Sage Journals: Discover world-class research

Abstract

Diabetic retinopathy (DR) is a leading cause of blindness among people living with diabetes. Despite high diabetes prevalence in Bahrain, data on DR awareness remain limited. This cross-sectional study assessed the knowledge and awareness of DR among 676 participants who were undergoing fundus photography at 7 primary healthcare centers. A pretested self-administered questionnaire evaluated sociodemographics, knowledge, awareness, and sources of information. Medical records confirmed diabetes diagnoses and provided comorbidity and glycated hemoglobin test data. The mean knowledge score was 73.0% ± 16.7, with 449 participants (66.4%) scoring 70% or higher. About 82.1% participants were aware of diabetes-related vision loss, 85.9% were aware that diabetes can cause blindness, and 18.5% accurately identified DR. Higher education was significantly associated with greater knowledge (P < .001), with participants holding a bachelor's degree or higher showing the highest scores (78.4%) compared with those with no formal education (67.2%) or primary/intermediate education (65.8%). Higher knowledge was also associated with a longer diabetes duration (median 8 years; P = .026) and having a relative or friend with a diabetes-related eye disease (27.7% vs 15.4%; P < .05). The main sources of information were healthcare providers (66%) and the internet/social media (50%). The study revealed significant knowledge gaps, highlighting the need for targeted educational interventions. Programs tailored to diverse education levels and utilizing digital platforms can enhance awareness, support prevention and management efforts, and reduce the burden of DR in Bahrain.

Keywords

diabetic retinopathy patient awareness health literacy primary healthcare

Introduction

Diabetes mellitus (DM) is a chronic metabolic disorder and a major global health challenge, with its prevalence continuing to rise across all regions of the world.¹ In 2021, an estimated 529 million people worldwide were living with diabetes, which is projected to exceed 1.31 billion by 2050.¹ The prevalence of diabetes varies geographically, with the highest age-standardized rates in the Middle East and North Africa (MENA) region at 9.3%, compared to the global prevalence of 6.1%.¹ Bahrain reported one of the highest age-standardized diabetes rates at 15% in 2018.^1,2

Diabetic retinopathy (DR) is a common microvascular complication of diabetes caused by chronic hyperglycemia, which damages retinal vessels and triggers neuroinflammation.³ It progresses from asymptomatic nonproliferative stages to advanced proliferative stages, which marks the importance of early detection and intervention.³ Globally, the prevalence of DR and diabetic macular edema (DME) between 2015 and 2019 was estimated at 27.0% for any DR, including 25.2% nonproliferative DR, 1.4% proliferative DR, and 4.6% DME.⁴ DR is a leading cause of vision impairment among working-age adults worldwide.⁴ The MENA region reports a prevalence of DR of approximately 33.8%, among the highest globally.⁴

DR has been recognized as a major cause of visual disability in Bahrain. A population-based visual disability survey conducted by the Ministry of Health and the National Committee for the Prevention of Blindness in 1997 identified DR as one of the leading causes of blindness and visual impairment in the country, which accounts for approximately 6% of disability cases.⁵

To address this growing burden, Bahrain implemented its first telemedicine-based DR screening program in 2003 within primary care settings.⁵ Six screening units were established across all 5 governorates, each equipped with nonmydriatic digital fundus cameras operated by trained ophthalmic technicians. Single-field 45-degree fundus photographs of dilated eyes were captured and transmitted electronically to a central reading center, where ophthalmologists reviewed and graded the images. Between 2003 and 2009, 17 490 individuals with diabetes were screened; 20% were diagnosed with DR, and approximately 31% of those required treatment.⁵ This program demonstrated the feasibility and effectiveness of teleophthalmology in primary care and underscored the importance of expanding screening coverage through continued investment in digital health infrastructure and training.⁵

Gaps in knowledge of DR screening and referral among primary care physicians have been identified.⁶ This study aims to assess patient knowledge and awareness of DR during routine fundus photography screening, providing insights to guide educational strategies, promote early detection, reduce disease progression, and improve quality of life while lowering healthcare costs in Bahrain.

Methods

Study Setting

The study was conducted at 7 primary health centers across Bahrain's governorates. These included Al-Naim and Shaikh Sabah Al Salem (Capital), Hidd (Muharraq), Shaikh Jaber Al Ahmed Al Sabah and A’Ali (Northern), Yousif A. Rahman Engineer and Hamad Kanoo (Southern). They offered only vision testing, intraocular pressure measurement, and fundus photography based on camera specifications. None of the screening units provided full ophthalmic services.

Study Design

This cross-sectional study was conducted between August 2021 and March 2022. Participants were recruited using convenience sampling, with all eligible individuals attending diabetic fundus screening clinics at local health centers during the study period being invited to participate. Data on participants’ demographics, knowledge, and awareness of diabetic eye disease were collected through a structured survey questionnaire.

Inclusion and Exclusion Criteria

Bahraini residents aged 18 years or older scheduled for fundus photography at local health centers were eligible for participation. Exclusion criteria included individuals under 18 years of age, cognitive or communication impairments, and any condition deemed by the investigator to interfere with participation or the ability to provide informed consent.

