Effectiveness Health Education Program For Type Diabetes Mellitus Patients Attending Zagazig University Diabetes Clinic, Egypt

Download as pdf or txt
Download as pdf or txt
You are on page 1of 21

J Eg!ypt Ptrblic Henltlt Assoc ​Vol. 85 ​No.

3 6 ​4, 2​ 070

Effectiveness ​Of ​Health Education Program 


For Type ​2 ​Diabetes Mellitus Patients Attending 
Zagazig University Diabetes Clinic, Egypt   
Naglaa M. Abdo, Mohamed ​E. ​Mohamed   
Comnr~iniiy kledicine 
De~~artriietrt and Clit7icul Pat/~ology, Faculty of 
Medicine, Zagczzig Urziver-sigl   

ABSTRACT   
Background:  Diabetes  mellitus  is  a  major  public 
health  problem.  Objectives:  To  i)  assess 
kt~owledge,  attitude,  random  blood  sugar  and 
glycosylated  hemoglobin  (HbAlc)  levels  in  type  2  diabetics,  ​ii) 
investigate  the  effect  of  different  socio​-​demographic  factors  on 
acquiring  knowledge  about  diabetes,  iii)  assess  the  effectiveness  of 
health  education  on  knowledge,  attitude,  blood  sugar  and  HbAlc 
levels  ​in  ​type  ​2  ​diabetics.  Methods:  This  intervention  study  was  carried 
out  on  122  randomly  selected  type  2  diabetics  attending  diabetes 
outpatient  clinic  in  Zagazig  University,  from  January  2009  to  April 
2009.  A  questionnaire  (pretest)  was  used  to  collect  data  on 
socio​-​demographic  characteristics,  knowledge  and  attitude,  then a blood 
sample  was  taken  for  testing  random  blood  sugar  and  HbAlc.  Patients 
were  subjected  to  the  first  health  education  session  where  information 
about  diabetes  was  provided.  In  the  second  visit  patients  were informed 
about  the  results  of  their  investigations,  and  the  remaining  part  of  the 
educational  message  was  delivered.  In  the  3rd  visit,  patients  were 
subjected  to  the  post  test  and  blood  samples  were  tested  for  random 
blood  sugar  and  HbAlc.  Results:  The  majority  of  patients  had 
low  levels  of  knowledge  regarding  different aspects of diabetes (Correct 
answers  ranged  from  16.39%  to  49.18%).  Knowledge  level  was 
significantly  poor,  among  females,  not  educated,  low  social  class,  and 
rural  residence  and  of  older  age  group.  After  implementation  of  the 
educational message, a  significant improvement was revealed ​in ​patients' 
knowledge  and  attitude  with lowering of  their mean levels of blood 
sugar  and  HbA  lc.    Conclusion  and  Recommendations:  Health 
education  was  an  effective  tool  that  implicated  change  in  diabetic 
patients'  knowledge,  attitude  towards  diabetes,  random  blood  sugar  and 
HbAlc levels. Training of   

 
Correspondixlg Author:   
​ . ​Abdo   
Dr. ​Naglaa M
Community Medicine Department   
Faculty o​ f ​Medicine, Zagazig University, Egypt   
E ​Mail: nanla abdo@hotmail.com  
Egypt ​Pilblic Hcnlth Assoc ​Vol. ​ 5 ​No.
8 3 b ​4,2010

health care providers working in outpatient diabetes clinic regarding 


different aspects of type 2 diabetes is highly needed.   

Keywords: ​Attitude, diabetes, education, klzowledge.   

INTRODUCTION   
Diabetes  mellitus  is  a  major  emerging  clinical  and  public  health 
problem  accounting  currently  for  5.2  % ​of  all  deaths  world​-​wide. 
According  to  ​WHO  ​estimates  (2007),  190  million  people  suffer  from 
  diabetes  world​-​wide  and  about  330  million  ones  are 
expected to be diabetic by the year 2025.W   
Egypt  had  been  estimated  to  be  the  9th  country  in  the prevalence of 
diabetes.  Recent  changes  ​in  ​physical  activity  and  dietary  patterns  have 
promoted  the  development  of  diabetes and if different preventive and 
control  activities  are  not  adopted,  by  the  year  2025,  more  than  9  million 
Egyptians  ​(13%  ​of  the  population  above  20  years  old)  will  have 
diabetes.(Z)   

