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Year : 2018  |  Volume : 15  |  Issue : 1  |  Page : 15-22

A cross-sectional survey to assess knowledge, attitude, and practices in patients with hypothyroidism in India

1 CARE Hospital, Hyderabad, Telangana, India
2 Dr. Khandelwal's Endocrinology Clinic, New Delhi, India
3 Abbott India Limited, Mumbai, Maharashtra, India

Date of Web Publication23-Mar-2018

Correspondence Address:
Dr. Upal Vyas
Abbott India Limited
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/trp.trp_25_17

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Objective: The objective of this study is to assess the knowledge, attitude, and practices (KAP) in patients with hypothyroidism in India.
Methods: This was a questionnaire-based, cross-sectional KAP study conducted in patients with hypothyroidism across 16 centers in India. The questionnaire was validated initially by a panel of experts, followed by 120 patients with primary hypothyroidism.
Results: Out of 500 patients enrolled, about three-fourths (72.4%) were women. Most patients had low levels of knowledge (66.6%), were quite concerned (46.6%), and practiced a moderate level of precaution (77.8%). Around 18.4%, 26.2%, 27.8%, and 37.6% of patients had incorrect/no knowledge that weight gain, fatigue, muscle aches/pain, and dry skin were effects of hypothyroidism, respectively. Patients had poor knowledge regarding various risks associated with hypothyroidism such as abnormal menstruation (41.6%), depression (47%), hypercholesterolemia (65.6%), and medications causing hypothyroidism (74.2%). Most patients (91.4%) affirmed the need to consult a physician for or seek medical advice before treatment initiation. However, a small percentage did not agree on testing pregnant women (20.2%) and family members (26.2%) for hypothyroidism. Most patients (93.2% and 92.6%) practiced compliance to frequency and timings for medications; however, one-thirds reported missing doses. There was lack of knowledge-seeking behavior both from online sources (57.4%) and treating doctors (24.2%). Significant associations were found between education and the levels of knowledge, concern, and precautions taken.
Conclusion: This study identified significant gaps in the knowledge about the risks associated with hypothyroidism, importance of laboratory investigation, and dietary precautions.

Keywords: Awareness, hypothyroidism, India, knowledge, patient education

How to cite this article:
Sethi B, Khandelwal D, Vyas U. A cross-sectional survey to assess knowledge, attitude, and practices in patients with hypothyroidism in India. Thyroid Res Pract 2018;15:15-22

How to cite this URL:
Sethi B, Khandelwal D, Vyas U. A cross-sectional survey to assess knowledge, attitude, and practices in patients with hypothyroidism in India. Thyroid Res Pract [serial online] 2018 [cited 2022 Dec 4];15:15-22. Available from: https://www.thetrp.net/text.asp?2018/15/1/15/228373

  Introduction Top

Hypothyroidism is prevalent in India and affects 1 in every 10 adults.[1],[2] Symptoms develop gradually and are nonspecific,[3],[4] leaving a significant number of cases undiagnosed.[5] Untreated hypothyroidism adversely affects the physical and mental well-being of the patients.[6],[7],[8]

Incomplete and unreliable information obtained from the Internet or known acquaintances may hamper disease management.[9],[10],[11] A knowledge, attitude, and practices (KAP) survey is a quantitative tool, based on a standardized questionnaire, that measures these domains in a predefined population. A KAP survey essentially records an “opinion” and is based on the “declaration” (i.e., statements).[12] The objective is to explore misconceptions, misunderstandings, and changes in KAP of the community, paramedical personnel, and medical practitioners after implementing an intervention such as disease education.[13],[14],[15]

We conducted this survey to identify the gaps in KAP of patients with hypothyroidism and help strategize future activities to improve disease outcome.

  Methods Top

Study design

This questionnaire-based, cross-sectional KAP study was conducted between August and September 2016 in a subset (n = 500) of a thyroid registry population across 16 centers in India. Adult literate patients who were taking treatment for hypothyroidism and who were able to read and write were invited to participate in the study. Patients unable to provide complete information as per the questionnaire were excluded from the study. The questionnaire was administered after written authorization was provided by willing patients.

