Assessment of Knowledge and quality of life for patients undergoing cataract surgery Neama Ahmed Mohamed 1

Assessment of Knowledge and quality of life for patients undergoing cataract surgery
Neama Ahmed Mohamed 1, Zienab Abd El-lateef Mohammad 2, Mohamed Saad Abdel Rahman3.

Head nurse in Assiut University Hospital 1,
Professor of Medical Surgical Nursing, Faculty of Nursing, Assuit University 2,
Professor of Ophthalmology Faculty of Medicine, Assuit University 3
Abstract:
Cataract is clouding in the natural lens of the eye. Aims: to evaluate patient’s information and quality of life for patients undergoing cataract surgery. Patients and methods: 60 adult patients from both sexes. This study carried in the ophthalmic department at Assiut university hospital. Tools: Two tools were utilized to collect data pertinent to the study. Tool I: Patient interview questionnaire sheet and it was divided into three parts concerning: patient’s socio-demographic data, medical data and assessment of patients’ knowledge regarding cataract. Tool II: The World Health Organization Quality of Life- BREF questionnaire. Results: the majority of patients (51.7%) were female, (73.4%) were illiterate, 48.3% were house wife, and (41.7%) their ages were between (60–65) years of age. The most of the patients (98.4%) had incorrect information about cataract. About (73.3%) taken poor quality of life, (15%) taken fair quality of life and (1.6%) taken good quality of life. statistical difference among information level and quality of life. Conclusion; the larger part of studied patients had incorrect information about cataract which mirrored on their quality of life. Recommendations; teaching programs are necessary to increase patients’ awareness which has a positive effect on their quality of life
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1172845740600500Key words: Cataract surgery, Knowledge, quality of life.

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Introduction:
Cataract is a visual disease that is characterized by increasing opacity of the lens resulting in visual impairment. Frequency of cataract increases with age and is one of the leading blindness and visual impairment in elderly populations in developing countries. (Mario and Angel, 2017)

Cataracts affect nearly 22 million Americans aged 40 and older, about half of all 65-year-old Americans are suffering from some degree of cataract formation. Cataracts worsen the effects of age-related problems by decreasing the ability to see in dark conditions. (Stroud and Walker, 2012)
Aging is the most common causes; Age related cataract progresses in two ways a clump of protein reduces the sharpness of the mage reaching the retina. Lens proteins denature and degrade over time and this progression is accelerated by diseases such as diabetes and hypertension. And the clear lens is reducing changes to a yellowish /brownish color, the color lens slowly changes color with age. (Aldwin and Gilmer, 2013)
Traumatic cataract happens due to mechanical injury, radiation, electrical current and chemical agents are accomplished of causing traumatic lens changes. Besides damaging the ocular surface, chemical injury can cause cataract. (Nitin and Nema, 2012) Traumatic cataract can progress very quickly, the opacity becoming apparent within 12-24 hours. (Pudner, 2010)
Systemic disease (such as diabetes); high levels of blood sugar cause the lens of the eye to swell with excess fluid, making diabetic patients more susceptible to cataracts, heredity, medications such as corticosteroids especially at high doses and in long-term use, arthritis.(Bruno et al., 2013)
In the early stages of a cataract, where vision is only minimally affected, new lenses for glasses give the sharpest vision possible. When the cataracts start to interfere with adult’s daily activities (ADL) and glasses cannot improve this vision, surgery is the only choice to remove the natural lens and change it with a new, artificial one. It is one of the safest and most successful procedures performed, but this is not equally available to all, and the operation which is available does not produce equal outcomes. (Charles et al., 2015)
Cataract surgery is done with local anesthesia or general anesthesia which ordinarily takes less than 1 hour. Topical anesthesia has lately become more widely used. The choice of anesthesia is determined by the surgeon. It includes insertion a local anesthesia (eye drops) on the cornea and conjunctiva. Commonly used local anesthesia includes Lidocain 2% jell, proparacain 0.5% and tetracaine 0.75%. (Anne and Jane, 2010)
Vision problems due to cataract have some negative effect on patients’ quality of life. (Navarro et al., 2016) According to the World Health Organization (WHO), Quality of life is (QOL) “an individual’s recognition of their position in life within the setting of the culture and esteem frameworks in which they live and in connection to their goals, wants, benchmarks and concerns”. (Navarro et al., 2016)
Activities of routine living, for example washing, wearing, food preparation, reading, watching television, can make harder to do as a result of impaired vision. More significantly, people who cannot detect ground-level hazards, such as steps, kerbs and pavement cracks, are more likely to fall and sustain injuries, such as a hip fracture,. Reduced sharing in social activities, meanwhile, can lead to a sense of isolation and loneliness, and even the gradual onset of depression (Watkinson, 2011).