Management of diabetes is dependent to a great extent on the affected 


person's own abilities to carry out self​-​care in his daily lives, and patient 
education is considered an essential component of aclueving this 
0bjective.Q) There is further evidence that people affected 
with the disease often have inadequate knowledge about the nature of   
diabetes, its risk factors and associated complications and that this lack of 
awareness may be the underlying factor. affecting attitudes and practices 
towards its care.(4) Diabetes education, with consequei~t 
improvement in knowledge, attitudes and skills, leads to 
better control of the disease, and is widely accepted to be an integral part 
of comprehensive diabetes care.(s)  

 
I Eyypt ​PtrbIic Henltlt Assoc ​ 5 ​No.
Vol. 8 3 6 ​4,2010

Obtaining  ​information  ​about  ​the  ​level  ​of  ​awareness  ​and  ​attitude 


about  ​diabetes  ​in  ​a  ​population  ​is  ​the  ​first  ​step  ​in  ​formulating  ​prevention 
and  ​education  ​programs  ​for  diabetes.W  ​We  ​conducted  ​this 
study ​to ​:

1. ​Assess ​knowledge, ​attitude, ​random ​blood ​sugar ​and HbA lc 


levels ​in ​type I1 ​diabetic ​patients,   
2. ​Investigate ​the ​effect ​of ​different ​socio​-​demographic ​factors ​on 
acquiring ​knowledge ​about ​diabetes.   
3.  ​Assess  ​the  ​effectiveness  ​of  ​diabetes  ​health  ​education  ​program  ​on 
knowledge,  ​attitude,  ​blood  ​sugar  ​and  HbA  lc  ​level  ​in  ​type  ​2 
diabetes  ​patients  ​attending  ​Zagazig  ​University  ​Diabetes  ​Outpatient 
Clinic.   

SUBJECTS ​AND ​METHODS   

Study design and setting:   


The  current  study  is  ​an  ​interventional  educational  pretest​-​posttest 
study  carried  out  at  the  Zagazig  University  Diabetes  Outpatient  Clinic 
during the period from January 2009 to April 2009.   

Sampling and Sample size:   


The  sample  size  was  calculated  using  Epi  Info  ​6  ​to  be  125  patients 
taking  into  consideration  that  the  diabetes  outpatient  clinic  serves  about 
1300  patients  with  type  2  diabetes  per  month,  statistical  level  of 
significance  at  0.05,  power  BOX,  10%  expected  drop  out  and  the 
expected  improvement  i​ n  ​the  overall  glycemic  control  after  health 
education would be 20x.0   

The  sample  subjects  were  selected  by  systematic  random  sampling 


technique  from  type  2  diabetes  patients  taking  oral  hypoglycemic  drugs 
and attending to the diabetes outpatient clinic. The necessary official  

 
J Egypt P~rblic Health Assoc Vol. ​85 ​NO. 3 6 ​4,2010

permissions  were  obtained  from  the  Dean  of  Zagazig  University 


Hospitals,  the  Head  of  Internal  Medicine  Department  and  the  Director 
of The Outpatient Clinics.   

The study was approved by Ethical Committee of the Faculty of 


Medicine, Zagazig University.   

Data collection tools:   


Data were collected ​by ​a pre​-​constructed and pre​-​tested 
questionnaire that was designed to include the following: ​- ​Personal 
data ​(name, ​age, ​sex, ​address, ​telephone, ​and ​marital   
status), ​socioeconomic ​data ​(occupation, ​education, ​and ​crowding 
index) ​and ​time ​of ​onset ​and ​duration ​of d​ iabetes.   
- ​Questions ​about ​knowledge ​and ​attitude ​towards ​different ​aspects
ok ​diabetes. ​We ​used ​closed ended ​questions ​to ​ask ​about 
knowledge ​regarding; ​symptoms, ​complications, ​treatment ​and 
prevention ​of ​complications. ​Scoring ​of ​the ​knowledge ​questions 
was ​as ​follows: ​a ​correct ​answer ​was ​given ​1 ​and ​the ​incorrect ​one 
was ​given ​zero, ​then ​a ​cut​-o​ ff ​point ​at ​50% ​was ​used ​in ​order ​to 
classify ​knowledge ​into ​adequate ​or ​inadequate.   
- ​Attitude ​of ​patients ​towards ​diet r​ egimen, ​exercise ​and ​the ​value ​of 
follow ​up ​was ​assessed ​by ​using ​open ​ended ​questions. ​The ​answer 
of ​each ​question ​was ​classified ​according ​to ​the ​following; ​positive 
attitude= ​3, ​neutral ​a ttitude=2 ​and ​negative
attitude=l ​.

