1. Introduction

1.1. Background

Worldwide

The Global report from the World Health Organization (WHO), published in 2016, estimated that 422 million of the adult population lives with diabetes the number of diabetic patients has dramatically increased 4 times over in the adult population, compared to 108 million in 1980. Diabetes Mellitus is a chronic metabolic disorder, which is caused by partial deficiency or total deficiency of insulin. Diabetic mellitus could be diabetes, which is type 1 complete deficiency of insulin and diabetes type 2, partial deficiency of insulin with receptor of insulin not functioning to facilitate enter glucose into cells for utilization and formation of units of energy. WHO has estimated that the number of diabetic patients will double by 2030. Diabetes is increasing more rapidly in low and medium income groups than higher income groups as well as in, developing countries compared to European countries, where there is less prevalence of diabetes. The top five countries with the highest prevalence of diabetes. Include the following: India, China, USA, UK, Bazile and Indonesia. Diabetes Type 1 most common in Scandinavian populations, Sardines, and Kuwait, and less common in Asia, Latin and European population.

Mozambique

Mozambique is located on the East coast of Africa (Wikipedia 2016). There are 274,700 diabetic patients and 9716 deaths due to diabetes, according to a report of 2015 (IDF 2015). This country is the setting for this study. There is the prevalence of obesity, poor knowledge regarding diabetes and lack of awareness of complication of diabetes. Most of the population uses traditional healer for treatment of diabetes. There are unhealthy food habits, sedentary lifestyle in urban population and increased economic growth amongst professions related to office work, which is one of the risk factors that causes diabetes and its complications. There are no professional health, diabetes educators and patients have little or no knowledge of self-management, adherence of treatment, awareness of complication. Among the group of patients who seek care in public hospitals, many are poor and cannot afford the cost of medication or healthy foods. There is an 80 dollar expenditure allotted to each patient of diabetes from the country’s Ministry of Health and supported by the government. Additionally, the ministry of health provides free medication for all chronic diseases, including diabetes and hypertension. Currently, there is no study that has been done on the effects of education in various modalities of diabetes for patients and its outcome. Accordingly, there is an extreme need to educate patients of diabetes to improve diabetic control and reduce its complication.

1.2. Objective and Hypothesis

Problem:

The population for this study are diabetic patients in the Central Hospital Nampula in Mozambique, who are from low and medium income groups. This group of patients has limited sources of incomes and, completely depends on the diabetic pharmacological treatment of the government hospital pharmacy, which gives medication free of cost. In the country of Africa, there is a generally poor health education regarding the diabetes. There are no professional diabetic health educators and patients receive advice from doctors and dieticians regarding their diets and directions on how to use their prescriptions of medicine so as to continue treatment at home. Due to the large size of patient loads in outpatient consultations of diabetes, it is not possible to sit with each patient and provide specific health education about diabetes. Also, these groups of patients do not access of the internet to seek their own self-education from different sources. It is clear that when diabetic patients only utilize pharmacological treatments that it is not sufficient to control diabetes and complication [3].

Objective:

1. There is a need for lifestyle modification, knowledge of diabetes and its complication, as chronic disease, so that patients can ability to detect small symptoms of complication and present physician, adherence of treatment and its important.

2. There are different types, categories, and levels of controlled diabetic patients and the each type requires different types of education, depending on complications and diseases associated with diabetes.

There following are the clinical categories patients:

1. Good control over blood sugar and without complication.

2. Fair/not controlled blood sugar with or without complication.

3. Good control of blood sugar and without complication, but other disease example HIV treatment, CVA etc.

Question statement

To conduct the study, used dependent variable fasting blood sugar and independent age, body mass index.

Positive hypothesis, the positive correlation of control of fasting blood sugar change of lifestyle modification includes diet and exercise. The positive correlation with control of fasting blood sugar to improve body mass index. The knowledge of diabetes could help in controlling diabetes and blood sugar in case implemented knowledge of diabetes in life style.