The questionnaire construct was based on three distinct domains, KAP:

  1. Knowledge section had 20 factual statements related to the symptoms, risk factors, diagnosis, and treatment of hypothyroidism. The responses were captured as true, false, or don't know (if not sure about the answer)
  2. Attitude domain included five statements to assess the attitude of patients toward their disease and treatment. A 5-point Likert scale ranging from 5 (strongly agree) to 1 (strongly disagree) was used to rank the responses
  3. Practice domain contained eight practice statements requiring a “Yes” or “No” response to indicate if the patients pursue a particular recommended practice.

Scoring convention

The scoring assessments of the three KAP domains were performed as follows:

  1. For knowledge, each correct answer (“Yes” for positive and “No” for negative statements) was given 1 point and an incorrect answer (“No” for positive and “Yes” for negative statements) including responses as “Don't know” was given 0 point. The level of knowledge was categorized as “low” (≤12 points), “average” (13–15 points), or “high” (≥16 points) as per the total score
  2. For attitude, the level of concern was categorized as “extremely concerned” (if agreement [point 4 or 5 on the Likert scale] was marked for all 5 statements), “quite concerned” (if agreement was shown for 3–4 statements), “little concerned” (if agreement was marked for 1–2 statements), and “not concerned” (no agreement)
  3. For practice, 1 point was given for each precautionary statements practiced by the patient (total score ranged from 0 to 8 points). A “high level” of precaution was considered for a score of ≥ 7 points, a “moderate level” if the score was between 4 and 6 points, and a “poor level” was assigned for scores <3 points.

Validation of the questionnaire

The constructed questionnaire was initially validated by a panel of experts and then tested in 120 patients with hypothyroidism undergoing treatment. Cronbach's alpha was calculated to measure consistency between responses to the individual questions and the questionnaire as a whole. The overall standardized alpha value for the questionnaire was 0.698 (~0.7), which is an acceptable Cronbach score and indicates good homogeneity.

Statistical analysis

Discrete data were summarized using frequency counts (n) and percentages (%). Continuous data were summarized using descriptive statistics. All the statistical analyses were performed using a two-sided test with 0.05 as level of significance. Chi-square/Fisher test was used for comparison across groups. Cronbach's alpha was also calculated for the surveyed population for revalidating the questionnaire.

  Results Top


The mean age of respondents was 43.0 (±13.6) years and 72.4% were women. Most patients were undergraduates (44.2%), followed by graduates (39.6%), and postgraduates (16.2%) [Table 1].
Table 1: Demographics and other baseline characteristics

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Knowledge about hypothyroidism

[Table 2] summarizes the responses given to all individual questions of the knowledge domain. A fair number of patients (64.6%) had correct knowledge about the shape of the thyroid gland. Among the effects of hypothyroidism, weight gain was most correctly identified by 81.6% of patients, followed by 73.8%, 72.2%, and 62.4% of patients who correctly identified fatigue, muscle aches/pain, and dry skin, respectively, as symptoms of hypothyroidism. Only 48.4% and 45.4% correctly identified cold intolerance and constipation, respectively, as manifestations of hypothyroidism. Further, 18.4%, 26.2%, 27.8%, and 37.6% of patients had incorrect/no knowledge of weight gain, fatigue, muscle aches/pain, and dry skin, respectively, as effects of hypothyroidism. Swelling in the neck associated with hypothyroidism was correctly identified by 59% of patients. A considerable number of patients had incorrect/no knowledge about the clinical manifestations of menstrual disturbances (41.6%) and depression (47%) in hypothyroidism. Approximately two-thirds (61.4%) did not know about the increased risk of hypothyroidism during pregnancy and 53.4% of patients were not aware that the risk for developing thyroid disorders may be hereditary. A considerable number of patients had incorrect/no knowledge about hypercholesterolemia (65.6%) or medications causing hypothyroidism (74.2%).
Table 2: Details of correct responses of patients on knowledge domain

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Most patients (85.8%) were aware that hypothyroidism could be diagnosed by testing thyroid-stimulating hormone (TSH), but 61.8% and 43.2% of patients had no knowledge about the increased levels of TSH and low-thyroid hormone levels in hypothyroidism, respectively. Furthermore, 45.4% of patients had incorrect/no knowledge that iodine deficiency may cause hypothyroidism. Only 20.4% were sure that alternative medicines are not useful in treating hypothyroidism.