Health education tools:   


concerning: 
An ​educational message was prepared to involve items ​
symptoms, complications particularly hypoglycemic coma, ​
, ​its 
symptoms and its management, effect of diabetes on eye and foot,  
treatment of diabetes and the importance of adherence to treatment, 
regular exercise and diet regimen, importance of regular follow up and  

 
1 ​Egypt Piiblic Hrrrlth Assoc VOI. $5 ​No. 3 6 
4,1070   

measuring of blood sugar and how to do self measurement. Also 


prevention of diabetes and its co~nplications 
particularly diabetic foot & ​hypoglycemic coma were 
included in the message.   
Prepared printed colored pictured papers about hypoglycemic 
coma, diet plan and importance of exercise were given to the 
participants.   

Follow up Tools:   
A printed follonr up sheet was used. One copy was given to the 
patient and the other was kept with the researcher. It 
includes the results of random blood sugar and the
HbAlc levels at the begirming of the study and at the 
time of the 3rd visit.   

Pilot study:   
A pilot study was conducted to assess the feasibility and the 
time needed to fill the questionnaire and to carry out health 
education. It was conducted on 20 patients who attended 
diabetes outpatient ​clinic. ​They were excluded from the main 
study sample. Data obtained from the pilot study were 
analyzed, and accordingly necessary modifications in the 
questionnaire, health education message and the way of its 
delivery were done. The time needed for filling the sheet was 
about ​10 ​minutes and the time needed for delivery of health 
education message was about 120 minutes. Accordingly, the 
llealth education message was delivered through two 
sessions, each of about 6​ 0 ​minutes.   

Data ​Collection Methods   


1​- ​Interview:   
A ​verbal consent was obtained from the patient after explaining 
the purpose of the study and reassuring him about 
the strict confidentiality of any obtained information, and that 
the study results would be used  

 
 

only for the purpose of research. Then the pre​-​test was filled by 
the researcher.   

2​- ​Investigations:   
A sample of venous blood was withdrawn from anticubital vein 
using 3cc intermedica syringes and stored in tubes containing 
Ethylene Diamine Tetra Acetic acid (EDTA) for measuring the 
I-IbAlc and heparin for random blood sugar. The blood 
samples were coded and sent to the laboratory for the estimation 
of the blood glucose@) and HbA1C.m   

The principle involved in the estimation of glucose is that first 


glucose is oxidized into gluconic acid and hydrogen peroxide. 
The hydrogen peroxide further reacts with phenol and 4​-​amino 
antipyrine by the catalytic action of peroxidase to form a red 
colored quinoamine dye complex from M/s.Crest 
Biosystems, Goa, India. (10)   

3​- ​Health education sessions:   

T&e f​ irst visit:   


Patients were subjected to the first session of health education 
message after taking blood samples from them.   

A spoken message was delivered by the researcher ​in ​the form of 
group discussjon. It included general knowledge 
about diabetes symptoms with stress on symptoms of 
hypoglycen​-​iic coma and how to deal with it. Also the 
importance of adherence to treatment was emphasized. Then the 
patient was given the printed pictured health education papers 
and asked to attend any of the next educational sessions at 
Thursday of each week to be informed about the results of their 
laboratory tests.  

 
C,qypt ​P~rltlic Hcnltlr Assoc Vol. 55 ​No​​ . ​3 b
4,2010   

The ​first ​health ​education ​session ​was ​repeated ​throughout 


diabetes ​outpatient ​clinic ​working d​ ays ​of ​the ​four ​weeks ​of 
January, wlule tlie seco~~d one ​was 
conducted ​only ​at ​each ​Thursday ​of ​January ​jn order ​to ​give ​a 
chance ​for ​patients ​to ​attend ​the ​day ​convenient ​to ​them.   

Tlze secotrd visit   


Patients who attended the 2nd sessions were informed about the 
results of laboratory tests and the time of the next visit ​(3 
months after the first one). Laboratory results and time of next 
visit were also recorded ​in ​their follow up sheet. In the 2nd 
education session patients were reminded rapidly by the 1st 
session contents then they were given information about 
exercise program, diet plan and value of measuring blood 
glucose as well as a demonstration on how to measure it. 
Complications of diabetes took a large sector of this session 
particularly diabetic foot. The message was provided by the 
researcher and took about an hour.   

