S ib e l K a l a ç a , P h . D . * / Ç a ğ r ı K a l a ç a , M . D . * * / E s in K a y a * * * B ü l e n t K ı l ı f * * * / İ b r a h i m S a r ı * * * / E m in M a d e n * * * / M . Z a f e r D i r i k * * * * D e p a r t m e n t o f P u b l i c H e a l t h , S c h o o l o f M e d i c i n e , M a r m a r a U n i v e r s i t y , I s t a n b u l , T u r k e y . ** D e p a r t m e n t o f F a m i l y M e d i c i n e , S c h o o l o f M e d i c i n e , M a r m a r a U n i v e r s i t y , I s t a n b u l , T u r k e y . * * * I n t e r n D o c t o r , S c h o o l o f M e d i c i n e , M a r m a r a U n i v e r s i t y , I s t a n b u l , T u r k e y . A B S T R A C T
O b je c tiv e : The aim of this descriptive study is to evaluate the knowledge of diabetic and non diabetic patients of "diabetes mellitus".
M e th o d s : E ighty-one d ia b e tic and 89 no n diabetic patients who attended different clinics at Marmara University Hospital were included in the study. A q u e stio n n a ire w as used fo r the evaluation.
R e s u lts : The mean knowledge score was 78.0 in diabetic patients and 63.0 in the other group; the difference between the scores was statistically significant. There was no statistically significant difference between knowledge and age, sex, m arital status, o ccupatio n in both groups. However a statistically significant association w as found betw een know ledg e and the educational level in the non-diabetic group. 16% of the diabetic patients reported that they had attended a structured educational session or course about diabetes mellitus (DM) in the past. The two main sources of knowledge of the diabetic patients were their physicians and the media, while friends were the main source for the group. There was no association between the knowledge score and duration of the disease in the diabetic group.
C o n c lu s io n : The results of this study may in d ica te th a t health care p ro vid e r-p a tie n t in te ra ctio n is one of the m ost im portant opportunities for patients to obtain knowledge concerning their illness.
K e y W o r d s : P a tie n t ed u ca tio n , p a tient em powerm ent, autonom y, diabetes mellitus.
IN T R O D U C T IO N
D iabetes m ellitus is a chronic disease. The disease is considered an im portant public health problem since it causes early m ortality and high m orbidity as well as a high cost to the com m unity (1-3). E ducating the p a tie n t on d iabete s is intended to enable patients to make inform ed decisions about their own diabetes care and to be fully responsible m em bers of the health-care system (4). This approach is an integrated model for health education and prom otion, fulfilling the patient's ethical right of autonom y. Supporting patients in m ananging their life with the reality of diabetes is as im portant as the treatm ent of the disease (5).
Patient training program s in the following areas are vital fo r sh o rt - and long - term goal
What do our patients know about DM?
achievem ent: pathophysiology of DM and the prevention of com plications, therapeutic options for optim um control and lifestyle flexibility, diet in stru ctio n /tra in in g , exercise integration, foot care, and sick day and m inor illness managem ent. Patients must be well versed in the integration of these principles into their daily lives (3).
In this descriptive study, we aimed at evaluating the knowledge of diabetic patients who attended different outpatient clinics at Marmara University Hospital in April 1999. For comparison, the level of knowledge about DM in another patient group -nondiabetics- w ho attended the same clinics was also evaluated.
M A T E R IA L S A N D M E T H O D S S tu d y g ro u p s :
Diabetic and non-diabetic patients were not matched according to any specific variable but som e inclusion criteria were used in the selection of the patients.
I n c lu s io n c r ite r ia f o r d ia b e t ic p a t ie n t s : • must be a Type II Diabetic patient • must be 19 years old or above
• must have been a diabetic patient for at least one year
• must not be a health personnel
I n c lu s io n c r ite r ia f o r n o n - d ia b e t ic p a t ie n t s : • must be 19 years old or above
• must not have anybody working in the health sector am ong the members of the household • must non be a health personnel
Data c o lle c tio n :
Both groups of patients were viewed face to face using a questionnaire w hile they were waiting for their turn or just after completion of their visits. Patients' perm ission was asked for participation in the study. Their questions about DM were answered at the end of the test.
The questionnaire consisted of 20 questions, which focused on 3 topics:
i. general knowledge of DM (i.e. mechanism of the disease, types of the disease etc.),
ii. life style in DM,
iii. the com plications of DM.
Each question was scored as 5 points, total score 100.
S ta tis tic a l a n a ly s is :
"SPSS for W indows" program was used for data analysis. S ignificance was assessed by Student's t test, chi-square and One-W ay Anova tests. A p value < 0.05 was considered statistically significant.
RESULTS
D e s c rip tiv e F in d in g s :
The two p a tient groups w ere com pared according to th e ir sociodem ographic characteristics and no differences were found in the distribution of sex and educational level (Table I). The level of education was higher in both diabetic and non-diabetic groups compared to the general level of education in Turkey. According to the results of Turkish Demographic and Health Survey-1998 (6), only 19% of the men and 12% of the wom en have completed secondary school or higher. In our study 37% of all the patients were high school graduates. Almost one fifth of the study group consisted of university graduates. This finding may reflect the sociodem ographic characteristics of the patients of the Marmara University Hospital.
