Posted: February 17th, 2022

Diabetes mellitus is a set of physiological dysfunctions

















I now declare that this project is my original work and, to the best of my knowledge, has not been presented elsewhere for approval and the award of a degree, diploma, or certificate.


Signature………………………….            Date…………………………….

Joseph Njuguna Kabuku




This is to certify that the research has been done and submitted under my guidance and supervision


Signature………………………………………..         Date………………………………

Mr. Boniface Chege

BScN, MScN (Medical Physiology)

School of Nursing

Dedan Kimathi University of technology



I dedicate this work to almighty God for the energy and good health he gave me to the completion of this research proposal project.



      I acknowledge God wholeheartedly for guidance, support and for enabling me to come up with and development of this project. I appreciate my supervisor Mr. Boniface Chege for her tireless effort in monitoring, correcting and supporting me through the entire project in the shortest time possible. Thank you for your motivation and stepwise approach that enabled me to complete this study.


List of abbreviations

T1DM – Type 1 diabetes mellitus

T2DM-Type 2 diabetes mellitus

DM- Diabetes Mellitus

HBM- Health Belief Model

Definition of concepts

Diabetes– Diabetes in this study refers to Type 2 Diabetes Mellitus (T2DM).

Knowledge– In this study, knowledge refers to an understanding of the meaning, causes, risk factors, signs, complications, treatment, and management of diabetes, as well as diabetes prevention methods.

Perceptions– Perceptions in this study refer to people’s interpretations of diabetes causes, complications, and treatment, as well as their understanding of the risk of developing this disease, participants’ convictions about diabetes prevention, and their perceptions about required behavior change.

Hyperglycemia– implies that there is too much sugar in the blood as a result of the body’s inability to produce enough insulin.

Poor Knowledge– All respondents with below the mean score on knowledge questions were included among those with poor knowledge.

Good knowledge– Respondents scoring above the mean on knowledge questions were regarded as having good knowledge.





Table of Contents




Definition of concepts. 3

Chapter one. 4


1.2 Problem Statement 5


1.4 Objectives. 7

1.4.1 Overall objectives. 7

1.4.2 Specific objectives. 7

1.5 Significance of the study. 7

1.6 Theoretical framework. 8

1.7 Variables. 9

1.71 Dependent 9

1.72 Independent 9

1.8 Conceptual framework. 11


Literature Review.. 12

2.0 Introduction. 12

2.1 what is diabetes?. 12

2.1.2 Diabetes Risk Factors. 12

2.1.3 signs and symptoms. 13

2.1.4 Complications of Diabetes mellitus. 13

2.1.5 Control and management 14

2.2 Sociodemographic Factors. 16

2.2.1 Age. 16

2.2.2 Sex. 16

2.2.3 Marital Status. 16

2.2.4 Level of education. 17

2.2.5 Economic status. 17

2.2.6 Exposure to Health Education. 18

2.3 Knowledge on Diabetes. 18

2.4 Perception. 19


3.1 Introduction. 20

3.2 Research design. 21

3.3 Study Area. 21

3.4. Study Population. 21

3.5        Inclusion and Exclusion Criteria. 21

3.5.1        Inclusion Criteria. 21

3.5.2        Exclusion Criteria. 22

3.6        Sample size calculation. 22

3.7 Sampling technique. 23

3.8.2        Participants Consenting Procedures. 23

3.9        Data Collection Instrument and measurement Procedures. 24

3.9.1        Study Instrument 24

3.9.2        Data Collection and measurements Procedures. 25

3.10. Validity and reliability. 25

3.12 Data management, analysis and presentation. 25

3.13          Ethical Considerations. 26

List of abbreviations. 26




Chapter one


Diabetes mellitus is a set of physiological dysfunctions defined by hyperglycemia caused by insulin resistance, insufficient insulin production, or excessive glucagon secretion. T1DM is an autoimmune illness that causes the death of pancreatic beta-cells. T2DM, which is far more frequent, is largely an issue of gradually poor glucose regulation caused by a combination of malfunctioning pancreatic beta cells and insulin resistance (Blair, 2016). Gestational diabetes develops during pregnancy. Its signs and symptoms include frequent urination, frequent thirst, weight loss and high glucose levels of 7mmol/L on two separate sets. Complications include nerve damage, risk to cardiovascular diseases, kidney damage, diabetic foot, among others. Diabetes complications can be reduced by early detection and management  (Papatheodorou et al., 2018). This entails a change in lifestyle, such as frequent exercise, a balanced diet, and weight loss, as well as pharmacological therapy. As a result, health literacy is an essential component of diabetes care(Caruso et al., 2018). Patients who are well-versed on diabetes and its complications seek appropriate treatment and care and take full control of their health.(Tiruneh et al., 2019). There is compelling evidence that people who are informed and vigilant about their diabetes self-care obtain better and more lengthy diabetic control. Individual perceptions have an impact on healthy behavior(Tankard & Paluck, 2016). The perception is founded on the health belief model(Green et al., 2020). The goal of this paradigm is to change people’s perceptions of a health threat and to influence their behavior toward health. Within the Health Belief Model, the perceived risk of acquiring diabetes mellitus is regarded as the major motivation for change, with the assumption that the greater the perceived threat, the more likely an individual will adapt his or her behavior to avoid that threat.


