PLOS ONE

RESEARCH ARTICLE

Factor structure of the diabetes knowledge

questionnaire and the assessment of the
knowledge of risk factors, causes,
complications, and management of diabetes
mellitus: A national population-based study in
Singapore
Kumarasan Roystonn ID1*, P. V. AshaRani1, Fiona Devi Siva Kumar1, Peizhi Wang1,
a1111111111
Edimansyah Abdin1, Chee Fang Sum2, Eng Sing Lee3,4, Siow Ann Chong1,
a1111111111
Mythily Subramaniam1,5
a1111111111
a1111111111 1 Research Division, Institute of Mental Health, Singapore, Singapore, 2 Clinical Research Unit, Diabetes
a1111111111 Centre, Admiralty Medical Centre, Singapore, Singapore, 3 Clinical Research Unit, National Healthcare
Group Polyclinics, Singapore, Singapore, 4 Lee Kong Chian School of Medicine, Nanyang Technological
University, Singapore, Singapore, 5 Saw Swee Hock School of Public Health and Department of Medicine,
National University of Singapore, Singapore, Singapore

* [email protected]
OPEN ACCESS

Citation: Roystonn K, AshaRani PV, Siva Kumar

FD, Wang P, Abdin E, Sum CF, et al. (2022) Factor Abstract
structure of the diabetes knowledge questionnaire
and the assessment of the knowledge of risk This study evaluated the knowledge of diabetes mellitus and predictors of the level of diabe-
factors, causes, complications, and management
of diabetes mellitus: A national population-based
tes knowledge among the general public of Singapore. Confirmatory factor analysis and
study in Singapore. PLoS ONE 17(8): e0272745. exploratory factor analysis were used to evaluate the fit of different factor models for the dia-
https://doi.org/10.1371/journal.pone.0272745 betes knowledge questionnaire. Multiple linear regressions were performed to determine
Editor: Muhammad Sajid Hamid Akash, the sociodemographic characteristics associated with diabetes knowledge. The final factor
Government College University Faisalabad, model identified three domains for diabetes knowledge: general knowledge, diabetes spe-
Pakistan, PAKISTAN
cific knowledge and causes of diabetes, and complications of untreated diabetes. Overall
Received: March 30, 2022 knowledge scores were 23.8 ± 2.4 for general diabetes knowledge, 2.3 ± 0.8 for diabetes
Accepted: July 26, 2022 specific knowledge, 2.3 ± 1.2 for causes, and 5.2 ± 1.2 for complications of untreated diabe-
Published: August 10, 2022
tes. Patients with diabetes were more knowledgeable than adults without diabetes in the
population. While the general public in Singapore has adequate knowledge of diabetes, mis-
Copyright: © 2022 Roystonn et al. This is an open
access article distributed under the terms of the
conceptions were identified in both groups which underscores the need to tailor specific edu-
Creative Commons Attribution License, which cational initiatives to reduce these diabetes knowledge gaps.
permits unrestricted use, distribution, and
reproduction in any medium, provided the original
author and source are credited.

Data Availability Statement: Data cannot be

shared publicly because of ethical and institutional
regulations. Data are available from the Institute of Introduction
Mental Health Institutional Research Review
Committee (contact via [email protected]) for
Diabetes mellitus is a complex and chronic disease associated with a state of chronic high
researchers who meet the criteria for access to blood glucose level, or hyperglycaemia. Diabetes comprises mainly two types, Type 1(insulin
confidential data. dependent) and Type 2 (non-insulin dependent) [1]. Type 2 diabetes affects more than 400

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PLOS ONE Assessment of diabetes knowledge in the general population of Singapore: A KAP study

Funding: This work was supported by the National million people around the world. By 2040, it is projected that there will be more than 640 mil-
Medical Research Council of Singapore, grant lion people with diabetes worldwide [2–4]. To date, the International Diabetes Federation has
number NMRC/HSRG/0085/2018. The funders had
estimated that Asia accounts for 60% of the world’s population with diabetes, with more than
no role in study design, data collection and
analysis, decision to publish, or preparation of the 50% of persons with type 2 diabetes being undiagnosed [4]. In Singapore, as in other countries
manuscript. in Asia, diabetes is a major public health concern [5]. In 2017, diabetes was the seventh leading
cause of morbidity and premature mortality in Singapore [6].
Competing interests: The authors have declared
that no competing interests exist. The development of Type 2 diabetes involves multiple factors and mechanistic pathways,
notably epigenetics, defective insulin activity, glucotoxicity, lipotoxicity, inflammation, oxida-
tive stress, and pancreatic β-cell dysfunction [6–11]. Environmental and lifestyle, as well as
genetic factors, can increase the risk of diabetes. Lifestyle factors including diet quality and
quantity, weight, and physical activity (i.e., excessive calorie intake, high fat diets, and
increased sedentary lifestyles) can lead to obesity and insulin resistance [12, 13]. The well-rec-
ognised symptoms of diabetes are polyuria, polydipsia and polyphagia [14]. Other symptoms
include tiredness, recurrent infections, slow-healing wounds, blurred vision and gastrointesti-
nal complications. Diabetes can further result in damage to various organs including the eyes,
heart and blood vessels, and kidneys, leading to diabetic neuropathy, blindness, heart diseases
and renal disorders [15]. Although it is well established that individuals can improve their dis-
ease outcomes and reduce the risk of complications by taking precautionary measures such as
lifestyle modifications [16], and regular monitoring of blood glucose levels (e.g., Haemoglobin
A1c; HbA1c) [17, 18], many people become aware that they have diabetes only after complica-
tions such as vision loss and renal complications manifest [19]. Early awareness of diabetes
risk thus provides an opportunity to introduce preventive interventions to stop or delay the
disease onset [20, 21].
Knowledge, attitude and practice (KAP) studies on diabetes worldwide have increasingly
demonstrated the importance for greater awareness of diabetes symptoms, risk factors, suitable
lifestyle practices and regular monitoring of blood glucose levels [22–25]. There are several
studies which have examined the knowledge of diabetes among Asian populations [25–27].
However, these studies were often conducted in small, community or clinic-based samples
and focused mainly on patients diagnosed with diabetes [26–29]. To date, there have been sev-
eral other studies in Asia which have evaluated diabetes related knowledge among adults with
diabetes and those without diabetes [30–33]. Yet, to our best knowledge, no other research has
thoroughly examined the current level of knowledge of diabetes in a national population-
based study in Singapore. Therefore, the current study aimed to assess the level of diabetes
related knowledge among adults with diabetes and those without diabetes in the general popu-
lation and evaluate the predictors associated with diabetes knowledge in Singapore.

