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ORIGINAL ARTICLE
Year : 2020  |  Volume : 9  |  Issue : 2  |  Page : 152-159

Primary care physicians' knowledge, attitudes, and practices related to diabetic retinopathy in Buraidah city, Qassim region, Saudi Arabia


Department of Ophthalmology, Unaizah College of Medicine, Qassim University, Buraydah, Saudi Arabia

Date of Submission31-May-2020
Date of Acceptance03-Jun-2020
Date of Web Publication21-Jul-2020

Correspondence Address:
Abdulrahman Abdullah Alasqah
Department of Ophthalmology, Unaizah College of Medicine, Qassim University, P.O. Box 4471 Unaizah 51911
Saudi Arabia
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/sjhs.sjhs_46_20

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  Abstract 


Background: Diabetic retinopathy (DR) is one of the severe complications of diabetes that can result in complete blindness when it presents late in the course of the disease. The role of primary care physicians (PCPs) in the screening, prevention, and possibly referral of patients with this complication is of great importance. Materials and Methods: An analytic cross-sectional study was conducted in all primary care clinics in Buraidah city, Qassim region, Saudi Arabia. The sampling technique used is convenience sampling. The sample is PCPs (PCPs). Data were collected using a pretested, semi-structured questionnaire with sections for assessment of knowledge, attitudes, and practices toward DR in the PCPs. Results: Out of a total of 106 physicians, 100 have answered the questionnaire with a response rate of 94%, 75% have received postgraduate training. Eighty-seven percent of the PCPs have agreed that an ophthalmoscope is needed in their clinic while only (35%) have agreed that they can do an ophthalmoscopic examination confidently to detect DR in patients with diabetes. Around 23% have disagreed that diabetic patients can have DR despite having a good vision, and only 56% have agreed that pregnancy can actually worsen DR. Conclusions: The knowledge, attitudes, and practices of PCPs are sub-optimal. Dilated Fundus Examination using a slit-lamp ophthalmoscope is the best technique used in the screening of DR. Primary care centers should be equipped with more technologically advanced ophthalmic devices, and tele-screening should be utilized to precisely diagnose DR. Moreover, the communication with and referral to ophthalmology should be done on findings that are suggestive of DR. PCPs should stress the importance of screening to their diabetic patients. Finally, more efforts should be placed to increase knowledge in certain areas like DR effects in pregnant patients.

Keywords: Awareness, diabetic retinopathy, primary care


How to cite this article:
Alasqah AA, Aldosari FI, Almutaz AI. Primary care physicians' knowledge, attitudes, and practices related to diabetic retinopathy in Buraidah city, Qassim region, Saudi Arabia. Saudi J Health Sci 2020;9:152-9

How to cite this URL:
Alasqah AA, Aldosari FI, Almutaz AI. Primary care physicians' knowledge, attitudes, and practices related to diabetic retinopathy in Buraidah city, Qassim region, Saudi Arabia. Saudi J Health Sci [serial online] 2020 [cited 2020 Oct 26];9:152-9. Available from: https://www.saudijhealthsci.org/text.asp?2020/9/2/152/290319




  Introduction Top


Diabetes is one of the most common diseases worldwide, affecting >400 million adults. In Saudi Arabia, the prevalence of diabetes is reported to be one of the highest worldwide. In fact, it is estimated that by 2022, the prevalence of diabetes in 25 years and older Saudi adults is 47%. As a result, an epidemic control program/multidisciplinary approach is needed to be adapted and applied widely because of the estimation of rising health burden due to diabetes mellitus to a catastrophic level. DR is one of the most serious complications of diabetes. It is estimated to be the most common cause of loss of vision in adults of working age and accounts for considerable work disability. It is thus the role of primary care physicians (PCPs) to screen and prevent the possible visual losing complication of diabetes. Furthermore, their role affects the quality of care, which is the center for future improvements addressed in the 2030 vision of the Ministry of Health (MOH) in Saudi Arabia.[1],[2],[3],[4],[5],[6],[7],[8]

