What's missing in patient education?

The treatment of chronic or progressive retinal disorders such as diabetic retinopathy (DR) varies depending on the extent of the disease. In most cases the reasons for patients to lose vision is not due to an inability to treat their disease, but to a lack of awareness. Raising awareness about chronic or progressive eye diseases is an important element for both early diagnosis and treatment.

To control or prevent deterioration of vision, appropriate education is mandatory. This helps to encourage the patients at risk to enter treatment in time. To ensure success, developing educational materials that are regionally and culturally appropriate is required.

Knowledge-Attitude-Practice

Knowledge-attitude-practice is a method to collect information about what patients know, believe and do in relation to a topic. Knowledge is referred to as the community’s understanding of any topic. Attitude refers to their feelings toward the subject and preconceived ideas they may have toward it. Practice is the way they demonstrate knowledge and attitude through actions.

A study by Khalaf et al¹ has been conducted to determine the level of knowledge, attitude and reported practice, and to identify the impact of an educational programme on a diabetic population. An interview questionnaire was designed by the researchers after reviewing the related literature to assess the details regarding socio-demographic data, knowledge, attitude, reported practices and degree of adherence to antidiabetic medication. This was followed by an exhaustive educational programme, conducted in a diabetic clinic.

The teaching time was scheduled according to availability of the participant and the coordination between the researchers and participants. Teaching methods and materials were simple, such as lecture, picture, video and discussion. Media handouts regarding DR were prepared and distributed to every participant at the end of the programme. The contents of the programme were divided into sessions, including an introduction to diabetes, definition, signs and symptoms, risk factors, complications and prevention of DR.

The results were less than encouraging. In light of results of the study by Khalaf et al¹, 16.5% of the study group did not know the type of diabetes they had. Among those who knew, 20.5% had type 1 and 63% had type 2 diabetes. This finding was not in line with Giloyan et al.², who found that 62.9% of participants did not know the type of diabetes they were suffering from, while only 2.9% of them knew they had type 1, and 34.2% had type 2 diabetes. This discrepancy is probably related to the level of education of the study population and the level of awareness about diabetes.

About half the studied group was obese, with a body mass index of 31.3. These results were in agreement with Cheung and Wong³,who reported that many eye diseases such as cataract, glaucoma and DR have been linked with obesity.

The results of the study by Khalaf et al.¹ disclosed that only 11.1% of participants measured their blood glucose regularly. This might be attributed to the fact that participants lacked information about necessary details such as importance of measuring blood sugar persistently. This result is similar to that reported by the study conducted by Balasubramaniyan et al.⁴, who studied awareness and practices of eye effects among people with diabetes in rural India. They reported that 88.6% tested their blood sugar at least once every 3 months. These results show that even basic knowledge about the disease entity is missing on a bigger scale.

Regarding ophthalmological consultations the results are somewhat incongruent, probably explainable by demographic factors. In the study by Khalaf et al.¹, 60% of those in the studied sample had consulted eye specialists and 35.4% of them had eye examinations at least within one year. This could be explained by the fact that patients were aware of the effect of diabetes on their eyes.

The study agreed with Mwangi and coworkers⁵, who reported 50% of all the respondents went for eye checkups. Of the 50% who went for eye checkups, 27% of them went once a year. Also, it agrees with Al Zarea⁶, who observed that about 95% of all the participants went for regular ocular examinations. However, these results are not in agreement with those of Prabhu et al.⁷ who reported only 16.5% of patients with diabetes were referred for an eye examination by their physicians.

Regarding the knowledge of DR, the results are shattering. Srinivasan et al.⁸ observed that only 4.5% of the studied sample had good knowledge about retinopathy. Geethadevi et al.⁹ found that 60.8% had no knowledge of DR, and Panigrahi et al.¹⁰ reported that 69.0% of the study population had poor knowledge of DR. This implies that a significant proportion of patients have poor knowledge of DR and that there is a need for an educational programme about DR.

