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Middle East African Journal of Ophthalmology Middle East African Journal of Ophthalmology
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Year : 2011  |  Volume : 18  |  Issue : 3  |  Page : 204-208  

Knowledge of primary prevention of diabetic retinopathy among general ophthalmologists, mid level eye care personnel and general physicians in Oman

1 Department of Non Communicable Disease Surveillance and Control, Eye Health Care, Ministry of Health, Oman
2 Dharamsey Eye Centre, Muscat, Oman

Date of Web Publication20-Aug-2011

Correspondence Address:
Rajiv Khandekar
Eye and Ear Health Care, Department of Non Communicable Disease Control, Director General of Health Affairs, Ministry of Health (HQ) POB: 393, Pin: 113, Muscat
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/0974-9233.84045

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Objective : We present the outcomes of knowledge of diabetes and associated ocular complications among personnel comprising the eye care team in Oman.
Materials and Methods : A closed ended questionnaire was administered during November 2008 and November 2009 to eye care team members in six regions of Oman, where trainings were held. All participants of these trainings were included in our study. The questionnaire comprised 15 questions that tested the knowledge of the diagnosis and treatment of diabetes and its ocular complications. They circled the most suitable reply for a list of choices. The replies were compared with the gold standard (answers from a medical retina specialist, a diabetologist's and general ophthalmologists answers). The participants were divided into two groups; acceptable (more than 50% score compared to gold standard) and less than desired (less than 50% score compared to gold standard.) We estimated the areas of acceptable level of knowledge in different subgroups.
Results : All 87 (100%) of eye care team members participated. Of the 42 general ophthalmologists, 30 (71.4%) had an acceptable level of knowledge about primary prevention, ideal blood sugar and blood pressure levels and complication of diabetes. The acceptable level of knowledge among mid level eye care providers and general physicians was found in 15 (54.5%) and 4 (33.3%) respondents respectively.
Conclusion : Less than the desired number of participants of the eye care team had an acceptable level of knowledge about primary prevention, ideal blood sugar and blood pressure levels and complications of diabetes. The training of eye care personnel need to enhance knowledge in the weak areas is identified in this study.

Keywords: Diabetes Mellitus, Diabetic Maculopathy, Knowledge, Non-Proliferative Diabetic Retinopathy, Proliferative Diabetic Retinopathy

How to cite this article:
Khandekar R, Deshmukh R, Vora U, Al Harby S. Knowledge of primary prevention of diabetic retinopathy among general ophthalmologists, mid level eye care personnel and general physicians in Oman. Middle East Afr J Ophthalmol 2011;18:204-8

How to cite this URL:
Khandekar R, Deshmukh R, Vora U, Al Harby S. Knowledge of primary prevention of diabetic retinopathy among general ophthalmologists, mid level eye care personnel and general physicians in Oman. Middle East Afr J Ophthalmol [serial online] 2011 [cited 2022 Jun 29];18:204-8. Available from: http://www.meajo.org/text.asp?2011/18/3/204/84045

   Introduction Top

Diabetes mellitus (DM) is a chronic metabolic disorder caused by an absolute or relative deficiency of insulin. Nearly, 75% of persons with diabetes for more than 20 years suffer from diabetic retinopathy (DR) - a blinding eye complication. [1] Strict glycemic control, control of hypertension and lipid levels prevent and delay the onset of sight threatening diabetic retinopathy (STDR) which is an advanced stage of DR. [2],[3]

Education of this sight threatening condition is crucial for healthcare staff to ensure diabetic patients are counselled properly. Eye care teams in secondary and tertiary level centers in Oman screen patients with diabetes to rule out associated ocular complications. [4] This screening examination is an ideal opportunity to reinforce the preventive modalities and address the risk factors of DR with patients. However, due to the heavy workload and lack of knowledge, eye care staff in Oman focus mainly on eye care related duties rather than patient counselling. In many countries, mid level eye care staff known as ophthalmic counsellors advise diabetic patients and their relatives on the importance of primary prevention and regular follow ups. Ophthalmic counsellors are absent in Oman; hence, patient counselling needs to be the responsibility of existing eye care staff. Therefore, assessing the knowledge of primary prevention of diabetes among eye care team members especially general ophthalmologists is crucial. To the best of our knowledge, an assessment of eye care team members has not been reported in English peer reviewed literature.

