This observational study was conducted in the Department of Ophthalmology at a tertiary care hospital in central India. Approval from the local Ethics Committee/Institutional Review Board (EC/IRB), All India Institute of Medical Sciences, Bhopal, India was obtained. The study adhered to the tenets of declaration of Helsinki.

The cases with DM attending ophthalmology OPD for DR screening during the period August 2014 to April 2015 were evaluated for inclusion in the study. Patients undergoing screening for the first time and willing to participate in the study were enrolled. Cases that were already diagnosed with DR or had undergone some intervention for DR were excluded from the study. Cases were subjected to a questionnaire as given in [Table/Fig-1]. The questionnaire was designed based on the review of literature done on previous studies published in the same domain [10-14]. The face validity of the questionnaire was established by a group of 6 ophthalmologists from three tertiary care institutes. The questionnaire included questions as mentioned in [Table/Fig-1] was pilot tested amongst 30 patients, who had proficiency in English language, and revised in accordance with the findings of the pilot study. The questionnaire was self-administered to patients having knowledge of either English or Hindi. The answers were taken in yes or no. According to the response by the study subjects, the following observations were made. Cases who replied positively to question number two to four were included in group I.

Demographic data was collected including age, sex, literacy level and SEC. The SEC of the participants was determined according to modified Kuppuswamy’s scale based on three variables: education, occupation of the head of the family, and per capita income per month [5]. Detailed history of the disease such as onset, type, family history of diabetes and duration of DM was noted. All cases were under treatment for DM and majority was on oral hypoglycaemic agents. Cases were asked about the source of information about DR. A comprehensive examination of the eye was done including retinal screening. The cases were then divided into two groups; Group-I included those who were aware about DR and group-II those who were unaware about DR. Various factors were then compared between these two groups using appropriate statistical analysis.

The data was recorded on a predesigned proforma and managed on a spreadsheet (Excel; Microsoft Corp, Redmond, WA). Qualitative data were compared by Chi-square and Fischer-exact test and quantitative data was compared by ANOVA one-way test. Non-parametric tests were applied wherever the sample size was less. A p≤0.05 were considered statistically significant.

A total 458 patients were screened for DR, out of which 330 were undergoing screening for the first time. The mean age of the study group was 52.8±11.3 years (26 to 78 years) with 54.5% (180) male cases. Most of the cases 95.8% (316) were suffering from type II DM. The mean duration of DM was 6.5 years. [Table/Fig-1] shows the awareness level about various aspects of DR amongst the study subjects, along with the questionnaire.

[Table/Fig-2] shows number of cases in Group I and Group II according to gender, literacy, SEC, type of diabetes, duration of diabetes, referral rate by PCP and presence of DR. Overall 68.5% (226) of cases were aware about DR. When both the groups were compared, it was found that the awareness was more in male patients (p<0.001), patients with positive family history of DM (p<0.001), patients with higher educational qualification (p<0.001) and higher SEC (p<0.001) [Table/Fig-2].

The type and duration of DM had no significant association with awareness of DR (p=0.351 and p=0.06 respectively). At the time of screening DR was present in 3.5% (8) of cases belonging to Group I and 13.5% (14) of the cases in Group II had DR, this difference in the two groups was statistically significant (p<0.001). The rate of referral by the first contact physician for routine DR screening was 21.2% (70). The source of information about DR for most of the cases in our study was print media (newspaper). In Group I, 23.5% (53) patients were aware that strict blood sugar control can prevent the visual impairment due to DR and only 11.5% (26) knew that early intervention (laser photocoagulation) can prevent the progression of vision loss. None of the cases were aware about intra-vitreal anti vascular endothelial growth factors (Anti-VEGF) as a treatment modality of DR.

Prevention is better than cure. This age old teaching requires some degree of awareness among the general population about the concerned disease. The current study evaluated the awareness of DR among a population cohort from central India. In the present study, the awareness about DR among the patients of DM was poor. The type and duration of DM had no significant association with the level of awareness of DR. Awareness was more in male patients and those with positive family history, higher educational qualification and higher SEC.

There is evidence that DR begins to develop years before the clinical diagnosis of DM and is present in seven per cent of newly diagnosed subjects [11]. The prevalence of DR in south India has been reported to be 17.6%, significantly lower than age-matched western counterparts [11,12]. In the present study 3.5% cases among group I and 13.5% among group II were found to have DR. The sample size and composition in the current study may not be representative of entire population, thus it is difficult to calculate the prevalence of DR from the above data. The difference in group-I and II in this study can be attributed to a better glycaemic control in Group-I.

In the present study 68.5% of the cases were aware about the sight threatening complication of DR. As per Dasbach EJ et al., the compliance for the screening program should be more than 80% for maximum gain [14]. Thus although good number of cases were aware but still there is a scope for betterment. The major factors associated with poor awareness in the present study were female gender, SEC and lack of education. Thus, appropriate measures must be taken to improve these factors. Previous studies have also emphasized over these factors [14-16]. Although, Raman R et al., in their study found that the difference in SEC did not influence the occurrence of DR the result of our study suggests this is important.

The role of ophthalmologist starts once PCP refers the patient. The PCP is often the first contact of DM patients to the health care services. In the present study only 21.2% of the cases were advised for DR screening by the PCP. Majority of the patients are not referred probably due to the negligence on the part of PCP. This clearly highlights the need for the sensitisation of PCPs to encourage the DM patients for routine DR screening. Ensuring a regular interaction between the ophthalmologist and the PCP by means of organising seminars and conferences will help to improve the practice pattern of PCP. In addition in countries like India the SEC and literacy of people often influences the choice of first contact physician. At times the first contact physician may not be trained enough, or may not be well aware of the recent advances in the field of DR and its prevention. Thus the training of physicians as well as improving the health infrastructure so that it reaches to every patient in the lower SEC is an important step in reducing the burden of blindness in India. Also, the tools to spread the awareness about DR should be such that even illiterates can understand the message clearly. Vashist P et al., proposed the concept of opportunistic screening of DR [9]. Patients with DM may visit the ophthalmologists for other eye care needs. They also visit physicians for medical needs. These patients visiting the health care providers for other problems may be screened for DR [9]. Not only the ophthalmologist but the PCP must be aware of the concept of opportunistic screening.

In the present study the source of information about DR was print media in most of the cases, thus other channel for spreading awareness like audio visual media should also be utilized for spreading awareness as used for other diseases like polio, TB, malaria etc. This highlights the room for improvement in DR prevention through increasing awareness and screening. Thus the approach to reduce the prevalence of DR not only lies upon the health care providers but also the government must try improvement in this field.

The major limitations of this study is that it is a single center based study and includes patients of only one geographical area hence the sample may not represent the entire population. Prevalence of DM is increasing thus the sample size may be small to draw any conclusive results. Further population based multicentric studies with large number of subjects will be more conclusive.

The outcome of this study helps us to pinpoint the factors which lead to poor awareness, so that targeted interventions can be formulated for increasing the awareness by modifying these factors. It highlights one of the important grey areas that is poor practice pattern of PCP. Improvement of the practice pattern of the PCP to increase the referral rate of DM cases for DR screening can improve the awareness level significantly. In present era of digital media, every effort must be made for the inclusion of all forms of mass communication along with improvement in the educational status and SEC for better prevention of DR. Lastly a coordinated approach by PCP and ophthalmologist is vital.