1.2 Problem Statement

Low health literacy has been shown to have a negative impact on care and health outcomes, as well as being a social determinant in low- and middle-income countries (Demaio et al., 2017). Globally, level of knowledge on diabetes mellitus varies from first world countries to third world  (Qiu et al., 2020).  In Sub-Saharan Africa, studies have revealed that the level of knowledge and perception is poor (Muhammad et al., 2021) Studies done show that 48% of diabetic patients had poor knowledge on diabetes (Jasper et al., 2019). In Kenya, diabetes awareness is extremely low in every region. A study on diabetes awareness carried out in Nyeri County, 2015, indicated that 59.4 % of respondents were unaware of the cause(s) of diabetes, 55.5 % were unaware of the symptoms of diabetes, and 92.1 % were uninformed that diabetes, if not effectively treated, can lead to major complications (Rachugo, 2015). Karatina, being one of the urban areas in Nyeri county, Type 2 Diabetes mellitus cases has been as well on the rise. Proper interventional measures would be important based on the assessment of knowledge gaps and perception that this study seeks to find out in patients attending Diabetes clinic at Karatina Subcounty hospital.


The most powerful weapon in the fight against diabetes mellitus is knowledge. People can use the information to estimate their diabetes risk, motivate them to seek appropriate medication and care, and inspire them to take responsibility for their disease. It has been demonstrated that diabetes knowledge and awareness can positively impact patient habits, perhaps leading to better diabetes control and, ultimately, a higher quality of life. Diabetes mellitus is a disease that must be combated with knowledge. The availability of information can help people assess their risk of developing DM. People will also be inspired to seek good care and to take charge of their sickness. Numerous researches have shown that in Kenya, the proportion of people who have a good understanding of diabetes mellitus is 27 percent. This research aims to understand better the current status of knowledge and perceptions in Karatina, Nyeri county. A better understanding of diabetes knowledge and perceptions in this region will direct and concentrate future non-communicable disease education for both CHWs and community members. Knowledge gaps must be addressed to control and minimize diabetes-related complications.

1.4 Objectives

1.4.1 Overall objectives. 

To assess knowledge and perceptions on type 2 diabetes among diabetic patients attending diabetes outpatient clinic at Karatina sub county hospital, Nyeri county


1.4.2 Specific objectives.

  1. To identify the sociodemographic characteristics of the Type 2 diabetic patient attending clinic at Karatina Subcounty Hospital.
  2. To determine the diabetic patient level of knowledge regarding Type 2 diabetes mellitus attending diabetes clinic Karatina Subcounty Hospital.
  3. To evaluate the diabetic patient’s perception of Type 2 diabetes mellitus attending diabetes clinic at Karatina Subcounty Hospital.


1.5 Significance of the study

Diabetes prevalence has increased significantly in Karatina, Nyeri County. Diabetes increases the risk of having other complications such as hypertension, kidney complications, and blindness, as well as the expense of treatment and productivity loss. As a result, there is a need for a strategy to raise people’s understanding and awareness of diabetes in order to assure disease prevention and early detection. The project’s findings may aid in identifying population knowledge gaps and diabetic behavior, which would aid in the establishment of diabetes health education initiatives.

