diabetes mellitus is a common noncommunicable disease in india , as well as the rest of the world . it has emerged as a major public health problem , with low- and middle - income countries facing the greatest burden . as of 2013 , india ranks second in the list of diabetes among people aged 2079 years next only to china . india had 65.1 million diabetic people aged 2079 years , while china had 98.4 million people . probably because of a staggering rise in obesity , diabetes has manifested as a global epidemic . the change in life expectancy and lack of improvement in healthcare are in part responsible for the astounding rise in the incidence of this disease . even in the rural indian , population is undergoing lifestyle transition due to socioeconomic growth which can also be cited as a reason for increasing incidence of diabetes in rural areas . diabetes is a chronic disease , requiring a multipronged approach for its management , wherein the patient has an important role to play . they are required to follow certain self - care practices to achieve an optimal glycemic control and prevent complications . these practices include regular physical activity , appropriate dietary practices , daily foot care practice , compliance with treatment regimen , and tackling complications such as hypoglycemic episodes . thus , the objective of this study was to assess the baseline knowledge and self - care behavioral practices regarding diabetes among the rural population so that it will serve as a benchmark for future comparisons to assess the effectiveness of any educational training program for the diabetic patients . a community - based , cross - sectional study was done among patients with type 2 diabetes mellitus in sullia taluk , karnataka , to assess their knowledge regarding the disease and the self - care practices that were followed by them . assuming that 50% of the diabetics had reasonable knowledge , and they followed self - care practices as advised and requiring a precision of 5% , the sample size was calculated using the formula , 4 pq / d . thus , the study was conducted among 400 patients with type 2 diabetes mellitus who were 20 years of age and above and who had the disease for at least 1 year and residing in that locality for more than a year . the patients were selected from forty villages of sullia by probability proportionate to sample size and then by a random sampling technique . a pretested , semi - structured questionnaire was handed over to each participant to collect sociodemographic details , diabetes - specific information , knowledge regarding diabetes , and the self - care practices that were followed by them . the questionnaire was reviewed by three professionals before being used  a public health expert , a diabetologist , and a statistician and their suggestions were utilized for improving the questionnaire thus ensuring consensus validity of the instrument . the questionnaire originally made in english was translated and back translated to and from kannada to ensure appropriateness of translation . ethical clearance was obtained from the institutional ethical committee before the actual start of the study . knowledge was assessed using closed - ended questions , and the study subjects were classified as having poor , average , and good knowledge depending on the score obtained . details regarding self - management activities were collected using the summary diabetes self - care activities questionnaire after making minor changes to it to suit the local study population . the following variables were checked for : smoking habits , checking of feet daily and checking the inside of the footwear , checking blood sugars regularly and as advised by the health - care provider , regular drug intake , exercise for at least 5 days in a week , and adherence to a healthy eating plan . since self - care practices can not be scored collectively and given a single value , it was partitioned into different habits and then scored accordingly . the data collected were entered in microsoft excel office 2007 and spss statistics version 20 ( ibm , new york , united states ) was used for statistical analysis . majority of the respondents were males ( 61.2% ) and belonged to 4049 years age group ( 31% ) . majority of the study population belonged to hindu religion ( 71% ) and were married ( 91.2% ) . most of the study population were either agriculturists or self - employed and belonged to the upper middle class as per modified bg prasad classification . fifty - one percent of the respondents had diabetes for 15 years , 35% for 610 years , and 11% of them for 1120 years . regarding the treatment profile of the study group , it was evident that 50% were treated by doctors with mbbs qualification and < 1% by specialists . characteristics of the study population among the participants , almost half of them ( 49.5% ) denied of having any comorbidity . among those who knew of comorbidities in them , majority of them accepted to have hypertension ( 32% ) followed by dyslipidemia ( 28.75% ) . the study population was questioned about the general features of diabetes , its risk factors , symptoms , mode of diagnosis , and complications to estimate the knowledge about the disease . it was seen that only 24% of the participants had good knowledge about the disease , 59% of them had an average knowledge , and 17% had poor knowledge . among the general questions that were asked on diabetes , more than 50% had good knowledge on diabetes being hereditary ( 65.25% ) and more than 50% of the study population did not know that age , high cholesterol , and low physical activity were risk factors of diabetes . about 50% of them did not know that fatigue , hunger , and thirst could be a symptom of diabetes . more than 70% of them were not aware that neuropathy , skin infection , and ophthalmic problems could be a complication of diabetes [ table 2 ] . frequency distribution of respondent 's knowledge regarding diabetes mellitus more than 50% were aware that fatigue ( 77% ) , excessive sweating ( 67.5% ) , and blurred vision ( 55.75% ) were signs of hypoglycemia . however , < 50% of them were aware that a headache ( 35.25% ) could be a symptom of hypoglycemia [ table 2 ] . more than 80% felt that diabetes can be detected by blood sugar estimation [ table 2 ] . regarding misconceptions about diabetes , more than 50% of the respondents ( 56.5% ) felt that drugs can be stopped once diabetes is controlled . it was noted that those participants who visited private establishments for their treatment were more knowledgeable than those who visited government facilities , and this was also found to be statistically significant (  = 9.09 , df = 1 , p = 0.003 ) . participants who visited health - care providers of modern medicine background ( allopathic practice ) were found to be more knowledgeable than those who visited ayush practitioners , and this was also found to be statistically significant (  = 12 , df = 1 , p = 0.001 ) . anova was done to compare the mean knowledge score obtained against various age groups , religion , educational status , occupation , and socioeconomic status . z - test was done to compare the knowledge score obtained between the two genders . it was noted that there was statistically significant difference in the knowledge among age groups ( f = 4.041 , p < 0.05 ) , religion ( f = 34.67 , p < 0.05 ) , occupation ( f = 17.54 , p < 0.05 ) , socioeconomic status ( f = 9.41 , p < 0.05 ) , and duration of diabetes ( f = 7.33 , p < 0.05 ) . among the self - care practices , it was seen that checking the feet daily and inspecting the inside of shoes / footwear daily were the two practices which were not followed by a majority of the study participants which accounted for 99.5% . the practices that were best followed were checking of blood sugars at least once in 3 months and as advised by the doctor which accounted for almost 65% and 73% of the respondents . only 48% of the respondents were regular in taking drugs and 20.5% exercised for at least 5 days in a week for 2030 min . the details of the adherence to self - care practices are given in table 3 . self - care practices among respondents logistic regression analysis of each self - care practice with blood sugars was done , and the results are shown in table 4 . it was seen that dietary practice is one of the important factors influencing the achievement of good blood sugars in the participants . the present study was done to assess the knowledge and practices regarding diabetes among the known diabetics residing in rural field practice area of a teaching hospital . most of the study participants were in the 4049 years age group , which was slightly lower than that seen in studies done by priyanka and angadi and shah et al . the age group is higher when compared to studies conducted in two places of karnataka , namely kolar and dharwad , by muninarayana et al . and patil et al . , respectively , where the majority of the participants were in the age group of 3045 and 3049 years , respectively . in the present study , the duration of diabetes in the participants was mostly 15 years in contrast to study done by hawal et al . where the majority of them had diabetes for more than 5 years . regarding the literacy status of the study participants , it was found that only 9.5% were illiterates as compared to 36.64% as seen in the study done by shah et al . it is generally thought that the duration of diabetes and a literacy rate of the participants have some influence on the knowledge regarding the disease . in our study , higher the education of the participant better was the knowledge on the disease but lesser the duration of the disease , higher the knowledge . one of the most important findings in this study is that only 24% of the respondents had an overall good knowledge regarding diabetes . this is a matter of concern because india has around 65.1 million diabetic people and poor knowledge about their own health status and disease may be one of the barriers for healthful living . further knowledge can serve as an important resource base for improving their own health and that of the society . the results of our study regarding knowledge of the participants are similar to chennai urban rural epidemiology study ( cures-9 ) study which also reflects the poor knowledge and awareness about diabetes among the chennai population . there was a misconception among 72% of our study participants that all bitter substances can treat diabetes against 53% which was seen in a study done by shah et al . in saurashtra . eighty - two percent knew the methods to diagnose diabetes mellitus which was slightly different from findings in a study done by gupta et al . where 90% of the study population in the rural area knew about accurate methods to diagnose diabetes . again , knowledge regarding complications of diabetes was also poor , which was also similar to cures study . only 30% of the participants knew that diabetes can cause ophthalmic problems against 15% of the participants in cures study . the results obtained in our study regarding the knowledge on complications were different from the results obtained by mehta et al . , who observed that 82% of his study subjects had knowledge about the disease and its complications . it was observed that mean composite knowledge score was better in the 3049 years age group , being a professional and belonging to upper class . with respect to the age group who also found that younger the age group , better the knowledge . it was also seen that those with < 5 years of disease had a better knowledge score . this is probably because the younger