Download A COMPARISON BETWEEN HBA1C LEVELS AND KNOWLEDGE

Acta Medica Mediterranea, 2015, 31: 681
A COMPARISON BETWEEN HBA1C LEVELS AND KNOWLEDGE AND ATTITUDES CONCERNING
DIABETES AMONG TYPE 1 AND TYPE 2 DIABETICS
ELIF ÜNSAL AVDAL1, NURCAN ÖZYAZICIOĞLU2*, GÜLSEV DIRIK3, AYŞEN AKKURT4
1
Katip Çelebi University, Faculty of Health Science, Izmir - 2Uludağ University, School of Health, Bursa - 3Uludağ University,
Faculty of Medical, Diabetes Nurse, Bursa - 4Uludağ University, Faculty of Medicine, Department of Pediatric Endocrinology,
Bursa, Turkey
ABSTRACT
Aim: The purpose of this study was to compare the knowledge of and attitude to diabetes with HbA1c levels in type 1 and type
2 diabetics.
Materials and methods: The sample of the study consisted of 118 type 1 diabetics and 125 type 2 diabetics, a total of 243 individuals. Sampling strength was 92%. A personal characteristics identification form, a diabetes knowledge assessment form (prepared
separately for type 1 and type 2 diabetics), a Diabetes Attitude Scale (DAS), and the HbA1c values of the participants for the previous three or six months were used.
Results: All diabetics had a good level of knowledge of diabetes, and their diabetes attitude scores showed that they had a
positive attitude. There was a strong correlation between the mean knowledge scores of the diabetics in the study and their mean
DAS scores for type 1 diabetics (r = 0.76, p< 0.001) and a medium level correlation for type 2 diabetics (r = 0.72, p< 0.001). A statistically significant negative correlation was found between HbA1c levels and knowledge and DAS scores of type 1 and type 2 diabetics. As knowledge of diabetes and DAS scores increase, so HbA1c levels fall.
Conclusion: Type 1 and type 2 diabetic patients, knowledge and attitude affects HbA1c levels. All healthcare staff and particularly nurses should eliminating lack of knowledge with the help of continuous education programs.
Key words: Type 1 diabetes, Type 2 diabetes, Knowledge level, Attitude to diabetes, HbA1c, Nursing education.
Received June 18, 2014; Accepted April 02, 2015
Introduction
Diabetes is a health problem which requires
long term care and treatment, creates problems for
individuals and society because of its complications, and whose prevalence is steadily increasing(1). World has 386,667.28 people with diabetes
(8.33%) having Turkey in upper extreme of prevalence of diabetes with 14.9%, seven percentage
points higher that Italy with 7.71% of prevalence(²).
From 1980 to 1998, the age-adjusted rate of diagnosed diabetes was similar for men and women.
However, in 1999, the rate for males began to
increase at a faster rate than that of females. From
1980 to 2011, the age-adjusted rate of diagnosed
diabetes increased 156% (from 2.7% to 6.9%) for
males and 103% (from 2.9% to 5.9%) for
females(³).
With the discovery of insulin and oral antidiabetic drugs, the life expectancy of increased, and
for this reason the attitudes of diabetics towards
diabetes ad their HbA1c levels have been affected
as they have begun to live longer. Diabetes is a
divergence from health, and it may not cause a
change in an individual’s attitude to diabetes in
order to cope with the new situation. The purpose
of diabetes management is to review the knowledge and attitudes of diabetics concerning to
improve treatment compliance, and achieve
glycemic control(1).
682
Increasing individuals’ motivation their positive attitudes and knowledge are the basis of diabetes treatment(4). In developing a positive attitude,
approaches must be adopted to discourage patients
from denying their illness and to ease the way for
them to accept the situation. It has been shown that
raising the level of knowledge of diabetes contributes to developing a positive attitude to the disease in diabetic patients(5-8).
One of the best indicators of glycemic control
in diabetics is the HbA1c level. As the attitude of
diabetic patients towards diabetes develops, so
their glycemic control is expected to improve(1). In
the literature it has been reported that knowledge
of diabetes and attitudes to diabetes affect HbA1c
levels(9-15).