Under the Ministry of Health, Oman, there are 10 regional hospitals and another 21 eye clinics. Approximately, 125 qualified ophthalmologists provide eye care to a population of 2.8 million in Oman. Seven ophthalmologists (mostly in the capital Muscat) are subspeciality trained in medical/ surgical vitreo-retina and the remainder are general ophthalmologists or experts in other ocular subspecialties. In Oman, general nurses, optometrists and selected general practitioners assist ophthalmologists in the eye department.

This study has been conducted to determine the level of knowledge of primary prevention of diabetes and associated ocular complications among general ophthalmologists, mid-level eye care team members and general physicians in six regions of Oman. Data on the level of knowledge will enhance training protocols geared specifically for diabetic eye disease.

   Materials and Methods Top

A closed ended questionnaire was administered to all members of the eye health care team who were attending "standard eye care for persons with diabetes" training workshops during November 2008 and November 2009. This survey was conducted as a pretest of participants in the training workshops that were held for capacity building and monitoring eye care team members in the health regions of Oman. Written and informed consents of all participants as well as verbal consent of the national and regional health administrators was obtained.

Confidentiality of the participants was maintained by using codes unique to the participant and known only to the participant. The questionnaire comprised a total of 15 multiple choice questions on general health regarding diabetes and diabetic retinopathy and the role of health personnel in counselling diabetic patients [Table 1]. All questions were pre-tested. We gave this questionnaire to three general ophthalmologists, three optometrists and three general physicians trained in primary eye care. They provided the feedback regarding clarity of questions in Arabic language. The questionnaire was revised accordingly. There were five questions regarding diabetes, one question on the primary prevention, seven questions on the ocular complications and care and two questions on the job responsibilities of health personnel for different components of eye care in Oman. The participants were asked to circle the most suitable answer of the four or five options for each question. The replies were compared with the gold standard answers from three experts - a medical retina specialist, a diabetologist and a general ophthalmologist.

Each participant's knowledge was based on the number of correct answers. For each correct answer, 10 points were scored. The score of correct responses was calculated out of a total score of 150. Participants who scored between 76 points and 150 points were considered having an acceptable grade of knowledge. This group was further divided into 'excellent' (111 or more points) and good (76 to 110 points). Participants who scored 75 points or less were considered having 'less than desired' grade of knowledge. This group was further divided into a poor grade (41 points to 75 points) and very poor (less than 40 points).
Table 1: Level of knowledge about diabetic retinopathy among eye care staff in Oman

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Frequencies and percentages were calculated with Open EPI (Dean AG, Sullivan KM, Soe MM. OpenEpi: Open Source Epidemiologic Statistics for Public Health, Version 2.3. www.OpenEpi.com) and Statistical Package for Social Science Version 16 (SPSS Inc., Chicago, Ill., USA) software for descriptive analysis and statistical validation. Univariate analysis and the parametric method were applied for statistical evaluation.

   Results Top

At four study sites, 87 eye care team members participated in this study. The study cohort consisted of 42 (48%) general ophthalmologists, 33 (38%) mid level eye care providers (optometrists and nurses in the ophthalmic department) and 12 (14%) general physicians (GPs).

The levels of knowledge among members of the cohort are presented in [Table 2]. The number of participants obtaining an excellent level for knowledge about primary prevention, level of high blood sugar and complications of diabetes were low [Table 2].
Table 2: Level of knowledge regarding diabetic retinopathy among eye care staff in Oman

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Of the 42 general ophthalmologists, 71.4% had an acceptable level of knowledge. Among other 33 mid level eye care providers and 12 GPs, approximately 54.5 and 33.3% respectively had an acceptable level of knowledge [Table 3].
Table 3: Grades of knowledge regarding diabetic retinopathy among eye care staff in Oman by health staff category

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An acceptable level of knowledge was present in 8 (50%) Dhahira-based participants, 10 (58.8%) Dhakhiliya-based participants, 18 (52.9%) North Batinah-based participants and 13 (65%) Sharqiya-based participants. The variation in the level of knowledge by study site was not statistically significant (c΂= 1.073, degrees of freedom = 3, P = 0.7835).

