Patient Education and Counseling 69 (2007) 47–54

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A comparison of knowledge of diabetes mellitus between patients

with diabetes and healthy adults: A survey from north Malaysia
Lai Shin Yun a, Yahaya Hassan b,*, Noorizan Abd. Aziz c, Ahmed Awaisu d, Rozina Ghazali e
a
School of Pharmaceutical Sciences, Universiti Sains Malaysia, 11800 Penang, Malaysia
b
Clinical Preceptor for Internal Medicine Clerkship, Clinical Pharmacy Programme, School of Pharmaceutical Sciences,
Universiti Sains Malaysia, 11800 Penang, Malaysia
c
Clinical Preceptor for Intensive Care Clerkship, Clinical Pharmacy Programme, School of Pharmaceutical Sciences,
Universiti Sains Malaysia, 11800 Penang, Malaysia
d
Clinical Pharmacy Programme, School of Pharmaceutical Sciences, Universiti Sains Malaysia, 11800 Penang, Malaysia
e
Department of Medicine, Penang General Hospital, Penang, Malaysia
Received 5 February 2007; received in revised form 16 May 2007; accepted 9 June 2007

Abstract
Objective: The primary objective of this study was to assess and compare the knowledge of diabetes mellitus possessed by patients with diabetes
and healthy adult volunteers in Penang, Malaysia.
Method: A cross-sectional study was conducted from 20 February 2006 to 31 March 2006. We randomly selected 120 patients with diabetes
mellitus from a diabetic clinic at the General Hospital Penang, Malaysia and 120 healthy adults at a shopping complex in Penang. Each participant
was interviewed face-to-face by a pharmacist using a validated questionnaire, and they were required to answer a total of 30 questions concerning
knowledge about diabetes mellitus using Yes, No or Unsure as the only response.
Results: The results showed that patients with diabetes mellitus were significantly more knowledgeable than the healthy volunteers about risk
factors, symptoms, chronic complications, treatment and self-management, and monitoring parameters. Educational level was the best predictive
factor for diabetes mellitus and public awareness.
Conclusion: Knowledge about diabetes mellitus should be improved among the general population.
Practice implications: This study has major implications for the design of an educational programme for diabetics and a health promotion
programme as a primary prevention measure for the healthy population in general, and especially for those at high risk. The results could be useful
in the design of future studies for evaluating patients’ and the general public’s knowledge about diabetes mellitus.
# 2007 Elsevier Ireland Ltd. All rights reserved.

Keywords: Diabetes mellitus; Knowledge; Patients with diabetes; Healthy population

