INTRODUCTION:

Diabetes mellitus (DM) is a public health problem that affects all levels of society, regardless of age, gender, ethnicity, or race. DM is a chronic metabolic syndrome of glucose intolerance, generally involving absolute or relative insulin deficiency, insulin resistance, or both.^1-3 According to WHO, the number of diabetics in India will rise to 79.4 million by 2030, the highest number of any nation in the world.⁴

Many studies have been reported regarding the impact of structured teaching programs (STP) on managing diabetes. An experimental study on GNM students showed that STP brought valuable changes in the knowledge of students regarding management of DM⁵. Another study reported STP was effective in enhancing self-care management leading to prevention of complications of DM in patients.⁶ Prior to STP, rural DM population of Rajkot had limited knowledge of life style modification for DM and STP was effective in enhancing the knowledge.⁷ A randomised controlled trial report showed that STP was effective in improving the self- care management and reduce complications of DM.⁸

Diabetic retinopathy (DR) is a long-term and most common microvascular complication of DM and is the leading cause of visual impairment in productive segments of the population^9-12 According to a study conducted in 2016 by the All India Ophthalmological Society, the prevalence of DR in India was 21.27%. According to the UK National DR Screening Service, the prevalence of DR was 56% in patients with type 1 diabetes and 30.3% in type 2 diabetes.^13,14DR is a preventable complication. Effective glycemic control is critical to the prevention of DR and to minimize the prevalence of DR, health authorities should implement programs to increase awareness of how to manage DR risk factors among patients and physicians.¹⁵

There is an urgent need to raise awareness of DR and the importance of retinal screening to reduce vision impairment caused by diabetes.¹⁶ The large diabetic population and increasing incidence of DR has become a significant burden on the healthcare sector in India. There is an urgent and critical need to pursue a coordinated and multi-sectoral approach to reduce the prevalence of DR, as well as to early identify and routinely screen for DR in people with diabetes. Patient education plays an important role in treating DM and preventing complications like DR. Most DM patients are ignorant and unaware of the serious after-effects of DR. Therefore, the researcher felt it was necessary to educate DM clients about the management of DM and the prevention of DR.

METHODS:

The present study adopted a quasi- experimental one group pre- test post- test design to evaluate the effectiveness of structured teaching program (STP) on knowledge regarding prevention of DR among diabetic clients at a tertiary care hospital, Karnataka, India. A non-probability purposive sampling technique was used to select 50 diabetic clients admitted to the hospital who could speak and understand Kannada or English or both languages and who were willing to participate in the study. Diabetic clients who were critically ill, clients who declined to participate in the study for various reasons and those who had already undergone formal teaching programs regarding prevention of DR were excluded from the study.

Sample size:

The sample size was calculated using the Raosoft online sample calculator with a 5% margin of error and 95% confidence level from a population size of 55. The calculated sample size was 49. However, data was collected from 50 subjects as they met inclusion criteria.

Instruments:

Data was collected from participants using investigator prepared interview schedule comprising 15 items in part 1 and 46 items in part 2. Part 1 items were related to demographic variables and part 2 items pertained to knowledge regarding DM and prevention of DR. Experts from nursing and medical fields validated the structured interview schedule and reliability of the schedule was established by Spearman Brown’s Prophecy Formula with a correlation co-efficient value of 0.98.

The 46 items of the structured interview schedule were distributed under the following 6 components: general information about DM (11 items), blood sugar control by diet, exercise and medication (8 items), monitoring of urine and blood glucose level (7 items), hypertension management (3 items), eye check-up (13 items) and prevention of anemia (4 items). Each correct response was assigned a score of 1 and a wrong response a score of 0. The highest score was 46 and the lowest score was 0.

The data was statistically analysed using SPSS version 20. Paired t test was applied to test for significant difference of pre and post-test mean values at 0.05 level of significance. A p value of <0.05 was considered statistically significant.

Ethical consideration:

Permission was obtained from Institutional Ethics Committee (Ref No: SSMC/MSc-N/IEC-01/2022) and higher authorities of tertiary care hospital. Participants were informed about the purpose of study and were ensured about the anonymity and confidentiality of the collected information. A written informed voluntary participation consent was taken from each study participant.

Intervention:

The pre-test knowledge of DM clients regarding prevention of DR was assessed using investigator prepared structured interview schedule. For each study participant, 8 to 10 minutes was required to collect data. After assessing pre-test knowledge, 4-5 patients together were educated using investigator prepared STP which has been validated by subject experts. On the seventh day, post-test was conducted using the same structured interview schedule. The duration of data collection was approximately 6 weeks. STP was titled as “Prevention of DR” and included: General information about DM; structure of eye; information about DR; management of diabetes to prevent DR: blood sugar control by diet, exercise and medication, monitoring of blood and urine glucose level, hypertension management, eye check-up, prevention of anaemia. The audio visual aids such as lectures using power point presentation, short video clippings, charts and real food items were used for the STP.

