Factors associated with diabetic retinopathy screening and regular eye checkup practice among diabetic patients attending Felege Hiwot Specialized Hospital

Sofonias Addis Fekadu, Mohamed Abdu Seid, Yonas Akalu, Yibeltal Yismaw Gela, Mengistie Diress, Mihret Getnet, Baye Dagnew, Yitayeh Belsti

1Department of Optometry, College of Medicine and Health Sciences, University of Gondar, Gondar P.O.BOX 196, Ethiopia

2Unit of Human Physiology, Department of Biomedical Science, College of Health Sciences, Debre Tabor University,Debre Tabor P.O.BOX 272, Ethiopia

3Department of Human Physiology, School of Medicine,College of Medicine and Health Sciences, University of Gondar, Gondar P.O.BOX 196, Ethiopia

Abstract

● KEYWORDS: diabetic retinopathy; eye checkup; eye screening; diabetes mellitus; Ethiopia

INTRODUCTION

Eye care service utilization is the use of services related to eye health to prevent and cure eye problems, promoting and maintaining eye health[1-4]. Diabetic retinopathy (DR) is one of the major complications of diabetes mellitus (DM)and the major cause of blindness accounting for 4.8% of the total 37 million blind cases worldwide[5]. Besides, more than one-third of patients with DM have some forms of DR and 10% had vision-threatening DR[6-8]. DR screening is one of the major successful practices in diabetes care that reduces/prevents DR-related eye complications which result in visual impairment and blindness[5]. Early detection and treatment of DR are achieved by screening and eye checkup practices as indicated by the American Academy of Ophthalmology[2,8].Since DR is usually asymptomatic until the late stages, the clinical signs that cause vision loss cannot be identified unless an earlier screening/eye checkup is regularly practiced in DM patients[9].Urban residence, private health insurance, lack of health education, lack of screening practices, older age, poor access to eye care service providers, poor knowledge/awareness of DR, and private health insurance are the most common factors associated with DR screening and eye checkup practices[10-11].DR screening is usually performed either directly by ophthalmologists or optometrists using 60, 78, and 90 diopter volk lenses with dilated pupil slit lamp examination or fundus photographic images are taken with dilated pupil by other trained professionals and sent to ophthalmologists for grading and interpretation[12]. People with DM have a higher risk of acquiring DR, cataracts, glaucoma, dry eye, and refractive error as compared to the general population[13]. Therapeutic approaches for diabetic patients who are at risk with DR include;blood glucose control[14], drug therapy to reduce modifiable risk factors, laser photocoagulation, and intraocular surgery[15].Generally, eye checkup practices and comprehensive eye screening programs are essential health promotion and prevention practices to reduce the late complications manifested in visual impairment and vision loss[12,14-15]. The American Diabetes Association (ADA) recommends screening for retinopathy should be given within 3 to 5y after the onset of type 1 and at/shortly after the diagnosis of type 2 DM[15-16]and regular eye checkups should be undertaken at least yearly in both cases of diabetes types[14].

DR is a microvascular complication of DM in which 100% of type 1 and 60% of type 2 diabetic patients develop some form of DR after 20y if early screening and eye checkups are not in place[6]. There are no more studies in Ethiopia as well as in the study area regarding the factors affecting DR screening and eye checkup practices among DM-diagnosed patients.Therefore, this study aimed to identify factors associated with DR screening and eye checkup practice among DM patients attending Felege Hiwot Specialized Hospital.

SUBJECTS AND METHODS

Ethical ApprovalEthical clearance was taken following the protocols and Declarations of Helsinki. The ethical process was approved by the University of Gondar, College of Medicine and Health Sciences Ethical Review Committee (reference VP/RTT/05/534/2019). After explaining the purpose of the study and getting permission to conduct the study, written informed consent was taken from each participant. Confidentiality of the participants was kept by avoiding identifiers like the names of the participants.

Study Setting, Area, and PeriodAn institution-based cross-sectional study was conducted from October 4, 2019,to January 12, 2020, at Felege Hiwot Specialized Hospital.The hospital is located in Bahir Dar city, Northwest Ethiopia located 545 kilometers away from Addis Ababa capital city of Ethiopia. It has an outpatient department for chronic followup patients and diabetic treatment has been provided two days per week. The hospital serves more than 7500 diabetic patients with different follow-up times[17].