Data Collection

Data were collected using the structured, researcher-administered questionnaire in the participant's preferred language while they waited for fundus photography, ensuring no disruption to care. The questionnaire included demographic details, 12 items on DR knowledge, sources of diabetes information, service feedback, and suggestions.

The questionnaire was first pretested on 20 diabetic participants attending a primary health center to assess clarity, language comprehension (Arabic and English), and completion time. Based on participant feedback, minor modifications were made to simplify the phrasing of 2 knowledge-related items and improve translation consistency. Pretest participants were excluded from the main study. The same optometrist conducted both the pretest and subsequent data collection.

For the main study, all participants provided written informed consent after a clear explanation of the study's purpose and procedures. Participation was voluntary, with no impact on care for those who declined. For participants with low literacy levels, the consent form was read aloud and signed.

Upon re-examining the completed questionnaires, 633 participants had used the Arabic version, and 43 participants had used the English version. Approximately 60% to 70% of participants completed the questionnaire independently, while 30% to 40% required it to be read aloud due to low literacy levels, visual difficulties, or for ease of answering.

Clinical data, including diabetes duration, comorbidities, and the most recent glycated hemoglobin (HbA1c) test levels, were extracted from electronic medical records to complement survey responses.

Data Management and Statistical Analysis

Data were analyzed using IBM SPSS Statistics (version 29, Armonk, NY, USA). Categorical variables were summarized using frequencies and percentages, while numerical variables were described using means and standard deviations for normally distributed data, and medians with interquartile ranges for skewed data. Normality was assessed through Q–Q plots and histograms. Knowledge-related responses and participant-reported experiences were summarized using frequency distributions with 95% confidence intervals. Responses regarding strategies to prevent DR and sources of information were presented as counts and percentages. An overall knowledge score was calculated as the percentage of correct responses, and the proportion of participants scoring ≥70% was determined. Associations between the knowledge score and participant variables were examined using independent t-tests (for binary categorical variables), 1-way analysis of variance (for variables with more than 2 categories), and Pearson's correlation (for continuous variables). The association between achieving a knowledge score of 70% or higher and other variables was assessed using a chi-square test. A P-value ≤.05 was considered statistically significant.

Results

Sociodemographic Characteristics

A total of 676 participants were included in the final analysis. The mean age was 56 years, ranging from 18 to 80 years. Males accounted for 55% of the study population, and the majority of participants were Bahraini (93%). About 44% had completed secondary education, while 31% held a university degree (bachelor's or higher) (see Table 1).

Table 1.

Sociodemographic Characteristics of the Participants.

Variable	Category	n (%)
Age (n = 668) in years	—	Mean ± SD: 55.96 ± 10.19 (range: 18-80)
Gender (n = 673)	Male	369 (54.8%)
	Female	304 (45.2%)
Nationality (n = 675)	Bahraini	629 (93.2%)
	Non-Bahraini	46 (6.8%)
Education (n = 573)	None	29 (5.1%)
	Primary or intermediate	112 (19.6%)
	Secondary or high school	254 (44.3%)
	Bachelor's degree or higher	178 (31.0%)

Clinical Characteristics and Diabetes Control

Medical records indicated that 38.9% of participants had hypertension, and 49.7% had hyperlipidemia (see Table 2). While 93% of participants self-reported having diabetes, the study population primarily comprised participants with type 2 DM (92.8%), with 3.3% participants with type 1 DM. Given this predominance, the findings and interpretations largely reflect type 2 diabetes, although both groups were included in the overall analysis. Notably, 50% of participants who did not believe they had diabetes were, in fact, medically diagnosed with it. Conversely, 3 participants who believed they were living with diabetes had no confirmed diagnosis. The median duration of diabetes was 8 years (range: 1-34 years), and 16.5% of participants had HbA1c on target (see Table 2).

Table 2.

Comorbidities and Diabetes-Related Variables of the Participants.

Variable	Category	Value
Comorbidities	Hypertension (n = 676)	263 (38.9%)
	Hyperlipidemia (n = 676)	336 (49.7%)
Diabetes status^a	Confirmed type 2 DM (n = 676)	627 (92.8%)
	Confirmed type 1 DM	22 (3.3%)
	Not diabetic	27 (4.0%)
Self-reported diabetes in the total population (n = 668)	Yes	624 (93.1%)
	No	46 (6.9%)
Self-reported diabetes in confirmed nondiabetics (n = 27)	Yes	3 (11.5%)
	No	23 (88.5%)
Diabetes status in self-reported nondiabetics (n = 46)	Confirmed not diabetic	23 (50.0%)
	Confirmed diabetic	23 (50.0%)
Duration of diabetes^b (n = 413)	Median (Q1-Q3)	8.00 (4.00-8.00) years
	Min-max	1-34 years
HbA1c levels^c (n = 650)	On target (<42 mmol/mol)	107 (16.5%)
	Not on target (≥42 mmol/mol)	543 (83.5%)

Abbreviations: DM, diabetes mellitus; HbA1c, glycated hemoglobin test.

