Diabetic eye disease, notably diabetic retinopathy, is a pressing public health concern in India, where the surging prevalence of diabetes is driving a rise in vision-threatening complications. In Himachal Pradesh, a predominantly rural state in northern India, the challenge of diabetic retinopathy is intensified by limited access to specialized eye care, widespread unawareness of its risks, and insufficient screening practices. Shimla, the state’s capital and a healthcare hub for both urban and rural populations, grapples with unique barriers due to its mountainous terrain, which hampers access to services, and an increasing diabetic population influenced by shifting lifestyles. Regular eye check-ups are vital for early detection and prevention of vision loss from diabetic retinopathy, yet public knowledge of this necessity remains largely unexplored, potentially leading to avoidable blindness in the region [1-5].

The socio-cultural and geographic landscape of Shimla significantly shapes attitudes toward diabetic eye disease prevention. Rural communities, who often seek healthcare in Shimla, frequently lack understanding of diabetes-related eye complications, mistaking vision changes for inevitable aging or benign consequences of diabetes. Misconceptions, such as assuming eye damage occurs only in severe diabetes or that screening is unnecessary without noticeable symptoms, contribute to low screening participation. Urban residents, despite better access to healthcare facilities, may overlook regular check-ups due to busy schedules, financial concerns, or inadequate awareness. National studies emphasize that low awareness of diabetic retinopathy and the critical role of preventive screening is a major obstacle to early intervention, with rural populations particularly disadvantaged due to scarce eye care services and limited health education resources [6-10].

Efforts to address diabetic eye disease in India, including public awareness campaigns and the integration of eye screening into diabetes care programs, have shown mixed success, with their impact in Shimla’s distinct urban-rural interface and high-altitude environment remaining poorly studied. The city’s diverse demographic, bridging rural and urban populations, provides a unique opportunity to investigate variations in awareness of diabetic retinopathy risks and the importance of regular eye check-ups. Understanding these factors is essential for developing targeted interventions to enhance screening uptake and reduce vision loss. This study aims to evaluate public awareness of diabetic eye disease and the necessity of regular eye check-ups in Shimla, with a focus on addressing knowledge gaps and overcoming barriers to preventive care in this hilly region.

Study Design

A descriptive, cross-sectional online survey was conducted to assess public awareness of diabetic eye disease, particularly diabetic retinopathy, the importance of regular eye check-ups, preventive screening practices, and perceived barriers among adults in Shimla, Himachal Pradesh.

Study Area and Population

The study targeted adults aged 18–60 years residing in or accessing healthcare in Shimla, encompassing both urban and rural populations. Eligible participants were proficient in Hindi or English, had access to internet-enabled devices (smartphones, tablets, or computers), and provided voluntary informed consent.

Study Duration

Data collection was conducted over two months, from January to February 2025.

Sample Size and Sampling Technique

Assuming a 50% awareness level of diabetic eye disease (due to limited prior data), with a 95% confidence interval and a 5% margin of error, the minimum required sample size was calculated as 384. To account for potential incomplete responses, a target of 420 completed responses was set. Convenience sampling was utilized, with the survey link distributed via social media platforms (WhatsApp, Facebook, Instagram) and community networks, including local health clinics, diabetes support groups, and Gram Panchayats.

Inclusion and Exclusion Criteria

Inclusion Criteria

Adults aged 18–60 years, residing in or accessing healthcare in Shimla, proficient in Hindi or English, with internet access, and willing to provide electronic consent.

Exclusion Criteria

Individuals diagnosed with diabetic retinopathy under active treatment, those employed in eye care or public health agencies, those unable to complete the questionnaire, or unwilling to participate.

Data Collection Instrument

A structured, pre-validated bilingual (Hindi and English) questionnaire was developed and hosted on Google Forms. The questionnaire comprised four sections:

• Socio-Demographic Information: Age, gender, education, occupation, marital status, and access to eye care services.

• Knowledge of Diabetic Eye Disease: Awareness of diabetic retinopathy, its causes, symptoms, and potential complications.

