THE PREVENTION AND MANAGEMENT OF OCULAR
COMPLICATIONS IN DIABETIC PATIENTS
by
PETER CHRISTOPHER CLARKE-FARR
Thesis submitted in fulfilment of the requirements for the degree Philosophiae Doctor in Higher Education Studies
(Ph.D. Higher Education Studies)
in
THE CENTRE FOR HIGHER EDUCATION AND DEVELOPMENT UNIVERSITY OF THE FREE STATE
BLOEMFONTEIN
DECEMBER 2005
Supervisor: Prof. Dr M.M. Nel Co-supervisor: Prof. Dr A. Wilkinson
DECLARATION
I hereby declare that the work which is submitted here is the result of my own independent investigation. Where help was sought, it was acknowledged. I further declare that the work is submitted for the first time at this university/faculty towards the Philosophiae Doctor degree in Higher education Studies and that it has never been submitted to any other university/faculty for the purpose of obtaining a degree.
……… ………..
P.C. CLARKE-FARR DATE
I hereby cede copyright of this product in favour of the University of the Free State.
……… ………..
DEDICATION
….to my mother, June Megan Clarke-Farr
“Lord, make me an instrument of Your peace. Where there is hatred, let me sow love; where there is injury, pardon;
where there is doubt, faith; where there is despair, hope; where there is darkness, light; and where there is sadness, joy. O, Divine Master,
grant that I may not so much seek to be consoled as to console; to be understood as to understand; to be loved as to love;
for it is in giving that we receive;
it is in pardoning that we are pardoned;
and it is in dying that we are born to eternal life.”
ACKNOWLEDGEMENTS
I wish to gratefully acknowledge the contributions of the following persons who made the completion of this research possible:
• My study promoter, Prof. Dr M.M. Nel, Head of Educational Development, Faculty of Health Sciences, University of the Free State, for her expert guidance, support and advice throughout the study.
• My co-study promoter, Prof. Dr A. Wilkinson, Centre for Higher education Studies and Development, University of the Free State, for her valuable advice and instruction for the research.
• Prof. P.P.C. Nel, Programme Organiser: Health Science, in the School of Medicine, University of the Free State, for his help and advice in the development of the Delphi questionnaire.
• Prof. F. Bonnici, President: Diabetes South Africa, for his guidance, enthusiasm and constant support for the nature of this research.
• The Dean of the Faculty of Applied Sciences, Cape Peninsula University of Technology, for his constant support of my further studies and academic career, as well as all my colleagues in the Faculty of Applied Sciences.
• The Cape Peninsula University of Technology for granting me the time and support needed to undertake the research and the writing of the thesis.
• The participants in the study who were willing to participate in the pilot testing and quality control of the patient and health care worker questionnaires and Delphi questionnaires.
• The patients, health care workers and Delphi panel involved in the research for their time and valuable contributions in completing the questionnaires. • Mr M. Jowell and Mr Z. Sirayi for the organisation of the diabetic patients and
• Ms R. Van Rooyen for her assistance in capturing the data from the diabetic patient and health care worker questionnaires.
• Ms A. Dunn, Ms H. Vember and Ms G. Lourens for their co-ordination of the questionnaires for the nurses and health care workers.
• Mrs S.C.J. Liebenberg, Centre for Higher education Studies and Development, for her help with language editing and referencing and meticulous attention to detail with the thesis.
• Ms R. Strydom of the Division of Educational Development at the Faculty of Health Sciences at the University of the Free State for her ongoing assistance throughout my research at the University.
• Mr R. Frans, Faculty of Applied Sciences, Cape Peninsula University of Technology and Mr Cloete Greeff, Multimedia Centre, University of the Free State, for their expertise in the production of the diagrams and graphics.
• Mr Gerard Dehlen and Mrs Cathy Dehlen, for their technical help and expertise in the compilation of the thesis.
TABLE OF CONTENTS
CHAPTER 1: BACKGROUND AND ORIENTATION TO THE STUDY
Page
1.1 INTRODUCTION ... 1
1.1.1 The role of diabetes education ... 2
1.1.2 Diabetes education for ocular complications ... 3
1.2 STATEMENT OF THE PROBLEM ... 5
1.3 THE GOAL, AIM AND OBJECTIVES OF THE STUDY ... 7
1.3.1 The overall goal of the study ... 7
1.3.2 The aim of the study ... 7
1.3.3 The objectives of the study ... 7
1.4 SCOPE OF THE STUDY ... 8
1.5 SIGNIFICANCE AND VALUE OF THE STUDY ... 10
1.6 DESIGN OF THE STUDY AND METHODS OF INVESTIGATION ... 10 1.6.1 Research design ... 10 1.6.2 Methods of investigation ... 12 1.6.3 Sample selection ... 13 1.6.3.1 Target population ... 13 1.6.3.2 Survey population ... 13 1.6.3.3 Sample size ... 13
1.6.3.4 Description of the sample ... 13
1.6.4 Research techniques ... 14
1.6.4.1 The Delphi technique ... 14
1.6.5.1 The questionnaires ... 15
1.6.5.2 The Delphi technique ... 15
1.6.6 Reliability, validity and trustworthiness ... 15
1.6.7 Ethical considerations ... 17
1.6.7.1 Health care w orkers and patients ... 17
1.6.7.2 The Delphi panel ... 17
1.7 DEFINING THE TERMINOLOGY ... 18
1.8 ARRANGEMENT OF THE THESIS ... 20
1.9 CONCLUSION ... 22
CHAPTER 2: CRITERIA FOR THE DEVELOPMENT OF POST-GRADUATE PROGRAMMES IN DIABETES EDUCATION 2.1 INTRODUCTION ... 24
2.1.1 List of acronyms in South African higher education ... 24
2.1.2 Higher education structures and statutory bodies in South Africa ... 25
2.1.2.1 Council on Higher education (CHE) ... 27
2.1.2.2 The South African Department of Education (DoE) ... 27
2.1.2.3 The South African Qualifications Authority (SAQA) ... 28
2.1.2.4 The National Qualifications Framew ork (NQF) ... 29
2.2 RESTRUCTURING HIGHER EDUCATION IN SOUTH AFRICA ... 32
2.2.2 Articulation principles, recognition of prior learning
and lifelong learning in higher education ... 36
2.3 OUTCOMES-BASED EDUCATION (OBE) ... 38
2.3.1 The principles of outcomes-based education ... 38
2.3.2 Outcomes-based education in academic programmes ... 44
2.3.3 The rationale for outcomes-based education in South Africa ... 46
2.3.4 Theoretical philosophies underpinning outcomes- based education in South Africa ... 48
2.3.5 Guiding principles for the implementation of outcomes- based education in South Africa ... 51
2.3.6 The rationale and support for outcomes-based education ... 56
2.3.7 Concerns and criticisms of outcomes-based education ... 58
2.3.8 Outcomes-based education in health programmes ... 63
2.3.8.1 Advantages of outcomes-based education in health programmes ... 64
2.3.8.2 Deriving outcomes for health programmes ... 66
2.3.8.3 The role of assessment in outcomes-based education health programmes ... 69
2.3.9 Using outcomes to guide instructional planning in South Africa ... 71
2.3.10 Implications of outcomes-based education ... 74
2.4 CURRICULUM DEVELOPMENT ... 76
2.4.1 Theories of curriculum ... 77
