School Health Nurse Supported Child-to-Family Strategy for Diabetic Retinopathy Prevention in Bhimeshwor Municipality, Dolakha, Nepal

This study aims to assess the effectiveness and feasibility of a school health nurse-supported child-to-family strategy to improve knowledge and preventive practices related to diabetic retinopathy (DR) among students and their families in Bhimeshwar Municipality, Dolakha, Nepal. The intervention specifically targets gaps in knowledge and preventive practices regarding DR, particularly among family members aged 30 and above. Materials For Students: • Health Pamphlets: Culturally relevant content on diabetes, DR prevention, lifestyle changes, and eye check-ups. • Pictorial Materials: Visual aids. • Intervention Toolkit: Printed and digital resources to support learning. For Family Members: • Health Pamphlets: Simple, culturally appropriate content on diabetes, DR prevention, lifestyle changes, and regular eye check-ups. Procedures: The school that receives the intervention will be the first school that gives written consent and meets the inclusion criteria. All schools will be informed about this process before giving consent. This method fits with our study design and helps us start the intervention smoothly and fairly. The intervention will involve school health nurses delivering educational sessions to students in Grades 7 and 8. Afterward, students will educate their family members, particularly those aged 30 and above, about DR prevention practices. Timeline and Frequency: The intervention will be conducted over six weeks, divided into two phases: Pre-Intervention Assessment: • Baseline Assessment of Parents: Conduct baseline assessments of parents to evaluate their knowledge and practices regarding diabetes and diabetic retinopathy before the intervention. • Educational Sessions for Intervention Students: Hold separate educational sessions for Grades 7 and 8 students in the intervention group. Topics will cover diabetes and diabetic retinopathy prevention, healthy lifestyle habits, eye check-ups, and developing communication and leadership skills to enable students to share health messages with their family members. • Pre-tests and Post-tests for Intervention Students: Administer pre-tests before the educational sessions and post-tests after the sessions to assess knowledge gain in the intervention group. • Pre-test for Control Group Students: Conduct a pre-test for the control group students to serve as a baseline for comparison of results in the later stages of the study. Post-Intervention Assessments: Six weeks after the initial phase, conduct post-intervention assessments for both parents (Intervention and Control groups) and students (Intervention and Control groups) to evaluate the impact of the educational sessions and the overall intervention. Sessions Frequency and Duration: 1. Student Education Sessions for Intervention Group: Week 1: Introduction and Group Formation Group Formation: Students will be divided into groups of 5-7 members, with one leader per group. An ambassador will be selected from each grade. Pre-test: A pre-test will be conducted before the educational sessions. Educational Sessions: Separate sessions are offered for Grades 7 and 8, covering DR prevention, communication strategies, and leadership skills, with each session lasting 3 hours for each grade. Examples of lifestyle changes emphasized to address and prevent diabetic retinopathy (DR): 1. Maintaining Healthy Blood Sugar Levels Example: Consistently monitoring and managing blood glucose levels through diet, exercise, and medication can prevent or slow the progression of diabetic retinopathy. 2. Healthy Diet Example: Eating a balanced diet rich in fruits, vegetables, whole grains, lean proteins, and healthy fats helps in maintaining optimal blood sugar levels and supporting overall eye health. 3. Regular Physical Activity Example: Engaging in regular exercise (such as walking, swimming, or cycling) helps regulate blood sugar levels, reduce body weight, and improve circulation, which can protect against the development of retinopathy. 4. Blood Pressure Control Example: Keeping blood pressure within a healthy range through a combination of diet, exercise, and medication reduces the risk of developing diabetic retinopathy, as high blood pressure can worsen eye damage. 5. Managing Cholesterol Levels Example: Monitoring and controlling cholesterol levels through diet, exercise, and medication helps protect the blood vessels in the eyes, which are at risk due to diabetes-related vascular damage. 6. Regular Eye Exams Example: Scheduling regular eye exams with an ophthalmologist to detect early signs of diabetic retinopathy. Early detection can lead to timely treatment and prevent vision loss. 7. Smoking Cessation Example: Quitting smoking helps improve circulation and overall health, reducing the risk of complications like diabetic retinopathy and other cardiovascular diseases. 