Table of Contents
Diabetes remains one of the four most prevalent non-communicable diseases (NCDs) in the world (1–3). It results in disability and premature death while creating an increasing burden on health systems, economic development, and the wellbeing of a large proportion of the global population (4). The most common forms of diabetes are type 1 diabetes, in which complete insulin deficiency causes the destruction of the pancreatic beta cells, and type 2 diabetes, in which insulin resistance can lead to hyperglycemia (5–7). Most diabetes cases (up to 95% of diabetic patients) are type 2 diabetes (so-called insulin-independent) (6, 7).
The International Diabetes Federation (IDF) estimates that as of 2021 there were 537 million people with diabetes worldwide, and this was predicted to increase to 783 million by 2045 (8). The incidence of diabetes is more prevalent in highly developed countries, but the highest rate of increase in cases is in developing countries (9). The continuing upward trend is mainly caused by the increase in the number of diabetes patients with type 2 diabetes (10), which is attributed to population growth and aging (39.7%), increased incidence (28.5%), and the interaction of these two factors (31.8%) (11). It is widely believed that the main cause of type 2 diabetes is a high-energy Western-style diet combined with a sedentary lifestyle, which underlines the role of lifestyle as the most important risk factor for type 2 diabetes (12).
Poland is a European Union (EU) member state with a high diabetes burden (13, 14). The prevalence of diabetes in Poland is estimated at 8% of the population (14). The prevalence of diabetes in Poland is significantly higher than in other EU (mean 6.3% of the population), and it is estimated that the prevalence of diabetes in Poland will rise to 11% in 2040 (15).
According to the Polish National Health Fund (a public payer in the universal health insurance system in Poland), most of the patients with diabetes who visited a doctor were females (55.1%), and the average life expectancy of diabetes patients was 15 years lower than the average for the general Polish population (16). Moreover, there are public health concerns about the under diagnosis of diabetes in Poland (14, 17). The COVID-19 pandemic may have a negative impact on the diagnosis of diabetes in Poland, as only 63% of adults in Poland had a blood sugar test during the COVID-19 pandemic (18).
Diabetes prevention, as well as disease management, requires both medications and lifestyle changes (19). Patients diagnosed with diabetes should be actively involved in disease management, as a high level of compliance may significantly in-crease the quality of life and prevent/delay long-term diabetes complications (20). The level of patients’ knowledge of diabetes plays an important role in the self-management of the disease. It is considered that patients with good disease knowledge have a better understanding of the nature and consequences of diabetes and are less prone to various complications and severe exacerbations of diabetes (21, 22). Both Polish and internationally recognized standards for the treatment of diabetes emphasize that all patients should receive diabetes education and self-management training and support (23, 24). In Poland, diabetes screening is carried out as a part of general screening program, without separated program addressed to high-risk populations.
Early detection of diabetes requires both health care practices and patients’ engagement (interest) based on their perception of this disease (individual health literacy level) (25). The level of health literacy affects people’s decisions and actions, which includes the ability to choose and access the appropriate form of health care (26). Thus, public knowledge and awareness of diabetes reduce the gaps in diabetes under diagnosis as well as prevent long-term complications among patients with a diabetes diagnosis. Regular monitoring of public awareness of diabetes is necessary to provide effective educational and preventive strategies.
Therefore, this study aimed to assess (1) public knowledge and awareness of diabetes among adults in Poland, with a particular emphasis on diabetes risk factors, complications, and prevention methods, as well as (2) to identify sociodemographic factors associated with public awareness of diabetes symptoms and risk factors.
This cross-sectional survey was carried out between 24 and 27 June 2022, on a non-probability random quota sample of 1,051 adults in Poland. Data were collected using a dedicated IT system (online panel) developed by the specialized poll company in Poland (The Nationwide Research Panel Ariadna) on behalf of the authors that pro-vide the scientific context of the study (27). A computer-assisted web interview (CAWI) method was used. Respondents were randomly selected from the dataset of 110,000 individual users of the Nationwide Research Panel Ariadna (27). Quota sampling was based on the stratification model (gender; age; place of residence) adjusted to the demographic characteristics of the Polish population according to the reports presented by the Central Statistical Office of the Republic of Poland. A similar research methodology was used in previous studies (28, 29).
