Knowledge and attitudes regarding effect of diabetes mellitus on eyes and community-based screening for diabetes, hypertension, and visual impairment in central India- a community-based cross-sectional study

INTRODUCTION

Globally, diabetes mellitus (DM) is now one of the most common non-communicable diseases (NCDs) and accounts for 4.2 million deaths annually. According to the International Diabetes Federation, approximately 463 million adults (20-79 years) were living with diabetes in 2019 and by 2045 this number will rise to 700 million. About 79% of adults with diabetes were living in low- and middle-income countries. The more worrisome fact is that about 50% of those with diabetes remain undiagnosed.¹ The prevalence of diabetes in India is 7.3% i.e. 62.4 million people living with diabetes in 2011 as per Indian Council of Medical Research- India diabetes (ICMR- INDIAB) population based cross-sectional study.²

DM is a silent disease in which many sufferers become aware that they have diabetes only when they develop one of its life-threatening complications. It causes significant morbidity owing to specific microvascular complications such as, retinopathy, nephropathy and neuropathy, and macrovascular complications such as, ischaemic heart disease, and peripheral vasculopathy. Ocular complications associated with DM are progressive and rapidly becoming the world’s most significant cause of morbidity and are preventable with early detection and timely treatment.³ Health education is one of the key components in ensuring better treatment and control of diabetes. Studies have shown that increasing knowledge regarding diabetes and its complications has significant benefits in terms of early diagnosis and compliance to treatment, thereby reducing the complications associated with diabetes.⁴ This study was planned to assess knowledge regarding diabetes mellitus and their views and perspectives on diabetes and eyes.

METHODS

A large cohort in western India underwent habitual visual acuity assessment (HVA), diabetes screening by random finger prick blood sugar, blood pressure screening. Participation in the screening was voluntary and all tests were provided free as part of a long-term diabetes and vision screening project in western India. The cohort for this study is from a screening project conducted in 2018 over a 10-day period. The screening was conducted in the community at a prominent location during annual holy celebrations in the metropolitan city of Mumbai. Approximately, 50,000-60,000 people a day and people of various ages, educational and socio-economic backgrounds visit this location which makes an ideal location to assess a heterogeneous cohort which would be representative of a population of a large urban city in western India.

In this research, a cross-sectional study design was applied in which a questionnaire survey was administered to every 5^th participant who registered for the free screening.

Inclusion criteria

The study included participants who were willing to give informed consent, participated in the screening program.

Exclusion criteria

The study excluded if the participant was not willing to give informed consent or participant found to be sick for any medical reasons.

If the 5^th participant refused participation, then the next participant was asked to participate. Trained professional survey personnel administered the questionnaire survey (Leadtech private limited, New Delhi). The surveys were designed to assess knowledge attitude and perspective of the participants regarding diabetes and diabetes related eye disease. The questionnaire was administered by using convenient sampling method during the day of screening; therefore, the sample size was 6300 participants. The study period was one day.

Validated questionnaire surveys were modified using community-based focus discussions. The survey questionnaire was designed in English and translated to Hindi and Marathi; the two most common languages used in Mumbai. Translation based discrepancies were checked by administering both the English and translated questionnaires to un-involved and un-biased local doctors (general practitioners, diabetologists and ophthalmologists) (n=50). Based on their observations, using the English questionnaire as the standard, the language of the translated questionnaires was modified. The modified questionnaire was then piloted amongst 100 random patients and relatives in the out-patient department. Based on the responses from the participants and the observations of the survey personnel the survey was further modified to ensure clarity of questions to the lay person irrespective of their educational status, clear understanding of the options for the questions and to ensure that the survey took no more than 7 minutes to complete. The modified survey was then piloted amongst 100 random volunteers at the hospital (none of them medical or para-medical professionals) and the survey was finalized.

Professional survey professionals using electronic devices like iPad and tablets administered the questionnaire survey. Leadtech has their proprietary survey software. All the questions had forced choice responses, multiple options (for some questions only 1 response was allowed and for some multiple responses could be selected) and there was no free text for responses of the questionnaire. No blank responses were permitted.

The first part of the survey collected basic socio-demographic data like age (18-40, 40-60 and >60), sex (male, female), educational status (<10^th standard, graduate, post-graduate), residence (Mumbai, other city or village), income (Rs 50000/year, 50,000-2,00,000/year and >2,00,000/year) and if the participant had a driving license (not driving, car, two-wheeler, bus/truck- the largest vehicle driven was selected). The second part of the survey collected the participants results from the screening tests; blood pressure, random blood sugar, HVA right and left eye. Following this were the questions regarding knowledge, attitude and perspective towards diabetes and diabetes related eye disease.

Ethical clearance was obtained from Institutional Ethics Committee, Ashwini Rural Medical College, Hospital and Research Centre, Kumbhari, Solapur.

Data analysis was done using Statistical Package for Social Science (SPSS) software version 23. All the variables were analysed using descriptive statistics to calculate frequencies, mean, range etc. By considering 95% level of significance, chi-square test, Fischer exact test and t test were applied to determine the association between different variables.

