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Knowledge, Attitude, and Practices of Type 2 Diabetic Patients Regarding Obesity at Odi District Hospital, Tshwane District, South Africa
Abstract
Background:
Obesity is a major public health problem worldwide due to its links with diabetes, cardiovascular diseases, musculoskeletal disorders, and other disorders related to metabolic syndrome. Being obese or overweight is the main modifiable risk factor for type 2 diabetes. In 2019, more than 2.1 billion (30%) adults 18 years and older were overweight or obese globally. In the same year, in South Africa, nearly 70% of women and 31% of men were overweight or obese. Obesity can be prevented largely by lifestyle modification.
Objective:
This study aimed to assess the knowledge, attitudes, and practices of type 2 diabetic patients regarding obesity at a district hospital in South Africa.
Methods:
This was a cross-sectional study using a modified and validated interviewer-administered questionnaire on patients with type 2 diabetes mellitus attending a medical outpatient department at a district hospital. Systematic sampling was used to enroll participants.
Results:
Two hundred participants were enrolled. Women (60.5%) were more than men (39.5%), 60.2% were married, over half (51.83%) had high school education and above, and mean age was 58.20 years ± 11.06), mean BMI for males was 26.39 ± 4.63, and mean BMI for females was 30.54 ± 7.32.
The mean percentage knowledge, attitude, and practice (KAP) scores were 70.13±13.46, 83.43±19.24, and 35.43±25.05, respectively. Participants with high school education had high knowledge and attitude scores as compared to those with no formal education, 14.1% versus 5.9% and 66.2% versus 47.1%, respectively. The females had better KAP scores, 70.72±13.50, 84.42±18.99, and 35.77±24.82 compared to males, 69.24±13.44, 81.92±19.64, and 34.90±25.55, respectively.
Conclusion:
The study showed a high level of knowledge as well as positive attitudes regarding obesity. However, this did not translate to practice, which was very poor regarding regular exercise and healthy dietary habits.
1. INTRODUCTION
The recognition of obesity as a disease was, in theory, established in 1998 by the World Health Organization (WHO) [1]. Obesity has become a global epidemic, with an estimated 2,1 billion people being overweight or obese in 2019 [2]. This epidemic was once considered a problem in high-income countries; however, obesity rates are rising worldwide and affecting both developed and developing countries [3]. Obesity prevalence in developed countries, such as the United States, is as high as 26,6% in men and 32,2% in women above 20 years [2]. The prevalence of obesity in South Africa increased from 11.8% in 1980 to 23.3% in 2019, with 70% of women and 31% of men being overweight or obese [2, 3].
The causes of obesity are multifactorial and include environmental and individual factors. High energy consumption of animal fat, protein, and refined sugar has been on the increase, while less energy expenditure in the form of a sedentary lifestyle has caused a decrease in physical activity [1, 4, 5].
Obesity is an important risk factor for several non-communicable diseases. It is associated with increased risks for type 2 diabetes mellitus, hypertension, dyslipidaemia, metabolic syndrome, insulin resistance and diabetes mellitus, cardiovascular diseases, and non-alcoholic fatty liver disease [6-9]. There is an increased mortality from endometrial cancer in obese women and colorectal cancer in obese men [10]. One of the strongest links between obesity and disease is those with type 2 diabetes. Excess weight is behind 64% of cases of diabetes in men and 77% of cases in women [6].
Obesity is one of the leading preventable causes of death worldwide, with increasing rates in adults and children [4]. In 2010, overweight and obesity were estimated to cause 3.4 million deaths, 3.9% of years of life lost, and 3.8% of disability-adjusted life-years (DALYs) worldwide [11].
The number of people aged between 20 and 79 years who were estimated to die from diabetes in 2017 was approximately 4.0 (3.2-5.0) million, which was equivalent to one death every 8 seconds. Diabetes accounts for 10.7% of global all-cause mortality among people in this age group [12].
Sustained physical activity and dietary programs are shown to improve glycaemic control and plasma lipid in overweight and obese patients with type 2 diabetes mellitus [2]. A study reported that the incidence of diabetes was reduced by 58% with lifestyle intervention and by 31% with metformin compared to placebo [13].
It is, therefore, of utmost importance to have a public health approach to develop population-based strategies to improve patient weight for the prevention of diabesity.
1.1. Study Problem
During the researcher’s clinical consultations, it was observed that most of the type 2 diabetic patients at a district hospital in South Africa were overweight with suboptimal blood glucose control. Further interaction with these patients revealed that most of them do not exercise or follow a healthy diet plan. These observations prompted the researchers to carry out this study to assess the knowledge, attitudes, and practices regarding obesity among type 2 diabetic patients attending a medical outpatient clinic.
