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According to the International Diabetes Federation, 382 million people had been diagnosed with Diabetes Mellitus by the end of 2013 and 592 million are still to be diagnosed by the end of 2035, with a further 175 million of these adults being undiagnosed (International Diabetes Federation,2013:30). As diabetes is a lifestyle disease that is influenced by lifestyle choices, the Theory of Planned behaviour (TPB) was used to explain why certain behaviours take place. The theory is used to explain health care workers behaviour. “A patient cannot be taught to catch a fish by a person who cannot catch fish themselves, or who is not interested in fishing.” Knowing the knowledge, attitudes and practices of these health care workers will be of great use, since the outcome of the survey will be used to develop a health dialogue model for patients with diabetes in the Free State public health sector.
This specific theory is often used internationally when health related behaviour is explained (Ajzen, Joyce, Sheikh & Cole, 2011: 103; Gherman, Schnur, Montgommery, Sassu, Veresui & David, 2011: 406). The TPB was used to describe the knowledge, attitude and practices (KAP) of health-care workers working with Type 2 Diabetes Mellitus patients. The determinants forming part of the knowledge component of the KAP survey are behavioural beliefs, normative beliefs, subjective norms, control beliefs and perceived behavioural control (Ajzen et al., 2011:101-103).
The first determinant behavioural beliefs refer to an individual's belief about consequences of a particular behaviour. The second determinant within the knowledge component is normative beliefs. Normative beliefs are created by members of society and they influence a person’s own belief system. The third determinant is control beliefs which influences perceived behavioural control referring to the person’s ability to perform the behaviour or not. However, the individual may be in a position to control some of these influences, referred to as perceived behaviour control beliefs (Ajzen et al., 2011:101-103).
In the study, the researcher grouped the following determinants to represent practice within the KAP survey, namely intention, actual behaviour control and behaviour. According to the TPB, a person’s intention is influenced by the strength of his attitude towards that behaviour. The stronger one’s attitude is towards something, the stronger it will influence the person’s intention to perform the specific behaviour in the end (Ajzen et al., 2011:101-103). Practice is closely linked with control beliefs and perceived control beliefs.
The TPB, further states that intention influences actual behavioural control, which in turn influences behaviour (Ajzen et al., 2011:102-103). Control beliefs influence perceived behavioural control, which refers to the individual’s assessment of his or her ability to perform the particular behaviour.
A study by Gherman et al. (2011:406) cited that the aim of Health Care workers (HCW’s) should be to strengthen patients’ behavioural, normative and control beliefs. This will enable HCW's to increase their own knowledge regarding diabetes, which could consequently influence the patients’ adherence towards treatment.
Methods:
A descriptive, cross-sectional quantitative design was used. The design was used to observe, count and classify phenomena. Data was collected by the researcher from a representative of the sample at the primary health clinics (PHC's) and Community health centres (CHC's) on a specified day.
The population consisted of HCW’s working in 10 CHC’s and 42 PHC's in the Free State. The population of the study included three (3) prominent groups of health care workers namely the nurse manager (NM), professional nurse (PN) and the community health care worker (CHCW) providing care to type 2 diabetes mellitus (T2DM) adult patients at CHC’s and PHC’s in the Free State public health sector. The population groups consisted of Nurse Managers (N=6), Professional Nurses (N=104) and Community Health Care Workers (N=260). All identified health care workers in the CHC’s in the five districts in the Free State and PHC clinics in one district, Mangaung Metro, were included in the population. The type of selection performed was two professional nurses and five CHCW,s per site. The sample from CHCs and PHCs for the study included NM (n=6), PN (n=42) and CHCW’s (n=105).Convenience sampling took place.
A questionnaire was used to gather information about the HCW’s. A literature search for existing instruments used in KAP surveys on patients with diabetes was done. Consultation of existing validated instruments from studies where the conceptual and as far as possible the operational definitions correspond with the planned study was identified (Dinesh, Izham, Vijay, Pranaya & Subish, 2012: 245-252; Makwero, 2011: 1; Bradley, 1994: 24).
Permission to conduct this study was obtained from the Faculty of Health Sciences Ethical Committee University of the Free State. Written permission was obtained from the Department of Health in the Free State to do the research.
