Assessment of knowledge and perceptions towards diabetes mellitus and its associated factors among people in Debre Berhan town, northeast Ethiopia.

BACKGROUND: Globally, diabetes is a major public health burden that results in more than 3.2 million adult deaths per year. Currently, diabetes is increasingly becoming a major threat to global public health, particularly in Sub-Saharan Africa. Although previous studies emphasized knowledge and health beliefs about diabetes among patients living with diabetes, there is minimal evidence about knowledge and perception of risk for developing diabetes at the community level.
OBJECTIVE: This study aimed to assess the knowledge and perception of diabetes mellitus and its associated factors among people in Debre Berhan town, northeast Ethiopia.
METHODS: A community-based cross-sectional study was conducted among 423 participants. The study was carried out from 25 February to 10 March 2019. Data were collected using a structured pretested questionnaire through face-to-face interviews. Data were entered into Epi data V 3.1 and exported to SPSS V 24 for analysis. A variable with p< 0.2 in bivariable analysis was entered into multivariable logistic regression. During multivariate analysis, variables with a p value of ≤ 0.05 were considered significantly associated. RESULT: A total of 237 (56.02%) participants had good general knowledge about diabetes mellitus. In the multivariable analysis, participants who were single (AOR = 9.08, CI: 1.72-48), had a family history of diabetes (AOR = 2.83; CI: 1.10-7.24), and had exposure to health education (AOR = 3.27; CI: 2.02-5.31) were associated with good knowledge. In this study, few respondents (20.1%) felt that they had a higher risk of developing diabetes. Two-thirds of respondents (62.4%) saw diabetes is a serious disease. On the other hand, approximately 67% agreed to the perceived benefits of screening.
CONCLUSION: Almost half of the Debre Berhan community was found to have inadequate knowledge of diabetes mellitus. Married, higher educational status, exposure to health education, and family history of diabetes mellitus were significantly associated with good knowledge. The perceived risk of developing diabetes was low at the community level, although many respondents felt that behavior change is important in the prevention of diabetes. Therefore, policy makers, healthcare managers, and healthcare workers need to work cooperatively to foster community knowledge towards diabetes mellitus.

Background

Diabetes mellitus (DM) is a common and devastating chronic disease [1]. Worldwide, the burden of DM is rising dramatically and reaching epidemic proportions [2]. The World Health Organization (WHO) estimates that DM affects at least 285 million people and causes 3.2 million deaths, equating to 8700 deaths every day [3]. Due to sedentary lifestyles, rapidly growing urbanization, and modified diets, tripling of the magnitude of diabetes mellitus is predicted within the next 25 years, as well as an overall global burden escalation [4]. According to WHO estimations globally, there are approximately 422 million adults living with diabetes mellitus [5], while the International Diabetes Federation (IDF) estimates that 382 million people in 2013 will rise to 592 million by 2035 [6]. A more recent estimate suggests that the global prevalence will reach 642 million people in 2040 [7].

In Sub-Saharan Africa (SSA), more than 12 million people have diabetes, and there are 330,000 diabetes-related deaths, yet less than 1% of health expenditure is allocated for diabetes [8]. In Ethiopia, approximately 4.36% (1.9 million) of the population was likely to live with diabetes, and the number of deaths attributed to diabetes reached 34,262 in 2013 [6]. Ethiopia is among the top four countries for high adult diabetic populations in developing countries [9]. Overall, diabetes seriously increases the risk of costly problems, including emotional distress, heart attack, stroke, kidney damage, blindness, neural damage leading to amputation, and reduced quality of life [10].

Public knowledge about diabetes helps combat not only the disease itself but also its complications and medical and socioeconomic consequences [11]. Simple lifestyle modifications, such as a healthy diet that includes reducing sugar intake, are considered to be essential for the prevention and reduction of the incidence of diabetes mellitus [12, 13]. Numerous studies have revealed that the proportion of good knowledge regarding diabetes mellitus was 27% in Kenya [14], 49% in Debre Tabor town, Ethiopia [15], 52.5% in Bale Zone administrative, Ethiopia [16], 41.9% in Malaysia [17], 49.9% in India [18], 28.2% in rural Indian state [19], and 15% in Sudan [20]. Several studies undertaken in different countries have shown that age, gender, educational level, socioeconomic status, and family history of diabetes mellitus were associated with good knowledge about diabetes mellitus [15, 21–23].

This study is based on the Health Belief Model (HBM), which consists of perceived threat, perceived susceptibility, perceived severity, perceived benefits, perceived barriers and cues for action [24]. The aim of this model is to increase the perception of individuals about a health threat and direct their behaviours towards health. Likewise, it focuses on a person’s health-related behavior and belief in predicting future actions. The perceived risk of people developing diabetes mellitus is considered to be the primary motive to change within the Health Belief Model, which assumes that the higher the perceived threat, the more likely an individual will modify his or her behavior to circumvent that threat [25]. It may be an important motivating factor for preventative health behaviors and control of disease [26]. In addition, according to this model, the decision to participate in preventive and screening programs is determined by many factors, such as awareness of the impact of disease on their health (perceived severity), perceived benefits of undergoing preventive measures, and perceived barriers and costs of the screening methods [24, 27]. Therefore, understanding individuals’ viewpoints and beliefs is essential for developing strategies to prevent, control, and increase awareness of the health risks of this disease [28].

Previous studies emphasized knowledge and attitudes towards diabetes mellitus. Local evidence is limited on public knowledge and risk perceptions towards DM using the health belief model in Ethiopia. Therefore, this study aimed to assess knowledge and risk perceptions towards diabetes mellitus and its associated factors among Debre Berhan community members. The results of this study may provide baseline data for future intervention programs to promote early detection and early management of diabetes mellitus.

Methods

Study design and setting

This community-based, cross-sectional study was conducted from 25 February to 10 March 2019 among Debre Berhan community members. Debre Berhan is one of the 13 zones of the Amhara regional state and the town of the North Shoa Zone. The town has nine kebeles, among which seven are primarily urban populations, while the remaining two kebeles have both urban and rural populations. The total population was 108,825, within 25,308 households. Moreover, there is one government hospital, one private hospital, three government health centers, nine health posts and 18 private clinics [29].

Study participants

All adults living in Debre Berhan town for at least six months, aged greater than or equal to 18 years and consenting to participate were included in the study. Persons who were critically ill during the data collection period and had complete loss of hearing and known DM patients were excluded from the study.

Sample size estimation

Sample size was calculated for each study objective. For the first objective, the sample size was determined based on the formula (Z1-α/2)2*(p(1-p))/d2, where (Z1-α/2) = 1.96, p = the proportion with knowledge of diabetes mellitus, which is 52.5% from a previously published study [16], and d = 0.05. We added 10% to the calculated sample size to compensate for the anticipated non-response rate, bringing the total sample size to 418 community members. Similarly, for the second objective, appropriate sample size was estimated using a single proportion formula, where n is the need sample size; d, marginal error (d = 0.05); Z, the required degree of accuracy at 95% confidence level, which is 1.96; P = 0.5 (50%) level of risk perception towards diabetes, as there was no study conducted in the study area to the best of literature search made. Using the above formula, after adding a 10% non-response rate, the final sample size of the study was 423 community members. Therefore, for this study, the largest sample size was taken to include 423 eligible study participants.

Sampling procedure

The numbers of households were obtained from the community’s administrative office. Three kebeles were selected by the lottery method out of nine kebeles in the town. Proportional allocation was used to obtain the desired number of samples from each kebele. Systematic random sampling was used to select the study unit among households. The first house was selected by the lottery method, and the next households were selected after calculating sampling intervals (K = 3). Then, every 3 households were taken until the required sample size was reached. The first person to be encountered in the household meeting the age criteria was interviewed. For those who failed to meet the inclusion criteria, a second person was interviewed, and if more than one individual meeting the age criteria was present in the same household, a lottery method was used. If there is no respondent in the selected households in two visits, the next household was considered until the desired sample size was achieved.

Study variables

Knowledge and perception towards DM were the outcome variables. Sociodemographics, source of information, and family history of DM were considered independent covariates.

