This study was conducted in Qassim University among the professionals involved in providing the health care services to the patient as well as teaching and training the students. The study conducted after ethical approval (No. 20.02.08) from the Deanship of Scientific Research, Qassim University dated 7/12/2020 was provided.

The questionnaire were targeted to medical professionals such as doctors, nurses and pharmacists to evaluate their knowledge, attitude and practice about the newly approved antidiabetic drugs called glucagon-like peptide-1 receptor agonists (GLP-1RA).

A questionnaire was developed in English language. The questionnaire was divided into two parts namely, socio-demographic section and KAP section. In socio-demographic part, information about the respondents such as age, sex, profession, qualification and experience was collected. While in the KAP, questions related to knowledge had set answers such as ‘Yes’, ‘No’ and ‘Don’t know’. The questions about the attitude and practice had the fixed-answers such as ‘Strongly agree’, ‘Agree’, ‘Neutral’, ‘Disagree’ and ‘Strongly disagree’. 14 The expert committee constituted by the department of pharmacology and toxicology validated the questionnaires. A pilot study was done before the questions were circulated for the data collection. Randomly selected medical personnel from different professions were used in the pilot study. The expert committee analyzed their feedback and modified the questionnaire accordingly. The members of the committee evaluated each question and determined the criteria for scoring the response. In addition, expert committee suggested the sample size for the present study depending on the parameters such as number of medical professionals employed in the University, confidence interval and margin of error.

This was a cross-sectional questionnaire-based survey. The professionals who are involved in providing the health care services as well as teaching and training the students such as physicians, nurses and clinical pharmacists were included in survey to assess their KAP about GLP-1RA. 15 The potential participants were contacted personally and the most suitable time for them was fixed to conduct the survey.

Those medical professionals in the Qassim University willing to participate in the questionnaire-based study were included while vice-versa was considered as exclusion criteria.

The criteria for scoring the responses were adopted from previous study.¹⁵There were 16 questions in total and each domain consisted of 6 questions. In the knowledge domain, correct answer to every question carried +1 mark while wrong -1 and don’t know carried 0 mark. This gave a total score range of +6 to -6 for knowledge. In the ‘attitude’ and ‘practice’ domains, the level of agreement or disagreement for the questions were calculated as; Strongly agree = +2, Agree = +1, Neutral = 0, Disagree = -1 and Strongly disagree = -2. Hence, for these domains the total score varies between +12 to -12. If the scoreswere above 70%, then the response was categorized as ‘Good’, between 51 – 69 % was categorized as ‘Fair’ and less than 50% was recorded as ‘Poor’. 16

All completed survey forms were evaluated and their response was recorded in an excel spreadsheet. The data was analyzed and statistical significance of the results was done through One-way ANOVA followed by non-parametric post-hoc test such as Mann-Whitney U test, Kruskal-Wallis H test and Chi-square test.17 Mann-Whitney U was used to compare scores of each domain with binary demographic groups: (Gender and Nationality). Kruskal-Wallis H was used to compare scores of each domain with demographic with more than two categories (Age, Qualification and Experience). Chi-square test was used to determine whether there is a significant association between each domain scores of the participants and Demographics. Pearson correlation analysis was used to find the relationship between the responses recorded for the domains of knowledge, Attitude and Practices. P< 0.05 was considered to indicate the significance.

A total of 154 medical professionals of Qassim University were approached, 112 agreed to participate in the survey (response rate = 72.7%) and 5 samples were rejected due to missing data. Physicians constituted the major repondents (≈ 50%) of the study, followed by nurses (33.6%) and pharmacists (16.8%). Among the respondents under physicians’ category, 64% were males and 35 % were females. Majority were aged less than 35 years (58%), non-Saudis nationals (67%), possessing masters’ or above qualification (60%) and less than 5 years of experience (30.1%) in the profession.

