Int J Clin Pharm (2011) 33:1028–1035

DOI 10.1007/s11096-011-9582-2

RESEARCH ARTICLE

Diabetes knowledge, medication adherence and glycemic control

among patients with type 2 diabetes
Harith Kh. Al-Qazaz • Syed A. Sulaiman • Mohamed A. Hassali •
Asrul A. Shafie • Shameni Sundram • Rana Al-Nuri • Fahad Saleem

Received: 1 April 2011 / Accepted: 31 October 2011 / Published online: 15 November 2011
 Springer Science+Business Media B.V. 2011

Abstract Background Most of interventions that have (SD = 9.16), 50.7% males and median HbA1C of 7.6 (IQR
attempted to improve medication adherence in type 2 was 6.7–8.9). The median total knowledge score was 7.0
diabetes have been educational; on the assumption that (IQR was 5.0–10.0) while the median adherence score was
knowledge regarding diabetes might affect patients’ 6.5 (IQR was 4.75–7.75). Significant correlations were
adherence to their treatment regimen. Objectives The pur- found between the three variables (HbA1C, knowledge and
pose of the study was to investigate any association of adherence). A significantly higher score for knowledge and
knowledge and medication adherence with glycemic con- adherence (P \ 0.05) was found in those patients with
trol in patients with type 2 diabetes mellitus. Setting The lower HbA1C. Higher diabetes knowledge, higher medi-
study was conducted at the Diabetes Outpatients Clinic, cation adherence and using mono-therapy were significant
Hospital Pulau Penang. Methods A cross-sectional study predictors of good glycemic control in the multivariate
was conducted with a convenience sample of 540 adult analysis. Conclusion Patients’ knowledge about diabetes is
patients with type 2 diabetes attending the clinic. A ques- associated with better medication adherence and better
tionnaire including previously validated Michigan Diabetes glycemic control. In addition to other factors affecting
Knowledge Test and Morisky Medication Adherence Scale medication adherence and glycemic control, healthcare
was used and the patients’ medical records were reviewed providers should pay attention to knowledge about diabetes
for haemoglobin A1C (HbA1C) levels and other disease- that the patients carry towards medication adherence.
related information. A total of 35 (6.48%) patients were
excluded after data collection due to lack of HbA1C Keywords Diabetes type 2
Glycemic control

results. Results Five hundred and five patients were inclu- Knowledge
Medication adherence
ded in the final analysis, with a mean age of 58.15 years

Impact of findings on practice

H. Kh. Al-Qazaz (&)
S. A. Sulaiman
Discipline of Clinical Pharmacy, School of Pharmaceutical • More knowledge about diabetes in diabetic patients is
Sciences, Universiti Sains Malaysia, 11800 Penang, Malaysia
associated with a better medication adherence and
e-mail: [email protected]
better glycemic control.
M. A. Hassali
A. A. Shafie
F. Saleem • There is a need for educational programs to improve the
Discipline of Social and Administrative Pharmacy, self-management people with type 2 diabetes.
School of Pharmaceutical Sciences, Universiti Sains Malaysia,
11800 Penang, Malaysia

S. Sundram
Hospital Balik Pulau, Balik Pulau, 11000 Penang, Malaysia Introduction
R. Al-Nuri
Advanced Medical and Dental Institute, Universiti Sains The prevalence of diabetes mellitus (DM) is continuously
Malaysia, 11800 Penang, Malaysia increasing. The high levels of morbidity and mortality due