The study protocol was reviewed and approved by the Ethical Review Board at the Centre of Postgraduate Medical Education, Warsaw, Poland (No. 70/2022; date of approval: 08 June 2022).
The research tool was a questionnaire developed for the purpose of this study. In preparation for the questionnaire, the previously published studies on diabetes awareness were analyzed. A particular emphasis was given to studies that used Diabetic Knowledge Questionnaire (DKQ24) (30) and Diabetes Knowledge Test (DKT) questionnaire (31). A particular emphasis was given to studies that used Diabetic Knowledge Questionnaire (DKQ24) (30) and Diabetes Knowledge Test (DKT) questionnaire (31). The questionnaire included ten questions related to the awareness of risk factors, symptoms, and complications of diabetes, as well as questions regarding the diagnosis of diabetes by a doctor and the history of diabetes in the family. Questions also addressed the personal characteristics of the respondents.
Respondents were asked about their awareness of the symptoms of diabetes, using the question: “What do you think are the symptoms of diabetes (please select all that apply)?” With ten mutually non-exclusive answers. Respondents were asked to select “yes” or “no” for each answer choice.
Respondents were asked about their awareness of the risk factors for diabetes, using the question: “What do you think are the risk factors for diabetes (please select all that apply)?” With eight mutually non-exclusive answers. Respondents were asked to select “yes” or “no” for each answer choice.
Respondents were asked about their awareness of the diabetes prevention methods, using the question: “What do you think are diabetes prevention methods (please select all that apply)?” With five mutually non-exclusive answers.
Respondents were asked about their awareness of diabetes complications, using the question: “What do you think are diabetes complications (please select all that apply)?” With six mutually non-exclusive answers.
Moreover, respondents were asked about their health status – “Has a doctor ever told you that you have diabetes?” (yes/no). Respondents who said yes, were asked about the type of diabetes diagnosed by a doctor (type 1 diabetes; type 2 diabetes; gestational diabetes; I do not know). Also, a question on the history of diabetes in the family was addressed.
The data were analyzed with SPSS software version 28 (IBM Corp, Armonk, NY, USA). The distribution of categorical variables was shown by frequencies and proportions. Cross-tabulations and chi-squared tests were used to compare categorical variables.
Associations between personal characteristics [(1) gender, (2) age group, (3) having higher education, (4) marital status, (5) having children, (6) place of residence, (7) a number of household members, (8) occupational status, (9) self-reported financial situation, (10) having diabetes, (11) history of diabetes in the family] and awareness of (1) diabetes symptoms and (2) risk factors for diabetes were analyzed using multivariable logistic regression models. The strength of association was measured by the odds ratio (OR) and 95% confidence intervals (95% CI). The level of statistical significance was set at p < 0.05.
Data were obtained from 1,051 individuals aged 18–85 years, 53.3% were females (Table 1). Most of the respondents were married (49.5%), 42.8% had higher education and one-third (32.3%) lived in rural areas. Among the respondents, 10.5% had diabetes. Out of 110 respondents with diabetes, 56.4% had type 2 diabetes, 15.5% had type 1 diabetes, and 11.8% had gestational diabetes. Among the respondents with diabetes, 16.4% were unaware of the type of diabetes they were diagnosed with. Out of all respondents, 43.8% declared that they have a history of diabetes in their family, wherein most of the respondents were not aware of the type of diabetes in their family (21.6% of all the respondents), 19% had a history of type 2 diabetes in the family, 6.5% type 1 diabetes and 1.5% reported gestational diabetes. Characteristics of the study population are presented in Table 1.
Table 1. Characteristics of the study population (n = 1,051).