2.4.2 Designing and developing the curriculum ... 83
2.4.3 Benefits of a systematic approach to course and curriculum development ... 88
2.5 MODELS OF CURRICULUM DEVELOPMENT ... 89
2.5.1 The OBE curriculum model in South Africa ... 93
2.5.2 The Tyler model for curriculum development ... 96
2.5.3 The Taba model for curriculum development ... 98
2.5.4 The Saylor, Alexander and Lewis model for curriculum development ... 100
2.5.5 The Oliva model for curriculum development ... 101
2.6 DESIGNING AND IMPLEMENTING THE CURRICULUM ... 104
2.6.1 The role of needs assessment in curriculum design ... 104
2.6.2 Decision-making for implementing the curriculum ... 108
2.6.3 Selecting the curriculum design and implementation team ... 110
2.6.4 Implementing the curriculum – adjusting the ideal to the real ... 112
2.7 EVALUATING THE CURRICULUM ... 114
2.8 CURRICULUM DEVELOPMENT IN SOUTH AFRICA ... 119
2.8.1 The National Qualifications Framework and curriculum development ... 121
2.8.2 Processes for post-graduate programme approval in South Africa ... 125
2.9 TOWARDS EXCELLENCE IN PROGRAMME AND CURRICULUM DEVELOPMENT ... 130
2.9.1 Principles underlying the development of quality academic programmes and qualifications ... 131
2.9.2 Steps to achieving quality academic programmes ... 133
2.9.2.2 Sensitisation in the programme context ... 135
2.9.3 Post-graduate programme development criteria ... 137
2.10 DIABETES EDUCATION ... 140
2.11 A CRITICAL ANALYSIS OF DIABETES EDUCATION PROGRAMMES ... 141
2.11.1 Standards and norms for diabetes education programmes ... 142
2.11.2 An overview of international diabetes education programmes ... 150
2.11.3 South African diabetes education programmes ... 154
2.12 THE NEED FOR AN EDUCATION PROGRAMME FOR THE PREVENTION AND MANAGEMENT OF THE OCULAR COMPLICATIONS OF DIABETES ... 156
2.13 CONCLUSION ... 158
CHAPTER 3: DIABETES AND DIABETIC EYE DISEASE 3.1 INTRODUCTION ... 159
3.2 OVERVIEW OF DIABETES MELLITUS ... 159
3.2.1 Classification of diabetes ... 160
3.2.1.1 Type I, insulin-dependent diabetes mellitus ... 160
3.2.1.2 Type II, non-insulin-dependent diabetes mellitus ... 160
3.2.2.1 Type I, insulin-dependent diabetes mellitus ... 164
3.2.2.2 Type II, non-insulin-dependent diabetes mellitus ... 164
3.2.3 The effects of diabetes mellitus on the human body ... 165
3.3 THE EPIDEMIOLOGY OF DIABETES ... 166
3.3.1 Global epidemiology of diabetes ... 166
3.3.2 Epidemiology of diabetes in South Africa ... 167
3.3.3 Global epidemiology of diabetic retinopathy ... 170
3.3.4 Epidemiology of diabetic retinopathy in South Africa ... 171
3.4 RISK FACTORS FOR DEVELOPING DIABETES MELLITUS ... 172
3.4.1 Risk factors for developing Type I diabetes ... 172
3.4.2 Risk factors for developing Type II diabetes ... 172
3.4.3 Risk factors for developing diabetic retinopathy ... 173
3.5 SYSTEMIC COMPLICATIONS OF DIABETES MELLITUS ... 181
3.5.1 Acute complications of diabetes mellitus ... 182
3.5.2 Long-term complications of diabetes mellitus ... 183
3.6 OCULAR COMPLICATIONS OF DIABETES MELLITUS ... 184
3.6.1 General ocular complications of diabetes ... 184
3.6.2 Diabetic retinopathy... 185
3.6.3 Pathogenesis of ocular retinopathy ... 185
3.6.4 Classification of diabetic retinopathy ... 186
3.6.4.1 Background diabetic retinopathy ... 186
3.6.4.2 Preproliferative diabetic retinopathy ... 187
3.6.4.3 Proliferative diabetic retinopathy ... 188
3.6.4.4 Diabetic maculopathy ... 189
3.7 DIABETIC RETINOPATHY AS AN INDICATOR OF SYSTEMIC DISEASE AND MORTALITY ... 194
3.8 MANAGEMENT OF DIABETIC EYE DISEASE ... 194 3.8.1 The role of prevention in the management of diabetic
eye disease ... 195 3.8.2 The treatment and management of diabetic eye disease ... 196
3.9 INTERNATIONAL STANDARDS FOR THE SCREENING
OF DIABETIC RETINOPATHY ... 197 3.9.1 General screening and referral protocols for
diabetic retinopathy ... 199 3.9.2 Screening and referral protocols for diabetic
retinopathy in South Africa ... 201 3.9.3 Recommended instrumentation for diabetic
retinopathy screening ... 203 3.10 SOCIO-ECONOMIC ASPECTS OF DIABETES ... 205
3.11 SOCIO-ECONOMIC ASPECTS OF DIABETIC EYE DISEASE ... 206
3.12 EDUCATION CONCERNING DIABETES AND ITS OCULAR
COMPLICATIONS ... 207 3.13 CONCLUSION ... 208
CHAPTER 4: RESEARCH METHODOLOGY
4.1 INTRODUCTION ... 209 4.2 THE ASSESSMENT OF HEALTH NEEDS ... 209 4.2.1 Methods of assessing health needs ... 210
4.2.2 The role of epidemiological research ... 211
4.3 THEORETICAL PERSPECTIVES ON THE RESEARCH DESIGN ... 212
4.3.1 Methods of sampling ... 212
4.3.2 Purposive sampling for qualitative research ... 213
4.3.3 Triangulated methods for quantitative research ... 214
4.3.4 Theoretical and methodological bases for the use of questionnaires ... 215
4.3.5 Theoretical basis for the use of a pilot study ... 219
4.3.6 Philosophical and methodological foundations of the Delphi technique ... 222
4.3.6.1 Advantages of the Delphi technique ... 226
4.3.6.2 Disadvantages of the Delphi technique ... 226
4.3.7 Implications for the use of the Delphi technique as a research method ... 227
4.4 METHODS AND PROCEDURES ... 229
4.4.1 The literature review ... 231
4.4.2 The measuring instruments ... 232
4.4.2.1 The diabetic patient questionnaire ... 232
4.4.2.2 The health care w orker questionnaire ... 235
4.4.2.3 The Delphi study first round ... 238
4.4.2.4 The Delphi study second round ... 243
4.4.2.5 The Delphi study third round ... 246
4.5 SAMPLE SELECTION ... 247
4.5.1 The diabetic patients ... 247
4.5.1.1 Target population ... 247
4.5.1.3 Sample size ... 247
4.5.1.4 Description of the sample ... 248
4.5.2 The health care workers... 248
4.5.2.1 Target population ... 248
4.5.2.2 Survey population ... 248
4.5.2.3 Sample size ... 249
4.5.2.4 Description of the sample ... 249
4.5.3 The Delphi panel ... 251
4.5.3.1 Target population ... 251
4.5.3.2 Survey population ... 251
4.5.3.3 Sample size ... 251
4.5.3.4 Description of the sample ... 251
4.6 DATA ANALYSIS ... 256
4.6.1 The diabetic patient and health care worker questionnaires ... 256
4.6.2 The Delphi technique ... 257
4.6.2.1 The first round ... 257
4.6.2.2 The second round ... 258
4.6.2.3 The third round... 258
4.7 RELIABILITY, VALIDITY AND TRUSTWORTHINESS ... 258
4.7.1 Reliability ... 259
4.7.2 Validity ... 260
4.7.3 Trustworthiness ... 261
4.8 ETHICAL CONSIDERATIONS ... 261
4.8.1 Health care workers and patients ... 262
4.9 CONCLUSION ... 262
CHAPTER 5: RESULTS AND DATA ANALYSIS 5.1 INTRODUCTION ... 264
5.2 DEMOGRAPHIC INFORMATION ... 265
5.2.1 Demographic information of the diabetic patients ... 265
5.2.2 Demographic information of the health care workers ... 266
5.2.3 Demographic information of the Delphi panel... 266
5.3 THE DIABETIC PATIENT QUESTIONNAIRE SURVEY ... 267
5.3.1 Descriptions of data and findings from the diabetic patients’ questionnaire ... 267
5.3.1.1 Diabetic patients’ know ledge of diabetes ... 267
5.3.1.2 Summative discussion on the diabetic patients’ know ledge of diabetes ... 270
5.3.1.3 Diabetic patients’ know ledge of the ocular complications of diabetes ... 272
