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ORIGINAL ARTICLE
Year : 2021  |  Volume : 28  |  Issue : 2  |  Page : 123-130  

Knowledge, attitude, and practice around diabetic eye disease among diabetic patients in Jazan Region, Saudi Arabia


1 Department of Ophthalmology, Imam Abdulrahman Bin Faisal University, Dammam, Saudi Arabi
2 Department of Ophthalmology, King Khalid University, Abha, Saudi Arabi
3 Department of Medicine, Armed Forces Hospital, Jazan, Saudi Arabi
4 Department of Emergency Medicine, King Fahad Central Hospital, Jazan, Saudi Arabi
5 Department of Ophthalmology, King Saud University, Riyadh, Saudi Arabi
6 Department of Family medicine, King Fahad Medical City, Riyadh, Saudi Arabi
7 Department of Ophthalmology, Prince Mohammed Bin Nasser Hospital, Jazan, Saudi Arabi
8 Department of Pediatrics, King Fahad Central Hospital, Jazan, Saudi Arabi

Date of Submission19-Dec-2020
Date of Acceptance11-Aug-2021
Date of Web Publication25-Sep-2021

Correspondence Address:
Dr. Wael Otaif
Department of Ophthalmology, King Khalid University, PO Box 960, Abha 62529

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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0974-9233.326671

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   Abstract 


PURPOSE: This study aims to assess knowledge, attitude, and practice (KAP) around diabetic eye disease in patients with diabetes mellitus (DM) attending primary health-care centers (PHCCs) in Jazan region, Saudi Arabia.
METHODS: All diabetic patients attending eight PHCCs in Jazan region between December 2018 and December 2019 were invited to participate in this cross-sectional study. Face-to-face interviews were held to gather responses to a validated 20-item questionnaire.
RESULTS: In total, 293 patients aged 9–90 years (mean 50 years, standard deviation 14 years) agreed to participate, including 189 (64.5%) females and 104 (35.5%) males. Most (n = 251; 85.7%) had type 2 DM, the remainder (42; 14.3%) having type 1 DM. The mean duration of DM was 8.2 ± 6.4 years. Eye complications were self-reported by 114 (38.9%) participants. More than one-third (36.2%) of the participants had never undergone an eye examination. Less than one-third of participants (29% and 28% respectively) had an excellent level of knowledge or practice about diabetic eye disease, and only 12% demonstrated very positive attitude. KAP levels were independently predicted by patients' age, gender, and eye complication status.
CONCLUSION: KAP relating to eye disease and eye care among Saudi patients with DM were less than desired. Rigorous efforts are required to raise awareness of eye complications among diabetic patients.

Keywords: Diabetes mellitus, diabetic retinopathy, Jazan Region, Knowledge, Attitude, Practice, Saudi Arabia


How to cite this article:
Najmi H, Otaif W, Najmi M, Basehi M, Tobaigy M, Alsalim W, Awaji M, Najmi A. Knowledge, attitude, and practice around diabetic eye disease among diabetic patients in Jazan Region, Saudi Arabia. Middle East Afr J Ophthalmol 2021;28:123-30

How to cite this URL:
Najmi H, Otaif W, Najmi M, Basehi M, Tobaigy M, Alsalim W, Awaji M, Najmi A. Knowledge, attitude, and practice around diabetic eye disease among diabetic patients in Jazan Region, Saudi Arabia. Middle East Afr J Ophthalmol [serial online] 2021 [cited 2022 Jun 28];28:123-30. Available from: http://www.meajo.org/text.asp?2021/28/2/123/326671




   Introduction Top


Diabetes mellitus (DM) is a metabolic disorder that is characterized by chronic high levels of blood glucose (known as hyperglycemia) due to relative insulin deficiency or no insulin being produced by the pancreas.[1] According to the International Diabetes Federation, there is an emerging global epidemic of DM affecting more than 463 million people worldwide, and new estimates show that the incidence rate of DM is increasing.[2] In Saudi Arabia, almost 15.8% of the population aged 20–79 have DM.[3] Poor glycemic control together with a long duration of DM and lack of knowledge of DM can lead to serious complications.[4] One of these complications is diabetic retinopathy (DR), in which the network of blood vessels that supply the retina can become blocked and damaged leading to permanent loss of vision.[5]