Null hypothesis, the diabetes more common with age of 45-60 but not uncontrolled by increase of age. The various reasons which can responsible for uncontrolled fasting blood sugar, in case not implemented knowledge of diabetes in life style.

Assumption and limitation

There is a need to implement before each consultation of control of diabetes for writing the prescription of medicine and controlling complication. There should be a 15 minute session of education to reemphasized, remember to patients to continue habits which helping to control diabetes. It is seen continues education help to keep continue positive habits to control diabetes. As increase period after education, some of patients come back to the same stage as they were started.

There were limitations as Mozambique is developing country as limited resources in hospital. To minimized expenditure, there are available only fasting blood sugar. There is no concept of doing the regular postprandial blood sugar. There was some time, none availability of reagent in the laboratory to evaluate blood sugar during the period of study. That makes statically results different from which was accepted. To choose topic also forced to see the available facility in a public hospital.

2. Method

This study was conducted on regular patients of the diabetic outpatient department of the Central Hospital of Nampula. The study investigated the effects of three sessions of the diabetes education program (baseline, first follow-up and second follow-up) on each patient at one-month intervals. The inclusion and exclusion criteria for participation in the education program are listed below.

Inclusion and exclusion criteria for the study

Table 1. Inclusion and exclusion criteria for the study

Conceptual framework

Figure 1. Conceptual framework

Sample number and characteristics

A sample of 648 participants was taken for this study. The inclusion criteria for participating in the diabetes education program dictated that patients should be in the OPD, willing to participate in the education sessions and willing to give consent to be included in the study. Participants were excluded if they had already completed three sessions of education or if they lived in a district that made it impossible for them to return within one month to the next education session.

Organization of education sessions

Amongst the group instructors were a diabetologist, dietician, psychologist, physiotherapist, and diabetic nurse. The following tasks had to be performed before each of the sessions:

The baseline session:

The diabetic nurse took consent and accessed the patient’s clinical history before conducting a physical examination that included checking vital signs and body mass index. The physical examination was to be done by a physician. They also noted the results of a blood analysis that tested for sugar, which had been conducted 2-3 days prior to the education session.

First follow up:

At the beginning of the session, the diabetic nurse measured the body mass index and noted the results of the blood analysis that tested for sugar, which had been conducted 2-3 days prior to the education session. The physicians and other specialists also noted the relevant patient information.

Second follow up:

At the beginning of the session, the diabetic nurse measured the body mass index and noted the results of the blood analysis that tested for sugar, which had been conducted 2-3 days prior to the education session. The physicians and other specialists also noted the relevant patient information.

Method of education

The education sessions were in the form of a conference with all specialists leading a class in various verbal forms, demonstrating real situations, operating the relevant apparatus and discussing any difficulties at the end of the session.

Pre- and post-testing:

There was a pre-test questionnaire that aimed to assess the existing knowledge of diabetes before starting the baseline education session. The same questions were asked after the completion of the second follow-up education session.

Description of Health Education Intervention

Description of the specialists that participated in giving the education sessions

The different types of specialists involved in the health education intervention were:

1. The psychologist oriented the patients with basic aspects of psychology to help them live with diabetes.

2. The diabetologist provided knowledge about the general concepts of diabetes.

3. The dietician provided information about the specific diet needed for diabetic patients.

4. The physiotherapist demonstrated important exercises that were specifically for sufferers of diabetes and were applicable to all individuals.

Group and individual education sessions

After a three-hour group education session, individual outpatient consultations were conducted in different rooms with different specialists. These patients could consult a diabetologist, dietician, physiotherapist, or psychologist individually according to the specific needs of each patient.

Organization of Health Education Sessions

Due to the shortage of separate spaces large enough to accommodate the number of participants in the baseline, first follow-up and second follow-up, sessions were limited to approximately 40-50 participants. To make education sessions more interesting and effective the beginning of each session was realized with baseline participants followed by first follow-up participants, and then second follow-up participants were taken for education of diabetes. There was no restriction for participants if they wanted to attend the same session twice.

Each session built upon the knowledge gained in the previous session. The health outcomes of each patient were assessed in outpatient service to monitor the implementation of the knowledge imparted in the education sessions in daily life.