5.3.1.4 Summative discussion on the diabetic patients’ know ledge of the ocular complications of diabetes ... 274
5.3.1.5 Diabetic patients’ know ledge of the management and treatment options for diabetes ... 276
5.3.1.6 Summative discussion on the diabetic patients’ know ledge of the management and treatment options for diabetes ... 278
5.3.1.7 Additional information from diabetic patients ... 283
5.3.1.8 Summative discussion on the additional information from the diabetic patients ... 285
5.3.2 Implications of the findings from the diabetic patients for the proposed education programme ... 289
5.4 THE HEALTH CARE WORKER QUESTIONNAIRE SURVEY ... 290
5.4.1 Descriptions of data and findings from the health care worker questionnaire ... 290 5.4.1.1 Health care w orkers' education and training for the
assessment of diabetes risk factors ... 291 5.4.1.2 Summative discussion on the health care w orkers’
education and training for the assessment of diabetes risk factors... 294 5.4.1.3 Health care w orkers' education and training for the
assessment of the ocular complications of diabetes ... 298 5.4.1.4 Summative discussion on the health care w orkers’
education and training for the assessment of the ocular complications of diabetes ... 302 5.4.1.5 Health care w orkers' education and training for
screening and managing diabetic eye disease ... 306 5.4.1.6 Summative discussion on the health care w orkers’
education and training for screening and managing
diabetic eye disease ... 308 5.4.1.7 Health care w orkers' education and training for the
counselling of diabetic patients ... 311 5.4.1.8 Summative discussion on the health care w orkers’
education and training for the counselling of diabetic
patients ... 314 5.4.2 Summative discussion on the open responses of the
5.4.3 Implications of the findings from the health care
workers for the proposed education programme ... 320
5.5 THE DELPHI STUDY ... 322
5.5.1 First round of the Delphi study ... 322
5.5.1.1 Analysis of responses ... 322
5.5.1.2 Summative discussion of the findings of the first round of the Delphi study ... 326
5.5.2 Second round of the Delphi study ... 327
5.5.2.1 Analysis of responses ... 327
5.5.2.2 Summative discussion of the findings of the second round of the Delphi study ... 331
5.5.3 Third round of the Delphi study ... 332
5.5.3.1 Analysis of responses ... 332
5.5.3.2 Summative discussion on the findings of the third round (final round) Delphi study ... 336
5.6 CONCLUSION ... 346
CHAPTER 6: THE DEVELOPMENT OF A POST-GRADUATE EDUCATION AND TRAINING PROGRAMME FOR HEALTH CARE WORKERS FOR THE PREVENTION AND MANAGEMENT OF THE OCULAR COMPLICATIONS IN DIABETIC PATIENTS 6.1 INTRODUCTION ... 348
6.2 PREMISES FOR THE DEVELOPMENT OF THE DIABETES EDUCATION PROGRAMMME ... 349
6.2.1 Background and needs to be addressed by the
education programme ... 349
6.2.2 Benefits of the proposed education programme to the community and society ... 352
6.3 POINTS OF DEPARTURE FOR THE DEVELOPMENT OF THE DIABETES EDUCATION PROGRAMME ... 353
6.3.1 The role of the patient in the prevention and management of the ocular complications of diabetes ... 355
6.3.2 The role of the health care worker in patient education and the prevention and management of the ocular complications of diabetes ... 356
6.4 THE DIABETES EDUCATION PROGRAMME IN THE CONTEXT OF HIGHER EDUCATION IN SOUTH AFRICA ... 357
6.4.1 Policies and procedures ... 358
6.4.2 Outcomes-based education ... 359
6.4.3 Development of the curriculum ... 360
6.4.4 Implementing and evaluating the curriculum ... 362
6.5 EDUCATIONAL AND PUBLIC HEALTH NEEDS THAT ARE ADDRESSED BY THE DIABETES EDUCATION PROGRAMME .... 364
6.5.1 Diabetic patients’ knowledge of diabetes ... 365
6.5.2 Diabetic patients’ knowledge of the ocular complications of diabetes ... 365
6.5.3 Diabetic patients’ knowledge of the management and treatment of diabetes ... 366
6.5.4 Health care workers’ knowledge of the management and treatment of diabetes ... 367
6.6 ACADEMIC AND ADMINISTRATIVE ASPECTS PERTAINING
TO THE DIABETES EDUCATION PROGRAMME ... 369
6.6.1 Mission and purpose of the diabetes programme... 370
6.6.2 Organisation and coordination of the programme ... 370
6.6.3 Role and value of the advisory committee ... 371
6.6.4 Mode of delivery of the programme ... 371
6.6.5 Admission requirements and learning assumed to be in place ... 372
6.6.6 Educational methodologies and learner assessment ... 373
6.6.7 Human resources and academic staffing ... 376
6.7 STANDARDS AND OUTCOMES FOR AN EDUCATION PROGRAMME FOR THE PREVENTION AND MANAGEMENT OF THE OCULAR COMPLICATIONS OF DIABETES ... 377
6.7.1 Critical cross-field outcomes for the education programme .. 379
6.7.2 Critical outcomes for health care workers ... 380
6.7.3 Outcomes relating to the classification and diagnosis of diabetes ... 382
6.7.4 Outcomes relating to the risk factors contributing to the development of diabetes ... 383
6.7.5 Outcomes relating to the systemic complications of diabetes ... 384
6.7.6 Outcomes relating to the ocular complications of diabetes ... 384
6.7.7 Outcomes relating to screening for diabetic eye disease ... 385
6.7.8 Outcomes relating to the management and treatment modalities for diabetic eye disease ... 386
6.8 PERSPECTIVES CONCERNING THE DEVELOPMENT AND DELIVERY OF THE PROPOSED DIABETES EDUCATION
PROGRAMME ... 387 6.8.1 The development of the programme according to the
Oliva model of curriculum development ... 389 6.8.2 Criteria for the submission of the diabetes education
programme ... 390
6.8.3 Approval and accreditation of the diabetes education
programme ... 394
6.9 CHALLENGES REGARDING THE DELIVERY OF THE
DIABETES EDUCATION PROGRAMME ... 403 6.9.1 Legislation and scope of practice of health care
workers’ professions ... 403 6.9.2 Policies of the South African Department of Health ... 405 6.9.3 Perceived benefits to health care workers ... 408
6.10 RECOMMENDATIONS MADE WITH REGARD TO THE
EDUCATION PROGRAMME ... 409 6.11 CONCLUSION ... 411
CHAPTER 7: CONCLUSION AND RECOMMENDATIONS
7.1 INTRODUCTION ... 412 7.2 CONCLUSION ... 412
7.3 LIMITATIONS OF THE STUDY... 415 7.4 RECOMMENDATIONS ... 416 7.5 CONCLUSIVE REMARK ... 417 BIBLIOGRAPHY……….418 PERSONAL COMMUNICATIONS………..442 APPENDICES………..443 APPENDIX A: APPENDIX B: APPENDIX C: APPENDIX D: APPENDIX E: APPENDIX F: APPENDIX G: APPENDIX H: APPENDIX I: APPENDIX J: APPENDIX K: APPENDIX L: APPENDIX M: APPENDIX N: APPENDIX O: APPENDIX P: APPENDIX Q:
APPENDIX R: APPENDIX S: APPENDIX T: APPENDIX U: APPENDIX V: APPENDIX W: APPENDIX X: APPENDIX Y:
LIST OF TABLES
TABLE 2.1: Summary of the NQF: Qualifications, levels and minimum credits ... 31 TABLE 2.2: Outcomes identified by the English National Board
for Nursing, Midwifery and Health Visiting ... 68 TABLE 2.3: The curriculum evaluation guide ... 115 TABLE 2.4: HEQC criteria for programme input ... 130 TABLE 2.5: International standards for diabetes education ... 144 TABLE 2.6: Summary of the standards and norms for diabetes
education programmes ... 147 TABLE 2.7: Exit level outcomes for the National Certificate in
