MedDocs Publishers
Annals of Epidemiology & Public Health
The effect of a hospital-based awareness program
on the knowledge of patients with type 2 diabetes
in Upper Egypt
Lamiaa Hamdy1; Amel Mohamed2; Ahmed Arafa1*
1
Department of Public Health, Beni-Suef University, Egypt
2
Department of Community Health, Beni-Suef University, Egypt
*Corresponding Author (s): Ahmed Arafa
Department of Community Health, Faculty of
Nursing, Beni-Suef University, Egypt
Email: ahmed011172@med.bsu.edu.eg
Received: Apr 04, 2018
Accepted: July 03, 2018
Published Online: July 10, 2018
Journal: Annals of Epidemiology and Public health
Publisher: MedDocs Publishers LLC
Online edition: http://meddocsonline.org/
Copyright: © Arafa A (2018). This Article is distributed
under the terms of Creative Commons Attribution 4.0
International License
Keywords: T2D; Knowledge; Egyptian patients; Awareness
program
Introduction
The International Diabetes Federation (IDF)has estimated
the total cases of T2Damongthe Egyptian adults (20-79 years)
in 2017 with more than 8 million patients and the number has
been suggested to double in the next 2 decades [1]. In Egypt,
T2D is the sixth cause of mortality, responsible for 2.4% all years
of life lost (YLL), and represents the sixth most important cause
of disability burden [2,3].
Cite this article: Hamdy L, Mohamed A, Arafa A. The effect of a hospital-based awareness program on the knowledge
of patients with type 2 diabetes in Upper Egypt. 2018; 1: 1005.
1
Open Access | Research Article
Abstract
Background: Type 2 diabetes (T2D) is a public health con-
cern due to its graving morbidities and mortalities. Knowl-
edge of patients may affect the disease outcome. The aim
of this study was to evaluate the knowledge of patients with
T2D and assess the impact of a hospital-based awareness
program on their knowledge.
Subjects and Methods: This awareness program was
conducted on March 2018 over 294 patients with T2D and
visiting the outpatient clinic of diabetes in Beni-Suef Univer-
sity hospital. All patients were assessed for their knowledge
about T2D (diagnosis, management, follow-up, and compli-
cations) using an interview questionnaire. Patients who an-
swered ≥ 60% of the questions were considered of optimal
knowledge.
Results: The age of patients ranged between 21 and 85
years, 38.4% were males and 61.6% were females, 52.7%
were illiterate, and 64.3% had positive family history of dia-
betes. Using multivariate analysis, sex and education were
determinants of knowledge. Following the awareness pro-
gram, percent of patients with optimal knowledge regard-
ing T2D diagnosis increased from 4.4% to 32%, manage-
ment from 29.6% to 55.8%, follow-up from 45.6% to 68.4%
and complications from 55.4% to 79.5% (p<0.001).
Conclusion: Knowledge of patients with T2D in Beni-Suef
was shown to be inappropriate, however the awareness pro-
gram achieved a positive impact on patients’ knowledge.
T2D is associated with abnormalities in carbohydrate, pro-
tein and fatmetabolism [4]. Patients with T2D have high risk of
many chronic complications; 10% coronary heart disorders [5],
29% peripheral neuropathy [6], 20% nephropathy [7], and 17%
retinopathy [8].
Awareness of patients about T2D has become an essential
part of care. This is because appropriate knowledge about T2D
may affect compliance to treatment, enhance self-care and in-