A few patients with visual impairment as a result of cataract experience depression, which influences their quality of life (Williamson and Seewoodhary, 2013). This condition should not be underestimated and nurses should be able to identify its core symptoms, which include persistent sadness, fatigue and anhedonic (loss of pleasure). Other associated symptoms include disturbance of sleep and appetite, poor concentration, agitation, low self-confidence, suicidal thoughts and/or acts; however, patients may not complain of depression and are more likely to refer to physical symptoms (WHO, 2011)
Impaired vision affects a person’s independence in self-care, work and lifestyle choices, sense of self-esteem, safety, ability to interact with society and the environment, and generally quality of life. In the meantime, patients can create more cheerful given more information and a better understanding of what it contains, and how it can support to promote a better-quality quality of life (Watkinson, 2011).

Aim of the study
The aim of the study was to evaluate patient’s knowledge and quality of life for patients undergoing cataract surgery.

Patients and Methods
Research design: descriptive research design was used to conduct this study.

Technical design:-
Setting: This study was conducted within the ophthalmic department at Assiut university hospital.

Patients:
60 adult patients from males and females their age ranged from (18-65) years. Patients were admitted in ophthalmic department for cataract surgery, both sexes (male and female).
Tools:

Tool I: Patient Interview Questionnaire Sheet: It covers of three parts:
Part one: Socio-demographic data about the patient: it contains age, sex, level of education, then occupation.

Part two: Medical data included: duration of cataract, previous eye surgery, and risk factors such as chronic disease (diabetes mellitus, hypertension, and cardiovascular disease), smoking and family history.
Part three: Assessment of patients’ knowledge regarding cataract includes; Definition of cataract, causes, risk factors, signs & symptoms, complications of cataract and preoperative and postoperative care.

Scoring system:
Every correct answer was given two degree. The overall score was (70 grade), these scores were converted into a percent score, the results of patient were classified into three categories (<50%) was poor knowledge, (50<70%) was fair knowledge and (?70%) was good knowledge.

Tool III: The World Health Organization Quality of Life- BREF questionnaire (WHOQOL-BREF): (Bonomi et al., 1997): It comprises 26 items, which measure the following wide dominions: physical health (7 items), spiritual health (6 items), social interactions (3 items), and environment (8 items). Two extra items measure overall QOL and general health. Items are evaluated on a 5-point Likert scale (low score of 1 to high score of 5) to define a raw item score.
Scoring system:
Agreeing to range of overall score lie among (26 -130), patients were categorized as: poor, fair or good quality of life. Good quality of life in case their whole score was ? 70%, fair 50<70% at that point were considered as taking poor quality of life in the event that their total score was < 50%.

Physical domain
This domain evaluate pain and inconvenience, energy and faintness, sleep and rest, movement, doings of everyday living, reliance on medicinal substances and medical helps and work capacity.

Spiritual domain
This domain covers numeral of questions around positive mental state such as thoughtful, learning, memory and concentration, self-confidence, bodily image and appearance, and negative emotional state such as religion and special beliefs.