Diabetes Nursing ... 155 TABLE 3.1: Criteria for the diagnosis of diabetes mellitus ... 162 TABLE 3.2: Criteria for the diagnosis of gestational diabetes
mellitus ... 162 TABLE 3.3: The epidemiology of diabetes mellitus ... 167 TABLE 3.4: The prevalence of non-communicable diseases in
the Western Cape and in South Africa ... 169 TABLE 3.5: The original classification of diabetic retinopathy ... 190 TABLE 3.6: Clinical diabetic retinopathy disease severity scale ... 191 TABLE 3.7: Australian classification of diabetic retinopathy ... 193 TABLE 3.8: General screening and referral protocols for
diabetic retinopathy ... 200 TABLE 3.9: Urgency of referral for diabetic retinopathy ... 202 TABLE 3.10: Recommended camera specifications for diabetic
TABLE 4.1: List of hospitals, clinics and community health
centres for participating health care workers ... 250 TABLE 5.1: Diabetic patients' knowledge of diabetes ... 268 TABLE 5.2: Diabetic patients' knowledge of the ocular
complications of diabetes ... 272 TABLE 5.3: Diabetic patients' knowledge of the management
and treatment options for diabetes ... 276 TABLE 5.4: Additional information from diabetic patients ... 284 TABLE 5.5: Health care workers’ education and training for
the assessment of diabetes risk factors ... 292 TABLE 5.6: Health care workers' education and training for the
assessment of the ocular complications of diabetes ... 299 TABLE 5.7: Health care workers' education and training for
screening and managing diabetic eye disease ... 306 TABLE 5.8: Health care workers' education and training for
the counselling of diabetic patients ... 312 TABLE 5.9: Analysis of responses from the Delphi Study
Round One ... 323 Table 5.10: Analysis of responses from Delphi Study
Round Two ... 328 TABLE 5.11: Analysis of responses from Delphi Study
Round Three ... 333 TABLE 5.12: Round Three (Final Round) Stability Statements ... 341
LIST OF FIGURES
FIGURE 2.1: The Demonstration Mountain ... 41 FIGURE 2.2: Developmental process from Tyler's rationale to
the Perennial Curriculum Model ... 91 FIGURE 2.3: A model for OBE curriculum design in South Africa ... 94 FIGURE 2.4: The Oliva model for curriculum development ... 102 FIGURE 4.1: A schematic overview of the research process ... 230 FIGURE 4.2: Example of feedback questionnaire for the
Delphi study ... 244 FIGURE 5.1: Patient responses to their diabetes type ... 270 FIGURE 5.2: Patients’ knowledge of the effects of diabetes
inside the eye ... 275 FIGURE 5.3: Importance of eye tests to patients ... 281 FIGURE 5.4: Frequency of diabetic patients' eye examinations ... 283 FIGURE 5.5: Patient beliefs on vision and health of the eyes ... 286 FIGURE 5.6: The need for eye examinations ... 287 FIGURE 5.7: Age of the patient as a risk factor for diabetes ... 295 FIGURE 5.8: The risk factors for Type I and Type II diabetes ... 298 FIGURE 5.9: The importance of blood sugar control ... 304 FIGURE 5.10: The influence of socio-economic status on the
development of the ocular complications of
diabetes ... 305 FIGURE 5.11: Training for the screening of diabetic retinopathy ... 311 FIGURE 5.12: The preparation and training of health care workers
for educating diabetic patients ... 315 FIGURE 5.13: Health care workers’ ability to educate and
FIGURE 6.1: Premises for the development of the Post-graduate
Diabetes Education Programme... 350 FIGURE 6.2: Points of departure for the development of the
Diabetes Education Programme... 354 FIGURE 6.3: Processes involved with the development of the
standards and outcomes for the prevention of the ocular complications of diabetes ... 378 FIGURE 6.4: Perspectives around the development and delivery
LIST OF APPENDICES
APPENDIX A: Letter of request to health care workers
APPENDIX B: Form of consent for health care workers
APPENDIX C: Letter of request for diabetic patients
APPENDIX D: Form of consent for diabetic patients
APPENDIX E: Letter of permission to conduct research with diabetic
patients
APPENDIX F: Diabetic patient record card and Education
Questionnaire in English
APPENDIX G: Diabetic patient record card and Education
Questionnaire in Xhosa
APPENDIX H: Diabetic patient record card and Education
Questionnaire in Afrikaans
APPENDIX I: Health care worker Diabetes Education Questionnaire
in English
APPENDIX J: Health care worker Diabetes Education Questionnaire
in Xhosa
APPENDIX K: Letter of invitation and request to Delphi panellists
APPENDIX L: Form of consent for Delphi panellists
APPENDIX M: Accompanying letter to Delphi panel Round One
APPENDIX N: Questionnaire for Delphi panel Round One
APPENDIX O: References for Delphi questionnaire Round One
APPENDIX P: Letter of feedback for Round One
APPENDIX Q: Feedback results to Delphi panel Round One
APPENDIX R: Accompanying Letter to Delphi panel Round Two
APPENDIX S: Questionnaire for Delphi panel Round Two
APPENDIX U: Combined Rounds One and Two Results feedback to Delphi Panel
APPENDIX V: Accompanying letter to Delphi panel Round Three
APPENDIX W: Questionnaire for Delphi panel Round Three (final
round)
APPENDIX X: Letter of feedback for Round Three (final round)
LIST OF ACRONYMS CE: Conformité Européene
CHE: Council on Higher education CMO: Cystoid Macular Oedema
CSMO: Clinically Significant Macular Oedema CESM: Classification of Educational Study Matter CHEC: Cape Higher education Consortium
DCCT: Diabetes Control and Complications Trial DoH: Department of Health
DoE: Department of Education DOTA: Declaration of the Americas DR: Diabetic Retinopathy
EMS: Emergency Medical Services ESRD: End Stage Renal Disease
ETQA: Education and Training Quality Assurer FET: Further Education and Training
FTE: Full Time Equivalent
HEQC: Higher education Quality Committee
HEQF: Higher education Qualifications Framework HPCSA: Health Professions Council of South Africa IDDM: Insulin Dependent Diabetes Mellitus IDF: International Diabetes Federation
IRMA: Intra-Retinal Microvascular Abnormalities MoE: Ministry of Education
NQF: National Qualifications Framework NVD: Neovascularisation at the Disk NVE: Neovascularisation Elsewhere
OBE: Outcomes-based Education PDR: Proliferative Diabetic Retinopathy PQM: Programme and Qualifications Mix NHS: National Health Service
NIDDM: Non-Insulin Dependent Diabetes Mellitus NPDR: Non-proliferative Diabetic Retinopathy NSB: National Standards Body
RPL: Recognition of prior learning SANC: South African Nursing Council
SAQA: South African Qualifications Authority SGB: Standards Generating Body
SETA: Sector Education and Training Authority UFS: University of the Free State
VEGF: Vascular Endothelial Growth Factor
WESDR: Wisconsin Epidemiologic Study of Diabetic Retinopathy WHO: World Health Organization
SUMMARY
• Key terms: Community health centres; curriculum; Delphi technique; diabetes mellitus; diabetes education; health care worker; higher education; nurse; optometrist; ocular complications of diabetes; outcomes-based education; patients; post-graduate education programme.
