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  1. 1. 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 Comnr~iniiy kledicine De~~artriietrt Clit7icul Pat/~ology, and 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: Dr. Naglaa M. Abdo Community Medicine Department Faculty of Medicine, Zagazig University, Egypt E Mail: nanla abdo@hotmail.com
  2. 2. Egypt Pilblic Hcnlth Assoc Vol. 85 N .3 b 4,2010 o 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 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)
  3. 3. I Eyypt PtrbIic Henltlt Assoc Vol. 85 No. 6 4,2010 3 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 l c 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 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
  4. 4. J Egypt P~rblic Health Assoc Vol. 85 NO. 6 4,2010 3 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 k 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 f 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
  5. 5. 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 60 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
  6. 6. 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 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.
  7. 7. 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 days of the four weeks of January, wlule tlie s e c o ~ ~ d was conducted only at each Thursday of January one 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,
  8. 8. 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 Occupation Working Not working Residence Urban Rural Gender Males Females Education + Literate illiterate Social class Middle Low Median age (years) Range Total Frequency % 50 72 40.98 59.02 41 81 33.61 66.39 45 77 36.89 63.1 1 51 71 41.80 58.20 83 39 68.03 31.97 50 (4 1----70) 122++ +: Literate iriclrrdes highly educated arid middle educated while illiter-ate ir~cludes educated arrd read and write group. not ++: 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;
  9. 9. 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 posttest (p<0.01). Table (2): Distribution of Patients' Knowledge about Type 2 Diabetes Before and After Health Education Correct answers Pre-test (1 22) Itenis Correct answers Post-test (1 22) No. Yo No. Y o P value@ 60 49.18 79 64.75 P<O.01 Symptoms l ~ ~ n i ~ . Hypoglycemia l~voidin~ Hypoglycemia l ~ f f e con eye t l~iabetic foot ( ~ i a b e t i foot prevention c Treatment of diabetes 2 @: 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 I Pre-test (122) Items NO. I Post-test (1 22) % NO. P value @ yo Positive attitude I @: McNeillor x lest ' I
  10. 10. 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 Bcoefficient SE OR(95%CI) 0.75 0.30 2.14 (1.8-3.88) Social class (Middle) 0.69 0.21 2.01 (1.31-3.07) Education (Literule) 1.45 0.66 1.47 (1.15-5.74) Residence (Urbnrz) 1.44 0.39 1.24 (1.06-5.17) Work (Working) 0.85 0.22 1.33 (1.19- 4.71) Age (Meci'iiarz oge < 50) 1.17 0.21 3.23 (2.1 1-4.95) 1 Gender (Male) I Variables n~ri//eri be/,11een brocke~s refer /o /lie refer-elice grotip Table (5): Means of Random Blood Glucose & Glycosylated Hemoglobin Measurements in the Studied Group Before and After Health Education Before (lS' visit) Random blood glucose (mgld L) Glycosylated hernoglobin (mmol) (3rd visit) After Statistical testes and p value 268.61i55.28 224.52241.22 Paircd t= 6.98 I)< 0.001 13.82kI .81 12.421.08 Paired t= 4.63 p< 0.01
  11. 11. 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
  12. 12. 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) Omani ones (760/0).(19) and 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 and 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 lower than that reported by Kame1 et al. (2003) but (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
  13. 13. 1 Egypt Piiblic 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. 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 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.
  14. 14. 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). On 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
  15. 15. 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 1. Lorenzo C , Williams K, Hunt KJ, Haffner SM. The National 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.full
  16. 16. Egypt Pllblic Henltlr Assoc Vol. 85 NO. 8 4,2010 3 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-InsulineMarket. 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. SivagnanamG, Namasivayarn K, Rajasekamn M, ThirumalaikolundusubramanianP, 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 practitioners (paid service). Ann N Y Acad 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 J , X 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.
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  18. 18. I Egypt Pt~blicffenlfl~ Assoc Vol. 85 KO. 6 4,201 0 . 3 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~attabMS. Predictors of self care behavior in adults with type 2 diabetes mellitus in Abu Khalifa VillageIsmalia -Egypt. Suez Canal Univ Med J . 2003; 6 (2) :185-95. 25. Hussein DM. Knowledge attitude and practice of diabetics attending Kasr El A u ~ 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 Y, Cannings-John R, Edwards-Adrian GK. Culturally appropriate health education for type 2 diabetes mellitus in ethnic minority groups. Cochrane Database of Systematic Reviews, 2008, issue 3. Art. No.: 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.