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To cite: Alemayehu HB,
Tilahun MM, Abebe MG,
et al. Sight-­threatening
diabetic retinopathy and its
predictors among patients
with diabetes visiting Adare
General Hospital in Southern
Ethiopia: a hospital-­based cross-­
sectional study. BMJ Open
2024;14:e077552. doi:10.1136/
bmjopen-2023-077552
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077552).
HBA, MMT, MGA and MTT
contributed equally.
Received 08 July 2023
Accepted 13 February 2024
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Correspondence to
Henok Biruk Alemayehu;
​henokbiruk37@​gmail.​com
Sight-­threatening diabetic retinopathy
and its predictors among patients with
diabetes visiting Adare General
Hospital in Southern Ethiopia: a
hospital-­based cross-­sectional study
Henok Biruk Alemayehu ‍ ‍,1 Mikias Mered Tilahun,2 Marshet Gete Abebe,3
Melkamu Temeselew Tegegn ‍ ‍2
ABSTRACT
Objective The study aimed to determine the prevalence
of sight-­threatening diabetic retinopathy and its predictors
among patients with diabetes attending Adare General
Hospital in Southern Ethiopia.
Design A hospital-­based cross-­sectional study was
conducted using a systematic random sampling method.
Setting The study was conducted at the diabetic clinic
of Adare General Hospital in Sidama region, Southern
Ethiopia.
Participants The study included 391 patients with
diabetes aged ≥18 years who had attended the diabetic
clinic of Adare General Hospital in Southern Ethiopia.
Main outcome measures Data were collected using
questionnaires completed by an interviewer, a review of
medical records and eye examinations.
Result The study included 391 patients with diabetes
with a median age of 49 years. The prevalence of sight-­
threatening diabetic retinopathy was 10.7% (95% CI: 7.7%
to 14%). Rural dwellers (adjusted OR (AOR)=2.17, 95% CI:
1.05 to 4.46), duration of diabetes ≥6 years (AOR=2.43,
95% CI: 1.06 to 5.57), poor glycaemic control (AOR=2.80,
95% CI: 1.03 to 7.64), low physical activity (AOR=2.85,
95% CI: 1.01 to 8.05), hypertension (AOR=3.25, 95%
CI: 1.48 to 7.15) and diabetic peripheral neuropathy
(AOR=3.32, 95% CI: 1.18 to 9.33) were significantly
associated with sight-­threatening diabetic retinopathy.
Conclusion This study showed a high prevalence of
sight-­threatening diabetic retinopathy. Sight-­threatening
diabetic retinopathy was significantly associated with
modified factors such as glycaemic control, hypertension,
physical activity and diabetic peripheral neuropathy.
Therefore, all patients with diabetes were recommended
to maintain normal blood glucose, avoid hypertension,
exercise regularly and have regular eye examinations.
INTRODUCTION
The International Diabetes Federation esti-
mates that 537 million people worldwide have
diabetes in 2021, and this number is expected
to rise to 643 million by 2030 and 783 million
by 2045.1 Diabetes mellitus is also the leading
Alemayehu HB, et al. BMJ Open 2024;14:e077552. doi:10.1136/bmjopen-2023-077552
Original research
STRENGTHS AND LIMITATIONS OF THIS STUDY
⇒ This study provided up-­
to-­
date evidence on the
magnitude and modifying factors associated with
sight-­
threatening diabetic retinopathy to reduce
blindness in patients with diabetes in Southern
Ethiopia.
⇒ Since this is a cross-­sectional study, this study can
show the temporal relationship between predictors
and sight-­ threatening diabetic retinopathy rather
than the actual cause–effect relationship.
⇒ Since the study was conducted in a single general
hospital for patients with diabetes, the results of our
study may not be generalisable to the entirety of pa-
tients with diabetes in Ethiopia.