This research was undertaken in order to develop a post-graduate education and training programme for health care workers for the prevention and management of the ocular complications in diabetic patients. This was necessary, as there appeared to be a clear need for health care workers to receive specific education and training in this regard, as well as for additional skills and knowledge to be acquired and used to screen and detect sight-threatening complications of diabetic disease in such patients.
The overall goal of the study was therefore to enhance the education, training and skills of health care workers managing diabetic patients in order to prevent and manage sight-threatening diabetic complications, the results of which would be to make a significant contribution to the quality of health care provided to diabetic patients in the public health sector.
The specific objectives of the study were to conceptualise the processes involved in the development of a post-graduate diabetes education programme; to gain information with regard to the knowledge and education of diabetic patients and health care workers about diabetes and its ocular effects; and to identify the core competencies and curriculum that would comprise the education programme to be developed for the health care workers. Therefore the aim of the study was to develop a post-graduate education and training programme for health care
workers with a view to the prevention and management of the ocular complications that occur in diabetic patients.
The research design was based on a descriptive survey research study which included cross-sectional and panel research. A quantitative as well as a qualitative approach to the research was followed. The methods which were used and which formed the basis of the study comprised a literature review, the use of questionnaires, and the Delphi process. The literature review was undertaken in order to contextualise the research problem as well as to provide information used to compile the questionnaires for the diabetic patients, the health care workers, and the Delphi study. In the empirical study, use was made of three different questionnaires.
First, the diabetic patients completed the questionnaires in order to obtain information about the patients’ knowledge about diabetes and its ocular complications as well as information on how they managed the condition. Second, the health care workers completed the questionnaires in order to provide information about their knowledge of diabetes and its ocular complications, as well as information about their education and training in this area of medicine and health care. Third, based on the literature review and the results of the questionnaires from the diabetic patients and health care workers, the Delphi questionnaire was developed for consideration by the Delphi panel with a view to the development of the education programme.
Consent was obtained from the Western Cape Department of Health for the purposes of conducting the research with the health care workers and diabetic patients. Each respondent, including the members of the Delphi panel who had
agreed to take part in the study, provided written consent to participate in the research.
The focus of the literature review was on the criteria for the development of post-graduate programmes in diabetes education. This would be in the realm of Higher education Studies. In order to develop such a programme, attention had to be paid to the processes involved with curriculum and programme development in South Africa, together with legislative requirements for the approval and offering of such programmes. The proposed programme had to be viewed against the higher education landscape in South Africa, together with the principles and policies guiding higher education.
The use of outcomes-based education had to be considered for this programme, particularly in terms of policies requiring educators to acknowledge the imperatives to redress the inequalities of the past, to open access for all learners to higher education, and to consider the recognition of prior learning as it relates to learners in pursuit of lifelong learning. Models of curriculum development were also considered in order to derive a mechanism for the development of the education programme as well as to consider how such a curriculum model would allow for the programme to be evaluated and improved.
It was also important for the literature review to analyse available diabetes education programmes and to consider whether any programmes had been developed specifically for the purposes that this research aimed to achieve. As there were no programmes available that dealt with the training of health care workers for the prevention and management of the ocular complications of diabetes, this research could then be considered to be unique and truly groundbreaking. It was also necessary to review all aspects of the medical
condition of diabetes and its systemic and ocular complications, as this information was used as background for all aspects of the research.
The Delphi questionnaire had to deal with seven major aspects pertaining to the development of the post-graduate education programme. These included aspects with regard to curriculum and programme development in the higher education sector of South Africa; questions about the education of diabetic patients; issues relating to the provision of public health in South Africa; issues relating to the academic and administrative aspects of a post-graduate diabetes education programme; issues relating to the standards and outcomes for a programme for the prevention and management of the ocular complications of diabetes; issues relating to the benefits of a programme for the prevention and management of the ocular complications of diabetes; and aspects that must be addressed in an education programme for the prevention and management of the ocular complications of diabetes.
Twelve experts were included in the Delphi panel and were selected according to criteria including their expertise in diabetes, public health, medicine, ophthalmology, optometry, nursing, and higher education programme development. The analysis of the various rounds of the Delphi process was done manually by the researcher and the results of the Delphi process are included in the Appendices. Pre-testing of the Delphi questionnaire, as well as of the patient and health care worker questionnaires was done through pilot studies. These actions were undertaken in order to ensure the reliability, validity and trustworthiness of the study.
The findings of the empirical study involving the diabetic patients and health care workers were reported on by means of Tables and Figures as well as a
summative discussion of the findings. Likewise, the Delphi study was similarly reported and discussed. These findings were used to develop the post-graduate diabetes education programme.
The development of the programme was summarised in terms of the following premises for the development of the diabetes education programme; points of departure; the diabetes education programme in the context of higher education in South Africa; educational and public health needs that are addressed by the diabetes education programme; academic and administrative aspects pertaining to the diabetes education programme; standards and outcomes for an education programme for the prevention and management of the ocular complications of diabetes; as well as perspectives and challenges with regard to the delivery of the diabetes education programme. The researcher proposed the way forward in terms of obtaining the necessary approval by the Department of Education followed by the accreditation processes required by the Higher education Quality Committee (HEQC) in order to obtain final registration with the South African Qualifications Authority (SAQA). Finally, conclusions were drawn and the limitations of the study, together with the proposed recommendations, were provided.
