The Knowledge-Practice Gap: Relationship Between Diabetes Knowledge and Adherence to Self-Care Practices Among Type-2 Diabetic Patients in Hospitals in Bayelsa State, Nigeria

Background: Diabetes self-care is central to preventing complications of type-2 diabetes mellitus (T2DM), and patient knowledge is widely assumed to be a precondition for good self-care practice. However, evidence from several settings suggests that knowledge does not consistently translate into adherent behaviour. This study examined whether the level of diabetes knowledge among T2DM patients in Bayelsa State, Nigeria, corresponded with their level of adherence to recommended self-care practices.

Materials and Methods: A descriptive cross-sectional survey was conducted among 357 T2DM patients attending diabetic clinics at the Federal Medical Centre (FMC) Yenagoa, the Niger Delta University Teaching Hospital (NDUTH) Okolobiri, and Everly Medical Centre. Purposive sampling was used, and data were collected with a structured, pre-tested questionnaire (Cronbach's alpha ≥ 0.70) covering knowledge of diabetes, knowledge of self-care, and adherence to eight self-care domains. Data were analysed with SPSS version 22 using descriptive statistics and Pearson chi-square tests, and the study tested the hypothesis that no significant correlation exists between diabetes knowledge and adherence to self-care.

Results: Overall, 72.9% of respondents demonstrated good knowledge of diabetes (p < 0.0001) and 79.92% demonstrated good knowledge of self-care practices (p < 0.0002). Adherence, by contrast, was consistently poor: daily home blood glucose testing (1.12%), daily foot care (9.61%), six-monthly dental assessment (3.36%), and weekly use of mouth gargles (3.08%). Adherence was comparatively better for annual eye examination (74.7%) and twice-daily tooth brushing (58.5%), while feeding habit and physical activity showed moderate compliance (approximately 40% reporting frequent adherence). Despite the high knowledge scores, no statistically significant correlation was found between diabetes knowledge and adherence to self-care; the null hypothesis was retained.

Conclusion: A clear knowledge-practice gap exists among T2DM patients in Bayelsa State. Knowledge, although necessary, is not sufficient to drive adherent self-care behaviour. Interventions should move beyond health education to address structural, economic, and behavioural barriers that separate what patients know from what they do.

Diabetes mellitus remains one of the fastest-growing non-communicable diseases globally, with the International Diabetes Federation estimating 463 million affected individuals worldwide and sub-Saharan Africa alone accounting for approximately 20 million cases (Ogurtsova et al., 2015). Nigeria carries the highest burden of diabetes in Africa, with an estimated 3.9 million people living with the condition. Beyond pharmacological therapy, the long-term management of type-2 diabetes mellitus (T2DM) depends heavily on sustained self-care, including glycaemic self-monitoring, foot care, dietary regulation, physical activity, and routine preventive screening for ocular, dental, and renal complications.

The behavioural science underpinning most diabetes education programmes assumes a largely linear relationship: that improved knowledge leads to improved self-care practice, which in turn leads to improved glycaemic and clinical outcomes. This assumption underlies substantial investment in patient education across health systems, including in Nigeria. However, a growing body of evidence from Africa, Asia, and the Caribbean has questioned this linear assumption. Studies in Trinidad and Tobago (Onuoha et al., 2017), Ethiopia (Niguse et al., 2019; Tewahido & Berhane, 2017), and South Sudan (Alexandre & BiliLongyingZha, 2018) have variously reported that adequate or even high diabetes knowledge among patients does not reliably translate into expert-level or even acceptable self-care practice.

In Bayelsa State, as in much of the Niger Delta region, diabetes care is complicated by dispersed rural populations, variable access to glucometers and specialist services, and the economic realities that shape dietary and lifestyle choices. Whether the knowledge-practice assumption holds locally has not been empirically established. Establishing this relationship, or the lack of it, has direct implications for how limited health education resources should be allocated: toward more intensive knowledge transfer, or toward practice-enabling interventions such as subsidized glucometers, structured reminder systems, and accessible screening services.