Study Population and Inclusion CriteriaAll diabetic patients attending Felege Hiwot diabetic clinic were the source population and all diabetic patients attending Felege Hiwot diabetic clinic during the study period were the study population. All adult diabetic patients who were attending the diabetic clinic during the study period were included in the study and pregnancy-related diabetic patients and other patients who were severely ill to carry out the interview were excluded from the study.

Sample Size Determination and Sampling TechniqueThe sample size was determined using Epi info 7 Stat CAL with the assumptions of power as 80%, 95% confidence interval (CI),proportion (P=0.5) since there was no previous study, and 5%margin of error (d). Finally, the minimum sample size was 384 and after considering a 10% non-response rate, the total sample size was 424.

A systematic random sampling technique was used to select the study participants after calculating the interval K by dividing the total diabetic patients attending the diabetic by the sample size.

Data Collection Tool and ProcedureThe data was collected by qualified 4 Bachelor of Science (BSc) holder Nurses and one Master of Science (MSc) holder Optometrist as a supervisor. A semi-structured questionnaire was used for a face-to-face interview to collect data on sociodemographic characteristics, medical history, economic, and behavioral characteristics, knowledge, attitude, and practice toward DR.The interview was just carried out as the participants had finished their examination. The practice of eye screening and eye checkups were assessed using a standardized questionnaire adapted from similar studies[5,8,18-19]. The participants were given full advice about the complications of DR and the advantages of eye screening and eye check-up practices at the end of the face-to-face interview.

Operational DefinitionDR screening was considered as“evaluated” when participants reported “yes” to the question“have you ever had an eye examination for diabetic related eye complications since you were diagnosed as DM[5,20]?”.

Regular eye checkup practice was considered good when participants answered the median and above of the questions related to regular eye checkups.

Knowledge of DR was assessed with 12 questions and respondents who gain median and above of the questions were considered as having good knowledge[1].

Attitude towards DR was taken as “positive” when participants respond to the mean and above of the attitude-related questions[21-22].

Data Quality AssuranceThe questionnaire was translated to the local language (Amharic) for data collection and back to English by language professionals. The training was given to the data collectors on how to approach study participants and ways of data collection before the actual data collection period. A pretest was done on 22 diabetic patients attending Addis Hiwot Hospital which is 2 km away from the study area to confirm its face validity and modification were made accordingly. Close supervision and checking of the collected data were made on each day of the data collection time.

Data Processing and AnalysisAfter cleaning, the data were entered into Epi Info software version 7 and then exported to SPSS software version 24 for statistical analysis. The summary statistics were presented with a mean (standard deviation), frequency (percentage), tables, and graphs. The reliability of the tool was checked with Cronbach alpha (α)which was found as 0.7. The model goodness of fit was checked with the Hosmer-Lemeshow goodness of fit test. A binary logistic regression statistical model was fitted between sociodemographic, medical, economical, knowledge, attitude,and practice-related variables, behavioral characteristics, and trends of eye screening/eye check-up practice. All variables with aP-value of less than 0.2 in bi-variable logistic regression were included in multivariable logistic regression. Finally,the strength of the statistical association between independent variables and the outcome variable was shown by the odds ratio (OR) with a 95%CI, and variables with aP-value of less than 0.05 were taken as statistically significant.

RESULTS

A total of 406 study subjects participated with a response rate of 95.7% and a mean age of 47±11.5y. More than half 238(58.6%) of the participants were males and slightly higher than one-third 157 (38.7%) of the participants were in the age group of 53-62y. Only 42 (10.3%) of the participants had health insurance and 151 (37.2%) of them had a monthly income of 1501-2500 Ethiopian Birr (ETB). More than two-thirds of 283(69.7%), and 282 (69.5%) of the study subjects were urban residents and married respectively (Table 1).

