Diabetic Retinopathy (DR), a severe microvascular complication of diabetes mellitus, poses a significant threat to global eye health. The intricate connection between diabetes and vision loss underscores the critical importance of understanding, awareness, and proactive management strategies. As we set our gaze on Himachal Pradesh, a region characterized by its unique cultural diversity and demographic nuances, there is a compelling need to unravel the existing knowledge gaps and cultivate awareness regarding Diabetic Retinopathy.

Globally, studies such as those conducted by Yau et al. [1] emphasize the escalating prevalence of Diabetic Retinopathy and its potential to cause irreversible vision impairment. The silent progression of this condition, particularly in its early stages, underscores the urgency of fostering awareness and advocating for preventive measures, notably blood sugar control. The significance of early detection and intervention in mitigating the burden sociocultural landscape of Himachal Pradesh is essential, of Diabetic Retinopathy has been extensively discussed by organizations such as the American Diabetes Association (ADA) and the International Council of Ophthalmology (ICO)[2-3].

In the Indian context, where the burden of diabetes is substantial, studies like the Chennai Urban Rural Epidemiology Study (CURES) shed light on the prevalence of diabetic complications, including retinopathy [4]. However, there is a notable dearth of comprehensive studies focusing on awareness levels and knowledge specific to Diabetic Retinopathy in the northern region, particularly in Himachal Pradesh.

The impact of Diabetic Retinopathy extends beyond individual health, affecting families and communities. The study by Rani et al. [5] emphasizes the role of public awareness campaigns, routine eye check-ups, and strict glycemic control in preventing and managing Diabetic Retinopathy. Adapting these strategies to the unique given its diverse population and geographical variations.

Against this backdrop, this research aims not only to gauge the current levels of awareness about Diabetic Retinopathy but also to understand the factors influencing knowledge gaps. By unraveling the layers of perception, educational needs, and cultural nuances specific to Himachal Pradesh, the study aspires to lay the groundwork for targeted awareness initiatives and community-based programs promoting blood sugar control.

As we embark on this journey to uncover the state of Diabetic Retinopathy awareness in Himachal Pradesh, the ultimate goal is to contribute not only to the academic understanding of eye health in the region but also to catalyze a positive change in the community's approach towards proactive diabetes management. "Navigating Diabetic Retinopathy Awareness" envisions a future where knowledge empowers individuals, fostering a community that values the significance of blood sugar control in preserving vision and preventing the onset of diabetic complications.

Objectives of the Study

The objective of this study is to gauge the levels of awareness and knowledge about Diabetic Retinopathy and the importance of blood sugar control among the general population of Himachal Pradesh

• Research Approach: Descriptive

• Research Design: Cross-sectional survey design

• Study area:  Himachal Pradesh

• Study duration- between August 2023 to November 2023

• Study population: The study's target population encompassed all adults aged 18 and above who had been residents of Himachal Pradesh for a minimum of 12 months

• Sample size: A robust sample size of 400 adults was determined using a 95% confidence level, an estimated knowledge level of 50% regarding Diabetic Retinopathy, a precise 5% absolute error margin, and a conservative 5% non-response rate. 

• Study tool: A google form questionnaire consisting of questions regarding socio-demography and knowledge regarding Diabetic Retinopathy was created. The questionnaire was initially pre-tested on a small number of participants to identify any difficulty in understanding by the respondents. 

Description of Tool

• Demographic data survey instrument: The demographic form elicited information on participants’ background: age, marital status, religion, employment, education and many more.

• Questionnaire: The questionnaire contains 20 structured knowledge related questions regarding Diabetic Retinopathy . One mark was given for each correct answer and zero for incorrect answer. The maximum score was 20 and minimum score was zero. Scoring was done on the basis of marks as >80%(16-20)=very good,60-79%(12-15) =Good,41-59% ( 8-11)=Fair,<40% (< 8)=poor

• Validity of tool: by the experts in this field

• Data collection: Data was collected under the guidance of supervisors. The google form questionnaire was circulated among the residents of Himachal Pradesh for responses using online modes like e-mail and social media platforms like Whatsapp groups, Facebook, Instagram and Linkedin till the 400 responses were collected. 

• Data analysis: Data was collected and entered in Microsoft excel spread sheet, cleaned for errors and analyzed with Epi Info V7 Software with appropriate statistical test in terms of frequencies and percentage. 

• Ethical Considerations: Participants confidentiality and anonymity was maintained.