Description of educational materials and information provided

The topics of the sessions were chosen according to local culture, socioeconomic conditions, beliefs, lifestyle, common complications and associated diseases. The aim was to improve the outcomes for diabetes patients and prevent complications. The information was presented in a manner that the participants could easily understand and would motivate them to implement the new information in their daily lives.

The topics of the diabetes education sessions

Ÿ Definition of diabetes and types of diabetes

Ÿ Symptoms of hypo- and hyperglycemia, both complications of diabetes

Ÿ Management of diabetes by diet and physical activity

Ÿ Psychological assistance

Ÿ Brief knowledge of medicines that are available in the pharmacy of the hospital

Ÿ Management of hypoglycemic medication

Ÿ Complications of diabetes and early detection

Ÿ Dental and foot care

Ÿ Diabetic control in special situations such as during Ramadan or when travelling

Ÿ Blood sugar monitoring using a glucometer

Ÿ How and where to inject insulin and how to prevent complications

Ÿ How to prevent primary and secondary stages of diabetes

Ÿ Participation of family members if willing and/or required

Description of the sequence of the diabetes education sessions

In groups:

1. Welcome address to participants from a diabetologist

2. First part of the education session: lessons on diabetes by, taught by a diabetologist

3. Second part of the education session: information on diet and nutrition, taught by a dietician

4. Third part of the education session: information on how to cope psychologically with the disease, taught by a psychologist

5. Fourth part of the education session: the benefits of exercise and demonstrations of general exercises that are applicable to all patients, taught by a physiotherapist

6. Fifth part of the education session: how to inject insulin and use a glucometer, taught by a nurse

On an individual basis:

7. Sixth part of education session: individual consultations with each patient with a diabetologist, dietician, psychotherapist, or physiotherapist to help participants with particular recommendations based on associated diseases and complications, if needed

Patient Interviews

The patients were interviewed in order to gather the following information:

Ÿ Identification details

Ÿ Medical history/past clinical history

Ÿ Blood pressure, body mass index

Ÿ Drug history (type of oral hypoglycemic agents, injectable form antidiabetic agents, drugs to maintain blood pressure and lipids)

Ÿ Analysis of fasting blood sugar before each session

Ÿ Specific findings, if noted by each specialists

Variables used and their ranges:

21-40 years

41-60 years

61-80 years

81-100 years

Information not given

Pre-education test score

Fair: <5

Good: 5-6

Very good: 7-8

Excellent: 9-10

Information not given

Post-education test score

Fair: <5

Good: 5-6

Very good: 6-8

Excellent: 9-10

Information not given

Body mass index (repeated for the baseline, first follow-up, and second follow-up)

Underweight: 0 <18.5 Kg/m²

Normal: 18.5-24.9Kg/m²

Overweight: >25kg/m²

Pre obese: 25-29.9kg/m²

Obese: > 30 kg/m²

Obese class 1: 30-34.9 kg/m²

Obese class 2: 35-39.9 kg/m²

Obese: >40 kg/m²

Information not given

Fasting blood sugar (repeated for the baseline, first follow-up, and second follow-up)

Hypoglycemic range: <3.9 mmol/dl

Normal: 4-5.8 mmol/dl

Mild hyperglycemic range: 5.9-11 mmol/dl

Moderate hyperglycemic range: 12-19 mmol/dl

Sever hyperglycemic range: > 20 mmol/dl

Problem with laboratory

Information not given

A Data was analyzed SPSS 17 version, and graphs made in Excel software.

