Use of Eye Care Services Among Diabetic Patients in Urban Indonesia

Diabetes and diabetic retinopathy (DR) are major public health problems in Indonesia. Recent studies have found an urban diabetes prevalence of 5.7% in individuals older than 15 years¹ and the total number of diabetic individuals is expected to reach 21.3 million by 2030,² giving Indonesia the fourth-largest number of diabetic individuals in the world.² Nearly all people with type 1 diabetes and 60% of those with type 2 diabetes will develop DR.³ In the Indonesian national VISION 2020 program, DR is acknowledged as a significant public health problem, but no strategies have yet been identified to manage it.

Although DR is one of the most common and devastating consequences of diabetes, high-quality trial data have demonstrated that significant reductions in risk may be achieved with tight glucose control,^{4 - 5} treatment of hypertension^{6 - 8} and hypercholesterolemia,⁹ and timely laser treatment.¹⁰ Laser treatment for DR is highly cost-effective and even cost saving.^{11 - 12} Annual examination with dilation of the pupil is widely recommended for patients with diabetes.^{13 - 16}

However, poor compliance with sight-saving treatment is common in many areas. In the developed world, one- to two-thirds of patients fail to comply with this standard^{17 - 18} ; in the developing world, the proportion receiving recommended ocular examinations may be even lower.^{19 - 21} In Indonesia, compliance is poor with guidelines for glucose and blood pressure control shown to reduce the risk of DR: Indonesian patients had the highest level of hemoglobin A_1c, the second-highest rate of hypertension, and the worst rate of hemoglobin A_1c monitoring among 11 countries surveyed in Asia and the West Pacific.²² However, little is known about the use of eye care among Indonesian diabetic individuals.

We performed a study in 1 tertiary and 2 community clinics in Jakarta, Indonesia, to evaluate the frequency of eye examinations among known diabetic patients in urban Indonesia. Potential predictors of failure to receive examinations were analyzed to provide a basis for strategies to improve the use of eye care services in this rapidly expanding group of patients.

A tertiary facility and 2 community health clinics located in separate areas of Jakarta were selected to represent the range of care available in urban Indonesia. Ethical approval was obtained from the University of Indonesia Ethical Review Board. All subjects gave written informed consent, and the study was conducted between March 17 and 24, 2009, in accordance with the tenets of the World Medical Association's Declaration of Helsinki.

The selected tertiary facility is the endocrinology clinic at Cipto Mangunkusumo Hospital, a national referral center and the main teaching hospital for the University of Indonesia Faculty of Medicine. The daily clinic volume is 50 patients, and the cost of services for patients without government social welfare insurance (who receive free care) is as follows: ocular examination with dilation of pupil, US $6.50; fundus photograph, US $10 to $11. Physicians providing diabetic care in the clinic include endocrinology consultants, clinical fellows, and internal medicine residents. Referrals for eye examinations are seen in the eye clinic of Cipto Hospital, which is located on another floor of the same building. Examinations are available on the same day as the general diabetic examination depending on the time of day and are provided by retinal specialists and ophthalmology residents. Facilities for diabetic eye examinations in the ophthalmology clinic include a digital fundus camera, Stratus optical coherence tomography, and a B-scan ultrasonographic unit.

The selected community health clinics are the diabetes clinic in Tebet Government Primary Health Center, with up to 20 diabetic patients seen daily, and the diabetes clinic in Kayu Putih Primary Health Clinic, recently opened in 2008, where fewer than 10 diabetic patients are seen daily. Diabetic care in both clinics is carried out by general health care practitioners and internists. Examination costs are similar to those at the tertiary clinic. The ophthalmology clinic in both facilities is located in the same building as the diabetes clinic but is open only 2 or 3 days a week. Diabetic examinations in the eye clinics are performed by senior ophthalmology residents from the University of Indonesia Faculty of Medicine, and patients requiring treatment are referred to the University of Indonesia Faculty of Medicine.

The methods of our study were designed to replicate those used in a companion investigation in Guangdong, China.²¹ Between February and April 2009, patients aged 18 years and older with physician-diagnosed diabetes were consecutively recruited from the 3 clinics described earlier, excluding those diagnosed less than 12 months previously or unable to cooperate with the interview. All interviews were conducted by a trained interviewer fluent in Bahasa Indonesian (C.O.).

The principal outcome of this study was having had an eye examination within the 12 months prior to the interview. In all of the clinics, a patient receiving an eye examination at the facility would receive a color-coded consultation form in his or her record. If no such form was found, patients were specifically asked whether their eyes had been examined within the last year and where, to exclude the possibility of an unrecorded examination at an outside facility.

All subjects reporting eye examinations were queried specifically as to whether the eyes were actually examined by an eye care professional after dilating the pupils. Routine examinations for glasses and minor complaints without dilation of the pupil were not included.

