Assessment Knowledge of diabetic Patients about Preventive Measures for Retinopathy in AL-Nasiriya City

Assessment Knowledge of diabetic Patients about Preventive Measures for Retinopathy in AL-Nasiriya City

Abbas Fadel Najee¹, Rajaa Ibrahim Abed ² *

1. Academic Nurse, Ministry of Health, Thi-Qar Health Directorate, Higher Institute of Health in Thi -Qar, Iraq;
2. Prof. Dr, Adult Health Nursing Department, College of Nursing, University of Baghdad, Iraq,

Corresponding author: Abbas Fadel Najee

Email: abbasalzai0@gmail.com.

ORCID

ABSTRACT

This descriptive evaluative study aimed to assess the knowledge of diabetic patients about preventive measures for diabetic retinopathy in the Diabetic and Endocrine Centre in Al-Nasiriya City, covering the period from 9th March 2022 to 1st December 2022. The study employed a constructed questionnaire based on an extensive literature review and guidance from the supervisor. The questionnaire was divided into three parts, covering socio-demographic characteristics, clinical information, and an assessment of diabetic patients' knowledge related to retinopathy prevention. Data was collected using interviews, and both descriptive and inferential statistical analyses were conducted. The results revealed that the majority of the study sample were males (68.3%) and most patients were aged 50 years and above (41.7%). Regarding education, the majority were high school or high institute graduates (25.0%), and a significant proportion were government employees (46.7%). The duration of diabetes for most patients ranged from 6 to 10 years (38.3%), and approximately 30.0% did not have any diabetes-related complications. Visual impairment due to diabetic eye problems was reported by 48.3% of the patients. Monitoring blood glucose weekly was the most common practice among the study participants (58.3%), and the majority (73.3%) did not have a history of hypertension. Furthermore, 55.0% of the patients had a history of dyslipidaemia. The study revealed a mean knowledge score of 0.238 (SD=0.0672) out of a maximum possible score of 0.46, indicating a poor to intermediate overall level of knowledge regarding preventive measures for diabetic retinopathy among diabetic patients. However, no significant relationships were found between patients' knowledge and their age, gender, education, diabetes duration, history of hypertension, or history of dyslipidemia conclusion, the study highlighted those diabetic patients had poor knowledge regarding diabetic retinopathy, despite being aware of its impact on eye health. As a recommendation, the study suggests implementing an intensive and comprehensive national-level educational program targeting a large population of diabetes mellitus patients to improve their knowledge about preventive measures for diabetic retinopathy. Health professionals, mass media, and illustrated posters in diabetic clinics and hospitals could play an effective role in this educational initiative.

Keywords: Assessment, diabetic Patients', Preventive Measures, Retinopathy

INTRODUCTION

Diabetes mellitus (DM) is regarded as a major medical issue worldwide. Diabetes causes a number of long-term complications that have a significant impact on the patient, family, and society, as the disease disrupts people during their most productive years (Elshemy et al., 2018). Diabetes will affect 642 million adults by 2040, with approximately 75% living in low- and middle-income countries. Jasim, and A. H., (2022) mention that Furthermore, if left unchecked over time, insulin deficiency can cause harm to various organs of the body, leading to devastating and life-threatening prosperity complications such as cardiovascular diseases (CVD), nerve harm (neuropathy), kidney harm (nephropathy), and eye disease (driving to retinopathy, visual incident and undoubtedly visual impedance). However, diabetic retinopathy (DR) affects one out of every three diabetic patients and is the leading cause of blindness in adults. (Wong & Sabanayagam, 2020). According to the WHO (2021), the number of people affected by diabetes increased from 108 million in 1980 to 422 million in 2014. Majid (2017) The prevalence has risen faster in low- and middle-income countries than in high-income countries.

In recent years, it has been assumed that the successful implementation of public health programs in developed countries will improve and modify the current state of public health methods such as risk factor control, screening, and care for DR. (Lin et al., 2016) DR is the most common microvascular complication of diabetes and the leading cause of visual deficiency and blindness in these patients. Nonetheless, research on the factors that contribute to DR is limited (Skid et al., 2021; Hosseini et al., 2021).

 Furthermore, identifying the impediment in various country income settings may hasten the development of a successful DR screening program (Piyasena et al., 2019). The long duration of the disease, glycemic control, hypertension, hyperlipidemia, smoking, anemia, age, puberty, and pregnancy are all risk factors for DR. Furthermore, some patients did not go to the ophthalmologist for their annual eye exam in the previous year. All of this will increase the demand for improved diabetes education in order to make DM patients more aware of their conditions and associated complications (Almalki et al., 2018).