Materials and methods

Sample and procedures
The present cross-sectional study is part of a larger, national population-based KAP study of
diabetes among Singapore residents [34]. The sample was randomly selected via a dispropor-
tionate stratified sampling design from a national database of Singapore citizens and perma-
nent residents (aged 18 years and above). In addition, certain minority sub-populations (i.e.,
Malay and Indian ethnic groups, and those aged 65 years and above) were oversampled to
improve the reliability of the parameter estimates for these groups.
The randomly selected residents were sent notification letters followed by home visits by a
trained interviewer from a survey research company to obtain their informed consent to par-
ticipate in the study. For residents who agreed to participate, face-to-face interviews were con-
ducted in their preferred language (English, Mandarin, Malay, or Tamil). Responses were

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PLOS ONE Assessment of diabetes knowledge in the general population of Singapore: A KAP study

captured using computer-assisted personal interviewing. Individuals who could not be con-
tacted due to incomplete or incorrect addresses, living outside of the country, institutionaliza-
tion, or hospitalization at the time of the survey, as well as, individuals who were incapable of
participating due to language barriers or severe physical or mental conditions were excluded
from the study. The study commenced in February 2019 but was temporarily suspended from
March 2020 –July 2020 due to the lockdown phase in response to the Coronavirus pandemic
in Singapore. The study resumed in August 2020 and was completed in September 2020,
achieving a sample size of 2895 and a study response rate of 66.2%. Written informed consent
was obtained from all participants prior to the survey and all study procedures. The study pro-
tocol and the study questionnaire were approved by the ethics committee, National Healthcare
Group Domain Specific Review Board (DSRB No. 2018/00463).

Diabetes knowledge questionnaire

The diabetes knowledge questionnaire was developed based on literature review and validated
by a panel of healthcare professionals who were experts in diabetes care and treatment [34].
Pretesting of the questionnaire was performed to evaluate the questionnaire’s readability, clar-
ity, acceptability and consistency among the population by ensuring a good representation
across age, gender, ethnicity and education of the sample. The questionnaire was also trans-
lated and tested in Mandarin, Malay, and Tamil. The diabetes knowledge questionnaire of 29
items, included questions on general diabetes knowledge, causes of diabetes, and likely compli-
cations of untreated diabetes. Sociodemographic information such as age, gender, ethnicity,
education, marital status, monthly personal income, and employment status were also
collected.

Statistical analysis
All analyses were conducted with Stata version 15 and Mplus version 8.2. Weighted means
and standard deviations are presented for continuous variables, while frequencies and
weighted percentages are displayed for categorical variables. To ensure representativeness of
the data to the general population, the survey sample was weighted by age and ethnicity to
account for the complex survey design.
Factor analysis of the diabetes knowledge questionnaire. A series of exploratory factor
analyses (EFA) and confirmatory factor analyses (CFA) were conducted with the diabetes
knowledge questionnaire. In Mplus, the CFA was first estimated and tested to evaluate the fac-
tor structure of the questionnaire. As there were items on the questionnaire measured on an
ordinal or binary scale, a weighted-least-squares with a mean-adjusted and variance-adjusted
(WLSMV) estimator was used to model the observed polychoric/tetrachoric correlation matrix
(the categorical option) with a pairwise deletion of missing data. However, due to the poor fit
of the initial CFA model, subsequent analyses were performed with approximately two split-
half samples (n = 1447; n = 1448) randomly generated from the study sample.
Using the WLSMV estimator in the factor analysis, pairwise deletion of missing data and
an oblique geomin rotation were conducted to explore the dimensionality of the first half-sam-
ple (n = 1447). The following criteria were utilized to determine the number of factors in the
EFA: (i) eigenvalues > 1 (ii) visual inspection of scree plot, (iii) identification of satisfactory
factor loadings on each factor (i.e., loadings >0.3, no cross-loadings), and (iv) the robustness
of interpretability for each solution. During each analysis, the factor loading of the question-
naire items were explored. Each rotated solution was examined in order to identify and
remove items based on the following ranked criteria: (i) consistently low loadings of <0.3

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PLOS ONE Assessment of diabetes knowledge in the general population of Singapore: A KAP study

across all factor models, (ii) consistently cross-loading across all models, (iii) lowest loading,
and (iv) cross-loading.
Derived factors from the EFA were then validated using CFA in the second half-sample
(n = 1448). A WLSMV estimator was applied to examine the underlying polychoric correlation
matrix. The following fit indices were utilized to compare the overall fit of the models and
their complexities: (i) root mean square error of approximation (RMSEA), (ii) comparative fit
index (CFI), (iii) Tucker-Lewis index (TLI). Both the CFI and TLI values range from 0 to 1,
with higher values representing better fit; CFI values above 0.95 and TLI values above 0.90
were considered to be of excellent fit [35]. With regards to the RMSEA, values below 0.08 indi-
cate moderate fit, while values of 0.05 or less indicate close fit to the observed data [36]. Stan-
dardized root mean squared residual values (SRMR) were also evaluated, which indicate
acceptable fit when values are smaller than 0.08 and excellent fit when values are smaller than
0.05 [35, 36]. Internal consistency of each scale was evaluated using the composite reliability
values for the best fitting model for the full sample, where the acceptable level was set at 0.70 or
greater [37]. Multiple linear regressions were conducted within the full sample to examine the
sociodemographic correlates (i.e., age, gender, ethnicity, education, marital status, employ-
ment, personal monthly income, and diabetes diagnosis) of each factor.

Results
Sociodemographic characteristics and the respective weighted percentages of the sample are
reported in Table 1. Of the 2895 participants, 823 (29.9%) were aged 21–34 years; 1474 (51.6%)
were female; 796 (75.8%) were Chinese; 1860 (61.7%) were married or cohabiting; and 637
(20.4%) had primary level education and below. Also, 436 (9.1%) were diagnosed with diabetes
and 2459 (90.9%) were not diagnosed with diabetes in this study.

Factor structure of the diabetes knowledge questionnaire

An initial CFA was conducted on the 29-item diabetes knowledge questionnaire within the
full sample, utilizing a four first-order factor structure. However, this indicated a poor fit to
the data (WLSMV χ2 = 1685.75, RMSEA = 0.03, CFI = 0.73, TLI = 0.70, SRMR = 0.11).
Descriptive information of all 29 items of the diabetes knowledge questionnaire can be found
in S1 Appendix. An inspection of the initial EFA results, the correlation matrix, as well as the
conceptual similarities among respective items in the half-sample (n = 1447) revealed that the
questionnaire conformed well to a three-factor model. The three-factor model was then uti-
lized for subsequent analyses. A series of EFAs were conducted to examine the underlying fac-
tor structure of each of the domains.
For Domain A, the plot of eigenvalues of the initial 10 items indicated that either a one-fac-
tor or two-factor solution was plausible. Upon examining the rotated factor models, four items
were removed due to a consistently low loading of < 0.3 and cross-loadings. This led to a sin-
gle factor solution of six items for the general knowledge (GK) scale, which was found to be
optimal. A CFA of this six-item unidimensional model resulted in an acceptable fit
(WLSMVχ2(9) = 40.78; RMSEA = 0.05; CFI = 0.96; TLI = 0.93; SRMR = 0.03). A total score
was calculated by summing all items, with higher scores indicating higher knowledge. The
composite reliability value for GK was acceptable at 0.71.
For Domain B, eigenvalues for the underlying correlation matrix indicated that a one-factor
to three-factor solution was plausible. After an examination of the rotated factor solutions, two
items were removed due to consistently low loadings of <0.3 and cross-loadings. A two-factor
solution comprising diabetes specific knowledge (DK) and knowledge of causes of diabetes
(CK) was found to be optimal. A CFA of the two-factor solution indicated an acceptable fit:

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PLOS ONE Assessment of diabetes knowledge in the general population of Singapore: A KAP study

Table 1. Sociodemographic characteristics of the sample (n = 2895).