Concerning the relation between participants’ knowledge in pre- or post- tests and socio-demographic characteristics, the results of the study by Khalaf et al.¹ revealed the lowest mean knowledge score, 5.20 plus or minus 0.1 was seen in illiterate respondents, while in educated respondents it was 5.74 plus or minus 0.2 and became 16.56 plus or minus 1.8 and 16.69 plus or minus 1.8, respectively, in the post-test (questionnaire and educational programme), with a statistically significant relation (P<.001). This further supports the proposition that education plays a significant role in improving patients’ information.

Theory of Planned Behaviour

According to the TPB (Theory of Planned Behaviour), a patient's attitude is their favourable or unfavourable evaluation to perform a particular behaviour that has been formed through their mental perceptions or past experiences (Figure). Due to the important role of patients with chronic retinal disorders in adopting health behaviours to prevent progression or complications, the importance of educational interventions based on appropriate behavioural theories for patients is a significant factor.

a Independent t test
b Paired t test
TPB, Theory of Planned Behaviour

Preventive care in the exemplary case of a patient with diabetes would include blood sugar control, regular visits to an ophthalmologist, timely eye examinations and adherence to a medication plan and to an adequate diet.

In a study by Hosseini et al¹¹ eye care behaviours in patients with diabetes have been taught based on TPB constructs and the effect of this training measured by assessing behaviour and blood sugar levels (Table 1).

The educational programme consisted of four consecutive sessions, with the first focusing on improving patients' awareness of diabetes, familiarity with the structure of the eye and proper eye care. The second session focused on patients' attitudes and subjective norms, including teaching them about the importance and benefits of proper eye care and the negative consequences of not taking care. The third session focused on perceived behavioural control, familiarising patients with the barriers to retinopathy and improving patients' intentions to take proper care of their eyes. In the fourth session, patients' retinopathy preventive behaviours were improved, including regular measurements of blood sugar, adherence to a proper diet, taking medication regularly and visiting an ophthalmologist at given intervals.

The evaluation was conducted 3 months after finalising the educational programme by using a questionnaire and measuring the blood sugar levels including hemoglobin A1C (HbA1C).

As a result, a significant difference could be shown between the intervention and control groups in terms of TPB constructs and preventive behaviours as well as blood sugar levels (Table 2). This study, consistent with the results of other studies,^12-14 clearly showed that the training of patients with diabetes based on TPB promoted preventive behaviours of ocular complications and improved control of fasting blood sugar and HbA1C regardless of patients' ethnic origins.

Of particular significance is the extent of the programme with this study clearly showing that changing patients' attitudes requires a longer intervention and individual personal training. Presenting educational booklets should not be the only way used to teach, as could be evaluated in a study by the Ottawa Hospital Research Institute,¹⁵ amongst others.

a Independent t test
b Paired t test
FBS, fasting blood suger; HbA1C, hemoglobin A1C

Conclusions

Teaching patients based on TPB rather than traditional methods such as handing out booklets does improve preventive behaviour. It is highly recommended to use educational approaches in which patients participate and are actively involved and to use visual media such as short videos to make the training more effective.

References

1. Khalaf FR, Fahmy HM, Ibrahim AK, et al. Does a diabetic retinopathy educational program raise awareness among elderly diabetic patients?. Diabetes Metab Syndr Obes. 2019;12:1867-1875. Published 2019 Sep 20. doi:10.2147/DMSO.S208072

2.Giloyan A, Harutyunyan T, Petrosyan V. The prevalence of and major risk factors associated with diabetic retinopathy in Gegharkunik province of Armenia: cross-sectional study. BMC Ophthalmol. 2015;15:46. Published 2015 Apr 30. doi:10.1186/s12886-015-0032-0

3. Cheung N, Wong TY. Obesity and eye diseases. Surv Ophthalmol. 2007;52(2):180-195. doi:10.1016/j.survophthal.2006.12.003

4. Balasubramaniyan N, Ganesh Kumar S, Ramesh Babu K, Subitha L. Awareness and practices on eye effects among people with diabetes in rural Tamil Nadu, India. Afr Health Sci. 2016;16(1):210-217. doi:10.4314/ahs.v16i1.28