1. Introduction region [2]. Looking at the trend of the pandemic potential of

Diabetes mellitus is a growing public health concern and its
prevalence is escalating exponentially, with a high frequency of
morbidity, premature mortality, disability, and loss of
productivity. According to population studies, the prevalence
of type 2 diabetes has reached epidemic proportions; it affected
approximately 171 million individuals worldwide in the year
2000 and is estimated to be 366 million by the year 2030 [1]. On
the basis of current trends, epidemiologists predict that almost
half of all diabetic individuals will be in the Asia/Oceania
* Corresponding author. Tel.: +60 4 653 3888x2387; fax: +60 4 657 0017.
E-mail address: yahaya@usm.my (Y. Hassan).
0738-3991/$ – see front matter # 2007 Elsevier Ireland Ltd. All rights reserved.
doi:10.1016/j.pec.2007.06.017
diabetes and the fact that it is usually diagnosed late, one must
be concerned about the global burden and the enormous cost of
treating its debilitating complications. Malaysia has undergone
a skyrocketing socioeconomic and demographic transformation
over the last two decades as a result of massive industrializa-
tion, globalization, mechanization, and an improved educa-
tional system. In this transition period, the country has
experienced rapid improvement in the standard of living and the
quality of life, a reduction in death rate, and concomitant ageing
of the population. Therefore, Malaysia, a multiethnic nation of
three major Asian races (Chinese, Indians, and Malays) with a
population of about 25 million is highly prone to an epidemic of
diabetes considering the global trend, the socioeconomic
transition in the country, and the well-known risk factors of the
48 L.S. Yun et al. / Patient Education and Counseling 69 (2007) 47–54
disease. The prevalence of diabetes in Malaysia has increased
steadily from 6.3% in 1986 to 8.3% in 1996, with Malaysian
Indians at greater risk with rates ranging from 3.5 to 16% [3–5].
This is despite the anticipated gross under-diagnosis of the
disease, since the Second National Health and Morbidity
Survey showed that the prevalence of undiagnosed diabetes was
2.5% [4]. Malaysia will almost certainly be affected by a
diabetic epidemic as there is already a major shift in the
lifestyles and longevity of the population [2]. The low level of
awareness of diabetes among the public, decision makers, and
health professionals, a low priority in national health policy and
plans, and limited availability and access to appropriate
preventive and curative care have been identified as major
issues [5]. A cross-sectional survey that evaluated the general
public’s knowledge of diabetes in Singapore conducted by the
Department of Pharmacy of the National University of
Singapore showed that the public was generally well informed
about diabetes [6]. In contrast, studies from other countries
showed that there was a low level of diabetes awareness
amongst diabetic patients [7–11]. One study concluded that
diabetes education programmes and self-monitoring of blood
glucose (SMBG) are important sources of improving knowl-
edge about diabetes in patients with type 2 diabetes [9].
Adequate knowledge is of paramount importance in improving
the quality of life of diabetic patients but, to our knowledge,
there is no report of a comparison of knowledge between
patients with diabetes and a healthy population even though a
great deal of effort has been devoted to educating the public
about diabetes through various forms of media [6]. The main
objective of this study was to assess and compare knowledge
pertaining to diabetes mellitus between diabetic patients and
healthy adults. In order to cope with the increasing prevalence
of diabetes, greater effort should be made towards primary
prevention and health promotion through counseling and
education. The importance of awareness and knowledge
amongst both the healthy and the diabetic patients cannot be
overemphasized. The Diabetes Care Data Collection Project
(DCDCP) found that the level of diabetes control was closely
related to socioeconomic factors, occupation, and educational
status [12]. Health promotion and education is to be
encouraged, since a plethora of evidence has shown a link
between socioeconomic factors and diabetes, and this should
include the use of the media in publicity campaigns, the
production and distribution of educational material, and the
education of people with diabetes, as well as their families and
carers. Educational and awareness programs will be beneficial
both to healthy subjects as preventive measures, and as effective
control measures for people living with diabetes.
2. Methodology
2.1. Study design and study population
A cross-sectional study was conducted from 20 February to
31 March 2006. We randomly selected 120 patients with
diabetes from the full list of patients attending a diabetic clinic
at the General Hospital Penang, Malaysia, using the clinic’s
electronic medical records. We recruited 120 healthy adults at a
shopping complex in Penang, using the diabetic patients’
characteristics to maximize comparability. The inclusion
criteria for both groups were as follows: age between 21 and
65 years, and the ability to understand the questionnaire.
Individuals were excluded from participating in the study if
they had significant cognitive impairment and/or psychiatric
comorbidity (hospital records). The volunteers were assumed to
be healthy on the basis of the information that they supplied.
Baseline demographic data of the diabetic group were recorded
to allow comparison of measurements between the groups.
2.2. Data collection/diabetes knowledge assessment
Each participant was interviewed face-to-face by a pharma-
cist (the researcher) using a standard questionnaire adapted from
that described by Wee et al. [6] and translated into Bahasa
Malaysia, which is the national language of the country. Two
senior faculty members, the researcher and two professional
translators were involved in the modification and linguistic
validation of the questionnaire. The participants were required to
answer a total of 30 questions using only Yes, No or Unsure as the
response. The questionnaire was divided into five main
categories: general knowledge about diabetes (6 questions);
risk factors (4 questions); symptoms and complications (9
questions); treatment and management (9 questions); and
monitoring (2 questions). Participants were awarded one point
for each question they answered correctly and zero for each
wrong or unsure response. Thus, the maximum score was 30.
2.3. Statistical methods/data analysis
All data were analyzed using the SPSS version 14.0 software
package (SPSS Inc., Chicago, IL) and Microsoft Excel. The x2-
test, Student’s t-test, the Mann–Whitney U-test and the
Kruskal–Wallis test were used as appropriate. The level of
statistical significance was set at p < 0.05 (two-sided p-values).
3. Results
The demographic characteristics of the study subjects are
presented in Table 1.There was no significant difference
between the diabetic and healthy groups for age, gender, race,
marital status, educational level, employment status or income.
(Table 1).
There was a significant difference between the diabetic and
healthy groups for mean total knowledge; diabetic 24.4  3.83
versus healthy 20.2  5.97. The diabetic group performed
better in the knowledge of risk factors, symptoms and chronic
complications, treatment and self-management, and monitoring
(Table 2). There was no significant difference between groups
for the mean score of general knowledge of pathology of
diabetes mellitus (diabetic 3.15  1.47 versus healthy 2.81 
1.46). None of the participants knew that there are different
types of diabetes; 35.8% of the patients with diabetes got it
wrong and the rest were unsure. Interestingly, 78.3% of the
diabetics and 62.5% of the healthy volunteers were aware that
 L.S. Yun et al. / Patient Education and Counseling 69 (2007) 47–54 49

