AbstractAims

To achieve better treatment decisions, type 2 diabetes patients need to be empowered also through knowledge increase. The aim of this study was to evaluate and compare the level of knowledge and overall perceptions of type 2 diabetes within the elderly diabetic patients before and after the National Diabetes Prevention and Care Development Programme 2010–2020.

Methods

Diabetes knowledge test was used in two cross-sectional studies in 2011 and 2020 where the samples of type 2 diabetes patients 65+ were surveyed. Besides descriptive statistics, non-parametric tests and general linear model were used to compare the level of knowledge.

Results

The comparison reveals that in the last decade the general knowledge about diabetes has not significantly changed (U = 16942, p = 0.809). The average scores in 2011 and 2020 were 7.98 ± 2.41 and 7.96 ± 2.36 respectively. The average level of knowledge has slightly worsened for patients in the age group 80+, while it remained approximately the same in the other three age groups (65−69, 70−74, 75−79).

Conclusions

Our study has shown that despite the National Diabetes Prevention and Care Development Programme the knowledge of elderly diabetic patients in Slovenia remained at the same level or worsened.

1. IntroductionDiabetes mellitus (DM) is a chronic disease and a leading cause of mortality and reduced life expectancy. The International Diabetes Federation (IDF) has estimated that 463 million adults live with diabetes worldwide in 2019 with a projected increase to 578 million by 2030 and 700 million by 2045 if no effective prevention methods are adopted [[1]International Diabetes Federation ]. Diabetes prevalence among adults 20–79 (diagnosed and age-standardised) was 6.2% on average in EU countries in 2019. The rates varied from 9% or more in Cyprus, Portugal, and Germany to less than 4% in Ireland and Lithuania, while Slovenia was slightly below EU average with 5.9% [[2]Health at a Glance: Europe 2020: State of Health in the EU Cycle.]. It is estimated that the prevalence of diabetes will rise to 7.3 in 2030 and 7.8 in 2045 [[1]International Diabetes Federation ]. Currently, half of the people with diabetes do not know that they have diabetes [[3]Saeedi P. Petersohn I. Salpea P. et al.Global and regional diabetes prevalence estimates for 2019 and projections for 2030 and 2045: results from the International Diabetes Federation Diabetes Atlas, 9th edition.]. The global increase in diabetes is associated with socioeconomic, demographic, environmental and genetic factors, starting with growing urbanisation and changing lifestyle habits [[1]International Diabetes Federation ].The prevalence of diabetes is higher among elderly. According to OECD [[2]Health at a Glance: Europe 2020: State of Health in the EU Cycle.], 19.3 million people aged 60–79 have diabetes across EU countries, representing 59.7% of all people with diabetes in EU [[2]Health at a Glance: Europe 2020: State of Health in the EU Cycle.]. Slovenia does not differ from the comparable developed countries. Also in Slovenia, the prevalence of type 2 diabetes (T2D) is increasing. According to the available data, there were 111,346 patients with T2D in 2017, among them 53% was male. Their average age was 66.6 years and 59.7% were 65+ years old []. The numbers were estimated based on the use of medicines.The first National Diabetes Prevention and Care Development Programme in Slovenia (NDPCDP) was adopted in 2010. The activities designed and implemented were targeted at the entire population and specifically for individuals at high risk for type 2 diabetes [[5]Prevention and Care Development Programme 2010–2020.]. The main aims of the activities were to reduce the incidence of diabetes, postpone or prevent T2D in high-risk individuals; increase the chances of early detection of diabetes; and reduce complications and mortality from diabetes. To achieve these aims, the actions prepared within the NDPCDP were implemented to empower the patient. Empowered people with diabetes have knowledge, understanding and skills related to their diabetes and are able to make decisions related to own health and quality of life; such patients enter the coordinated and patient-centred care process and live in an active society that is aware of the importance of the burden of diabetes on the individual, his/her family and loved ones, the community and society as a whole [[6]Prevention and Care Development Programme 2020–2030, Development Strategy.].In the period from 2010 to 2020, the access to education has been strengthened [[6]Prevention and Care Development Programme 2020–2030, Development Strategy.], especially at the primary level, by upgrading family medicine teams to include graduate nurses and by upgrading health promotion centres with new diabetes management programs. The functioning of family medicine teams has been improved through care coordinator, which supports the implementation of comprehensive care. To support education, a mentoring network between healthcare levels was introduced.As studies show, empowered patients can achieve a better level of confidence on the basis of knowledge, experience and skills that will enable the decision on treatment in accordance with the objectives [7Lambrinou E. Hansen T.B. Beulens J.W.J. Lifestyle factors, self-management and patient empowerment in diabetes care., 8Powers J.K. Bardsley M.C. Cypress M. et al.Diabetes self-management education and support in adults with type 2 diabetes: a consensus report of the American Diabetes Association, the Association of Diabetes Care & Education Specialists, the Academy of Nutrition and Dietetics, the American Academy of Family Physicians, the American Academy of PAs, the American Association of Nurse Practitioners, and the American Pharmacists Association., 9Funnell M.M. Brown T.L. Childs B.P. et al.National standards for diabetes self-management education., 10Gómez-Velasco D.V. Almeda-Valdes P. Martagón A.J. et al.Empowerment of patients with type 2 diabetes: current perspectives., 11Bailo L. Guiddi P. Vergani L. et al.The patient perspective: investigating patient empowerment enablers and barriers within the oncological care process.]. In addition to basic knowledge, T2D patients need a regular, systematic education throughout their lives to ensure the maintenance of the knowledge level and information on the new principles and procedures in the treatment of diabetes [12Chronic disease self-management education programs: challenges ahead., 13Self-management education and support in chronic disease management., 14Lee S.K. Shin D.H. Kim Y.H. Lee K.S. Effect of diabetes education through pattern management on self-care and self-efficacy in patients with type 2 diabetes.].The last study to evaluate the general knowledge of patients with DM in Slovenia has been conducted in 201 [[15]Turk E. Palfy M. Prevolnik Rupel V. Isola A. General knowledge about diabetes in the elderly diabetic population in Slovenia.], just before the implementation of National Diabetes Prevention and Care Development Programme 2010–2020. As one of the primary goals of the Programme was to educate and empower the patient, it is proper to check whether the knowledge of patients has improved during the last decade. The aim of the study was to evaluate the level of knowledge and overall perceptions of DM within the elderly diabetic patients 65+ in Slovenia after the National Diabetes Prevention and Care Development Programme 2010–2020 has run out and at the same time to evaluate whether the Programme has contributed to higher levels of general knowledge about DM among patients.2. Methods2.1 Study population and sampling

