2009

CHANGE IN LIFE-STYLE FOR A BETTER MANAGEMENT OF

Qualitative
DIABETES: Research Methods
Knowledge, Attitude and Practices of Diabetic
Patients ‘
In Ndop Health District, Cameroon.

By
ESENE IGNATIUS NGENE
 CHANGE IN LIFE-STYLE FOR A BETTER MANAGEMENT OF
DIABETES:

Knowledge, Attitude and Practice of Diabetic

Patients
In Ndop Health District, Cameroon.

By,

ESENE IGNATIUS NGENE, MD

 INTRODUCTION

Diabetes is an iceberg disease affecting vast populations worldwide. In contradiction with long-standing conventional
wisdom that it is a rich country's disease, diabetes mellitus, which is the most frequent form of diabetes is increasingly a
major concern in developing countries, especially in sub-Saharan Africa, Cameroon inclusive.Helath Care facilities have
not kept pace with the sharp increase in diabetes mellitus. World Health Organization has predicted a worldwide rise in
the prevalence of diabetes that is expected to affect 300 million people by 20251. This progression is more flagrant in
developing countries particularly in sub-Saharan Africa. In these countries, the expansion of diabetes is part of a broader
demographic, nutrition and epidemiologic transitions, from transmissible diseases to non-transmissible diseases. A
number of factors are causing this transition including aging of the population and change in lifestyle (sedentarity, obesity,
diet, alcohol consumption and smoking).2
Diabetes is one of the most common conditions seen in primary health care. The estimated prevalence of diabetes in Africa
is 1% in rural areas, up to 5% to 7% in urban sub-Saharan Africa.2
In Cameroon the prevalence of diabetes is 1‐9% and 0.5‐7% in urban and rural areas respectively and currently, the
population of Cameroon is predominantly rural (40% urban), but by 2025, more than 70% of the population will live in the
urban areas3,4.At the Ndop Health District covering a semi-urban population of about 250 000 inhabitants, no local
prevalence studies have been done but currently close to 100 diabetics are registered at the Diabetic Clinic 5 .An aging
population together with rapid urbanization will lead to an increase in the prevalence of diabetes such that by the year
2025, the prevalence of diabetes in Cameroon is expected to more than double the current figures 3 .
The global management of diabetic patients involves the use of drugs and the adoption of a better life style, the latter via
education. Since the mortality and morbidity related to diabetic complications poses great threat and burden to a nation’s
economy, educating the patient for the adoption of a healthy lifestyle is essential for prevention of complications 6, 7.
The most important challenge in the care of diabetic patients is to avoid or postpone several complications of the disease.
There is now clear evidence that an effective control of blood glucose and blood pressure significantly decreases the risk
of complications of diabetes8. There is also a growing body of evidence of effective interventions to improve the
management of diabetes such as patients' adherence to glucose monitoring, medication regime and adoption of healthy
lifestyle.
All patients if given proper guidance and education regarding diabetic care should be able to make significant
improvements in their life style which would be helpful in maintaining good glycaemic control. Patients’ lack of
understanding or attitude hinders proper guidance about disease. Even in developed countries it has been observed that
improper guidance and communication could lead to poor compliance 9. Education is likely to be effective if we know the
characteristics of the patients in terms of knowledge, their attitude and practices about diabetes10 .For the planning of
effective education programs identification of vulnerable groups and characteristics of the sufferers provides useful
information.11 In a developing country like Cameroon where literacy rate are low, the chances of improper guidance about
disease due to lack of understanding of patients characteristics (i.e. the personality and attitude of the patients) are high.
Since the inclusion of diabetes in the Cameroon National Health Strategic Plan, no studies have been done to explore
patients’ perception and behavior in relation to diabetes whereas the non-pharmacologic treatment (modification of
lifestyle) is an essential and complementary component in its global management. Thus our study will be conducted to
assess the general characteristics, knowledge, attitude and practices of diabetic patients attending the monthly diabetic
clinic at the district hospital in Ndop, Cameroon. This study will highlight the need for better health information for the
improvement of lifestyle for the diabetic patients through large scale awareness programmes so as to improve the
knowledge and encourage a positive attitude of our public regarding diabetes thus reducing the burden of the condition.

GOAL
 Reduce the morbidity, mortality and cost associated with the management of diabetes mellitus.

