Awareness of Diabetes and Risk Factors for Diabetic Retinopathy Among Patients Attending the Eye Outpatient Department of a Tertiary Care Centre in Northeast India
Nabajani Dutta, Bharati Basumatari, Anjan J Bhuyan, Krishangi Kashyap, Shubra Das, Harsha Bhattacharya, Putul Mahanta
TL;DR
This study examines diabetes and diabetic retinopathy awareness among eye clinic patients in northeast India, finding moderate knowledge but gaps in understanding lifestyle risk factors.
Contribution
The study provides insights into diabetes awareness and risk factor knowledge in a specific Indian region, highlighting socio-demographic influences.
Findings
Most participants had moderate to high knowledge of diabetes and its risk factors for retinopathy.
Diabetics were more aware of symptoms like blurred vision but less informed about blood sugar monitoring ranges.
Socio-demographic factors like age, religion, and residence significantly influenced diabetes and retinopathy awareness.
Abstract
Introduction Over half a billion individuals worldwide suffer from diabetes mellitus (DM). Among people of working age, diabetic retinopathy (DR) is the leading cause of blindness and one of the most prevalent side effects of DM. DR screening and care in this part of the country are severely hampered by a lack of awareness of the consequences of diabetes and by infrequent screening, especially among individuals with diagnosed diabetes. The present study aims to assess the awareness of DM and its risk factors for DR and to identify the associated factors among patients attending the eye outpatient department (OPD) of a tertiary care centre in northeast India. Method The present hospital-based cross-sectional study included 1757 patients aged 23 years or older with or without DM and DR who visited the eye OPD at a tertiary care centre in Northeast India. A structured questionnaire was…
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| Variables | Categories | Total (%) |
| Age group | <55 years | 854 (48.6%) |
| ≥55 years | 903 (51.4%) | |
| History of diabetes mellitus | No | 980 (55.8%) |
| Yes | 777 (44.2%) | |
| Gender | Female | 748 (42.6%) |
| Male | 1009 (57.4%) | |
| Religion | Hindu | 1162 (66.1%) |
| Christian | 180 (10.2%) | |
| Others | 154 (8.8%) | |
| Family type | Joint | 593 (33.8%) |
| Nuclear | 1164 (66.2%) | |
| Place of residence | Rural | 646 (36.8%) |
| Urban | 1111 (63.2%) | |
| Marital status | Married | 1246 (70.9%) |
| Unmarried | 289 (16.4%) | |
| Widow/ Divorced/ Separated | 222 (12.6%) | |
| Socioeconomic status | Upper | 53 (3.0) |
| Upper middle | 406 (23.1%) | |
| Lower middle | 898 (51.1%) | |
| Upper lower | 367 (20.9%) | |
| Lower | 33 (1.9%) | |
| Dietary habit | Non-vegetarian | 1490 (84.8%) |
| Vegetarian | 267 (15.2%) |
| Variables | Categories | Diabetes status | Age | ||||
| Non-diabetic (n=980) | Diabetic (n=777) | z test (p-value | <55 years (n=854) | >55 years (n=903) | z test (p-value | ||
| The risk factors for DM include | Family history | 630 (64.3%) | 602 (77.5%) | -5.9 (<0.01) | 582 (68.1%) | 650 (72.0%) | -1.7 (0.08) |
| Being overweight | 608 (62.0%) | 555 (71.4%) | -4.1 (<0.01) | 612 (71.7%) | 551 (61.0%) | 4.7 (<0.01) | |
| Physical inactivity | 656 (66.9%) | 650 (83.7%) | -7.9 (<0.01) | 649 (76.0%) | 657 (72.8%) | 1.5 (0.12) | |
| Smoking | 447 (45.6%) | 331 (42.6%) | 1.3 (0.20) | 452 (45.9%) | 326 (36.1%) | 7.1 (<0.01) | |
| Alcohol | 552 (56.3%) | 318 (40.9%) | 6.4 (<0.01) | 506 (59.3%) | 364 (40.3%) | 7.9 (<0.01) | |
| Intake of Junk food | 659 (67.2%) | 496 (63.8%) | 1.5 (0.13) | 647 (75.8%) | 508 (56.3%) | 8.6 (<0.01) | |
| Women on oral contraceptive pills | 278 (28.4%) | 227 (29.2%) | -0.4 (0.69) | 277 (32.4%) | 228 (25.2%) | 3.3 (<0.01) | |
| Symptoms of high blood sugar include | Frequent urination | 623 (63.6%) | 647 (83.3%) | -9.2 (<0.01) | 624 (73.1%) | 646 (71.5%) | 0.7 (0.47) |
| Increased thirst | 591 (60.3%) | 632 (81.3%) | -9.5 (<0.01) | 605 (70.8%) | 618 (68.4%) | 1.1 (0.27) | |
| Extreme hunger | 566 (57.8%) | 525 (67.6%) | -4.2 (<0.01) | 530 (62.1%) | 561 (62.1%) | -0.02 (0.97) | |