The 2011 study was a cross-sectional study that was conducted among non-insulin dependent patients with diabetes mellitus type 2 in North-East Slovenia who were older than 64 years. 300 questionnaires were delivered to a diabetologic outpatient clinic, private specialist practice, family physician practice and a nursing home. The subjects were selected using a convenience sample of patients visiting physicians for their check-ups. The nurses in the practices were asked to hand the questionnaire to patients that came into the practice. The patients filled out the questionnaire on the spot and returned it to the nurse, who collected the questionnaires. The time frame of data collection was May–August 2011. A total of 225 individuals returned the questionnaire, which represents 75% response rate. Out of these, 45 were excluded due to unmet age requirements, 1 questionnaire was excluded for being incomplete, which resulted in a sample of n = 179 respondents.

The 2020 cross-sectional study investigated the same target population of patients with diabetes, only that they were recruited from different health centres. The study was conducted in two community health centres: Zdravstveni dom Ljubljana, which is the largest health centre in urban environment in Ljubljana and in Zdravstveni dom Ravne na Koroškem, a rural health centre. The potential respondents were required to meet the following inclusion criteria at the time of the study in order to be considered: (a) they were patients at health centres Ljubljana or Ravne na Koroškem, (b) they were at least 65 years old, (c) they had been diagnosed with type 2 diabetes (T2D) and (d) they gave their consent to participate in the study. The time frame of data collection was February–October 2020. A total of 198 individuals were given the questionnaire at the point of their visit in health centre. Each patient filled out the DKT questionnaire as well as provided data on social and demographic variables. 7 of the questionnaires were excluded due to unmet age requirements, which resulted in a convenient sample of n = 191 respondents.

2.2 InstrumentIn 1998, the diabetes knowledge test (DKT) was validated and introduced as a reliable instrument for the evaluation of patients’ general knowledge of diabetes [[16]Chrvala C.A. Sherr D. Lipman R.D. Diabetes self-management education for adults with type 2 diabetes mellitus: a systematic review of the effect on glycemic control.]. DKT has since been translated into many languages, including Spanish, Greek, Navajo, Norwegian, Arabic, and Malaysian [[17]Fitzgerald J.T. Funnell M.M. Anderson R.M. et al.Validation of the revised brief Diabetes Knowledge Test (DKT2).]. DKT was translated into Slovenian in 2010 [[15]Turk E. Palfy M. Prevolnik Rupel V. Isola A. General knowledge about diabetes in the elderly diabetic population in Slovenia.]. DKT consists of 23 knowledge test items. The first segment, represented by the first 14 questions is general and is appropriate for adults with type 1 and type 2 diabetes. An additional nine items constitute the insulin-use subscale that is appropriate for adults with type 1 diabetes and type 2 patients using insulin. In our studies, only the first 14 items were used as the samples included patients with and without insulin. The highest score obtainable if all questions were answered correctly was 14 points. The test takes approximately 8−10 min to complete. Scoring is done by summing the number of questions answered correctly [[18]Fitzgerald J.T. Funnell M.M. Hess G.E. et al.The reliability and validity of a brief diabetes knowledge test.]. Higher scores indicate greater knowledge about diabetes and management of diabetes. The DKT should not be used to evaluate diabetes self-management education/training because the questions do not match item-to-item with diabetes self-management program’s educational components, but rather it should be used as a measure of general diabetes knowledge [].2.3 Ethics

