Awareness of Diabetic Retinopathy Among Patients With Type 2 Diabetes Attending the Outpatient Clinic in the General Hospital in Rabigh, Saudi Arabia: A Cross-Sectional Study

Introduction: Diabetic retinopathy (DR) is a common microvascular complication of type 2 diabetes (T2D) and a major cause of blindness. DR awareness is important for early identification and management in patients with T2D. This study aimed to estimate the level of awareness of DR and its risk factors among patients with T2D in Saudi Arabia. Methods: We conducted a cross-sectional study to analyze data collected from 291 patients with T2D attending outpatient clinics in the General Hospital in Rabigh during 2020-2021. We collected demographic information and level of awareness about T2D and DR. Results: Among 291 patients with T2D, 42.3% had T2D for more than five years, and 37.8% had T2D for two to five years. In our study population, 32.3% of participants obtained high school education, and 42.3% had moderate income. Over half of respondents (56.4%) had their last eye exam within the past year, and 68.4% of participants believed high blood glucose levels might cause vision problems. The mean ± standard deviation of the DR awareness score was 7.23 ± 2.74. Most participants had moderate level of awareness (39.5% of participants), 31.6% had good level of awareness, and 28.9% had poor level of awareness about T2D and DR. Participants without DR or who had DR for less than two years and those who had their eyes checked by a doctor last year had a significantly higher DR awareness level. Conclusion: We asked patients with T2D to assess their level of DR awareness. Most patients had moderate awareness levels, indicating a need for improved awareness of T2D complication on retina and treatment options. Patients should also be motivated for retinal screening to reduce the risk of visual complications. Furthermore, DR screening programs should not be limited to eye care centers. Improved awareness and access to screening programs will help patients and their healthcare providers achieve optimal outcomes in prevention of DR.


Introduction
Diabetes mellitus is characterized by chronic hyperglycemia and impaired carbohydrate metabolism due to a complete or partial lack of insulin secretion and/or action [1]. Type 2 diabetes (T2D) is the most common type of diabetes, accounting for 90%-95% of all patients with diabetes [2]. Global estimates indicate that 439 million people will be diagnosed with T2D by 2030 [3]. Most cases of T2D are caused by the interplay of genetic, environmental, and behavioral risk factors [4].
Diabetes is becoming more common in high-and low-income countries [5]. Saudi Arabia was rated seventh out of 10 highest countries in prevalence of diabetes in 2013, with 24% of adults aged 20-79 years diagnosed with diabetes, and the incidence is expected to climb [6]. Diabetes can damage organ systems resulting in serious problems over time, such as retinopathy, neuropathy, and nephropathy [1]. Because of its ocular consequences, T2D is a leading cause of blindness worldwide [7].
Diabetic retinopathy (DR) is one of the diabetic complications causing blindness around the world [8]. DR consists of early nonproliferative DR (NPDR) and advanced proliferative DR (PDR). The clinical features classify NPDR, such as retinal hemorrhages, microaneurysms, venous caliber changes, and intraretinal microvascular abnormalities. PDR is differentiated by pathologic preretinal neovascularization [9]. Studies in Saudi Arabia reported that the prevalence of DR is 16.7%-31% [10][11].
The duration of diabetes, poor blood glucose management, and the presence of other systemic disorders such as hypertension (HTN) are risk factors for DR [12][13]. Early screening, detection, and treatment of DR among patients with T2D require a strong awareness of DR and its risk factors to avoid potential visual damage [13][14]. Lack of knowledge regarding T2D, DR, the need for routine eye exams, and treatment advantages can result in poor adherence to recommendations, referral delays, and presentation with advanced DR [15][16]. This study aimed to assess the level of DR awareness and its associated risk factors among patients with T2D in Rabigh, Saudi Arabia.

