prevent them from diabetes mellitus. Knowledge is important for device to prevent diabetes complication, their risk factor and also pharmacological and non-pharmacological management of diabetes mellitus. This study was assessing knowledge gap and also association of knowledge, practice, and attitude in diabetes mellitus in Debre Markos town.

Methods And Materials
Study area and setting Community based cross sectional study was conducted at DMRH. Debre Markos is a capital city of East Gojam Zone. It is 299 km away from Addis Ababa capital city of Ethiopia and 265 km from Bahir Dar the capital city of Amhara regional state. Debre Markos town consists of 7 Keble's. It has 105326 populations, of which 50337 are male and 54784are females. In Debre Markos town, there are 20KG, 23 primary school, 3 high schools, 2 preparatory, 20 different colleges and one University. It has also1 referral hospital, 4 health center, 20 private pharmacies, 9Private clinic, 2 diagnostic laboratory, and 13 traditional healers, which are from different professional expertise. The study was conduct in Debre Markos town form may 2020G.C to July 2020G.C.

Operational de nition
Knowledgeable -Those participants who answered greater than or equal to the mean of knowledge related questions correctly considered as knowledgeable.
Inadequate knowledge-Those participants who answered less than or equal to the mean score of knowledge related question will be considered as Inadequate knowledge.
Favorable attitude-Those participants who were positively worded and scored points more than the mean in the attitude questionnaire considered as favorable attitude.
Unfavorable attitude-Those participants who were negatively worded and scored points less than the mean in the attitude questionnaire considered to be unfavorable attitude.
Good practice-participants who answered the mean or above the mean score of practice related questions will be considered as good practice.
Poor practice-the respondents who answered below the mean score of practice related questions considered as poor practice.

Sample size and sampling technique
Sample size determination The sample size for this study was calculated using the single population proportion formula: ni = Where n = sample size (the desired sample size) Z α/2 = standard normal deviation, set at 1.96, to correspond to the 95% con dence interval. p= Good knowledge of diabetes 49% (0.49) taken from study done in Debre Tabor (16) q = 1.0-p d = margin of error/an absolute precision = 5% = 0.05 ni = (1.96)2 (0.49) (1-0.49)/(0.05)2 = 384 By considering 5% non-response rate; the total nal sample size was 403.
Debre Markos town administration was selected to our study. First by using lottery method two Keble: kebele02 and 06 will be select which represent the town. Then systematic random sampling technique was used to get the households after selection of the rst house through lottery method. The interval K value will determine by dividing the number of household (N) by the desired sample size (n).K=N/n since we collect data from two Kebles was used population proportion allocation formula.

Were
K1=Keble 02 k value K2=kebele06 k value n= total sample size N1=kebele02 total household Nt =total household of kebele02 and06 After dividing the town in to kebeles and among seven kebeles; kebele 02 and 06 was selected by lottery method which represents the town. From the selected kebeles 186 households select from kebele 02 and 217 households from kebele06 by using population allocation formula. After this, respondents were selected at every 9 th interval, whereas the rst respondent was select by lottery method, then continuing to every 9 th respondent until the desired sample size was attained.

Data collection technique and procedure
The data was collected by using structured and standard questions. The questions were developed by reviewing pervious literature about Diabetes Mellitus related to knowledge, attitude, practice and their associated factor. Self-administered questions were used to collect data; the questionnaire consists of socio demographic situation like sex, age, marital status, family history of DM, educational status, level of income, and residency. Diabetic related knowledge like symptoms of DM, risk of DM, and complication of DM. Attitude towards diabetes and individuals practice related to the disease diabetes.

Statistical analysis
After data collection complete, data being entered into epi-data 3.2 and transform to version 25 Statistical packages for the social science (SPSS) for analysis. Then binary logistic regression analysis was used to see the independent variable effect of predicators on the dependent variable and predicates with Pvalue at 95% CI and Bivariable binary logistic regression was considered as signi cant at P-value ≤0.25 were entered in multiple logistic regression analysis model to identify the nal predicator knowledge, attitude and practice level after controlling other independent variable. Odds ratio and 95%con dence interval was calculated p≤0.05 was considered statistically signi cant I multivariable logistic regression.
Mean score of knowledge, attitude and practice was calculated. To calculate mean score of knowledge participants answered yes was considered correctly answered, No consider as incorrectly answer the mean score of knowledge were 5. The same technique also use for practice as knowledge the mean score was 5. Liker's scale was used to classify poor and good attitude set as strongly agree1, agree2, neutral3, disagree4 and strongly disagree5, the mean score was 19. After data analysis was complete the result was present in percent, frequency tables and gures respectively.

Ethical consideration
The study was carried out after getting approval from Debre Markos University College of health science research and ethical review committee. All the study participants were informing about the purpose of the study and their right to refuse and con dentiality was maintained. Birr. Increase level of education highly signi cant with good attitude secondary and above school level 0.39 times (AOR=0.39, COR=0.21, 0.74) more likely good knowledge than those who below secondary educational level(table6).

Factors associated with practice
Educational status, DM status and knowledge were signi cant association with practice in the multivariate logistic regression analysis:-persons who were in secondary educational level were 2.338 times (AOR=2.33, CI=1.14, 0.78) more likely practice than those with able to read and write and persons in primary educational level. DM patients 2.811 times (AOR=2.81, CI=0.99, 7.97) highly practice than those who were non diabetic one respectively. Those who had inadequate knowledge about DM were 0.54 times less likely practice than those knowledgeable (table7).