| Unexplained weight loss | 463 (47.2%) | 547 (70.4%) | -9.7 (<0.01) | 521 (61.0%) | 489 (54.2%) | 2.9 (<0.01) | |
| Blurred vision | 641 (65.4%) | 724 (93.2%) | -13.9 (<0.01) | 651 (76.2%) | 714 (79.1%) | -1.4 (0.15) | |
| Dry mouth | 510 (52.0%) | 606 (78.0%) | -11.2 (<0.01) | 483 (56.6%) | 633 (70.1%) | -5.9 (<0.01) | |
| Recurrent urine infection | 408 (41.6%) | 530 (68.2%) | -11.1 (<0.01) | 413 (48.4%) | 525 (58.1%) | -4.1 (<0.01) | |
| Awareness statement | Response (Yes) | Diabetes status | Age | ||||
| Non-diabetic (n=980) | Diabetic (n=777) | z test (p-value) | <55 years (n=854) | >55 years (n=903) | z test (p-value | ||
| DM can be detected by | blood test | 837 (85.4%) | 710 (91.4%) | -3.8 (<0.01) | 764 (89.5%) | 783 (86.6%) | 1.8 (0.07) |
| Normal range for FBS | 70-110 mg/dl. | 295 (30.1%) | 265 (34.1%) | -1.7 (0.07) | 264 (30.9%) | 296 (32.8%) | -.8 (0.40) |
| Normal range for PPBS | 140-200 mg/dl. | 384 (39.2%) | 350 (45.0%) | -2.5 (0.01) | 340 (39.8%) | 394 (43.6%) | -1.6 (0.10) |
| Normal range for % HbA1c level | >5.7 to < 6.5% | 281 (28.7%) | 191 (24.6%) | 1.9 (0.05) | 240 (28.1%) | 232 (25.7%) | 1.1 (0.25) |
| The risk of DM can be reduced by | Dietary control | 910 (92.9%) | 762 (98.1%) | -5.0 (<0.01) | 793 (92.9%) | 879 (97.3%) | -4.4 (<0.01) |
| Regular physical exercise | 863 (88.1%) | 642 (82.6%) | 3.2 (<0.01) | 714 (83.6%) | 791 (87.6%) | -2.4 (0.02) | |
| Avoiding intake of alcohol & tobacco | 579 (59.1%) | 415 (53.4%) | 2.4 (0.02) | 441 (51.6%) | 553 (61.2%) | -4.0 (<0.01) | |
| Regular Health check-up | 840 (85.7%) | 729 (93.8%) | -5.5 (<0.01) | 739 (86.5%) | 830 (91.9%) | -3.6 (<0.01) | |
| Obese people are more likely to develop diabetes | 587 (59.9%) | 431 (55.5%) | 1.9 (0.06) | 542 (63.5%) | 476 (52.7%) | 4.6 (<0.01) | |
| Prediabetes is reversible | 476 (48.6%) | 412 (53.0%) | -1.8 (0.06) | 537 (62.9%) | 351 (38.9%) | 10.1 (<0.01) | |
| Gestational diabetes occurs in pregnancy. | 180 (18.4%) | 177 (22.8%) | -2.3 (0.02) | 201 (23.5%) | 156 (17.3%) | 3.2 (<0.01) | |
| DM can cause long-term damage in the | Kidney | 760 (77.6%) | 659 (84.8%) | -3.8 (<0.01) | 747 (87.5%) | 672 (74.4%) | 6.9 (<0.01) |
| Eyes | 863 (88.1%) | 771 (99.2%) | -9.1 (<0.01) | 794 (93.0%) | 840 (93.0%) | -0.04 (0.96) | |
| Nerves | 453 (46.2%) | 491 (63.2%) | -7.1 (<0.01) | 547 (64.1%) | 397 (44.0%) | 8.4 (<0.01) | |
| Awareness questions | Response categories | Diabetes status | Chi-square (p-value) | Age group | Chi-square (p-value) | ||
| Non-diabetic (n=980) | Diabetic (n=777) | <55 years | >=55 years | ||||
| Diabetes patients should visit a physician at least | Once a month (n=664) | 393 (40.1%) | 271 (34.9%) | 5.5 (0.14) | 382 (44.7%) | 282 (31.2%) | 43.4 (<0.01) |
| Once in 3 months (n=555) | 294 (30.0%) | 261 (33.6%) | 264 (30.9%) | 291 (32.2%) | |||
| Once a year (n=361) | 199 (20.3%) | 162 (20.8%) | 144 (16.9%) | 217 (24.0%) | |||
| Twice in a year (n=177) | 94 (9.6%) | 83 (10.7%) | 64 (7.5%) | 113 (12.5%) | |||
| Treatment of diabetes includes | Insulin only (n=206) | 163 (16.6%) | 43 (5.5%) | 52.4 (<0.01) | 104 (12.2%) | 102 (11.3%) | 24.7 (<0.01) |
| Oral Anti Diabetic Drugs (n=338) | 171 (17.4%) | 167 (21.5%) | 124 (14.5%) | 214 (23.7%) | |||
| Exercise (n=16) | 9 (0.9%) | 7 (0.9%) | 10 (1.2%) | 6 (0.7%) | |||
| All of the above (n=1197) | 637 (65.0%) | 560 (72.1%) | 616 (72.1%) | 581 (64.3%) | |||
| Awareness level | Frequency |
| Low awareness (<29) | 680 (38.7%) |
| Moderate Awareness (29-33) | 551 (31.4%) |
| High awareness (>33) | 526 (29.9%) |
| Variables | Categories | Awareness level categories | Chi-square value | p-value | ||
| Low awareness (n=680) | Moderate awareness (n=551) | High awareness (n=526) | ||||
| Age-group | <55 years (n=854) | 281 (32.9%) | 278 (32.6%) | 295 (34.5%) | 26.9 | <0.01 |
| >=55 years (n=903) | 399 (44.2%) | 273 (30.2%) | 231 (25.6%) | |||
| History of diabetes mellitus | No (n=980) | 464 (47.3%) | 255 (26.0%) | 261 (26.6%) | 71.0 | <0.01 |
| Yes (n=777) | 216 (27.8%) | 296 (38.1%) | 265 (34.1%) | |||