crease the chances of the disease management, while subop-
timal awareness may have a negative impact on the outcome.
Diabetic education can help patients initiate self-care, optimize
metabolic control, prevent complications, and improve quality
of life [9].
However, little is known about knowledge of patients with
T2D in Upper Egypt regarding diagnosis, management, follow-
up scheduling and complications of their disease, and whether a
short intensive awareness program could improve their knowl-
edge. We believe that knowledgeable patients are more likely
to control their T2D. In this regard, the aim of this study was to
evaluate the knowledge of patients with T2D and implement an
awareness program to improve this knowledge.
Subjects and methods
All patients with T2D who were attending the outpatient
clinic of diabetes in Beni-Suef University hospital, during the
first couple of weeks of March 2018, were recruited to partici-
pate in this interventional program.
The sessions of the program have been given at Beni-Suef
University hospital throughout the same period. The study
locale, Beni-Suef University hospital, offers primary, secondary
and tertiary healthcare services for the inhabitants of Beni-Suef
Governorate that is situated 110km south to Cairo.
The sample size was calculated using Epi-Info version 7 Stat
Calc, [Center for Disease Control (CDC), WHO], based on the fol-
lowing criteria; improvement rate of 50%, confidence level of
95%, margin of error of 5% and response rate of 75%.
Of the 368 patients who attended the outpatient clinic of
diabetes during the period of the study, 294 participated in the
study giving us a response rate of 79.8%. The main reasons for
non-participation were not having enough time (72%) and feel-
ing unsure about the effect of the program (14%).
Before starting the program, all patients were assessed us-
ing an Arabic-language questionnaire that included questions
about the socio-demographic characteristics of the patients
and their T2D medical history.
Then, the knowledge of patients about T2D was assessed
by the investigators using interview questionnaire that was de-
signed based on reviewing previous studies [9-13]. The assess-
ment included knowledge of patients about 4 aspects; diagno-
sis of T2D, management, follow-up, and complications.
The diagnosis aspect included questions about the clinical
manifestations and lab readings used to diagnose T2D, while
the management aspect focused on the knowledge of patients
about the nature of the prescribed medications, dietetics and
physical activity. The follow-up aspect evaluated the knowledge
of patients about organs that patient should check-out in addi-
tion to follow-up scheduling, and the complications aspect in-
cluded questions about the different complications of T2D and
the side effects of the used medications.
Every knowledge aspect was formed ofmulti-choice ques-
tions when correct answers were given 1 point versus 0 point
for wrong answers, then translatedover a linear scale of 100.
Later, the average of the 4 aspects was calculated to get the
total knowledge scoreand patients with scores ≥ 60% were con-
sidered of optimal knowledge whether in the aspector total-
lyand those with lower scores were considered of suboptimal
knowledge.
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Before putting the questionnaire in practice, it was piloted
on 30 patients and reliability analysis, as detected by Cronbach’s
test, was 0.77 whereas the content validity was evaluated by a
diabetologist.
The awareness program, designed by the investigators, in-
cluded 4 sessions; 20 minutes each, and carried out within 1
day. Each session focused on improving the awareness of the
patients over only 1 aspect of T2D knowledge. Arabic-language
brochures and leaflets, supported by illustrated figures and
graphs, have been distributed as take-home notes. Patients
who missed sessions throughout the program have been given
wrap-ups of what they have missed.
After the program, all patients were assessed again over
their knowledge about the 4 aspects using the same question-
naire and scoring system. Interview and score assessment of
the patient, whether at the baseline or after the awareness ses-
sions, have been conducted by the same investigators to avoid
observer bias.
Data entry, verification, and validation were carried out us­ing
standard computer software. Data were analyzed using the soft-
ware, Statistical Package for Social Science (SPSS Inc. Released
2009, PASW Statistics for Windows, version 18.0: SPSS Inc., Chi-
cago, Illinois, USA), then processed and tabulated. Frequency
distribution with its percentage and descriptive statistics with
mean and standard deviation were calculated. Chi-square and
t-test were done whenever needed, while multivariate regres-
sion analysis was performed to detect the independent risk fac-
tors. P values of less than 0.05 were considered significant.
The study was conducted in full accordance with the guide-
lines for Good Clinical Practice and the Declaration of Helsinki,
and data for each patient were collected only after obtaining
the patient’s consent.
Results
The mean age of the 294 patients with T2D who participated
in this study was 53.3±11.3 (21-85) years, 113 (38.4%) were
males and 181 (61.6%) were females, 113 (38.4%) were residing
urban areas and 181 (61.6%) rural areas, more than half were
illiterate, and almost two thirds had positive family history of
diabetes, however less than third reported regular follow-up
(Table 1).
Baseline assessment of patients’ knowledge about T2D
showed that only 13 (4.4%) had optimal knowledge about the
diagnosis for T2D, 87 (29.6%) had optimal knowledge about T2D
management, 134 (45.6%) about T2D follow-up, 163 (55.4%)
about T2D complications, and 46 (15.6%) had total optimal
knowledge about T2D (Figure 1).
When patients with optimal knowledge were compared to
those with suboptimal knowledge, male sex, urban residence,
higher education, positive family history and longer disease
duration correlated positively with knowledge (p<0.05), while
the differences between both groups regarding age and type
of medication were statistically indifferent (p>0.05). After ad-
justing the correlating factors with patients’ knowledge using
multivariate analyses; only sex and education were found to be
independent risk factors (p<0.05) (Table 2).
Our results also showed that knowledge of patients regarding
different aspects of T2D knowledge; diagnosis, management,
follow-up, complications was not associated with patients’
follow-up (p>0.05), and although patients with optimal total
2

