Diabetes mellitus constitutes one of the most significant non-communicable disease burdens of the twenty-first century, with its global prevalence estimated at over 537 million adults in 2021 and projected to reach 783 million by 2045.1 Pakistan bears a disproportionately heavy burden of this epidemic: the International Diabetes Federation estimates Pakistan's diabetic population at approximately 33 million, positioning the country among the top ten most affected nations globally.2 Within this context, diabetic retinopathy (DR) emerges as one of the most devastating microvascular complications of diabetes, representing the leading cause of preventable visual impairment among working-age adults in Pakistan.3

The prevalence of DR in Pakistani patients with diabetes has been reported at between 18% and 30% in various hospital-based studies, with proliferative diabetic retinopathy (PDR) accounting for a clinically significant subset.4 These figures may underestimate the true disease burden given the limited penetration of systematic screening programs in both urban centers such as Bannu and rural districts of Khyber Pakhtunkhwa (KPK). Bannu, as the referral hub for peripheral south areas of KPK and a major referral hub, services a heterogeneous population with marked disparities in health literacy, access to tertiary care, and financial capacity to sustain long-term treatment regimens.5

The management of diabetic retinopathy has been transformed in recent decades by the advent of intravitreal pharmacotherapy, particularly anti-vascular endothelial growth factor (anti-VEGF) agents such as bevacizumab, ranibizumab, and aflibercept. These agents, administered as intravitreal injections, have demonstrated superior outcomes compared to laser photocoagulation alone in the treatment of diabetic macular edema (DME) and proliferative DR.6 However, the utilization of intravitreal injections in Pakistan remains suboptimal. Cost constraints, limited availability of approved agents at subsidized rates in public-sector hospitals, and persistent patient hesitancy born of inadequate disease understanding collectively impede the delivery of guideline-concordant care.7

Patient awareness and health literacy are increasingly recognized as foundational determinants of healthcare engagement, treatment adherence, and clinical outcomes. In the Pakistani healthcare landscape, characterized by a dual-track public-private system, significant urban-rural divides, and frequent interaction with unqualified healthcare providers, patient knowledge deficits carry particular clinical and public health significance.8 Studies conducted in other South Asian nations have documented that low awareness of DR is independently associated with delayed presentation, loss to follow-up during anti-VEGF treatment, and consequently greater rates of irreversible visual loss.9

Crucially, the Pakistani healthcare context differs fundamentally from Western models in several respects. Urdu and Pashto remain the dominant languages in KPK, and health communication materials are predominantly available in English — a language inaccessible to a significant proportion of the patient population. Furthermore, cultural beliefs regarding eye diseases, including fatalistic attitudes and reliance on traditional healers, may delay formal ophthalmological consultation.5 Gender dynamics also exert a substantial influence: female patients in KPK frequently face structural barriers to independent healthcare access, which are reflected in their lower representation in retinal clinic populations and their demonstrably reduced levels of DR awareness.8

Despite the recognized importance of patient education in DR management, systematic data quantifying awareness levels specifically among patients attending ophthalmology services in Bannu are conspicuously absent from the published literature. Existing Pakistani studies have predominantly been conducted in Punjab-based tertiary centers, with findings that may not be directly transferable to the ethnolinguistic, cultural, and socioeconomic milieu of KPK.4 The present study was therefore designed to assess the level of awareness and knowledge of diabetic retinopathy and its treatment modalities — with particular emphasis on intravitreal injection therapy — among patients attending ophthalmology outpatient departments at a tertiary care center in Bannu. Secondary objectives included identification of demographic, educational, and socioeconomic predictors of knowledge level to guide future health education programs.

