Knowledge, attitude, practice and
quality of life assessment in glaucoma- a cross sectional survey
Elfride F.S.1, Philip
S.2, Kishore S.R.3
1Dr Elfride Farokh Sanjana, Professor, Department of Ophthalmology,
Pondicherry Institute of Medical Sciences, Kalapet, Pondicherry, India, 2Dr. Serin Philip Medical Claim Officer, Dar al Shifa hospital, Kuwait, 3Dr. Kishore Sastha Ram V., Lecturer, Department of Pharmacy, College
of Health sciences, Mizan Tepi University SNNPR, Ethiopia
Address for
Correspondence: Dr Elfride Farokh Sanjana, Professor,
Department of Ophthalmology, Pondicherry Institute of Medical Sciences,
Kalapet, Pondicherry. Email: elfridesanjana@gmail.com
Abstract
Aim: To
determine knowledge, attitude and practice of patients with glaucoma
and to analyze the quality of life of patients with glaucoma using the
GQL-15 questionnaire. Materials
and Methods: 62 patients with a known diagnosis of
glaucoma and started on medical management were included in the study.
On the first visit patients were counseling about the nature of the
disease, dose, duration and frequency of medications, were informed of
side effects and technique of instillation. On the second visit
patients were assessed with a validated KAP questionnaire and GQL-15
quality of life questionnaire. The questions were administered in the
local language by trained optometrists and health care personnel. Results: The inter
item correlation between knowledge, attitude and practice was found to
be 0.897, 0.877 and 0.765 there by validating the
questionnaire. Forty nine (87.5%) of patients were found to
have adequate knowledge regarding disease, drug, dose , frequency and
proper method of instillation of eye drops. Forty one (73.32%) of
patients were found to have a positive attitude towards usage of eye
drops and the remaining 15(26.78%) negative attitude. Safe
practice was followed by 49 ( 87.5%) of patients and unsafe with 7(
12,57%) GQL-15 questionnaire applied at the time of second visit showed
40 (71.42%) of patients with low GQL score. Conclusion: Our
study highlights that awareness and dissemination of information on
basic eye drop instillation technique improves patient knowledge
awareness and practice patterns of this asymptomatic disease and can
help patients adhere to management.
Key words:
Attitude, Glaucoma, Knowledge, Practice, Quality of life
questionnaire
Manuscript received: 04th
December 2016, Reviewed:
10th December 2016
Author Corrected: 19th
December 2016, Accepted
for Publication: 27th December 2016
Introduction
Global data on visual impairment has stated glaucoma to be a leading
cause of irreversible blinded worldwide [1] with 11 million of these
patients from India [2] with an estimated projection to 16 million by
the year 2020 [3]. Due to its asymptomatic nature and lack of awareness
amongst the people it largely remains under diagnosed [4,5]. To
compound matters most patients are diagnosed in the advanced stages
where very little can be done to salvage useful filed of vision in this
vulnerable group of population [6.7]. Several studies have estimated
the awareness of this slowly progressive asymptomatic condition in
southern India [8,9,10]. The other element in deciding the burden of
glaucoma is the effective utilization of eye services. Several studies
had estimated this social economic aspect of Glaucoma. [11,12].
Lowering of intraocular pressure is the only known means of treating
glaucoma however it is only a surrogate marker for control of the
disease. Quality of life indicators with the use of validated
questionnaires has provided important insights that help make
therapeutic choices and suggest alterations in the patients home
environment to minimize problems and obstacles [13,14]. Such
adaptations might permit more years of unassisted living for the
elderly. Information from QOL studies can help educate newly diagnosed
patients as to what may lie ahead as the disease progresses with a
possible additional benefit of reinforcement for the need for adherence
to the prescribed regimen despite the asymptomatic nature of the
disease.
There isn’t available literature that assesses both
knowledge, attitude and practice of patients with glaucoma who are also
subjected to QOL evaluation. This holistic approach might ensure better
control of the intraocular pressure with subsequent slowing in the
progression of the disease. In this study we have attempted the same.
Materials
and Methods
This study was conducted on 62 patients of either sex with a known
diagnosis of glaucoma. In addition to being subjected to a detailed
comprehensive eye examination a specifically designed Knowledge,
Attitude and Practice questionnaire was used on their second visit to
evaluate patients knowledge and eye drop instillation technique [8].
