European Journal of Cardiovascular Medicine

Diabetes Mellitus (DM) is a major noncommunicable disease which is increasing in prevalence and incidence worldwide. By 2040, India is estimated to have 123.5 million diabetes patients. (1)

Major characteristic feature of DM is insulin resistance, which leads to hyperglycemia and eventually gives rise to micro and macrovascular complications. Diabetic Retinopathy(DR) is the most common microvascular complications of DM. There are 2 types of DR, proliferative and non proliferative DR. 1.5% of DR patients in India suffer from blindness. (2) DR is a major cause of visual disability leading to irreversible blindness among adults.(3) PDR is a more advanced stage of DR, which is characterized by neovascularization. During this stage, the patients may experience severe vision impairment because of the new vessels bleeding into the vitreous or when tractional retinal detachment occurs. The most common cause of vision loss in patients with DR is diabetic macular edema (DME). DME is characterized by swelling or thickening of the macula due to sub- and intra-retinal accumulation of fluid in the macula triggered by the breakdown of the blood-retinal barrier (4)

Awareness about DR among DM patients is an important factor for early diagnosis and the treatment of the disease to avoid further complications such as visual impairment. (5,6,7)

It is recommended that all the level of health care workers and the members of various medical associations, senior citizen forums etc must be involved in increasing awareness, improving screening coverage and establishing referral linkages between screening and treatment centres. Although majority of our general population feel that the patients with DM should undergo frequent eye check-ups, very few of the patients with DM check for diabetic retinopathy. General practitioners and physicians are usually the first access points of the patients with DM.(8)

We find that many diabetic patients who come to the outpatient clinics and inpatient wards of our hospital, a tertiary eye care centre in South India, have advanced diabetic retinopathy, and have not undergone screening, treatment or follow up for retinopathy according to the standard recommendations. If diabetic retinopathy had been detected in these patients at an early stage, irreversible visual impairment could have been prevented. Several investigators from India as well as from other parts of the globe, have expressed similar concerns, regarding the lacunae in knowledge about the disease, and ‘less than effective’ screening methods for early detection of this silently blinding disease.

We conducted this study to document the Knowledge, Attitude and Practice (KAP) patterns of diabetic patients regarding diabetic retinopathy in this part of the country and to determine the association between KAP patterns. (8)

Objective:

1. To assess the knowledge, attitude and practices of diabetes patients towards Diabetic Retinopathy

To determine the association of knowledge and attitude with practice.

A cross sectional study was conducted on randomly selected  type 2 diabetes mellitus patients attending as out-patients in the department of Ophthalmology at Kanachur Institute of Medical Sciences. The study was conducted from August 2021 to October 2022. (8)

and the sample size was calculated to be 82 .The sampling procedure was done by simple random sampling  Approval from the institutional ethics committee was obtained before starting the study. Written informed Consent was received from all patients in the study. Study was conducted in ophthalmology outpatient department at Kanachur Hospital attached to Kanachur Institute of Medical Sciences , Mangalore.

Inclusion Criteria: Type 2 adult diabetic patients having retinopathy, ≥18 years old, who were on oral hypoglycemics or on insulin. 

Exclusion criteria: Patients less than 18 years of age, patients with type 1, gestational diabetes, mentally challenged patients who are unable to give informed consent or respond meaningfully to the questions administered, were excluded from the study.

The socioeconomic and educational status of each patient was graded using Modified Kuppuswamy classification. The presence and level of diabetic retinopathy was assessed by dilated fundus examination using slit lamp binocular indirect ophthalmoscopy. Diabetic retinopathy was classified according to the Modified Airlie House Classification.

Data regarding KAP patterns, and barriers to compliance with follow up and treatment regimens for diabetes and diabetic retinopathy was collected using a validated questionnaire. After obtaining the consent, the patients were requested to answer the questionnaire by using face to face interview method. The content validity of the questionnaire was established by submitting the tool to the experts (Specialists having 10 or more years of experience) in the field of Ophthalmology. 

