Abstract

Background; diabetic retinopathy can lead to serious vision problems, patient education plays an important role in the management of retinopathy and the Compliance to treatment is a primary determinant of treatment success. Aim of the Study; The study aimed to evaluate the Impact of educational intervention program on diabetic retinopathy patient's compliance. Study Hypothesis; Patients knowledge about diabetic retinopathy will be improve post program than before and Patients compliance will improved after receiving the program. Design; Quasi experimental design used to achieve the aim of the study. Setting; the study was conducted at ophthalmology clinic at Benha University Hospital. Subjects; Convenience sample of 60 patients from both genders selected under criteria. Tools: two tools were used; Structured questionnaire regarding knowledge of diabetic and diabetic retinopathy; which used to assess patient's knowledge about diabetic and diabetic retinopathy and patient's compliance of diabetic retinopathy; to assess patient' compliance It included questionnaire about nutrition and eating habits , physical activity and treatment. Results; mean score of age was age 42.067 ± 9.716 also 56.7% are male, (78.3%) are married. Regarding to medical history 70.0% use insulin. and so 78.3% of them post hyperglycemia exposure caused by Sweet diet. Regarding total knowledge pre-program was 93.3 % of patients had unsatisfactory while 80.0% had satisfactory of knowledge post program. Regarding total compliance 95.0 % of patients not adherent preprogram while 96.7% had adherent post program. Also there were positive and highly significant correlations in post program between total knowledge and total compliance. Conclusion: there were highly significant statistically improvement in all items of knowledge and compliance post than preprogram regarding diabetic retinopathy. Recommendations; The need for increasing awareness and also the provision of access to retinopathy screening services to patient, Urgent need to evolve strategies to educate diabetic patients about potential retinopathy complication of diabetes.

1. Introduction

Retinopathy(DR) is a common complication in diabetic patients, and one of the main causes of blindness in ophthalmology, the prevalence of blindness reaches 30% especially in diabetic patients with proliferative diabetic retinopathy within two years ^{1, 2}. This is when high blood sugar levels cause damage to blood vessels in the retina. These blood vessels can swell and leak or they can close, stopping blood from passing through. Sometimes abnormal new blood vessels grow on the retina. All of these changes can steal the vision ³.

Complications of diabetic retinopathy can lead to serious vision problems, including; vitreous hemorrhage occurs when new blood vessels bleed into the vitreous fluid, retinal detachment develops when damaged blood vessels form scar tissue and Glaucoma. This condition can lead to damage in the optic nerve, the bundle of nerve fibers that transmits visual information from the eye to the brain. If left untreated, glaucoma may cause permanent blindness ⁴. The complications of diabetes can have a devastating effect on patients and their families. This is often intensified by the loss of a patient’s ability to self-manage, which may have physical and psychosocial implications ⁵.

All nurses who care for patients with diabetes have an important role to play in preventing complications, and it is important to establish clear communication between the health professionals in different disciplines in all settings who provide care for these patients ⁵. Patients with diabetic retinopathy can be management by controlling their blood sugar levels, exercising regularly, keeping to a healthy diet and also take their prescribed medication. Those who smoke need to quit and avoid alcohol as much as possible. Because earliest stages of diabetic retinopathy have no detectable visual symptoms, diabetics need to have their vision tested regularly with a dilated eye examine to catch this condition while it is still treatable ⁶.

Patient education plays an important role in the management of retinopathy, as increased awareness is linked with motivation to adhere to self-management goals patients with sight-threatening retinopathy may need educating regarding a potential loss of vision as well as a clear explanation of the treatment options ⁵.

Compliance to treatment is a primary determinant of treatment success. The term compliance describes the extent to which patients follow treatment recommendations given by their health care providers. The rate of treatment compliance varies according to the disease characteristics, treatment regime and patient features. The noncompliance rate in chronic disorders is known to be about 50% on average. Compliance with treatment is very important in managing diabetes. Patients requiring a change in their usual lifestyle to comply with the rules of treatment may experience compliance problems. In diabetic patients, noncompliance means poor glycemic control and long-term health complications, such as retinopathy, neuropathy, and renal disease ⁷.

