R E S E A R C H A R T I C L E P I L O T S T U D Y B l a c k F e m a l e Pa t ie n t s w it h T y p e 2 D i a b e t e s M e l l i t u s : K n o w l e d g e , A t t i t u d e s a n d P h y s ic a l A c t iv it y A B S T R A C T : The a im o f this stu d y w as to obtain baseline data fr o m fe m a le Type 2 D iabetes M ellitu s (Type 2 D M ) p a tie n ts on th eir genera l health status, dem ographics, their kn ow ledge o f and a ttitud es tow ards dia betes a n d exercise, as w ell as th eir p re se n t p h y sic a l activity levels. The sa m p le o f convenience co nsisted o f 93 p a tie n ts betw een the a ges o f 36 a n d 70 years, w ho were atten ding the M am elodi H o spital D iabetic O utpatient Clinic. D em ographic, clinical, d ia betes know ledge, d iabetes attitu de and p h y sic a l activity data w ere captured. D a ta were su m m arized with d e sc rip tiv e statistics. P ea rso n p r o d u c t-m o m e n t co rrela tio n w as em p loyed to a ssess relationships a n d C ro n b a c h ’s alpha m ea su red reliability. It w as fo u n d th a t the sa m p le h ad a low educationa l level. (84% scho oling up to S t 7) Several risk fa c to r s f o r the control o f dia betes w ere id en tified in the sa m ple.(C lass I obesity, H b A I c-levels a ccepta b le to com prom ised, 75% on treatm ent f o r hyperten sio n) They h a d low scores on know led ge o f dia betes ( m ea n ,S D = 4 .7 2 ,2 .0 5 out o f 15) a n d low levels o f p h y sic a l activity. (mean, S D —2.85,2.09) P atients a greed w ith the attitude in the scale th a t the health care p ro fessio n als require skills to educate a n d counsel diabetic p atients, as w ell as bring a bo u t b eha vio ra l changes in the p a tie n ts.( r= 0.62) They also a greed that diabetes has a su b sta n tia l p sych o so cia l im p a ct on th eir lives. (r= 0.41) The h ig hest correlation betw een to sub-sca les w as betw een the need f o r sp ecia l trainin g o f health care pro fessio n a ls who care f o r diabetic p a tien ts a nd the p sych o so cia l im pact o f the disease. (r= 0.41) P atients sh o u ld be ed u ca ted a bo u t the basic p h ysio lo gy o f diabetes, insulin action a n d causes o f hypoglycaem ia. They sh o u ld a lso be m o tiva ted to increase p h ysica l activity on a continuous basis. C ulturally sen sitive research is needed to identify health beliefs, m otivation f o r the control o f d ia betes a nd environ­ m en ta l a n d p e rso n a l barriers to exercise a n d p h y sic a l a ctivity in this population. K E Y WORDS: T Y P E 2 D IA B E T E S M E L LIT U S, K N O W LE D G E , A TT ITU D E , P H Y SIC A L AC TIVITY, E X E R C IS E VAN ROOIJEN AJ, MSc Physiotherapy (UOFS)'; RHEEDER P, M.MED (Internal Medicine) (UP)2; EALES CJ, PhD (WITS)3; BECKER P, PHD (UNISA)4 1 Department o f Physiotherapy, University of Pretoria. Study leader/ C linica l Epidem iology Unit, University of Pretoria C o-study leader, D epartm ent of Physiotherapy W its M edical School Statistician, M edical Research Council, Pretoria INTRODUCTION Type 2 D iabetes M ellitus (Type 2 DM ) is present in the populations o f alm ost all the co u n tries in the w orld, and represents a significant disease burden in m ost developed countries. Type 2 DM probably results from an interaction o f genetic and environ- CORRESPONDENCE TO: AJ Van Rooijen D epartm ent o f Physiotherapy U niversity o f Pretoria P O Box 667, Pretoria 0001 Tel: (012) 354-2018 Fax: (012) 354-1226 Email: tvrooije@ m edic.up.ac.za m ental factors. E conom ic and prosperity advancem ent lead to lifestyle changes and w este rn isa tio n in d eveloping countries. Lifestyle behaviours, which include obesity, lack o f physical activity and diet influence the developm ent o f the d isease (Songer, 1995). F urther increases in Type 2 DM may be expected in the Third World as the econom ic advancem ent o f these countries continues (Songer, 1995). King, A ubert and H erm an (1998), estim ated that globally 325000 fem ale patients in the age group 45 -64 will have d iabetes by 2025. S tu d ies in Durban, the greater C ape Town and M angaung areas in the 1990’s reported prevalence rates for A fricans o f between 5 and 8% (O m ar et al, 1993). Type 2 DM occurs p rim arily in adults and the diag n o sis is usually m ade after the age o f 40, although onset may occur e a rlie r in h ig h -risk g ro ups (Songer, 1995). P erso n s w ith Type 2 DM can still produce insulin, but may be insulin resistant. Risk factors for Type 2 DM include dem ographic and environm ental charac­ teristics such as age, obesity, physical activity, a sedentary lifestyle, dietary habits, sm oking and the degree o f w est­ ernisation. Type 2 DM is often charac­ terised by late stage c o m p licatio n s, inclu d in g retin opath y, nephropathy, neuropathy and m acro-vascular disease (Songer, 1995). 