generation is more educated , aware , and more exposed to the media which make them knowledgeable . this poor knowledge indicates that most of them are not educated regarding their disease by their primary care physicians and field - level health workers . one of the reasons for the lack of providing education could be that field workers are themselves not aware or not motivated to educate the public . physician 's failure in this part may be due to the heavy load of patients that they see in their daily practice and thus the lack of time to educate . this emphasizes that the already existing field - level workers like ashas should be educated , trained , and motivated in this aspect . education through mass media can also bring about a change . among the self - care practices , good dietary behavior was present only in 24% of the study participants . this was quite different from a study done by rajasekharan et al . in an urban area where 46% of the participants followed a diet plan regularly . emphasis should be given to good dietary practices as it is a determinant of both glycemic control and weight management . the world health organization recommends at least 400 g of fruits and vegetables per day which was not followed by most of the study participants . consumption of these minimum recommended levels of fruits and vegetables will also protect an individual from cardiovascular diseases , stroke , and gastrointestinal diseases . in our study , only 3% of the participants consumed the recommended fruits and vegetables for at least 5 days or more in a week . where 26% of the participants included fruits and vegetables in their diet on all days of the week . however , it was interesting to see that only 4% of the study participants included high - fat diet on 5 or more days of the week . these findings are almost similar to those seen in studies done by rajasekharan et al . and gopichandran et al . regarding the physical activity , only 19% of the study participants followed the recommended 2030 min exercise per day for at least 5 days a week . regularly will have many benefits ranging from reduced insulin resistance , blood pressure control , and cardioprotective role . sixty - five percent of the study participants checked their blood sugars at least once in 3 months . emphasis should be laid on checking blood sugars as the effectiveness of the treatment regimen can be ascertained only by checking their blood sugars . forty - eight percent of the participants take the recommended hypoglycemic agents and insulin daily and regularly , which were lower than the study conducted elsewhere . regarding foot care , only 0.5% of them checked their feet and inspected the inside of their shoes daily which is < 9% and 12% , respectively , which was observed in a study done by raithatha et al . none of them wore footwear inside their houses , which was in contrast to a study done in mumbai by chandalia et al . logistic regression of self - care practices against the blood sugar levels showed that dietary practice is one of the important factors influencing the maintenance of good blood sugar levels in the participants . these findings are slightly different from a study conducted by wynn nyunt et al . where following a healthy diet , following exercise for at least 5 days in a week , and compliant to drug therapy were all associated statistically with the achievement of glycemic control . as evidenced by the study , it was noted that only about one - fourth of diabetics had a good knowledge . the respondents were very poor with regards to the daily checking of foot and inside of footwear and also in adherence to exercises . although the indian urban population has access to reliable screening methods , antidiabetic medications , counseling services , and preventive services , such health benefits , are not often available to the rural patients . there is a disproportionate allocation of health resources between urban and rural areas and in addition , poverty in rural areas may be responsible for this poor knowledge and self - care practices . food insecurity , illiteracy , poor sanitation , and dominance of communicable diseases may also contribute which suggests that both policy makers and local governments may be undermining and underprioritizing the looming threat of diabetes . such inadequacies contribute to an infrastructure that may result in poor diabetes screening and preventive services , nonadherence to diabetic management guidelines , lack of available counseling , and long distance travel to health services . regular health education services which will make them knowledgeable about the disease and encouraging self - care management in those who are diagnosed as diabetic will reduce the health - care burden and help in achieving glycemic control and thus minimizing complications . as this study is done to assess the knowledge and self - care practices among diabetic patients only , the results can not be generalized to the whole community . one more limitation is that the blood sugar values that have been obtained for this study are not done by the author . the last blood sugar values done by the patient at different times have been taken for this study . and also the questionnaire that is used is closed ended , and they can sometimes be guessed by the respondents . as this study is done to assess the knowledge and self - care practices among diabetic patients only , the results can not be generalized to the whole community . one more limitation is that the blood sugar values that have been obtained for this study are not done by the author . the last blood sugar values done by the patient at different times have been taken for this study . and also the questionnaire that is used is closed ended , and they can sometimes be guessed by the respondents .