• Awareness and Practice of Eye Check-ups: Understanding of the role, frequency, and benefits of regular eye screening for diabetes management.

• Barriers to Preventive Screening: Logistical, cultural, psychological, and informational obstacles.

The questionnaire was pilot-tested among 25 adults (excluded from final analysis) to ensure clarity, cultural appropriateness, and technical functionality. Adjustments were made based on feedback.

Data Collection Procedure

Participants accessed an information sheet outlining study objectives, confidentiality, and voluntary participation. Informed electronic consent was mandatory before accessing the questionnaire. Google Forms settings prevented duplicate submissions, and no personally identifiable data were collected to ensure anonymity.

Scoring and Categorization

Knowledge-based questions were scored with one point per correct answer. Knowledge levels were categorized as:

• Very Good Awareness:              ≥80% correct answers

• Good Awareness:                        60–79% correct answers

• Fair Awareness:                                          40–59% correct answers

• Poor Awareness:                         <40% correct answers

Attitudes and barriers were analyzed separately to identify prevailing perceptions and obstacles.

Data Analysis

Data were exported from Google Forms to Microsoft Excel and analyzed using IBM SPSS Statistics version 27.0. Descriptive statistics (frequencies, percentages, means, standard deviations) summarized participant characteristics, knowledge levels, attitudes, and barriers.

Ethical Considerations

The study adhered to ethical guidelines, ensuring participant autonomy, confidentiality, and voluntary participation per the Declaration of Helsinki. 

The results offer a detailed overview of the socio-demographic profile, knowledge, attitudes, and barriers related to diabetic eye disease and the importance of regular eye check-ups among 420 participants in Shimla. 

The data reveal a moderate level of awareness, with significant gaps that underscore the urgent need for targeted educational and screening interventions to prevent vision loss from diabetic retinopathy in this hilly region.

Table 1 delineates the socio-demographic profile of the 420 participants, reflecting a diverse representation of age, gender, education, occupation, marital status, and access to eye care services. The predominance of young to middle-aged adults and a notable rural segment, with 32.4% reporting limited access to eye care services, highlights the study’s focus on addressing diabetic eye disease challenges in Shimla’s urban-rural interface.

Table 1: Socio-Demographic Characteristics of Participants

Table 2 presents responses to 20 new, comprehensive questions assessing knowledge of diabetic retinopathy, its causes, symptoms, preventive screening, and barriers, distinct from the previous version. Crafted to capture a broad spectrum of diabetic eye disease literacy, the questions include correct answers in bold, highlighting moderate awareness but critical gaps in understanding screening protocols and risk factors, vital for preventing vision loss.

Table 2: Awareness and Attitudes Toward Diabetic Eye Disease and Regular Eye Check-ups

Table 3 categorizes participants’ knowledge levels based on their performance on the 20 knowledge-based questions, illustrating a range of awareness. While the majority exhibited good awareness, the notable proportion with Fair or Poor awareness signals an urgent need for enhanced education on diabetic eye disease to promote preventive screening in Shimla.

Table 3: Knowledge Score Classification

This study provides a critical examination of public awareness of diabetic eye disease and the necessity of regular eye check-ups in Shimla, offering valuable insights into the knowledge, attitudes, and barriers that shape preventive eye care in a region with a unique urban-rural interface and high-altitude environment. The findings reveal a moderate level of diabetic eye disease literacy, with 80.0% of participants correctly recognizing that eye screenings can identify diabetic retinopathy before symptoms appear and 81.9% understanding that vision loss from retinopathy is not always immediate. High awareness of timely intervention halting retinopathy progression (83.3%) and fear of diagnosis as a barrier to check-ups (85.0%) suggests that public health campaigns and diabetes care programs have made inroads into Shimla’s diverse communities. The strong recognition of symptoms like difficulty reading (73.6%) and the role of ophthalmologists in screenings (80.0%) further indicates a baseline understanding of diabetic eye disease prevention, reflecting the gradual impact of health education efforts in Himachal Pradesh.