Background retinopathy will eventually progress to the more severe forms in the majority of individuals. If left untreated, 50% of those with proliferative DR will lose their sight within two years and 90% risk losing any useful vision after 10 years. Patients who undergo treatment have their risk of moderate visual loss reduced from 30% to 15% over the subsequent three years. Those who have PRP have their risk of severe visual loss reduced by 50%, compared with untreated individuals with a similar severity of disease ⁸. DR is one of the leading causes of blindness in the world. It develops in nearly all individuals with type 1 diabetes and in more than 75% of individuals with type 2 who survive for over 20 years with the disease ⁹.

The study aimed to evaluate the impact of educational intervention program on diabetic retinopathy patient's compliance; this aim will be achieved through the following:

• Assessing patient's knowledge of diabetic retinopathy.

• Developing and implementing program of diabetic retinopathy for the studied patients

• Evaluate the impact of implementing the program of diabetic retinopathy on patient's compliance.

1. Patients knowledge about diabetic retinopathy will be improved post program than pre-program.

2. Patients compliance will improved after receiving the program.

2. Subjects and Method

Quasi experimental design used to achieve the aim of the study.

The study was conducted at ophthalmology clinic at Benha University Hospital

Convenience sample of 60 patients from both genders selected under the following criteria:

1. Accept to participate in the study.

2. All patients have diabetic more than 5 years.

3. Adult male and female from 20 – 60 years.

Two tools were designed to collect data

Tool (I): Structured questionnaire regarding knowledge of diabetic and diabetic retinopathy; which was developed by the researchers to assess patient's knowledge about diabetic and diabetic retinopathy. It included four parts;

A. Demographic characteristics of the patients: as age, gender, marital status, educational level, residence and occupation.

B. Medical history of the patients: such as: weight, height, duration of diabetic, family history of diabetic , types of treatment and complication of diabetic.

C. Patient's Knowledge about diabetic including: Meaning of diabetic mellitus causes, s&s, risk factors, diagnosis, treatment and complication

D. Patient's Knowledge about diabetic retinopathy including: meaning, causes, types , signs& symptoms , risk factors, diagnosis , a complication and prevention.

Knowledge scoring system:

All knowledge variables were weighted according to the items included in the answer of each question. The data collected from the knowledge test was computed and the test received a grade out of 18 questions, the scores were allocated as follows: complete (2), incomplete (1), wrong (0).

The total score of all questions will be represented in 100% and categorized into two levels, unsatisfactory (<60%) and satisfactory (≥ 60%).

Tool (II): patient's compliance of diabetic retinopathy It was developed by the researchers to assess patient's compliance for medication, physical activity and diet. Compliance was measure by using questionnaire about nutrition and eating habits (19items), physical activity (6 items) and treatment (7 items).

Scoring system:

Scoring of patient compliance was assigned to score according to its number of sub-items. For each sub-item, if Adherence (1), and if not adherence (zero) would be given. The scoring system of the compliance tool was computed and the sheet received a grade out of total 32points.

The total score of all questions will be represented in 100% and categorized into two levels, not adherent (<60%) and adherent (≥ 60%)

The experts check the relevancy, clarity, comprehensiveness and applicability of the tools. According to their opinions appropriate modifications were done by seven professions and experts of medical surgical nursing in the faculty of nursing and medicine at Benha University. Reliability was done by cronbach, alpha test (0.87).

A pilot study was carried out on 6 patients of study to test the content of the questionnaire as well as to estimate the time needed for data collection and the necessary modifications were done. Patients who shared in the pilot study were excluded from the study sample.

The purpose of the study was explained to the patients and informed consent was obtained from them to participate in the study. They were given an opportunity to withdraw from the study without given a reason, they were assured that anonymity and confidentiality of information was protected. Ethics, values, culture, and beliefs were respected. Also the approval taken from the Ethics Committee in the Faculty of Nursing to conduct this study.

