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Scientific Reports volume 15, Article number: 40094 (2025) Cite this article

Abstract

Good near-visual acuity is essential for the independent administration of insulin and monitoring of diabetes. Older individuals with diabetes often experience a significant rate of near-visual impairment, which can impact their future functional status and quality of life. Despite this, there is limited evidence regarding the prevalence of near-visual impairment and its associated factors in Africa, including Ethiopia. This study aimed to determine the prevalence and associated factors of near visual impairment among adult diabetic patients attending the diabetic care clinic of Adare General Hospital in southern Ethiopia, 2023. A hospital-based cross-sectional study was conducted on 503 adult diabetic patients at Adare General Hospital in southern Ethiopia from April 23 to June 8, 2023. Systematic random sampling was employed to select the participants for the study. Data were collected through face-to-face interviews, medical record reviews, and eye examinations. To identify potential factors associated with near visual impairment, binary logistic regression was performed. The strength of the associations was expressed as adjusted odds ratios with a 95% confidence interval. A variable with a P-value of less than 0.05 was considered statistically significant. The prevalence of NVI was 75% (95%CI: 71.1–78.7). Age greater than 65 years (AOR = 5.38, 95% CI: 2.00–14.48), being married (AOR = 4.09, 95% CI: 2.01–8.34), diabetes duration of ≥ 7 years (AOR = 2.43, 95% CI: 1.31–4.52), hypertension (AOR = 2.06, 95% CI: 1.02–4.21), distance visual impairment (AOR = 3.59, 95% CI: 1.35–9.55), and diabetic retinopathy (AOR = 7.46, 95% CI: 3.06–18.19) were positively associated with near visual impairment. This study revealed a high prevalence of near visual impairment among adult diabetic patients, significantly associated with older age, marital status, longer duration of diabetes, hypertension, distance visual impairment, and diabetic retinopathy. Routine near vision screening and timely optical correction should be considered as part of comprehensive diabetic care.

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Introduction

Near-Visual Impairment (NVI) is a major public health concern affecting approximately 1.8 billion people worldwide, of whom 826 million suffer from NVI due to inadequate or lack of vision correction1. While most research on visual impairment in diabetic populations has focused on distance vision2,3, near vision is equally critical, particularly for older adults, as it directly affects the ability to perform daily activities such as reading, cooking, and managing medications4. Both near and distance visual impairment have been linked to a significant decline in functional abilities over time, and having both types of impairment may lead to even greater challenges5.

Evidence from international studies indicates that NVI is linked to limitations in basic and instrumental activities of daily living, as well as reduced social participation6. In people with diabetes, the prevalence of NVI is notably higher, and it may further exacerbate functional decline and reduce quality of life7,8,9. Several factors including older age, rural residency, low educational level, poor weight management, smoking, alcohol consumption, and hypertension have been identified as contributors to the onset and progression of NVI, underscoring the multi-factorial nature of the condition8,10,11,12,13,14. Despite these insights, most studies have been conducted in non-African populations, and there is limited evidence on the burden and determinants of NVI among diabetic patients in African settings.

In Ethiopia, diabetes mellitus has emerged as a growing public health challenge15. Maintaining good near vision is essential for diabetic patients to manage daily self-care tasks effectively, including reading medication labels, self-monitoring blood glucose, and adhering to treatment regimens9. However, the prevalence of near visual impairment and its associated factors remain poorly characterized in the Ethiopian context, representing a critical knowledge gap. Addressing this gap is essential to inform the planning and prioritization of healthcare programs aimed at the early detection and management of NVI among diabetic patients.

Therefore, this study aimed to assess the prevalence and associated factors of near visual impairment among diabetic patients attending a diabetic care clinic in South Ethiopia in 2023. The findings are expected to provide evidence to guide interventions that improve functional independence and quality of life in this population.