Medical and Behavioral Characteristics of Study ParticipantsNearly half of 201 (49.5%) of the participants had type 2 DM and half of 203 (50.0%) of the participants had DM with a duration of 5-10y. More than two-thirds of 276 (68.0%) of the participants had gotten health education about DM or its complication. More than three-fourths of 338 (83.7%) of the participants had not any known systemic diseases other than DM and 138 (34.0%) of them had either distance or near vision-related problems (Table 2).

Diabetic Retinopathy Screening and Regular Eye Checkup PracticeAlmost three-fourths 308 (75.9%) of the studyparticipants got eye examination/screening for DM complications in the eye. Among those participants who had undergone DR screening, 180 (26.6%) of them adhere to their regular eye checkups in retinal ophthalmic clinics and 81 (26.3%) of themgot advice as having some form/stages of DR. Long distance 46 (35.9%) and high cost 36 (28.1%) were the most common barriers that affect the regular eye checkups of participants(Table 2).

Table 1 Sociodemographic characteristics of study participants attending Felege-Hiwot Referral Hospital, Northwest Ethiopia,January 2020

Table 2 Medical and behavioral characteristics of study participants attending Felege-Hiwot Referral Hospital, Northwest Ethiopia,January 2020

Figure 1 Knowledge, attitude and practice towards DR among study participants attending Felege-Hiwot Referral Hospital, Northwest Ethiopia, January 2020 DR: Diabetic retinopathy.

Knowledge, Attitude, and Practice Toward Diabetic RetinopathyMost of the participants 215 (53.0%) had poor knowledge about DR and 168 (41.0%) of the participants had a positive attitude towards DR (Figure 1).

Factors Associated with DR ScreeningVariables including:educational status, duration of DM, getting health education,knowledge about DR, awareness of DR, presence of visionrelated problems, family history, residence, and marital status were associated with having screened for DR in bi-variable logistic regression with aP-value of ＜0.2 whereas variables including educational status of college/university, having good knowledge about DR, and family history of DM were significantly associated with the DR screening. Participants who had an educational level of college/university were 3.25 times more likely to undergo DR screening as compared to those who had an education level of unable to read and write[AOR=3.25 (1.40, 8.78)]. The odds of having screened for DR among participants who had good knowledge about DR was 2.50 times more as compared to those who had poor knowledge about DR [AOR=2.50 (1.55, 4.46)]. In addition,participants who had a positive family history of DM were 2.15 times more likely to undertake DR screening as compared to those who had no positive family history of [AOR=2.15 (1.41,3.85); Table 3].

Factors Associated with Regular Eye Checkup PracticeVariables including: educational level, monthly income, family history of DM, knowledge toward DR, attitude towards DR,other systemic disorders, residence, occupation, and duration of DM were associated in bi-variable logistic regression with aP＜0.20, and then only variables; rural residence and negative attitude towards DR were significantly associated with poor regular eye checkup practice with aP＜0.05. Ruralresidents were 3.11 times more likely of having poor regular eye checkup practice [AOR=3.11 (1.89, 5.02)] and the odds of having poor regular eye checkup practice among participants with undesirable attitudes towards DR were 5.65 times more as compared to those with a positive attitude [AOR=5.65 (3.14,8.76); Table 4].

Table 3 Factors associated with DR among study participants attending Felege-Hiwot Referral Hospital, Northwest Ethiopia, January 2020

DISCUSSION

Increasing eye care service utilization by early screening and regular eye checkups is a public health prevention priority among patients with DM to reduce visual impairment/blindness as well as improve quality of life. The proportion of participants who had screened for DR among DM patients was 308 (75.9%, 95%CI: 71.5, 79.8). This result is higher than a study done in China 56.8%[11], Tanzania 59.1%[23],South Africa 49.0%[10], Saudi 61.15%[19], Bangladesh 32%[5],California 55%[8], the United States 59.2%, 65%[24]and lower than a study carried out in the United States 82%[25].Furthermore, the proportion of participants with good regular eye checkup practice was 180 (44.3%, 95%CI: 39.6, 49.2).This finding is lower than studies done in the United States 50.1%[26], Saudi Arabia 95%[27], France 50%[9], and Switzerland 70.5%[28], and higher than a study done in Ethiopia 39.6%[1].Differences in economic status, study design, educational level of participants, and level of health setting might be the main reasons for variations in the proportion of results observed in different studies. The present study was conducted on DM patients who were having a better chance of getting counseling for DR screening which might increase the proportion of DR screening in this study. Unavailability of sufficient eye care centers might affect the regular eye checkups even after screening and this could reduce the proportion of eye checkups in the present study.

