Introduction

Diabetes is a chronic metabolic disease that is common in Korea. There are a large number of complications associated with diabetes varying in severity [1] which may be preventable by following guidelines provided by health-care professionals [2–4]. It is therefore important for people with diabetes to implement health behaviors to manage their blood glucose levels [5,6]. However, it has been reported that most individuals with diabetes do not effectively follow the diet and exercise guidelines provided [7], and this leads to an increasing number of complications over time [8–9].

Educational needs are subjective and vary according to the individual [10]. Educational programs need to include knowledge or skills related to health promotion, health problems, and disease prevention [10], which is the foundation of motivating individuals to perform good health behaviors [11,12]. It was reported that people without diabetes complications who had a high educational and socioeconomic status, had high educational needs [13]. Providing education for disease management could increase self-care behavior by enhancing self-efficacy [14].

Previous studies have examined the educational needs of people with complications in diabetes. Perceptions about the disease, their cognitive function, activities of daily living, and depression status have been reported [15,16]. However, few studies have rigorously investigated the factors associated with these needs, for example, the examination of whether educational needs were influenced by severity of complications of diabetes.

It has been argued that the way people perceive the risk of diabetes needs to be considered when planning and implementing education programs [17]. It was also reported that risk perceptions were the main concept explaining behavioral changes [18]. The perception of, and attitude towards diabetes, as well as the intellectual level of individuals should be explored in order to identify educational needs [19]. People usually accept and follow medical advice from health care professionals when they perceive themselves as being more likely to have a severe illness/condition [20–22]. However, they may ignore such advice if they think there is no possibility that they would develop a condition such as diabetes [23]. Optimism bias refers to a tendency that people believe they have a lower probability of experiencing negative events [24,25]. Yet, optimism bias is an illogical underestimation of possible risks that can happen in the life, and is a subjective judgment based on vague expectations, rather than representing a logical judgment based on objective data [25,26].

It was observed that only 14.6% of those who developed diabetic retinopathy actually perceived the actual condition affecting them [27]. It was also reported that approximately 40% of people with diabetes did not understand the importance of managing lipid levels and blood pressure, to prevent complications of diabetes [27]. Older adults with diabetes often had incorrect knowledge about diabetes and foot care [28]. Some studies have shown that compliance with foot care is low among individuals with diabetes, which could be a causal factor leading to foot amputation [29,30]. It is assumed that these findings are related to how people with diabetes perceive the risk of diabetes complications such as diabetic retinopathy, hypertension, and foot problems. This has not been previously investigated in Korea. In order to implement education or assess educational needs, it is crucial to examine comparative risk perception across a group [17,31] rather than the risk perception of an individual developed over their lifetime, which inevitably will be different to another individuals risk perception [32]. It has also been suggested that health care professionals should tailor health-related messages according to the risk perceptions of each individual [17,31]. This study focused on educational needs in terms of complications and the comparative risk perceptions of individuals with type 2 diabetes. The study investigated the relationship between educational needs, level of type 2 diabetes complications, and comparative risk perceptions amongst a type 2 diabetes population, to identify factors associated with educational needs. The present study aimed to provide fundamental data for developing an education program for self-care by the individual with type 2 diabetes. The objectives of this study were as follows:

1. Determine the general characteristics of study participants.

2. Examine educational needs related to the level of type 2 diabetes complications

3. Examine educational needs related to comparative risk perceptions

4. Identify the relationships between educational needs, level of type 2 diabetes complication, and comparative risk perceptions.

5. Identify predicting factors of the educational needs among people with type 2 diabetes.

Materials and Methods

1. Design

This was a cross-sectional descriptive study examining the relationships between educational needs, complications of diabetes, and comparative risk perception, a variety of educational needs depending on complications and comparative risk perceptions, and the factors associated with educational needs among people with type 2 diabetes.