Patient education about DR will be essential for further advancements in DR management and prevention. Patients should be informed that they play an important role in their diabetes management and eye care. In Iraq, studies to assess the level of knowledge about DR among DM patients and identify associated factors with low DR awareness are lacking. As a result, establishing preventive efforts requires obtaining knowledge about the awareness of people at risk in order to develop preventive strategies.

METHOD

Study Design:

A descriptive evaluative study design was utilized to assess the knowledge of diabetic patients regarding preventive measures for retinopathy at the Diabetic and Endocrine Center in Al-Nasiriya City.

Sampling Method:

A non-probability purposive sampling method was employed to select a representative and accurate sample of diabetic patients. The study included 60 diabetic patients who were recruited from the centre’s outpatient department. Patients were either referred from primary healthcare centres or had scheduled appointments/consultations at the department.

Data Collection Period:

Data collection took place from 9th March 2022 to 1st December 2022.

Study Instrument:

A questionnaire was developed for data collection based on guidance from the supervisor and an intensive review of relevant literature and studies. The questionnaire consisted of three parts:

Part I - Socio-Demographic Characteristics:

This section aimed to gather demographic data from the patients through an interview questionnaire. Information such as age, gender, education level, occupation, household monthly income, residential area, smoking status, and alcohol consumption was collected.

Part II - Clinical Characteristics:

The second part aimed to collect clinical information from the patients using an interview questionnaire. This information included the duration of diabetes, complications due to diabetes, diabetic eye problems, frequency of blood glucose monitoring, history of hypertension, duration of hypertension, history of dyslipidemia, previous eye surgeries, medical treatment for diabetes, adherence to medication, and visits to an eye specialist.

Part III - Assessment of Diabetic Patients' Knowledge:

This section was designed to assess the patients' knowledge about preventive measures for retinopathy. It consisted of 24 questions related to general information about diabetic retinopathy and specific preventive measures, such as blood glucose control, blood pressure control, blood lipids control, smoking cessation, regular eye screening, and follow-up.

Data Collection Method:

Data collection was carried out using face-to-face interviews with the diabetic patients at the Diabetic and Endocrine Center in Al-Nasiriya City.

Data Analysis:

The collected data were compiled and analyzed using descriptive statistics, such as percentages, mean, and median. The Chi-square test was used to assess relationships between certain variables. Statistical analysis was conducted using the software SPSS version 26, and a significance level of 0.05 (p < 0.05) was considered for the statistical tests.

RESULTS

Table 1 presents the demographic characteristics of the study participants. The majority of the participants were male, accounting for 68.3% of the sample. Additionally, 41.7% of the patients were aged 50 years and above. In terms of education, 25.0% of the patients were high school graduates or had completed a high institute program. Moreover, 46.7% of the participants were government employees. Most of the patients (33.3%) reported a monthly household income within the range of 601,000 to 900,000, or 901,000 to 1,200,000 units. Furthermore, 90.0% of the participants lived in urban areas, and 80.0% were ex-smokers.

Table 2 provides insights into the clinical characteristics of the study participants. A significant proportion (38.3%) of the patients had been living with diabetes for 6 to 10 years. Notably, 30.0% of the patients did not have any diabetic complications. Diabetic eye problems, specifically visual impairment, were reported by 48.3% of the patients. Regarding blood glucose monitoring, the majority (58.3%) monitored their blood glucose on a weekly basis. Furthermore, 73.3% of the patients did not have a history of hypertension, and 55.0% had a history of dyslipidemia. Notably, all participants (100%) reported no history of eye surgery, and 63.3% had not undergone any other surgery. Most patients (70.0%) were on oral antidiabetic medication, and 56.7% reported irregular adherence to their medication. The majority (83.3%) had never visited an eye specialist. Moreover, 46.7% of the patients were classified as overweight (BMI 25-29.9).

Table 3 displays the knowledge scores of the study participants regarding preventive measures for retinopathy. The mean knowledge score was 0.238 (SD=0.0672) out of a maximum possible score of 0.46. Notably, all answers to the knowledge assessment questions were incorrect, indicating a poor to intermediate level of knowledge among diabetic patients concerning preventive measures for retinopathy.

Table 4 presents the analysis of relationships between patients' knowledge and various demographic and clinical factors. The results revealed no significant relationship between patients' knowledge and their age, gender, education level, diabetes duration, history of hypertension, or history of dyslipidemia (p-value > 0.05). These findings suggest that the participants' knowledge levels were not significantly influenced by these demographic and clinical factors.