Table 1
Sociodemographic data of diabetic and healthy groups
No. (%) x2 p-Value

Diabetic (n = 120) Healthy (n = 120)

Age (mean years  S.D.) 55.57  8.733 53.67  7.904 – 0.079 (NS)
21–35 years 2 (1.6%) 2 (1.6%)
36–45 years 19 (15.8%) 19 (15.8%)
46–55 years 36 (30.0%) 38 (31.7%)
56–65 years 63 (52.6%) 61 (50.9%)
Gender
Male 54 (45%) 58 (48%) 0.268 0.605 (NS)
Female 66 (55%) 62 (52%)
Race
Malay 45 (37.5%) 41 (34.2%) 2.950 0.229 (NS)
Chinese 49 (40.8%) 61 (50.8%)
Indian 26 (21.7%) 18 (15.0%)
Marital status
Single 11 (9.2%) 13 (10.8%) 0.185 0.667 (NS)
Married 109 (90.8%) 107 (89.2%)
Educational level
None 10 (8.3%) 7 (5.8%) 1.664 0.797 (NS)
Primary 50 (41.7%) 55 (45.8%)
Secondary 45 (37.5%) 44 (36.7%)
High school/diploma 6 (5.0%) 8 (6.7%)
University 9 (7.5%) 6 (5.0%)
Employment status
Unemployed 57 (47.5%) 55 (45.8%) 1.641 0.801 (NS)
Government 13 (10.8%) 10 (8.3%)
Private 25 (20.8%) 29 (24.3%)
Retired 21 (17.5%) 19 (15.8%)
Self-employment 4 (3.3%) 7 (5.8%)
Income
No income 67 (55.8%) 57 (47.5%) 4.337 0.362 (NS)
<RM1000 15 (12.5%) 12 (10.0%)
RM1000–1999 21 (17.5%) 29 (24.2%)
RM2000–2999 16 (13.3%) 18 (15.0%)
>RM3000 1 (0.8%) 4 (3.3%)
Sources of information
Friends/relatives 44 (37%) 57 (47.5%) 81.819 0.000 (S)
Health professionals 65 (54%) 6 (5%)
Books/magazines 11 (9%) 57 (47.5%)
Years with diabetes
Mean years  S.D. 8.23  6.706 – – –
0–3 years 36 (30%)
4–7 years 31 (25.8%)
8–11 years 28 (23.3%)
12–15 years 8 (6.7%)
>15 years 17 (14.2%)

The difference between diabetic and healthy groups was assessed by x2-test in all, except the mean age in which Student’s t-test was used. p < 0.05 is considered significant (S = significant;
NS = not significant).

Table 2
Knowledge score between diabetic and healthy groups
Knowledge score Maximum Mean  S.D. p-Value
possible score
Diabetic Healthy
A. General knowledge 6 3.15  1.47 2.81  1.46 0.072 (NS)
B. Risk factors 4 3.37  0.99 2.78  1.36 0.000 (S)
C. Symptoms/complications 9 8.54  1.08 6.75  2.53 0.000 (S)
D. Treatment/self-management 9 7.57  1.29 6.36  1.89 0.000 (S)
E. Monitoring 2 1.82  0.39 1.50  0.65 0.000 (S)
Mean total score 30 24.4  3.83 20.2  5.97 0.000 (S)
The difference between diabetic and healthy groups was assessed by t-test. p < 0.05 is considered significant (S = significant; NS = not significant).
50 L.S. Yun et al. / Patient Education and Counseling 69 (2007) 47–54

