Diabetes Mellitus (DM) affects more than seven million adults in Pakistan (6.9% of the total population), and it is estimated that a further three million who have the disease remain undiagnosed. Diabetic Retinopathy (DR) is a complication of DM that affects the blood vessels of the retina in the eye. DR affects an estimated one third of all people with DM and it is the leading cause of avoidable blindness in the working age population worldwide.
DM and DR are chronic conditions that require long term care and which can only be effectively controlled when the affected individuals are aware of the conditions and follow best practices. Limited evidence is available about the Knowledge Attitudes and Practices (KAPs) relating to DM and DR among DM patients in Pakistan. However, studies from other countries in the region indicate that awareness of DR is limited to less than one third of the population.
Aims
The present study aims to investigate the KAPs relating to DM and DR among people with DM in Pakistan, with a view to design and implement a customized awareness campaign.
Methods
This study was carried out in the Matiari and Lahore districts of Pakistan. The targeted respondents of the survey were men and women aged 20 years or older who had DM at the time of data collection. A total of 783 participants were selected for the survey using a multi-stage random sampling technique and interviewed by the study team in their home.
Results
More than two thirds of respondents (68.3%) only became aware that they suffered from DM after experiencing symptoms; this was the case for a greater proportion of participants in Matairi (72.2%) than in Lahore (66.6%), however this difference was not statistically significant (p=0.085). Approximately one-third of respondents reported that they had been diagnosed with DR (31.2%).
The majority of patients (84.7%) were aware of DM symptoms, particularly those from Lahore (89.5%). The most common risk factors identified by respondents were diet and genetics (29.7% and 27.2%, respectively). Patients with a relatively high socioeconomic background (SEB) were more likely to report that diet is the main risk factor for the development of DM, compared with those with a relatively low SEB (32.5% cf 17.1%; p=0.014). On the other hand, respondents with a relatively low SEB were more likely to claim that DM is “a disease of rich people”, compared to respondents from relatively high SEB (59.4% cf 42.2%; p=0.007).
Most respondents were aware that uncontrolled DM can cause complications (88.1%), and approximately two thirds (68.2%) knew that DM can cause blindness. Fewer (22.4%), however, were aware of DR specifically. The most commonly reported symptoms of DR were eye pain (41.43) and blurred vision (35.4%). The most commonly reported risk factors for DR were the time since onset of diabetes (40.0%) and poor control of blood sugar level (35.4%).
Almost all respondents indicated that they receive treatment for DM regularly, (92.7%); with patients from Lahore spending almost double to manage their DM than those from Matiari (PKR4,859 cf. PKR2,191; p<0.001). Most of the male respondents independently decided to seek care for DM, while less than half of women reported that they could make this decision independently (85.6% cf. 45.3%; P<0.001). More than one-third of the respondents (36.7%) reported lack of adequate transport as a barrier to seeking care. Other common barriers were reported as financial issues (25.9%) by Matiari patients and distance (23.7%) by Lahore Patients.
The survey revealed that only 39.2% of patients had visited an ophthalmologist regularly. Many patients (41.4%) believed that they do not need eye check-ups if their vision is good. A significantly higher numbers of male patients were able to take this decision by themselves as compared to female (86/1% cf. 46.02; p<0.001).
Conclusion
Findings indicate that knowledge of DM and particularly DR among people with DM is limited. Our findings also suggest that there are geographical, socio-economic, and gender disparities across KAPs. Awareness raising campaigns and comprehensive interventions that focus on education should be tailored for different target groups and should focus on prevention as well as management of DM and DR.

Knowledge attitudes and practices relating to diabetes and diabetic retinopathy in Pakistan