It has been established that patients with a
negative attitude to diabetes encounter more obstacles in their care, and that their HbA1c levels are
higher(16).
Education given by nurses is of great importance in developing the attitudes and knowledge of
diabetics towards their own health. Positive results
can be obtained in the control and treatment of diabetes by means of a simple nursing intervention
program(17-20).
This study was planned with the aim of determining the relationship between knowledge level,
attitude to diabetes and HbA1c levels in the management of diabetes. One study was found examining these three factors together in diabetics in
Turkey.
The aim of this study was to investigate the
knowledge of diabetes and attitudes to the disease
among type 1 and type 2 diabetics by comparing
them with their HbA1c levels.
Materials and methods
The study was carried out in the endocrinology
clinic and outpatients’ department of a university in
the province of Bursa, Turkey. It was conducted as a
descriptive study to determine the level of knowledge of diabetics, their DAS scores and their HbA1c
levels, and the correlation between them.
Participants and sample of study
The population of the study comprised type 1
and type 2 diabetics registered at the clinic and outpatients’ department of the Endocrinology Clinic of
Uludağ University Medical Faculty Hospital.
The sample consisted of a total of 243 diabet-
Elif Ünsal Avdal, Nurcan Özyazicioğlu et Al
ics, 118 with type 1 diabetes and 125 with type 2
diabetes, between the ages of 18 and 65, diagnosed
with diabetes at least six months previously.
Data collection
A personal characteristics identification form, a
diabetes knowledge assessment form (prepared separately for type 1 and type 2 diabetics), a diabetes
attitude scale (DAS), and the HbA1c values of the
participants for the previous three or six months
were used in the collection of data.
The personal characteristics identification form
was created by the researchers, benefiting from the
relevant literature(1). The form included space for
age, gender, education level, marital status, diabetes
type, duration of diabetes, education on diabetes,
individuals in the family with diabetes, and diabetes
complications.
The Diabetes Information Knowledge
Assessment Form
The diabetes information knowledge assessment form was prepared for type 1 and type 2 diabetics separately by the researchers, making use of
the literature(1). This form was created in order to
assess the level of knowledge of the diabetics
included in the study. The knowledge assessment
form created for type 1 diabetics consisted of 35
questions on all the knowledge included in diabetic
education, while that prepared for type 2 diabetics
consisted of 33 questions on all knowledge included
in diabetes education. The questions on these forms
were evaluated as correct (1), or incorrect or unanswered (0). Raw scores of 0-35 for type 1 diabetics
and 0-33 for type 2 diabetics were obtained and converted to a scale of 0-100 for ease of interpretation.
A high total score on the diabetes knowledge assessment form showed that the patient had sufficient
knowledge of his/her illness.
The original form of The Diabetes Attitude
Scale (DAS) was developed by America National
Diabetes Commission and the Turkish adaptation
and validity and reliability studies(Cronbach alpha
0.90) were carried out by Özcan in 1999. The DAS
consists of 34 Likert-type questions and is applicable to type 1 and type 2 diabetic adults. Its test-retest
correlation coefficient is 0.71, and the general scale
Cronbach on the subgroups and their correlations
were evaluated, and were found to be within the
limits of 0.39-0.94. The results show that the scale
can be used with diabetics as a valid and reliable
means of measurement. The scale is composed of a
A comparison between HbA1c levels and knowledge and attitudes concerning diabetes ...
total of seven sub-scales, and the items are evaluated
with Likert-type scoring ranging from 1 to 5. A
score of >3 denotes a positive attitude, while a score
of ≤3 shows a negative attitude (16). Higher or
lower scores strengthen the attitude in the same
direction.
The patients’ HbA1c values from the previous
three or six months were obtained from their files.
Data collection
Research data was collected at the hospital by
the researcher by means of one-to-one interviews
with the patients.
Statistical analysis
All the statistical analyses were carried out
using the SPSS 20.0 for Windows. In the evaluation
of the data, numerical values, percentages, Pearson
correlation and multiple regression analysis were
used.
Ethical aspects of the study
Permission was obtained to carry out the study
from the ethics committee of the Medical Faculty
Hospital of the University. In addition, the necessary
explanation was given to the patients who consented
to take part in the study, and written approval was
obtained from them.