   Discussion Top

Assessing the level of knowledge of diabetic patients and health care personnel involved in primary care has been documented both in Oman and other countries. [5],[6],[7],[8],[9] A study in Alexandria, Egypt revealed that information on causes and complications of diabetes was very good among physicians but knowledge about the diagnosis and management of diabetes and its complications was poor. The nurses in this study had less knowledge compared to the physicians. [10] However, to our knowledge, data on the existing capacity of the eye care team members to deal with primary prevention of diabetes does not exist in the literature. Hence, the outcomes of this study are useful in enhancing Oman's approach to diabetes education for health care personnel and likely for other countries with similar goals. Training health care personnel regarding diabetic retinopathy will help in reducing visual disability due to diabetes.

More than half of the staff who were evaluated in our study had an acceptable level of knowledge. The study cohort consisted of ophthalmologists, mid level eye care providers and GPs. The knowledge of ophthalmologists was better than that of mid level eye care personnel and GPs. This mixture of different types of health care staff likely explains the overall low levels of knowledge among participants of our study. However, these are all personnel who routinely interact with diabetic patients and evaluation of knowledge levels is imperative.

The comparison of our study with similar studies evaluating the knowledge of different categories of health staff suggested that the level of knowledge about diagnosis of diabetes, its management and its complication was low [Table 4]. However, comparison to previous studies should be interpreted with caution due to the inclusion of different levels of health care personnel in our study compared to other studies.
Table 4: Studies assessing knowledge regarding diabetes and associated ocular complications

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The majority of ophthalmologists (71.4%) in the current study had an acceptable level of knowledge. General ophthalmologists working in the Ministry of Health institutions of Oman are often from different countries. Therefore, their formal training might have dictated a different focus on controlling the risk factors of DR. This may explain the 28.6% ophthalmologists who had an unacceptable level of knowledge.

In our study, only 45% of eye care personnel and 33% of the general physicians had an acceptable level of knowledge. It should be noted that there were a number of questions on eye care for diabetic retinopathy. Ancillary staff are likely not as well versed in the details of management of DR.

Primary prevention is significant for reducing or stopping the progress of DR. Preventive measures include a healthy lifestyle, controlling hypertension, stringent lipid control and periodic ophthalmic examinations. [11] In the absence of good primary prevention, laser therapy and other efforts by an ophthalmologist will not result in the expected outcomes and could result in poor satisfaction among patients and their family. Therefore, proper counselling of patients with sight threatening DR for preventive measures prior to reaching the stage of laser treatment can result in a significant reduction of visual morbidity.

In countries with adequate resources, patient education is performed by well-trained ophthalmic counsellors, staff of primary health centers and those involved in non-communicable disease control programs. [12] However, opportunities for reemphasizing the need of primary prevention by ophthalmic staff at the time of the regular check up should not be a wasted opportunity to re-educate and reinforce the preventive measures to diabetic patients. In Oman, education of health care personnel regarding the current modalities of primary prevention among is urgently required. A limitation of this study is that only six regions in Oman are evaluated. Hence extrapolation of the outcomes to all regions of Oman may not be accurate without further study.

Our survey was administered prior to a workshop and the outcomes of the study were shared with the participants. The training workshop was altered accordingly to ensure more stress on the weak areas of knowledge. We found that among participants, less than a desirable number of staff had acceptable knowledge about the primary prevention and the diagnosis of diabetes. The department of diabetes control may consider focusing their training effort cover the weak areas indicated in this study and there needs to periodic trainings of all eye care team members not just physicians. Almost 10% of the Omani population over 20 years of age have diabetes mellitus, [13],[14] resulting in an estimated 80,000 people with diabetes. In a hospital-based survey in 2003, we found 14.4% of the diabetic population visiting eye hospitals had diabetic retinopathy. [15] In view of the high magnitude of both diabetes and diabetic retinopathy (DR) currently and in the coming years, ophthalmologists in Oman are facing a challenge in providing standard eye care to reduce/delay visual disability due to diabetes. General ophthalmology and allied eye care trainings often do not focus on details of posterior segment diseases and their management. The limited medical retina specialists will not be able to deal effectively with the significant patient load. Therefore, general ophthalmologists will have to contribute in the early detection and prevention of the progress of the DR. Oman's efforts in building the capacity of existing general ophthalmologists will be the first step in this direction. In this regard, the findings of our study would be useful for future comparison. Additionally, the outcomes of the current study can be used as baseline data about their level of knowledge of diabetes and eye care which would be very useful for evaluating the impact of the capacity building in coming years.

