Developing and standardizing a tool to assess the health education needs of diabetic patients at Jazan Armed Forces Hospital

doi:10.21203/rs.3.rs-3758790/v1

Objectives

To develop a tool for identification of health education needs of individuals living with diabetes in Jazan Armed Forces Hospital (JAFH) and to standardize the questionnaire by assessment of its reliability and validity.

Methods

A cross-sectional design was used in the present work, which included 303 participants living with diabetes. An expert panel in family medicine and endocrinology created a comprehensive and mutually exhaustive questionnaire that covered every potential area of health education needs. It included five socioeconomic questions and a 5-point Likert scale (15 items) to determine the participants' needs for health education. To assess the Likert scale's reliability, Cronbach's alpha was used. The exploratory factor analysis was used to assess the Likert scale's construct validity.

Results

The total number of males was 123 (40.6%) and that of females was 180 (59.4%). Their ages had a mean of 55.9 ± 12.9, ranging from 18 to 94 years. The reliability of the 15-item Likert scale was 83%, and it increased to 90% when the redundant items (n = 5) were eliminated. The test had 86% test-retest reliability when repeated. Also, the final 10-item Likert scale has significant face, content, and construct validity. Two components with Eigenvalues over one (generic knowledge about diabetes and diabetes and travel) could be extracted out of the 10-item Likert scale.

Conclusion

The final 10-item Likert scale offers a good degree of validity and reliability for determining the health education needs of individuals living with diabetes. The two Likert scale components and their contributing items were identified from the questionnaire, which is standardized and helpful in both practice and research, in order to ascertain patients' needs and develop structured health education programs.

diabetes

health

education

Likert

scale

questionnaire

Diabetes is a dangerous and intricate metabolic illness that has a significant impact on the lives of those who have it as well as their families. Diabetes in kids and teens can make it more difficult for families to function and impede their normal social and psychological growth. Its incidence is becoming epidemic-like on a worldwide basis. The International Diabetes Federation projects that by 2035, there would be 592 million cases worldwide¹.

An essential component of managing diabetes is diabetes self-management education and training ². Patients with diabetes should understand the causes, symptoms, risks, and treatments associated with their condition³. It is crucial to raise community awareness of the unique requirements of those who live with diabetes.

Primary care and secondary prevention are important, and diabetes educators should emphasize this. Many of the tactics employed to achieve the objectives have the power to positively alter an individual's behavior and foster greater understanding throughout the community, dispelling misunderstandings related to diabetes. A supportive environment at work, home, and in recreational places facilitates change more easily and sustains it longer⁴. Studies indicate that individuals who engage in diabetes education are more likely to adopt optimal behaviors and experience reduced health care expenses^5-6.

According to the Declaration of Alma-Ata, 1978 ⁷, one of the key objectives of primary health care is to educate patients and families about common health issues and how to prevent and control them through the use of scientifically sound methods and technology. Family physicians are best suited to offer structured diabetes health education programs. Determining the health educational needs of people with diabetes is essential for developing patient-centered programs that will enhance the treatment of diabetes. It is very necessary to build a need assessment instrument with a scientific basis.

2.1 Study design and setting: A cross-sectional analytic design was used in the present work that was conducted at Jazan Armed Forces Hospital (JAFH). Jazan is the capital city of Jazan region that lies in the southwest corner of Saudi Arabia on the Red Sea coast, just north of Yemen and has a large agricultural community. The JAFH is a 100-bed secondary hospital that provides health care for military personnel and their families (approximately 100000).

2.2 Sample size justification and Sampling procedure: Based on a prior study's estimated 23.7% diabetes prevalence⁸, a 95% confidence coefficient, a 5% confidence interval, and a 10% nonresponse rate, a sample size⁹ of 303 people was determined. Every third patient, based on their chronological attendance at the reception desk in various JAFH outpatient clinics, was chosen for the study using a systematic random sample technique.