2. Study participants

This study applied arbitrary sampling extraction to 177 people with type 2 diabetes who visited the endocrinology outpatient clinic of a university hospital located in the Republic of Korea from December 10, 2016 to February 10, 2017. All patients with type 2 diabetes who visited the outpatient clinic were asked to participate in the survey. There were 177 patients who agreed to complete the survey after receiving detailed information of the study. Trained researchers were available to help participants understand the questions being asked in the survey. The inclusion criteria for this study were (1) aged 19 years or older, (2) people attending clinics on a regular basis (as recommended by their doctor) after being diagnosed with type 2 diabetes, (3) those who are able to interpret written Korean and communicate in spoken Korean, and (4) those who are able to complete, understand the purpose, and agreed to participate in the study.

The sample size was calculated using the G power 3.1 program. Since the study was measuring educational needs based on the classification of diabetes complications and comparative risk perception, there were 3 groups per the classification of complications and comparative risk perception. With a level of significance (α) set at 0.05 for ANOVA, a medium effect size of 0.25, a power of 0.80, and 3 factors, the sample size required was 158. Considering attrition rate, a total of 182 participants were recruited. After excluding 5 incomplete responses, 177 participants were included in the final analysis.

3. Instruments

3.1. Educational needs

The educational needs of each participant were measured using a tool developed by Park [31]. This tool comprises the following 7 subscales with a total of 44 items: characteristics of disease/condition (4 items), risk factors (8 items), medication administration (4 items), diet (10 items), physical activity and exercise (4 items), consistent care (6 items), and complications (8 items). Each item is scored on a 4-point Likert scale where 1 to 4 points are assigned to an individual’s answer and a total score range of 44–176 points. A higher score indicates a higher educational need: “I never want to know” (1 point), “I do not want to know” (2 points), “I want to know” (3 points), and “I desperately want to know” (4 points). Cronbach’s α was 0.74 in the study by Park in 2012 [31], and 0.97 in this current study.

3.2. Comparative risk perceptions

Comparative risk perceptions were measured using a scale (RPS-DM) developed by Walker et al [33] and validated by Kang [34]. This survey comprised of composite risk perception and risk knowledge as the main categories. The composite risk score included a total of 26 items in 5 subscales: personal control (4 items), worry (2 items), optimistic bias (2 items), personal risk (9 items), and environmental risk (9 items). Each item in comparative risk perception had a score ranging from 1 to 4 for each item (a total score range: 26–104), a higher score indicated a greater comparative risk perception. Risk knowledge included 5 questions to measure the knowledge that individuals with diabetes had about diabetes complications. Each item in risk knowledge had a correct answer score of 1 point, and a total maximum score of 5 for all 5 questions. A higher score indicated a greater knowledge of diabetes complications. This tool was developed in both English and Spanish. Since this tool had never been used in Korea, it was translated from English to Korean by the authors of this current study, and back-translated by a Korean nurse registered in the United States for more than 20 years. Two certified medical interpreters finalized the Korean version through an in-depth review and discussion.

The Cronbach’s α score for the entire survey tool was 0.65, and for the subscales of personal control, worry, optimistic bias, personal risk, environmental risk, and risk knowledge were 0.65, 0.64, 0.76, 0.86, 0.83, and 0.64, respectively in the study by Walker et al [33]; the corresponding values in this study were 0.90, 0.51, 0.73, 0.70, 0.92, 0.89, and 0.62, respectively.

4. Data collection

This study was approved by 2 institutional review boards: G hospital and K university. There were 177 study participants who were randomly selected from the individuals with type 2 diabetes who visited the outpatient department (endocrine clinic) of a general hospital located in G city, Republic of Korea. Data were collected from December 10, 2016 through to February 10, 2017. The researchers explained the purpose and process of the study to the participants in a diabetes education classroom before the participants signed an informed consent form. The consent form provided information about the background and methods of the study, the confidentiality of the participants, and their freedom to stop participating in the study at any time. Data collection was conducted using a structured, paper-based survey.

