Content uploaded by Abubakr Yousif
Author content
All content in this area was uploaded by Abubakr Yousif on Jan 18, 2019
Content may be subject to copyright.
Available via license: CC BY 4.0
Content may be subject to copyright.
Pharmacology & Pharmacy, 2019, 10, 21-30
http://www.scirp.org/journal/pp
ISSN Online: 2157-9431
ISSN Print: 2157-9423
DOI:
10.4236/pp.2019.101003 Jan. 17, 2019 21
Pharmacology & Pharmacy
Assessing Knowledge of Hypoglycemia
Symptoms among Type 2 Diabetic Patients
Using Insulin, Khartoum, Sudan
Abdelhaleem Mustafa Madani1, Asma Noureldaim Mahmoud2,
Hisham Mohammed Abdelrahim3, Tarig Mohammed El-Hadiyah4, Abubakr Khidir Yousif5*
1Pharmacology Department, Faculty of Pharmacy, International University of Africa, Khartoum, Sudan
2Department of Pharmacy Practice, Faculty of Pharmacy, International University of Africa, Khartoum, Sudan
3University of National Ribat, Khartoum, Sudan
4Department of Pharmacology, Faculty of Pharmacy, International University of Africa, Khartoum, Sudan
5Ministry of Health, Wadmadani City, Sudan
Abstract
Background:
Hypoglycemia is a traumatic dilemma that
has a critical impact
on not only the patient’s quality of life but also their families and communi-
ties. Improving Patient’s awareness and knowledge regarding h
ypoglycemia
symptoms is crucial to avoid serious implications like loss of consciousness
and even death.
Objective:
This study aimed to assess patients’ knowledge of
hypoglycemia symptoms and source of diabetes information among insulin
users type 2 diabetes.
Methods:
A single centre, hospital-
based, analytical,
and cross-sectional study was carried out among diabetic patients using insu-
lin attended to Ribat University Hospital Diabetes Clinic (RUHDC), Khar-
toum State
, Sudan during a period of study. A validated questionnaire was
used to obtain socio-demographic characteristics of respondents and the pa-
tients’ knowledge regarding hypoglycemia symptoms was
assessed whether
good, medium or poor. Data were analyzed, using (SPSS). Descriptive (fre-
quencies) and inferential statistics (association used chi-
square) were used at
a level of confidence p ≤ 0.05.
Results:
A majority of patients (52%
) had poor
knowledge of hypoglycemia symptoms and the common symptoms known to
patients were hands tremor (67.2%), blurred vision (52.8%
) and sweating
(65.6%). No associations were found among hypoglycemia symptoms know-
ledge, socio-demographic and diabetes duration. Only (25.6%
) had regular
visiting to educating center and physicians were the major source of diabetes
knowledge (74.4%).
Conclusion:
This study proved low patients hypoglyce-
mia symptoms knowledge and physician were the main sources of informa-
How to cite this paper:
Madani, A.M.,
Mahmoud, A
.N., Abdelrahim, H.M.,
El
-Hadiyah, T.M. and Yousif, A.K. (2019
)
Assessing Knowledge of Hypoglycemia
Symptoms among Type 2 Diabetic Patients
Using Insulin, Khartoum, Sudan
.
Pharm
a-
cology & Pharmacy
,
10
, 21-30.
https://doi.org/10.4236/pp.2019.101003
Received:
November 28, 2018
Accepted:
January 14, 2019
Published:
January 17, 2019
Copyright © 201
9 by author(s) and
Scientific
Research Publishing Inc.
This work
is licensed under the Creative
Commons Attribution International
License (CC BY
4.0).
http://creativecommons.org/licenses/by/4.0/
Open Access
A. M. Madani et al.
DOI:
10.4236/pp.2019.101003 22
Pharmacology & Pharmacy
tion about diabetes at RUHDC. Further ideas are required in collaboration
and integrated approach to filling the gap of patients’ awareness and multi-
disciplinary team in diabetes management.