8. Stress Management Example: Practicing stress management techniques such as meditation, yoga, or mindfulness helps in managing blood sugar levels and reduces the risk of developing complications related to diabetes. Post-test: A post-test will be administered after the session. Pamphlets and Logbook: Students will receive pamphlets and a daily tracking logbook to monitor their engagement. These logbooks will be reviewed weekly by the school health nurse, who will also collect and verify that the weekly educational activities were completed by students with their family members. Support and Troubleshooting: If any challenges arise while providing education to family members, they will be discussed within the team or with the school health nurse. Week 2: Reinforcement of Key Concepts The school health nurse will conduct follow-up educational sessions for both grades to reinforce the concepts covered in Week 1, with each session lasting 2 hours for each grade. Week 3: Group Presentations and Peer Learning Each group will present their learnings for 15 minutes, followed by a question-and-answer session to promote peer learning. The total session will last 3 hours for each grade. Week 4: Debate Competition A debate on diabetic retinopathy (DR) prevention will be held for 10 minutes per group between groups from each grade. Prizes will be awarded to the top three groups from each grade, with health teachers serving as judges. The total session time will be 2 hours. Week 5: Role-Play Activities Students will perform a 10-minute role-play on DR prevention, conducted separately for each grade to demonstrate their understanding interactively. The session will last for 2 hours. Week 6: Student-Led Educational Sessions and Final Assessments Voluntarily, students will lead educational sessions for their classmates for 10 minutes to reinforce key concepts. The session will last for 2 hours. Post-intervention assessments will be conducted 42 days after the first educational session in both the intervention and control groups to evaluate knowledge retention among students and changes in knowledge. 2. Family Education Sessions: Daily Family Sessions: Students will conduct daily educational sessions with their family members aged 30 and above (5-20 minutes). Logbook Recording: Students will record the daily activities in a logbook. If a session is not conducted, students will document the reason for not providing the educational message. This helps track consistency and provides insight into any barriers faced. Content Delivery Method: Face-to-face sessions will be delivered by the students to their family members using printed health pamphlets as support materials. Key Personnel: School Health Nurse: A trained healthcare professional responsible for delivering educational sessions to students and supervising the intervention. Students: Grades 7 and 8 will be trained by the school health nurse to communicate DR prevention effectively to their families. Research Team: Monitors the intervention and collects data under the guidance of the principal investigator. Location: Intervention Settings: The intervention will take place in selected schools in Bhimeshwar Municipality, Dolakha. Family Settings: Family-based education will occur in students' homes by students. Intervention Modifications: Engagement Challenges: If challenges arise in participant engagement, materials may be modified with additional visual aids or more relatable examples, based on feedback from students and families. Adherence and Fidelity: Supervision: Close monitoring of educational sessions by the school health nurse and research team. Student Monitoring: Students will report on their interactions with family members and any difficulties encountered. Strategies for Maintaining Fidelity: Ongoing support for the school health nurse. Regular feedback loops to assess the intervention’s effectiveness. Refresher sessions if necessary to maintain fidelity. Allocation to Intervention/Control Group: Study Design: The intervention will be implemented in one school, and two schools will serve as control schools. These schools have been purposively selected based on the availability of a school health nurse and the number of students. Control Group: The control schools will continue with their standard practices without the intervention, allowing for comparison with the intervention school. Allocation Process: The intervention school will be assessed first, with assessments conducted before and after the intervention. The control schools will receive the intervention after the first set of schools have completed the intervention phase. Planned vs. Actual Adherence: Planned Adherence: Ensuring students and families receive and understand the educational material within the established timeline. Actual Adherence: Monitored through session attendance, intervention completion, and feedback from students and families.