| Gender | Female (n=748) | 291 (38.9%) | 250 (33.4%) | 207 (27.7%) | 4.0 | 0.13 |
| Male (n=1009) | 389 (38.6%) | 301 (29.8%) | 319 (31.6%) | |||
| Religion | Hindu (n=1162) | 438 (37.7%) | 431 (37.1%) | 293 (25.2%) | 189.0 | <0.01 |
| Muslim (n=261) | 113 (43.3%) | 76 (29.1%) | 72 (27.6%) | |||
| Christian (n=180) | 46 (25.6%) | 7 (3.9%) | 127 (70.6%) | |||
| Others (n=154) | 83 (53.9%) | 37 (24.0%) | 34 (22.1%) | |||
| Place of residence | Rural (n=646) | 270 (41.8%) | 209 (32.4%) | 167 (25.9%) | 8.5 | 0.01 |
| Urban (n=1111) | 410 (36.9%) | 342 (30.8%) | 359 (32.3%) | |||
| Type of family | Joint (n=593) | 220 (37.1%) | 167 (28.2%) | 206 (34.7%) | 10.4 | 0.005 |
| Nuclear (n=1164) | 460 (39.5%) | 384 (33.0%) | 320 (27.5%) | |||
| Marital status | Unmarried (n=289) | 92 (31.8%) | 125 (43.3%) | 72 (24.9%) | 82.4 | <0.01 |
| Married (n=1246) | 461 (37.0%) | 353 (28.3%) | 432 (34.7%) | |||
| Widowed/widower/separated (n=222) | 127 (57.2%) | 73 (32.9%) | 22 (9.9%) | |||
| SES | Upper (n=53) | 36 (67.9%) | 15 (28.3%) | 2 (3.8%) | 65.4 | <0.01 |
| Upper middle (n=406) | 129 (31.8%) | 112 (27.6%) | 165 (40.6%) | |||
| Lower middle (n=898) | 345 (38.4%) | 292 (32.5%) | 261 (29.1%) | |||
| Upper lower (n=367) | 155 (42.2%) | 114 (31.1%) | 98 (26.7%) | |||
| Lower (n=33) | 15 (45.5%) | 18 (54.5%) | 0 (0.0%) | |||
| Variables | Categories | <55 years (n=854) | ≥ 55 years (n=903) | ||||||||
| n | Awareness level | Chi-square value (p-value) | n | Awareness level | Chi-square value (p-value | ||||||
| Low (n=281) | Moderate (n=278) | High (n=295) | Low (n=399) | Moderate (n=273) | High (n=231) | ||||||
| History of diabetes mellitus | No | 594 | 214 (39.0%) | 166 (30.2%) | 169 (30.8%) | 26.1(<0.01) | 431 | 250 (58.0%) | 89 (20.6%) | 92 (21.3%) | 66.5 (<0.01) |
| Yes | 305 | 67 (22.0%) | 112 (36.7%) | 126 (41.3%) | 472 | 149 (31.6%) | 184 (39.0%) | 139 (29.4%) | |||
| Gender | Female | 342 | 90 (26.3%) | 150 (43.9%) | 102 (29.8%) | 33.6 (<0.01) | 406 | 201 (49.5%) | 100 (24.6%) | 105 (25.9%) | 12.4 (0.002) |
| Male | 512 | 191 (37.3%) | 128 (25.0%) | 193 (37.7%) | 497 | 198 (39.8%) | 173 (34.8%) | 126 (25.4%) | |||
| Religion | Hindu | 536 | 159 (29.7%) | 215 (40.1%) | 162 (30.2%) | 89.3 (<0.01) | 626 | 279 (44.6%) | 216 (34.5%) | 131 (20.9%) | 132.0 (<0.01) |
| Muslim | 104 | 40 (38.5%) | 28 (26.9%) | 36 (34.6%) | 157 | 73 (46.5%) | 48 (30.6%) | 36 (22.9%) | |||
| Christian | 124 | 41 (33.1%) | 4 (3.2%) | 79 (63.7%) | 56 | 5 (8.9%) | 3 (5.4%) | 48 (85.7%) | |||
| Others | 90 | 41 (45.6%) | 31 (34.4%) | 18 (20.0%) | 64 | 42 (65.6%) | 6 (9.4%) | 16 (25.0%) | |||
| Place of residence | Rural | 295 | 107 (36.3%) | 95 (32.2%) | 93 (31.5%) | 2.7 (0.25) | 351 | 163 (46.4%) | 114 (32.5%) | 74 (21.1%) | 6.2 (0.046) |
| Urban | 559 | 174 (31.1%) | 183 (32.7%) | 202 (36.1%) | 552 | 236 (42.8%) | 159 (28.8%) | 157 (28.4%) | |||
| Type of family | Joint | 255 | 69 (27.1%) | 54 (21.2%) | 132 (51.8%) | 49.4 (<0.01) | 338 | 151 (44.7%) | 113 (33.4%) | 74 (21.9%) | 4.7 (0.09) |
| Nuclear | 599 | 212 (35.4%) | 224 (37.4%) | 163 (27.2%) | 565 | 248 (43.9%) | 160 (28.3%) | 157 (27.8%) | |||
| Marital status | Unmarried | 168 | 30 (17.9%) | 97 (57.7%) | 41 (24.4%) | 107.0 (<0.01) | 121 | 62 (51.2%) | 28 (23.1%) | 31 (25.6%) | 57.8 (<0.01) |
| Married | 580 | 210 (36.2%) | 128 (22.1%) | 242 (41.7%) | 666 | 251 (37.7%) | 225 (33.8%) | 190 (28.5%) | |||
| Widow/ widower/separated | 96 | 41 (38.7%) | 53 (50.0%) | 12 (11.3%) | 116 | 86 (74.1%) | 20 (17.2%) | 10 (8.6%) | |||
| SES | Upper | 21 | 16 (76.2%) | 3 (14.3%) | 2 (9.5%) | 76.5 (<0.01) | 32 | 20 (62.5%) | 12 (37.5%) | 0 (0.0%) | 59.2 (<0.01) |
| Upper middle | 195 | 46 (23.6%) | 49 (25.1%) | 100 (51.3%) | 211 | 83 (39.3%) | 63 (29.9%) | 65 (30.8%) | |||
| Lower middle | 494 | 196 (39.7%) | 159 (32.2%) | 139 (28.1%) | 404 | 149 (36.9%) | 133 (32.9%) | 122 (30.2%) | |||
| Upper lower | 144 | 23 (16.0%) | 67 (46.5%) | 54 (37.5%) | 223 | 132 (59.2%) | 47 (21.1%) | 44 (19.7%) | |||
| Lower | - | 33 | 15 (45.5%) | 18 (54.5%) | 0 (0.0%) | ||||||