Data collection tool and procedure

A data collection tool was developed from previous similar literature [19, 30, 31] that contains socio-demographic data, knowledge, and perceptions based on the Health Belief Model. Moreover, the three-part data collection tool was designed based on study objectives. The first part of the questionnaire focused on the sociodemographic information that included age, sex, marital status, level of education, occupation, average family monthly income, family history of diabetes mellitus, exposure to health education about DM, and source of health information. The second part assessed the level of knowledge about diabetes mellitus among the study participants and the level of participants’ understanding of various aspects of DM, including definition, causes/risk factors, signs/symptoms, control and management. Respondents answered either “yes”, or “no”, or “I do not know” options. Correct responses were scored as one point, while the responses “No” or “I do not know” were scored as zero points. All respondents with below the mean score on knowledge questions were included among those with poor knowledge, while respondents scoring above the mean on knowledge questions were regarded as having good knowledge.

The third part of the tool is regarding perceptions towards DM based on the constructs of the Health Belief Model scale; this scale has five subscales: Perceived susceptibility to having disease was assessed by using three items. The first item inquired as to “My chances of getting diabetes mellitus in the next few years are high”. The second regarding perceived seriousness of DM was assessed by four items (e.g., “If I had diabetes, I would be worried and depressed”). Perceived benefits of undergoing a preventive measure and screening were assessed by five items (e.g., “I believe maintain a normal body weight help to control diabetes.”). Finally, perceived barriers to screening and healthy lifestyle were evaluated using five items (e.g., “I think having a regular health check-up takes too much time.”) [24, 27]. All items of the subscales use five-point Likert-type response choices: Strongly Agree (5 points), agree (4 points), neutral (3 points), disagree (2 points) and strongly disagree (1 point). Using previous studies [32, 33], we categorized agree, neutral and disagree as a baseline. Each of the subscales was assessed separately, and the total score was not calculated. Subscale scores were calculated for each construct. Higher scores indicated stronger feelings about that construct. In the original test, Cronbach’s alpha coefficients for the five subscales were observed to fall between 0.65 and 0.87. In this study, Cronbach’s alpha coefficients of 0.83 were observed for the five subscales. Data were collected through face-to-face interviews by six trained data collectors. The principal investigator of the study was controlling the overall activity.

Data quality assurance

Pretesting was performed among 5% of study participants two weeks prior to the actual data collection period among non-sampled kebeles to avoid information contamination bias. The questionnaire was modified based on the responses to the pretest. In addition, the questionnaire was initially developed in English, then translated to the local language (Amharic) by an expert and then back to English to ensure consistency. Training on data collection was given to data collectors and supervisors for one day before actual data collection. All data collectors were trained on their responsibilities for the purposes of the study, how to collect the data, how to maintain confidentiality, and how to ensure genuine replies on questions. Furthermore, the principal investigator strictly followed the overall activities of the data collection on a daily basis to ensure the completeness of the questionnaires and to give further clarification. Double data entry was employed.

Data processing and analysis

The collected data were checked for completeness, coded, entered into Epi Data VS 3.1 and then exported to SPSS VS 22 for analysis. Descriptive statistics were used to describe the study participants in relation to relevant variables. Then, bivariate and multivariate logistic regression was used to identify the possible associations between independent and outcome variables. Variables with p-values less than 0.2 during bivariable analysis were exported to multivariable analysis to control for confounding effects. Variables with a p-value of ≤ 0.05 in the multivariable analysis were considered significantly associated with the outcome variable. Assumption tests and model goodness of fit were checked. Finally, the results of the study are presented in tables, figures, and text.

Ethics consideration

This study was approved by the ethical review committee of the Institute of Medicine and College of Health Sciences, Debre Berhan University. An official letter of permission was provided to the Debre Berhan town administration. After explaining the purpose of the research to the study participants, verbal informed consent was obtained prior to data collection. The data obtained were maintained in a manner to ensure confidentiality.

Results

Sociodemographic characteristics of the study participants

A total of 423 respondents participated, yielding a response rate of 100%. Within this sample, 231 (54.6%) were females; nearly half of the participants [195 (46.1%)] were married. More than half [235 (55.6%)] of the study participants were educated at the college and above; nearly two-thirds (64.3%) had an average family income greater than 1,540 Ethiopian birrs per month. Most of the study participants, 255 (60.3%), were previously exposed to health education about DM (Table 1).

Table 1

Sociodemographic characteristics of study participants in Debre Berhan town, northeast Ethiopia.

Variables	Category	Frequency	Percent (%)
Sex	Female	231	54.6
	Male	192	45.4
Marital status	Married	195	46.1
	Single	194	45.9
	Divorced/separated	18	4.3
	Widowed	16	3.8
Educational status	Unable to read and write	28	6.6
	Grade 1–4	25	5.9
	Grade 5–8	52	12.3
	Grade 9–12	83	19.6
	College and above	235	55.6
Occupation	Housewife	58	13.7
	Student	86	20.3
	Merchant	70	16.5
	Government/private employee	167	39.1
	Day laborer	42	9.9
Average monthly income	≤1,539 ETB	151	35.7
	≥1540 ETB	272	64.3
Exposure to health education about DM	Yes	255	60.3
	No	168	39.7
Family history of DM	Yes	54	12.8
	No	369	87.2
Source of information	Public media	121	47.5
	Health care worker	79	31.0
	Friends	34	13.3
	Other (teacher & religious leader)	21	8.2

N.B. ETB; Ethiopian birr.

Knowledge of participants about diabetes mellitus

In general, the total mean score for correctly answered knowledge questions was 11.4 ±4.9. Two hundred thirty-seven (56.02%) scored above the mean and were considered to have good knowledge. In contrast, 186 (43.98%) scored below the mean were poorly knowledgeable. Among 423 participants, approximately 47% responded correctly defined DM as high levels of sugar in the blood, and approximately 40.7% said DM is incurable. In addition, regarding risk factors, the percentage of participants correctly naming family history of DM was 54.4%; being overweight or obese was 64.1%; and sedentary lifestyle was 60.8% of participants. Significant proportions of study participants (79.7% and 79.2%) reported excessive hunger and feeling of weakness as signs and symptoms of DM, respectively. Moreover, related to the management of DM, they described DM as being controlled by insulin injection (77.1%), regular exercise (66.2%) and a healthy diet (73.8%) (Table 2).

Table 2

Participants’ knowledge about diabetes mellitus in Debre Berhan town, northeast Ethiopia.

Variables	Yes		No
	number	%	number	%
What is/are DM
DM is a condition of insufficient insulin production	120	28.4	303	71.6
DM is a condition of the body which not responding for insulin	115	27.2	308	72.8
DM is a condition of high level of sugar in the blood	199	47.0	224	53.0
DM is not curable	251	59.3	172	40.7
What are the risk factors of DM
Older age	213	50.4	210	49.6
Genetic or family history of diabetes mellitus	230	54.4	193	45.6
Being overweight /Obesity	271	64.1	152	35.9
Sedentary life /Poor dietary habits	257	60.8	166	39.2
What are the signs and symptoms of DM
Frequent urination	206	48.7	217	51.3
Excessive thirst	214	50.6	209	49.9
Excessive hunger	337	79.7	86	20.3
Weight loss	223	52.7	200	47.3
High blood sugar	258	61.0	165	39.0
Blurred vision	233	55.1	190	44.9
Slow healing of cuts and wounds	249	58.9	174	41.1
Feeling of weakness	335	79.2	88	20.8
Control and management of DM
Insulin injection is available for control and management of DM	326	77.1	97	2.9
Tablets & capsule are available for control and management of DM	226	53.4	197	46.6
Regular exercise	280	66.2	143	33.2
Practices healthy diet	312	73.8	111	26.2

Factors associated with participants’ knowledge about DM

In the multivariable analysis, participants who were married were almost eleven times more likely to be knowledgeable than those who were widowed (AOR = 10.97, CI; 2.33, 51.64). Likewise, participants who were unable to read and write were 81% less likely to have good knowledge than those who had college and above educational status (AOR = 0.19, CI; 0.53, 0.68). Similarly, participants who had a family history of DM were almost three times more knowledgeable than those who did not have a family history of DM (AOR = 2.83, CI: 1.11, 7.25). Participants who had diabetes health education exposure were slightly more than three times as knowledgeable as those who did not have diabetes health education exposure (AOR = 3.28, CI; 2.02, 5.31) (Table 3).