Overall knowledge

Most patients (66.6%) had a low level of knowledge, and only few had high awareness (12%). The low level of knowledge was significantly more in males and was most prevalent (72.7%) in the age group of 41–50 years (P = 0.0006). There was also a significant association between education levels and knowledge. Low and high levels of knowledge were more prevalent in undergraduates (76.9%) and postgraduates (34.6%), respectively. [Table 3] mentions the details of association between knowledge and other parameters.
Table 3: Evaluation of association of different levels of knowledge with gender, age groups, and educational qualifications

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Most patients (68%–91%) had agreement on all the statements in the attitude domain. Highest agreement (91.4%) was found for the statement “treatment for hypothyroidism should be initiated after consultation with a physician only.” However, 20.2% and 26.2% of patients did not agree that pregnant and family members should be tested for hypothyroidism.

Overall scores of the attitude domain showed that females (89%) were more concerned (extremely and quite) than males (84.7%). There was a significant association between age and the level of concern (extremely and quite) among individuals. Both levels (extremely and quite) were more prevalent in the age group of 31–40 years and 41–50 years, respectively. There was a significant association between the level of education and the level of concern. A considerable number of undergraduates (50.2%) were quite concerned about hypothyroidism while most postgraduates were extremely concerned (60.5%).

Details of responses to the attitude questions are given in [Table 4], and the association between attitude and demographics is described in [Table 5].
Table 4: Details of responses of patients on attitude domain (N=500)

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Table 5: Evaluation of association of different levels of attitude with gender, age groups, and educational qualifications

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Practices pursued

Most patients (93.2%) adhered to their medications. However, 34.4% responded that they occasionally skip medications. TSH levels were tested regularly by 87.4% of patients. One-thirds (33.0%) responded that they took other medications with hypothyroidism medications. A considerable number of patients (57.4%) did neither look for information from online sources nor did they (24.2%) seek additional information from their doctors. More than half of the patients (54.6%) did not avoid cabbage, cauliflower, or soya.

Overall practice scores illustrated that most patients (77.8%) practiced a moderate level of precaution. Furthermore, 80.7% of females followed moderate level of precaution compared with 70.3% of male counterparts (P ≤ 0.0001). There was also a significant association between age groups and moderate level of precaution; both the younger (18–30 years: 81.1%) and the older (>60 years: 81.7%) age groups showed higher percentages for a moderate level of precaution. A significantly higher percentage (84.0%) of postgraduates pursued a moderate level of precaution (P ≤ 0.0001).

[Table 6] describes the detailed practice domain responses, and [Table 7] describes the association between the practice domain and demographic parameters.
Table 6: Details of responses of patients on practice domain (N=500)

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Table 7: Evaluation of association of different levels of practice with gender, age groups, and educational qualifications

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Cronbach's alpha

The overall standardized alpha value for all three domains was 0.714, indicating good homogeneity among all items.

  Discussion Top

This KAP survey has highlighted a low level of knowledge in almost two-thirds (66.6%) of a treatment-experienced hypothyroid population. More than half (55.8%) of the population was composed of graduates or postgraduates. Lack of knowledge about the disease in educated individuals is a disturbing aspect in the management of hypothyroidism. Thyroid disorders are more likely to occur in females;[1],[2] this survey participation had a female dominance. A significantly lower percentage of females had a low level of knowledge compared with males.

KAP of an individual can considerably influence disease perception and management. Hypothyroidism can be adequately treated with a regular daily dose of levothyroxine to normalize serum TSH levels. Concomitant diseases, age, body weight, medication, and diet influence the absorption of levothyroxine. The complete effect of thyroid hormone replacement on TSH is evident only 6–8 weeks after treatment initiation and may require further titrations in the prescribed dose. Once dosage is stabilized, patients require less frequent clinical evaluation and biochemical monitoring (semiannual or annual). Overall management of hypothyroidism requires considerable commitments from the physician and the patient.[16]

The study results show that 64.6% of patients had correct knowledge about the shape of the thyroid gland and that it need not influence their disease management. Poor knowledge about the risks of untreated hypothyroidism may interfere with compliance and optimal treatment. A large percentage of patients (65.6%) were not aware that their cholesterol levels might increase because of hypothyroidism. Levothyroxine therapy will be additionally appreciated if the patients have knowledge about reduction in total cholesterol levels after hypothyroid treatment.[17],[18]

Patients need counseling on dietary modifications, method of taking the medication, and futility of alternate systems of medicines, and interfering concomitant medications. Changes in thyroid hormones that occur during pregnancy and during the postpartum period may resolve; however, in most cases, there is no cure for hypothyroidism. This warrants for a lifelong commitment to hypothyroidism treatment.