Method and materials

Study design and setting

A hospital-based, cross-sectional study was conducted at the diabetic care clinic of Adare General Hospital from April 23 to June 8, 2023. Adare General Hospital is located in Hawassa City, the capital of the Sidama Regional State, which is approximately 275 km from Addis Ababa. According to the hospital’s planning and information office, it provides both preventive and curative healthcare services to nearly three million people. Additionally, Adare General Hospital offers diabetic care to over 600 patients each month.

Source and study population

The study included all adult patients aged 18 years and older with either type I or type II diabetes who were receiving diabetic care at Adare General Hospital during the survey period. However, we excluded adult patients who were admitted to the inpatient unit due to serious illnesses, those with gestational diabetes, patients with mental health issues who were unable to complete the questionnaire, and those with less than three months of follow-up.

Sample size determination and sampling procedures

The sample size was determined using a single population proportion formula. The expected proportion of NVI among diabetic patients was estimated at 76.12%, based on a similar study conducted in the Republic of Congo13, 95% confidence level and maximum allowable error of 4%. The calculated sample size was 437. The initial calculated sample size was 437 participants. After accounting for a non-response rate of 15%, the final required sample size increased to 503. To select the study participants, a systematic random sampling procedure was employed with an interval of 2. The first participant was chosen by drawing a single number using a lottery method, and subsequent participants were selected at every Kth interval. The interval (K) was determined by dividing the expected number of diabetic patients visiting the clinic during the data collection period (N = 1024) by the calculated sample size (n = 503), resulting in K = N/n.

Operational definitions

NVI is defined as a presenting near visual acuity (PNVA) worse than 6/12 (20/40) at 40 cm16. It is classified as mild (worse than 6/12–6/18, N8–N10), moderate (worse than 6/18–6/60, N10–N18), and severe (worse than 6/60, N18)17,18.

Symptomatic dry eye was defined as those participants who had a score of 13 and above points based on the OSDI questionnaire19,20.

Blood glucose control was classified as good when the current fasting blood glucose (FBS) level was < 152 mg/dl, and poor when ≥ 152 mg/dl21.

Body mass index (BMI) was calculated as weight in kilograms divided by height in meters squared (kg/m²) and classified according to World Health Organization criteria: normal (18.5–24.9), and abnormal includes underweight (< 18.5), overweight (25–29.9), and obese (≥ 30)23.

Distance visual impairment was defined as presenting distance visual acuity worse than 6/12 in the better eye, according to the International Classification of Diseases 11th definition of visual impairment24.

Diabetic retinopathy was diagnosed and classified based on the Early Treatment of Diabetic Retinopathy Study25.

Data collection tools and procedure

Data were collected through personal interviews, medical record reviews, and eye examinations. Two trained nurses conducted the personal interviews and medical record reviews, including the measurement of participants’ height and weight. Eye examinations were performed by two experienced optometrists.

The nurses carried out face-to-face interviews using a pretested and structured questionnaire that gathered information on Sociodemographic characteristics such as age, sex, marital status, residence, educational and occupational status, and monthly income. The questionnaire also included behavioral data like cigarette smoking, use of visual display devices, sleep duration, and sunlight exposure, as well as ocular histories that covered intravitreal injections, pan-retinal photocoagulation, vitrectomy, cataract surgery, and prior eye examinations. Additionally, data on systemic comorbidities, including asthma and sinusitis, were collected along with responses to the Ocular Surface Disease Index (OSDI) questionnaire19,20. The reliability of the questionnaire was assessed with a Cronbach’s alpha value of 0.94. Clinical data related to diabetes, such as type, fasting blood glucose level, duration of diabetes, treatment type, and other systemic comorbidities like hypertension, heart disease, dyslipidemia, diabetic neuropathy, arthritis, thyroid disease, and Parkinson’s disease were recorded from the participants’ medical records. Weight was measured using a balance-beam scale, and height was recorded with a wall-mounted stadiometer, with participants dressed in underwear and without shoes.