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to DM, constitute an increasing health problem worldwide. to assess: (1) the general level of diabetes knowledge and
More than 171 million people were affected by diabetes in medication adherence in patients with type 2 diabetes; (2)
2,000 and the prevalence of this disease is estimated to be the correlation between demographic characteristics (age,
366 million in 2030 [1]. According to the Third National gender, race, and educational level) with both general
Health and Morbidity Survey (NHMS III) in Malaysia, the diabetes knowledge and medication adherence; and (3) the
prevalence of type 2 DM in adults aged 30 years and above associations between patient knowledge, medication
stands at 14.9% increasing from 8.3% in 1996 [2]. Studies adherence and glycemic control.
on diabetes in Malaysia reported that a large proportion of
patients (72–59%) had poor or suboptimal glycemic con-
trol and the mean HbA1C was higher than the recom- Methods
mended HbA1C level (6.5%) according to Malaysian
guideline [3–5]. Ethical approval
A low level of awareness within the population, health
professionals and a low priority to initiate an appropriate This study received approval from the Ministry of Health
preventive care plan have been identified as major issues in Ethical Committee (MREC) and Hospital Pulau Penang.
the management of diabetes [6]. A low level of diabetes Written consent was also obtained from the patients prior
knowledge among patients with diabetes has been identi- to the commencement of the study.
fied in other countries [7–13]. Diabetes self-management is
a cornerstone for the proper management of patients with Participants and setting
diabetes, and diabetes education has a role in improving
diabetes outcomes [14]. World Health Organisation A cross-sectional study design was used to elaborate the
(WHO) defines adherence as ‘‘the extent to which a per- study data. The study was conducted in the Diabetes Clinic
son’s behavior—taking medication, following a diet, and/ of Hospital Pulau Penang, Penang, Malaysia. This is the
or executing lifestyle changes, corresponds with agreed largest public and tertiary institute in Penang state. Being
recommendations from a health-care provider’’ [15]. generalized in nature, it provides health care and emer-
Positive health outcomes and lower mortality among gency treatment for all illnesses and accidents. Most
patients with diabetes have been associated with good Malaysian patients (70%) consult the government health-
adherence compared with those patients with poor adher- care system [21].
ence [16–18]. A number of interventional trials have been The estimated sample size was 400 patients out of the
conducted to improve self management in diabetes and 10,600 eligible patients registered in the clinic. An auto-
advances in medication therapy, however, adherence to mated software program, (Raosoft sample size calculator:
diabetes medication remains suboptimal [19]. (http://www.raosoft.com/samplesize.html) was used to cal-
One of the most important targets in the management of culate the required sample size for this study. In order to
patients with diabetes is to control blood glucose level by minimize erroneous results and increase the study reliability,
proper treatment including adherence to prescribed treat- the target sample size was increased to 500 patients. There-
ment. Management of DM is a lifelong process that fore, a convenience sample of 540 type 2 diabetes outpatients
requires continuous efforts, both from the physicians and was identified between October 2009 and April 2010.
patients. Patients are required to properly adhere to their The inclusion criteria was (1) Patients diagnosed with
daily medication intake and to their new lifelong lifestyle type 2 diabetes at least 1 year before inclusion in the study,
modifications. Patients need to follow their medication, (2) Patients treated for diabetes with oral medications for at
meal plans, adjust their physical activity, lose weight if least 1 year before inclusion in the study (3) Age
they are obese and monitor their blood glucose. Patients C30 years old (4) Patients able to recognize their diabetes
must be proficient to successfully manage, maintain life- medications from the total medications that they have to
style changes and make daily decisions to meet their take daily, (5) Patients willing to participate, who have
objectives while health care providers have the responsi- given written consent to participate in the study. Patients
bility to help patients to make the right decision and cope using only insulin for diabetes treatment and those unable
with the difficulties and barriers through education, support to answer the questionnaire independently, without assis-
and advice [20]. tance from caregivers were excluded.
To date, few papers have assessed both patient diabetes
knowledge and medication adherence in type 2 diabetes, Data collection form
and there is paucity of data exploring the association
between medication adherence and diabetes knowledge Data were collected using a set of questionnaires including
with glycemic control. Therefore, the present study aimed previously validated instruments among diabetes type 2

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who attended the Diabetes Outpatient Clinic. Three main of type 2 diabetes, HbA1C values above 6.5% are indica-
variables, (1) general diabetes knowledge of the patients, tive of poorly controlled glycemic levels, and thus poor
(2) medication adherence, and (3) glycemic control were diabetes management [5].
selected to be measured in addition to socio-demographic
and diabetes related data. Procedure