Keywords
Hypoglycemia Symptoms, Knowledge, Type 2 Diabetes, Insulin-Users, Sudan
1. Introduction
Hypoglycemia is a true medical emergency [1] and has a critical effect on mor-
tality, morbidity, and quality of life [2]. Hypoglycemia is a major barrier for at-
taining treatment goals and reduction of long-term complications in diabetes
management and therefore it is an important reason for increased costs of med-
ical care [3].
The American Diabetes Association defines the hypoglycemia as “any abnor-
mally low plasma glucose concentration that exposes the subject to potential
harm”, and proposes a threshold of <70 mg/dl [4]. The spectrum of symptoms
depends on the duration and severity of hypoglycemia and varies from auto-
nomic activation to behavioral changes to altered cognitive function to seizures
or coma and even death [5].
Two types of hypoglycemia symptoms are documented. The first one is neu-
roglycopenia which causes symptoms such as blurred vision, fatigue, concen-
trating disturbance, confusion and behavioral changes, and may lead to loss of
consciousness, seizures, brain damage, and death [6] [7]. The second one is
neurogenic symptoms and this occurs by the hormones and neurotransmitters
delivered as a result of low brain glucose levels, causing symptoms such as tre-
mor, palpitation, anxiety, sweating, hunger, dizziness and drowsiness [7] [8].
Patient’s awareness and knowledge of every hypoglycemia symptoms are very
important to be early recognized and to take measures for treatment and avoid
risks that may even cause death [7].
Many studies [9] [10] report that younger diabetes patients have high know-
ledge about diabetes in general and this is because older have a low cognitive
function which hinders diabetes education programs, whilst younger ages have
higher motivation [11] and adaptability towards disease.
Higher educated patients usually have higher knowledge about diabetes and
this is attributed to the fact that educated patients can easily respond to educa-
tion programs and have the ability to communicate with other sources of know-
ledge that provides medical programs such as television, radio, and internet [11].
Diabetes management is a complex and cost-effective process and requires an
integrated multi-disciplinary team consisting of physicians, nurses, dietitians,
exercise specialists, pharmacists, dentists, podiatrists, and mental health profes-
sionals, however, unless the presence of educated patients who are able to care
about themselves. The efforts of this team will not provide effective care. Partic-
A. M. Madani et al.
DOI:
10.4236/pp.2019.101003 23
Pharmacology & Pharmacy
ipation of diabetic patients in diabetes self-management education (DSME) is an
essential element of diabetes care [12]. Education helps people with diabetes to
initiate effective self-management and cope with diabetes when they are first di-
agnosed. DSME helps patients to optimize metabolic control, prevent and man-
age complications, and maximize the quality of life in a cost-effective manner
[13].
In the past few decades, a great shift has occurred regarding tradition clinical
pharmacists role, as medications dispenser, to direct patients’ pharmaceutical
care such as diabetes management [14] [15] including diabetes patients’ educa-
tion [16].
Knowledge and awareness of symptoms of hypoglycemia in diabetes prevent
patients from many risks of diabetes; however, the presence of studies that check
patient’s knowledge about this important part of diabetes self-management is
scarce and fragmented in Sudan.
2. Methods
2.1. Patients Characteristics
All type-2 diabetic patients on at least three-month insulin treatment attended to
Ribat University Hospital Diabetes Clinic (RUHDC) during the period of Au-
gust 2012 to February 2013 were recruited in this study, except those who re-
fused to participate (just two patients).
2.2. Instrument of Data Collection
Self-administered questionnaire constructed from recent literature and validated
by a discussion with experts group in diabetes management at Ribat University.
Then the questionnaire was piloted randomly to ten diabetic patients. After mi-
nor changes, the questionnaire distributed directly to all selected sample, whilst
patients’ cards were also used to obtain some patients data.
2.3. Hypoglycemia Symptoms Knowledge Assessment
Information including socio-demographic characteristics and the patients’
knowledge of hypoglycemia symptoms was assessed by using closed questions
(yes or no). Symptoms variables included in the questionnaire were dizziness,
weakness, drowsiness, hands tremor, sweating, palpitation, excessive hunger,
and blurred vision. Patients able to identify more than four hypoglycemia
symptoms in the questionnaire considered having good knowledge, those identi-
fied four were medium and those identified less than four had poor knowledge.