After completing the interviews, all participants underwent a comprehensive eye examination. Initially, distance visual acuity was assessed in each eye using a Snellen chart (tumbling E) at a distance of 6 m under good lighting conditions. Next, near visual acuity was evaluated in the right eye, left eye, and both eyes at a distance of 40 cm, also utilizing a Tumbling E chart under normal room illumination. Binocular visual acuity was used to assist in diagnosing NVI. Finally, a slit-lamp biomicroscope equipped with a 90-diopter Volk lens was employed for the posterior segment eye examination, with the pupils dilated using 1% tropicamide eye drops to diagnose diabetic retinopathy.

Data processing and analysis

After verifying the completeness and consistency of the data, we entered it into the Epidemiological Information (EPI INFO) 7 software and subsequently exported it to the Statistical Package for Social Sciences (SPSS) version 25 for analysis. We assessed multicollinearity using the variance inflation factor and tolerance metrics. Proportions and summary statistics were calculated for the descriptive data. We conducted bivariable binary logistic regression, followed by multivariable binary logistic regression, to identify potential factors associated with NVI. The strength of the association between the dependent and independent variables was expressed as an adjusted odds ratio (AOR) with a 95% confidence interval (CI). To ensure model fitness, we employed the Hosmer and Lemeshow goodness of fit test. A variable was considered statistically significant if its P value was less than 0.05.

Results

Socio-demographic and behavioral characteristics of the study participants

A total of 488 participants were enrolled, with a response rate of 97.0%. The median age was 56 years (IQR: 47–65). Of these, 260 (53.3%) were male, 421 (86.3%) were married, and 284 (58.2%) had no formal education. Nearly half of the participants 249 (51.0%) reported a history of eye examinations, and 157 (32.2%) reported using spectacles (Table 1).Table 1 Socio-demographic characteristics of study participants and distribution of near visual impairment among adult diabetic patients attending Adare general hospital in Southern Ethiopia, 2023 (n = 488).

Full size table

Clinical and systemic Co-Morbidities of the study participants

In this study, most participants (352, 72.1%) were diagnosed with type II diabetes, and nearly half (225, 46.1%) exhibited poor glycemic control. A history of hypertension was reported by 145 participants (29.7%). Visual complications were also common, with 150 participants (30.7%) experiencing distance visual impairment and 206 (42.2%) diagnosed with diabetic retinopathy (Table 2).Table 2 Clinical and systemic co-morbidities of adult diabetic patients attending Adare general hospital in Southern Ethiopia, 2023 (n = 488).

Full size table

Prevalence of near visual impairment

The prevalence of near visual impairment in this study was 75% (95% CI: 71.1–78.7). Among affected participants, 61 (12.5%) had mild, 176 (36.1%) had moderate, and 129 (26.4%) had severe NVI. The condition was particularly common in participants over 65 years (90.8%), males (77.3%), those living in rural areas (81.4%), and individuals with type I diabetes (78.7%) (Table 3).Table 3 Age, sex, residency, and type of diabetes-specific prevalence of presenting near visual impairment among diabetic patients attending Adare general hospital in Southern Ethiopia, 2023 (n = 488).

Full size table

Factors associated with near visual impairment

In the bivariable binary logistic regression analysis, factors such as age, residency, marital status, occupational status, duration of diabetes, glycemic control, body mass index, hypertension, distance visual impairment, symptomatic dry eye, and diabetic retinopathy were found to be independently associated with NVI. However, in the multivariable binary logistic regression analysis, the significant factors associated with NVI included older age, marital status, duration of diabetes, hypertension, distance visual impairment, and diabetic retinopathy.

Participants older than 65 years were 5.38 times more likely to have NVI (Adjusted Odds Ratio [AOR] = 5.38, 95% CI = 2.00, 14.48) compared to those aged 45 years or younger. Participants who were married were 4.09 times more likely to experience NVI compared to those who were unmarried (AOR = 4.09, 95%CI = 2.01, 8.34).