| Variables | Categories | Non-diabetic (n=980) | Diabetic (n=777) | ||||||||
| n | Awareness level | Chi-square value (p-value) | n | Awareness level | Chi-square value (p-value) | ||||||
| Low (n=464) | Moderate (n=255) | High (n= 261) | Low (n=216) | Moderate (n=296) | High (n= 265) | ||||||
| Gender | Female | 453 | 196 (43.3) | 143 (31.6%) | 114 (25.2%) | 13.6 (0.01) | 295 | 95 (32.2%) | 107 (36.3%) | 93 (31.5%) | 4.7 (0.097) |
| Male | 527 | 268 (50.9%) | 112 (21.3%) | 147 (27.9%) | 482 | 121 (25.1%) | 189 (39.2%) | 172 (35.7%) | |||
| Age | <55 years | 549 | 214 (39.0%) | 166 (30.2%) | 169 (30.8%) | 35.1 (<0.01) | 305 | 67 (22.0%) | 112 (36.7%) | 126 (41.3%) | 14.0 (0.001) |
| >=55 years | 431 | 250 (58.0%) | 89 (20.6%) | 92 (21.3%) | 472 | 149 (31.6%) | 184 (39.0%) | 139 (29.4%) | |||
| Religion | Hindu | 653 | 292 (44.7%) | 225 (34.5%) | 136 (20.8%) | 142.7 (<0.01) | 509 | 146 (28.7%) | 206 (40.5%) | 157 (30.8%) | 95.2 (<0.01) |
| Muslim | 115 | 73 (63.5%) | 20 (17.4%) | 22 (19.1%) | 146 | 40 (27.4%) | 56 (38.4%) | 50 (34.2%) | |||
| Christian | 122 | 44 (36.1%) | 2 (1.6%) | 76 (62.3%) | 58 | 2 (3.4%) | 5 (8.6%) | 51 (87.9%) | |||
| Others | 90 | 55 (61.1%) | 8 (8.9%) | 27 (30.0%) | 64 | 28 (43.8%) | 29 (45.3%) | 7 (10.9%) | |||
| Type of family | Joint | 325 | 136 (41.8%) | 74 (22.8%) | 115 (35.4%) | 19.1 (<0.01) | 268 | 84 (31.3%) | 93 (34.7%) | 91 (34.0%) | 3.1 (0.21) |
| Nuclear | 655 | 328 (50.1%) | 181 (27.6%) | 146 (22.3%) | 509 | 132 (25.9%) | 203 (39.9%) | 174 (34.2%) | |||
| Place of residence | Rural | 418 | 219 (52.4%) | 92 (22.0%) | 107 (25.6%) | 8.7 (0.01) | 228 | 51 (22.4%) | 117 (51.3%) | 60 (26.3%) | 24.0 (<0.01) |
| Urban | 562 | 245 (43.6%) | 163 (29.0%) | 154 (27.4%) | 549 | 165 (30.1%) | 179 (32.6%) | 205 (37.3%) | |||
| Marital status | Unmarried | 147 | 49 (33.3%) | 61 (41.5%) | 37 (25.2%) | 77.6 (<0.01) | 142 | 43 (30.3%) | 64 (45.1%) | 35 (24.6%) | 30.7 (<0.01) |
| Married | 688 | 307 (44.6%) | 167 (24.3%) | 214 (31.1%) | 558 | 154 (27.6%) | 186 (33.3%) | 218 (39.1%) | |||
| Widowed/widower/separated | 145 | 108 (74.5%) | 27 (18.6%) | 10 (6.9%) | 77 | 19 (24.7%) | 46 (59.7%) | 12 (15.6%) | |||
| SES | Upper | 27 | 16 (59.3%) | 11 (40.7%) | 0 (0.0%) | 121.2 (<0.01) | 26 | 20 (76.9%) | 4 (15.4%) | 2 (7.7%) | 119.0 (<0.01) |
| Upper middle | 231 | 73 (31.6%) | 73 (31.6%) | 85 (36.8%) | 175 | 56 (32.0%) | 39 (22.3%) | 80 (45.7%) | |||
| Lower middle | 503 | 238 (47.3%) | 125 (24.9%) | 140 (27.8%) | 395 | 107 (27.1%) | 167 (42.3%) | 121 (30.6%) | |||
| Upper lower | 201 | 137 (68.2%) | 28 (13.9%) | 36 (17.9%) | 166 | 18 (10.8%) | 86 (51.8%) | 62 (37.3%) | |||
| Lower | 18 | 0 (0.0%) | 18 (100.0%) | 0 (0.0%) | 15 | 15 (100.0%) | 0 | 0 | |||
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Taxonomy
TopicsRetinal Diseases and Treatments · Retinal Imaging and Analysis · Ophthalmology and Visual Impairment Studies
Introduction
Metabolic syndrome is an increasingly common condition that predisposes individuals to diabetes mellitus (DM) [1]. DM affects around half a billion people globally and a projected 783 million people will have diabetes by 2045 [2]. Over 90% of people with diabetes have type 2 DM, which is impacted by socio-economic, demographic, environmental, and genetic factors. Rapid urbanisation, an ageing population, a sedentary lifestyle, and a rise in the prevalence of overweight and obesity all contribute to the rise of type 2 DM [3]. As of 2019, India has 77 million adults with diabetes, making it the second highest in the world. The number of those afflicted has been rising rapidly, representing a significant public health burden [4].