RESULTS:

The data in Table 1 show that the maximum number of subjects (36%) were from the age group of 56-65 years and the next highest number of subjects (22%) were from the age group of 46-55 years. Only 6% and 2% of the subjects were from the age groups of less than or equal to 35 years and above 75 years respectively. In terms of gender of the participants in the study, both genders were almost equal. About 76% and 24% of the participants were from urban and rural areas respectively. The distribution of the subjects on the basis of diabetes associated complications has been presented in Table 2.

Results of statistical data analysis in Table 3 show that there is a significant increase in the mean percentage of the knowledge score of the subjects in the post- test when compared to the pre- test knowledge score in each of the component. The data shows that the structured teaching programme is effective in increasing the knowledge score of the subjects with the maximum enhancement being in the area of eye check-up. The results of the application of paired t-test to pre-test and post-test knowledge scores in Table 4 show that there is significant improvement in the mean value of various components post-test when compared to pre-test (p< 0.05).

Table 1: Sample distribution on the basis of demographic characteristics

Demographic character	Frequency	Percentage (%)
Age in years
≤ 35	3	6
36-45	7	14
46-55	11	22
56-65	18	36
66-75	10	20
≥ 75	1	2
Gender
Male	26	52
Female	24	48
Place of residence
Urban	38	76
Rural	12	24
Education status
No formal education	18	36
Primary	15	30
Secondary	15	30
College	2	4
Occupation
Unemployed	22	44
Private service	10	20
Daily wager	11	22
Agriculture	2	4
Retired from service	3	6
Business	1	2
Government service	1	2
Marital Status
Married	41	84
Unmarried	1	2
Widower	2	4
Widow	6	12
Type of family
Joint	25	50
Nuclear	25	50
Dietary pattern
Vegetarian	9	18
Mixed	41	82
Monthly income (INR)
≤ 10000	4	8
10001-20000	29	58
20001-30000	10	20
30001-40000	6	12
>40000	1	2
Interference in daily activity
Never	7	14
Frequently	20	40
Very often	23	46
Type of medication
Oral hypoglycemic agents (OHA)	46	92
Insulin	3	6
OHA and Insulin	1	2
Family History of DM
None	27	54
Yes	23	46

Table 2: Distribution of subjects on the basis of diabetes associated complications

Complication	Male	Female	Total
Complication	Male	Female	No	%
None	5	2	7	14
Chest pain	-	1	1	2
Foot ulcer	1	1	2	4
Recurrent infection	-	1	1	2
Tingling foot	2	3	5	10
Visual impairment	4	1	5	10
Visual impairment and tingling foot	3	2	5	10
Visual impairment and weight loss	3	-	3	6
Tingling foot and weight loss	1	-	1	2
Visual impairment and foot ulcer	-	1	1	2
Visual impairment, foot ulcer and tingling foot	2	2	4	8
Visual impairment, tingling foot and weight loss	2	2	4	8
Visual impairment, tingling foot and chest pain	1	2	3	6
Visual impairment, weight loss and chest pain	-	1	1	2
Tingling foot, weight loss and chest pain	-	1	1	2
Foot ulcer, recurrent infection and chest pain	1	-	1	2
Visual impairment, tingling foot, recurrent infection and chest pain	-	1	1	2
Visual impairment, tingling foot, recurrent infection and weight loss	1	-	1	2
Visual impairment, tingling foot, foot ulcer and weight loss	-	1	1	2
Visual impairment, tingling foot, weight loss and chest pain	-	2	2	4
Total	26	24	50	100

Table 3: Results of statistical data analysis of pre-test and post-test knowledge scores (component-wise)

Component	Max score	Pre-test knowledge			Post-test knowledge
Component	Max score	Mean	SD	Mean %	Mean	SD	Mean %
General information about DM	11	5.08	2.74	46.18	10.42	0.88	94.73
Diet	4	1.18	0.98	29.50	3.54	0.50	88.50
Exercise	2	1.34	0.67	67.00	2.00	0.00	100.00
Medication	2	0.26	0.57	13.00	1.38	0.67	69.00
Monitoring glucose level	7	2.22	1.50	31.71	5.86	1.25	83.71
Hypertension management	3	1.74	0.97	58.00	2.88	0.33	96.00
Eye check up	13	1.84	1.20	14.15	11.02	1.49	84.77
Prevention of anemia	4	1.50	0.93	37.50	3.84	0.37	96.00
Total	46	15.16	6.61	32.96	40.94	3.61	89.00

Table 4: Results of paired t test on pre-test and post-test knowledge scores

Component	Pre-test		Post-test		t value	P value
Component	Mean	SD	Mean	SD	t value	P value
General information about DM	5.08	2.74	10.42	0.88	16.05	<0.05
Diet	1.18	0.98	3.54	0.50	18.13	<0.05
Exercise	1.34	0.67	2.00	0.00	7.09	<0.05
Medication	0.26	0.57	1.38	0.67	11.03	<0.05
Monitoring glucose level	2.22	1.50	5.86	1.25	19.23	<0.05
Hypertension management	1.74	0.97	2.88	0.33	9.51	<0.05
Eye check up	1.84	1.20	11.02	1.49	40.26	<0.05
Prevention of anemia	1.50	0.93	3.84	0.37	19.52	<0.05
Total	15.16	6.61	40.94	3.61	42.06	<0.05