Diabetes knowledge Data collection was done by face-to-face interviews from

the patients by principal investigator who is a pharmacist
The brief diabetes knowledge test developed by the Michi- and his assistants stationed at the hospital. A total of 505
gan Diabetes Research and Training Center (MDRTC) patients were eligible and included in the final analysis
known as Michigan diabetes knowledge test (MDKT) [22] (93.5%). The patients were free to choose the language for
was used to assess the general knowledge of diabetes. The answering the questionnaire (English and Malaysian).
MDKT was translated into the Malaysian language and Medical records were reviewed for recent hemoglobin A1C
tested for validity and reliability (Cronbach’s a = 0.702) (HbA1C) levels (within 6 months of the inclusion) retro-
[23]. The general MDKT consists of 14 items with one spectively, the number of hypoglycemic medications and
choice answer from multiple choices for each question. The whether the patient used insulin or not on the same day.
knowledge score is determined by giving one point for each
correct answer and zero for wrong or no response. The total Statistical analysis
knowledge scores ranges from 0 to 14 with higher scores
indicating higher level of diabetes general knowledge. In Descriptive statistics were used to describe demographic and
order to avoid any interferences with real patients’ knowl- disease characteristics of the patients and their diabetes
edge about diabetes, patients who need assistances to answer knowledge scores. Percentages and frequencies were used
the study questionnaire were excluded. for the categorical variables, while mean and standard
deviations were calculated for the normally distributed
Medication adherence continuous variables. Non-parametric statistical tests were
used accordingly. Mann–Whitnney test and Kruskal–Wallis
Morisky scale, also known as Morisky Medication Adher- test were used to test the differences in the MMAS and
ence Scale (MMAS) [24] was used for the assessment of MDTK scores between groups. Bonferroni post hoc proce-
medication adherence. The MMAS was translated into the dure [29] was applied if differences were found by using the
Malaysian language and tested for validity and reliability Kruskal–Wallis test. Spearman correlation coefficient was
(Cronbach’s a = 0.675) [25]. MMAS consists of 8 items used to identify relationship between knowledge scores,
with a dichotomous response (yes/no) for items 1–7 and a 5 adherence scores and HbA1C results. Multivariate binary
point Likert response for the last item. The total score ranges logistic regression analysis and adjusted odds ratios were
from 0 to 8 with a higher total score indicating higher med- used to identify factors predicting good glycemic control.
ication adherence. The total score for each patient is the Variables with significant P values, or P values less than 0.25
summation of the scores in each item. The MMAS showed a from the univariate analysis, were included in the multivar-
good predictive power and was significantly associated with iate model. The use of P values less than 0.25 has been
drug pharmacy refill as it showed a 75% concordance [26]. suggested as appropriate for selection of variables in logistic
The validated Malaysian MMAS scale has an internal con- regression models, because the selection of traditional
sistency of 0.675 (Cronbach’s alpha value) with a significant P values less than 0.05 often fails to identify important
test–retest reliability of 0.816. The MMAS sensitivity and variables [30]. All statistical analyses were performed using
specificity, with positive and negative predictive values were SPSS version 15.0 (SPSS Inc., Chicago, IL). The signifi-
77.61, 45.37, 46.84 and 76.56%, respectively. cance level was set at P less than 0.05.

Glycemic control
Results
HbA1C is a biochemical marker whose levels correlate
with patient blood glucose levels over a defined time period Demographic and diabetes related data
(2–3 months) and measurement of HbA1C levels is an
accurate way to assess glycemic control over a defined time The study included 540 patients with type 2 diabetes in
period [27, 28]. The current study used HbA1C as an which 35 patients were excluded after data collection due
indicator of glycemic control among patients. As recom- to lack of either HbA1C results (n = 23) or insufficient
mended by the Malaysian Guidelines for the management information about their disease (n = 12). The demographic

