Diabetes mellitus is one of the most common chronic diseases worldwide and there are two types of diabetes: type 1 and type 2 [1, 2]. Type 1 diabetes mellitus, also known as insulin dependent diabetes is caused by the failure of the pancreas to produce insulin, which is an important hormone that helps the glucose get into the cells [1]. This type of diabetes develops commonly in children and affects only 5% of diabetic patients. Similarly, type 2 diabetes mellitus, which is also known as non-insulin dependent diabetes, is the most common type that affects around 95% of diabetic patients [2]. It occurs either when the pancreas is not able to produce enough insulin or when the body’s cell resists the insulin.

In relation with this disease, approximately 463 million adults (20-79 years) in the world had diabetes in the year 2019 [3]^. Among 195 countries in the world, Saudi Arabia ranked number 13 in the prevalence of diabetes worldwide in 2019 [4]. Also, 15.80% of the population of Saudi Arabia (20-79 years) had type 1 or type 2 diabetes in 2019 [4].

On the other hand, over these years, there was a remarkable growth in the social media networking all over the world. The statistics showed that the total number of smartphone users worldwide was 3.2 billions in 2019 [5]. In particular, it was identified that Saudi Arabia had 20 million smartphone users in 2019 [6]. In addition, social media applications also have become an important medium for exchanging healthcare information. In this sense, several studies have shown the effectiveness of social media in managing health conditions [7-11]. Specifically, Twitter has been considered as one of the most popular mobile application used worldwide. It is an online application where users can either read only or post messages called “tweets”. With more than 152 million users as of January 2020, the 5 top leading countries of Twitter users (in millions of people) were the United States (59.35), Japan (45.75), the United Kingdom (16.7), Saudi Arabia and Brazil [12, 13].

According to several studies, social networking has great effects on the acquisition of healthcare awareness and medical knowledge about specific diseases [7-11, 14-18]. For example, a web-based survey carried out between February and March 2015 showed that social media was an important source for seeking medical information and indicated that Twitter had a significant role in increasing medical knowledge [7]. Also, that study showed that there was a persistent need to get evidence-based health information from social media sources. Another study in 2012 indicated that 83% of the participants used some kind of social media to get medical information [8]. Additionally, 56% of them wanted to communicate with their healthcare providers via social media for answering their questions, setting an appointment, reporting test results, and providing health information needed. Moreover, a previous study in 2011 indicated that one third of the participating physicians received friend requests from the patients and their families [9]. One more study in 2011about healthcare consumers showed that 37% of the United State (US) patients searched for their attending physician ratings, which indicated the benefit of social networks to provide health knowledge [10] Further, as it was concluded in a “social media and clinical care” study in 2013, social media had affected healthcare especially in the field of clinical care [11]. Also, Twitter was used for breast cancer awareness in 2013 [14]. That study showed a high breast cancer awareness tweeting interaction in October (breast cancer awareness month). During that month, 1,351,823 tweets were transmitted by 797,827 different users [14]. Likewise, a Twitter account was used for teaching radiology courses [15]. The study suggested that the use of Twitter contributed to enhance education in this field [15]. Another research pointed out that Twitter was a potential data source for cardiovascular disease information [16].

In relation to diabetes mellitus, social media has an incredible role in controlling the growth of this disease. It stimulates the learning process of people who have diabetes mellitus, by encouraging them to ask questions, share experience, and adopt new habits with other people in similar situation. A study conducted in 2015 showed that the Facebook and Skype tools have improved the control of glucose level among patients with type1 diabetes mellitus [17]. The study was carried out with two groups of people: the control group (29 patients) was treated using the standard medical protocol with regular visits at the clinic. While the second group (intervention group) integrated by 27 patients was treated with an insulin pump. The intervention was given via Facebook (chats) and Skype (Video calls). They concluded that social media had a great role in raising knowledge and spreading awareness about diabetes mellitus [17]. Moreover, a meta-analysis study presented the effectiveness of mobile technologies in managing diabetes mellitus. The results revealed that these technologies have improved glycated hemoglobin level for type 2 diabetes [18]. In another research, people with diabetes used Facebook for sharing their clinical information to help each other, receive emotional support, and request guidance [19].

Twitter in specific has been one of the effective social media tools for information dissemination, awareness and knowledge creation among the public. Due to its effective reachability and point-to-point information sharing by linking the relevant users, it can be an effective tool for disseminating information specific to a cause. Unlike other social media tools, twitter can be useful in sending short and relevant information relating to different aspects, which can save readers time in accessing information and also attract their attention. Furthermore, twitter was identified to be effective in creating awareness in various industries. For instance, twitter was used in creating awareness construction safety knowledge in different countries [20]. Furthermore, twitter was also found to be effective in promoting the dialogues among physicians for various activities such as sharing scientific information, crowdsourcing new ideas, conducting discussing and challenging emerging research [21]. Similarly, twitter was also found to be effective in creating awareness among the public in relation to various chronic conditions such as cancer, visual impairment, etc [14, 22, 23]. Twitter can also promote information exchange between diverse groups, effectively engaging different people in information exchange and awareness creation. For example, a study on the information exchanges on twitter related to diabetes [24] revealed that a tendency for homophily in which communication among users of differing status and expertise levels is unlikely to exist. Thus, twitter may be effective for promoting information exchange between diverse groups. Moreover, twitter is being used by local health departments in the US for disseminating diabetes information among the local communities, reflecting the potential use of twitter in creating health awareness [25].

