Diabetes Awareness Among Subjects Attending Teaching Health Facility of North India: A Cross-Sectional Study

INTRODUCTION

Diabetes mellitus, being a health problem leading to more than 3.4 million deaths annually worldwide, poses a major clinical and public health challenge. As per the International Diabetes Federation, it is estimated that globally, currently around 589 million people have diabetes, with 81% of them living in low and middle-income countries.^[1] According to the most recent national data from the ICMR-INDIAB (Indian Council of Medical Research-India Diabetes) study and corroborated by the International Diabetes Federation, India now has approximately 101 million adults living with diabetes as of 2025, reflecting a dramatic increase from earlier years. The national prevalence of diabetes among adults has reached around 11.1%.^[2] However, an alarming fact is that about 50% of those affected with diabetes are not diagnosed.^[3]

Improving education is crucial in ensuring better treatment and control of diabetes. Research shows that increasing knowledge of diabetes and its complications has significant benefits, including enhancing compliance with treatment and reducing associated complications.^[4] Moreover, preventing type 2 diabetes should be the top priority, and research indicates that educating the public about diabetes and its risk factors can significantly help prevent it.^[5] Given the growing prevalence of type 2 diabetes in India, it is necessary to assess the knowledge of diabetes risk factors, complications, and prevention in order to develop culturally suitable educational approaches. Previous studies in India have explored the knowledge of diabetes in the general population and individuals with diabetes.^[6-8] This cross-sectional study on participants visiting an urban health facility in northern India assessed diabetes awareness.

MATERIAL AND METHODS

This cross-sectional study took place at an urban health and training centre of the Era’s Lucknow Medical College in North India from July 2020 to December 2020 after obtaining due ethical approval from the Institutional Ethics Committee vide letter no ELMC&H/R Cell/EC/2020/03. 

Study population and sampling strategy

In this study, consecutive convenience sampling was utilised to recruit 480 adults, of both sexes, who were willing to participate, including diabetic and non-diabetic subjects from attendees of the UHTC [Figure 1].

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Figure 1:

Flowchart of the study. UHTC: Urban Health and Training Centre.

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Data collection tools: Participants were included in the study after obtaining informed consent. A pre-tested, structured questionnaire was used as represented in Supplementary Material 1. It comprises the following validated instruments:

• 1.

  Socio-demographic Profile: Age, sex, education, socio-economic status (Modified Kuppuswamy scale 2020),^[9] diabetes status, and medical information.

• 2.

  Diabetes awareness: A previously reported questionnaire used in the ICMR-INDIADB study^[10,11] for determining awareness of diabetes was used for this study [Annexure 1]. The questionnaire contained inquiries related to the subjects’ familiarity and understanding of different aspects of diabetes. The questionnaire incorporated distinct questions to evaluate the participants’ knowledge of the risk factors, causes, complications, and prevention methods related to diabetes.

For this study, a previously mentioned composite score^[10] was used to evaluate the participants’ knowledge of diabetes. The scoring system was as follows: (a) Correct responses to closed questions were graded as 1, and incorrect responses (including “do not know”) were graded as zero. (b) Regarding the risk factors of diabetes, subjects who noted obesity, high blood pressure, lack of physical activity, or family history of diabetes were awarded the highest score of ‘4’. At the same time, ‘3’ was given to those who ticked “unhealthy diet,” ‘2’ to those who ticked “mental stress,” and ‘1’ for any other sensible or nearly identical answer, and ‘0’ for all other answers. (c) Therefore, the lowest possible score was ‘0’ if all responses were incorrect, and the highest was eight if all responses were correct. (d) A composite score percentage was calculated by dividing the individual’s score by the maximum possible score. For instance, if participants scored ‘6’, their composite score would be 6/8 × 100 = 75%. In this study, scores below 60% were classified as “Low” knowledge, scores between 60-79% as “Moderate,” and scores of 80% and above as “High.”