Additionally, participants with a diabetes duration of seven years or more since diagnosis had odds of developing NVI that were 2.43 times higher than those with a duration of less than seven years (AOR = 2.43, 95% CI = 1.31, 4.52). Furthermore, participants with hypertension were 2.06 times more likely to develop NVI than their counterparts without hypertension (AOR = 2.06, 95% CI = 1.02, 4.21).

Participants with distance visual impairment had a 3.59 times higher likelihood of experiencing NVI compared to those without distance visual impairment (AOR = 3.59, 95%CI = 1.35, 9.55). Moreover, individuals with diabetic retinopathy were 7.46 times more likely to have NVI than those without diabetic retinopathy (AOR = 7.46, 95% CI = 3.06 to 18.19) (Table 4).Table 4 Factors associated with near visual impairment among adult diabetic patients attending Adare general hospital in Southern Ethiopia, 2023 (n = 488).

Full size table

Discussion

Based on our comprehensive literature review, the prevalence of near visual impairment and its associated factors among diabetic patients are not well understood in the Ethiopian context, highlighting a significant knowledge gap. Filling this gap is crucial for guiding the planning and prioritization of healthcare programs focused on the early detection and management of near visual impairment among diabetic patients.

In this study, the prevalence of near visual impairment was 75% (95%CI: 71.1, 78.7). This finding is consistent with studies conducted in Finote Selam, Ethiopia 78.69%26, India 73.8%27 and North China 78.1%28.

However, it is lower than previous studies conducted in Brazil 81.1%11, and Inner Mongolia 80.3%18. This discrepancy may be attributed to variations in socio-demographic characteristics and the definitions of NVI. For instance, in the Brazilian study, NVI was defined as a visual acuity of less than 20/32 in either eye, while in the current study, it is defined as binocular visual acuity of less than 20/40. This difference in definitions may contribute to the lower prevalence reported here. Additionally, the studies conducted in Brazil and Inner Mongolia included older participants, which could lead to a higher rate of NVI due to age-related eye diseases such as glaucoma and macular degeneration.

On the other hand, the results of this study were higher than those found in similar studies conducted in France 17.4%8 and the United Kingdom (13.6%)9. Additionally, the result of this study was also higher than other studies conducted in the Republic of Congo (68.8%)13, India states (51.2%, 58.3%)29,30, Nepal 66.1%12, USA 13.6%31, Southern China 68.58%32 and Australia 21.6%10. This variation may stem from differences in the study populations, settings, sample sizes, socio-demographic characteristics of participants, and the presence of systemic comorbidities. For instance, studies conducted in the Republic of Congo, India, USA, Southern China, and Australia involved community-level populations with older participants. These older individuals may have a higher likelihood of undergoing cataract surgery, whereas our study specifically focused on diabetic patients8,13. Furthermore, the availability and accessibility of eye care services, as well as the eye care-seeking behaviors of the participants, may also contribute to the differences observed in the study results.

Participants over the age of 65 were 5.38 times more likely to experience NVI compared to those aged 45 and younger. This finding is consistent with studies conducted in India27, Nepal12, and North China28. One possible explanation for this correlation is that as individuals age, they may become more susceptible to age-related eye diseases, such as diabetic retinopathy, degenerative maculopathy, and glaucoma. These conditions can contribute to neovascularization involving the iris among older diabetic patients33.

Studies conducted in Southern Ethiopia34 and Singapore35 reported that being single (never married, widowed, or divorced) was significantly associated with distance visual impairment. In contrast, our study found that married individuals were 4.09 times more likely to experience NVI compared to those who were unmarried. This association may reflect that married individuals encounter greater barriers to healthcare access, potentially due to dependence on a spouse for transportation or healthcare decision-making, which can cause delays in diagnosis and treatment. Additionally, married individuals may have increased household and caregiving responsibilities that limit the time and priority they can dedicate to their own health. On the other hand, unmarried individuals might place greater emphasis on self-care and proactive health management due to their autonomy and need for independence35. Social support dynamics and cultural factors within marriage may also influence health-seeking behaviors and access to care differently than in unmarried individuals.