Patients also were asked about the source of knowledge of diabetes and their
regular visiting to diabetes educating team at RUHDC.
2.4. Data Analysis
Data analyzed, using social package for social science (SPSS) version 16, to assess
patient’s answers. Descriptive (frequencies) and inferential statistics (association
A. M. Madani et al.
DOI:
10.4236/pp.2019.101003 24
Pharmacology & Pharmacy
used chi-square) were used at a level of confidence p ≤ 0.05.
3. Results
A total of 125 respondents recruited in this study, 96 (76.8%) were females. Age
of participants between 41 and 60 years were 65 (52%), patients with basic edu-
cation level were 53 (42.4%) and 80 (64%) had low financial status. Majority of
patients, (52%) had poor hypoglycemia symptoms knowledge No associations were
found between hypoglycemia symptoms knowledge, socio-demographic and diabetes
duration (Table 1 demonstrated the Association between Socio-Demographic va-
riables and patients’ hypoglycemia knowledge). The common symptoms known
to patients were hands tremor (67.2%), blurred vision (52.8%) and sweating
(65.6%), see Table 2. The hypoglycemia symptoms were interpreted to three
Table 1. Association between patients’ hypoglycemia knowledge and some variables.
Socio-demographic
Hypoglycemia knowledge
p value
N = (%)
Good
Medium
Poor
1-Sex
0.737
Male 13 (10.4) 1 (0.8) 15 (12)
Female 39 (13.2) 7 (5.6) 50 (40)
2-Age
0.718
20 - 40 4 (3.2) 0 (0.0) 4 (3.2)
41 - 60
26 (20.8)
6 (4.8)
33 (26.4)
Above 60
22 (17.6)
2 (1.6)
28 (22.4)
3-Educational level
0.086
Basic 20 (16) 2 (1.6) 31 (24.8)
High secondary 9 (7.2) 2 (1.6) 13 (10.4)
University 11 (8.8) 1 (0.8)) 4 (3.2)
Non-formal 1 (0.8) 1 (0.8) 0.0 (0.0)
Illiterate 11 (8.8) 2 (1.6) 17 (13.6)
4-Financial status
0.354
High 20 (16) 1 (0.8) 24 (19.2)
Low
32 (25.6)
7 (5.6)
41 (32.8)
5-Diabetes duration
0.263
1 - 5
8 (6.4)
1 (0.8)
8 (6.4)
6 - 10
7 (5.6)
14 (11.2)
4 (3.2)
11 - 15
15 (12)
2 (1.6))
20 (16)
16 - 20
5 (4)
0 (0.0)
8 (6.4)
21 - 25
2 (1.6)
1 (0.8)
11 (8.8)
Above 25 8 (6.4) 0 (0.0) 3 (2.4)
A. M. Madani et al.
DOI:
10.4236/pp.2019.101003 25
Pharmacology & Pharmacy
categories poor, medium and good (see Figure 1). The physicians were the ma-
jor source of hypoglycemia knowledge for patients (74.4%), see Figure 2. Only
(25.6%) had regular visiting to educating. center (see Figure 3).
4. Discussion
This study was carried out among 125 type 2 diabetes attending RUHDC and
more than half of the patients in this study had poor hypoglycemia symptoms
knowledge and these findings was less than reported by Almalki
et al.
[17] who
reported 85% of patients had sufficient knowledge about the symptoms of
hyperglycemia and this high percent is attributed to the fact that more than half
of his patients received information about diabetes management from medical
Table 2. Knowledge of symptoms of hypoglycemia among insulin users type 2 DM pa-
tients.
Symptoms
Symptoms knowledge of hypoglycemia frequency
Percent (%)
Hands tremor
84
67.2
Blurred vision
66
52.8
Sweating
82
65.6
Drowsiness
53
42.4
Dizziness
50
40
Palpitation
38
30.4
Excessive hunger
10
8
Fatigue
7
5.6
Figure 1. Interpretation of patients knowledge about hypoglycemia symptoms.
A. M. Madani et al.
DOI:
10.4236/pp.2019.101003 26
Pharmacology & Pharmacy
Figure 2. Patients source of information about diabetes.
