these misconceptions have a significant influence on the day - to - day life including the search for treatment in times of illness . a number of studies have reported that misconceptions and inadequate knowledge present significant barriers to effective management of diabetes . it is imperative for physicians to understand myths and misconceptions in a particular community about a disease to improve patient care , especially when dealing with chronic diseases like diabetes . diabetes mellitus ( dm ) is one of the most common noncommunicable diseases in the world and its prevalence is increasing dramatically . currently , there are around 285 million diabetic patients around the world , and the numbers are predicted to rise to 439 million by 2030 , with the largest increase in the developing rather than in the developed world . its dramatic increase began a few decades ago with the rapid urbanization and development in the country . studies in the 1980s showed a trend towards an increase among adult saudis especially females . a large study of saudi patients from 1995 to 2000 revealed prevalence of 23.7% . however , a study in 2011 showed a significant rise in prevalence reaching 34.1% in men and 27.6% in women . correct knowledge about diabetes and its management has an enormous impact on attitude and practice of diabetic patients . a study of diabetic patients in new york , reported that patients with diabetes frequently had beliefs of the disease and medication that were false and even dangerous . it is imperative that awareness of diabetes and its correct management be created and various myths and misconceptions surrounding its course and management be removed . a few excellent studies about prevailing misconceptions about diabetes have already been carried out in the saudi population , more specifically in female diabetic teachers , in the eastern region , western region and qasim region . however , no studies have examined in detail the determinants of the misconceptions of diabetic patients . therefore , this study was undertaken to identify the determinants of prevailing misconceptions on diabetes and the management of diabetic patients registered at a diabetes clinic of a tertiary care hospital in the eastern region of saudi arabia . this cross - sectional study was carried out at the diabetes clinic of a tertiary care hospital , in eastern saudi arabia . this clinic has a registered patient population of 2000 diabetic patients . at a confidence level of 95% , response distribution of 50% and accepted margin of error of 10% , we calculated a sample size of 200 . a table of random numbers was used to select patients from the medical record numbers of the registered patients of the diabetes clinic . the inclusion criteria were all saudi patients who had been registered at the diabetes clinic of the tertiary care hospital in saudi arabia for 6 months or more since diagnosis and on continuous treatment . no freshly diagnosed patient was included . in the same vein uncooperative or nonconsenting patients , as well as patients with any illness ( physical or psychological ) that was likely to influence reliable , valid responses to the interviewer 's questions were excluded . the same interviewer spoke to all the selected patients on their scheduled follow - up visits after taking their informed consent . when a prospective participant refused to take part , the next patient on the list of random numbers was asked until the sample size was completed . all attendees were interviewed in standardized conditions with prior information to ensure valid reliable responses . the data collection instrument was an interviewer - filled questionnaire prepared in accordance with  brief illness perception questionnaire  and  belief about medicines questionnaire . the demographic and classification data included age categories ( < 20 , 21 - 40 , 41 - 60 or > 60 years ) , gender ( male and female ) , area of residence ( urban or rural ) , education ( primary , middle , high school , graduate and above ) , family history of diabetes ( present or absent ) , type of diabetes ( type 1 or type 2 ) , time since diagnosis ( < 5 , 6 - 10 , 11 - 15 or > 15 years ) , type of treatment ( oral hypoglycemic or insulin ) , self - monitoring ( yes or no ) and diet control as per doctor 's advice ( yes or no ) . in order to establish validity and reliability of the questionnaire , a pilot study was conducted in a sub - sample of attendees who were not included in the study proper . necessary changes were made in the questionnaire as well as the interview style as necessary . questions on the commonest reported misconceptions relating to etiology , types , pathogenesis , day - to - day life , diet and treatment of diabetes were included after a review of studies from saudi arabia , usa , india , nepal , and pakistan . an answer in  yes  to a misconception question was considered a misconception and a score of one was given . the total number of misconception questions was 36 ; therefore , the possible maximum score for any patient was 0 - 36 . low ( scores 0 - 12 ) , moderate ( scores 13 - 24 ) , and high ( scores of 24 - 36 ) . chi - square test was used to determine the association of the socio - demographic variables with the three categories of misconception scores . stepwise logistic regression