The third visit   


Each patient was subjected to the following:   
a. ​A ​blood sample was taken for measuring random blood sugar 
and HbAlc.   
b. The post​-​test questionnaire (the same as pretest) was 
completed.   

Statistical analysis   
Data was coded, entered and analyzed by the ​SPSS ​program 
version 12, using Mc​-​Nemar chi square test for analyzing paired 
qualitative data.   

Logistic regression analysis was performed to predict the effect 


of different socio​-​demographic characteristics (gender, social 
class,  

 
1 ​Egypt P~rblic Henltlr Assoc Val. ​85 ​No. ​3 &
4,2010

education, residence, working status and age) on acquiring 


adequate knowledge. Social class was classified according to 
El​-​Sherbini and Fahmy (1983).(11)   

RESULTS   
The highest percentage of the studied group were not working 
(59.02 %), ​residing in rural area (66.39%), females 
(63.11%), illiterate (58.20%) and of middle 
social class (68.03%) Table (1). Their age ranged from 41 to 70 
years with ​a ​median of ​50 ​years (Table 1
​ ).   

Table ​(1): ​Socio​-​demographic ​Characteristics ​of ​the ​Studied 


Type ​2 ​Diabetes ​Patients   
Characteristics ​Frequency ​%
Occupation   
Working ​50 ​40.98   
Not ​working ​72 ​59.02   
Residence   
Urban ​4 1 ​33.61   
Rural ​8 1​ ​66.39   
Gender   
Males ​45 ​36.89   
Females ​77 ​63.1 ​1   
Education ​+
Literate ​5 1​ ​41.80   
illiterate ​7 1​ ​58.20   
Social ​class   
Middle ​83 ​68.03   
Low ​39 ​31.97   
Median ​age ​(years) ​5 ​0   
Range ​(4 1 ​-​---​70)   
Total 122++   
+: ​Literate iriclrrdes ​highly ​educated a​ rid ​middle educated
while illiter-ate   
ir~cludes  not ​educated a​ rrd r​ ead a​ nd ​write g​ roup.   
++: ​3  patients were ​droppedfr-orn the
sanple.   

Table ​(2) ​shows a statistically significant difference between pre 


and post test results in all items of knowledge after the 
implementation of health education program. The improvement 
was marked regarding;  
​ riblic Hcnltlr Assoc
Qypt P Val. ​85 ​No. 3 6 ​4,2010

symptoms,  effect  of  diabetes  on  eyes  and  treatment  of 


diabetes  (50%  and  more  of  patients  correctly  answered  relevant 
questions in the posttest (p<0.01).   
Table (2): Distribution of Patients' Knowledge about Type 2 Diabetes 
Before and After Health Education   
Correct answers Correct answers   
Pre​-​test Post​-​test   
Itenis ​(1 ​22) ​(1 ​22)   
P value@ 
​ o. ​Yo
No. ​Yo N   

Symptoms   
l~~ni~. Hypoglycemia   
l~voidin~ Hypoglycemia   
l~ffect on eye   

l~iabetic foot   
(~iabetic foot prevention   
Treatment of diabetes 60 49.18 79 64.75 P<O.01 @: ​McNerlzar
x​
2
test   

Table ​(3) ​shows the changes ​in ​the attitude of the studied group, 
where a highly significant increase ​in ​the percentages of their 
positive attitude regarding different aspects of diabetes after the 
application of the health education message is noticed.   

Table ​(3): ​Distribution of Patients' Attitude towards Type 2 Diabetes 


Before and After Health Education   

​ -​test Post​-​test ​I​ ​Items


I Pre​ ​(122) (1 22) ​P value @ NO. ​%
NO. ​yo   
Positive attitude   

I @: ​McNeillor x'

lest I  

 

 
Eqllpt Piiblic Henltl~ Assoc   
 

Table ​(4) ​shows that patients who were males, of middle social  class, 
literate,  working,  residing  urban  areas  and  below  50  years  of  age  were 
significantly more likely to acquire adequate knowledge.   

