J Eg!ypt Ptrblic Henltlt Assoc
Vol.85 No. 3 6 4, 2070
Effectiveness Of Health Education Program For
Type 2 Diabetes Mellitus Patients Attending
Zagazig University Diabetes Clinic, Egypt
Naglaa M. Abdo, Mohamed E. Mohamed
kledicine De~~artriietrt Clit7icul Pat/~ology,
Faculty of Medicine,
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
Dr. Naglaa M. Abdo
Community Medicine Department
Faculty of Medicine, Zagazig University, Egypt
E Mail: nanla firstname.lastname@example.org
Egypt Pilblic Hcnlth Assoc
Vol. 85 N .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.
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
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
There is further evidence that people affected
aclueving this 0bjective.Q)
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
Vol. 85 No. 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 :
Assess knowledge, attitude, random blood sugar and HbA lc levels
in type I1 diabetic patients,
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 l c level in type 2
diabetes patients attending Zagazig University Diabetes Outpatient
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 in 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
Vol. 85 NO. 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 diabetes.
Questions about knowledge and attitude towards different aspects o
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-off point at 50% was used in order to classify knowledge
into adequate or inadequate.
- Attitude of patients towards diet regimen, exercise and the value o
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:
An educational message was prepared to involve items
concerning: 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
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
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.
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 60 minutes.
Data Collection Methods
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
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@)
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 first 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.
Vol. 55 No.3 b 4,2010
The first health education session was repeated throughout
diabetes outpatient clinic working days of the four weeks of January,
wlule tlie s e c o ~ ~ d was conducted only at each Thursday of January
jn order to give a chance for patients to attend the day convenient to
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
b. The post-test questionnaire (the same as pretest) was completed.
Data was coded, entered and analyzed by the SPSS program
version 12, using Mc-Nemar chi square test for analyzing paired
Logistic regression analysis was performed to predict the effect of
different socio-demographic characteristics (gender, social class,
1 Egypt P~rblic
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
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
Median age (years)
+: Literate iriclrrdes highly educated arid middle educated while illiter-ate
ir~cludes educated arrd read and write group.
++: 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;
Val. 85 No.3 6 4,2010
Qypt Priblic Hcnltlr Assoc
symptoms, effect of diabetes on eyes and treatment of diabetes (50%
and more of patients correctly answered relevant questions in the
Table (2): Distribution of Patients' Knowledge about Type 2 Diabetes
Before and After Health Education
l ~ ~ n i ~ .
l ~ f f e con eye
( ~ i a b e t i foot prevention
Treatment of diabetes
@: McNerlzar x 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
P value @
@: McNeillor x lest
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
Characteristics of the Studied Patients and its Effect on
Acquiring adequate Knowledge
Social class (Middle)
1.33 (1.19- 4.71)
Age (Meci'iiarz oge < 50)
3.23 (2.1 1-4.95)
refer /o /lie refer-elice grotip
Table (5): Means of Random Blood Glucose & Glycosylated Hemoglobin
Measurements in the Studied Group Before and After Health
Random blood glucose
and p value
Paircd t= 6.98
Paired t= 4.63
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;
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
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
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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) Omani ones (760/0).(19)
When our participants were asked "what 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) Libyan
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 lower than that reported by Kame1 et al. (2003)
The discrepancy between our results and the others may be
attributed to difference in the tools used for assessing patient's
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
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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.
who found that
This finding is in agreement with Kamel et al. (1999)("Q
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
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
Vol. 85 No.3 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
Kame1et 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 knowledge 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) 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
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VOI. 85 NJ.
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.
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