The 2011 study was carried out as a part of a wider study on patient reported outcomes of the elderly population with type 2 diabetes mellitus in Slovenia, which was approved by the National Medical Ethics Committee of the Republic of Slovenia. The 2020 study was conducted within Horizon 2020 study Scale-up Hypertension and Diabetes Care (SCUBY). It was approved by the Committee for Medical Ethics no. 0120-219/2019/4 on 24 May 2019.

2.4 Analysis

Descriptive statistics were used to describe participant characteristics. Non-parametric tests (Mann–Whitney U and Kruskal–Wallis) were used to compare the level of knowledge according to demographic variables and general linear model was used to test the interaction effects between the time of measurement (2011 and 2020) and demographic variables. R version 4.01 and SPSS statistical packages were used in the analysis.

3. Results

Out of 191 participants with T2D included in the study in 2020, 55.5% were women. The average age of the participants was 74.9 ± 6.6 years with minimum age of 65 and maximum age of 98 years. Most of the respondents had secondary school (55.5%), 21.5% had primary school and the rest (18.8%) had tertiary education. Almost all participants were retired (98.4%). Two thirds of the participants came from urban and one third from rural environment.

The average score on the research questions regarding the general knowledge about diabetes among diabetic patients 65 years and older was 7.96 ± 2.36 with a minimum score of 1 and a maximum score of 13 points (out of 14 in total). The level of general knowledge about diabetes was analysed according to gender, regions, education and age groups using the non-parametric Mann–Whitney U and Kruskal–Wallis tests for independent samples. All significance tests were two-tailed and a probability value of less than 0.05 was considered statistically significant. The results of Mann–Whitney U test suggest that general knowledge does not differ according to gender (U = 4639, p = 0.7223) and rurality (U = 3640.5, p = 0.1782). Using the Kruskal–Wallis test for multiple independent samples, the general knowledge differs according to the education level (K–W = 10.614, p = 0.005) and age groups (K–W = 13.193, p = 0.004). The average scores achieved by participants with primary education, secondary education and tertiary education (Fig. 1, Table 1) were 7.0 ± 2.7, 8.0 ± 2.1 and 8.8 ± 2.3 respectively. The average scores (Fig. 2, Table 1) achieved by participants in age groups 65−69, 70−74, 75−79 and 80+ were 8.5 ± 2.1, 8.3 ± 2.0, 8.1 ± 2.3 and 6.8 ± 2.7, respectively.

Fig. 1Knowledge distribution by education levels, 2020.

Table 1Average knowledge scores and changes in the level of knowledge across demographic subgroups in period 2011–2020.

Fig. 2Knowledge levels by age groups, 2020.

The results of the 2011 study describing the general knowledge about diabetes among patients and bivariate comparisons of the level of knowledge according to demographic variables (gender, age, education, rurality) have been summarized in a previous study [[15]Turk E. Palfy M. Prevolnik Rupel V. Isola A. General knowledge about diabetes in the elderly diabetic population in Slovenia.].

Comparison of knowledge level between 2011 and 2020 reveals that in the last decade the general knowledge about diabetes has not significantly changed (U = 16942, p = 0.809). The average scores in 2011 and 2020 were 8.00 ± 2.4 and 8.00 ± 2.4 respectively. To test if significant changes in knowledge occurred in particular sub-segments of the sample, a general linear model was used to test the interaction effects of the time of measurement (2011 vs. 2020) with demographic variables (gender, age, education, rurality).

