Prevalence and determinants of comprehensive eye care in a group of patients with diabetes: a cross-sectional study in a sub-Saharan African setting
Jingi et al. BMC Res Notes
Prevalence and determinants of comprehensive eye care in a group of patients with diabetes: a cross-sectional study in a sub-Saharan African setting
Ahmadou M. Jingi 2
Jean Jacques Noubiap 0
Yannick Bilong 1
Aurel T. Tankeu 2
Côme Ebana Mvogo 1
0 Department of Medicine, Groote Schuur Hospital and University of Cape Town , 7925 Observatory, Cape Town , South Africa
1 Department of Ophthalmology, Faculty of Medicine and Biomedical Sciences , Yaounde , Cameroon
2 Department of Internal Medicine and Specialties, Faculty of Medicine and Biomedical Sciences , Yaounde , Cameroon
Objectives: We aimed to investigate the determinants of comprehensive eye examination in diabetes patients. We conducted a cross-sectional study at the eye department of the Douala General Hospital. Adult patients with diabetes were consecutively interviewed on the history of their diabetes. Main outcomes were a first ever comprehensive eye examination including fundoscopy, and diagnosis-to-fundoscopy time. Results: 52 patients were included of whom 59.6% were males with a mean age of 55.9 ± 10.9 years. 51.9% have had counselling on the risk of visual impairment and blindness due to diabetes, and 61.5% [95% CI 47-74.7] have had a comprehensive eye examination. Of those with a first ever fundoscopy, only 21.9% had the test performed within 1 year of diagnosis. Thus, after an average of 10 years of the diagnosis of diabetes, 13.5% (7/52) of patients have had a comprehensive eye examination within 1 year of diagnosis. Only dose with duration of diabetes of more than 10 years were 7-24 times more likely to have a comprehensive eye examination. In summary, patients with diabetes in this low-income setting do not receive a comprehensive eye care as recommended. Most patients will get an eye examination at least 10 years after the diagnosis of diabetes.
Diabetes; Eye; Fundoscopy; Sub-Saharan Africa
Diabetes has reached epidemic proportions with the
greatest burden on low-to-medium income settings [
where it is under-diagnosed, under-investigated, and
]. For, instance, it affects about 6.5% of
adults Cameroonians [
]. This high disease burden is
associated with low availability of investigation tests and
essential medicines for the management of diabetes [
This translates into high rates of vascular complications
which occurs early in the course of the disease [
which carries a high morbidity and mortality. Thus, after
6 years of diagnosis of diabetes in low-income settings,
about 40% of patients with type 2 diabetes have diabetic
retinopathy, of whom 15–17% have sight threatening
]. Prevention of diabetic retinopathy and
diabetes related blindness requires strict control of risk
factors, regular eye checks with timely laser therapy .
Most patients with diabetes in low-income settings are
first cared for by primary care physicians. There is
evidence of a gap in the diagnosis and management of
diabetes in low-income settings [
]. However, evidence on
the standard of care to prevent diabetes related
blindness, as well as the determinants of standard care are
lacking in low-income settings. We report on the
prevalence and determinants of comprehensive eye care in a
group of patients with diabetes in a sub-Saharan African
Study design and setting
This was a cross-sectional study in the eye department
of the Douala General Hospital between August and
September 2006. It is a tertiary centre in the economic
capital of Cameroon (a low-income setting located in
sub-Saharan Africa), with a catchment population of
over three million inhabitants. The eye department of
this hospital served as the reference centre for entire
Country and the sub region in terms of retinal
pathologies, and likely to receive patients from all walks of life.
Participants were adult patients aged ≥ 18 years, of
both sex having diabetes (type 1 or 2), who gave their
inform consent. Pregnant women were excluded.
Before the comprehensive eye examination, each
patient was interviewed using a standard questionnaire.
The questionnaire used in this study was designed
specifically for this study and was not pre-tested.
Information registered are presented in Additional file 1.
Patients then underwent a comprehensive eye
examination. Outcome: The main outcome was a first ever
comprehensive eye examination or at least a dilated fundus
examination. The secondary outcome was haven been
counseled on the risk of visual impairment and
blindness due to diabetes. Possible determinants of having
an eye examination were age, sex, residence, duration
of diabetes, health insurance, level of education,
sector of activity, treating physician, counseled on diabetes
complications, associated hypertension, difficulties to
reach the eye clinic, low visual acuity,
Sample size and power
With an estimated catchment population of three
million, an expected prevalence of diabetes to be 5.4 and
80% power, and an accepted error of 5%, the estimated
number of participants needed for the descriptive study
Data were analyzed using Epi-Info version 7. Baseline
characteristics are presented by sex. Continuous
variables are presented as mean ± standard deviation (SD),
and discrete variables as frequencies and percentages,
with their 95% confidence intervals. To calculate
potential determinants (unadjusted Odds) for the first ever
comprehensive eye examination, all variables were
categorized. Chi squared test or Fisher exact test was used
where appropriated to test for statistical significance.
A two-sided P < 0.05 was considered statistically
A total of 52 (67% of expected) patients were included in
the study, of whom 31 (59.6%) were males. Their mean
age was 55.9 ± 10.9 years, and ranged from 20 to 84 years.
Baseline characteristics are summarized in Table 1. Most
of the patients had type 2 diabetes (92.3%) that has been
evolving for about 10 years. Most patients had
secondary school level of education (38.5%) and lived in Douala
(69.2%). Only nine (17.3%) had health insurance. The
treating physician who referred the patient for eye
examination was a diabetologist in 53.9% of cases. Most of the
treating physicians also lived in Douala (73.1%).