Outline of presentation of statically analysis as follows:

A. Descriptive Analysis

1. Frequency and percentage tables of various variables with graphic presentations.

2. Central tendency (Mean), standard deviation (stander scores).

B. Correlation Analysis

1. Person Correlation with simple correlation among variables

2. Regression-predictive-ability independent and dependent variable

C. Analyzing difference between groups

1. T-test

2. ANOVA

3. Post hoc Turkey test

4. P - Value of less than 0.05 were considered to be significant.

D. Tables and graphs use for results

3. Results

A sample of 648 participants was taken for this study. This study was conducted on regular patients of the diabetic outpatient department of the Central Hospital of Nampula. The study investigated the effects of three sessions of the diabetes education program (baseline, first follow-up and second follow-up) on each patient at one-month intervals. The inclusion criteria for participating in the diabetes education program dictated that patients should be in the OPD, willing to participate in the education sessions and willing to give consent to be included in the study. Participants were excluded if they had already completed three sessions of education or if they lived in a district that made it impossible for them to return within one month to the next education session. Amongst the group instructors were a diabetologist, dietician, psychologist, physiotherapist, and diabetic nurse. There was a pre-test questionnaire that aimed to assess the existing knowledge of diabetes before starting the baseline education session. The same questions were asked after the completion of the second follow-up education session. There were various variables to assess from baseline to second follow up education session. The variables were assessed age groups, body mass index, blood pressure, and fasting blood sugar in patients with diabetes mellitus.

Descriptive analysis of Pre-test and post-test score at before baseline and after second follow up

A sample of 648 patients with diabetes mellitus, those who had participated in educational sessions concerning diabetes mellitus, was taken for study in order to determine the effect of education on improving knowledge levels in diabetes. The analysis of knowledge increased of diabetes mellitus among participants was performed pre-test at the beginning baseline, and post-test at the end second follow up. The results are shown in Table 2, below. Briefly, the percentage of patients with a fair level of knowledge (65.3%) increased from beginning of baseline to very good level of knowledge of diabetes by 52.5% at the end of the second follow up.

Table 2. Descriptive analysis of Pre-test and post-test score

Figure 2.1. Pie chart: In the above charts we see that the distribution of the compared pre-test and post-test scores at baseline and after the second follow up after diabetes education among participants

Figure 2.2. Bar chart: In the above charts we see that the distribution of the compared pre-test and post-test scores at baseline and after the second follow up after diabetes education among participants

Figure 2.3. Bar chart: In the above charts we see that the distribution of the compared pre-test and post-test scores at baseline and after the second follow up after diabetes education among male and female participants

Figure 2.4. Linear chart: In the above charts we see that the distribution of the compared pre-test and post-test scores at baseline and after the second follow up after diabetes education among participants

Descriptive analysis of body mass index of baseline, first follow up, second follow up:

A sample of 648 patients with diabetes mellitus, those who had participated in educational sessions concerning diabetes mellitus, was taken for study in order to determine the effect of education on improving body mass index levels in diabetes. The measurement of body mass index was performed at baseline, at the first follow up and in the second follow up. The results are shown in Table 3, below. Briefly, percentage of patients with Underweight < 18.5 kg/m² decreased from baseline (4.5%) to the first follow up (3.4%), and to the second follow up (2.5%). The percentage of patients with pre obese 25-29.9 kg/m² were observed to decrease from baseline (35.2%) to the first follow up (27.9%), to the second follow up 920.4%). The percentage of patients with obesity class 1 -30-34.9 kg/m² decreased at each follow up from the baseline (15.6%) to the first follow up (13.1%), to second follow up (8.2%). The percentage of patients with obesity class 2- 30-34.9 kg/m² decreased at each follow up from the baseline (5.7%) to the first follow up (4.5%), to the second follow up (2.8%) respectively.

Table 3. Descriptive analysis of body mass index at baseline, first follow up and second follow up

Figure 3.1. Bar chart: In the above charts we see that the distribution of the compared body mass index at baseline, first follow up, and second follow up after education among participants

Figure 3.2. Pia chart: In the above charts we see that the distribution of the compared body mass index at baseline, first follow up, and second follow up after education among participants

Figure 3.3. Bar chart: In the above charts we see that the distribution of the compared body mass index with grades of obesity at baseline, first follow up, and second follow up after education among participants

Figure 3.4. Linear chart: In the above charts we see that the distribution of the compared body mass index at baseline, first follow up, and second follow up after education among participants