Results
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type 1 and type 2 diabetics and their HbA1c levels.
It can be said that variations in HbA1c levels in 76%
of the type 1 diabetics and in 72% of the type 2 diabetics can be ascribed to their knowledge levels and
their attitudes to diabetes (Table 3).
Identifying
Characteristics
Type 1
Type 2
Gender
No
%
No
%
Female
62
52.54
75
60
Male
56
47.46
69
40
Duration of Diabetes
1-5 years
12
10.16
19
15.2
6-10 years
33
27.96
34
27.2
11-15 years
25
21.18
32
25.6
16-20 years
28
23.72
18
14.4
<21
20
16.94
22
17.6
Diabetes education
Yes
85
72.04
72
57.6
No
33
27.96
53
42.4
X±Sd
X±Sd
35.59 ± 9.29
52.79 ± 6.19
HbA1c *
%6.6 ± 1.1
%6.8 ± 1.5
Diabetes
Knowledge
Score *
71.0 ±11.3
68.0 ±9.4
DAS total
4.58±0.62
3.65±0.43
Age *
score*
Among the Type 1 diabetics, 52.54% were
female, 29.66% were high school graduates, 27.96%
had had diabetes for 6-10 years, 72.03% had
received diabetes education, and their average age
was 35.59 years. 60% of the Type 2 diabetics were
female, 26.4% were high school graduates, 27.2%
had had diabetes for 6-10 years, 57.6% had received
diabetes education, and their average age was 52.79
years. Table 1 shows patients’ average scores on the
subscales of the diabetes attitude scale and on the
total scale.
The strongest positive attitude of the type 1
diabetics was Attitude to Team Care, and the weakest positive attitude of the type 2 diabetics was
Attitude to Adaptation to the disease (Table 2)
The results of the multiple regression analysis
showed that the attitudes to diabetes and the knowledge scores of the type 1 and type 2 diabetics had a
statistical effect on their HbA1c levels. It was determined that there was a statistically negative correlation between the knowledge and DAS scores of the
Table 1: Identifying Characteristics of Type 1 and Type
2 Diabetics (n:243).
*Average.
Type 1 Diabetes
X±Sd
Type 2 Diabetes
X±Sd
DAS subgroups
Need for special education
3.95±0.33
3.57±0.41
Attitude to adaptation to the illness
3.79±0.89
3.48±0.53
Severity of diabetes
4.01±0.40
3.73±0.52
Blood glucose control and complications
3.71±0.47
3.68±0.52
Effect of diabetes on patient’s life
4.15±0.43
3.78±0.5
Attitude to patient autonomy
3.95±0.28
3.61±0.34
Attitude to team care
4.95±0.17
3.66±0.32
Total DAS score
4.58±0.62
3.65±0.43
Table 2: Average scores of Diabetics on the Diabetes
Attitude Scale.
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Elif Ünsal Avdal, Nurcan Özyazicioğlu et Al
Independent
Type 1
Type 2
Variables
B
β
P
R
R Square
B
β
P
R
R Square
DAS
-19.79
0.71
.000
0.87
0.76
-19.45
0.73
.000
0.85
0.72
Knowledge Level
-16.88
0.73
.000
-16.23
0.7
.000
Table 3: Examination of the Independent Variables Affecting the HbA1c levels of Type 1 and Type 2 Diabetics (n:243).
Discussion
Diabetic patient education consists mainly in
provide knowledge about diet, exercise and drug
treatment in relation to glycemic control, enabling
the patient to feel better(1,21-22). In our study, 72.03%
of type 1 diabetes patients and 57.06% of type 2
diabetes patients had received diabetes education.
It has been reported that diabetes education is
effective in changing the lifestyle of patients, that
their attitude and perceptions in relation to the disease are more positive after education, and that
they can manage their illness better(23). In Turkey
there are follow-up programs in the struggle
against diabetes. Also in Turkey, it was found in a
study by Dündar et al. (24) that half (51.4%) of a
study group over the age of 20 had sufficient
knowledge of diabetes.