The mean ages for the diabetic patients and non diabetic patients were 56.0 (SD= 12.7) and 47.7 (SD= 14.8) respectively; and the difference was sta tistica lly sig n ifica n t (p<0.05) (Table I). Statistically significant differences were found also concerning the m arital status and occupations of the patient groups (p<0.05). A majority of the diabetic patients were married. The proportion of governm ent employees in the diabetic patient group was higher, while private em ployees were higher in the other patient group (Table I).
A lm ost half of the patients in both groups reported that they read a daily newspaper. 86.4% of the diabetic patients and 49.4% of the other patients reported that they had not had any kind of inform ation about DM. While their physicians and the m edia w ere the main sources of knowledge for the diabetic patients (57.1% and 35.7%, respectively), friends and media were the main sources of knowledge (45.5% and 50.0% respectively) for the other patient group. As expected there was a significant difference for the source of knowledge between the two groups (x2= 39.7 df=2, p<0.05).
Table I. Sociodemographic Characteristics in Patient Groups (İstanbul, 1999)
D iab e tic P atie n ts Other P atie n ts
(n = 8 1) (n= 89) Sex N % n % Male 40 49,5 34 38,3 Female 41 50,5 55 61,7 x2= 2,15 df= 1 p= 0,16 Age Groups N % n % 34 and below 3 3,7 20 22,5 35-44 7 8,6 15 16,8 45-54 30 37,0 23 25,8 55-69 27 33,3 25 28,1 70 and above 14 17,3 6 6,7 x2= 19,3 d f= 4 Q. II o’ o O M arital status N % n % Married 65 80,2 57 64,0 Single 3 3,7 17 19,1 Widow 13 16,0 15 16,9 x2= 10.11 df=2 p= 0,006 Educatio nal N % n % Status Literate 2 2,5 3 3,4 Primary School 21 25,9 14 15,7 Secondary School 11 13.6 20 22,5 High School 31 38,3 32 36,0 University 16 19,8 20 22,5 x2= 4,3 df= 4 p= 0,36
Diabetic patients w ere also asked w hether they had participated in any structured educational session or course on DM; 16% of them (13 patients) had. They stated they had all received the education from d iffe re n t hospital-ba sed- courses. There was not any significant difference in the sociodem ographic characteristics of these 13 patients com pared to the other diabetic patients in the study group.
Level o f K n o w le d g e :
The questionnaire consisted of 20 questions and the maximum score was 100. The mean score was 78.0 in the diabetic patient group and 63.0 in the other group. The difference was statistically significant (p<0.05) (Table II). 25% of the patients in the diabetic group had a score of 70 or below,
Table II. Mean Knowledge Scores of the Patient Groups (İstanbul, 1999)
Patient Groups N M ean Score Sd
Diabetic patients 81 78,0 16,0
Other patients 89 63,0 14,7
t= 3.89 df= 168 p<0,05
25% had a score of 90 or above (median score= 80). In the other grop 25% of the patients had a score of 50 or below, 25% of them had 75 or above (median score= 65) (Fig. 1).
K now ledg e of d ia b e te s w as investigate d according to different characteristics in both groups and no difference was found in age, sex, marital status and occupation.
In the non-diabetic group a statistically significant difference was found between knowledge and educational level. In univariate analysis, the m ean know ledg e sco re in cre a se d fo r n o n d ia b e tic p a tie n ts as th e e d u ca tio n a l level increased (Table III, Fig. 2). This association was detected between the secondary and high school as well as between secondary school and higher education. A sim ilar association did not arise in the diabetic patient group. In the diabetic patient group, attending structured DM education did not affect the mean know ledge scores.
The association between knowledge scores and reading a daily new spaper was investigated in both groups. The mean score of patients who read a daily new spaper was higher than that patients of who did not. This finding was valid both for diabetic and non-diabetic patient groups (Table IV).
T a b l e I I I . Association Between the Mean Knowledge Scores and Educational Status in the Non-Diabetic Group (İstanbul, 1999)
Edu catio n al statu s n M ean S co re Sd
Uneducated 3 55,0 0,0
Primary School 14 58.2 15,0
Secondary School 20 54,7 14,7
High School 32 68,7 15,9
Higher Education 20 69,7 14,4
(One Way Anova test) Li-II CMCM p<0.05
T a b l e I V . A s s o cia tio n B e tw e e n R ead in g a N e w sp a p e r and K n ow ledge S cores (Istanbul, 199)
R e ad in g a N ew sp ap er Not R e ad in g a N ew sp aper
Patient Groups N Mean Sd n Mean Sd
Diabetic P. 41 82,0 11,9 40 75,1 16,6
Non-diabetic P. 48 68.9 15,4 41 57,5 14,6 t - 2,16 df= 79 p<0,05 t= 3,55 df= 87 p<0,05
What do our patients know about DM?