The survey was conducted by trained optometrist and health care
personnel who had adequate knowledge about the questionnaire. The
questionnaire was available in the local language and reading
assistance to the illiterate was provided. Informed consent was
obtained and ethics committee approval was obtained before embarking on
the study .The questionnaire included three domains
–knowledge which comprised of 12 closed ( yes or no)
questions on the patients awareness about the disease , name ,dose
,strength, frequency and storage conditions of the drug prescribed to
them on a prior visit. Along with this parameters such as affordability
and technique of eye drop administration was assessed. The second
domain - attitude comprised of 7 closed ended questions and the third
practice consisted of 4 closed ended questions and 7 descriptive
questions regarding the practices and usage of eye drops. Each question
was allocated a score of 1 if yes and 2 if no. Each question per
patient was counted for their response and expressed as a percentage.
Similarly each domain was summated and knowledge of patients was
expressed as adequate and inadequate, attitude as positive and negative
and practice as safe and unsafe respectively in percentage. Cronbachs
alpha coefficient measures the overall correlation between items within
a scale/questionnaire. AN internal consistency of greater than 0.7 and
less than 0.9 was considered acceptable in justifying its use. A high
alpha value suggests that the items measure the same single underlying
condition. It is used to validate the specially prepared KAP
questionnaire.
Glaucoma quality of life (GQL-15) Questionnaire is a specific tool for
assessing quality of life in glaucoma patients [13,14]. Questions focus
on visual ability, specific task performance and the impact of reduced
visual ability on patients quality of life. It contains 15 rating
scored questions used to assess the degree of disability caused by
glaucoma. Six questions related to actions demanding functional
peripheral vision, 6 relating to dark adaptation and glare, and two
relating to central and near vision and one to outdoor mobility.
Patients were instructed to circle the correct answer on a scale from
1-5
Results
The inter item correlation between knowledge, attitude and practice was
found to be 0.897, 0.877 and 0.765 there by validating the
questionnaire (Table 1). Forty nine (87.5%) of patients were found to
have adequate knowledge regarding disease, drug, dose, frequency and
proper method of instillation of eye drops. Remaining 7 (12.5%) were
found to have inadequate knowledge (Table 2).
Table-1:
Cronbachs’ Alpha Correlation Coefficient for KAP Questionnaire
|
Domain
|
Number
of items
|
Cronbach’s
alpha coeff
|
|
Knowledge
|
12
|
0.897
|
|
Attitude
|
7
|
0.877
|
|
Practice
|
4
|
0.765
|
Table-2: Knowledge,
attitude and practice scores- Knowledge
|
S.No
|
Scores
|
Knowledge
|
Subjects
|
Percentage
|
|
1
|
>15
|
Adequate
|
49
|
87.5
|
|
2
|
<15
|
Inadequate
|
7
|
12.5
|
Table- 3: Knowledge,
attitude and practice scores- Attitude
|
S.No
|
Score
|
Attitude
|
Subjects
|
Percentage
|
|
1
|
<15
|
Positive
|
41
|
73.32
|
|
2
|
>15
|
Negative
|
15
|
26.78
|
Table 4: Knowledge,
attitude and practice scores- Practice
|
S.No
|
Score
|
Practice
|
Subjects
|
Percentage
|
|
1
|
<15
|
Safe
|
49
|
87.5
|
|
2
|
>15
|
unsafe
|
7
|
12.57
|
Table-5: Glaucoma Quality
of life score (GQL-15)
|
S.No
|
Score
|
GQL
|
Subjects
|
Percentage
|
|
1
|
<35
|
Low
QOL
|
40
|
71.42
|
|
2
|
>35
|
High
QOL
|
16
|
28.57
|
Forty one (73.32%) of patients were found to have a positive
attitude towards usage of eye drops and the remaining 15(26.78%)
negative attitude (Table 3). Safe practice was followed by 49 (87.5%)
of patients and unsafe with 7(12,57%) (Table 4)
GQL-15 questionnaire applied at the time of second visit showed
40(71.42%) of patients with low GQL-15 score (Table 5)
Discussion
The need for health education to improve knowledge, awareness and self
care practices amongst both rural and urban India cannot be over
emphasized. This study evaluated the knowledge, attitude and practice
on methods of instillation of eye drops as well as the GQL-15
questionnaire only after the patients were counseled and instructed
regarding the dose, dosing interval, method of instillation of drops in
the form of pictorial leaflets in English and local language leaflets
during their first consultation. Among 56 patients who reported for the
second visit all patients had adequate knowledge about their disease,
43(76.78%) were aware of the name of the drug, dosage frequency and
storage conditions. The right method of eye drop instillation was
observed in 49(87.5%) and 41(73.21%) of patients were aware of
nasolacrimal duct occlusion maneuver. In a study by Dandona R et all,
awareness about the disease glaucoma in an urban population in South
India was very poor-2.3% [8]. Another study amongst rural South India
by Krishnaiah S et al a total of 61.1%of people did not even know what
glaucoma was [9]. This study also provided insights on improving
awareness amongst rural population by better ease and access to health
care delivery systems and poor awareness was directly related to
socioeconomic status and level of literacy [9]. In a study by
Satyamangalam R.Ve women and those with a family history of glaucoma
were more likely to be aware and had good knowledge of glaucoma [10].