1.6 Theoretical framework

Major concepts in health behavior models are health beliefs and knowledge. The HBM is an intrapersonal model used in health promotion that is based on individuals’ beliefs and knowledge theory (Jones, Smith, & Llewellyn, 2014) The HBM theoretical constructs are based on cognitive psychology theories. This study is based on the Health Belief Model (HBM), which includes perceived threat, vulnerability, severity, benefits, barriers, and action cues. The goal of this paradigm is to change people’s perceptions of a health threat and to influence their behavior toward health. It also looks at a person’s health-related behavior and belief in foreseeing future events. Within the Health Belief Model, the perceived risk of getting diabetes mellitus is regarded to be the major motivation for change, with the assumption that the greater the perceived threat, the more likely an individual will adapt his or her behavior to avoid it. It could be a powerful motivator for healthy lifestyle choices and disease management. Furthermore, according to this model, many factors influence people’s decisions to participate in preventive and screening programs, including their awareness of the disease’s impact on their health (perceived severity), the perceived benefits of taking preventive measures, and the perceived barriers and costs of screening methods. According to the HBM, a trigger or cue is required to encourage participation in health-promoting behaviors. Cues to perform can be both external and internal. Physiological signals such as pain feelings are examples of internal cues, whereas external cues include events or information from the media, family and friends, and healthcare practitioners participating in health-related actions (Zareban et al., 2013). Medical practitioners’ reminders, family and friends’ experiences, and health product labels are all examples of cues to action. The strength of the cues is required to drive quick action, which differs amongst individuals based on perceived susceptibility, relevance, benefits, and barriers. The HBM model has been applied to diabetes in order to better understand the condition’s awareness and behavior. As a result, understanding people’s perspectives and beliefs is critical for establishing ways to prevent, control, and raise awareness of the disease’s health dangers. The findings of this study would serve as a foundation for future intervention programs aimed at promoting diabetes mellitus early identification and management among people of Karatina.

1.7 Variables

1.71 Dependent

Type 2 Diabetes Mellitus awareness.

1.72 Independent


  1. Sociodemographic factors.



Marital status

Level of education

Level of education


Monthly Income

Exposure to Health education

  1. Knowledge

 Risk Factors

 Signs and symptoms


Control and Management

  1. Perception

Perceived severity

Perceived susceptibility

Perceived benefit

Perceived barriers












1.8 Conceptual framework

Sociodemographic factors



Marital status

Level of education


Monthly Income

Exposure to Health Education





Signs and Symptoms

Control and Management


  Type 2 Diabetes Mellitus Awareness




Perceived Severity


Perceived Susceptibility

Perceived Barriers




Literature Review

2.0 Introduction

This section review literature on diabetes as a public health concern. It will describe what diabetes is, risk factors, signs and symptoms, complications, control and management, sociodemographic factors, studies on knowledge and perception.

2.1 What is diabetes?

Diabetes Mellitus (DM) is an endocrinological illness that refers to a set of metabolic disorders caused by an abnormality in insulin secretion, action, or both. In turn, the absence or reduction of insulin results in persistent abnormally high blood sugar levels and glucose intolerance(Abudawood, 2019). There are three main types of diabetes. Type 1 diabetes mellitus (T1DM), commonly known as autoimmune diabetes, is a chronic illness that causes hyperglycemia due to insulin insufficiency caused by pancreatic-cell loss. Necessitates regular insulin administration (Katsarou et al., 2017). Type 2 diabetes is marked by insulin resistance and relative insulin insufficiency. The body makes ineffective use of insulin. It accounts for 90 percent of all diabetic patients worldwide(Zheng et al., 2018). The third type is gestational diabetes mellitus (GDM) that is hyperglycemia that occurs during pregnancy and resolves postpartum. If not identified and managed effectively, it can lead to poor pregnancy outcomes(American Diabetes Association, 2019).

2.1.2 Diabetes Risk Factors

A risk factor is any characteristic or exposure of an individual that raises the probability of contracting a disease.  It is  anything that increases the probability of getting the disease(Freeman et al., 2021). The following are some examples of diabetes risk factors according to diabetes leadership Forum 2010.

  • Demographics- People between the ages of 45 and 59 are 8.5 times more likely to have diabetes than those between the ages of 15 and 29, and those above the age of 60 are 12.5 times more likely to develop diabetes. 
  • Obesity- Abnormal or excessive fat deposition in the belly, which may be harmful to                 one’s health. Obesity is recognized as a major risk factor for a variety of non-communicable diseases, particularly type 2 diabetes. This strong link gave rise to the term “diabesity.”(Leitner et al., 2017). In a 2014 study, a connection between BMI and diabetes was discovered, confirming the significance of obesity as a cause of diabetes across Africa. (Okamura et al., 2019). If these individuals were not obese, 52,4 % of T2DM could be averted, and at the population level, % of T2DM could be avoided if obesity did not exist (Bertoglia et al., 2017)
  • Poor Dietary Habits- Consumption of low-density lipoprotein-rich foods, found in red meat, eggs and dairy products. Refined starches, like refined sugars, are linked to an increased risk of Type 2 diabetes mellitus. Many studies have found a link between a high sugar intake and the development of T2DM. Patients should also be well-informed about the condition and diet; to this end, health-care practitioners must advise patients to make modifications in their nutritional habits and food preparations (Sami et al., 2017)
  • Sedentary Lifestyle- The researchers discovered that as the amount of time spent sitting increased, so did the risk of type 2 diabetes and other chronic diseases. The tendency to be inactive has increased as a result of busy office occupations. People ride in vehicles to work, utilize lifts, and sit for long periods of time. Sedentariness is responsible for 64% of T2DM, and if people become more active, 62% of diabetes cases may be averted (Bertoglia et al., 2017)


