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Background: Diabetes is a highly prevalent chronic disease and Bahrain is ranked amongst the top ten. Diabetes has many complications. Retinopathy caused by diabetes if considered number one leading cause of blindness world wild. This study explore the factors influencing the uptake of the Digital Retinopathy Screening Programs (DRGP). Methods: Five of the Primary Care centers in the country providing the (DRSP) have been visited on daily basis for two weeks in row and patients attending for the test have been questioned, defaulters were called and questioned through the phone for the causes. Results: A total of 367 type II DM patients were enrolled in the study with a (42.5%) are within the age range of 50-59. 75.2 % of the sample attended for the screening and were questioned and the remaining non attendees were questioned through the phone. A Comparison between the characteristics and reasons behind attendance and non attendance amongst the two groups was conducted statistically by SPSS using Chi Sequare test and Fisher’s exact test. Results using P-Value showed that the major reasons for non attending the appointments are forgetting the appointment, ignorance, neglect, some special circumstances like sickness or travel and miscommunication between patients and staff or physicians. While on the other hand, reminders and physician recommendations have show to be of a positive influence over patients’ attendance. Conclusion: It is quiet essential to work on strategies that decrease the percentage of defaulters and improve the uptake of an important screening program such as the DRSP. Reminder systems, Improvement of the communications between patients and health care provider and increasing physicians’ recommendations to enhance patients’ awareness are all modifiable factors that can influence best on improving such service. Copyright @ 2019: This is an open-access article distributed under the terms of the Creative Commons Attribution license which permits unrestricted use, distribution, and reproduction in any medium for non-commercial use (NonCommercial, or CC-BY-NC) provided the original author and source are credited. INTRODUCTION The prevalence of Diabetes Mellitus (DM) for all age-groups worldwide was estimated to be 2.8% in 2000 and 4.4% in 2030. The total number of people with diabetes is projected to rise from 171 million in 2000 to 366 million in 2030 [1]. DM is highly prevalent among both sexes in member states of the WHO Eastern Mediterranean Region. Its prevalence in these countries ranges from 3.5% to 30% [2]. The prevalence of Type 2 DM was reported as 30% among the Bahraini population in 1998 [3]. in 2007, around 14.3% of the population in Bahrain suffers from DM with prevalence ranking 5 compared to other countries worldwide [4]. Diabetic retinopathy (DR) is one of the main complications of diabetes accounting for approximately 5% of all blindness globally [5]. In Bahrain, a cross sectional survey in 1997 found that DR is responsible for 6% of the cases of visual disability [6]. The practical guidelines for management of diabetes in Bahrain recommends annual screening for diabetic retinopathy starting from the time of diagnosis for type 2 Diabetic patients [7]. A local study done in 2007 to report the results of Bahrain DR screening program found that 25.3% of the patients had nonproliferative diabetic retinopathy and 1% had proliferative retinopathy changes [8]. Although diabetic retinopathy screening (DRS) programs are available in Bahrain, there are still diabetic patients who are not receiving any form of such a screening. Patients who do not attend diabetic eye screening were found to have increased risk of developing sight-threatening diabetic retinopathy [9]. Afaf Abdulmonem Ali et al; Saudi J Med Pharm Sci, Nov. 2019; 5(11): 956-960 © 2019 |Published by Scholars Middle East Publishers, Dubai, United Arab Emirates 957 This study is conducted to explore the factors influencing the attendance of adult patients with type II DM for retinopathy screening in order to identify the characteristics of the attendees and non-attendees. The aim is to develop strategies that improve the uptake of the screening program and hence early detection and possible management to prevent blindness. METHODS Digital Retinopathy screening (DRS) program in Bahrain is freely available in most Primary Care Center, covering the five governorates of Bahrain. There are twenty four primary health centers; one of which in each governorate receives the referrals to the DRS. Diabetic patients undergo this examination annually and they can either be referred from the general clinic or the diabetic clinic with intraocular pressure (IOP) measurements and vision documented in the referral paper. Appointments are then given for patients. On Each day, the appointment Lists are printed and patients who attend are interviewed. (IOP + Vision) are being measured while other Laboratory data are obtained from the laboratory computer system. A cross-sectional study was