Figure 3. Patients’ commitment to regular visit to diabetes educating team.
providers. On the other hand, Kazi and his colleagues [18] reported only 17.2%,
whilst El-Khawaga from Egypt reported 48.1% [19].
Older patients with type 2 diabetes have a higher risk of developing a severe
episode of hypoglycemia due to low cognitive function [20]. Comprehensive
A. M. Madani et al.
DOI:
10.4236/pp.2019.101003 27
Pharmacology & Pharmacy
evaluations for this group of patients, including assessment of their knowledge
about symptoms of hypoglycemia, can help in preventing the risk of hypoglyce-
mia. This study did not reveal an association between age and knowledge about
hypoglycemia symptoms and this finding contradicted with that reported by
Thomson and his colleagues [9].
No association was found between hypoglycemia symptoms knowledge and
sex in this study and this consistent with Herath and his colloquies who revealed
no significant relationship between sex and diabetes knowledge [21]. On the
other hand, this result reflects another picture that different from Awad study
who reported that Sudanese female usually cope less well with diabetes, this may
be due to equality in the chance of education between male and female in Sudan
during last decades [22].
Usually, diabetic patients with high education level have good knowledge score
about diabetes [23], diabetes risk factors [24] and diabetes self-management how-
ever education level showed no effect on hypoglycemia symptoms knowledge in
this study. This result was consistent with Chinnappan and his colleagues who
revealed no relationship between education level and patients diabetes know-
ledge [25].
Although high relation between patients’ diabetes self-management know-
ledge and diabetes duration was found [26], however, no significant relationship
was found between diabetes duration and hypoglycemia symptoms knowledge
in this study and this consistent with that reported by Shriraam study [7].
Regarding hypoglycemia symptoms knowledge, sweating, tremor of hand and
blurred vision were the most symptoms identified by our patients in this study,
whilst Shriraam [7] reported that most common symptoms known to his pa-
tients were dizziness (81.4%), weakness (73.8%), and drowsiness (72.1%).
Diabetes treatment is complex and multidisciplinary team expert in diabetes
management can provide effective health care service, including diabetes
self-management knowledge. The ideal team may consist of physicians, nurse
practitioners, physician assistants, nurses, dietitians, exercise specialists, phar-
macists, dentists, podiatrists, and mental health professionals [27].
Almost three-quarter of patients in this study revealed that physicians were
the main source of diabetes knowledge, whilst pharmacist reported only minor
role. This finding consisted with Al-Maskari [28] who reported 2.1% for phar-
macist as a source of diabetes knowledge. This week role of the pharmacist in
addition to the poor commitment of patient to a regular visit to diabetes educat-
ing team gave justification for low percent of hypoglycemia symptoms know-
ledge in this study.
5. Conclusion
This study proved low patients hypoglycemia symptoms knowledge and the
physicians were the main source of information about diabetes at RUHDC, and
this subsequently increased the burden on physicians and decrease the effective-
A. M. Madani et al.
DOI:
10.4236/pp.2019.101003 28
Pharmacology & Pharmacy
ness of diabetes management. Great efforts are required as collaboration and in-
tegrated multidisciplinary team, including effective participation of the clinical
pharmacist, to fill the gap of the patients’ awareness of complex diabetes man-
agement.
Limitation
Although RUHDC is one of the largest centers in Sudan, conducting this study
in a single centre will not give the complete picture about patients’ knowledge of
hypoglycemia symptoms and source of diabetes information among insulin us-
ers type 2 diabetes in Sudan as a whole, so generalized study funded by consi-
derable organization or research institute is strongly recommended.
Ethics Approval and Consent to Participate
Ethical approval to the study from Higher Graduated Studies, University of Ri-
bat was issued. All participants were informed verbally about the aims of the
study and gave chance to participate or refuse.
Authors’ Contributions
The first Author planned, collected, analyzed data, findings and wrote the paper.
While the others were deeply involved in all steps as supervisors to the study
from proposal up to writing manuscript, revising and approval of the final ver-
sion.
Acknowledgements
The Authors appreciated the RUHDC workers, doctors and patients for their
kind participation, response, and patience during the period of the study.
