The assessment composed of a total of 26 items across three domains: knowledge, attitude, and practice (see supplementary figure 1). Specifically, there were 13 items related to knowledge, 6 items pertaining to attitudes, and 7 items concerning practices. The knowledge score was assessed by summing the "Yes" responses to a set of 13 questions related to GLP-1 RA therapy. Participants received a score of +1 for each correct response, -1 for incorrect responses, and 0 for 'don't know'. This resulted in a total score range of +13 to -13. Higher scores indicating a greater level of knowledge about GLP-1 RA therapy. Attitudes were evaluated based on a scale where 'Strongly agree' was assigned a score of +2, 'Agree' received +1, 'Neutral' was scored as 0, 'Disagree' was -1, and 'Strongly disagree' was -2, leading to a score range from -12 to +12. Similarly, the practice domain used the same scoring system, resulting in scores ranging from -14 to +14. Categorization of responses was done based on the percentage scores, with scores above 70% categorized as 'Good', those between 51% and 69% as 'Fair', and scores less than 50% recorded as 'Poor'.

The statistical analysis was conducted using RStudio software (R version 4.3.1.). Descriptive statistics were utilized to summarize demographic and occupational characteristics, including frequencies and percentages for categorical variables. Statistical differences in demographic and occupational characteristics across participants' knowledge, attitude and practice levels regarding GLP-1 RA were assessed using Fisher's exact test. Statistical significance was set at p < 0.05. Additionally, inferential analysis was performed using the Wilcoxon rank sum test and Kruskal-Wallis rank sum test for the overall knowledge score. Multivariable regression analysis was employed to examine factors associated with the knowledge score, with beta coefficients and 95% confidence intervals (CIs) reported. Statistical significance was set at p < 0.05.

The responses of a total of 51 participants were analyzed in the current study. About a half of physicians surveyed were female (51.0%), and most of them were Saudis (98.0%). Most participants were aged less than 35 years (92.2%) and had educational qualifications ranging from residents (45.1%) to Medicine bachelor, Bachelor of Surgery, MBBS, (41.2%). Internal medicine was the predominant department (58.8%), with the majority of physicians specializing as internal medicine residents (54.0%). Additionally, a significant proportion of respondents had less than or equal to 2 years of experience (62.7%). Notably, a majority of physicians reported not having authorization for GLP-1 RA prescription (72.5%) [Table 1].

Out of a total score of 13, the median (IQR) knowledge score across all the participants was 10.0 (8.0 to 11.00). Among the factors associated with the knowledge score among participants, significant differences were observed in terms of department (p = 0.010) and specialization (p = 0.024) and years of experience (p = 0.027). On the multivariable regression model comprising the significantly associated variables of knowledge, physicians specializing as family medicine residents exhibited a higher knowledge score compared to those in general practice, with a beta coefficient of 3.34 (95% CI, 0.31 to 6.36, p = 0.037). Additionally, physicians with 2 to 5 years of experience showed a significantly higher knowledge score compared to those with less than or equal to 2 years of experience, with a beta coefficient of 1.72 (95% CI, 0.11 to 3.34, p = 0.043) [Table 2].

Participants’ responses to knowledge, attitudes, and practice items (see supplementary tables 1 and 2) .

In the knowledge category, approximately 31.4% of participants were categorized as having a fair level of knowledge, while nearly half, or 49.0%, were classified as having a good understanding. About 19.6% of respondents fell into the poor knowledge category. Regarding attitudes, a smaller proportion, at 17.6%, were rated as fair, while 19.6% were classified as having a good attitude. However, the majority, comprising 62.7%, exhibited a poor attitude response. In the practice category, a similar pattern emerged, with 17.6% categorized as fair, 23.5% as good, and the majority, around 58.8%, as poor (Figure 1). In general, knowledge items were scored correctly in 77.2% of participants. And around half of the group 51.6% showed a positive attitude toward GLP-1RA, reflected as strongly agree and agree in the questionnaire. And only 55.2% of participant showed good practice in term of utilization of GLP-1RA.