N (sample) Weighted %
Age group
21–34 823 29.9%
35–49 719 28.2%
50–64 774 26.8%
65 and above 579 15.1%
Gender
Female 1,474 51.6%
Male 1,421 48.5%
Ethnicity
Chinese 796 75.8%
Malay 974 12.7%
Indian 918 8.6%
Others 207 2.9%
Education
Primary and below 637 20.4%
Secondary School 684 20.3%
Pre-University/Junior College 126 4.8%
Vocational Institute/ITE 267 6.6%
Diploma 479 18.5%
Degree, Professional Certification and above 702 29.5%
Marital status
Married/cohabiting 1,860 61.7%
Single 731 29.2%
Divorced/separated 154 5.0%
Widowed 149 4.1%
Employment
Employed 1,933 70.5%
a
Economically inactive 829 25.4%
Unemployed 133 4.1%
Monthly personal income (SGD)
Below 2,000 1,455 45.3%
2,000 to 3,999 698 23.9%
4,000 to 5,999 318 12.8%
6,000 to 9,999 183 7.8%
10,000 & above 117 5.7%
Undisclosed 124 4.5%
Diabetes diagnosis
No diabetes 2459 90.9%
Has diabetes 436 9.1%

Frequencies and percentages may not tally to 100% due to missing data.
a
Economically inactive includes retired, homemaker, student, and the physically disabled.

https://doi.org/10.1371/journal.pone.0272745.t001

(WLSMVχ2(13) = 24.34, RMSEA = 0.03, CFI = 0.94, TLI = 0.9, SRMR = 0.06). Scores on the
domain were generated by summing the correct responses on the respective items, with higher
scores indicating higher knowledge. The composite reliability of DK and CK was poor, at 0.50
and 0.66 respectively.

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PLOS ONE Assessment of diabetes knowledge in the general population of Singapore: A KAP study

Table 2. Fit statistics of the final CFA models for each domain of the diabetes knowledge questionnaire (19 items).
Final model (Domain A)
Fit statistics of CFA model Item description Standardized Factor
Loading
WLSMV χ2 (df 40.78, General knowledge of diabetes (GK)
9) p < 0.001
RMSEA 0.049 Diabetes can be prevented. 0.446
CFI 0.959 Diabetes is treatable. 0.452
TLI 0.932 Lipid (e.g., Cholesterol) and blood pressure control is necessary in diabetic patients. 0.519
SRMR 0.026 Achieving your ideal weight helps control diabetes. 0.703
High fibre foods (e.g., wholegrain, oatmeal, broccoli etc) help to keep blood sugar levels steady. 0.573
If untreated, diabetes can reduce a person’s life-expectancy (an average time a person is expected to live, 0.521
based on their current age and other demographic factors including gender).
Final model (Domain B)
Fit statistics of CFA model Item description Standardized Factor
Loading
WLSMV χ2 (df 24.338, Diabetes specific knowledge (DK)
13) p = 0.028
RMSEA 0.025 A fasting blood sugar level of 13millimoles per litre (>200miligrams/ 100millilitres) is too high 0.509
CFI 0.938 There are two main types of diabetes: Type 1 (insulin-dependent) and Type 2 (non-insulin dependent). 0.618
TLI 0.9 Lack of insulin in blood 0.362
SRMR 0.06 Causes of diabetes (CK)
Eating less sugar 0.456
High blood pressure 0.561
Mental stress 0.548
Underweight 0.701
Correlation coefficient between two latent factors -0.298
Final model (Domain C)
Fit statistics of CFA model Item description Standardized Factor
Loading
WLSMV χ2 (df 23.14, Complications of untreated diabetes (CPK)
9) p = 0.006
RMSEA 0.033 Kidney damage / Kidney failure 0.699
CFI 0.964 Heart failure 0.847
TLI 0.94 Stroke 0.802
SRMR 0.063 Loss of feeling in the hands, fingers and feet 0.591
Cuts and other minor injuries heal more slowly 0.499
Oral health problems 0.547

All standardized factor loadings were significant at p < 0.001

https://doi.org/10.1371/journal.pone.0272745.t002

For Domain C, the plot of eigenvalues for the underlying correlation matrix suggested a
one-factor to three-factor solution. However, upon inspection of the EFA solutions, four items
were removed due to consistently low loadings of <0.3 and cross-loadings, and a unidimen-
sional structure for complications of untreated diabetes (CPK) was found to be most optimal.
The CFA of this six-item unidimensional model indicated an acceptable fit: (WLSMVχ2(9) =
24.14, RMSEA = 0.03, CFI = 0.96, TLI = 0.94, SRMR = 0.06). A score was calculated by sum-
ming the number of correct responses of all items on the CPK scale, with higher scores indicat-
ing higher knowledge. The composite reliability of CPK was high at 0.83.
The statistical fit of the final models and domains are presented in Table 2. The final
19-item questionnaire consists of three knowledge domains: Domain A, a single factor

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PLOS ONE Assessment of diabetes knowledge in the general population of Singapore: A KAP study

model consisting of six items on the general knowledge of diabetes (GK), measured on a
five-point Likert scale ranging from strongly agree to strongly disagree; Domain B, a two-
factor model with binary response options of correct and incorrect, consisting of a 3-item
sub-scale on diabetes specific knowledge (DK) and a 4-item sub-scale on the causes of dia-
betes (CK); and Domain C, a single factor model consisting of six items on the complica-
tions of untreated diabetes (CPK) measured on binary response options of correct and
incorrect.

