الفهرس 
INTRODUCTIONOnly 14 pages are availabe for public view
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Abstract
Diabetes is a significant health condition in elderly individuals, and it is projected to further rise due to population ageing. Diabetes is a chronic condition that needs substantial self-care, continuous education and regular follow-up. Diabetes knowledge and self-care activities mostly depend on verbal instructions by health care professionals in addition to printed educational materials which need an adequate degree of health literacy (HL) in order to be understood and applied by the patient to achieve target outcome.
Awareness of significant determinants of HL, diabetes knowledge and self-care practice will definitely enable health-care personnel to focus available resources and create effective strategies tailored to elderly diabetic patients of poor education and income to effectively manage a challenging chronic disease, such as diabetes.
The aim of this study was to evaluate the effectiveness of an educational intervention program on diabetes literacy among elderly patients with diabetes in Alexandria. Specific objectives included; identifying the health profile of a sample of elderly patients with diabetes in Alexandria, assessing health and diabetes literacy and self-management practices, and their determinants, constructing, implementing and evaluating an educational intervention program designed to improve diabetes literacy and self-care activities among elderly patients with low diabetes literacy.
The study was conducted in two phases:
Phase I: A cross-sectional design in which 2 diabetes clinics affiliated to the health insurance organization in Alexandria were visited to recruit eligible patients. A total of 400 elderly patients with type 2 diabetes (60 years or more), with no communication barriers, who accepted to participate were included in the study. All the patients interviewed completed a pre-designed questionnaire to collect socio-demographic data, personal habits, and medical and diabetes history. Moreover, anthropometric measures and blood pressure were measured for each patient. Fasting blood sugar (FBS) and glycated hemoglobin (HbA1c) were obtained from medical records. All patients were also subjected to the Arabic version of all aspects of health literacy scale (AAHLS), numeracy section of Short Test of Functional Health Literacy in Adults (STOHFLA), Summary of Diabetes Self-Care Activities scale (SDSCA), the Revised Brief Diabetes Knowledge Test (DKT2), Katz Index for Activity of Daily Living (ADL) and Lawton scale for Instrumental Activities of Daily Living (IADL). These scales were used to assess health literacy, diabetes knowledge and self-care activities among elderly patients with diabetes and to recruit the patients with the least diabetes literacy scores into the intervention phase.
Phase II: A quasi-experimental study was conducted to evaluate the impact of an educational intervention program on diabetes literacy and self-care activities among a sample of elderly patients with the least diabetes literacy score in the DKT2. They were divided into two equal groups (30 patients in the intervention group and 30 patients in the control group). A comprehensive educational intervention program was designed to improve diabetes knowledge and self-care activities, aiming at a better diabetes control and reduction in incidence of diabetes complications. The intervention group was divided into 5 groups; each included 6 patients. The program consisted of 6 sessions; each session lasted 90-120 minutes, delivered once weekly for each group for 6 weeks. The program was performed using lectures, power point presentations, printed educational materials and open discussion at the end of each session. The evaluation of the program was done twice; immediately after the end of the program and 3 months later for both groups (intervention and control) using STOHFLA, DKT2, SDSCA and the measurement of body mass index (BMI), HbA1c (only after 3 months), FBS and blood pressure.
The main results of this study could be summarized as follows:
• The mean age of the patients was 65.75 ± 5.15 years and 56.2 % of the patients were males. The mean duration of diabetes was 10.61 ± 5.28 years, 14.3 % were illiterate and 37.2 % of the patients were university graduates. Moreover, 78% of our sample did not practice regular physical activities, 85.5 % did not smoke, 67.8 % were on oral hypoglycemic drugs and 71.8 % did not have another place for diabetes follow up.
• According to AAHLS results, the highest mean percent score of AAHLS was in communicative health literacy (83.9%), followed by functional health literacy (51.5%), while the least score was in the empowerment section (14.83%).
• Regarding the numeracy section of STOHFLA, the highest correct answers were in understanding clinic appointment details (88.5%), understanding prescription instructions (75.2 %), followed by understanding instructions on medication label (61.3 %) and the lowest correct answers were for understanding normal blood sugar ranges (32.3 %).
• According to DKT2 results, 77.8% of patients had low diabetes knowledge and only 6% had high diabetes knowledge. The mean percent score of diabetes knowledge in the study sample was 47.52 ± 14.87 %.
• As for SDSCA, it was found that 73.5 % of elderly patients with diabetes had poor self-care activities (< 3), while 26.5% had good self-care activities (≥ 3). The highest scores were found in diet (3.55) and foot-care (3.42) while the least scores were among blood glucose testing (0.98) and exercise (0.83).