Descriptive analysis of fasting blood sugar at baseline, first follow up and second follow up

A sample of 648 patients with diabetes mellitus, those who had participated in educational sessions regarding diabetes mellitus, was taken for study in order to observe the effect of education on improving fasting blood sugar concentration in diabetes. The analysis of fasting blood sugar levels was performed at baseline, at the first follow up and in the second follow up. The results are described in Table 4, below. Briefly, the percentage of patients with hypoglycemic concentrations <3.9 mmol/dl improved from baseline (4.8%), to the first follow up (4.2%), to the second follow up (5.1%). The percentage of patients with a normal fasting blood sugar range of 4.0-5.8 mmol/dl decreased from baseline (21.8%), to the first follow up (19.0%), to the second follow up (15.0%). The percentage of patients with mild hyperglycemic concentrations of 5.9-11.0 mmol/dl decreased at each follow up from the baseline (41.4%), to the first follow up (37.0%), to the second follow up (28.2%). The percentage of patients with moderate hyperglycemic levels of 12.0-19.0 mmol/dl was observed to decrease at each follow up from the baseline (22.2%), to first follow up (17.9%), to second follow up (12.5%). The percentage of patients with severe hyperglycemic levels of >20.0 mmol/dl decreased from baseline (7.9%), to the first follow up (4.5%), to the second follow up (3.2%).

Table 4. Descriptive analysis of fasting blood sugar at baseline, first follow up and second follow up

Bar Chart

Figure 4.1. Bar chart: In the above charts we see the distribution of comparing fasting blood sugar scores at baseline, first follow up, and second follow up after diabetes education among participants

Pie Chart

Figure 4.2. Pie chart: In the above charts we see the distribution of comparing fasting blood sugar scores at baseline, first follow up, and second follow up after diabetes education among participants

Figure 4.3. Bar chart: In the above charts we see the distribution of comparing fasting blood sugar scores with grades at baseline, first follow up, and second follow up after diabetes education among participants

Figure 4.4. Linear chart: In the above charts we see the distribution of comparing fasting blood sugar scores at baseline, first follow up, and second follow up after diabetes education among participants

Figure 4. Bar chart: In the above charts we see the distribution of comparing fasting blood sugar scores at baseline, first follow up, and second follow up after diabetes education among participants

Summary table of descriptive Statistics Mean and standard Deviation:

A sample of 648 patients with diabetes mellitus, who had participated in educational sessions regarding diabetes, was taken for study in order to determine the effect of education on improving outcomes in diabetes. The mean and standard deviation were calculated using plain coding, without grouping into categories. For the evaluation of basic knowledge regarding diabetes mellitus, prior to participating in the baseline education sessions, and assessment was performed on the pretest score. The average was 2.33 (SD=2.11). For the evaluation of knowledge gained after completing the second follow up session of diabetes education, the assessment revealed an average posttest score of 7.34 (SD=1.43). The average age of participants was 49.79 years (SD=13.06 years). The average body mass index (BMI) of the participants at baseline was 26.89 kg/Miter2 (SD=5.69 kg/Miter2), followed by an average BMI at the first follow up to 26.43 kg/Miter2 (SD=5.35 kg/Miter2), and an average BMI at the second follow up to 26.18 kg/Miter2 (SD=5.03 kg/Miter2). This showed that a very small decrease in BMI from baseline to the second follows up occurred. The average fasting blood glucose concentration at baseline was 10.15 mmol/dl (SD=6.00 mmol/dl), at the first follow up 9.32 mmol/dl (SD=5.17 mmol/dl), and in the second follow up 8.89 mmol/dl (SD=5.19 mmol/dl). Therefore, a gradual decrease in the fasting blood glucose concentration was observed from baseline to the second follow up.

Table 5. Descriptive statistics mean and standard Deviation of variables

Chi-squared test

Chi-squared tests were performed in order to determine the effect of education on patients with diabetes mellitus regarding controlling various parameters of health and diabetic complications, the knowledge gained concerning diabetes and factors involved in diabetes control, and the relationship between these effects.