Sociodemographic determinants of diabetes knowledge

Table 3 presents the weighted percentages of the responses on the diabetes knowledge ques-
tionnaire. Overall, mean (± SD) knowledge scores on the respective sub-scales were 23.8 ± 2.4
(out of 30) for GK, 2.3 ± 0.8 (out of 3) for DK, 2.3 ± 1.2 (out of 4) for CK, and 5.2 ± 1.2 (out of
6) for CPK. Almost all (98.1%) of the participants knew that cuts and other minor injuries heal
more slowly in persons with diabetes. The majority (92.0%) of participants were also aware
that kidney damage or kidney failure were likely complications of untreated diabetes. Most
participants thought that high blood pressure (66.3%) and mental stress (54.9%) cause diabetes
(Table 3).
From Fig 1, both the participants with diabetes (90.9%), and those without diabetes
(92.5%), were aware that if left untreated, diabetes can reduce one’s life expectancy. Partici-
pants without diabetes (42.1%) were not aware of high blood sugar levels, while 83.3% of par-
ticipants with diabetes knew that a blood sugar level of 13 millimoles per litre is too high. Of
the 2459 participants without diabetes, 16.6% were not aware that there are two main types of
diabetes (Type 1 and Type 2), compared to 88.6% of participants with diabetes who knew this
(Fig 1). While participants with no diabetes (86.6%) and those diagnosed with diabetes
(83.8%) both knew that diabetes can be prevented, about 13.3–16.8% of the participants with-
out diabetes were unaware that high fibre food, and having good weight and lipid control
helps to control diabetes (Fig 1).
Results of the multiple linear regression analyses are presented in Table 4. After accounting
for listwise deletion of missing data, respective cases in the multiple linear regression model
for GK was n = 2677, DK was n = 1786, CK was n = 2586, and CPK was n = 2532.
The multiple linear regression analyses revealed significantly higher GK and DK scores
among ethnic minorities, i.e., Malays [GK (β = 0.83, p< 0.01); DK (β = 0.18, p< 0.01)] and
Indians [GK (β = 0.91, p< 0.01); DK (β = 0.26, p< 0.01)] as compared to the Chinese. DK
was additionally found to be higher among those with diabetes (β = 0.22, p = 0.01) compared
to those without diabetes. CK was particularly high among those who were single (β = 0.21,
p = 0.03) while CPK scores were significantly higher among ethnic Malays (β = 0.16,
p = 0.02), Indians (β = 0.14, p = 0.03), and Others (β = 0.43, p< 0.01) (vs. Chinese). GK
scores were negatively associated with being single (β = -0.62, p< 0.01), unemployed (β =
-0.91, p = 0.01), or having lower levels of education (primary or lower (β = -0.77, p< 0.01),
secondary (β = -0.78, p< 0.01), vocational training (β = -0.61, p = 0.04) vs. degree and
above).
DK scores were significantly lower among those who were single (β = -0.21, p = 0.01), had a
higher personal income ($6,000 - $9,999) (β = -0.26, p = 0.05), and secondary education (β =
-0.23, p = 0.03) or vocational training (β = -0.26, p = 0.03). Also, CK scores were significantly
lower among Indians (β = -0.22, p< 0.01), those with lower personal income ($2,000 - $3,999)
(β = -0.20, p = 0.03), and those with secondary education (β = -0.25, p = 0.03) or primary edu-
cation and below (β = -0.54, p< 0.01). Also, males (β = -0.19, p = 0.01), and being single (β =
-0.33, p< 0.01) were significantly associated with lower scores for CPK.

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PLOS ONE Assessment of diabetes knowledge in the general population of Singapore: A KAP study

Table 3. Weighted percentages of responses on the diabetes knowledge questionnaire (19 items).
General knowledge of diabetes (GK)
Strongly Agree Neither Disagree Strongly Don’t
Agree Disagree Know
n % n % n % n % n % n %
1. Diabetes can be prevented. 651 20.5% 1,854 65.7% 219 8.3% 149 5.0% 11 0.5% 11 0.1%
2. Diabetes is treatable. 461 12.8% 1,997 66.9% 231 9.3% 177 9.7% 22 1.2% 7 0.2%
3. Lipid (e.g., Cholesterol) and blood pressure control is necessary in diabetic patients. 582 16.3% 2,000 70.0% 189 8.2% 83 3.8% 5 0.1% 36 1.6%
4. Achieving your ideal weight helps control diabetes. 588 17.2% 1,904 65.4% 204 8.7% 164 7.0% 11 0.5% 24 1.1%
5. High fibre foods (e.g., wholegrain, oatmeal, broccoli etc) help to keep blood sugar levels 551 16.3% 1,984 68.4% 224 8.8% 71 3.8% 6 0.1% 59 2.6%
steady.
6. If untreated, diabetes can reduce a person’s life-expectancy (an average time a person is 678 21.6% 1,930 70.7% 140 3.4% 115 3.7% 23 0.5% 9 0.2%
expected to live, based on their current age and other demographic factors including
gender).
Diabetes specific knowledge (DK)
Incorrect Correct Don’t Know
n weighted % n weighted n weighted
% %
1. A fasting blood sugar level of 13millimoles per litre (>200miligrams/ 100millilitres) is 603 24.8% 1,339 38.2% 953 37.0%
too high
2. There are two main types of diabetes: Type 1 (insulin-dependent) and Type 2 (non- 353 13.7% 2,201 71.3% 341 15.1%
insulin dependent).
3. Lack of insulin in blood (likely causes diabetes) 317 10.8% 2,326 80.6% 252 8.6%
Causes of diabetes (CK)
Please indicate the likely causes of diabetes: Incorrect Correct Don’t Know
n weighted % n n weighted n
%
1. Eating less sugar 542 18.1% 2,343 81.5% 10 0.4%
2. High blood pressure 1,821 63.5% 970 33.7% 104 2.8%
3. Mental stress 1,622 51.5% 1,178 45.1% 95 3.4%
4. Underweight 1,073 32.8% 1,743 64.7% 79 2.6%
Complications of untreated diabetes (CPK)
Please indicate the likely complications of untreated diabetes: Incorrect Correct Don’t Know
n weighted % n n weighted n
%
1. Kidney damage / Kidney failure 164 6.2% 2,675 92.0% 56 1.8%
2. Heart failure 533 20.9% 2,263 75.9% 99 3.2%
3. Stroke 556 22.5% 2,256 74.9% 83 2.7%
4. Loss of feeling in the hands, fingers and feet 287 13.0% 2,535 84.4% 73 2.6%
5. Cuts and other minor injuries heal more slowly 66 1.7% 2,816 98.1% 13 0.2%
6. Oral health problems 342 11.9% 2,425 83.4% 128 4.7%
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Discussion
This study aimed to examine the general public’s level of knowledge of diabetes among indi-
viduals diagnosed with diabetes and those without diabetes in Singapore. In this study, partici-
pants’ knowledge was assessed based on their understanding of diabetes, which included the
likely causes, risk factors, symptoms, and complications of diabetes. Overall, despite a lack of
awareness in certain aspects, this study found that there was adequate knowledge of diabetes
among adults with no diabetes and those with diabetes in the whole population.
This finding is in line with other studies [32, 38–40], which reported better scores on diabe-
tes related knowledge among those with diabetes compared to individuals with no diabetes.

