Authors
Dr Mohammad Arif Shahar
Dr Mohd Faiz Md Tahir
First published: 5 August 2020
Last updated: 29 September 2022
Framework:
Objectives:
- To reflect on why humans adopt to certain behaviours
- To put forth an improved hypothesis based on the Knowledge, Attitude and Practice model
- To use ‘health seeking behaviour’ and ‘religious perspective’ as models to demonstrate the 2nd objective above
Key points:
Interesting observations about the KAP model:
- Negative K,A and P seem to be parallel to each other.
- While negative KAP notions tend to be consistent; positive K fluctuates between good and poor A and P.
Insight is the missing link between knowledge and attitude, practice. It is the determinant of attitude and practice that follows good knowledge
Our ‘Laws of Insight’ explains human behaviour towards change and adherence to a particular attitude and practice. It states that: In an environment where external factors are non-obstructive,
- Knowledge is a prerequisite of insight
- Attitude and practice are consequence of insight
- Good insight leads to positive and consistent attitude and practice (i.e. steadfastness)
- Poor insight is a risk for negative and/or inconsistent attitude and practice
In the religious sense, knowledge can be acquired; but insight is bestowed by God. Insight is closely related to guidance (huda) and He alone changes people heart.
Brief Explanation:
Introduction
Have you ever wondered why people act in a certain way; sometimes opposing what they already know?
This article hopes to answer the question as to why people behave in a certain manner. Why they adopt a certain behaviour? What are the factors that influence their choices?
We explore the Knowledge, Attitude and Practice model; while attempting to provide a rational answer for the issues at hand. Although our arguments are based on observations and may be considered as circumstantial, we hope to spark interest in the study of humanity and further the science of human behaviour.
We looked at the mysteries of human behaviour based on the KAP model through two perspectives: in ‘health seeking behaviour among diabetes patients’ and in ‘the religious sense’.
Model 1:
Why do some diabetes patients continue to indulge in behaviours that is not helping their medical condition?
Interesting observations about the KAP model in adherence to medical treatment and health seeking behaviour among patients with type 2 Diabetes Mellitus
Patients’ non-adherence to medications and therapeutic lifestyle changes has made us wonder: What were they thinking? What makes adherence, especially to lifestyle modification and medication so difficult?
This is where measuring Knowledge, Attitude and Practice (KAP) is useful. KAP studies was first used in the 1950s in the field of family planning and population. It has gained popularity over the years because of its simplicity.[1] It measures quantitatively the patients’ knowledge on the subject, their attitude towards the subject and their practice. By using a KAP study, we can explore the relationship between patients’ knowledge and his/her attitude towards management of type 2 diabetes mellitus; and subsequently attempt to demonstrate whether his/her practices are reflective of their knowledge and attitude.
Various KAP questionnaires has been developed for local use in Malaysia. Many have attempted to measure knowledge, attitude and practice in diabetic population.[2] For example, Dr Lai and team developed a diabetes, hypertension and dyslipidemia knowledge questionnaire as an assessment tool for patients’ understanding.[3] Similar effort has also been done not only for the urban population, but also for the indigenous population of Malaysia.[4]
In terms of findings, a KAP study – among 100 diabetic patients visiting a diabetes care unit – done in Pakistan demonstrated that the overall knowledge regarding diabetes was poor (54% of them had poor knowledge on diabetes, 67% of the patients did not practice regular exercise and more than 50% of had wrong dietary habits.[5] Many studies concluded that the poor KAP results of diabetic patients are probably due to several factors; which includes inadequate information, non-availability of educational material and improper guidance.[6] This is not surprising at all (i.e. poor diabetic knowledge leads to poor diabetic outcome). Results with regard to negative K,A and P seem to be parallel to each other.