Table 4 Factors associated with poor regular eye checkups among study participants attending Felege-Hiwot Referral Hospital, Northwest Ethiopia, January 2020

This study established that having good knowledge about DR was statistically significant with the status of having DR screening. This is supported by studies done in China[11],Tanzania[23], Saudi[19], and Bangladesh[5]. This might be because having good knowledge about DR initiated the participants to decide on DR screening to know the status of their eye for DM complications. People with lower educational status are less likely to participate in health care practices including DR screening[29].

Having a positive family history was significantly associated with DR screening in this study which is supported by a study done in Rural Bangladesh[5]. This could be justified as those participants with a positive family history of DM have a better chance of getting knowledge/information that might enable them to carry out eye screening practices. A family history of DM is pointing toward a genetic and epigenetic basis for DR which might give memories and trends to the participants to participate easily in the screening of diabetic-related complications including DR[29].

Furthermore, the present study showed that higher educational status was significantly associated with the status of having eye screening for DR complications. Individuals with higher educational status have a higher tendency to acquire a better knowledge regarding health-related services like DR screening[28]and might have a better chance to read, listen and follow social media which might lead them to participate in DR screening in a better way as compared to those with low educational status[18].

This study indicated that participants with rural residency were significantly associated with poor regular eye checkup practice which was supported by a similar study done in China[11].The unavailability of sufficient eye care services and eye care professionals in Ethiopia could be the main barrier to attending regular eye checkups for DM patients. Long-distance of rural residents from the institution, high cost, and extended waiting time were the main barriers raised by participants in low and middle-income countries including Ethiopia[18,30-31]. Poor economic conditions for both transport and other accommodations might affect rural residents to follow their eye checkups regularly. Whereas a study carried out in the United States[25]contradicts this finding which states rural residency is a significant factor for regular eye checkups. This might be due to differences in educational and economical differences between the two study areas.

Besides, in line with a study done in China[11]and Tanzania[23],the present study confirmed that participants with undesirable attitudes towards DR were significantly associated with the practice of poor regular eye checkups. Undesirable attitude towards DR and other ocular complications might affect the practice of eye checkups even after gaining sufficient counseling about the risks of losing follow-ups. It is through addressing the modifiable factors by changing the attitudes and practices of DM patients that we can stop the complications of DM including DR[15]. Worrying about losing vision might affect participants to develop a positive attitude toward DR and its complication. This intern might initiate/obligate participants to adhere to their regular eye checkups[11]. Education is the main weapon that changes humans’ attitude towards health care practices including DR screening and regular checkups[30].Health insurance, duration of DM, type of DM, and age were the most common factors associated with DR screening and eye checkup practice in different studies. These variables were not associated with DR screening in this study. Different study designs and varied environmental and economic conditions might affect the factors manifested as significant in different studies.

In conclusion, more than three-fourths (75.9%) of participants were screened for DR in this study. Higher education, family history, and good knowledge were associated with DR screening. In addition, rural residence, and undesirable attitude toward DR were associated with regular eye checkup practice.There were limitations of the study. Most of the administerbased interviews were based on self-reported responses which may be subject to social desirability and recall bias. The attitudes and practices of health care providers towards DR screening and regular eye checkups were not included in this study.

ACKNOWLEDGEMENTS

We would like to acknowledge to Felege Hiwot Referral Hospital administrative office for their technical support and the participants for devoting their time to carry out this study.

Authors’ contributions:All authors made a significant contribution to the work reported, whether that is in the conception, study design, execution, acquisition of data,analysis, and interpretation, or in all these areas; took part in drafting, revising, or critically reviewing the article; gave final approval of the version to be published; have agreed on the journal to which the article has been submitted; and agree to be accountable for all aspects of the work.

Conflicts of Interest: Fekadu SA,None;Seid MA,None;Akalu Y,None;Gela YY,None;Diress M,None;Getnet M,None;Dagnew B,None;Belsti Y,None.