Funding
This study was not funded by a grant from any organization. It is original work
of the First Author as Research for M Sc Degree in clinical pharmacy.
Conflicts of Interest
The authors declare that they have no competing interests.
References
[1] Shafiee, G.,
et al
. (2012) The Importance of Hypoglycemia in Diabetic Patients.
Journal of Diabetes & Metabolic Disorders
, 11, 17.
https://doi.org/10.1186/2251-6581-11-17
[2] Bruce, D.,
et al
. (2009) Severe Hypoglycaemia and Cognitive Impairment in Older
Patients with Diabetes: The Fremantle Diabetes Study.
Diabetologia
, 52, 1808.
https://doi.org/10.1007/s00125-009-1437-1
[3] Bhutani, G.,
et al
. (2015) Effect of Diabetic Education on the Knowledge, Attitude
and Practices of Diabetic Patients towards Prevention of Hypoglycemia.
Indian
Journal of Endocrinology and Metabolism
, 19, 383.
A. M. Madani et al.
DOI:
10.4236/pp.2019.101003 29
Pharmacology & Pharmacy
https://doi.org/10.4103/2230-8210.152781
[4] Association, A.D. (2018) 6. Glycemic Targets: Standards of Medical Care in Di-
abetes—2018.
Diabetes Care
, 41, S55-S64. https://doi.org/10.2337/dc18-S006
[5] Ejegi, A., Ross, A.J. and Naidoo, K. (2016) Knowledge of Symptoms and
Self-Management of Hypoglycaemia amongst Patients Attending a Diabetic Clinic
at a Regional Hospital in KwaZulu-Natal. African Journal of Primary Health Care &
Family Medicine, 8, 1-6. https://doi.org/10.4102/phcfm.v8i1.906
[6] Towler, D.A.,
et al.
(1993) Mechanism of Awareness of Hypoglycemia: Perception
of Neurogenic (Predominantly Cholinergic) Rather than Neuroglycopenic Symp-
toms.
Diabetes
, 42, 1791-1798. https://doi.org/10.2337/diab.42.12.1791
[7] Shriraam, V.,
et al.
(2015) Knowledge of Hypoglycemia and Its Associated Factors
among Type 2 Diabetes Mellitus Patients in a Tertiary Care Hospital in South India.
Indian Journal of Endocrinology and Metabolism
, 19, 378.
https://doi.org/10.4103/2230-8210.152779
[8] Cefalu, C.A. and Cefalu, W.T. (2005) Controlling Hypoglycemia in Type 2 Diabetes:
Which Agent for Which Patient? At Each New Stage of Treatment, Choices Can Be
Made to Reduce Risk
. Journal of Family Practice
, 54, 855-863.
[9] Thomson, F.,
et al
. (1991) Lack of Knowledge of Symptoms of Hypoglycaemia by
Elderly Diabetic Patients.
Age and Ageing
, 20, 404-406.
https://doi.org/10.1093/ageing/20.6.404
[10] Mutch, W. and Dingwall-Fordycet, I. (1985) Is It a Hypo? Knowledge of the Symp-
toms of Hypoglycaemia in Elderly Diabetic Patients.
Diabetic Medicine
, 2, 54-56.
https://doi.org/10.1111/j.1464-5491.1985.tb00593.x
[11] Shrestha, N.,
et al
. (2015) Diabetes Knowledge and Associated Factors among Di-
abetes Patients in Central Nepal.
International Journal of Collaborative Research on
Internal Medicine & Public Health
, 7, 82.
[12] Mulcahy, K.,
et al
. (2003) Diabetes Self-Management Education Core Outcomes
Measures.
The Diabetes Educator
, 29, 768-803.
https://doi.org/10.1177/014572170302900509
[13] Nicholas, D.,
et al
. (2001) Digital Health Information Provision and Health Out-
comes.
Journal of Information Science
, 27, 265-276.
https://doi.org/10.1177/016555150102700409
[14] Chisholm-Burns, M.A.,
et al
. (2010) US Pharmacists’ Effect as Team Members on
Patient Care: Systematic Review and Meta-Analyses.