The prevalence of DR in Saudi Arabia is high, at between 30.0% and 36.8% with regional variations.[6],[7],[8],[9],[10] Previous studies have suggested that knowledge, attitude, and practice (KAP) toward DM play a vital role in preventing retinopathy among patients with this disease, especially in influencing their behavior related to eye care.[11],[12],[13],[14],[15] In Oman, a cross-sectional study[15] of 750 people with DM found that the levels of knowledge about diabetes-related eye care and complications were satisfactory though the levels of attitude and practice were less than desired. However, a smaller (n = 103) study conducted in Nigeria[15] found that most diabetic patients had poor knowledge about DR and less than one-third had undergone an eye examination. Similarly, studies in Sri Lanka and Kenya have found that most (over two-thirds) of their patients with diabetes have poor knowledge of DR.[14],[16] Among 439 diabetic patients in the Al-Jouf and Hail province of Saudi Arabia, the majority (over 75%) were aware that diabetes can cause eye disorders.[13] Almost 74% of participants agreed that people with diabetes should have regular eye examinations and about two-third (65%) of patients knew they should visit an ophthalmologist if they developed an eye problem. These findings suggest a high level of KAP related to diabetic eye disease in Saudi Arabia. However, other research in the same country found lower levels of awareness, indicating variations in knowledge and awareness within the country.[16]

To the best of our knowledge, no study on KAP related to diabetic eye disease has been conducted in Jazan region, Saudi Arabia. Therefore, we conducted this study to assess KAP around diabetic eye disease in patients with DM attending primary health-care centers (PHCCs) in Jazan region, Saudi Arabia.


   Methods Top


This was a cross-sectional study to assess the levels of related to diabetic eye disease among patients with diabetes. The study was conducted among diabetic patients registered at eight PHCCs in Jazan city, Saudi Arabia. Ethical approval was obtained from the Research Ethics Committee at Jazan General Hospital. This study adhered to the tenets of the Declaration of Helsinki. All patients with DM attending the PHCCs during the period December 2018 to December 2019 were invited to participate in this study. All of those who accepted provided signed, informed consent. Face-to-face interviews were held to gather responses to a validated 20-item questionnaire developed[12] to measure knowledge (10 items), attitude (6 items), and practice (4 items) about diabetic eye complications and eye care [Appendix 1]. In addition, the questionnaire asked about age, region of residence, type and duration of diabetes, and any ocular complications. Responses to each item were measured on a 5-point scale (ranging from “Fully agree” to “Fully disagree”). Each item was scored out of a maximum of 10 points and minimum of 10 points, with a neutral response (“I am not sure”) being awarded zero points. Responses were considered “correct” or “incorrect.” For example, “I fully agree” or “I agree” in response to the item “Diabetes can damage eyesight” would be considered correct. The total scores for KAP-related questions were grouped into four categories as follows: 75% to 100% “excellent,” 50% to 74% “satisfactory,” 25% to 49% “poor,” and 0% to 24% “very poor.” The Statistical Package for the Social Sciences (SPSS) (version 20, SPSS, IBM Corp., Armonk, NY, USA) was used for data entry and analysis. Data were described using mean and standard deviation (SD) for normally distributed continuous variables, while median and interquartile range were used for those not normally distributed. Frequencies and percentages were calculated for categorical (such as socio-demographic) variables. Spearman's rho was used to test the relationship between KAP outcome and the ordinal predictor variable (Likert scales). The Chi-square test was used to look for significant associations between categorical variables. The categorical variables found to have significant associations were entered into a logistic regression. In all statistical tests, P > 0.05 was considered statistically significant.


   Results Top


In total, 293 patients aged 9–90 years (mean 50 years, SD 14 years) agreed to participate, including 189 (64.5%) females and 104 (35.5%) males. Most (n = 251; 85.7%) had type 2 DM, the remainder (42; 14.3%) having type 1 DM. The mean duration of DM was 8.2 ± 6.4 years. Eye complications were self-reported by 114 (38.9%). More than one-third (36.2%) of the participants had never undergone an eye examination [Table 1].
Table 1: Demographic characteristics of the study sample (n=293)

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[Table 2] shows the distribution of responses to the questions assessing KAP. As shown in [Table 3], knowledge of eye disease in patients with DM was excellent in 28.7% (95% confidence interval [CI]: 23.6–34.2). Very positive attitudes were observed in 12.3% (95% CI: 8.8–16.6). Practice was excellent in 27.6% (95% CI: 22.6–33.1).
Table 2: Assessment of knowledge, attitude, and practice regarding eye complications and eye care among patients with diabetes mellitus

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Table 3: Knowledge, attitude, and practice among the study population

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The multiple logistic regression model suggested that significant independent predictors of higher knowledge levels were older age (P < 0.01), female gender (P < 0.01), and eye complication status (P < 0.01). The duration of DM has no significant effect on KAP (P > 0.05) [Table 4]; on the other hand, there was a significant difference in KAP between the group that “never” had an eye examination to those who had (P < 0.05) [Table 5]. The single predictor of more positive attitudes toward diabetic eye disease had eye complications (P < 0.01). Finally, better practice related to diabetic eye disease was significantly predicted by female gender (P < 0.01) and positive eye complication status (P < 0.05). The results of the multiple logistic regression analysis are summarized in [Table 6].
Table 4: Numbers and percentages of participants reaching each of the four categories of knowledge, attitude, and practice score per diabetes mellitus duration

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Table 5: Numbers and percentages of participants reaching each of the four categories of knowledge, attitude, and practice score per eye examination

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Table 6: Multiple logistic regression analysis of relationship between the participants' characteristics and their knowledge, attitude, and practice grade*

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KAP findings between the group that “never” had an eye examination (36.2%) to those who had.