Attitude was measured and 15(26.78%) patients experienced difficulty in
using eye drops. Good self care practices of eye
drop instillation was followed in 49(87.5%) patients
The impact of the disease on patients quality of life can be
assessed with quality of life questionnaire .a study by Severn P. et al
assessed the strengths and weaknesses of the several quality of life
questionnaires. GQL-15 instrument established a graded response from no
difficulty to severe difficulty in performing daily activities. The
GQL-15 questionnaire is a disease specific questionnaire, easier to
use, and had shown good internal consistency. It is a 15 item, 4 domain
tool that is short and easy to use [15]. This questionnaire however
neglects other aspects such as mental health, dependency or general
health. In another study by Spaeth G, published literature on quality
of life in patients with glaucoma was assessed. And they concluded that
such an assessment is as important as the treatment offered by health
care providers in the management of glaucoma [13]. The purpose of this
survey highlights the importance of patient counseling and a
significant improvement in the knowledge, attitude and practice of
glaucoma in comparison to similar such studies that showed a low level
of understanding of the disease process. A study by Rewri et al [16]
did not find a relationship between age or gender and glaucoma
awareness. Rewri et al also established a higher understanding of
glaucoma amongst patients with higher level of education and in those
with acquaintances with glaucoma patients. Similar trends were reported
on other glaucoma awareness related studies [8].
Overall awareness on glaucoma in Indian population based studies is
poor [8,9,10]. In yet another study by Kaur D et al concurred there is
no gold standard quality of life assessment tool [17]. Severn P et al
and Schacknow PN et al in their study on QOL assessment concluded that
glaucoma specific and vision specific tools are better than generic
tools to assess the impact of glaucoma on the quality of life of
affected patients [15,18].
This study highlights the importance of patient counseling having
benefits in managing glaucoma. Limitations of our study include the
small sample size, the possibility of an interviewer bias and lack of a
comparative pre and post KAP questionnaire to show the effectiveness of
counseling in this cohort of patients. Lester M et al established a
significant (P<0.0001) correlation between the quality of life
using the Viswanathan et all’s questionnaire and MD (r=0.79),
PSD (r=-0.68) and CPSD( r= -0.61)[19].
With the increasing incidence of ocular surface disease with the use
with anti glaucoma medication with BAK, Skalicky et al evaluated the
relation between ocular surface disease and glaucoma quality of life
and found an increased OSDI index in patients with increasing severity
of glaucoma [20].
Conclusion
Our study highlights that awareness and dissemination of information on
this asymptomatic disease can help patients adhere to management and
follow up and in turn reduce the national and global burden of
blindness due to glaucoma with simple measures such as improving
knowledge, attitude and practice on instillation of eye drops in the
right manner. There exist numerous quality of life questionnaires for
glaucoma but each with its own limitations. A holistic approach beyond
medical knowledge can help patients understand the nature of the
disease and retard progression ensuring better quality of life for
those afflicted with glaucoma.
Dr Elfride Farokh Sanjana: Previous affiliation: (when the study was
done) Associate Professor, Department of Ophthalmology, Sri Ramachandra
Medical College and Research Institute, Chennai −600116
Funding:
Nil, Conflict of
interest: None initiated.
Permission from IRB:
Yes
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How to cite this article?
Elfride F.S., Philip S., Kishore S.R. Knowledge, attitude, practice and
quality of life assessment in glaucoma- a cross sectional survey. Int J
Med Res Rev 2016;4(12):2199-2204.doi:10.17511 /ijmrr. 2016.i12.20.