2.3 Inclusion criteria:

Patients living with diabetes.
Eligibility for medical care at JAFH
Consent to participate in the survey.

2.4 Exclusion Criteria: Complaint regarding a serious issue that occurred during the survey and may have affected the gathering of data.

2.5 Tools of the Study (Health education questionnaire for need assessment):

A team of experts in endocrinology and family medicine created the questionnaire. It was divided into two sections. The first section included five questions (Qs 1, 2, 3, 4, and 20) to gather information about the participants' age, sex, type, and duration of diabetes as well as the source of the health education resource they thought was the best. The second section had fifteen items (Qs 5–19) designed in a Likert scale manner to determine the participants' needs in terms of health education. The Likert scale items covered every potential area of need for health education and were mutually exhaustive. Participants' answers varied from strongly agreeing (very important) to strongly disagreeing (not significant at all)

Prior to the survey, the face validity of the questionnaire was evaluated. The question of whether a test seems to measure what it is intended to measure is known as face validity. When a questionnaire appears to be measuring what it is intended to, it is said to have good face validity¹⁰. In order to evaluate the questionnaire's face validity, thirty individuals—nurses, doctors, and diabetics—were asked to examine the items and determine whether or not they were appropriate for gauging the participants' needs for health education. They were asked to respond to the following inquiries: Are the questionnaire's items pertinent to the subject being measured? Do individuals with diabetes seem to have a need for health education that can be measured using this particular method? Does the measure appear to be suitable for identifying the health education requirements of the participants? Reviewers of the questionnaire concurred that it was valid after a few small changes, such as adding some explanation phrases to the responses on the 5-point Likert scale.

2.6 Data collection: After providing participants with a suitable explanation of the survey's objective, a group of trained nurses—including those who had taken part in the questionnaire's face validity assessment—collected the necessary data between October 1, 2023, and November 16, 2023. On November 15 and 16, 2023, the test was administered again to the first 40 patients via phone consultation following data collection from all participants (n = 303). Evaluating test-retest reliability was the goal of the retest.

2.7 Statistical Design: Data analysis was done using SPSS version 18.0, the Statistical Package for Social Sciences. Depending on the types of variables, relevant significance tests and descriptive statistics were applied. Regarding continuous variables, a group t-test was applied. Since all of Likert scale statements were positive, the 5-point Likert scale was converted into scores that varied from 1 for strongly disagree to 5 for strongly agree. Cronbach's alpha was then used to assess the internal consistency of the Likert scale. Regression analysis and Pearson's correlation were used to evaluate test-retest reliability. In order to evaluate the construct validity of the Likert scale for health

The survey was conducted from October 16, 2023, to November 16, 2023. There were 303 participants in all. The survey had a 100% response rate. Of the total, 123 (40.6%) were men and 180 (59.4%) were females. Their ages ranged from 18 to 94 years old, with a mean of 55.9±12.9 years. The male age, 57.4 ± 12.8 years, did not differ significantly from female age, 54.9 ± 12.9 years (t-value, 1.590 and P, 0.113). The duration of diabetes ranged from 1 to 40 years, with a mean of 9.1± 6.9 years. There is only one patient under the age of fourteen. Seven (2.3%) of the 303 patients were under 25, 107 (35.3%) were between the ages of 25 and 50, and 189 (62.4%) were beyond 50.

About 2.3% of the study group consisted of pregnant patients with gestational diabetes, while type 2 diabetes afflicted the majority of participants (n = 287; 94.7%). Nine (3%) of the 303 people did not know what kind of diabetes they had. Most participants (87.1%) believe that speaking with a medical professional is the best way to learn about diabetes. For 15 (5%) of all patients, social media was thought to be the best way to proceed and 18 (5.9%) think that the best sources of information regarding diabetes are social media and medical professionals. Out of the 303 participants, 6 (2%) believe that diabetes awareness events, brochures, and posters are suitable means of educating people about diabetes. Table-1 illustrates the frequency distribution of the participants' responses to 15-item Likert scale that ranged from strongly agree to strongly disagree,