Figure 1

Statistically significant differences were observed in the distribution of knowledge levels among participants based on their department (p = 0.041) and specialization (p = 0.042). Specifically, within the department variable, a higher proportion of respondents from the family medicine department demonstrated a good level of knowledge (66.7%), compared to those from internal medicine (36.7%).

Regarding specialization, participants categorized as senior registrars showed the highest percentage of good knowledge (100.0%), followed by family medicine residents (63.6%), while the lowest proportion was observed among internal medicine residents (33.3%) and DM fellows (0.0%) [Table 3].

Statistically significant differences were found in attitude level towards GLP-1 RA among participants based on gender (p = 0.019). Specifically, a higher proportion of female participants exhibited a good attitude (34.6%) compared to male participants (4.0%), who had a larger proportion categorized under the poor attitude level (76.0%) [Table 4].

Table 4

		Attitude level
Characteristic	Missing	Good N=10	Fair N=9	Poor N=32	p-value
Gender	0 (0%)				0.019
Male		1 (4.0%)	5 (20.0%)	19 (76.0%)
Female		9 (34.6%)	4 (15.4%)	13 (50.0%)
Nationality	0 (0%)				>0.999
Saudi		10 (20.0%)	9 (18.0%)	31 (62.0%)
Non-Saudi		0 (0.0%)	0 (0.0%)	1 (100.0%)
Age (Years)	0 (0%)				0.479
Less than 35		9 (19.1%)	8 (17.0%)	30 (63.8%)
36 to 45		0 (0.0%)	0 (0.0%)	1 (100.0%)
45 to 55		1 (50.0%)	1 (50.0%)	0 (0.0%)
Above 56		0 (0.0%)	0 (0.0%)	1 (100.0%)
Educational Qualification	0 (0%)				0.141
Resident		3 (13.0%)	5 (21.7%)	15 (65.2%)
MBBS*		3 (14.3%)	3 (14.3%)	15 (71.4%)
Board-certified		4 (57.1%)	1 (14.3%)	2 (28.6%)
Department	0 (0%)				>0.999
Family medicine		4 (19.0%)	4 (19.0%)	13 (61.9%)
Internal medicine		6 (20.0%)	5 (16.7%)	19 (63.3%)
Specialization	1 (2.0%)				0.68
General Practice		0 (0.0%)	0 (0.0%)	4 (100.0%)
Family medicine resident		2 (18.2%)	3 (27.3%)	6 (54.5%)
Internal medicine resident		5 (18.5%)	5 (18.5%)	17 (63.0%)
Senior registrar		2 (28.6%)	1 (14.3%)	4 (57.1%)
DM fellow		1 (100.0%)	0 (0.0%)	0 (0.0%)
Year(s)of Experience	0 (0%)				0.583
≤2		5 (15.6%)	7 (21.9%)	20 (62.5%)
>2 to 5		4 (26.7%)	1 (6.7%)	10 (66.7%)
> 5		1 (25.0%)	1 (25.0%)	2 (50.0%)
Authorization of GLP-1 RA prescription	0 (0%)				0.94
No		8 (21.6%)	7 (18.9%)	22 (59.5%)
Yes		2 (15.4%)	2 (15.4%)	9 (69.2%)
Do not know		0 (0.0%)	0 (0.0%)	1 (100.0%)

n (%)

Statistically significant differences were observed in practice level related to GLP-1 RA among participants based on their educational qualification (p = 0.034). Notably, a higher proportion of participants with board certification demonstrated a good practice (71.4%) compared to those with MBBS (14.3%) or residency qualifications (13.0%) [Table 5].

