**Background**
Diabetic retinopathy (DR) is a common microvascular complication of diabetes mellitus (DM) and a leading cause of preventable blindness worldwide. In Saudi Arabia, the prevalence of DM in adults is 17.7%, and retinopathy affects 28.1% to 45.7% of diabetic patients. DR accounts for 4.8% to 17.5% of vision-threatening conditions among diabetics. Despite established guidelines recommending annual eye examinations for those with retinopathy and initial screening at diagnosis for type 2 DM, many patients do not participate in DR screening due to lack of awareness. This study aimed to assess the knowledge, attitude, and practice (KAP) regarding DR screening and eye management among diabetic individuals in Saudi Arabia to identify gaps and inform future educational initiatives.
**Methods**
This cross-sectional study was conducted in Saudi Arabia from October 2022 to January 2023. Inclusion criteria were Saudi and non-Saudi diabetic patients aged 18 years and older who consented to participate. Exclusion criteria were non-diabetic individuals, those under 18, and those living outside Saudi Arabia. The sample size was calculated using Open Epi Version 3.0, based on an estimated 7 million diabetic patients in Saudi Arabia, a 95% confidence interval, and a 50% frequency percentage, requiring 384 participants; the study aimed to maximize the sample to 1,391 participants, distributed equally across five regions. Data were collected via an organized, self-administered online questionnaire (Arabic version) adapted from a previous study. The questionnaire included sections on demographics, disease characteristics, diabetic complications, knowledge (yes/no responses), attitude (five-point Likert scale), and practice (yes/no responses). Knowledge and attitude were graded as good/positive if the score was ≥60%; practice was considered safe if the sum of responses was >50%. A pilot study of 40 patients was conducted, and Cronbach's alpha coefficients were 0.77 (knowledge), 0.83 (practice), and 0.69 (attitude). The survey was distributed via WhatsApp, Twitter, Snapchat, and Facebook. Statistical analysis used frequencies, percentages, chi-square tests, and Pearson correlation coefficients, with significance set at p<0.05. Ethics approval was obtained from Umm Al-Qura University (approval number: APO-02-K-012-2022-11-1228).
**Key Results**
A total of 1,391 diabetic patients completed the questionnaire. Among participants, 859 (61.8%) were female, 565 (40.6%) were aged 18–30 years, 816 (58.7%) had a university degree, and 652 (46.9%) had type 2 DM (T2DM). Self-reported diabetic complications included DR in 191 (13.7%), glaucoma in 161 (11.6%), and cataracts in 139 (10.0%). Overall, 736 (52.9%) patients had good knowledge, 1,124 (80.8%) had a positive attitude, and 1,000 (71.9%) had good practice regarding DR screening and management. Good knowledge was significantly associated with higher educational level (p=0.017), T2DM (59.4% vs. 54.3% for type 1 DM; p=0.001), longer duration of DM (p=0.023), and injection therapy (61.8%; p=0.001). Positive attitude was significantly associated with region of residence (central region 85.0% vs. southern region 75.6%; p=0.038), not working/studying in the health field (82.9% vs. 73.7%; p=0.001), and T2DM (84.2% vs. 79.4% for type 1 DM; p=0.003). Good practice was significantly associated with region (southern region 35.6% vs. others; p=0.015), older age (41.7% in >60 years vs. 23.2% in 18–30 years; p=0.001), lower education (38.1% in below high school vs. 27.0% in college degree; p=0.041), T2DM (p=0.001), longer duration (40.6% in >15 years vs. 17.7% in <1 year; p=0.001), and injection therapy (p=0.001). Pearson correlation showed significant positive correlations between knowledge and attitude (r=0.14, p=0.001), knowledge and practice (r=0.27, p=0.001), and attitude and practice (r=0.8, p=0.008).
**Clinical Implications**
This study reveals that while most diabetic patients in Saudi Arabia have a positive attitude and good practice regarding DR screening, only about half have adequate knowledge. The significant associations between knowledge and factors such as education, diabetes type, duration, and treatment type suggest that targeted educational interventions are needed, particularly for patients with lower education, type 1 DM, shorter disease duration, and those not on injection therapy. The unexpected finding that healthcare workers had less positive attitudes warrants further qualitative investigation. The positive correlation between knowledge, attitude, and practice supports the potential of education to improve screening adherence. Given the high prevalence of diabetes and DR in Saudi Arabia, coordinated efforts between health authorities and media to raise awareness, along with interactive interviews and medical record reviews in clinical settings, are recommended to enhance early detection and prevent vision loss.