Medical record diagnosis of diabetes was based on reviewing established record diagnosis, medication, and lab results.

Mean and standard deviations (SD) were 8.78 and 6.39 years, respectively

The HbA1c cut-off of <42 mmol/mol is based on the local Bahraini laboratory reference range under the Ministry of Health system, where values below 42 mmol/mol are considered within the normal or optimal range.

Knowledge and Awareness of DR

The mean overall knowledge score was 73.0 ± 16.7%, with 449 participants (66.4%) scoring 70% or higher. About 82.1% of participants reported being aware of the relationship between diabetes and eye health, and 85.9% knew that diabetes can cause blindness. However, only 18.5% said they actually knew what DR is. Additionally, 40% were not familiar with the HbA1c test. About 16% of participants reported experiencing diabetes-related eye problems, and around 30% knew a family member or friend who had eye problems due to DM (see Table 3).

Table 3.

Knowledge, Experiences, and Sources of Information About the Relationship Between Diabetes and the Eye and the Fundus Examination.

Question	Response	n (%)	95% CI
Q1. Do you think there is a relationship between diabetes and the eye? (n = 632)	Yes	519 (82.1%)	79.1%-85.1%
	No	113 (17.9%)	—
Q2. Do you suffer from any problems with your eyes because of diabetes? (n = 666)	Yes	105 (15.8%)	13.0%-18.5%
	No	561 (84.2%)	—
Q3. Do you know any member of your family or a friend who has eye problems due to diabetes? (n = 659)	Yes	197 (29.9%)	26.4%-33.4%
	No	462 (70.1%)	—
Q4. Do you think diabetes can lead to blindness? (n = 624)	Yes	536 (85.9%)	83.2%-88.6%
	No	88 (14.1%)	—
Q5. Do you know what the glycated hemoglobin (HbA1c) blood test is? (n = 636)	Yes	387 (60.85%)	57.1%-64.6%
	No	249 (39.15%)	—
Q6. Is it important to have fundus eye exams in symptom-free diabetic patients? (n = 667)	Yes	646 (96.2%)	95.5%-98.2%
	No	21 (3.2%)	—
Q7. Is a baseline fundus exam important at diabetes diagnosis? (n = 668)	Yes	647 (96.9%)	95.5%-98.2%
	No	21 (3.1%)	—
Q8. Should people living with diabetes have regular fundus examinations? (n = 669)	Yes	646 (96.6%)	95.2%-97.9%
	No	23 (3.4%)	—
Q9. Do you know what diabetic retinopathy is? (n = 650)	Yes	120 (18.5%)	15.4%-21.4%
	No	530 (81.5%)	—
Q10. Most important factor to reduce the chance/progression of diabetic retinopathy? (n = 640)	Taking medication regularly	17 (2.7%)	—
	Healthy lifestyle	111 (17.3%)	—
	Regular fundus exams	23 (3.6%)	—
	Medication + healthy lifestyle	16 (2.5%)	—
	Lifestyle + fundus exams	15 (2.3%)	—
	All of the above	446 (69.7%)	—
	None: no relation exists	12 (1.9%)	—
Q11. Main source of information about diabetes and complications?^a (n = 652)	Doctors and the health system	437 (67.0%)	—
	Newspapers and magazines	71 (10.9%)	—
	TV	51 (7.8%)	—
	Internet and social media	326 (50.0%)	—
	Other sources	34 (5.2%)	—

Abbreviation: CI, confidence interval.

Multiple answers are permitted.

Nearly all participants recognized the importance of fundus examinations: 96.9% believed it is essential at the time of diabetes diagnosis, 96.6% supported regular follow-up exams, and 96.2% agreed they are important even in the absence of symptoms or complaints (see Table 3).

When participants were asked about the most important factor in reducing the risk or progression of DR (n = 640), the majority (69.7%) selected “all of the above,” indicating a combination of medication, healthy lifestyle, and regular fundus exams. Individually, 17.3% chose a healthy lifestyle, 3.6% regular fundus exams, 2.7% taking medication regularly, 2.5% medication plus healthy lifestyle, and 2.3% lifestyle plus fundus exams. Only 1.9% believed that none of these measures were related to reducing the risk of DR. About two-thirds of participants reported the medical community as their primary source of information, while 50% cited the internet and social media as their main sources for learning about diabetes and its complications (see Table 3).

Determinants of Knowledge of DR, Diabetes Control, and Self-Reported Diabetes

Associations existing between participants’ variables and overall knowledge of DR, diabetes control, and self-reported diabetes were examined (see Table 4 and Table S1 in the Supplemental materials). Education level was significantly associated with knowledge scores (P < .001), with participants holding a bachelor's degree or higher scoring the highest (78.4 ± 15%) compared with those with no formal education (67.2 ± 13.9%) or primary/intermediate education (65.8 ± 19.3%).

Table 4.

Association Between Participants’ Variables and Overall Knowledge Score and Diabetes Control.