AIM

To assess the demographic profile and investigate their knowledge, attitude and practices with regards lifestyle
modification for better glycaemic control of diabetic patients attending the Diabetic Clinic at the Ndop District Hospital
between January to June 2010.

OBJECTIVES

To explore current knowledge of the staff at the Diabetic Clinic at the Ndop District Hospital(i.e. a measure of what they
are supposed to know and whether it is being delivered according to recommended the guidelines);
• To describe the distribution of the study population with respect to socio-demographic background;
• To assess the knowledge of patients on diabetes in general (signs and symptoms and complications) and its management
[life-style modification: assessing what they are supposed to do and how they are doing it];
• To investigate the attitudes and beliefs of patients with regards to modification of lifestyle for better management of
diabetes (i.e. a measure of their attitude in complying to the prescribed life-style modification tasks);
• To understand the health seeking behaviour and assess the current practices of diabetes patients (i.e. performance
measures of the important life-style tasks diabetics are supposed to do to manage their condition);
• To find out the correlation between knowledge, attitude and practice of diabetics with regards to lifestyle modification.
 To contribute ideas and options for policy makers to enhance better health information for the improvement of lifestyle in
the diabetic patients.

METHOD AND METHODOLOGY

The Knowledge, Attitude and Practices (KAP) of diabetic patients attending the Monthly Diabetic Clinic at the Ndop
District hospital between the 1st January 2010 and 30th June 2010 will be explored using a qualitative approach by the
researchers. Unlike quantitative studies, our qualitative study on lifestyle modification for a better management of diabetes
mellitus will have the scope to explore different views and to identify and address issues on the perception and behaviour
of diabetic patients. The methods used in this study will reflect this qualitative outlook, and we will use focus group
discussions (FGDs) and semi structured interviews to explore these issues.

Study Design
Qualitative research method using an in-depth semi structured interviews and focus group discussions.

Study Site (Setting)

Diabetic Clinic Unit of the Ndop District hospital, Cameroon.

Study Population
 • sample size
Sampling will be purposive and will involve all patients identified to be attending the Diabetic Clinic and staff of the
treatment unit.
• inclusion criteria
All diabetes patients in Ndop Health District willing to participate in the study as well as staff of the Diabetic Unit.
• exclusion criteria
Refusal to join the study

Methodology
Sampling will be purposive and will involve diabetic patients and staff at the diabetic clinic.A research planning
framework will be developed before fieldwork so that possible issues can be identified which will assist in the
development of interview and focus group discussion themes. Secondary data will be sought for. The current protocol on
the management of diabetes in Cameroon will be used and recommendations in the guideline will serve as a standard to
which patients’ knowledge, attitude and practices will be referred to.
The research will be explained to all the participants, and informed consent in their local language and in English/French
for their participation will be sought for before any procedure will occur. Confidentiality will be discussed and all
participants will know that tapes used will be destroyed after transcription, and transcription data, whether on paper or
electronic, will the stored safely and locked away when not in use. Information obtained will only circulate within
members of the research teams. Participants will also know that names will not be recorded or used in the transcriptions.
The taped and transcribed focus groups and interviews will be coded thematically.

1. Focus Group Discussions

The qualitative method of focus groups is an effective means for examining issues relevant to the primary care setting in
general and specifically diabetes care.12,13,14,15 .In this study, FGDs will be conducted with diabetic patients attending the
diabetes clinic at the Ndop District hospital.
Our study will be seeking to understand the diabetic patients’ perception and behaviour vis-à-vis lifestyle changes
prescribed to complement the pharmacologic treatment of diabetes as well as knowledge and diabetic care delivery by
staff of the diabetic unit. FGDs facilitate the expression of criticism and the exploration of different types of solutions and
are thus invaluable as the aim of this research is to improve on patients’ treatment. FGDs are applicable to this study as
they will be held among groups that share similar characteristics i.e. Diabetics residing in Ndop, and attending the clinic
at the Ndop District Hospital (the only health unit delivering such services within the entire health district).
Furthermore, FGDs will therefore be chosen in this study because they will generate data by capitalizing on
communication between research participants (diabetics). By encouraging participants to talk to one another about the
topic will allow exploration of people’s knowledge and experience not forgetting its cost effectiveness.16
FGDs will be held in an environment that is comfortable for the participants (hospital conference rooms), and will be
made up of 6 to8 people of sharing similar characteristics. Diabetics attending the clinic at the district hospital have
common characteristics of community status, levels of education, habits and lifestyles. FGDs do not require that people
are literate, and so will be particularly applicable to our study population, as illiteracy which is a factor for poor
compliance to diabetic treatment could have otherwise affected our study since our study population is mixed literacy-
wise.17 FGDs will therefore provide a safe, comfortable environment for people to explore their attitudes, provide an
opportunity for participants to share ideas and trigger off suggestions via interaction. Where appropriate, participatory
research methods will be used as part of these FGDs, particularly problem trees and ranking of the issues raised, and body
mapping where relevant, all of which will assist the participants and the researchers to elucidate the issues and to
document any suggestions made by the participants that will address these issues.
FGDs will be held among diabetics attending clinic at the district hospital to explore the participants’ knowledge on the
management of diabetes and will be composed of 6 to 8 diabetes patients an appropriate number to identify a variety of
views without losing group cohesion.However,the number of participants will be adjusted with respect to on-the-field
situation. Little or no stigmatization is associated with diabetes so assembling patients wouldn’t pose be difficult. Patients
are usually reminded of their meeting days via the local community radio and other communication channels which we
will exploit to the advantage of our study too.