Diabetic retinopathy (DR) is one of the most common consequences of DM and the primary cause of blindness in the working-age population, which typically shows no symptoms until it is too late [5,6]. People with diabetes in India had a 16.9% prevalence of DR and a 3.6% prevalence of sight-threatening DR (STDR) [7]. Every person with diabetes should ideally undergo routine vision-threatening DR screening. Early screening and awareness need to be provided by educated medical professionals and retina specialists. However, inequitable care delivery and low disease knowledge are two of India's biggest challenges [8]. The majority of patients who present to India's eye care institutions with advanced and irreversible diabetic eye disease are due to low utilisation of healthcare facilities caused by a lack of knowledge about available treatment alternatives and inadequate physician referrals. Awareness of DM and DR can be raised through practice-orientated education, promoting facilities tailored to the appropriate demographics at each level of an eye health pyramid, and continuing fundus and glucose screening programmes [9]. Lack of knowledge of the need for regular DR screening has turned many patients into the advanced stage of DR before their first eye check-ups. A study in Nepal found that although patients with diabetes are generally aware of the negative visual effects of DR, their readiness to undergo retinal examinations was inadequate [10]. Often, patients view DR screening as basic eye exams that include vision tests, refraction measurements, and non-dilated pupil exams [11].
Despite being traditionally considered low risk due to active lifestyles and diet, diabetes prevalence in the northeastern states of India is steadily increasing due to urbanisation, changing diets, and reduced physical activity [12]. DR remains underdiagnosed in Northeast India due to poor access to ophthalmic care. Limited access to retinal care specialists in hilly and tribal areas, a lack of knowledge about the effects of diabetes, and infrequent screening even among those with confirmed diabetes are major challenges in DR screening and management in this part of the country.
The primary objective of the present study was to assess the level of awareness regarding DM and its risk factors for DR among patients attending the eye outpatient department (OPD) of a tertiary care centre in Northeast India. The secondary objectives were to identify socio-demographic factors associated with participants' levels of awareness regarding age and diabetes status. Thus, the present study aims to assess the level of awareness regarding diabetes and its risk factors for diabetic retinopathy and to identify associated factors among patients attending the eye OPD of a tertiary care centre in Northeast India. The diabetic group showed significantly greater awareness of the effects of diabetes on other organs. Regarding age group, participants aged 55 years and older showed significantly higher knowledge of various preventive measures for diabetes.
Materials and methods
The present hospital-based cross-sectional study included 1757 patients who visited the Eye OPD of Sri Sankaradeva Netralaya (SSDN), Guwahati, Assam, between April 17, 2023, and June 29, 2024. Every patient was questioned about their awareness of diabetes and diabetic retinopathy, irrespective of their DM status. Written informed consent was obtained from all the participants. Ethical approval for this study was obtained from the Institutional Ethics Committee of SSDN, Guwahati, Assam (No. SSN/IEC/JANUARY/2019/21, dated January 12, 2019).
Inclusion and exclusion criteria
The study included participants aged 23-94 years with or without DM and DR who were willing to participate and provided consent. Severely ill or mentally incapacitated patients and patients with uncorrectable severe visual impairment or hearing loss were excluded.
Data collection tool
A structured questionnaire was used to collect the data (Annexure 1). The first part of the questionnaire collected demographic information for each participant, including age, gender, religion, family type, place of residence, marital status, history of diabetes mellitus, and dietary habits. Socio-economic status was determined using the updated, modified Kuppuswamy scale (2022), which is based on the head of the family's education and occupation level and the family's monthly income in rupees [13].