This study therefore examined the relationship between diabetes-related knowledge (of the disease and of self-care practices) and actual adherence to recommended self-care behaviours among T2DM patients attending diabetic clinics in Bayelsa State, with the aim of determining whether knowledge alone is a sufficient driver of adherent self-care.

Study Design and Setting

A descriptive, correlational, cross-sectional survey was conducted among T2DM patients attending diabetic clinics at two tertiary health facilities, the Federal Medical Centre (FMC) Yenagoa and the Niger Delta University Teaching Hospital (NDUTH) Okolobiri, and a private facility, Everly Medical Centre, all in Bayelsa State, Nigeria.

Study Population and Sample Size

Eligible participants were adults aged 20 years and above with a confirmed diagnosis of T2DM, attending the designated diabetic clinics, and who were physically and mentally able to read and respond to a written questionnaire. Sample size was determined using Taro Yamane's formula for each facility (FMC, n = 223; NDUTH, n = 118; Everly Medical Centre, n = 16), yielding a total target sample of 370. A purposive sampling technique was used to select respondents on clinic days.

Data Collection Instrument

Data were collected using a structured, interviewer-administered questionnaire in four sections: socio-demographic characteristics; knowledge of diabetes (10 items, five-point Likert scale); knowledge of self-care practices (10 items, five-point Likert scale); and adherence to self-care (32 items covering frequency of practice across eight domains, including home blood glucose testing, foot care, dental and eye assessment, oral hygiene, feeding habit, and physical activity). The knowledge sections were adapted from the instrument used by Jackson et al. (2014) in their study of self-care knowledge among T2DM patients in two Nigerian states, while the adherence section was adapted from an unpublished instrument developed locally by Eniojukan et al. on psychometric predictors of physical activity and self-management behaviour among T2DM patients at FMC Yenagoa. The instrument was pre-tested on 20 patients at two facilities not included in the main study, and Cronbach's alpha of 0.70 or higher was accepted as evidence of internal consistency. Face and content validity were established through expert review.

Data Collection and Analysis

Questionnaires were administered directly by the principal investigator and two trained research assistants on clinic days. Completed questionnaires were serially numbered, screened for completeness, and entered for analysis. Of 370 questionnaires distributed, 357 were retrieved complete, giving a response rate of 96.5%. Data were analysed using SPSS version 22, GraphPad, and Microsoft Excel. Knowledge and adherence scores were dichotomized and summarized descriptively as proportions, and Pearson chi-square tests were used to assess associations between socio-demographic variables and knowledge/adherence outcomes. The relationship between overall knowledge and overall adherence was assessed by comparing the pattern and statistical significance of both sets of findings against the prior hypothesis that no significant correlation exists between diabetes knowledge and adherence to self-care practices.

Ethical Considerations

Ethical approval was obtained from the ethics committees of the participating health institutions prior to data collection. Participation was voluntary, and informed consent was obtained from all respondents.

Socio-Demographic Characteristics

Of the 357 respondents, 197 (55.2%) were male, 60% were aged between 41 and 60 years, 75.1% were married, and 56.3% had attained tertiary education. Civil servants constituted the largest occupational group (39.7%), followed by the self-employed (23%). Most respondents (70%) resided in urban areas, 95.8% were Christian, and 44.8% reported a monthly income of between ₦150,000 and ₦200,000.

Knowledge of Diabetes and Self-Care

Overall, 72.9% of respondents demonstrated good or appreciable knowledge of diabetes, a statistically significant finding (p less than 0.0001). Knowledge of self-care practices was similarly good, at 79.92% (p less than 0.0002). Occupation, educational level, place of residence, and income level were significantly associated with both knowledge of diabetes and knowledge of self-care practices, while gender, marital status, age, and religion showed little or no association. Table 1 summarizes these findings.

Table 1: Comparison of knowledge of diabetes and knowledge of self-care practices among respondents (N = 357).