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characteristics of the patients are presented in Table 1, educational level (Kruskal–Wallis test) (P \ 0.05).
including the frequency distribution of the study patients Patients using more than three medications per day had
and disease-related data. The mean age of the patients was higher HbA1C levels comparing to patients using 1–3
58.16 years (SD = 9.16), ranging from 32 to 80 years, medications per day (Kruskal–Wallis test). Significant
with 50.7% males. Race distribution was 39.4% Chinese, lower HbA1C values were seen in patients on mono-ther-
33.7% Malay and 26.9% Indians. The majority of patients apy and without insulin in their diabetes treatment (Mann–
had secondary level of education. The mean duration of Whitney test) (P \ 0.05).
diabetes was 9.68 years (SD = 6.31). The median number HbA1C was significantly correlated with MDKT scores
of total medications per day was 4.0 (IQR was 3.0–5.0). (r = -0.390, P \ 0.01) and also with MMAS (r =
Majority of patients were on combination oral anti-diabetes -0.505, P \ 0.01). Higher score of knowledge as well as
medicines and did not use insulin for their diabetes higher score of adherence was correlated with lower level
management. of HbA1C. MDKT scores correlates significantly with
MMAS scores (r = 0.456, P \ 0.01).
Patients’ knowledge The previous univariate analysis did not take into
account the effect of confounding factors which may affect
The median score was 7.0, (IQR, 5.0–10.0). As shown in the relationship between these factors and glycemic control
Table 1, significant difference in MDKT scores was found in patients with diabetes. From the univariate analysis, age,
between age groups of the patients, educational level race of the patients, educational level, therapy type, insulin
(Kruskal–Wallis test) and insulin use (Mann–Whitney use and medication number were found to have a level of
test). Patients aged less than 65 years had higher median significance P \ 0.25. Moreover, general diabetes knowl-
knowledge scores than those aged over 65 years edge and medication adherence were included in the
(P \ 0.05). The MDKT scores increased as the educational multivariate model. Multiple logistic regression analysis
level of patients increased (P \ 0.05). The study found that found that using mono-therapy, higher diabetes knowledge
MDKT scores were lower in patients using insulin and higher medication adherence as statistical predictors of
(P \ 0.05). good glycemic control as shown in Table 3. Multiple
logistic regression analysis also found that variables like
Medication adherence age, race, educational level, insulin use and medication
number were not significantly associated with good gly-
The median was 6.5 (IQR, 4.75–7.75). Significant differ- cemic control.
ence in MMAS scores was found between educational
levels, as those patients with higher educational level had
better medication adherence (Kruskal–Wallis test). Patients
taking between 1 and 3 medications daily were found to Discussion
have higher score of MMAS comparing with those taking
more that 3 medications daily (Kruskal–Wallis test) as In the present study, significant difference in knowledge
shown in Table 1. score was found in age groups, educational level and
Comparing the MDKT scores and MMAS scores insulin use. Previous studies had consistently reported the
between the two groups of glycemic control, significant relationship between low education and older patients with
higher scores of both MDKT and MMAS were found in diabetes knowledge [31, 32]. It has been also reported that
the good glycemic control group comparing with poor every 10 years increase in patients’ age was associated
glycemic control group (P \ 0.05) as shown in Table 2. with a 3% decrease in the diabetes knowledge score [33].
More years of formal education was the only socio-
Glycemic control demographic characteristic associated with higher knowl-
edge about HbA1c [34]. Patients with higher educational
Glycemic control represented by the percentage of HbA1C level also in a higher socioeconomic status and might have
was at target in only 20.8% of the study population more opportunity to obtain knowledge from the press,
(HbA1C B 6.5%). The median HbA1C was 7.6 (IQR, books and internet. In addition, they might have fewer
6.7–8.9%). Significant difference in HbA1C was reported barriers in communicating with healthcare providers.
between the three races of the study patients (Kruskal– Lower scores of MDKT were found among patients using
Wallis test), in which, Chinese patients had lower HbA1C insulin. This finding was in agreement with a study con-
values comparing with Malay and Indian patients. HbA1C ducted among lager sample of patients (n = 5,114) and
values were significantly lower in patients with higher level using the same MDKT scale [35]. The use of 14-item scale
of education comparing with those patients with lower of MDKT might be a reason for this finding.

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Table 1 Demographic and disease characteristics of the study patients with differences in knowledge and adherence total scores (N = 505)
Variables Frequency (%) MDKT MMAS HbA1C
Median (IQR) P Median (IQR) P Median (IQR) P