2.1.3 signs and symptoms

Signs and symptoms of diabetes include frequent urination, excessive thirst, excessive hunger, weight loss, high blood sugars (MOH, 2020)

2.1.4 Complications of Diabetes mellitus

Diabetic patients are at a higher risk of developing life-threatening health complications. According to one study, patients with type 2 diabetes mellitus frequently have comorbidities and complications (Ekoru et al., 2019). Diabetes chronic complications are classified broadly as microvascular and macrovascular, with the former having a far higher prevalence than the latter (Deshpande et al., 2008). Neuropathy, nephropathy, and retinopathy are examples of microvascular problems, whereas cardiovascular disease, stroke, and peripheral artery disease are examples of macrovascular complications (PAD). Diabetic foot syndrome is characterized as the presence of a foot ulcer in conjunction with neuropathy, peripheral artery disease, and infection, and it is a leading cause of lower limb amputation (Tuttolomondo et al., 2015).The most prevalent comorbidity was shown to be renal impairment, whereas retinopathy was discovered to be the most common diabetes complication. Diabetic nephropathy and retinopathy impact around 25% of people with T2DM; diabetic neuropathy affects over 50% of the diabetic population; and erectile dysfunction affects 35% of diabetic men. T2DM duration, as well as glycemic, blood pressure, and cholesterol control, are all known risk factors for the development of these problems (Faselis et al., 2020). This stresses the importance of a screening and preventive program aimed at early, asymptomatic detection of comorbidities and the initiation of treatment, particularly for patients with longer disease duration (Jelinek et al., 2017) .Adults with type 2 diabetes are more likely to develop brain or mental problems such as stroke, dementia, and depression(van Sloten et al., 2020).

2.1.5 Control and management

Diabetes management’s long-term goal is to improve quality of life and prevent early mortality; the short-term goal is to ease symptoms and acute complications. Long-term objectives include achieving adequate glycemic, reducing concurrent risk factors, and treating chronic medication (Longo et al., 2019). Diabetes care necessitates the expertise of specialists as well as the active engagement of the patient. In Kenya, National Clinical Guidelines for Diabetes Management provides step-by-step assistance to health personnel in providing best care (MOPH 2010). They are based on clinical guidelines for diabetes management in Sub-Saharan Africa developed by the International Diabetes Federation (IDF) Africa. The goal of these guidelines is to provide simple and practical methods for assessing diabetic patients, making the correct diagnosis, and providing the best medication and care.

They also support health care clinicians in identifying regionally relevant and sustainable methods of improving diabetes treatment, as well as in mainstreaming diabetes management within the health care system. Poor awareness among diabetic patients, regardless of gender, is one of the factors influencing the progression of diabetes and associated complications, both of which are mostly avoidable. It is critical for all patients to understand the appropriate blood sugar range in order to avoid both short-term discomfort and long-term consequences. Frequent testing can assist patients in avoiding dangerously high or low blood sugar levels. Self-management is the cornerstone for achieving optimum diabetes control and avoiding diabetic complications by increasing knowledge and awareness of efficient diabetes management approaches. Patients must have access to appropriate medical care, the means to pay for services, and the knowledge and abilities to manage their diabetes on a daily basis for effective primary prevention of complications. As a result, socioeconomic mediators play a role in these processes. Control of diabetes entails both pharmacological and non-pharmacological interventions.  Non-pharmacological practices include; 

  • Physical activity- Physical activity increases insulin sensitivity. Physical activity not only improves glycemic management in T2DM patients, but it also lowers body weight and blood pressure. It improves the unfavorable lipid profile by lowering total cholesterol and low-density lipoprotein (LDL) cholesterol while boosting HDL cholesterol. This, in turn, lowers the risk of numerous cardiovascular events in T2DM patients(Raveendran et al., 2018).
  • Dietary modification- The blood glucose response to particular food items changes depending on the diet’s glycemic index (GI) and glycemic load (GL). Low GI diets lower postprandial blood glucose excursions, which improves glycemic management. Increasing dietary fiber intake also helps glycemic control. In T2DM, hypocaloric and low carbohydrate diets aid in weight management as well as metabolic control.(Jaworski et al., 2018)
  • Pharmacologic Therapy-Tablets and capsule e.g., metformin and daily Insulin Therapy.