Table 3

Bivariate and multivariate logistic regression analysis to characterize factors associated with knowledge of diabetes mellitus in Debre Berhan town, northeast Ethiopia.

Variable	Category	Knowledge		COR(95%CI)	AOR(95% CI)
		Good Knowledge	Poor knowledge
Sex	Male	130	62	1.05(0.69, 1.57)	0.86(0.49, 1.49)
	Female	154	77	1	1
Marital status	Single	129	65	8.6(2.36, 31.25)*	9.08(1.72, 48.00)*
	Married	144	51	12.24(3.35, 44.68)*	10.97(2.33, 51.64)*
	Divorced	8	10	3.467(0.72, 16.53)	4.23(0.67, 26.58)
	Widowed	3	13	1	1
Educational status	Unable to read &write	9	19	0.17(0.07, 0.39)*	0.19(0.53, 0.68)*
	Grade 1–4	11	14	0.28(0.12, 0.65)*	0.24(0.07, 0.82)*
	Grade 5–8	37	15	0.88(0.45, 1.72)	0.87(0.36, 2.07)
	Grade 9–12	54	29	0.66(0.39, 1.14)	0.72(0.37, 1.39)
	College and above	173	62	1	1
Occupational status	House wife	34	24	0.88(0.26, 3.04)	0.75(0.15, 3.65)
	Student	56	30	1.16(0.35, 3.88)	0.40(0.09, 1.77)
	Merchant	44	26	1.05(0.31, 3.57)	0.46(0.11, 1.95)
	Farmer	9	4	1.40(0.27, 0.71)	2.28(0.30, 17.10)
	Government employer	125	42	1.86(0.57, 5.99)	0.67(0.17, 2.64)
	Daily labor	8	8	0.62(0.14, 2.76)	0.57(0.09, 3.36)
	Driver	8	5	1	1
Exposure to health education	Yes	202	53	3.99(2.60, 6.13)*	3.27(2.02, 5.31)*
	No	82	86	1	1
Family history of DM	Yes	44	10	2.37(1.15, 4.85)*	2.83(1.10, 7.25)*
	No	240	129	1	1

* For statistically significant variables at p<0.05 both at bivariable and multivariable analysis: 1 reference variable; COR: crude odds ratio; AOR; adjusted odds ratio.

Perceptions towards diabetes mellitus based on the health belief model

The findings showed that 20.1% of the participants considered themselves to be at risk of developing DM in the future (perceived susceptibility). Additionally, 62.4% of the participants agreed to the statements related to the seriousness of the disease. Regarding the perceived benefits of the screening and preventive measure, approximately two-thirds of the participants believed that undergoing regular health care visits can help find DM early and save lives. Twenty-seven percent of the participants had experienced barriers to undergoing screening and implementing lifestyle changes, while 31.2% of participants never heard or read anything encouraging them to have regular health check-up and 25.1% of participants felt having a regular health check-up takes too much time (Table 4).

Table 4

Health belief model scores of participants in Debre Berhan town, northeast Ethiopia.

Variables	Category	Agree	Neutral	Disagree
		N (%)	N (%)	N (%)
Perceived susceptibility	My chances of getting diabetes in next few years is great	79(20.2)	46(11.7)	266(68.1)
	I feel I will get diabetes sometime during my life	70(16.5)	68(16.0)	286(64.5)
	I believe all population are equally likely to develop diabetes	106(24.3)	45(10.3)	285(65.4)
	Average score (%)	85(20.1)	53(12.5)	285(67.4)
Perceived severity	If I had diabetes, I would be worried and depressed	299(73.6)	6(1.6)	101(24.8)
	If I had diabetes, I would have to have my diabetes taken off by medication	356(83.6)	3(0.7)	67(15.7)
	DM can be a serious disease if you don’t prevent it.	116(28.6)	38(9.3)	252(62.1)
	If I had diabetes, it would cause me to die	285(66.1)	2295.1)	124(28.8)
	Average score (%)	264(62.4)	23(5.4)	136(32.2)
Perceived benefits	I believe diabetes can be cured easily	160(37.8)	51(12.1)	212(50.1)
	I believe maintain a normal body weight help to control diabetes	275(64.6)	57(13.4)	94(22.0)
	Regular health care visit can help finding diabetes early and save my life	373(88.2)	18(4.3)	32(7.5)
	I believe that eat low sugar snacks & low-fat meals prevent DM in the future	295(77.0)	31(8.1)	57(14.9)
	I believe that regularly physical exercise will help to prevent diabetes	298(70.5)	64(15.1)	61(14.4)
	Average score (%)	284(67.1)	44(10.5)	95(22.4)
Perceived barriers	I don't want to know if i have diabetes or not	72(16.8)	128(30.0)	227(53.2)
	I think having a regular health check-up takes too much time.	106(32.9)	44(13.7)	172(53.4)
	Not having enough money would keep me from having a check-up.	92(21.5)	84(19.7)	251(58.8)
	I never heard or read anything encouraging having regular health check-up.	132(30.9)	77(18.0)	218(51.1)
	I could not have enough time to exercise	85(19.8)	18(4.2)	325(76.0)
	Average score (%)	114(27.0)	70(16.6)	239(56.4)

Discussion

The current study showed that approximately 56.02% (95% CI: 53.82, 59.47) of the study participants were knowledgeable about DM. This result is in line with a study performed in the Bale zone, Ethiopia, which reported 52.2% [16]. Our finding was higher than a study in Debre Tabor town at 49% [15], 41.9% in Malaysia [17], 15% in Sudan [20], 27.2% in Kenya [14], 49.9% in India [18], and 49.7% in Namibia [34]. This variation might be due to the study period since the studies were conducted, for instance, in Sudan (2014), Kenya (2010), India (2008), and Malaysia (2014). The other possible explanation could be that diabetes is now emerging as an epidemic of the 21st century. To curb this scourge of diabetes, studies have shown that knowledge is the greatest weapon in the fight against DM [35, 36]. In line with this evidence, the Ethiopia government has designed a strategy to increase community awareness and knowledge of diabetes mellitus through public media and incorporated noncommunicable disease prevention and control programs as one core component of health extension programs [37].

In the present study, approximately 40.5% of study participants knew the definition of DM, with 60.7% having good knowledge about symptoms of DM, 57.4% of participants correctly identifying the risk factors of DM, and 65.7% showing good knowledge on control and management of DM. This finding is in line with a study undertaken in a semi-urban Omani population on diabetes definition and classical symptoms, which were reported as 46.5% and 57.0%, respectively [38]. Likewise, a study conducted in Debre Tabor Town found that 60.3% knew the definition, 39.1% had good knowledge about symptoms of DM, 49% identified the risk factors of DM, and 44% respondents had good knowledge on the control and management of DM [15]. In contrast, our results were higher than those of a study conducted in Kenya on DM sign/symptom (29%) and risk factors (26%) [14] and one in Nigeria on knowledge of respondents on risk factors of DM was 19.0% and symptoms of diabetes mellitus was 18.2% [39]. The differences might be due to the Ethiopia government’s strategy to reduce the burden of noncommunicable diseases, particularly diabetes, through incorporating a noncommunicable disease prevention program under the health extension package, which includes extensive print media [40].

Study participants who were unable to read and write had 81% less likely good knowledge about DM than those whose educational status was college and above. These findings were supported by studies conducted in semi-urban Omani populations [38], in Debre Tabor [15], and in Bangkok [23]. This finding might reflect that respondents who had higher education would have the chance to obtain different information, such as leaflets and manuals, which make them more aware about DM. Furthermore, this more highly educated group is more likely able to communicate more easily with health care providers regarding questions or concerns.

