Entered 15/10/03

PATIENTS' KNOWING-DOING GAP EXPOSED
Chan, Y. M. and Molassiotis, A.(1999) The Relationship Between Diabetes Knowledge And Compliance... Journal of Advanced Nursing; August 30:2 p431-439

Does knowledge acquisition equate to skill development ? Does a one-day training program produce automatically competent professionals ? Does intellect translate into action ? This study examined voluntary diabetic patients from Hong Kong. Could researchers find a positive correlation between quality of disease knowledge and quality of therapy-compliant behaviour ('compliance'). This study confirms a KM rule-of-thumb...knowledge is PERSONAL...become a quasi-psychologist !

30 % of Hong Kong's hospital admissions are due to poorly controlled diabetes. Diabetic patients are expected to follow a complex set of behavioural actions to care for themselves on a daily basis, such as following a meal plan and engaging in appropriate physical activity. Would better disease knowledge correlate with better compliance and disease control ?

A sample of 52 Chinese in Hong Kong with type II diabetes receiving out-patient diabetes care with diabetes education support participated in the study on a voluntary basis. In other words, this sample group had received high quality disease education in recent times. Disease knowledge levels were then assessed via a standard questionnaire. Compliance levels were assessed by using a self-reporting Compliance Behaviour Questionnaire, by inspecting patients' feet and by a health indicator value (HbA1c). Descriptive and correlational statistical analyses were used to analyse the data. Over half (67.3%) had been diagnosed with diabetes for ~5 years and 26.9% for ~1 year.

RESULTS

Patient Diabetes Knowledge

Above 80 % correct response from the questionnaire was considered acceptable knowledge. Only 19 % of patients achieved this level. Despite extended teaching provided to these patients most were still not knowledgeable enough about their disease.

'Only 19.2% of the patients were knowledgeable and no one was able to answer all questions correctly.'

More concerning was patients' low understanding of the causes of potentially fatal low blood sugar levels (hypoglycaemia) with only 25% of patients answered the question correctly.

'This implied that it was more difficult to improve patients' comprehension of the underlying principles of diabetes management and that would hinder their anticipation and prevention of avoidable negative consequences of diabetes.
(Dunn 1986).'

Patient Compliance

Although self-reporting feedback showed good compliance to all key areas of compliance, foot care examinations and the healthcare indicator results showed a different picture to compliance.

> Self - Reporting Questionnaire.

'Overall, about 94% of the subjects had achieved acceptable (self-rated) compliance.'

An example of the knowing-doing gap is the serious issue of preventing oneself from having hypoglycaemia. Despite 100 % of the diabetics knowing the procedure (carrying always with them sugar supplements), only 50 % declared they had done so. More demanding habits like exercise were achieved even less.

> Foot Care

Visual testing of the feet showed an unacceptable low compliance level.

'Only 63.5% of the patients received a pass mark in the inspection of the feet. A potential high-risk behaviour was discovered. The findings of the study indicated that the routine diabetes care did not provide effective education in appropriate foot care.'

> Health Indicator HbA1c

Many patients still had out-of-control diabetes which is a worrying sign.

'38% (of patients) had unsatisfactory metabolic control'

RESEARCHERS' DISCUSSION

The researchers were discouraged at the findings. Current education methods did not produce adequate cognitive understanding nor did it translate into real compliance for atleast a third of the participants. It was deduced that, from the negative correlations seen in the data, patients must have been scoring themselves much higher in the several key compliance areas than they really were doing.

'The findings showed that knowledge is no guarantee of behaviour change in diabetic patients. This is the infamous 'knowledge-action gap.'

'Based on the findings of the study, the present standardized diabetes educational programme failed to capitalize on the uniqueness of the individual because clients have different needs and abilities.'

Providing knowledge is only one step in the process of facilitating patient participation and compliance.

It is essential to understand the individual's belief and attitude, motives, demands and priorities in order to understand his/her compliance behaviour. It is suggested that effective diabetic teaching programmes should involve changes in the personal meaning of diabetes and in patients' attitudes and motivation to comply with the regimen.

It is also suggested that methodologies to enhance the patients' self-efficacy and confidence in self-care management should be incorporated. '

'The findings indicated that most of the patients did not have the skills of problem-solving, decision-making and action-taking. '

'The key to getting patients to change their habits is to make diabetes meaningful to them by first changing their attitudes before trying to change their behaviour.'

CONCLUSION

Seeing only neutral or negative correlations amongst the patient data led the researchers to clear conclusions. There was no association between the quality of knowledge given or memorised and the respective desired behaviours.

'The findings indicated that there was no association between diabetes knowledge and compliance. There was a gap between what the patients were taught and what they were actually doing. Most of the patients gained higher marks on factual knowledge on diabetes but lost marks on the application of knowledge to their real life situations.'

The researchers implicitly warn that mortality and morbidity from diabetes complications in Hong Kong will continue to skyrocket unless patient education methods are radically changed.

So even when you may have acquired good knowledge about your disease and its management you do not automatically translate it into skills, behaviours nor habits. Information availability and acquisition DOES NOT equate to new behavioural performance. Other determinants like motivation may be more crucial. 'Knowing-about' on its own does not seem to lead to changed behaviours.

Next....

1 | 2