The second part of the questionnaire was designed to obtain information on participants' awareness of diabetes and risk factors for DR. It comprised 18 questions assessing participants' awareness of the characteristics, symptoms, diagnosis, management, treatment, and consequences of diabetes. The responses to the questions included both multiple-choice and single-choice options. Each correct response was scored as 1, while incorrect responses were scored as 0. The overall total awareness score was 48.
The questionnaire was initially developed in English and further translated into Assamese. Content validity was conducted by experts from various fields of medical sciences, and the final tool was implemented for data collection. The data collection tool was pre-tested for accuracy, completeness, and consistency on 5% of patients attending the eye OPD before data collection. Data collection commenced following changes to the tool based on pre-test results and content validity. The questionnaire was interviewer-administered by a single investigator. Data with incomplete participant information were excluded to avoid errors. The patients were given a pamphlet on diabetes and DR after completing the questionnaire.
Statistical analysis
The data analysis was conducted using Statistical Package for the Social Sciences (SPSS) version 22 (IBM Corp., Armonk, New York). The distributions of the variables were summarised using descriptive statistics, viz., frequency, percentage, mean, and standard deviation. The total awareness score for each participant was computed by adding all the individual response scores. The response proportions were compared using a z-test for two proportions for different variable categories. The level of awareness was further categorised into three categories - low, moderate, and high - based on the 50th and 75th percentiles of the data. The chi-square test was used to assess the potential association between awareness level and socio-demographic factors. A p-value <0.05 was considered significant, while a p-value <0.01 was considered highly significant.
The data were analysed separately by age group and by participants' diabetes mellitus status. The findings were combined and presented in a single table for comparison.
Results
The study included 1757 patients who regularly visited the Eye OPD at SSDN in Guwahati, Assam. The participants' ages ranged from 23 to 94 years, with the majority (903, 51.4%) aged 54 years or older. The male:female ratio was observed to be 1.35:1. The proportion of known diabetics was 44.2% (n=777). Most of the participants (70.9%) were married (n=1246). Participants mostly followed Hinduism (n=1162, 66.1%), were from urban areas (n=1111, 63.2%), and belonged to nuclear families (n=1164, 66.2%). More than half (51.1%) of the participants had a lower-middle-class (n=898) socio-economic status. Almost 85% (n=1490) of the participants were non-vegetarian (Table 1).
Respondents' awareness regarding diabetes and risk factors for diabetic retinopathy as per age and diabetes mellitus status
Regarding the risk factors of diabetes, known diabetics showed significantly more awareness regarding various risk factors and symptoms of diabetes mellitus. Physical inactivity (83.7%, n=650), family history of diabetes (77.5%, n=602), and being overweight (71.4%, n=555) were the most common reported risk factors among people with diabetes. While both groups showed less awareness regarding behavioural risk factors, non-diabetics showed more awareness of the risk of alcohol consumption (z-test value 6.4, p<0.01). Compared to non-diabetics, a significantly higher proportion of people with diabetes identified blurred vision (n=724, 93.2%) as a symptom of diabetes mellitus. On the other hand, the age-group comparison revealed that the younger age group (below 55 years) was more aware of most risk factors and symptoms of diabetes mellitus. More than 75% of participants in both age groups were aware that diabetes mellitus can cause blurred vision (Table 2).
*Table 2: Awareness regarding risk factors and symptoms of diabetes mellitus as per diabetes mellitus status and age of the participants (n=1757)The data have been represented as the frequency (n) of positive responses and as percentages (%); total sample N=1757. Response proportions were compared separately as per the age and diabetes status of the participants; DM: Diabetes mellitus; p < 0.05 was considered statistically significant for z- test.
As shown in Table 3, more than 90% (n=710) of people with diabetes were aware of blood testing, but only 45% (n=350) were aware of the normal postprandial blood sugar (PPBS) range. Awareness of the normal ranges for fasting blood sugar (FBS) levels and glycated haemoglobin (HbA1c) is very low in both groups. No significant difference in awareness of the various components of diabetes monitoring was observed between age groups. In the prevention case, the diabetic group significantly perceived that dietary control (98.1%, n=762) and regular health check-ups (93.8%, n=729) can prevent diabetes. On the other hand, the non-diabetic group reported significantly more regular physical exercise (88.1%, n=863) and avoidance of alcohol and tobacco (59.1%, n=579) to prevent diabetes. Also, the diabetic group showed significantly greater awareness of the effects of diabetes on other organs. Additionally, participants aged 55 years and above showed higher awareness of various preventive measures for diabetes, whereas the younger age group was more aware that a prediabetic condition is reversible. Participants from both age groups were highly aware of the effect of diabetes on eye health (Table 3).
*Table 3: Awareness on monitoring, prevention and the effect of diabetes mellitus on other organs as per diabetes mellitus status and age of the participantsThe data have been represented as the frequency (n) of positive responses and as percentages (%); total sample N=1757. Response proportions were compared separately by age and diabetes status; DM: Diabetes mellitus; FBS: Fasting Blood Sugar; PPBS: Postprandial blood sugar; p < 0.05 was considered statistically significant for the test.
There was no significant difference in perceived duration of the physician visit between diabetics and non-diabetics. Whereas the younger age group mostly perceived that a diabetes patient should visit a physician at least once a month (44.7%, n=382). A significant difference in awareness of diabetes treatment options was observed between diabetics and non-diabetics (chi-square value: 52.4, p<0.01) and between the two age groups (chi-square value: 24.7, p<0.01). Participants mostly reported that diabetes treatment includes a combination of insulin, oral drugs, and exercise (Table 4).