In the present study, those who had diabetes health education exposure were almost three times more knowledgeable than those who did not have diabetes health education exposure. This finding was consistent with the study conducted in Bangladesh [21] and the finding also supported by the study done in Bale zone [16]. On the other hand, in the current study, participants who had a family history of DM were nearly three times more knowledgeable than those who did not have a family history of DM, which is similar to findings in a semi-urban Omani population [38], in Debre Tabor town [15], and in Southwest Ethiopia [41]. In this study, married individuals were eleven times and single individuals nine times more knowledgeable than those who were widowed, reflecting findings from a previous study performed in Southwest Ethiopia [41]. This could be due to the proportion of participants who were married in our study sample. Therefore, the authors suggest that future study is required to investigate the correlation between marital status and level of knowledge.

According to the present study, approximately 20.1% of participants had perceived susceptibility to developing diabetes in the future. This is consistent with the findings in Rwanda [42] found that the majority of respondents thought that there was almost no chance or no chance at all that they would develop diabetes. Additionally, 62.4% of the participants correctly agreed to the statements related to the seriousness of the disease. Regarding perceived severity, our finding is lower than a study done in Rwanda, where approximately 79.4% thought of DM as a severe disease [43] and 71% in Namibia reported as a serious disease [34]. This may reflect that there are other diseases that take priority and are viewed as more serious. In addition, not knowing the seriousness of a condition could be due to a lack of education interventions that can assist in alerting communities about these health conditions.

Concerning perceived benefits of the screening and preventive measure, approximately 67% of the participants believed that undergoing regular health care visits can help find DM early and save lives. Twenty-seven percent of the participants had experienced barriers to undergoing screening and implementing lifestyle change. For example, 31.2% of participants never heard or read anything encouraging about having regular health check-up; 25.05% of participants considered having a regular health check-up takes too much time; and 21.7% of the participant did not have enough money, which would keep them from having a check-up. This finding suggests that there is a need for education campaigns in the district to reduce barriers to diabetes screening about all aspects of barriers, such as time consumption and misinformation. It is therefore important to identify interventions that reduce people's perceived barriers despite their levels of knowledge of diabetes mellitus.

Limitation of the study

Despite extensive efforts, the results of this study are subject to certain limitations. First, the cross-sectional nature of the study design makes it impossible to form causal relationships between exposure and outcome variables. Second, the study is conducted in one community and one cultural group; therefore, the findings might not necessarily be generalized to be the same in rural areas.

Conclusion

This community-based cross-sectional study showed that the overall knowledge about DM was moderate. Educational status, marital status, family history of DM and exposure to health education had significant associations with the mean knowledge of the study participants. The majority of the sample had a low perception of the risk for developing diabetes. Therefore, policy makers, healthcare managers, and healthcare workers should plan health education interventions that can enhance public knowledge and the correct perception of the risk of developing diabetes. The use of the HBM, as in this study, could form the framework for further research on diabetes prevention among the Ethiopian population. Furthermore, future nationwide studies based on this framework are recommended to help develop more effective DM prevention interventions among the adult population in Ethiopia.

English version of the questionnaire.

(DOCX)

Click here for additional data file.

Amharic version of the questionnaire.

(DOCX)

Click here for additional data file.

22 Jun 2020

PONE-D-20-04491

Assessment of Knowledge and Perception towards Diabetes Mellitus and Its Associated Factors among People in Debre Berhan Town, Northeast Ethiopia:

PLOS ONE

Dear Dr. shiferaw,

Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process.

Please submit your revised manuscript by Aug 06 2020 11:59PM. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at plosone@plos.org. When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file.

Please include the following items when submitting your revised manuscript:

A rebuttal letter that responds to each point raised by the academic editor and reviewer(s). You should upload this letter as a separate file labeled 'Response to Reviewers'.

A marked-up copy of your manuscript that highlights changes made to the original version. You should upload this as a separate file labeled 'Revised Manuscript with Track Changes'.

An unmarked version of your revised paper without tracked changes. You should upload this as a separate file labeled 'Manuscript'.

If you would like to make changes to your financial disclosure, please include your updated statement in your cover letter. Guidelines for resubmitting your figure files are available below the reviewer comments at the end of this letter.

If applicable, we recommend that you deposit your laboratory protocols in protocols.io to enhance the reproducibility of your results. Protocols.io assigns your protocol its own identifier (DOI) so that it can be cited independently in the future. For instructions see: http://journals.plos.org/plosone/s/submission-guidelines#loc-laboratory-protocols

We look forward to receiving your revised manuscript.

Kind regards,

Cindy Gray, Ph.D.

Academic Editor

PLOS ONE

Additional Editor Comments:

Abstract:

I am not clear what an institutional-based study is. Also, the end of the 3rd paragraph in the introduction suggests there have been a number of community studies including two in Ethiopia.

This sentence is not clear to me: The finding shows that 20.1% of the participants were agreed related to perceived susceptibility of the disease.

This is not very informative without some more context: About 62.4% of the participants agreed to the statements related to the seriousness of the disease.

Please keep decimal points the same.

The conclusion needs to go further than simply more or less restate the results.

Where is the HBM here?

Introduction:

Keep statements about increasing global prevalence in the same place (1st paragraph) and perhaps keep developing countries statements together.

Keep the Health Belief model statements together

Scantly is not a very scientific term.

The link between the HBM and its utility for interventions needs to be more clearly made.

All in all the introduction needs some careful reworking to improve the coherence and logic of the argument made.

Method:

It is not entirely clear what variable your sample size calculation is based on

The sampling procedure is very hard to follow. It needs carefully re-written taking account of the comments below

Lottery method was used to select the study unit among households who have more than one eligible participant. I don’t understand what you mean here.

I also don’t understand this next households were selected after calculating skip fraction (K=x)

There appears to be some repetition, which makes the sampling procedure hard to follow.

In Study variables (and elsewhere), is According to the current study needed?

Data collection tool – How can individuals give information about community-level variables

I don’t understand this: According to this study, good knowledge reflected when respondents scored above the mean score on knowledge questions; whereas, poor knowledge was determined when respondents’ answers were below the mean score on knowledge questions. Is this a mean split?

Need references for the previous studies for the HBM scale categorisation

Additional ldata were collected through face to face interviews by six traineddata collectors – I don’t understand this

What modifications were done following the pre-testing?

Results:

Table 1 is hard to follow which categories belong to which variables

In the knowledge table – should it be clearer which answers are correct?

Sort out labelling of tables – there are mistakes. Figure 1 doesn’t add much – consider removing.

Why do you not highlight low education association with poor knowledge in the text?

Table 3 Title could be more informative

Table 4 needs percentages throughout – not just for average score – also what is the average score relating to? Is this numbers?

Should screening and healthy lifestyle be part of the same construct?

Again make sure decimal points for figures are consistent throughout

Discussion

What evidence is there for improvements in paragraph 1 – this argument needs to be made more compelling. – e.g. were the other studies done some time ago, are health systems etc better in Ethiopia?

Provide a reference for the Ethiopian Government’s NCD strategy in para 2

The consistency might be due to the widowed individuals are at risk of psychological distress or may be older?. This is too vague – what is the evidence for this?

The second limitation reads like a bullet point

All in all the discussion needs to more directly address the HBM and how the results might inform what interventions are needed.

In general the manuscript needs to be carefully checked for typos. There are a lot that need addressed.

Journal Requirements:

When submitting your revision, we need you to address these additional requirements.

1. Please ensure that your manuscript meets PLOS ONE's style requirements, including those for file naming. The PLOS ONE style templates can be found at

https://journals.plos.org/plosone/s/file?id=wjVg/PLOSOne_formatting_sample_main_body.pdf and

https://journals.plos.org/plosone/s/file?id=ba62/PLOSOne_formatting_sample_title_authors_affiliations.pdf

2. Please include additional information regarding the survey or questionnaire used in the study and ensure that you have provided sufficient details that others could replicate the analyses. For instance, if you developed a questionnaire as part of this study and it is not under a copyright more restrictive than CC-BY, please include a copy, in both the original language and English, as Supporting Information. Moreover, please include more details on how the questionnaire was pre-tested, and whether it was validated.

3. Thank you for stating the following financial disclosure:

"none"

At this time, please address the following queries:

Please clarify the sources of funding (financial or material support) for your study. List the grants or organizations that supported your study, including funding received from your institution.