1.2. Significance of the Study
Regrettably, not much research has been done on the knowledge, attitudes, and practices of type 2 diabetic patients regarding obesity, especially in developing countries. The results of this study will not only add to the body of knowledge on obesity but will also provide the baseline data needed for the implementation of strategies for the prevention and management of obesity.
1.3. Ethical Considerations
The research protocol was approved by the Sefako Makgatho Health Sciences University Research and Ethics Committee (SMUREC/M/365/2015: PG).
The permission to conduct the study at Odi District Hospital was obtained from the CEO of the hospital.
All participants signed written consent prior to the study, and they were made aware that they could withdraw from the study at any time. The confidentiality of the participants was maintained by anonymising data obtained from the study.
2. MATERIALS AND METHODOLOGY
2.1. Study Aim and Objectives
The aim of the study was to assess the knowledge, attitudes, and practices regarding obesity among type 2 diabetic patients attending the medical outpatient clinic at Odi district hospital.
The objectives of the study were;
1. To determine the demographic characteristics of type 2 diabetic patients attending the diabetic clinic at Odi district hospital.
2. To determine the knowledge of obesity among type 2 diabetic patients at Odi district hospital.
3. To determine the attitudes of type 2 diabetic patients regarding obesity at Odi district hospital.
4. To determine the practice of type 2 diabetic patients at Odi district hospital regarding obesity.
2.2. Study Design
This was a descriptive cross-sectional study using an interviewer-administered questionnaire.
2.3. Study Setting
The study was conducted at the medical outpatient department of Odi district hospital, situated in the Tshwane region of South Africa. It is a 227-bed level-one hospital that offers services, such as eye and dental clinics, a rehabilitation unit (social work, audiology, physiotherapy and dietician), and reproductive health. The hospital also has medical, surgical, paediatric, neonatal and maternity wards, as well as a 24-hour emergency unit and theatre services. It serves as a referral centre to about 19 clinics around the region. The region is peri-urban; the inhabitants are mainly black South Africans of low socioeconomic status.
2.4. Study Population
The study population was composed of all type 2 diabetic patients aged 30 years and above, attending the medical outpatient department from the 2nd of August to the 25th of October, 2016.
2.5. Sample Size
About four hundred type 2 diabetic patients visit the medical outpatient department at Odi district hospital monthly on average. This means that approximately a total of 1,200 patients were expected to be seen during the three-month period of the study. The sample size of 196 participants was estimated using Epi infoTM 7 at a 95% confidence interval with a prevalence of 18.75%. However, the researcher sampled 200 participants.
2.6. Inclusion Criteria
Type 2 diabetic patients aged 30 years and above who attended the medical outpatient department and were willing to participate in the study by giving written consent were included.
2.7. Exclusion Criteria
Patients with other types of diabetes mellitus, as well as type 2 diabetic patients who were too sick to participate in the study, were excluded.
2.8. Sampling Technique
A systematic sampling method was used to select 200 participants from a total of 1,200 type 2 diabetic patients who attended the medical outpatient department from the 2nd of August to the 25th of October, 2016. The formula k = N/n = interval size was used, where k = 1200/200 = 6. This means that every 6th eligible participant was included in this study, beginning with a randomly selected starting point between 1 and 6 [14].
2.9. Data Collection
The data were collected by the researcher and his two trained local assistants using an adapted standardized questionnaire. The assistants helped in administering the questionnaires, while the anthropometric measurements were done by the researcher.
The questionnaire was adapted from the questionnaire used by Okonta et al. in 2014 [15]. The questionnaire was validated by a pilot study that was conducted on 10 type 2 diabetic patients at the family practice unit of Dr. George Mukhari Academic Hospital.
The aim and objectives and the inclusion and exclusion criteria were explained to the participants. The eligible and willing participants signed a written informed consent before being enrolled in the study.
The questionnaire was divided into three sections:
2.9.1. Demographic Data
This section provides data on sex, age, marital status, and educational status.
2.10. Data Analysis
Data was captured on Microsoft Excel 2007 by the researcher, and a statistician analysed the data using SPSS version 23 programme software. There were twenty-three questions on knowledge, seven questions on attitude, and seven questions on practice. One mark was given for each correct answer to the question.