On the other hand…
Knowledge, attitude and practice alone does not correlate with better diabetic control. A study reported a strong association between K and A; as well as K and P (P<0.05), however good KAP score did not correlate with blood glucose control.[9] Similarly, we found that majority of patient with poorly controlled Diabetes (median HbA1C of 9.5%) thinks that their diabetes was excellent or at least moderately under control. Less than 13% of patients perceived correctly that their diabetes is of poor control.[10] This study was conducted in Kuantan, a town in East Coast of Malaysia, where we work.
We concluded from available studies that poor diabetes knowledge (K) results in negative attitude (A), poor practice (P) and outcome. However good diabetes knowledge may not necessarily translates into positive attitude, good practice and outcome. Some proportion of those with good knowledge persisted on negative attitude, poor practice and thus negative outcome. While negative KAP notions tend to be consistent; positive K fluctuates between good and poor A and P. Therefore, we postulate that there were missing components that determine positive attitude, good practice and good outcome – more than knowledge alone.
So, what is the missing component that diverts good knowledge towards poor attitude, practice and outcome?
In 2013, we studied another factor, which we called ‘Perception‘, alongside KAP. We found that ‘Perception’ correlates well with outcome (i.e. correct perception was associated with good outcome, wrong perception was associated with negative outcome). Those with good outcome has higher K, A and P scores (Figure 2 and 3).[11]
Similar with our findings, studies done in the Europe and UK have consistently shown that patients with diabetes have poor ‘Perception’ and understanding of their glycaemic control, which subsequently translates into increased diabetes-related complications.[12]
Therefore we figured that ‘Perception’ could be the missing link between K and AP.
After much debate, we believed that ‘Perception’ is merely a window into something more important in determining a person’s behaviour, namely ‘insight’ (i.e. ‘perception’ is the manifestation of ‘insight’). We hypothesized that good insight translates into correct perception and poor insight translates into wrong perception. Thus the actual missing link between K and AP is Insight (Figure 4).
Insight: the missing link
Apart from health literacy (i.e. knowledge), we postulate that insight may be one of the factors that influences patient attitude towards therapy and self-care behaviour. In psychiatry, insight is defined as the patient’s awareness and understanding of the origins and meaning of his attitudes, feelings, behaviour and that of abnormal symptoms experienced. Briefly, insight is defined as acknowledging owns condition. In mental illness, insight is graded into 3 levels; (1) complete denial of illness, (2) slight awareness of being sick and needing help and denying it at the same time, and (3) awareness of being sick but blaming it on others, on external events. (Geider M, Gath D, 1983)
Insight plays a major role in the overall treatment adherence (Horne & Weinman, 2002). Theoretically, if healthcare professionals are able to assess insight of patients, increase the awareness and understanding of disease, patients are likely to adhere to therapy. Treatment adherence can be increased by several methods. These include educating the patient with regards to their illness, address misunderstandings and beliefs that are against the idea of the treatment prescribed and also enhancement of management that are patient friendly.[13] It is imperative that patient education and effective communication between the health care provider and patients becomes part of treatment adherence management.[14] And in order to achieve a high level of adherence to treatment, the patient’s insight with regards to his illness becomes a crucial component.
Those who have insight are considered wise. In Arabic, ‘hikmah’ (wisdom) is acting on knowledge. Someone is considered wise when he acts on the knowledge that he has. Being knowledgeable and being wise are two different things. A classical simple example is someone who knows that fire burns is considered knowledgeable. If he touches the fire despite knowing that is may burn him is considered unwise. Knowing that fire burns, and avoid touching it is wisdom; a manifestations of having ‘insight’.
Now consider a person who already knows about the harm of something but continues to do it. We can say that his action is unwise. He would be classified as a person having poor insight of the situation, wouldn’t he?
Before classifying him as having poor insight, we must first look at what we coined as the ‘Laws of Insight’.