Questions were administered by the interviewer, and responses were recorded on the forms based on the participants’ answers. The form was in English and interpreted by the interviewer in the local language (Hindi) for those who could not understand or read English. After obtaining all the answers, the level of knowledge and awareness was analysed.

RESULTS

Among the 480 participants, the majority were aged 30-49 years (47.9%), followed by <30 years (29.2%) and ≥50 years (22.9%), with a mean age of 38.7 years. Males constituted a higher proportion (59.0%) than females (41.0%) [Table 1]. Regarding education, most participants had completed secondary school (38.5%), whereas 8.8% were illiterate and only 5.8% were graduates or above [Table 1]. Based on the Modified Kuppuswamy scale, nearly half (41.3%) belonged to the lower-middle socio-economic group. The majority were non-diabetic (90.5%), predominantly vegetarian (60.4%), with 25.0% hypertensive and 31.3% reporting a family history of diabetes [Table 1].

Table 1 shows the socio-demographic characteristics and their association with diabetes knowledge levels among the 480 participants. Although participants aged <30 years had the highest proportion with low knowledge (57.1%), the association between age and diabetes knowledge was not statistically significant (χ² = 8.96, p = 0.062). Sex distribution showed no significant difference in knowledge levels (χ² = 2.03, p = 0.362), with similar proportions of low, moderate, and high knowledge among males and females.

Education level strongly correlated with diabetes knowledge (χ² = 31.50, p <0.001). Participants with higher secondary education and graduates had greater proportions with high knowledge (33.3% and 35.7%, respectively), whereas those who were illiterate or had only primary schooling exhibited higher rates of low knowledge [Table 1]. Socio-economic status also correlated significantly with knowledge level (χ² = 19.27, p = 0.013), with upper and upper-middle groups demonstrating higher awareness than lower strata [Table 1].

Regarding clinical characteristics, diabetic participants had significantly higher diabetes knowledge than non-diabetics (χ² = 29.58, p <0.001), with 43.5% of people with diabetes scoring high knowledge compared to only 14.7% of non-diabetics. Similarly, a positive family history of diabetes was associated with better knowledge (χ² = 18.48, p <0.001). Hypertension status showed no significant association with knowledge (p = 0.294).

Results for composite knowledge scores revealed that nearly half of the participants fell into the low knowledge category (47.5%), while just over a third demonstrated moderate knowledge (35.0%), and a small proportion achieved high knowledge (17.5%). These distributions indicate substantial gaps in diabetes awareness, with fewer than one in five participants attaining high composite scores.

Table 2 presented the percentage of correct responses for each diabetes awareness questionnaire item. Almost 90% had heard of diabetes, and over 85% recognised that its prevalence is increasing. Participants commonly identified overweight (62.5%) and high blood pressure (45.8%) risk factors. Awareness that diabetes affects other organs was high (83.3%), with eyes (66.7%), kidneys (56.3%), and heart (47.9%) most frequently recognised as affected organs. The majority (77.1%) believed diabetes can be prevented, with diet (65.6%) and exercise (58.3%) identified as key preventive measures.

Multivariate logistic regression analysis identified several independent predictors of high diabetes knowledge as illustrated in Table 3. Higher education (OR 2.85, 95% CI 1.95-4.15, p <0.001), higher socio-economic status (OR 1.65, 95% CI 1.09-2.50, p = 0.02), having diabetes (OR 3.40, 95% CI 2.05-5.62, p <0.001), and family history of diabetes (OR 2.12, 95% CI 1.40–3.20, p <0.001) were significantly associated with increased odds of having high diabetes knowledge. Age and sex were not significant predictors.

These findings highlight the critical roles of education, socio-economic factors, and personal or familial exposure to diabetes in shaping awareness, underscoring the need for targeted education strategies to improve knowledge among lower-educated and socio-economically disadvantaged populations.