For knowledge questions, the score ranges of 17 to 23, 8 to 16, and less than 8 were regarded as good, average, and poor knowledge, respectively. For questions on attitude, score ranges of 6 to 7, 3 to 5, and 0 to 2 were regarded as positive, neutral, and negative attitudes, respectively. For questions on practice, score ranges of 6 to 7, 3 to 5, and 0 to 2 were regarded as good, average, and poor practices, respectively.
The mean and standard deviation were used to describe knowledge, attitudes, and practice scores, while frequency and percentage were used to describe demographic and anthropometric data. P-values were calculated to ascertain the statistical significance of the findings. Results are displayed in tables.
2.11. Reliability and Validity
To ensure reliability, the researcher adapted the questionnaire used from a previously validated questionnaire.
To ensure validity, a pilot study on 10 type 2 diabetic patients was conducted at Dr. George Mukhari Academic Hospital.
2.12. Bias
2.12.1. Selection Bias
To minimise selection bias, a systematic sampling method was used to select all participants from all eligible type 2 diabetic patients.
3. RESULTS
3.1. Demographic Characteristics of Participants
There were 79 male participants (39.5%) and 121 female participants (60.5%) Table (1).
The majority of participants, 87 (43.7%), were more than 60 years old. Sixty-seven of the participants (33.7%) were in the age group 51-60; 30 participants (15.1%) were in the age group 41-50, while 15 participants (7.5%) were in the age 30-40 Table (1).
The results showed that 118 (60.2%) of the participants were married, 54 participants (27.6%) were single, 16 participants (8.2%) were divorced, and 8 participants (4.1%) were widowed Table (1).
| Variable | Frequency | Percentage |
|---|---|---|
| Sex | ||
| Male | 79 | 39.5 |
| Female | 121 | 60.5 |
| Total | 200 | 100.0 |
| Age groups (Years) | ||
| 30 – 40 | 15 | 7.5 |
| 41 – 50 | 30 | 15.1 |
| 51- 60 | 67 | 33.7 |
| >60 | 87 | 43.7 |
| Total | 199 | 100 |
| Marital Status | ||
| Single | 54 | 27.6 |
| Married | 118 | 60.2 |
| Divorced | 16 | 8.2 |
| Widowed | 8 | 4.1 |
| Total | 196 | 100 |
| Level of Education | ||
| No education | 17 | 8.9 |
| Primary school | 75 | 39.3 |
| High school | 92 | 48.2 |
| Tertiary education | 7 | 3.7 |
| Total | 191 | 100 |
A total of 92 participants (48.2%) completed high school education, 75 participants (39.3%) completed primary school education, 7 participants (3.7%) completed tertiary education, and 17 participants (8.9%) did not have any formal education Table (1).
3.2. Anthropometric Characteristics of Participants
3.2.1. Body Mass Index of Participants
A total of 77 participants (39.5%) were overweight; 34 of them (17.4%) had class 1 obesity, 15 of them (7.7%) had class ll obesity, 16 of them (8.2%) had class lll obesity while 53 participants (27.2%) had normal BMI Table (2).
| Variables | Frequency | Percentage |
|---|---|---|
| 18.5 – 24.9 | 53 | 27.2 |
| 25 – 29.9 | 77 | 39.5 |
| 30 – 34.9 | 34 | 17.4 |
| 35 – 39.9 | 15 | 7.7 |
| >40 | 16 | 8.2 |
| Total | 195 | 100 |
3.2.2. Body Mass Index Versus Sex of Participants
More female participants (79.4%, 86.7%, 87.5%) were obese as compared to the male participants (20.6%, 13.3%, 12.5%) Table (3).
| BMI | Sex | P-value | |
|---|---|---|---|
| Male | Female | ||
| 18.5 – 24.9 | 30 (56.6%) | 23 (43.4%) | 0.345 |
| 25 – 29.9 | 36 (46.8%) | 41 (53.2%) | 0.578 |
| 30 – 34.9 | 7 (20.6%) | 27 (79.4%) | 0.004 |
| 35 – 39.9 | 2 (13.3%) | 13 (86.7%) | 0.027 |
| >40 | 2 (12.5%) | 14 (87.5%) | 0.020 |
3.3. Knowledge Assessment of Participants
3.3.1. Individual Knowledge Characteristics
Table 4 presents a breakdown of the knowledge characteristics which were used to assess the individual participant’s knowledge regarding obesity and their responses recorded as yes, no, and not sure. A total of 92% of the participants knew that obesity is a serious health problem, and 89.4% that healthy habits can control weight.
