COMMUNITY EYE CARE
Year : 2004 | Volume
: 52 | Issue : 3 | Page : 247--51
A pilot study on awareness of diabetic retinopathy among non-medical persons in South India. The challenge for eye care programmes in the region.
P Namperumalsamy, R Kim, K Kaliaperumal, A Sekar, A Karthika, Praveen K Nirmalan
Aravind Medical Research Foundation, Aravind Eye Care System, Madurai, India
Aravind Medical Research Foundation, Aravind Eye Care System, Madurai
This study was conducted to determine awareness and practices relating to diabetic retinopathy among non-medical persons in a south Indian population. In this population-based cross-sectional study, trained social workers conducted face-to-face interviews using a semi-structured questionnaire with 200 randomly selected paramedical personnel and 204 persons randomly selected from the community. Responses were graded on a five-point scale. Over half of respondents were not aware of risk factors for diabetic retinopathy. Only one-fifth of paramedics and one-tenth of persons from the community were aware that uncontrolled diabetes was a risk factor for retinopathy. Over 75% of respondents were not aware of either laser or surgery as an intervention for retinopathy. Although 80% of respondents from the community felt that yearly eye examinations were essential, only 43.5% had ever visited an ophthalmologist. Nearly three-fourths of paramedical personnel did not have any material related to diabetes for health education. It is evident that considerable effort is required to improve awareness of diabetic retinopathy, and to translate this improved awareness to actual utilisation of services.
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Namperumalsamy P, Kim R, Kaliaperumal K, Sekar A, Karthika A, Nirmalan PK. A pilot study on awareness of diabetic retinopathy among non-medical persons in South India. The challenge for eye care programmes in the region. Indian J Ophthalmol 2004;52:247-51
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Namperumalsamy P, Kim R, Kaliaperumal K, Sekar A, Karthika A, Nirmalan PK. A pilot study on awareness of diabetic retinopathy among non-medical persons in South India. The challenge for eye care programmes in the region. Indian J Ophthalmol [serial online] 2004 [cited 2023 Feb 5 ];52:247-51
Available from: https://www.ijo.in/text.asp?2004/52/3/247/14579
The estimated 57 million persons with diabetes in India by 2025 (an estimated 195% increase from the number of persons with diabetes in 1995) has implications for the National Programme for Control of Blindness in India. There is a high potential for vision loss in persons with diabetes, with approximately two-thirds of persons having had vision loss after 35 years of diabetes. Current treatment modalities are effective in preventing as much as 98% of vision loss and blindness due to severe retinopathy, if treatment is provided at the appropriate time. ,,, However, issues related to utilisation of services remain a major challenge. A previous study from south India reported that only one-fourth of persons identified with moderate to severe retinopathy in a screening program returned for follow-up examinations to the hospital within two months. The challenge posed to the eye care programme in India is underscored when one considers that approximately one-fifth to one-third of all persons with diabetes will have retinopathy - there may be approximately 11-20 million persons with diabetic retinopathy by 2025 in India, including approximately 5.7 million people with severe retinopathy who require either laser or surgical intervention to preserve vision. ,, Eye care programmes should be able to attract and examine all the potential 57 million persons with diabetes if vision impairment due to retinopathy is to not add to the already existing burden of blindness in India. This will require that persons with diabetes are aware of the sight-threatening potential of diabetes and the need for regular eye examinations. Appropriate eye health education may encourage people at risk to seek timely and appropriate care. This will require developing educational materials that are regionally and culturally appropriate, and an understanding of current knowledge, attitudes and practices in the community.
We designed a pilot project in 3 districts of Tamil Nadu state in south India aimed at 1) developing a screening protocol for diabetic retinopathy in the community, and 2) to determine current levels of knowledge, attitudes and practices regarding retinopathy in the community to aid development of appropriate health education materials. This manuscript reports on awareness regarding diabetic retinopathy, and current practices in a south Indian population.
Materials and Methods
Respondents for this study included persons representing paramedical personnel currently active in the region and members of the community of the three project districts. We collected details of paramedical personnel in the study area from the existing records of the Joint Director of Public Health, Deputy Director of Health Services, and Deans of Medical Colleges in the study area. We then used a simple systematic random sampling strategy to identify 200 paramedical personnel for the study from the list. To identify persons from the community for this study, we created a sample frame of all panchayats and wards in the study districts. We used a simple random sampling strategy to identify 88 panchayats or wards from this frame. We randomly selected 204 persons to represent the community from these 88 panchayats or wards for the study on awareness.