Materials And Methods
We conducted a cross-sectional study in the general hospital in Rabigh having patients with T2D diagnosed at least one year before the study started. The study included any Saudi adults age 25 or older with any degree of education, male or female. The study excluded patients with type 1 diabetes, patients younger than age 25, or pregnant patients. This study was approved by the institutional review board of King Abdulaziz University . We met the patients in person in the clinic and used a selfconstructed questionnaire from previous study which validated by revision of two community medicine and one internal medicine consultant to collect the data. The questionnaire was divided into two sections; the first concerned patient demographic information (e.g., age, gender, nationality, place of residence, and education level), and the second measured personal level of awareness of T2D and DR.
Twelve questions assessed participant level of awareness regarding DR using Likert-Type Scales [17]. Each right or positive answer was given a score of "1," and a score of "0" was given for the wrong and "I don't care" answers. The highest possible score is 12. Participants were classified according to their level of awareness into those having a poor level of awareness (i.e., scores < 6), a fair level of awareness (scores of [6][7][8][9], and a good level of awareness (scores of [10][11][12]. The data were coded, entered, cleaned, and analyzed using IBM SPSS Statistics for Windows, Version 22.0. (IBM Corp., Armonk, NY). Qualitative variables were presented using frequencies and percentages, while quantitative variables were shown as the mean ± standard deviation. A Chi-squared test was used to compare between two qualitative variables. We used a 95% confidence interval, and p<0.05 was considered statistically significant. And there was no multivariate analysis test. Table 1 presents the distribution of 291 participants according to demographic data. The most common age range was 46-55 years (31.6%), 56.4% of the study population was male, 91.1% had a Saudi nationality, and 74.2% were from the Rabigh region. Approximately one-third (32.3%) of the participants had a high school education, 74.9% were married, 42.3% had a monthly income of 5000-10000 Saudi Riyals (SR), and 56.4% were employed. Also, 10% of participants were current smokers, and 10% engaged in regular physical activity. Most of them (60.8%) had chronic diseases, the most common of which was HTN; 44.7%. Approximately Table 3 also showed that participants without DR or who had DR for less than two years and those who had their eyes checked by a doctor last year had a significantly higher DR level of awareness score (p<0.05). We found a nonsignificant relationship between the level of participants' DR level of awareness and duration of T2D, type of T2D treatment, history of vitamin B12 intake, history of hospitalization for high blood glucose, and frequency of checking blood glucose (p>0.05).

Results
Participants who had their last eye examination less than one year ago had a significantly higher level of awareness regarding DR (Figure 1; p<0.05).

Discussion
Our study explored patient awareness of DR and related risk factors in patients visiting an outpatient clinic in the general hospital in Rabigh. We found that 39.5% of patients with T2D had moderate levels of awareness regarding DR, 31.6% had good levels of awareness, and 28.9% had poor levels of awareness. Several studies have documented the levels of awareness of T2D patients regarding DR. In a study in Tabuk, 47.1% had poor levels of awareness, 27.7% had moderate levels of awareness, and 25.1% had good levels of awareness [18]. In another study in Jeddah, 82.6% were aware of DR [19]. This difference could be related to a range of socioeconomic factors and geographic location. Most of the patients in our study (n=213; 73.2%) were aware that T2D could impair the eyes, and 55.3% thought DR could lead to blindness. In Tabuk, 86.9% of patients were aware that diabetes could affect the eyes, and 78.5% reported that DR could lead to blindness [18]. These results were similar to a study conducted in Jordan in which 88.2% of patients with diabetes were aware that diabetes could affect the eyes, and 81% thought DR could lead to blindness [20].
The differences in awareness are often due to different educational levels. Most patients in our study believed that good control of their diabetes would prevent DR, but our population had relatively lower awareness than other studies done in Tabuk (94%) and Jordan (82.7%); this indicates a lack of awareness and the necessity for programs to improve awareness in our population [18,20]. Patients were asked how often they thought their eyes should be checked after being diagnosed with diabetes, and 41.9% said every six months, while 30.6% answered yearly or every two years, and 17.5% said only when vision is affected. Nearly half of respondents in Jordan (50.6%) answered every six months, 20.7% answered every year, 5.1% answered every two years, and 23.6% answered that retinal assessment is important only when vision is affected [20]. Some 60.8% were aware of the existence of the treatment of DR. These findings were lower in comparison to the studies done in Malaysia (72.3%) and Tabuk (86.1%) [18,21]. These variances could be due to differences in sample size and sampling procedure.