Identify causal mechanisms for improved knowledge, attitude, practice and outcomes in an educational intervention


A majority of diabetes self-management programs have been shown to improve knowledge, attitude, practice, and health care outcomes. However, in the literature the underlying causal mechanisms for the improvement attributable to health education have not been explored, especially, how diabetes educational intervention may affect diabetes care outcomes. The purpose of the present study was to identify the causal mechanisms responsible for improved knowledge, attitude, practice and outcomes, so that educational interventions can be tailored efficiently and effectively to patients who are most likely to benefit from self-care management. The study used the knowledge, attitude, practice and outcome (KAP-O) framework. The specific purpose of the study was to examine the causes of variation in the outcomes of glycated hemoglobin (A1C), low-density lipoprotein cholesterol (LDLC), functional capacity (FC), and poor perceived health (PPH). An experimental study with a randomized control trial design involving 141 participants was conducted. The experimental group (N = 87) and control group (N = 52) were comparable in terms of demographics and major diagnoses. The experimental group received diabetes education. The control and experimental groups received usual customary care. Knowledge, attitude, practice, functional capacity and poor perceived health were measured before and after intervention using reliable and valid instruments. The study used a tailored attitudinal instrument. Glycated hemoglobin (A1C) and low-density lipoprotein cholesterol (LDLC) were measured before and after intervention. Multiple analytic strategies were applied to examine the experimental data. The four outcome variables of (A1C), (LDLC), (FC), and (PPH) did not constitute one common factor measurement model for outcome evaluation. Results of the Independent sample t-test showed that health educational intervention directly improves knowledge about diabetes. The path analysis of panel regression showed that health educational intervention directly lowers glycated hemoglobin (A1C). The causal modeling of {(Exp_Status)-(K-T2)-(A-T2)-(P-T2)} model showed that health educational intervention also indirectly improves preventive practice via knowledge. The effect of attitude (A-T2) was greater than the effect of knowledge on preventive practice of self-care. The difference-in-differences analysis showed that difference in practice (DP) statistically significantly affects the difference in glycated hemoglobin (DA1C). The greater the preventive practice, the greater the lowering of glycated hemoglobin (A1C), indicating a better control of diabetes. The data from this experiment do not support a strong causal path of experimental effects on outcomes via knowledge, attitude, and practice of self-care. The study should be replicated using the KAP-O model in research based on multi-centers, multiple providers, and a diverse population of Type 2 diabetes patients. The study should assess outcomes more than four times over a period of one to two years to elicit the trajectory of change in outcome variables. Knowledge and attitude should be assessed at baseline and continuously improved for the duration of the study.


If this is your thesis or dissertation, and want to learn how to access it or for more information about readership statistics, contact us at

Graduation Date





Wan, Thomas T. H.


Doctor of Philosophy (Ph.D.)


College of Health and Public Affairs

Degree Program

Public Affairs; Public Administration








Release Date

December 2015

Length of Campus-only Access


Access Status

Doctoral Dissertation (Open Access)


Dissertations, Academic -- Health and Public Affairs; Health and Public Affairs -- Dissertations, Academic