Investigators trained in social work conducted face-to-face interviews focused on assessing current levels of awareness regarding diabetic retinopathy with subjects identified for the study. We used a semi-structured questionnaire for the interview that included items regarding organs or systems of body affected by diabetes, patients at risk for retinopathy, and treatment for retinopathy. We also explored responses to other items related to practice patterns and attitudes that were different for paramedical personnel and the community. Responses to attitudes were noted using a five-point scale that ranged from strong disagreement to strong agreement. Prior to finalising the questionnaire, we pre-tested the instrument among paramedical staff and members of the community and made necessary modifications. The questionnaire was translated into the local language for easy administration. We used SPSS version 9.0 for statistical analysis.
This study was conducted according to the principles of the Helsinki Declaration on research involving human subjects. Verbal informed consent was obtained from all subjects who participated in the study. Our Institutional Review Board approved the protocol for the study.
We received responses to the questionnaire from 199 (99.5%) paramedics [Table 1], and 204 (100.0%) members of the community. The mean age of paramedical personnel was 42.4 years (range 24-58 years), and 153 (77.3%) were females. The mean age of respondents from the community was 44.5 years (range 20-75 years), and 138 (67.6%) were males. Sixty-nine (33.8%) respondents from the community were self-reported persons with diabetes.
[Table 2] shows responses to questions relating to knowledge. Only 5 (2.5%) of the paramedical personnel and one (0.5%) person from the community were aware that diabetes could affect all 5 major systems listed. A majority of paramedical personnel (n=177, 88.5%) and the community (n=108, 52.9%) felt that the eye was most commonly affected by diabetes. However, over half the respondents from among both paramedical personnel (n=109, 55.1%) and the community (n=110, 53.9%) were not aware of risk factors for retinopathy. Only a fifth of paramedical personnel and one-tenth of persons from the community felt that uncontrolled diabetes was a risk factor for retinopathy. Close to three quarters of paramedical personnel (n=151, 75.9%) and members of the community (n=145, 71.1%) did not know of either laser or surgery for diabetic retinopathy. A majority (n=33, 16.2%) of the subjects from the community and paramedical staff (n=33, 16.2%) cited medical or paramedical staff as the main source of knowledge on diabetic retinopathy.
A majority of the paramedical personnel and members of the community showed strong agreement with the statements relating to attitudes [Table 3]. A majority of respondents among paramedical personnel (n=162, 81.0%) and the community (n=125, 61.3%) felt that persons with diabetes were more at risk of having problems relating to the eye. Over 80% of respondents from the community felt that all persons with diabetes should have a yearly eye examination by an ophthalmologist.
Nearly three-fourths of paramedical personnel did not have any educational material related to diabetes to provide health education [Table 4]. Over a third (n=30, 43.5%) of the 69 self-reported diabetic respondents from the community had never had an ophthalmic examination. Only half (n=71, 52.6%) of the non-diabetic respondents from the community referred persons whom they knew to be diabetic for an ophthalmic examination.
Our results suggest the need for focused efforts to impart health education regarding diabetes and retinopathy to this population such that people at risk seek appropriate and timely care. Although a large proportion of respondents mentioned eye as the organ most commonly affected by diabetes, it is possible that the response was influenced by the fact that they knew the interviewers were from an eye institute. The large proportion of persons who were not aware of risk factors for retinopathy is a matter of concern. A better understanding of risk factors by persons with diabetes may be essential to improve compliance to preventive measures among those at risk. It is also a matter of concern that nearly three-fourths of the respondents were not aware of available options to treat diabetic retinopathy. Although most respondents from the community felt that all persons with diabetes should have annual ophthalmic examinations, a large proportion of self-reported persons with diabetes had not had a prior ophthalmic examination and just over half the respondents from the community referred persons with diabetes for an ophthalmic examination. These results demonstrated a large gap between attitudes, knowledge, and actual practice within the community.
