ايبلا ئلم ءاجرب جمانربلا يف كارتشلال ةرامتسلاا ميلست و ةقدب تان
ل ةنطابلا ةدايع .
Please complete this form to enroll
يف ايوفش اما ركسلا ضرم نع نيكرتشملا ةيعوتب يفشتسملا موقتس تاميلعت و حئاصن اهب تابيتك عيزوتب وأ فشكلا فرغ
لومحملا يلع ةريصق لئاسر مادختساب وأ .
Awareness will be via verbal in-clinic instructions, a booklet, or SMS messages
اناجم نيترم يركسلا نيبولجوميهلا ليلحت نيكرتشملا عيمجل يفشتسملا رفوتس امك دعب و كارتشلاا دنع
رهشأ ةثلاث
. . رهشأ ةثلاث ةدمل يفشتسملا مهل اهددحتس ديعاوم يف اناجم يئاوشعلا ركسلا سايق نيكرتشملل حاتيس امك
The hospital will provide to participants 2 free HbA1c tests and random blood sugar measurements at preset times
F M Sex Age Name
Can you open and read SMS messages?
لا معن ؟لومحملا يلع لئاسرلا ةءارق و حتف عيطتست له
Do you live with someone that can open and read SMS messages?
عيطتسي نم تيبلاب كعم له
Same program info as above
لئاسر مادختساب وأ تاميلعت و حئاصن اهب تابيتك عيزوتب وأ فشكلا فرغ يف ايوفش اما ركسلا ضرم نع نيكرتشملا ةيعوتب يفشتسملا موقتس لومحملا يلع ةريصق ع اناجم نيترم يركسلا نيبولجوميهلا ليلحت نيكرتشملا عيمجل يفشتسملا رفوتس امك. رهشأ ةثلاث دعب و كارتشلاا دن
. .رهشأ ةثلاث ةدمل يفشتسملا مهل اهددحتس ديعاوم يف اناجم يئاوشعلا ركسلا سايق نيكرتشملل حاتيس امك
ىميلعتلا يفافك داعس يفشتسم B.3 Pre-study Questionnaire
ةماع تامولعم Body weight and random blood glucose level .٣
Other chronic diseases you suffer form:
.٧ اهنم يناعت يرخأ ةنمزم ضارمأ :
...
...
Other medications you regularly take:
.٨ رارمتساب اهلوانتت يرخأ ةيودأ :
...
How often do you visit the hospital’s outpatients?
.٩
Current diabetes medications and medication times:
.١١
Who do you see for your diabetes?
.١٢ نطاب ركس يئاصخأ ؟ركسلا ضرم عباتت نم عم ي
GP diabetes specialist
ىميلعتلا يفافك داعس يفشتسم
How often do you see your diabetes doctor?
.١٤
Do you commit to seeing your doctor at preset times? 1 ١٥
In the last 3 months, how many times were you admitted to the ER or hospital because of your diabetes? 2
How often do you check your blood sugar? 1, 3 .١٧
Where do you check your blood sugar?
.١٨
Do you record your results? 1 .١٩
Why don’t you check regularly?
.٢١
ىميلعتلا يفافك داعس يفشتسم
ايجولونكتلا و مولعلل رصم ةعماج
Misr University for Science & Technology Souad Kafafi Teaching Hospital
171
Do you take your medications/insulin on time? 1 .٢٣
Excluding times you forget, are you sometimes careless taking your medicine/insulin? 4 .٢٤
At what rate do you miss taking your medications on time?
.٢٥
What makes you miss taking your medications on time?
.٢١
Do you sometimes forget to take your medication/insulin? 4 Do you take the right insulin dose? 1
.٢٨
Do you adjust your insulin dose based on your blood sugar measurements? 1 .٢٩
Do you suffer from any medication side effects?
.٣١
Do you stop your medication/insulin when not feeling well? 4 .٣٢
ىميلعتلا يفافك داعس يفشتسم
ايجولونكتلا و مولعلل رصم ةعماج
Misr University for Science & Technology Souad Kafafi Teaching Hospital
172
Do you stop your medication/insulin when feeling better? 4 .٣٣
Are you aware of diabetes complications? 5 .٣٤
Are you aware of diabetes follow-up tests and their times? 5 .٣٥
Do you take these tests regularly? 1 .٣١
Have you taken any of the following tests?
.٣٧
When were your last tests and how were the results?
.٣٨
Do you check your feet?
.٤١ يسفنب معن ؟كيمدق صحفب موقت له
لا بيبطلا دنع معن
No Yes, at doctor’s Yes, myself How often do you check your feet?
.٤١
Are you aware of the type of diabetes you have? 5 ٤٢
How do you think diabetes (will) affect(s) your daily life?
.٤٣
What difficulties do you (think you will) experience monitoring your diabetes?
.٤٤
ىميلعتلا يفافك داعس يفشتسم
ايجولونكتلا و مولعلل رصم ةعماج
Misr University for Science & Technology Souad Kafafi Teaching Hospital
173
Do you suffer any eye, foot, kidney or heart complications?
.٤١ عاضم نم يناعت له ؟بلقلا وأ يلكلا وأ نيعلا وأ مدقلا يف لكاشم لثم ركسلا ضرمل تاف
...
...
Does someone at home help you take care of your diabetes?
.٤٧ ؟ركسلا ضرمب ةيانعلا يف تيبلا يف نم كدعاسي له ...
Have you received instructions on how to take care of your diabetes? When and where?
