DOI: https://doi.org/10.21203/rs.3.rs-2134204/v1
Purpose: The purpose of this study is to assess the knowledge of diabetic retinopathy and associated factors among adult diabetic patients at Adare General Hospital, Southern Ethiopia, Hawassa.
Methods: A cross-sectional study was conducted at Adare General Hospital on 419 adult diabetic patients. Systematic random sampling was applied to select the study participants. Data were collected via a structured questionnaire, checklist, and physical examination. Binary logistics regression and descriptive statistical analyses were done using SPSS version 20. Variables having p-values of less than 0.05 were considered statistically significant. An adjusted odds ratio with a 95% Confidence Interval (CI) was used to determine the strength of association between the dependent and independent variables.
Results: Among the total participants, 41.3% [95% CI (36.8-46.1)] had good knowledge about diabetic retinopathy. Urban residence [AOR=3.01, 95% CI; (1.39-6.52)], high income [AOR=4.68, [95% CI; (1.40-4.62)], type II diabetes [AOR=3.18,95% CI; (1.15-8.80)], long duration of diabetes [AOR=6.28,95% CI (3.26-12.10)], family history of diabetes [AOR=2.54, 95% CI (1.40-4.62)], history of eye disease [AOR=2.64,95% CI (1.45-4.80)] were significantly associated with knowledge on diabetic retinopathy.
Conclusions: The proportion of diabetic patients with good knowledge in this study was found to be low (41.3%). Health education and promotion interventions on diabetic retinopathy and eye check-ups could enhance their knowledge and practice.
Diabetes mellitus (DM) is a group of metabolic diseases in which characterized by persistent hyperglycemia [1]. Diabetic retinopathy (DR), the most common ocular complication of DM, is a microvascular abnormality of the retina, because of prolonged hyperglycemia [2]. The number of persons with visual impairment because of DR worldwide is rising and represents an increasing proportion of all blindness. Globally, DR was 22.27% among diabetic patients [3]. Diabetic retinopathy caused blindness for 0.8 million people and visual impairment for 3.7 million people [4]. In Ethiopia, the prevalence of diabetic retinopathy was 19.48% and from the overall estimate, 12.48% was in Southern Ethiopia [5].
The annual cost of diabetic eye disease is high, which causes loss of productivity at personal, societal and national level [6–8].
The main reasons for blindness among diabetic patients are poor diabetes self-management such as lack of sufficient knowledge (about the course of the disease, risk factors, and treatment options), failure to have an early screening and regular eye check-ups [9, 10].
Detecting and treating diabetic eye diseases at earlier stages of the disease course may provide 90% effectiveness in the prevention of severe visual loss [11]. Improving the knowledge is vital to eliminate avoidable blindness and associated economic burden [12].
In developing countries like Ethiopia, where the core of the health system is prevention, it is essential to assess the level of knowledge and practice of its population towards such ruinous disease to plan intervention mechanisms. Hence, this study aims to determine the proportion of knowledge on diabetic retinopathy and associated factors among diabetic patients at Adare General Hospital, southern Ethiopia.
The study was conducted at Adare General Hospital (AGH) Southern Ethiopia from May-July 2021. The hospital is in Hawasssa, the regional city of Sidama Regional State in Southern Ethiopia 275 km away from the capital city Addis Ababa. According to the hospital planning and information office, the hospital is providing preventive and curative health services for about three million people in the region. It has the largest diabetic center in Hawassa city and approximately 5,000 diabetic patients are attending the Hospital. Internal medicine specialists, medical residents and nurses have been involved in caring for diabetes patients. The Ophthalmology department is providing comprehensive eye care service for the community. There are currently 1 ophthalmologist and 5 optometrists delivering the service.
All adult diabetic patients having diabetic care follow-ups at Adare General Hospital were included in the study. Diabetic patients who were critically ill and with mental illnesses that preclude giving appropriate responses during the interview were excluded.
The sample size was calculated based on the previous study, proportion of knowledge (47.4%) [13] with a precision of 5% and an alpha error of 0.05, non-response rate of 10%, the calculated sample size was 422.