DR develops in almost all patients with type 1 diabetes mellitus and around 60% of type 2 diabetes patients during the first 20 years of the onset of the disease.[9] Its prevalence among diabetic patients in Saudi Arabia is reported in one study to be at 31.3% in one center in Riyadh region, Saudi Arabia. In a more recent study, which was conducted in the same region but which has excluded the capital itself and which has included larger sample size, has demonstrated a prevalence of 45% in patients aged 40 years or older.[6],[7] Similarly, a similar study, which was conducted in Al Taif and included patients aged 50 years or older, has demonstrated a prevalence of 36.8%.[10] Other studies conducted in other regions in Saudi Arabia have also demonstrated similar numbers regarding the prevalence of DR in the Saudi population including Abha, AlHassa, and Al Madinah regions which have a prevalence of 36.4%, 30%, and 36.1%, respectively.[11],[12],[13]

Because of the progression rate of the disease that can be rapid and for the possible beneficial effects of therapy for both symptom reduction and amelioration, the importance of regular screening of DR, therefore, cannot be overemphasized. It is, therefore, a crucial role of PCP, who has a central role in managing diabetic patients and in screening for this severe complication.[14]

We have conducted this study due to the lack of data in the literature regarding the knowledge, attitudes, and practices of PCPs toward DR in Buraidah city, Qassim region, Saudi Arabia.


  Materials and Methods Top


This is a quantitative observational analytical cross-sectional study conducted on January 25, to February 20, 2020, and it is approved by the regional research committee of the MOH (1441-1-83441) in the Qassim region, Saudi Arabia. Written consent was obtained from each participant.

The study was conducted on all primary care clinics of the MOH in Buraidah city, Qassim region, Saudi Arabia. The total number of primary care centers in this city is 44. The study participants are samples of primary care physicians. The number of participants is calculated using data obtained from the MOH and calculated using the web-based calculator. The total sample size calculated is 106 to achieve a 95% confidence interval with a 5% margin of error. Out of 106 physicians who have received the questionnaire, about 100 physicians have answered all of the items, with a response rate of 94%. The sampling technique used is convenience sampling.

Data were collected using a pretested, semi-structured, previously validated questionnaire. It was adapted from another study in the literature.[4] It is written in English and consists of four sections with items pertaining to the demographic data, knowledge, attitudes, and practices toward DR in the primary care physicians at Buraidah city, Qassim region, Saudi Arabia. The section of demographic data has 13 items, which included both open as wells as close-ended questions. The section of knowledge included 12 statements, where the section of practices has included 11 statements. Finally, the section of attitudes included nine statements. The data were entered and analyzed using the Statistical Package for the Social Sciences (SPSS) version 25 (IBM Corporation, Armonk, NY, USA) for data analysis and presentation. The Chi-square test for the association is used for qualitative data, and (t) Student's test is used for comparing quantitative data. P < 0.05 was considered statistically significant.


  Results Top


Characteristics of the participants

A total of 101 PCPs have participated in this study. More than half of them (52.5%) have practiced in primary care for >10 years, while about a third (33.7%) have practice between 5 and 10 years. Most physicians (74.3%) that have participated have received postgraduate training, whereas 25% did not have postgraduate training. Other demographic data are summarized in [Table 1].
Table 1: Demographic data of the participants (n=100)

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Knowledge of the physicians toward diabetic retinopathy

The majority of the physicians (95%) have agreed that in Saudi Arabia, the prevalence of diabetes is high, while around a fourth of them (26%) have agreed that DR is not related to the duration of diabetes. Around (35%) of the physicians have disagreed with the statement that diabetics can have advanced diabetic retinopathy (DR) despite having a good vision. Other responses are summarized in [Table 2].
Table 2: Knowledge of the physicians

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Practices of the physicians toward diabetic retinopathy

Most of the physicians (95%) agreed that diabetic patients should be asked for their vision on every visit to the primary care clinic. About 87% agreed that ophthalmoscopes are needed in their clinic, while only 35% of them have agreed that they can do an ophthalmoscope confidently in the retinal exam. Other responses are represented in [Table 3].
Table 3: Practices of the physician

