A Review on Knowledge, Attitude, Practice in Type 2 Diabetes Mellitus Patients with Chronic Kidney Disease

A variety of physiological diseases linked to aberrant renal function and a persistent deterioration in glomerular filtration rate (GFR) are collectively referred to as Chronic Kidney disease (CKD), a non-communicable disease. There are five phases of kidney impairment associated with Chronic Kidney disease, ranging from modest dysfunction to kidney failure.[1] Predisposing and initiating factors of Chronic Kidney Disease (CKD) include a wide range of risk factors, such as age, sex, family history of kidney disease, primary kidney disease, urinary tract infections, cardiovascular disease, diabetes mellitus, and nephrotoxins (antibiotics, non- steroidal anti- inflammatory drugs). [1] A metabolic condition known as type 2 diabetes (T2D) affects the bodys capacity to absorb insulin, which can result in elevated blood sugar levels. One of the most dreaded side effects of type 2 diabetes in chronic kidney disease, which is the ninth greatest cause of mortality globally. [2]

Hyperglycemia is a hallmark of diabetes mellitus (DM). Diabetes Mellitus (DM) is associated with anomalies in the metabolism of proteins, lipids, and carbohydrate. These abnormalities leads to chronic consequences, such as neuropathy, microvascular and macrovascular problems. According to estimates from the International Diabetes Federation (IDF), one in eleven adults have diabetes. [3]

Over 40% of dialysis patients have diabetic kidney disease (DKD), a major complication of diabetes and a major cause of end-stage renal disease (ESRD). [4]

Knowledge, Attitude, and practice (KAP) are essential to managing diabetes. Numerous research have employed a KAP-based questionnaire to evaluate peoples knowledge, attitudes, and behaviours regarding diabetes mellitus, and they have confirmed the necessity of raising awareness to risk factor control in order to avoid diabetes. Research indicates that patients with diabetes who are well-informed and have a high level of health literacy are better able to control and manage their condition. [2] A thorough grasp of patients knowledge, attitudes, and practices (KAP) surrounding the disease is necessary for both controlling and preventing DKD. While attitudes determine health- seeking behaviour and willingness to undertake lifestyle alterations, awareness and knowledge influence early identification and adherence to preventive interventions. [4] When evaluating the outcomes of health education for patients with diabetes, patient knowledge, attitude, and practice (KAP) are important considerations. KAP, which stands for knowledge about diabetes, attitude toward the condition, and self-management regarding the condition(practice), is recognized to influence compliance and play a significant role in diabetes management. [5] The aim of the study is to perform a review on assessing the Knowledge, Attitude, Practice (KAP) in type 2 diabetes mellitus patients with chronic kidney disease.

Pathophysiology of Diabetic Kidney Disease

The pathogenesis of diabetic kidney disease (DKD) is complex and characterised by a major metabolic deficit; hyperglycemia's upstream influence causes tissue fibrosis, inflammatory lesions, enhanced apoptotic processes, and dysregulated intracellular metabolism. Three essential processes form the basis of DKD injury: (1) glomerular hypertrophy resulting in hyperfiltration. Up to 40% of T2DM patients have glomerular hyperfiltration, which is a common characteristic of early DKD symptoms; (2) glomerular and tubulointerstitial inflammation, which is linked to the activation of chemokines, cytokines, and profibrotic factors. (3) altered extracellular matrix and dysregulated cellular apoptosis. These processes result in tubular injury, podocyte depletion, mesangial matrix enlargement, and thickening of the glomerular basement membrane. Each of these elements may contribute to the development of DKD. [6]

Risk Factors

It has been proposed that common risk factors that enhance the likelihood of diabetic complications include smoking, obesity, hypertension, longer duration of diabetes, impaired metabolic regulation, and hyperlipidaemia. Reduced renal function and increased kidney damage have been linked to low blood pressure (BP) and glycaemic management. Similarly, it has been demonstrated that a number of context factors, including age, smoking, and BMI, are positively associated with CKD. [7]

Stages

Knowledge, Attitude, Practice (KAP)

KAP questionnaire on chronic kidney disease (CKD) in patients with type 2 diabetes mellitus were created after a thorough study of the literature and expert consultation. Databases including PubMed, Scopus, and Google Schloar. The definition of CKD, risk factors, symptoms, complications, and type 2 dm preventive treatments were included in Knowledge. Measures that focused on attitudes about CKD prevention, severity, and vulnerability. Practice items evaluated self-care practices, including regular kidney function tests, medication adherence, blood glucose monitoring, dietary change and physical activity.  

Development Of KAP

Knowledge:

The CKD knowledge part had items pertaining to general disease knowledge, diagnosis, risk factors, complications, and disease management. The majority of the questions focused on technical details about CKD, which are well-defined by the most recent KDOQI/KDIGO recommendations. There were 42 knowledge items in all, with three possible answers—yes, no, and do not know—and only one right response. The questionnaire was expanded to include both positive and negative items. A higher score denotes greater knowledge. One point is awarded for each right response, and 0 points are awarded for each wrong response.The knowledge score can therefore range from 0 to 42 points.