A  significant  reduction  in  the  mean  random  blood  sugar  and 


HbAlc  levels  in  the  studied  group  after  application  of  program  is 
revealed (p<0.01, Table 5).   
Table  ​(4):  ​Logistic  Regression  Analysis  of  Socio​-​demographic 
Characteristics  of  the  Studied  Patients  and  its  Effect  on 
Acquiring adequate Knowledge   

B  

coefficient S
​ E OR(95%CI)   
Gender
1​ (Male) ​0.75 0.30 2.14 (1.8​-​3.88) Social ​class ​(Middle) 0
I​
​ .69 0.21 
2.01 (1.3 1​-​3.07)   
Education (Literule) 1​ .45 0.66 1.47 (1.15​-​5.74) ​Residence
​ .44 0.39 1.24 (1.06​-​5.17) ​Work (​ Working) 0​ .85 0.22 1.33 (1.19​- ​4.71) 
(Urbnrz) 1
Age (Meci'iiarz oge < ​50) 1​ .17 0.21 3.23 (2.1 1​-​4.95) ​Variables 
n~ri//eri be/,11een brocke~s refer /o /lie refer​-​elice g​ rotip 
  
Table  ​(5):  ​Means  of  Random  Blood  Glucose  & ​Glycosylated 
Hemoglobin  Measurements  in  the  Studied  Group  Before  and 
After Health Education   

Before After Statistical testes   


(lS' ​visit) (3rd ​visit) and p ​value   
Random blood glucose
268.61i55.28 224.52241.22 Paircd
t= ​6.98 (mgld ​L) I)< ​0.001   
Glycosylated  13.82kI  .81 12.421.08 Paired
t= ​4.63 ​hernoglobin ​(mmol) p< ​0.01  

 
 

DiSCUSSION   
Health education is a process that bridges .the gap ​between 
health information and health practice. ​An ​important step in 
planning health education intervention is to identify 
predisposing factors like; knowledge, attitude, practice and 
different socio​-​demographic characters of
patients.cl2) Health education is not an addition to treatment, 
but it is one of the treatment tools that has a great effect on 
enhancing the diabetic patients own abilities to carry out 
self​-​care through providing adequate knowledge changing their 
attitude, and empowering them with skills that are essential for 
better control of the disease.(5)   

The current study showed that the majority of the studied 


patients had low levels ​of ​correct knowledge (ranging from 
16.39% to 49.18%) regarding different aspects of diabetes such 
as; symptoms of the disease, symptoms of hypoglycemia and its 
prevention, effect of   
diabetes on the eye and foot and treatment (Table ​2). ​This 
finding is consistent with many Egyptian studies; Bahgat et al. 
(2008) and Kame1 et al. (1999)(13,14) who conducted 
their studies at Zagazig, and Ismalia respectively. 
The similarity between our finding and those Egyptian studies 
might be justified by common share of the cultural background 
of diabetic patients in Egypt despite their geographic variation. 
Only 38.52% of patients had correct knowledge about 
symptoms of diabetes. This result is in agreement with 
Upadhyay et al. (2008) and Perez and Cha
(2007)('5J@ who found nearly similar results among Nepalian 
patients (37.91% ​) ​and Hmong ones (38%).   
Concerning type 2 diabetes complications; ​in ​the current study 
the complications assessed included; hypoglycemia, diabetic 
retinopa thy and diabetic foot disease. Though 
Hypoglycemia is a serious problem with significant morbidity 
and mortality, yet only 20.5% of the studied  

 
1 ​Egypt Ptrblic Hcaltlr Assoc VoJ. ​85 hrs ​3 &
4,2010

patients were aware of the symptoms of hypoglycemia and only 


18.85% of them were aware of how to avoid it (Table 2). 
Tlus result is lower than that reported by many studies; 
among Libyan patients (62.2%),(17) Saudi patients 
(50°h)(18) and Omani ones (760/0).(19)
  
When our participants were asked ​"w ​ hat is meant by diabetic 
foot and ​"​how to avoid it​"​, a minority of them (17.2%, 16.4%) 
correctly indicated its meaning and how to avoid (Table 
2). This finding is lower than that reported among Caribbean 
patient~.(~O) However it is more than that reported 
among Nepalian patients (12.6'/0 and 9.7%).(15) 
  
Despite that our studied patients were more aware about diabetes 
ocular complications (36.89%) than hypoglycemia
(20.5%) and diabetic foot disease (17.21°h), yet their 
knowledge percentages are much lower than that reported 
among Australian patients (78.5%)(*1,22) and 
Libyan ones (73.4%).(17)   
Concerning medications, it should be pointed out that basic 
knowledge about medications and adherence to treatment are 
important aspects in controlling diabetes.(23) Our 
study revealed that nearly half of our participants (49.2%) had 
some knowledge about frequency of intake and the purpose of 
their drugs. Our finding regarding medications knowledge is 
much higher than that reported by Hussein ​1999 (8%)(lV 
but lower than that reported by Kame1 et al. (2003) 
(100%).(24) The discrepancy between our results and 
the others may be attributed to difference in the tools used for 
assessing patient's knowledge.   