Table 1: The frequency distribution of the participants' response to Likert scale^▲

	Extremely important (Strongly agree)	Very important (Agree)	I don’t know	Not so important (Disagree)	Not at all important (strongly disagree)
Q5: Risk factors and prevention of diabetes.	225 (74.3)	69 (22.8)	4 (1.3)	5 (1.7)	0.0 (0.0)
Q6: Prediabetes (causes, symptoms, and treatment).	220 (72.6)	74 (24.4)	5 (1.7)	4 (1.3)	0.0 (0.0)
Q7: General Information about Diabetes (pancreas and insulin, causes of diabetes, diagnosis, symptoms, and types).	226 (74.6)	66 (21.8)	5 (1.7)	6 (2.0)	0.0 (0.0)
Q8: HbA1c and normal blood glucose levels	234 (77.2)	65 (21.5)	1 (0.3)	3 (1.0)	0.0 (0.0)
Q9: Treatment of hypoglycemia by common oral agent	221 (72.9)	67 (22.1)	7 (2.3)	8 (2.6)	0.0 (0.0)
Q10: Medical treatment by insulin (Types, storage, sites of injection, and insulin pump).	90 (29.7)	49 (16.2)	40 (13.2)	120 (39.6)	4 (1.3)
Q11: Diabetes and complementary therapies.	44 (14.5)	55 (18.2)	47 (15.5)	157 (51.8)	0.0 (0.0)
Q12: Acute complications of diabetes (Hypoglycemia, Diabetic ketoacidosis, etc.	205 (67.7)	84 (27.7)	2 (0.7)	11 (3.6)	1 (0.3)
Q13 Chronic complications of diabetes, causes, symptoms, and treatment	219 (72.3)	78 (25.7)	2 (0.7)	4 (1.3)	0.0 (0.0)
Q14: Importance of annual eye screening to prevent diabetic eye complications	221 (72.9)	74 (24.4)	2 (0.7)	6 (2.0)	0.0 (0.0)
Q15: Diabetes and travel.	225 (74.3)	62 (20.5)	9 (3.0)	5 (1.7)	2 (0.7)
Q16: Diabetes and Fasting.	228 (75.2)	58 (19.1)	7 (2.3)	8 (2.6)	2 (0.7)
Q17: Diabetes and pilgrimage.	206 (68.0)	41 (13.5)	11 (3.6)	39 (12.9)	6 (2.0)
Q18: Diabetes and work and driving	42 (13.9)	19 (6.3)	35(11.6)	156 (51.5)	51 (16.8)
Q19: Diabetes and school.	10 (3.3)	20 (6.6)	36(11.9)	175 (57.8)	62 (20.5)

^▲, number and percent in parentheses

3.1 Reliability of the questionnaire: Cronbach's alpha is most commonly used to quantify internal consistency (also known as "reliability"). The Likert scale we used had a high degree of internal consistency, with a Cronbach's alpha of 0.832 for the 15 items. After removing the statements (n= 5) that result in a greater Cronbach's alpha if deleted, the final Cronbach's alpha increased to 0.900. The Cronbach's Alpha item-total statistics for the final 10 item Likert scale are displayed in Table 2.

Table 2: The Item-Total Statistics of Cronbach's Alpha for final Likert Scale after deleting redundant items.