5. Data analysis

Data were analyzed using the IBM SPSS software 20.0 (IBM Corp., Armonk, NY, USA). Descriptive statistics was used to analyze the general characteristics, educational needs, levels of complications, and comparative risk perceptions of the participants. Pearson correlation was used to analyze the relationships between educational needs, levels of complications, and comparative risk perceptions. ANOVA was used to analyze educational needs related to the level of complication, comparative risk perceptions, and general characteristics of the participants, and Scheffé’s test was applied as a post-hoc test when the ANOVA indicated a significant difference. Multiple regression analysis was also used to identify predicting factors of educational needs.

Results

1. General characteristics

There were 126 (71.2%) males and 51 (28.8%) females, with an average age of 54.38 ± 9.97 years (mean ± SD; Table 1). The largest proportion of participants were in their 50s (n = 65; 36.7%), married (n = 153; 86.4%), high-school graduates (n = 89; 50.3%), and with a monthly income of 3,000,000 to 5,000,000 Korean Won (KRW) (approximately 3,000 to 5,000 USD) (n = 63; 35.6%). The duration of having type 2 diabetes was 9.03 ± 6.40 years, and the largest proportion of participants in the study were those diagnosed 5 to 10 years previously (n = 47; 26.6%). Diabetes education had not previously been received in 104 (58.8%) of the participants themselves, or by the families of 147 (83.1%) of the participants.

2. Educational needs related to the level of type 2 diabetes complications

Diabetes complications were classified into 3 levels: (1) none; (2) mild to moderate complications (high blood pressure, vision problems, or numbness on feet); and (3) severe complications (heart attack, foot amputation, cancer, stroke, blindness, or kidney failure). The educational needs did not statistically significantly differ with the level of type 2 diabetes complications (Table 2).

3. Educational needs related to comparative risk perceptions

After classifying the comparative risk perception scores into low (n = 44; lower quartile), median (n = 87; middle quartiles), and high (n = 46; upper quartile), the educational needs were observed to differ with the comparative risk perceptions (F = 8.84; p < 0.001). Scheffé’s test revealed that participants with low comparative risk perceptions had statistically significantly lower educational needs than those with high comparative risk perceptions (Table 3).

4. Relationship between educational needs, comparative risk perceptions, and the level of type 2 diabetes complications

Educational needs had a statistically significantly positive relationship with comparative risk perceptions (r = 0.241; p = 0.001). Comparative risk perceptions had statistically significant relationship with level of diabetes complications (r = 0.253; p = 0.001). However, educational needs were not related to the level of type 2 diabetes complications (r = −0.015; p = 0.842; Table 4).

5. Factors influencing educational needs

Using regression analysis to search for the factors predicting educational needs, the level of complication, and comparative risk perceptions were imputed as independent variables, and educational need was imputed as a dependent variable. In addition, age, marital status, and educational level were added as independent variables which were significant to educational needs in univariate analysis. Multicollinearity among independent variables was also tested, which resulted in multicollinearity not being observed.

The statistically significant factors influencing the educational needs of the participants were comparative risk perceptions (p = 0.007), and marital status (p = 0.004). For comparative risk perceptions, people with a high comparative risk perception had higher educational needs than those with low comparative risk perceptions. In terms of marital status, married people had a higher educational need than those who were single, divorced, or bereaved. However, the level of diabetes complications, age, and educational levels were not factors that statistically significantly influenced educational needs. This result had an explanatory power of 10.8% (Table 5).

Discussion

This study examined which factors were significant to the educational needs among people with type 2 diabetes, focusing on the level of diabetes complications, and comparative risk perceptions. There was a statistically significant correlation between educational needs and comparative risk perceptions, whereas no significant correlation was observed between educational needs and the level of diabetes complications. This indicates that people with higher comparative risk perceptions have greater educational needs, which suggests that their comparative risk perceptions should be considered when the individual’s educational needs are assessed.