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PLOS ONE Assessment of diabetes knowledge in the general population of Singapore: A KAP study

Fig 1. Assessment of diabetes knowledge among participants with diabetes and those without diabetes.
https://doi.org/10.1371/journal.pone.0272745.g001

These patients could have received diabetes health education during their interactions with the
healthcare system. Thus, an encouraging explanation of these high scores among persons with
diabetes could be that they reflect the quality of diabetes education received at the diabetes
clinics where patients attend regularly.
One possible reason for the knowledge deficiencies observed in the current study may be
attributed to misconceptions surrounding certain issues like the risk factors and preventative
measures related to diabetes. In this study, Singaporeans were generally able to identify the
symptoms and complications of diabetes, though they were not as well versed in the risk fac-
tors that may lead to the disease. Majority of the participants in this study, believed that high
blood pressure and mental stress are likely causes of diabetes, which are one of the most com-
mon misconceptions reported in other population studies as well [32, 41].
Interestingly, while more than 80% of the general population in the current study knew that
diabetes and its complications could be prevented, individuals with no diabetes did not know
that it can be managed or prevented through lifestyle measures such as high fibre foods, lipid
control, and good weight control. These findings are similar to a study conducted in India
[42], and also with studies elsewhere [43–45]. The study with the Indian adult population
revealed that a majority (82%) believed diabetes was not preventable by altering lifestyle

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PLOS ONE Assessment of diabetes knowledge in the general population of Singapore: A KAP study

Table 4. Results of the multiple linear regression examining correlates of diabetes knowledge.
General knowledge of Diabetes specific knowledge Causes of Diabetes(CK) c Complications of untreated
diabetes(GK) a (DK) b diabetes(CPK) d
β 95% CI p β 95% CI p β 95% CI p β 95% CI p
Lower Upper Lower Upper Lower Upper Lower Upper
Age
18 to 34 ref ref ref ref
35 to 49 0.17 -0.25 0.58 0.44 -0.02 -0.19 0.15 0.80 0.08 -0.12 0.28 0.44 -0.12 -0.35 0.10 0.29
50 to 64 0.11 -0.37 0.60 0.65 0.08 -0.11 0.28 0.39 0.07 -0.17 0.31 0.56 -0.06 -0.32 0.20 0.66
65 and above 0.27 -0.29 0.83 0.35 0.09 -0.14 0.33 0.44 0.16 -0.12 0.45 0.26 0.15 -0.12 0.42 0.28
Gender
Female ref ref ref ref
Male -0.10 -0.38 0.17 0.47 -0.10 -0.22 0.02 0.09 -0.01 -0.15 0.12 0.85 -0.19 -0.33 -0.05 0.01
Ethnicity
Chinese ref ref ref ref
Malay 0.83 0.58 1.09 0.00 0.18 0.06 0.29 0.00 -0.13 -0.26 0.00 0.06 0.16 0.03 0.30 0.02
Indian 0.91 0.66 1.15 0.00 0.26 0.16 0.35 0.00 -0.22 -0.34 -0.10 0.00 0.14 0.02 0.27 0.03
Others 0.45 -0.06 0.96 0.08 0.11 -0.08 0.30 0.25 -0.13 -0.34 0.08 0.24 0.43 0.24 0.62 0.00
Education
Degree, professional certification, and above ref ref ref ref
Primary and below -0.77 -1.28 -0.26 0.00 -0.20 -0.44 0.04 0.11 -0.54 -0.82 -0.26 0.00 0.18 -0.08 0.45 0.18
Secondary -0.78 -1.25 -0.32 0.00 -0.23 -0.44 -0.03 0.03 -0.25 -0.48 -0.02 0.03 0.03 -0.21 0.27 0.80
Pre-University/Junior College -0.51 -1.35 0.33 0.23 0.16 -0.07 0.38 0.17 -0.08 -0.40 0.23 0.60 0.25 -0.07 0.58 0.12
Vocational training -0.61 -1.19 -0.03 0.04 -0.26 -0.50 -0.03 0.03 -0.08 -0.36 0.20 0.57 -0.28 -0.64 0.08 0.12
Diploma -0.11 -0.54 0.31 0.60 0.05 -0.12 0.21 0.60 -0.10 -0.29 0.10 0.33 0.06 -0.16 0.27 0.60
Marital Status
Married/Cohabiting ref ref ref ref
Single -0.62 -1.03 -0.21 0.00 -0.21 -0.37 -0.05 0.01 0.21 0.02 0.40 0.03 -0.33 -0.55 -0.11 0.00
Divorced/Separated/ Widowed -0.19 -0.63 0.25 0.41 -0.11 -0.29 0.08 0.27 -0.09 -0.34 0.15 0.45 -0.05 -0.27 0.17 0.65
Employment
Employed ref ref ref ref
Economically inactive -0.16 -0.50 0.17 0.33 0.02 -0.14 0.18 0.79 -0.02 -0.21 0.17 0.86 -0.04 -0.23 0.14 0.63
Unemployed -0.91 -1.63 -0.19 0.01 -0.24 -0.53 0.05 0.10 0.05 -0.31 0.40 0.80 0.03 -0.37 0.43 0.89
Monthly Personal Income (SGD)
Below 2,000 or no income ref ref ref ref
2,000–3,999 -0.05 -0.41 0.30 0.76 -0.02 -0.19 0.14 0.78 -0.20 -0.39 -0.02 0.03 -0.01 -0.20 0.18 0.91
4,000–5,999 0.19 -0.29 0.68 0.44 -0.04 -0.26 0.18 0.72 0.05 -0.19 0.30 0.66 -0.09 -0.34 0.15 0.45
6,000–9,999 -0.17 -0.81 0.47 0.60 -0.26 -0.52 0.00 0.05 -0.06 -0.36 0.24 0.68 -0.23 -0.56 0.09 0.16
10,000 and above 0.26 -0.46 0.98 0.48 0.11 -0.18 0.39 0.46 -0.06 -0.43 0.32 0.77 0.22 -0.15 0.60 0.24
Diabetes Diagnosis
No Diabetes ref ref ref ref
Has Diabetes -0.03 -0.42 0.36 0.89 0.22 0.06 0.38 0.01 -0.11 -0.35 0.14 0.39 0.12 -0.08 0.32 0.25

β–Unstandardized regression coefficient; 95% CI– 95% confidence interval of β

a
After accounting for listwise deletion of missing data, cases in multiple linear regression model: 2677. Mean: 23.8 ± 2.4
b
After accounting for listwise deletion of missing data, cases in multiple linear regression model: 1786. Mean 2.3 ± 0.8
c
After accounting for listwise deletion of missing data, cases in multiple linear regression model: 2586. Mean 2.3 ± 1.2
d
After accounting for listwise deletion of missing data, cases in multiple linear regression model: 2532. Mean 5.2 ± 1.2

https://doi.org/10.1371/journal.pone.0272745.t004

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PLOS ONE Assessment of diabetes knowledge in the general population of Singapore: A KAP study