Table 4: Awareness treatment of diabetes mellitus as per the diabetes mellitus status and age of the participantsThe data has been represented as frequency (n) of positive response and percentage (%); total sample N=1757. Response proportions were compared separately by age and diabetes status; p < 0.05 was considered statistically significant for the chi-square test.
Awareness scores for diabetes and its associated factors were calculated from responses to the awareness questionnaire. The mean overall awareness score (SD) was 29.8 (5.7). The total awareness scores were further divided into three categories based on the 50th and 75th percentiles. The 50th and 75th percentiles of the data were 29 and 34, respectively. Therefore, the categories are defined as low awareness (awareness score <29), moderate awareness (29<awareness score<34) and high awareness (awareness score ≥34). A high level of awareness of diabetes and its associated factors was observed in 526 patients (29.9%), while 551 patients (31.4%) had a moderate level of awareness (Table 5).
Association of awareness of DM and awareness of diabetes, and risk factors for diabetic retinopathy with socio-demographic variables
The level of awareness was considerably low in the above-55 age group (44.2%, n=399/903) and among those with no history of DM (47.3%, n=464/980). A high level of awareness was noted among the Christian community (70.6%, n=127/180). Participants from a rural background (41.8%, n=270/646), those residing in nuclear families (39.5%, n=460/1164), and the widow/widower or separated group (57.2%, n=127/222) also showed lower awareness. The awareness level was considerably higher in the upper-middle-class group (40.6%, n=165/406), but 36 of 53 (67.9%) participants in the upper class showed a low level of awareness. The awareness levels were significantly associated with age group, history of diabetes mellitus, religion, place of residence, family type, marital status, and socio-economic status of the participants (Table 6).
Table 6: Association of awareness of diabetes mellitus with socio-demographic variables (n=1757).The data has been represented as frequency (n) and percentage (%); total sample N=1757. SES: Socio-economic status; p < 0.05 was considered statistically significant for the chi-square test
Association of awareness of diabetes and risk factors for diabetic retinopathy with socio-demographic variables according to age
As shown in Table 7, participants with diabetes mellitus who were younger than 55 years had a relatively high level of awareness (41.3%, n=126/305). Also, younger female participants had a significantly higher level of awareness (chi-square value: 33.6; p<0.01) than men, whereas in the 55+ age group, the opposite outcome was observed. The Christian community showed a higher level of awareness in both age groups. Participants from joint families showed a higher level of awareness in the age group below 55 years (chi-square value: 49.4; p<0.01). Elderly participants who were unmarried or those who had lost their spouse showed a significantly low level of awareness. Surprisingly, participants in both age groups from the upper class showed a relatively low level of awareness. Also, in the above 55-year age group, participants in the upper, lower, or lower socio-economic status groups had a low level of awareness (chi-square value: 59.2; p<0.01). It was observed that diabetes mellitus status, gender, religion, and socio-economic status were significantly associated with participants' awareness levels across both age groups (Table 7).
Table 7: Association of awareness of diabetes and risk factors for diabetic retinopathy with socio-demographic variables according to age-groups The data has been represented as frequency (n) and percentage (%); total sample N=854 for the age group <55 years and N=903 for the age group ≥ 55 years. SES: Socio-economic status; p < 0.05 was considered statistically significant for the chi-square test.
Association of awareness of diabetes and risk factors for diabetic retinopathy with socio-demographic variables according to diabetes mellitus status
Among the non-diabetic group, those aged 55 years or older (chi-square value: 13.6; p=0.01) and men (chi-square value: 35.1; p<0.01) had significantly lower awareness of diabetes and its related factors. The Christian participants showed a significantly higher level of awareness, regardless of diabetic status (chi-square values: 142.7 for non-diabetics and 95.2 for people with diabetes; p<0.01). The non-diabetic participants from nuclear families (chi-square value: 19.1; p<0.01) and from rural backgrounds (chi-square value: 8.7; p=0.01) showed lower levels of awareness. Rural diabetics were significantly more aware than their urban counterparts (chi-square value: 24.0; p<0.01). In both groups, participants from upper socio-economic status showed a relatively low level of awareness. Also, participants in the upper, lower, or lower socio-economic status groups showed relatively low to moderate levels of awareness. It was observed that participants' awareness level was significantly associated with age, religion, place of residence, and marital status in both age groups (Table 8).
Table 8: Association of awareness of diabetes and risk factors for diabetic retinopathy with socio-demographic variables according to diabetes mellitus statusThe data have been presented as frequencies (n) and percentages (%); total sample sizes are N=980 for non-diabetics and N=777 for people with diabetes. SES: Socio-economic status; p < 0.05 was considered statistically significant for the chi-square test.
Discussion
Over the past three decades, India's diabetes burden has significantly increased. Effective diabetes control and management require a combination of primary prevention through community-based health education, dietary counselling, and physical activity promotion initiatives, along with secondary prevention strategies such as systematic screening and prompt clinical management [12]. One of the most prevalent microvascular problems in diabetic patients is DR, which is also a major cause of visual impairment. According to population-based research, 10% of diabetes patients have vision-threatening DR episodes, while 33% of patients have indications of DR [14]. Lack of awareness on diabetic screening and the effect of diabetes on eye and retinal health often leads to poor health-seeking behaviour among people with diabetes, increasing DR prevalence and related complications [15]. The present hospital-based study included 1757 patients attending the eye OPD of a tertiary care centre in Northeast India to assess awareness of DM and its risk factors for DR, and to identify associated factors.