This research aims to make a significant contribution towards the delivery of eye care in the public health sector in South Africa and, specifically, for the prevention and management of the ocular complications that occur in diabetic patients.
OPSOMMING
• Sleutelterme: gemeenskapsgesondheidsentrums; leerplan;
Delphitegniek; diabetes mellitus; diabetesonderwys; gesondheidsorgwerker; hoër onderwys; verpleegster; oogkundige; okulêre komplikasies van diabetes; uitkomsgebaseerde onderwys; pasiënte; nagraadse onderwysprogram.
Hierdie navorsing is onderneem om ‘n nagraadse onderwys- en opleidingsprogram vir gesondheidsorgwerkers te ontwikkel met die oog op die voorkoming en bestuur van van okulêre komplikasies by diabetiese pasiënte. Dit was nodig omdat daar klaarblyklik ‘n duidelike behoefte aan gesondheidsorgwerkers om spesifieke onderwys en opleiding in hierdie verband te ondergaan, bestaan het. Verder was dit nodig om addisionele vaardighede en kennis te verkry en te gebruik om visie-bedreigende komplikasies van diabetiese siekte in sulke pasiënte op te spoor.
Die oorhoofse doel van die studie was daarom om die onderwys, opleiding en vaardighede van gesondheidsorgwerkers wat in beheer is van diabetiese pasiënte met die oog op die voorkoming en hantering van visie-bedreigende diabetiese komplikasies, te verhoog. Die gevolge hiervan sou wees om ‘n beduidende bydrae te lewer tot die kwaliteit van gesondheidsorg wat aan diabetiese pasiënte in die openbare gesondheidsektor voorsien word.
Die spesifieke doelwitte van die studie was om die prosesse wat betrokke is by die ontwikkeling van ‘n nagraadse diabetesonderwysprogram te konseptualiseer; om inligting te verkry rakende die kennis en onderwys van diabetiese pasiënte en gesondheidsorgwerkers aangaande diabetes en die okulêre effekte daarvan; asook om die sleutelvaardighede en die kurrikulum waaruit die onderwysprogram wat vir die gesondheidsorgwerkers saamgestel sou word, te identifiseer. Daarom
was die doel van die studie om ‘n nagraadse onderwys- en opleidingsprogram vir gesondheidsorgwerkers te ontwikkel met die oog op die voorkoming en beheer van die okulêre komplikasies wat by diabetiese pasiënte voorkom.
Die navorsingsontwerp is gebaseer op ‘n beskrywende oorsignavorsingstudie wat dwarsprofiel- en paneelnavorsing ingesluit het. ‘n Kwantitatiewe sowel as ‘n kwalitatiewe benadering tot die studie is gevolg. Die metodes wat gebruik is en wat die basis van die studie gevorm het, het bestaan uit ‘n literatuuroorsig, die gebruik van vraelyste, en die Delphiproses. Die literatuuroorsig is onderneem om die navorsingsprobleem te kontekstualiseer, asook om inligting te voorsien om die vraelyste vir die diabetiese pasiënte, die gesondheidsorgwerkers, en die Delphistudie op te stel. In die empiriese studie is drie verskillende vraelyste gebruik.
Eerstens het die diabetiese pasiënte die vraelyste voltooi met die oog daarop om inligting te verkry oor hul kennis van diabetes en die okulêre komplikasies daarvan, asook om inligting in te win oor hoe hulle die toestand beheer het. Tweedens het die gesondheidsorgwerkers die vraelyste ingevul met die oog daarop om inligting te voorsien aangaande hul kennis van diabetes en die okulêre komplikasies daarvan, asook om inligting te versamel oor hul onderwys en opleiding op hierdie gebied van die geneeskunde en gesondheidsorg. Derdens, gebaseer op die literatuuroorsig en die resultate van die vraelyste van die diabetiese pasiënte en die gesondheidsorgwerkers, is die Delphivraelys ontwikkel vir nadere ondersoek deur die Delphipaneel met die oog op die ontwikkeling van die onderwysprogram.
Toestemming is verkry van die Departement van Gesondheid van die Wes-Kaap met die oog daarop om navorsing te doen oor die gesondheidsorgwerkers en
diabetiese pasiënte. Elke respondent, insluitende die lede van die Delphipaneel wat toegestem het om aan die studie deel te neem, het geskrewe toestemming verleen om aan die navorsing deel te neem.
Die fokus van die literatuuroorsig was op die kriteria vir die ontwikkeling van nagraadse programme in diabetesonderwys. Dit val onder die afdeling Hoëronderwysstudies. Met die oog op die ontwikkeling van so ‘n program, moes aandag geskenk word aan die prosesse wat betrokke is by kurrikulum- en programontwikkeling in Suid-Afrika, tesame met wetlike vereistes vir die goedkeuring en aanbieding van sulke programme. Die voorgestelde program moes gesien word in die lig van die hoëronderwyslandskap in Suid-Afrika, tesame met die beginsels en beleide wat rigting gee aan hoër onderwys.
Die gebruik van uitkomsgebaseerde leer moes in aanmerking geneem word vir hierdie program, veral in terme van beleidsaspekte wat vereis dat opvoeders die ongelykhede van die verlede moes regstel; om toeganklikheid vir alle leerders tot hoër onderwys daar te stel; en om die erkenning van voorafleer soos dit betrekking het op leerders wat lewenslange leer nastreef, te oorweeg. Modelle van kurrikulumontwikkeling is ook oorweeg met die oog daarop om ‘n meganisme in plek te kry vir die ontwikkeling van die onderwysprogram, asook om te oorweeg hoe so ‘n kurrikulummodel hom sou leen tot die evaluering en verbetering van die program.
Dit was verder belangrik vir die literatuuroorsig om beskikbare diabetesonderwysprogramme te ontleed en om te oorweeg of enige programme spesifiek ontwikkel is vir die doelwitte wat hierdie navorsing wou bereik. Aangesien daar geen programme beskikbaar was wat spesifiek gehandel het oor die opleiding van gesondheidsorgwerkers vir die voorkoming en beheer van die
okulêre komplikasies van diabetes nie, kan hierdie navorsing dus as uniek en as ware baanbrekerswerk beskou word. Dit was ook nodig om alle aspekte van die mediese toestand van diabetes en die sistemiese en okulêre komplikasies daarvan in oënskou te neem, aangesien hierdie inligting as agtergrond vir alle aspekte van die navorsing gebruik is.
Die Delphivraelys moes sewe hoofaspekte wat betrekking het op die ontwikkeling van die nagraadse onderwysprogram ondersoek. Hierdie het aspekte ingesluit rakende die kurrikulum- en programontwikkeling in die hoëronderwyssektor in Suid-Afrika; vraagstukke rakende die onderwys van diabetespasiënte; vraagstukke met betrekking tot die voorsiening van openbare gesondheid in Suid-Afrika; vraagstukke rakende die akademiese en administratiewe aspekte van ‘n nagraadse diabetesonderysprogram; vraagstukke rakende die standaarde en uitkomste vir ‘n program vir die voorkoming en beheer van die okulêre komplikasies van diabetes; vraagstukke met betrekking tot die voordele van ‘n program vir die voorkoming en beheer van die okulêre komplikasies van diabetes; asook aspekte wat aangespreek moet word in ‘n onderwysprogram vir die voorkoming en beheer van die okulêre komplikasies van diabetes.