	Scale mean if item deleted	Scale variance if item deleted	Cronbach's Alpha if Item Deleted
Q5: Risk factors and prevention of diabetes.	42.0528	16.507	0.884
Q6: Prediabetes (causes, symptoms, and treatment).	42.0660	16.499	0.884
Q7: General Information about Diabetes (pancreas and insulin, causes of diabetes, diagnosis, symptoms, and types).	42.0594	16.281	0.883
Q8: HbA1c and normal blood glucose levels	42.0000	17.219	0.889
Q9: Treatment of hypoglycemia by common oral agent	42.0957	16.425	0.890
Q12: Acute complications of diabetes (Hypoglycemia, Diabetic ketoacidosis, etc.	42.1617	16.315	0.894
Q13 Chronic complications of diabetes, causes, symptoms, and treatment	42.0594	16.857	0.887
Q14: Importance of annual eye screening to prevent diabetic eye complications	42.0660	17.287	0.896
Q15: Diabetes and travel.	42.0891	16.783	0.897
Q16: Diabetes and Fasting.	42.0924	16.740	0.899

Forty of the 303 participants took the test (survey) again, and the total Likert scores of those individuals (60.2± 4.9) were compared using Pearson's Correlation to see if there was any correlation with their results from the initial measurement (60.2± 4.7). The two measurements showed an extremely significant association (r, 0.864; P, 0.000). Thus, the survey's test-retest reliability is excellent, we might conclude. This indicates that the study group was able to memorize it with ease. The regression line between the two measurements is shown in Figure 1. the figure shows a highly significant linear association between the two measurements by regression analysis.

3.2 Validity of the questionnaire:

Content and face validity: As previously stated under the study's tool, the Likert scale's was face and content valid.
Construct validity: To evaluate the Likert scale's construct validity for health education, exploratory factor analysis (EFA) was used. Utilizing the 10 Likert scale variables (items) that were obtained from the previously described Cronbach alpha analysis, factor analysis (also known as principal component analysis, or PCA) was performed. To determine whether the data were suitable for factor analysis, KMO and Bartlett's test were performed first. The data are appropriate for factor analysis since the Kaiser-Meyer-Olkin sampling adequacy score was 0.870 (P, 0.000).

Table-3 shows that the number of factors with Eigenvalues greater than one is limited to two. In the factor analysis, both factors account for 68.6% (54.7 for Factor-1 and 13.9 for Factor-2) of the total loading variance. According to the factor analysis Scree Plot, Component 2 has an "elbow" joint in it. This is the tipping point where it might not be as advantageous to extract more components. We selected two components with Eigenvalues greater than one (high-quality factors) using the scree plot, as shown in Figure-2.

Table 3: principal component analysis: total variance of extracted factors with Eigenvalue above one^▲

Component	Initial Eigenvalues			Extraction sum of squared loadings			Rotation sum of squared loadings
Component	Total	% of variance	Cumulative %	Total	% of variance	Cumulative %	Total	% of variance	Cumulative %
1	5.46	54.666	54.666	5.46	54.666	54.666	4.17	41.721	41.721
2	1.39	13.906	68.572	1.39	13.906	68.572	2.68	26.851	68.572
3	0.80	8.071	76.643
4	0.64	6.406	83.048
5	0.44	4.438	87.486
6	0.39	3.957	91.443
7	0.28	2.833	94.276
8	0.26	2.667	96.943
9	0.18	1.848	98.792
10	0.12	1.208	100.000

^▲, Extraction method: Principal component analysis

To determine the name of the component, the researcher examined the factor analysis Component Matrix, which displays Pearson's correlation coefficients of different Items (variables) with the two components that were extracted. Question 7 (general information about diabetes) had the highest correlations with component one. The strongest association between Factor-2 and Question-15 (diabetes and travel) is found. Thus, we may deduce that component-1 is titled "General Information about Diabetes," while component-2 is titled "Diabetes and Travel".

The findings of a rotated component matrix are shown in Table-4 to help identify the variables that have a strong correlation with each component. Factor-1 (Component-1) exhibited noteworthy associations with Q5: Diabetes risk factors and prevention, Q6: Prediabetes (causes, symptoms, and treatment), Q7: General information about diabetes (disease causes, diagnosis, symptoms, and kinds), and Q8: Pancreas and insulin Q9: Common oral medications for treating hypoglycemia; Q8: HbA1c and normal blood glucose levels; and Q12: Acute problems related to diabetes, such as hypoglycemia and diabetic ketoacidosis. On the other hand, Q15: Diabetes and travel; Q16: Diabetes and fasting; Q13: Chronic complications of diabetes, causes, symptoms, and treatment; and Q14: The significance of the yearly eye screening to prevent the diabetic eye complications were the Likert scale items that were contributing more and were linked to compenent-2 (Diabetes and travel). Table 4 shows the final standardized Likert scale items, which has excellent reliability and validity.