3.3.2. Global Knowledge of Participants Regarding Obesity
Table 5 shows that only 3 participants (1.5%) had scores ranging from 0 to 7, indicating poor global knowledge of obesity; 155 participants (77.5%) had average global knowledge of obesity with scores ranging from 8 to 16, while 42 participants (21.0%) with scores ranging from 17 to 23 had good global knowledge of obesity.
| Knowledge Characteristics | Yes | No | Not Sure |
|---|---|---|---|
| The meaning of obesity | 97 (49%) | 82 (41.4%) | 19 (9.6%) |
| Obesity is a serious health problem | 183 (92%) | 8 (4%) | 8 (4%) |
| Regular exercise can help in controlling weight | 193 (96.5%) | 6 (3%) | 1 (0.5%) |
| Regular exercise helps to reduce blood sugar | 166 (84.7%) | 17 (8.7%) | 13 (6.5%) |
| Regular exercise helps to reduce blood pressure | 152 (76.4%) | 38 (19.1%) | 9 (4.5%) |
| Regular exercise helps to enhance insulin action | 70 (36.1%) | 91 (46.9%) | 33 (17%) |
| Regular exercise helps to improve blood circulation | 175 (88.4%) | 14 (7.1%) | 9 (4.5%) |
| Regular exercise helps to improve sex life | 111 (55.8%) | 52 (26.1%) | 36 (18.1%) |
| Regular exercise helps to decrease stress | 177 (89.4%) | 15 (7.6%) | 6 (3%) |
| Healthy habits can control weight | 177 (89.4%) | 19 (9.6%) | 2 (1%) |
| Healthy habits can reduce blood sugar | 182 (91.9%) | 11 (5.6%) | 5 (2.5%) |
| Healthy habits can reduce blood pressure | 165 (83.8%) | 24 (12.2%) | 8 (4.1%) |
| Eating low-fat foods is a recommended healthy lifestyle | 191 (95.5%) | 5 (2.5%) | 4 (2%) |
| Eating less carbohydrates is a recommended healthy lifestyle | 158 (79.4%) | 33 (16.6%) | 8 (4%) |
| Eating fibre-rich foods is a recommended healthy lifestyle | 141 (71.2%) | 31 (15.7%) | 26 (13.1%) |
| Eating protein-rich foods is a recommended healthy lifestyle | 167 (84.3%) | 19 (9.6%) | 12 (6.1%) |
| sugar intake is a recommended healthy lifestyle | 66 (33.2%) | 124 (62.3%) | 9 (4.0%) |
| Skipping meals is a recommended healthy lifestyle | 69 (34.7%) | 118 (59.3%) | 12 (6.0%) |
| Regular fruit intake is a recommended healthy lifestyle | 157 (80.8%) | 31 (16%) | 6 (3.1%) |
| Alcohol intake is a recommended healthy lifestyle | 86 (43%) | 105 (52.8%) | 8 (4.0%) |
| Cigarette smoking is a recommended healthy lifestyle | 82 (41%) | 107 (53.5%) | 11 (5.5%) |
| Any food in the right portion is a recommended healthy lifestyle | 131 (67.5%) | 45 (23.2%) | 18 (9.3%) |
| Knowledge Score | Number of Participants | Percentage (%) |
|---|---|---|
| Poor knowledge (less than 8) | 3 | 1.5% |
| Average knowledge (8 -16) | 155 | 77.5% |
| Good knowledge (17 – 23) | 42 | 21.0% |
| Total | 200 | 100% |
3.3.3. Demographic Characteristics vs. Knowledge Score
Table 6 shows the participants’ demographic characteristics (sex, age, education status, and marital status) versus their obesity knowledge scores indicated as good, average and poor. All male participants had good or average knowledge regarding obesity (20.3% and 79.7%, respectively). Only 2.5% of female participants had poor knowledge regarding obesity. There were no participants with high school education who had poor knowledge regarding obesity. Moreover, 11.8% of participants with no education had poor knowledge regarding obesity.
3.4. Attitude Assessment of Participants
3.4.1. Individual Attitude Characteristics
Table 7 shows attitude characteristics assessed for each participant and their attitude scores recorded as correct, incorrect, and not sure. A majority (91.3%) of the participants had the correct attitude about the need to control their weight and that exercise and dietary management can prevent obesity (93.8 and 90.2%, respectively).