knowledge were more likely to report follow-up, the calculated
difference was statistically insignificant (p=0.063) (Table 3).
After the awareness program, the rates of patients with op-
timal knowledge about diagnosis, management, follow-up and
complications improved significantly from 4.4%, 29.6%, 45.6%
and 55.4% to a high of 32%, 55.8%, 68.4% and 79.5%, respec-
tively, and the percent of patients with total optimal knowledge
increased from only 15.6% to 40.1% (p<0.001) (Table 4).
Discussion
This study highlightedthe deficiency in patients’ knowledge
regarding T2D diagnosis (4.4%), management (29.6%), follow-
up (45.6%) and complications (55.4%). Previous studies from
developed and underdeveloped countries have reported that
diabetes knowledge is generally poor among patients. In a
cross-sectional study over 100 patients with T2D in Bangladesh,
most patients had poor to average knowledge about definition,
symptoms, management and complications of T2D, and pa-
tients with lower knowledge had lower ability of self-manage-
ment and worse outcome [9]. Another study over 404 patients
with T2D from Tunisia showed limited knowledge about the
definition and pathophysiology of T2D [10]. In Kuwait, knowl-
edge deficits among 5114 patients were remarkable especially
regarding T2D management [11]. A study on patients with T2D
in Pakistan reported that the participants had low knowledge
of the symptoms, treatments, and complications of T2D [14].
However, it is not simple to compare our results to others, since
most of the studies used different data collecting tools and were
conducted over study populations with different demographic
characteristics.
In our study, females had significantly lower knowledge,
which consisted with previous reports [9,15,16], but conflicted
others [17,18]. This may be due to the higher illiteracy rate
among females in Upper Egypt which make them less exposed
to diabetes education.
As predicted, illiterate patients and those with lower levels
of education had poorer knowledge compared to their coun-
terparts with high education, which agreed with other studies
[9,15-18]. Compared to the illiterates, educated people can ac-
cess more sources of knowledge that make them aware of their
health condition.
Patients residing rural areas were more likely to have lower
knowledge. Our findings agreed with previous studies emerging
from rural communities [9,11]. In Upper Egypt, where the ac-
cess to healthcare for residents of rural villages may be lacking,
diabetes awareness hardly reaches patients living in rural areas.
In addition, patients residing rural areas have lower levels of
education and limited sources of awareness that result intheir
poor knowledge about different diseases.
In agreement with previous studies [15,16,19], patients with
positive family history had better knowledge. Having a close
relative with T2D may be a good source of health information.
Further, patients in Upper Egypt prefer accompanying relatives
while visiting doctors which increase their chances to be knowl-
edgeable about the diseases of their relatives.
Our results also showed that patients with longer disease
duration had better knowledge, which consisted with previous
reports [16,17]. This could be because they visited more doc-
tors, were instructed to more labs and experienced more com-
plications.
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The awareness program that has been implemented in this
study achieved a positive impact in improving the rates of op-
timal knowledge about diagnosis, management, follow-up and
complications from 4.4%, 29.6%, 45.6% and 55.4% to 32%,
55.8%, 68.4% and 79.5%, respectively.
The efficacy of our awareness program could be attributed
to many reasons. First, the awareness sessions have been given
at Beni-Suef University hospital where patients were consulting
their physicians, which encouraged them to attend and contin-
ue in the program. Every session discussed only 1 aspect related
to T2D to ensure that patients reached good understanding of
this aspect. Patients were encouraged to express their personal
experiences which offered effective integrative communication.
Further, the program was designed to be suitable for illiterate
patients and those with lower education by using simple and di-
rect phrases and distributing brochures and illustrating figures.
Previous studies showed that diabetic education cannot just
improve the knowledge of patients but can help them control
their glycemic state and improve their quality of life [19-25].
However, these programs were conducted on study populations
from different backgrounds, targeted improving specific areas
of diabetes knowledge and were carried out throughout variant
durations.
It should be noted that this study is not without limitations.
First, since Beni-Suef University hospital has no registries for pa-
tients with T2D, we resorted to a convenience sampling which
may not be truly representative of all patients with T2D. Pa-
tients who attend the outpatient clinics in Beni-Suef University
hospital, which offers free health services, usually come from
relatively lower socio-economic and educational backgrounds
which might hinder the ability of generalization. Also, the study
assessed only the immediate effect of the awareness program
and did not evaluate the long-term impact.
In conclusion, our findings demonstrate that knowledge of
patients with T2D about the diagnosis, management, follow-up
scheduling and complications of their disease is limited. The
study emphasizes the need for comprehensive diabetes edu-
cation encompassing the diagnosis, management, follow-up,
complications of T2D. Since the improved knowledge may facili-
tate patient management and improve the outcomes, further
research should focus on the impact of the awareness programs
on changing the practices of patients and controlling their man-
ifestations. It is therefore crucial to direct more resources to
improving the knowledge of patients with T2D and developing
different educational models that suit the Egyptian patients.
Figures
Figure 1: Assessment of the baseline knowledge of the par-
ticipating patients (n=294) about type 2 diabetes, Beni-Suef Uni-
versity hospital, 2018.
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Tables
Table 1: Socio-demographic and clinical characteristics of the participating patients
(n=294), Beni-Suef University hospital, 2018.