In the nursing profession, majority were female staff (56.6%), aged less than 35 years (69%), belonging to non-Saudi nationality (78%), possessing bachelors’ degree qualification (67%) and professional experience of 6-10 years (33.3%). Majority of pharmacists participated in this study were males (66.6%) having less than 35 years age (56%), Saudi nationals (55.5%), possesing masters’ or above qualification (61%) and having less than 5 years of professional experience (33%) (Table 1).

The frequency of physicians’ correct response for the knowledge-based questions varied between 58% to 81%, while the nursing staff was 42% to 70% and pharmacists’ was 50% to 82%. Most of the physicians’ correctly answered that GLP-1 RA are the latest addition in the management of type-2 diabetes (81%) and the least frequency of correct response was for the question ‘GLP-1 RA carry the potential risk of thyroid C-cell neoplasm’ (58%). The most frequent correct answer by the nursing staff was for the question that GLP-1 RA can reduce blood pressure (70%) and least frequent was for the potential risk of thyroid C-cell neoplasm associated with GLP-1 RA (42%). Most of the pharmacists indicated that they have the knowledge the GLP-1 RA belongs to the antidiabetic class (82%) and least frequency of answer was found to be for ‘GLP-1 RA induced pancreatitis in diabetic patients’ (50%). Overall, the medical personnel has good knowledge about GLP-1 RA as the therapeutic class for diabetes mellitus (82%) and least knowledge about the incidences of thyroid C-cell neoplasm with GLP-1 RA (61%). Comparison of various responses for the knowledge questions indicated no-signficant variation.

The frequency of correct answer to the attitude questions by medical professionals are; physicians – 90% (taking consent from patients before starting GLP-1 RA), nurses – 80% (selecting specific needle for parenteral administration of GLP-1 RA) and pharmacists – 84% (discussing benefits and risks of GLP-1 RA with patients). The least frequent correct answer was observed for physicians is ‘eating small portion of meals under GLP-1 RA therapy (59%), for nurses ‘selecting specific GLP-1 RA for patients’ (44%) and for pharmacists was ‘choosing specific size of needle for parenteral administration of GLP-1 RA’ (46%). Altogether, majority of medical professionals agreed that consent of patients is important before starting the GLP-1 RA therapy (95%) and the least was for selecting the specific GLP-1 RA for the patients (61%). The question about the specific needle size for parentereal administration of GLP-1 RA indicated significant variation (P=0.043). However, other responses were found to be insignificantly varied.

The most frequent correct answers for practice domain given by physicians’ was ‘possible transient nausea as the side effect after GLP-1 RA treatment’ (92%) and least was ‘literature review for recent additions of GLP-1 RA (70%). The nursing staff’s correct answer was for ‘asking patients to report immediately the side / adverse effect’ (74%) and least was for refering the history of patient before starting the GLP-1 RA therapy (42%). The pharmacist’s correct response was for ‘literature review for checking the latest addition of GLP-1 RA’ (83%) and least was for ‘transient nausea after GLP-1 RA medication’ (52%).

Overall, the most frequent correct answer of medical personnel was for ‘reporting immediately possible side / adverse effect of GLP-1 RA (89%) and the least was for ‘localized irritation of nodule formation at the site of injection (70%). ‘Refering to patient history before treating with GLP-1 RA’ questionnairs’s response showed significant variation (P = 0.039), while other replies to this domain did not show significant variation (Table 2).

The KAP scores of the healthcare professionals against the demographic variables is summerized in Figure 1. The knowledge scores of the professionals varies between 4.29 to 5.2 (out of maximum 6). The least score was found to be for the medical professionals who hold the diploma degree (4.29 / 6) as a qualification and the highest scores was observed for the female professionals (5.2 / 6).

Figure 1

Note: The values are represented as scores.

Statistics: One-way Anova followed by specific non-parametric post-hoc tests as per variables.

*P value less than 0.05.