practices and less than a third of them knew that diet and weight were important components
of effective diabetes management [42].
This current study also revealed that a significant proportion of individuals without diabe-
tes did not know there are different types of diabetes, and were not as aware of abnormal
blood glucose levels. The findings remain consistent with a previous study conducted in Singa-
pore [38], and could be attributed to a lack of personal interest, access, and exposure to the
information regarding diabetes.
Research has revealed that poor self-management is a significant barrier to effective preven-
tion or management of diabetes complications [46]. Participation in preventative care strate-
gies such as self-monitoring of blood glucose levels have been shown to reduce the incidence
and progression of the disease [47]. It is necessary for health care services to know what people
think about a disease and its prevention and management, as misconceptions act as a formida-
ble barrier for the management and prevention of a disease. It is clear that if prevention is to
be effective, diabetes education needs to address these gaps in knowledge with more rigour.
Other research have demonstrated positive results in altering misconceptions through educa-
tion for example, regarding risk factors and self-monitoring of blood glucose levels [47, 48]. In
addition, healthcare services at various levels should become more aware of the need to screen
for, and educate individuals with inadequate knowledge of diabetes [49].
This study revealed a relationship between income levels and diabetes knowledge. Other
reports are in agreement with our results, that is, lower income levels were associated with
poorer diabetes knowledge [26, 29–31]. Of all the significant predictors of diabetes knowledge,
education was the only modifiable risk factor in this study. Consistent with other research
[27–33], higher education levels were associated with higher levels of diabetes knowledge in
this study. One possible explanation is that those of higher academic levels (and hence, higher
income levels) are more able to obtain knowledge from various media sources. In addition,
they may have fewer communication barriers with health care professionals, and a better abil-
ity of comprehending information. Expectedly, those with little or no formal education were
observed to be the least knowledgeable across diabetes knowledge domains in this study.
The current study found that ethnic minority groups (Indians, Malays, and Others) were
significantly more knowledgeable about symptoms and complications, insulin deficiency, and
abnormal blood glucose levels when compared to Chinese Singaporeans. Our results differ
from a few other studies [30, 32]. One plausible explanation could be that the ethnic minorities
such as Indians and Malays, are more susceptible to the development of diabetes and its com-
plications than the Chinese [50]. As such, they could have been exposed to diabetes health edu-
cation delivered as part of their regular interactions with the healthcare system, or they may
have acquired the information through close contacts with a history of diabetes. Consequently,
the diabetes knowledge gap among the Chinese must be addressed with culturally-tailored dia-
betes education.
The study has some limitations. Individuals who were institutionalised, hospitalised or
uncontactable during the study period, as well as those with language difficulties were excluded
from the study. Hence, the results may have been underestimated or overestimated. Moreover,
the cross-sectional nature of the study does not allow for causal relationships to be established.
Nonetheless, the current study has its strengths in that it was a nationwide population-based
study with a representative public sample, ensuring high quality of data and generalizability of
the findings. The factor analyses revealed a marked stability and robust factor model for the
diabetes knowledge questionnaire in the study. This study has provided more precise and valu-
able data for the purposes of policy-making, development of diabetes literacy and health pro-
motion programs, as well as for future research.

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PLOS ONE Assessment of diabetes knowledge in the general population of Singapore: A KAP study

Conclusions
The level of knowledge of diabetes in persons with diabetes and persons without diabetes was
found to be adequate, except in one situation where both groups thought that high blood pres-
sure and mental stress cause diabetes. Individuals without diabetes also did not know about
the levels of blood glucose that were considered abnormal compared to patients with diabetes.
These misconceptions can be effectively addressed through suitable diabetes health education.
Knowledge regarding diabetes can vary greatly depending on one’s education, ethnicity and
socioeconomic status. Understanding these variables will be important in designing preven-
tion and management strategies for diabetes. This study reinforces the view that the main
approach to managing diabetes effectively is to improve understanding and management of
the disease by means of suitable widespread educational campaigns.

Supporting information
S1 Appendix. Descriptive statistics of the initial 29 items of the diabetes knowledge ques-
tionnaire.
(PDF)

Author Contributions
Conceptualization: Kumarasan Roystonn, Chee Fang Sum, Eng Sing Lee, Siow Ann Chong,
Mythily Subramaniam.
Data curation: Fiona Devi Siva Kumar, Peizhi Wang, Edimansyah Abdin, Mythily
Subramaniam.
Formal analysis: Edimansyah Abdin.
Funding acquisition: Siow Ann Chong, Mythily Subramaniam.
Investigation: P. V. AshaRani, Chee Fang Sum, Siow Ann Chong, Mythily Subramaniam.
Methodology: Edimansyah Abdin, Siow Ann Chong, Mythily Subramaniam.
Project administration: Kumarasan Roystonn, P. V. AshaRani, Siow Ann Chong, Mythily
Subramaniam.
Resources: Chee Fang Sum, Eng Sing Lee.
Software: Edimansyah Abdin.
Supervision: P. V. AshaRani, Siow Ann Chong, Mythily Subramaniam.
Validation: Edimansyah Abdin, Mythily Subramaniam.
Visualization: Kumarasan Roystonn, P. V. AshaRani, Chee Fang Sum, Eng Sing Lee, Siow
Ann Chong, Mythily Subramaniam.
Writing – original draft: Kumarasan Roystonn.
Writing – review & editing: Kumarasan Roystonn, Fiona Devi Siva Kumar, Peizhi Wang, Edi-
mansyah Abdin, Chee Fang Sum, Eng Sing Lee, Siow Ann Chong, Mythily Subramaniam.

References
1. World Health Organization (WHO). Global status report on non-communicable diseases. WHO; 2014.
https://www.who.int/news-room/fact-sheets/detail/noncommunicable-diseases

PLOS ONE | https://doi.org/10.1371/journal.pone.0272745 August 10, 2022 12 / 15

PLOS ONE Assessment of diabetes knowledge in the general population of Singapore: A KAP study