Variable	Overall Knowledge Score, % ± SD	P-Value	Diabetes Control, n (%)	P-Value
Age (years)
≤57	73 ± 16.6	.804^†	56 (16.8%)	.872
>57	73.4 ± 16.8	—	51 (16.3%)	—
Gender
Male	72.6 ± 17.5	.471	58 (16.4%)	.999
Female	73.6 ± 15.7	—	49 (16.6%)	—
Nationality
Bahraini	73.0 ± 16.6	—	105 (17.3%)	.035*
Non-Bahraini	73.4 ± 17.4	.895	2 (4.8%)	—
Education
None	67.2 ± 13.9	<.001*	5 (17.9%)	.546
Primary or intermediate	65.8 ± 19.3	<.001*	13 (11.8%)	—
Secondary or high school	73.6 ± 15.5	—	43 (17.5%)	—
Bachelor's degree or higher	78.4 ± 15	—	29 (17.3%)	—
Hypertension
Yes	74.4 ± 14.9	.184	45 (17.4%)	.999
No	68.8 ± 19.8	—	4 (17.4%)	—
Hyperlipidemia
Yes	74.5 ± 15.2	.015*	58 (17.4%)	.999
No	63.5 ± 18	—	1 (10.0%)	—
Source of knowledge^a
Medical community: Yes	73.9 ± 16.2	—	73 (17.3%)	.536
Medical community: No	72.8 ± 15.6	.413	32 (15.4%)	—
Newspaper: Yes	77.1 ± 14.3	—	14 (20.9%)	.329
Newspaper: No	73.1 ± 16.2	.049*	91 (16.2%)	—
TV: Yes	80.6 ± 13.5	.001*	11 (22.9%)	.229
TV: No	73.0 ± 16.1	—	94 (16.2%)	—
Internet and social media: Yes	76.4 ± 15.9	—	55 (17.4%)	.630
Internet and social media: No	70.7 ± 15.7	<.001*	50 (16.0%)	—
Family/friend with diabetic eye problems
Yes	77.4 ± 14.9	—	28 (15.1%)	.511
No	71.5 ± 16.9	<.001*	77 (17.2%)	—
Duration of diabetes
Knowledge score ≥70%	9.2 ± 6.6	.026*^§	HbA1c on target	7.7 ± 6.2
Knowledge score <70%	7.7 ± 5.9	—	HbA1c not on target	8.9 ± 6.5
People with HbA1c on target
Yes (<42 mmol/mol)	75.7 ± 14.6	.073	—	—
No (≥42 mmol/mol)	72.8 ± 17.0	—	—	—

Abbreviation: HbA1c: glycated hemoglobin test.

^aPatients could use more than 1 source of information.

*Significant differences at the 5% level between groups. ^†Pearson correlation coefficient R = 0.011; P-value = .778. ^§Pearson correlation coefficient R = 0.132; P-value = .007.

Participants with hyperlipidemia had higher knowledge scores (74.5 ± 15.2%) than those without (63.5 ± 18%, P = .015) (see Table 4).

Among sources of information, higher knowledge scores were observed in participants who reported obtaining information from newspapers (77.1 ± 14.3%, P = .049), TV (80.6 ± 13.5%, P = .001), and the internet/social media (76.4 ± 15.9%, P < .001). Additionally, participants without a family or friend affected by diabetic eye problems had lower knowledge scores (71.5 ± 16.9%) compared with those with affected relatives (77.4 ± 14.9%, P < .001) (see Table 4).

Diabetes duration was also associated with knowledge: participants with knowledge scores ≥70% had a longer duration of diabetes (9.2 ± 6.6 years) than those with scores <70% (7.7 ± 5.9 years, P = .026) (see Table 4).

Nationality was significantly associated with diabetes control, with Bahraini participants more likely to have HbA1c on target (17.3%) compared with non-Bahrainis (4.8%, P = .035) (see Table 4).

Participants who cited the medical community as a source of information were significantly more likely to report having diabetes (94.5%) compared with those who did not (90.1%, P = .022). A significant association was observed between glycemic control and self-reported diabetes status. Participants whose HbA1c was on target (<42 mmol/mol) were less likely to self-report having diabetes (85.0%) compared with those not on target (96.3%), and this difference was statistically significant (P < .001) (see Table S1 in the Supplemental materials).

Associations between specific knowledge questions and participants’ variables were also examined (see Table S2 in the Supplemental materials). Bahraini participants were more likely than non-Bahrainis to recognize that diabetes can lead to blindness (86.3% vs 71.4%, P < .05). Participants with hypertension or hyperlipidemia demonstrated higher knowledge in key areas, including the importance of regular fundus examinations (hypertension: 97.7% vs 87.5%, P < .05; hyperlipidemia: 97.6% vs 83.3%, P < .05) and the HbA1c test (hyperlipidemia: 60.1% vs 25.0%, P < .05).

Knowledge was also higher among participants who obtained information from newspapers (91.3% vs 81.9%, P < .05), TV (awareness of DR: 34.8% vs 17.2%, P < .05; prevention strategies: 85.4% vs 70%, P < .05), or internet/social media (relation between diabetes and eye: 87.1% vs 78.7%, P < .05; diabetes-related blindness: 89.7% vs 83%, P < .05; HbA1c test: 65.6% vs 55.7%, P < .05; DR: 23.6% vs 13.5%, P < .05; prevention strategies: 75.5% vs 66.9%, P < .05).