A previous study showed that the patient’s perception of diabetes differed according to the presence of complications [15]. Another study observed that individuals with severe complications of diabetes had a tendency to become more depressed [16]. However, in the present study there was no significant difference in educational needs when the level of complication was considered as a factor, but there was a statistically significant difference in educational needs factoring for the level of risk perception. This result may be due to the fact that people do not realize the severity of their health condition in type 2 diabetes as it progresses gradually. Several studies have indicated that people with type 2 diabetes had a low level of awareness about complications such as problems with vision, foot numbness, and hypertension [27,28]. It was reported that they did not perceive managing hypertension and dyslipidemia as important in the prevention of complications in type 2 diabetes [27]. Many people with diabetes often receive misinformation or have incorrect knowledge about the value of diabetes foot care [28]. These studies imply that complications experienced by people with type 2 diabetes do not directly influence their educational needs, except when the complications are perceived as a risk.

This current study showed that married people with type 2 diabetes had higher educational needs than those who were single, divorced, or bereaved. Unfortunately, there is no previous study investigating marital status and educational needs but 1 previous study showed that married people with diabetes had higher compliance with the treatment of diabetes, compared with those that were unmarried [35]. A study of the relationship between marital status and educational needs is necessary in the future.

Diabetes education programs should consider the educational needs, intellectual level, awareness, attitude, and risk perceptions of individuals [17,19–23,36,37]. None of the previous studies investigated the association between educational needs and comparative risk perceptions, or how risk perceptions influenced the health behaviors of individuals with diabetes. However, the findings of this current study suggest that health-care professionals should focus on identifying individuals’ comparative risk perceptions, rather than only objectively assessing the condition when planning and implementing education. This will ensure that they receive an optimal education.

This study identified comparative risk perceptions as an important factor associated with educational needs, a finding not previously identified [31,37,38]. However, this study was conducted at 1 local hospital in South Korea and therefore generalizations cannot be made. Further robust studies are necessary to examine factors influencing educational needs in addition to comparative risk perceptions.

Conclusion

This study was conducted to identify the relationships between the educational needs, levels of diabetes complications, and comparative risk perceptions among people with type 2 diabetes, with the aim of providing fundamental data for enhancing the self-care abilities of people with diabetes. This study showed that comparative risk perceptions and marital status were significant factors in predicting a diabetes patient’s educational needs, whilst the level of type 2 diabetes complication was not significant: High comparative risk perceptions and being married were associated with high educational needs. Thus, to assess the educational needs of type 2 diabetic patients, comparative risk perceptions should be considered rather than just objective complications. However, the relationship between educational needs and comparative risk perceptions was not particularly strong, and so it is difficult to conclude that comparative risk perceptions were the main factor contributing to increased educational needs. Therefore, further studies are needed to thoroughly investigate the factors influencing educational needs and risk perceptions among people with type 2 diabetes for the purpose of developing optimal programs for individualized interventions and education.

Article information

Conflicts of Interest

The authors have no conflicts of interest to declare.