2 0 SA J o u r n a l o f P hysiotherapy 2001 V o l 57 No 3 R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. ) mailto:tvrooije@medic.up.ac.za W estaw ay and co -w orkers (1998) conducted a study on the health status and q u ality o f life am o n g st urban black patients with Diabetes M ellitus in the M a m elo d i com m u nity. T hey recom m ended a com prehensive diabetes health p ro m o tio n al pro gram m e that focuses on self-m anagem ent by diabetics through active participation in their care. The core com ponents o f such a pro­ gram m e should include know ledge and understanding o f diabetes, the develop­ m ent o f skills for dietary, exercise and treatm ent adherence, the role o f social support and the use o f self-incentives for controlling diabetes. The aim o f this study was to obtain baseline data from fem ale Type 2 DM patients on their general health status, dem ographics, their know ledge o f and attitudes towards diabetes and exercise, as well as their present physical activity levels. METHOD Ethical clearance fo r the study was obtained from the Ethics C om m ittee o f the P re to ria A cadem ic H ospital (N um ber 116/99). The superintendent and m atron o f the M am elodi Hospital also consented to the study. SUBJECTS The convenience sam ple consisted o f 93 fem ale Type 2 DM patients between the ages o f 36 and 70 years, attending the M am elodi Hospital D iabetic O utpatient C linic in M amelodi. The only exclusion criterion was m ental incompetence. The research was conducted parallel to a research project on the diabetic foot by P ro f P R heeder and team m embers. Patients came for two visits, during which the in terview s w ere co n d u cted and the clinical data obtained. Patients were com pensated fo r their transp ortation costs. The data capturing com m enced on the 27th o f M arch 2000 and was com pleted on the 31st o f July 2000. Four to six patients reported daily to the research venue at 08h00 on the m orning o f their appointm ents. Each patient was w elcom ed, introduced to the research team members and asked which language they preferred. Inform ed consent was obtained from each patient after the aims, procedures and benefits o f the study w ere explained to them. Subjects had an opportunity to ask questions before the consent form was signed, w itnessed and each subject received a signed copy o f her own consent form. INSTRUMENTATION D em ographic, clinical, diabetes know l­ edge, diabetes attitude and physical activity data were captured. The Diabetes K now ledge Form C (D K N C ) scale w as d ev elo p ed by Dunn and associates (1984), and has been used in the elderly from a variety o f ethnic backgrounds. The scale com ­ prises o f fifteen q u estions sam pling know ledge in five broad categories. The categories were: basic physiology o f diabetes including insulin action, hypoglycaem ia, food groups and sub­ stitutions, sick day m anagem ent and general diabetes care. D KN C scores are expressed as raw scores out o f 15, or as percentag e o f co rrect answ ers, with higher scores indicating better diabetes k now ledge. T he in tern al relia b ility (0.76) o f the D KNC is m oderate and acceptable for use with Type 2 DM - sam ples (Beeney et al, 1996). The scale was therefore regarded as valid. The M odified B aecke questionnaire on physical activity for older adults was developed to enable discrim ination between physically active and inactive eld erly p eople liv in g independen tly (Voorrips et al ,1991). It consists o f scores for household and sporting activi­ ties, and other physically active leisure time activities, for exam ple gardening. T hese scores, classified by an intensity code, together with data on the num ber o f hours spent on the activity and the season o f the year in w hich the activity was perform ed, resulted in a total acti­ vity score. In a study by Voorrips et al, (1991), the subjects at the upper end o f the scale with an activity score higher than 17 w ere lab elled the p h y sically active group. Subjects at the low er end o f the scale, with an activity score under 9, were labelled the “sedentary group” . (R eliab ility 0.89, R elative V alidity 0.72-0.78) T he R evised D iab etes A ttitu d e S cale-Ill (D A S-III) was used to assess the im pact o f diabetes education pro­ gram m es on the attitudes o f patients and to ex p lo re the relatio n sh ip betw een attitudes and behaviour (Anderson et al, 1990). It consists o f 5 constructs, co n ­ taining 35 Likert scale items (1, strongly agree; 2, agree; 3, neither agree or dis­ agree; 4, disagree; 5, strongly disagree). The scale was revised in order to sim ­ plify the wording o f the original item s and to elim inate technical term s and the reading level was lowered from 12th to the 10th grade. It was tested on a sam ple o f 1202 patients, consisting o f 65% fem ale patients with a mean age o f 50.7 years. T he