5. Mwangi MW, Githinji GG, Githinji FW. Knowledge and Awareness of Diabetic Retinopathy Amongst Diabetic Patients in Kenyatta National Hospital, Kenya. Vol 1.; 2011:140-141

6. Al Zarea BK. Knowledge, Attitude and Practice of Diabetic Retinopathy amongst the Diabetic Patients of AlJouf and Hail Province of Saudi Arabia. J Clin Diagn Res. 2016;10(5):NC05-NC8. doi:10.7860/JCDR/2016/19568.7862

7. Prabhu M, Kakhandaki A, Chandra K R P, Pramod. A hospital based study on awareness of diabetic retinopathy in diabetic individuals based on knowledge, attitude and practices in a tier-2 city in South India. Indian J Clin Exp Ophthalmol 2015;1(3):159-163

8. Srinivasan NK, John D, Rebekah G, Kujur ES, Paul P, John SS. Diabetes and Diabetic Retinopathy: Knowledge, Attitude, Practice (KAP) among Diabetic Patients in A Tertiary Eye Care Centre. J Clin Diagn Res. 2017;11(7):NC01-NC07. doi:10.7860/JCDR/2017/27027.10174

9. Geethadevi M, Thampi B, Antony J, Raghavan RR, Sasidharan R, Mohan A. A study of knowledge, attitude and practice in diabetic retinopathy among patients attending a primary health care centre. Int J Res Med Sci. 2018;6:3020.

10. Panigrahi S, Sahu RK, Jali S, Rath B, Pati S, Kerketta M. Knowledge, attitude and practice regarding diabetic retinopathy among medical and nursing students of a tertiary care teaching hospital of Odisha: a cross sectional study. IOSR J Dent Med Sci. 2017;16:1–7. doi:10.9790/0853-1608050107

11. Hosseini SS, Shamsi M, Khorsandi M, Moradzadeh R. The effect of educational program based on theory of planned behavior on promoting retinopathy preventive behaviors in patients with type 2 diabetes: RCT. BMC Endocr Disord. 2021;21(1):17. Published 2021 Jan 14. doi:10.1186/s12902-021-00680-2

12. Bandurska-Stankiewicz E, Zabłocki M, Falkowska-Gilska B, Tarasiewicz U. Wpływ kompleksowego programu edukacyjno-rehabilitacyjnego u inwalidów wzroku z powodu cukrzycy na stopień wyrównania metabolicznego [The effect of an education and rehabilitation program for blind diabetics on the level of metabolic equalization]. Pol Arch Med Wewn. 1998;100(2):145-152.

13. Taheri M, Amini M, Delavari S, Bazrafkan L, MazidiMoradi J. Effect of Peer Assisted Learning (PAL) education on knowledge, attitude and behavior related to prevention and control of diabetes. BMC Res Notes. 2019;12(1):227. Published 2019 Apr 15. doi:10.1186/s13104-019-4261-9.

14. Adam L, O'Connor C, Garcia AC. Evaluating the Impact of Diabetes Self-Management Education Methods on Knowledge, Attitudes and Behaviours of Adult Patients With Type 2 Diabetes Mellitus. Can J Diabetes. 2018;42(5):470-477.e2. doi:10.1016/j.jcjd.2017.11.003.

15.Grimshaw JM, Presseau J, Tetroe J, et al. Looking inside the black box: results of a theory-based process evaluation exploring the results of a randomized controlled trial of printed educational messages to increase primary care physicians' diabetic retinopathy referrals [Trial registration number ISRCTN72772651]. Implement Sci. 2014;9:86. Published 2014 Aug 6. doi:10.1186/1748-5908-9-86.

Albert J. Augustin, MD | E: albertjaugustin@googlemail.com

Augustin is professor of ophthalmology and chairman of the Department of Ophthalmology at the Karlsruhe Municipal Hospital, Germany.
He has no financial disclosures related to this article.