Table 3
Factors influencing performance of total knowledge score among diabetic and healthy group
Mean total knowledge K–W test Mean total knowledge K–W test
score (DM group) score (healthy group)
Age
21–35 years 24.50 0.305 (NS) 19.50 0.489 (NS)
36–45 years 26.53 19.00
46–55 years 25.08 20.13
56–65 years 23.44 20.62
Race
Malay 24.82 0.746 (NS) 19.61 0.795 (NS)
Chinese 24.24 20.75
Indian 24.15 19.61
Educational level
None 18.90 0.000 (S) 9.86 0.000 (S)
Primary 23.80 19.24
Secondary 25.24 21.80
High school/dip 27.33 24.00
University 28.22 24.17
Employment status
Unemployed 23.14 0.005 (S) 18.16 0.019 (S)
Government 26.54 22.00
Private 25.60 20.54
Retired 25.24 22.68
Self-employment 24.75 17.57
Income
No income 23.28 0.000 (S) 18.59 0.139 (NS)
<RM1000 24.67 22.75
RM1000–1999 25.48 19.62
RM2000–2999 27.50 21.78
>RM3000 28.00 20.88
Source of information
Friends/relatives 21.73 0.000 (S) 16.96 0.000 (S)
Health professionals 25.94 23.17
Books/magazines 26.45 23.11
Years with diabetes
0–3 years 22.81 0.147 (NS) – –
4–7 years 25.90
8–11 years 24.11
12–15 years 25.25
>15 years 25.41

Mean total knowledge M–W U-test Mean total knowledge M–W U-test
score (DM group) score (healthy group)
Gender
Male 24.89 0.184 (NS) 20.02 0.593 (NS)
Female 24.08 20.35
Marital status
Single 26.18 0.123 (NS) 20.92 0.909 (NS)
Married 24.27 20.10
Kruskal–Wallis (K–W) test was used to assess the effect of age, race, educational level, employment status, income level, source of information, years with disease on
the total knowledge score. Mann–Whitney (M–W) U-test was used for gender and marital status. p < 0.05 is considered significant (S = significant; NS = not
significant).

diabetics are not encouraged to donate blood. All of the diabetic
patients understood the need to establish goals for blood
glucose and blood pressure.
Among the diabetics, there were significant differences of
knowledge (total score) associated with educational level,
employment status and income level. However, there was no
significant difference associated with age, race, gender or
marital status (Table 3). Among the healthy group, there was a
significant difference of knowledge (total score) associated
with educational level and employment status, but no
significant difference associated with age, race, gender, marital
status or income level (Table 3). Multivariate analysis was
carried out using logistic regression modeling to determine
significant predictors of overall knowledge of diabetes mellitus.
 L.S. Yun et al. / Patient Education and Counseling 69 (2007) 47–54
Fig. 1. Respondents’ sources of information on diabetes mellitus.
In the final model, educational level and number of years with
the disease were the most important predictors of knowledge of
diabetes, and can predict it 93.3% of the time. This analysis was
conducted irrespective of the disease status of the study
subjects. To better predict the factors that determine the degree
of knowledge amongst subjects with diabetes and those without
it, the same procedure was utilized. In the healthy group,
logistic regression modeling with a maximum likelihood ratio
of 86% confirmed that educational level was the most
significant predictor variable correlated with increase in the
knowledge of the disease. Conversely, in the diabetic group,
income was the most significant predictor of knowledge of the
disease and explains the outcome 98.3% of the time.
The results showed also that most of the diabetic patients’
information was obtained from health-care professionals such
as medical officers, pharmacists and nurses (Fig. 1). On the
other hand, most of the healthy group obtained information
through friends and relatives or from books and magazines.
Further categorization of the degree of knowledge shown in
Table 4 reveals that 85% of people with diabetes have from
good to very good knowledge of the disease, whereas only
55.8% of the healthy population has the same degree of
knowledge. Table 5 provides greater details on the performance
of study subjects in various knowledge domains.
4. Discussion and conclusion
4.1. Discussion
The overall findings of this study indicate that there was
more awareness and knowledge among patients with diabetes
Table 4
Total score of knowledge
Total score of knowledge Status of knowledge
10 Very poor
11–15 Poor
16–20 Moderate
21–24 Good
25 Very good
Mean total score  S.D. = 22.32  5.44.
51
compared to their healthy counterparts, perhaps because they
were concerned that their lack of knowledge might worsen their
clinical conditions. The high scores of knowledge amongst
patients with diabetes may reflect the greater emphasis now
placed on diabetes education. This aspect of care is given
priority at the diabetic clinics where patients attend on a
regular-basis. A positive interpretation of these high scores
would be that they are a reflection of the adequate education
received by the diabetic patients. The effective management of
diabetes rests on the consistent application of preventive and
clinical interventions, including efforts to detect the disease,
promote effective self-management, reduce the incidence of
complications, and increase the coping skills of people with
diabetes and the related conditions [5]. In Malaysia, the
National Diabetes Prevention and Control Programme appears
to have improved the management of diabetes, yet there is
much to be done to achieve the overall objectives of the
programme [5]. The lack of significant difference between
diabetic and healthy adults in the mean score of general
knowledge of pathology highlights the need for more concerted
effort towards educating the patients with diabetes about the
basics and pathophysiology of the disease. The majority of both
the diabetic and healthy groups did not know that there are
different types of diabetes, possibly due to lack of under-
standing of the information they received during education and
counseling. A study by Beeney et al. concluded that clinicians
giving a diagnosis should: (1) be aware of patient variability in
the need for emotional support and information preferences; (2)
ask patients for their preferences and offer choices if available;
and (3) provide more information about treatment and increase
patient involvement in discussions about therapy [13]. Health-
care professionals should encourage diabetic patients to be
proactive in self-care and the management of the disease [14].
It was not unexpected that the diabetic patients had
significantly better knowledge of screening risk factors, but
the healthy population should be more aware of disease
prevention and health promotion activities. A major confounder
was whether any member of the healthy group had a relative or
friend with diabetes and thus be more likely to know about the
disease. Concerted efforts are needed to educate the general
public about preventable and modifiable risk factors. Targeted
public health efforts are needed to help in collecting
information about family history to share with health-care
providers and educate or assist providers to interpret
information effectively [15]. The Felda Study, a 10-year
n (%)
Diabetic (n=120) Healthy (n=120) Total (n=240)
1 (0.8) 11 (9.2) 12 (5.0)
3 (2.5) 12 (10) 15 (6.3)
14 (11.7) 30 (25) 44 (18.3)
37 (30.8) 38 (31.7) 75 (31.2)
65 (54.2) 29 (24.1) 94 (39.2)
52 L.S. Yun et al. / Patient Education and Counseling 69 (2007) 47–54

