Effect of school health nurse-supported child-to-family strategy for Diabetic Retinopathy prevention in Bhimeshwor Municipality of Bagmati Province, Nepal: A quasi-experimental study.
A school health nurse-supported child-to-family intervention significantly improved DR-related knowledge, attitudes, and psychosocial factors among students and family members, but no significant change was observed in actual diabetic retinopathy preventive practices, likely due to the short intervention period.
Key Findings
Results
Students in the intervention group showed a significant increase in diabetic retinopathy knowledge following the six-week nurse-led education program.
Median knowledge score increased from 0 to 16 post-intervention (p < 0.001)
Effect size for knowledge and skills was large at 0.853
Study used a quasi-experimental pre-test-post-test control group design
70 intervention students were compared against 70 control students selected via proportionate random sampling
Control group schools did not receive the intervention
Results
Family members in the intervention group demonstrated significant improvements across multiple psychosocial domains related to diabetic retinopathy prevention.
Family member knowledge median score increased from 0 to 10 (p < 0.001)
Significant improvements were observed in attitude, perceived behavioral control, subjective norms, perceived severity, and self-efficacy (all p < 0.001)
Each of the 140 students was paired with a co-residing family member aged ≥30 years
Family members were assessed via face-to-face interviews using semi-structured questionnaires
Improvements were in 'experiential processes' of DR prevention rather than behavioral outcomes
Results
No significant change in actual diabetic retinopathy preventive practices was observed among family members following the intervention.
The change in DR preventive practices was not statistically significant (p = 0.875)
Practices assessed included regular eye check-ups, health tests (blood sugar and blood pressure), balanced diet, and physical activity
Authors attributed the lack of behavioral change to the short intervention period
The intervention period was six weeks in duration
This finding was supported by qualitative data gathered through focus group discussions
Results
Approximately half of the intervention students maintained high retention in sharing health information with their families.
The paper states 'approximately half of the students maintained high retention in sharing health information with their families'
Retention was assessed as part of the student-led home session component of the intervention
Student-led sessions at home followed the initial six-week school nurse-led education program
Qualitative data from focus group discussions highlighted improved family-level engagement
One focus group was conducted with students and one with family members
Results
Qualitative findings supported quantitative results, indicating improved awareness, behavioral intentions, and family-level engagement in the intervention group.
Qualitative data were gathered through focus group discussions (one with students and one with family members) and a key informant interview with the school health nurse
Qualitative findings were described as supporting the quantitative results
Authors noted improvements in 'awareness, behavioral intentions, and family-level engagement'
The school health nurse was involved as a key informant, reflecting on the program's implementation
Qualitative methods complemented the quantitative self-administered and interview-based questionnaires
Methods
The intervention used a child-to-family strategy with a six-week school nurse-led education program followed by student-led health sessions conducted at home.
The study was conducted in Bhimeshwor Municipality, Bagmati Province, Nepal, in purposively selected government schools with grades 7 and 8
Schools were required to have a school health nurse to be eligible
One school was assigned as the intervention site and two schools as controls
Grades 7 and 8 students (n=140 total; 70 intervention, 70 control) participated
The study was registered in the Australian New Zealand Clinical Trials Registry (ACTRN12625000560493)
Conclusions
The authors concluded that strengthening experiential processes is feasible but longer follow-up is needed to promote sustained behavioral change in diabetic retinopathy preventive practices.
The intervention showed 'medium-to-high improvements in the experiential processes of diabetic-retinopathy prevention (knowledge, attitudes, subjective norms, perceived severity, perceived behavioral control and self-efficacy)'
Behavioral change in actual preventive practices was 'not evident, likely due to the short intervention period'
Authors called for 'further research with longer follow-up' to assess sustained behavioral change
The study was described as a quasi-experimental pre-test-post-test control group design
Non-parametric tests were used for quantitative data analysis
What This Means
This research suggests that training schoolchildren about diabetic retinopathy (a leading cause of blindness in people with diabetes) and then having them share that knowledge with their families can meaningfully improve awareness and health-related attitudes at the family level. The study was conducted in Nepal and involved about 140 students in grades 7 and 8, each paired with an adult family member aged 30 or older. Students who received a six-week health education program led by school nurses—and then conducted their own informational sessions at home—showed large improvements in their knowledge about diabetic retinopathy. Their family members also significantly improved in knowledge, attitudes, and several psychological factors related to health behavior such as confidence in their ability to act and understanding of disease severity.
However, this research suggests that improved knowledge and attitudes do not automatically translate into changed behavior in a short time frame. Despite the gains in awareness, family members showed no statistically significant change in actual preventive behaviors, such as getting regular eye check-ups, monitoring blood sugar and blood pressure, eating a balanced diet, or being physically active. The authors note this is likely because six weeks is too short a period for behavior change to take hold. Additionally, only about half of the students consistently shared health information with their families, suggesting the child-to-family relay of health messages needs reinforcement.
This research matters because it points to both the promise and the limitations of using children as health messengers in low-resource settings. The approach appears feasible and effective for raising awareness and changing mindsets, but longer programs and follow-up periods may be necessary to shift people's actual health behaviors. Future studies with extended intervention and follow-up periods are needed to understand whether these early gains in knowledge and attitudes eventually lead to real-world prevention behaviors that could reduce the burden of diabetic retinopathy.
Shrestha R, Adhikari C, Shrestha M, Paneru D, Dawadi A, D C U. (2026). Effect of school health nurse-supported child-to-family strategy for Diabetic Retinopathy prevention in Bhimeshwor Municipality of Bagmati Province, Nepal: A quasi-experimental study.. PloS one. https://doi.org/10.1371/journal.pone.0357023