Laws of Insight
Our ‘Laws of insight’ states that: In an environment where external factors are non-obstructive,
- Knowledge is a prerequisite of insight
- Attitude and practice are consequence of insight
- Good insight leads to positive and consistent attitude and practice (i.e. steadfastness)
- Poor insight is a risk for negative and/or inconsistent attitude and practice
The First Law of Insight: Knowledge is a Prerequisite for Insight
We cannot determine the insight of an individual on a particular subject unless the person is equipped with adequate knowledge. It is only fair that a substantial amount of information be given to a person; and it is a must that the person understands the information before we can determine whether the person’s insight is good or poor. In other words, a person cannot be deemed as having poor insight unless he has adequate knowledge about the subject matter.
Take patient X – who has diabetes for 7 years – and loves eating cakes, as an example. Patient X works as a doctor in a local hospital. We cannot say that he has poor insight if he is unaware that cakes are rich in carbohydrates; eating cakes causes blood sugar to rise. If he knows that particular fact, and still eats large amount of cakes without external compelling forces, we could very well conclude that he has poor insight with regards to his diabetes.
The Second Law of Insight: Attitude and practice are consequence of insight
Good insight would cause positive attitude and good practice, while poor insight would cause negative attitude and poor practice.
With all the knowledge that a person has, he may fall into poor attitude and practice because of poor insight. Knowing how cakes cause rise in blood sugar does not guarantee abstinence from consuming it. Rather having good insight along with the relevant knowledge facilitates correct attitude and practice.
Insight must come first before attitude and practice.
The Third Law of Insight: Good insight leads to positive and consistent attitude and practice
Not only that good insight leads to positive attitude and good practice, it will also lead to consistency in holding to that attitude and practice. In other words, ‘steadfastness’.
In various situations, if patient X has good insight, he would not be taking large amount of cakes regardless; whether in public or private, in the presence or absence of his treating physician.
Good insight determines adherence.
The Fourth Law of Insight: Poor insight is a risk for negative and/or inconsistent attitude and practice
On the contrary, poor insight is a risk for inconsistent attitude and practice, apart from causing the negative. Patient X would be controlling his diet in front of his doctor, however would be non-compliant whenever he is alone if he has poor insight.
In the medical sense, knowledge is the prerequisite for good insight, positive attitude and practice towards therapy.
As health care providers (HCPs), we should remove all external factors (as much as we can) which are obstructive such as non-availability of therapy, non-supportive social circumstances and financial difficulties, in order to facilitate and enhance positive attitude and practice towards treatment to manifest from the good insight.
The HCP’s role is to provide information and knowledge, and motivate, hoping to maintain patient’s good insight.
It occurred to us that the ‘insight’ issue applied to various situations in explaining human behaviour; not only for adherence to diabetes treatment. From health issues, financial aptness, political stance and demeanour, as well as religiosity. ‘Insight’ is the pivotal key to embracing change.
Hence, let’s look at the second model as follows.
Model 2:
Why some people have not accepted guidance despite knowing its truth?
The Religious Sense: Insight and Revelation
In the religious sense, knowledge and guidance is a prerequisite for good insight. This is where revealed knowledge and guidance from God comes into play.
In Islam, although knowledge come from a single source (i.e. from God), there are two types of readily identifiable knowledge. The (1) Revealed knowledge and (2) acquired knowledge. Revealed knowledge are divine revelation given to humankind through the angel Gabriel. These include the Quran, the Injiil (Gospels) of Jesus Christ, the Taurat (Old Testament) of Moses and the Zaboor (Psalms) of David. Muslims are obliged to accept these books as revelation from God. On the other hand, acquired knowledge are information gathered through human experiences, experiments and observations in science.
Now, consider ‘good knowledge’ in Islam is defined as understanding the Revelation (i.e. Quran) and the message of Islam. Without insight, people may have negative attitude towards Revelation and unwanted (poor) practice (i.e. rejecting Islam). Apart from the contribution of good knowledge (understanding) towards ‘insight’, guidance also play a huge role.