Systematic random sampling was done to select study participants from the total diabetic patients on follow-up. The diabetic center at AGH provides service for at least 2000 diabetes patients in three months. Considering 422 sample sizes and taking 2000 as population size, the determined K value is approximately 4. The first sample was randomly selected then every 4th patient attending the diabetic center was included in the study after completion of all medical check-ups and treatments at the diabetic center.
Knowledge was assessed by asking 12 questions about the cause, prevention and treatment of DR. Correct answers were given a score of 1 and incorrect answers a score of 0. Respondents who scored greater than or equal to fifty percent of knowledge questions were considered as having good knowledge and those who scored below 50% of the knowledge questions were considered as having poor knowledge.
The knowledge and practice questionnaire were prepared from reviewed literatures [13–18] in English and translated to Amharic and then translated back to English by an independent translator. The Amharic version structured questionnaires and physical examination were employed to collect the data. Three BSc nurses collected the data through face-to-face interviews with the selected diabetic patients after completion of their medical checkups. The visual acuity of study participants was measured using Snellen’s ‘illiterate E’ acuity charts and all relevant information from the chart extracted by the data collectors. Two porters were involved in the identification and sorting of charts.
The questionnaire was pretested on 22 diabetic patients at Hawassa comprehensive
specialized hospital chronic diseases follow-up clinic to check if questions could be
Understood by study participants. The reliability was assessed using Cronbach’s alpha. Data collectors were nurse professionals who were trained on data collection procedures including interviews, visual acuity measurement and how to review the documents as per the data extraction format was given to data collectors. The principal investigator was involved in the supervision of the data collectors and checking for completeness of each questionnaire.
After checking the data for its completeness and consistency, it was coded and entered into EpiData version 4.4 and exported to SPSS version 20 for analysis. Descriptive and analytical statistics were performed. Bi-variable logistic regression was used to identify candidate variables. Variables with p-value ≤ 0.2 in Bi-variable logistic regression were entered into a multivariable logistic regression model. Variables having p-values of less than 0.05 were considered statistically significant. Adjusted odds ratio with 95% CI was used to determine the strength of association between the dependent and independent variables. The model fitness was checked by Hosmer and Lemeshow goodness-of-fit test.
The study was conducted under the Declaration of Helsinki and approved by the University of Gondar, School of Medicine Ethical Review committee and Adare General Hospital administration office. Verbal informed consent to be included in the study was obtained from each study participants.
In this study, 419 participants completed the study with a response rate of 99.28%. The median age of the respondents was 51 years (IQR, 17). Most of the participants were male 218 (52.0%) and married 309 (73.7%). One-third of participants 134 (32.0%) had no formal education. The median family monthly income of the study participants was USD 100.82 (IQR, 90.74) (Table 1).
| Variable | Frequency | Percent |
|---|---|---|
| Age < 44 44–51 52–61 > 62 | 66 134 112 107 | 15.8 32.0 26.7 25.5 |
| Gender Female Male | 201 218 | 48.0 52.0 |
| Marital status Married Currently single | 309 110 | 73.7 26.3 |
| Residence Urban Rural | 309 110 | 73.7 26.3 |
| Education No formal education Completed primary school Completed secondary school Collage and above | 134 81 111 93 | 32 19.3 26.5 22.2 |
| Monthly income (USD) < 64.52 64.52-100.82 100.82–155.40 > 155.40 | 116 113 94 96 | 27.7 27.0 22.4 22.9 |
| Health insurance Yes No | 74 345 | 17.7 82.3 |
The majority of participants were diseased with type II DM. Among the total 419 study participants, 104 (24.8%) of them had additional systemic co-morbidities on top of DM. Participants with a history of any eye disease were 185 (44.2%). Among those who had a history of eye disease, 45 (24.3%) had a history of diabetic eye disease, of which 34 (69.3%) had DR (Table 2).