2.2 Sociodemographic Factors

2.2.1 Age

Aging is a major risk factor for metabolic illnesses such as obesity, decreased glucose tolerance, and type 2 diabetes. Many studies have shown that the prevalence of type 2 diabetes rises with age (older persons are twice as likely as middle-aged adults to have the disease) and peaks between the ages of 60 and 74 (Ogurtsova et al., 2017)Most endocrine activities deteriorate over time, mainly owing to age, and this can cause major disruptions in metabolic homeostasis.

2.2.2 Sex

Many studies have also found that females had a higher DM prevalence than males(Peters & Woodward, 2018). Women also have relatively high levels of estrogen and progesterone, both of which can impair insulin sensitivity throughout the body. Furthermore, a study found that the frequency of physically inactive women was lower than that of men in all World Health Organization areas (WHO)

2.2.3 Marital Status

Studies have shown that having a partner participate in diabetes education programs improves outcomes when compared to people who do not have a spouse (Fottrell et al., 2018). A study carried out in Ethiopia suggested that married people were eleven times more knowledgeable while single people were nine times more knowledgeable than widowed people(Shiferaw et al., 2020). However, further research is needed to evaluate the relationship between marital status and level of knowledge. 

2.2.4 Level of education

Previous research has linked an increase in the prevalence of diabetes to lower educational attainment (Agardh et al., 2011). DM and educational level have been proven to be inversely related in studies from both developing and developed countries. It’s possible that this is because better-educated people are more inclined to be health-conscious (Steele et al., 2017) . Higher receptivity to health information and proper communication with healthcare practitioners are likely to result from education-based understanding. It was discovered that the lower the educational level, the greater the chance of developing T2DM (Agardh et al., 2011). Low educational attainment may have an impact on nutrition quality, physical inactivity, and unhealthy behaviors, thereby affecting diabetes clustering. Individuals with a higher education, on the other hand, maybe deemed to have more understanding on prevention, allowing them a greater ability to modify their lifestyle toward healthy behavior and effective utilization of health care systems(Herath et al., 2017) . The educational level is also highly related to adherence, with the greater the education level, the better the adherence to treatment regimens(Ishak et al., 2017). Respondents with a greater level of education would be able to receive other types of material, such as booklets and manuals, which would make them more aware of DM. Furthermore, this better educated group is more likely to be able to engage with health care providers about questions or concerns more easily(Shiferaw et al., 2020).

2.2.5 Economic status

Higher SES, self-efficacy, and quality of life were all connected with better diabetes outcomes. People with the least financial security are also more likely to get diabetes, and if they do, they lack access to critical services to help them manage their disease appropriately. Income is also proven to influence diabetes individuals’ utilization of health care. It is clear that the disease’s prevalence is increasing disproportionately with income level (Seiglie et al., 2020).

2.2.6 Exposure to Health Education

According to a study conducted in Debre, Ethiopia, people who received diabetic health education were nearly three times more knowledgeable than those who did not receive diabetes health education(Shiferaw et al., 2020). Inadequate health literacy is associated with worse glycemic control and higher rates of retinopathy in primary care patients with type 2 diabetes. Inadequate health literacy may contribute to disadvantaged populations bearing a disproportionate burden of diabetes-related problems. Patients with low educational attainment are more likely to have poor health literacy(Dahal & Hosseinzadeh, 2020).