3 represents the KAP level of healthcare professionals on the recently approved antidiabetic drugs. At the professional level, physicians were found to have good knowledge (66.8%), attitude (58.6%) and practice (52.9%) followed by pharmacists [knowledge – 55.1%, attitude – 49.3% and practice – 47.3%] and nurses [knowledge – 42.6%, attitude – 40.7% and practice – 36.2%]. A significant variation (P = 0.03) was found when the responses were compared between each other.

In the gender variables, female professionals have good knowledge (62.9%), while males have better attitude (50.1%) and practice (58.7%). The age variable indicated that less than 35 years old professionals have good knowledge (70.1%) and attitude (59.8%), but above 35 years have good practice (66.3%) towards GLP-1 RA. The responses for this found to be significantly varied (P = 0.02). In the nationality criteria, Saudis were found to have good knowledge (66.9%) and attitude (57.9%) while non-Saudi nationals have proper practice (66.7%). The highest level of knowledge (63.8%), attitude (52.6%) and practice (57.7%) was observed for masters’ or above qualified personnels. The experience variable indicated that medical professionals having 6–10 years of experience has good knowledge (66.6%), slightly better attitude (56.4%). While professionals with more than 15 years of experience have proper practice (60.5%) about the GLP-1 RA. No statistical significant variations were observed except those mentioned above.

The correlation analysis between knowledge, attitude and practice is represented in Table 4. The observation suggested that the knowledge response of the healthcare members is weakly related with the attitude and the statistical analysis indicated that the difference is insignificant (r = 0.14, P = 0.11).

However, the knowledge response of the participants is fairly correlated with the practice and the variation was found to be significant (r = 0.52, P = 0.04). The correlation between the attitude and practice domain replies were found to be moderately correlated but the variation was non-significant (r = 0.66, P=0.08).

The present study evaluated the knowledge, attitude and practice about the new class of antidiabetics called glucogon-like peptide-1 receptor agonists (GLP-1 RA) among the healthcare personnel of Qassim University. The demographic characteristics revealed a mixed nationality of participants. Most of the respondents were aged below 35 years, holding bachelor degree as qualification in their specialization and having less than 5 years of experience in their profession. The survey study included the participation of both male and female professionals working in the University (Table 1).

The medical practitioners are an integral and vital component of society since they are involved in providing and maintaining the health of population. Our findings indicated that the medical professionals of the University have ‘good’ knowledge, ‘better’ attitude and ‘proper’ practice about the newer therapeutic agents in diabetes. The overall ‘correct’ responses to the questions of knowledge domain were found to be 73.5%, attitude – 78.5% and practice – 80.3% (Table 2). The findings of the study are close to the previous research where the healthcare workers indicated similarity in the response. 18

GLP-1 RAs are one of the latest additions of medication for the treatment of type-2 diabetes in adults. This class of drugs reported to increase glucose-mediated production of insulin from pancreatic beta cells. Other actions indicated for this class of drugs include delay in gastric emptying, decreased fasting endogenous glucose release by reducing the glycogenolysis and reduction in food intake through CNS action. 19 These actions have the tendency to reduce the blood glucose but at controlled levels. 9 Previous report also suggested that administration of GLP-1RA carry the risk of thyroid C-cell neoplasm and pancreatitis. 10 For these questions, the overall response of the medical professionals in our study is above 60%. However, the individual responses of the healthcare members for these questions were found to be less than 50%, such as for two questions in knowledge domain [Q-3 (Nurses-44%), Q-6 (Nurses-42%)], two questions of attitude domain [ Q-9 (Nurses-44%), Q-10 (Pharmacists- 46%)] and one question of practice domain [Q-14 (Nurses-42%)]. Although, the professionals better answered these questions who are directly concerned, but lack of information is reported to jeopardize the concept of better healthcare system. 20