Twaalf deskundiges is in die Delphipaneel ingesluit. Hulle is gekies volgens die kriteria insluitende hul deskundigheid in diabetes, openbare gesondheid, geneeskunde, oftalmologie, optometrie, verpleegkunde, asook hoëronderwysprogramontwikkeling. Die analise van die verskillende rondtes van die Delphiproses het per hand deur die navorser geskied en die resultate van die Delphiproses word in die Bylaes ingesluit. Vooraftoetsing van die Delphivraelys asook van die pasiënte- en die gesondheidsorgwerkervraelyste het deur middel van loodsstudies geskied. Hierdie aksies is onderneem om die betroubaarheid, die geldigheid en die geloofwaardigheid van die studie te verseker.
Die bevindinge van die empiriese studie wat die diabetiese pasiënte en die gesondheidsorgwerkers betrek het, is deur middel van Tabelle en Figure asook ‘n samevattende bespreking van die bevindinge gerapporteer. Die bevindinge van die Delphistudie is op ‘n soortgelyke wyse gerapporteer en bespreek. Hierdie bevindinge is gebruik om die nagraadse diabetesonderwysprogram te ontwikkel. Die ontwikkeling van die program is opgesom in terme van die volgende uitgangspunte vir die ontwikkeling van die diabetesonderwysprogram; vertekpunte; die diabetesonderwysprogram in die konteks van hoër onderwys in Suid-Afrika; opvoedkundige en openbare gesondheidsbehoeftes wat aangespreek word deur die diabetesonderwysprogram; akademiese en administratiewe aspekte wat betrekking het op die diabetesonderwysprogram; standaarde en uitkomste vir ‘n onderwysprogram vir die voorkoming en beheer van die okulêre komplikasies van diabetes; asook perspektiewe en uitdagings met betrekking tot die onderrig van die diabetesonderwysprogram. Die navorser het die pad vorentoe voorgestel in terme van die verkryging van die nodige goedkeuring van die Departement van Onderwys, gevolg deur die akkreditasieprosesse wat deur die Hoëronderwyskwaliteitskomitee (HOKK) (HEQC) vereis word met die oog daarop om finale registrasie by die Suid-Afrikaanse Kwalifikasie-owerheid (SAKO) (SAQA) te verkry. Uiteindelik is gevolgtekkings gemaak en die beperkinge van die studie, tesame met die voorgestelde aanbevelings, is voorsien.
Die doel van hierdie navorsing is om ‘n beduidende bydrae tot die lewering van oogsorg in die openbare gesondheidsektor in Suid-Afrika te lewer en, meer spesifiek, met die oog op die voorkoming en bestuur van die okulêre komplikasies wat by diabetiese pasiënte voorkom.
THE PREVENTION AND MANAGEMENT OF OCULAR
COMPLICATIONS IN DIABETIC PATIENTS
CHAPTER 1
BACKGROUND AND ORIENTATION TO THE STUDY
1.1 INTRODUCTION
One of the most sight-threatening complications of diabetic disease is diabetic retinopathy. The National Guidelines for the Prevention of Blindness from the South African Department of Health (DoH) (RSA DoH 2002:12) indicate that diabetic retinopathy accounts for 8% of blindness in South Africa and that this figure is rising daily. The screening and appropriate referral of this condition is therefore an essential aspect of any public health programme designed to eliminate preventative blindness. Furthermore, the early screening for the detection and treatment of diabetic retinopathy fulfils the requirements of the World Health Organization’s (WHO) requirements for a screening programme (Tomlinson 2002:70). In order for such screening to be reliable, repeatable and accurate, health care workers dealing with diabetic patients in community health clinics must have a comprehensive and diabetes-specific educational foundation in order to deal with diabetic retinopathy as well as with the various other ocular complications which may arise in diabetic patients.
The levels of education and training of health care workers at community health centres in the management and treatment of diabetic eye disease were unknown
at the commencement of this research. The research then aimed to evaluate the diabetes-specific knowledge and education of health care workers employed in the public health sector. Another important feature of the research was to evaluate the patients’ knowledge of diabetes as well as to identify their own particular lifestyle factors that might have an influence on the course of their disease and the complications that might arise as a result thereof. Once these aspects had been analysed, an appropriate educational intervention could then be designed and developed in the form of the education programme for the prevention and management of the ocular complications of diabetes.
1.1.1 The role of diabetes education
Diabetes education is recognised as a key component of diabetes management (Worldwide Initiative for Diabetes Education 2003:2) with the main aims of diabetes education being to enhance knowledge and to foster behavioural change in order to promote self-education. The diabetes educator’s role is therefore to help people with diabetes to learn how to manage their disease and to prevent the complications of such a disease. The main challenges for diabetes educators are common to most regions of the world and, according to the Worldwide Initiative for Diabetes Education (2003:2), more skilled educators are required to meet these growing needs.
The International Diabetes Federation (IDF) has an even more aggressive approach to diabetes education. According to its Position Statement on Diabetes Education (IDF 2004:1), the combination of lack of access to quality medical management and diabetes education leads to poor clinical outcomes, a reduced quality of life, as well as high health-related costs. The position of the IDF is as follows:
• All people with diabetes, no matter where they live, have the right to learn about their disease.
• Health care professionals must be educated to be responsible for the prevention and provision of diabetes care.
• People at risk as well as the wider public must know the risks and learn about prevention.
• Health ministries have to ensure that they have a comprehensive diabetes education strategic plan integrated into their National Diabetes Programme (IDF 2004:1).
The researcher therefore found it imperative that, in the South Africa context, appropriate protocols and educational initiatives should be developed in order to better manage diabetic patients and their possible ocular complications in the community/public health sector.
1.1.2 Diabetes education for ocular complications
Although there are a large number of education programmes designed for people living with diabetes, there are relatively few such programmes specifically aimed at educating patients and health care workers regarding the ocular complications that stem from diabetes.
One such programme was, however, recently developed by the California Lions Club (as cited by NewsRx.com in Diabetes Week 2002:9). In this programme, a comprehensive initiative for diabetic retinopathy education was developed which focused on diabetic patients living in Southern California. The programme featured educational materials and free eye screenings by local health care professionals. The most important aspect of the programme, however, was the education of patients about the possible ocular complications of their diabetic
disease. The Diabetes Education Study Group (1998:1-5) of the European Association for the Study of Diabetes also developed an education programme for Type II Diabetes Education and Diabetic Retinopathy. In this programme, patients were educated with regard to eye problems stemming from Type II diabetes and taught how early detection by trained health care workers could help prevent sight-threatening retinopathy. The programme also outlined important guidelines that must be adhered to by the patient in terms of controlling their diabetes and undergoing regular eye examinations. The overarching principles of diabetic patient education were developed by the National Center for Chronic Disease Prevention and Health Promotion (2004:4). These principles emphasise that patients must be informed that sight-threatening eye disease is a common complication of diabetes and that there are important benefits for the early treatment of diabetic retinopathy.
A study on the clinical cost-effectiveness of patient education models for diabetes by Loveman, Cave, Green, Royle, Dunn and Waugh (2003:22) suggested that education programmes offered as part of intensified treatment interventions could result in significant and long-lasting improvements in metabolic control and a reduction in systemic complications. It is important to note that these benefits occurred when education was part of an overall intensive treatment plan. However, the study found that it was not possible to draw conclusions about the potential effects of education per se in Type I diabetes and that no clear characterisation as to what features of diabetes education may be beneficial for patients with Type II diabetes.