| Variable | Frequency | Percent |
|---|---|---|
| Type of DM Type I Type II | 44 375 | 10.5 89.5 |
| Duration of DM ≤ 5 years > 5years | 264 155 | 63.0 37.0 |
| History of eye disease Yes No | 185 234 | 44.2 55.8 |
| Visual Impairment Yes No | 71 348 | 16.9 83.1 |
| Systemic co morbidities other than DM Yes No | 104 315 | 24.8 75.2 |
| Family history of DM Yes No | 185 234 | 44.2 55.8 |
Of the total of 419 participants, 366 (87.4%) knew that diabetes could affect the eye and among those 173(47.3%) of them had good knowledge about diabetic retinopathy. Of the total participants, only 41.3% CI (36.8–46.1) of them had good knowledge about diabetic retinopathy. Regarding their source of information, nearly half of participants (51.1%) found their information about DR from media while only 37.5% got information about DR from diabetic care and follow-up service givers. And also, 161 (38.4%) of participants had a positive attitude towards eye checkups. Among the total study participants, 235 (56.1%) answered that diabetic retinopathy always causes visual symptoms at the beginning of the disease course. Of the total 419 study participants, 257 (61.3%) do not know that all diabetes should undergo regular eye check-ups even without visual symptoms.
In bi-variable analysis, age, residence, educational status, occupation, average household income, type of DM, duration of DM, history of DM in family, and history of eye disease were factors associated with good knowledge. However, upon multivariable binary logistic regression analysis, urban residence [AOR = 3.01, 95% CI; (1.39–6.52)], high income [AOR = 4.68, [95% CI; (1.40–4.62)], type II diabetes [AOR = 3.18,95% CI; (1.15–8.80)], long duration of diabetes [AOR = 6.28,95% CI (3.26–12.10)], family history of diabetes [AOR = 2.54, 95% CI (1.40–4.62)], history of eye disease [AOR = 2.64,95% CI (1.45–4.80)] were significantly associated with knowledge on diabetic retinopathy (Table 3).
| Variable | Knowledge Good Poor | COR (95%CI) | AOR (95%CI) |
|---|---|---|---|
| Age <44 44–51 52–61 >61 | 21 45 64 70 45 67 43 64 | 1.00 1.96(1.05–3.64) 1.44(0.76–2.73) 1.44(0.75–2.75) | 1.00 1.17(0.47–2.90) 1.44(0.52–3.94) 0.89(0.31–3.10) |
| Gender Female Male | 66 135 107 111 | 1.00 1.97(1.33–2.93) | 1.00 1.27(0.66–2.38) |
| Residence Urban Rural | 156 153 17 93 | 5.58(3.18–9.80) 1.00 | 3.01(1.39–6.52)* |
| Educational level No formal education Primary school Secondary school Collage and above | 30 104 20 61 62 49 61 32 | 1.00 1.14(0.59–2.17) 4.39(2.52–7.62) 6.61(3.66–11.92) | 1.00 0.58(0.23–1.45) 2.31(0.96–5.55) 2.24(0.87–5.76) |
| Occupation Civil servant Retired Private Unemployed | 54 45 22 16 71 106 26 79 | 3.65(2.01–6.60) 4.18(1.91–9.13) 2.03(1.19–3.48) 1.00 | 1.58(0.59–4.17) 1.15(0.33–4.01) 1.32(0.56–3.11) 1.00 |
| Average monthly household income <3200 3200–5000 5001–7700 >7700 | 22 94 38 75 43 51 70 26 | 1.00 2.16(1.18–3.97) 3.60(1.94–6.67) 11.50(6.026–21.96) | 1.00 1.67(0.74–3.77) 1.90(0.82–4.38) 4.68(1.88–11.57)** |
| Type of DM Type I Type II | 11 33 162 213 | 1.00 2.28(1.12–4.65) | 1.00 3.18(1.15–8.80)* |
| Duration of DM </= 5years >5 years | 63 201 110 45 | 1.00 7.79(4.98–12.20) | 1.00 6.28(3.26–12.10)*** |
| Family history of DM Yes No | 120 65 53 181 | 6.30(4.10–9.69) 1.00 | 2.54(1.40–4.62)* 1.00 |
| History of eye disease Yes No | 120 66 34 180 | 6.01(3.92–9.22) 1.00 | 2.64(1.45–4.80)** 1.00 |
| *p-value < 0.05 ** p-value < 0.01 ***P- value < 0.001 | |||
The proportion of good knowledge of diabetic retinopathy in this study was found to be 41.3% (95% CI (36.8–46.1)). This result was in line with studies done in South Africa (42%) [19], India Kerala (39.19%) [20], and India Chennai (37.1%) [21].