cause of morbidity in Ethiopia, and the
national prevalence of diabetes in Ethiopia is
6.5%.2
Diabetic retinopathy (DR) is a serious
complication of microvasculature in diabetes
that results from progressive damage to
the blood vessels of the retina in the eyes.3
Clinically, DR can be divided into non-­sight-­
threatening diabetic retinopathy (STDR)
with mild and moderate non-­ proliferative
abnormalities and STDR with severe non-­
proliferative abnormalities, proliferative
abnormalities and diabetic maculopathy.4 5
Worldwide, the prevalence of DR and
STDR in patients with diabetes was 22.27%
and 6.17%, respectively.6 A meta-­ analysis
based on a clinical survey in Africa found that
the prevalence of DR ranged from 7.0% to
62.4%, that of proliferative DR from 0% to
6.9% and that of diabetic maculopathy from
1.2% to 31.1%.7 8 Furthermore, the national
prevalence of DR in Ethiopia was 19.48%.9
In addition, studies conducted in Africa
including Ethiopia have shown that the
prevalence of STDR ranges from 5.2% to
1
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36.0%.10–17 Evidence has been demonstrated that STDR
was significantly associated with longer duration of
diabetes,4 14 17–19 poor glycaemic control,4 20–22 hyperten-
sion,14 17 22 diabetic peripheral neuropathy,22 23 low phys-
ical activity24 25 and low monthly income.17
STDR is one of the main causes of preventable visual
impairment in the working-­ age population, which
accounts for 3.7 million people with visual impair-
ment worldwide.26 Visual impairment due to STDR can
increase unemployment, loss of productivity, social isola-
tion (limited social participation) and medical costs, as
well as interfere with performing activities of daily living
such as preparing healthy meals, exercising, and taking
insulin and medication to maintain constant blood
glucose levels. Patients with diabetes have a lower quality
of life as a result of this condition.27
Vision loss due to STDR can be prevented by effective
screening, timely laser treatment, intraocular injection of
steroids and antivascular endothelial growth factor agents,
and intraocular surgery.28 However, advanced thera-
peutic options for sight-­threatening diabetics like laser
phototherapy and intravitreal injection therapy are not
available in Adare General Hospital as well as public eye
clinics in Ethiopia, and inadequate studies are addressing
the prevalence of STDR and its predictors in Ethiopia as
well as in the study region. So, to develop advanced ther-
apeutic options for STDR in Ethiopia and the study area,
up-­to-­date knowledge on the extent of STDR is needed.
Therefore, the main objective of this study was to deter-
mine the prevalence of STDR and its predictors among
patients with diabetes attending Adare General Hospital
in Southern Ethiopia.
METHODS AND MATERIALS
Study design and setting
From 30 May to 15 July 2022, we conducted a hospital-­
based cross-­sectional study among adult patients with
diabetes at Adare General Hospital in the Sidama region.
The hospital is located in Hawassa, the capital of Sidama
Regional State, 275 km from Addis Ababa. Adare General
Hospital treats more than 600 patients with diabetes every
month and provides comprehensive healthcare services
to approximately 3 million people in the Sidama region.
Study population and sample size
All adult patients with type I or type II diabetes who
attended the diabetes clinic at Adare General Hospital
during the study period were eligible to participate in the
study. Adult patients with diabetes who were admitted to
the inpatient unit due to a serious illness that prevented
slit-­lamp examination, patients with gestational diabetes
and patients with mental health problems who were
unable to complete the questionnaire were excluded
from the study.
The sample size was determined using a single popu-
lation proportion formula with the assumption that the
expected prevalence of STDR was 10.7%, which was taken
2 Alemayehu HB, et al. BMJ Open 2024;14:e077552. doi:10.1136/bmjopen-2023-077552
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from a previous study conducted in Gondar, Ethiopia,16
95% confidence level, 3% degree of precision and then
adding a 5% non-­response rate. Based on these, the total
computed sample size was 428. The study participants
were chosen using a systematic random sampling method.
Patient and public involvement
Patients and/or the public were not involved in the study
design, conduct of the study or plan to disseminate the
result of this study to the study participants.
Operational definitions
Physical activity: participants who performed regular
activities for less than 150 min (3–5 days) per week were
considered to have low physical activity; otherwise, they
were considered to have high physical activity.29
Glycaemic control was classified as good when the
current fasting blood sugar (FBS) was 152 mg/dL and
lower, and poor when the current FBS was 152 mg/dL
and above based on the American Diabetes Association
Standards of Medical Care in Diabetes-­2020.30
Body mass index (BMI) was calculated as the weight
of the participant (kg) divided by their height in metres
squared (m2). In this study, BMI (kg/m2) was categorised
as normal/non-­obese if the BMI was less than 24.9 kg/m2,
and abnormal/obese if the BMI was ≥25 kg/m2.31
Marital status was categorised as currently married and
currently single (single, divorced and widowed).
Education status was classified as non-­ formal educa-
tion (illiterate, able to write and read with no formal
schooling) and formal education (from primary school
to university).
Occupational status was categorised as employed
(including government and non-­government employee,
farmer, merchant and daily labourer) and non-­employed
(individuals who had no job at the time of data collection,
students, retired and housewives).
Data collection procedures
The data were collected by interview, inspection of the
medical records and an eye examination. The personal
interview, medical record review, and measurement
of participants’ height and weight were conducted by
two trained nurses. The interview was conducted using
pretested structured questionnaires. The questionnaires
included questions on sociodemographic and economic
parameters, behavioural aspects (alcohol consumption,
smoking, physical activity), diabetes care and eye exam-
ination practices.