analysis was applied to the socio - demographic variables showing significant association with the misconception score by chi - square test and values of -coefficient , chi - square , odds ratio , and confidence interval were reported . a total of 200 responses for each item in the questionnaire were recorded from 200 subjects . the distribution of subjects in the age groups was 32 ( 16% ) in < 20 years , 62 ( 31% ) in 21 - 40 years , 81 ( 40.5% ) between 41 and 60 years and 25 ( 12.5% ) in > 60 years . the subjects from urban areas were 168 ( 84% ) and those from rural areas were 32 ( 16% ) . those with the highest level of education were 7 ( 3.5% ) who had up to postgraduation , 36 ( 18% ) were university graduates , 76 ( 38% ) high school , 43 ( 21.5% ) middle , 29 ( 14.5% ) primary and 9 ( 4.5% ) illiterate . there was a family history of diabetes in 147 ( 73.5% ) and no history in 53 ( 26.5% ) . those with type 1 diabetics were 78 ( 39% ) while 122 ( 61% ) had type 2 diabetes . the time since diagnosis was < 5 years in 73 ( 36.5% ) , 6 - 10 years in 72 ( 36% ) , 11 - 15 years in 21 ( 10.5% ) and > 15 years in 34 ( 17% ) subjects . the type of treatment was insulin in 105 ( 52.5% ) and oral hypoglycemics in 95 ( 47.5% ) indicating that many type 2 diabetic patients were also on insulin . self - monitoring of blood glucose was done by 124 ( 62% ) of the subjects while 76 ( 38% ) did not . diet control was used by 112 ( 56% ) subjects while 88 ( 44% ) did not . a total of 167 ( 83.5% ) had received formal  diabetes awareness education  while 33 ( 16.5% ) had not . the total misconception score was low ( 0 - 12 ) in 115 ( 57.5% ) , moderate ( 13 - 24 ) in 77 ( 38.5% ) and high ( 24 - 36 ) in 8 ( 4% ) respondents ( n = 200 ) . table 1 demonstrates the frequency distribution of respondents according to misconceptions about etiology , types and pathogenesis of diabetes . the most common misconceptions identified on etiology , types and pathogenesis were that  overweight causes diabetes  ( 89% ) ,  diabetes is only a hereditary disease  ( 80.5% ) and  eating too much sugar causes diabetes  ( 69% ) . in addition , this table shows the distribution of subjects with reference to misconceptions about daily life . the most frequent misconceptions about the daily life of diabetics were that  diabetics can not lead a normal social life frequency of respondents with misconceptions about etiology , types , pathogenesis and day - to - day life of diabetes ( n=200 ) table 2 illustrates the distribution of respondents according to misconceptions about diet . the second misconception on treatment was that  there is no need to take medicines when blood glucose is normal table 3 shows the association of the selected socio - demographic variables on the misconception score . it shows that female gender , living in a rural area , little or no education , < 5 or > 15 years since diagnosis , lack of self - monitoring , poor compliance with dietary control and no diabetes education were significantly ( p < 0.05 ) associated with moderate or high misconception score . however , age , family history of diabetes , type of diabetes and type of treatment were not significantly associated with the misconception score . frequency of respondents with misconceptions about diet and treatment ( n=200 ) association of misconception score category with sociodemographic variables table 4 gives stepwise logistic regression to determine the predictive value of independent variables [ showing significant association as per table 3 ] with the misconception score ( dependent variable ) . it indicates that diabetes education , gender , education and time since diagnosis are good predictors of misconception score . every chronic disease necessitates long - term commitment from the patient , family and health care professionals . health care is a full package that includes the proper education of society in general and the patient in particular , about all aspects of the disease in question . a label of  no definitive cure  on chronic diseases generates many myths and misconceptions . these misconceptions are affected by socio - demographic factors and are propagated by opportunists who take advantage of patients to market their products . understanding the myths and misconceptions about a disease , like dm , is important for the provision of excellent care and health education to both patients and healthy individuals . these myths and misconceptions are generally about forbidden foods , the use of herbs , life - style changes , side - effects of treatment and so - called  dependence on medicines . they usually interfere with self - management plans for diabetic patients leading to undesirable complications . the frequency of common misconceptions reported by other studies is more or less similar to what our report presents . a previous study in eastern saudi arabia that was carried out on adult male attendees of primary health centers found misconceptions about the etiology of diabetes in 21.2% of those studied , about general concepts of diabetes in 13.8% and diet in 10.7% of the patients . however , our study population was different , in that all of them were diabetics . a study in western saudi arabia reported that the top misconceptions that diabetic patients had were that  oral medications might be more effective than insulin ,   medications might cause habituation and serious complications ,   the efficacy of medications depends on their cost ,   cure is expected following a short course of treatment  and  a diabetic could eat anything as long as medications were taken . the prevailing myths reported in the population of qassim region of saudi arabia were that  consuming sugar results in diabetes , diabetics should avoid sweets ,   some type of dates do not increase sugar level ,   honey intake does n't increase sugar level ,  and  diabetes in its early stages can affect sexual performance .  