relia b ilitie s fo r the five su b -scales ran g ed from 0 .6 1 fo r the seriousness o f Type 2 DM ( 3 item s) to 0.71 for the need for special training (7 items). These reliabilities o f the DAS-3 sub-scales are adequate for group com ­ parisons (A nderson et al, 1990). All the scales were originally devel­ oped and validated in English. A trained m ultilingual interview er was asked to freely translate the question­ naires into the idiom o f the com munity. A second trained interview er was asked to translate the questionnaires back into English. A pilot study was conducted during w hich the first interview er asked the questions, while the second inter­ viewer also com pleted the questionnaires to see if the p atients’ answers were inter­ preted correctly by the interviewer. The sam e in terv iew er w as used fo r the first 45 interviews, after w hich she was unavailable to continue with the work. A second trained m ultilingual interview er was then used to com plete the rem aining 48 interviews. The patients were gener­ ally exam ined by a trained observer, participating in the diabetic foot project for the clinical data as follows: Height was determ ined to the nearest 0.1 cm using a m easuring stick attached to the wall. W eight was determ ined to the nearest 0.1 kg standing barefoot in light clothing on a calibrated electronic scale (Tanita (r)). Body m ass index (Hartl, 1997) is defined as weight (in kg) divided by the square o f o n e ’s height (in m ) : kg/m2. The normal value is predicted as 20-25 kg/m2 (R eference range pre-obese: BM1= 25-29.9 kg/m2 C lass I obese= 30-34.9kg/m2, Class II obese= 35-39.9 kg/m 2 , SA J o u r n a l o f Physiotherapy 2001 V o l 57 No 3 21 R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. ) Class III obese =40 kg/m2 ). Blood pressure was m easured using a M ercury B aum anom eter according to published guidelines (W estaway et al, 1998) (Reference values: Systolic blood pres­ sure: optim al ( 130, acceptable 131-150, poor (150. D iastolic b lood pressure: optimal ( 85, acceptable 86-90, poor (90). T he g ly c o c y la te d heam o g lo b u lin - values H b A lc (B eckm an L X 20(r) ), w hich give an indication o f the average blood glucose concentration over a six to eight w eek period and is a good m onitoring test, was used. In the 88 patients who returned for their second visit 85 sets o f blood sam ples were obtained. In two cases obesity precluded the investigators from obtaining suffi­ cient blood sam ples. One sam ple was insufficient for analysis (Reference val­ ues: 4.5% -6.5% , acceptable ( 2% points above norm al, com prom ised ( 2 % points above norm al) (Ligtenberg et al, 1997 and Greeff, 2000). Statistical Analysis D ata were entered into a file on the S tatistix -program on the com puter, screened for m issing values and range checked. D ata were analysed using Statistix (r), StatSoft’s Statistica (r) and Stata (r) soft­ ware. D ata were sum m arised w ith descrip­ tive statistics, i.e. m ean, SD, m edian, ran ge, freq u en cy and percen tag e. P earson pro duct-m om ent correlations w ere em ployed to assess relationships. C ronbach’s alpha m easured the reliability o f the R evised Diabetes A ttitude Scale-3 in this population. A lpha coefficients o f > 0.70 was regarded as satisfactory, based on N un n ally ’s (1978) recom m en­ dation. A m ean score was calculated for each sub-scale for each individual. Then the sam ple m ean was calculated o f the construct averages for the 93 subjects. The sub-scale scores w ere inter-cor- related, using Pearson product-m om ent correlation. RESULTS The results are be presented in the fol­ low ing order: D em o g rap h ic, c lin ical, D iabetes know ledge scale, DAS-3 scale, M odified Baecke Scale and integrated results. Demographical data The dem ographics o f this sam ple by age group, educational level, em ploym ent status and housing are provided in Table 1. Table 1: Demographic data Demographics n % Age 3 6 - 3 9 2 2 4 0 - 4 9 1 3 1 4 5 0 - 5 9 2 8 3 0 6 0 - 6 9 4 8 5 2 7 0 2 2 Educational level N o n e 1 6 1 7 S t 1 - 4 2 8 3 0 S t 5 - 7 3 4 3 7 S t 8 - 1 0 1 3 1 4 Post S t 1 0 2 2 Employment status N o n e 2 3 2 5 P a rt-tim e 1 2 1 3 F u ll-tim e 1 5 1 6 P e n s io n e r 4 3 4 6 Housing Lives w it h p a r tn e r 7 8 Lives w it h fa m ily 81 8 7 Lives a lo n e 5 5 Eighty four percent o f the sam ple group had schooling only up to St 7. The sam ple consisted o f 46% pensioners. The m ajority (87% ) o f the patients lived with their fam i­ lies at the time o f the interviews. All the subjects in the sam ple w ere black females. Clinical Data The num ber o f patients, m ean, standard deviation, m edian and range for the clinical data o f the sam ple is presented in Table 2. Table 2: Descriptive statistics for clinical data Variable N Mean SD Median Range Age 9 3 5 8 . 2 9 8 . 1 8 6 0 . 