Chi-squared correlation of age with other variables

2. Correlation of age with BMI. The results of the chi-squared tests were significant, with the following associations observed: age correlated with BMI at baseline (value=172.04^a, df=48, P< .001), at the first follow up (value=136.10^a, df=48, P<.001) and in the second follow up (value 140.52^a, df =48, P<.001).

3. Correlation of age with fasting blood glucose concentration. The results of the chi-squared tests were significant, with the following associations observed: age correlated with fasting blood glucose concentrations at baseline (value=56.69^a, df=36, P<.001), at the first follow up (value=103.52^a, df=36, P<.001) and in the second follow up (value=73.06^a, df =36, P<.001).

Table 6. Descriptive Chi-Square Tests among variables

Pearson Correlation

In order to examine the effect of education regarding diabetes mellitus on controlling various variables of health and the control of diabetic complications, and to determine the amount of knowledge gained after diabetes education, a Pearson correlation matrix was created using all variables in order to determine the relationship between them.

Table 7. Correlation of age with BMI: The table below shows the results of the Pearson correlation tests performed. Age was significantly positively correlated with BMI at baseline, at the first follow up and in the second follow up (P<. 001)

Table 8. Correlation of age with fasting blood sugar concentrations: The table below shows the results of the Pearson correlation tests performed. Age was significantly positively correlated with fasting blood sugar concentrations at baseline, at the first follow up and at the second follow up (P=. 001)

Table 9. Correlation of age with pretest and posttest scores: The table below shows the results of the Pearson correlation tests performed. Age was significantly positively correlated with pretest and posttest scores (P=. 01)

Table 10. Correlation of the post-test score with BMI: The table below shows the results of the Pearson correlation tests performed. The posttest scores were significantly positively correlated with BMI at baseline, at the first follow up and at the second follow up (P=. 01)

Table 11. Correlation of the post-test score with fasting blood sugar concentration: The table below shows the results of the Pearson correlation tests performed. The posttest scores were significantly positively correlated with fasting blood sugar concentrations at baseline, at the first follow up and at the second follow up (P=. 01)

ANOVA and Regression Analysis

In order to examine the effect of diabetes education on the control of diabetes a multiple linear regression was conducted. This allowed an assessment of the control of fasting blood sugar concentrations at baseline as a dependent variable, with the independent variables of baseline blood pressure, BMI, and post-test score.

The results of the linear regressions were significant (F (7,637) = 2.44, P=. 018, R2=. 026), suggesting that fasting blood sugar levels at baseline and baseline blood pressure, BMI, and the post-test score, accounted for 2.6% of variance in the control of fasting blood sugar levels. The individual predictors were then examined; it was found that fasting blood sugar level was a significant predictor for diabetic control (B=1.94, P<. 001), suggesting that for each unit increase in baseline fasting blood sugar concentration, the other variables of baseline BMI increased by 1.94 units. Baseline post-test score was not found to be significant predictors for the control of fasting blood sugar levels.

A post hoc Turkey test showed that baseline BMI when compared with the dependent variable, were significant (P=. 05) at baseline and follow up for fasting blood sugar levels.

Table 12. ANOVA and Regression Analysis

First Follow Up

In order to examine the effect of diabetes education on the control of diabetes mellitus and on the occurrence of complications, a multiple linear regression was conducted to assess the control of fasting blood sugar levels at the first follow up as a dependent variable with the independent variables of BMI, and the post-test score at the first follow up.

The result of the linear regression was significant (F (7,. 673) = 52.34, P<. 001, R2=. 365), suggesting that BMI, and the post-test score accounted for 36.5% of the variance observed in the control of fasting blood sugar levels at the first follow up. The individual predictors examined further revealed that fasting blood sugar was a significant predictor for diabetic control (B=0. 42, P<. 001), suggesting that for each unit increase at the first follow up of fasting blood sugar levels, the other variables of BMI, increased by 0.42 units at the first follow up. The post-test score was not found to be significant predictors for the control of fasting blood sugar.