Now, consider these historical examples:
Abu Hakam ‘Amr Ibn Hisham, known as Abu Jahl among Muslims did not accept Islam. In fact, he declared war against Islam. He died during the battle of Badr (624 AD) which occurs 2 years after the Prophet’s migration (Hijra) to Madina.
Abu Jahl had good knowledge with regards to the Revelation (i.e. the Quran). The Quran was read unto him; and he understood the language. However he has poor insight. In his case the poor insight manifested as miss-prioritization between losing political power and submission to God. There were no external factor that could have prevented him from having a positive attitude (accepting Islam) and good practice (struggling alongside the Prophet) because he was among the rulers of Mecca. In his case, good knowledge did not result in positive attitude and good/wanted outcome because his insight of the situation was poor.
Unlike Abu Sufyan ibn Harb who fought against the Prophet in the early years of Islam, he later accepted Islam in the 7th year after migration (Hijra). His insight actually improved from ‘poor’ to better. In his case, he had good knowledge about the revelation; poor insight earlier but later developed better insight; and it manifested as a positive attitude towards revelation and good practice (accepting Islam) later.
In the case of Ammar Ibn Yassir who was being forced to say disbelief (Kufr). Ammar was among the earliest follower of the Prophet Muhammad. He has good knowledge, good insight but was being tortured (i.e. there was external obstructive force) which has resulted in inconsistent attitude and practice (i.e. uttering disbelief). He was a true Muslim; rather he was coerced -forced, rather – to utter blasphemy in front of his assailant.
The KIAP model
Having realized the importance of insight in explaining the relationship between knowledge, attitude and practice. We propose the KIAP model (Figure 5); where insight in the missing link which explains attitude and practice that are inconsistent with good knowledge.
We would not be bringing anything new to the Knowledge, Attitude and Practice model, unless we are able to measure insight.
Insight assessment tools has been created for conditions which require behavioural changes such as obesity. The obesity Awareness and Insight Scale (OASIS) was designed to look at the awareness of obesity among individuals.[15] However, the use of OASIS in obesity management has not been documented. To date there are no studies specifically looking into insight of patients with diabetes and how impaired insight influences their sugar control.
We have designed a tool for assessing insight for patients with diabetes. Research on its validation is still in progress. For the levels of insight among patients with diabetes, we proposed the following categorization:
| Level | Definition |
| Level 1a: | Acknowledge high blood sugar readings/indices as indication of diabetes |
| Level 1b: | Attribute diabetes symptoms to concurrent high blood sugar |
| Level 2: | Acknowledge that treatment is warranted for high blood sugar |
| Level 3: | Attribute the reduction of blood sugar and/or resolution of symptoms to treatment prescribed |
Good insight is diagnosed when patients are able to achieve level 3.
Conclusions
Despite these current limitations, we are attempting to redesign the landscape on how HCPs have been approaching poor compliance and adherence amongst patients, especially those inflicted with chronic illnesses. İt’s not a one way street anymore where patient takes the large load of blame. By understanding the KIAP model proposed, it is hoped that both parties, patient and HCPs, would be able to work together with the sole objective, to live healthily as optimal as possible.
And for the more religious individuals- regardless of role, it is just another way to pave the road to Paradise by being steadfast in calling people to goodness without giving up when faced with resistance.
We implore researchers and scientists to study these notions.
Finally, perhaps one of the crucial questions to ask ourselves is, “Why have we not change?” – As a person, as a community, an institution or as a nation –
“Between K, I, A and P… Which is missing?”