   Acknowledgment Top

We thank health administrators who permitted us to undertake this research. We thank all members of the Eye care team for being so cooperative during this study.

   References Top

1.The effect of intensive treatment of diabetes on the development and progression of long-term complications in insulin-dependent diabetes mellitus. The Diabetes Control and Complications Trial Research Group. N Engl J Med 1993;329:977-86.  Back to cited text no. 1
2.Stratton IM, Kohner EM, Aldington SJ, Turner RC, Holman RR, Manley SE, et al. UKPDS 50: Risk factors for incidence and progression of retinopathy in Type II diabetes over 6 years from diagnosis. Diabetologia 2001;44:156-63.  Back to cited text no. 2
3.Matthews DR, Stratton IM, Aldington SJ, Holman RR, Kohner EM; UK Prospective Diabetes Study Group. Risks of progression of retinopathy and vision loss related to tight blood pressure control in type 2 diabetes mellitus: UKPDS 69. Arch Ophthalmol 2004;122:1631-40.  Back to cited text no. 3
4.Khandekar R, Mohammed AJ, Al Lawati JA. Care of diabetic retinopathy patients in Oman. Sultan Qaboos Univ Med J 2008;8:5-9.  Back to cited text no. 4
5.Shera AS, Jawad F, Basit A. Diabetes related knowledge, attitude and practices of family physicians in Pakistan. J Pak Med Assoc 2002;52:465-70.   Back to cited text no. 5
6.Khandekar R, Shah S, Al Lawatti J. Retinal examination of diabetic patients: Knowledge, attitudes and practices of physicians in Oman. East Mediterr Health J 2008;14:850-7.  Back to cited text no. 6
7.Goodman GR, Zwarenstein MF, Robinson II, Levitt NS. Staff knowledge, attitudes and practices in public sector primary care of diabetes in Cape Town. S Afr Med J 1997;87:305-9.  Back to cited text no. 7
8.Khandekar R, Al-Harby S, Al-Harthy H, Al-Lawatti J. Knowledge, attitude and practice regarding eye complications and care among Omani persons with diabetes: A cross sectional study. Oman J Ophthalmol 2010;3:60-5.  Back to cited text no. 8
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9.Muecke JS, Newland HS, Ryan P, Ramsay E, Aung M, Myint S, et al. Awareness of diabetic eye disease among general practitioners and diabetic patients in Yangon, Myanmar. Clin Experiment Ophthalmol 2008;36:265-73.  Back to cited text no. 9
10.Chatziralli IP, Sergentanis TN, Keryttopoulos P, Vatkalis N, Agorastos A, Papazisis L. Risk factors associated with diabetic retinopathy in patients with diabetes mellitus type 2. BMC Res Notes 2010;3:153.  Back to cited text no. 10
11.Koura MR, Khairy AE, Abdel-Aal NM, Mohamed HF, Amin GA, Sabra AY. The role of primary health care in patient education for diabetes control. J Egypt Public Health Assoc 2001;76:241-64.  Back to cited text no. 11
12.Balcou-Debussche M, Debussche X. Type 2 diabetes patient education in Reunion Island: Perceptions and needs of professionals in advance of the initiation of a primary care management network. Diabetes Metab 2008;34:375-81.  Back to cited text no. 12
13.Asfour MG, Lambourne A, Soliman A, Al-Behlani S, Al-Asfoor D, Bold A, et al. High prevalence of diabetes mellitus and impaired glucose tolerance in the Sultanate of Oman: Results of 1991 National Survey. Diabet Med 1995;12:1122-5.  Back to cited text no. 13
14.Sulaiman AJ, Al-Riyami A, Farid S, Ebrahim GJ. Oman Family Health Survey 1995. J Trop Pediatr 2001;47:1-33.  Back to cited text no. 14
15.Khandekar R, Al Lawatii J, Mohammed AJ, Al Raisi A. Diabetic retinopathy in Oman: A hospital based study. Br J Ophthalmol 2003;87:1061-4.  Back to cited text no. 15


  [Table 1], [Table 2], [Table 3], [Table 4]

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