2. Interviews
• In this study there will be both key informant and semi-structured interviews. The main informants will be the
Coordinator of the Diabetic Unit and the District Health Officer, Ndop Health District. This interview will explore the
current guidelines and protocols for the management of diabetes in Cameroon, the interviewees’ perception of barriers
faced by diabetics in following the protocol and future strategies and plans for the improvement of the management of
diabetes in Cameroon.
• Semi-structured interviews will be conducted with diabetics, and staff of the diabetic clinic. Interviews provide an
opportunity for private conversation to explore the issues in-depth, and can generate data which can then be further
clarified and explained.
• An assessment of the knowledge of the staff of the diabetic clinic will be primordial as they are the care givers and the
correctness of knowledge transmitted to the patients will depend on their know-how. Also their involvement in the
study will be of utmost importance as they are the ones who deal with patients’ daily problems.

PROCEDURE
The study will be carried out at the Ndop District Hospital, under the supervision of the ministry of health, Cameroon. I
will be the principal researcher, and I will be helped by two research assistants who are fluent in the local language. The
research assistants will be made familiar with current protocols and recommendations for the management of diabetes in
Cameroon as well as with FGD and interview techniques. Any issues about these will be addressed before field research
starts and any questions about the topic or procedure that the research assistants do not understand will be discussed as
they arise. I will carry out familiarisation at the beginning of the field research, before any interviews or FGDs occur. One
of the research assistant will serve as the translator should need be, and will translate data exactly, without modification.
The research assistant will also be advised about the importance of confidentiality in all aspects of this research.
A semi-structured interview guide will begin with questions on current patients’ attitude and practices and included
specific probes to stimulate discussion about the various barriers to and facilitators of the use of standard recommended
lifestyle guidelines.
This study will present some limitations stemming from the fact that it will be conducted only among the patients
attending the clinic. However, since the study will involve all the patients attending the diabetic clinic at the district
hospital (the clinic covers the whole health district) credibility could be ascertained and transferability to a greater extend
as only a small proportion of patients residing in the health district seek for health care elsewhere.
The strength of our study will be based on the fact that it will involve both patients and health care providers so that after
controlling for KAP gaps attributable to care delivery, we will be able to explore and discern differences arising from
patients perceptions and behaviours.