Participants with a family member or friend affected by diabetes-related eye problems had higher knowledge regarding the relation between diabetes and the eye (87.8% vs 79.9%, P < .05), HbA1c testing (69.5% vs 57.8%, P < .05), and DR (27.7% vs 15.4%, P < .05). Longer duration of diabetes was associated with the better understanding of HbA1c testing (9.0 ± 6.6 vs 7.3 ± 5.3 years, P < .05) and DR (10.7 ± 7.0 vs 8.1 ± 6.1 years, P < .05). Finally, participants with HbA1c level on target (HbA1c < 42 mmol/mol) were more likely to recognize the link between diabetes and the eye (87.5% vs 81.1%, P < .05), diabetes-related blindness (89.3% vs 85.1%, P < .05), and prevention strategies (77.2% vs 69.4%, P < .05).

Discussion

This study reveals a significant knowledge gap regarding DR in Bahrain among the participants. In this study, although most participants were aware that diabetes can affect vision, fewer than 1 in 5 could accurately identify DR. These findings align with previous studies demonstrating limited awareness of DR among people with diabetes,^7,9,10 even when general knowledge about diabetes-related eye complications is present.⁹ Similarly, research from Saudi Arabia by Alqahtani et al and Al-Yahya et al has also reported inadequate knowledge of DR.^8,11

Blindness from DR is largely preventable through early screening, timely treatment, and good glycemic control.¹² Systematic screening programs, such as those implemented in the United Kingdom, have significantly reduced diabetes-related vision loss,^13,14 demonstrating the effectiveness of organized screening initiatives. These findings underscore the importance of participant knowledge in enhancing screening uptake and facilitating timely intervention.

Efforts to improve screening rates must target both system-level barriers, such as the availability of trained primary care providers and eye care specialists, and participant-level challenges. Even where screening programs are accessible, attendance can remain suboptimal, and misinformation or limited awareness of the consequences of missed screening has been identified as a key barrier. Evidence from Almohsen et al in Bahrain,⁶ as well as from international studies,^15–18 highlights the combined impact of participant-level and system-level factors on DR screening uptake. A comprehensive, multipronged approach addressing both diabetes management and DR education is therefore essential to improve participant outcomes in Bahrain.

Higher education levels and specific sources of information, particularly the internet and social media, were associated with better knowledge about DR. Longer duration of DM and having a friend or family member affected by DR also positively influenced a participant's knowledge. These findings align with previous research demonstrating that higher formal education and targeted educational interventions are associated with the better knowledge of DR.^19–24 Incentives and barriers, participant-related factors (like lack of awareness or perceived need) and system-level factors (such as accessibility and reminders) significantly affect screening participation.¹⁹ Moreover, studies have shown that the internet and social-media platforms can serve as effective channels for participant education in diabetes.^25,26 Our findings, in combination with existing studies, further emphasize the role of ensuring health literacy and digital platforms in the dissemination of crucial health information.

Socio-demographic factors can also serve as barriers. A study in Saudi Arabia identified the absence of gender-specific screening professionals as a significant barrier to eye care for people living with diabetes.²⁷ Although regional and local data remain limited, evidence suggests that educational programs can improve participant knowledge and thereby promote more favorable attitudes, behaviors, and outcomes related to DR prevention.^28–30 Educational interventions and awareness campaigns must be evidence-based and well-regulated to ensure accurate information is delivered via trusted sources. Our findings indicate that half the participants relied on the internet and social media for information about diabetes and eye health, whereas those who consulted the medical community demonstrated greater awareness of their diagnosis. These results support educational campaigns tailored to diverse educational levels and delivered via trusted digital platforms with the support of the medical community to enhance DR knowledge in Bahrain.

It is important to recognize that screening is only 1 component of DR prevention and management. Screening should be accompanied by regular follow-up and evidence-based management of DR and associated risk factors. In our study, almost all participants acknowledged the importance of regular eye examinations, even in the absence of symptoms; however, nearly one-third (29%) were unaware that medication, a healthy lifestyle, and routine fundus examinations are all necessary for DR prevention. The development of DR is influenced by both nonmodifiable and modifiable risk factors. While diabetes duration cannot be altered, elevated HbA1c and the presence of complications such as diabetic nephropathy are major modifiable predictors of vision-threatening DR, which can be addressed through pharmacological and lifestyle interventions.³¹ Achieving tight glycemic control has been shown to reduce the risk of DR progression, as demonstrated in the UKPDS and ACCORD follow-up studies.^32,34 Similarly, reductions in blood pressure and lipid levels are associated with a decreased DR risk.^33,35 In our study, 16.5% of participants achieved the target glycemic control (HbA1c < 42 mmol/mol), underscoring significant gaps in diabetes management. These findings are consistent with regional data³⁶ and global trends outlined by the International Diabetes Federation.³⁷ Our findings also revealed gaps in participant knowledge extending beyond DR complications to diabetes diagnosis itself, as half of the participants with confirmed diabetes were unaware of their condition, while a few incorrectly believed they had diabetes. These observations underscore the pivotal role of healthcare providers in enhancing participant knowledge and outcomes.^38,39

