Assessment of Healthcare Providers’ Knowledge on Diabetes Management: A Cross-Sectional Study from South India

INTRODUCTION

India faces a massive diabetes burden, projected to reach 124 million cases by 2045.^[1] Because this population drastically outnumbers available physicians, diabetes management increasingly relies on multidisciplinary teams, particularly nurses.^[2] In India, nurses provide insulin training to over half of patients,^[3] and nurse-led care models have proven more effective than physician-led care in improving HbA1c levels and self-management behaviours.^[4,5] Given their crucial role as the primary point of community care, nurses must be adequately equipped to educate patients.^[6,7] However, multiple studies highlight a critical competence gap. Many graduating and practicing nurses lack essential teaching skills and significantly overestimate their actual diabetes and insulin knowledge.^[8-10] This lack of awareness acts as a major barrier to seeking further education necessary for optimal patient support. The majority of the healthcare infrastructure in India is concentrated in tier 1 cities. Tier 2 cities have fewer healthcare facilities, hospital beds, and healthcare workers. Adequate knowledge of diabetes by the nurses and other support staff would likely improve care of patients, especially in resource-poor regions with a lower doctor-to-patient ratio.

We conducted a cross-sectional survey among healthcare providers predominantly constituted by nurses from various hospitals across a tier-2 city in the southern part of India to assess their basic knowledge of diabetes and its management.

MATERIAL AND METHODS

We conducted a cross-sectional survey on 192 healthcare providers who attended a diabetes education program by endocrinologists in a tier-2 city in the southern part of India. All the participants of the program who were health care providers (predominantly practicing nurses, nursing students, general practitioners, dieticians, etc.) were included in the study. A questionnaire was administered to the participants. The questionnaire administered was the Diabetes Knowledge Test 2 (DKT2), which is validated for assessment of the knowledge of people living with diabetes as well as nurses.^[11] The original DKT2 developed by James T. Fitzgerald was used for this study after obtaining permission from the author. Also, some questions were modified for the local population as suggested by Fitzgerald. Eg: replacement of \”American\” with \”Indian\”, replacement of \”Swiss cheese\” with \”Paneer\”, and replacement of \”baked potato\” with \”rice\”.

The questionnaire that was administered to the participants consisted of 30 multiple-choice questions. All questions pertained to the knowledge aspect of diabetes and care of patients with diabetes. Each question was assigned 1 point, with no negative scoring for any incorrect answers. The maximum total score was 30, and the minimum was zero. The procedures followed were in accordance with the ethical standards of the responsible committee on human experimentation (institutional or regional) and with the Helsinki Declaration of 1975, as revised in 2000.

RESULTS

The present study assessed the knowledge of diabetes management among 192 participants. The mean age of the respondents was 33.35 ± 11.56 years, indicating a relatively young workforce. The majority were female (92.2%), while only a small proportion were male (7.8%). Nearly half of the respondents (49.5%) reported having a family member with diabetes, while 50.5% did not.

Nurses constituted 97.4% (187) of the study subjects of the total 192 participants. The largest proportion was practicing nurses (85.4%), followed by nursing students (8.3%), nurses not currently practicing nursing (3.6%), and a few other health professionals, such as dietitians and general practitioners, constituting a small percentage (2.6%). Among nurses, most were employed in medical colleges/teaching hospitals (74.34%), while 24.6% worked in private clinics/non-teaching hospitals. A smaller number were attached to primary health centres (1.06%)

When asked about the type of diabetes in patients they were primarily involved in caring for, half of the respondents (50.52%) reported managing patients in both medical and surgical wards, while about 35% specifically dealt with medical ward patients with diabetes, and 12.5% with surgical ward patients with diabetes. About 1% participants dealt with patients with diabetes in a private clinic setting, while another 1% were not actively involved in the care of patients with diabetes.

Regarding prior exposure to training, only 18.2% of the respondents had previously attended a formal diabetic education/training program, whereas the majority (81.8%) had not received such training [Table 1].

The knowledge scores on diabetes management were measured using a 30-item questionnaire. Out of a maximum possible score of 30, the mean score was 18.57 ± 4.09, with scores ranging from 6-29. On average, they achieved around 62% of the total possible score, reflecting a moderate level of knowledge. The relatively wide range of scores (6-29) indicates that while some participants had very limited knowledge, others were able to answer nearly all questions correctly. The standard deviation of 4.09 points suggests moderate variability in knowledge levels among the respondents.