• Uncontrolled diabetes (HbA1c ≥ 7) was found among 79.4 % of the patients, 81.8 % had controlled mean arterial pressure (MAP) (<105.6 mmHg) and 35.3 % were obese (BMI ≥ 30 kg/m2).
• After applying multiple linear regression analysis, two variables proved to be significant predictors of health literacy (AAHLS); level of education and HbA1c (p<0.001 and 0.027 respectively), three variables proved to be significant predictors of health literacy (STOHFLA); level of education, income level and HbA1c (p<0.001, 0.043 and p<0.001 respectively), four variables proved to be significant predictors of diabetes self-care activities; level of education, practicing regular physical activities, FBS and HbA1c (p<0.001, p<0.001, p=0.004 and p<0.001 respectively), and three variables proved to be significant predictors of diabetes knowledge; level of education, practicing regular physical activities and HbA1c (p<0.001, p=0.007 and p=0.024 respectively).
• A significant strong positive linear correlation was found between AAHLS and STOHFLA (0.77, p<0.001) and a significant medium positive correlation with found between AAHLS and both SDSCA (0.378, p <0.001) and DKT2 (0.337, p<0.001). STOHFLA showed a significant medium positive correlation with both SDSCA (0.338, p<0.001) and DKT2 (0.392, p<0.001) and also, a significant medium positive linear correlation was found between SDSCA and DKT2 (0.377, p<0.001).
•After the intervention program, the mean score of DKT2 increased from (32.83) in pre-intervention to (67.60) in post-intervention 1 to (68.44) in post-intervention 2 (108.68 % increase after 3 months) (p<0.001).
•The total mean score of SDSCA increased from (1.24) in pre-intervention to (1.63) in post-intervention 1 to (2.54) in post-intervention 2 (136.57% increase after 3 months)(p<0.001).
•The mean FBS of the intervention group improved from 205 in pre-intervention to 193 in post-intervention 1 and to 170.96 in post-intervention 2 (14.76 % reduction after 3 months) (p<0.001).
•It was noted that the mean HbA1c of the intervention group decreased, 3 months after the program, from (10.36 ) in pre-intervention to (9.28) in post-intervention 2 (4.52 % reduction) (p<0.001).
•The mean BMI of the intervention group decreased, 3 months after the program, from 29.49 in pre-intervention to 28.92 in post-intervention 2 (0.24 % reduction) (p=0.003).
6.2. Conclusion
Health literacy (HL) significantly affects health outcomes and health-related quality of life. Level of education, marital status, income level, occupation, living condition, practicing physical activities, and glycated hemoglobin (HbA1c) level are all significant factors that affect HL levels. The most significant predictors of HL are level of education and HbA1c. Health literacy has a significant positive association with diabetes knowledge and self- care activities.
Diabetes knowledge has a statistically significant association with level of education, income level, occupation, practicing physical activities, having another place for diabetes follow-up, number of comorbid conditions, mean arterial pressure (MAP), body mass index (BMI), fasting blood sugar (FBS) and HbA1c. Level of education, practicing physical activities and HbA1c are significant predictors of diabetes knowledge in elderly diabetic patients.
Diabetes self-care activities are affected by age, level of education, income level, practicing regular physical activities, smoking status, MAP, BMI, FBS and HbA1c. The most significant factors affecting self-care activities among elderly diabetic patients are level of education, practicing physical activities, FBS and HbA1c.
The current quasi-experimental study provided evidence of the effectiveness of diabetes educational intervention programs on elderly diabetic patients resulting in statistically significant improvements in diabetes knowledge, self-care activities, FBS, HbA1c, MAP and BMI, 3 months after the program.
6.3. Recommendations
Accordingly, the following recommendations are suggested:
1. Including educational programs in different health-care settings providing care for patients with diabetes in general and elderly patients in particular and assuring sustainability of these programs.
2. In addition to health education programs, proper drug management according to the latest guidelines and assurance of compliance to medications and self-care activities to achieve better outcome for elderly patients with diabetes.
3. In-service training for all members of the health-care team regarding:
a) Best methods of communication with elderly patients and ways to simplify health-related information that could improve their health literacy.
b) Proper illustration of self-care management including; regular blood glucose monitoring, proper diet, physical exercise, foot care and medication compliance.
4. Proper utilization of mass media to increase community awareness about significance of health and diabetes literacy for the whole population in general and for the elderly in particular.
5. Policy makers need to increase and facilitate health promotion programs for the whole population and particularly for the elderly.
6. Encouraging and developing mass campaigns for screening and early detection of non-communicable diseases such as the “100 million healthy lives” campaign.
7. More research is needed in the fields of health and diabetes literacy:
a) Community based studies to find out what is lacking for the proper health literacy of the whole population.
b)To formulate, implement and evaluate long-term educational programs applied to many focus groups of elderly patients with diabetes.