State what role the funders took in the study. If the funders had no role in your study, please state: “The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.”

If any authors received a salary from any of your funders, please state which authors and which funders.

If you did not receive any funding for this study, please state: “The authors received no specific funding for this work.”

Please include your amended statements within your cover letter; we will change the online submission form on your behalf.

4. We note that you have indicated that data from this study are available upon request. PLOS only allows data to be available upon request if there are legal or ethical restrictions on sharing data publicly. For information on unacceptable data access restrictions, please see http://journals.plos.org/plosone/s/data-availability#loc-unacceptable-data-access-restrictions.

In your revised cover letter, please address the following prompts:

a) If there are ethical or legal restrictions on sharing a de-identified data set, please explain them in detail (e.g., data contain potentially identifying or sensitive patient information) and who has imposed them (e.g., an ethics committee). Please also provide contact information for a data access committee, ethics committee, or other institutional body to which data requests may be sent.

b) If there are no restrictions, please upload the minimal anonymized data set necessary to replicate your study findings as either Supporting Information files or to a stable, public repository and provide us with the relevant URLs, DOIs, or accession numbers. Please see http://www.bmj.com/content/340/bmj.c181.long for guidelines on how to de-identify and prepare clinical data for publication. For a list of acceptable repositories, please see http://journals.plos.org/plosone/s/data-availability#loc-recommended-repositories.

We will update your Data Availability statement on your behalf to reflect the information you provide.

5. Please include a copy of Table 2 which you refer to in your text on page 11.

[Note: HTML markup is below. Please do not edit.]

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #1: Yes

**********

2. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: I Don't Know

**********

3. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #1: No

**********

4. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #1: No

**********

5. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: General points:

1. The authors have not provided the ethical statement requested by the journal

2. The authors need to use one of the data availability statements provided by the journal

3. The limitations section appears incomplete and contains what appears to be drafting notes

4. Insufficient care to distinguish types of DM – it is not a single condition

Introduction

• Change “which means” to “equating to” when describing deaths per day.

• Remove erroneous ‘g’ and rephrase sentence – “Numerous studies have revealed the proportion of good knowledge respecting g diabetes mellitus was reported as…”

• I would like to see the authors engage critically with the health belief model and justify its use.

• Use “scant” not “scanty”

Methods

• Check the grammar and punctuation carefully – there are missing full stops, shifts of tense and duplicated words eg:

o “The town of North Shoa Zone The town”

o “The total population were 108,825, within 25,308 households” [should be ‘was’]

o “All adults living in Debre Berhan town for at least for six months…”

• The authors should share the questionnaire used as an appendix or supplementary file.

• This sentence needs to be more precise and should be referenced: “Using previous studies, as a baseline we have categorized in to agree, neutral and disagree”

Results

• In table 1, income currency should be specified

• General checking of tenses required e.g. “was widowed” should be “were widowed”

• Table reporting knowledge of DM is labelled table 1, but it is the second table in the manuscript. The formatting of the table is also hard to read- we need additional spaces and or bold text between the sections relating to description of DM, risk factors, symptoms, and control

Discussion

• The discussion compares findings of the study to other relevant studies well, but it does not consider the meaning of the findings presented in the paper- what does this new study add to our knowledge of diabetes in this setting?

• Also, what do the findings suggest should happen or be prioritised? E.g. for those patients who experienced barriers to diabetes screening, what can/should be done?

• The final paragraph of the discussion is quite confusing and is not clearly written.

• The limitations paragraph is incomplete and contains drafting notes.

**********

6. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files.

If you choose “no”, your identity will remain anonymous but your review may still be made public.

Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy.

Reviewer #1: No

[NOTE: If reviewer comments were submitted as an attachment file, they will be attached to this email and accessible via the submission site. Please log into your account, locate the manuscript record, and check for the action link "View Attachments". If this link does not appear, there are no attachment files.]

While revising your submission, please upload your figure files to the Preflight Analysis and Conversion Engine (PACE) digital diagnostic tool, https://pacev2.apexcovantage.com/. PACE helps ensure that figures meet PLOS requirements. To use PACE, you must first register as a user. Registration is free. Then, login and navigate to the UPLOAD tab, where you will find detailed instructions on how to use the tool. If you encounter any issues or have any questions when using PACE, please email PLOS at figures@plos.org. Please note that Supporting Information files do not need this step.

20 Jul 2020

Author’s response to editor and reviewers

Title: Assessment of Knowledge and Perception towards Diabetes Mellitus and Its Associated Factors among People in Debre Berhan Town, Northeast Ethiopia.

Version 1: June 30, 2020

Dear editor

To PLOS ONE, we are pleased to resubmit for publication version of “Assessment of Knowledge and Perception towards Diabetes Mellitus and Its Associated Factors among People in Debre Berhan Town, Northeast Ethiopia” with manuscript ID of “PONE-D-20-04491” for a review as original research in PLOS ONE. The comments of the editor and reviewers were highly insightful and enabled us to greatly improve the quality of our manuscript. Therefore, based on the editor and reviewers’ concerns we have made extensive edition in our manuscript. The formatting of the text and document (text sizes and grammatical errors) were also edited. In the following pages, we have addressed yours’ concerns in a point by point format.

We look forward to hearing from you at your earliest convenience.

Once again, thank you for considering our manuscript in PLOS ONE!

Kind regards,

Wondimeneh Shibabaw shiferaw

On behalf of all the authors

Author’s response to Editor Comments

Abstract:

1. I am not clear what an institutional-based study is. Also, the end of the 3rd paragraph in the introduction suggests there have been a number of community studies including two in Ethiopia.

Response: We thanks and accept your feedback. Based on your insightful feedback authors have been made appropriate modification in the revised manuscript. In fact you are right, two studies have been conducted in Ethiopia, however, both of them focus on knowledge, attitude, and practices towards diabetes mellitus. But, our study is unique because it emphasized on public knowledge and risk perception towards DM using the health belief model in northeast Ethiopia.

2. This sentence is not clear to me: The finding shows that 20.1% of the participants were agreed related to perceived susceptibility of the disease.

Response: we accept your concern and appropriate correction has been made in the revised manuscript. Therefore, the statement has been restated as “In this study, few respondents 20.1% felt that they have higher risk of developing diabetes”.

3. This is not very informative without some more context: About 62.4% of the participants agreed to the statements related to the seriousness of the disease.

Response: we accept your comments and necessary correction has been made within the revised manuscript by rephrasing as “In the current study, two third of respondents 62.4% saw diabetes as a seriousness disease”.

4. Please keep decimal points the same.

Response: we accept your feedback.

5. The conclusion needs to go further than simply more or less restate the results.

Response: right you are. Based on your comments authors rephrase the conclusion.

6. Where is the HBM here?

Response: in the revised document authors made further attempt to summarize the five pillars construct of HBM with short sentence particularly risk perception as “the perceived risk of developing diabetes was low at the community level, though many respondents felt that behavior change has importance in the prevention of diabetes’.

Introduction:

1. Keep statements about increasing global prevalence in the same place (1st paragraph) and perhaps keep developing countries statements together. Keep the Health Belief model statements together

Response: We accept your suggestion and necessary correction has carried out throughout the introduction section.

2. Scantly is not a very scientific term.

Response: we accept and correction has been taken.

3. The link between the HBM and its utility for interventions needs to be more clearly made.

Response: To the best of our maximum effort the link between HBM and its usefulness for intervention has been clearly stated in the revised document page#4. Additionally, to make it clear the health belief model was developed to explain preventive health behaviours and control of disease. The aim of this model is increasing the perception of individuals about a health threat and directs their behaviours towards health. This model is a comprehensive pattern which represents the association between beliefs and behaviours; it has been widely applied to various health behaviours, especially screening behaviours and plays a significant role in prevention of the disease. Therefore, understanding individuals’ view points and beliefs is essential for developing the strategies of controlling diabetes. Moreover, the Health Belief Model is one of the models that widely used as a guiding framework for health behaviour interventions.