Total Knowledge Score
F ig . 1 Knowl edge Scores In Two Patient Groups (İstanbul. 1999)
Total Knowledge
Score
120' 100 -N =Uneducated Primary S Secondary S High S. Higher
Educational Status
F ig .2 . : Association Between Total Knowledge Score and Educational Status in the Non-Diabetic Group (istanbul, 1999)There was no significant difference between kn ow ledg e scores and the duration of the disease in the diabetic patient group.
Some of the selected questions and the mean knowledge scores of two patient groups are shown in Table V. Diabetic patients had higher
scores in "the duration" and "type" of disease, "where blood sugar level can be measured", "im portance of foot care" and "later recovery of wounds". For other questions, any significant d ifference betw een p a tient groups was not detected. Som e question s w ere answered correctly by most of the patients in both groups.
Table V. Knowledge Scores in Selected Questions (Istanbul, 1999)
Diabetic Patients Other Patients P**
Questions (n=81) (n=89)
Mean Score* Mean Score*
DM is a life long familial disease 4.5 3,7 <0,05
There Is only one type of DM 3,1 2.1 <0,05
DM occurs in persons eating too much sugar 4,1 3.5 >0,05
DM cannot be cured 3,8 3,7 >0.05
DM is transmitted via blood 3.9 3.9 >0.05
Blood sugar level can only be measured in a hospital 4.1 2,3 <0,05
DM patients should pay attention to their toot care 4,2 3,5 <0,05
Wounds recover later in DM patients 4.7 3,5 <0,05
DM may cause cancer in the long term 2,8 2,9 >0,05
Having any other disease does not have any effect on DM 4,0 3.4 >0,05
' Maximum score for each question is 5 points. ** Calculated by Student’s t test
For instance patients in both groups had higher scores on the question w h e th e r "DM is transm itted via blood” or not. However, there was lack of knowledge in both groups in some topics such as the "relationship between cancer and DM". Also it is interesting to observe that many DM patients thought that "DM occurs in persons eating too much sugar" and there was not any significant difference between patient groups. These fin d in g s raise q u e stio n s about the knowledge levels of DM patients concerning the basics of their disease.
D IS C U S S IO N
In our study, d ia b e tic pa tie n ts had higher knowledge scores as expected. Some studies showed that knowledge scores increased as the years of formal education increased (7). Also in our study, the know ledg e level differs sig n ifica n tly am ong groups of d iffe re n t educational levels in the non-diabetic group. However, the know ledg e level of d ia b e tic patients was not changed by the educational level. This difference between the two studies may be caused by different tests assessing different levels of knowledge.
This finding may indicate that within the period of "being a diabetic patient", patients learn the basic facts about their disease. However, the "learning period" and "the content" are questionable: How are they learning? W hom are they learning from?
W hat are they learning: evidence-based facts, or anacdotes, or even rum ors?
The findings of this study inticate that provider- patient interaction is a very effective source and opportunity for patient education. Education and counseling during DM m onitoring is the primary responsibility of the physician and it should be structured according to the personal needs of every single patient (5).
We found that only one of six patients had had any structured educational session or course about diabetes m ellitus in the patient group. However, there is no inform ation about the contents and the quality of educational methods of these sessions. Keeping this fact in mind and rem em bering the basic level of our test, it is not suprising to see that there is no difference in knowledge scores between the DM patient who had structured etucation and the patient who had none.
A n o th e r im p o rta n t fin d in g related to this insufficiency is the fact that know ledge level does not change according to the duration of disease in the diabetic patient group. Patients probably learn most about their disease in the beginning phase of their clinical course. This finding may also in d ica te th a t th e ir kn o w le d g e is not refreshed over time.
In general, it may be expected that suffering from a chronic disease could provide patients with
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What do our patients know about DM?
many opportunities for improving their knowledge and experience: if the patient has a chronic diesase, medical care should be continuous, frequent use of related health services is needed, p h y s ic ia n -p a tie n t in te ra ctio n is closer, and patients have more chance to meet each other and share experiences. The finding of this study indicate that, such opportunities may be critical, but insufficent. S tructured patient education program s are also necessary in order to improve the knowledge level of the patients which should be one of the basic objectives of DM m anagem ent porgrams.
It has been show n that structured patient e ducatio n p rovides the patients with better know ledg e, as w ell as im proved m etabolic control param eters. Patient education should be a va ila b le fo r all patients not only at a physician's office, but also in the community through patient groups (7, 8). Diabetes education and self-care classes for patients and family m em bers provide necessary inform ation and skills otherw ise not available in a busy clinician's office (2). Patient groups are very im portant for the education and counseling of DM, by which patients share their point of views, values a b o u t health and illness, exchange experiences, and learn many from each other. Standards for diabetes education have been established by the diabetes com m unity in the United States. In the United States The National Diabetes Education Program (NDEP) plans to develop a partnership of public and private o rg a n iza tio n s and im plem ent educational activité s to help reduce the m orbidity and m ortality a sso cia te d w ith diabetes and its com plications (9).
This study d e m o n stra te s the gap in the educational needs of DM patients. However, this requirem ent should be elaborated by detailed valid tests in order develop community-based,
culturally-oriented, multi-disciplinary, acceptable inform ation, education and com m unication programs for DM patients
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