Knowledge about diabetic retinopathy, eye check-up practice and associated factors among patients with diabetes mellitus attending Debark hospital, northwest Ethiopia

Background: Routine eye examination plays a vital role in detecting diabetic retinopathy in its earliest stage before Patients’ knowledge about the nature and the consequences of diabetic retinopathy and routine eye checkup helps in timely identification and early treatment. However, there is limited evidence on knowledge of patients with diabetes mellitus on diabetic retinopathy and their eye check-up practices in Ethiopia in general and the study area in particular. Purpose: The aim of this study was to assess knowledge, eye check-up practice and associated factors of diabetic retinopathy among diabetic patients at Debark hospital, Northwest Ethiopia. Materials and Methods: Institution based cross – sectional study was conducted at Debark hospital, Northwest Ethiopia, from April 20/2018- May 20/2018. A pretested interviewer administered structured questionnaire was used to collect data among 230 diabetic patients aged 18 years and above. Data were entered in to Epi Info version 7 and exported to SPSS version 20 for analysis. Bivariable and multivariable binary logistic regression analyses were done. Odds ratio with 95% confidence level was determined and variables with p–value of < 0.05 were considered as statistically significant. 119 The mean age the nine participants good 91 CI: monthly income

provision of appropriate health education.

Introduction
Diabetic retinopathy(DR) is defined as a damage to the micro vascular system of the retina, accompanied by structural changes in the retina due to a prolonged hyperglycemia (1,2). Worldwide, 34.6%(93 million) of diabetic patients are living with DR (3). In 2007, Out of 39 million global blindness due to various eye disease, 4.8%(1.8 million) was due to DR (4).
Nowadays, diabetes mellitus (DM) (5) and DR (6) are becoming a public health concern in developing countries. Estimates of proportion of African patients with diabetes who are visually impaired are high even compared with older European Americans (7). Loss of productivity and quality of life due to DR leads to socioeconomic burdens on the community.
Routine eye examination is necessary for early detection of DR and prevention of blindness. This requires knowledge of sight threatening potential of DR and the need for regular eye examination.
The knowledge and practice of regular eye cheek-up was reported as poor in developed countries (8).
This is expected to be worse in developing countries where most DM patients do not apply the recommended ocular examination aimed at preventing visual impairment and blindness from DR (9).
There are different factors which affects the knowledge and eye check-up practice of DR among diabetic patients (10,11). Sex being female (9,12), Long duration of diabetes (13,14) higher educational level (11,13) and Higher socioeconomic status (11,15)were positively associated factors with good knowledge of DR. Older age (10,11), Language and ethnicity16), Residence being urban (16) were positively associated with eye checkup practice..
Determining the level of knowledge, eye checkup practice and associated factors of DR could help the health authorities in planning for the prevention and elimination of modifiable risk factors for poor knowledge and poor eye checkup practice. However, there is limited data regarding knowledge and eye cheek-up practice of DR among DM patients in Ethiopia. Therefore, this study was aimed to assess the knowledge, eye check-up practice and associated factors of diabetic retinopathy among diabetes mellitus patients attending diabetic clinic in Debark hospital.

Study design, setting and sampling
A hospital based cross sectional study was conducted to assess the knowledge, eye check-up practice and associated factors of diabetic retinopathy among diabetic patients attending Debark hospital from April 20 to May 20, 2018, northwest Ethiopia.
A total of 238 sample size was determined using Open Epi computer software with a single population proportion formula considering a total population of adult diabetic patients 485, which is the total number of diabetic patients seen monthly, since there is no data on the level of knowledge and eyecheckup practice for diabetic retinopathy among diabetic patients in Ethiopia p = 50% was taken, margin of error was = 5%. The generated sample size was found to be n = 384. After correcting for a finite population the sample size was 216. Considering 10% for non-response rate the total sample size was 238.
All adults with diabetes mellitus aged ≥ 18 years, attending Debark hospital outpatient diabetic follow-up clinic were included in the study. Every other participant was selected to be a sample. Knowledge: Respondents who scored greater than or equal to the mean (≥5.55) of knowledge questions were considered to have good knowledge and those who scored below the mean were considered as having poor knowledge (5,17).

Operational definitions
Scoring: participant's knowledge of DR was assessed by 12 questions with a maximum score of 14 points. Answer choices were given a numerical value of 1 for having correct response and 0 for incorrect response.
Eye check-up practice: participants who had undergone ocular examination within the last one year were considered as having good eye checkup practice while those without any eye examination within the last one year were labeled as having poor eye checkup practice (9,18). Regular diabetic checkup: participants who are undertaking investigations at least every one month since diagnosis of diabetes were considered as having regular diabetic checkup (5,19).