| Demographic Characteristic | Knowledge Score | ||
|---|---|---|---|
| Good 17 – 23 | Aver 8 – 16 | Poor < 8 | |
| Sex | |||
| Male | 16 (20.3%) | 63 (79.7%) | 0 (0) |
| Female | 26 (21.5%) | 92 (76.0%) | 2 (2.5%) |
| P-value (Male vs. Female) | 0.138 | 0.022 | - |
| Age group | |||
| 30 – 40 years | 5 (22.2%) | 10 (66.7%) | 0 (0.0%) |
| 41 – 50 years | 4 (13.3%) | 26 (86.7%) | 0 (0.0%) |
| 51 – 60 years | 20 (29.9%) | 45 (67.2%) | 2 (3.0%) |
| > 60 years | 13 (14.9%) | 73 (83.9%) | 1 (1.1%) |
| P-value (≤50 vs >50 years) | 0.002 | < 0.0001 | - |
| Education | |||
| No education | 1 (5.9%) | 12 (82.4%) | 2 (11.8%) |
| Primary school | 24 (32%) | 50 (66.7%) | 1 (1.3%) |
| High school | 13 (14.1%) | 79 (85.9%) | 0 (0.0%) |
| Tertiary education | 4 (57.1%) | 3 (42.9%) | 0 (0.0%) |
| P-value (no high school education versus high school education) | 0.232 | 0.138 | - |
| Marital status | |||
| Single | 12 (22.2%) | 41 (75.9%) | 1 (1.9%) |
| Married | 23 (19.5%) | 93 (78.8%) | 2 (1.7%) |
| Divorced | 6 (37.5%) | 10 (62.5%) | 0 (0.0%) |
| Widowed | 1 (12.5) | 7 (87.5%) | 0 (0.0%) |
| Attitudes Characteristics | Correct | Incorrect | Not Sure |
|---|---|---|---|
| The need for people to control their weight | 179 (91.3%) | 15 (7.7%) | 2 (1%) |
| The need for people to change their weight | 140 (71.8%) | 46 (23.6%) | 9 (4.6%) |
| Exercise improves one’s condition | 178 (90.8%) | 14 (7.1%) | 4 (2%) |
| Healthy eating diet can improve diabetes | 163 (83.6%) | 26 (13.3%) | 6 (3.1%) |
| Diabetics are responsible for self-care | 150 (76.9%) | 38 (19.5%) | 7 (3.6%) |
| Obesity can be prevented by exercise | 183 (93.8% | 10 (5.1%) | 2 (1%) |
| Obesity can be prevented by dietary management | 175 (90.2%) | 17 (8.8%) | 2 (1%) |
3.4.2. Global Attitude Scores
Table 8 shows that only 11 participants (5.5%) had scores ranging from 0 to 2, indicating a negative attitude towards anti-obesity intervention; 52 participants (26.0%) had scores ranging from 3 to 5, indicating a neutral attitude; and 137 participants (68.5%) had scores ranging from 6 to 7, indicated positive attitude towards anti-obesity interventions.
| Attitude Score | Frequency | Percentage (%) |
|---|---|---|
| Negative attitude (0 – 2) | 11 | 5.5% |
| Neutral attitude (3 – 5) | 52 | 26.0% |
| Positive attitude (6 – 7) | 137 | 68.5% |
| Total | 200 | 100% |
3.4.3. Demographic Characteristics vs. Attitude Scores
Table 9 shows the participants' demographic characteristics (sex, age, education status and marital status) versus their attitude scores, indicated as positive, neutral, and negative. More female than male participants had a positive attitude regarding obesity (71.1% and 64.6%, respectively). Participants with high school education had a positive attitude regarding obesity more than those with no education (66.3% and 47.1%, respectively).
3.5. Practice Assessment of Participants
3.5.1. Individual Practice Characteristics
Table 10 shows that only 62 (46.3%) of the 131 participants who said they exercise regularly actually exercise at least 5 times per week, and only 26 (19.7%) of them exercise 30 minutes or more per day. Of the 66 (34.2%) participants out of 199 participants who answered yes to following a healthy diet plan, only 39 (53.4%) of them followed the healthy diet plan regularly. Only 50 (25.1%) of the participants monitored their weight, while 85 (42.7%) still added table sugar to their tea/food.