Most of the respondents declared a moderate (46.3%) level of knowledge of diabetes and only 17.3% of respondents declared rather good or very good knowledge of diabetes (Table 2). Out of 10 symptoms of diabetes analyzed in this study, high blood sugar (80.7%) and chronic fatigue, feeling sleepy during the day (74.6%) were the most recognized symptoms. Most of the respondents (57.4%) were aware that polydipsia is a symptom of diabetes, but only 42% of respondents indicated polyuria as a symptom of diabetes (Table 2). Persistent skin itching (19.7%) and increased risk of infections (22.6%) were the least recognized symptoms of diabetes. Out of 8 diabetes risk factors analyzed in this study, overweight/obesity (80.4%), unhealthy diet (74.1%) and genetic predisposition (69.5%) were the most recognized diabetes risk factors (Table 2). Tobacco use (22.7%) was the least recognized risk factor for diabetes. Approximately three quarters of respondents were aware that limited consumption of carbohydrates (sugars) in the diet (77.1%), weight reduction in overweight or obese people (75.1%) or regular physical activity (73%) are diabetes prevention methods. Diabetic foot was the most recognized diabetes complication (79.8%). More than half of respondents were aware that diabetes may lead to vision problems (56.9%), kidney damage (52.1%) or cardiovascular diseases (50.2%). Details are presented in Table 2.
Table 2. Respondents’ knowledge of diabetes (n = 1,051).
There were statistically significant differences in the percentage of respondents who correctly indicated diabetes symptoms by gender, age, educational level, marital status, having children, and place of residence. Moreover, respondents who were diagnosed with diabetes or those with history of diabetes in the family more often correctly indicated diabetes symptoms (Table 3). There were significant differences (p < 0.05) in the percentage of respondents who correctly indicated diabetes risk factors depending on the gender, age, educational level, having children, number of household members occupational status (Table 4). Those who had diabetes more often indicated overweight/obesity as diabetes risk factors. Moreover, the percentage of respondents who correctly indicated diabetes risk factor was higher among those respondents who had history of diabetes in the family (Table 4).
Table 3. Awareness of diabetes symptoms by sociodemographic factors (n = 1,051).
Table 4. Awareness of risk factors for diabetes by sociodemographic factors (n = 1,051).
In general, the percentage of respondents who correctly indicated diabetes complications was higher among females (Table 5). Moreover, public awareness of diabetes complications increased with the age (Table 5). The percentage of respondents who correctly indicated diabetes complications was higher among those respondents who had higher education (Table 5). Respondents who had children more often indicated vision problems, limb amputation, and diabetic foot as a diabetes complication (p < 0.05). In general, the percentage of respondents who correctly indicated symptoms of diabetes increased with the size of the place of residence (Table 5). There were no statistically significant differences in the percentage of respondents who correctly indicated diabetes complications by self-reported financial situation or number of household members (Table 5). Individuals diagnosed with diabetes or those with a history of diabetes in the family were more aware of diabetes complications (Table 5).
Table 5. Awareness of diabetes complications by sociodemographic factors (n = 1,051).
The percentage of respondents who correctly indicated diabetes prevention methods was higher among females (Table 6). Moreover, public awareness of diabetes prevention methods increased with age and educational level (Table 6). Those who had ever been married as well as those who had children more often correctly indicated diabetes prevention methods. The percentage of respondents who were aware that limited sugar intake and weight reduction in overweight/obese individuals are diabetes prevention methods was higher among those who lived in the largest cities (p < 0.05). Respondents who lived with at least one person more often declared that a limited intake of sugar is a diabetes prevention method (p < 0.05). Moreover, those with passive occupational status more often declared limited sugar intake as a diabetes prevention method (p < 0.05). Individuals diagnosed with diabetes or those with a history of diabetes in the family were more aware of diabetes prevention methods. There were no differences (p > 0.05) in public awareness of diabetes prevention methods de-pending on financial status or having a diagnosis of diabetes.
Table 6. Awareness of diabetes prevention methods by sociodemographic factors (n = 1,051).