4. All in all the introduction needs some careful reworking to improve the coherence and logic of the argument made.

5. Response: we accept your comments and extensive edition has been taken to the entire part of introduction section.

Method:

1. It is not entirely clear what variable your sample size calculation is based on

Response: The sample size was calculated based our study objective. The primary objective is to assess level of knowledge towards diabetes among Debre Berhan town residents northeast Ethiopia. Second, to determine the perceived risk of developing diabetes among Debre Berhan town community. Therefore, for the first objective sample size was calculated using single population proportion formula with an assumption of 95% confidence level, 5% degree of precision and 52.5% of respondents had good knowledge towards diabetes in accordance with previous literature report. For the second objective due to lack of available data on risk perception towards diabetes 50% proportion has been taken to estimate the sample size. Finally, by comparing the estimated sample size in both objectives, authors have decided to take the largest sample size which is found from the second objective (risk perception) which is 423. Additionally, to make it clear calculated the sample size of the present study the following assumption has been taken in to consideration, single population proportion was 50%, Za/2=95%, and 5% margin of error.

2. The sampling procedure is very hard to follow. It needs carefully re-written taking account of the comments below

2.1. Lottery method was used to select the study unit among households who have more than one eligible participant. I don’t understand what you mean here.

Response: We accept your valuable feedback. This statement is our technical error and after evaluating we remove the sentence from the revised document.

2.2. I also don’t understand this next households were selected after calculating skip fraction (K=x).

Response: right you are. It has been vague in the document, but now based on your comment necessary correction has been carried out. To make it clear, in the present study, the study unit was selected using systematic random sampling technique. First, the total frame size (number of households) and sample size was determined. Then we determine the number of sampling intervals K by dividing households by sample size. Then we select the random start (the first sampling unit) from the first interval in the frame with lottery method. Then every Kth unit was taken until the required sample size was achieved. Therefore, in this study K=N/n; 1,347/423=3.2 approximately 3.

2.3. There appears to be some repetition, which makes the sampling procedure hard to follow.

Response: We thanks and appropriate modification has been made.

3. In Study variables (and elsewhere), is According to the current study needed?

Response: right you are and correction has been carried out.

4. Data collection tool – How can individuals give information about community-level variables

Response: In fact our narration has the problem. To make it clear, it is obvious that each individual is the part of the community, therefore by incorporating adequate sample of participants through scientifically sounded method, authors can inference appropriate conclusion based on his/her hypothesis. However, in the present study authors provide corrections with respect to the nature of variables are made to be considered as personal level.

5. I don’t understand this: According to this study, good knowledge reflected when respondents scored above the mean score on knowledge questions; whereas, poor knowledge was determined when respondents’ answers were below the mean score on knowledge questions. Is this a mean split?

Response: This mean is not split, but to make it clear the measurement for knowledge about diabetes mellitus comprised of questions entailing the causes /risk factors, signs and symptoms and complications of diabetes mellitus. Using mean scores, the respondents were categorised into varying levels of knowledge namely 'good' and 'poor'. All respondents with below the mean score on knowledge questions were included among those with poor knowledge while respondents scoring above the mean on knowledge questions were regarded as having good knowledge. Therefore, the above statement has been provided appropriate correction within the revised manuscript.

6. Need references for the previous studies for the HBM scale categorisation

Response: We accept your comments and necessary citation has been included in the revised manuscript.

7. Additional l data were collected through face to face interviews by six trained data collectors – I don’t understand this

Response: right you are the sentence has the problem. Therefore, based on your insightful comments, modification has been carried out in the revised document as “Data were collected through face to face interviews by six trained data collectors’.

8. What modifications were done following the pre-testing?

Response: after pre-test necessary correction has made in the document such as improved language clarity, arrangement of data from low to difficult questions, and modify the context of some questions.

Results:

1. Table 1 is hard to follow which categories belong to which variables

Response: we thanks so much. Based on your comment, authors change the design of the table to make clear which category is belong to which variables in the revised manuscript page#8-9 table 1.

2. In the knowledge table – should it be clearer which answers are correct?

Response: your concern is very interesting. In the knowledge table 2 the authors state the each question items based on the response of the study participants either the question has negative or positive statement. However, when we calculating the overall mean score of knowledge questions, we have rearrange positive and negative statement based on the nature of the question. Hence, it has negative impact when estimating the overall mean score.

3. Sort out labelling of tables – there are mistakes.

Response: We accept your suggestion and correction has been taken for each.

4. Figure 1 doesn’t add much – consider removing.

Response: We thanks so much. Based on your suggestion figure 1 had been removed from the document.

5. Why do you not highlight low education association with poor knowledge in the text?

Response: right you are this is our problem. But, now based on your comments authors clearly describe the association of educational status on knowledge of diabetes mellitus within the revised document as “participants who are unable to read and write were 81% less likely to have good knowledgeable than those who have college and above educational status (AOR=0.19, CI; 0.53, 0.68)”.

6. Table 3 Title could be more informative

Response: we accept your suggestion and the title has corrected as “Bivariate and multivariate logistic regression analysis to characterize factors associated with knowledge of diabetes mellitus in Debre Berhan town, Northeast Ethiopia”.

7. Table 4 needs percentages throughout – not just for average score – also what is the average score relating to? Is this numbers?

Response: we accept your suggestion and apply percentage throughout the table 4. The average score is related to the response of participants (numbers) from each constructs of HBM. Subscale average scores were calculated for each constructs. Therefore, higher scores indicated stronger feelings about that construct. Hence, all HBM constructs are not able to sum up due to their different items within each constructs. Previous studies evidence also supports the present analysis.

8. Should screening and healthy lifestyle be part of the same construct?

Response: By taking in to consideration your idea, authors extensive discuss on this issue then after decide to put HBM construct independently related to screening and healthy lifestyle. Therefore, we have restated this construct as “perceived barriers”.

9. Again make sure decimal points for figures are consistent throughout

Response: We accept your suggestion and uniform decimal points have been used throughout the revised manuscript.

Discussion

1. What evidence is there for improvements in paragraph 1 – this argument needs to be made more compelling. – e.g. were the other studies done some time ago, are health systems etc better in Ethiopia?

Response: To make it clear the possible variation could be the study period since the studies were conducted for instance in Sudan (2014), Kenya (2010), India (2008), and Malaysia (2014); because currently diabetes mellitus (DM) has become an increasing trend globally and a growing public burden related to this public knowledge and awareness have grown parallel. The other possible explanation could be diabetes is now emerging as an epidemic of the 21st Century. To curb this scourge of diabetes, it is known that knowledge is the greatest weapon in the fight against DM. Related to this currently Ethiopia government has design strategy to increase the community awareness and knowledge towards diabetes mellitus through public media and also incorporate NCD prevention and control program as one core component of health extension program to the nation [Workie et al. The health extension program in Ethiopia].

2. Provide a reference for the Ethiopian Government’s NCD strategy in para 2

Response: We accept your comments and appropriate reference has been provided in the revised manuscript.

3. The consistency might be due to the widowed individuals are at risk of psychological distress or may be older?. This is too vague – what is the evidence for this?

Response: In fact authors have been put their possible reason instead of scientific evidence. Therefore, in the revised manuscript we have deleted the previous possible justification and recommended for future researcher to investigate the reason related to this issue.

4. The second limitation reads like a bullet point

Response: Right you are. Based on your feedback necessary correction has been taken in the revised manuscript.

5. All in all the discussion needs to more directly address the HBM and how the results might inform what interventions are needed.

Response: we thanks so much. Based on your suggestion maximum effort has been carried out to link our finding with HBM.

6. In general the manuscript needs to be carefully checked for typos. There are a lot that need addressed.

Response: we accept your comment and appropriate correction has been made throughout the revised manuscript.

Journal Requirements:

When submitting your revision, we need you to address these additional requirements.

1. Please ensure that your manuscript meets PLOS ONE's style requirements, including those for file naming. The PLOS ONE style templates can be found at

https://journals.plos.org/plosone/s/file?id=wjVg/PLOSOne_formatting_sample_main_body.pdf and

https://journals.plos.org/plosone/s/file?id=ba62/PLOSOne_formatting_sample_title_authors_affiliations.pdf

Response: we accept your suggestion and the format is revised based on PLOS ONE journal style.