A post hoc Turkey test showed that, at the first follow up, BMI, when compared with the dependent variable of blood sugar concentration at the first follow up were significant (P=. 005).

Table 13. ANOVA and Regression Analysis

Second Follow Up

In order to examine the effect of diabetes education on diabetes control and on the incidence of complications, a multiple linear regression was conducted. This allowed the assessment of the control of fasting blood sugar levels in the second follow up as a dependent variable with the independent variables in the second follow up of BMI, and post-test scores.

The results of the linear regression were significant (F (8,632) = 66.37, P<. 001, R2 =. 450), suggesting that at the second follow up, BMI, and the post-test score accounted for 45% of the variance in the control of fasting blood sugar levels. The individual predictors examined further identified fasting blood sugar as a significant predictor for diabetic control (B = -. 165, P<. 001), suggesting that for each unit decrease at the second follow up of fasting blood sugar concentration, the other variables of BMI, decreased by -. 165 units at the second follow up. The post-test score was not found to be significant predictors for the control of fasting blood sugar levels.

A post hoc Turkey test showed that, at the second follow up, BMI when compared with the dependent variable of fasting blood sugar concentration at the second follow up, were significant (P=. 005).

Table 14. ANOVA and Regression Analysis

4. Summary of Main Findings

A sample of 648 participants was taken for this study. This study was conducted on regular patients of the diabetic outpatient department of the Central Hospital of Nampula. The study investigated the effects of three sessions of the diabetes education program (baseline, first follow-up and second follow-up) on each patient at one-month intervals. The inclusion criteria for participating in the diabetes education program dictated that patients should be in the OPD, willing to participate in the education sessions and willing to give consent to be included in the study. Participants were excluded if they had already completed three sessions of education or if they lived in a district that made it impossible for them to return within one month to the next education session. Amongst the group instructors were a diabetologist, dietician, psychologist, physiotherapist, and diabetic nurse. There was a pre-test questionnaire that aimed to assess the existing knowledge of diabetes before starting the baseline education session. The same questions were asked after the completion of the second follow-up education session. There were various variables to assess from baseline to second follow up education session. The variables were assessed age groups, body mass index, and fasting blood sugar.

Table 15. Descriptive statistics mean and standard deviation

Table 16. Chi-square tests

Table 17. Pearson correlation

Table 18. Regression, ANOVA analysis and post hoc Turkey test

5. Discussion

The present study found that educational intervention was highly effective in controlling anthropometric parameters (BMI), as these had significantly decreased from baseline at the second patient follow up visit. Metabolic control (blood sugar) also showed a significant positive improvement from baseline in the second follow up visit. Finally, participants also showed an improvement in knowledge through diabetes education. This was assessed by a pretest prior to the commencement of education and a posttest after the completion of the second follow up educational sessions at the central hospital in Nampula. The knowledge provided by the education helped the participants to improve and change their lifestyle, especially their dietary and exercise habits, their psychological adjustment and their attitude to living with diabetes.

Similar studies have previously been performed, with some comparable findings being reported. Newly diagnosed diabetic patients need self–management education, as this helps to increase their level of knowledge of diabetes and to provide them with skills to manage their diabetes life long, as it is a chronic condition [3]. A Cochrane review [25] concluded that a reduction in blood sugar concentrations, and increased knowledge of diabetes. A Cochrane review [25] concluded that through group education of diabetes patients get motivated, start adherence to treatment and understand diabetes. Meta analyses and the outcome of various studies have shown positive impacts after receiving diabetes education, and enhanced knowledge of diabetes has been presented by Ricci-Cabello et al. [17]. In order to promote diabetes awareness, self-care behaviors can be useful. [23] described innovative strategies for the improvement of diabetic control and glycemic improvement in Chinese patients through the continuing education of diabetes mellitus during patient examination and by increasing family involvement via diabetic knowledge [6], emphasized repeated diabetic education sessions to control and improve metabolic parameters. [8], using experimental and control groups regarding diabetes education.

The effect of pre- and posttests, showed a reduction in HbA1c, but no effect on BMI.