Socio-demographic characteristics Total; n=294 (%)

Male 113 (38.4)

Sex
Female 181 (61.6)

Age (Mean±SD) years 53.3±11.3

Urban 113 (38.4)

Residence
Rural 181 (61.6)

Illiterate 155 (52.7)

Education Elementary 98 (33.3)

High 41 (13.9)

Disease duration (Mean±SD) years 7.9±6.9

Positive 189 (64.3)

Family history
Negative 105 (35.7)

Oral 153 (52.0)

Medications
Insulin 141 (48.0)

Yes 84 (28.6)
Regular follow-up
No 210 (71.4)

Table 2: Association between the socio-demographic and clinical characteristics of the participating pa-
tients (n=294) and their knowledge about type 2 diabetes, Beni-Suef University hospital, 2018.

Optimal knowledge Suboptimal knowledge

Socio-demographic characteristics P value
n=46 (%) n=248 (%)

Male 38 (82.6) 75 (30.2)

Sex <0.001**
Female 8 (17.4) 173 (69.8)

Age (Mean±SD) years 54.9±11.8 53.1±11.2 0.304

Urban 37 (80.4) 76 (30.6)

Residence <0.001*
Rural 9 (19.6) 172 (69.4)

Illiterate 4 (8.7) 151 (60.9)

Education Elementary 21 (45.7) 77 (31.0) <0.001**

High 21 (45.7) 20 (8.1)

Positive 37 (80.4) 152 (61.3)

Family history 0.008*
Negative 9 (19.6) 96 (38.7)

Disease duration (Mean±SD) years 11.4±9.2 7.2±6.2 <0.001*

Oral 20 (43.5) 133 (53.6)

Medications 0.135
Insulin 26 (56.5) 115 (46.4)

*
P value is considered significant by univariate analysis
**
P value is considered significant by multivariate analysis

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Table 3: Association between knowledge of the participating patients about type 2 diabetes (n=294) and follow-up, Beni-
Suef University hospital, 2018.

Follow-up No follow-up
Knowledge P value
n=84 (%) n=210 (%)

Optimal 3 (3.6) 10 (4.8)

Diagnosis 0.464
Suboptimal 81 (96.4) 200 (95.2)

Optimal 25 (29.8) 62 (29.5)

Management 0.537
Suboptimal 59 (70.2) 148 (70.5)

Optimal 42 (50.0) 92 (43.8)

Follow-up 0.202
Suboptimal 42 (50.0) 118 (56.2)

Optimal 51 (60.7) 112 (53.3)

Complications 0.154
Suboptimal 33 (39.3) 98 (46.7)

Optimal 18 (21.4) 28 (13.3)

Total 0.063
Suboptimal 66 (78.6) 182 (86.7)

Table 4: Improvement of the knowledge of the participating patients (n=294) about type 2 diabetes after the awareness
program,Beni-Suef University hospital, 2018.

Knowledge Before After P value

Optimal 13 (4.4) 94 (32.0)

Diagnosis <0.001*
Suboptimal 281 (95.6) 200 (68.0)

Optimal 87 (29.6) 164 (55.8)

Management <0.001*
Suboptimal 207 (70.4) 130 (44.2)

Optimal 134 (45.6) 201 (68.4)

Follow-up <0.001*
Suboptimal 160 (54.4) 93 (31.6)

Optimal 163 (55.4) 213 (79.5)

Complications <0.001*
Suboptimal 131 (44.6) 81 (20.5)

Optimal 46 (15.6) 118 (40.1)

Total <0.001*
Suboptimal 248 (84.4) 126 (59.9)

Acknowledgement betic neuropathy in type 2 diabetes mellitus in a tertiary care

We would acknowledge Beni-Suef Medical Students Re-
search Group for their help in data entry and recruitment of
patients.
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