Awareness of diabetic retinopathy among patients with type-2 diabetes mellitus in Abha, Saudi Arabia: A survey-based research study.

Context: Diabetic retinopathy (DR) is an avoidable retinal disorder affecting the retina and is deemed the most common microvascular complication of diabetes mellitus (DM). Aims: This study aimed to estimate the awareness and attitude of type 2 diabetic patients toward DR. Methods and Materials: A study questionnaire was distributed among Saudi patients with type 2 DM who visited primary health care at Abha, Saudi Arabia, after obtaining an ethical approval. It was a modified questionnaire and included basic demographic characteristics of the patients, general knowledge and awareness of DM and DR, and their practices toward eye examination. Statistical Analysis Used: Data analysis was performed using SPSS software. Chi-square and z-proportionality tests were applied where appropriate.
Results: A total of 381 patients with DM responded to our survey; 36% of them had DM for five years or less. Notably, 93.5% of participants knew that diabetes can cause eye disease but only 63.3% agreed that regular eye examination for diabetic patients is necessary, with a significant difference of DM duration (p = 0.01). A total of 217 (57%) patients thought that there is no need to visit an ophthalmologist if diabetes is under control. However, 74.5% believed that patients with type 2 DM should go for an eye examination once diagnosed, with a significant difference between disease duration subgroups (p = 0.006).
Conclusion: The current study demonstrated high levels of awareness regarding the effect of DM on the eye and importance of early eye assessment. However, we need to improve the patients' awareness to the value of regular eye checking and standard practices. Copyright:

Introduction

Diabetes mellitus (DM) is a metabolic health problem related to defect in either insulin secretion or function, which results in elevated blood glucose levels, known as hyperglycemia.[1] DM can be categorized into three major types; type 1 (T1DM), type 2, (T2DM), and gestational diabetes.[1] In 2011, the prevalence of DM worldwide has reached 8% and is anticipated to rise to 10% by 2030.[2] Saudi Arabia and Middle East nations have high prevalence of DM. Of note, Saudi Arabia is ranked as the second-highest prevalence country with DM in the Middle East and the seventh worldwide. It is predestined that approximately seven million Saudi people have diabetes and about three million are pre-diabetic.[3]

DM can cause different complications including diabetic retinopathy (DR), peripheral neuropathy, and cardiovascular problems.[4] DR is an avoidable retinal disorder affecting the transmission of oxygen and nutrients to the retina and is deemed the most common microvascular complication among diabetic patients.[4] DR is a devastating complication that may induce visual impairment and complete blindness.[4] It has been estimated that DR can affect 24% of individuals who have suffered DM for 10–15 years.[5] Moreover, around 35% of worldwide DM patients develop a degree of DR.[6] In Saudi Arabia, the prevalence for DR was found to be 28–36% among diabetic patients in studies from different areas of the country.[789] Published reports in the literature showed that increased blood sugar, high blood pressure, and lengthy course of DM are main risk factors for incidence of DR.[10] As the condition remains asymptomatic in the earlier stage, it may worsen with lack of constant screening. A previous study showed that early screening and intervention of DR can stop vision loss by about 57%.[11]

The degree of knowledge and understanding of DR is essential for prompt diagnosis and intervention for any probable visual impairment.[12131415161718] Diabetic patients usually follow up with family medicine physicians or primary health care centers. Patients may aim to report any changes with their vision or diabetes control to their primary healthcare doctors. Of note, delayed referral of DR patients may affect the patient’s quality of life and the economic burden on the healthcare system.[19]

Studies aiming to evaluate the knowledge, attitude, and awareness of DR among DM patients were conducted previously in Saudi Arabia.[12131415] While these studies demonstrated a high level of awareness for DR, there is a limited attitude toward the periodic visual examination and screening.[12131415] Abha is the capital of the Asir region in Saudi Arabia, it is to the best of our knowledge that no previous study assessing knowledge and awareness of DR among diabetic patients has been carried out in Abha. Therefore, this study aimed to estimate awareness, attitude, patients’ practices, and compliance to regular checks of DR among subjects with type 2 DM.

Material and Methods

Study setting

This is a questionnaire-based cross-sectional study carried out in primary health care at Abha, which is the capital of the Asir region, Saudi Arabia. The study has followed all ethical principles and its protocol was notarized by the research ethics committee in General Health Affaires Aseer, Ministry of Health, Saudi Arabia.

Study population and sample size

We invited Saudi patients with type 2 DM who visited primary health care at Abha to fill the study survey. The selection was limited to Saudi diabetic individuals aged 35–75 years. Subjects who; (i) had type 1 DM, (ii) were non-Saudi, (iii) aged less than 35 or older than 75 years, (iv) have had congenital eye diseases, and (v) have suffered from previous eye trauma, were excluded from our study. There were no limitations regarding any other specific characteristic. The patients have not received any incentives for joining and filling study questionnaire. The sample size was calculated based on Cochran’s sample size formula with a margin of error at 5% and the confidence level at 95%, which yielded a total of 381 needed subjects.