Medical Care
, 923-933.
https://doi.org/10.1097/MLR.0b013e3181e57962
[15] Simpson, S.H.,
et al
. (2011) Effect of Adding Pharmacists to Primary Care Teams on
Blood Pressure Control in Patients with Type 2 Diabetes: A Randomized Controlled
Trial.
Diabetes Care
, 34, 20-26. https://doi.org/10.2337/dc10-1294
[16] Farsaei, S.,
et al
. (2011) Effect of Pharmacist-Led Patient Education on Glycemic
Control of Type 2 Diabetics: A Randomized Controlled Trial.
Journal of Research in
Medical Sciences
:
The Official Journal of Isfahan University of Medical Sciences
, 16,
43.
[17] Almalki, M.H.,
et al
. (2018) Assessment of Ramadan Education and Knowledge
among Diabetic Patients.
Clinical Medicine Insights
:
Endocrinology and Diabetes
,
11. https://doi.org/10.1177/1179551417751611
[18] Kazi, R.N., Bote, M.M. and Raikar, K.J. (2017) Knowledge, Attitude and Practices
about Diabetes Mellitus and Its Complications in T2DM Patients Attending the
UHC in Mumbai.
International Journal of Community Medicine and Public Health
,
4, 2793-2797. https://doi.org/10.18203/2394-6040.ijcmph20173325
A. M. Madani et al.
DOI:
10.4236/pp.2019.101003 30
Pharmacology & Pharmacy
[19] El-Khawaga, G. and Abdel-Wahab, F. (2015) Knowledge, Attitudes, Practice and
Compliance of Diabetic Patients in Dakahlia, Egypt.
European Journal of Medical
Research
, 3, 40-53.
[20] Punthakee, Z.,
et al
. (2012) Poor Cognitive Function and Risk of Severe Hypogly-
cemia in Type 2 Diabetes: Post Hoc Epidemiologic Analysis of the ACCORD Trial.
Diabetes Care
, 35, 787-793.
[21] Herath, H.M.,
et al
. (2017) Knowledge, Attitude and Practice Related to Diabetes
Mellitus among the General Public in Galle District in Southern Sri Lanka: A Pilot
Study.
BMC Public Health
, 17, 535. https://doi.org/10.1186/s12889-017-4459-5
[22] Mohamed Ahmed, A. and Hassan Ahmed, N. (2001) Diabetes Mellitus in Sudan:
The Size of the Problem and the Possibilities of Efficient Care.
Practical Diabetes
International
, 18, 324-327. https://doi.org/10.1002/pdi.292
[23] Al-Adsani, A.,
et al
. (2009) The Level and Determinants of Diabetes Knowledge in
Kuwaiti Adults with Type 2 Diabetes.
Diabetes & Metabolism
, 35, 121-128.
https://doi.org/10.1016/j.diabet.2008.09.005
[24] Aljoudi, A.S. and Taha, A.Z. (2009) Knowledge of Diabetes Risk Factors and Pre-
ventive Measures among Attendees of a Primary Care Center in Eastern Saudi Ara-
bia.
Annals of Saudi Medicine
, 29, 15. https://doi.org/10.4103/0256-4947.51813
[25] Chinnappan, S.,
et al
. (2017) Assessment of Knowledge of Diabetes Mellitus in the
Urban Areas of Klang District, Malaysia.
Pharmacy
, 5, 11.
https://doi.org/10.3390/pharmacy5010011
[26] Ko, S.-H.,
et al
. (2012) Influence of the Duration of Diabetes on the Outcome of a
Diabetes Self-Management Education Program.
Diabetes & Metabolism Journal
, 36,
222-229. https://doi.org/10.4093/dmj.2012.36.3.222
[27] McGill, M.,
et al
. (2017) The Interdisciplinary Team in Type 2 Diabetes Manage-
ment: Challenges and Best Practice Solutions from Real-World Scenarios.
Journal of
Clinical & Translational Endocrinology
, 7, 21-27.
https://doi.org/10.1016/j.jcte.2016.12.001
[28] Al-Maskari, F.,
et al
. (2013) Knowledge, Attitude and Practices of Diabetic Patients
in the United Arab Emirates.
PLoS ONE
, 8, e52857.
https://doi.org/10.1371/journal.pone.0052857