Clinical data such as diabetes type, duration of diabetes,
blood glucose level, treatment modality and systemic
comorbidities such as hypertension, peripheral diabetic
neuropathy, diabetic nephropathy, heart disease and
anaemia were assigned to study participants based on their
medical records and physician-­confirmed diagnoses. To
determine the presence or absence of diabetic peripheral
neuropathy, a senior nurse performed physical examina-
tions such as foot inspection, vibration perception, ankle

reflex test and monofilament test, in addition to medical
record review. Weight was then measured with a beam
balance and height was measured with a wall-­mounted
stadiometer, with patients appearing in underwear and
without shoes.
Ophthalmic examination and evaluation of DR
Experienced optometrists examined the fundus (retina)
using a slit-­lamp biomicroscope with a 90-­dioptre folk lens
(binocular indirect slit-­lamp funduscopy) after dilating
the pupil with 1% tropicamide eye drops in each eye.
DR was classified into no retinopathy, mild non-­
proliferative DR, moderate non-­proliferative DR, severe
non-­proliferative DR and proliferative DR based on the
Early Treatment Diabetic Retinopathy Study.32
Also, diabetic macular oedema was defined by the pres-
ence of retinal thickening or hard exudates within the
central fovea area.32 For study participants who presented
with difficult cases or had doubts about STDR, a senior
ophthalmologist was consulted, and data collectors were
given an agreed diagnosis of STDR. STDR was deter-
mined based on the condition of the severely damaged
eye with DR. The presence of severe non-­proliferative
DR, proliferative DR and/or diabetic macular oedema
was designated as STDR.4 5 Interexaminer reliability was
assessed, and Cohen’s kappa statistic was 0.99.
Statistical analysis
After checking the completeness and consistency of the
data, data were coded and entered into EpiData V.3.1 and
then exported to SPSS V.25 for analysis. Both descriptive
and analytical statistics were performed. Multicollinearity
was checked using the variance inflation factor and toler-
ance. A binary logistic regression model was fitted to iden-
tify the potential predictors for STDR. The strength of
the association between predictors and outcome variables
was shown using an adjusted OR (AOR) with a 95% CI.
The model of fitness was ensured through the Hosmer
and Lemeshow goodness of fit. A variable with a p value of
0.05 in multivariable binary logistic regression was consid-
ered statistically significant.
RESULTS
Sociodemographic characteristics of the study participants
A total of 391 participants were involved in this study, with
a response rate of 91.4%. The median age of participants
was 49 years (IQR: 40–58). Out of 391 participants, 197
(50.4%) were male, 151 (38.6%) had no formal education
and 214 (54.7%) did not have health insurance (table 1).
Clinical, behavioural and systemic comorbidities
Of all study participants, 69.6% had type II diabetes, and
174 (44.5%) had checked their glycaemic level every
2 months. The median value for current FBS was 160 mg/
dL (IQR: 130–179 mg/dL). The median duration of
diabetes was 6 years (IQR: 3–9). The most common
Alemayehu HB, et al. BMJ Open 2024;14:e077552. doi:10.1136/bmjopen-2023-077552
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systemic comorbidity was hypertension (60, 15.3%),
followed by peripheral diabetic neuropathy (31, 7.9%)
and diabetic heart disease (9, 2.3%). Of the 391 partici-
pants, 112 (28.6%) were visually impaired, whereas only 8
(2.0%) had received ocular treatment (table 2).
Sight-threatening diabetic retinopathy
The overall prevalence of DR in this study was 15.3%
(95% CI: 11.8% to 18.9%), whereas the prevalence of
STDR was 10.7% (95% CI: 7.7% to 14.1%). STDR was
more prevalent in participants aged ≥49 years (15.7%),
those living in rural areas (15.4%) and those with type II
diabetes (12.1%) (table 3).
Predictors of STDR
In the bivariable binary logistic regression analysis,
age, place of residence, educational status, duration of
diabetes, glycaemic control, physical activity, BMI, hyper-
tension and peripheral diabetic neuropathy were posi-
tively associated with STDR. However, in multivariable
binary logistic regression analysis, place of residence,
diabetes duration, glycaemic control, physical activity,
hypertension and peripheral diabetic neuropathy were
significantly associated with STDR.
