The key to the management of diabetic foot complications is prevention. To achieve this, good education guides must be made available to teach patients on care of diabetes, foot care and foot wear. Whilst several guides are available in literature, many are written in technical language, making it difficult to comprehend by patients.

The objectives of this project were firstly to design a survey questionnaire covering as comprehensively as possible all aspects patients need to know on the care of diabetes and secondly, to design a new education package based on the results better suited to teach patients on all important aspects of diabetes care.

The survey was conducted on a cohort of 40 people with diabetic foot problems managed by the National University Hospital Diabetic Foot team headed by the senior author (A. Nather) from February 2014 to May 2014. The package was then specifically designed to cover all gaps in knowledge on diabetes care. It is written in English in an easy-to-read fashion and produced with good illustrations to make them easier to understand.

The percentage of correctly answered questions for the individual questions from each section ranges from 53 to 85% (General knowledge), 98% (Diagnosis), 80 to 85% (Medication), 25 to 98% (Treatment) and 10 to 93% (Healthy lifestyle).

Our survey showed that whilst current education booklets exist, they do not cover gaps in knowledge of diabetes care that patients need. This newly designed booklet addresses these gaps to help educate patients more effectively.

Abbreviations: NIL

Diabetes mellitus is one of the top four chronic diseases that plague one million Singaporeans [1]. Since the early 90s, diabetes has been deemed as a priority condition for disease control in Singapore. The increasingly sedentary lifestyles and aging population in Singapore has led to a rising proportion of individuals diagnosed with diabetes [2]. If not properly managed, diabetes can lead to the onset of severe complications which may endanger patients’ lives. According to the Ministry of Health, Singapore, the high medical costs of treatment usually arise due to the onset of complications when treatment is delayed. Treatment is often delayed as patients lack knowledge on the early identification and proper management of diabetes. The effective management of diabetes requires control over an interplay of factors that affect blood glucose level in diabetic patients [3]. These include dietary habits, daily lifestyle and method of coping with diabetes. As most of the factors are closely related to patient behaviour, it appears evident that the attainment of long-term management is the consequence of effective patient education. Hence, patient education is crucial for early prevention [2].

Education has been proven to contribute significantly to sustained success of diabetes management through the prevention or delay of long-term complications [3,4]. A study conducted by Tan., et al. in a government outpatient clinic showed that educating patients on general diabetes knowledge led to an improvement in their knowledge of diabetes, self-management and long-term regulation [5]. Another study by Tham., et al. in 2004 found that even though the state of diabetic education has improved tremendously, ‘some key aspects of diabetes and self-care were either missed out, or the subjects forgot or did not understand their importance, resulting in their ignorance’ [6].

The objectives of this research were to determine the level of knowledge patients have about diabetes in Singapore and subsequently, produce a directed education package that addresses these gaps in knowledge that patients have.

This pilot study was split into four phases: designing of survey questionnaire, carrying out the survey, designing a comprehensive syllabus for producing a new education package to address all the gaps in knowledge that patients may have (Figure 1).

Designing the Survey Questionnaire
Literature review was carried out on previous research papers which focused on developing effective indicators to determine how much patients know about diabetes [7-10]. Elements that increased the accuracy of survey questionnaires in determining the level of knowledge patients have, such as the ‘I don’t know’ option and the multiple-choice format, were retained while the lack of scope in previous questionnaires was improved on.

The re-developed survey questionnaire was produced in the multiple-choice format. All questions featured an ‘I Don’t Know’ option to reduce the ambiguity of whether patients know the answer to a certain question. Simple and concise terms were used for easy communication with patients. The survey questionnaire was also structured to cover all topics in the syllabus for the education package. Questions were spread evenly over the four main areas. These areas include ‘What is Diabetes?’ (9 questions), ‘Diagnosis’ (1 question), ‘Treatment’ (7 questions) and ‘Healthy Lifestyle’ (8 questions) (Table 1). This ensured that the survey questionnaire was able to give a holistic review of what patients know about diabetes.

Clinical Setting and Method of Conducting the Survey
This study was a randomized pilot study conducted in the National University Hospital, Singapore. The survey questionnaire was conducted over a period of 70 days from 26 February 2014 to 6 May 2014. Subjects were chosen from diabetic patients with foot problems managed by the National University Hospital Diabetic Foot Team headed by the senior author (A. Nather). 1 patient had Type 1 diabetes and 39 patients had Type 2 diabetes. They were aged 29 to 72 years old. They were able to speak English, Mandarin, Malay or Hokkien. Those who were too ill to be interviewed were excluded. Informed consent was obtained and participation was voluntary. A system of positive point allocation was employed with one points awarded for a correct answer but none for incorrect or unsure answers. The maximum possible score was 25.

Designing the Education Package
Apart from taking into consideration results from the survey questionnaire, the National University Hospital Diabetic Foot Team also conducted a thorough review of available print education resources in Singapore which include both booklet (Figure 2) and online website (Figure 3).

At present, the National University Hospital uses the ‘BE aWARE of Diabetes’ booklet produced by the Health Promotion Board, Singapore (Figure 2). This booklet covered a reasonable scope of information. However, some information presented was too wordy and unnecessary which may not be so effectively conducted by patients. Texts which are difficult to comprehend and take too long to read will not be able to hold the attention of patients. The essence of key points will be lost.

Certain practical information that patients need to know are also unavailable. For instance, important information on what patients should do and take note of before, during and after exercising was not included in any of the current education sources in Singapore.

Following the review of current resources and the incorporation of results from the survey questionnaire, the team designed a new syllabus that not only emphasized on areas patients were lacking in but covered a holistic scope of diabetes knowledge.

The booklet produced had key features specially designed so that information was presented in a more effective manner. Sentences were kept short and concise. Only knowledge important for patients was included. More tips and guidelines were given in the booklet as it would be more convenient for patients with a fixed and direct set of instructions to follow (Figure 4).

Formatting of the booklet was also simple but with more colours for easy reading. Illustrations were carefully chosen and designed for patients to better understand (Figure 5).

A total of 40 subjects were interviewed. All were diabetic patients with foot problems. The average age of this pilot study population was 25 years old. Majority of the respondents received secondary education.

Respondents were the most informed about the method of diagnosis for diabetes with 97.5% (Figure 6) giving correct answers for Q10. On the contrary, this study population was least informed on how often they should visit relevant medical professionals such as podiatrists and specialists for regular check-ups with a minority of 32.5% on average giving correct answers (Figure 6). Patients were also poorly equipped with knowledge regarding the importance of exercise as part of their diabetes management plan. An average of 40% (Figure 6) correct answers were given for the two questions that cover the frequency patients should exercise and things to take note of before and after exercising (Q22 and Q23). More than half of the study population was able to give correct answers on questions that cover the causes of diabetes, the symptoms of diabetes, complications of diabetes, medication, regular monitoring, diet as well as smoking and alcohol consumption with 71.1%, 62.5%, 71.0%, 82.5%, 83.8%, 61.9% and 70.0% on average getting these types of questions correct respectively.