Table 4: Rotated Component Matrix: Identification of the final Likert scale items that are highly correlated with the two extracted components^▲

	Component
	1 (General information about diabetes)	2 (Diabetes and travel)
Q5: Risk factors and prevention of diabetes.	0.917
Q6: Prediabetes (causes, symptoms, and treatment).	0.884
Q7: General Information about Diabetes (pancreas and insulin, causes of diabetes, diagnosis, symptoms, and types).	0.853
Q9: Treatment of hypoglycemia by common oral agent	0.766
Q8: HbA1c and normal blood glucose levels	0.730
Q12: Acute complications of diabetes (Hypoglycemia, Diabetic ketoacidosis, etc.	0.549
Q15: Diabetes and travel.		0.874
Q16: Diabetes and Fasting.		0.860
Q13 Chronic complications of diabetes, causes, symptoms, and treatment		0.657
Q14: Importance of annual eye screening to prevent diabetic eye complications		0.549

*, Extraction method: principal component analysis, Rotation Method: Varimax with Kaiser Normalization

To the best of our knowledge, no standardized instrument for evaluating patient needs related to diabetes health education has been published in the literature. Therefore, there is a pressing need to build an assessment instrument with scientific bases. Diabetes education needs to be adapted to the demands of those who are living with the disease and take cultural sensitivity into consideration¹¹. Patient education has long been seen as a vital and crucial element of effective diabetes care ¹². The current work questionnaire was created utilizing a modified Delphi panel procedure in a systematic way. A set of twenty expert panelists in the fields of endocrinology and family medicine were given a uniform background by the researchers through the creation of a summary of pertinent literature. The specialists got together in person.

In order to summarize the results following the first round, a summary report was created and irrelevant information was removed. The experts convened virtually for the second round to deliberate on the outcomes of the initial round and identify common ground. This approach yielded guidelines with content validity¹³. Following the expert panel discussion, a 5-point Likert scale comprising 15 items was developed to determine the participants' needs in terms of health education. The Likert scale is an ordered scale that is best suited for assessing attitudes, views, and perceptions in research¹⁴.

Our 15-item scale has a good degree of internal consistency, as shown by the Cronbach's alpha of 0.832. The internal consistency of the questionnaire increased to 0.900 when redundant items (n, 5) were removed from the Likert scale. Based on this rise, we may conclude that the questionnaire has an internal consistency of 90%. The study's 86% test-retest reliability provided evidence in favor of the easily remembered findings. Furthermore, the completed survey exhibits noteworthy construct, face, and content validity. Through factor analysis, the 10-item Likert scale can be reduced down into two factors (components) with Eigenvalues greater than one.

The demands for health education found in this study align with those found elsewhere. For instance, in order to determine the needs for health education among adult individuals with diabetes, a qualitative study was carried out. The authors of the study reported on a number of related topics, including risk factors for diabetes, primary prevention to safeguard friends and family, the nature of the disease, complications, recent medication use, causes of blood sugar fluctuations, and managing diabetes during pregnancy ¹⁵.