0 0 3 6 - 7 0 Weight 9 2 7 8 . 5 5 1 3 . 8 3 7 6 . 9 0 5 1 . 4 - 1 1 9 . 4 Height 9 2 1 5 6 .7 1 5 . 7 4 1 5 6 . 2 0 1 4 4 . 5 - 1 7 3 . 3 BMI 9 2 3 1 . 9 6 5 . 1 4 3 1 .5 1 2 0 . 8 8 - 4 5 . 6 1 Systolic BP (SBP) 9 3 1 4 9 . 9 4 2 5 . 5 9 1 4 7 . 0 0 9 6 - 2 0 5 Diastolic Blood Pressure (DBP) 9 3 8 9 . 0 9 1 1 . 0 9 9 0 . 0 0 6 0 - 1 2 0 H b A lc % 8 5 9 . 8 2 2 . 2 3 9 . 9 0 5 . 3 - 1 3 . 9 N = n u m b e r o f p a tie n ts S D = s ta n d a r d d e v ia tio n t h e s a m p le c a n b e c la s s ifie d as C la s s I o b e s e . M e a n s c o re = 3 1 . 9 6 ( 3 1 . 5 1 ) . M e a n H b A l c- le v e ls in d ic a t e d t h a t th e s a m p le g r o u p w a s in th e a c c e p t a b le to c o m p r o m is e d c a te g o r y . M e a n s y s to lic a n d d ia s to lic b lo o d p re s s u re re s u lts in d ic a te d t h a t th e p a tie n ts w e r e in th e a c c e p t a b le c a t e g o r y ( m e a n = l 4 9 , 9 4 ) . H o w e v e r , f o r th e a v e r a g e s y s to lic b lo o d p re s s u re , 4 3 % w e r e c la s s ifie d a s p o o r c o n tr o l a n d f o r th e a v e r a g e d ia s to lic b lo o d p re s s u re , 3 8 2 2 SA J o u r n a l o f P hysiotherapy 2001 V o l 57 No 3 R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. ) Seventy five percent o f the sam ple were on oral hypoglycaem ic agents, with 21% patients using insulin for their diabetes. Seventy six percent o f the subjects w ere on treatm ent for hypertension. Diabetes Knowledge Each item is assigned a score o f 1 for a correct response and 0 for an incorrect response. Items 1 to 12 in the questionnaire had a single correct answer. For item s 13 to 15, several answers are correct and a score o f 1 was allocated if all the answers w ere correct. Only scores of 0 or 1 were used, partially correct answers scored 0. The mean (SD) total score of the Diabetes K now ledge scale for the sam ple group was 4.72 (2.05) and the m edian was 5.00. Scores ranged form 0 - 1 1 out o f 15. The percentage o f correct answers was 31 %. The distribution of the scores in the five broad categories of the questionnaire is reported in table 3. Table 3: Scores in five broad knowledge categories Category of knowledge N Mean SD Median Range correct answers % Basic physiology of diabetes including insulin action (Total category score) 93 0.99 0.72 1 0-3 18 In s u lin use d u r in g u n u s u a lly h e a v y e x e rc is e (Ite m s c o re ) 9 3 0 .1 1 0 .3 1 0 0 -1 11 E ffe c t o f in s u lin o n b lo o d s u g a r 9 3 0 . 7 5 0 . 4 3 1 0 -1 31 H ig h b lo o d o r u r in e s u g a r le ve l a n d in s u lin 9 3 0 . 1 3 0 . 3 4 0 0 -1 1 3 Hypoglycaemia 93 0.96 0.79 1 0-3 32 N o r m a l r a n g e fo r b lo o d g lu c o s e 9 3 0 . 5 2 0 . 5 1 0 -1 5 2 S y m p to m s n o t a s s o c ia te d w ith h y p o g ly c a e m ia 9 3 0 . 3 8 0 . 4 9 0 0 -1 3 8 C a u s e s o f h y p o g ly c a e m ia 9 3 0 . 0 7 0 . 2 5 0 0 -1 7 Food groups and substitutions 93 2.09 0.95 2 0-4 41.8 F o o d g r o u p r ic e 9 3 0 . 7 5 0 . 4 3 1 0 -1 7 5 F o o d r ic h in c a r b o h y d r a t e 9 3 0 . 7 3 0 . 4 5 1 0 -1 7 3 F o o d g r o u p o f w h ic h c a n e a t lim itle s s a m o u n t 9 3 0 . 5 4 0 . 5 1 0 -1 5 4 F o o d a p p r o v e d b y th e d ia b e t ic c lin ic : 9 3 0 0 0 0 0 S p e c ia l d ia b e t ic fo o d s 9 3 0 . 0 7 0 . 2 5 0 0 -1 7 Sick d ay management 9 3 0 . 1 8 0 . 3 9 0 0 -1 9 III a n d u n a b le to e a t p r e s c r ib e d d ie t 9 3 0 . 1 8 0 . 3 9 0 0 -1 1 8 V o m itin g a n d d ia r r h o e a 9 3 0 0 0 0 0 0 G e n e r a l d ia b e te s c a r e 9 3 0 . 9 5 0 . 6 7 1 0 - 2 4 8 P r e p a r a tio n o f fo o d 9 3 0 . 2 3 0 . 4 2 . 0 0 -1 2 3 W e ig h t c o n tr o l 9 3 0 . 7 2 0 . 4 5 1 0 -1 7 2 A very low percentage of correct answers in the category on the basic physiology, including insulin action is seen. The sam ple scored higher in the category o f know l­ edge about hypoglycaem ia, but did not know the causes o f hypoglycaem ia. The subjects could answer the questions about basic food groups, but not the questions about special d iab etic foo ds and food approved by the diabetes clinic. They were well inform ed about weight control in diabetes care, but scored low on the question about food prepara­ tion. T h e ir know ledge about w hat to do when they becom e ill was nearly non existent. Leisure and household physical activity The total physical activity score result­ ing form the M odified B aecke Physical A ctiv ity Q u estio n n aire ran g ed from 0.1 to 13.4. (M edian = 2.23) The mean score(SD ) for the questionnaire was 2.85 (2.09). The distribution o f the total scores in household, sport and leisure time acti­ vities is reflected in Table 4. (See Table 4) O f the subjects, although all did do household activities, only 11% were involved in heavy household activities on a continuous basis as can be seen in table 5. Subjects m ainly used public transport when going