| Demographic Characteristic | Attitude Score | ||
|---|---|---|---|
| Positive (6 – 7) | Neutral (3 – 5) | Negative (0 – 2) | |
| Sex | |||
| Male | 51 (64.6%) | 22 (27.8%) | 6 (7.6%) |
| Female | 86 (71.1%) | 30 (24.8%) | 5 (4.1%) |
| P-value (Male vs. Female) | 0.004 | 0.228 | 0.777 |
| Age group | |||
| 30 – 40 years | 12 (80.0%) | 1 (6.7%) | 2 (13.3%) |
| 41 – 50 years | 18 (60.0%) | 11 (46.7%) | 1 (3.3%) |
| 51 – 60 years | 49 (73.1%) | 15 (22.4%) | 3 (4.5%) |
| > 60 years | 57 (65,5%) | 25 (28.7%) | 5 (5.7%) |
| P-value (≤50 vs >50 years) | <0.0001 | 0.007 | 0.191 |
| Education status | |||
| No education | 8 (47.1%) | 6 (35.3%) | 3 (17.6%) |
| Primary school | 55 (78.7%) | 15 (20.0%) | 1 (1.3%) |
| High school | 61 (66.3%) | 25 (27.2%) | 6 (6.5%) |
| Tertiary education | 5 (71.4%) | 2 (28.6%) | 0 (0.0%) |
| P-value (no high school education vs. high school education | 0.930 | 0.399 | 0,556 |
| Marital status | |||
| Single | 40 (74.1%) | 11 (20.4%) | 3 (5.6%) |
| Married | 82 (69.5%) | 30 (25.4%) | 6 (5.1%) |
| Divorced | 11 (68.8%) | 4 (25.0%) | 1 (6.3%) |
| Widowed | 4 (50.0%) | 3 (37.5%) | 1 (12.5%) |
| Practice Characteristics | Yes | No | Not Sure |
|---|---|---|---|
| Exercising regularly | 131 (65.5%) | 61 (30.5%) | 8 (4%) |
| Exercising ≥ 5 times/week | 62 (46.3%) | 72 (53.7%) | 0 (0.0%) |
| Exercising ≥ 30 mins/day | 26 (19.7%) | 106 (80.3%) | 0 (0%) |
| Following a healthy diet plan | 68 (34.2%) | 125 (62.8%) | 6 (3%) |
| Following a healthy diet plan regularly | 39 (53.4%) | 34 (46.6%) | 0 (0.0%) |
| Adding sugar to tea/food | 85 (42.7%) | 103 (51.8%) | 11 (5.5%) |
| Monitoring weight | 50 (25.1)% | 135 (67.8%) | 14 7%) |
3.5.2. Global Practice Scores
The majority of the participants, 101(50.5%), had scores ranging from 0 to 2, indicating poor practice regarding obesity; 91 participants (45.5%) had average practice in the range of 3 to 5, while 8 participants (4%) had good practices regarding obesity with scores ranging from 6 to 8 (Table 11).
| Practice Score | Frequency | Percentage |
|---|---|---|
| Good (6 – 7) | 8 | 4% |
| Average (3 -5) | 91 | 45.5% |
| Poor (0 -2) | 101 | 50.5% |
| Total | 200 | 100% |
| Demographic Characteristic | Practice Score | ||
|---|---|---|---|
| Good (6 – 7) | Average (3 -5) | Poor (0 -2) | |
| Sex | |||
| Male | 4 (5.1%) | 35 (44.3%) | 40 (50.6%) |
| Female | 4 (3.3%) | 56 (46.3%) | 61 (50.4%) |
| P-value (Male vs. Female) | 1.000 | 0.034 | 0.041 |
| Age group | |||
| 30 – 40 years | 1 (6.7%) | 7 (46.7%) | 7 (46.7%) |
| 41 – 50 years | 0 (0.0%) | 13 (43.3%) | 17 (56.7%) |
| 51 – 60 years | 3 (4.5%) | 32 (47.8%) | 32 (47.8%) |
| > 60 years | 4 (4.6%) | 39 (44.8%) | 44 (50.6%) |
| P-value (≤50 vs. >50 years) | 0.112 | <0.0001 | <0.0001 |
| Education status | |||
| No education | 0 (0.0%) | 6 (35.3%) | 11 (64.7%) |
| Primary school | 6 (8.0%) | 38 (50.7%) | 31 (41.3%) |
| High school | 2 (2.2%) | 42 (45.7%) | 48 (52.2%) |
| Tertiary education | 0 (0.0%) | 2 (28.6%) | 5 (71.4%) |
| P-value (no high school vs. high school) | 0.237 | 1.000 | 0.225 |
| Marital status | |||
| Single | 2 (3.7%) | 19 (35.2%) | 33 (61.1%) |
| Married | 5 (4.2%) | 58 (49.2%) | 55 (46.6%) |
| Divorced | 0 (0.0%) | 10 (62.5%) | 6 (37.5%) |
| Widowed | 1 (12.5%) | 4 (50.0%) | 3 (37.5%) |
3.5.3. Demographic Characteristics vs. Practice Scores
Table 12 shows the participants' demographic characteristics (sex, age, education status and marital status) versus their practice scores indicated as good, average, and poor. Only 5.1% of males and 3.3% of females had good practice scores. All participants of different age groups and education statuses had poor practice scores.