One of the participants' demands for health education in this study was travel with diabetes, which made up the second component of our final Likert scale. Traveling can be viewed as an essential aspect of our lives, regardless of the purpose—business, pleasure, sports, or pilgrimage. Numerous travelers have diabetes as a result of the worldwide diabetes epidemic. Even for those who have diabetes under control before their trip, the most typical obstacles are changes in food, activity, time zones, surroundings, and stress. Family doctors are in the best position to offer preventive health care for travelers with diabetes, and counseling is crucial for potential travelers with diabetes to avoid complications^16,17

In this study, there was a need for education regarding fasting throughout Ramadan. As family physicians, we should be proactive in our approach when consulting with patients who have diabetes prior to Ramadan ¹⁸. Structured education and support for safe fasting are useful in managing diabetes during Ramadan^{18, 19}. The study participants were in need, also, for health education about chronic complication of the disease, the 3rd item of the 2nd factor of the final Likert scale. It should be mentioned that persons with diabetes are thought to have an unmet demand for health education regarding the chronic complications of their disease ¹⁵. Additionally, one of our participants' educational demands was the significance of yearly eye exams, which ranked as the fourth item on the final Likert scale. Actually, diabetic retinopathy is a major worldwide public health concern, and screening for it can save lives by reducing vision impairment ²⁰.

Consistent with previous research, the majority of participants in this survey believe that consulting a medical practitioner is the best way to learn about diabetes ²¹. For fifteen patients (5%) social media was deemed the most effective method. Social networks are thought to be a useful tool for diabetic self-care management improvement and health education ²².

4.1 Strengths and limitations

Strengths: 1. Appropriate sample size. 2. There is no selection bias because the study sample was chosen at random. 3. The study sample, at 303, was greater than the minimum needed for factor analysis (the minimum number needed for principal component analysis should be at least 200). 4. The study group, which consisted of individuals with diabetes, was chosen from among all outpatient clinics across several departments at JAFH. 5. The evaluation of the questionnaire's face validity involves both the patients and the data collectors. In order to determine patients' needs, we may infer that the questionnaire is standardized and useful in both practice and research. Limitations: The study only covers one hospital in the Jazan region.

In conclusion, the final 10-item Likert scale is quite valid and reliable for identifying the demands of participants who have diabetes. The standardized questionnaire can be used in research and practice to determine what health education needs people have. Furthermore, policymakers and decision-makers and healthcare providers can use our findings about the needs for health education as a guide when developing health education programs. These programs will focus on two aspects of the Likert scale: basic diabetes information and traveling with diabetes.

EFA: exploratory factor analysis.

HbA1c: Glycosylated hemoglobin.

JAFH: Jazan Armed Forces Hospital.

SPSS: Statistical Package for the Social Sciences.

Ethics approval and consent to participate:

The study was conducted according to the guidelines of the Declaration of Helsinki and approved by the Jazan Armed Forces Hospital Research and Ethics Committee. All participants signed informed consent forms prior to study enrollment.

Consent for publication:

Not applicable

Availability of data and material:

The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.

Competing interests:

The authors declare that they have no competing interests.

Funding:

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Author contributions

H. A. A. contributed to all steps of the research, including the study design, data analysis, the results, discussion and manuscript writing. H.M.D. contributed to the conception and design of the study, literature review and discussion. G. M. M. substantially contributed to discussion and critical revision of the manuscript. W. A. Q. contributed to the conception and the study design, discussion, and manuscript writing. T. J. A. and N. Y. I. contributed in questionnaire design. All authors have critically reviewed and approved the final draft and are responsible for the content and similarity index of the manuscript.

Acknowledgement

The authors express their gratitude to Abeer Hoseen, Fatma Hanbashy, Monera Hamdy, Zinab Halwi, Ohood Damery, Abdalla Jelly, and Zarah Ghazwan, the nurses who took part in the data collecting. We especially thank Meaad Hendi, the JAFH nursing director, who made the data collection procedure easier.

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Developing and standardizing a tool to assess the health education needs of diabetic patients at Jazan Armed Forces Hospital

Status:

Version 1

Abstract

Objectives

Methods

Results

Conclusion

Figures

1 Introduction

2 Materials and methods

3 Results

4 Discussion

5 Conclusion

Abbreviations

Declarations

References

Status:

Version 1