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Attitudes of the physicians toward diabetic retinopathy

Almost all of the physicians (96%) have disagreed that an eye examination is needed only when the vision is affected. Most (91%) have also disagreed that an eye examination is needed only at 5 years interval in newly diagnosed patients with diabetes. While the majority (63%) have agreed that laser treatment can prevent blinding complications of DR, (37%) have disagreed. Most of the physicians (98%) agreed that general practitioners or diabetologists should be periodically retrained in the management of diabetes mellitus, and the vast majority (94%) have agreed that all general practitioners or primary physicians need to have a re-training in the eye examination for DR. Other responses are summarized in [Table 4].
Table 4: Attitudes of the physicians

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Knowledge and practices of physicians who had a course in diabetic retinopathy versus physicians who did not

Most of the physicians (69%) who did not take a course in the DR have agreed that diabetics can have advanced DR despite having a good vision, with a statistically significant difference between those who did take a course in DR and those who did not (P < 0.05). The majority of PCPs (93.1%) who did not take a course in DR have also disagreed with the statement that serum lipid profile is not related to the severity of diabetic maculopathy, with a statistically significant difference between the two groups (P < 0.05). Half of the PCPs who did not have a course in DR (50.6%) have agreed that pregnancy can worsen the course of DR, with a statistically significant difference between the two groups (P < 0.05). The vast majority (79%) of PCPs who did not take a course in DR have agreed that an ophthalmoscope is needed in their clinic, with a statistically significant difference between the two groups (P < 0.05). Other findings are summarized in [Table 5] and do not yield statistical significance between the two groups.
Table 5: Knowledge and practices of physicians who had a course in diabetic retinopathy versus physicians who did not

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  Discussion Top


DR is one of the severe complications that diabetic patients can develop over time. This can present asymptomatically only to evolve into an advanced stage in which complete blindness may occur causing severe disability and an increase in morbidity in patients with diabetes that constitute a large percentage of the Saudi population.[3] The role of PCP in the screening, education and referral for higher centers to prevent this, therefore, is of great importance.

To address this issue, this study was done to provide an assessment of the knowledge, attitudes, and practices of the primary care physicians towards this complication in Buraidah which has most of the primary care clinics in Al Qassim region which is considered to be one of the largest regions in Saudi Arabia. This, in combination with other studies in other regions, can provide a good representative sample for the primary care practice in Saudi Arabia regarding DR knowledge, attitudes, and practices and can also provide a basis in which interventions implemented to improve the quality of primary care in the region can be established.

In our study, most of the participants (75%) have received postgraduate training; hence, the age group of 35–45 has constituted around half (48%) of the study sample. 36% of the study sample are those who are not specialized yet (general practitioners) whereas more than half of the study sample (51%) were specialized in family medicine. In addition, more than half of the participants (52%) have practiced in primary care for >10 years. For this reason, the results of this study do not show a statistical difference in many aspects of knowledge and attitudes in PCPs who has done a course in DR versus PCPs who did not receive such course. Most of the physicians who did not have a course in DR did recognize that serum lipid profile is related to the severity of DR with statistical significance between the two groups (P < 0.05). Most of them, however, did not appreciate the fact that patients with DR can present with a good vision with statistical significance between the two groups (P < 0.05). This shows the lack of knowledge in critical areas that can truly affect the patient care since such early presentations can be missed easily. In a similar study done in AlTaif region by Al Ghamdi et al. which has a larger sample size (180) and more physicians who practice as general practitioners than those who are specialized in any specialty and who also has a short duration of practice which is in contrast to our study, has revealed that the knowledge of the prevalence of DR in KSA and the awareness of its diagnosis and management is adequate, our study has yielded similar compatible results with similar numbers.[4]