Adherence to Self-Care Practices

In marked contrast to the knowledge findings, adherence to recommended self-care practices was consistently poor across most domains. Daily home blood glucose testing was practiced by only 1.12% of respondents, daily foot care by 9.61%, and six-monthly dental assessment by 3.36%. Weekly use of mouth gargles was reported by just 3.08% of respondents, although twice-daily tooth brushing was more common (58.5%). Annual eye examination showed the highest adherence of any domain (74.7%), and feeding habit and physical activity showed moderate, though inconsistent, compliance, with approximately 40% of respondents reporting frequent adherence. These patterns were statistically significant (p less than 0.001 for most domains), reflecting a highly significant negative trend in adherence relative to recommended practice standards. Table 2 summarizes adherence across the assessed domains.

Table 2: Adherence of respondents to recommended self-care practices, by domain (N = 357).

Relationship Between Knowledge and Adherence

Despite the majority of respondents demonstrating good knowledge of both diabetes and its self-care requirements, this knowledge was not reflected in their adherence to recommended practices. The proportion of respondents with good knowledge (72.9% to 79.92%) stood in sharp contrast to adherence rates that fell below 10% in most self-care domains. On this basis, the null hypothesis, that there is no significant correlation between diabetes knowledge and adherence to self-care practices, was retained, while the alternate hypothesis was rejected.

This study set out to determine whether diabetes-related knowledge among T2DM patients in Bayelsa State corresponded with their adherence to recommended self-care practices. The findings revealed a pronounced knowledge-practice gap: respondents were, on average, well informed about diabetes and its self-care requirements, yet their actual practice of these recommendations was poor across most domains. This pattern echoes findings from Trinidad and Tobago, where Onuoha et al. (2017) reported that adequate knowledge among participants did not translate into expert-level self-care practice, and from Ethiopia, where Niguse et al. (2019) similarly documented high knowledge alongside poor practice among 388 participants. Tewahido and Berhane (2017) offered a plausible explanation rooted in patients' habitual reliance on medication rather than lifestyle self-management, even where relevant knowledge exists.

The specific pattern of adherence observed in this study is instructive. Home blood glucose testing, arguably the most actionable and clinically consequential self-care behaviour, had the lowest adherence of all domains (1.12%), a finding broadly consistent with Dinesh et al. (2016), who reported that only 29% of their Indian cohort monitored blood glucose consistently, and with Mukeshimana et al. (2015), who found that more than half of diabetic patients attending a Kigali clinic did not even know the recommended frequency of blood glucose testing, despite general awareness of diabetes self-management. This convergence across geographically distinct settings suggests that poor glucose self-monitoring is unlikely to be primarily a knowledge deficit; it more plausibly reflects the cost of glucometers and test strips, limited access to functioning devices, and the absence of structured reminder or support systems within the health system.

Similarly, the low adherence to six-monthly dental assessment (3.36%) and weekly mouth gargle use (3.08%), against comparatively strong adherence to annual eye examination (74.7%), suggests that adherence is shaped less by what patients know and more by the practical burden each behaviour imposes. Annual screening requires only a single low-frequency visit, while daily or weekly practices compete continuously with work schedules, cost, and the perceived urgency of the underlying complication. Alexandre and BiliLongyingZha (2018) reported a comparable pattern in Juba, South Sudan, where infrequent, low-burden screening behaviours showed markedly higher adherence than daily self-management tasks, and attributed this to the practical demands of guideline-recommended practices, particularly among working-age and elderly patients.

The absence of a statistically demonstrable correlation between knowledge and adherence in this study is consistent with, and adds to, an emerging evidence base indicating that health education, while necessary, is an insufficient lever for behaviour change in chronic disease self-management. This has direct implications for pharmacists and other health professionals involved in diabetes care: continuing to invest primarily in knowledge transfer, without addressing the structural and economic barriers to practice, such as the cost of monitoring supplies, distance to screening services, and the absence of behavioural reinforcement mechanisms, is unlikely to close the gap identified in this study.

