The study was adherent to the strengthening of the reporting of observational studies in epidemiology (STROBE) statement “see Supplementary File 1”
This study aimed to: (1) to investigate PHC nurses’ level of diabetes-related nutrition knowledge; (2) to assess PHC nurses’ perception about knowledgeability and role in provision of diabetes nutrition education; (3) to explore the relationship between nurses’ diabetes-related nutrition knowledge with nurses’ background and organizational support.
A cross-sectional descriptive correlation research design was undertaken.
This study was conducted in the province of Jazan, which is located in the southern region of Saudi Arabia. Jazan was selected because approximately 74% of diabetic patients in Jazan have been found to have poor glycemic control and a lack of understanding about diabetes management , with increasing in diabetes complications . This province has 173 PHC centers, which provide free curative, preventive, health-promoting, and rehabilitative services. For the purposes of this study, 25 PHC centers, which are located in different neighborhood and have the highest numbers of nurses, were selected.
A convenience sample of 163 nurses who had been working in PHC centers was recruited. The institutional ethics committee of King Saud University and MOH approved this study. Nurses are eligible if they had been working in PHC centers for more than six months and provide direct patient care. A total number of 200 questionnaires were distributed, and 163 were returned resulting in 81.5% completion rate. To determine the required sample size, Sample Size Calculator by Raosoft was used and showed that the required sample size was 163 participants. Rates of item-level missing data were < 1% for all variables. As well, to determine the required sample size for two tails correlation test, G-Power was used with an alpha of 0.05, a power of 0.80, a medium effect size (ρ = .3). The minimum sample size was 82.
In May 2019, the researcher met the head nurses of each PHC center and informed them about the purpose of the study and inclusion criteria and sought their permission to collect data. The nurses were given a copy of the written instructions and objectives of the study. Written informed consent was taken from all the participants. Questionnaires were given to nurses who agreed to take part of the study. After one week, the researcher collected the questionnaires from the nurses. To examine the test-retest reliability of the scale, the assessment was administered a second time (i.e., after one week); 135 participants agreed to complete the assessment a second time, but 28 of them declined the invitation.
Data were collected using self-administered questionnaire. It included three part, first part includes the Nutritional Management of Diabetes Knowledge Test [32, 33]. This 20-item test assesses nurses’ knowledge about diabetes. The questionnaire has five items about diabetes in general, one item about treating a hypoglycemic patient, and 14 items about basic meal planning for diabetic patients. It includes 12 multiple-choice items and eight questions with right and wrong answers. The score can range from 0 to 20, where 20 means the highest level of knowledge. Originally, the questionnaire was developed in accordance with the recommendations of the WHO and Nutrition Guidelines of the ADA with evidence of validity. The questionnaire was tested, according researcher developed it , the survey reviewed by a focus group expert, members of the Drexel nursing faculty and two Certified Diabetes Educators/Registered Dietitians for content validity and clarity. Appropriate changes were made based on the reviewers' feedback. Several questions were eliminated from the survey because they were interpreted differently by reviewers indicating unreliability. The survey was pilot tested with graduate nutrition students who had received similar diabetes education as nursing students. Nutrition students reported that it took approximately 10-15 minutes to complete the survey . This scale has been used in past published studies that have aimed to assess nurses’ knowledge about diabetes and diabetes nutrition [32, 33, 34].
The second part has nine survey questions to assess nurses’ perceived knowledgeability and role about provision of diabetes nutrition education . In the third part, seven survey questions were included to assess the extent to which nurses’ organizations had supported them in their efforts to enhance their knowledge about diabetes nutrition . As well, background questions, such as age, gender, and years of experience were asked.
An integrated method of adapting and translating the measure was used to develop a linguistically and culturally equivalent translation of the instrument . The conceptual equivalence of the adapted scale was assessed by rating the comprehensibility and cultural relevance of each item on a 10-point scale that ranged from not at all to very much . This assessment was undertaken by five bilingual healthcare professionals who were knowledgeable about diabetes and the dietary habits of Saudi individuals. They were required to offer recommendations to modify items. The most items were found to be clear and comprehensible (i.e., comprehensibility scores > 5). Some items were modified to reflect the dietary habits of Saudi individuals. The content validity index was computed. Based on the reviewers’ recommendations, a few items were modified to improve their clarity and cultural relevance. Then, two translators translated the assessment into Arabic. The final pool of items was pilot tested to examine whether the items were clear and easy to understand and estimate the time that would be required to complete it. A convenience sample of 27 nurses was recruited from PHC centers. Items that were found to be unclear were modified and refined. As a part of the main study, the test-retest reliability of the scale was examined to ascertain the level of consistency between repeated measurements. The results of reliability analysis revealed that the scale has excellent test-retest reliability. The intraclass correlation (ICC) coefficients ranged from 0.955 to 0.977 (average = 0.968).
The Statistical Package for Social Sciences (SPSS) version 25 was used to analyze the data. Descriptive statistics (i.e., frequencies, percentages, means, and standard deviations) were computed to describe the sample and the questionnaire items. Both Pearson’s correlation analysis and Spearman’s rank-order correlation analysis were conducted to examine the relationships between nurses’ diabetes-related nutrition knowledge and background characteristics (i.e., age, years of experience, number of nutrition-related courses completed, and counseling patients with diabetes) as well as between nurses’ diabetes-related nutrition knowledge and organizational support (e.g., the availability of time to attend courses on diabetes and read about diabetes at work, being informed about time and venue programmers of diabetes diet)
The institutional ethics committee of King Saud University and MOH approved this study. The nurses were informed that their participation in the study was voluntary and this study was not a “test” or an evaluation. The informed consent form contained the aims of the study. It also included sections that outlined their right to decline or withdraw their participation, the anonymity and confidentiality of their data, and the risks and benefits of participation. The researcher’s contact information was included in the informed consent form so that the participants could contact her regarding any queries. All participant data were anonymized and kept confidential as all participants were assigned identification numbers (IDs).