Perceptions of diabetic retinopathy-related educational resources in a community in Oman

study proposes to conduct further health promotional activities using social media platforms.


Introduction
Diabetic retinopathy (DR) is one of the most prevalent complications of both type 1 and type 2 diabetes mellitus (DM). It contributes 1%, out of the total 37 million blind individuals globally. 1 In Oman, 12.3% of the community aged over 18 years are affected with DM, and 10% of the affected individuals have sight-threatening DR. 2 Considering the prevalence of DM within the age group of 18 years and above within the region, 2 such individuals are at a higher risk of DR. The eye health systems along with working on diagnostic and therapeutic strategies can further serve on preventive measures with the aid of the concerned stakeholders. 3 Educating at-risk communities about the condition and preventive actions, and timely diagnosis and treatment can reduce the risk of visual impairment by approximately 90%. Hence, to reduce the burden related to this condition, the World Health Organization has categorised DR under the priority ocular issues and has recommended the involved nation members include it under the Vision 2020 WHO plan. 1 Health education concentrates on building up the communities' or individuals' health or diseaselinked knowledge and enhancing their attitudes. 4 Treatment and management of DM are vital for reducing the magnitude and impact of the condition. Patient education and awareness about the condition are directly correlated with the impact on preventive and treatment measures. The impact of treatment is lower in poorer compliance groups. 5 To deal with this challenge, an organised model of patient care may be more favourable. 6,7 http://www.avehjournal.org Open Access National standards for DM self-management education have set evidence-based norms for DM-related education. 5

Methods
This is a prospective, cross-sectional and online questionnairebased study. The survey was circulated among community members with a convenient snowball sampling technique using social media platforms. The volunteering participants were asked to further circulate the questionnaire, and adult responses from the Omani population above the age of 18 years who responded to the questionnaire using the online mode were considered for the study survey. All the Omani population matching the eligibility criteria and willing to respond to the questionnaire within the study duration of six months were included in the study. Minors (< 18 years), participants unable to respond online and disadvantaged individuals were excluded from the study.
A self-administered online questionnaire was constructed through a literature review 4,5,6,7 incorporating the items of DRrelated educational resources. The survey was distributed among the community members associated and not associated with a medical field. Participants associated with a medical field except eye care as well as from non-medical fields were given equal opportunities to participate in the study. Their association with medical fields or eye care was self-declared.
Google Forms were used to develop an online survey. The same form comprised the English and Arabic versions, and participants had the choice to read and reply in their language of convenience. Five optometry subject experts, two experts having doctoral qualifications and three experts with master's level qualifications, approved the questionnaire using the content validity approach. The native Arabic language expert evaluated the Arabic version of the document. The data were collected from March 2017 till September 2018. The questionnaire contained three sections. The initial section of the questionnaire collected information on the participant's demographic information.
Sections 2 and 3 involved a total of 29 elements. The second section collected information on the source of DR-related health education. This part also collected feedback on the member's perception of the availed DR material utilising a five-point Likert scale from strongly disagree to strongly agree. The perception section also collected responses using the fivepoint Likert scale focusing on the factors of ease of availability, content, timing, presentation, cultural appropriateness and service delivery related to the DR health promotional tool. The third section collected responses to the participant's preferred source of information as described by the participants.
From the total 11 provinces of the Sultanate, the mean population size was calculated. Provinces having a population size below the mean were categorised with low province population size, and provinces having a population size equal to or more than the mean were categorised with high province population size. The province's mean population size was 252 134 people. Muscat, Al Batinah North, Al-Dakhiliyah and Al-Batinah South were found to have high province population sizes. Dhofar, Ash Sharqiyah South, Ash Sharqiyah North, Al Dhahirah, Al-Buraymi, Al-Wusṭa and Musandam were found to have low province population sizes. 9

Data storage and statistical analysis
The data were saved on two different personal computers running Microsoft Excel 2013. IBM ® Statistical Package for Social Sciences version 21 was employed for data analysis. Descriptive statistics were used for analysing the demographic profile of the participants. Association between perceptions and other research variables were analysed using the chi-square test, Fisher's exact test and multinomial logistic regression analysis.

Ethical considerations
The study adhered to the tenets of the Declaration of Helsinki. Because of the online nature of the questionnaire, the participant's readiness to respond to the questionnaire was considered as their consent. The Research and Ethics Committee of the College of Health Sciences of the University of Buraimi in Oman approved the study. The study used a validated questionnaire-based tool. The tool was assessed based on the content and social and cultural appropriateness. The content validity was assessed by the optometry subject experts, and social and cultural appropriateness was approved by the Research and Ethics Committee of the College of Health Sciences.

Demographic summary of the study participants
The survey was circulated to 275 participants of which we received responses from 253 participants, providing a survey response rate of 92%. The survey analysis included 253 participants of which 51 (20.2%) were male and 202 (79.8%) were female. The majority (67.2%) of the participants were from provinces with high population density. About 54.1% of the participants were associated with the medical field, and parents of only 15.8% of the total study population were associated with the medical field (Table 1).

Followed and preferred sources of information for diabetic retinopathy
Only 155 (61.3%) of the study participants received DRrelated health information. Optometrists (30.3%) were the primary source of information, and sources such as radio, newspaper, leaflet and a friend (0.6% each) were the least followed sources. Approximately 24.5% of the study participants wished to obtain condition-related information from ophthalmologists, but only 7.7% of this study population could get the information from that source. Social media was the third (16.6%) most popular information source. Most printed health promotional materials such as newspapers and leaflets were unpopular sources.