2. Please include additional information regarding the survey or questionnaire used in the study and ensure that you have provided sufficient details that others could replicate the analyses. For instance, if you developed a questionnaire as part of this study and it is not under a copyright more restrictive than CC-BY, please include a copy, in both the original language and English, as Supporting Information. Moreover, please include more details on how the questionnaire was pre-tested, and whether it was validated.

Response: first the questionnaire both English and Amharic version have been included as supplementary file in the revised manuscript. Second, before going to the actual data collection, the questionnaire was pretested in a similar setting outside the study district 5% (21) in Shewarobit city administration. The questionnaire was modified based on the response after it was pre-tested, and modification was made into the final version of the data collection tool. In addition, internal validity in this study was ensured through the piloting of the questionnaire in order to improve the data collection and to also identify any problems relating to understanding of the tool by respondents. With regard to external validity, the fact that the study context was specifically within the environment of urban areas, the sampling method and the sample size suggested that the findings might not necessarily be generalized to be the same in rural areas that is not similar to urban areas, because urban lifestyle differs from rural lifestyle. Moreover, Content validity of questionnaire was confirmed by 10 health education and promotion experts through calculating the content validity index (CVI) and content validity ratio (CVR).

3. Thank you for stating the following financial disclosure:

"none"

At this time, please address the following queries:

a. Please clarify the sources of funding (financial or material support) for your study. List the grants or organizations that supported your study, including funding received from your institution.

b. State what role the funders took in the study. If the funders had no role in your study, please state: “The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.”

c. If any authors received a salary from any of your funders, please state which authors and which funders.

d. If you did not receive any funding for this study, please state: “The authors received no specific funding for this work.”

Response: Authors consider your suggestion and included in the revised manuscript.

Please include your amended statements within your cover letter; we will change the online submission form on your behalf.

4. We note that you have indicated that data from this study are available upon request. PLOS only allows data to be available upon request if there are legal or ethical restrictions on sharing data publicly. For information on unacceptable data access restrictions, please see http://journals.plos.org/plosone/s/data-availability#loc-unacceptable-data-access-restrictions.

In your revised cover letter, please address the following prompts:

a) If there are ethical or legal restrictions on sharing a de-identified data set, please explain them in detail (e.g., data contain potentially identifying or sensitive patient information) and who has imposed them (e.g., an ethics committee). Please also provide contact information for a data access committee, ethics committee, or other institutional body to which data requests may be sent.

b) If there are no restrictions, please upload the minimal anonymized data set necessary to replicate your study findings as either Supporting Information files or to a stable, public repository and provide us with the relevant URLs, DOIs, or accession numbers. Please see http://www.bmj.com/content/340/bmj.c181.long for guidelines on how to de-identify and prepare clinical data for publication. For a list of acceptable repositories, please see http://journals.plos.org/plosone/s/data-availability#loc-recommended-repositories.

We will update your Data Availability statement on your behalf to reflect the information you provide.

Response: the data availability statement has been improved. Therefore, all relevant data are within the paper and it’s supporting information files. There is no separate data set to share.

5. Please include a copy of Table 2 which you refer to in your text on page 11.

Response: We accept your suggestion and appropriate correction has been taken.

[Note: HTML markup is below. Please do not edit.]

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #1: Yes

2. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: I Don't Know

3. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #1: No

4. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #1: No

5. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Author’s response for reviewers

Reviewer #1: General points:

1. The authors have not provided the ethical statement requested by the journal

Response: right you are. Based on your comment authors provided ethical statement which requested the journal in the revised manuscript.

2. The authors need to use one of the data availability statements provided by the journal

Response: accept you suggestion and included in the revised manuscript.

3. The limitations section appears incomplete and contains what appears to be drafting note

Response: right you are. However, necessary correction has been made in the revised manuscript.

4. Insufficient care to distinguish types of DM – it is not a single condition

Response: It is obvious that the study is done to assess public knowledge and perception towards diabetes mellitus. Therefore, the study is emphasized on both type of diabetes mellitus.

Introduction

1. Change “which means” to “equating to” when describing deaths per day.

Response: we accept your suggestion and appropriate measure has been taken in the revised manuscript.

2. Remove erroneous ‘g’ and rephrase sentence – “Numerous studies have revealed the proportion of good knowledge respecting g diabetes mellitus was reported as…”

Response: right you are. After removing erroneous “g” we have rephrase the statement as you suggested.

3. I would like to see the authors engage critically with the health belief model and justify its use.

Response: to the best of our effort attempts have been made extensively to link the relationship between health belief model and the aim of the present study. The aim of health belief model is increasing the perception of individuals about a health threat and directs their behaviours towards health. This model is a comprehensive pattern which represents the association between beliefs and behaviours; it has been widely applied to various health behaviours, especially screening behaviours and plays a significant role in prevention of the disease. Therefore, understanding individuals’ view points and beliefs is essential for developing the strategies of controlling diabetes.

4. Use “scant” not “scanty”

Response: editor also raised an issue related to this “scanty” not a very scientific term. Therefore, by taking in to consideration editor and reviewer feedback, authors made necessary correction within the revised manuscript.

Methods

1. Check the grammar and punctuation carefully – there are missing full stops, shifts of tense and duplicated words eg:

o “The town of North Shoa Zone The town”

o “The total population were 108,825, within 25,308 households” [should be ‘was’]

o “All adults living in Debre Berhan town for at least for six months…”

Response: right you are. Based on your comments all the above issue has been resolved in the revised manuscript appropriately.

2. The authors should share the questionnaire used as an appendix or supplementary file.

Response: we accept your comment and based on your suggestion the tool has been included as supplementary file both the Amharic and English version questioners.

3. This sentence needs to be more precise and should be referenced: “Using previous studies, as a baseline we have categorized in to agree, neutral and disagree”

Response: appropriate citation has been provided in the revised manuscript.

Results

1. In table 1, income currency should be specified

Response: right you are. We are specified as Ethiopian birr (ETB).

2. General checking of tenses required e.g. “was widowed” should be “were widowed”

Response: We accept your suggestion. Based on your recommendation extensive grammar edition has been carried out.

3. Table reporting knowledge of DM is labelled table 1, but it is the second table in the manuscript. The formatting of the table is also hard to read- we need additional spaces and or bold text between the sections relating to description of DM, risk factors, symptoms, and control

Response: Accept your recommendation and modification has been made in the revised manuscript.

Discussion

1. The discussion compares findings of the study to other relevant studies well, but it does not consider the meaning of the findings presented in the paper- what does this new study add to our knowledge of diabetes in this setting?

Response: based on your comments appropriate correction has been taken to the revised manuscript.

2. Also, what do the findings suggest should happen or be prioritised? E.g. for those patients who experienced barriers to diabetes screening, what can/should be done?

Response: your concern is very interesting. Based on your comments authors have integrate perceived barrier to diabetes screening and possible recommended measures. This finding suggest that there is a need for education campaigns in the district to reduce barriers to diabetes screening about all aspects of barriers such as time consuming, and misinformation. It is therefore important to identify interventions that decrease people's perceived barriers despite their levels of knowledge on diabetes mellitus.

3. The final paragraph of the discussion is quite confusing and is not clearly written.

Response: right you are. When we reevaluate the statement lacks meaning, therefore authors totally remove the sentence and some of the idea was included in the conclusion section of revised document.

4. The limitations paragraph is incomplete and contains drafting notes.

Response: right you are. Based on your and editor feedback necessary modification have been carried out.

6. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files.

If you choose “no”, your identity will remain anonymous but your review may still be made public.

Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy.

Reviewer #1: No

[NOTE: If reviewer comments were submitted as an attachment file, they will be attached to this email and accessible via the submission site. Please log into your account, locate the manuscript record, and check for the action link "View Attachments". If this link does not appear, there are no attachment files.]