Discussion
Current study showed that 65.4% of the respondents were knowledgeable about DM. these is higher than a study done in Pakistan54% [6], Nigeria34.1% [7], Kenya 27.2% [8], Debre Tabor49% [9], Felegehiwot hospital Bahir-Dar 49.8% [10] and Ambo [11] respectively. The difference might be due to those studies done in rural area in addition to urban community. Whereas it is relatively low compare with a study done in Saudi-Arabia which was 75% were knowledgeable [12]. These may be due to less participation of media and limited organized diabetes education. To knowledge of participants about DM symptoms the participant high rate which is frequent urination (52.6%), excessive thirsty (48.4%) and excessive hanger (38.3%) were symptoms of diabetes mellitus. These is relatively consistent with a study done in Debre Tabor which was frequent thirsty (48%), frequent urination (44.7% [9]. where as relatively low to a study done in Bale zone which was excessive hanger (79.6%) [13]. The difference may be due to inadequate level of information, and limited source of information.
In this study, overweight (36.1%), poor diet habit (57.6%) pregnancy 26.8% and age 29.1%were risk factors of Diabetes Mellitus. This supported by study done in Debre Tabor overweight 35.9%, pregnancy 21.9% and age 26%were risk factor of DM whereas higher regarding to dietary style33.7%, respectively [9]. Regarding to controlling and management modality of DM 32.8% of the participants were stated that use insulin injection to control DM, these is relatively low with similar study done in bale zone which was70% [13].
Regarding to complication of DM eye problem40.1%, renal 37.1% and heart problem32.6% were complication of DM. This showed that relatively low compared with studies in Bale zone Ethiopia eye problem43.9% and heart failure39.2% rated by the respondent [7]. The difference may be inadequate level of information, limited source of information and low involvement of media. In this study attitude of the study participant were53.4% with mean score of 19.This showed that higher as compared with a studies done in pakistan28 % [6], Saudi arbia46 % [12], kenya49% [8] and Debre Tabor 39.5 % [9]. These are because of time, attitude of community changes time to time. 37.8.% of the participant strongly agree with do you agree to examine for diabetes mellitus these is relatively low with a study done in Bale zone which rates 44% of the participants strongly agree to examine their blood glucose level [13]. In this study showed that 53.4% of the participant was favorable attitude. These is relatively high compare with Study done in Sri Lanka 12% of the study participant were good attitude [14].
According to practice of our study was 37.8% good practice while 62.2% of the participant were poor practice, these is consistent with a study done in Felegehiwot hospital 36.8 % [10]. Based on our nding 64.9% Of the participant consumed fatty food,(31.6%) of the participant did physical exercise and 72.7% of the study participant not check their blood glucose level, relative to other study the habit of consume fatty food is high in our study while habit of physical exercise was law and blood glucose checking practice was low. when compare with study done in Bale zone38.2% consume fatty food, and31.8% did physical exercise 41% of the participant not check there blood glucose [13]. 30% study participants in Sri Lanka were had habit of check there blood glucose level [14], compare with our study were 27.3% and low blood checking practice habit. 31.6% of the participant were had practice physical exercise these is high regarding to a cross-sectional study conducted in Sri Lanka was 20 % [14].
In this study knowledge of the participant highly associated with marital status, practice and income at p=0.003, 0.005 and 0.002 respectively these showed that consistent relative to other studies done Saudi Arabia [12] about diabetes mellitus revealed that knowledge strongly associated with marital status, location, DM status and level of income. Attitude of respondents highly associated with family history of DM, age and educational status and consist with other studies done in Egypt [15]. Educational status was highly signi cant with P=0.02 with good practice towards DM. practice was also signi cantly associated with level of education, location, DM status, knowledge and attitude. It is consistent Compared with other study conducted in Feleghiwot hospital about diabetes mellitus showed that lower age and high level of educational status was signi cantly associated good practice [10].

Conclusion
As reported in this study majority of the participant's relatively knowledgeable on diabetes but there is also still inadequate knowledge regarding to some aspects of DM. there were a gap in risk factor and management of diabetes. Attitude of the participant towards diabetes mellitus were relatively favorable. And most of the participants not perceived that DM is curable while some participants considered as DM is curable. Majority of the study participants were poor practice regarding to DM controlling and management. Knowledge of the participant high signi cant association with marital status income and practice, practice also strong association with level of education and attitude strongly associated with family history of DM. Therefore these study used as baseline for the national diabetes awareness campaign and modify the approach towards education on DM give more emphasis to change their attitude increase practice to control diabetes, especially for the study area. Debre Markos town health administration o ce bitter to give emphasis on non-communicable disease like DM by create awareness at community level and rise community awareness about DM, controlling and risk factors especially to increase their positive practice to reduce risk of DM. Debre Markos Town administration o ce should work with collaboration of other health centers and prepare campaign and give health education about prevention, sign and symptom, risk factors and complication of DM at school level, at community by using lea ets, banners and posters. Debre Markos health Science College also gives its concern for that non-communicable disease like DM especially at study area. Researchers to give emphasize on DM to by assess at community level Strength and Limitation of the study Strength of the study was using SPSS to analysis data and calculates mean, median association and other descriptive statistics and use community based data collection which can represent the community.
The main limitation of our study was using self-administration questions these may be lead to miss understanding of questions and leads to false felling of the questions and those illiterate persons not included. On the other hand like other descriptive cross-sectional studies this study cannot detect cause and effect relationship, we cannot also assess homelessness and street peoples.