The study found that participants with a rural residence
had a 2.17-­ fold higher risk of developing STDR than
participants with an urban residence (AOR=2.17, 95% CI:
1.05 to 4.46). Participants with a diabetes duration of 6
years or more were 2.43 times more likely to develop STDR
(AOR=2.43, 95% CI: 1.06 to 5.57) than participants with
a diabetes duration of less than 6 years. The likelihood
of developing STDR was 2.80 times (AOR=2.80, 95% CI:
1.03 to 7.64) higher in participants with poor glycaemic
control than in participants with good glycaemic control.
Participants with low physical activity were 2.85 times
more likely to develop STDR than participants with high
physical activity (AOR=2.85, 95% CI: 1.01 to 8.05). Partic-
ipants with hypertension were 3.25 times (AOR=3.25,
95% CI: 1.48 to 7.15) more likely to develop STDR than
their counterparts. The odds of developing STDR for
participants with peripheral diabetic neuropathy were
3.32 times (AOR=3.32, 95% CI: 1.18 to 9.33) higher than
for participants without peripheral diabetic neuropathy
(table 4).
DISCUSSION
This study found that the prevalence of STDR was
10.7% (95% CI: 7.7% to 14.1%), which is consistent with
the studies conducted in Mainland China (12.6%),19
India (8.7%),33 Zimbabwe (11.4%),11 Gondar, Ethiopia
(10.7%)16 and Debre Tabor, Ethiopia (13.7%).17 However,
this result was higher than in the studies conducted in
the USA (4.2%)4 and Egypt (5.2%).10 This discrepancy
could be due to differences in the characteristics of the
study population, such as duration of diabetes, glycaemic
control status, age and differences in the study settings.
3
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Table 1 Sociodemographic characteristics of patients with diabetes visiting Adare General Hospital in Sidama region,
Southern Ethiopia, 2022 (n=391)
Sight-­threatening diabetic retinopathy
Variables Type I (%) Type II (%) Type I (%) Type II (%) Total (%)
Overall 119 (100) 272 (100) 9 (100) 33 (100) 42 (100)
Age (in years)
 <49 87 (73.1) 106 (39.0) 5 (55.6) 6 (18.2) 11 (26.2)
 ≥49 32 (26.9) 166 (61.0) 4 (44.4) 27 (81.8) 31 (73.8)
Sex
 Male 61 (51.3) 136 (50.0) 6 (66.7) 15 (45.5) 21 (50.0)
 Female 58 (48.7) 136 (50.0) 3 (33.3) 18 (54.5) 21 (50.0)
Residency
 Rural 50 (42.0) 99 (36.4) 5 (55.6) 18 (54.5) 23 (54.8)
 Urban 69 (58.0) 173 (63.6) 4 (44.4) 15 (45.5) 19 (45.2)
Marital status
 Unmarried 46 (38.7) 55 (20.2) 4 (44.4) 7 (21.2) 11 (26.2)
 Married 73 (61.3) 217 (79.8) 5 (55.6) 26 (78.8) 31 (73.8)
Educational status
 Non-­formal education 41 (34.5) 115 (42.3) 4 (44.4) 19 (57.6) 23 (54.8)
 Formal education 78 (65.5) 157 (57.7) 5 (55.6) 14 (42.4) 19 (45.2)
Occupational status
 Employed 85 (71.4) 176 (64.7) 6 (66.7) 21 (63.6) 27 (64.3)
 Non-­employed 34 (28.6) 96 (35.3) 3 (33.3) 12 (36.4) 15 (35.7)
Monthly income (ETB)
 <6000 50 (42.0) 116 (42.6) 5 (55.6) 17 (51.5) 22 (52.4)
 ≥6000 69 (58.0) 156 (57.4) 4 (44.4) 16 (48.5) 20 (47.6)
Health insurance
 Yes 64 (53.8) 113 (41.5) 4 (44.4) 14 (42.4) 18 (42.9)
 No 55 (46.2) 159 (58.5) 5 (55.6) 19 (57.6) 24 (57.1)
n=sample size.
Age and monthly income were categorised based on the median value of the data.
ETB, Ethiopian birr.

In contrast, the outcome of this study was lower than the
studies conducted in Hangzhou, China (80%),34 Indo-
nesia (26.3%),24 India (33.8%),21 Fiji (27%),35 Malawi
(29.4%),14 Zambia (36.0%),15 Cameroon (18.2%)13 and
Uganda (14.6%).12 The discrepancy could be due to
differences in sociodemographic and clinical characteris-
tics of participants’ duration of diabetes, age, presence of
hypertension and study settings. For instance, the studies
were conducted in China, Fiji, Malawi and Cameroon in
an eye clinic, which may increase the prevalence of DR
through the screening effect. In addition, more than half
of the study participants in Cameroon and Malawi had
a history of hypertension. Because of lower blood flow
and stretched vascular endothelial cells, hypertension is
an important systemic component in promoting diabetic
vascular problems such as retinopathy.36
Regarding the type of diabetes, the prevalence of STDR
in type I diabetes was 7.6% (95% CI: 3.2% to 12.4%),
which was consistent with the study conducted in Slovakia
(5.76%).37 In contrast, this result was lower than in the
studies from Zambia (57%),15 Malawi (18.8%)38 and
Debre Tabor, Ethiopia (15.3%).17 This discrepancy could
be explained by differences in diabetes duration, ethnicity,
late diagnosis, limited access to medical care and systemic
conditions such as hypertension and diabetic peripheral
neuropathy.