References

• 1. Korean Diabetes Association [Internet]. Diabetes fact sheet in Korea 2018 [cited 2019 Nov 13]. Available from: https://synapse.koreamed.org/Synapse/Data/PDFData/2004DMJ/dmj-43-487.pdf.
• 2. Bus SA, van Netten JJ. A shift in priority in diabetic foot care and research: 75% of foot ulcers are preventable. Diabetes Metab Res Rev 2016;32( Suppl 1). 195−200. PMID: 10.1002/dmrr.2738.ArticlePubMed
• 3. Dyson PA, Twenefour D, Breen C, et al. Diabetes UK evidence-based nutrition guidelines for the prevention and management of diabetes. Diabet Med 2018;35(5). 541−7. PMID: 10.1111/dme.13603. PMID: 29443421.ArticlePubMed
• 4. Mendes R, Sousa N, Almeida A, et al. Exercise prescription for patients with type 2 diabetes-a synthesis of international recommendations: Narrative review. Br J Sports Med 2016;50(22). 1379−81. PMID: 10.1136/bjsports-2015-094895. PMID: 26719499.ArticlePubMed
• 5. Kim JH, Chang SA. Effect of diabetes education program on glycemic control and self-management for patients with type 2 diabetes mellitus. Diabetes Metab J 2009;33(6). 518−25.Article
• 6. Sim KH, Wang BR, Noh JW, et al. Diabetes education compliance and Knowledge among diabetes patients: Analysis of patients who refuse diabetes education at an academic medical center. J Korean Diabetes 2014;15(1). 51−6. PMID: 10.4093/jkd.2014.15.1.51.Article
• 7. Reynolds AN, Mann JI, Williams S, et al. Advice to walk after meals is more effective for lowering postprandial glycaemia in type 2 diabetes mellitus than advice that does not specify timing: A randomized crossover study. Diabetologia 2016;59(12). 2572−8. PMID: 10.1007/s00125-016-4085-2. PMID: 27747394.ArticlePubMedPDF
• 8. Huang ES, Laiteerapong N, Liu JY, et al. Rates of complications and mortality in older patients with diabetes mellitus: The diabetes and aging study. JAMA Intern Med 2014;174(2). 251−8. PMID: 10.1001/jamainternmed.2013.12956. PMID: 3950338.ArticlePubMedPMC
• 9. Yeap BB, McCaul KA, Flicker L, et al. Diabetes, myocardial infarction and stroke are distinct and duration-dependent predictors of subsequent cardiovascular events and all-cause mortality in older men. J Clin Endocrinol Metab 2015;100(3). 1038−47. PMID: 10.1210/jc.2014-3339.ArticlePubMed
• 10. Jang M-S, Hwang MS. Comparison of hospital nurses’ knowledge, emergency coping ability and educational need according to nursing care experience for patient applied the home mechanical ventilator. J Korean Acad Soc Home Care Nurs 2017;24(2). 121−32.
• 11. Jo S, Kim Y, Choi JS. Influencing factors on preventive health behaviours for Zika virus in pregnant women and their partners. J Clin Nurs 2019;28(5–6). 894−901. PMID: 10.1111/jocn.14698.ArticlePubMed
• 12. Lawn S, Westwood T, Jordans S, et al. Support workers as agents for health behavior change: An Australian study of the perceptions of clients with complex needs, support workers, and care coordinators. Gerontol Geriatr Educ 2017;38(4). 496−516. PMID: 10.1080/02701960.2016.1165218.ArticlePubMed
• 13. Rodríguez-Sánchez B, Cantarero-Prieto D. Socioeconomic differences in the associations between diabetes and hospital admission and mortality among older adults in Europe. Econ Hum Biol 2019;33:89−100. PMID: 10.1016/j.ehb.2018.12.007. PMID: 30771640.ArticlePubMed
• 14. Wonggom P, Kourbelis C, Newman P, et al. Effectiveness of avatar-based technology in patient education for improving chronic disease knowledge and self-care behavior a systematic review. JBI Database System Rev Implement Rep 2019;17(6). 1101−29. PMID: 10.11124/JBISRIR-2017-003905. PMID: 31021975.ArticlePubMed
• 15. Kim DJ. Satisfaction with high deductible policies among patients with diabetes in the Korean general/university hospital system. J Korean Diabetes 2011;12(4). 179−82. PMID: 10.4093/jkd.2011.12.4.179.Article
• 16. Jung YJ. [Dissertation]. Factors related to mental health status in elderly type 2 diabetes patients. Suwon (Korea): Ajou University; 2011.