| KAP Scores | Mean ± Standard Deviation |
|---|---|
| Knowledge mean score | Mean 70.1 ± 13.5 |
| Attitude mean score | Mean 83.4 ± 19.2 |
| Practice mean score | Mean 35.4 ± 25.1 |
3.6. Knowledge, Attitude, and Practice (KAP) Scores
The participants’ knowledge and attitude mean scores, 70.1 ± 13.5 and 83.4 ± 19.2, respectively, were higher as compared to their practice mean score of 35.4 ± 25.1 (Table 13).
4. DISCUSSION
4.1. Age Distribution of Participants
A majority of the participants belonged to the age groups above 60 years (43.7%) and 51 to 60 (33.7%). This reflects the fact that type 2 diabetes usually has an onset after 40 years. According to the American Diabetes Association, adults aged 45 to 64 were the most diagnosed age group for diabetes. This finding is similar to the study published in 2014 by Okonta et al., where the majority of the participants (42.9%) fell within the age group 51 to 60 years [15]. Another study on the knowledge, attitude, and practices of adult patients with type 2 diabetes in the Free State province of South Africa also reported similar age trends where the median age of participants was 57 years [16]. It is important to note that 7.5% of participants belong to the age group 30 to 40 years. Although type 2 diabetes usually has an onset above age 40 years, it is becoming more common in adolescents and young adults due to poor lifestyle habits [16].
4.2. Sex Distribution of Participants
The majority of the participants (60.5%) were females as compared to 39.5% of males. This finding is in agreement with the results from a similar study by Okonta et al., in which 81.1% of the participants were female and 18.9% were males [15]. A similar study conducted in 2019 in the Free State province of South Africa also reported the majority of the participants to be females, i.e., 76.1% [16]. Another study on the assessment of glycaemic control in stable type 2 black South African diabetics attending a peri-urban clinic reported that 72.5% of the participants were females while 27.5% were males [17]. The higher number of female patients could be attributed to the fact that females are more likely than males to seek medical help.
4.3. Distribution of Participants by Level of Education
Most of the participants had a high school education (48.2%). Only 8.9% of the participants had no formal education. This contrasts with the findings by Okonta et al., where it was reported that 93.4% of the respondents either had no formal education (49.5%) or had only primary education (43.9%) [15]. Erasmus et al. also reported that 70.6% of the patients in their study had less than standard 8 education [17]. However, the level of education of the participants in this study is in concordance with the findings by Roux et al., who also reported that only 9.8% of the participants had no formal education [16].
4.4. Knowledge Assessment of Participants
The participants in this study had a high overall knowledge of obesity, as evidenced by an overall knowledge score of 70.1%. This is consistent with the knowledge score of 60% recorded in a similar study in Bangladesh by Saleh et al. [18].
Surprisingly, the high knowledge is in contrast to the finding of extremely poor knowledge documented in a similar study in South Africa, where 92.6% of participants had poor knowledge [15]. The high knowledge level could be attributed to the on-going health education during clinic consultation as well as the relatively good level of education among the participants. The nurses provide health education on some topics, such as diet, exercise, adherence to medication, and self-foot care, to the patients in the medical outpatient department of Odi District Hospital. The study by Okonta et al. also reported a low level of education, where only 6.6% and none of the participants had high school education and tertiary education, respectively, compared to 48.2% and 3.7% of participants in this study [15].
Another contrasting result was reported in a study among adult type 2 diabetic mellitus patients in Free State, South Africa, in which the majority of the participants (n = 222; 87.1%) were black women who were overweight and obese. The study reported poor knowledge in a very high percentage of the participants, which might contribute to morbidity and mortality [16].
Similarly, a study in Pakistan on knowledge, attitude, and practices of patients visiting a diabetes care unit, in which fifty-seven percent of the patients were overweight or obese, reported a poor overall knowledge about diabetes mellitus by 54% of the participants while only 13% of the participants had good knowledge about the disease [19].
4.5. Attitude Assessment of Participants
A significantly high proportion of the participants (83.43%) showed a positive attitude toward anti-obesity interventions, which is consistent with the findings of high positive attitudes among participants in a similar study by Okonta et al., where 84.3% of the respondents had positive attitudes [15]. This finding is also in agreement with the findings of a similar study where an attitude score of 79.30% was reported [18].