conducted in which characteristics of attendees and none attendees were compared. For those non attendees, contact numbers were traced from the registry computer system and patients received a phone call from a researcher to inquire about the causes of non-attending. In addition, patients answered the questionnaire over the phone. (IOP + Vision) were not obtained in these cases. After examination is being completed on those attendees, images of the retinas are saved to a Software system and at the end of the day are taken to Salmaniya Medical Complex (SMC); the main secondary hospital in the country; attached with the Copy of the referral paper to all patient who undergone the screening on that day to be reviewed by an Ophthalmologist. For those who show normal Retinal imaging, papers were filed back. If imaging shows any pathological changes in the retina; patients then will be scheduled for a follow up appointment with an Ophthalmologist in SMC. The inclusion criteria was all patients with type II diabetes aged 20 years and older referred from primary health care doctors for DRS. Patients who refused to participate, those with communication or language barrier, non-respondents or with contact number problems were excluded from the study population. Over the period of the study, 547 patients were identified. Among the 322 attendees; 276 satisfied the criteria and were included in the study. In comparison, among the 225 non-attendees; 91 patients were identified as they met the criteria of inclusion. The natures and objectives of the study were explained to the participants and consent forms were obtained from all patients. Questionnaires were coded and entered into computer. Data were analyzed using the SPSS program. ChiSquare and Fisher-exact tests were used to identify the significant factors which are related to attendance by comparing both groups. PValue was considered significant if ≤ 0.05. RESULTS A total number of 367 type 2 diabetic patients were enrolled in the study. Of those, (75.2%) had attended the screening test. The age of patients ranged from 20 to 94 years, and (42.5%) are within the age range of 50-59. Female constitute (55%) of the sample. The majority were Bahrainis (82.6%). Almost half of the sample (53.9%) were graduates of secondary school or college. However, most of the participant were unemployed (Domestics 43.6%, retired 16.1%. unemployed 0.5%). Smokers constitute 26.2 %. It has been noticed that most of the referral were from the Diabetic clinic (71.7%) as compared to the general clinic, and (63.5%) have done the test before. When comparing the demographic data between attendees and non-attendees, there was no significant difference between the two groups Table-1. The medical characteristics of participants showed that around half of the referral (51.8%) were for patients with duration of diabetes of less than 5 years. Those who use insulin were (16.3%). Regarding Diabetes complications, (3.8%) have nephropathy, (7.6%) neuropathy, and (14.7%) with eye problems. However, (55.3%) have high blood pressure and (73.7%) have dyslipidemia. Diabetes control was identified using Fasting Blood Sugar (FBS) and Glycated Hemoglobin (HbA1C). Uncontrolled FBS was in (70.9%) of the participants, and poor control of HbA1C in (42.3%). However, there is no significant difference between the attendees and non attendees. Most participants (62.9%) claimed that they received diabetic information from their medical team, (95.9%) think that diabetes can affect eyes,( 91.3%) think it may lead to vision loss, (44.1%) did not receive any recommendation from their physician to have a regular eye test, though (94.8%) think that its important. Most patients think that Diabetic retinopathy always comes with symptoms (66.8%) and (86.4%) think that it can be treated if detected early (Table-1). Afaf Abdulmonem Ali et al; Saudi J Med Pharm Sci, Nov. 2019; 5(11): 956-960 © 2019 |Published by Scholars Middle East Publishers, Dubai, United Arab Emirates 958 There was no differences in the knowledge between the attendees and non-attendees towards diabetic retinopathy, except that (88.4%) of the attendees think that DM retinopathy can be treated if detected early as compared to (80.2%) of non-attendees, and this difference is significant (p-value 0.048). Surprisingly, 100% of the non-attendees think that DM can affect eyes as compared to (94.6%) of the attendees (p-value 0.027) (Table-1). Factors which discouraged diabetic patients from attending the screening test are outlined in (Table 2 & 3). unavailability of transport was considered as a factor preventing patients attendance among (32.7%) of the total sample, followed by busy schedule (29.2%) forgetting the appointment (28.6%) and ignorance/neglect in (23.7%). However, comparing between attendees and non attendees using Chi-square test or Fisher’s test, a significant value was for forgetting the appointment (p-value 0.000)

Factors Influencing the Attendance of Patients with Type II Diabetes to Retinopathy Screening Series; a Primary Care Based Study in Bahrain