The study questionnaire additionally contained 4 sections: general and demographic information including age, sex, and contact information; socioeconomic status, including educational level, monthly income, and details of medical insurance; vision care status, including date of the most recent eye examination and instructions received from the health care provider; and knowledge about DR, including attitudes, beliefs, awareness, concerns, and actual practice regarding DR. Questions were constructed in a multiple-choice or true/false format. Interviewers were trained to instruct the participants to avoid giving responses of not sure or unknown. Patients without an eye examination in the last year were asked to select the reason from a list of possible responses generated during pilot testing at one of the clinics.

Additionally, a record review was carried out for all subjects. The following data were abstracted: type and duration of diabetes, use of insulin, and presence or absence of hypertension and hypercholesterolemia.

To represent subjects' knowledge of DR, a score was calculated based on responses to 6 questions in the knowledge section, with 1 point awarded for a correct response and 0 points for an incorrect or uncertain answer. All questions were in a true/false format, except for a question asking how frequently diabetic patients should receive eye examinations, where 1 point was given for answers of every 2 years or more frequently and 0 points for answers indicating longer periods, never, or don't know. Univariate analyses were carried out to evaluate differences between examined and unexamined patients with regard to potential demographic, socioeconomic, and medical predictors. The χ² test and t test were used to compare categorical and continuous outcomes, respectively. Fisher exact test was used when the expected percentages in the cells were less than 5%. All variables significant at the .05 level in univariate analyses were then entered into multiple logistic regression models. Odds ratios (ORs) and 95% confidence intervals (CIs) were calculated for all potential predictors of having had an eye examination in the last 12 months. P < .05 was considered statistically significant. Data analysis was performed using Stata version 9.0 statistical software (StataCorp LP, College Station, Texas).

A total of 198 diabetic subjects meeting inclusion criteria were approached to participate in the study. Two subjects declined to take part and 196 (99.0%) agreed. The 2 patients who declined to participate were a 67-year-old woman and a man of unrecorded age. The mean (SD) age of the 196 participants undergoing interview and record review was 58.4 (9.4) years, and 61.5% were female. Type 2 diabetes had been diagnosed in 100% of participants. The mean (SD) duration of known diabetes history was 5.58 (6.01) years. Comorbid hypertension and hypercholesterolemia were present in 56.6% and 37.2% of subjects, respectively. A total of 119 patients (60.7%), 26 patients (13.3%), and 51 patients (26.0%) were enrolled from the university hospital and Kayu Putih and Tebet community health clinics, respectively.

Among these respondents, only about one-sixth (30 patients [15.3%]) had undergone an eye examination in the 12 months prior to the interview. Forty-five of the 196 patients (23.0%) had never had an eye examination.

In univariate analyses of demographic characteristics, age, sex, education, income, and insurance coverage were not significantly associated with having had an examination in the last year (Table 1).

Unexamined patients were less likely than examined patients to have been informed by their health care provider that an eye examination should be a regular part of diabetes care (37.6% vs 66.7%, respectively; P = .003) and to wear glasses daily (78.8% vs 93.3%, respectively; P = .05). Rates of examination at the university diabetes clinic did not differ significantly from those at the 2 community clinics (Table 2).

Knowledge about DR was significantly poorer among subjects without eye examinations. Fewer such patients knew that diabetes can cause blindness than examined patients (33.7% vs 63.3%, respectively; P = .002), and their DR knowledge scores were significantly worse (P < .001) (Table 3).

On record review, patients having had examinations had more severe diabetes and comorbidities compared with unexamined subjects. They were more likely to have a history of hypertension (76.7% vs 56.1%, respectively; P = .04) and hypercholesterolemia (59.3% vs 36.8%, respectively; P = .03), and their duration of disease was longer (mean, 8.93 vs 4.97 years, respectively; P < .001) (Table 4).

In multiple logistic regression models of potential predictors of having an eye examination in the last year (Table 5), significant independent correlates included having a higher DR knowledge score (OR = 1.52; 95% CI, 1.09-2.11; P = .01) and years since being diagnosed as having diabetes (OR = 1.56; 95% CI, 1.09-2.78; P = .04 for second vs first tertile; OR = 1.71; 95% CI, 1.49-4.78; P = .02 for third vs first tertile) (Table 5).

When asked about their reasons for not having sought eye examinations, 160 of 166 unexamined subjects (96.4%) responded. The most common reasons were “felt vision was good, no need to examine the eyes” (72 of 160 [45.0%]), “felt examination was inconvenient” (28 of 160 [17.5%]), and “did not know the eyes should be examined regularly” (25 of 160 [15.6%]). Financial reasons were cited by only 22 of 160 respondents (13.8%) (Table 6).

