HbA1c test awareness, sociodemographic characteristics and lifestyle behaviour among type 2 diabetes mellitus patients

INTRODUCTION

Type 2 diabetes mellitus (T2DM) is one of the most common chronic non-communicable diseases worldwide.¹ In 2019, an estimated 463 million people were affected by diabetes, and this number is projected to rise to 578 million by 2030, with the greatest burden occurring in urban settlements and in high income countries.² In India, the prevalence of diabetes has reached alarming levels and continues to increase owing to rapidly increasing sedentary lifestyle in individuals across all age groups.³ Patients with poor glycaemic control are at higher risk of developing diabetes-related complications which adversely affect their overall well-being and quality of life.^4,5 Thus, maintaining optimal glycaemic control remains the primary goal of diabetes management.⁶ Good glycaemic control improves quality of life and helps prevent or delay the onset of long-term complications.⁷

Regular monitoring plays a crucial role in guiding treatment decisions for diabetic patients.^8-10 The haemoglobin A1c (HbA1c) test is widely recognized as a reliable biomarker for assessing glycaemic control and has been approved by the World Health Organization (WHO) both for diagnosing diabetes and for monitoring long-term glycaemic status.^10-12 Routine testing of glycated haemoglobin should be encouraged, as it provides valuable information on long-term blood glucose levels that cannot be obtained through standard clinical measurements.^13,14 Moreover, the HbA1c test has the advantage of being performed at any time without the need for fasting, while reflecting the average blood glucose concentration over the previous three months. This makes it one of the most effective tools for the long-term management of T2DM.^1,15

Despite its importance, awareness of the HbA1c test among diabetic patients remains limited, particularly in resource-constrained settings. Therefore, it is necessary to explore the association between HbA1c awareness and demographic as well as lifestyle factors among individuals with T2DM. The objective of the present study was to assess the level of awareness regarding the HbA1c test among patients with T2DM and to examine its correlation with demographic and lifestyle characteristics.

METHODS

Study design and participants

The participants for this cross sectional study was recruited from outpatient and laboratory department of a private medical college hospital in Mangaluru, Karnataka, India. For this study, a purposive sampling of 230 participants were selected. The participants who were physician diagnosed type 2 diabetes mellitus, 30 years and above, diagnosed with T2DM for at least one year and willing to participate in the study were included. Participants who were unable to understand or follow instructions, with uncorrected hearing or visual impairment, cognitively impaired, terminal ill, or unwilling to participate were excluded from the study.

Data collection

The awareness of HbA1c test was assessed by asking patients whether they have heard of “HbA1c test”. The response was marked “yes” if the participant was aware of the test.

Demographic (age, gender, education, employment, income) and lifestyle variables (smoking, alcohol use, physical activity, adherence to prescribed exercise and diet) were collected for the study.

Statistical analysis

Data was analyzed using statistical package for the social sciences (SPSS) version 23.0 with a sample size of 230 participants. Categorical variables were expressed as frequency and percentage. The correlation between HbA1c awareness and demographic and lifestyle variables were examined using the Chi-square test.

The significance level for the study was set at a 95% confidence interval with p<0.05 considered statistically significant.

RESULTS

The majority of participants were aged between 50–69 years (62.6%), followed by those aged 30–49 years (31.3%), and a smaller proportion aged 70–89 years (6.1%). Males constituted 56.5% of the study population, while females accounted for 43.5%. Regarding education, 61.7% had studied below the 10th grade, 20.0% had completed 10th–12th grade, and 18.3% had education beyond 12th grade. In terms of occupation, 47.0% were working, 44.8% were unemployed, and 8.3% were retired. Monthly income data showed that 31.7% earned more than ₹5000, 25.2% earned between ₹3000–₹5000, 22.6% earned less than ₹1000, and 20.4% had a monthly income between ₹1000–₹3000 (Table 1).

Most participants had been diabetic for either 5–10 years (36.5%) or less than 5 years (36.1%), while 27.4% had diabetes for more than 10 years. Regarding smoking status, the majority (89.1%) were non-smokers, with only 8.7% currently smoking and 2.2% being ex-smokers. A large proportion (93.5%) were non-alcoholic, 4.3% were current alcohol users, and 2.2% were ex-alcoholics (Table 2).

In terms of anti-diabetic medication adherence, 89.1% always adhered, 9.6% followed most of the time, and 1.3% only sometimes. Most participants monitored their blood glucose at least once a month (68.6%), while others did so less frequently: 14.6% less than once every six months, 10.9% at least once every three months, 5.2% weekly, and 0.4% always (Table 2).