Table 5

	Practice level
Characteristic	Missing	Good N=12	Fair N=9	Poor N=30	p-value
Gender	0 (0%)				0.115
Male		3 (12.0%)	4 (16.0%)	18 (72.0%)
Female		9 (34.6%)	5 (19.2%)	12 (46.2%)
Nationality	0 (0%)				>0.999
Saudi		12 (24.0%)	9 (18.0%)	29 (58.0%)
Non-Saudi		0 (0.0%)	0 (0.0%)	1 (100.0%)
Age (Years)	0 (0%)				0.473
Less than 35		11 (23.4%)	8 (17.0%)	28 (59.6%)
36 to 45		0 (0.0%)	0 (0.0%)	1 (100.0%)
45 to 55		1 (50.0%)	1 (50.0%)	0 (0.0%)
Above 56		0 (0.0%)	0 (0.0%)	1 (100.0%)
Educational Qualification	0 (0%)				0.034
Resident		3 (13.0%)	5 (21.7%)	15 (65.2%)
MBBS*		4 (19.0%)	3 (14.3%)	14 (66.7%)
Board-certified		5 (71.4%)	1 (14.3%)	1 (14.3%)
Department	0 (0%)				0.158
Family medicine		8 (38.1%)	3 (14.3%)	10 (47.6%)
Internal medicine		4 (13.3%)	6 (20.0%)	20 (66.7%)
Specialization	1 (2.0%)				0.196
General Practice		0 (0.0%)	0 (0.0%)	4 (100.0%)
Family medicine resident		4 (36.4%)	2 (18.2%)	5 (45.5%)
Internal medicine resident		3 (11.1%)	6 (22.2%)	18 (66.7%)
Senior registrar		3 (42.9%)	1 (14.3%)	3 (42.9%)
DM fellow		1 (100.0%)	0 (0.0%)	0 (0.0%)
Year(s)of Experience	0 (0%)				0.723
≤2		7 (21.9%)	7 (21.9%)	18 (56.3%)
>2 to 5		4 (26.7%)	1 (6.7%)	10 (66.7%)
> 5		1 (25.0%)	1 (25.0%)	2 (50.0%)
Authorization of GLP-1 RA prn (%)escription	0 (0%)				0.944
No		9 (24.3%)	6 (16.2%)	22 (59.5%)
Yes		3 (23.1%)	3 (23.1%)	7 (53.8%)
Do not know		0 (0.0%)	0 (0.0%)	1 (100.0%)

n (%)

The study highlights the critical insights into the knowledge, attitudes, and practices (KAP) of healthcare providers regarding GLP-1 receptor agonists (GLP-1 RA) in diabetes management. Male and female physicians were surveyed and most of them were Saudis. Majority of participants were aged less than 35 years. Educational qualifications ranged between training residents to MBBS holders. On the departmental level, internal medicine was the predominant. Most respondents had less than or equal to 2 years of experience. GLP-1 RA prescription authorization was limited for most physicians.

Our findings demonstrated varied levels of knowledge among participants, with almost half demonstrating good understanding but a significant portion showed fair or poor comprehension. Knowledge items were scored correctly in 77.2% of participants which is close to previous studies 16, 17. Significant differences were observed based on department and specialization. Family medicine department demonstrated a good level of knowledge compared to internal medicine.

On the other hand, a study published by American College of Cardiology compared GLP-1 RA prescription pattern across specialties; endocrinologists had highest prescription rate (33%) followed by primary care physicians (29%) and lastly cardiologist (4.5%) 18. Similarly, in a survey done by Slater et al, only 11% of cardiologists felt obligated to provide diabetes management i.e. GLP-1RA for patients following acute coronary syndrome 19. While majority of cardiologists chose to refer to the specialist diabetes team 19. This was attributable to lack of practical knowledge, possible side effects, patient and interdisciplinary boundaries invasion which mandate raised awareness and attitudinal change 18, 19. Likewise, significant difference in overall GLP-1RA understanding variations between physicians of various hospital levels was noticed. It demonstrated that tertiary hospitals have a higher GLP-1RA understanding than secondary and lower-level hospitals 20. Regarding qualification, senior registrars showed the highest percentage of good knowledge followed by family medicine residents, while internal medicine residents showed the lowest percentage.