2.3 Knowledge on Diabetes

Good diabetes control and the prevention of complications are heavily reliant on patient behavior, so it is preferable that patients have a comprehensive understanding of diabetes and its management(Ahmed et al., 2019). Most patients suffer from diabetes complications as a result of a lack of awareness. Diabetes education is a critical integral part of diabetes care(Gul, 2018). Diabetes patients who want to live their lives without constraints will need to learn a lot about their disease. Comprehensive patient education is required to provide the patient with the necessary self-management skills to achieve good glycemic control (Alanazi et al., 2018). According to epidemiologic data, a large number of patients do not receive the necessary care or education to develop such self-management abilities(Mikhael et al., 2019). To emphasize the importance of patient education, the American Diabetes Association (ADA) has designated self-management education as the cornerstone therapy for diabetes patients.  The importance of education in diabetes management is frequently discussed, but education is not provided to patients in standard clinical settings(Chinnappan et al., 2017). It will be difficult to control the diabetes epidemic unless people are educated and made aware of the problem. Diabetes education, awareness, and motivation for self-care not only improves care and reduces the burden of complications, but it also indirectly lowers the overall economic costs of diabetes(Mustapha et al., 2017). A population’s level of awareness about a condition, as knowledge is a critical component in behavior change. People are more likely to participate in prevention and control activities after they have gained knowledge(Chawla et al., 2019). Therefore, to better inform patients, families, and communities about this chronic disease, methods for increasing knowledge and awareness of diabetes must be integrated into existing healthcare systems and processes.

2.4 Perception


Perception is based on HBM. The HBM includes numerous basic principles that predict why people would take action to prevent, screen for, or control medical problems, such as susceptibility, seriousness, benefits and barriers to a behavior, cues to action, and, most recently, self-efficacy (Green et al., 2020). Individuals are more likely to take action if they believe they are susceptible to a condition, believe that condition has potentially serious consequences, believe that a course of action available to them would be beneficial in reducing either their susceptibility to or severity of the condition, and believe the anticipated benefits of taking action outweigh the barriers to (or costs of) action (Strecher et al., 1997). The goal of this paradigm is to change people’s perceptions of a health threat and to influence their behavior toward health. Similarly, it focuses on a person’s health-related behavior and certainty in predicting future actions. Within the Health Belief Model, the perceived risk of acquiring diabetes mellitus is regarded as the major motivation for change, with the assumption that the greater the perceived threat, the more likely an individual will adapt his or her behavior to avoid that threat.(DeBarr, 2004). It could be a powerful motivator for healthy lifestyle choices and disease management. Furthermore, according to this model, participation in preventive and screening programs is influenced by a variety of factors, including awareness of the impact of disease on their health (perceived severity), perceived benefits of undergoing preventive measures, and perceived barriers and costs of screening methods (Shabibi et al., 2017)However, it is critical to identify interventions that minimize people’s perceived barriers, regardless of their level of diabetes mellitus knowledge(Mohammadi et al., 2018) As a result, understanding people’s perspectives and beliefs is critical for establishing ways to prevent, control, and raise awareness of the disease’s health dangers.


Thus, the chapter on literature review delved deeply into the description of diabetes disease, risk factors, complications, control and management, socio-demographics, and knowledge and perception.



3.1 Introduction 

Chapter three will include the methodology which the researcher will use in the study. The chapter on research methodology includes the research design, the study area, the target population, the sample and the sample selection, inclusion and exclusion criteria, data collection instruments for collecting data, instrument’s validity, instrument’s reliability, the data collection procedure, the data analysis technique to be used and ethical consideration.

3.2 Research design

This study will adopt a Cross-sectional study design to assess knowledge and perceptions on Type 2 Diabetes among diabetic patients attending clinic at Karatina sub county hospital, Nyeri County. A descriptive cross-sectional study is one in which the disease or condition and potentially related factors are measured for a defined population at a specific point in time.

3.3 Study Area 

This study will be conducted in outpatient diabetes clinic at Karatina sub-county hospital which is located in Nyeri county. The hospital is a government funded level 4 hospital located approximately 2 km from Karatina town, Mathira East district. It is the only public hospital in Karatina and offers all level 4 hospital services including outpatient care: approximately 800 patients per day, clinics which run each on specific week days. The average number of patients who attend the clinic on a monthly basis is approximately 

3.4. Study Population 

The study population will include those patients attending the diabetes outpatient clinic at Karatina Subcounty hospital.

3.5       Inclusion and Exclusion Criteria

3.5.1    Inclusion Criteria

Patients with Type 2 diabetes receiving diabetes care at the diabetes unit’s outpatient department.

Voluntary informed consent to participation was a requirement and allowed to participate only after consenting.

3.5.2    Exclusion Criteria

Those patients suffering from a severe disease that prevents them from responding to questionnaires, those unable to communicate.

3.6        Sample size calculation

The Fisher et al. 1998 formula will be used to determine the sample size. Estimates number of diabetic patients who attends karatina sub-county Hospital clinic  is approximately 130 on monthly clinics that are conducted on Tuesdays and Fridays weekly(MOH 204 B).