Designed educational intervention program was developed by the researchers after review of literatures, then revised and modified according to the expertise comments, it was written in clear, Arabic language with pictures, colors and it included tow part: theoretical part (knowledge about meaning of diabetic, causes, diagnosis, treatment and complication. knowledge about diabetic retinopathy; types, causes, singes and symptoms, treatment and precaution). Practical part (compliance) which include nutrition and eating habits, physical activity and treatment of diabetic retinopathy.

Assessment phase:

At the beginning the researchers visited the ophthalmology clinic to collect necessary data about working days (from three day of week), frequency of cases (about 2 to 6 cases per week) and get the agreement to conduct the research .The researchers meets the patient after a registration to clinic time (9 am to 10 am) and introduces their self; explain the aim of the study to each patient to gain their cooperation to share in the study. The researchers initiated data collection by interviewing each participant for assessing socio-demographic data, medical and family history by using a structured interviewing questionnaire. Also, each patient was asked to answer certain questions to evaluate his knowledge about diabetic, diabetic retinopathy, instructions about diet, physical activity ,healthy life style. The average number per day around one patients and each patient took an average 10-15 minutes.

Implementation phase:

The intervention program was developed and implemented for the studied patients. They attended two sessions; the first was included health education about general information about diabetes as; definition, causes, diagnosis, treatment strategies and complication. The duration of the session was 15-20 minute .Second session which included information about diabetic retinopathy (definition, causes, diagnosis, treatment strategies and complication), knowledge about compliance health diet, physical activity and treatment. The duration of the session was 15-20 minute .Each session followed by a summary of essential points. The teaching media included an illustrative structured colored booklet.

Evaluation phase:

At the end of the sessions the evaluation of the educational program were done post implementation regarding their knowledge, and their compliance using the same tools that was used in the pretest .

Upon completion of data collection through the previously mentioned tools, data were computed and analyzed using the Statistical Package for Social Sciences (SPSS), version 20.0.0.0. Data were presented in tables using numbers, percentages, personal correlation, X2 and P value. Level of significance was threshold at 0.05.

3. Results

Table 1: Socio-demographic characteristics of the studied patients. This table shows that regarding to age 56.7% of the studied group ranged between 41- 60 years old also 56.7% are male, (78.3%) are married. Regarding to residence 51.7% was from rural areas, 40.00% illiterates. As well as, regarding to occupation 38.3% not working.

Table 2: Description of medical data among the studied patients. This table shows that regarding to medical history 45.0% of the studied group the duration of their diabetic ranged between-5- 10 years. The 68.3% of the studied group have family suffering of diabetic & measurement of hemoglobin. Also 70.0% have treatment by insulin. Also shows that 66.7% had eye complication from diabetic, and so 78.3% of them post hyperglycemia exposure caused by Sweet diet. Finally 80.0% make eye examine from one year to less 3 years.

Table 3: Distribution of Knowledge regarding diabetes mellitus for studied patients between pre and post program implementation. This table showed that 43.3% and 46.7% of patients had the poor levels of knowledge preprogram implementation regarding symptom of diabetic and importance of eye disease respectively. While post program implementation they was 81.7% and 83.3% of patients were good level of knowledge in define and important of eye diseases.

Table 4: Distribution of knowledge regarding retoinophy for studied patients between pre and post program implementation. This table showed that 53.3% of patients had the lowest levels of knowledge preprogram implementation among all subjects. While post program implementation they were was the majority of knowledge (81.7%) in changes, loss of vision, investigation or Diagnosis and ways of prevention in diabetic retinopathy, besides (80.0%) in define, stage, Persons at risk and types of treatment in diabetic retinopathy. With a highly signification different between knowledge level (pre &post program implementations).