Data collection tool and procedures
A structured face to face interviewer administered questionnaire was used to collect the data. The questionnaire was developed from Indian guideline for conducting a knowledge, attitude and practice study for diabetic retinopathy (20). Data regarding knowledge and eye check-up practices related to DR, socio-demographic variables such as age, sex, income, marital status, education, religion, occupation, ethnicity, health profile variables such as type of DM, duration of diabetics and history of eye disease were collected. Questions in the knowledge section included definition, risk factors, screening for diabetic retinopathy and treatment options for diabetic retinopathy. Questions included in the eye check-up practice section were designed to assess the eye check-up behavior, referral and regular diabetic follow-up of the diabetic patients with regard to diabetic retinopathy.
Two trained optometrists and two ophthalmic nurses from Debark hospital staffs were involved in the data collection process. One optometrist supervised the data collection procedure. The patients were informed that participation in the study is voluntary and the information gathered will be used solely for academic and intended purposes. Patients who are willing to participate in the study were sign the consent form.

Statistical analysis
After cleaning and coding, the collected data were entered to EPI info 7 and exported to Statistical Package for the Social Sciences (SPSS) version 20 for analysis. Both descriptive and analytical methods were used for analysis. Summary statistics, frequencies and cross tabulations were performed for the descriptive analysis of the data.
Binary logistic regression analysis was done to see the independent effect of risk factors on the dependent variables and predictors with a significance level of P-value ≤ 0.2 were entered to the multivariable logistic regression analysis model by using enter method to identify final factors for knowledge and eye check-up practice after controlling other independent variables. The Hosmer-Lemshow goodness of fit statistic was used to assess whether the necessary assumptions for the application of multiple logistic regression were fulfilled. Adjusted odds ratio with 95% confidence interval was used to determine the strength of the association and P-value less than 0.05 was considered as statistically significant.