   Discussion Top


This is the first study assessing KAP related to eye disease in diabetic patients in Jazan Province, Saudi Arabia. The study revealed that less than one-third of this sample with DM had excellent KAP of diabetic eye disease and eye care. The level of KAP was independently predicted by patients' age, gender, duration of DM, and the presence of eye complications.

Previous studies have reported various levels of KAP related to eye disease in patients with DM in a range of geographical locations.[14],[15],[17] Possible reasons for such variability include the use of different instruments and grading systems, as well as participants' characteristics such as levels of literacy and cultural differences. In comparison to a previous study using the same questionnaire and grading system, we demonstrated a lower KAP level than had been found among patients with DM in Oman.[16] Some of the previous studies conducted in Saudi Arabia have found that Saudi patients with DM had high to acceptable levels of DR awareness,[8],[18],[19],[20],[21] while other studies did not. For example, Alanazi et al. used a systematic random sample of Saudi patients with DM to evaluate the awareness of DM complications in the Arar region and reported that only 24.5% had adequate awareness of DR.[16]

In the present study, the results showed that age was a strong independent factor predicting the level of knowledge of eye disease in DM. Consistent with this, previous research in India found that patients aged 30 years or above were more aware than younger patients of all eye diseases except night blindness.[22] Older diabetic patients are more likely to have longer durations of DM, which has been correlated with better knowledge about DM complications including DR.[23] However, our current study did not provide this level of differentiation, which is considered a limitation in this study, and can be included in future studies. In addition, the current analysis showed that DM duration did not independently predict KAP as has been reported by some authors,[20],[24] suggesting instead that KAP are outcomes of the interaction of multiple factors rather than one factor. Possible explanations for the high levels of KAP about diabetic eye disease among older patients include frequent interaction with health staff and past experience with DM complications including hypoglycemia and hyperglycemia.[23]

Our analysis of the association between gender and knowledge of eye disease yielded a female predominance in patients with satisfactory levels of knowledge and practice. Some of the previous studies did not find gender as a factor determining KAP of diabetic eye disease[18],[19],[24] or showed that males were more likely than females to be aware of DR.[20] Although there is a large body of evidence suggesting that women seek health care more than men,[25],[26] our data could have been affected by the uneven gender distribution (female-to-male ratio: 1.8:1), and thus, the relationship between female gender and satisfactory KAP found in this study warrants further investigation to reach definitive conclusions.

Patients who already had eye complications outscored those who did not on all levels of KAP. This is unsurprising since these patients are likely to have had more exposure to health information about the disease diagnosis, periodic check-ups, treatment options, and prognosis. As a preventive strategy, we recommend educating patients with DM about-related complications including DR in early stages of the disease.

This study increases understanding of KAP around eye disease in diabetic patients in a region of Saudi Arabia. Limitations of the study include the relatively small sample size and the use of a questionnaire that had been validated in a middle eastern population, but it had not been validated in Saudi Arabia. As discussed above, our sample consisted of more females than males though every possible effort was taken to equally distribute the questionnaire among both genders. Therefore, the findings of this study should be cautiously interpreted and extrapolated to the general population of Jazan region. Despite these limitations, the study has shed some light on diabetic patients' KAP around eye disease and eye care in this location.

The present study highlights a need for increased awareness among diabetic patients in this part of Saudi Arabia about the links between systemic disease and related eye complications, and about the importance of regular eye examinations. Our results also showed that KAP relating to eye disease and eye care among Saudi patients with DM were less than desired. KAP levels were independently predicted by patients' age, gender, and eye complication status.

The present study is a frequency analysis and presents the quantitative component. A separate paper will present the qualitative analysis. Rigorous efforts are required to raise awareness of eye complications among diabetic patients.


   Conclusion Top


The present study showed that knowledge of, attitudes toward, and practice of DR among Saudi patients with DM were less than desired. KAP levels were independently predicted by patients' age, gender, and retinopathy status. Rigorous efforts are required to raise awareness of eye complications among diabetic patients.