Thus the calculation is: 


 z = is the Z value for the corresponding confidence level (i.e., 1.96 for 95% confidence); 

d = is the margin of error (i.e., 0.05 = ± 5%)

p = is the estimated value for the proportion of a sample that have the state of interest and in this case, in this case a proportion of 12.6 will be used.






For a population less than 10,000 the following formula by Fisher et al. (1998) is used; 

nf =     __n__

         1+ (n/N) 

Where nf represents desired sample of population, < 10,000

is the sample when the total population is more than 10,000 

is the estimated number of patients attending outpatient clinic monthly (130)

nf = 169.22÷ (1+ 169.22/130) = 73.5

Therefore, a sample size of 74 diabetic patients.





3.7 Sampling technique

Convenience sampling method used in the study to obtain 74 participants.

  1. Pretesting

    Pretesting to be conducted on 10% of sample size one week prior to actual data collection period at Nyeri General Hospital. This will ensure that the research instrument is accurate in terms of collecting relevant data and information required in the study


3.8.2    Participants Consenting Procedures

Those participants who will meet the requirements of inclusion and exclusion criteria will participate in research. According to the government policy of Kenya, consent can only be given by persons above the age of 18. The procedure and the objectives of the research will be explained to the participants. Once they agree to participate in the research, they will be asked to sign the consent forms. In case the participant is below the age of 18yrs, then informed consent will be given by the parent or guardian. Informed consent process may take the form of verbal informed consents or the written consents. For the verbal consent, the following steps will be initiated: first, the study is explained to the participant, providing all information concerning the purpose, the procedures, risks, benefits, alternatives to participation, etc. and the participant is given an opportunity to ask questions. Secondly, following the verbal communication, the study information sheet is given to the participant and the participant is given sufficient time to understand the sheet and hence decide whether or not to participate in the study. After the patient has read the study sheet, he/she may ask any additional questions so as to get additional clarification.

In written consent, the consent document will be used as a guide for explanation of the study, and not the substitute for the will involve: giving the participant adequate information about the study, providing an adequate opportunity for the participant to consider all the options and hence select appropriate one without any influence, responding to the questions of the participants, obtaining the participants agreement to take part in the study. The written form will then be signed by the participant to take part in the study. The researcher will also sign the consent form clearly indicating the date on which the agreement was reached. The subject will be provided with a copy of the consent form for reference purposes.



3.9       Data Collection Instrument and measurement Procedures

                        3.9.1    Study Instrument

Questionnaires: Data from individuals willing to participate in the study will be collected using structured questionnaires so as to obtain quantitative data. The following questionnaires will be used to collect data. A data collection tool based on the Health Belief Model will be used to collect data from previous similar literature that contained socio-demographic data, knowledge, and perceptions. Furthermore, the three-part data collection tool was created with the study objectives in mind. The first section of the questionnaire focuses on sociodemographic information such as age, gender, marital status, level of education, occupation, average family monthly income, family history of diabetes mellitus, exposure to diabetes health education, and source of health information. The second part will assess the study participants’ level of knowledge about diabetes mellitus and their understanding of various aspects of DM, such as definition, causes/risk factors, signs/symptoms, control, and management. Respondents will select one of three options: “yes,” “no,” or “I don’t know.” Correct responses to receive one point, while “No” or “I don’t know” responses received zero points. All respondents who score below the mean on knowledge questions will be considered to have poor knowledge, whereas those who score above the mean on knowledge questions will be considered to have good knowledge. The third section of the tool addresses perceptions of diabetes based on the constructs of the Health Belief Model scale, which has five subscales: Three items will be used to assess people’s perceived susceptibility to disease. Four items will be used to assess the perceived seriousness of DM in the second. Five items will be used to assess the perceived benefits of undergoing a preventive measure and screening. Finally, five items will be used to assess perceived barriers to screening and a healthy lifestyle. All subscale items have five-point Likert-type response options: Strongly Agree (5 points), Agree (4 points), Neutral (3 points), Disagree (2 points), and Strongly Disagree (1 point). As a baseline, the perception will be classified as agree, neutral, or disagree. Each subscale to be evaluated independently, and the total score not computed. For each construct, subscale scores will be computed. Higher scores indicate more positive feelings toward that construct.


3.9.2    Data Collection and measurements Procedures 

In collecting data, introductory letter to be obtained from the Dedan Kimathi University of Technology (DKUT). Permission from the Karatina hospital administration to be sought. The hospital administration to forward the researcher to the relevant departments, i.e., the outpatient department. The purpose of the study is to be explained to the administration of the hospital and questionnaires and informed consent obtained.