Specifically, 35 of them (18.2%) scored <15 and were classified as having poor knowledge, while 125 subjects (65.1%) fell within the score range of 15-22, indicating an average level of knowledge. Only 32 (16.7%) achieved a score of ≥23, reflecting a good level of knowledge.

Table 2 shows the association between healthcare providers’ present workplace and history of diabetes in family members with their level of knowledge on diabetic management. Among those working in academic settings, 60% had poor knowledge, 61.6% had average knowledge, and 68.8% had good knowledge, while the corresponding proportions in non-academic settings were 40%, 38.4%, and 31.3%, respectively. However, the difference in knowledge levels between academic and non-academic workplaces was not statistically significant (χ² = 0.670, df = 2, p = 0.715). Similarly, those with a family history of diabetes showed a higher proportion of good knowledge (59.4%) compared to those without a family history (40.6%), but this association was also not statistically significant (χ² = 1.891, df = 2, p = 0.389). Overall, the findings indicate that neither the present workplace nor family history of diabetes had a significant influence on knowledge scores related to diabetic management among healthcare providers [Table 2].

The demographic profile of the respondents regarding years of experience has been presented in Table 3. The median work experience in managing patients with diabetes was 5 years (IQR: 1-14.75 years), suggesting that while some were relatively new to diabetes care, others had substantial experience extending to over a decade. The largest group of respondents had <1 year of experience (n = 54, 28.1%), followed by those with 1-5 years of experience (n = 46, 24.0%). Mid-career professionals with 6-10 years of experience comprised 15.1% (n = 29) of the sample, while those with 11-15 years accounted for the smallest portion at 11.5% (n = 22). Finally, a significant portion of the participants (21.4%) reported having >15 years of experience (n = 41) [Table 3].

Table 4 depicts the association between years of work experience in managing patients with diabetes and knowledge scores on diabetic management among healthcare providers (97.4% constituted by nurses). Among those with poor knowledge scores, participants with <1year experience constituted the maximum number (54.3%), while those with >15 years of experience showed the highest proportion of good knowledge (46.9%) and the lowest proportion of poor knowledge (2.9%). As the years of experience increased, there was a clear shift from poor to average and good knowledge levels. The association between years of work experience in managing patients with diabetes and knowledge scores was statistically significant (χ² = 35.134, df = 8, p <0.001), indicating that greater work experience is significantly associated with better knowledge of diabetic management among healthcare providers.

The present study assessed the knowledge of healthcare providers, predominantly constituted by nurses (97.4%), on diabetes management. Regarding prior exposure to training, only 18.2% of the respondents had previously attended a formal diabetic education/training program, whereas the majority (81.8%) had not received such training. Out of a maximum possible knowledge score of 30, the mean score was 18.57 ± 4.09, with scores ranging from 6-29. On average, respondents achieved around 62% of the total possible score, reflecting a moderate level of knowledge. The distribution of knowledge scores among the 192 healthcare providers on diabetes management revealed that the majority had an average level of knowledge. Specifically, 35 of them (18.2%) scored <15 and were classified as having poor knowledge, while 125 of them (65.1%) fell within the score range of 15-22, indicating an average level of knowledge. Only 32 participants (16.7%) achieved a score of ≥23, reflecting a good level of knowledge. No statistically significant associations were found between workplace (p = 0.715) or family history of diabetes (p = 0.389) and knowledge scores (p >0.05). The median work experience in diabetes care among participants was 5 years. Greater work experience was significantly associated with better knowledge of diabetic management among healthcare providers, particularly those with >15 years of experience (p <0.001).

DISCUSSION

This cross-sectional study evaluated the knowledge of nurses regarding diabetes management in a tier-2 city of South India and highlights important gaps with direct implications for patient care. Given the rapidly increasing burden of diabetes in India and the critical role nurses play in patient education and daily diabetes care, assessing and strengthening their knowledge base is essential.^[1,2]

In the present study, the overall knowledge of healthcare providers predominantly constituted by nurses (97.4%) was moderate, with a mean score of 18.57 ± 4.09 out of 30, corresponding to ∼62% of the total possible score. A mean score of 62% shows that an individual has a basic understanding of how to manage diabetes, but this “moderate” level of proficiency has an immense impact on the quality of clinical care. In a practical context, this gap indicates that although they may be proficient in routine tasks, they may lack the essential decision-making skills necessary for complex situations, such as interpreting variable glycaemic trends, managing hypoglycaemic emergencies, or delivering nuanced lifestyle counselling. Drass et al. observed that overlooked knowledge deficiencies can hinder nurses from procuring essential resources. In a Tier-2 environment with restricted specialist access, nurses frequently serve as the principal educators for patients; hence, a 38% knowledge deficit may directly result in inadequate patient self-management and poor long-term glycaemic control. It is not just an intellectual exercise to fill this gap; it is also necessary for patient safety.^[9]