Despite these positive trends, significant knowledge gaps and attitudinal barriers highlight the challenges of promoting preventive eye care in Shimla’s hilly terrain. Only 60.0% of participants correctly identified the annual frequency for diabetic eye exams, and awareness of the asymptomatic progression of diabetic eye disease (63.8%) and the preventive role of proper diabetes management (61.7%) was suboptimal. These gaps are particularly concerning, as they may lead to delayed screening, increasing the risk of irreversible vision loss from diabetic retinopathy, a condition exacerbated by prolonged high blood sugar (74.8% awareness) and risk factors like obesity (65.7%) and high cholesterol (67.6%). The moderate awareness of smoking as a risk factor (73.8%) aligns with findings from national studies, which underscore low diabetic eye disease literacy as a barrier to early intervention, particularly in rural areas with limited access to specialized care. This suggests a broader regional challenge in translating general awareness into specific, actionable screening behaviors.

The socio-demographic profile, with 72.8% of participants aged 18–35 and 32.4% reporting limited access to eye care services, underscores both opportunities and systemic constraints. The younger cohort, likely more engaged with digital platforms, represents an ideal target for awareness campaigns, as evidenced by the study’s effective use of social media for recruitment. However, the significant proportion with limited access reflects logistical barriers, such as geographic isolation in Shimla’s mountainous terrain and the scarcity of eye care facilities, which align with similar access challenges noted in the emergency health (32.7%) and NCD (31.9%) studies. These findings suggest a shared regional issue of reaching underserved rural populations. The high recognition of dietary changes (73.6%) and retinal photography (73.6%) as preventive measures indicates some understanding of management strategies, but their adoption may be hindered by cultural misconceptions, such as equating vision changes with aging, and practical barriers like cost and distance.

The knowledge score classification reveals a notable divide in diabetic eye disease literacy: while 46.2% demonstrated "Good" awareness and 27.6% achieved "Very Good" awareness, a concerning 26.2% fell into the "Fair" or "Poor" categories. This subgroup is at heightened risk of undiagnosed or untreated retinopathy, perpetuating the burden of preventable blindness in Shimla, particularly among rural communities with limited access to care. The online survey methodology, while effective in reaching a diverse sample, may have favored more educated and digitally connected individuals, potentially underrepresenting rural populations with lower literacy or no internet access, a limitation consistent across the previous studies. Social desirability bias may have influenced responses, particularly on questions about screening intentions or awareness, leading to an overestimation of knowledge. These limitations suggest caution in generalizing the findings to the entire population of Shimla.

The implications of these findings are significant for diabetic eye disease policy and practice in Shimla. The moderate awareness levels indicate that existing campaigns have established a foundation, but they must be intensified and tailored to address specific gaps, such as annual screening protocols and asymptomatic disease risks. Community-based interventions, leveraging local health clinics and Gram Panchayats, could enhance outreach in rural areas, while diabetes support groups could target urban populations. Integrating eye screenings into primary healthcare and subsidizing costs are critical to addressing the 32.4% with limited access, particularly in remote areas. Digital platforms offer a promising avenue for education, though efforts must ensure inclusivity for those without internet access. Future research should explore longitudinal trends in diabetic eye disease awareness and evaluate the impact of targeted interventions in reducing vision loss in Shimla’s urban-rural interface.

This study illuminates the complex landscape of diabetic eye disease awareness in Shimla, revealing moderate knowledge of diabetic retinopathy risks and the importance of regular eye check-ups, alongside critical gaps and barriers that hinder preventive screening, particularly in rural communities. While encouraging recognition of early detection, intervention benefits, and barriers like fear of diagnosis exists, deficiencies in understanding annual screening frequency, asymptomatic disease progression, and specific risk factors, coupled with limited eye care access for 32.4% of participants, underscore the urgent need for comprehensive interventions. To prevent vision loss, multi-faceted strategies are essential, including targeted educational campaigns, integrated eye screenings, community-based outreach, and inclusive digital initiatives, ensuring that Shimla’s residents have a “clear vision ahead” through timely and accessible preventive care.

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