Most of the PCPs in our study have agreed that an ophthalmoscope is needed in their clinic (87%). However, only (35%) have agreed that they can actually do an ophthalmoscopic examination confidently to detect DR in patients with diabetes, and only (38%) have agreed that they do it routinely in patients with diabetes. Furthermore, nearly one-third of the physicians (29%) have disagreed that an ophthalmoscope can be used to diagnose DR. In the study done in AlTaif region by Al Ghamdi, Rabiu, Al Qurashi et al., around (75%) of the physicians have said that they have an ophthalmoscope in their clinic, however, only (43.9%) can confidently do retinal examintion to find DR with an ophthalmoscope. Most of the physicians (69.4%) in that study have also said that they do an ophthalmoscopic exam routinely for diabetic patients. These results suggest the need to equip all primary care clinics with ophthalmoscopes, which is widely used in the primary care clinics in Al Qassim region.[15] Its use, nonetheless, is limited by the inexperience of the PCPs and by the magnification effect as well as the limited field of view.[16] Therefore, a dilated fundus examination (DFE) by a slit-lamp ophthalmoscope is recommended by the American Diabetes Association and the American Academy of Ophthalmology for accurate screening for DR in patients with diabetes.[17],[18] However, the current practice of primary care clinics in this region is limited by the lack of trained staff and a DFE may not be a feasible option for the majority of the patients.[15] As a result, more technologically advanced, sophisticated devices used to diagnose DR (e.g., optical coherence tomography [OCT], Fundus Camera) should be implemented in primary care centers in the region and tele-screening should be utilized to improve the quality of care even further.[19] The screening interval should be done according to the guidelines of the American Academy of Ophthalmology, the American Diabetes Association and the American College of Physicians.[17],[18] Furthermore, PCPs should stress the importance of regular screening and should educate their patients about DR and other microvascular complications related to diabetes as the data from the literature has showed that the most significant factor which could improve adherence to the screening guidelines is when it is recommended to the patients by their physician.[20] PCPs should also be encouraged to refer patients with findings suggestive of DR to higher centers and to have efficient communication with the ophthalmologists when addressing these issues. In addition, other simple tools like the Snellen chart can also be utilized to test for the visual acuity in diabetic patients.

Although the PCPs are mainly responsible for the follow-up, management and screening of pregnant patients with diabetes, only (56%) have agreed that pregnancy can worsen the course of DR. This comes in accordance with another study conducted in Riyadh region, Saudi Arabia, by Raghad Al-Rasheeda and Al Adel in which around one-third of the physicians have recognized pregnancy as a risk factor for the development of DR.[21]

In a study conducted in the AlQassim region by Al-Rashidi et al. have shown a lack of appropriate skills needed to do a fundoscopic exam in the general practitioners.[15] The study by Raghad Al Rasheeda and Fadwa Al Adel, which is done in the Riyadh region also supports these findings.[21] In another study conducted in Khartum, Sudan by Elnagieb and Saleem, in which the sample was obtained from physicians working in the hospitals and who are divided into those who are general practitioners (32%) and those who are residents in medicine (68%), has revealed that most of the study participants showed poor knowledge with regard to the findings on retinal examination that hints toward DR which implies poor ability to diagnose diabetic patients for DR and is in accordance with the results of the current study.[22] This does further imply the need for a hands-on training course for PCPs to address this issue and to improve the quality of care provided to diabetic patients in primary care clinics.

The limitations of this study are the need for a much larger scale study with an assessment of the skills of the PCPs to diagnose DR in all primary care clinics in the region. In addition, a comparison between the knowledge and practice of physicians who practiced in the general hospitals and those who work in private health centers were not assessed.


  Conclusions Top


The knowledge, attitudes, and practices of PCPs are sub-optimal. DFE using a slit-lamp ophthalmoscope is the best technique used in the screening of DR. Primary care centers should be equipped with more technologically advanced ophthalmic devices such as OCT and Fundus Camera, and tele-screening should be utilized to precisely diagnose DR. Moreover, the communication with and referral to ophthalmology should be done upon findings that are suggestive of DR. Primary care physicians should stress the importance of screening to their diabetic patients. Finally, more efforts should be placed to increase knowledge in certain areas like DR effects in pregnant patients.

Acknowledgment

We thank Dr. Ali Mansour for his valuable contribution to the data analysis.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



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



 

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