determinants of myths and misconceptions are the factors that are directly related to generation or propagation of these wrong beliefs . knowledge of the determinants of any misconception , attitude or behavior is very important to the management of disease . our results indicate that around 42.5% of the subjects had a moderate to high misconception score , indicating that there was much room for improvement in our patients ' education . the mean misconception score was 10.29  4.92 , while 38.5% had moderate ( 1324 ) and 4% high ( 24 - 36 ) misconception scores . the factors which had a significant association with high misconception scores were female gender , rural residence , little or no education , < 5 years or > 15 years since diagnosis , no self - monitoring , poor diet control and no prior education about diabetes . the relationships of different determinants of misconceptions studied in our study are discussed below . female gender was found to be significantly ( p < 0.05 ) associated with moderate to high misconception score . this was not a totally unexpected finding due to social norms of a conservative society with significantly less exposure of women to information . this finding gave us a clear task to target our female patients to provide them with the correct knowledge about diabetes and its management . a study carried out on female school teachers of alkhobar showed that their understanding of diabetes was inadequate . similarly , a sudanese study also found poor compliance to therapy , poor glycemic control and poor knowledge about diabetes in women as compared to men . this association was also reported in misconception studies carried out in new york and in india . however , a study carried out in qasim did not find gender to be associated with myths and misconceptions . the proportion of patients from rural areas was very low in our study as a result of the saudi government 's policy of ensuring that patients access health facilities nearest to their homes . however , the proportion of patients with moderate to high misconception scores was higher in patients from rural areas . this shows that certain socio - demographic factors render people from those areas more vulnerable to misconceptions . however , there are other associated factors that can modify beliefs of urban populations as well . in a study carried out in a low income population of new york , a survey carried out in the 4 largest city of india , chennai , on around 26000 subjects concluded that even though there had been diabetes education campaigns from as far back as 1948 , the level of lack of knowledge and misconceptions was unacceptable . as expected , the proportion of subjects with moderate to high misconception was highest in the illiterate group , and this decreased as the level of education rose . the study by sabra et al . in eastern saudi arabia found high misconception scores in 23.5% of illiterate or those who could only read - and - write . a study in new york found that participants with less than a high school education were more likely to have misconceptions . a study of myths and misconceptions in the qasim region also found significant differences in responses according to educational status . this necessitates the identification of the less educated from the beginning in order to design special educational programs that suit their respective levels of education . time since diagnosis was found to be significantly associated ( p < 0.05 ) with misconception scores . it also had a high predictive value for the misconception score . patients who had been diagnosed with diabetes > 15 years before were more prone to have a moderate to high misconception score , and the chances of having misconceptions decreased in categories as times since diagnosis lessened . this might be due to better current diabetes awareness programs as well as the ease of access to information for freshly diagnosed diabetics who are curious . the knowledge of the subjects presenting for the 1 time has generally been reported to be inadequate and other studies have indicated this relationship . the patients who reported that they were controlling their diabetes by self - monitoring of blood glucose had low misconception scores . this group comprised 62% of the total number of patients , about two - thirds of whom had low misconception scores . on the other hand , two - thirds of those who were not self - monitoring had moderate to high misconception scores . this shows that making the patient take charge of his or her diabetes control develops an interested attitude . in addition , a clear picture of alterations in blood sugar by medicines , diet control and life - style changes help in removing of