South Sudan is one of the world’s youngest nations

South Sudan is one of the world’s youngest nations. The population has been affected by several health issues and extreme poverty. Diabetes mellitus is currently leading to substantial clinical and economical consequences in the country. Akway et al. indicated that prevalence of diabetes mellitus in South Sudan was 11.8%1. The disease steadily increase across the country and the limitation of resources, ongoing civil war and inexperience diabetes care personnel embrangle the management and control of the disease1, 2. Several studies revealed that education and providing knowledge for diabetes patients has an extraordinary effects on management of disease and improving the quality of life3-5. International organizations such as world health organization, international diabetes federation and american diabetes association regularly published guidelines worldwide for prevention and management of diabetes. The guidelines provide medical practice directed towards health professionals and patients to improve the management of disease6-8.The adherence of clinicians and patients to guidelines may shows positive effects on patients outcomes such as hospitalization, travel to health facilities, complications and HbA1C values9-11. Type 2 diabetes associated with micro and macro vascular complications that may cause death or disability. Therefore, patients require routine clinical follow-up to delay or prevent complications. The WHO report that complications of diabetes exert a tremendous economic burden on patients, families, health system and the society as a whole12. Studies recognized that education on T2D forms an integral element of the diabetic care13. As a complex disease, it involve the patients to make various lifetime choices including lifestyle modifications, dietary changes, blood glucose control as well as medications and exercises14. Hence adequate knowledge about the disease is essential to improved management15. South Sudan one of the countries have not developed their own national guidelines for management and prevention of diabetes. Recently their established division of non-communicable diseases but has limited capacity and is lacking formulation of a strategy to deal with prevention and treatment of diseases. Several studies highlighted that good knowledge and adherence to guidelines has a significant consequences in controlling the disease4, 16. Therefore, the objectives of this study were to assess the level of knowledge, adherence to recognized guidelines for management of type 2 diabetes and to detect the attributes associated factors. South Sudan is a country without official national guidelines. Guidelines allow patients to consider their personal needs and priority in selecting best option and to make more informed healthcare choices. Adherence to the recognized guidelines and recommendations is crucial to reduce risks of diabetes complications and death. Guidelines also have a greatest potential benefits to improve health outcome and consistency of care28. Several studies revealed certain factors incompatibly associated with poor adherence to the guidelines, they include age, long duration of diabetes29, 30. In this study, 28%, 27%, 46.6%, 10.2% and 20.5% of the patients had at least one HbA1c test, lipid profile, retinal, renal and dental check-up respectively, and similarly 22.9%, 17%, 9.2% and 14.1% for Sudanese diabetic patients in 201531. Guidelines recommended that HbA1c test which is required 2-4 times a year. This study found strong inverse association between knowledge score and HbA1C value was lower with each one-unit increase in knowledge score among participants. Studies from China and Maryland also underlined this association32, 33. Frank A. et al.34 Showed that 53% of diabetes patients had a yearly eye exam compared to our findings 46.6%. in 2015,Chen Y. Et al. showed 59.5% of diabetic patients had at least one lipid profile compared to 27%35. Among respondents, 15% were active smokers, only 1.7% of patients engaged in minimum of 150 minutes exercises per week as recommended by the American diabetic society8. This might be due to South Sudanese cultures of being less likely to incorporate daily exercises in their routines. This study found that patients who vigorous activity had normal HbA1C levels compared to patients who undertook no physical activity, BoulĂ© et al. indicates the similarities36. Physical activity have a greatest effect in minimizing diabetes complications such as dyslipidemia and hypertension and reducing weight in diabetic person. With regard to dietary, almost 50% of respondents were habitual not following diet recommendations. Also, the finding of a statistically significant association between HbA1C level and diet for type 2 diabetes appears logical. People who were always following diet recommendations are likely to have lower HbA1C level, which may boost diabetes management. The high cost of and low availability of food and medicines in South Sudan is always linked to poor management and may associate with more clinic visit. Economic factors affected the affordability of ant-diabetic medication and accesses to recommended food37. These findings may serve as an indication of the priority of education to patients and communities as most health promotion interventions. Understanding the situation of the disease and comply with management plays a significant part in living with disease and delay or prevent the complications. One of the objectives of this survey was to identify the knowledge gap among survey participants. Fifty-eight percent of participants had poor knowledge about all aspects of disease and its complications. This due to several factors i.e. literacy or lower education, the study found that patients having lower education had significantly low knowledge scores about diabetes. The findings in knowledge gaps are in contrast with Kiberenge, et al., which reported very low levels of knowledge (27%) in Kenya20. In Ethiopia, Kassahun et al., found significantly low knowledge level, poor self-care behaviours and poor adherence to medication among patients with diabetes21. Similarly, in the United Arab Emirates, Al-Maskari et al. In a cross-sectional study reported significantly low levels of knowledge among diabetic patient22. This study discovered a highest knowledge score in participants at middle ages and higher educational background. The association were statistically significantly (P;0.05)and similarities are found in other studies23-26. It is important to note that most of these findings are based on cross sectional studies that usually do not conduct any intervention to measure participant’s knowledge over time. One important component of diabetes control is the ability to monitor and maintain a stable glucose level. Heisler et al