Even though there are many studies that measure the role of social media to increase health-related knowledge and information, there was no study in Saudi Arabia that examined the role of Twitter in raising awareness about diabetes. Therefore, the objective of this research was to evaluate the role of Twitter in increasing the awareness and knowledge of diabetes among citizens of Saudi Arabia.

In this research we used a purposive sampling method and carried out a quantitative experimental study design. The variables analyzed in this study were continuous and categorical. The dependent variable (continuous) was the level of diabetes knowledge, while the independent variables (categorical) were the age, gender, and educational level.

The demographic characteristics of the control and intervention participants are represented in Table 2. Regarding the control group, out of 82 participants, 42.7% were between 20 and 29 years old. Moreover, 65.9% of the participants were female. Also, most of them (62.2%) were academic. In contrast, in the intervention group, out of 70 participants, 88.6% of them were between 20 and 29 years old. Furthermore, 84.3% of the participants were female, and the majority of the respondents (81.4%) were academic.

Table 3 shows the statistical information of the DKT scores of the control and intervention groups before and after the intervention process. At the baseline, this table indicates that the mean (M) for the intervention group was 13.57, and the standard deviation (SD) was 3.46. After the intervention process, the mean (M) increased to 17.06 and the standard deviation (SD) decreased to 2.35. Instead, for the control group, the mean (M) was 13.68, and the standard deviation (SD) was 3.72. During the study process, the mean (M) of the control group increased to 14 and the standard deviation (SD) augmented to 3.59. In addition, this table depicts the mean difference (MD), the standard deviation of the mean difference (SDMD), the standard error of the mean (SEM), the skewness (SK) and the kurtosis (KU) of the data, the 99.5% confidence interval (CI), the t-test values and the probability values (p-values).

Likewise, Table 4 exhibits the comparison of the mean differences and p-values of the age, gender and educational level of the control and intervention groups, using the ANOVA and the independent t-test.

The findings of this study showed that the use of Twitter (SANAD account) had a positive impact on increasing diabetes knowledge among Saudi Twitter users. This proposition was obtained by testing the null and the alternative hypothesis of this research. In this sense, the null hypothesis specified in this study was that the means of the DKT scores before and after the intervention process were the same. In contrast, the alternative hypothesis stated that the means of the DKT scores obtained before and after the intervention practice were not equal.

The results of the paired t-test shown in Table 3 indicated that during the intervention process, the mean of the DKT scores increased to 3.49 in the intervention group, and 0.32 in the control group.

According to this table, the paired t-test showed that in the intervention group there was a statistically significant difference in means of the DKT scores before and after implementing the educational program (p-value < 0.05). Therefore, we can reject the null hypothesis and conclude that the change was due to the educational program which had an effect on participant’s knowledge (t= -12.95, p-value < 0.05). In other words, the use of Twitter had an influence on increasing diabetes awareness and diabetes knowledge among the participants. In addition, the skewness and kurtosis indicated a normal distribution of data because their values were located between +2 and -2.

In contrast, for the control group, the results presented in Table 3 suggested that, according to the paired t-test, there was no statistically significant difference in means of the DKT scores before and after the process (p-value > 0.05). Therefore, we cannot reject the null hypothesis and concluded that in the control group there was no effect on increasing awareness and knowledge about diabetes among the participants. The observed little difference in DKT scores means was due to chance.

This result is consistent with a similar previous study which stated that breast cancer awareness was increased due to the promotion of health-related knowledge using social media tools such as Facebook [27]. Another research showed that the use of Facebook and Skype had improved the control of glucose level among patients with type1 diabetes mellitus [17]. The intervention carried out in the mentioned study decreased the glucose level from 7.8 ± 1.9 to 6.4 ± 1.6. Also, comparable to our results, several preceding studies showed that the use of Twitter can improve learning abilities and knowledge of participants in several educational settings [15, 28-32]. Another additional study suggested the potential impact of social media in enhancing diabetes management, care and outcomes [33].

On the other hand, the results shown in Table 4 related to the application of the independent sample t-test and one-way ANOVA revealed that other factors such as age (p-value =0.07), gender (p-value =0.16), and educational level (p-value=0.14) had no statistically significant influence in increasing diabetes knowledge. This demonstrated the high effectiveness and impact of Twitter (SANAD account) in increasing the awareness and diabetes knowledge of the participants, whereas the other factors (age, gender and educational level) had no effect on it.

The main limitations of this research were the sample size, and the fact that a necessary rewarding mechanism was used to encourage the participant to refill the questionnaire. These limitations were due to the lack of time. In future studies, we will try to avoid these limitations that threat the internal and external validity of this study.

The results of this research suggested that social media can contribute to the acquisition of knowledge and the creation of awareness about the treatment of chronic illnesses, such as diabetes and other diseases. In particular, Twitter (SANAD account) had a positive impact on increasing awareness and diabetes knowledge among Saudi adult twitter users. This is an excellent way to use social media tools to promote health awareness, increase health knowledge, and monitor the health status of human beings.