Abstract

PURPOSE Erectile dysfunction (ED) is frequently undermanaged due to communication barriers, particularly among Asian men. We looked at how ED discussion and treatment were affected by the patient’s prompt sheet and the Knowledge Translation Tools in the Management of Erectile Dysfunction (LASTED).

METHODS We conducted a quasi-experimental study in a primary care clinic in Kedah, Malaysia involving 120 Asian men with diabetes. In the intervention group, patients were given a prompt sheet to indicate their intention to discuss or receive ED treatment, and physicians were provided with LASTED to assist with ED consultation. The control group patients received standard care from their physicians.

RESULTS The intervention increased the initiation of ED discussion up to 66.7% compared with 8.3% in the control group. In the intervention group, 57.5% of patients were prescribed phosphodiesterase-5 inhibitors and men with ED of moderate severity were more likely to be prescribed oral ED medication. Use of the LASTED flipchart was associated with prescription of phosphodiesterase-5 inhibitors (P = .011) and patient satisfaction with ED consultation (P <.001).

CONCLUSION Our study suggests that using the LASTED flipchart and patient’s prompt sheet together may encourage ED conversation and medication prescription particularly when working with Asian men who frequently view ED as a taboo subject.

Key words: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.

METHODSDevelopment of LASTED

The development of the LASTED flipchart was based on a literature review, guidelines,21,22 and discussions with experts in men’s health, including urologists, family physicians, and medical educators. The LASTED flipchart is a printed infographic that has been designed and validated in Malay language and English.

Study Design and Setting

This was a non-equivalent group type of quasi-experimental design conducted in a public primary care clinic in Kedah, Malaysia. Patients eligible for inclusion were men with type 2 diabetes aged 18 years or more. Patients with cognitive impairment and psychiatric disorders were excluded. Seven physicians and 125 patients consented to participate in the study.

Control and Intervention Groups

Participating physicians received a brief introduction to the fundamentals of ED treatment before the data collection to ensure familiarity with the subject. Data collection for the control group took place in September 2021 and for intervention group in October 2021. After data collection of the control group was completed, the physicians were introduced and briefed on the LASTED flipchart.

At the clinic, men of both groups were directed to a common station for routine blood pressure, weight, and random capillary glucose measurements, before the consultation with the physician. After the consultation, patients returned to the common station to complete the data collection sheet, which included demographic information and the 5-item International Index of Erectile Function (IIEF-5).23,24 The total IIEF-5 score defined 4 groups: no ED (score 22-25); mild ED (score 17-21); moderate ED (score 8-16); and severe ED/not sexually active (score 1-7). Patients were also asked about initiation of an ED discussion, prescription of PDE5 inhibitors, use of LASTED flipchart (for the intervention group), and satisfaction with the consultation overall.

In the control group, if ED was discussed during the consultation, it occurred with mutual agreement of both parties. No prompt sheet or LASTED flipchart was used.

In the intervention group, patients received the prompt sheet at the common station before consultation with the physician. The prompt sheet contained brief information on ED and options for ED discussion.17 The 4 options were: “I do not want to discuss ED;” “I want to discuss the risk of ED;” “I want to discuss treatment of ED;” and “I want to discuss the severity of ED.” The patients were asked to give the completed prompt sheet to their physician at the beginning of the consultation. The consultation then proceeded with the physician using the LASTED flipchart based on the options selected on the prompt sheet.

Data Analysis

Data were analyzed using SPPS version 26 (IBM Corp). The association between variables was analyzed using the χ2 and Fisher’s exact tests. Logistic regression was conducted to examine the associated factors for ED discussion and prescription of PDE5 inhibitors with a 95% CI. A P value less than .05 was considered to have a significant association.

Ethical Consideration

The Human Research Ethics Committee of The National University of Malaysia (FF-2020-424) and Medical Research and Ethics Committee (NMRR-20-1985-55688 IIR) approved this study.

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).

Table 1.

Sociodemographic Characteristics of Participants (N = 120)

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).

Table 2.

Initiation of Discussion and Prescription of a PDE5 Inhibitor Between Groups (N = 120)

Table 3.

Simple Logistic Regression of Associated Factors for Initiation of Discussion and Prescription of a PDE5 Inhibitor in the Intervention Group (N = 60)

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 4.

Use of LASTED on Discussion Satisfaction and Prescription of PDE5 Inhibitors in the Intervention Group (N = 40)

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.

Table 5.

Topics and Types of Treatment Discussed in the Intervention Group (N = 40)

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.

Strength And Limitation

The effectiveness of combining ED interventions to address patient and physician barriers in the same setting was investigated for the first time in this study. The interventions provide a strategic approach to tackle barriers to discussion of ED, especially among populations where sexual health is still taboo. There are some limitations that may affect the interpretation of the results of this study. The control and intervention groups were carried out at the same study site, which might cause cross-contamination of information. Hence, different time periods of data collection for the control and intervention groups were used. Also, with no blinding in this study, the physicians were only exposed to the LASTED flipchart and prompt sheet after the data collection for the control group had been completed. Apart from that, the rate of prescribing of PDE5 inhibitors may not equal the number of prescriptions that were filled and taken by the patient as that is hard to monitor. Therefore, we suggest a follow-up study to analyze the rate of prescribing of PDE5 inhibitors and consumption to better understand the effect of LASTED on ED treatment.

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.

Acknowledgment

We would like to express our most incredible gratitude to the Simpang Kuala Health Clinic staff for their support in the data collection processes.

Received for publication October 13, 2022.Revision received May 25, 2023.Accepted for publication July 18, 2023.© 2023 Annals of Family Medicine, Inc.