Knowledge, Attitude and Practice Pattern Among Health Care ...

164 AIOC 2010 PROCEEDINGSAUTHORS’S PROFILE:Dr. MAHESH G.: M.B.B.S. (‘95); D.O (‘97), M.S. (‘99), Medical College, Trivandrum; D.N.B.(2000), FRCS (Edinburgh, 2001); Fellow, VR Surgery, Sankara Nethralaya, Chennai. PresentlyConsultant, Vitreoretinal services, Giridhar Eye Institute, Kochi-682020, Kerala.E-mail: maheshgopalakrishnan@yahoo.comKnowledge, Attitude and Practice Pattern Among Health CareProviders Regarding Diabetic RetinopathyDr. Mahesh G, Dr. A. Giridhar, Dr. S. J. Saikumar, Dr. Ram Kumar, Dr. Savita Bhat(Presenting Author: Dr. Mahesh G)Diabetic retinopathy is a major public healthproblem. It is one of the most commonvascular complications of diabetes mellitus (DM)and one of the main causes of new cases ofblindness among active people in the workplace.Diabetes mellitus affects 4 per cent of the world’spopulation, almost half of whom have somedegree of DR at any given time. It is estimatedthat in the developed world, the increase isapproximately 46%, from 55 million in 2000 to 83million in 2030; whereas, among developingnations, the increase is approximately 150%, from30 million in 2000, to 80 million in 2030. India had31.7 million diabetics in year 2000 with aprojection to reach 79.4 million by year 2030 asper the World Health Organization (WHO)estimates.Prevalence of DR in Wisconsin EpidemiologicalStudy of Diabetic Retinopathy (WESDR) was50.1% and 54.2% in the diabetes control andcomplications trial (DCCT) in IDDM and 35-39%in United Kingdom Prospective Diabetes Study(UKPDS) in NIDDM. In the Andhra Pradesh EyeDisease Study (APEDS) of self-reported diabetics,the prevalence of DR was 22.4%.This study was conducted to evaluate theknowledge, attitude and practice (KAP) patternsin the management of Diabetic Retinopathy (DR)among ophthalmologists and physicians.

COMMUNITY / SOCIAL OPHTHALMOLOGY SESSION165Materials and methods:The study was a cross-sectional study conductedamong medical professionals who includedgeneral physicians and ophthalmologists.Responses were obtained using a semi-structuredmulti point questionnaire survey that includedbasic demographic data regarding therespondents and the setup in which they wereworking. The survey questionnaire did notinclude personal details of the responders.Questions regarding diabetic retinopathy wereassessed in 3 sections of knowledge; attitude andpractice patterns. A separate questionnaire wasused for physicians and ophthalmologists.Physician’s questionnaire included basics ofophthalmology and diabetic retinopathy taughtat the undergraduate level. It included 10questions about knowledge, 7 questions aboutattitude and 5 questions about practice patternsfor diabetic retinopathy. The questionnaire forophthalmologists included 8 questions aboutknowledge, 7 questions about attitude and 7questions about practice patterns. Verbalinformed consent was obtained from all subjectswho participated in the study.ResultsA total of 76 ophthalmologists and 29 physicianshad responded to the survey questionnaire.Analysis of data was done separately forophthalmologists and physicians.OPHTHALMOLOGISTSDemographic data: A total of 76 ophthalmologistsresponded who included 26 males (34.21%)and 47 females (61.84%). Mean age of responderswas 42.42 ± 9.47 yrs. (minimum 27 to maximum61 yrs). 59 out of 76 (77.64%) respondentshave been practicing ophthalmology for morethan 5 years. 31of 76 40.79% responders were ingovernment service. 57 of the responders (75%)were general ophthalmologists while only 9 of76 (11.84%) were retina specialists. Percentage ofdiabetic patients seen in their general practicewere less than 10% in 06 (7.89%), 10 to 25% in 35(46.05%), 25 to 30% in 20 (26.32%) and more than50% of patients in 10 (13.16%).Knowledge pattern: 50 respondents (65.79%)said that they diagnose clinically significantmacular edema using slit lamp biomicroscopy. 22(28.95%) respondents stated that FBS more thanor equal to 110 and PPBS more than or equal to130 was criteria for diabetes mellitus while 34(44.74%) stated that FBS more than or equal to120 and PPBS more than or equal to 140 can beconsidered diagnostic of diabetes mellitus. 75(98.68%) stated that refractive error can be altereddue to blood sugar level. 67 responders (88.16%)stated that lipid profile ,glycaemic control,hypertension and renal disease can affect theprogression of retinopathy. IndirectOphthalmoscopy with Slit lamp Biomicroscopywas considered ideal examination to evaluate thediabetic fundus by 71 (93.42%). 