Social interactions domain
It includes friends, relatives, companions, age group, and societal support also sexual activity.

Environmental domain
It comprises physical safety and security, home environment, , financial assets, well-being also social care, chances for obtaining fresh knowledge and skills, and chances for recreation/leisure, physical environment and transportation.
II Operational design
The study was passed out on three stages:
1-Preparatory stages
An analysis of current and past, nearby and worldwide related literature as textbooks, articles, diaries, periodicals, and magazines, study tools were defined, and this stage done by substance validity and pilot study.

2- Implementation stages:
Statistics were collected amid the period starting July/2016 to May/2017.
An official endorsement for information collection was gotten from the head of authorized organization in ophthalmic department at Assuit university hospital just before conduct the study.

At first meeting the researcher presented herself to start link of communication so that help the carrying out of the implements.

The content validity was finished by five expertise from the staff of medicine and nursing field to check subjects used for transparency and completeness of the implements.

Patient’s agreement for voluntary sharing was found when the determination and nature of the study were described.

– Statistics were collected secrecy and anonymity and were collected utilizing the pre-mentioned study implements.
– A pilot study about was conducted on 10% (6 patients) of the test to assess the appropriateness and clarity of the tools, gauge the time required for information collection, and test the achievability of conducting the research after analyzing the pilot study result, minimal modifications were done appropriately. These patients were not included within the real study.
– The researcher interview by each patient individually and verbal agreement for voluntary participation in the study was taken from the patients after the study and its aims were explained.
3-Evaluation stages:
Evaluation stage was conceded out through filling (tool I and II) for the examined test.

Administrative design:
An official letter was issued from the Dean of faculty of nursing to the head of Assiut University Hospitals and the head of the Ophthalmic Department. The researcher met ophthalmic surgeons’ specialists for clarifying the reason of the study to pick up their participation. In expansion verbal authorization was gotten from each patient to be involved within the study.

Ethical considerations:
Research proposal was approved from Ethical Committee in the faculty of nursing.

There is no risk for study subjects during application of the research.

The study followed common ethical principles in clinical research.

Written consent was obtained from patient’s who participated in the study, after explaining the nature and purpose the study.

Confidentiality and anonymity was assured.

Study subject have the right to refuse to participate and or withdraw from the study without any rational any time.

Study subject privacy was considered during collection of data.

Statistical design:
Statistics were collected and analyzed by computer program SPSS. Information communicated as mean, standard deviation, number and rate. Tests for importance were connected, t-test, and one way ANOVA test, T-test is utilized to decide importance for numeric variables. Chi-square test is utilized to decide importance for non-parametric variables. A probability level of 0.05 was embraced as a level of importance for testing the research hypotheses.

RESULTS
Table (1): Distribution of the studied test according to socio-demographic characteristics (n=60)
Items N. % 
Age groups 18<40 years 13 21.6%
40<60 years 22 36.7%
60- 65 years 25 41.7%
Sex Male 29 48.3%
Female 31 51.7%
Marital status Single 4 6.7%
Married 48 80%
Divorced 0 0%
Widow/er8 13.3%
Level of education Illiterate 44 73.4%
Read and write 6 10%
Primary school 5 8.3%
Secondary education 5 8.3%
High education 0 0%
Occupation Worker 9 15%
Farmer 12 20%
House wife 29 48.3%
Manual work 4 6.7%
Not working 6 10%
Table (2): Distribution of the studied test about their medical data
Items N. % N. %
1-Duration of cataract. Yes. % No. %
one month 8 13.3% – –
Two months 9 15% – –
Three months 14 23.4% – –
More than three months 29 48.3% – –
2-Previous eye surgery. 22 36.6% 38 63.4%
3-Risk factors.