The KAP score analysis suggested that the response of the participants for the knowledge domain was 4.27 (71%) to 5.2 (86%), attitude – 7.65 (64%) to 9.81 (82%) and practice – 8.07 (67%) to 9.96 (83%). These scores for the KAP in the previous study suggested that the participants have good knowledge, better attitude and proper practice. 18 The lowest and highest scores of KAP indicated interesting correlation. The response to the knowledge domain was found to be weakly related to attitude (r value = 0.14). The correlation between the replies of knowledge and practice was found to be moderately related (r value = 0.52). In addition, the correlation data between attitude and practice was found to be again moderately related (r value = 0.66). Further, the correlation analysis indicated significant variation when comparison was done between knowledge and practice (Table 4). The data suggests that enhancing the knowledge might not always improve the attitude but knowledge improvement could influence positively the practice domain. 21

The observation of this study indicated that the lowest scores for the KAP were found for those possessing the diploma degree as qualification. Their levels of scores were found to be significantly low (P<0.05) compared to the corresponding highest scores recorded forother demographic variables (Figure 1). In an earlier study, similar variation was observed in different qualified groups of professionals. 22 Earlier study suggests that diploma degree holders attain specific knowledge needed for their profession and are mostly trained in the skill activities. 23 This could be the reason for significant lower KAP scores for this group of participants when compared with others.

The highest scores seen in the knowledge domain were for the female participants and for practice, the masters’ or above qualified personnel (Figure 1). Female participants in the previous study also reported to possess good knowledge and better attitude. Their attitude can be directly linked to their knowledge as they were reported to be more conscious and serious in their activities including the professional works. 24 The masters’ or above qualified persons in the past study also showed ‘proper’ practice. The possible reason suggested for this is their qualification, which makes them more confident while practicing their profession. 25

For the level of KAP about the GLP-1 RA drugs, the present data suggested that there is a significant variation in the knowledge domain for professional (P = 0.03)and for age (P = 0.02) criteria (Table 3). Earlier studies suggested that distinctions in profession might cause variation in the knowledge level because each specializationsare trained for certain skills.23, 25 Our observations also suggested that nursing staff members’ response to the questions which are more specific to physicians (Q-3,6,14) is low (< 45%) and pharmacists response to the nursing profession related question (Q-10) is low (< 50%) (Table-2). Further, the age criterion has been reported to influence the knowledge domain of the participants. The participant having less than 35 years showed better knowledge since they have attained the most recent information about the variation therapeutic options available for treating a disease. 26

The level of KAP for the other variables was observed to be ≈ 80%. The important highlights include that physicians have ‘better’ KAP compared to other professionals. Females and Saudi nationals have ‘better’ knowledge and attitude whilemales and non-Saudis have ‘proper’ practice. Increase in the level of qualification enhanced the level of KAP. Medical professionals with less years of experience have ‘better’ knowledge and attitude while more years in profession have ‘proper’ practice (Table 3). Previous studies suggest that the level of KAP can differ among the study-population and several factors such as profession, qualification and experience could contribute to this. 27

Although, the response of the participating group of medical professionals for the KAP questionnaire is satisfactory, but the information such as glycemic level after GLP-1 RA, potential risks, selecting the suitable GLP-1 RA, size of needle and referring patient’s history before starting the GLP-1 RA medication requires suitable strategies for improvement.28, 29 As the study did not include all the members of healthcare team of University, research that is more detailed is essential. From the present study data, it can be proposed that updating the information about the new additions in the therapy of chronic disease such as diabetes is essential for all the members of healthcare providers. Continuous education program such as lectures, research meeting, group discussion, presentations, seminars, conferences and symposium could provide the opportunity to enlighten the medical information about the recent advances in medical profession.30

Due to time constraint, not all the healthcare professionals of the University could becontacted. Hence, the results of the study might not truly reflect the opinion of the entiremembers of the University.

The data from the study indicated that the healthcare professionals of Qassim University has significant knowledge, attitude and practice towards the glucagon-like peptide-1 class of antidiabetic drugs. However, some of the critical information such as the monitoring parameters and potential risks associated with the therapy needs update and can be achieved through continuing medical education programs.