Diabetes-Related Knowledge, Attitude and Practices of Patients With Diabetes in the Free State, South-Africa

Purpose:

Type 2 Diabetes Mellitus (T2DM) is a growing public health problem worldwide (International Diabetes Federation, 2013:11) and is linked to overweight and obesity (Xu et al., 2010:4). Many patients with T2DM in South Africa are overweight or obese due to rapid urbanisation in South Africans over the past 20 years. The urbanisation has resulted in a nutrition transition, characterised by a transition from healthier traditional diets to a more Western unhealthy diet and sedentary lifestyle.  Thus, before considering any intervention it was imperative to assess present diabetes-related knowledge, attitude and practices (KAP) of patients with T2DM.

Many models have been developed over the years to explain practices or behaviour, but the Theory of Planned Behaviour is considered to be one of the most effective and influential theories for the prediction of different types of behaviour and has been widely used to understand the barriers in health-related behaviour (Ajzen et al., 2011:102).

According to the Theory of Planned Behaviour, patients with T2DM have certain beliefs which influence their behaviour or practice eventually (Ajzen et al., 2011:102).

Three groups of beliefs are identified, namely behavioural, normative and control beliefs (Ajzen et al., 2011:102). Firstly, Behavioural beliefs depict the link between a specific T2DM-related behaviour and a consequence that leads from this behaviour.

Secondly, Normative beliefs reflect the link between a specific T2DM-related behaviour and an expectation the patient may have due to the enacted behaviour. Flowing from the normative beliefs are subjective norms. The subjective norm not only provides a link between the specific T2DM-related behaviour, but now the probability is linked to the expectations of peers, family members and other important people in the patient’s life. Thirdly, Control beliefs describe factors the patient perceives could either support or hinder him or her in being in control of T2DM-related issues.

Lastly, the patients’ perceived behavioural control reflects the link between a specific T2DM-related behaviour and the patient’s perception of his or her ability to accomplish the specific behaviour.

In line with the KAP survey, specific attention is further given to the attitude of the patient as an element playing a role in the actual T2DM-related behaviour/practice of the patient. Patients’ attitudes towards T2DM-related issues as well as their subjective norms and perceived behavioural control of such issues all strengthen or weaken the patients’ intention to perform a specific T2DM-related behaviour.

The researcher regarded Ajzen’s reference to behaviour as equal to what the KAP survey refers to as Practice. Therefore, patients’ T2DM-related behaviour will depend on their intention to act out behaviour as well as the actual behavioural control the patient has in the long run over performing such behaviour.

Emphasis should therefore be placed on knowledge that guides the behaviour of interest or beliefs about the behaviour. Once the behavioural, normative and control beliefs have been identified in the population of interest, knowledge on the beliefs that are contradictory to the behaviour can be addressed and the supportive beliefs that lead to the formation of new beliefs and desired behaviour can be strengthened (Ajzen et al., 2011:116).

Behaviour modification through health promotion is essential to address the burden of T2DM. Behaviours related to healthy eating habits, exercise, regular blood sugar monitoring and medication adherence are especially important (Smalls et al., 2012: 385).

The purpose of this study was to determine current diabetes-related KAP of adults with T2DM in the Free State. This descriptive study, together with 3 other studies, forms part of a bigger study with the title: “Health dialogue with adult patients with chronic disease in the Free State: Towards a model for low and middle income countries”.

Methods:

This research study was designed as a quantitative descriptive observational study.

The population of this study included adult patients above 18 years with T2DM visiting 10 Community Health Centres and 12 Primary Health Care clinics in the five districts in Free State. Within the selected facilities convenience sampling took place of the adult patients with T2DM.

An adapted SA-Diabetes KAP questionnaire was used to gather information about the demographics and associated factors, quality of life and KAP.

The questionnaires were piloted with a sample of 5 adult patients with T2DM in Mangaung Metro district. Ethical approval was obtained from the University of Free State.

Results:

Two hundred and fifty five questionnaires were completed in 22 public health facilities. The majority of participants were Black Africans (92%, n- 235), which is a reflection of the national distribution where the majority of the citizens are black (80%). Only 8.6% completed high school and 10% were illiterate, which can be attributed to the inequalities in education in South Africa during apartheid.

The mean age of participants was 57 years and the mean age of diagnosis of was 48 years, which is the trend in low and middle income countries due to growing populations and lifestyles. In high-income countries these challenges emerged over decades and their health systems were able to adapt to the new demands (Checkley et al., 2014:3). The predominance of females (75%; n-193) was attributed to glucose intolerance that is associated with higher visceral fat in females.

An overwhelming 87% of participants were either overweight or obese. This is higher than in high-income countries (Al-Amoudi & Alrasheedi, 2013:1121).  The majority of the participants (67% of males and 98% of females) in the present study had a waist circumference above the cut-off points which is associated with an increased risk of developing T2DM in both sexes (Erasmus et al., 2012:844). It was therefore not surprising that the majority (61%; n-155) were diagnosed with T2DM following metabolic syndrome related symptoms and another 11% (n-29) with other health related symptoms.

Although it is a common assumption that improvements in knowledge, attitude and practices would be the answer to the diabetic epidemic, researchers agree that a positive relationship between KAP, does not always translate to behaviour change (Gautam et al., 2015:5).

Participants in the present study had poor knowledge of T2DM. Only half of the participants knew the normal range of blood sugar although almost 90% knew the common signs of high blood sugar and two thirds were knowledgeable about complications associated with diabetes. Participants were ignorant about food groups, which is a cause for major concern as health eating is a pivotal aspect of treatment. Diet recommendations are often incompatible with patients’ lifestyle and culture and they are therefore reluctant to adhere, hence affecting their behavioural beliefs (Wermelink et al., 2014:8).

The attitude of the participants in the present study was mostly negative which concurs with studies in high income countries (Al-Maskari et al., 2013:6). The majority (81%, n-206) of participants felt that they would be quite a different person if they did not have diabetes. A further 71% (n-181) felt that diabetes was the worst thing that ever happened to them and 79% (n-201) felt embarrassed about having diabetes.

Poor practices were reported in the present study mainly due to low levels of physical exercise and poor eating habits. This concurs with a study in a high income country (Saaddine et al., 2006:468).

Ajzen’s TPB is supported in the participants’ knowledge and practice of physical exercise. The majority (96%; n-245) of the participants were knowledgeable about the benefits of physical exercise, while only 31% (n-78) reported to exercise every day in the past week. The poor practices are also reflected in the high rates of overweight and obesity which can be attributed to a lack of physical activity and a sedentary lifestyle. 

In the present study a statistically significant correlation was found between knowledge and attitudes, indicating that better knowledge about diabetes could be associated with a more positive attitude towards diabetes.

The various educational groups differed significantly in terms of their knowledge and attitude scores, but not, interestingly, in their practice scores. These results support Ajzen’s TPB that knowledge is not sufficient to produce the desired behaviour (Ajzen et al., 2011:102).

Conclusion:

Diabetes-related KAP of participants in this study population was found to be poor. Patients with T2DM in the Free State require sufficient knowledge, attitude and practices. The TPB could be applied to the majority of variables in this study, but not all. Beliefs influencing behaviour related to healthy eating habits and regular exercise should be further researched to address the burden of T2DM in the Free State.