Chronic diseases. -Diabetes 7 11.6% 53 88.4%
-Hypertension 7 11.6% 53 88.4%
-Heart disease 2 3.3% 58 96.7%
Smoking 10 16.6% 50 83.4%
Family history 18 30% 42 70%
Figure (1): Distribution of the studied sample according to their knowledge about cataract

Figure (2): Distribution of Quality of life total for the studied test n= (60)

Table (3): Relation between socio-demographic characteristics and level of knowledge (n= 60).
Items knowledge P value
Poor Fair N. % N. % Gender: n.sMale 23 38.4% 6 10% Female 29 48.3% 2 3.3% Age: n.s18 < 40 12 20% 1 1.6% 40 <60 19 31.7% 3 5% 60- 65 years 21 35% 4 6.7% Marital status: n.sSingle 4 6.7% 0 0.0% Married 40 66.7% 8 13.3% Divorced 0 0.0% 0 0.0% Widowed 8 13.3% 0 0.0% Level of education: n.sIlliterate 37 61.7% 7 11.8% Read and write 5 8.3% 1 1.6% Primary education 5 8.3% 0 0.0% Secondary education 5 8.3% 0 0.0% High education 0 0.0% 0 0.0% Occupation : n.sEmployee 9 15% 0 0.0% Farmer 8 13.3% 4 6.7% Manual work 4 6.7% 0 0.0% House wife 27 45% 2 3.3% No work 4 6.7% 2 3.3% Table (4): Relationship among knowledge & quality of life
Items quality of life n= (60)
knowledge level Poor Faire Good P value
N. % N. % N. % 0.00*
44 58.4% 15 15% 1 0.0% Table (5): Relation between educational level & quality of life n= (60)
Items Poor Faire Good P value
N. % N. % N. % 0.007*
Illiterate 35 58.4% 9 15% 0 0.0% Read and write 4 6.7% 1 1.6% 1 1.6% primary school 1 1.6% 4 6.7% 0 0.0% Secondary school 4 6.7% 1 1.6% 0 0.0% Table (1): reveals that, regarding age (41.7%) of the studied patients their age range between (60 – 65) years old, (36.7%) age among (40-60) years also (21.6%) of the studied patients age was among (18-40) years old. Regarding sex (51.7%) of the studied patients were females. In relation to marital status, (80%) were married. As regard to occupation the highest percentage was house wives and illiterate.

Table (2): shows that, 16 (26.7%) of studied patients had chronic disease {diabetes mellitus, hypertension (11.6%) and heart disease (3.3%)}. Smoking (16.6%) and less than half of patients were family history 18 (30%).

Table (3): explains that, there was not any significant statistical difference among patients’ knowledge around cataract and their demographic characteristics.

Table (4): displays that; there was a significant statistical difference among knowledge level and quality of life.
Table (5): demonstrates that, there was a significant statistical difference among level of education & quality of life.

Figure (1): demonstrates that, the vast majority of the studied patients (98.4%) had inappropriate information around cataract.

Figure (2): shows that, (73.3%) of the studied patients taken poor quality of life, (15%) taken fair quality of life then (1.6%) taken good quality of life.

Discussion
A cataract is defined as cloudiness or loss in transparency in the crystalline lens of the eye. When a cataract interferes with transmission of light to the retina, some loss in visual acuity and possible complete loss of vision may result. ( HYPERLINK “https://www.google.com.eg/search?hl=ar;tbo=p;tbm=bks;q=inauthor:%22Jahangir+Moini%22” Moini, 2015)
Visual impairment is devastating for patients, it has negative effects on health-related quality of life (QOL) it is associated with restrictions in mobility, activities of daily living and physical performance. (Michalos et al., 2012)
In the present study, findings regarding socio- demographic characteristics revealed that, patients’ ages were between 60 – 65 years old this may be due to the effect of cataract on old age and predisposing factors for cataract incorporate systemic disease. This result is in agreement with (Pundareekaksha, 2016) who found the same result.