End notes
[1] Launiala (2009) How much can a KAP survey tell us about people’s knowledge, attitudes and practices? Some observations from medical anthropology research on malaria in pregnancy in Malawi. Anthropology Matters Journal. Vol 11 (1)
[2] Yun, L.S., Hassan, Y., Aziz, N.A., Awaisu, A. & Ghazali, R. (2007) A comparison of knowledge of diabetes mellitus between patients with diabetes and healthy adults: a survey from north Malaysia. Patient Educ Couns 69, 47-54
[3]Lai, P.S., Chua, S.S., Tan, C.H. & Chan, S.P. (2012) Validation of the diabetes, hypertension and hyperlipidemia (DHL) knowledge instrument in Malaysia. BMC Med Res Methodol 12, 18
[4] Ahmad, B., Ramadas, A. & Quek, K.F. (2010). The development and validation of diabetes knowledge questionnaire for the Indigenous population in Malaysia. Med J Malaysia 65, 273-276
[5] Badruddin, N., Basit, A., Hydrie, M.Z.I. & Hakeem, R. (2002) Knowledge, Attitude and Practices of Patients Visiting a Diabetes Care Unit. Pakistan Journal of Nutrition 1, 99-103
[6] Upadhyay, D., Palaian, S., Shankar, R. & MIshra, P. (2008) Knowledge, Attitude and Practice about Diabetes among Diabetes Patients in Western Nepal. Rawal Med J 33, 8-11
Miloradović, D., et al. (2009) Knowledge, Attitude And Behaviour Towards Own Disease Among Patients With Type 2 Diabetes. Acta Fac Med Naiss 26, 195-201
Badruddin, N., Basit, A., Hydrie, M.Z.I. & Hakeem, R. (2002). Knowledge, Attitude and Practices of Patients Visiting a Diabetes Care Unit. Pakistan Journal of Nutrition 1, 99-103.
[7] Ng, S.H., et al. (2012) Reality vs Illusion: Knowledge, Attitude and Practice among Diabetic Patients. International Journal of Collaborative Research on Internal Medicine & Public Health 4, 723-732
[8] Saadia, Z., Rushdi, S., Alsheha, M., Saeed, H. & Rajab, M. (2010) A Study Of Knowledge Attitude And Practices Of Saudi Women Towards Diabetes Mellitus. A (KAP) Study In Al-Qassim Region. The Internet Journal of Health 11
[9] Ng, S.H., et al. (2012) Reality vs Illusion: Knowledge, Attitude and Practice among Diabetic Patients. International Journal of Collaborative Research on Internal Medicine & Public Health 4, 723-732
[10] Shahar, M. A., Md Tahir, M. F., & Marzuki, O. A. (2017). Perception of Diabetes Control Among Patients with Poor Glycated Hemoglobin. International Medical Journal Malaysia, 16(1), 37.
[11] Shahar, Mohammad Arif and Anwardeen, Azmad Kareem and Jalunis, Mohamad Mustakim and Mohammad Isa, Muhammad Syafiq and Omar, Ahmad Marzuki and Kamaruddin, Nor Azmi (2013) How well have we been educating our patients? Patients’ perception of control and knowledge, attitude and practice of their diabetes mellitus management. In: Malaysian Endocrine and Metabolic Society Annual Congress 2013, 23 – 26 May 2013, Pullman Putrajaya Lakeside, Putrajaya.
[12] Beard, E., Clark, M., Hurel, S., & Cooke, D. (2010). Do people with diabetes understand their clinical marker of long-term glycemic control (HbA1c levels) and does this predict diabetes self-care behaviours and HbA1c? Patient Education and Counseling, 80(2), 227–232. https://doi.org/10.1016/j.pec.2009.11.008
[13] Morisky, D. E., Ang, A., Krousel-Wood, M., & Ward, H. J. (2008). Predictive Validity of a Medication Adherence Measure in an Outpatient Setting. The Journal of Clinical Hypertension, 10(5), 348-354. doi:10.1111/j.1751-7176.2008.07572.x
[14] Ibid.
[15] Gerretsen, P., Kim, J., Shah, P., Quilty, L., Balakumar, T., Caravaggio, F., … Graff-Guerrero, A. (2018). OASIS – Obesity Awareness and Insight Scale. Obesity Medicine. https://doi.org/10.1016/j.obmed.2018.02.001