Although most participants demonstrated an average level of knowledge, nearly one-fifth had poor knowledge, and only 16.7% achieved good knowledge scores. These findings are consistent with earlier studies from India and other regions that have reported gaps in diabetes-related knowledge among nursing staff.^[8-14] Feustel first highlighted this issue by demonstrating that graduating nurses were inadequately prepared to provide diabetes education, a concern that appears to persist decades later.^[8]

A notable finding of this study is that >80% of nurses had not attended any formal diabetes education or training program. Similar observations have been reported in previous studies, where a lack of structured diabetes training among nurses was common.^[10,13,14] Evidence suggests that structured and repeated educational interventions can significantly improve nurses’ knowledge, attitudes, and practices related to diabetes care. Zhou et al. demonstrated that long-term, regular training of diabetes liaison nurses resulted in sustained improvements in diabetes-related knowledge and self-reported clinical practices.^[15] Furthermore, nurse-led models of diabetes care have been shown to improve glycaemic outcomes and diabetes self-management behaviours, reinforcing the importance of investing in nurse education.^[4,5]

In the present study, no statistically significant association was found between workplace setting (academic vs. non-academic institutions) and knowledge scores. This finding is consistent with previous reports that failed to demonstrate a clear relationship between the type of healthcare institution and nurses’ diabetes knowledge.^[16] These results suggest that working in an academic environment alone may not ensure better diabetes-related knowledge unless supported by targeted and continuous training programs.

Although nurses with a family history of diabetes demonstrated slightly higher knowledge scores compared to those without such a history, this difference was not statistically significant. This finding aligns with earlier studies suggesting that personal exposure to diabetes does not necessarily translate into adequate professional knowledge.^[9,16]

The correlation between years of experience and diabetes knowledge among nurses is inconsistent; few studies indicate that more experienced nurses possess superior abilities, but knowledge deficiencies remain. A cross-sectional survey of diabetes-specialist nurses from China indicated a substantial correlation among years of experience, level of education, and understanding of care of patients with diabetes.^[17] The study conducted in Gambia indicated that nurses with over four years of experience demonstrated superior practical skills, such as insulin delivery, although they lacked particular theoretical understanding, including definitions of hypoglycaemia or expiration dates.^[18] In the present study, the median work experience in diabetes care among participants was 5 years. There was a significant association with years of experience and diabetes knowledge, particularly with those with >15 years of experience scoring the maximum. This aligns with results from the study conducted by Albagawi et al., which demonstrated that those with longer work experience, particularly beyond 15-16 years, had higher knowledge scores.^[16] However, practical skills were not assessed in the present study, and it was limited to the assessment of theoretical knowledge.

Another important consideration is the previously documented disparity between perceived and actual knowledge among nurses. Perceived knowledge of diabetes was not assessed in the current survey, however. Drass et al. reported an inverse relationship between perceived and actual knowledge of diabetes, suggesting that unrecognized knowledge deficits may reduce motivation to seek additional training.^[9] This highlights the need for objective assessments and structured educational interventions rather than reliance on self-perceived competence.

This study highlights the urgent need for continuous, structured diabetes education for nurses in resource-limited settings. Because nurses are primary educators, enhancing their competencies directly improves patient self-care and clinical outcomes. To bridge knowledge gaps, policymakers should shift from sporadic training to systematic, multimodal interventions. Specifically, we recommend implementing cost-effective mobile micro-learning apps for brief lessons on insulin and hypoglycaemia management, alongside bedside simulation workshops that provide hands-on practice instead of passive lectures. Furthermore, earning annual Continuing Nursing Education (CNE) credits in diabetes management should be mandatory for nursing performance reviews. Adopting these low-infrastructure strategies ensures vital skills are continuously reinforced, ultimately enhancing glycaemic outcomes and overall patient care.

CONCLUSION

This cross-sectional study among healthcare providers, predominantly consisting of nurses in a South Indian Tier-2 city, reveals that they possess predominantly average to poor diabetes management knowledge. Despite their crucial caregiving role, the majority lack formal training. Furthermore, knowledge scores showed no association with workplace setting or family history, indicating that practical experience alone is insufficient for adequate competency. These findings highlight a critical need for structured, continuous diabetes education across all healthcare settings. Bridging these gaps requires regular training, periodic assessments, and integrating diabetes management into both nursing curricula and in-service programs.