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Table 1. Distribution of the sample by socio-demographic characteristics (n= 60 patients)

Table 2. Distribution of the sample according to their clinical characteristics (n= 60 patients)

Table 3. Overall assessment of patient’s knowledge about preventive measures for retinopathy

Table 4. Correlation between diabetic patient's knowledge scores regarding preventive measures for retinopathy and their clinical and socio-demographic characteristics

DISCUSSION

Results in this table revealed that (68.3%) are male, (41.7%) of patients are within the age group (50 years and more). Concerning the educational level, the majority of patients in the study (25.0%) are high school graduates, high institute graduates. Related to occupation status (46.7%) patients in the study are Government employees. The study presented that the majority of patients’ household monthly income of the study sample salary (601.000-900.000,901.000-1.200.000) equal percent are (33. 3%). (90.0%) of patients in the study they live in Urban areas. Smoking status, (80.0%) of patients in the study are ex-smoker.

The current study backs up Tripathi et al (2022) The study included 272 patients with diabetes mellitus (44.4% females and 55.5% males). The study population's average age was 53.4 10 years. These findings are consistent with the findings of Mafwiri et al. (2016), who found that half of the patients (212, 51.5%) were between the ages of 41 and 60, with 133 (32.3%) being under the age of 40. The researcher believed that diabetic mellitus affects a population of (18-58 and older) years, with males constituting the majority of patients.

 This was demonstrated in the study conducted by Banerjee et al (2021) Furthermore, housewives (41.22%) were the most common group of patients, followed by service (19.85%), business (13.74%), agriculture (12.21%), and others (12.98%). Approximately 63.36% of the patients enrolled in the study were illiterate, while 36.64% were literate. Among the literate patients, 19.85% had completed the school level, 9.92% had completed the intermediate level, 3.82% had completed the bachelor level, and 3.05% had completed the master’s level.

  According to Lubna et al. (2017), 56.5 percent of patients were illiterate but did not achieve matriculation, while 42 percent of patients had qualified for matriculation or higher educational levels. and Salil et al. (2018) reported that 39.41% of patients in studies were self-employed, and Wakyusa et al (2017) One-third (158, 38.2%) were self-employed, 71 (17.2%) were retired, and 97 (23.5%) did not work. Before retirement, more than a third (102, 35.4%) were professionals, while another third (100, 34.7%) were peasants. The researcher confirmed that the patients with low literacy have poor knowledge about their disease and may have difficulties learning the advanced Preventive Measures for Retinopathy needed to improve diabetic patients’ self-care, and the majority of patients with diabetes in the study were self-employed or retired.

The current study is consistent with the findings of Sami et al. (2018), who found that nearly 80% of patients had a monthly income of less than 10,000 Saudi Riyals.        According to Assem et al. (2020), in the study Knowledge about diabetic retinopathy, eye check-up practice, and associated factors among adult patients with diabetes mellitus attending Debark Hospital, Northwest Ethiopia, 230 patients participated, yielding a 96.68% response rate. The participants' average age was 49(17.6) years. The median monthly income was 850 ETB [IQR 500-3500ETB], and 123% of the population lived in cities. The majority of DM patients, according to the researcher, are from the middle socioeconomic class.

 According to Alswaina N. F. (2021), the current study included 307 patients with type 2 diabetes, 37 of whom were active smokers and 227 (73.9%) of whom did not exercise regularly. Liu et al. (2021) published a study titled Association between smoking history and optical coherence tomography angiography findings in diabetic patients without diabetic retinopathy. This study included 1099 eyes from 1099 diabetic patients with DM, with 750 nonsmokers and 349 smokers.

 According to previous studies and the findings of the research, we discovered that diabetics have a small number of smokers, but it may interfere with the complications of diabetes in the eye, as we discovered in previous studies.

Results in this table revealed that (38.3%) of patients with diabetes who have diabetes durations from (6-10 years) in the study. The results indicated that the majority of (30.0%) from the study don’t have diabetic complications. Diabetic Eye problems, the results showed that (48.3%) of patients from a study suffer from visual impairment. Monitor blood glucose, the highest percentage (58.3%) of study patients who monitor blood glucose weekly.