Data collection and questionnaire

Our study used a modified questionnaire from a previously published study after obtaining the authors’ consent.[12] The questionnaire was translated into Arabic and reviewed by family medicine and ophthalmology consultants. The questionnaires included basic demographic characteristics including age, sex, marital status, economic level, and disease duration. It also covered questions of general knowledge and awareness of DM, DR, and subjects’ practices toward eye examination.

Statistical methods

All data analysis was carried out using SPSS software Version 19. Percentages, mean, and standard deviation were calculated. Also, Chi-square and z-proportionality tests were applied where appropriate.

Results

General demographic characteristics of study participants

A total of 381 patients with DM responded to our structured survey. Male gender was predominated as 61.2% of the sample. Almost half of the sample were more than 55 years old (n = 198, 52%), and 33.6% were between 46 and 55 years. Regarding the socioeconomic status, the majority of participants were married (93.2%) and has monthly income between 5000 and 15000 R.S (69.3%). However, only 16.8% who were graduated or had higher studies, the primary education was counted the highest in the sample (26.5%) followed by secondary education (24.7%), illiterate (23.9%), and lastly intermediate education (8.1%). Duration of DM as reported by responders; 137 (36%) participants had DM for five years or less, and almost similar percentages in other groups, 86 (22.6%) patients had DM for 6 to 9 years, 80 (21%) patients for 9 to 14 years and 78 (20.5%) patients for more than 15 years. Detailed basic demographic characteristics are shown in Table 1.

Table 1

Characteristic of our participants

Item	n	%	Z
Gender
Male	233	61.2	<0.001
Female	148	38.8
Age
35-45 years	55	14.4	<0.001
46-55 years	128	33.6
>55 years	198	52.0
Social status
Married	355	93.2	<0.001
Widowed	21	5.5
Divorced	3	0.8
Single	2	0.5
Economic status
<5000 RS	107	28.1	<0.001
5000-15000 RS	264	69.3
>15000 RS	10	2.6
Educational status
Illiterate	91	23.9	<0.001
Primary	101	26.5
Intermediate	31	8.1
Secondary	94	24.7
Graduate or higher	64	16.8
Duration of DM
5 years or less	137	36.0	<0.001
6-9 years	86	22.6
9-14 years	80	21.0
>15 years	78	20.5
Work
Retired	145	38.1	<0.001
Employed	121	31.8
Housewife	113	29.7
Not reported	2	0.5
Type of living
Rent	218	57.2	<0.001
Own house	161	42.3
Not reported	2	0.5

Subjects’ response on the general awareness of diabetic retinopathy questions

Notably, 93.5% of participants knew that diabetes can cause eye disease, with no significant difference with respect to DM duration (P = 0.119). However, only 241 (63.3%) participants agreed that regular eye examination for diabetic patients is necessary. A significant difference was noted with regard to subgroups of DM duration (p = 0.01). On the other hand, almost more than half of the sample (n = 217, 57%) thought that there is no need to visit an ophthalmologist if diabetes is under control, there was no significant difference observed concerning disease duration. A total of 97.6% of the responder agreed on the usefulness of early eye examination and timely treatments to prevent or delay diabetes damage to the eyes [Table 2].

Table 2

General awareness of diabetic retinopathy among diabetic patients

Item	Answer	Duration of diabetes				P between duration of DM	Total n (%)	P
		≥5	6-9	9-14	>15
Do you know that diabetes can cause eye disease?	No	7	4	10	4	0.119	25 (6.6)	<0.001
	Yes	130	82	70	74	356 (93.4)
Should persons with diabetes go for regular eye examinations?	No	65	26	27	22	0.011	140 (36.7)	<0.001
	Yes	72	60	53	56	241 (63.3)
There is no need to visit ophthalmologist if a person is having diabetes under control?	No	51	34	39	40	0.136	164 (43)	<0.001
	Yes	86	52	41	38	217 (57)
Timely treatment can prevent/delay damage due to diabetes in eyes?	No	2	1	5	1	0.84	9 (2.4)	<0.001
	Yes	135	85	75	77	372 (97.6)

Knowledge of choice of healthcare professional and available treatment for diabetic retinopathy

A total of 99.5% of the sample reported they would consult ophthalmologist in the event of eye problem, yet 18 cases reported that they may also consult optometrist (4.7%), seven for general practitioner (1.8%), and one participant may also consult any specialist (non-ophthalmologist). This difference was statistically significant (p < 0.001). A total of 99.2% of participants reported that control of diabetes and modification of lifestyle are available lines of treatments in DR management. Moreover, 97.6% of the participants knew about surgical procedures and alternative medical therapies in DR treatment. However, 81.4% replied that only medication is the available treatment for DR. Only six (1.6%) participants thought that no available treatment for DR. This difference was considered statistically significant (p < 0.001) [Table 3].