53 (69.74%) wereof the opinion that Clinically significant macularedema and High risk PDR are indications forlaser photocoagulation. 71 (93.42%) opined thatnormal visual acuity in the presence of significantdiabetic retinopathy warrants treatment. Mostcommon indications of fluorescein angiographywere CSME before laser photocoagulation 39(51.32%).Attitude pattern: 31 responders (40.76%) use Slitlamp and Lenses while another 33 (43.42%) useboth slit lamp with lenses and indirectophthalmoscopes in their routine practice. 60(78.95%) are of the opinion that fasting bloodsugar level of Less than 120 is ideal for apreoperative cataract surgery patient on the dayof surgery. 73 (96.05%) ophthalmologists wouldlike to know the recent blood sugar level beforeprescribing glasses to their patients. 69 (90.79%)treating ophthalmologists would like to know therecent serum cholesterol and renal parameters ofdiabetic patients. 65(85.53%) are of the opinionthat visual acuity is not the single most importantindicator for the treatment of diabeticretinopathy. 64 (84.21%) are of the opinion thatretinal examination should be performed onlyafter dilatation. 51 (67.11%) are of the opinionthat FFA is not required for treatment of alldiabetic retinopathy cases.Practice pattern: Only 56 (73.68%) do slit lampbiomicroscopy examination in all diabeticpatients. 52 (68.42%) check blood sugar in allpreoperative cases on the day of surgery while 21(27.63%) do not check sugars. only 56 (73.68%)check the fasting blood sugar of their diabeticpatients routinely. 41 (53.95%) do not routinelyask for the serum lipid profile, HbA1c and renalparameters. 37 (48.68%) use indirectophthalmoscopy and slit lamp biomicroscopyroutinely for fundus evaluation followed by 16

166 AIOC 2010 PROCEEDINGS(21.05%) who use direct Ophthalmoscopy andslit lamp biomicroscopy. 44 (57.89%)ophthalmologists refer their patients to a retinaspecialist when they suspect proliferativediabetic retinopathy. 44 (57.89%) are of theopinion that frequency of periodic retinalevaluation depends on stage of retinopathy andvisual acuity while 25 (32.89%) respondersconsider yearly examination is enough forfundus examination.PHYSICIANSDemographic data: A total of 29 physiciansresponded who included 19 (65.52%) males and10 females (34.48%).Mean age of respondentswas 55.36 ± 8.97 yrs. (35 to 78 yrs). 25 (86.21%)had been practicing for more than 15 years. 14(48.28%) were doing Individual Private Practice.12 (41.38%) physicians said that diabeticsconstitute less than 10% of their patients while 11(37.93%) said that diabetics constitute 10 -25% oftheir patients.Knowledge pattern: 29 (100%) physicians are ofthe opinion that diabetic retinopathy is a blindingdisease. 27 (93.10%) are of the opinion thatretinopathy is related to the duration of diabetesmellitus. 26 (89.66%) agreed that patients canhave advanced diabetic retinopathy changes inspite of having good vision. 28 (96.55%) said thatall diabetic patients should have periodicalretinal examination. 22 (75.86%) opined thatLaser treatment is curative for diabeticretinopathy. Only 18 (62.07%) said that surgicaltreatment is available for advanced diabeticretinopathy. 27 (93.1%) agree that serum lipidprofile is related to the severity of diabeticmaculopathy. 29 (100%) agree that hyper tensionand renal disease can influence the diabeticretinopathy. 20 (68.97%) are of the opinion thatpregnancy can worsen diabetic retinopathy. 16(55.17%) said that fundus fluoresceinangiography is the ideal method to detectdiabetic retinopathy.Attitude pattern: 26 (89.66%) disagree with thestatement that eye examination is required indiabetic patients only when vision is affected. 15(51.72%) are of the opinion that a newly detecteddiabetic patient do not require eye check ups. 27(93.1%) are of opinion that diabetic patientsrequire an eye examination at yearly interval. 26(89.66%) agree that Laser treatment can preventblinding complications in up to 50% cases withdiabetic retinopathy. 22 (75.86%) of physiciansthink that FFA is required for evaluation of alldiabetic retinopathy cases. 25 (86.21%) agree thata good lipid profile is essential for preventingvision loss in diabetic retinopathy.Practice pattern: 24 (82.76%) advise diabeticpatients an eye evaluation as soon as diabetes isdetected. 