The attitude of the studied patients towards different aspects of 


diabetes was low except that for follow up (83.6). These findings 
are lower than those reported by Kame1 et al. (2003) in 
Ismailia(24) and by  

 
1 ​Egypt P
​ iiblic Hcnltli Assoc Vul. ​85 ​No​​ . ​3 6 4,2i)10

Hussein et al. (1999)(25) among diabetics attending Kasr El-Eni 


Outpatient Clinic in Cairo, Egypt.   

On  Studying  the  effect  of  different  socio demographic factors of the 


study  population  on  acquiring  knowledge,  a  significant  difference 
between  males  and  females  regarding  level  of  knowledge  was  noticed; 
females had lower level of knowledge regarding different aspects of   
diabetes  compared  with  males.  This  result  is  expected as males are more 
likely to be better educated and employed outside the home than  females 
which  may  expose  them  more  to  information  than females. This  finding 
was in accordance with Kamel et a1.(1999).(14)   
In addition, our study reported a significant positive relationship between 
the level of knowledge and the educational level, working status and the 
social class; ifiterates and those not working and of low social 
classes were more likely to have lower level of knowledge compared 
with literates, working and those belonging to high class. This finding is 
in agreement with Kamel et al. (1999)("Q who found that 
knowledge related to disease improved with a corresponding 
increase in the level of education and socioeconomic status and with 
working status. Those of a higher educational level and of a better 
socioeconomic standard have a greater probability of obtaining 
knowledge from books ​/
and  other  sources  such  as  mass  media.  They  have  no  barriers  in 
communicating  with  the  health  care  team,  and  they  may  grasp 
knowledge correctly.   

Regarding  residence  and  the  level  of  knowledge,  those  living  ​in ​the 
rural  areas  had  sigruficantly  lower  level  of  knowledge  compared  with 
those  living  in  urban  areas  (Table  ​4).  ​This  finding  is  consistent  with 
Rafique  et  al.  ​(2006)  in  Pakistan.(ls)  It  is  mostly  attributed  to  less 
access to information among rural residents.  

 
Egypt ​Ptcblic Health Assoc ​ 5 ​N​ . ​3
Vol. 8 o​
8 ​4,2010

A significant relationship between level of knowledge and age 


of patients was explored in this study where older patients had 
lower level of knowledge than younger ones. This finding is 
in agreement with Kame1 et al. (1999).(14) Younger 
patients were likely to be more educated and new 
sufferers of diabetes and thus were keen to have more 
knowledge about their disease.   

After the application of our educational message, a significant 


improvement in knowledge and attitude of the 
studied group towards all aspects of diabetes was observed 
(Tables 2&3). This result is in accordance with Atak 
(2005) who found marked statistically significant change in 
the knowledge and attitude of a group of Turkish
patients.(26)   
Moreover, in a meta analysis involving eleven interventional 
studies an improvement ​in k​ nowledge of the intervention 
groups after application of culturally appropriate health 
education was revealed.(27,   

Regarding glycosylated hemoglobin (HbAlc) and random 


blood sugar, a statistically significant improvement 
was found in their mean levels after application of our 
educational message. This result reflects that the changes that 
occurred in the studied patients concerning their knowledge 
and attitude towards diabetes were effective in changing 
patients' behavior regarding diabetes into a more healthy one 
(Table 5). This finding is similar to that found by
others.(2*.29) On the other hand, Duke et al. (2009) in their 
systematic review found that patients' knowledge and attitude 
changes were not enough to imply significant effect in their 
glycemic control.(30) The apparent discrepancy 
between these findings may be related to methodological 
differences. In the systematic review, out of the 9 studies 
included in the review, only 2 investigated the effect of group 
education on glycemic control as compared to individual 
education. They concluded that there was ​an ​equal impact on 
HbAlc at 12 to 18 months and hence recommended  

 
J ​Egiipf Plrblic Health ​Assoc ​VOI. 85 ​NJ. 3 8 
4,2010

carrying out further studies to delineate these findings. None of 


the studies ​in ​this review compared group care to usual care.   