Limitations

The present study is the first and the largest (676 total participants) attempt to assess the level of knowledge and awareness of DR among people living with diabetes in Bahrain who are presenting to their local health center for routine fundus (retina) photography screening. This study has a few limitations. A methodological limitation of this study is that participants’ knowledge of DR was assessed using a single open-ended item asking whether they were aware of DR, which may not have fully captured the depth of their understanding. This cross-sectional design limits the ability to infer causality between knowledge levels and participant characteristics. Reliance on self-reported data may introduce recall or response bias. Furthermore, participants were recruited from primary healthcare centers undergoing fundus photography screening, which may limit the generalizability of the findings to the broader diabetic population in Bahrain.

Conclusion

This study identified significant gaps in knowledge and awareness of DR among participants in Bahrain. Enhancing education is essential for effective prevention and management. Tailored interventions, including the use of digital platforms and trusted information sources, are recommended to address these gaps. Further research is needed to explore the determinants of DR and support targeted intervention strategies. More detailed or structured assessment tools are needed to address the methodological limitations of the current study.

Supplemental Material

sj-docx-1-jpx-10.1177_23743735261416361 - Supplemental material for Knowledge and Awareness of Diabetic Retinopathy Among Patients Undergoing Fundus (Retina) Photography Screening at Primary Healthcare Centers in Bahrain

Supplemental material, sj-docx-1-jpx-10.1177_23743735261416361 for Knowledge and Awareness of Diabetic Retinopathy Among Patients Undergoing Fundus (Retina) Photography Screening at Primary Healthcare Centers in Bahrain by Ahmed Alsatrawi, Sayed Mohamed Khalaf, Isa Alaradi and Hawra Abunaseeb in Journal of Patient Experience

Footnotes

Acknowledgments

The authors wish to thank Nancy Al Akkary, MSc, BSc, from Phoenix Clinical Research, for her support in the preparation of this manuscript. The authors also thank Ruqaya Hasan, BOptom, Optometrist, Sharif Albarqawi, Dip., Optometrist, and Ahmed Abdulla, Dip., Optometrist, from the Government Hospitals, Bahrain, for their contribution to data collection.

Ethical Considerations

Before data collection, this study was approved by the Primary Health Care Research Committee (2021) and the Secondary Health Research Committee (2021) under the Ministry of Health, Kingdom of Bahrain (Approval No. 51250321). The study followed relevant institutional and national ethical guidelines. An addendum approval (Approval No. 86-18072023) acknowledging Roche as a publication sponsor was obtained from the Research Ethics Committee, Government Hospitals, Kingdom of Bahrain.

Author Contributions

All authors were involved in methodology, analysis, supervision, data curation, review, and editing of the draft. In addition to the above, Dr. Ahmed Al Satrawi was also involved in the conceptualization and the funding acquisition.

Consent to Participate

Written informed consent was obtained from the participants for their anonymized responses to be published in this article.

Funding

The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: Roche provided an unrestricted research grant to support medical writing and publication charges. All authors contributed voluntarily and did not receive any form of payment. Roche did not influence the content of the manuscript or the decision to publish.

Declaration of Conflicting Interests

Roche provided an unrestricted research grant to support medical writing and publication charges. Roche did not influence the content of the manuscript or the decision to publish. No additional conflicts of interest were reported.

Data Availability

All relevant data are included within the article and its .

Supplemental Material

Supplemental material for this article is available online.

ORCID iD

Ahmed Alsatrawi

References

Ong

Stafford

McLaughlin

, et al. Global, regional, and national burden of diabetes from 1990 to 2021, with projections of prevalence to 2050: a systematic analysis for the global burden of disease study 2021. Lancet. 2023 Jul;402(10397):203‐34. Doi: 10.1016/S0140-6736(23)01301-6

Ministry of Health, Information & eGovernment Authority (iGA), World Health Organization. Bahrain National Health Survey 2018. Manama (BH): Ministry of Health; 2018.

Maluleke

Mahomed

A narrative review of the knowledge, attitudes, and practices of healthcare professionals toward diabetic retinopathy. Front Med (Lausanne). 2025 Aug 7;12:1536822. Doi: 10.3389/fmed.2025.1536822

Thomas

Halim

Gurudas

Sivaprasad

Owens

DR.

IDF diabetes atlas: a review of studies utilizing retinal photography on the global prevalence of diabetes related retinopathy between 2015 and 2018. Diabetes Res Clin Pract. 2019 Nov;157:107840. Doi: 10.1016/j.diabres.2019.107840.

Al Alawi

Ahmed

. Screening for diabetic retinopathy: the first telemedicine approach in a primary care setting in Bahrain. Middle East Afr J Ophthalmol. 2012 Jul 1;19(3):295‐8. Doi: 10.4103/0974-9233.97928

Almohsen

MAH

Khella

MMH

Alfayez

FN.

