Waikato Diabetes Education Study Ross Lawrenson Grace Joshy Yoska Eerens Wayne Johnstone

Background Patients that have had a comprehensive education and training program are more likely to lose weight and have better quality of life (Davies et al. 2008). We know that patients from ethnic minorities or those who are from deprived communities are less likely to achieve optimum control of their diabetes. We hypothesize that this is because they have not received a satisfactory/appropriate education program. We believe all patients with newly diagnosed Type 2 diabetes should receive adequate disease specific education within 6-months of diagnosis. Needed an understanding of what is happening in the Waikato

Methods All patients identified with type 2 diabetes on the Waikato Regional Diabetes Register with a year of diagnosis of 2007 were selected as the study group. A questionnaire was developed asking a series of question collecting basic demographic data as well as a series of questions regarding the education received, who provided it and self perceived knowledge. Input into the design of the questionnaire was obtained from a diabetes nurse, a dietician, a Maori researcher, a GP and consumer representatives. The questions were focused on important aspects of diabetes care such as diet, blood glucose, blood pressure, cholesterol, foot care, eye care, exercise and smoking. Questionnaire was posted All non respondents were followed up by telephone

Results 675 questionnaires sent out 667 possible responses (6 deceased,2 with IGT excluded) 255 responded initially 85 further on follow up – these were more likely to be Maori (28% vs 13%) and tended to be younger (mean age 60.9 vs 63.0) Remainder refused or were not contactable by phone 340/667 (51%) response Mean age of respondents 63 years compared with 59 for non respondents

Response rate by ethnicity EthnicityNumberNumber responded % Responded European % Maori % Indian % Asian1119% Pacific21419% Other361336% Total %

Response rate by self identified ethnicity – 91% agreement EthnicityNumber responded WRDS Self identified ethnicity European (243) Maori5558 (55) Indian108 (5) Asian14 (1) Pacific410 (3) Other133 (2) Total (309)

Self reported year of diagnosis – 75% agreement or 95% within 1 year either side Not known4

Results – 333 analysed (7 who were diagnosed between 1988 and 2004 excluded) NumberPercent Age Gender Male Female Ethnicity Maori Non Maori

Who were you diagnosed by ? By your General Practitioner300 (90%) By your local hospital20 (6%) By someone else - please tell us who this was 13 (4%)

Method of diagnosis Have symptoms and go to your doctor expecting you might have diabetes?42 (12.6%) Go to your doctor/hospital with an illness but not think of diabetes as a diagnosis?69 (20.9%) Have a routine blood test which showed diabetes? 207 (62.2%) Some other route to diagnosis15 (4.5%) 198/333 (59.5%) diagnosed by a routine blood test from GP

Belong to a support group 47/333 (14%) belong to Diabetes NZ Mean knowledge score of Diabetes NZ members was 7.3 vs 6.9 for non members 8/57 (14%) Maori and 39/276 (14%) non-Maori 6 others belonged to another group Age

Use of the Internet – 28% use the Internet to find out information about diabetes 22/57 (38.6%) Maori had access to Internet at home and 28/57 (49%) had access either at home or elsewhere 150/276 (54.3%) non-Maori had access to Internet at home and 175/276 (63%) had access either at home or elsewhere 9/57 (15.8%) Maori (9/28 of those with access %) said they had used the Internet to look for information about diabetes 85/276 (30.8%) non- Maori (85/175 of those with access %) said they had used the Internet to look for information about diabetes Only 8 people said they got most of their information about diabetes from the Internet

Access at home and use of the Internet by age category (non-Maori only) Age

Initial information about diabetes 272/307 (89%) of people who answered the question said they got most of their information about diabetes from their GP surgery (no difference between Maori and non-Maori) 25/57 (43.9%) of Maori had a family member included in their education compared with 87/276 (31.5%) of non-Maori Of those that answered the question 14/34 (41.2%) Maori and 46/157 (29.3%) non-Maori said they would like their family included

Group education Only 22/333 (6.6%) of respondents said they had attended a group education session Maori were twice as likely (12.3%) as non-Maori (5.4%) to have attended a group session Of those who stated a preference, 145/255 (56.9%) said they did not want to attend group sessions. Non Maori (59.3%) were more likely to say they did not want a group session than Maori (43.9%) 61/255 (23.9%) said they were happy to attend group sessions if individual sessions were not available (no difference between Maori and non-Maori) 36/255 (14.1%) said they would prefer group sessions – Maori were twice as likely to say they wanted group sessions (24.4%) compared with non-Maori (12.1%)

General knowledge 24/333 (7.2%) said that they were not given any information when they were first diagnosed Most common source of information was the practice nurse (199), the GP (179), the Diabetes Nurse (51) or a hospital doctor (11) Mean knowledge score out of 10 was 6.9 – the score for Maori was 6.3 compared with 7.1 for non-Maori

Dietary advice Only 16 patients said they had not received dietary advice 30% of patients said they had seen a dietician (42% of Maori and 28% of non-Maori) 63.5% said that they had dietary advice from the practice nurse Mean score on knowledge about diet was 7.0

Blood glucose monitoring 49/333 (14.7%) had not had information about blood glucose monitoring Most common source of information was the GP or practice nurse One poignant comment was that the patient who had a monitor but no one had shown them how to use it.

Blood pressure 88/333 (26.4%) had not had information about blood pressure monitoring Most common source of information was the GP or practice nurse Mean knowledge score was 6.4

Cholesterol 63/333 (18.9%) had not had information about cholesterol Most commonly mentioned source of information was the GP -178/237 (75%) Mean knowledge score was 6.4

Foot care 63/333 (18.9%) had not had information about foot care Most common source of information was the practice nurse 117/248 (47%) 21/333 (6.3%) had seen a podiatrist Mean knowledge score was 6.6

Eye care 34/333 (10.2%) said they had not had information about eye checks Most common source of information was the GP 115/265 (43%) 69 mentioned an optometrist or ophthalmologist as having given advice Mean knowledge score was 6.8

Exercise 48/333 said that they had not had advice about exercise 55% had advice from their GP and 45% from a practice nurse

Smoking 41/48 (85%) had been given advice to give up smoking although only 21 mentioned a health professional

Qualitative data Large amount of qualitative data available for analysis

Limitations Poor response rate – especially from Maori, Pacific and Asian Some missing data Need to analyse qualitative data

Summary Diabetes is most commonly diagnosed in asymptomatic patients who attend their general practitioner 93% of patients have received education about diabetes and generally knowledge is rated at 7/10 Lowest scores were related to BP and cholesterol Only 1/3 had increased the exercise they took Small differences between Maori and non-Maori but 60% Maori were non-respondents High non-respondent rate from Asians Commonest source of information is the GP and the practice nurse. 28% of patients use the Internet for information about diabetes