Table 5
Knowledge evaluation by section
Question Correct (%) Wrong (%) Unsure (%)
DM H DM H DM H
General knowledge on pathology of diabetes
Diabetes is a condition of high blood sugar 89.2 89.2 6.7 9.2 4.2 1.7
Diabetes is a condition of lack of insulin 46.7 40.8 5.8 17.5 47.5 41.7
Insulin is a protein hormone which is produced in pancreas 27.5 21.7 16.7 25.0 55.8 53.3
Insulin regulates blood sugar 60.8 47.5 1.7 5.8 37.5 46.7
Diabetes is non-contagious 90.0 81.7 5.0 10.8 5.0 7.5
There are different types of diabetes 0 0 35.8 27.5 64.2 72.5
Knowledge of screening risk factors of diabetes
Family history of diabetes mellitus 88.3 75.0 9.2 16.7 2.5 8.3
Age  35 years 88.3 70.8 5.8 20.8 5.8 8.3
Obesity 85.8 76.7 9.2 15.0 5.0 8.3
Pregnancy 74.2 55 6.7 29.2 19.2 15.8
Knowledge on symptoms and chronic DM complications
Thirst 97.5 71.7 0.8 10.8 1.7 17.5
Frequent urination 95.8 57.5 3.3 16.7 0.8 25.8
Blurred vision 96.7 77.5 2.5 9.2 0.8 13.3
Slow healing of cuts and wounds 96.7 85.0 2.5 5.0 0.8 10.0
Tiredness and weakness 98.3 89.2 1.7 2.5 – 8.3
Diabetic foot (e.g. decaying limbs requiring surgical removal) 95.8 79.2 3.3 4.2 0.8 16.7
Retinopathy (Eye problems leading to blindness) 95.0 79.2 4.2 10.0 0.8 10.8
Nephropathy (Kidney problems) 85.8 70.0 5.8 10.8 8.3 19.2
High blood pressure or peripheral vascular disease 92.5 65.8 2.5 16.7 5.0 17.5
Knowledge of treatment and self-management of diabetes
Insulin injections is used for treatment 85 55.8 0.8 9.2 14.2 35.0
Oral tablets are also available 100 91.7 0 0.8 0 7.5
Diabetics should carry sweets when they are out 45.0 27.5 40.8 51.7 14.2 20.8
Exercise plays a role in control of diabetes 95.8 91.7 4.2 7.5 0 0.8
Good weight control is necessary in diabetes control 95.8 90.0 2.5 5.0 1.7 5.0
Regular eye check-up is necessary 96.7 70.0 1.7 15.0 1.7 15.0
Diabetics should not consume alcohol and smoke 100 95.8 0 0 0 4.2
Diabetics should not donate blood 78.3 62.5 6.7 18.3 15.0 19.2
Diabetics should not skip meals when busy 60.0 50.8 21.7 20.8 18.3 28.3
Knowledge of monitoring parameters
Diabetics should do blood glucose and BP monitoring 100 91.7 0 1.7 0 6.7
Diabetics should do urine test for protein 81.7 58.3 7.5 16.7 10.8 25.0
H = Healthy group; DM = Diabetes Mellitus group.