However, this finding was higher than a study done in India, Tamil Nadu (4.5%) [16]. This variation could be attributed to the exclusion of diabetic patients with ocular diseases like cataract, retinal vein occlusion, or ocular ischemic syndrome in India, Tamil Nadu study.
On the other hand, the result was lower than studies in Debark (47.4%) [13], Sudan (46.6%) [22], Malaysia (49.4%) [23] and Bangladesh (55%) [15]. The slight difference observed with the study in Ethiopia, Debark could be because of sources of information on DR. More than half of the study participants in Debark found their information about DR from Medical staff at DM centers while 51.1% of participants in this study found their information about DR from the media. Since medical staff gives more detailed updated information than media, study participants in Debark could increase their knowledge. The variation from Sudan, Bangladesh and Malaysia studies could be due to the method of assessment of knowledge. In those studies, a single question was used to assess the knowledge that might overestimate the result. While in this study, a participant has to give a correct answer at least to fifty percent of 12 knowledge questions to be considered as having good knowledge.
In this study, participants who live in urban areas were three times more likely to have good knowledge of diabetic retinopathy. It is supported by studies in Debark and Bangladesh [13, 15]. This could be explained by urban residents having more access to different information sources like media, printed materials and eye care services.
Participants who had high income were 4.7 more likely to have good knowledge as compared to lower-income. The possible reason could be participants with better income could afford access to general health services as well as eye care services, which increase contact with professionals, ultimately increasing the chance to get information about the disease.
According to this study patients with type II DM were three times more likely to have good knowledge about DR compared to Type I. Type II diabetes have better eye care service visits (33%) compared to type I which might have increased their contact frequency with eye care professionals and explore more knowledge on DR.
Spending a longer duration with DM (> 5years) increased the risk six times to have good knowledge of DR. This finding was also reported in other studies in Debark, India [16] and Oman [12]. This is because of longer duration of DM is one of the risk factors for the development of diabetic retinopathy [24]. Due to the longer duration, the participant has the probability of developing complications and to have frequent contact with health care providers, which eventually increases opportunities to get information and advice regarding diabetes complications, including DR.
Study participants with a positive family history of DM were 2.54 times more likely to have good knowledge of DR. A study done in Egypt supported this finding [25]. The explanation for this finding is exploring information about the disease through talks and discussion between family members would increase knowledge about its complications. Participants with a history of eye disease are also 2.6 times more likely to have good knowledge of DR. This might be due to contact with eye care professionals, which creates a chance to gain some basic knowledge about the disease.
The study had the following limitations; it was conducted in a single hospital. The result of the study may not reflect the overall knowledge of the condition in the general diabetic population.
The proportion of diabetic patients with good knowledge was low. Residence, average monthly household income, type of diabetes, duration of diabetes, history of DM in family and history of eye disease are factors significantly associated with good knowledge on DR. Health education and promotion interventions on diabetic retinopathy and eye check-ups could enhance their knowledge and practice.
Ethics approval and consent
The study was conducted under the Declaration of Helsinki. Verbal informed consent to be included in the study was obtained from each study participants. University of Gondar, School of Medicine Ethical Review committee and Adare General Hospital administration office approved the ethical issue of the study.
Verbal informed consent via their legal guardian was taken for those who have no formal education/illiterate participants.
Consent for publication
Not applicable
Availability of data and materials
The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.
Competing interests
The authors declare that they have no competing interests.
Funding
There is no fund for this study.
Authors' contributions
All authors contributed to the study conception and design. Material preparation, data collection and analysis were performed by [Kalkidan Atinafu], [Getasew Mersha] and [Fisseha Adimassu]. The first draft of the manuscript was written by [Nebiyat Feleke] and all authors commented on previous versions of the manuscript. All authors read and approved the final manuscript.