Figure 1 Conceptual Framework of Study (Adapted from Health Promotion Model by Pender)

Conceptual framework:

A conceptual framework in research helps in incorporating facts into rationale. A conceptual or theoretical framework in nursing research can help to provide a clear and concise idea of the knowledge in the area. The conceptual framework developed by the investigator for this study is based on the health promotion model proposed by Pender.¹⁷ Pender's model framework was designed to be a complementary counterpart to models of health protection.

This model focuses on three functions:

First, it identifies factors (demographic data) that enhance or decrease participation in health promotion. Second, cues to action: explains likelihood of a client participating in a structured teaching programme. Third, participation in health promotion behaviour resulting in gain of knowledge about the prevention of diabetic retinopathy.

DISCUSSION:

The present study evaluated the effectiveness of a structured teaching programme on knowledge regarding management of DM and prevention of DR at a tertiary care hospital. The study findings reveal that the overall mean percentage of the pre-test knowledge score of the subjects was less (32.96%) with the individual component mean percentage values being as follows: 13% in the component of medication, 14.15% in eye check-up, 29.5% diet, 31.7% in monitoring of glucose level, 37.5% in prevention of anaemia, 46.18% general information about diabetes mellitus and 58% in hypertension management and 67% in exercise.

There is a significant increase in the overall mean percentage (89%) of knowledge along with an increase in score of each component in the post- test when compared to the pre-test mean percentage knowledge score with the individual component mean percentage values being as follows: 69% in the component of medication, 84.77% in eye check-up, 88.50% in diet, 83.71% in monitoring of glucose level, 96% in prevention of anaemia, 94.73% general information about DM and 96% in hypertension management and 100% in exercise. These findings are supported by similar studies to assess the knowledge regarding prevention of DR among the DM patients and the effectiveness of a planned teaching program on knowledge regarding prevention of DR among the DM patients by a quantitative approach using pre- experimental one group pre-test post-test design. Planned teaching program was given to 60 patients selected using a non- probability convenience sampling in various hospitals. The study concluded that the planned teaching program is effective.¹⁸

A pre-experimental one group pre-test post-test study reported that STP effectively empowered DM clients with knowledge on foot care and prevention of diabetic foot ulcer.¹⁹STP was effective in enhancing the knowledge of antenatal women regarding gestational DM.²⁰STP led to significant improvement in the post test score indicating the effectiveness of STP in enhancing the knowledge of self management of DM amongst type 2 DM alcoholic males.²¹Another study to determine the effectiveness of STP regarding management of hypoglycaemia amongst DM patients reported significant improvement in the post-test scores indicating the impact of STP on increasing the knowledge about management of hypoglycaemia.²²The results of a study to assess the effect of STP on knowledge and practice about administration of insulin amongst DM patients and care givers indicated significant improvement in knowledge. All the participants showed their interest in learning about the proper way of administering the insulin.²³ The results of another study to evaluate the effectiveness of STP on management of type 2 DM showed significant impact of STP on improving the knowledge of patients about DM.²⁴ Evaluation of impact of STP by pre-test and post-test score in a study showed that STP is effective in improving the knowledge about DM. ²⁵ A study to check the effectiveness of STP in enhancing the detection and prevention of visual impairment and treatment reported the STP to be significantly effective in old people towards taking care of eyes and preventing visual impairment. ²⁶ Another study reported the assessment of the effectiveness of a video assisted teaching programme on knowledge regarding prevention of DR among DM clients. A pre-experimental research design with one group pre-post-test was done with 50 clients through convenient sampling technique. Data was collected by structured questionnaire and analysed using descriptive and inferential statistics in terms of mean, frequency distribution, percentage and ‘t’test. The study concluded that the video assisted teaching program is effective in prevention of DR ²⁷

LIMITATIONS:

The study was limited to a single setup without a control group and small sample size that limits the generalization of present study findings

CONCLUSION:

On the basis of comparison of the pre-test and post-test scores, the present study results show an appreciable increase in knowledge regarding prevention of DR after implementation of STP. Nursing professionals working in the hospital setting will be able to find opportunities to teach and improve the knowledge of patients regarding prevention of DR during their working hours. Nurses should place health in the hands of the patient, especially for diabetic clients as they are in need of long-term care. The teaching program developed by the investigator may be used by the nurses to educate the diabetic clients on prevention of DR.

CONFLICTS OF INTEREST:

There are no conflicts of interest

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Received on 24.03.2023 Modified on 09.05.2023

Int. J. of Advances in Nur. Management. 2023; 11(3):165-171.

DOI: 10.52711/2454-2652.2023.00038