Current efforts at health education do not appear to optimally utilise the large paramedical force available. Few paramedical personnel had educational material in any form; what was available was primarily in the form of printed materials. It is debatable how useful a print campaign may be among populations that are predominantly illiterate. We are unable to comment on the quality of the content provided in the educational materials, as our study was not designed to ascertain this aspect. Although having medical professionals impart education may improve the quality, it may not be the most optimal use of their services in situations where medical services are scarce. Utilising the large paramedical force available in the country for health education may ensure wider coverage and accessibility. This will require continued updating of knowledge of paramedical personnel, and providing all personnel with standardised materials that are culturally, linguistically, and regionally appropriate.
Although recommendations and guidelines for screening persons with diabetes exist, studies have shown that such recommendations are not always adhered to even in the developed world. ,,, Delivering ophthalmic care at the appropriate time to persons with diabetes can provide eye care programmes with huge cost savings besides reducing the personal suffering caused by blindness and vision impairment. ,, Due to the chronic nature of diabetes, the major challenge for eye care programmes will be to ensure regular follow-up examinations of persons with diabetes, quite unlike the cataract program where a single surgical procedure in each eye has the potential to restore vision. Compliance to such repeat examination will require committed patients who are aware and who understand the dangers of missing ophthalmic examinations. Data from our study suggest that a lot of effort is required to increase awareness regarding diabetic retinopathy in this population and to transform this increased awareness to actual utilisation of services.
|1||King H, Aubert RE, Herman WH. Global burden of diabetes, 1995-2025: prevalence, numerical estimates and projections. Diabetes Care 1998;21:1414-31.|
|2||Klein R, Klein BEK, Moss SE. Visual impairment in Diabetes. Ophthalmology 1984;91:1-9.|
|3||Ferris FL. How effective are treatments for diabetic retinopathy? JAMA 1995;269:1290-91. |
|4||Ferris FL. Issues in management of diabetic retinopathy. Hospital Practice 1993:79-89. |
|5||Rohan TE, Frost CD, Wald NJ. Prevention of blindness by screening for diabetic retinopathy: A quantitative assessment. BMJ 1989;299:1198-201. |
|6||Agardh E, Agardh CD, Hansson-Lundblad C. The five-year incidence of blindness after introducing a screening programme for early detection of treatable diabetic retinopathy. Diab Med 1993;10:555-59.|
|7||Namperumalsamy P, Nirmalan PK, Kim R. Developing a screening program to detect sight threatening diabetic retinopathy in south India. Diab Care 2003;26:1831-35.|
|8||Narendran V, John RK, Raghuram A, Ravindran RD, Nirmalan PK, Thulasiraj RD. Diabetic retinopathy among self-reported diabetics in southern India: A population-based assessment. Br J Ophthalmol 2002;86:1014-18.|
|9||Dandona L, Dandona R, Naduvilath TJ, McCarty CA, Rao GN. Population based assessment of diabetic retinopathy in an urban population in southern India. Br J Ophthalmol 1999;83:937-40.|
|10||Rema M, Ponnaiya M, Mohan V. Prevalence of retinopathy in non insulin dependent diabetes mellitus at a diabetes center in southern India. Diabetes Res Clin Pract 1996;34:29-36.|
|11||Retinopathy Subcommittee of the Australian Diabetes Society for Diabetes Australia. Diabetes and the Eye . Melbourne: Diabetes Australia, 1994.|
|12||Brechner RJ, Cowie CC, Howie LJ, Herman WH, Will JC, Harris MI. Ophthalmic examination among adults with diagnosed diabetes mellitus. JAMA 1993;270:1714-18. |
|13||Witkin SR, Klein R. Ophthalmologic care for persons with diabetes. JAMA 1984;251:2534-37. |
|14||Moss SE, Klein R, Klein BEK. Factors associated with eye examinations in persons with diabetes. Invest Ophthalmol Vis Sci 1994;35:1141.|
|15||Javitt JC, Canner JK, Frank RG, Steinwachs DM, Sommer A. Detecting and treating retinopathy in patients with type I diabetes mellitus: A health policy model. Ophthalmology 1990;97:483-94. |
|16||Javitt JC, Aiello LP, Bassi LJ, Chiang YP, Canner JK. Detecting and treating retinopathy in patients with type I diabetes mellitus: savings associated with improved implementation of current guidelines. Ophthalmology 1991;98:1565-73. |
|17||Javitt JC, Aiello LP, Chiang Y, Ferris FL 3rd , Canner JK, Greenfield S. Preventive eye care in people with diabetes is cost saving to the federal government: implications for health care reform. Diab Care 1994;17:909-17.|