In this study, the prevalence of STDR in type II diabetes
was 12.1% (95% CI: 8.6% to 16.1%), which was compa-
rable with the results of studies from Brunei Darussalam
(9.7%)39 and Debre Tabor, Ethiopia (11.9%).17 However,
this result was higher than in the studies from Southern
China (2.5%)20 and Slovakia (3.35%)37 and lower than
in Zambia (44%)15 and Malawi (19.7%).38 This variation
could be due to differences in socioeconomic status and
lifestyle (dietary habits and physical activity) of the study
population. In addition, this variation could be due to

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Table 2 Clinical characteristics and systemic comorbidity of patients with diabetes concerning sight-­threatening diabetic
retinopathy visiting Adare General Hospital in Sidama region, Southern Ethiopia, 2022 (n=391)
Sight-­threatening diabetic retinopathy
Variables Type I (%) Type II (%) Type I (%) Type II (%) Total (%)
Overall 119 (100) 272 (100) 9 (100) 33 (100) 42 (100)
Duration of diabetes (years)
 <6 66 (55.5) 127 (46.7) 2 (22.2) 10 (30.3) 12 (28.6)
 ≥6 53 (44.5) 145 (53.3) 7 (77.8) 23 (69.7) 30 (71.4)
Glycaemic control
 Good 45 (37.8) 89 (32.7) 2 (22.2) 4 (12.1) 6 (14.3)
 Poor 74 (62.2) 183 (67.3) 7 (77.8) 29 (87.9) 36 (85.7)
Treatment modality
 Tablet 5 (4.2) 188 (69.1) 0 (0.0) 22 (66.7) 22 (52.4)
 Insulin 111 (93.3) 48 (17.6) 2 (22.2) 8 (24.2) 10 (23.8)
 Combined 3 (2.5) 36 (13.2) 7 (77.8) 3 (9.1) 10 (23.8)
Diabetes check-­up
 Every 1 month 48 (40.3) 87 (32.0) 3 (33.3) 10 (30.3) 13 (31.0)
 Every 2 months 50 (42.0) 124 (45.6) 5 (55.6) 13 (39.4) 18 (42.9)
 Every 3 months 21 (17.7) 66 (22.4) 1 (11.1) 10 (30.3) 11 (26.1)
2
BMI (kg/m )
 Normal 99 (75.6) 192 (70.6) 5 (55.6) 16 (48.5) 21 (50.0)
 Abnormal 29 (24.4) 80 (29.4) 4 (44.4) 17 (51.5) 21 (50.0)
Physical activity
 High 44 (37.0) 78 (28.7) 0 (0.0) 5 (15.2) 5 (11.9)
 Low 75 (63.0) 194 (71.3) 9 (100.0) 28 (84.8) 37 (88.1)
Alcohol consumption
 Yes 2 (1.7) 6 (2.2) 1 (11.1) 1 (3.0) 2 (4.8)
 No 117 (98.3) 266 (97.8) 8 (88.9) 32 (97.0) 40 (95.2)
Hypertension
 Yes 12 (10.1) 48 (17.6) 4 (44.5) 12 (36.4) 16 (38.1)
 No 107 (89.9) 224 (82.4) 5 (55.5) 21 (63.6) 26 (61.9)
Diabetic peripheral neuropathy
 Yes 9 (7.6) 22 (8.1) 0 (0.0) 7 (21.2) 7 (16.7)
 No 110 (92.4) 250 (91.9) 9 (100.0) 26 (78.8) 35 (83.3)
Heart disease
 Yes 3 (2.5) 6 (2.2) 0 (0.0) 0 (0.0) 0 (0.0)
 No 116 (97.5) 266 (97.8) 9 (100.0) 33 (100.0) 42 (100)
Diabetic nephropathy
 Yes 1 (0.8) 1 (0.4) 0 (0.0) 0 (0.0) 0 (0.0)
 No 118 (99.2) 271 (99.6) 9 (100.0) 33 (100.0) 42 (100)
Anaemia
 Yes 1 (0.8) 4 (1.5) 0 (0.0) 1 (3.0) 1 (2.8)
 No 118 (99.2) 268 (98.5) 9 (100.0) 32 (97.0) 41 (97.6)
History of ocular surgery
 Cataract surgery 2 (1.7) 2 (0.7) 1 (11.1) 0 (0.0) 1 (2.4)
 Vitreoretinal surgery 0 (0.0) 4 (1.5) 0 (0.0) 4 (12.1) 4 (9.5)
 No surgery 117 (98.3) 266 (97.8) 8 (88.9) 29 (87.9) 37 (88.1)
Continued

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Table 2 Continued
Sight-­threatening diabetic retinopathy
Variables Type I (%) Type II (%) Type I (%) Type II (%) Total (%)
Visual impairment
 Yes 21 (17.6) 91 (33.5) 8 (88.9) 33 (100.0) 41 (97.6)
 No 98 (82.4) 181 (66.5) 1 (11.1) 0 (0.0) 1 (2.4)
Eye check-­up practice
 Yes 42 (45.3) 83 (30.5) 3 (33.3) 12 (36.4) 15 (35.7)
 No 77 (64.7) 189 (69.5) 6 (66.7) 21 (63.6) 27 (64.3)
BMI, body mass index.