It was found in our study that the DAS score
of the type 1 diabetics was 4.58±0.62, and that of
the type 2 diabetics was 3.65±0.43. In a study in
this topic by İnkaya and Karadağ(25) the diabetes
attitude score was found to be 4.06, Kartal et al(5)
found it to be 3.48, and in a study by Mollaoğlu et
al.(6) it was found that those who had previously
received diabetes education had a DAS score of
3.95±0.28, while those who had not scored
3.66±0.34.
As Table 2 shows, the type 1 diabetics had the
highest positive score in the subdimension of
Attitude to Team Care, and the type 2 diabetics had
the lowest positive score in the Attitude to
Adaptation to the Illness; this shows strong satisfaction with the approach of the health team, and
medium satisfaction with Adaptation to the Illness.
The high attitude scores of the type 1 diabetics
may be explained by the fact that this age group
was younger, and more open to change, novelty
and communication. It can be said that the average
DAS score of over 3 means that both groups were
successful in adapting to the illness.
In the regression analysis in Table 3, it was
found that the patients’ scores on attitudes and
knowledge concerning diabetes statistically affect-
ed HbA1c levels. It was determined that there was
a positive relation between knowledge scores and
DAS, and a negative correlation between knowledge and attitude scores and HbA1c.
Similarly, Ambigapathy et al.(26) established
that there was a positive correlation between
patient knowledge levels and attitudes, and that
those who had a good knowledge of diabetes had a
better attitude to the disease. It has been found in
other studies that knowledge of diabetes is effective in developing a more positive attitude to diabetes and in raising attitude scores(24,27-29). Kartal et
al. (5) reported that the average DAS scores of
patients whose levels of conformity to treatment
were good were higher than those of patients
whose levels of conformity to treatment were poor.
It is known that those who have adequate
knowledge of the illness achieve better glycemic
control than those whose knowledge is not adequate (30). Similarly to the findings of our study,
McPherson et al.(15) reported that there was a negative relationship between knowledge scores and
HbA1c. In other studies, increase in the level of
knowledge of diabetes has been found to lower
HbA1c levels(9,13-15) and an improvement in the levels of HbA1c has been observed(12).
Results which did not accord with those of
our study were seen in a study by Hu et al.(31). No
correlation was found between the level of knowledge of diabetes and glycemic control. It is thought
that this result could be for physiopathological reasons such as patients’ reactions to drugs, or inadequate diabetes self-management by the patients.
The management of diabetes requires a multidisciplinary approach, and the team should not be
overcome by the rapidly changing knowledge of
diabetes. Nurses have an important role in creating
a professional database, obtaining up-to-date information and making this information easy to
use (32,33). Continuous patient education and the
achievement of glycemic control seem possible.
There are studies of interventional responses by
nurses by means of education and the improvement
of deteriorating HbA1c values(17-20).
A comparison between HbA1c levels and knowledge and attitudes concerning diabetes ...
Hilliard et al.(34) reported that the quality of
life of type 1 and type 2 diabetics was improved
with continuous education programs, and better
glycemic control was achieved.
According to these findings, it can be said
that an increase in the level of diabetes knowledge
has an effect on the development of a positive attitude to the illness, and that it lowers HbA1c levels.
7)
8)
9)
Conclusion
In conclusion, it was found that HbA1c levels
were similar in type 1 and type 2 diabetics. It was
seen that previous diabetic education had a positive
effect, raising knowledge of and attitude to diabetes,
and lowering HbA1c levels. In addition, as diabetes
knowledge scores and DAS scores rose in the diabetics in the study, so HbA1c levels fell. The DAS
scores of both groups were above average, although
those of the type 1 diabetics were higher.
It is principally nurses who, with the help of
continuous education programs, can determine the
knowledge, beliefs and attitudes concerning diabetes, identify shortcomings and solve problems by
working to change patients’ knowledge and attitude
and to monitor HbA1c levels. For this reason, it may
be recommended that further studies be conducted
to determine and increase knowledge of diabetes
and attitude of adaptation to diabetes.
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Correspoding author
NURCAN ÖZYAZICIOĞLU, Assoc. Prof.
Uludağ University, School of Health
Bursa
(Turkey)