26 (89.66%) will advise another eyecheckup after an year if there is no retinopathy atinitial examination. 29 (100%) physicians checkthe lipid profile of their diabetic patients. 16(55.17%) advise retinal evaluation every trimesterfor diabetic pregnant patients. 17 (58.62%) dodirect ophthalmoscopy to examine diabeticpatients.DiscussionThe American Academy of Ophthalmology(AAO) recommends that the first fundusexamination (FE) in patients with type 1 diabetesshould be performed 5 years after diagnosis ofthe disorder, because retinopathy is rarelyobserved before this period. However, patientswith type 2 diabetes should be examinedimmediately when they are diagnosed, becausethe duration of the disease is uncertain, so somedegree of retinopathy may be present at this time.The findings at this first examination willdetermine the frequency of subsequent tests.76 ophthalmologists and 29 physicians participatedin the multi point questionnaire survey.Among the ophthalmologists 52.26% were notsure about the current definition of diabetesmellitus. 93.4% knew that the ideal method ofexamination is indirect ophthalmoscopy with slitlamp biomicroscopy. But this was practiced byonly 48.6% ophthalmologists. Even though theknowledge about the role of hyperlipidemia andglycosylated hemoglobin in the pathogenesis ofDR was good (89.5% correct) only 40.78%checked it routinely. 32.9% felt once a year checkup for DR was adequate whatever the stage ofretinopathy be. Among the physiciansinterviewed the knowledge regarding the role ofduration of diabetes, its blinding complicationsand the role of systemic parameters were good(>75% responses correct). Some of themisconceptions were laser is curative in DR(75.9%), a newly detected diabetic does notrequire retinal evaluation (51.7%) and fluoresceinangiography is required for the diagnosis of DR

COMMUNITY / SOCIAL OPHTHALMOLOGY SESSION167(75.9%). 58.6% physicians used directophthalmoscope to evaluate retinopathy.The survey highlights some of the lacuna in ourhealth care systems. Most of theophthalmologists are well aware about theconsequences of diabetic retinopathy. Theyknow the ideal method of examination beingindirect ophthalmoscopy and slit lampbiomicroscopy. But this is not practiced bymany. The ophthalmologists are not sure aboutthe current definition of diabetes mellitus. Sothere is a need for awareness creation amongophthalmologists about the recent changes in themanagement of diabetes mellitus. Nearly all theophthalmologists would like to know the bloodsugars before prescribing glasses. But only 40%uses slit lamp and indirect ophthalmoscope todetect blinding diabetic retinopathy. Here thereis a disparity between knowledge level andpractice pattern. Slit lamp, indirectophthalmoscope and lenses are not veryexpensive accessories in an ophthalmic practice.But for most of our responders who are fromGovernment sector, this may not be available intheir practices. Here lies the importance ofimproving the infrastructure by providing thisbasic material for the fundus examination.Individual practitioners can consider getting allinstruments which will improve the quality oftheir work. Once the infrastructure is availableit need not be a problem for the ophthalmologistto put their knowledge into practice. All that isrequired is to make the ophthalmologists awareabout this simple practice which can detect earlydiabetic retinopathy. Continuing medicaleducation programme can be had for generalophthalmologists to improve their examinationskills.Regarding physicians, many of them know the1. Klein R, Klein BEK, Moss SE, Davis MD, DeMetsDL. The Wisconsin Epidemiologic Study of DiabeticRetinopathy IV. Diabetic macular edema.Ophthalmology. 1984;91:1464-74.2. Moss, SE, Klein, R, Klein BEK. The 14-yearincidence of visual loss in a diabetic population.Ophthalmology. 