Our results indicate that fewer than 1 in 6 persons (15.3%) diagnosed as having diabetes in 3 urban Indonesian clinics has received an eye examination in the last year. This figure is roughly one-half the rate of examinations observed in a study using the identical protocol and questionnaires in southern China (33%) and is even lower than the 19% of diabetic patients with recent examinations in the rural site included in the Chinese study.²¹ The rate of recent examinations observed in Indonesia was considerably lower than those reported for the developed world (35%-60%),^{23 - 24} even among ethnic minority groups at risk for poor access to health care (35%-42%).^{18 ,25} Although few other data are available for the developing world, the observed rate of examinations within the last 12 months in Indonesia was lower than the rate of 29% reported for Tanzania.¹⁹

Although the rates of compliance with standard eye examination were quite low in Indonesia, it does not appear that financial barriers were of paramount importance in preventing patients from seeking care. Education, income, housing area, and insurance coverage were not significantly associated with having had recent eye care in either univariate or multivariate analyses (Table 1). Furthermore, financial barriers were cited by only an eighth of unexamined respondents when asked why they had not sought examinations. The finding that financial barriers were not significantly associated with the uptake of eye care is consistent with reports from elsewhere in Asia regarding cataract surgery^{26 - 27} and also with the results of our companion study of diabetic eye examinations in China.²¹ This is in contrast with several studies from the United States, which did find financial barriers important in determining acceptance of eye care among diabetic persons.^{24 ,28 - 29} While it might in theory be argued that cultural differences (such as lack of comfort in discussing financial difficulties in Asia) could underlie the relative lack of prominence given to financial barriers in patients' responses there, this is unlikely to explain the absence of an association between eye examinations and income, housing size, and insurance status in logistic models in both Indonesia and China.²¹ Because more than a third (12 of 30 patients [40.0%]) of those who did receive eye examinations in Indonesia paid out of pocket (Table 1), it appears that the cost of services there may be sufficiently affordable to patients that it does not constitute an impediment to care.

A consistent finding in this study and the companion investigation in China²¹ is the importance of knowledge as a determinant of care seeking. A higher DR knowledge score was significantly associated with having been examined recently in both Jakarta and Guangdong.²¹ Furthermore, 97 of 160 unexamined patients (60.6%) in Indonesia gave responses indicative of a lack of understanding of the role of eye examinations in unsymptomatic diabetic patients when asked why they had not sought care (this figure includes 72 patients who “felt vision was good, no need to examine the eyes” and 25 who “did not know the eyes should be examined regularly”) (Table 6). These findings echo those of recent studies of cataract surgery^{26 - 27} and refraction^{30 - 31} in highlighting the lack of knowledge as a barrier to eye care in Asia. They are also consistent with reports from the developed world indicating that lack of knowledge presents a major barrier to DR care.^{17 - 18 ,32} This includes the mistaken belief that DR is usually symptomatic,³³ an opinion held by three-quarters of all patients (145 of 196 [74.0%]) enrolled in this study.

As in the companion report from China,²¹ it appears that physician as well as patient education is an important determinant of receiving timely diabetic eye care: fewer than half of all patients (82 of 196 [41.8%]) reported having been told of the need for a regular eye examination by their physician. Whether or not this accurately reflects the content of physician-patient discussions in this setting, it appears clear that optimal communication of an important piece of diabetic health education has not occurred. A further indication of the need for physician education in this setting is the fact that even in the tertiary diabetic clinic, only 1 in 6 patients (19 of 119 [16.0%]) reported having had an eye examination within the last year. This may be contrasted to a figure of 55% for the tertiary care clinic surveyed in Guangdong.²¹

This study has several practical implications for program planners in Indonesia. More than 80% of diabetic patients appear not to be receiving optimal eye care, even in the capital, Jakarta. It is likely that the true scope of the problem may be even larger: a recent population-based study in urban Indonesia reported that only about one-quarter of diabetes was diagnosed.¹ Access to eye care is presumably even worse among the majority of diabetic persons with unrecognized disease. The results of this study suggest that educational strategies aimed at both patients and physicians are needed. It is encouraging that the majority of patients even without recent examinations were aware that persons with diabetes are at risk for eye disease and that regular eye examinations are needed. It appears that the challenge is to educate patients about how regularly these examinations are needed, as is supported by the fact that three-quarters of patients had ever had an eye examination, a higher figure than reported in our companion study in China.²¹ Available results suggest that long-term educational interventions aimed at both patients^{19 ,34 - 35} and health care providers³⁵ can have a sustained impact on a variety of diabetes care outcomes, including improved compliance with eye examinations, hemoglobin A_1c level, and serum creatinine level.

The results and implications of this study must be evaluated in the context of its limitations. The study was not population based and included only 3 urban clinics; for this reason, the results may be applied to other cohorts and locations only with caution. The results, however, are consistent in most respects with our companion study conducted with the same protocol in urban and rural southern China. The cross-sectional design raises potential questions of inference with regard to cause and effect. We have presumed in our discussion that better knowledge of diabetes and DR results in a greater likelihood of receiving optimally scheduled eye examinations. However, the possibility cannot be excluded that receiving a diabetic eye examination could in and of itself lead to an increase in knowledge. Prospective studies of educational interventions would be needed to establish cause and effect with greater certainty. Finally, the limitations of true/false questions in gauging knowledge and of the small sample size of recently examined patients must also be acknowledged.

Despite its limitations, this study provides some of the first data of which we are aware on uptake of sight-saving care among diabetic individuals in one of the world's most populous countries. Our results suggest concrete strategies to improve the current poor access to vision services in this rapidly growing group.