METHODOLOGY AND SETTINGS Study Design: This was a cross-sectional, observational study designed to assess patient awareness and knowledge regarding diabetic retinopathy and its treatment at a single point in time. The cross-sectional design was selected for its feasibility within the study period, its suitability for estimating prevalence of knowledge levels, and its established utility in health awareness research conducted in similar low- and middle-income country (LMIC) settings. Study Settings: The study was conducted in the Department of Ophthalmology, Khalifa Gul Nawaz MTI Hospital Bannu— a major referral center for ocular disease in South of KPK. The study period was from July 2025 to September 2025. Sampling Technique: Non-probability consecutive sampling was employed. All eligible patients presenting sequentially to the ophthalmology outpatient department during the data collection period who met the inclusion criteria were invited to participate until the required sample size was achieved. Sample Size Calculation: Sample size was calculated using the Raosoft online sample size calculator, the most commonly referenced tool in Pakistani health sciences research literature.10 Based on an estimated proportion of patient awareness of diabetic retinopathy of 35%, derived from a comparable Pakistani study by Mumtaz et al. (2019) conducted in Lahore,4 a margin of error of 5%, a 95% confidence interval, and an estimated annual population of 5,000 diabetic patients attending the study site, the minimum required sample size was calculated at 355 participants. Adjusting for an anticipated non-response rate of 8%, a final target of 385 participants was set and successfully enrolled. Inclusion Criteria: Participants were eligible if they met all of the following criteria: 1. Confirmed diagnosis of diabetes mellitus (type 1 or type 2) per American Diabetes Association (ADA) diagnostic criteria, supported by medical records or physician confirmation. 2. Age 18 years or above. 3. Ability to communicate in Urdu or Pashto. 4. Attending the ophthalmology outpatient department at Khalifa Gul Nawaz MTI Hospital Bannu during the study period. 5. Provision of voluntary written informed consent. Exclusion Criteria: Patients were excluded if they: 1. Had a previously documented non-diabetic retinal condition as the primary ophthalmic diagnosis (e.g., age-related macular degeneration, retinal vein occlusion unrelated to diabetes). 2. Were cognitively impaired or unable to complete the interview due to acute systemic illness. 3. Had previously participated in a formal structured DR education program within the preceding six months. 4. Refused to provide informed consent. 5. Were healthcare professionals with formal medical training who might confound awareness assessments. Data Collection Procedure: Data were collected through structured, interviewer-administered questionnaires conducted in either Urdu or Pashto by trained research assistants. All interviewers received standardized training to ensure uniformity of questionnaire administration and minimize interviewer bias. The questionnaire was developed based on a review of existing DR awareness instruments adapted for Pakistani populations and was piloted on 30 patients at Khalifa Gul Nawaz MTI Hospital Bannu, prior to the main study; internal consistency was confirmed with a Cronbach's alpha of 0.79. The questionnaire comprised four domains: (1) sociodemographic and clinical characteristics, including age, gender, education level, residence, duration of diabetes, and diabetes control status; (2) general awareness of diabetic retinopathy, including knowledge of its existence, relationship with diabetes, symptoms, and risk factors; (3) knowledge of treatment modalities, specifically awareness of intravitreal anti-VEGF injections, laser photocoagulation, and vitrectomy; and (4) prior sources of information regarding eye complications of diabetes. An aggregate knowledge score was computed for each participant, with scores classified as poor (0-40%), moderate (41-70%), or adequate (71-100%). Statistical Analysis: Data were entered and analyzed using IBM SPSS Statistics version 22.0. Descriptive statistics were used to summarize sociodemographic characteristics and knowledge scores, with continuous variables expressed as mean ± standard deviation (SD) and categorical variables as frequencies and percentages. Chi-square tests were used to assess bivariate associations between categorical variables. Independent-sample t-tests were used to compare mean knowledge scores across groups. Binary logistic regression was performed to identify independent predictors of adequate DR knowledge, with results expressed as adjusted odds ratios (OR) with 95% confidence intervals (CI). A p-value of less than 0.05 was considered statistically significant throughout.

Sociodemographic and Clinical Characteristics:

A total of 385 patients were enrolled. The mean age was 54.3 ± 10.8 years (range 22-78 years). Male participants constituted 57.4% (n=221) of the cohort and females 42.6% (n=164). Regarding educational attainment, 28.1% (n=108) had no formal education, 34.3% (n=132) had completed primary or middle schooling, 24.4% (n=94) had secondary or higher secondary education, and 13.2% (n=51) held a graduate or postgraduate qualification. Urban residents comprised 58.4% (n=225), and 41.6% (n=160) were from rural or peri-urban areas. The mean duration of diabetes mellitus was 9.6 ± 5.7 years. Type 2 diabetes accounted for 96.1% (n=370) of cases. Glycaemic control was poor (HbA1c ≥8%) in 61.3% (n=236). Full details are presented in Table 1.

Table 1. Sociodemographic and Clinical Characteristics of Study Participants (N=385)

DM = Diabetes Mellitus; SD = Standard Deviation; HbA1c = Glycated Haemoglobin.