1998;105:998-1003.3. Klein HA, Moorehead HB. Statistics on blindness inthe Model Reporting Area, 1969-1970. Bethesda,Maryland: U.S. Department of Health, Educationand Welfare; 1973. DHEW publication no. 1970;73-Referencesconsequences of untreated diabetic retinopathy.But there are some misconceptions amongphysicians like laser is curative for diabeticretinopathy and FFA is needed for diagnosis ofdiabetic retinopathy. Physicians need to betrained regarding management of strategies ofdiabetic retinopathy. It is good to see that manyphysicians do simple direct ophthalmoscopy tolook for diabetic retinopathy. In another surveydone by us in one whole panchayath inErnakulam most of the self confessed diabeticpatients felt that they were not adequatelyinformed about the need for periodic evaluationand the significance of blinding problems ofdiabetic retinopathy. Only 1/3 of the patientswere informed by the treating physicianregarding all these. Here also there is disparitybetween the knowledge of the physician andpracticing. Physicians have to be made awareabout the need for patient education by them.This simple practice can detect early treatableretinopathy in a considerable number of cases.Even though the number of participants is few inour study it gives a glimpse to knowledgeattitude and practice pattern among health careproviders in our study. It is unique in the sensethat both ophthalmologists and physicians aresurveyed. They constitute the main health careproviders in diabetic retinopathy. To ourknowledge there are no such published reportsof similar studies. In this highly literate state withhighly knowledgeable health care providers itrequires just a little motivation to put all theseknowledge into practices. A combined effort byGovernment and nongovernmental organization,physicians, ophthalmologist and otherparamedical staff can result in better patient care.This can avert an explosive situation of diabeticblindness which is snowballing in our country.427.4. American Academy of Ophthalmology: PreferredPractice Pattern: Diabetic Retinopathy. SanFrancisco: American Academy Ophthalmology,1993.5. Early Treatment Diabetic Retinopathy StudyResearch Group. Photocoagulation for diabeticmacular edema. Early Treatment DiabeticRetinopathy Study report number 1. ArchOphthalmol. 1985;103:1796-806.6. Early Treatment Diabetic Retinopathy Study

168 AIOC 2010 PROCEEDINGSResearch Group. Early photocoagulation fordiabetic retinopathy: ETDRS report no. 9.Ophthalmology. 1991;98:766-85.7. Indications of photocoagulation treatment ofdiabetic retinopathy: Diabetic Retinopathy StudyReport no. 14. The Diabetic Retinopathy StudyResearch Group. Int Ophthalmol Cli 1987;103:1796-806.8. Wild S, Roglic G, Green A, Sicree R, King H. Globalprevalence of diabetes: estimates for the year 2000and projections for 2030. Diabetes Care 2004;27: 1047-53.9. Agarwal S, Mahajan S, Rani PK, Raman R, Paul PG,Kumaramanickavel G et al. How high is the nonresponserate of patients referred for eyeexamination from diabetic screening camps?Ophthalmic Epidemiology 2005;12(6): 393-4.10. Dandona R, Dandona L, John RK, McCarty CA, RaoGN. Awareness of eye diseases in an urbanpopulation in southern India. Bulletin of the WorldHealth Organisation 2001;79(2): 96-102.11. Rani PK, Raman R, Agarwal S, Paul PG, Uthra S,Margabandhu G et al. Diabetic retinopathyscreening model for rural population:awarenessand screening methodology. Rural and RemoteHealth 5(4): 350. (Online) 2005. Available:www.rrh.org.au (Accessed 8 July 2008).12. Vision 2020. KAP study protocol. (Online) no date.Available:http://laico.org/v2020resource/files/KAPStudyMethodology.pdf (Accessed 24 March2008).13. Namperumalsamy P, Kim R, Kaliaperumal K, SekarA, Karthika A, Nirmalan PK. A pilot study onawareness of diabetic retinopathy among nonmedicalpersons in South India. The challenge foreye care programmes in the region. Indian Journal ofOphthalmology 2004; 52:247-51.14. Rajiv R, Pradeep GP, Padmajakumari R, Tarun S.Knowledge and attitude of general practitionerstowards diabetic retinopathy practice in SouthIndia. Community Eye Health Journal 2006;19:13-4.15. Chengamanadu diabetic retinopathy awarenessstudy : Mahesh G and A Giridhar. Presented inKSOS annul meeting in 2005 and VRSI annualmeeting 2006.16. Prevalence of diabetic retinopathy in a ruralpopulation of south India: Mahesh G and AGiridhar. Presented in KSOS 2006 annual meeting.Discussion Comment by Dr. Subhash GuptaThis paper is also a new concept in which the introspection in form of knowledge, implementation and attitude ofthe other personnels who deals cases of DR is discussed and to our surprise lot more to be done. During discussionit was advised that being a life style disease the course, causes,history, medication and health education is theneed of the hour and it is the mutispeciality disorder and the ophthamlogist should be updated and should give moretime to patients. It is eye-opener that rural population is equally suffering from DM.