Results
Socio-demographic characteristics of study participants Out of 238 sample, 230 were participated, giving a 96.68% response rate. The mean age of the participants was 49(±17.6) years. The median monthly income was 850 ETB [IQR of 500-3500ETB].
(  Source of information about diabetic retinopathy The major sources of information about diabetic retinopathy for the respondents were medical staffs from diabetic clinic and followed by their relatives or friends. (Figure 1) Eye The reasons for not getting eye checkup were reported as lack of visual symptoms (didn't think it necessary) in 56.7% of participants and followed closely by 32.1% who felt they needed to be referred by their physician before getting their eyes examined and lack of convenient facility in 11.2% of participants.
Factors associated with knowledge of diabetic retinopathy Age, religion, residence, ethnicity, occupation, education, monthly income, type of DM, duration of DM from diagnosis and previous eye disease were significant from the bivariable analysis and entered in to multivariable analysis.    However, the result in this study is lower than the studies conducted in Bangladesh (17) and Saudi Arabia (22) which were 76% and 64% respectively. This difference might be due to lack of organized diabetic education facilities, less participation of media and non-governmental organizations in awareness creation about diabetic retinopathy in present study setting.
One hundred sixty-seven (72.6%) [95% CI: 67.0%-78.4%] study participants thought that diabetes affects the eye which is consistent with the study done in India(6), Saudi Arabia (12) and Nigeria (23)which were reported as 74.3%, 75.6% and 69.9% respectively. This might be due to similarity in the study design and setting. In Contrary, this is lower than the study conducted in Malaysia (24), South Africa (25)and Kenya (26)which were reported as 87.2%, 97.3% and 83% respectively. This difference might be due to the study participants in Malaysia and South Africa were patients from retina clinic who came for routine eye examination and they might have more exposure on DR information.
In this study 44 (26.8%) participants were able to mention diabetic retinopathy as a complication of DM and 30 participants (18.3%) defined diabetic retinopathy correctly. This result is lower than the study reported in Bangladesh (17) which was 55%. It might be due to limited source of information and inadequate involvement of the media in the present study.
Knowledge on risk factors like poor control of blood glucose level was 42.6% and longer duration of DM was 36.6%, this finding is higher as compared to a study done in India(6) which were reported as 33.7% and 17.9% respectively. This could be due to variation in the level of information given by the physicians on risk factors and their consequences.
In this study one hundred-nine (66.6%) study participants realized the importance of regular eye check-up. This finding is consistent with a study done in Nigeria (13)  The reasons for not getting eye examination were lack of visual symptoms in 56.7% participants and followed by 32.1% who felt they needed to be referred by their physician before getting their eyes examined. This result is consistent with the finding reported from Nigeria (23). This is explained by poor perception of participants about the need for regular eye examination.
According to this study the odds of good knowledge among urban residence participants was 2.6 times more as compared to those from rural residence. This is supported by a study conducted in Bangladesh (28). This could be explained by people living in urban have multiple source of information to know about diabetic retinopathy; health centers, mass media and higher people interactions than those live in rural.
Higher monthly income level was significantly associated with good knowledge in the present study.
This finding is consistent with studies done in India (11,15), where good knowledge was positively associated with higher socioeconomic status. The possible explanation for this finding could be people with high income level might have more exposure to medias and inter personal interaction than those who had low income level.
It is also indicated that study participants who knew the type of DM diagnosed were more knowledgeable regarding diabetic retinopathy than those who didn't know.
This study had revealed a positively association between long duration of DM and good knowledge of diabetic retinopathy. This finding is supported by studies conducted in Nigeria and Iran (13,14). This could be due to frequent contact of the participants with the health care provider which creates opportunity to getinformation regarding diabetes complications.
History of eye disease at least once in their life was significantly associated with good knowledge about DR in this study. This might be due to the health education given for patients coming for eye examination help them to acquire some basic knowledge about the disease.
In the previous studies, sex (9,12) and age (12,14) were significantly associated with knowledge of DR. However, in the present study sex and age were not significantly associated with knowledge of DR. In this study educational level didn't significantly associated with knowledge. In contrast, educational level was significantly associated with knowledge of DR in a studies done in Nigeria and India (11,13). This might be due to variation in study participants characteristics, where most of the study participants were illiterate in present study and this could mask the significance of educational level in present study.
Longer duration of DM was positively associated with good eye checkup practice in the present study.
This is supported by a study conducted in Bangladesh (28) and India (29). This might be due to as the disease duration increases their knowledge to eye screening increases as evidenced by the association of knowledge and disease duration. This might be also due to continued counseling and health education programs.
Good knowledge of diabetic retinopathy was significantly associated with good eye check-up practice.
This result is supported by the studies conducted in Ireland (18), Bangladesh (17) and Ghana (9). This might be due to having a good knowledge creates a firm belief in need for annual eye check-up and as showed the major reason for poor eye check-up was the wrong perception of eye screening needed only if there is a visual symptom.
The odds of good eye check-up practice among participants who had history of previous eye disease was 2.4 times more as compared those who hadn't it. This finding is supported by a study conducted in Ireland (18) and Nigeria (23). This might be due the fact that most patients go for eye examination if they develop a visual symptom.
In previous studies age (10,11) and ethnicity (16) were significantly associated with eye check-up practice. However, the data in the current study didn't support this. This variation might be due to difference in study design, because the study done in United Kingdom useda qualitative study design and also it might be due to small number of cases in the present study.
Over all this study assess the knowledge, eye checkup practice and associated factors of diabetic retinopathy among patients attending diabetic medical OPD at Debark hospital. However we didn't assess the attitude of participants towards diabetic retinopathy, which might affect the knowledge and eye checkup practice assessment.

Conclusions
In conclusion, finding from this study revealed a good knowledge on nearly half (47.4%) of study participants and good eye check-up practice on more than one third (39.6%) of study participants regarding diabetic retinopathy among diabetes mellitus patients attending debark hospital, Northwest Ethiopia. Being urban resident, higher monthly income, knowledge of type of DM diagnosed, history of eye disease and longer duration of diabetes were the factors positively associated with good knowledge of participants. Similarly, factors associated with good eye checkup practice were longer duration of diabetes mellitus, previous eye disease and good knowledge of diabetic retinopathy.

Ethical approval and consent to participate
The study was conducted in accordance with the Declaration of Helsinki and approved by the University of Gondar Institutional Review Board. Ethical clearance was obtained from the University of Gondar, college of medicine and health science, school of medicine ethical review committee.
Informed verbal consent was obtained from each respondent. Oral informed consent was considered since the data were collected by using interview administered structured questionnaire and also there was no any invasive examination procedure done for the patients for the sake of this research.
Patient information was obtained with no identifier and confidentiality was maintained.

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. Figure 1 Source of information about diabetic retinopathy among diabetes patients at Debark hospital, Northwest Ethiopia, 2018 (n=167)

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