  3.10. Validity and reliability

Validity in research is described as the proper tools to be used to evaluate the variables while reliability is defined as the research tool provides steady and consistent findings (Leung, 2015). Validity and reliability will be adhered to in the following ways: similar questionnaires will be used for all the respondents, the reason for the research explained to the participants and they will be required to sign the informed consent after understanding the purpose of the research, a pre-test will be conducted to ensure correctness of the study tool and, all ambiguous questions will be explained to the respondents in order to promote understanding.

3.12 Data management, analysis and presentation

After data collection, responses will be carefully cross-checked to detect errors and omissions, consistency and completeness. The data collected will be systematically arranged according to the questionnaire codes to facilitate analysis. Each question will be coded and labeled into variables for entry and computation into Microsoft excel for accuracy and completeness then transferred to  STATA software version 9.10. Data will be analyzed for means, frequency and percentage 


3.13     Ethical Considerations

An introductory letter from Dedan Kimathi University, School of Nursing. Permission to conduct the study will be obtained from Hospital Director’s office, Karatina Subcounty Hospital

Prior to the study, participants’ informed full consent should be obtained.

The confidentiality of research participants must be protected. A sufficient level of confidentiality for the research data must be ensured.

Individuals taking part in the research must remain anonymous.

Particularly the rights of the participants should prevail over the interests of this research, the research to be safely conducted and the participants to be able to consent.

Justice will be ensured by making sure that all the participants are equally treated regardless of social classes.

All the participants will be respected regardless of their age and they will be addressed informal language.

 Beneficence will also be observed since the data provided by the participants will be used to improve their health and to come up with more effective treatment modalities. 

Researcher informed the participants on confidentiality of all the study materials.



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Questionnaire ID No.__________ 

Instruction: Please  fill in the blank space that the respondent best describe.

Part-I: Respondent’s socio-demographic information

  1. Sex
  2. Age
  3. Marital status
  4. Level of education 
  5. Occupation
  6. Average family monthly income
  7. Exposure to health education about DM
  8. If “Yes” for Q-106 your sources of information? 
  9. Family history of DM



Part-II:  Knowledge questions related to DM

  1. What is/are DM?
  2. What are the risk factors of DM?
  3. What are the signs and symptoms of DM?
  4. Control and management of DM
  5. What are the complications of diabetes?


Part III.  Questions on Perception about diabetes mellitus based on HBM

  1. What are the chances of developing diabetes complications in future?
  2. What do you do to prevent developing diabetes complications?
  3. What do you think controls your diabetes condition?
  4. Do you think the diabetic medications are of any help?
  5. What are the barriers to screening and healthy lifestyle?
  6. Do you think there is a need for people to know about DM?
  7. Do you think DM is curable?
  8. Do you think that someone with DM can live life in full?
  9. How serious your diabetes will have a bad effect on your future health?





Transport fees: 


from my area of residence to and my area of study



from my area of residence to the area of study to conduct a pre-visit

 KSH. 200/=


Data access fee


Internet access Wi-Fi /bundles ksh 500/=



Printing and photocopy Printing and photocopying of relevant materials for research e.g. questionnaires, consent forms etc. KSH. 1000/=
Lunch  During data collection 600

                                                                                                     Total: 3300/=


Questionnaire ID No.__________ 

Instruction: Please  fill in the blank space that the respondent best describe.

Part-I: Respondent’s socio-demographic information

  1. Sex
  2. Age
  3. Marital status
  4. Level of education 
  5. Occupation
  6. Average family monthly income
  7. Exposure to health education about DM
  8. If “Yes” for Q-106 your sources of information? 
  9. Family history of DM



Part-II:  Knowledge questions related to DM

  1. What is/are DM?
  2. What are the risk factors of DM?
  3. What are the signs and symptoms of DM?
  4. Control and management of DM
  5. What are the complications of diabetes?


Part III.  Questions on Perception about diabetes mellitus based on HBM

  1. What are the chances of developing diabetes complications in future?
  2. What do you do to prevent developing diabetes complications?
  3. What do you think controls your diabetes condition?
  4. Do you think the diabetic medications are of any help?
  5. What are the barriers to screening and healthy lifestyle?
  6. Do you think there is a need for people to know about DM?
  7. Do you think DM is curable?
  8. Do you think that someone with DM can live life in full?
  9. How serious your diabetes will have a bad effect on your future health?






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