unfounded baseless misconceptions . no other study has reported this association . however , a study from western saudi arabia has shown an association of  discontinuity of treatment  with a high level of misconception . noncompliance to the recommended diet control was found to be a major determinant of misconceptions . surprisingly , most of patients with the highest misconception scores ( 7 out of 8) reported to have little or no diet control . this reflects a general carefree attitude of these patients to all aspects of life - style changes associated with the management of diabetes . however , most of the patients using the recommended diet control were found to have less misconception scores . this suggests that we must identify patients with a carefree attitude from the beginning and design proper education programs , with psychotherapy sessions if possible for them . the majority of the patients ( 83.5% ) reported some formal instruction by health care professionals about diabetes and its management . as expected most of the subjects who had undergone a proper education about diabetes ( presentation , management and life - style changes ) had low misconception scores . not surprisingly , this was the most significant single determinant of removing misconceptions about diabetes . the results also indicated that there was room for improvement in the education of the large proportion of patients with moderate to high misconception scores . in our study , family history of diabetes , type of diabetes and type of treatment were not found to have any significant association with misconception scores . as in our study similarly , the age of our subjects did not show a significant association with misconception score . however , the proportion of subjects with moderate to high misconception scores was highest in the categories of the youngest and the oldest patients ( < 20 and > 60 years ) . though not statistically significant , it still shows that we must make an extra effort to educate these two vulnerable age groups about their disease . suboptimal knowledge and beliefs are potentially modifiable and are logical targets for educational interventions to improve diabetes self - management . knowledge of all the identified determinants of moderate to high misconception scores will help in streamlining the awareness programs for patients in accordance with these factors . similarly , it will act as a guideline for other units in our region to develop better patient education programs . if the patients are given proper guidance and education on diabetes care , there would be a significant improvement in their life - style which would in turn help in producing good glycemic control . we conclude that myths and misconceptions about diabetes and its management are common in our patients . the strongest determinants of the misconceptions in our study population are female gender , rural area of residence , illiteracy or little education , < 5 or > 15 years since diagnosis , no self - monitoring of blood glucose , poor diet control and no education about diabetes . therefore , diabetes educational programs should focus on individuals with one or more of these predictors .
objective : to identify the determinants of misconceptions about diabetes in patients registered with a diabetes clinic at a tertiary care hospital in eastern saudi arabia.materials and methods : this cross - sectional survey was carried out at a diabetes clinic of a tertiary care hospital in eastern saudi arabia , from january to december 2012 . 
 a total of 200 diabetic patients were interviewed using a questionnaire comprising 36 popular misconceptions . 
 the total misconception score was calculated and categorized into low ( 0 - 12 ) , moderate ( 13 - 24 ) and high ( 25 - 36 ) scores . 
 the association of misconception score with various potential determinants was calculated using chi - square test . 
 step - wise logistic regression was applied to the variables showing significant association with the misconception score in order to identify the determinants of misconceptions.results:the mean age was 39.62  16.7 and 112 ( 56% ) subjects were females . 
 type 1 diabetics were 78 ( 39% ) , while 122 ( 61% ) had type 2 diabetes . 
 insulin was being used by 105 ( 52.5% ) , 124 ( 62% ) were self - monitoring blood glucose and 112 ( 56% ) were using diet control . 
 formal education on diabetes awareness had been received by 167 ( 83.5% ) before the interview . 
 the mean misconception score was 10.29  4.92 with 115 ( 57.5% ) subjects had low misconception scores ( < 12/36 ) . on the chi - square test , female gender , rural area of residence , little or no education , < 5 or > 15 years since diagnosis , no self - monitoring , no dietary control and no diabetes education were all significantly ( p < 0.05 ) associated with higher misconception scores . 
 step - wise logistic regression suggested that diabetes education , gender , education and time since diagnosis were significant ( p < 0.05 ) predictors of misconception scores.conclusions:the strongest determinants of misconceptions about diabetes in our study population were female gender , rural area of residence , illiteracy or little education , < 5 or > 15 years since diagnosis , no self - monitoring , no diet control and no education about diabetes .