CONCLUSION ​AND ​RECOMMENDATIONS   


The knowledge level of the studied diabetic patients was poor, 
particularly among females, illiterates, low social class, rural 
residents and those older than ​50 ​years. Their attitude towards 
different aspects of diabetes was unfavorable. The applied 
health education message was an effective tool that implicated a 
significant change in patients' knowledge and attitude towards 
different aspects of diabetes. Moreover, random blood sugar 
and glycosylated hemoglobin levels significantly declined 
reflecting the effectiveness of the health education message ​in 
changing the studied patient's behaviors.   

The results of this study send a strong message to diabetes 


health care providers and educators for the actual need for 
developing education and prevention programs about diabetes 
targeting type ​2 ​diabetes patients at outpatient clinics. Training 
and empowering providers working in diabetes clinic with 
skills for delivering adequate health education message tailored 
to knowledge needs of type ​2 ​diabetic patients is highly needed.   

REFERENCES   
​ illiams ​K,
1. ​Lorenzo ​C ​, W ​ J, ​Haffner ​SM. ​The National 
Hunt K
Cl~olesterol Education Program​-​Adult Treatment Panel 
111, ​International Diabetes Federation, and World Health 
Organization Definitions of the Metabolic Syndrome as Predictors of 
Incident Cardiovascular Disease and Diabetes. International Diabetes 
Federation (IDF) ​(2007). ​[cited ​2010 ​June 31 ​Available from:
http:/
/care.diabetesiour~1als.or~/content/30/1/8.fu​ll  
 
Egypt ​Pllblic Henltlr Assoc Vol. ​85 ​NO. 3 8 ​4,2010

The World Diabetes Market Report (2009). ​An ​Analysis of Diabetes 


Drug and Insulin Market from 2007​-​2025. [cited 2010 June 31. 
Available from: http: ​/ /
www.bharatbook.com/upload/ ​World​-​Diabetes​-​Drug​-​Insuline​ ​Market​.   
Tan AS, Yong LS, Wan S, Wong ML. Patient education in ​the 
management of diabetes mellitus. Singapore Medical Journal. 1997 
Apr; ,38(4):156-60. Sivagnanam ​G, 
Namasivayarn ​K, Rajasekamn ​M, 
Thirumalaikolundusubramanian 
P, Ravindranath C. ​A ​comparative study of the 
knowledge, beliefs and practices of diabetic patients cared for at a 
teaching hospital (free service) and those cared for by private 
​ A
practitioners (paid service). Ann ​N Y ​ cad Sci. 2002
Apr;958:416-9.   
Nicolucci A, Ciccarone ​E, ​Consoli A, Di Martino G, ​La 
Penna G, Latorre A, et al. Relationship between patient 
practice-oriented knowledge and metabolic control in intensively 
treated type ​1 ​diabetic patients: Results of the validation of the 
Knowledge and Practices Diabetes Questionnaire. Diabetes 
Nutr.Metab. 2000 Oct;13(5):276-83.   
Mohan D, Raj ​D, Shanthiram CS. Awareness and 
knowledge of diabetes ​in Cheruiai-The Chennai urban 
rural epidemiology study. J ​Assoc Physicians India. 2005; 
53: 283​-​5.   
Bruce ​JX, Davis WA, Culle CA, Davis TM. ​Diabetes 
education and knowledge ​in ​patients with type 2 diabetes from the 
community: the Fremantle Diabetes Study. Journal of Diabetes and 
Complications. 2003; 17 (2): 82-9.   
Srikanth ​M, Rao ​GV, ​Rao KRSS. Modified assay 
procedure for the estimation of serum glucose using microwell 
reader. Indian J​ ​Clin Biochem. 2004;19(1):34-5.   
Thai ​AC, ​Ng ​WY, ​Lui ​KF, ​Cheah JS. Rapid desktop method for the 
measurement of glycated haemoglobin HbAlc. 
Singapore Med.J. 1993
Dec;34(6):493-5.   

Trinder P. Determination of glucose in blood using glucose 


oxidase with an alternative oxygen receptor. Ann
Clin Biochem. 1969; ​6: ​24-7.  