Most participants in this study were men and aged 54 years or older. The percentage of known diabetics was 44.2% (n=777), and half of the participants had a lower-middle-class socio-economic background. A moderate to high level of awareness of diabetes and risk factors for DR was observed in 1070 (61.3%) patients. The findings agree with other similar studies [16-18]. A study from South India reported that 55% of patients were unaware of specialised eye treatment for DR [19].
In the present study, known diabetics showed significantly more awareness of various risk factors and symptoms of DM. But both diabetics and non-diabetics were less aware of the lifestyle risk factors of diabetes. On the other hand, the age-group comparison revealed that the younger age group (below 55 years) was more aware of most risk factors and symptoms of DM. However, more than 75% of participants in both age groups were aware that DM can cause blurred vision. The difference in awareness might be attributed to the fact that complication-affected individuals with DM typically know more about the disease and its risk factors than people without complications [20]. Only 45% (n=350) of people with diabetes knew the typical range of PPBS levels, and both diabetics and non-diabetics had relatively little knowledge of the normal range for FBS levels and HbA1c. Low awareness of monitoring levels may affect patients' self-monitoring of blood glucose and periodic laboratory checks, leading to underdiagnosis or late diagnosis of the disease. Late diagnosis of type 2 diabetes may result in unchecked progression of DR and other micro- and macrovascular complications [21]. Suboptimal blood glucose management, hypertension, and dyslipidaemia are the traditional controllable variables linked to the development and progression of DR. The aberrant distribution of adipose tissue, as well as lifestyle factors such as diet, vitamin intake, exercise, and smoking, are among the less well-known modifiable factors that may be important [22]. The current findings suggest a lack of awareness among the participants regarding diabetes monitoring and prevention strategies, making them more vulnerable to DR and other major complications.
In the present study, awareness regarding DM and DR was significantly associated with age, DM status, religion, place of residence, family type, marital status, and socio-economic status. Previous studies have reported that older adults are more aware of DM, which contradicts our findings [23]. However, unawareness was more commonly reported in the non-diabetic group. In the present study, unawareness was more prevalent among the upper socio-economic class. A study from West Bengal reported that diabetes risks were much higher in the richest adults compared to the poorest adults due to a sedentary lifestyle, dietary habits and poor lifestyle behaviour. Policy-making to reduce economic inequality and awareness campaigns on diabetes care and treatment-seeking behaviour are important, particularly among older adults [24]. Similar to our findings, another study reported an association between Christianity and knowledge about DR. Higher educational levels among Christians were attributed to greater awareness among participants [25]. Awareness of DR was previously documented to be significantly correlated with gender, length of diabetes, and place of residence [17]. In the present study, urban diabetics showed a high level of awareness, while rural diabetics mostly showed a moderate level of awareness about diabetes and DR. Also, the awareness level was considerably low among the rural non-diabetics. The present findings support the observation of the Indian Council of Medical Research's India Diabetes Study [26]. Non-diabetics who were from joint families also showed a significantly high level of awareness. Many generations live together in joint families, which can make older family members more susceptible to chronic diseases like diabetes. One can gain more informal knowledge regarding diabetic complications, such as DR, by seeing the experiences and management practices of families with the disease.
The widowed, widowers, or separated individuals were observed to have lower awareness levels than their married counterparts, particularly those aged 54 or older (chi-square value=57.8; p<0.01) and non-diabetics (chi-square value=77.6; p<0.01). Widowed, widowed, or separated non-diabetic persons in India exhibit a notable lack of awareness of DM and DR due to their increased socio-economic vulnerability, restricted access to health information, and cultural barriers, especially for women [27]. In the current study, most participants were non-vegetarians. Previous studies have reported protective effects of fish and meat consumption on DR risk [28,29].
Limitation
The hospital-based study design limits the generalisability of the findings. The single-institution setting and the study's short duration limit its external validity. Moreover, the evidence in the current study is based on self-reported data. Future studies in multi-institutional settings or community-based longitudinal assessments could help gauge the level of awareness of diabetes and its risk factors for DR, as well as the factors that influence it, among the general population. Participants showed limited awareness of blood glucose monitoring levels, which might affect self-monitoring of blood glucose and periodic laboratory checks, leading to underdiagnosis or late diagnosis of the disease.
Conclusions
A moderate to high level of awareness regarding diabetes and the risk factors for DR was demonstrated by the majority of participants. Individuals with a history of DM had a markedly higher level of awareness of the symptoms and risk factors of the disease. However, the lifestyle risk factors for diabetes were less well-known to both diabetics and non-diabetics. Patients' age, DM status, religion, place of residence, family type, marital status, and socio-economic position were found to be substantially correlated with their awareness of DM and DR. The majority of DM risk factors and symptoms were better known to the younger age group.
To reduce the prevalence of DR and enhance treatment planning, the results of this study could serve as a basis for awareness campaigns among the targeted patient group and medical professionals. To ensure that everyone in remote locations, especially those at risk, receives a dilated eye test at the time of first diagnosis and at least once a year thereafter, screening and awareness programmes are required.
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