Female gender and having higher education were the most important factors associated (p < 0.05) with a higher level of awareness of most of the diabetes symptoms (Table 7). Older respondents were more aware (p < 0.05) that high blood sugar, polyuria, polydipsia, slow-healing wounds, deterioration of vision, and chronic fatigue are the symptoms of diabetes (Table 7). Respondents who lived in cities from 20,000 to 99,999 residents were more likely to indicate unexpected excessive weight loss, numbness/tingling of hands or feet, and persistent skin itching as diabetes symptoms. Respondents who were diagnosed with diabetes were more likely (p < 0.05) to indicate polyuria, polydipsia, unexpected excessive weight loss, deterioration of vision, and numbness/tingling of hands or feet as diabetes symptoms. In general, respondents with a history of diabetes in the family had a higher level of knowledge of diabetes symptoms (Table 7). In the multivariable logistic regression model, there was no influence (p > 0.05) of (1) marital status, (2) having children, (3) number of household members, (4) occupational status, and (5) financial situation on the respondents’ awareness of diabetes symptoms.
Table 7. Factors associated with awareness of diabetes symptoms among adults in Poland (n = 1,051)—multivariable logistic regression model.
Females were more likely (p < 0.05) to indicate overweight/obesity, low physical activity level, unhealthy diet, and genetic predisposition as diabetes risk factors (Table 8). Respondents over 40 years were more likely to indicate overweight/obesity, unhealthy diet, and genetic predisposition as diabetes risk factors (p < 0.05). Respondents with higher education were more aware of diabetes risk factors (p < 0.05). Respondents who had children were more likely to indicate overweight/obesity as a diabetes risk factor (p = 0.04). Respondents who lived alone were less likely to indicate excessive alcohol consumption as a diabetes risk factor (p = 0.02). Occupationally active individuals were more likely to indicate excessive alcohol consumption as a diabetes risk factor (p = 0.03). Respondents with a good financial situation were more likely to indicate overweight/obesity and an unhealthy diet as diabetes risk factors. General, respondents with a history of diabetes in the family had a higher level of knowledge of diabetes symptoms (Table 8). In the multivariable logistic regression model, there was no influence (p > 0.05) of the place of residence and health status (having diabetes) on the respondents’ awareness of diabetes symptoms.
Table 8. Factors associated with awareness of risk factors for diabetes among adults in Poland (n = 1,051)—multivariable logistic regression model.
To the authors’ best knowledge, this is the most up-to-date study on the public awareness of diabetes among adults in Poland. This study revealed a limited level of public awareness of diabetes. The percentage of respondents who declared a lack of knowledge or little knowledge about diabetes was more than double the percentage of respondents who reported having good or rather good knowledge about this disease. Out of 10 symptoms of diabetes analyzed in this study, just half of them were correctly indicated by more than 50% of the respondents. Less than a quarter of respondents were able to point out such symptoms as increased risk of infections and persistent skin itching. Most of the respondents were able to correctly point overweight/obesity, unhealthy diet, and genetic predisposition as risk factors for diabetes, while excessive alcohol consumption, arterial hypertension, and being over 40–45 years old were recognized by less than one-third of respondents. Tobacco use was the least recognized diabetes risk factor. Respondents were also able to correctly identify most of the complications caused by diabetes, as well as preventive measures. Public awareness of selected aspects of diabetes varied by sociodemographic factors, of which gender, age, and educational level were the most important.
According to the review conducted by Gautam and Gupta knowledge is considered a key element in the control of diabetes mellitus epidemics (32). However, data on public awareness of diabetes are limited (33–36). Most recently published articles refer to studies conducted in developing countries such as India (33), Pakistan (34), Jordan (35), and Kenya (36). In contrary to this study, the abovementioned studies were carried out among respondents already diagnosed with diabetes or healthcare workers – not the general population (33–36). In Poland, the most recent available study on public awareness of diabetes was conducted in 2017 by Sobierajski (37). According to a 2017 study, general knowledge about risk factors, symptoms, and complications of diabetes in Poland was low. In 2017, only two (high blood sugar level, feeling sleepy) out of 16 symptoms of diabetes analyzed in the study, two out of 18 complications (diabetic coma, diabetic foot), and one out of 12 risk factors (overweight/obesity) were correctly identified by more than a half of respondents (37). When compared to 2017, findings from our study suggest that the level of public awareness of diabetes in Poland has increased. Nevertheless, significant gaps in public awareness of diabetes in Poland still exist, especially related to awareness of diabetes risk factors.