Statistical analysis: Data was analysed using statistical software SPSS version 21. Values were expressed as mean ± SD (standard deviation). Comparison of parameters was done by using Student’s t test. Correlation between two parameters was done using spearman ’s correlation test.  p value of less than 0.05 was considered as statistically significant.

Out of total 82 study participants 26 (31.7%) were females and 56 (68.3%) were males. 

Table 1: Knowledge regarding Diabetic retinopathy among Diabetes mellitus patients. 

Table 2: Attitude regarding Diabetic retinopathy among Diabetes mellitus patients. 

Table 3: Practice regarding Diabetic retinopathy among Diabetes mellitus patients. 

 Table 4: Correlation of knowledge, attitude and practice with age and duration of Diabetes mellitus .

Note: r (p value) is reported; Statistical test used: Spearman rank correlation  *p value <0.05 is considered statistically significant 

Table 5: Comparison of knowledge, attitude and practice score with gender.

Statistical test used: Mann Whitney U test 

*p value <0.05 is considered statistically significant

Table 6: Overall Mean score obtained in knowledge, attitude and practice sections.

DR is a complication of uncontrolled, long standing DM which can lead to blindness. Key to prevent DR is regular blood sugar monitoring and control.

Our study was a hospital based study which included 82 patients who visited out patient department of ophthalmology for various reasons. 

Questionnaire had 19 questions in which 10 are knowledge, 4 are attitude and 5 checked practices. Out of 82 patients, 26 (31.7%) were females and 56(68.3%) were males. 

In our study, 10 questions were asked to assess their level of knowledge. 90.2% of the patients are aware of the tests done to diagnose DM. but 87.8% of the patients did not know how to keep DM under control. 85.4% were not aware of the eye problems DM can give. 53.7% agreed that DM can cause blindness. 

Our study is in contrast to study by  Al raza et al in Peshawar in which patients had good knowledge about DM and DR. 59% patients also knew about risk factors and treatment options(9). Other studies by Rani et al in southern districts of Tamil Nadu(10) and Malavika et al (11) also demonstrated good knowledge in the study group about disease and  with knowledge of  37% and 39.19% respectively.

A study done in Saudi Arabia (5) had the best knowledge of 75.6%, study population knew that DM of more than 10 years can cause DR 72.9%. Some Indian studies by Nirupama et al (12) and a study in Hyderabad (13) also had high knowledge of 50.9%, 71.67% respectively.  In a study in Gujarat (2), patients had good knowledge about DM symptoms, risk of DR, but had poor knowledge on the symptoms, causes and treatment options of DM and DR.

Sen et al (1) study patients showed good knowledge about DM but only 7.6% had some knowledge about DR. A study conducted in Odisha showed 69.28 % were aware that DM affects eyes and causes blindness which is higher than in our study (14).

Our study showed 63.4% patients were not aware that DM can affect retina, whereas Saudi Arabia (5) study patients had 82.8% who were aware. 73.2% of patients were not aware of the eye check up for DR in our study. 58.5% didn’t know that DR can have normal vision. 78% patients agreed that the doctor is the best reliable source of information regarding DR. 70.7% patients think DR treatment regains vision. 95.1% patients were totally unaware of the treatment options available.

The present study patients were asked 4 questions to check their attitude towards DR. 51.2% agreed that eating sweets occasionally was alright. 56.1% agreed that they should not forget to take medications ever. Saudi Arabia study (5) also showed good attitude of the patients towards disease, they agreed that good glycaemic control is needed to prevent complications.  A study done in CMC Vellore (8) showed 29.2% positive attitude. Rani et al (10) showed high percentage of 93.3% positive attitude.

Our study participants had positive attitude towards these 2 questions. 57.3% patients disagreed for eye checkup when blood sugars are under control. 58.5% agreed that regular eye checkup is needed even if there are no eye problems as advised by their doctor.

The present study patients had good practices on taking medicines regularly as advised by the physicians.(87.8%). And they did go for regular follow up advised by their physician (85.4%). Many studies showed patients agreeing that doctors specially physicians and ophthalmologists are the best source of information (5,8,10). 