DISCUSSION

This urban cross-sectional study adds to the growing evidence on diabetes awareness in North India. The findings reveal widespread gaps in diabetes knowledge, with nearly half (47.5%) of the population exhibiting low awareness. These results align with previous research conducted in both urban and rural settings, which reported that <40% of participants demonstrated strong awareness of diabetes risk factors, prevention, and complications, particularly among non-diabetics and those with lower educational levels.^[12]

Our study confirms that diabetes status is a robust independent predictor of disease understanding. Diabetic individuals in our cohort were markedly more likely to exhibit moderate or high knowledge scores compared to their nondiabetic counterparts, mirroring the gradient reported by Deepa M in the multicentric ICMR-INDIAB study: urban and rural patients with diabetes consistently had better health literacy and greater engagement with educational resources than the general population.^[10] Such patterns are often attributed to increased healthcare interaction post-diagnosis and the experiential learning loop with chronic disease management.

Education also emerged as a dominant driver of diabetes knowledge in this study, with higher secondary and graduate participants displaying the most significant proportions of high knowledge. This echoes national findings, most recently analysed by Maiti S, demonstrating that among adults in India, both diabetes awareness and effective disease control are strongly stratified by formal educational attainment.^[13] These results advocate a public health emphasis on functional and health-specific literacy as foundational elements of any community diabetes program.

Socio-economic position, as classified by the Modified Kuppuswamy scale, further amplified disparities in diabetes knowledge. Individuals from upper and upper-middle socio-economic groups reported significantly higher awareness, while those from lower strata, although increasingly affected by the diabetes epidemic, continued to exhibit substantial information deficits. This social gradient has been widely recognised, including in the work of Hill-Briggs et al., which emphasises the layered impact of the social determinants of health on the burden of chronic disease. Factors like wealth, education, and urban infrastructure involve access to care and the pathways through which individuals acquire health knowledge and adopt preventative behaviours.^[14]

Notably, the present findings also confirm that having a family history of diabetes is associated with higher levels of knowledge. Awareness may be enhanced by the family’s collective experience of the disease. These relational effects were highlighted by Ferreira PL, who reported that familial exposure supports greater knowledge retention and a greater likelihood of engaging in preventive or early management behaviours.^[15]

In contrast, sex, age group, and hypertension status did not reach statistical significance concerning knowledge distribution in our population. While this could reflect successful narrowing of historical gaps through urban health campaigns, it is also possible that the absolute level of knowledge remains insufficient across these groups. Further community-based work by Kurian B in Kerala underscores the persistent knowledge deficits among adults regardless of these demographic subgroups, suggesting that population-wide educational approaches remain necessary.^[16]

While previous large-scale surveys, such as ICMR-INDIAB and NFHS, provide valuable national-level estimates of diabetes prevalence and general awareness, our study uniquely contributes by offering a focused, granular assessment of diabetes knowledge among participants attending an urban health facility in North India. The recently published 2025 IDF updates emphasise a continuing rise in diabetes burden and highlight prevention challenges shaped by urbanisation and lifestyle shifts.^[17] The IDF’s recognition of social determinants such as education and socio-economic status as pivotal in disease risk and management echoes our multivariate analysis results, reinforcing that improving educational attainment and resource access is necessary to enhance diabetes awareness and self-care capacity. Moreover, the IDF’s emphasis on modifiable lifestyle factors aligns with our observation that awareness of key risk factors like unhealthy diet and physical inactivity remains limited. The strengths of this study include the comprehensive composite scoring method used, the robust sample size, and the inclusion of a broad range of demographic determinants. Limitations encompass the cross-sectional nature of the survey, which restricts causal inference, and the urban study setting, which may have led to overestimation of knowledge scores compared to more remote or underserved areas.

CONCLUSION

This research underscores that diabetes knowledge in urban India is deeply intertwined with diabetes status, education, socio-economic position, and family history. The persistent gaps, especially among non-diabetics, the less educated, and lower socio-economic groups, highlight the need for targeted, accessible awareness campaigns. Only by systematically addressing these disparities can India hope to curb the rising tide of diabetes and its associated health burden.