Awareness of symptoms of diabetes is crucial to early detection of the disease. However, the current study revealed a low level of awareness of major symptoms of diabetes in the general population in Poland. High blood glucose remained the most recognizable symptom of diabetes, as was pointed out by over 80% of respondents. This is a significant change compared to the 2017 study by Sobierajski (37) in which this symptom was identified by 56.5% of respondents. Other symptoms were indicated by a comparable percentage of respondents in 2017 and the current study. High blood glucose was also the most recognized symptom of diabetes indicated in studies carried out in developing countries (33–36). In this study, older respondents (aged 50 and over) were over three times more likely than younger respondents to indicate high blood glucose as a symptom of diabetes. Better knowledge of disease symptoms among older people is contrary to a study by Sørensen et al., who observed a decreasing health literacy with the age (38).
In this study, females, those with higher education, respondents diagnosed with diabetes as well as those with a history of diabetes in the family were more likely to correctly indicate symptoms of diabetes. This observation is in line with the study by Dos Santos et al. (39) (gender differences), and Kim et al. (40), who reported gender and educational differences in the level of public knowledge of diabetes. In this study, marital status, self-reported financial situation, and occupational status had no significant influence on public awareness of symptoms of diabetes. This is contrary to findings by Duplaga, who identified that health literacy in Poland was related to age, marital and vocational status (41).
A healthy lifestyle pattern is a well-known factor associated with decreased risk for diabetes, especially type 2 diabetes (42). Our study showed that knowledge about risk factors of diabetes in Poland is insufficient and unevenly distributed. Most of the respondents were able to point out overweight/obesity, unhealthy diet, and genetic predisposition as diabetes risk factors. Females and respondents over 40 years were significantly (up to three times) more likely to indicate these risk factors than other respondents. Having a higher education also influenced the public awareness of risk factors of diabetes (except for excessive alcohol consumption). As over 25% of Poles aged 15 and over are daily smokers and alcohol dependency remains one of the key problems in Poland, the public awareness of tobacco and alcohol use as a risk factor for diabetes is very limited (28).
Out of 11 different factors analyzed in this study, the number of household members, occupational status, and history of diabetes in the family were significantly associated with a higher level of awareness of excessive alcohol consumption as a diabetes risk factor. The number of household members and educational level were the only factors significantly associated with a higher level of awareness of tobacco smoking as a diabetes risk factor. In this study, a high level of awareness of overweight/obesity and unhealthy diet as a risk factor for diabetes may result from extensive campaigns on di-et-related diseases that were carried out in Poland in recent years (43). We can hypothesize that a low level of awareness of alcohol and tobacco consumption as a risk factor for diabetes may result from a relatively low number of educational campaigns on diabetes risk factors or its limited effectiveness. Particular attention should be paid to males who are at higher risk of substance use and presented a lower level of aware-ness of diabetes risk factors, especially alcohol and tobacco use.
Findings from this study on awareness of diabetes prevention methods reflect the knowledge of respondents about its risk factors. The most recognized diabetes prevention methods were limited consumption of carbohydrates (sugars) in the diet, weight reduction, and regular physical activity. A higher level of awareness of diabetes prevention methods was associated with higher age and educational level, as well as being married and having children.
