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  • The sample consists of 3104 participants aged ≥30 years from the general population of the Banshgram Union in Narail district. They were recruited using a multilevel cluster random sampling from each of the total 18 villages in this rural district from December 2012 to March 2013. The sample size was based on the prevalence of diabetes in adults in Bangladesh of 6.3% in 2012 estimated by the International Diabetes Federation’s Diabetes Atlas. [16] The sample was sufficiently large enough to detect a 3% difference in the proportion of attaining awareness or attitudes related to common eye diseases between males and females, and those with no schooling and primary or secondary level of education (statistical power > 80%, p = 0.05). The study location is approximately 200 km southwest of the capital city Dhaka and has an adult population aged 30 years or above of approximately 5,500. [17] The population density of the study location was 722 per km2 compared to the population density 873 per km2 in rural districts in Bangladesh. The study location was selected as it was considered to be typical of a rural demographic in Bangladesh. Narail has a population literacy rate of 48.6%, which is comparable to the national literacy rate of 51.8%. The recruitment strategy involved identifying participants aged ≥ 30 years from each of the selected households within 18 clusters of villages. This age range was selected as previous studies have demonstrated that this is an acceptable threshold of age above which the prevalence of diabetes increases. [18] Recruitment started from the far east corner of a village and selected every second households using a systematic random sampling technique and continued until at least 50% of the total eligible adults were interviewed from each of the villages. All eligible adults from the same family were recruited and they were required to attend data collection over two days. On day one, the participants were interviewed using a semi-structured questionnaire following a door-to-door recruitment strategy which took approximately 35 minutes to interview each participant. The interview assessed participants’ awareness, attitudes and practice about diabetes and common eye diseases and other socio-demographic factors including level of educational attainment, and socio-economic status (SES). After interviewing the participants, the data collectors informed participants to attend the nearest community center or school on the next morning (day two) for clinical examination including measuring height, weight, blood pressure and the measurement of fasting capillary glucose. There were four teams of trained data collectors with 4–5 members in each team who received training from the same medical doctor interviewed the participants on day one and collected anthropometric and other measurements on day two. Different teams worked independently. All team members participated in an intensive two day training program before the commencement of the survey. Excluded were those younger than 30 years, and those who were acutely unwell to attend the centre for clinical examination on day 2. Less than 15% of participants interviewed on day one failed to present for day two assessment, with a participation rate above 85%. For this particular study, we have used data collected only from day one based on the household survey. Therefore, it is expected that there should not be any effect on our results from participation or non participation on day 2. A detailed interviewer-administered questionnaire was developed to collect socio-demographic data and to assess participant awareness, attitudes and practice regarding diabetes and common eye diseases. For eye disease, awareness was operationalized by whether or not participants had heard about the disease (nine items), attitudes by their evaluation of treatment if they had a disease (one item), and practice was ascertained based on how frequently they were checking their eyes (one item). The items assessing awareness, attitudes and practice of eye diseases were adapted from a validated instrument used in Cambodia to assess KAP of common eye diseases. [19] The questionnaire was translated into Bengali separately by a local senior educator as well as by the principal investigator. The two versions were then combined and finalised with an agreement on the translated version, using local language for a better understanding by participants where needed. For example, “trachoma” is known as “chok utha” in the local language which is familiar to most of the people. Therefore, “chok utha” was used instead of “trachoma” in the Bengali questionnaire. Five women and five men who are not included in the study were asked to assess comprehension, wording, and appropriateness of the questionnaire before it was finalised. The questionnaire is presented in detail elsewhere. [20] Questions assessing awareness of and attitudes to common eye diseases or symptoms had binary responses options (Yes/No) and questions assessing practice related to eye care had the following response options: Frequently (more than once a year), Regularly (at least once a year), Whenever I have an eye problem, and Never. The socio-demographic data included gender, age in categories (Less than 35, 35–44, 45–54, 55–64, above or equal 65 years), educational level in categories (no schooling, primary school 1–5 years, high school 6–10 years, Secondary School Certificate (SSC) or above) and socio-economic status (SES). Since most participants had no taxable income a crude measure of SES was used following Cheng et al. [21] asking whether "over the last twelve months, in terms of household food consumption, how would you classify your socio-economic status?" The possible answers were: (i) Insufficient funds for the whole year, (ii) Insufficient funds some of the time, (iii) Neither deficit nor surplus (balance), and (iv) Sufficient funds most of the time. We have reported the study sample, recruitment strategy, data collection, awareness, attitudes and practice questionnaire and socio-demographic factors in detail elsewhere. [20, 22, 23] Participant’s age, level of education and SES were compared across gender using Chi-square tests. Chi-square tests were also used to detect any differences in awareness across gender, age categories, level of education and SES. The Chi-square Linear-by-Linear Associations option was used to present p values for ordinal categorical trends such as level of education. The participants were categorised based on the number of items out of nine they had heard about, such as at least 5 items, at least six items and so on and the association of socio demographic factors with the categorical outcome of at least six items vs. less than six items was reported using Chi-square tests. Logistic regression techniques were used to report odds ratios (OR), and 95% confidence interval (CI) for positive attitudes towards treatment of eye diseases adjusting for age, gender, religion, level of education and SES. Socio-demographic factors were also compared for practice of regular eye check using chi-square tests. Statistical software SPSS version 21(IBM SPSS, Armonk, NY, USA) was used for all analyses.
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