som ew here, with only 31% indicating that they walked. O nly 11 % o f the sam ple indicated that they walked m ore than 5 stairs per day. (See Table 5) Only 3 subjects indicated that they w ere p articip atin g in a spo rt (two did bow ling and one skipping) at the tim e o f the interview s as can be seen from the low sport activity score in Table 4. Seventy three percent responded that they did take part in sport activities at school. S even ty-seven percen t o f subjects in d icated that they did leisu re­ time physical activities consisting of w alking, gardenin g, n eedlew ork and light exercises and com binations there of. The leisure-tim e activity score was calculated as the cross product o f codes for intensity, hours per week and m onths per year for each activity sum m ed across all activities. The unitless intensity code is based on energy costs. The num ber o f patients, m ean, stan­ dard deviation, m edian and range for the intensity of, the hours per w eek and m onths per year spend on leisure-tim e activities are presented in Table 6. (See Table 6) SA J o u r n a l o f P hysiotherapy 2001 V o l 57 No 3 2 3 R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. ) Table 4: Physical activity scores (mean, median, range and standard deviation) Variable N Percentage % Mean SD - Median Range H o u s e h o ld a c tiv itie s 9 3 1 0 0 2 . 0 5 0 . 5 6 2 . 1 0 0 . 1 0 - 3 . 4 0 S p o r t a c tiv itie s 3 3 0 .0 1 0 . 1 0 0 . 0 0 0 . 0 0 - 0 . 9 4 L e is u re -tim e a c tiv itie s 7 2 7 7 0 . 7 9 1 .8 5 0 . 0 3 0 . 0 0 - 1 0 . 7 0 Table 5: Frequency distribution of household activity scores Household actvity Value patients Number of of patients Percentage (%) Light housework N e v e r 9 1 0 ( D u s tin g ,w a s h in g S o m e tim e s 1 5 1 6 d is h e s , r e p a ir in g c lo th e s ) M o s tly 11 1 2 A lw a y s 5 8 6 2 Heavy housework N e v e r 4 8 51 ( w a s h in g flo o rs , w in d o w s , S o m e tim e s 2 2 2 4 c a r r y in g tra s h b a g s ) M o s tly 1 3 1 4 A lw a y s 1 0 11 Prepare warm meals N e v e r 8 9 S o m e tim e s 2 0 2 2 M o s tly 1 8 1 9 A lw a y s 4 7 5 0 Flights of stairs N e v e r 5 8 6 2 1 - 5 s ta irs 2 5 2 7 6 - 1 0 s ta irs 8 9 + 1 0 s ta irs 2 2 Use of transport to go somewhere N e v e r 1 1 C a r 2 2 P u b lic tr a n s p o r t 61 6 6 W a lk in g 2 9 31 Go out shopping N e v e r 7 6 8 2 1 / w e e k 11 1 2 2 - 4 / w e e k 3 3 d a ily 3 3 Table 6: Descriptive statistics for clinical data Variable N Mean SD Median Range Intensity 9 3 0 . 7 7 0 . 5 7 0 . 8 9 0 - 1 . 8 9 Hours per week 9 3 1 .6 6 2 . 2 6 0 . 5 0 - 8 . 5 Months per year 9 3 0 . 1 5 0 . 3 2 0 0 - 0 . 9 2 The intensity o f the leisure-tim e activities varied from sitting, using arm and m ovem ents to standing, walking, using body, arm and hand movem ents. The subjects spend less than 3 hours per week and less than 3 m onths a year doing leisure-tim e activities. Attitudes towards Diabetes and its treatment T he m ean score fo r each sub -scale was calculated for the 93 patients. The item s which did not contribute to the reliability o f the construct as m easured by C ro n b a c h ’s alpha w ere excluded from the final analysis. Table 7 presents the descriptive statistics and C ronbach’s alpha for each o f the defined sub-scales after the item s had been excluded. Individuals were classified into one o f two groups. If an individual’s score on a given sub-scale was less than 3.00, she was placed in the positive attitude group (Pos). If an individual’s score was m ore or equal to 3.00, she was placed in the negative attitude group (Neg). . (See Table 7) The mean is equal to the sam ple mean o f construct averages. The reliabilities ranged from 0.41 for the psychosocial im pact (5 item s) to 0.62 for special training (4 items). The sam ple m ean reflects that the sam ple agrees with respect to sub-scale 1: the a ttitu d e that the health care professionals who care for patients with diabetes need teaching, counselling and change in behavioural skills. They also agree with respect to sub­ scale 4: an attitude that diabetes usually has a substantial psychosocial im pact on the lives o f people with Type 2 DM The sam ple reacted neutrally with respect to sub-scale 2: that Type 2 DM is a serious disease. They also reacted neutrally to sub-scale 3: the relative value o f tight glucose control. The sam ple disagreed with respect to sub-scale 5, reflecting the attitude that patients should be the prim ary decision­ m akers regarding the daily self-care of their diabetes. Individuals who scored m ore or equal to 3.00, were placed in the negative attitude group. A substantial num ber of the responses for certain sub-scales was a “3” , indicating a neutral response. The items with the highest neutral scores were item 21 : “ ...Type II diabetes is a very serious disease" and item 25 : “...Type II is as serious as Type I dia­ betes. ” T he Pearson product-m om ent corre­ lations for the five subscales are presented in Table 8. (See Table 8) 2 4 SA J o u r n a l o f Physiotherapy 2001 V o l 57 No 3 R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. ) Table 7: Descriptive statistics for mean sub-scale scores of 93 individuals on the Revised DAS-3 Scale. Subscale N No Of items Mean SD Range Cronbach's alpha % Pos % Neg S p e c ia l tr a in in g 9 3 4 1 .8 7 0 . 