Diabetic retinopathy: knowledge, awareness, and practices in primary-care centers in the kingdom of Bahrain. J Family Med Prim Care. 2024 Mar;13(3):964‐70. Doi: 10.4103/jfmpc.jfmpc_1398_23.

Lian

McGhee

Gangwani

Lam

CLK

Yap

MKH

Wong

DSH.

Awareness of diabetic retinopathy and its association with attendance for systematic screening at the public primary care setting: a cross-sectional study in Hong Kong. BMJ Open. 2018 Apr 13;8(4):e019989. doi: 10.1136/bmjopen-2017-019989

Alqahtani

Alqarehi

Mulla

, et al. Knowledge, attitude, and practice regarding diabetic retinopathy screening and eye management among diabetics in Saudi Arabia. Cureus. 2023;15(9):e46190. doi: 10.7759/cureus.46190.

Mersha

Alimaw

Woredekal

Assaye

Zeleke

TC.

Awareness and knowledge of diabetic retinopathy in diabetic patients at a general hospital in northwest Ethiopia. SAGE Open Med. 2021 Jan 22;9:205031212110549. DOI: 10.1177/20503121211054994

10.

Lin

Ramulu

Lamoureux

Sabanayagam

Addressing risk factors, screening, and preventative treatment for diabetic retinopathy in developing countries: a review. Clin Exp Ophthalmol. 2016 May;44(4):300‐20. doi: 10.1111/ceo12745. PMID: 26991970.

11.

Al-Yahya

Alsulaiman

Almizel

Barri

Al Adel

Knowledge, attitude, and practices (KAP) of diabetics towards diabetes and diabetic retinopathy in Riyadh, Saudi Arabia: cross-sectional study. Clin Ophthalmol. 2020 Oct; 14:3187‐94. Doi: 10.2147/OPTH.S269524

12.

Hristova

Koseva

Zlatarova

Dokova

Diabetic retinopathy screening and registration in Europe—narrative review. Healthcare (Basel). 2021 Jun 17;9(6):745. doi: 10.3390/healthcare9060745. PMID: 34204591.

13.

Wong

Sabanayagam

Strategies to tackle the global burden of diabetic retinopathy: from epidemiology to artificial intelligence. Ophthalmologica. 2020;243(1):9‐20.

14.

Liew

Michaelides

Bunce

A comparison of the causes of blindness certifications in England and Wales in working age adults (16–64 years), 1999–2000, with 2009–2010. BMJ Open. 2014 Feb;4(2):e004015.

15.

Pandey

Morgan

Murphy

, et al. Irish National diabetic RetinaScreen programme: report on five rounds of retinopathy screening and screen-positive referrals. (INDEAR study report no. 1). Br J Ophthalmol. 2022 Mar;106(3):409‐14.

16.

Strutton

Du Chemin

Stratton

Forster

. System-level and patient-level explanations for non-attendance at diabetic retinopathy screening in Sutton and Merton (London, UK): a qualitative analysis of a service evaluation: Table 1. BMJ Open. 2016 May 18;6(5):e010952.

17.

Lake

Browne

Rees

Speight

What factors influence uptake of retinal screening among young adults with type 2 diabetes? A qualitative study informed by the theoretical domains framework. J Diabetes Complications. 2017 Jun;31(6):997‐1006.

18.

Hipwell

Sturt

Lindenmeyer

, et al. Attitudes, access and anguish: a qualitative interview study of staff and patients’ experiences of diabetic retinopathy screening. BMJ Open. 2014 Dec 15;4(12):e005498.

19.

van Eijk

KND

Blom

Gussekloo

Polak

BCP

Groeneveld

Diabetic retinopathy screening in patients with diabetes mellitus in primary care: incentives and barriers to screening attendance. Diabetes Res Clin Pract. 2012 Apr;96(1):10‐6. Doi: 10.1016/j.diabres.2011.11.003

20.

Jansen

Rademakers

Waverijn

Verheij

Osborne

Heijmans

The role of health literacy in explaining the association between educational attainment and the use of out-of-hours primary care services in chronically ill people: a survey study. BMC Health Serv Res. 2018 Dec 31;18(1):394. Doi: 10.1186/s12913-018-3197-4

21.

Raghupathi

The influence of education on health: an empirical assessment of OECD countries for the period 1995-2015. Arch Public Health. 2020 Apr 6;78:20. Doi: 10.1186/s13690-020-00402-5.

22.

Khalaf

Fahmy

Ibrahim

, et al.

Does a diabetic retinopathy educational program raise awareness among elderly diabetic patients?

Diabetes Metab Syndr Obes. 2019 Sep 20;12:1867‐75. doi: 10.2147/DMSO.S208072.

23.

AlHargan

AlBaker

AlFadhel

AlGhamdi

AlMuammar

AlDawood

HA.

Awareness, knowledge, and practices related to diabetic retinopathy among diabetic patients in primary healthcare centers at Riyadh, Saudi Arabia. J Family Med Prim Care. 2019 Feb;8(2):373‐7. doi: 10.4103/jfmpc.jfmpc_422_18.