The present study found that participants had age group with diabetes mellitus was 41-60 years, of which 56% were male. A further study found that, regarding type of diabetes, diabetes mellitus type 2 was detected at the highest prevalence of 87.5%, however the prevalence of diabetes mellitus type 1 was 5.1%.

6. Conclusions

Diabetes mellitus is a chronic and progressive disease, the prevalence of which is rapidly increasing. Uncontrolled diabetes mellitus may cause severe and irreversible untreatable complications, such as cardiovascular disease, retinopathy, nephropathy and cataract development. There is therefore a need to control anthropometric and metabolic parameters within an acceptable range in order to avoid the development of complications.

Currently, it is not only wealthy countries that have a high prevalence of diabetes mellitus; low and mid-level economic counties are also progressively showing an increase in the prevalence of diabetes mellitus. This includes Mozambique, which shows a progressive increase in the number of patients with diabetes mellitus due to the lack of a healthy diet, a sedentary lifestyle and urbanization. Regarding patients with diabetes mellitus in a central hospital in Nampula, it was recognized that there was a need for organizing, education concerning diabetes, such as regarding the diabetic diet, increasing patient knowledge of diabetes to avoid the risks of complications, physical activity and its importance, and the psychological motivation to live with diabetes.

Diabetes education was performed with general and specific groups of patients, according to the needs of the patients, the complications of the diabetes mellitus and other diseases associated with them. Three education sessions were organized, at an interval of one month (baseline, first follow up and second follow up). Each participant was evaluated in each session regarding their BMI, blood sugar. The statistical analysis showed strong significantly positive effects on controlling each of these parameters. Prior to the commencement of the baseline education session, an evaluation of the evolution of patient knowledge regarding diabetes mellitus (the pre-test) was performed. At the end of the second follow up, a post-test was performed, which showed strong significant increases in the knowledge of diabetes.

The study also showed that the majority of the participants had diabetes mellitus type 2, were in the 41-60-year age group.

Motivational quote

“Exercise and diet can help prevent or even totally reverse metabolic conditions like diabetes and cardiovascular disease – only thing is, you’ve got to catch them young… You know, while these conditions are still of ‘impressionable minds’!”

– Deepak ‘The Fitness Doc’ Hiwale

There is currently a need to design a national policy and program for diabetes education. Clinicians and health educators should continue to reemphasize that patients with diabetes mellitus make healthy behavioral changes in order to control their diabetes and reduce the occurrence of complications.

The limitations of this study include that some of the diabetic patients used traditional medications, some did not adhere to treatment, and some were lost to follow up, all of which can cause uncontrollable diabetes and increase the incidence of complications. Patients were very interested in taking medicine free of charge in a government hospital. Limitations were also found here, such as the intermittent non-availability in the results of blood sugar results due to a lack of laboratory reagents. Patients who lived district, distance from the hospital, not able to regularly attend three education sessions. Patients were more interested in obtaining medication than on lifestyle modification. Patients were generally from a poor or lower income group, and were unable to buy the recommended food. It was also noted that some patients had an insufficient economic condition to take small and frequent meals. Some of the patients presented with a delayed diagnosis, with irreversible complications.

One of the strengths of this study is that patients, at the commencement of educational sessions, were encouraged to participate and to bring laboratory results and other activities to the follow up sessions by reminding them that they would receive prescription medicine at the end of the successful completion of all of the essential activities involved in the education sessions. This encouraged patients to take a further interest in the study, and the majority of these patients then implemented the required changes in their lives and achieved significant positive outcomes in controlling their diabetes.

7. Contribution to Knowledge

This study adds to the current body of knowledge regarding lifestyle modification and patient knowledge of diabetes. The education provided in this study allowed patients to understand diabetes and to control and minimize related complications.

8. Suggestion for Future Research

However, a need remains to involve other departments in future studies, for example, emergency and intensive care medicine, district hospitals and the effect of education of diabetes of family members to control the diabetic of the patient, in order to see effect of education of diabetes to improve the knowledge of diabetes in public for primary prevention of diabetes in society.