RESULTS

A total of 6300 participants were surveyed. Demographic characteristics of the subjects and gender differences are shown in Table 1. Most of the study participants were in the age group of 20 to 40 years and 5.2% were elderly. Out of 6300 participants, 73.7% were males and 26.3% were females. More than half (52%) of the study participants had below higher-level education and majority (96.6%) of the them were living in urban area. Majority (97.8%) of them belonged to Hindu religion and as much as 43.9% of study participants had annual income of less than 50,000.

More than two third of the study participants (79.5%) know about diabetes and raised blood sugar level causes problem. Around 87.3% had good knowledge about diabetes. Almost half of the participants believe that diabetes occurs only after 60 years. Only 58% of the participants have ever checked their blood sugar level. Out of 6300 participants, 40.5% were already diagnosed with raised blood sugar level.

Unfortunately, 42.7% of the study participants never had eye examination in their lifetime but about 34.3% had previous eye check in less than one year. Half of them (50.7%) answered that they will have eye check-up from eye specialist and around 66.8% of study participants believes their vision is normal.

On screening, nearly 40% of participants were screened positive for hypertension and 23.9% had raised blood sugar level. Unfortunately, 6.0% had visual impairment on visual acuity examination (Table 4).

It was found that the participants agreed for factor such as diabetes can occur after 60 years, eats lots of sweets, do not exercise had a significantly raised blood sugar level compared to the participants who did not agree for the given factors. The participants who did not agree for factors such as diabetes affects less than 20 years, obese people, village people had a significantly raised blood sugar level compared to the participants who did agree for the given factors.

It was found that the participants agreed for factor such as diabetes can occur after 60 years, affect people without family history had a significant abnormal vision compared to the participants who did not agree for the given factors.

DISCUSSION

This study was undertaken among 6300 study participants, to assess their knowledge and perception about diabetes. Around 60% of participants were in the age group of 20-40 years and more than two third were male. Among these, 87.3% had correct knowledge about diabetes, 58% of participants have ever checked their blood sugar and about 40.5% were diagnosed with raised blood sugar. On visual examination, more than 94% of them had normal vision, 3% had mild and 2.9% moderate vision impairment and 0.2% had severe impairment

In current study we assessed the knowledge, attitude, practices and perception of diabetes mellitus with the help of set of questionnaires. Out of the total participants, around 60% of the study participants were in the age group of 20-40 years and 5% were elderly. Most of our participants were in younger age group which can be compared with National ICMR INDIAB study but this is contrary to the study conducted by Tejaswi et al as it was conducted in tertiary care hospitals in central India where most of the study participants were in age group of >40 years.⁵

More than two-third of our study participants were male. This gender distribution is not similar to ICMR-INDIAB study which was done at a national level across fourteen states in which the gender distribution was almost equal in Maharashtra. This is also supported by the study conducted by Tejaswi et al as it was conducted in tertiary care hospitals in central India.⁵ And almost 96.6% of our study participants were living in urban area. This is high as compared to INDIAB study where about 56.5% belong to urban area in Maharashtra. In our study, near about 58% of participants have ever checked their blood sugar and about 40.5% were diagnosed with raised blood sugar. But when we checked random blood sugar of all participants, around one third (23.9%) had raised blood sugar. The self-reported raised blood sugar in our study is higher as compared to INDIAB study in Maharashtra (10.9%).⁶

In our study, around 80% knows about diabetes mellitus, which is comparable to the study conducted by Kurian et al in a rural community in Kerala (89%), but in INDIAB study, only 43.2% were aware about diabetes mellitus.^7,8 In current study, nearly about 87.3% of study participants had answered correctly on knowledge about diabetes mellitus. This is high compared to the study conducted by Tejaswi et al as it was conducted in tertiary care hospitals in central India in which 16% of the participants had good level of knowledge.⁵

In our study, less than half of them (44.7%) feels that diabetes occurs after 60 years and nearly 46.1% agrees that the disease can affect people less than 20 years. More than half of them (59.3%) aggress that diabetes can occur without family history, 34.7% of them agreed that disease occurs in rich people, 34.7% agreed that disease mainly occur in fat people. More than half of study participants agreed that disease affects people who eats lots of sweet and who do not exercise. These findings were almost similar to the study conducted by Kurian et al in a rural community in Kerala in which the most common risk factor identified by respondents was diet (57.4%) followed by heredity (17.2%) and physical inactivity (4.9%).^7-9 In present study, it was found that the participants agreed for factor such as diabetes can occur after 60 years, eats lots of sweets, do not exercise had a significantly raised blood sugar level compared to the participants who did not agree for the given factors and participants who did not agree for factors such as diabetes affects less than 20 years, fat people, village people had a significantly raised blood sugar level compared to the participants who did agree for the given factors. The perception among participants were similar to the existing literature on risk factors of diabetes mellitus. This is also evident in a study conducted by Adhikary et al among rural resident in Delhi where the risk factors identified were age more than 60 years, family history of diabetes and sedentary work.¹⁰ An another study by Tripathy et al, a large community based study in Punjab, in which family history and age group (45-69 years) were identified as a risk factor for diabetes.¹¹