 
J Egllyt Piiblic Hcnlth Assoc Vol. 85 ​No​ .​ ​3 b ​4,2010

11. Fahmy SI, El-Sherbini AF. Determining simple parameters 


for social classifications for health research. Bd High 
Inst Pub1 Health 1983;13(5):95-108.   
12. Nutbeam D. Health literacy as a public health goal: a challenge for 
contemporary health education and communication strategies 
into the 21st ​ ealth Promotion International. 
centuly ​. H
2000; 15(3): 259 -​67.   
13. Bahgat SM. Assessment of the biopsychosocial model of 
consultation versus the hospital model on the outcome 
of type ​I1 ​diabetic patients i​ n ​Zagazig diabetic outpatient clinic​-​A 
randomized controlIed clinical trial [Thesis]. Zagazig, 
Egypt: Zagazig University, 2008.   
14. Kame1 NM, Badawy ​YA, ​el Zeiny ​NA, ​Merdan ​IA. 
Sociodemographic determinants of management behaviour of 
diabetic patients. Part I​ . ​Behaviour of patients in relation to management of 
their disease. East Mediterr Health J. ​1999
Sep;5(5):967-73.   
15. Upadhyay DK, Palaian S, Shankar PR, Mishra
P. ​Knowledge, attitude and practice about diabetes among 
diabetes patients in Western Nepal. Rawal Med ​J. 
2008;33(1):8-11.   
16. Perez1 ​MA, Cha ​K. ​Diabetes knowledge, beliefs, and 
treatments in the hrnong population: ​an ​exploratory study. 
Hmong Studies Journal. 2007; 8: ​1​-​21. 17. ​Roaeid ​RB,
Kablan ​AA. ​Profile of diabetes health care at Benghazi Diabetes  
Centre, Libyan Arab Jamahiriya. EMHJ. ​2007 ​Jan​-​Feb; l3(1): 168-76. 
  
18. Rafique ​G, ​Azam SI, White ​F. ​Diabetes knowledge, beliefs and 
practices among people with diabetes attending a university hospital ​in 
Karachi, Pakistan. EMHJ ​. ​2006; 12 (5):590-8.   
19. Baomer AA, Elbushra HE. Profile of diabetic Omani pilgrims to 
Mecca. East African Medical Journal. 1998; 75(4): 2114.   
20. Gulliford MC, Mahabir ​D. ​Diabetic foot disease and foot 
care in a Caribbean community. Diabetes Research and Clinical 
Practice. 2002; 56 (1):3540.  

 
I Egypt ​Pt~blic ffenlfl~ ​Assoc Vol. 8.5 ​KO. 3 6 
4,201 0   

21. Tapp RJ. Diabetes care ​in ​an Australi'm population: frequency of 
screening examinations for eye and foot complications of 
diabetes. Diabetes Care. 2004; 27(3):688-93.   
22. Gregg EW. Use of diabetes preventive care and complications risk in 
two African​-​American communities. Am ​J ​Prev Med. 2001; 
21(3):197-202. 23. Shama ME. Study of pattern of 
compliance behaviour of diabetic patients attending diabetic health 
insurance clinics in Alexandria [Thesis] Alexandria, Egypt: University 
of Alexandria, 1997.   
24. Kame1 MH, Ismail MA,El Deib A, H~attab MS. Predictors 
of self care behavior ​in ​adults with type 2 
diabetes mellitus ​in ​Abu Khalifa Village Ismalia ​-​Egypt. 
Suez Canal Univ Med ​J ​. ​2003; 6 (2) :185-95.   
25. Hussein DM. Knowledge attitude and practice of diabetics 
attending Kasr El Au~i outpatient clinic related to disease 
management. Cairo, Egypt: Cairo University; 1999.   
26. Atak ​N. ​A pilot project to develop and assess a health education 
programme for type 2 diabetes mellitus patients. Health Education 
Journal. 2005; 64(4): 339-46.   
27. Hawthorne K, Robles ​ annings​-​John R, 
Y, C
Edwards​-​Adrian ​GK. ​Culturally appropriate health education for type 2 
diabetes mellitus ​in ​ethnic minority groups. Cochrane Database of 
Systematic Reviews, 2008, ​ rt. ​No.:
issue ​3. A
CD006424.   
28. Funnel1 MM, Tang TS. From DSME to DSMS: Developing 
empowerment based diabetes self​-​management support. 
Diabetes Spect. 2007; 20:2214.   
29. ​Steven ​J, Stanton ​P, Newman, Cooke D, Steed E, 
Nunn A, et al. A randomized control trial of continuous 
glucose monitoring devices on HbAlc -​ ​The MITRE Study. 67th 
Scientific American Diabetes Association Meeting, 2007.   
30. Duke SA, Colagiuri S, Colagiuri R. Individual patient education for 
people with type 2 diabetes mellitus. Cochrane Database Systematic 
Iievews. 2009; Jan 21; (1): CD00526.  

You might also like