Attitude:

This section's items concentrated on views concerning dialysis, kidney damage and results, and overall attitudes regarding CKD disease. During the literature review stage, a total of fifteen items were created using data from earlier research and comparable instruments. The attitude part now includes both positive and negative questions. A 5-point Likert scale, which includes "strongly disagree," "disagree," "neutral," "agree," and "strongly agree," was used to score each item. For each of the 12 positive items, one point is awarded for "strongly disagree," and five points are awarded for "strongly agree." Points are awarded in ascending order. Additionally, three negatively structured items were included, and during analysis, reverse scoring was used. An overall attitude score was calculated by adding the scores from each individual item; higher scores denoted a more positive attitude. The attitude section's overall score varied from a minimum of 15 to a maximum of 75.

Practice

This section contained information on general CKD disease behaviours, GFR estimation, disease monitoring, and CKD consequences. The CKD-KAP questionnaire was expanded to include a total of 13 practice items on a frequency scale with a response scale with four values: "never," "seldom," "often," and "always." Additionally, reverse scoring was used on three negatively structured items. For every positively structured item on the scale, one point is awarded for the lowest frequency, or "never," and four points are awarded for the maximum frequency, or "always." The practice score is calculated by adding the points from each item, with a minimum potential score of 13 and a maximum possible score of 52. Better CKD practices are indicated by a higher score. [8]

Validation Of KAP

Phase I: Item generation and questionnaire design

A thorough analysis of the literature and expert comments led to the development of 62 items in total. The knowledge, attitude, and practice of chronic kidney disease (CKD), including its risk factors, signs and symptoms, consequences, and preventative treatments, were divided into three subscales. A three-point rating scale was used to evaluate the knowledge domain, which included items 1 through 30. The response options were "Yes" (scoring 2), "No" (score 0), and "I don't know" (score 1). A five-point Likert scale, ranging from "Strongly Disagree" (score 1) to "Strongly Agree" (scoring 5), was used to measure the attitude domain, which comprised items 31 to 48. The remaining items made up the practice domain, which assessed participants' health-related behaviours and practices relevant to managing and preventing chronic kidney disease. .[9]

Phase II: Content validity

The degree to which the items on a measuring scale determine the same content is known as content validity. An expert panel consisting of three medical professionals—two senior nephrology professors with over 15 years of experience in tertiary care settings and one academic researcher with expertise in the relevant field—determined the content validity of the CKD. Each item in the CKD was graded as "essential," "useful," or "not necessary" by the expert panel according to its appropriateness, correctness, and degree of uncertainty. The expert panel's recommendations led to changes to the questionnaire.

Phase III: Face validity

Face validity plays a special and significant function in determining how responders view a test's appropriateness. The CKD-KAP was tested among ten doctors in a tertiary care facility to determine its face validity following content validity. The researcher gave the doctors CKD-KAP and instructions on how to complete the questionnaire. Every doctor was asked to fill out the CKD-KAP and was encouraged to raise questions on unclear or confusing issues. Trained researchers then provided more thorough explanations for these things. After clarification, the questions that remained unclear were eliminated from the CKD-KAP

Phase IV: Construct validity

The underlying hypothetical notions that the test was intended to assess are measured by construct validity. Exploratory Factor Analysis (EFA) and Item Response Theory (IRT) were used to perform the construct validity since one of these models is unable to suit the knowledge, attitude, and practices scale simultaneously. The knowledge scale was fitted using a one-parameter logistic item response model based on item response theory. using STATA 14.0. Since 2P IRT modelling requires a larger sample size, this model was used because all knowledge items have a dichotomous scale and because the sample size of 100 physicians was small. The coefficient of difficulty was calculated for every item, while the coefficient of discrimination was calculated as a single value for every item. A difficulty level between 3 and +3 was deemed acceptable (17). The chi-square goodness-of-fit p-value for each item was used to assess item fit, while Cronbach's alpha and item-total correlation were used to assess internal consistency. Because every item in the attitude and practices sections had four to five response items on an ordinal Likert scale, an EFA model was fitted using SPSS version 22.0. The EFA used the primary axis factoring extraction approach with varimax rotation. To estimate the dimensionality (number of variables) of the items, each section's items were regarded as continuous responses. Eigenvalues > 1.0, parallel analysis, and scree plot inspection were used to determine the number of retrieved factors. Factor loadings greater than 0.4 were deemed appropriate. Using Cronbach's alpha, the number of extracted factors with eigenvalues greater than 1.0 was examined for internal consistency across all included items.

Phase V: Reliability analysis

Internal consistency, one of the frequently used methods to assess any instrument's reliability, was used for the reliability analysis. The goal of internal consistency and dependability is to examine how closely and similarly objects or a group of things respond to one another inside a domain. The inter-item correlation was used to assess the reliability analysis using internal consistency. The reliability coefficients (Cronbach's alpha) were also calculated because the attitude and practice parts of the CKD-KAP contain continuous data. A reliability coefficient (Cronbach's alpha) of 0.6 is appropriate and acceptable for exploratory research, according to Drasgow et al. For this study, however, a more conservative cut-off Cronbach's alpha value of 0.7 was chosen. [8]