• 17. Veláazquez WR, Potts CS. Unrealistic optimism, sex, and risk perception of type 2 diabetes onset: Implication for education programs. Diabetes Spectr 2015;28(1). 5−9. PMID: 10.2337/diaspect.28.1.5.ArticlePubMedPMC
• 18. Ferrer R, Klein WM. Risk perceptions and health behavior. Curr Opin Psychol 2015;1(5). 85−9. PMID: 10.1016/j.copsyc.2015.03.012.Article
• 19. Park SY, Oh PJ. Factors influencing diabetes educational needs in patients with diabetes mellitus. J Korea Acad Ind Coop Soc 2014;15(7). 4301−9.Article
• 20. Cho SY. Predicting women’s cervical cancer prevention behaviors extending health belief model. J Korean Soc Advert Educ 2011;91:348−77.
• 21. Gallivan J, Brown C, Greenberg R, et al. Predictors of perceived risk of the development of diabetes. Diabetes Spectr 2009;22(3). 163−9. PMID: 10.2337/diaspect.22.3.163.Article
• 22. Guess ND, Caengprasath N, Dornhorst A, et al. Adherence to NICE guidelines on diabetes prevention in the UK: Effect on patient knowledge and perceived risk. Prim Care Diabetes 2015;9(6). 407−11. PMID: 10.1016/j.pcd.2015.04.005. PMID: 25979539.ArticlePubMed
• 23. Thompson TL, Dorsey A, Miller K, Parrott R. Handbook of health communication. London (UK): Lawrence Erlbaum Assoc Inc; 2003.
• 24. Chapin JR, Coleman G. Optimistic bias: What you think, what you know, or whom you know? N Am J Psychol 2009;11(1). 121−32.
• 25. Weinstein ND. Unrealistic optimism about future life events. J Pers Soc Psychol 1980;39(5). 806−20. PMID: 10.1037/0022-3514.39.5.806.Article
• 26. Lee MY, Lee JS. The Effects of message frame and involvement on optimistic bias. Korean J Commun Info 2009;48:191−210.
• 27. Lee DW, Park CY, Song SJ. Study on survey of knowledge and awareness level of diabetic retinopathy in type 2 diabetes patients: Results from Seoul metro-city diabetes prevention program survey. J Korean Ophthalmol Soc 2011;52(11). 1296−301. PMID: 10.3341/jkos.2011.52.11.1296.Article
• 28. Yang NY. Knowledge, self-efficacy and self-care behavior regarding foot care among elderly diabetes mellitus patients. Korean J Adult Nurs 2009;21(4). 413−22.
• 29. Choi GA, Jang SM, Nam HW. Current status of self-management and barriers in elderly diabetic patient. Diabetes Metab J 2008;32(3). 280−9.Article
• 30. Kim JY, Lee KT, Young KW, et al. A clinical study on the diabetic foot wound. Diabetes Metab J 2007;31(1). 89−95.Article
• 31. Park SY. [Dissertation]. A study on the correlation between diabetes patients’ knowledge, self-care behavior and the educational demand Seoul (Korea), Sahmyook University. 2012.
• 32. Brown VJ. Risk perception: It’s personal. Environ Health Perspect 2014;122(10). 276−9. PMID: 10.1289/ehp.122-A276.Article
• 33. Walker EA, Caban A, Schechter CB, et al. Measuring comparative risk perceptions in an urban minority population: The risk perception survey for diabetes. Diabetes Educ 2007;33(1). 103−13. PMID: 10.1177/0145721706298198. PMID: 17272796.ArticlePubMed
• 34. Kang SJ. Testing of risk perception survey: Diabetes mellitus in Korea. J Korean Data Info Sci Soc 2016;27(2). 477−86.Article
• 35. Mirahmadizadeh A, Delam H, Seif M, et al. Factors affecting insulin compliance in patients with type 2 diabetes in South Iran, 2017: We are faced with insulin phobia. Iran J Med Sci 2019;44(3). 204−13. PMID: 31182886. PMID: 6525732.PubMedPMC
• 36. Song MS, Kim HS. Difference in knowledge and learning needs of the coronary artery disease according to the general characteristics of the patients with type 2 diabetes mellitus. J Korean Acad Fundam Nurs 2007;14(3). 323−30.
• 37. Kim NR. [Dissertation]. A study on the knowledge for coronary artery and educational needs of diabetes patients Seoul (Korea), Sungkyunkwan University. 2003.
• 38. Yang NH, Park JK, Jung YJ, et al. The effects of self-efficacy on the relationships between familial support and self-care of diabetes mellitus patients. Korean J Hum Ecol 2008;11(1). 73−85.

Figure & Data

References

Citations

Citations to this article as recorded by