This inter-professional difference pattern with variable qualifications was observed in many other studies 16, 21, 22. Nevertheless, in United Kingdom, no significant difference was observed between general practitioners and specialist perception about diabetes injectable therapy 23. Most of our physicians answered correctly that GLP-1 RA are the latest addition in the management of type-2 diabetes 78.4% compared to 81% in another study, however, our physician showed much better knowledge regarding the question ‘GLP-1 RA carry the potential risk of thyroid C-cell neoplasm’ 74.5% compared to 58% 16. 37 % of participant did not know that GLP- RA can reduce the blood pressure which might necessitate targeted educational interventions.

Positive attitudes were generally prevalent, with a majority feeling a moral obligation to discuss GLP-1 RA benefits and risks with patients, although a substantial 62.7% of participants still exhibiting poor attitudes. This inconsistency may stem from varying levels of confidence and understanding. Poor attitude was attributed to consent form ignorance, choice of appropriate GLP-RA, mealtime while using GLP-RA and blood glucose self-monitoring encouragement (27.5%, 33.3%, 45.1% and 29.4% respectively). Significant differences were found in attitude level of female participants which exhibited a good attitude compared to male participants, who had a larger proportion categorized under the poor attitude level 76.0%. One the other hand, Aldhobaib et al, found that male participants had better attitude 50.1%. 16

Practice patterns showed commitment to patient safety, with many providers informing the patients about potential side effects. Similarly, this was observed in earlier study with a response about 92% 16. On the other hand, the gaps on safety were evident in areas like recommending oral contraceptives and keeping abreast of new GLP-1 RA developments. Practice towards prescribing GLP-RA to pregnant and nursing patients are variable. Our study demonstrated that 41% of participant agreed to avoid prescribe GLP-RA, while 47% are neutral. Nevertheless, another study demonstrated that 78% of participant avoided GLP-RA prescription to pregnant and nursing patients 16. Poor Practice was noted towards GLP-RA literature update follow up, referring to patients’ history and advise about local irritation at injection site (43.1%, 19.6% and 43% respectively). Significant differences were observed in practice based on educational qualification. Board certification demonstrated a good practice compared to those with MBBS or residency qualifications. While clinical experience did not show statical significance in our study, Gourgari et al. found that lack of clinical experience is a major barrier for GLP-1RA prescription, especially higher than 5 years of clinical experience 24 Liu et al. survey exhibited a limited understanding of GLP-1RA along with low prescription patterns 20. Low levels of deep knowledge about guidelines and consensus of diabetes management were a major reason for these results 20. A recent review showed that GLP-1 RA had potential barriers in their prescription 25. Which include safety concerns, patient selection, level of diabetes control, understand of treatment effects, side effects, sociodemographic, clinical and laboratory characteristics of diabetic patients managed with GLP-1 RA 25. Therefore, filling gaps in current evidence-based recommendations is considered a priority for future efforts 25. Strategies like empowering future research methodologies and implementation of knowledge must be applied 25. All in all, the Chinese study supported clearly that exposure to updated guidelines, diabetes consensus statements, continuous medical education and scientific training activities significantly increased tertiary hospital physicians’ knowledge and understanding about GLP-1 RA and other diabetes treatments 20.

These findings suggest that continuous professional development and systematic well-organized training programs are crucial to bridge knowledge gaps and refine practice patterns. By addressing these areas through targeted education and fostering a culture of continuous learning, healthcare providers can improve the effective and safe management of diabetes using GLP-1 RA, ultimately enhancing patient outcomes. Future research should explore barriers to effective GLP-1 RA implementation and the impact of educational initiatives on improving KAP and patient outcomes.

The study showed that physicians of Prince Mohammed bin Abdulaziz Hospital and primary health care have significant knowledge, attitude but limited practice towards the glucagon-like peptide-1 class of antidiabetic medication. However, focused education and implementing vivid scientific environment for continuous learning would effectively and safely enhance the management of diabetes using GLP-1 RA, therefore, enhancing patient outcomes. In order to explore the barriers of effective GLP-1 RA implementation, further scholar and educational initiatives are highly recommended.