follow-up study undertaken in a rural community in Malaysia
was designed to identify the main modifiable risk factors of
diabetes mellitus and subsequently devise simple and prag-
matic programmes to protect the community involved [16]. The
results of this study with Malaysia’s position in the midst of an
epidemic of diabetes warrant educational intervention to
contain the predictable consequences. Therefore, the crusade
against the problems of a diabetes epidemic in Malaysia must
start with mass education and awareness campaigns targeting
healthy lifestyles, and health-care professionals should play a
pivotal role in this as well as in the detection of the disease,
especially in high-risk groups. In addition, both the American
Diabetes Association (ADA) and the Malaysian diabetes
Association have suggested that screening for diabetes as part
of routine medical care might be appropriate for individuals
with one or more risk factors [17,18].
Diabetics have a better understanding of symptoms and
chronic complications as well as treatment and self-manage-
ment of diabetes when compared to the healthy population.
With adequate knowledge of the severity of symptoms and
complications, both diabetics and non-diabetics would prob-
ably take the necessary actions and/or seek medical attention
promptly. Furthermore, it is useful to educate healthy
populations, so that they can educate and guide their diabetic
relatives or friends to comply with follow-up and treatment.
This may reduce the medical and economic burden of diabetes
and its complications [6]. It is not clear whether the study
subjects knew the rationale behind the discouragement of blood
donation by diabetics, i.e. the danger of slow wound healing,
which increases the risk of infection [6]. The subjects might
have had the misconception that diabetes can be transmitted
through transfusion of blood products.
In the healthy group, logistic regression analysis confirmed
that educational level was the most significant predictor
variable correlated with increase in the knowledge of the
disease. This was in agreement with other results showing that
educational level was an important predictor of knowledge and
awareness, irrespective of disease status. Studies have reported
 L.S. Yun et al. / Patient Education and Counseling 69 (2007) 47–54
that less educated patients often have difficulty in under-
standing physicians’ explanations about diabetes and its
management [14,19]. However, in the diabetic group, income
was the most significant predictor of disease knowledge,
although this could have a relationship with educational level
and employment status.
Only a few healthy adults obtained their knowledge from
health professionals, suggesting that health professionals must
be involved in education of the general public about diabetes.
The public do come into contact with general practitioners and
community pharmacists, who are encouraged to provide
educational material during visits and to supply relevant
information to high-risk groups. In this survey, it was clear that
the majority of diabetic patients do not actively seek
information by reading. Therefore, health education literature
and techniques should be designed to suit the needs and
comprehension of less educated, non-English-speaking and
low-income populations. For instance, health professionals
might supply the literature with other aids, such as personal
instructional sessions or audio–visual aids [20].
This survey failed to identify whether patients had type 1 or
2 diabetes. It is worth noting, however, that this study was not
designed to assess diabetic patients’ attitudes and practices
about diabetes mellitus. Therefore, studies with a similar
context but wider scope and much larger sample sizes are
recommended to confirm the findings of this study. Lastly, we
were not certain whether the members of the healthy group
were truly healthy or were simply individuals without diabetes
or had not been diagnosed with diabetes or other chronic
illness.
The evidence gathered so far regarding epidemiological
trends involving type 2 diabetes indicates the need for a serious
review of existing policies and strategies for prevention and
management [2]. One study estimated that the direct cost of
outpatient treatment for the 60,000 diabetics registered with the
Ministry of Health in Malaysia was about RM 14.5 million per
year (equivalent to US$ 4.14 million) [21]. Primary prevention
and lifestyle modification can have a significant impact on
reduction of the dramatic consequences of diabetes that affect
people of all ages. If there is no intervention, the number of
diabetes cases in Malaysia is projected to reach 2 million by the
year 2025 [22]. This is especially serious when healthy
individuals and, more worrying, diabetics do not have
awareness and knowledge of the disease and its management.