Figure 1: Distribution of total knowledge pre and post program implementation among studied patients. This figure shows that 93.3 % of the studied patients had unsatisfactory of knowledge preprogram implementation. While 80.0% of the studied patients had satisfactory of knowledge post program implementation. There were highly statistically significant differences observed with P= 0.00.

Table 5: Distribution of compliance items among studied patients' related to pre and post program implementation. This table showed that 96.7% and 95.0% of patients not adherent preprogram implementation regarding with diet & treatment respectively. As compare of 85.0% & 83.3 had adherent post program implementation regarding with diet & treatment respectively. There were highly statistically significant differences observed with P< (0.00).

Figure 2: Total compliance pre and post program implementation among studied group. This shows that 95.0 % of studied patients not adherent preprogram implementation .While 96.7% had adherent post program implementation. There were highly statistically significant differences observed with P= 0.00.

Table 6: shows Correlations between total knowledge, and total compliance pre and post program implementation. There were positive and highly significant correlations in post program.

Table 7: Relation between total diet compliance and selected soici-demographic variables among studied patients with retinopathy. This table reveals that there are highly statistically significant in relation between socio-demographic variable (age, duration of diabetes) and total diet compliance preprogram while there were no statistically significant post program.

Table 8: Relation between total activity compliance and selected variables among studied patients with retinopathy. This table reveals that there no statistically significant relation between sociodemographic data and total activity compliance pre and post program.

Table 9: Relation between total treatment compliance and selected variables among studied patients with retinopathy. This table reveals that there no statistically significant relation between sociodemographic data and total treatment compliance pre and post program.

4. Discussion

The number of patients diagnosed with diabetes worldwide is projected to increase from 415 million in 2015 to 642 million in 2040, putting these patients at an increased risk for developing other comorbidities. Retinopathy is a common complication in diabetic patients, and one of the main causes of blindness in ophthalmology. Therefore the study aimed to evaluate the Impact of educational intervention program on diabetic retinopathy patient's compliance at Benha University Hospital. The discussion of current study cover four main parts; the first part Socio-demographic characteristics of patients and patient medical history, second part patient's knowledge pre/post program, the third part patient's compliance pre / post program, and finally the relations between some variables of patient's characteristics and compliance.

Regarding age, the present study revealed that about half of the studied subjects were in the age category between 41- 60 years old. This result agreed with the study conducted by ¹⁰ about "Diabetic retinopathy management guidelines" and found that, most of patient's in age category (45-64) years old. In the same line with the study conduct by ¹¹ about "Epidemiology of diabetic retinopathy in Egypt: a hospital-based study" which showed that most patient in age 49 years old.

The present study revealed 56.7% of studied subject had males, 40 % illiterate , 38.3% un working, 51.7% from rural places and 78.3% married. This result may attribute to more stressors they had. The results of study in line with ¹² who studied "Factors that influence the patient uptake of diabetic retinopathy" which showed that 58 % of the study subjects were males. In congruence with the study of ¹³ about "Effectiveness of Health Education on Knowledge and Attitude Regarding Diabetes in Type II Diabetes Mellitus" who documented 40% being illiterates and unemployed 67%. This result disagreed with the study conduct by ¹¹ who reported the prevalence of DR was statistically significantly higher in females .Also disagreed with ¹⁴ who studied "Improving of Type 2 Diabetic Patients’ Knowledge, Attitude and Practice Towards Diabetes Self-care" which showed that The majority of participants in all groups are females.

Regarding to medical history; the result revealed more than two fifths (forty five percent) of studied subject had diabetic from 5-10 years, about two third had eye complication from diabetic, and the majority of them make eye examine from one year to less 3 years. This result agree with ¹¹ who reported that 82% of patients with longer diabetes disease duration .Also in the same line with ¹² which showed that Twenty-eight percent had a history of diabetic retinopathy and/or other eye disease, 33% screen diabetic retinopathy or other eye disease.