It is believed that effective diabetes education can minimize the risk of long-term diabetes complications (44). Findings from this study show that only the most visible complications of this disease (diabetes foot, limb amputation) were widely recognized by adults in Poland. This finding corresponds with a high rate of lower limb amputations performed in Poland (approx. 7–8 thousand each year) of which over a half is performed in diabetic patients (1.7 per 1,000 patients diagnosed with diabetes) (45). This study showed a low level of awareness of diabetes-related nephropathy or neuropathy among adults in Poland. This finding underlines the need to increase the level of public awareness of long-term diabetes-related complications, especially those which do not show any visible symptoms for many years. As in the case of risk factors, symptoms, and prevention methods, awareness of diabetes-related complications was significantly associated with female gender, older age, and higher education level.
Out of 11 sociodemographic factors analyzed in this study, gender and education-al level were the most important factors significantly associated with a higher level of general knowledge on diabetes. In this study older age was associated with better knowledge about the disease which is contrary to the study by Sørensen et al. (38). Findings from this study also showed, that having a person with diabetes in the family leads to a better understanding of this condition. We can hypnotize that this is due to a specific character of diabetes – as a chronic disease, that manifests in older age and the patient often requires family support and engagement in disease management. These may supplement, but should not substitute a proper diabetic education, that should be provided as a part of a public health intervention on diabetes. In this study, diagnosis of diabetes had a limited impact on the level of knowledge on diabetes (two out of six questions on complications and none of the questions on prevention methods), so we can hypothesize that the effectiveness of currently available educational activities targeted to patients with diabetes is limited and requires further improvements.
This study has numerous practical implications for public health interventions in Poland. It reveals an insufficient level of public awareness of diabetes, its risk factors, symptoms, and complications, as well as available preventive methods. This finding underlines a need to conduct a nationwide educational campaign on diabetes. Personalized communication should be targeted to younger individuals as well as males without higher education, as these groups were identified as those with the lowest level of awareness of diabetes. Moreover, this study indicates poor quality of education for patients already diagnosed with diabetes in Poland. General practitioners as well as internal medicine specialists and diabetologists should be actively involved in educational activities targeted to patients at higher risk of diabetes. Findings from this study also underline the positive influence of having a family member with diabetes on the level of awareness of diabetes among other family members. The COVID-19 pandemic has a negative impact on diabetes care in Poland (13, 46), so public health interventions aimed to increase the level of public awareness of diabetes are needed to reduce the diabetes burden in Poland. Further studies should analyze the impact of the health system and diabetes education provided by healthcare workers on public awareness of diabetes.
This study has some limitations. The study was carried out using the CAWI re-search method, which excludes the direct interaction of the interviewer with the respondent (e.g., the ability to assess the competencies of the respondents, and her/his ability to understand the questions asked). The study questionnaire was limited to the most prevalent symptoms, risk factors, and complications. History of diabetes (both diagnosed by a doctor and diabetes in the family) was self-declared, and medical records were not verified due to the study design. Moreover, this research method includes only subjects who have internet access (though more than 92% of households in Poland now have internet access) (47). Nevertheless, this is the most comprehensive and up-to-date study on public knowledge and awareness of diabetes that was carried out among adults in Poland, after the COVID-19 pandemic outbreak.
This study demonstrated insufficient public awareness of diabetes among adults in Poland. Gender and educational level were the most important factors significantly associated with the awareness of the selected aspects of diabetes, while self-reported financial situation and place of residence had none or marginal influence. Moreover, the current study indicated significant gaps in the knowledge about risk factors for diabetes and its complications, as well as methods to prevent them. The presented data manifest the importance of adopting a comprehensive education strategy regarding diabetes in Poland.
The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.
The study protocol was reviewed and approved by the Ethical Review Board at the Centre of Postgraduate Medical Education, Warsaw, Poland (No. 70/2022; date of approval: 08 June 2022). The patients/participants provided their written informed consent to participate in this study.
KS: conceptualization, data curation, formal analysis, investigation, project administration, visualisation, and writing an original draft. JG-S: conceptualization, investigation, methodology, and manuscript review and editing. JP: conceptualization, supervision, and manuscript review and editing. MJ: conceptualization, formal analysis, and manuscript review and editing. All authors contributed to the article and approved the submitted version.
The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.
All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.
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