 The current study is consistent with Raza et al. (2019), who published a study of diabetic retinopathy - knowledge, attitude, and practices in diabetic patients admitted to tertiary care centers and reported that 66% of the sample had diabetes for the last 10 years, 22.7% had diabetes for 11 to 20 years, and 11.1% had diabetes for more than 20 years. According to Bahaeddin et al. (2017), the patient’s diabetes duration was less than 5 years (N=47), 5-10 years (N=21), and more than 10 years (N=47). Van et al. (2015) reported that the years of DM from initial diagnosis were 5 (38.1%), 5-10 (30.3%), and > 10 (31.6%).

 The reason for the comparatively better knowledge among patients with 6-10 years' duration is probably because the former has had more time to learn about diabetes and its ocular manifestations from various sources, including medical officers and other diabetic patients.

According to Alwazae et al. (2019), in terms of non-ocular complications of diabetes, cardiac complications ranked first (27.7%), followed by neuropathy (16.1%), and foot ulcer (11.4%); nephropathy (9.2%) was the least-reported complication. One or more diabetic ocular complications (46.8%) were self-reported, including cataracts in 31.2%, DR in 20%, glaucoma in 6.2%, and macular edema in only 2.5%. Notably, 53.2% reported no diabetes-related ocular complications. This result differs from the findings of a search conducted by Achigbu et al. (2016), who published a study on the Knowledge, Attitude, and Practice of Diabetes Patients Regarding Eye Care. Diabetes can affect the eyes, as 72 (69.9%) of respondents correctly stated. However, only 42 (40.77%) of those polled mentioned diabetes complications. Cataract was mentioned by 12 (11.65%) respondents, and blindness was mentioned by 30 (29.12%). This could be because the occurrence of diabetic eye complications is unpreventable, but the complications causing visual impairment were the main reason given by patients for not getting an early diabetic eye screening, such as diabetic retinopathy.

 The current study is in line with Raiturcar et al. (2019) found that 41% of diabetic retinopathy patients checked their blood sugar levels on a daily basis. Mansy et al. (2022) also reported weekly blood glucose and blood pressure monitoring. The researcher confirmed that most diabetic patients monitor their blood sugar levels weekly. This reflects the patients' lack of knowledge about blood sugar control, which is one of the risk factors for retinopathy.

 73.3 percent of patients in the study group did not have a history of hypertension. According to the table, 55.0 percent of the patients in the study have a history of dyslipidemia. In eye surgery, the results showed that (100%) of patients in the study did not have any eye surgery, and other surgery in their body, the results showed that (63.3%) of patients in the study did not have any surgery.

 According to the table above, the majority of patients in the study (70.0%) take oral diabetes medications. The majority of patients in the study (56.7%) have irregular medication adherence. Visiting an eye specialist, the study's (83.3%) patients who never visited an eye specialist. According to the above table, the majority of patients in the study (46.7%) were overweight (25-29.9).

According to Das et al. (2016), one or more comorbidities were present in 172 (71.66%) patients, with hypertension being the most common (detected in 126 (52.5%) patients. Dahal (2017) reported that 53.44% of patients had concomitant hypertension and 9.16% had nephropathy in addition to new diabetic cases. And, according to Lee et al. (2020), we studied 563 patients with type 2 diabetes who had hypertension (83.66%) and dyslipidemia (73.36%).

 This finding may be related to hypertension, which was found in the majority of these patients and was the only significant comorbidity possibly contributing to vision-threatening diabetic eye disease such as retinopathy. Despite these facts, there was a general lack of understanding of diabetic eye disease, particularly the lifestyle changes required to reduce the risk of diabetic eye disease and the risk factors for the development of eye complications.

 The current study is consistent with the findings of Zhou et al. (2018), who reported that six studies examined the differences in TC levels between patients with and without DR (487 DR patients and 3545 controls). The random-effects model revealed no significantly higher levels in DR cases (MD 3.77 mg/dL, 95% CI: -2.45 to 9.98, P =.24, I2 = 41%, P-heterogeneity =.13). Furthermore, Cardoza et al. (2021) discovered that the prevalence of dyslipidemia in our study was 75.50%. ( 151 patients). The mean SD of LDL(mg/dL) in diabetic retinopathy was 118.86 40.58mg/dl and 103.97 36.34mg/dl in nondiabetic retinopathy patients. The researcher confirmed that the finding could be linked to dyslipidemia. The only significant risk factor possibly contributing to retinopathy was detected in the majority of these patients. Despite these facts, there was a general lack of understanding of diabetic eye disease, particularly the lifestyle changes required to reduce the risk of diabetic eye disease and the risk factors for the development of eye complications.