Type-2 diabetic patients attending clinics in Bayelsa State demonstrated good knowledge of diabetes and its self-care requirements, yet this knowledge did not correspond with adherence to recommended self-care practices, particularly home blood glucose monitoring, foot care, dental assessment, and use of mouth gargles. This knowledge-practice gap indicates that health education alone is unlikely to be sufficient to improve self-care outcomes in this population.

Diabetes care programmes in the region should therefore complement patient education with practice-enabling interventions: subsidized or freely accessible glucose self-monitoring supplies, structured reminder or follow-up systems, workplace-friendly scheduling for routine screening, and behavioural support strategies that address the specific barriers separating knowledge from practice. Future studies should compute direct correlation statistics between individual knowledge and adherence scores, and should explore the specific structural and economic barriers underlying non-adherence identified in this study.

Limitations

This study assessed the knowledge-adherence relationship through comparative analysis of dichotomized knowledge and adherence proportions rather than through a single computed correlation statistic (such as Spearman’s rho) linking individual-level knowledge scores to individual-level adherence scores. While this comparative approach is consistent with the descriptive design of the parent study and with similar prior studies in the region, future research should compute a direct correlation coefficient at the individual level to more precisely quantify the strength and direction of the knowledge-adherence relationship. Additionally, the cross-sectional design precludes causal inference, and purposive sampling may limit generalisability beyond the study facilities.

Contribution to Knowledge

This study contributes empirical evidence, specific to Bayelsa State and the wider Niger Delta region, that directly tests an assumption underlying most diabetes education programming in Nigeria: that improving patient knowledge is sufficient to improve self-care behaviour. By demonstrating good knowledge (72.9% to 79.92%) alongside consistently poor adherence across most self-care domains, this study provides local, quantified evidence of a knowledge-practice gap in T2DM self-care, an issue previously documented in other African, Asian, and Caribbean settings but not, until now, characterized for this population.

The study further identifies which specific self-care domains carry the widest gap between knowledge and practice, namely home blood glucose testing, foot care, dental assessment, and mouth gargle use, information that can guide the targeting of pharmacist-led and other practice-level interventions rather than continued investment in generic health education alone. This domain-level resolution is a distinct contribution beyond the descriptive, prevalence-only reporting that characterises much of the existing regional literature.

Public Health Implications

The findings carry direct implications for how diabetes self-care is supported within the Nigerian health system. First, they suggest that continued reliance on health education as the primary strategy for improving self-care adherence is unlikely, on its own, to close the gap identified in this study, and that resources should be redirected toward practice-enabling interventions, including subsidized or freely accessible glucometers and test strips, community-based glucose monitoring support, and structured reminder systems for low-frequency but clinically important screening such as dental and foot assessment.

Second, the markedly low adherence to home blood glucose testing (1.12%) is a public health concern in its own right, given its centrality to preventing acute and long-term complications of T2DM. Health facilities and pharmacist-led diabetes clinics in the region should consider point-of-care monitoring support and task-shifted glucose-testing services as a practical substitute where patients cannot sustain home testing.

Third, the significant association between occupation, education, place of residence, and income with knowledge levels indicates that future health education efforts should be deliberately targeted at rural, lower-income, and less-educated subgroups, who remain at higher risk of poor knowledge and, by extension, poor self-care capacity, even though this study shows that knowledge alone will not resolve adherence. Finally, the findings support the case for community pharmacists and primary care providers to be resourced and positioned as adherence-support agents, rather than being confined to a purely educational role, within Nigeria's evolving approach to non-communicable disease management.

Conflict of Interest

The authors declare no conflict of interest.

Ethical Approval

Obtained from the ethics committees of the Federal Medical Centre Yenagoa, the Niger Delta University Teaching Hospital, and Everly Medical Centre.

Data Availability

Data are available from the corresponding author on reasonable request.