2. da Rocha Fernandes J, Ogurtsova K, Linnenkamp U, Guariguata L, Seuring T, Zhang P, et al. IDF Dia-
betes Atlas estimates of 2014 global health expenditures on diabetes. Diabetes Research and Clinical
Practice. 2016 Jul; 117:48–54. https://doi.org/10.1016/j.diabres.2016.04.016 PMID: 27329022
3. Zhou B, Lu Y, Hajifathalian K, Bentham J, Di Cesare M, Danaei G, et al. Worldwide trends in diabetes
since 1980: a pooled analysis of 751 population-based studies with 4�4 million participants. The Lancet.
2016; 387(10027):1513–30. https://doi.org/10.1016/S0140-6736(16)00618-8 PMID: 27061677
4. Cho NH, Shaw JE, Karuranga S, Huang Y, da Rocha Fernandes JD, Ohlrogge AW, et al. IDF Diabetes
Atlas: Global estimates of diabetes prevalence for 2017 and projections for 2045. Diabetes Research
and Clinical Practice. 2018 Apr; 138:271–81. https://doi.org/10.1016/j.diabres.2018.02.023 PMID:
29496507
5. Png ME, Yoong J, Phan TP, et al. Current and future economic burden of diabetes among working-age
adults in Asia: conservative estimates for Singapore from 2010–2050. BMC Public Health. 2016;
16:153. https://doi.org/10.1186/s12889-016-2827-1 PMID: 26880337
6. Epidemiology & Disease Control Division. The burden of disease in Singapore, 1990–2017: an overview
of the global burden of disease study 2017 results. 2019. http://www.Healthdata.Org/sites/default/files/
files/policy_report/2019/GBD_2017_Singapore_Report.pdf
7. Akash MSH, Haq ME ul, Qader A, Rehman K. Biochemical investigation of human exposure to aflatoxin
M1 and its association with risk factors of diabetes mellitus. Environmental Science and Pollution
Research. 2021 Jul 3; 28(44):62907–18. https://doi.org/10.1007/s11356-021-14871-w PMID:
34216342
8. Rehman K, Jabeen K, Awan FR, Hussain M, Saddique MA, Akash MSH. Biochemical investigation of
rs1801282 variations in PPAR-γ gene and its correlation with risk factors of diabetes mellitus in coronary
artery disease. Clinical and Experimental Pharmacology and Physiology. 2020 May 31; 47(9):1517–29.
https://doi.org/10.1111/1440-1681.13339 PMID: 32416637
9. Akash MSH, Rehman K, Liaqat A. Tumor Necrosis Factor-Alpha: Role in Development of Insulin Resis-
tance and Pathogenesis of Type 2 Diabetes Mellitus. Journal of Cellular Biochemistry. 2017 Jun 22;
119(1):105–10. https://doi.org/10.1002/jcb.26174 PMID: 28569437
10. Rehman K, Akash MSH. Mechanism of Generation of Oxidative Stress and Pathophysiology of Type 2
Diabetes Mellitus: How Are They Interlinked? Journal of Cellular Biochemistry. 2017 May 31; 118
(11):3577–85. https://doi.org/10.1002/jcb.26097 PMID: 28460155
11. Akash MSH, Rehman K, Chen S. Role of inflammatory mechanisms in pathogenesis of type 2 diabetes
mellitus. Journal of Cellular Biochemistry. 2013 Jan 22; 114(3):525–31. https://doi.org/10.1002/jcb.
24402 PMID: 22991242
12. Rehman K, Haider K, Jabeen K, Akash MSH. Current perspectives of oleic acid: Regulation of molecu-
lar pathways in mitochondrial and endothelial functioning against insulin resistance and diabetes.
Reviews in Endocrine and Metabolic Disorders. 2020 Mar 3; 21(4):631–43. https://doi.org/10.1007/
s11154-020-09549-6 PMID: 32125563
13. Rehman K, Akash MSH. Nutrition and Diabetes Mellitus: How are They Interlinked? Critical Reviews in
Eukaryotic Gene Expression. 2016; 26(4):317–32. https://doi.org/10.1615/CritRevEukaryotGeneExpr.
2016016782 PMID: 27910746
14. American Diabetes Association. Diagnosis and Classification of Diabetes Mellitus. Diabetes Care. 2008
Dec 31; 32(Supplement_1):S62–7. https://doi.org/https://doi.org/10.2337/dc09-S062
15. Litwak L, Goh S-Y, Hussein Z, Malek R, Prusty V, Khamseh ME. Prevalence of diabetes complications
in people with type 2 diabetes mellitus and its association with baseline characteristics in the multina-
tional A1chieve study. Diabetology & Metabolic Syndrome. 2013 Oct 24; 5(1). https://doi.org/10.1186/
1758-5996-5-57 PMID: 24228724
16. Yamaoka K, Tango T. Efficacy of Lifestyle Education to Prevent Type 2 Diabetes: A meta-analysis of
randomized controlled trials. Diabetes Care. 2005 Oct 25; 28(11):2780–6. https://doi.org/10.2337/
diacare.28.11.2780 PMID: 16249558
17. Abbasi A, Sahlqvist A-S, Lotta L, Brosnan JM, Vollenweider P, Giabbanelli P, et al. A Systematic
Review of Biomarkers and Risk of Incident Type 2 Diabetes: An Overview of Epidemiological, Prediction
and Aetiological Research Literature. Herder C, editor. PLoS ONE. 2016 Oct 27; 11(10):e0163721.
https://doi.org/10.1371/journal.pone.0163721 PMID: 27788146
18. Lim W-Y, Ma S, Heng D, Tai ES, Khoo CM, Loh TP. Screening for diabetes with HbA1c: Test perfor-
mance of HbA1c compared to fasting plasma glucose among Chinese, Malay and Indian community
residents in Singapore. Scientific Reports. 2018 Aug 20; 8(1). https://doi.org/10.1038/s41598-018-
29998-z PMID: 30127499
19. Tabák AG, Jokela M, Akbaraly TN, Brunner EJ, Kivimäki M, Witte DR. Trajectories of glycaemia, insulin
sensitivity, and insulin secretion before diagnosis of type 2 diabetes: an analysis from the Whitehall II

PLOS ONE | https://doi.org/10.1371/journal.pone.0272745 August 10, 2022 13 / 15

PLOS ONE Assessment of diabetes knowledge in the general population of Singapore: A KAP study

study. The Lancet. 2009 Jun; 373(9682):2215–21. https://doi.org/10.1016/s0140-6736(09)60619-x

