Diabetes is a chronic disease with different levels of complications that requires broad knowledge and management [22]. Unfortunately, like some studies in Africa [23] and the Middle East [24, 25], this study reveals poor diabetes knowledge, suggesting a need for interventions to improve understanding of the condition among diabetic patients. However, past work with mixed results exists, with some studies reporting lower results similar to ours [1, 26], but others reported higher levels of diabetes knowledge among patients with diabetes [27, 28]. It is difficult to compare our results with others, as these studies used different instruments or were carried out among different ethnic or age groups. Specifically, in this study, patients could generally define diabetes and were able to indicate its risk factors, signs, and symptoms, as well as strategies to control the disease and its complications, as previously observed in Cotonou [14]. However, a shallow frequency was noted on diabetes as a condition of insufficient insulin production, hypoglycemia symptoms, healthy blood sugar level, the importance of hemoglobin A1C, and correct foot care as well as the relationship between physical activity, heart failure, and diabetes. These findings highlight the need to improve the quality of care that can ultimately result in reduced morbidity.
In the case of diabetes attitude, we found a poor level of attitude compared to studies from South India and the United Arab Emirates, which reported a more positive attitude among patients with diabetes [29, 30]. Our results were similar to Anderson et al.’s study in the US [31], where most respondents firmly stated that diabetes had a significant negative influence on their life. This finding suggests that diabetes and its complications detract significantly from the quality of life for most patients in the surveyed community. Most respondents in our study agreed that health care professionals should have specialized training to care for diabetic patients, as recommended by Pastakia et al. [32]. They were also supportive of patients being in charge of their diabetes management, consistent with the traditional view of the doctor-patient relationship [33]. However, this belief may be counterproductive in the surveyed community as the management of diabetes requires daily self-management behaviors (e.g., self-monitoring of blood glucose) and frequent decisions about medication, diet, and activity levels. Indeed, most patients believe they should be in charge of their diabetes management, but they are not actually managing it well on their own, and they go to the doctor infrequently, so they do not realize it, or get help with it.
Surprisingly, most of the respondents did not view diabetes as a severe disease, probably due to their belief that people who do not take insulin to treat their diabetes have mild disease. Another possible explanation is the perception of diabetes patients who attributed the occurrence of diabetes to witchcraft or bewitchment in Cotonou [14]. Patients’ belief about the severity of diabetes has important implications for patient education because diabetes control requires long-lasting and challenging behavior changes. Such changes are unlikely sustainable unless patients understand and accept the severe nature of the disease. It will be crucial for health care professionals to strike a balance between false reassurance of insulin-dependent diabetes and unnecessary fear when discussing noninsulin-dependent diabetes with patients. Moreover, most respondents did not believe in the relationship between blood glucose control and complications, although most diabetic patients are encouraged to control their blood glucose to prevent the complications of diabetes. One possible explanation is the fatalistic attitude observed by Al-Sahouri et al. [34]. Because of the multiple possibilities for patients to misunderstand the seriousness of their condition, a holistic approach to diabetes management is needed to assist patients in the region [35].
Although behavior changes and intensive lifestyle interventions are critical components in the management of T2D, the mean score of T2D-related practices was low. This score is part of a more complex picture, however. In our study, 47% and 61% of participants were knowledgeable about the benefits of exercise and healthy diet; however, only 30% reported having a meal plan and exercising every day, suggesting that efforts should be made to close the gap between knowledge and practice. In that same vein, we observed that less than 30% of patients checked their eyes yearly, examined their feet daily, or had their blood sugar checked, and 42% visited a doctor. Similar results were found by Alassani et al. in Cotonou, where difficulties encountered among patients with diabetes were related to physical activity, diet, and glycemic control and observed respectively at 56%, 20%, and 8% of patients [14]. The reasons given were laziness, shame, and fatigue for physical activity, hunger for the diet, and lack of financial means and distance between the residence and the laboratory for glycemic control. This finding suggests complementary education with other interventions such as programs that help coordinate transportation to the laboratory or that send phlebotomists into the community.
Some participants’ bad behaviors and demographic factors associated with increased diabetes-related distress were also observed in the present study. Indeed, control of obesity is essential for better glycemic control and prevention of complications, but it is evident in this study that diabetic subjects do not attain this ideal goal, as 49% are overweight/obese. This finding is in line with studies in Sudan [36] and Tanzania [37]. Another factor of concern is the wrong perception of the majority of the patients to assess their weight. Participants were asked to evaluate their body size, and 64% of overweight patients do not consider themselves to be in that group. Our study also revealed that most patients were diagnosed with T2D after 40, as previously observed in low- and middle-income countries [1], suggesting a need to start screening at an earlier age. Finally, the increased burden of T2D in the region could be explained by the high prevalence of risk factors observed in the present study, such as physical inactivity, smoking, harmful alcohol use, and food habits [11]. There is thus an urgent need to improve education strategies to prevent or delay diabetes-related consequences and hazards.
Similar to studies in Ethiopia [13, 23] and Dhaka [25], our study found significant associations between diabetes-related knowledge with levels of education, marital status, occupation, and duration of the disease. However, contrary to our study, males have a better knowledge of the disease than females in India [38] and Zimbabwe [39]. We also found that marital status, duration of diabetes, and knowledge towards the disease were significantly associated with attitude, as observed in Ethiopia [13, 27] and South Africa [40]. Finally, similar to studies in Ethiopia [13, 27] and South Africa [40], education, duration of diseases, and diabetes knowledge diabetes showed a significant association with practice. Our findings also indicated that diabetes knowledge had the highest percentage score followed by attitude and then practice, suggesting that diabetes knowledge and attitude among patients with diabetes are not reflected in their daily practice, as previously observed in Jordan [29]. However, the fact that good knowledge was significantly associated with attitude and practice indicates that interventions aimed at improving knowledge could benefit patients in more than one way.
To our knowledge, this study is the first to assess KAP levels and associated factors among patients with diabetes seen in Benin's four health centers. However, there are some limitations. First, this study was restricted to one geographic region and cannot generalize results to all patients with diabetes in Benin. Second, this was a cross-sectional survey; therefore, only associations, and not causations, can be determined. Third, socioeconomic status or income is a social determinant of disease outcome, but we could not use it in our study because of incomplete or missing data. Fourth, data of the two sexes reported were not analyzed separately. It is important to note the significant difference in the percentage of female and male participants in the study. Finally, self-reported questionnaires were used for most of the reported measures. Thus, bias may be present due to inaccurate self-reporting, misunderstanding of the questionnaire items, or social desirability.