Perception scores for different components of the provided educational material
Of the seven assessed components related to perception towards DR-related health educational material, ease of availability had the highest mean score of 69.1%. (standard deviation [s.d.] = 22.3%). The lowest score was for the presentation of the health educational material with a mean score of 65.2% (s.d. = 21.8%) (see Table 2).

Association between the overall perception score with the other study variables
Perception scores of more than or equal to 50% are classified as having a positive perception of being availed of DR-related educational resources. Scores of less than 50% are classified as having a negative perception. Out of the total 155 members receiving DR-related health education, 78.7% (n = 122) of the study participants had a positive perception and 21.3% (n = 33) of the study participants had a negative perception of the obtained resources.
The associations of the perception scores were evaluated with other study variables using the chi-square test.
There was a statistically insignificant relationship between the type of perception with the variables of gender, personal education level, self-education related to the medical field, the population size of the participant's province, medically related occupations, father's and mother's educational level and the parent's association with the medical field. The chi-square, degree of freedom, significance level and effect size for these variables are included in Table 3.

Association of the degree of satisfaction with study variables
The study performed a multinomial logistic regression analysis to model the relationship between the degree of satisfaction with the other study variables. As shown in Table 4, fathers' educational level was a significant contributor, while the other factors had statistically non-significant associations.

Comparison of percentage perception score with the other independent study variables
The non-parametric Mann-Whitney U test was employed to compare the percentage perception scores with the independent groups of the study variables of gender, medical relationship with self or parent education or occupation. All were statistically non-significant (Table 5).

Discussion
The study investigated the community's perception of DR-related health educational resources. Educational interventions help to develop condition-related managerial skills among health professionals. For instance, the quality of life of affected individuals is observed to improve communities receiving sufficient and quality DM-related education. 7 Hence, the study evaluated the DR-related informational mode received by the communities and their perception of these resources.
This study used a prospective cross-sectional questionnairebased design to evaluate the participant's perception of DRrelated health education material. A systematic review by Iquize et al. identified the improvement in self-perception of individuals with DM and skill enhancement among the involved health professionals. 7 Findings of this study provide a baseline for evaluating the community's DR health education resource-related perception.
This study included participants from the general population compared with the other studies having DM population or health professionals. 7,8 The dissimilarities of the perception related to the educational material compared with the previous studies could also be because of the variability of the educational tool and the type of study populations.
Health education can be provided in groups during the counselling sessions, telephonic or using online platforms. It may also target the at-risk population along with the affected individuals.
Of the total respondents, 61.3% of our study population received DR-related health education. This study observed that optometrists (30.3%) were the most common source of information about their condition. An effective knowledge source can be key in the management of DR. A study by Pereira et al. observed a higher knowledge level related to DM post-intervention among the group receiving health information compared to the non-receiver group. 10 As observed in our study, although 24.5% of the study participants    wish to obtain condition-related information from an ophthalmologist, only 7.7% of this study population could get the information from that source. This could be because of the higher clinical burden on the tertiary health service providers within the health system. Indirect platforms such as social media can be helpful to outsource this task, reducing the chair time of the involved health professionals. Social platforms may be the most convenient in terms of economy, duration, flexibility and recitation. These study findings support this approach as a similar percentage of this study population have availed (18.7%) and preferred (16.6%) this approach.  11 The level of patient motivation, while attaining the health educational material, can also impact their perception towards the resource.
The study observed no statistically significant association between the type of perception with the other study variables. Most participants had a positive or very positive perception of the availed DR-related health educational material. A study by Chen et al. observed that a higher educational level and a family history of DM were associated with a higher understanding of health education or instructions. 12 However, the association of the type of perception with each type of educational resource should be further explored with larger sample sizes.
Because of the multifactorial systemic involvement, DM differentiates itself from other disease conditions. For instance, a person with DM needs follow-ups with different medical specialties including diabetologists, nutritionists, ophthalmologists and dentists. 7 Keeping a DM patient motivated to comply with the associated conditional management can be a daunting task. The burden on the individual needs to be considered. Hence, it would be beneficial to provide the services to this population in a convenient and simplified manner. The use of health management tools within these groups can be useful.
The study highlighted the current gaps in DR-related health educational resources. It identified the main source of information within the community and their preferred sources. The findings can help design future health educational resources related to the condition. The identified preferred platform can also be chosen for promoting health and carrying a significant positive impact.

Suggestions for future research
As this study included only the participants able to respond to an online questionnaire, the participants are assumed to be mainly from higher educational and socio-economic backgrounds. This population could be expected to have better health educational exposure compared with the population having lower educational and socio-economic status. Hence, the study observations cannot apply to the latter population. A similar study should be conducted for such a population. Even though the participant perceptions were positive towards the DR promotional resources, the study did not link the participant's perception of the condition-related knowledge, attitudes or practice levels, and these aspects should be explored separately.

Conclusion
Only 61.3% of participants received DR-related health information. Most of the participants had a positive perception of DR-related health educational resources.
Optometrists are the main source for providing information.
Considering the relatively insufficient circulation of health information related to DR among the community, it is necessary to conduct further health promotional activities related to the condition and social media platforms could help communicate such information.