Our study is in consistent with Saudi Arabia study (5) where 30% went for annual check up, 72% regular check up. Anitha et al study (14) showed 69.3 % periodic check up and 21.9% every 6 months check up . However 63.4% patients had not shown interest in regular exercise. 59.8% patients did not get their eyes checked to know whether DM has affected their eyes. We noticed in our study there is decline in the level of knowledge as age and duration of diabetes increase. And it was statistically significant with duration of DM. Attitude has negative correlation with age and duration which suggests which is not statistically significant. Practice also showed negative correlation though statistically insignificant which shows their disinterest in practicing. There is no statistically significant difference between male and female in knowledge, Attitude and practice.  

It can be concluded by saying that our study population had good knowledge about the tests done to detect DM, awareness that it can cause blindness, physician being the right person of information and they also know that treatment for DR can regain vision. But what information they lack is knowledge about keeping DM under control, problems arising from the disease, about eye check up frequency, DR affecting retina, treatment options available for DR. looking at the above pattern it may be understood that our patients have good knowledge about DM but they are not aware of the complications and especially DR. our study group belonged to low socioeconomic status and their educational qualification is not great. 

Overall attitude was positive. They agreed that they should take regular medications, visit doctor frequently. But what they mis understood is, thinking that eating sweets occasionally is alright and if their blood sugars are normal they need not visit doctor. This shows that they have poor knowledge regarding DR so their attitude towards it is not good.

Our study subjects had good practice in taking medicines as advised by physicians, and follow up, but they don’t practice regular exercise, regular eye check up . This again can be attributed to their poor knowledge about DR. 

After analysing the data it can be said that we have to educate our patients and bring awareness regarding DR in them. Only if they know more about the disease and its eye complications their attitude will change and they will start good practice.

This may be done by various methods. We can start with displaying pictures of information about DR outside OPD, near billing section and patient waiting lounges. Brief information about DR, symptoms, complications, treatment options should be displayed. Information should be provided in local language as our patients are comfortable with it.

Ophthalmologists should insist patients on regular eye checkups every 6 months and its benefits should be explained. Educating the patients can be done even by medical and Optometry interns posted in the department considering the time constraint and work burden of ophthalmologists. Proper education of interns towards the disease is a prior requisite.  

We have to educate family members also because majority of the patients were elderly and had DM more than 10 years. Over the years they become less compliant to the treatment and show less interest in regular follow ups. So it becomes family members’ responsibility to bring them for follow ups. And it should be stressed that proper treatment and regular eye check up can reduce complications and prevent blindness

Using multimedia for providing information can also be implemented. Awareness talks by doctors in television and radio channels can also be tried.

Regular eye check up camps by doctors should be conducted in villages where we have identified maximum number of cases. Rewarding the patients who are regular on treatment and visits, can motivate other noncompliant patients.

Our CBME curriculum by NMC stresses on family adoption programmes. This programme can be efficiently used to identify DM and recognise early symptoms of DR and providing timely treatment. Regular visits by MBBS students to these patients’ houses will enable them to identify the disease and motivate the patient to visit doctor.

Our study showed negative correlation of knowledge, attitude and practice with age and duration of diabetes. Correlation of knowledge with duration is statistically significant. This shows that as age advances patients show less interest in learning about disease. Aged patients with long duration of the disease slowly develop disinterest in taking care of them and may become burden on the family members. In this case family should be educated and motivated.

They should be made aware of the treatment options and how we can prevent blindness using treatment methods.

Ours study did not show any significance in the knowledge, attitude and practice levels among two genders.

Implications: This study will help us in understanding the existing limitations in health care system in early detection of DR and can help in strengthening strategies and improving upon the existing policies to decrease the DR-related blindness burden. In spite of adequate awareness for DR, there is lack of motivation for regular eye screening. The knowledge about the preventive measures and treatment modalities is poor among patients. This necessitates more aggressive health promotional programs at different levels stressing on regular screening for retinopathy among diabetic patients.

Limitations: Our sample size was less. Questionnaire did not have questions related to their diet and treatment history. Glycaemic status was not taken into consideration. 

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