2 9 1 . 0 0 - 2 . 5 0 0 . 6 2 9 8 2 S e rio u s n e s s o f TYPE 2 D M 9 3 3 3 . 0 4 0 . 5 6 1 . 6 7 - 4 . 0 0 . 5 8 2 4 7 6 V a lu e o f t ig h t c o n tr o l 9 3 3 2 . 7 9 0 . 4 9 1 . 6 7 - 3 . 6 7 0 . 5 5 3 7 6 3 P s y c h o s o c ia l im p a c t 9 3 5 2 . 2 0 0 . 4 2 1 . 2 0 - 3 . 2 0 0 .4 1 6 7 3 3 P a tie n t a u to n o m y 9 3 4 3 . 9 5 0 . 4 2 3 . 0 0 - 4 . 7 5 0 . 5 5 1 2 8 8 1 = S tr o n g ly a g r e e 2 = A g r e e 3 = N e u tr a l 4 = D is a g r e e 5 = S tr o n g ly d is a g r e e Pos = p o s itiv e N e g = n e g a tiv e Table 8: Pearson product-moment correlations between subscales No Sub-scale(SC) S C I SC2 SC3 SC4 SC5 1 S p e c ia l tr a in in g - 2 S e rio u s n e s s o f TYPE 2 D M 0 . 2 9 - 3 V a lu e o f tig h t c o n tr o l 0 . 2 8 - 0 .0 1 - 4 P s y c h o s o c ia l im p a c t 0 .4 1 0 .1 1 0 . 1 7 - 5 P a tie n t a u to n o m y 0 . 3 3 0 . 0 7 - 0 . 2 7 0 . 1 2 - N o = s u b -s c a le n u m b e r S C = s u b -s c a le The highest correlation betw een two sub-scales was between the need for special training and the psychosocial im pact o f the disease (r = 0.41). The rem ain in g co rrela tio n s w ere low to m oderate, indicating that the sub-scales w ere m easuring relatively independent attitudes; however, it is recognised that the sub-scale reliabilities attenuate these correlations to som e degree (A nderson et al, 1990) DISCUSSION In this study, baseline d ata w ere captured about the general health status, demographical profile, knowledge o f and attitudes towards diabetes and exercise, as well as their present physical activity levels. The sam ple consisted o f mainly older urban black fem ale Type 2 DM patients in M am elodi (m ean, median =58,60 years). The convenience sam ple com prised o f 93 fem ale Type 2 DM patients in M am elodi who voluntarily jo in e d the D iabetes F oot pro ject to w hich the current study was linked. The sam ple size was too small for the use o f the instrum ents. Nunnely (1978), stated that the sam ple size should have ten respondents per item in a question­ naire in order to test the reliability and validity o f the instrum ent. However, the results can be used as a pilot study to obtain baseline data. No attem pt was m ade to control for extraneous factors such as stress, physical illness and the use o f drugs, which can affect blood glucose levels. The design o f the study was sufficient to obtain baseline data, because all the data were collected at the sam e tim e and patients w ere contacted only once. The study was relatively cheap and easy to carry out. The principal findings o f this study are the identification o f several risk factors for the control o f diabetes. The patients were mainly older and with a low educational level. Clinical data showed that they were C lass I obese and that their glucose control w ere acceptable to com prom ised. A lthough 75% o f the sam ple were on hypogly- caem ic agents and 21% w ere using insulin for their diabetes, they had little know ledge about the basic physiology o f diabetes and insulin action, sym ptom s associated with hypoglycaem ia, sick day m anagem ent and preparation o f food. The physical activity score showed that although 62% and 77% o f the patients did household and leisure-tim e activities respectively, it w ere m ainly light household tasks and that they spend less than 3 hours per week, less than 3 months a year doing leisure-tim e activities. The relevance o f these findings was com ­ pared to other studies and will now be discussed. T he total sco re o f the D iabetes K now ledge scale (4.7) com pares favour­ ably to the score reported by Cam pbell (1996). He reported total scores o f 4.8 to 5.8 out o f a possible total score o f 15 in a sam ple o f 229 Type 2 DM patients, whose mean age was 59 years and o f w hom 52% w ere fem ale. H o w e v er Beeney and co-w orkers (1996) reported a mean score o f 7.6 , in a sam ple o f 460 m ostly older Type 2 DM population., which is 50% correct answers com pared to the 33% o f the current study. The subjects’ higher scores in the categories o f know ledge about hypo­ glycaem ia , basic food groups and weight control indicate that they had received some education, m ost probably at the M am elodi Diabetes Clinic. The lack o f know ledge about the basic physiology o f diabetes, insulin action and causes of hypoglycaem ia is an im portant finding, since 97% o f the patients were on either oral