Table 3

Knowledge of proper healthcare professional and available treatment choices

Item	Answer	Duration of diabetes				P between duration of DM	Total n (%)	P
		≥5	6-9	9-14	>15
Knowledge of choice of healthcare professional in the event of eye problem. Whom do you consult in the event of eye problem?
Ophthalmologist	No	1	0	0	1	0.6	2 (0.5)	<0.001
	Yes	136	86	80	77		379 (99.5)
Optometrist	No	134	81	75	73	0.378	363 (95.3)	<0.001
	Yes	3	5	5	5		18 (4.7)
General practitioner	No	136	85	78	75	0.378	374 (98.2)	<0.001
	Yes	1	1	2	3		7 (1.8)
Any specialist (Non-ophthalmologist)	No	137	86	80	77	0.273	380 (99.7)	<0.001
	Yes	0	0	0	1		1 (0.3)
Knowledge of available treatment for diabetic retinopathy?
No treatment available	No	136	84	80	75	0.185	375 (98.4)	<0.001
	Yes	1	2	0	3		6 (1.6)
Control of diabetes	No	2	1	0	0	0.532	3 (0.8)	<0.001
	Yes	135	85	80	78		378 (99.2)
Modification of life style	No	1	1	1	0	0.8	3 (0.8%)	<0.001
	Yes	136	85	79	78		378 (99.2)
Only medication	No	19	18	19	15	0.29	71 (18.6)	<0.001
	Yes	118	68	61	63		310 (81.4)
Alternative medical therapies	No	4	4	1	0	0.216	9 (2.4)	<0.001
	Yes	133	82	79	78		372 (97.6)
Surgical procedures	No	5	3	1	0	0.287	9 (2.4)	<0.001
	Yes	132	83	79	78		372 (97.6)

Attitude regarding diabetic retinopathy

Most of the participants showed an average accepted attitude regarding DR; 259 (68%) participants reported that they go for eye examination yearly while 111 (19.2%) participants denied going to eye examination. No significant difference was noted between diabetes years subgroups. More than two-thirds (74.5%) of the sample believed that patients with type 2 DM should go for an eye examination once diagnosed, with a significant difference between disease duration subgroups (p = 0.006). A total of 97.6% thought that the process needed to refer patients from primary health care to ophthalmology clinics is simple. Moreover, 35% of participants reported that they were able to get an ophthalmology appointment after a referral from a family medicine clinic after two months, while 88 (23%) participants were able to have an appointment after three months. Only 4% reported that they could get the appointment within less than one month. No significant difference was noted between diabetes duration subgroups. Patients’ evaluation regarding the DR awareness in primary health care was estimated as excellent and very good by 54.1% and 40.4% of the participants, respectively. [Table 4]

Table 4

Patients’ attitude regarding diabetic retinopathy

Item	Duration of diabetes				P	Total n (%)	P
	≥5	6-9	9-14	>15
How often you go for eye examination?
Monthly	0	1	1	0	0.08	2 (0.5)	<0.001
Every six months	0	3	2	4		9 (2.4)
Yearly	86	60	55	58		259 (68)
I have not	51	22	22	16		111 (29.1)
When should type 2 diabetic patient go for eye examination?
After five years	14	14	11	8	0.006	47 (12.3)	<0.001
After one year	29	9	10	2		50 (13.1)
On diagnosis	94	63	59	68		284 (74.5)
Referral from primary health care to ophthalmology clinic in general hospital, was it a simple process?
No	4	1	3	1	0.618	9 (2.4)	<0.001
Yes	133	85	77	77		372 (97.6)
How often you get ophthalmology appointment after referral from family medicine clinic?
<1 month	5	5	4	1	0.735	15 (4)	<0.001
1 month	27	14	12	15		68 (17.8)
2 months	47	31	29	26		133 (35)
3 months	27	25	17	19		88 (23)
>3 months	31	11	18	17		77 (20.2)
Your evaluation regarding awareness to diabetic retinopathy in primary health care?
Excellent	66	49	43	48	0.593	206 (54.1)	<0.001
Very good	63	33	33	25		154 (40.4)
Good	8	4	4	5		21 (5.5)
Bad	0	0	0	0		0

Discussion

Diabetes is a global disease and a growing burden, hence its complications, including DR, are expected to rise. However, this risk may be decreased by sufficient screening and tight control of blood sugar.[10] It is worth noting that lack of public awareness of DM and its complications may considerably impact the delivery and costs of health care.[12131415] Thus, our study aimed to check the level of awareness and attitude toward DR among Saudi patients with DM.