Educational strategies for the prevention and control of diabetes
can be considered at three different levels and should span from
primary prevention to tertiary prevention. The primary
prevention covers activities aimed at preventing diabetes from
occurring in susceptible populations or individuals. Secondary
and tertiary prevention measures for diabetes are geared
towards early diagnosis, and effective control to avoid or delay
the disease progression and prevention of complications and
disabilities, respectively [22]. The target population for an
educational programme as a primary prevention strategy should
include individuals at risk for diabetes (e.g. obesity, older than
40 years, family history of diabetes) or a community-wide
approach to reduce overall levels of risk factors [22].
53
The results of this study highlight the need for an
educational programme designed as a primary prevention for
healthy individuals at risk, and a programme for secondary and
tertiary prevention for patients with diabetes. The primary
educational programme should address basic knowledge of
diabetes and its causes, particularly the modifiable risk factors.
The programme should emphasize the need for the prevention
and reduction of obesity through promotion of healthy diet and
increasing physical activity. The educational programme will
need to be well-structured and delivered through mass media
publicity for the healthy group, through lecture series in the
form of modules at clinics for diabetics, and through
distribution of educational literature for everybody. The
healthy individuals’ programme should address causes, risk
factors, diets, exercise, and screening. In addition to these, the
diabetics’ programme should address self-care and monitoring,
medication compliance, and screening for complications.
Facilities such as urine albumin measurement and a fundus
camera are available in most government hospitals in Malaysia.
Therefore, unprecedented opportunities exist for people with
diabetes to be aware of this and to seek care and support. One
example of a curriculum for a diabetes education programme is
that developed on the recommendations of the American
Diabetes Association (ADA). This programme comprises five
sections that cover: (1) the definition of diabetes mellitus; (2)
dietary control and meal plans; (3) urine and blood glucose
testing; (4) action of insulin and oral hypoglycemic agents; and
(5) symptoms and treatment of hypoglycemia and uncontrolled
hyperglycemia, foot care, and exercise [23].
4.2. Conclusion
In conclusion, diabetic patients are more knowledgeable in
terms of the disease than non-diabetic individuals. Patients are
typically more concerned about treatment and outcomes as
compared with healthy adults. Educational and income levels
were found to be the predominant predictive factors of
knowledge in all study participants. Therefore, awareness about
diabetes mellitus among the less privileged healthy population
with low income and education needs to be improved. A well-
structured educational programme is recommended for both
diabetics and healthy individuals. This can be done at many
levels, including schools, work places, and the general public.
The promotion of a healthy lifestyle is encouraged through
enhancing individual, family, and community responsibilities.
Separate education programmes should be designed for healthy
individuals and for patients with diabetes. The focus of the
healthy individuals’ programme should be on healthy lifestyle
and should include information about risk factors, diet, exercise,
and screening. Our proposed model can serve as the basis of a
community-based and a hospital-based programme as contribu-
tions to the control and prevention of diabetes in Malaysia.
4.3. Practice implication
This study has major implications for the design of diabetes
education programmes. A sound and successful education
54 L.S. Yun et al. / Patient Education and Counseling 69 (2007) 47–54
programme will rely on knowledgeable and motivated health
professionals with relevant competence in diabetes care. Some
certificated programmes in diabetes can be offered in the form
of continuing professional development (CPD). These pro-
grammes should be designed to train and upgrade the clinical
skills and knowledge of practicing pharmacists and other health
professionals who are interested in expanding their practice in
the area of diabetes mellitus. Such efforts can produce
competent diabetes educators who would be capable of
designing and implementing a sustainable diabetes control
and prevention programme.
Acknowledgements
We confirm that all patient/personal identifiers have been
removed or disguised so that the patients/persons described are
not identifiable and cannot be identified through the details
given here.
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