differences in awareness of the importance of controlling
blood glucose levels in reducing the risk of developing
DR.
This study found that participants residing in rural
areas were 2.17 times more likely to develop STDR than
participants residing in urban areas. This finding was
consistent with the findings in India.33 The most likely
explanation for this association is that residents of rural
areas have poorer access to eye care services due to the
lack of eye care services and professionals, distance from
eye care facilities, low socioeconomic status, and lack of
knowledge about diabetes and diabetes-­related compli-
cations, all of which contribute to the advanced disease
in these patients. Consequently, we need to work hard to
improve clinical care in rural populations.
Participants with diabetes duration of 6 years or more
were 2.43 times more likely to develop STDR than
participants with diabetes duration of <6 years. This result
was consistent with the findings in the USA,4 Singapore,18
Norway,23 Hangzhou, China,34 Mainland China,19 India,21
Malawi,14 and Debre Tabor, Ethiopia.17 Long-­term
diabetes can reduce the production of insulin hormones
in the pancreas or lead to target cell resistance, increasing
the risk of developing STDR and other advanced diabetic
complications.36 To reduce the overall burden of the
disease, a greater clinical focus should be placed on those
with a longer history of diabetes.
In the current study, participants with poor glycaemic
control were 2.80 times more likely to develop STDR than
participants with good glycaemic control, which is similar
to the findings in the USA,4 Southern China,20 India,21
Saudi Arabia,22 Malawi14 and Debre Tabor, Ethiopia.17
One possible explanation for this link is that high glucose
levels in the endothelial cells of the retinal artery lead to

Table 3 Age, sex, residency and type of diabetes-­specific prevalence of DR and STDR among patients with diabetes visiting
Adare General Hospital in Sidama region, Southern Ethiopia, 2022 (n=391)
Stage of DR
Mild-­moderate Severe
Variables No DR (%) NPDR (%) NPDR (%) PDR (%) DME (%) Any DR (%) STDR (%)
Age (years)
 <49 (n=193) 173 (89.6) 9 (4.7) 5 (2.6) 2 (1.0) 4 (2.1) 20 (10.4) 11 (5.7)
 ≥49 (n=198) 158 (79.8) 9 (4.5() 12 (6.1) 9 (4.5) 10 (5.1) 40 (20.2) 31 (15.7)
Sex
 Male (n=197) 166 (84.3) 10 (5.1) 6 (3.0) 6 (3.0) 9 (4.6) 31 (15.7) 21 (10.7)
 Female (n=194) 165 (85.1) 8 (4.1) 11 (5.7) 5 (2.6) 5 (2.6) 29 (14.9) 21 (10.8)
Residency
 Rural (n=149) 123 (82.6) 3 (2.0) 6 (4.0) 7 (4.7) 10 (6.7) 26 (17.4) 23 (15.4)
 Urban (n=242) 208 (86.0) 15 (6.2) 11 (4.5) 4 (1.7) 4 (1.7) 34 (14.0) 19 (7.9)
Type of DM
 Type I (n=119) 107 (89.9) 3 (2.5) 4 (3.4) 1 (0.8) 4 (3.4) 12 (10.1) 9 (7.6)
 Type II (n=272) 224 (82.4) 15 (5.5) 13 (4.8) 10 (3.7) 10 (3.7) 48 (17.6) 33 (12.1)
Overall (n=391) 331 (84.7) 18 (4.6) 17 (4.3) 11 (2.8) 14 (3.6) 60 (15.3) 42 (10.7)
STDR was included in severe NPDR, PDR and DME.