Overall Awareness and Knowledge of Diabetic Retinopathy:

Overall DR knowledge was categorized as adequate (score 71-100%) in 34.8% (n=134), moderate (41-70%) in 38.2% (n=147), and poor (0-40%) in 27.0% (n=104) of participants. The mean aggregate knowledge score was 52.4 ± 18.6 out of 100. Awareness that diabetes can affect the eyes was present in 61.8% (n=238). Only 47.3% (n=182) knew that DR could occur in the absence of visual symptoms, and only 29.4% (n=113) were aware that regular eye examinations are recommended even without visual complaints. Knowledge that poor blood glucose control accelerates retinopathy progression was present in 43.6% (n=168), and awareness of hypertension as a compounding risk factor was documented in 38.4% (n=148). Domain-level awareness data are presented in Table 2.

Table 2. Patient Awareness of Diabetic Retinopathy by Knowledge Domain (N=385)

Chi-square (χ²) test used for all comparisons. DR = Diabetic Retinopathy. p < 0.05 considered statistically significant.

Knowledge of Treatment Modalities:

Awareness of intravitreal anti-VEGF injection therapy was present in only 21.3% (n=82) of participants. Among those who had received intravitreal injections previously (n=118; 30.6%), only 54.2% (n=64) could correctly identify the purpose of the injection, and 31.4% (n=37) were unaware that repeat injections would be required. Awareness of laser photocoagulation was higher at 36.6% (n=141), though only 19.5% (n=75) understood its mechanism or indication. Awareness of surgical vitrectomy for advanced DR was present in 14.3% (n=55). Notably, 18.7% (n=72) believed that diabetic retinopathy was untreatable once vision was affected. These data are summarized in Table 3.

Table 3. Patient Awareness of Diabetic Retinopathy Treatment Modalities (N=385)

Chi-square test versus expected equal distribution. anti-VEGF = anti-Vascular Endothelial Growth Factor; DR = Diabetic Retinopathy.

Sources of Information Regarding Diabetic Eye Disease:

The most frequently cited information source was the treating ophthalmologist or eye clinic staff (48.6%; n=187), followed by family members or friends (24.4%; n=94), general physicians or diabetologists (18.2%; n=70), television or radio (11.4%; n=44), internet or social media (9.1%; n=35), and printed health education materials (6.8%; n=26). Notably, 17.4% (n=67) of participants reported receiving no information about eye complications of diabetes from any source prior to their ophthalmic consultation. Sources are ranked in Table 4.

Table 4. Sources of Information Regarding Diabetic Eye Disease Reported by Participants (N=385)

Participants could cite more than one source; percentages do not sum to 100%. Ranked by frequency of citation.

Factors Associated with Adequate Knowledge of Diabetic Retinopathy:

On bivariate analysis, adequate DR knowledge was significantly associated with higher educational attainment (p<0.001), urban residence (p<0.001), male gender (p=0.003), diabetes duration greater than 10 years (p=0.002), and prior receipt of intravitreal injections (p=0.008). On multivariate binary logistic regression, independent predictors of adequate DR knowledge were: secondary or higher education (adjusted OR 3.42; 95% CI 2.11-5.54; p<0.001) versus no formal education; urban residence (adjusted OR 2.78; 95% CI 1.67-4.62; p<0.001); diabetes duration greater than 10 years (adjusted OR 2.15; 95% CI 1.30-3.56; p=0.003); and prior receipt of intravitreal injection therapy (adjusted OR 1.88; 95% CI 1.09-3.24; p=0.023). Female gender was independently associated with lower odds of adequate knowledge (adjusted OR 0.54; 95% CI 0.33-0.89; p=0.015). The Hosmer-Lemeshow goodness-of-fit test confirmed adequate model fit (χ²=7.42; p=0.49), with correct classification of 71.4% of cases. Multivariate results are presented in Table 5.

Table 5. Multivariate Binary Logistic Regression: Independent Predictors of Adequate DR Knowledge (N=385)

OR = Odds Ratio; CI = Confidence Interval; DR = Diabetic Retinopathy. Reference categories: no formal education, rural residence, diabetes duration < 5 years, male gender. Hosmer-Lemeshow χ²=7.42; p=0.49. Model correctly classified 71.4% of cases.

