Retinal screening remains below target in a diabetes clinic with eye care on site
Among adults with diabetes receiving follow-up at Menelik II Comprehensive Specialized Hospital in Addis Ababa, fewer than four in ten completed retinal screening at an adequate frequency. The finding is difficult to ignore because diabetic retinopathy is one of the most preventable causes of vision loss, yet it develops silently for long stretches before symptoms appear. Once visual complaints emerge, structural retinal injury may already be advanced, and prevention has already slipped into delayed rescue care.
The study enrolled adults with type 1 or type 2 diabetes who had been on follow-up for at least three months and used interviewer-administered questionnaires to assess knowledge, attitude, and screening behavior. Of 404 patients approached, 371 were included in the analysis, giving a response rate of 91.8%. Adequate diabetic retinopathy screening practice was present in 139 participants, or 37.5% of the cohort. The gap is striking because the hospital setting already co-located eye services with diabetes care, removing one of the most familiar structural barriers to referral.
A single sentence captures the clinical problem: access alone did not produce prevention.
Knowledge, prior eye disease, and education tracked closely with screening behavior
The strongest predictor of adequate practice was adequate knowledge, which carried an adjusted odds ratio of 5.10. Patients who already knew enough about diabetic eye disease were far more likely to act on that knowledge, which fits the biology and the behavior. Retinopathy is asymptomatic until retinal microvascular injury has progressed, so a patient who understands the disease must act before vision changes occur; without that understanding, screening is easily postponed in favor of more immediate concerns such as glycemic control, medication access, or work obligations.
A known eye disorder also predicted screening practice, with an adjusted odds ratio of 3.96. The pattern suggests that many examinations were triggered by existing ocular symptoms or diagnoses rather than by preventive routines. In practical terms, patients appear more likely to seek retinal assessment after the eye has already become part of the clinical story. Prevention is being initiated by disease visibility, not by disease risk.
Higher education was associated with better screening practice as well, with an adjusted odds ratio of 3.82. Education likely improves health literacy, the ability to interpret chronic risk, and the confidence needed to navigate specialty care. Age also played a role: participants aged 41 to 65 years were more likely to demonstrate adequate practice than younger adults, with an adjusted odds ratio of 3.15. Married participants also had higher odds of adequate screening practice, with an adjusted odds ratio of 1.73, suggesting that social support may help sustain follow-up behavior in a chronic disease that demands repeated appointments over years, not weeks.
The screening gap was behavioral, not infrastructural alone
The most important clinical message from this cohort is not that ophthalmology was unavailable. It was available. Yet screening still lagged. The mismatch points toward a failure of routine integration during diabetes follow-up, where retinal examination should function as a standard preventive step rather than a separate, optional action. When patients must recognize the need, remember the timing, overcome travel costs, and sacrifice work or family responsibilities, uptake predictably falls.
The study identified cost, lack of time, and travel distance as the leading barriers. Each of those obstacles is familiar in chronic disease care, but together they create a cascade that pushes a preventive eye exam to the bottom of the list. Cost can deter even when fees are modest. Time pressure is especially important for adults managing employment or caregiving. Distance remains a blunt but powerful barrier, particularly when a clinic visit requires coordination across multiple services or multiple days.
This is where a co-located eye service should matter most, yet its benefit depends on a direct referral pathway, active counseling, and a workflow that does not rely on patient initiative alone. A diabetes clinic that measures glucose, reviews medications, and discusses complications can also make retinal screening a default element of care. If that step is left to patient memory, the system quietly converts a preventive intervention into an elective one.
Preventive eye care needs to be built into the diabetes visit
The prevalence of adequate knowledge in this cohort was 62.0%, and 72.8% of participants had a favorable attitude toward screening. Those numbers are higher than the screening rate itself, which means awareness and positive sentiment were not enough to ensure action. This separation between attitude and behavior is common in chronic disease management, but it has a specific consequence in diabetic retinopathy: the retina does not wait for readiness. It deteriorates according to vascular injury, duration of hyperglycemia, and cumulative exposure to metabolic stress.
That biological reality argues for system-level solutions. Patient education during diabetes follow-up should explicitly connect hyperglycemia with retinal microvascular damage, not just mention eye checks in passing. Referral should be immediate and visible. Eye review should be framed as part of routine diabetes surveillance, not as a separate specialty errand that patients must organize on their own. For patients with known eye disease, the association with better practice suggests a teachable moment: once ocular pathology becomes real, adherence improves. The challenge is to create that same urgency before symptoms appear.
The findings also raise a broader concern for tertiary care settings that assume proximity equals access. The data show otherwise. Even in a hospital with on-site specialist eye care, many adults with diabetes still did not meet the threshold for adequate screening practice. Structural availability does not guarantee preventive use unless the care pathway is built to trigger action automatically.
Why this cohort matters for diabetic eye disease prevention
Diabetic retinopathy is often framed as a complication of long-standing diabetes, but its public health burden depends on something simpler: whether patients are screened before symptoms force the issue. In this Ethiopian cohort, the preventive system was underused despite a favorable setting for referral. The association with knowledge, education, and existing eye disease points toward a care process that activates too late and too unevenly.
The study was cross-sectional, so it cannot establish causality, and it did not measure long-term visual outcomes. Even so, the screening gap itself is clinically meaningful. When only 37.5% of adults with diabetes undergo adequate retinal examination, preventable vision loss remains a credible future outcome, not a distant one. The next step is not more evidence that diabetic retinopathy is dangerous. The next step is a diabetes clinic workflow that treats retinal screening as routine preventive medicine, because patients are unlikely to close that gap on their own.