The development of the educational programme for diabetic patients and community health care workers relied on the results obtained from the patient and health care worker questionnaires. It was important to assess the patients’
knowledge of the effects that diabetes had on their general health, as well as on their eyes, and to determine which lifestyle factors positively or negatively influenced the course of the disease and its ocular complications. Furthermore - since it was envisaged that the education programme was to be developed for both health care workers and patients - the knowledge, skills and experience of the health care workers were also assessed in relation to the management and treatment of diabetic patients with specific emphasis on the prevention of ocular complications.
1.2 STATEMENT OF THE PROBLEM
As a result of the increasing number of diabetic patients attending community health centres and clinics, the associated cases of diabetic ocular pathology are also expected to increase significantly. The Department of Ophthalmic and Wellness Sciences of the Cape Peninsula University of Technology where the researcher is employed, provides eye care services to disadvantaged communities of the Western Cape. A large number of patients attending the eye clinic present with diabetes and related ocular pathology and, upon further investigation, the extent of their knowledge and education regarding diabetes and its complications proved to be extremely limited. This further exacerbated both their systemic condition of diabetes and their risk of developing sight-threatening ocular complications.
Not only have there been few informal and no formal screening programmes for diabetic eye disease in community health clinics, but there was also no evidence of nurses and health care workers undergoing any specific educational training for the screening and identification of patients suffering from the ocular complications of diabetes. Furthermore, owing to the increasing number of patients seeking treatment at community health centres, there were no specific
days set aside specifically for diabetic patients to attend the community clinic as the practice had been historically (Hartley 2004). This means that diabetic patients are treated as part of the daily routine of the clinic/health centre, with no specific emphasis being placed on diabetes or its ocular complications in the community health care centres of clinics.
Against this background, it appeared that there was a lack of a comprehensive diabetes education programme for the health care workers or for the diabetic patients themselves. Such a programme should aim to provide the necessary skills to optimally screen and manage the treatment for diabetes in order to prevent the sight-threatening complications of the disease. It was felt that research should be conducted into the diabetes-specific education and training of health care workers, as well as into the knowledge and understanding of the diabetic patients about their condition and its possible complications. Given the above-mentioned problems, the following research questions regarding the current situation in community health care clinics were addressed:
• What is the degree of education and training of health care workers specifically for the management of diabetic patients?
• What knowledge, skills and education do health care workers have for the lifestyle risk factors that may contribute to diabetic eye complications?
• What knowledge and education do the diabetic patients have with regard to diabetes and the lifestyle risk factors that may contribute to diabetic eye complications?
• What educational interventions are required for the health care workers and the patients in order to best manage and prevent sight-threatening complications in diabetic patients?
It is proposed that, at the conclusion of the research process, these questions will be answered and that appropriate proposals and interventions will have been developed to address these issues.
1.3 THE GOAL, AIM AND OBJECTIVES OF THE STUDY
1.3.1 The overall goal of the study
The overall goal of the study was to enhance the education, training and skills of health care workers managing diabetic patients in order to prevent and manage sight-threatening diabetic complications. Such an initiative should make a significant contribution to the quality of health care provided to diabetic patients in the public sector, while the educational programme developed is groundbreaking in its approach to training health care workers for screening and managing the ocular complications of diabetes.
1.3.2 The aim of the study
The study was aimed at developing a post-graduate education and training programme for health care workers with a view towards the prevention and management of the ocular complications occurring in diabetic patients. It should therefore enable health care workers to effectively detect, manage and refer diabetic patients at risk of developing sight-threatening ocular complications. Furthermore, an important feature of the model would be the ability of the patients to receive specific education at the community health clinics about the ocular complications of their disease.
1.3.3 The objectives of the study
• Conceptualising the processes involved in the development of a post-graduate education programme. In order to achieve this, an extensive literature review was undertaken of the educational criteria for the development of post-graduate education and training programmes. In addition, the literature review entailed a critical analysis of existing diabetes education programmes. A literature survey on diabetes and the possible ocular complications that might occur in diabetic patients was also conducted.
• Gaining information with regard to the knowledge and education of diabetic patients and health care workers about diabetes and its ocular effects. This was achieved by means of a research instrument involving questionnaire surveys for these two groups of participants.
• Identifying the core competencies and curriculum that would comprise the education programme to be developed for the health care workers. The results of the literature review and the questionnaires from the diabetic patients and health care workers informed the development of the Delphi questionnaire as well as the subsequent Delphi process which was used to identify these outcomes.
• The information obtained from the results of the questionnaires and the Delphi process was used to develop the post-graduate education and training programme for the prevention and management of ocular complications in diabetic patients.
1.4 SCOPE OF THE STUDY
The scope of this study is in the field of Higher education Studies. The study is also interdisciplinary in that some aspects of the research lie in the fields of health education and, more specifically, in the fields of optometry, nursing and public health. This emphasises the concept that education forms the foundation of these professions. In addition, the study also focuses specifically on curriculum
development for the purposes of developing a post-graduate education and training programme for health care workers. The diabetic patient and health care worker participants involved in the study were from the Western Cape region of South Africa. The following geographic and demographic demarcations were involved:
• The municipal Districts of the City of Cape Town. • The West Coast/Winelands region.
• The Overstrand region.
The actual demographic profile of the participants of the research was all persons participating in the research who were diabetic as well as the health care workers. The research had no specific inclusion or exclusion criteria based on age, race, gender or socio-economic status.
In terms of the study population, the research entailed the following inclusion criteria for participation in the research:
• Nurses and clinic managers dealing with diabetic patients in community health centres and clinics.
• Optometrists involved with diabetic patients in the public health sector. • Diabetic patients from community health centres and clinics.
• Other health care workers, including medical practitioners and ophthalmologists managing and treating diabetic patients.
• Academic staff involved in the education and training of nurses, optometrists, health care workers and diabetic patients.
The population group benefiting from the results of the research would be the diabetic patients, as well as the nurses and health care workers.
1.5 SIGNIFICANCE AND VALUE OF THE STUDY
The development of an education programme for health care workers dealing with diabetic patients will have significant advantages, not only for the patients and workers themselves, but also for the higher education institution offering such a programme. Currently there is no post-graduate education and training programme in South Africa for health care workers managing diabetic patients with potentially sight-threatening diabetes complications. The Western Cape Department of Health for Chronic Diseases proposed that the educational training of ophthalmic nurses at community level should take place with specific reference to the screening and identification of diabetic retinopathy (Bonnici 2003). The implementation of such a programme should then provide the opportunity for such post-graduate training.
The value of this proposed education programme will go even further and will not restrict such training to ophthalmic nurses, but will include all health care workers treating diabetic patients, thereby enhancing the delivery of significantly improved health services to such patients. Most importantly, appropriate educational training of these workers should help to prevent the occurrence of sight-threatening complications in diabetic patients.
1.6 DESIGN OF THE STUDY AND METHODS OF INVESTIGATION
1.6.1 Research design
The study design was based on a descriptive survey research design. Included in the study design was cross-sectional as well as panel research. Initially, a thorough literature study was conducted on diabetes and the ocular complications