The findings of the present study reveal a critically insufficient level of patient awareness and knowledge regarding diabetic retinopathy and its treatment modalities in Bannu. Only 34.8% of enrolled participants demonstrated adequate knowledge of DR, and awareness of intravitreal anti-VEGF injection therapy — the current cornerstone of treatment for diabetic macular edema — was present in merely 21.3% of the study cohort. These results are broadly concordant with findings from comparable studies conducted in other cities of Pakistan and in South Asian nations with analogous healthcare infrastructure, while simultaneously highlighting the particularly pronounced knowledge deficit characterizing the KPK patient population. Mumtaz and Ali, in a cross-sectional study of 300 diabetic patients attending a tertiary care ophthalmology centre in Lahore, reported that 38% of patients were aware of DR as a complication of diabetes, and only 24% had knowledge of laser treatment.4 The slightly higher awareness in the Lahore cohort compared to the present Bannu study may plausibly be attributed to the greater urbanization, higher literacy rates, and more extensive community-level diabetes education infrastructure present in Punjab relative to KPK. This regional disparity underscores the inadequacy of a uniform national health education strategy and advocates for tailored, province-specific interventions that account for language, literacy, and cultural context. Comparisons with Indian studies are instructive. Vashist, Singh, Gupta, and Saxena reported DR awareness levels of approximately 40-45% in urban Indian diabetic populations, while awareness in rural populations of comparable states remained below 20%.11 The urban-rural knowledge gradient documented in these South Asian contexts mirrors the findings of the present study, where urban residence was an independent positive predictor of DR knowledge (OR 2.78; p<0.001). In the KPK setting, this gradient is further amplified by geographic barriers to information access, the limited reach of Pashto-language health education materials, and lower female literacy rates in rural areas — factors that converge to create a compounded knowledge deficit among rural women. Educational attainment emerged as the strongest independent predictor of adequate DR knowledge (OR 3.42; p<0.001), consistent with findings reported by Ahmed, Shaikh, and Ahmed from Karachi, who similarly identified education as the primary determinant of diabetes-related knowledge in their cohort of 410 patients.12 This relationship argues for educational materials and counseling approaches that do not rely on written communication alone, but harness visual aids, videos, and community health worker-mediated oral communication in local languages. The extremely low awareness of intravitreal anti-VEGF therapy (21.3%) reflects a systemic failure at the patient-physician communication level. Iqbal, Afzal, and Khan documented similar knowledge gaps regarding intravitreal bevacizumab in a cohort of retinal disease patients at Rawalpindi, noting that patient misconceptions regarding the injection route, frequency, and necessity were among the most significant barriers to treatment initiation and adherence.13 These findings argue for the integration of structured pre-treatment counseling protocols into retinal clinic workflows in Pakistani tertiary care settings. The contrast with patient awareness levels documented in high-income Western settings is stark and merits contextualization. Studies from the United Kingdom and the United States have reported DR awareness rates exceeding 60-70% in diabetic populations, attributable to population-wide diabetic retinopathy screening programs, robust primary care integration, and high health literacy.14 Direct extrapolation of Western awareness-enhancement strategies to Peshawar would be inappropriate. Lessons must rather be drawn from successful awareness campaigns in comparable LMICs — such as India's LVPEI model of task-sharing with trained vision technicians15 — and adapted to the specific sociocultural context of KPK.

This cross-sectional study conducted at a tertiary care ophthalmology centre in Bannu, Pakistan, has documented alarmingly low levels of awareness and knowledge of diabetic retinopathy and its treatment modalities among patients with diabetes mellitus. Only one in three patients demonstrated adequate knowledge of the disease, and awareness of intravitreal anti-VEGF injection therapy was present in fewer than one in four participants. Female gender, rural residence, low educational attainment, and shorter diabetes duration were independently associated with poorer DR knowledge. These findings underscore the urgent need for structured, culturally sensitive, and linguistically accessible patient education programs targeting the diabetic population of Khyber Pakhtunkhwa. Integration of systematic DR counseling into both ophthalmology and primary diabetes care services, development of Pashto and Urdu-language educational resources, and community-based outreach initiatives are critical steps toward reducing the preventable burden of DR-related blindness in this high-risk population.

AUTHORS' CONTRIBUTIONS

Dr. Muhammad Shahid Kamran: Study conception, data collection, manuscript drafting. Dr. Afzal Qadir: Study design, supervision, critical revision of manuscript. Dr. Muhammad Kashif Kamran: Data analysis, statistical interpretation. Dr. Waqas Ahmad: Literature review, manuscript editing and revision. All authors have read and approved the final version of the manuscript.

CONFLICT OF INTEREST

The authors declare no conflict of interest. No funding was received from any commercial or non-commercial entity for this study.

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