Ageb 0.005 0.845 0.196

\45 years 32 (6.3) 8.0 (6.0–11.7) 6.25 (4.5–7.6) 7.5 (6.5–9.3)
45–54 years 147 (29.1) 8.0 (5.0–10.0) 6.5 (4.7–7.7) 7.9 (6.8–9.3)
55–64 years 211 (41.8) 8.0 (6.0–10.0) 6.5 (5.2–7.5) 7.6 (6.7–8.9)
C65 years 115 (22.8) 6.0 (5.0–9.0) 6.75 (4.7–7.7) 7.4 (6.8–8.2)
Gendera 0.220 0.060 0.574
Male 256 (50.7) 7.0 (5.0–10.0) 6.5 (4.7–7.0) 7.6 (6.7–8.9)
Female 249 (49.3) 7.0 (5.0–10.0) 6.75 (5.1–8.0) 7.7 (6.8–8.9)
Raceb 0.996 0.082 0.003
Malay 170 (33.7) 7.0 (5.0–10.0) 6.125 (4.7–7.1) 7.9 (6.8–9.1)
Chinese 199 (39.4) 7.0 (5.0–10.0) 6.75 (5.5–8.0) 7.3 (6.6–8.3)
Indian 136 (26.9) 7.0 (5.0–9.7) 6.5 (4.7–7.4) 7.8 (6.9–8.9)
Educationb \0.001 \0.001 \0.001
No formal 34 (6.7) 6.0 (4.0–7.0) 5.75 (4.7–7.1) 7.9 (7.1–8.9)
Primary 139 (27.5) 5.0 (4.0–7.0) 6.0 (4.7–7.0) 7.9 (6.9–9.3)
Secondary 292 (57.8) 8.0 (6.0–10.0) 6.75 (5.2–7.5) 7.6 (6.7–8.4)
University 40 (7.9) 11.0 (10.0–12.0) 8.0 (6.6–8.0) 6.8 (6.3–7.5)
Diabetes durationb 0.140 0.156 0.483
\5 years 116 (23.0) 6.0 (5.0–7.0) 5.75 (4.5–6.7) 7.7 (7.1–9.1)
5–9 years 155 (30.7) 7.0 (5.0–8.0) 6.75 (4.7–7.0) 7.6 (6.9–9.1)
10–14 years 114 (22.4) 8.0 (6.0–10.2) 6.75 (5.6–7.7) 7.9 (6.5–8.7)
C15 years 120 (23.8) 9.0 (6.0–11.0) 6.75 (5.5–8.0) 7.5 (6.5–7.9)
Therapy typea 0.279 0.576 \0.001
Mono therapy 125 (24.8) 8.0 (5.0–10.0) 6.75 (4.7–7.7) 6.9 (6.3–7.9)
Multi therapy 380 (75.2) 7.0 (5.0–10.0) 6.5 (4.7–7.7) 7.85 (6.9–9.0)
Insulin usea 0.043 0.383 \0.001
Yes 111 (22.0) 7.0 (5.0–9.0) 6.5 (4.5–7.0) 8.2 (7.1–9.9)
No 394 (78.0) 8.0 (5.0–10.0) 6.5 (5.0–7.7) 7.5 (6.7–8.9)
Medication numberb 0.06 \0.001 \0.001
1–3 149 (29.5) 8.0 (5.0–10.0) 6.75 (4.7–7.6) 7.5 (6.4–8.6)
4–6 313 (62.0) 7.0 (5.0–10.0) 6.5 (5.5–7.7) 7.6 (6.8–8.7)
C7 43 (8.5) 6.0 (5.0–9.0) 5.0 (4.5–6.0) 8.7 (7.8–10.6)
a b
Mann–Whitney U test, Kruskal-Wallis test

Table 2 Differences in knowledge scores and medication adherence scores between two groups of glycemic control
Variables Frequency (%) MDKT MMAS
Median (IQR) P Median (IQR) P

Glycemic control \0.001 \0.001

Good (HbA1C B 6.5) 105 (20.8) 10.0 (8.0–12.0) 8.0 (6.7–8.0)
Poor (HbA1C [ 6.5) 400 (79.2) 7.0 (5.0–9.0) 5.75 (4.7–7.0)

This study evaluated medication adherence in patients medication adherence reported that in prospective studies,
with diabetes using the validated MMAS. The median many patients had poor adherence to oral diabetes regi-
MMAS scores showed that the study patients had low level mens which ranged from 67 to 85% and the overall
of adherence. Recently, the systematic reviews of diabetes adherence rate was from 36 to 93% in patients [36, 37].