While revising your submission, please upload your figure files to the Preflight Analysis and Conversion Engine (PACE) digital diagnostic tool, https://pacev2.apexcovantage.com/. PACE helps ensure that figures meet PLOS requirements. To use PACE, you must first register as a user. Registration is free. Then, login and navigate to the UPLOAD tab, where you will find detailed instructions on how to use the tool. If you encounter any issues or have any questions when using PACE, please email PLOS at figures@plos.org. Please note that Supporting Information files do not need this step.

Submitted filename: author response R1.docx

Click here for additional data file.

29 Sep 2020

PONE-D-20-04491R1

Assessment of Knowledge and Perception towards Diabetes Mellitus and Its Associated Factors among People in Debre Berhan Town, Northeast Ethiopia:

PLOS ONE

Dear Mr Shiferaw,

Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process.

Please submit your revised manuscript by 15th October 2020. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at plosone@plos.org. When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file.

Please include the following items when submitting your revised manuscript:

A rebuttal letter that responds to each point raised by the academic editor and reviewer(s). You should upload this letter as a separate file labeled 'Response to Reviewers'.

A marked-up copy of your manuscript that highlights changes made to the original version. You should upload this as a separate file labeled 'Revised Manuscript with Track Changes'.

An unmarked version of your revised paper without tracked changes. You should upload this as a separate file labeled 'Manuscript'.

If you would like to make changes to your financial disclosure, please include your updated statement in your cover letter. Guidelines for resubmitting your figure files are available below the reviewer comments at the end of this letter.

If applicable, we recommend that you deposit your laboratory protocols in protocols.io to enhance the reproducibility of your results. Protocols.io assigns your protocol its own identifier (DOI) so that it can be cited independently in the future. For instructions see: http://journals.plos.org/plosone/s/submission-guidelines#loc-laboratory-protocols

We look forward to receiving your revised manuscript.

Kind regards,

Professor Kwasi Torpey, MD PhD MPH

Academic Editor

PLOS ONE

Additional Editor Comments (if provided):

The manuscript has addressed the comments provided and the quality has significantly improved. However, a number of issues remain

1. The manuscript has a lot of grammatical errors and typos that need to be a addressed. Thorough copyediting by native speaker is required. Some examples of error observed

a. Abstract: Result : Diabetes is a seriousness disease: Should read diabetes is a serious disease

bAbstract: Results : agreed in the perceived benefits should read agreed to the perceived benefits

c. Abstract: Conclusion: Behavior change has importance in prevention...... should read behavior change is important.......

d. diabetic mellitus should ready diabetes mellitus

e. Results: sociodemographic : ample should read sample

f. thorough copyedit document

2. All references need to properly checked and ensure the names and initials are accurate. They are several errors in the initials. Make sure the referencing is consistent with the journal requirement. Remove CAPS in the references (#33 and 42). Ensure first letter in names are appropriately capitalized. Include year in all the listed publications (#39). Correct all errors in references esp #2,3,4,9,13,15,17,18,19,20,23,26,30,33,42,37,39

[Note: HTML markup is below. Please do not edit.]

[NOTE: If reviewer comments were submitted as an attachment file, they will be attached to this email and accessible via the submission site. Please log into your account, locate the manuscript record, and check for the action link "View Attachments". If this link does not appear, there are no attachment files.]

While revising your submission, please upload your figure files to the Preflight Analysis and Conversion Engine (PACE) digital diagnostic tool, https://pacev2.apexcovantage.com/. PACE helps ensure that figures meet PLOS requirements. To use PACE, you must first register as a user. Registration is free. Then, login and navigate to the UPLOAD tab, where you will find detailed instructions on how to use the tool. If you encounter any issues or have any questions when using PACE, please email PLOS at figures@plos.org. Please note that Supporting Information files do not need this step.

30 Sep 2020

Author’s response to editor and reviewers

Title: Assessment of Knowledge and Perception towards Diabetes Mellitus and Its Associated Factors among People in Debre Berhan Town, Northeast Ethiopia.

Version 2: September 30, 2020

Dear editor

To PLOS ONE, we are pleased to resubmit for publication version of “Assessment of Knowledge and Perception towards Diabetes Mellitus and Its Associated Factors among People in Debre Berhan Town, Northeast Ethiopia” with manuscript ID of “PONE-D-20-04491” for a review as original research in PLOS ONE. The comment of the editor was highly insightful and enabled us to greatly improve the quality of our manuscript. Therefore, based on the editor concerns we have made extensive edition in our manuscript. The formatting of the text and document (text sizes and grammatical errors) were also edited. In the following pages, we have addressed yours’ concerns in a point by point format.

We look forward to hearing from you at your earliest convenience.

Once again, thank you for considering our manuscript in PLOS ONE!

Kind regards,

Wondimeneh Shibabaw Shiferaw

On behalf of all the authors

Author’s response to Editor Comments

The manuscript has addressed the comments provided and the quality has significantly improved. However, a number of issue remain

1. The manuscript has a lot of grammatical errors and typos that need to be a addressed. Thorough copyediting by native speaker is required. Some example of error observed.

a. Abstract: Result: diabetes is a seriousness disease. Should read diabetes is a serious disease

Response: We thanks and accept your suggestion.

b. Abstract: results: agreed in the perceived benefits should read agreed to the perceived benefits

Response: Accept your suggestion

c. Abstract: Conclusion: behavior change has importance in prevention….should read behavior change is important. ..

Response: We accept your suggestion

d. Diabetic mellitus should ready diabetes mellitus

Response: We accept your suggestion

e. Results: sociodemographic: ample should read sample

Response: We thanks and accept your suggestion.

f. Thorough copyedit document

Response: Based on your suggestion, we have made extensive edition in the entire document by native speaker (Dr. Ryan Bell).

2. All references need to be properly checked and ensure the names and initials are accurate. They are several errors in the initials. Make sure the referencing is consistent with the journal requirement. Remove CAPS in the references (#33 and 42). Ensure first letter in names are appropriately capitalized. Include year in all the listed publications (#39). Correct all errors in the references esp # 2,3,4,9,13,15,17,18,19,20,23,26,30,33,42,37,39.

Response: Really the comment is constructive. Based on your feedback appropriate modification has been made in the entire references section in the revised manuscript.

Submitted filename: author response R2.docx

Click here for additional data file.

5 Oct 2020

Assessment of Knowledge and Perception towards Diabetes Mellitus and Its Associated Factors among People in Debre Berhan Town, Northeast Ethiopia:

PONE-D-20-04491R2

Dear Mr Shiferaw,

We’re pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it meets all outstanding technical requirements.

Within one week, you’ll receive an e-mail detailing the required amendments. When these have been addressed, you’ll receive a formal acceptance letter and your manuscript will be scheduled for publication.

An invoice for payment will follow shortly after the formal acceptance. To ensure an efficient process, please log into Editorial Manager at http://www.editorialmanager.com/pone/, click the 'Update My Information' link at the top of the page, and double check that your user information is up-to-date. If you have any billing related questions, please contact our Author Billing department directly at authorbilling@plos.org.

If your institution or institutions have a press office, please notify them about your upcoming paper to help maximize its impact. If they’ll be preparing press materials, please inform our press team as soon as possible -- no later than 48 hours after receiving the formal acceptance. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information, please contact onepress@plos.org.

Kind regards,

Professor Kwasi Torpey, MD PhD MPH

Academic Editor

PLOS ONE

Additional Editor Comments (optional):

Reviewers' comments:

7 Oct 2020

PONE-D-20-04491R2

Assessment of Knowledge and Perceptions towards Diabetes Mellitus and Its Associated Factors among People in Debre Berhan Town, Northeast Ethiopia

Dear Dr. Shiferaw:

I'm pleased to inform you that your manuscript has been deemed suitable for publication in PLOS ONE. Congratulations! Your manuscript is now with our production department.

If your institution or institutions have a press office, please let them know about your upcoming paper now to help maximize its impact. If they'll be preparing press materials, please inform our press team within the next 48 hours. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information please contact onepress@plos.org.

If we can help with anything else, please email us at plosone@plos.org.

Thank you for submitting your work to PLOS ONE and supporting open access.

Kind regards,

PLOS ONE Editorial Office Staff

on behalf of

Professor Kwasi Torpey

Academic Editor

PLOS ONE