Iran Journal of Nursing

Introduction
Although all people in different age groups and with different demographic and health characteristics are exposed to COVID-19, their conditions and severity of symptoms and the need for hospitalization and special care are different and worse in people with chronic diseases such as diabetes. Their knowledge, attitude, and practice (KAP) are of special importance for having preventive behaviors, self-care and appropriate health-seeking behaviors. Success or failure in dealing with COVID-19 depends highly on these behaviors. This study aims to assess the KAP towards COVID-19 in patients with diabetes .

Methods
In this descriptive cross-sectional study, participants were 384 patients with type 1 and type 2 diabetes referred to Firouzgar and Hazrat Rasool-e Akram hospitals in Tehran, Iran. For sampling, a continuous method was used. Two questionnaires were used to collect data. The first questionnaire was a demographic form surveying age, gender, educational level, occupation, marital status, type of diabetes, duration of disease, and having other chronic diseases such as high blood pressure, heart disease, asthma or chronic lung diseases. The second questionnaire measures the KAP towards COVID-19 designed by Honarvar et al. [29], which has 46 items, 17 for knowledge, 10 for attitude, and 18 for practice (the ways of transmission, methods of prevention, and treatment). The total score of knowledge is between 0 and 25, where a higher score indicates higher knowledge. Based on the scores, the knowledge level was divided into three groups: adequate (>70% of the total score), moderate (40-70% of the total score) and poor (<40% of the total score). The total score of practice subscale is between 0 and 70. Based on these scores, the practice level was divided into three categories: Adequate, moderate, and poor. To determine the validity of the KAP tool, it was sent to 5 members of the Faculty of Nursing and Midwifery, Iran University of Medical Sciences. After applying their opinions, the validity was confirmed. Also, to ssess the reliability, the questionnaire was given to 20 patients with diabetes who met the inclusion criteria and were excluded from the study after completing the instruments. The Cronbach’s alpha coefficient was obtained 0.78, 0.75, and 0.81 for knowledge, attitude, and practice subscales, respectively.

Findings
In this study, the mean age of participants was 40.15±15.01 years, and the mean duration of diabetes in them was 11.76±8 years. Most of participants were male (51%), married (70.6%), with associate degree and bachelor’s level degree (38.8%). More than half of them had type 1 diabetes (56.3%). In addition to diabetes, 31.5% of patients had hypertension, 9.9% heart disease, and 2.6% asthma or chronic lung disease. According to the findings, the knowledge of COVID-19 in 52.6% of patients was at moderate level, 42.2% had at an adequate level, and 5.2% at a poor level. The mean score of attitude towards COVID-19 was 30.90±4.89. The practice regarding COVID-19 in 57.8% of patients was at an adequate level; 40.9% had at a moderate level, and only 1.3% had poor practice. A significant relationship was observed between the knowledge level of patients and their marital status (P=0.006), employment status (P<0.001), and duration of disease (P<0.001). In addition, there was a statistically significant relationship between the employment status and attitude level (P=0.018) and also between practice level and the variables of gender (P=0.010), marital status (P=0.001), and type of diabetes (P<0.001).

Conclusion
The findings of this study showed that the KAP of patients with diabetes in Tehran were at moderate to adequate level. The findings indicate the effectiveness of information and public awareness and confirm the importance of education and its impact on preventive measures during the pandemic. It is recommended that similar studies be carried out on other patients who are at high risk of contracting COVID-19, such as people with high blood pressure, autoimmune diseases, patients receiving drugs that weaken the immune system, etc.

Ethical Considerations
Compliance with ethical guidelines
This study was approved by the ethics committee of Iran University of Medical Sciences (Code: IR.IUMS.REC.1400.796). All ethical principles were considered in this study.

Funding
This study was extracted from a master thesis approved by the School of Nursing and Midwifery, Iran University of Medical Sciences. It was not funded by any organizations.

Authors' contributions
Conceptualization: Samad Shojaeimotlagh , Maryam Ehsani; Sampling: Samad Shojaeimotlagh; Data analysis: Samad Shojaeimotlagh, Shima Haghani and Maryam Ehsani; Approval of final draft: All authors.

Conflict of interest
The authors declare no conflict of interest.

Acknowledgments
The authors would like to thank the Personnel of Hazrat-e Rasool and Firouzgar hospitals and all participants for their cooperation.


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