.٤٨ ؟نيأ و يتم ؟هب ةيانعلا وأ ركسلا ضرم نع قباسلا يف تاميلعت تيقلت له ...
...
How do you rate your diabetes awareness level? 5 .٤٩
How do you feel about having diabetes?
.٥١ ؟ركس ضيرم تنأ و رعشت فيك ...
...
What do you wish to learn about diabetes?
.٥١
Are you satisfied with your control of your diabetes and blood sugar levels?
.٥٢
What did you do at times of increase or decrease of your blood sugar levels? 5 .٥٤ What is your biggest concern about monitoring your diabetes?
.٥٥
Are you aware of the healthy diet for diabetics? 5 .٥١ ؟ركسلا يضرمل يحصلا يئاذغلا ماظنلا وه ام ملعت له 5
لا معن
No Yes
ىميلعتلا يفافك داعس يفشتسم
How many meals do you have per day?
.١١ يف لوانتت ةبجو مك ؟مويلا
...
What types of meals and at what times do you have them?
.١١ ؟اهديعاوم و تابجولا ةيعون يه ام ...
...
...
Do you commit to the preset meal times? 1 .١٢
Do you regularly eat snacks between main meals? 1 .١٣
Do you carry something sweet as you leave home? 1 .١٤
Do you drink canned juices or sodas?
.١١
Do you regularly exercise or exert any physical activity? 1, 6 .١٧
ىميلعتلا يفافك داعس يفشتسم
What kind of exercise do you do? Do you walk 30mins a day? 6 .١٩
Do you exercise strenuously? 1 .٧١
Does your health condition affect your ability to be physically active?
.٧١ ؟ةكرحلا يلع كتردق يلع ةيحصلا كتلاح رثؤت له ...
...
Are you aware of exercise benefits for diabetics? 5 .٧٢
Can you afford the costs of treatment?
.٧٣
How confident are you to:
Not at all slightly moderately highly fully Eat every 4-5 hrs? 7
Commit to your meal plan even when eating with non-diabetics? 7 .٧٥
Pick the right type of food when feeling hungry (e.g. between meals)? 7 .٧١
ىميلعتلا يفافك داعس يفشتسم
ايجولونكتلا و مولعلل رصم ةعماج
Misr University for Science & Technology Souad Kafafi Teaching Hospital
176
Exercise 30 mins/day? 7 .٧٧
Do what’s right to keep your blood sugar level from dropping during exercise? 7 .٧٨
Know what you need to do when your blood sugar level is higher or lower than normal? 7
Know when you must see your doctor? 7 .٨١
Control your diabetes so that it doesn’t stop you from doing anything you like? 7 .٨١
Control your diabetes and avoid its complications?
.٨٢
Let your doctor monitor your diabetes? 8 .٨٣
How do you rate your level of satisfaction with your doctor monitoring your diabetes? 9 .٨٤ How do you rate your level of satisfaction with your doctor’s communication with you? 9 .٨٥
If you were to receive the SMS messages, when would you prefer to get them?
٨٦
Superscripted questions are to rate the following:
1 treatment adherence (using the diabetes self-care inventory)
2 rate of hospital/ER visits and stays
3 average frequency of blood glucose measurement
4 medication adherence (using Morisky scale)
5 diabetes knowledge
6 exercise
7 patient confidence (using diabetes empowerment scale short form and Stanford self-efficacy for diabetes)
8 patient confidence in healthcare provider
9 patient satisfaction
ىميلعتلا يفافك داعس يفشتسم B.4 Post-study Questionnaire
ةماع تامولعم
In the last 3 months (since start of program):
No Yes, I reduced by: Yes, I stopped Did you stop or reduce smoking?
Were you diagnosed with other chronic disorders?
.٥
Did you switch from pills to insulin?
٦
How often did you see your diabetes doctor?
.٧
Did you commit to seeing your doctor at preset times? 1 ٨
How many times were you admitted to the ER or hospital because of your diabetes? 2 .٩
How often did you check your blood sugar? 1, 3 .١١
ىميلعتلا يفافك داعس يفشتسم
ايجولونكتلا و مولعلل رصم ةعماج
Misr University for Science & Technology Souad Kafafi Teaching Hospital
178
Where did you check your blood sugar?
.١١
Did you record your results? 1 .١٢ Why didn’t you check regularly?
.١٣
Did you take your medications/insulin on time? 1 .١٥
Excluding times you forgot, were you sometimes careless taking your medicine/insulin? 4 .١١
At what rate did you miss taking your medications on time?
.١٧
What made you miss taking your medications on time?
.١٨ Did you sometimes forget to take your medication/insulin? 4
ىميلعتلا يفافك داعس يفشتسم
ايجولونكتلا و مولعلل رصم ةعماج
Misr University for Science & Technology Souad Kafafi Teaching Hospital
179
Did you take the right insulin dose? 1 .٢١
Did you adjust your insulin dose based on your blood sugar measurements? 1 .٢١
Did you stop your medication/insulin when you were not feeling well? 4 .٢٣
Did you stop your medication/insulin when you felt better? 4 .٢٤
Did you become more aware of diabetes complications? 5 .٢٥
Did you become more aware of diabetes follow-up tests and their times? 5 .٢١
Did you take these tests regularly? 1 .٢٧
Did you take any of the following tests?
.٢٨
When were your last tests and how were the results?
.٢٩ How often did you check your feet?
.٣٢