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Table 3 Multivariate association between factors and glycemic unexpected. Oral diabetes medications and insulin are
control generally added as a result of worsening metabolic control,
Variable Crude OR Adjusted OR 95% CI P value it is logical that a strong association would exist between
the required intensity of therapy and HbA1C level. How-
Therapy type \0.001
a
ever, patients with poor adherence to medication and other
Combined 1.00 1.00 measures of management (lifestyle and exercise) might end
Mono 3.730 5.042 2.624–9.689 up with poor control of diabetes and the addition of greater
MDKT scores 1.390 1.334 1.176–1.513 \0.001 number of medicines.
MMAS scores 2.25 2.010 1.550–2.606 \0.001 The main objective of this study was to evaluate the
Model Chi-square = 153.118, P \ 0.001, Hosmer and Lemeshow association of diabetes knowledge and medication adher-
goodness of Fit test: (7.708, P = 0.462, n = 505, df = 8) ence with glycemic control among patients with type 2
a
Reference group, CI confidence interval diabetes. The results revealed that glycemic control was
associated with both variables. Several studies have shown
that proper and adequate knowledge of diabetes was
The present study findings regarding the association of effectively associated with good diabetes control [35, 47].
educational level and medication adherence was consistent Previous studies confirmed that better diabetes control was
with previous studies [38]. Higher educational background significantly dependent on the adherence to medication [16,
of the patients might be associated with their awareness 18, 39, 46, 48–52]. The higher Spearman correlation
and concern to adhere to medication; they may understand coefficient value between MMAS and HbA1C (r =
and benefit from physician’s recommendations about the -0.505) found in this study compared with that between
importance of their medication. In the present evaluation of MDKT and HbA1C (r = -0.390) may indicate that med-
medication adherence, a significant higher MMAS score ication adherence has more impact on glycemic control
among patients taking fewer than four medications per day than diabetes knowledge. However, it indicated that med-
was found and is consistent with other studies [39, 40]. The ication adherence was not the only factor that associated
addition of more than one diabetes medication might be of with glycemic control and diabetes knowledge was another
clinical importance for management of the disease because important factor. MMAS and MDKT scores have been
it adds more load to the treatment regimen for the patients. found to be predictors of HbA1C. It was also suggested that
To date, the relationships between patients diabetes medication adherence alone may not be enough to predict
knowledge and medication adherence have not been very good glycemic control and that knowledge of the patients is
well studied [41]. However, evidence in the literature another important variable which needs to be assessed in
suggests that knowledge about diabetes and its medications clinical practice.
is among the factors that affect or contribute to the deter-
mination of medication adherence [36, 42]. Reduced
knowledge of diabetes were correlated to a lower adher- Limitation
ence rate to medication [43]. The present study found a
significant positive relationship between diabetes knowl- The data derived for the study was limited to one hospital
edge and medication adherence. in Penang and restricted to the outpatient clinic for dia-
Around one-fifth of this study patients (20.8%) were betes. However, the sample size of the study was large
able to control their diabetes and reached the recommended enough to evaluate the expected differences and associa-
level of HbA1C. In the present study, HbA1C was found to tion between variables. Self reported assessment of medi-
dramatically decrease with increasing education level of cation adherence may be over-estimated by patients;
the patients. The significant association between diabetes however, self reported scale for medication adherence
control and education level was also reported in previous proved to have good reliability and validity with the ease of
studies [44–46]. Patients with a higher educational level application. Face-to-face interview and use of self-report
were found to have better knowledge about diabetes and to might generate social desirable answer. Lack of informa-
adhere more to their medication. Therapy type whether it tion about the history of attending an educational class
was mono or combination therapy, was found to be asso- about diabetes also adds a limitation for this study. Many
ciated with glycemic control in the final multivariate variables were unavailable for study inclusion, such as the
analysis (Table 3) after controlling for the other variables severity of type 2 diabetes, information on dietary habits,
in the model. It was found that patients treated with daily exercise assessment and patient glucose self-moni-
mono-therapy were 5.04 times more likely to have good toring. Assessment of these factors might provide a clearer
glycemic control. The association of therapy type (mono picture about diabetes knowledge, medication adherence
or combined) with worsened metabolic control was not and glycemic control. Another point that might limit the

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1034 Int J Clin Pharm (2011) 33:1028–1035

generalization of the study results is the selection of 9. Bruce D, Davis W, Cull C, Davis T. Diabetes education and
patients who know their diabetes medication. Those knowledge in patients with type 2 diabetes from the community:
the Fremantle diabetes study. J Diabetes Complic. 2003;17(2):
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knowledge results. chosocial and diabetes factors to diabetes knowledge. Int J Pharm
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Factors affecting adult knowledge of diabetes in Narlidere Health
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demographic variables associated with knowledge about type 2
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glycemic control. Younger patients’ age and having higher 2005;42(1):36–45.
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knowledge test and these factors may affect the compre- chandran A. Awareness about diabetes and its complications in
the general and diabetic population in a city in southern India.
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(1001/PFARMASI/811119) from the Universiti Sains Malaysia. 19. Briesacher B, Andrade S, Fouayzi H, Chan K. Comparison of
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