In our study, the participants agreed for factor such as diabetes can occur who do not have family history, can affect athletes/sportsmen had a significantly raised blood sugar level compared to the participants who did not agree for the given factors. This finding is contrary to the study conducted by Adhikary et al and Tripathy et al where family history was identified as a risk factor for diabetes.^10,11

In current study, it was found that around 42.7% of participants had never undergone eye examination. About more than one third of study participants feels their vision is abnormal but on eye examination, more than 94% of them had normal vision, 3% had mild and 2.9% moderate vision impairment and 0.2% had severe impairment. This finding is almost similar to the National Blindness and Visual Impairment survey (2015-2019), in which mild visual impairment in all age groups were 2.9%, moderate were 1.84% and severe were 0.35%.¹² Our study was a community-based study for assessing the level of knowledge, attitudes and practices regarding effect of diabetes on eye. We also screened the participants for diabetes, hypertension and visual impairment, thereby initiating the treatment who are found to be confirmed with the disease. However, our study also has some limitations where the findings are reflective to the population at study and cannot be generalized. There are other variables or determinants which may determine the level of knowledge, attitude and belief which could not be assessed in this study.

CONCLUSION

Our study showed that majority of the study participants never underwent eye examination. Many participants also believed that diabetes mellitus may affect the eye and may lead to impaired vision. Majority of the participants had the knowledge of diabetes, risk factors associated with diabetes and complications. Therefore, primary prevention methods like awareness, health education, counselling may play a vital role in reducing the burden of eye diseases due to diabetes. It is also recommended that routine eye screening of people with diabetes mellitus may help in early identification of people who are at higher-risk of developing diabetic-related eye disease and help in early initiation of treatment.

Funding: No funding sources

Conflict of interest: None declared

Ethical approval: The study was approved by the Institutional Ethics Committee Ashwini Rural Medical College, Hospital and Research Centre, Kumbhari, Solapur

REFERENCES

1. 1. International Diabetes Federation- Facts and figures. Available from: https://www.idf.org/aboutdiabetes/what-is-diabetes/facts-figures.html. Accessed on 17 October 2020.
2. 2. Anjana RM, Deepa M, Pradeepa R, Mahanta J, Narain K, Das HK, et al. Prevalence of diabetes and prediabetes in 15 states of India: results from the ICMR–INDIAB population-based cross-sectional study. Lancet Diabetes Endocrinol. 2017;5(8):585-96.
3. 3. Sayin N. Ocular complications of diabetes mellitus. World J Diabetes. 2015;6(1):92.
4. 4. Deepa M, Bhansali A, Anjana R, Pradeepa R, Joshi S, Joshi P, et al. Knowledge and awareness of diabetes in urban and rural India: The Indian Council of Medical Research India Diabetes Study (Phase I): Indian Council of Medical Research India Diabetes 4. Indian J Endocrinol Metab. 2014;18(3):379-85.
5. 5. Tejaswi P, Dhakre S, Reddy P, Goyal C. Evaluation of the knowledge, attitudes and practices of diabetic patients in a tertiary care hospital in Central India. Int J Med Res Rev. 2018;6(01):24-32.
6. 6. Mohan V, Anjana M, Pradeepa R, Unnikrishnan R, Kaur T, Das AK. Burden of diabetes in India the ICMR INDIAB study- a compendium of type 2 diabetes in India: lessons learnt for the nation. Progr Med. 2017;1104.
7. 7. Kurian B, Qurieshi M, Ganesh R, Leelamoni K. A community-based study on knowledge of diabetes mellitus among adults in a rural population of Kerala. Int J Noncommun Dis. 2016;1(2):59.
8. 8. Deepa M, Bhansali A, Anjana R, Pradeepa R, Joshi S, Joshi P, et al. Knowledge and awareness of diabetes in urban and rural India: The Indian Council of Medical Research India Diabetes Study (Phase I): Indian Council of Medical Research India Diabetes 4. Indian J Endocrinol Metab. 2014;18(3):379-85.
9. 9. Babu MS, Gowdappa HB, Kalpana T, Vidyalaxmi K, Nikhil B, Chakravarthy T. Knowledge, Attitude and Practices of Diabetic Patients-A Cross Sectional Study in a Tertiary Care Hospital in Mysore. J Assoc Phys India. 2015;63(8):96.
10. 10. Adhikary M, Chellaiyan VG, Chowdhury R, Daral S, Taneja N, Das TK. Association of risk factors of type 2 diabetes mellitus and fasting blood glucose levels among residents of rural area of Delhi: a cross sectional study. Int J Community Med Public Health. 2017;4(4):1005.
11. 11. Tripathy JP, Thakur JS, Jeet G, Chawla S, Jain S, Pal A, et al. Prevalence and risk factors of diabetes in a large community-based study in North India: results from a STEPS survey in Punjab, India. Diabetol Metab Syndr. 2017;9(1):1-8.
12. 12. Desai A, Mehta P. Dr. Rajendra Prasad Centre for Ophthalmic Sciences, AIIMS (2020) National Blindness and Visual Impairment Survey India 2015-2019: A Summary Report. New Delhi. Open J Ophthalmol. 2021;11(4).