Our study showed that 93.5% of participants knew that diabetes can cause eye disease, but only 63.3% agreed that regular eye examination for diabetic patients is necessary. In a previous study in Saudi Arabia, the level of awareness of DR was high among DM patients; more than two-thirds of subjects knew that DR may cause vision loss, and majority of sample knew that DM can affect retina. Moreover, most of the study responders knew that controlled blood sugar may decrease the risk of DR.[13] These results come in consistent with studies from regional countries such as Oman (93%), Jordan (88%), and Turkey (88%) where they also showed high levels of awareness toward DM effect on the eyes.[202122]

Our results showed statistical significance and association with DM duration regarding two questions “if regular eye examination is necessary for diabetic patients”, and “when should diabetic patient attend for eye examination”. In a study from Turkey, patients with type 2 DM more than 10 years had higher awareness about DR.[20] These findings were consistent with a report from Saudi Arabia.[23] In the study by Alsaidan et al.[15], the level awareness toward DR was affected by DM duration.

It is recommended to annually check the eye of diabetic patients for earlier diagnosis of DR and prevention of its complications as it has a silent course at first stages. In our study, 68% of patients reported that they go for eye examination yearly and 74.5% believed that patients with DM type 2 should go for an eye examination once diagnosed. In a previous study by al Zarea, approximately 95% of subjects attended regular eye examinations with 48.97% of them attending a yearly assessment.[12] A nearly similar percentage was reported by AlHargan et al.[13] where 48% of study participants went for annual ocular examination. Of note, these two aforementioned studies were carried out in different regions in Saudi Arabia.[1213] These percentages are lower than what previously shown in published reports from different countries such as Switzerland (71%) and Jordan (76%).[2224]

Our study reported that 57% of patients thought that there is no need to visit an ophthalmologist if diabetes is under control. This is in contrast to what is reported by Al-Yahya et al.[14] where most of participants agreed on the importance of regular ocular evaluation regardless of blood sugar level but more than 60% of them did not believe it is essential to do check-up if their vision is good. This may reflect the defect in diabetic patients’ knowledge of DR. While they demonstrated high awareness and good knowledge of DR, this does not necessarily indicate their good practice.[14] In a study by Funatsu et al.,[25] more than 98% of patients were aware of eye-associated problems in DM; however, only 69.5% of the patients attended the regular ophthalmology examinations. Similarly, in a study by Alzahrani et al.,[26] although more than 82% of study subjects were aware of DM complications on eyes, only 65% went to periodic eye examination.

There are several strength points in the present study; (i) it has investigated awareness of diabetic individuals in detail and assessed the overall knowledge, (ii) it has included a relatively larger sample population compared with published reports in the literature, (iii) patients were invited from primary health care, which makes them representative for the level of awareness and real practices, and minimizes the selection bias. Nonetheless, this study is not limitation-free. It has been limited by being conducted in one city in Saudi Arabia which may affect the generalization of our findings. A second limitation is the fact that the participants’ answers regarding DM duration and attitude toward DR were self-reported and were not compared with their medical records, which makes the results subject to overreporting by some patients. Future studies may consider addressing these issues. Although the level of awareness of aye affection by DM may be high in the present study and previous studies, policymakers should establish education programs to enhance diabetic patients’ awareness of DR and highlight the value of regular eye check-ups. Moreover, future studies are needed to investigate more variables that may influence the degree of knowledge and awareness of DR. Primary healthcare doctors should offer novel ways and contribute to patients’ education about the impact of DM and DR on their health. Appropriate guidance and immediate referral by family medicine physicians for patients presenting with early features of DR could lessen the long-term impact.[1927] This approach will allow specialists to establish a comprehensive treatment plan together with following up any progression by family medicine doctors.

Key points

• Diabetic retinopathy is a serious complication of diabetes millets and a major cause of vision loss worldwide.

• The current study showed high levels of awareness regarding the effect of diabetes on the eye and risk factors of diabetic retinopathy.

• The current study also showed that diabetic patients have a high awareness level regarding the usefulness of early eye examination and timely treatments of diabetes-related eye damage.

Conclusion

DR is a serious avoidable complication of DM and a leading cause of vision loss worldwide. The current study demonstrated high levels of awareness regarding the effect of DM on the eye, risk factors of DR, and the usefulness of early eye examination and timely treatments in prevention of eye damage. However, we need to improve the patients’ awareness to the value of regular eye checking and available treatment options for DR. Our results shed the light on the importance of DM education since awareness is substantial in limiting diabetes-associated complications and improving their outcomes. Our inferences need further confirmation by data from large multi-center randomized studies.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.