The general knowledge about diabetes slightly improved in females and slightly worsened in males (Table 1). The interaction between the time of measurement and gender is statistically significant (F(1, 365) = 4.742, p = 0.030).In the observed period 2011–2020, the average levels of knowledge has slightly worsened for patients in the age group 80+, while it remained approximately the same in the other three age groups (Table 1). The changes in knowledge for the observed age groups in the last decade are not statistically significant (F(3, 363) = 0.126, p = 0.945). Likewise, the changes in knowledge among different education level groups were not statistically significant in the last decade (F(2, 365) = 0.946, p = 0.389). The average level of general knowledge is positively correlated with the level of education; in the last decade, the average knowledge scores slightly decreased among patients with secondary and tertiary education, but remained approximately the same among patients with primary education. No significant changes in knowledge in the 2011–2020 period are present neither in the segment of patients living in urban areas nor in patients living in rural areas (F(1, 367) = 0.000, p = 0.990).4. DiscussionThe activities, designed and implemented within the first National Diabetes Prevention and Care Development Programme2010–2020 in Slovenia, were aimed to reduce the incidence of diabetes and to educate and empower the patient. In spite of the strengthened access to the education programs, the general level of diabetes knowledge has not improved over the course of the ten years NDPCDP and remained at the same level. While there were slight changes in knowledge in some subgroups of the population, the general level of knowledge stays the same. On average, the patients scored 8 points out of total of 14. This overall poor knowledge of the elderly diabetic patients raises concerns about the involvement of patients in their disease management and improving the health outcomes. Previous research has shown that diabetes knowledge is related with successful self-management and health outcomes [[20]Kueh Y.C. Morris T. Ismail A.A.S. The effect of diabetes knowledge and attitudes on self-management and quality of life among people with type 2 diabetes.,[21]Gomes M.B. Santos D.C. Pizarro M.H. et al.Does knowledge on diabetes management influence glycemic control? A nationwide study in patients with type 1 diabetes in Brazil.]. The current results are particularly worrisome in times of the pandemic whe access to traditional diabetes education is affected.

However, the results demonstrate that the area of living regarding the rurality does not influence the level of general knowledge alongside gender. Age and education of the patients seems to have an impact on the knowledge level: knowledge declines with increasing age and with lower education.

A study, conducted in 2020 [[22]Prevolnik Rupel V. Ogorevc M. Mori Lukančič M. Poplas Susič T. Costs and quality of life in patients with type 2 diabetes. In: Z. Klemenc Ketiš (ed.).], claims that the participation in education organized in form of workshops at health promotion centres is extremely low. Multiple reasons are listed as a cause: well-organized and sufficient education within primary and secondary visits resulting in no further need for information and education, lack of motivation, non-attractive presentation and promotion of workshops from the side of the nurse or organizational inconvenience. It would be worth conducting a qualitative research to discover the underlying reasons and rethinking options to improve or change the education program in health promotion centres or even transfer or join all the education programs currently running at different places.As the preparation of new National Diabetes Prevention and Care Development Programme 2020–2030 is currently underway, it is worth to reflect on the results of the study and form the new solutions and recommendations for the education programs development in the area of T2D, which would be more effective. The upcoming program has to take into account the didactical principles suitable for the elderly which consider the individual needs and learning styles of the patients [] as well as avoid organizing redundant educational workshops on topics where patients already have sufficient information. Also, an organizationally suitable way of presenting information in terms of contents and timing of the workshops is suggested; for example, taking into consideration the age and type of audience the content is being delivered to as well as the time of day that audience is able to attend [[22]Prevolnik Rupel V. Ogorevc M. Mori Lukančič M. Poplas Susič T. Costs and quality of life in patients with type 2 diabetes. In: Z. Klemenc Ketiš (ed.).]. Slovenia is currently carrying out a project with one of the aims to review and analyse existing activities for improving health literacy (ZaPis) for 10 selected chronic diseases []. Knowledge about the disease represents a part of broader health literacy and our study can serve as a contribution to the review and evaluation of health literacy in T2D.

The lack of a randomized sample and the use of a convenience sample in both studies limit the ability to generalize the results. Because the study in 2011 was conducted in a single region of Slovenia and the study in 2020 in two Slovenian regions, it cannot be claimed that the results reflect the knowledge at the national level. Furthermore, only older population was included in the study while self-management of the disease is also very important for younger patients. A larger sample would provide more power to detect significant relationships between the study variables and differences between groups of patients. Also, the results of the time comparison should be interpreted with caution as the direct comparability of the two samples is questionable.

5. Conclusions

The central objective of this research was to evaluate the level of knowledge and overall perceptions of T2D within the elderly diabetic patients 65+ in Slovenia before and after the National Diabetes Prevention and Care Development Programme 2010–2020. Our study has shown that despite the NDPCDP, the knowledge of elderly T2D patients in Slovenia remained at the same level or even worsened. Given the findings, we call for different action on educating diabetic patients about their disease. Our study suggests that further educational efforts, more adapted to age and specific needs of the T2D patients are needed in times where general information about the disease is widely accessible. It is important to engage patients in discussions about T2D, so that they can become empowered co-creator of their disease management, reduce avoidable complications and improve their health outcomes. The COVID-19 pandemic offers an opportunity to rethink the diabetes education in light of new emerging needs. The national strategy needs to foresee and take into account innovative ways of education and consider digital solutions to engage and better educate the older diabetic patients.