Data collection process
A pilot study was conducted at the Gabriel Dichabe Clinic in the Mangaung District. After completion of the pilot study an appointment was made with the provincial nurse manager and the nurse managers responsible for chronic diseases in the districts, to interview them regarding the data collection plan that would be followed.
Results:
Due to the questionnaires being completed by the researcher, the response rate was very high with Nurse Managers (n=6), Professional Nurses (n =54) and Community Health Care Workers (n=46). The results will be explained according to demographics, knowledge, attitude and practice.
Demographics
A significant percentage of the nurse managers had a diploma 33, 33% (n=2), whereas more than half of the professional nurses had a diploma 74, 07% (n=40). The majority nurse managers 66.67% (n=4) had managed to obtain a degree, but only 24.07% (n=13) of the professional nurses had a degree. Only 1.85% (n=1) of the professional nurses had completed a master’s degree. More than half of the Community Health Care Workers (58.70%; n=27) managed to complete grade 12.
Knowledge
All the nurse managers, and 96.30% (n=52) of the professional nurses knew that poorly controlled diabetes mellitus can result in a greater chance of complications and that a substantial decrease in body mass index will lower a patients’ risk profile. A similar study conducted by the heart and stroke foundation of South Africa (2015:2) states that continuous uncontrolled diabetes can damage body parts of an individual.
Polyphagia and polyuria were indicated by all nurse managers as symptoms that would give a high index of susceptibility for diabetes, compared to professional nurses, where only 57.69% (n=30) indicated polyphagia and 94.44% (n=51) indicated polyuria.
Only 21.74% (n=10) of the CHCW’s were knowledgeable about the normal range of blood glucose, whereas 15.22% (n=7) did not know and 60.87% (n=28) indicated that they were unsure.
Attitude
All nurse managers felt that most people find it difficult to adjust to having diabetes whereas 90.74%, (n=49) of professional nurses and two thirds of CHCW’s 76.09% (n=35) felt that most people find it difficult to adjust to one’s lifestyle.
Of the nurse managers, 66.67% (n=4) disagreed about feeling embarrassed about having diabetes, compared to 74.07% (n=40) of professional nurses. Of the CHCW’s, 78.26% (n=36) agreed to tell people that they had diabetes. The study shows that HCW's have a negative attitude towards diabetes.
Two-thirds of the nurse managers 66.67% (n=4) disagreed with the statement that one needed to be more sympathetic in the treatment of patients diagnosed with diabetes, compared to almost half 46.30% (n=25) of the professional nurses, who disagreed with the statement. More than half of the CHCW’s 54.35% (n=25) agreed with the statement that one needed to be more sympathetic in the treatment of patients diagnosed with diabetes.
A study conducted in India regarding the attitude of health care workers involved in the management of diabetes by Kumar, Gupta & Kumar (2014:92-95) evidenced increasing age and more exposure to formal education as being the most important determinants of HCW's attitude toward diabetes.
Practice
Very few nurse managers, only 16.67%;(n=1) indicated that a patient above 45 years should be screened for diabetes, the majority 66.67%; (n=4) indicated that patients with a family history of diabetes should be screened, whereas only 46.30% (n=25) of the professional nurses indicated that the above-mentioned group was screened for diabetes and 81,48%; (n=44) of the professional nurses indicated that patients with a family history of diabetes should be screened at the PHC's and CHC's.
In this study all the CHCW’s advised patients above 45 years and had a family history of diabetes to go for diabetes testing.
The American Diabetes Association (2014:1) evidenced that patients presenting with overweight and a body mass index of above 25kg/m2 should be screened for diabetes.
Conclusion:
HCW’s knowledge, attitude and practice of T2DM is poor and needs attention in order to improve the quality of the patient’s life at the CHC's and PHC's.
Recommendations
Knowledge
The Provincial Department of Health should provide updated training according to Primary Care 101 guidelines for nurse managers and professional nurses.
CHCW’s should be trained by the Regional Training Centre according to the Quality Council for Trades and Occupations Curriculum and Assessment Policy for CHCW’s.
Attitude
Positive attitudes regarding caring of DM patients should be created by means of knowledge amongst HCW’s as it influences the care provided.
Practice
Files completed by HCW’s should be audited by nurse managers to identify and address gaps.
CHCW’s should increase primary prevention awareness of chronic diseases in the community.
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