The second part of the discussion was regarding the effect of program intervention on patient's general knowledge about diabetic, the results of study revealed that there was highly significant improvement in the level of knowledge after implementing the program than before included knowledge related to define of DM & diagnosis, causes & important of eye diseases). This result supported by ¹⁵ who study "The effect of educational intervention on knowledge, attitude and glycemic control in patients with type 2 diabetes mellitus". They showed significant improvement in knowledge was observed after intervention regarding symptoms of diabetes, risk factors, complications, In this respected ¹⁶ about" Health education intervention on diabetes in Sikkim" documented Majority participants had poor knowledge about diabetes and negative attitude towards the disease before the health education intervention and improved after the intervention.

Regarding the effect of intervention program on patient's knowledge about diabetic retinopathy, the results revealed that there was highly significant improvement in the level of knowledge after implementing the program than before. This result supported by ¹⁷ who stressed "Influencing factors on compliance of timely visits among patients with proliferative diabetic retinopathy in southern China: a qualitative study" who report that majority participants had poor knowledge about diabetes retinopathy before the health education intervention and improved after the intervention. In congruence with this, ¹⁸ about "Knowledge of diabetes and diabetic retinopathy among rural populations in India, and the influence of knowledge of diabetic retinopathy on attitude and practice". Reported only half of the population studied knew about the effect of good control of diabetes on DR.

The third part of the discussion was regarding the effect of program intervention on patient's compliance of diabetic retinopathy; the result revealed highly statistically significant differences between pre and post program. Which indicated that not adherent preprogram implementation regarding medication & diet, while adherent post program. This result supported by ¹⁹ about "Medication adherence in patients with type 2 diabetes mellitus treated at primary health clinics in Malaysia" who document adherence was observed only in study population. Also recommended that patient education on medication regimens is essential in order to improve adherence.

The researchers' opinions pointed out the difficulties resulting from following an appropriate diet. A lack of good knowledge about recommended products and their availability on the market was the most common problem reported by participating families. A proper understanding of portion sizes was also problematic. Moreover, cultural and social barriers were one of the main obstacles in introducing the diet. Numerous subjects of the study normally do not consume products recommended for diabetic patients.

The four part of the discussion was regarding the relations between items of compliance (diet, physical activity, treatment) and selected soico-demographic variables (age, level of education, gender) and duration of diabetes among studied patients. The current results revealed that there was statistical significant preprogram between age, duration of diabetes and diet compliance (p= 0.012 and p= 0.004) respectively. While in post program there were no statistical significant. The study was disagree with ²⁰ about "Adherence to dietary recommendations in diabetes mellitus: disease acceptance as a potential mediator" reported that no statistically significant difference was found between the socio-demographic variables and non-adherence to diet preprogram.

Regarding the relation of items of compliance and duration of diabetic, the study revealed that there was statistical differences pre- program (p= 0.004), this mean the patients who 15-20years of duration of diabetes were more adherence of diet than 5-10 years of duration. But post program the majority of patient with diabetic from 5-10 years adherence to diet. The researchers thought if the patients understand and know about their disease and the treatment, they will be better able to understand the importance of the recommendations and adhere to the activities that multi-professional health team has programmed.

This result was disagree with ²¹ who study "Adherence to diabetes mellitus treatment and socio-demographic, clinical and metabolic control variables " the studies show that patients with a shorter length of diagnosis and in the initial phase of the treatment are less adherent to the treatment and to self-care in diabetes.

Therefore, it seems to be a key importance for diabetic patients to gain knowledge about diet, physical activity and treatment from health care provider, as well as receive support from their closest environment. To adherent to their treatment

5. Conclusion

In the face of our results, the present study illustrated that there were highly significant statistically improvement in all items of knowledge and compliance post than pre- program regarding diabetic retinopathy.

6. Recommendation

In the light of the results of the current study, the following recommendations are suggested:

- The need for increasing awareness and also the provision of access to retinopathy screening services to patient.

- Urgent need to evolve strategies to educate diabetic patients about potential retinopathy complication of diabetes.

- Further research is necessary to measure long term adherence to healthy life style among patients with diabetic retinopathy.

References