DM, diabetes mellitus; DME, diabetic macular oedema; DR, diabetic retinopathy; NPDR, non-­proliferative diabetic retinopathy; PDR,
proliferative diabetic retinopathy; STDR, sight-­threatening diabetic retinopathy.

6 Alemayehu HB, et al. BMJ Open 2024;14:e077552. doi:10.1136/bmjopen-2023-077552

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BMJ Open: first published as 10.1136/bmjopen-2023-077552 on 21 February 2024. Downloaded from http://bmjopen.bmj.com/ on February 22, 2024 by guest. Protected by copyright.
Table 4 Sociodemographic and clinical characteristics associated with sight-­threatening diabetic retinopathy among patients
with diabetes visiting Adare General Hospital in Sidama region, Southern Ethiopia, 2022 (n=391)
Sight-­threatening diabetic retinopathy
Variable Yes No COR (95% CI) AOR (95% CI) P value
Age (in years) 0.064
 <49 11 182 1.00 1.00
 ≥49 31 167 3.07 (1.50 to 6.31) 2.17 (0.96 to 4.91)
Residency
 Rural 23 126 2.14 (1.12 to 4.09) 2.17 (1.05 to 4.46) 0.036
 Urban 19 223 1.00 1.00
Educational status 0.173
 Non-­formal education 23 133 1.97 (1.03 to 3.75) 1.64 (0.80 to 3.36)
 Formal education 19 216 1.00 1.00
Duration of diabetes (years)
 <6 12 181 1.00 1.00
 ≥6 30 168 2.69 (1.34 to 5.43) 2.43 (1.06 to 5.57) 0.036
Glycaemic control
 Good 6 128 1.00 1.00
 Poor 36 221 3.48 (1.43 to 8.47) 2.80 (1.03 to 7.64) 0.044
2
Body mass index (kg/m ) 0.164
 Normal 21 261 1.00 1.00
 Abnormal 21 88 2.97 (1.55 to 5.69) 1.71 (0.80 to 3.63)
Physical activity
 Low 5 117 1.00 1.00
 High 37 232 3.73 (1.43 to 9.75) 2.85 (1.01 to 8.05) 0.048
Hypertension
 Yes 16 44 4.27 (2.12 to 8.58) 3.25 (1.48 to 7.15) 0.003
 No 26 305 1.00 1.00
Diabetic neuropathy
 Yes 7 24 2.71 (1.09 to 6.74) 3.32 (1.18 to 9.33) 0.023
 No 35 325 1.00 1.00
AOR, adjusted OR; COR, crude OR.

impaired glucose uptake and increased oxidative stress
of these cells, which favour the development of advanced
DR.40 This means that maintaining optimal blood glucose
level is crucial to prevent the onset and progression of
STDR.
Physical activity is an important factor influencing
STDR. Participants with low physical activity were 2.85
times more likely to develop STDR than participants
with high physical activity. This finding is consistent with
a meta-­analysis41 and with studies from Indonesia24 and
Australia.25 An inappropriate lifestyle (lack of exercise)
can cause insulin resistance by increasing visceral adipose
tissue and consequently releasing significantly more
free-­
fatty acids, tumour necrosis factor-α, adipokines
and hyperglycaemia, leading to increased inflamma-
tion, oxidative stress and endothelial dysfunction. Ulti-
mately, these conditions may exacerbate the progression
of microvascular complications in patients with diabetes
such as STDR.41 The integration of physical activity should
be considered in the future therapy of STDR.
Participants with hypertension were 3.25 times more
likely to develop STDR than participants without hyper-
tension. Similar observations were made in other studies
conducted in Indonesia,24 India,21 Saudi Arabia,22
Malawi14 and Debre Tabor, Ethiopia.17 High blood
glucose levels are thought to disrupt the autonomic regu-
latory mechanism of the retinal capillaries and make
the capillary endothelium susceptible to damage from
increased blood pressure, leading to retinal ischaemia
(reduced blood supply to the retina) and eventually reti-
nopathy.42 This finding showed that adequate attention
must be paid to hypertension in patients with diabetes,
as its inadequate control/treatment can accelerate vision
loss due to DR.