hypoglycaem ic agents, insulin or a com bination. The lack o f know ledge of the subjects is further em phasised by the finding that only 52% o f the sample knew the accep table H b A lc values. B eeney and co-w orkers (1996) stated: “ Patients with previous form al diabetes education w ho are not treated with exogenous insulin should still under­ stand the p h y sio lo g ical action o f endogenous insulin secretion and its role in diabetes.” The low education level and the high mean age o f the subjects can be co n sid ered as co n trib u tin g factors to the lack o f knowledge, since the ability o f the elderly to learn and practise self-care, may be com prom ised SA J o u r n a l o f P hysiothera py 2001 V o l 57 No 3 2 5 R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. ) by d em o g ra p h ic and en v iro n m en tal factors. (Songer, 1995) N ilsson et al (1998), report that the relative m ortality risk is increased in women who are less well educated, single and lacking socio­ econom ic resources. In a population based study am ong 48 315 adults with diabetes in 21 states in Am erica, B eckles et al (1998), found that insulin use, socio-econom ic status (as judged by level o f education), access to care and extent o f continuing edu­ catio n (as ju d g e d by aw aren e ss o f H b A lc ) were im portant factors related to diabetes m anagem ent. T he m easu rem en t o f kn o w led g e rem ains im portant to diabetes m anage­ ment and is essential before an effective educational program m e can be im ple­ mented. (W estaway et al, 1998) Every patient should be provided with full and accurate in fo rm atio n ab o u t the underlying patho-physiology o f diabetes as a rationale for its treatment. Logically it would seem that more know ledge will enable the patient to put into practice those self-care behaviours which will contribute to im provem ent in m etabolic control. However, Tu and co-w orkers (1993) reported in a study on diabetes self-care know ledge, behaviours and m etabolic control o f older adults in a sam ple o f 27 Type 2 DM patients, mean age o f 65, including 18 fem ales and 13 black subjects, that focus o f education for older adults with diabetes should be placed on effecting changes in self- care behaviours. Adherence should not be measured based solely on metabolic values. This viewpoint is shared by Locking- ton et al, (1988) w ho did a study on know ledge profile and control on 72 Type 2 DM patients, m ean age 58 years. T hey recom m ended that for good blood glucose control, a m inim um level o f know ledge is necessary above which other factors, including attitudes, health beliefs and m otivation, are likely to be o f much greater im portance. Anderson and co-w orkers (1993) in a study on 1202 subjects o f whom , 769 were Type 2 DM, 64% fem ale, mean age 59 years, reported that patients who reported high adherence to exercise recom m endations expressed low er agreem ent on the sub­ scale for negative im pact o f diabetes. Little is known about the health beliefs and m otivation related to the culture o f the present sample. The subjects scored very low on the M o d ified B aeck e Q u estio n n aire on Physical A ctivity and can be classified as having a sedentary lifestyle (Beeney & Dunn, 1990). The more active subjects w ere doing household and leisure tim e activities, but not on a regular basis. In a study on 255 white postm enopausal women, aged 50-65 years, Cauley and co-workers (1987), reported work, leisure and sport indices o f respectively 2.7,3.1 and 2.2. T he household score o f the present study com pares favourably with the one reported by Cauley et al,(1987), but the leisure and sport indices o f the present study are m uch low er than the scores reported by them. Ligtenberg et al (1997) showed a mean physical activity score o f 8.7(5.2) in their study on the effects o f physical training on m etabolic control in 58 Dutch Type 2 DM patients with a mean age o f 64 including 38 fem ales. U nfortunately only the total question­ naire score was reported, but it is well above the total score obtained by the subjects in the present study. A d eclin e in physical activ ity is generally observed with ageing and the reduced energy expen diture, w ithout adjusted energy intake m ay lead to overweight. The class I obesity status and sedentary lifestyle o f this sam ple are risk factors for cardiovascular disease (Ligtenberg et al 1995), and they may also lead to c o m p licatio n s such as o ste o -a rth ritis o f the w eig h t-b e arin g joints (Voorrips et al, (1992). Overweight and obese people are less likely to engag e in physical activity, because excess body w eight may increase the difficulty o f physical activity and this m ay lead to functional lim itations (Blair et al, 1998). In a study to assess p hy­ sical activity behaviour and its corre­ lates ( i.e. physical activity know ledge, barriers and outcom e expectations) in 260 older adults with Type 2 DM, Hays and C lark (1999) found that individuals who were older, had ( 12 years o f edu­ cation and perceived their health as fair or poor w ere less likely to be physically active. They also showed that socio­ dem ographic variables have an im por­ tant influence on the odds o f being physically active. All the above mentioned factors are present in this study, such as the m ean age o f the subjects, the low level o f education and clinical data. The encouragem ent o f physical activity am ong these patients has becom e an im portant goal o f preventative medical practice. However, initiating and m ain­ taining a physically active lifestyle is a com plex health behaviour (Blair et al, 1998). Personal barriers to physical acti­ vity participation o f these subjects are unknown and should be investigated. U nderstanding the self-care behaviour o f patients with diabetes and responding to their needs with appropriate patient education requires som e know ledge o f their attitudes toward the disease and diabetes care (Anderson and Fitzgerald, 1993). Patients who report high levels o f adherence for diet and exercise and m onitoring reported higher levels o f understanding diabetes, had more posi­ tive attitudes toward diabetes and better overall health (Anderson & Fitzgerald, 1993). N in ety e ig h t p e rc e n t o f sub jects agreed that there is a need for special training o f health care p ro fessionals taking care o f d iab ete s p atients. (C ronbach’s alpha = 0.62, % Positive answers (Pos) = 98). This finding shows that patients w ant special expertise from th eir h ealth care p ro fessio n a ls. T he results o f the present study correlate with a large study by Anderson et al, (1990) consisting o f 65% fem ale sub­ jects with a m ean age o f 51 years. He reported a C ronbach alpha = 0.71 and % Pos= 99.7 The sam ple also agreed with the attitude that diabetes has a substan­ tial im pact on their lives, w hich suggests that diab ete s and its co m p licatio n s detract from the quality o f life for m ost patients. (C ronbach’s alpha = 0.41, % Pos = 67% ) . A nderson et al, (1990) reported a C ronb ach’s alpha o f 0.68 and 94% p o sitiv e answ ers. T his finding supports the study by W estaway et al, (1998) that health status and quality o f life are poorer for diabetic patients than for well persons in a sim ilar sam ple from M am elodi. P earson pro duct- m om ent correlation between sub-scales showed that the need for special training correlated strongly with the psychoso­ cial im pact o f the disease (r = 0.41). 2 6 SA J o u r n a l o f Physiotherapy 2001 V o l 57 No 3 R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. ) A nderson et al, (1990) found this to be 0.35. The neutral and negative responses to sub-scales 2, 3 and 5 are in contrast to results by A nderson, who reported posi­ tive responses to all three o f the m en­ tioned sub-scales. This finding suggests that the patients did not understand all the q uestions. A lth o u g h the rev ised Diabetes A ttitude Scale was rew ritten to elim inate technical term s and the read­ ing level was lowered from the 12th to the 10th grade, it is clear that som e o f the co n cep ts w ere unkno w n to the patients, for instance “tight control” . O ne possible explanation may be the average low educational level o f the sam ple. D espite the fact that the second interview er received sim ilar training to the first interviewer, the use o f two inter­ viewers m ay have influenced the results. The process o f translation o f the m ea­ suring instrum ents into the idiom o f the com m u nity was a lim itation o f this study. A lthough the process described by A nderson et al, (1990) was followed, the free translation o f the questionnaires may have resulted in altering the m ean­ ing o f certain items. It is suggested that in addition to the translation process that w as fo llo w ed in the p re sen t study, the translated instrum ents should be reviewed by diabetes educators, speaking the local languages to clarify am biguous w ords or terms. The instrum ent should then be pilot-tested with a sam ple of diabetic patients, and the understanding o f each item o f the instrum ent should be discussed with those patients. This may ensure that the patient’s understanding o f the term s used m atches the investi­ g a to r’s definition. CONCLUSION Several risk factors for the control o f diabetes w ere identified in this sample o f urb an, b lack fem ale patien ts in M am elodi. They are older patients who have a low educational level. The patients have poor know ledge o f their disease and are not physically active. D iabetes health education program m es are needed to im prove the know ledge of the patients. 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