 The current study supports what Konstantinidis et al. (2017) discovered in their study about Awareness and practices regarding eye diseases among diabetic patients. Whereas the vast majority (83.3%) had type 2 diabetes, 57.5% were on insulin and/or other anti-diabetic injections. According to Alzahrani et al. (2018), approximately 60% of the patients were being treated with OHD or a combination of diet, exercise, and OHD, and the majority of them were being treated by either general or family physicians. The study found that the majority of patients used oral diabetes medications to treat their diabetes.

  According to Rajesh et al. (2016), 3604 (58.02%) had previously sought eye consultations, with 3264 (52.5%) of them wearing spectacles. According to Ahmed et al. (2017), only 8% of eye-care patients monitored their blood sugar daily, 10% checked their blood pressure daily, and 43% always took medications as prescribed by their doctors. Approximately 37% saw an eye specialist once a year to prevent vision loss and other diabetes-related eye complications. This could be because the majority of patients did not have regular eye exams and did not visit an eye specialist. This could be done due to insufficient patient education, as previously discussed, a lack of health insurance, cultural and other barriers, and so on.

 The current study is in line with According to Takele et al. (2022), the average BMI of study participants was 22.9 kg/m2 (SD 2:1). And, according to Foster et al. (2015), the majority of patients (61.4%) were overweight with a BMI greater than 25 kg/m2. Males' BMI ranged from 17.9 to 31.1 kg/m2 (mean 24.5 6.6). Females' BMI ranged from 17.7 to 34.1 (mean 25.9 8.2). We discovered a high percentage of overweight participants in the study due to diabetics' lack of knowledge about maintaining an ideal weight, which poses a risk of increasing the incidence of retinopathy.

The present study revealed that the mean (+SD) knowledge score of study participants about preventive measures for retinopathy was mean= 0.238 SD= 0.0672 with a maximum possible score of 0.46, and all answers to questions are incorrect, indicating a poor to intermediate overall level of knowledge regarding preventive measures for retinopathy among DM patients. According to Assem et al. (2020b), the average (+SD) knowledge score of study participants about DR was 5.55 (4.66) with a maximum possible score of 14. One hundred twenty-one (52.6%)] participants had poor knowledge about diabetic retinopathy. Chintala et al. (2019) also reported that among the 108 diabetic patients, 12 (11.11%) had poor knowledge of diabetic retinopathy, 53 (49.07%) had average knowledge, and 43 (39.81%) had good knowledge. A total of 40 patients (37.04%) were aware that diabetes can affect the eye, 64.81% were unaware that frequent screenings for diabetic retinopathy are required, and 15.79% had never been screened.

Patients lack information regarding preventive measures for retinopathy, poor information may be due to their limited knowledge about diabetes self-management, which may be attributed to the unavailability of educational programs for Iraqi diabetic patients, and thus, most patients received their education about diabetes self-management from other patients or Internet sites.

The present study revealed that the no significant relationship between patients’ knowledge with their (age, gender, education, diabetes duration, history of hypertension, history of dyslipidemia) among study sample evidenced by insignificant differences at p-value ≤ 0.05. According to Bakkar et al. (2017), Univariate analysis revealed that awareness of DR was not significantly associated with patients' gender (p=0.479), age (p=0.78), or family history of DM (p=0.177). However, a study conducted in Egypt by Aly etal. (2022) found a significant positive correlation between diabetic patients' knowledge scores regarding the prevention of retinopathy and all items of their socio-demographic characteristics with p=0.001 (0.001).

CONCLUSIONS

The diabetic patients aware of the fact that diabetes affects the eye, have poor knowledge about diabetic retinopathy and the study presented no significant relationship between patients’ knowledge with their (age, gender, education, diabetes duration, history of hypertension, medical treatment for diabetic, history of dyslipidemia) among study sample evidenced by insignificant differences at p-value ≤ 0.05.

Based on the study conclusions, the study recommends that an intensive comprehensive large population-based (national level) educational program could be conducted to improve diabetes mellitus patient's knowledge of Preventive Measures for Retinopathy. The following measures can play an effective role; prompt counseling by health professionals, mass media, and illustrated posters in the diabetic clinics of public and hospitals.

ETHICAL CONSIDERATIONS COMPLIANCE WITH ETHICAL GUIDELINES

This study was completed following obtaining consent from the University of Baghdad.

FUNDING
This research did not receive any grant from funding agencies in the public, commercial, or non-profit sectors.

AUTHOR’S CONTRIBUTIONS

Study concept, Writing, and Review the final edition by all authors.

DISCLOSURE STATEMENT:

The authors report no conflict of interest.

ACKNOWLEDGEMENTS

We thank the anonymous referees for their useful suggestions.

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