Physical activity was reported by 78.3% of participants, while 21.7% were physically inactive. Regarding exercise, 75.7% never exercised, 13.9% always did, 6.1% exercised sometimes, and only 4.3% followed exercise most of the time. Diet advice adherence was high, with 97.4% following dietary advice and only 2.6% not adhering (Table 2).

Among the 230 patients with T2DM, only 16.1% were aware of the HbA1c test, while a significant 83.9% had no awareness of it, indicating poor awareness about this important diagnostic marker among the majority (Figure 1 and Table 3).

Among the various socio-demographic and behavioral variables analyzed for their association with awareness of the HbA1c test among type 2 diabetes mellitus patients, physical activity and advice to exercise were found to have statistically significant associations (p<0.001). A greater proportion of those who were aware of HbA1c reported being physically inactive (54.1%) and had received advice to exercise, compared to those not aware. Other factors such as age, gender, education, employment, income, smoking status, alcoholic status, medication adherence, and dietary advice adherence did not show any significant association with awareness (p>0.05) (Table 4).

DISCUSSION

The present study explored the level of awareness regarding HbA1c and its association with glycemic control among patients with T2DM. Our findings revealed that a considerable proportion of participants demonstrated limited awareness about the role of HbA1c testing, its target values, and its implications for diabetes management. This aligns with earlier studies from India and other developing countries, where inadequate patient awareness has been reported as a key barrier to achieving optimal glycemic outcomes.^1,3,6

Several studies have emphasized that awareness of HbA1c is positively associated with better diabetes self-management and improved glycemic control.^16,17 A study done by Trivedi et al reported that patients in United States who were familiar with HbA1c targets demonstrated greater adherence to medication and lifestyle modifications compared to those unaware of the same.¹⁷ Similarly, Al-Khaldi et al observed in Saudi Arabia that poor understanding of HbA1c was strongly correlated with uncontrolled diabetes.¹⁶

The UK Prospective Diabetes Study (UKPDS) has long established the relationship between glycemic control and the risk of both microvascular and macrovascular complications.⁴ Consistent with these findings, our study reinforces the clinical importance of patient education, as lack of HbA1c awareness may delay treatment intensification and increase the risk of complications. International guidelines, including those from the American Diabetes Association (ADA) and the International Diabetes Federation (IDF), recommend HbA1c monitoring at least twice annually in patients with stable glycemic control and quarterly in those not achieving targets.^11,19 However, awareness of these guidelines among patients remains insufficient, particularly in low- and middle-income countries.¹⁸

From a psychosocial perspective, lack of knowledge about HbA1c has been associated with reduced motivation and poor quality of life among diabetic patients.^7,8 Glasgow et al demonstrated that patients with limited understanding of their glycemic targets often report frustration and helplessness, which can further impede adherence suggesting that along with clinical care, structured patient education programs is essential for the diabetes care.⁷

In India, cultural, educational, and socioeconomic factors play a significant role in patient awareness. Studies by Pradeepa and Mohan have highlighted the increasing burden of type 2 diabetes in the country, where disparities in healthcare access may compound the problem of low HbA1c literacy.³ Our findings are in line with these observations, as a notable proportion of participants were unaware of the test despite being on regular follow-up with their diabetes management.

This study also raises important implications for clinical practice. Strengthening patient education through targeted interventions such as structured diabetes education programs, use of visual aids, and digital health platforms could improve HbA1c awareness and thereby enhance overall disease management.²⁰

Furthermore, integrating HbA1c education into routine consultations could empower patients to actively participate in treatment decisions, potentially improving long-term outcomes. This study includes important confounding factors like age, gender, duration of diabetes, BMI, educational level and income.

Limitations

Although our study provides valuable insights, certain limitations must be acknowledged. The use of non-probability sampling and T2DM patients may limit the generalization of the findings. The cross-sectional design prevents establishing causality between HbA1c awareness and glycemic control. The study was conducted in a limited number of center, which may restrict generalizability.

CONCLUSION

Despite its important role in monitoring long-term blood sugar control, the study indicates that a large number of T2DM patients are still unaware about the HbA1c test. The study found a significant relationship between HbA1c test awareness and lifestyle, education and age. Better care for diabetes, less complications, and better health outcomes essentially depend on routine HbA1c testing and better patient education.

Recommendations

Future longitudinal studies with larger, more diverse populations and their target values are recommended to validate these findings and evaluate the effectiveness of structured educational interventions.

ACKNOWLEDGEMENTS

The authors would sincerely like to thank all the participants, teaching and non-teaching staff for their support for the study.