Symptoms of hypothyroidism are nonspecific and likely to overlap with other disease conditions. Fatigue is the most common symptom and may be the most misleading. Although 70%–80% of participants had good knowledge about weight gain, fatigue, and muscle aches, 20%–40% of participants had incorrect/no knowledge of other symptoms associated with hypothyroidism. Knowledge of disease symptoms is essential for patients to identify treatment effects, disease progression, and narrate the clinical experience to the treating physician during follow-up visits.

Little knowledge about the importance of the thyroid function test may lead to reluctance in routine laboratory investigation. Given the importance of frequent TSH measurements to monitor and stabilize the dose of thyroid replacement therapy, even the small number of patients (12.6%) who did not take up TSH measurement as requested by the physician (practice domain) stand out as significant outliers. More than half of the patients were unaware of the genetic predisposition associated with hypothyroidism, which may be the reason for almost 25% of patients not being conscious about getting their family members tested for the disease. Similarly, about 21% of patients were less concerned about hypothyroidism in pregnancy probably because they were not aware that hypothyroidism could occur in pregnancy. Complications in pregnancies associated with untreated hypothyroidism are complex and serious, with increased likelihood of maternal morbidity, perinatal morbidity, and mortality.[19] Studies on the absorption of levothyroxine suggest that levothyroxine should be taken between 30 and 60 minutes before eating breakfast.[20],[21] A small (7.40%) but a significant number of patients who did not follow this instruction need counseling. Foods such as cauliflower, cabbage, and soya, release a compound called goitrin when hydrolyzed or broken down.[22],[23]

Several of the gaps identified in the knowledge domain remain true that only 42.6% of patients read for additional information and around 24.2% did not bother to seek additional information from their caregivers. Other consistent finding in this study relates to the levels of KAP and education. As the level of education increased from undergraduation to postgraduation, a significant increase in the level of knowledge was observed. Similar trends were also observed in the level of concern and precautions practiced with increase in education. The younger age group (31–40 years) had a high level of knowledge and practiced a high level of precaution.

Some studies have studied the KAP domains in the thyroid population.[9],[24],[25] The knowledge about excessive weight gain and obesity with hypothyroidism was similar among patients in various studies. Singh et al.[25] mentioned that 79.5% of patients attributed weight gain to hypothyroidism while 81.6% of patients in this study agreed that hypothyroidism causes weight gain.

This KAP survey was conducted as a substudy of a pan-India thyroid registry. The patients were recently diagnosed and were being prescribed thyroxine treatment before enrolment. By enrolling this group of patients, the study provided an opportunity to explore hypothyroidism-related KAP prevailing in the patients who were considered to have equivalent knowledge as that of general community. At the same time, the practices regarding treatment compliance could be explored, which could not have been explored in a general community-based KAP survey. Overall, this study indicates that although patients were better aware of symptoms, they were less aware about the risks associated with hypothyroidism, importance of laboratory investigations, and dietary precautions. Compliance to medication and regular thyroid function testing can be influenced only if patients are aware about the consequences of their disease condition. This aspect can, therefore, be emphasized in patient awareness programs. Almost three-fourths of the patients sought information from health-care professionals rather than the Internet. This emphasizes the need for continuous counseling by physicians and increasing the consultation time to educate patients. A low level of education among patients was associated with lower knowledge, lower concern, and lesser precautions taken for hypothyroidism. Thus, these patients need to receive more tailored inputs from their treating physicians.

The strengths of our study were the large sample size and the use of a validated questionnaire with an acceptable Cronbach's alpha value. Patient education is the most effective way to avoid serious complications of a disease or its therapy. This study has identified the areas that can be addressed by health advocacy groups to improve the KAP of hypothyroid patients. The study findings also call for a robust strategy to target mass awareness at the regional and national levels. We intend to survey the registry population later regarding thyroid-specific management, such as lifelong treatment, TSH levels before pregnancy, and treatment modifications required during pregnancy.


Writing assistance was provided by Sciformix Technologies Pvt. Ltd. Dr. Shalini Nair, Abbott India Ltd, provided additional review and editorial support for this manuscript.

Financial support and sponsorship

The study was funded by Abbott India Limited.

Conflicts of interest

There are no conflicts of interest.

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  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7]


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