24.

Almalki

Alswat

Diabetic retinopathy knowledge and awareness assessment among the type 2 diabetics. Open Access Maced J Med Sci. 2018 Mar 9;6(3):574‐7. doi: 10.3889/oamjms.2018.121.

25.

Thomas

Alabraba

Barnard

, et al. Use of social media as a platform for education and support for people with diabetes during a global pandemic. J Diabetes Sci Technol. 2021;17(2):353‐63. doi:10.1177/19322968211054862

26.

Safdari

Nejat

Abolfathi

Mehrabi

Rafiei

Effect of social media-based education on self-care status, health literacy, and glycated hemoglobin in patients with type 2 diabetes. Front Public Health. 2025 Jan 20;13:1507726. doi: 10.3389/fpubh.2025.1507726.

27.

Al-Alawi

Al-Hassan

Chauhan

Al-Futais

Khandekar

. Knowledge, attitude, and perception of barriers for eye care among diabetic persons registered at employee health department of a tertiary eye hospital of central Saudi Arabia. Middle East Afr J Ophthalmol. 2016 Jan-Mar;23(1):71‐4. doi: 10.4103/0974-9233.164629.

28.

Hosseini

Shamsi

Khorsandi

Moradzadeh

The effect of an educational program based on the theory of planned behavior on promoting retinopathy preventive behaviors in patients with type 2 diabetes: RCT. BMC Endocr Disord. 2021 Jan 14;21(1):17. doi: 10.1186/s12902-021-00680-2.

29.

Khalaf

Fahmy

Ibrahim

, et al.

Does a diabetic retinopathy educational program raise awareness among elderly diabetic patients?

Diabetes Metab Syndr Obes. 2019 Sep 20;12:1867‐75. doi: 10.2147/DMSO.S208072.

30.

Alharbi

AMD

Alhazmi

AMS.

Prevalence, risk factors, and patient awareness of diabetic retinopathy in Saudi Arabia: a review of the literature. Cureus. 2020 Dec 9;12(12):e11991. doi: 10.7759/cureus.11991.

31.

Yan

Chen

, et al. Prevalence and predictors of developing vision-threatening diabetic retinopathy within the first three years of type 2 diabetes. Front Endocrinol (Lausanne). 2023 Dec 20;14:1305378. Doi: 10.3389/fendo.2023.1305378.

32.

Hemmingsen

Lund

Gluud

, et al. Intensive glycaemic control for patients with type 2 diabetes: systematic review with meta-analysis and trial sequential analysis of randomised clinical trials. Br Med J. 2011 Nov 24;343:d6898. Doi: 10.1136/bmj.d6898.

33.

Wang

Zhang

, et al. Effects of RAS inhibitors on diabetic retinopathy: a systematic review and meta-analysis. Lancet Diabetes Endocrinol. 2015 Apr;3(4):263‐74. doi: 10.1016/S2213-8587(14)70256-6. Epub 2015 Feb 6. Erratum in: Lancet Diabetes Endocrinol. 2015 Apr;3(4):e3. PMID: 25660574.

34.

Action to Control Cardiovascular Risk in Diabetes Follow-On (ACCORDION) Eye Study Group and the Action to Control Cardiovascular Risk in Diabetes Follow-On (ACCORDION) Study Group. Persistent effects of intensive glycemic control on retinopathy in type 2 diabetes in the action to control cardiovascular risk in diabetes (ACCORD) follow-on study. Diabetes Care. 2016 Jul;39(7):1089‐100. Doi: 10.2337/dc16-0024.

35.

Shi

Zhao

Wang

, et al. Effects of lipid-lowering agents on diabetic retinopathy: a meta-analysis and systematic review. Int J Ophthalmol. 2018 Feb 18;11(2):287‐95. doi: 10.18240/ijo.2018.02.18.

36.

Alrasheedi

AA.

Glycaemic control among adults with type 2 diabetes mellitus in the gulf cooperation council countries: an updated review. Endokrynol Pol. 2024;75(2):159‐69. doi: 10.5603/ep.99519.

37.

International Diabetes Foundation. Diabetes Atlas. 10th ed. (Internet). 2021. https://www.diabetesatlas.org/data/en/country/174/sa.html

38.

Sharkiya

Quality communication can improve patient-centred health outcomes among older patients: a rapid review. BMC Health Serv Res 2023;23, 886. 10.1186/s12913-023-09869-8

39.

Liu

Ansari

Debo

Iravani

SMR

. Survey on patient–provider communication in healthcare systems: an operational perspective. IISE Trans Healthcare Syst Eng. 2024;15(1), 73‐95. 10.1080/24725579.2024.2415100

Supplementary Material

Please find the following supplemental material available below.

For Open Access articles published under a Creative Commons License, all supplemental material carries the same license as the article it is associated with.

For non-Open Access articles published, all supplemental material carries a non-exclusive license, and permission requests for re-use of supplemental material or any part of supplemental material shall be sent directly to the copyright owner as specified in the copyright notice associated with the article.

0.00 MB

0.03 MB