Funding: No funding sources

Conflict of interest: None declared

Ethical approval: The study was approved by the Institutional Ethics Committee

REFERENCES

1. 1. Almutairi JS, Almigbal TH, Alruhaim HY, Mujammami MH, AlMogbel TA, Alshahrani AM, et al. Self-awareness of HbA1c and its association with glycemic control among patients with type 2 diabetes: A multicenter study. Saudi Med J. 2022;43(3):291-300.
2. 2. Saeedi P, Petersohn I, Salpea P, Malanda B, Karuranga S, Unwin N, et al. Global and Regional Diabetes Prevalence Estimates for 2019 and Projections for 2030 and 2045: Results from the International Diabetes Federation Diabetes Atlas, 9th Edition. Diabetes Res Clin Pract. 2019;157(157):107843.
3. 3. Pradeepa R, Mohan V. Epidemiology of type 2 diabetes in India. Indian J Ophthalmol. 2021;69:2932-8.
4. 4. Stratton IM, Adler AI, Neil AW, Matthews DR, Manley SE, Cull CA, et al. Association of glycaemia with macrovascular and microvascular complications of type 2 diabetes (UKPDS 35): prospective observational study. BMJ. 2000;321(7258):405-12.
5. 5. American Diabetes Association. Diagnosis and classification of diabetes mellitus. Diabetes Care. 2010;33(1):S62-9.
6. 6. Bin Rakhis SA, AlDuwayhis NM, Aleid N, AlBarrak AN, Aloraini AA. Glycemic Control for Type 2 Diabetes Mellitus Patients: A Systematic Review. Cureus. 2022;14(6):e26147.
7. 7. Glasgow RE, Ruggiero L, Eakin EG, Dryfoos J, Chobanian L. Quality of Life and Associated Characteristics in a Large National Sample of Adults With Diabetes. Diabetes Care. 1997;20(4):562-7.
8. 8. Samuels TA, Bolen S, Yeh HC, Abuid M, Marinopoulos SS, Weiner JP, et al. Missed opportunities in diabetes management: A longitudinal assessment of factors associated with sub-optimal quality. J Gen Intern Med. 2008;23(11):1770-7.
9. 9. Rodondi N, Peng T, Karter AJ, Bauer DC, Vittinghoff E, Tang S, et al. Therapy Modifications in Response to Poorly Controlled Hypertension, Dyslipidemia, and Diabetes Mellitus. Ann Intern Med. 2006;144(7):475-84.
10. 10. Sherwani SI, Khan HA, Ekhzaimy A, Masood A, Sakharkar MK. Significance of HbA1c test in diagnosis and prognosis of diabetic patients. Biomark Insights. 2016;11:95-104.
11. 11. Kahn R, Hicks J, Muller M, Panteghini M, John G, Deeb L, et al. Consensus statement on the worldwide standardization of the hemoglobin A1C measurement. Diabetes Care. 2007;30(8):2399-400.
12. 12. Bonora E, Tuomilehto J. The pros and cons of diagnosing diabetes with A1C. Diabetes Care. 2011;34(2):S184-90.
13. 13. Sacks DB, Arnold M, Bakris GL, Bruns DE, Horvath AR, Kirkman MS, et al. Position statement executive summary: Guidelines and recommendations for laboratory analysis in the diagnosis and management of diabetes mellitus. Diabetes Care. 2011;34(6):1419-23.
14. 14. Mawson TMH. HbA1c: More than just a number. Aust J Gen Pract. 2021;50(9):628-32.
15. 15. Al-Khaldi YM, Al-Sharif AI, Al-Mogbil TI, Al-Kahtani HS. Awareness and knowledge of HbA1c among type 2 diabetic patients in primary health care centers in Saudi Arabia. Saudi J Med Med Sci. 2018;6(1):12-7.
16. 16. Trivedi B, Shah J, Pansare M, Thakkar H, Patel A. Patient awareness of HbA1c and its association with diabetes outcomes: A cross-sectional study in the US. Diabetes Ther. 2017;8(2):455-64.
17. 17. Kumpatla S, Medempudi S, Manoharan D, Viswanathan V. Knowledge and outcome measure of HbA1c testing in Asian Indian patients with type 2 diabetes from a tertiary care center. Indian J Community Med. 2010;35(2):290-3.
18. 18. American Diabetes Association. Standards of Medical Care in Diabetes—2025. Diabetes Care. 2025;48(1):S1-S154.
19. 19. Shrivastava SR, Shrivastava PS, Ramasamy J. Role of self-care in management of diabetes mellitus. J Diabetes Metab Disord. 2013;12:14.
20. 20. Stratton IM, Adler AI, Neil HA, Matthews DR, Manley SE, Cull CA, et al. Association of glycaemia with macrovascular and microvascular complications of type 2 diabetes (UKPDS 35): prospective observational study. BMJ. 2000;321(7258):405-12.