The primary objective of this study was to gauge the understanding of Diabetic Retinopathy among the general population of Himachal Pradesh. A total of 400 participants took part in the study, with 272 (68%) residing in rural areas and 128 (32%) in urban areas (Table : 1).

In the present study 25.5% (102)  participants had very good knowledge (16-20 marks) towards Diabetic Retinopathy, 31.5% (126) had good knowledge (12-15 marks), 24.5% (98) had fair knowledge  (8-11 marks) and 18.5% (74) having poor knowledge  (<8 marks)(Table : 2).

The findings of this study provide insightful perspectives into the current levels of awareness and knowledge about Diabetic Retinopathy (DR) among the diverse population of Himachal Pradesh. The results depict a spectrum of understanding, with 25.5% of participants demonstrating very good knowledge, 31.5% exhibiting good knowledge, 24.5% possessing fair knowledge, and 18.5% having poor knowledge regarding Diabetic Retinopathy and the importance of blood sugar control.

The prevalence and impact of Diabetic Retinopathy resonate with global concerns highlighted by Yau et al. [1]. The escalating prevalence of DR globally emphasizes the imperative for increased awareness and preventive measures. National studies, such as the Chennai Urban Rural Epidemiology Study (CURES) by Rema et al. [4], contribute to the broader context of DR awareness in India. Additionally, studies like the Aravind Comprehensive Eye Survey [6] shed light on the prevalence of diabetic complications in different regions of the country.

Our study underscores regional variations in DR awareness within India, particularly in the northern region of Himachal Pradesh. While studies like CURES shed light on the prevalence in southern states, there is a  distinct  lack  of  comprehensive  studies focusing on awareness levels in Himachal Pradesh. This highlights the need for more localized research. Moreover, the Gujarat Diabetic Retinopathy Study (GDRS) [7] and the Rajasthan Eye Disease Study [8] offer insights into regional variations and awareness levels in different parts of India.

Table 1 : Knowledge regarding Diabetic Retinopathy among Study Participants

Table 2: Knowledge Scores Towards Diabetic Retinopathy among Study Participants

An exploration of sociodemographic factors, including residence, age, and education, could reveal correlations with higher levels of awareness. Studies like the Andhra Pradesh Eye Disease Study [9] have shown the influence of these factors on awareness levels and could guide targeted interventions in Himachal Pradesh. Additionally, studies like the Kerala Urban Rural Gap in Diabetes and Eye Study [9] and the Sankara Nethralaya Diabetic Retinopathy Epidemiology and Molecular Genetics Study [7] provide valuable information on sociodemographic factors influencing DR awareness in specific regions.

Aligning with the recommendations of Rani et al. [5], our study emphasizes the importance of tailoring public awareness campaigns to the unique sociocultural landscape of Himachal Pradesh. Regional variations necessitate customized strategies to effectively disseminate information and promote preventive measures, especially blood sugar control. Insights from the Karnataka Rural Eye Study [10] further support the need for community-specific strategies.

Insights from the study highlight the need for community-based programs focusing on diabetes management. Integrating lessons from studies like the Hyderabad Diabetic Retinopathy Study [5] and the Pune Urban Rural Epidemiology Study [11] can enhance the effectiveness of these programs. Given the high prevalence of diabetes in India, holistic approaches that address not only DR but also broader diabetes management are essential.

The positive correlation between knowledge about DR and the importance of regular eye examinations echoes findings from studies like the India Glaucoma Management Survey [12]. Emphasizing this link becomes pivotal in preventing late-stage diagnoses and aligns with the recommendations for routine eye check-ups by Rani et al. [5].

The study reveals variations in knowledge levels between rural and urban residents, with 68% residing in rural areas. This distinction underscores the need for targeted educational initiatives, particularly in rural settings. Strategies should consider the unique challenges and accessibility issues prevalent in these areas, drawing insights from studies like the Rajasthan Eye Disease Study [8].

The open-ended question in the questionnaire, garnering responses from 48.25% of participants, provides qualitative insights into community perspectives. Analyzing these responses, coupled with findings from local studies, can guide the formulation of community-specific strategies to enhance DR awareness.

In conclusion, this study contributes not only to the academic understanding of Diabetic Retinopathy awareness in Himachal Pradesh but also provides a foundation for targeted community interventions. Recognizing regional variations and addressing sociodemographic influencers on knowledge levels are crucial in developing effective strategies for promoting both DR awareness and broader diabetes management in the diverse population of Himachal Pradesh.

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4. International Council of Ophthalmology. ICO guidelines for diabetic eye care. 2017, https://www.icoph.org/downloads/ICOGuidelinesforDiabeticEyeCare.pdf.

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