Acknowledgment

The authors are thankful to Dr. Afnan Ahmed Zogeeli and Dr. Ammar Abdullah Hakami from Jazan University, Jazan, Saudi Arabia, for their assistance in collecting data for this study.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

Appendix 1

Ministry of Health aims to strengthen the eye care of diabetics. Counseling them is one of the strategies. We want to know how much you know about effect of diabetes on eyes and vision, available treatment. We invite you to participate in this study. This information will be confidential. A trained interviewer will read questions. You select the response you think is the most appropriate. The interviewer will note them. For further questions about this study please contact Mr. Saleh A Harby, National supervisor of eye care.

(A) Personal information:

Name: __________________________________________________________ Gender: M/F

Age: ___ Region: ___________ Wilayat: __________ Diabetes Register #: _________

Duration of diabetes: ____ Years Type of diabetes: IDDM/NIDDM/Other

Eye complication: Present/Absent Eyes checked in 2007: Y/N 2006: Y/N 2005: Y/N

Please put 'v' mark in one of the relevant box for each question:

(B) Questions related to Knowledge

  1. Diabetes can damage my eyesight.


  2. I fully agree

    I agree

    I am not sure

    I do not agree

    I totally disagree



  3. Retina is the main part of eyes that is damaged due to diabetes.


  4. I fully agree

    I agree

    I am not sure

    I do not agree

    I totally disagree



  5. Eye doctor will examine eyes using special equipment to find effects of diabetes.


  6. I fully agree

    I agree

    I am not sure

    I do not agree

    I totally disagree



  7. Timely treatment can prevent/ delay damage in eyes due to diabetes.


  8. I fully agree

    I agree

    I am not sure

    I do not agree

    I totally disagree



    Please turn page for more questions on Page: 2

  9. I must control my Blood sugar and lipids for eye treatment to be effective.


  10. I fully agree

    I agree

    I am not sure

    I do not agree

    I totally disagree



  11. In diabetes, my one eye may be affected first followed by the other eye.


  12. I fully agree

    I agree

    I am not sure

    I do not agree

    I totally disagree



  13. Children with diabetes also have risk of developing eye complications.


  14. I fully agree

    I agree

    I am not sure

    I do not agree

    I totally disagree



  15. An eye treated successfully with laser for diabetic retinopathy does not need laser treatment again.


  16. I fully agree

    I agree

    I am not sure

    I do not agree

    I totally disagree



  17. Laser treatment of diabetes is painful.


  18. I fully agree

    I agree

    I am not sure

    I do not agree

    I totally disagree



  19. If vision is damaged due to diabetes, a person can use 'low vision' aids & continue daily work.


  20. I fully agree

    I agree

    I am not sure

    I do not agree

    I totally disagree



    (C ) Questions related to Attitude and believes

  21. If my vision is good, my eyes are not affected due to diabetes. Hence I need not visit eye doctor every year.


  22. I fully agree

    I agree

    I am not sure

    I do not agree

    I totally disagree



  23. The information on eye problems due to diabetes should be given only by eye doctor.


  24. I fully agree

    I agree

    I am not sure

    I do not agree

    I totally disagree



  25. If I am taking treatment for my eye problem, I need not worry about controlling my sugar & lipid.


  26. I fully agree

    I agree

    I am not sure

    I do not agree

    I totally disagree



    Please turn page for more questions on Page: 3

  27. If my eye is treated with laser once, I don't need laser treatment again in that eye to treat complications of diabetes.


  28. I fully agree

    I agree

    I am not sure

    I do not agree

    I totally disagree



  29. Patients with diabetes often waste their time and money in eye check ups as most of the time eyes of diabetics are normal.


  30. I fully agree

    I agree

    I am not sure

    I do not agree

    I totally disagree



  31. One should not be treated with laser as eye treatment of diabetes is very painful.


  32. I fully agree

    I agree

    I am not sure

    I do not agree

    I totally disagree



    (D) Questions related Practice:

  33. I go to eye doctor regularly as advised by my family doctor


  34. I fully agree

    I agree

    I am not sure

    I do not agree

    I totally disagree



  35. I control my blood sugar and lipid even if my eye doctor has given treatment for eye problem due to diabetes.


  36. I fully agree

    I agree

    I am not sure

    I do not agree

    I totally disagree



  37. I was informed properly by staff in eye department about prevention measures and treatment options for eye complications of diabetes


  38. I fully agree

    I agree

    I am not sure

    I do not agree

    I totally disagree



  39. My vision due to complications of diabetes is less. Hence I am using special low vision devices.


I fully agree

I agree

I am not sure

I do not agree

I totally disagree



Name of interviewer: ____________________________ Date of interview: ________________



 
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    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]



 

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