PMID: 19515410
20. Knowler WC, Barrett-Connor E, Fowler SE, Hamman RF, Lachin JM, Walker EA, et al. Reduction in the
incidence of type 2 diabetes with lifestyle intervention or metformin. The New England journal of medi-
cine. 2002; 346(6):393–403. https://doi.org/10.1056/NEJMoa012512 PMID: 11832527
21. Abbasi A, Peelen LM, Corpeleijn E, van der Schouw YT, Stolk RP, Spijkerman AMW, et al. Prediction
models for risk of developing type 2 diabetes: systematic literature search and independent external val-
idation study. BMJ. 2012 Sep 18; 345:e5900–0. https://doi.org/10.1136/bmj.e5900 PMID: 22990994
22. Tuomilehto J, Lindström J, Eriksson JG, Valle TT, Hämäläinen H, Ilanne-Parikka P, et al. Prevention of
Type 2 Diabetes Mellitus by Changes in Lifestyle among Subjects with Impaired Glucose Tolerance.
New England Journal of Medicine. 2001 May 3; 344(18):1343–50. https://doi.org/10.1056/
NEJM200105033441801 PMID: 11333990
23. 10-year follow-up of diabetes incidence and weight loss in the Diabetes Prevention Program Outcomes
Study. The Lancet. 2009 Nov; 374(9702):1677–86. https://doi.org/10.1016/S0140-6736(09)61457-4
PMID: 19878986
24. Norris SL, Engelgau MM, Venkat Narayan KM. Effectiveness of Self-Management Training in Type 2
Diabetes: A systematic review of randomized controlled trials. Diabetes Care. 2001 Mar 1; 24(3):561–
87. https://doi.org/10.2337/diacare.24.3.561 PMID: 11289485
25. Li G, Zhang P, Wang J, An Y, Gong Q, Gregg EW, et al. Cardiovascular mortality, all-cause mortality,
and diabetes incidence after lifestyle intervention for people with impaired glucose tolerance in the Da
Qing Diabetes Prevention Study: a 23-year follow-up study. The Lancet Diabetes & Endocrinology.
2014 Jun; 2(6):474–80.
26. Al-Maskari F, El-Sadig M, Al-Kaabi JM, Afandi B, Nagelkerke N, Yeatts KB. Knowledge, Attitude and
Practices of Diabetic Patients in the United Arab Emirates. PLoS ONE. 2013 Jan 14; 8(1):e52857.
https://doi.org/10.1371/journal.pone.0052857 PMID: 23341913
27. Rani P, Raman R, Subramani S, Perumal G, Kumaramanickavel G, Sharma T. Knowledge of diabetes
and diabetic retinopathy among rural populations in India, and the influence of knowledge of diabetic ret-
inopathy on attitude and practice. Rural and Remote Health. 2008 Jul 24; 8:838. PMID: 18656993
28. Chen A, Chidarikire T, Sarswat D, Parissi C, Nwose EU. Diabetes mellitus literacy in a regional commu-
nity of a developed country. Acta Bio-medica. 2019 Dec 23; 90(4):482–8. https://doi.org/10.23750/abm.
v90i4.7687 PMID: 31910173
29. Oba S, Yamamoto M, Horikawa Y, Suzuki E, Nagata C, Takeda J. Knowledge of diabetes and its deter-
minants: a cross-sectional study among adults in a Japanese community. BMJ Open. 2019 May; 9(5):
e024556. https://doi.org/10.1136/bmjopen-2018-024556 PMID: 31152029
30. Yun LS, Hassan Y, Aziz NA, Awaisu A, Ghazali R. A comparison of knowledge of diabetes mellitus
between patients with diabetes and healthy adults: a survey from north Malaysia. Patient education and
counseling. 2007; 69(1–3):47–54. https://doi.org/10.1016/j.pec.2007.06.017 PMID: 17720351
31. Murugesan N, Snehalatha C, Shobhana R, Roglic G, Ramachandran A. Awareness about diabetes and
its complications in the general and diabetic population in a city in southern India. Diabetes Research
and Clinical Practice. 2007; 77(3):433–7. https://doi.org/10.1016/j.diabres.2007.01.004 PMID:
17291622
32. Fatema K, Hossain S, Natasha K, Chowdhury HA, Akter J, Khan T, et al. Knowledge attitude and prac-
tice regarding diabetes mellitus among Nondiabetic and diabetic study participants in Bangladesh.
BMC Public Health. 2017; 17(1).
33. Herath HMM, Weerasinghe NP, Dias H, Weerarathna TP. Knowledge, attitude and practice related to
diabetes mellitus among the general public in Galle district in Southern Sri Lanka: a pilot study. BMC
Public Health. 2017; 17(1). https://doi.org/10.1186/s12889-017-4459-5 PMID: 28571566
34. AshaRani PV, Abdin E, Kumarasan R, Siva Kumar FD, Shafie S, Jeyagurunathan A, et al. Study proto-
col for a nationwide Knowledge, Attitudes and Practices (KAP) survey on diabetes in Singapore’s gen-
eral population. BMJ Open. 2020 Jun; 10(6):e037125. https://doi.org/10.1136/bmjopen-2020-037125
PMID: 32540891
35. Kline RB. Principles and practice of structural equation modeling. New York Guilford; 2016.
36. Hu L, Bentler PM. Cutoff criteria for fit indexes in covariance structure analysis: Conventional criteria
versus new alternatives. Structural Equation Modeling: A Multidisciplinary Journal. 1999 Jan; 6(1):1–
55.
37. Sarstedt M, Ringle CM, Hair JF. Partial least squares structural equation modeling. In: Handbook of
Market Research. Cham: Springer International Publishing; 2017;1–40.
38. Wee HL, Ho HK, Li SC. Public awareness of diabetes mellitus in Singapore. Singapore Medical Journal.
2002; 43(3):128–34. PMID: 12005338

PLOS ONE | https://doi.org/10.1371/journal.pone.0272745 August 10, 2022 14 / 15

PLOS ONE Assessment of diabetes knowledge in the general population of Singapore: A KAP study

39. Raj CP, Angadi M. Hospital-based KAP study on diabetes in Bijapur, Karnataka. Indian Journal of Medi-
cal Specialities. 2011; 1(2):80–3.
40. Al Shafaee MA, Al-Shukaili S, Rizvi SG, Al Farsi Y, Khan MA, Ganguly SS, et al. Knowledge and per-
ceptions of diabetes in a semi-urban Omani population. BMC Public Health. 2008; 8(1):249.
41. Siddiqui R, Rukhsana N, Arif AU, Khan B, rizwan S, Fahim MF. Assessment of knowledge of diabetes
among diabetic and non-diabetic individuals. Rawal Medical Journal. 2021, 46(4):795–98.
42. Konduru SS, Ranjan A, Karthik SM, Shaik S, Vakkapatla LS. Assessment of diabetes related knowl-
edge, attitude and practice among diabetics and non-diabetics using self-prepared questionnaire for
awareness of health promotion. Indian Journal of Pharmacy Practice. 2017; 10(1):32–8.
43. Gillani A, Amirul Islam F, Hayat K, Atif N, Yang C, Chang J, et al. Knowledge, Attitudes and Practices
Regarding Diabetes in the General Population: A Cross-Sectional Study from Pakistan. International
Journal of Environmental Research and Public Health. 2018 Sep 2; 15(9):1906. https://doi.org/10.3390/
ijerph15091906 PMID: 30200534
44. Steyn NP, Mann J, Bennett P, Temple N, Zimmet P, Tuomilehto J, et al. Diet, nutrition and the preven-
tion of type 2 diabetes. Public Health Nutrition. 2004 Feb; 7(1a):147–65. https://doi.org/10.1079/
phn2003586 PMID: 14972058
45. Amere LT, Adesola A O, Olatade MJ, Leslie T D, Magret I O, Kaneng Mary D. Knowledge, Attitude And
Practices Regarding Lifestyle Modifications Among Type 2 Diabetes Mellitus Patients Attending Dia-
betic Clinic At General Hospital, Gbagada, Lagos State. International Journal of Scientific and Research
Publications (IJSRP). 2020 May 18; 10(05):558–64.
46. Shrivastava SR, Shrivastava PS, Ramasamy J. Role of self-care in management of diabetes mellitus.
Journal of Diabetes & Metabolic Disorders. 2013 Mar 5; 12(1):14. https://doi.org/10.1186/2251-6581-
12-14 PMID: 23497559
47. Norris SL, Lau J, Smith SJ, Schmid CH, Engelgau MM. Self-management education for adults with type
2 diabetes: A meta-analysis of the effect on glycemic control. Diabetes Care. 2002; 25(7):1159–71.
https://doi.org/10.2337/diacare.25.7.1159 PMID: 12087014
48. Foma MA, Saidu Y, Omoleke SA, Jafali J. Awareness of diabetes mellitus among diabetic patients in
the Gambia: a strong case for health education and promotion. BMC Public Health 2013; 13:11–24.
https://doi.org/10.1186/1471-2458-13-1124 PMID: 24304618
49. Chowdhury HA, Paromita P, Mayaboti CA, Rakhshanda S, Rahman FN, Abedin M, et al. Assessing ser-
vice availability and readiness of healthcare facilities to manage diabetes mellitus in Bangladesh: Find-
ings from a nationwide survey. PLoS ONE. 2022 Feb 16; 17(2):e0263259. https://doi.org/10.1371/
journal.pone.0263259 PMID: 35171912
50. Phan TP, Alkema L, Tai ES, Tan KHX, Yang Q, Lim W-Y, et al. Forecasting the burden of type 2 diabe-
tes in Singapore using a demographic epidemiological model of Singapore. BMJ Open Diabetes
Research & Care. 2014 Jun; 2(1):e000012. https://doi.org/10.1136/bmjdrc-2013-000012 PMID:
25452860

PLOS ONE | https://doi.org/10.1371/journal.pone.0272745 August 10, 2022 15 / 15

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