DATA COLLECTION AND ANALYSIS

Data collection:
Data collection will be by audiotape recorders for the interview and FGDs. One of the research assistant will act as the
moderator in FGDs held in the local language and I will act as recorder and the other assistant the observer, and vice versa
if the FGD is held in English or French. In the interviews I will be the principal interviewer if the interviewee speaks
English/French comfortably, and either of the research assistants will be the principal interviewer if the interviewee does
not.
Analysis 18,19
All FGDs audio taped will be transcribed verbatim. The transcribed data will be translated if necessary, and analysis will
start as soon as possible after the data are collected, so that any concepts generated will be incorporated into further
interviews and FGDs as part of the iterative, inductive process associated with qualitative research. The Framework
analysis will be used to ensure logical, rigorous use of the data generated in the fieldwork. After each FGD, we
(investigators) will compare field notes and discuss the group process. Strategies of constant comparison analysis will be
used were each of the investigators will be allowed to independently examine the transcribed and translated scripts to
identify key words, phrases and concepts emerging in each group. Content analysis will then begin after data scrutiny and
the data sorted under headings and subheadings.
Similarities and potential connections among key words, phrases and concepts within and among each of the focus groups
will be determined by team analysis. This will lead to clarification, confirmation and consensus of the central themes
emerging in all the focus groups. Another stage of the analysis will involve comparing the central themes identified across
all the focus groups. This will enable the identification of relationships or patterns between and among the central themes
and also served to condense the data and to identify phrases that most accurately illustrated the themes to enhance coding.
A thematic conceptual framework will be developed from this, using Computer Assisted Qualitative Data Analysis (QDA)
software together with manual techniques to index the data. Thematic charts will be created to reduce and organise the
data, one chart for each theme that emerges, and patterns within the data will be sought. The data will then be interpreted
to show if participants’ characteristics are associated with any particular perceptions or beliefs, or if any perceptions are
held by more than one group of participants. Triangulation between the data generated from different groups as well as
from both methods of research will be sought to ensure the trustworthiness of the data.

TIME FRAME

The study will run through from January to June 2010.

WORKPLAN
 January February March April May June July
TASKS

Preparation
Literature Search
Writing of Proposal
Preparation and Submission of Ethics application
to Cameroon Ethical Committee
Search for secondary data
Field Work
Interview with District Health Officer
Training of Research Assistance
Interviews and Focus Group Discussions
Presentation of data at District Level
WRITE UP
Translation and Transcription
Analysis
Submission to Ministry of Health Cameroon

This research will take place in 2010. Preparatory work will be done from January to March, and will include a literature
search on the subject, the development of a planning framework, and sourcing of secondary data, which will be from the
Cameroon national statistical data base service, and the internet. Consent for the research will be sought for from the
ethics committees of the Cameroon Medical Ethical Committee.
Fieldwork at the Ndop district hospital will be done in a three months from April to June 2009. The key informants will be
interviewed, and training of the research assistants will take place in the first two weeks. The following 6 weeks will be
dedicated to data collection, and in the last month presentation of the data will be made to informants and staff of the
diabetic clinic. Translation, transcription and analysis of the data will start as soon as the fieldwork starts, and will
continue after the end of the fieldwork until the research is fully completed and the results fully described and submitted to
Ministry of health Cameroon.

TRUSTWORTHINESS20
Trustworthiness of the data will be ensured by the rigorous application of trustworthiness techniques by the researchers.
Credibility, transferability, dependability and confirmability will be considered to ensure rigor without sacrificing the
relevance of qualitative research.
At the start of any interviews or FGDs, local terminology relating diabetes will be explained so that participants will be
able to have a clear understanding of the research, and so that the researchers will not miss or misinterpret data because of
the lack of use of some words or misunderstanding of word meanings. If necessary, the data will be translated and the
translation will be checked by another translator translating it back into the local language and checking that this agrees
with the original data.
A diary will be kept during the fieldwork to record impressions, thoughts and explanations for ongoing decisions, which
will help explain the process when the analysis is being done, and to check if the analysis reflects the research process.
Participant checking will take place at the end of focus group discussions and interviews. This will involve making a
summary of the issues raised and checking that the participants agree with it using role play, and asking the participants to
rank the issues. The generated data will be checked for triangulation, between data from interviews and FGDs, between
different groups of participants, and between the researcher and the research assistants.
Credibility will be enhanced by periodical peer examination before the final analysis. The process of reflexivity will be
used to explore how the researcher may have influenced the data, through personal bias or assumptions, and also to look at
how the principal investigator as a medic, may have positively or negatively influenced the responses given by
participants. However, throughout the process, the researchers will attend to personal and professional biases that
potentially could influence their interpretation of the data.
Transferability will be ensured by comparing our sample to other demographic data whereas triangulation and peer
examination will ensure dependability and confirmability through reflexivity and triangulation.
The process of analysis will be transparent and documented making it possible for anyone interested to be able to check
that the sampling was extensive, the analysis systematic, and that the interpretations emerge from the data.