Regarding marital status, the current study clear up that, more than half of the patients are female and less than half are male this result is in difference with (Pundareekaksha, 2016) who found that more than half of the tests are male and less than half are females. Another study by (Mary et al., 2015) also found the same result. This result is in agreement with (Mary et al., 2015) & (Athiya et al., 2011) who found that the majority of studied patients were married; the highest percentage was house wives and illiterate.

As regards to educational level, the findings of the current study characterized by that, the maximum percentage were illiterate This because of more than half of them were females and less than half of them were house wife. This finding is agreed with (Duker & Yanoff, 2014) who reported that, a high level education is related with little hazard of age-related cataract for the reason that, this might be related to smoking, alcohol intake and increased sun exposure in people with low education. in contrast, it disagrees with (Hegazy et al., 2012) who represented that highly educated are more likely to have cataract surgery.

The present study indicated that studied patients had chronic disease, diabetes mellitus and hypertension. This result agreed with (Timby and Smith, 2013) who stated that a high incidence of cataracts occurs among people with diabetes and those with a family history. It can also be supported by (Duker & Yanoff, 2013) who stated that, Diabetes mellitus and systemic hypertension are common in the population predisposed to operable cataract formation and these conditions may adversely influence both the surgery and the post operative course of events.

The results of the current study established that; less than half of patients were family history. This result is in agreement with (Solberg, et al.,2016) who found that both cataract development and age-related macular degeneration, the leading causes of severe visual impairment and blindness, are directly accelerated by smoking and significantly linked to this harmful habit. It can also be supported by (Timby and Smith, 2013) who indicated that a high occurrence of cataracts happens between persons with diabetes and those with a family history.

The outcomes of the present-day study too revealed that; the majority of studied patient’s incorrect knowledge around cataract. This can be clarified through the fact that, patients didn’t obtain sufficient information from health care group also the majority of the studied patients were illiterate. In this aspect (Pundareekaksha, 2016) said that the majority of patients did not have satisfactory information about cataract.
As concerns to quality of life the present-day study indicated that, the majority of the studied samples taken poor quality of life. This result is in contract with (Elfride et al., 2016) who revealed that, the majority of the studied samples taken poor quality of life. This might be clarified by the fact that, patients didn’t get enough knowledge from health care group which returned on their quality of life.

In additional, this outcome is in difference with (Abraham et al., 2016) who state that majority of the studied samples had good quality of life.

About correlation among knowledge level and quality of life there was a greatly significant statistical difference between knowledge level and quality of life. This result is differs with (Abraham et al., 2016) who denoted that There is no significant relationship among the knowledge and quality of life as regards Benign Prostatic Hyperplasia. This result is in contract with (Shah and Pokharel, 2013) who found that there is positive relationship among the knowledge and quality of life.
The results of the present study showed that; there was a significant statistical difference between level of education & quality of life. This result is in agreement with (Zibadi et al., 2013) who reported that, high level of education is associated with lower risk of cataract due to awareness about causative factors. Uneducated or people with little education are ignorant about the hazardous effects of tobacco usage, smoking, alcoholism, sunlight and less vitamins supplement intake. Also this result is in agreement with ( HYPERLINK “https://www.ncbi.nlm.nih.gov/pubmed/?term=Barbareschi%20G%5BAuthor%5D;cauthor=true;cauthor_uid=21187264” Barbareschi et al., 2011) reported that, Patients with low educational levels had most exceedingly bad quality of life.

Conclusion
Grounded on the results of the current study it can be decided that:
The larger part of studied patients had incorrect information about cataract which mirrored on their quality of life.

A statistical difference among information level and quality of life
A statistical difference among level of education & quality of life.
Recommendation
Grounded on the results of the current study, the researcher come up with the following recommendations:
teaching programs are necessary to increase patients’ awareness which has a positive effect on their quality of life
Increase patient’s mindfulness around the significance of follow up to prevent developing any complications after cataract surgery
Nurses ought to be mindful of the guidelines that must be given to patients before discharge and tell patients about them.

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