Improving Erectile Dysfunction Management Among Asian Men With Diabetes Using the Knowledge Translation Intervention

INTRODUCTION

Erectile dysfunction (ED) is the most frequent male sexual dysfunction encountered worldwide, especially among men with type 2 diabetes.^1,2 The risk of developing ED is significantly associated with age, duration of type 2 diabetes, lower physical activity, microvascular complications, and depression.^3-5 Despite the high prevalence of ED, it is still underdiagnosed and undertreated.⁶ It is alarming that many men with ED do not seek professional help or voice their concerns despite wishing to be treated.^7-9 In many cases, this is a result of cultural perceptions of sex and shame upon seeing a female physician.^10-13 Barriers among physicians in delivering services related to sexual health include a lack of knowledge and confidence in ED management.¹⁴ Despite our focus on Asian men with type 2 diabetes, there is substantial cultural diversity among those with sexual dysfunction across the continents;¹⁵ the lack of communication between physician and patient is not unique to Asians. A global study showed that only 9% of men had been asked about their sexual health by a doctor.¹⁶

Therefore, developing cost-effective interventions is essential to removing obstacles to efficient ED management. Use of knowledge translation (KT) tools involves a dynamic and iterative process designed to strengthen knowledge applications in the health care system.¹⁷ It helps to improve patient knowledge by simplifying sophisticated medical information, thus enhancing their understanding of risk.¹⁸ The KT tool in the form of a patient prompt sheet provides an organized delivery of information and questions designed to aid the patient in discussing a difficult topic with their doctor. The use of an ED prompt sheet (Supplemental Appendix 1) aided in communication and helped patients overcome their hesitation to bring up sexual dysfunction.¹⁹ As a result, patients discussed sexual health problems in more effective and patient-centered consultations.²⁰

There is a lack of knowledge regarding the use of flipcharts to help doctors deliver ED information during clinical consultations. Hence, we developed a flipchart called “Knowledge Translation Tools in the Management of Erectile Dysfunction” (LASTED) to assist physicians in primary care clinics (Supplemental Appendix 2). In the primary care setting, we evaluated if the use of a patient prompt sheet combined with the LASTED flipchart changed discussions about ED and prescription of phosphodiesterase-5 (PDE5) inhibitors for Asian men with diabetes.

METHODS

RESULTS

A total of 125 men with diabetes were screened for study eligibility. Four refused to participate due to time constraints, and 1 patient was symptomatic for hyperglycemia. We recruited 60 patients for each arm resulting in a response rate of 96%. The mean age of participants was 59.4 (SD = 10.7) years, and 76.7% had ED. There were no significant sociodemographic differences between the control and intervention groups (Table 1).

In the intervention group, 66.7% of patients discussed ED-related issues with their physician, compared with only 8.3% of the control group (Table 2). Those who received ED KT tools were 8 times more likely to discuss ED issues than the control group (P <.001). Prescriptions for PDE5 inhibitors were provided to 57.5% of patients in the intervention group, but none in the control group (Table 2). Patients with moderate ED were more likely to be prescribed PDE5 inhibitors compared with those having mild ED (Table 3).

Physicians used the LASTED flipchart in 82.5% of intervention group consultations. Use of the LASTED flipchart was significantly associated with patient satisfaction with ED discussion (P <.001) (Table 4). All the intervention group patients considered the LASTED flipchart useful and were satisfied (extremely satisfied and satisfied) with the consultation (Table 4). Of those consulted using the LASTED flipchart, 66.7% received PDE5 inhibitor prescriptions compared with only 14.3% of those consulted without use of the LASTED flipchart (P = .011) (Table 4).

Table 5 summarizes the discussion topics during the consultations using the LASTED flipchart in the intervention group. Only 17.5% discussed the cardiovascular risk of ED despite the vital link between ED and cardiovascular diseases.

DISCUSSION

The results of our study found that integrating a patient prompt sheet and a physician LASTED flipchart can be a promising strategy to enhance ED-related communication as compared with using a prompt sheet alone.¹⁹ The prompt sheet alerted clinicians to the patient’s receptiveness to sexual health questions while the LASTED flipchart addressed the physician’s perceived competence in managing patients with ED.²⁵ This comprehensive strategy in a time-constrained primary care visit may improve ED screening and management.

Our study reported that use of LASTED flipchart during an ED consultation may improve overall patient satisfaction. To the best of our knowledge, no previous study has assessed the impact of an ED flipchart on ED management. Earlier studies on flipcharts evaluated the effect of knowledge in nutrition education²⁶ and medication adherence²⁷ but did not explore user satisfaction. The LASTED flipchart may improve patient satisfaction as it provides a visually engaging tool to help them actively participate in the discussion. Satisfaction could also be attributed to the consultation outcome of a PDE5 inhibitor prescription as patients feel their sexual problems are being addressed and treated.

However, KT tools must be adapted to diverse cultures because cultural values substantially influence discussion of ED.¹⁵ Asian men are more conservative about discussing sexuality than European men, despite having a higher rate of sexual dysfunction.^28,29 Malaysian men and those from neighboring Asian countries like China, Japan, Korea, and Taiwan may share similar characteristics related to sexual health.³⁰ A cross-cultural adaptation of this KT tool may yield outcomes similar than those in this study, especially in Asian populations and among Asian immigrants residing in the West.

The use of PDE5 inhibitors among Asians particularly in Malysia is low as this medicine is not widely available in public primary care clinics and physicians are not familiar with the drug.³¹ The current study found an increase in prescription of PDE5 inhibitors especially in men with moderate ED which was not assessed in the previous study.¹⁹ ED is associated with increasing age³² and presence of comorbidities such as cardiovascular diseases,² and in some cases, PDE5 inhibitors may not be the first-line or safest option for this population. Conversely, those with mild ED can typically resume sexual activity without oral medicines.

Similar to a previous study,³³ the self-reported ED in this study was low. Patients might be ignoring this sexual problem due to a lack of knowledge regarding the diagnosis and treatment of ED. Therefore, patients might not volunteer to discuss ED-related concerns during clinic encounters. Active screening by health care workers with KT tools might be beneficial to overcome this issue.

CONCLUSION

Combining the LASTED flipchart and prompt sheet as KT tools may improve ED discussion and prescription of PDE5 inhibitors. Knowledge translation tools are potentially a cost-effective strategy in ED management to break communication barriers between patients and physicians. This study has shed light on ED management frameworks by addressing patient and physician factors in the same setting.