The main outcome is summarized in Table 1. About
half of the patients (51.9%) have had counselling on the
risk of visual impairment and blindness due to diabetes,
and 32 (61.5%) have had a comprehensive eye
examination. Of those with a first ever fundoscopy, 7 (21.9%) had
the test performed within 1 year, and 25 (78.1%) had the
test performed after 1 year of diagnosis. Thus, after an
average of 10 years of the diagnosis of diabetes, 13.5%
(7/52) of patients have had a comprehensive eye
examination within 1 year of diagnosis. All fundoscopy was
performed by an ophthalmologist. The possible
determinants of a comprehensive eye examination are
summarized in Table 2. Only dose with diabetes duration of
more than 10 years were 7–24 times more likely to have
a comprehensive eye examination. Those who admitted
having no problem to seek comprehensive eye care were
less likely to have a fundoscopy done. The main
difficulties faced by patients in seeking eye care are summarized
in Fig. 1. This is mostly due to the cost of healthcare,
transportation, feeding and lodging. This was followed
by lack of physical assistance (often a relative) to the
This study aimed to determine the prevalence and
determinants of a comprehensive eye examination in a group
of patients with diabetes in Cameroon. About 60% of
the patients have had a comprehensive eye examination,
and only about a fifth of these had an eye examination
within the first year of diagnosis of diabetes. The
duration of diabetes (more than 10 years) was associated with
a 7–24 times more likely to have a comprehensive eye
Most of the patients who presented for screening and/
or treatment for sight threatening retinopathy were seen
by internists/diabetologists. Similar findings of the
likelihood of referral by internists were reported by several
]. Few general practitioners (who make up the
Data are mean ± standard deviation, level of significance set at p < 0.05
* Significant difference
bulk of the primary care physicians) refer patients with
diabetes for eye examination. Similar findings in several
studies showed that a significant number of primary care
physicians do not follow the recommended guidelines set
forth for diabetic eye care [
]. The findings suggest
that general practitioners in this low-income setting lack
awareness on the natural history of diabetic retinopathy,
and of the success of current treatment. A similar finding
was reported by Edwards .
The rate of awareness of the ocular complications of
diabetes is low in this group of patients (51.92%)
compared to that reported by Tapp et al. [
] in Australia,
who found that 90% of participants were aware that
diabetes was associated with visual impairment and
blindness. This could be due to the implementation of
Overall (N = 52)
education and awareness programs for diabetic
retinopathy, and developing the role of primary care providers in
screening for retinopathy in Australia [
]. This suggests
that existing education and awareness strategies be
reinforced with primary care providers occupying key role in
A high proportion of patients (78.13%) had their first
dilated fundus examination > 2 years after the diagnosis
of diabetes, a rate far higher than that reported by Tapp
et al. [
], who found 23%. We recommend the education
of non-ophthalmologist to detect and to appropriately
refer patients who are at risk for vision loss, as suggested
by Awh et al. [
Health insurance status was not related to the patients’
ability to afford for quality health care.
In summary, patients with diabetes in this low-income
setting in SSA do not receive a comprehensive eye care as
recommended. Most patients will get an eye examination
at least 10 years after the diagnosis of diabetes. The cause
of this sub-optimal care is probably multifactorial, from
lack of awareness on the part of the primary care
physicians, to high cost of healthcare and associated ill-health
on the part of the patients. Findings of this study revealed
that most of diabetes patients have an important delay in
eye examination. Considering the prevalence of this
disorder in our context and importance of eye examination
in detecting and diagnosis diabetes eye complications,
such delay is worrying and must addressed. This will first
required more studies with greater sample size which
can investigate both determinants and outcomes of
comprehensive eye examinations in order to find if there is a
relation between this delay in eye examination and
diabetes eye complications in these patients even. Considering
the fact that diabetes eye examination can progress
insidiously and given that eye examination is the only method
to detect or diagnose such condition, it seems obvious
that this delay in eye examination may influence
development of eye complication but this need to be assessed by
further studies. Also, measures must be taken to increase
awareness of general population, diabetes individuals and
general practitioners on the importance of having a
comprehensive eye examination as soon as diagnosis is made
or at least within 1 year as recommend.
Our findings should be interpreted in the light of the
limitations. The sample size was small (less than 80% of
expected), thus underpowered to detect statistically
significant risk for not having a comprehensive eye
examination. Also, this study was a specialist hospital based,
and does not represent the general population of patients
with diabetes. Thus, the proportion of those with eye
examination reported could be overestimates. Despite
these shortcomings, we provide baseline data for future
large scale and community research. Also, our data was
derived from patients so as to reduce reporting bias with
the physician approach. However, there is a high risk of
recall bias with this approach.
Additional file 1. Questionnaire.
SSA: sub Saharan Africa; WHO: World Health Organization.
Conception and design: CEM, AMJ. Data collection: CEM, AMJ. Data analysis
and interpretation: AMJ, JJN, YB. Drafting of manuscript: CEM, AMJ, JJN, ATT
and YB. JJN is the guarantor of this work. All authors read and approved the
We thank the patients for participating in this study. We also thank the
ophthalmic nurses of the eye department of the Douala General Hospital for
assisting with patient care.
The authors declare that they have no competing interests.
Availability of data and materials
The datasets generated and/or analyzed during the current study are available
from the corresponding author on reasonable request.
Consent for publication
Ethics approval and consent to participate
This study was performed in accordance with the guidelines of the
Helsinki Declaration and was approved by the Institutional Research Ethical
Committee of the Faculty of Medicine and Biomedical Sciences of Yaoundé
and by the institutional review board of the Yaoundé Central Hospital of
Cameroon. All participants provided written informed consent.
Springer Nature remains neutral with regard to jurisdictional claims in
published maps and institutional affiliations.
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