Alemayehu HB, et al. BMJ Open 2024;14:e077552. doi:10.1136/bmjopen-2023-077552 7

 Open access
Participants with peripheral diabetic neuropathy were
3.32 times more likely to develop STDR than participants
without peripheral diabetic neuropathy. This finding was
confirmed by studies in Norway,23 Kerala, India,43 Saudi
Arabia22 and Malawi.38 As peripheral diabetic neuropathy
progresses, it leads to the development of vascular abnor-
malities such as thickening of the capillary basement
membrane and endothelial hyperplasia with subsequent
reduction in oxygen tension and hypoxia of the retina,
leading to the development of DR.36
As far as we know, this was the first study in Southern
Ethiopia, so this study will serve as baseline data for further
studies. Limitations of our study include the following:
since the study was conducted in a single general hospital
for patients with diabetes, the results of our study may not
be generalisable to the entirety of patients with diabetes
in Ethiopia, and since this is a cross-­sectional study, this
study can show the temporal relationship between predic-
tors and STDR rather than the actual cause–effect rela-
tionship. In addition, current fasting blood glucose was
used instead of glycated haemoglobin to assess glycaemic
control because there are no facilities to assess glycated
haemoglobin in the study area. As optical coherence
tomography was not available in the study area, the diag-
nosis of STDR was made by binocular indirect slit-­lamp
funduscopy.
CONCLUSION
The study revealed a high prevalence of STDR. Rural
dwellers, longer duration of diabetes, poor glycaemic
control, low physical activity, hypertension and periph-
eral diabetic neuropathy were significantly associated
with STDR. Therefore, all diabetics were advised to main-
tain normal blood glucose levels, avoid having high blood
pressure, exercise regularly and have their eyes examined
regularly.
Author affiliations
1
Department of Ophthalmology and Optometry, College of Medicine and Health
Sciences, Hawassa University, Hawassa, Ethiopia
2
Department of Optometry, University of Gondar College of Medicine and Health
Sciences, Gondar, Ethiopia
3
Department of Ophthalmology and Optometry, Hawassa University College of
Medicine and Health Sciences, Hawassa, Ethiopia
Acknowledgements The authors would like to thank the study participants for
their participation in the study and the data collectors.
Contributors HBA conceptualised the research design, formulated the research
questions, takes full responsiblity for the work, designed and implemented the
research methodology, and conducted extensive reviews of the manuscript. MMT
contributed to refining the research objectives and conceptualisation of the study,
conducted statistical analyses and interpreted the results. MGA assisted in refining
the methodological approach and methodological decisions, led the data collection
efforts, organised and managed datasets, and ensured data quality and integrity.
MTT conducted statistical analyses, interpreted the results, drafted the initial
manuscript, outlining the research background, methodology and results, and
reviewed the manuscript. HBA acts as a guarantor.
Funding The authors have not declared a specific grant for this research from any
funding agency in the public, commercial or not-­for-­profit sectors.
Competing interests None declared.
8 Alemayehu HB, et al. BMJ Open 2024;14:e077552. doi:10.1136/bmjopen-2023-077552
BMJ Open: first published as 10.1136/bmjopen-2023-077552 on 21 February 2024. Downloaded from http://bmjopen.bmj.com/ on February 22, 2024 by guest. Protected by copyright.
Patient and public involvement Patients and/or the public were not involved in
the design, or conduct, or reporting, or dissemination plans of this research.
Patient consent for publication Consent obtained directly from patient(s).
Ethics approval This study involves human participants and was conducted
as per the principles laid down in the Declaration of Helsinki. Ethical approval
was obtained from the Ethical Review Committee of the University of Gondar,
College of Medicine and Health Sciences, School of Medicine (reference number:
SOM/1556/2022). Moreover, an official permission letter was obtained from the
medical director of Adare General Hospital. Each study participant provided written
informed consent after being given a detailed explanation about the purpose of the
study. All study participants were informed of their right to withdraw from the study
at any time. Confidentiality was maintained by omitting any personal identifiers
from the data collection tool. Finally, participants with sight-­threatening diabetic
retinopathy and other ocular problems were referred to an eye clinic for proper
therapy and follow-­up.
Provenance and peer review Not commissioned; externally peer reviewed.
Data availability statement All data relevant to the study are included in the
article or uploaded as supplemental information.
Open access This is an open access article distributed in accordance with the
Creative Commons Attribution Non Commercial (CC BY-­NC 4.0) license, which
permits others to distribute, remix, adapt, build upon this work non-­commercially,
and license their derivative works on different terms, provided the original work is
properly cited, appropriate credit is given, any changes made indicated, and the use
is non-­commercial. See: http://creativecommons.org/licenses/by-nc/4.0/.
ORCID iDs
Henok Biruk Alemayehu http://orcid.org/0000-0002-1604-437X
Melkamu Temeselew Tegegn http://orcid.org/0000-0003-1519-3848
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