Similarly, the overall level of attitude was found to be good both in type 2 diabetic and nondiabetic participants in a knowledge, attitude, and practice study regarding diabetes mellitus among nondiabetic and diabetic study participants in Bangladesh [20].
The positive attitude of the participants towards anti-obesity interventions found in the study could be due to the positive linear relationship between knowledge and attitude.
4.6. Practice Assessment of Participants
An important finding of this study is a very low mean practice score of 35.43% among the participants. A majority (62.8%) of the participants had poor dietary practices, 80.3% did not exercise up to 30 minutes per day, and 67.8% did not monitor their weight. These findings were consistent with findings in similar studies by Okonta et al. [15], where 97.7% of the respondents had poor practices, and by Kiberenge et al. [21], where 75.6% of the respondents were reported to have bad practices. However, a similar study in Bangladesh recorded a high mean practice score of 55.5%, where it was found that males had significantly better practice compared to females [18]. It is a disturbing fact that the high level of knowledge and attitude did not translate to a high level of practice. A reasonable explanation is that the most overweight and obese participants are females. Females are less likely to go for exercise early in the morning or late in the evening by themselves for fear of being attacked and/or raped. Moreover, participants in this study are from a low socioeconomic background and, hence, can neither afford to pay for a well-equipped indoor training facility nor afford to maintain a good dietary plan.
CONCLUSION AND RECOMMENDATIONS
The study showed a high level of knowledge as well as a positive attitude regarding anti-obesity interventions. However, this did not translate to practice, which was poor regarding regular exercise and healthy dietary plans. The fact that 72.8% of the participants were either overweight or obese reflects the poor practices as well as the strong link between obesity and type 2 diabetes. There is an urgent need to develop programs that can help increase physical exercise and adherence to healthy dietary plans in the community. These programs will go a long way in controlling the diabetes of the patients as well as ameliorating the negative impact of obesity on the health of these patients.
The researcher recommends the following at Odi district hospital:
1. Continuing health education and promotion should be ensured during hospital visits.
2. Healthcare practitioners should be trained to provide brief counselling and motivational interviews for patients with obesity and overweight on diet/lifestyle changes that suit their economic status.
3. There is a need for the South African district health facilities to develop and make education programs focusing on empowering the patients to transform their knowledge and attitude into practice.
4. Through the help of ward-based community outreach teams, patients should be encouraged to do home-based exercises, like brisk walking, for at least 30 minutes five to seven days a week.
LIMITATIONS OF THE STUDY
The researchers used a cross-sectional study design; hence, the cause and effect of the research findings could not be established. Furthermore, the study was conducted in a predominantly African community with low socioeconomic status, so the findings might not be a true reflection of the multiracial South African population. Finally, the paucity of literature on the knowledge, attitude, and practice of type 2 diabetic patients regarding obesity, especially in Africa, made it difficult for the researcher to have a lengthy discussion.
Future studies should include:
• The impact of daily 30 minutes of brisk walking on overweight and obese diabetic type 2 patients in the same setting as this study.
• Knowledge, practice, and attitude of type 2 diabetic patients of affluent communities of South Africa.
• The perception of overweight and obesity among diabetic patients living in poor communities of South Africa.
• The individual characteristics of this study participants on their knowledge, attitude, and practice regarding obesity need discussion.
AUTHORS’ CONTRIBUTIONS
UE. O conducted the study and drafted the manuscript. K.E. H supervised the study, edited, and proofread the manuscript. Both authors agreed to submission to the Open Public Health Journal for publication.
ETHICS APPROVAL AND CONSENT TO PARTICIPATE
The research protocol was approved by the Sefako Makgatho Health Sciences University Research and Ethics Committee (SMUREC/M/365/2015: PG).
The permission to conduct the study at Odi district hospital was obtained from the CEO of the hospital.
HUMAN AND ANIMAL RIGHTS
No animals were used in this research. All procedures performed in studies involving human participants were in accordance with the ethical standards of institutional and/or research committee and with the 1975 Declaration of Helsinki, as revised in 2013.
CONSENT FOR PUBLICATION
Informed consent was obtained from all the participants of this study.
AVAILABILITY OF DATA AND MATERIALS
The data supporting the findings of this article is still under lock and key with the Main researcher, Dr Umeadim Okafor. However, l am making an arrangement to transfer the data to Sefako Makgatho University department of Family Medicine as soon as possible.
STANDARDS OF REPORTING
STROBE guidelines were followed.
FUNDING
This study was funded by Discovery Foundation. The award number is 036940
