Main findings of study and comparison with previous literature
This was the first study in Malaysia determining the distribution of type 2 diabetes patients who were willing to accept training to speak to their offspring to prevent diabetes and the factors associated with it. Our study shows that 61.6% were willing to accept training to speak to their offspring, a figure comparable to that (56%) from a previous study in Ireland . A subsequent study conducted by the same group of researchers comparing type 2 diabetes patients in Ireland and Bahrain showed that the proportion of patients willing to speak to their family members was significantly higher in Ireland compared to Bahrain (75% vs. 54%, p < 0.001) . These findings suggest that type 2 diabetes patients in these countries are willing to accept training if offered. This opportunity should be explored further and a training module for type 2 diabetes patients should be developed as a potential means of preventing diabetes in their offspring. At present, the evidence on effectiveness of this intervention is lacking. A randomised controlled trial is required to prove its value.
In the multivariate analysis, six variables were found to be significantly associated with the willingness of type 2 diabetes patients to accept training to speak to their offspring. These are i) having a family history of type 2 diabetes, ii) correctly identifying that overweight is a diabetes risk factor, iii) correctly identifying age ³ 40 years old as a diabetes risk factor, iv) perceiving the benefit of speaking to offspring to help prevent the from developing diabetes, v) perceiving not having much contact with offspring as a barrier and vi) perceiving their offspring to not being open to advice from them as a barrier.
Type 2 diabetes patients who have a positive family history were twice as likely to be willing to accept training compared to those who did not have a family history [Adj. OR 2.06 (95% CI: 1.27, 3.35)]. Direct comparison to other studies is not possible as no data was presented in the same manner. Our finding is unique and highlights the importance of targeting those with a strong family history of diabetes in our population in terms of training them to speak to their offspring to prevent diabetes.
With regards to knowledge of risk factors, participants who had the correct knowledge that being overweight [Adj. OR 1.49 (95%CI: 1.01, 2.29)] and age ³ 40 years old [Adj. OR 1.88 (95%CI: 1.22, 2.90)] are risk factors for type 2 diabetes were more likely to be willing to accept training compared to those who did not know. Again, direct comparison to other studies is not possible as no data was presented in similar manner. Our study shows that enhancing knowledge of type 2 diabetes risk factors among patients would potentially improve their willingness to accept training for diabetes prevention in their offspring.
In terms of perceived susceptibility, our multivariate analysis did not reveal that these items were significantly associated with willingness to accept training. Direct comparison with other studies was not possible as no data was presented in a similar presentation. However, Whitford et. al. found that Irish type 2 diabetes patients who worried about their children developing diabetes were more likely to speak to their family members about their risk of diabetes [OR 4.37 (95% CI: 1.75, 10.92)] .
Regarding perceived benefits, patients who agreed that speaking to their offspring would help them to prevent type 2 diabetes, were four times more likely to be willing to accept training compared to those who disagreed [Adj. OR 4.34 (95%: 1.07, 17.73)]. This is consistent with the study by Whitford et. al. which showed that patients who exhibited an increased appreciation of the benefits of speaking to their offspring were more likely to have engaged in preventive behaviours . Perceived benefit is reflected as the individual’s estimate of a likelihood that a given action will achieve a specific goal . However, in the context of preventing diabetes, the challenge would be to educate those who do not appreciate the importance of speaking to their offspring.
In terms of perceived barriers, patients who were neutral with the statements ‘I do not have much contact with my offspring’ [Adj. OR: 0.31 (95% CI: 0.12, 0.810] and ‘my offspring are not open to advice from me’ [Adj. OR: 0.63 (95% CI: 0.31, 0.84], were more likely to be willing to accept training compared to those who agreed with the negative statements. This is comparable to a study by Becker et. al. which found that ‘perceived barriers’ construct of the HBM to be the most powerful construct across various preventive health study designs and behaviour . However, our findings are unique as patients who were neutral with the statements on communication with their offspring are more likely to be willing to accept training.
Our study therefore suggests that emphasizing HBM parameters when consulting type 2 diabetes patients in the clinical setting may lead to an increased willingness to accept training to initiate discussion with their offspring.
Strengths and limitations of the study
The main strength of this study is the novelty of its findings in demonstrating the willingness of type 2 diabetes patients to accept training to speak to their offspring and the factors associated with it. Another strength is the utilisation of the DMOQ Malay version which is a valid and reliable tool to assess the perceptions of type 2 diabetes patients towards their offspring’s risk of developing type 2 diabetes and the possibility of prevention based on the HBM. One of the study limitations was that the DMOQ Malay version could only be administered to participants who were able to read and understand the Malay language. As a result of this, a majority of patients who were included in this study were of the Malay ethnic group. Thus, findings of this study would only be generalisable to the type 2 diabetes patients who could read and understand the Malay language. Another limitation was the use of non-probability sampling method which could be vulnerable to sampling bias. However, efforts were made to invite all patients with type 2 diabetes in the waiting area of both clinics to participate in this study during the data collection period. The results from this study revealed a high percentage of Malay type 2 diabetes patients (87.8%). Thus the findings may not be generalisable to the Malaysian population which currently consists of Bumiputra including Malay (69.3%), Chinese (22.8%), Indian (6.9%) and other ethnicities (1%) .
Implications for clinical practice and future research
Findings from this study suggest that type 2 diabetes patients in Malaysia are willing to accept training if offered. A training module should be developed to train type 2 diabetes patients to speak to their offspring as a potential means of preventing diabetes. Due to the potential of social influence within families as shown in this study, interventions should be designed with the goals to enhance knowledge, attitude and skills of type 2 diabetes patients to become family health educators and model healthy behaviours. It should also facilitate intra-familial communication about risk-reducing behaviours. The module should include i) strengthening knowledge on diabetes risk factors, ii) improving attitude and perception towards the benefit of speaking to offspring to help prevent them from developing diabetes and iii) enhancing communication skills to speak to their offspring. Further research should involve other primary care clinics in Malaysia with multi-ethnic background to ensure generalisability of the findings to the Malaysian population. There is also a need for further research to explore the views of perceived diabetes risk in the offspring of type 2 diabetes patients and their willingness to engage in preventive lifestyle behaviour. Future research should include a pragmatic randomised controlled trial to evaluate the effectiveness of the training module