CONSENT/ETHICAL CONSIDERATIONS

Ethical approval for this study will be sought from the Cameroon Medical Ethics Committee who will be made to
understand the importance of the topic’s relevance at present and the contribution it will bring towards the global
management of diabetes in Cameroon. Any information about a participant which is revealed advertently or unwittingly in
the course of an interview or FGD will be treated with complete confidentiality. All participants will be assured that
participation or non participation in the research will not have any influence over their access to health care in the future.
All participants will be treated with respect and courtesy. All forms of transcribed data will be stored safely and locked
away when not in use. Any computer used will be password protected giving access only to researchers.
All participants will be asked for written, informed consent in their local language before participation, and by a third
party if feasible. The consent will include a description of the research and why the participant has been asked to take part,
and assurance that participation is voluntary. The participant will be able to refuse to answer a question or withdraw at any
time without consequences. The consent will also include a confirmation of confidentiality, a description of the expected
course of the interview or FGD, and any potential negative or positive consequence of participation.

REFERENCES
1. WHO. The world health report conquering suffering humanity. World Health Organization Geneva 1997.

2. Motala AA, Omar MA, Pirie FJ. Diabetes in Africa: epidemiology of type 1 and type 2 diabetes in Africa. J
Cardiovascular Risk. 2003; 10: 77–83.
3. Jean Claude MBANYA. Evidence-based policy development: the development of a National Diabetes
Control Programme in Cameroon* Presentation made at Forum 11, Beijing, People's Republic of China, 29
October - 2 November 2007.
4. Sobngwi E, Mauvais-Jarvis F, Vexiau P, Mbanya JC, Gautier JF. Diabetes in Africans, I: epidemiology
and Clinical specificities. Diabetes Metab. 2001; 27: 628–634.
5. Esene I.N.Epidemiologic Profile of Diseases at the Ndop health District.2007
6. Lantion-Ang L.C.Epidemiology of Diabetes in Western Pacific region, Diabetes Res.,Clinical Practice,50
suppl..2: S 29-34.
7. Lorenz R.A., J.W.Picort, S.J.Enns and S.L Hanson. Impact of Organizational Interventions on
the Delivery of patient Education in a Diabetes Clinic. Patient Edu.Couns. 1986; B: 115-23.
8. Khunti K, Ganguli S, Baker R, Lowy A. Features of primary care associated with variations in process and
outcome of care of people with diabetes. Brit Gen Practice 2001; 51: 356-360.

9. Nutrition Sub-Committee of the British Diabetic Association’s Medical Advisory Committee, 1982. “The
Role of Dietitian In The Management of Diabetes”. A Policy Statement by the British Diabetic Association.
Human Nutrition: Applied Nutrition, 36A: 395-400.

10. Mazzuca SA, Moorman NH, Wheeler ML, et al.The Diabetes Education Study: a controlled trial of the
effects of diabetes education. Diabetes Care1986; 9: 1-10.

11. Naeema Badruddin, Abdul Basit, M.Zafar Iqbal Hydrie and Rubina Hakeem . Knowledge, Attitude and
Practices of Patients Visiting a Diabetes Care Unit. Pakistan Journal of Nutrition Vol 1(2): 99-102, 2002.
12. Hunt LM, Pugh J, Valenzuela M. How patients adapt diabetes self-care recommendations in everyday life. J
Fam Pract 1998; 46: 207–215.

13. Maillet NA, D’Eramo MG, Spollett G. Using focus groups to characterize the health beliefs and practices of
black women with non-insulin-dependent diabetes. Diabetes Educ 1996; 22:39–46.

14. Crabtree BF, Miller WL, Aita VA et al. Primary care practice organization and preventive services delivery:
a qualitative analysis. J Fam Pract 1998; 46: 403–409.

15. Sullivan ED, Joseph DH. Struggling with behavior changes: a special case for clients with diabetes. Diabetes
Educ 1998; 24: 72–77.

16. Kitzinger J. Introducing focus groups. Br Med J 1995; 311: 299–302.

17. Waleed Sweileh, Ola Aker, & Saed Hamooz.Rate of Compliance among Patients with Diabetes Mellitus and
Hypertension. An-Najah Univ. J.Res.(N. Sc.),Vol. 19, 2005

18. Brown JB. The use of focus groups in clinical research. In Crabtree BF, Miller WL (eds). Doing Qualitative
Research. Thousand Oaks (CA): Sage Publications, 1999: 109–124.

19. Morgan DL. Successful Focus Groups: Advancing the State of the Art. Newbury Park (CA): Sage, 1993.
20. Krefting, L.. Rigor in qualitative research: The assessment of trustworthiness. The American Journal of
Occupational Therapy,1991; 45(3), 214-222.