This study found that the odds of developing NVI were 2.43 times higher among participants with a diabetes duration of seven years or more compared to those with a duration of less than seven years. This association may be explained by the fact that longer diabetes duration increases the risk of ocular complications such as diabetic retinopathy, glaucoma, cataracts, and diabetic macular edema, which in turn contribute to visual impairment, particularly near visual impairment.

Participants with hypertension were 2.06 times more likely to develop near-visual impairment compared to those without hypertension. This finding aligns with a study conducted in the Republic of Congo13. High blood glucose levels are believed to disrupt the autonomic regulatory mechanisms of retinal capillaries, making the capillary endothelium more susceptible to damage from increased blood pressure. This can lead to retinal ischemia and, eventually, retinopathy36. Additionally, one of the major ocular consequences of hypertension is glaucoma, which can result NVI37.

The likelihood of experiencing NVI is 3.59 times greater in participants with distance visual impairment compared to those without. This finding aligns with studies conducted in Japan38 and Singapore39. In diabetic patients, there is a strong correlation between distance and NVI. Factors such as poor glycemic control, a longer duration of diabetes, and older age significantly elevate the risk of both types of visual impairment.

Participants with diabetic retinopathy are 7.46 times more likely to develop NVI compared to those without the condition, as supported by a study conducted in South Korea40. Diabetic retinopathy, a leading cause of vision loss, is strongly linked to NVI, particularly due to complications like diabetic macular edema, which can cause blurred vision and difficulties with close-up tasks8. Additionally, individuals with diabetic retinopathy who undergo pan-retinal photocoagulation (PRP) may experience reduced near visual acuity. This decline can occur due to pupillary mydriasis and accommodation paresis after PRP; the enlarged pupil reduces the depth of focus, and accommodation paresis hinders sharp focus on the fovea41,42. These findings indicate that improving care for retinopathy in older adults with diabetes could further reduce the risk of NVI.

Strengths and limitations of the study

This study represents the first research conducted among diabetic patients in Ethiopia, providing baseline data for future studies. As this is a cross-sectional study, it can indicate the temporal relationship between predictors and NVI rather than an actual cause-and-effect relationship.

Conclusion

This study revealed a high prevalence of near visual impairment among adults with diabetes. Older age, marital status, longer duration of diabetes, hypertension, distance visual impairment, and diabetic retinopathy were significantly associated factors. Strengthening routine blood glucose and blood pressure control, together with regular eye examinations, is essential to reduce the burden of visual impairment. Integrating near vision screening into diabetic care services in Ethiopia and raising community awareness on the importance of early eye care could further improve prevention and management efforts.

Data availability

All data relevant to the study are included in the article.

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Acknowledgements

We would like to express our appreciation to the study participants for their willingness to participate in this study. The authors would also like to acknowledge the dedicated data collectors.

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.

Author information

Authors and Affiliations

  1. Department of Optometry, College of Medicine and Health Sciences, Comprehensive Specialized Hospital, University of Gondar, P.O. Box: 196, Gondar, EthiopiaMelkamu Temeselew Tegegn, Yezinash Addis Alimaw, Matiyas Mamo Bekele, Abebech Fikade Shumye, Biruk Lelisa Eticha, Endalew Mulugeta Worku, Getachew Kassahun Desalegn, Hirut Gebremeskel Mengistu, Abebizuhan Zigale Bayabil, Mebratu Mulusew Tegegne, Merkineh Markos Lorato, Getenet Shumet Birhan & Zinachew Mulat Bogale
  2. Department of Ophthalmology, Goba Referral Hospital, Madda Walabo University, Goba City, EthiopiaAsnake Gezahegn Bekele

Contributions

MTT conceptualized the research design, developed proposal, developed data collection tool, analyzed and interpreted the data, wrote up the result and discussion of research. YAA, MMB, AFS, BLE, EMW, GKD, HGM, AZB, MMT, MML, AGB, GSB, and ZMB revised research design, research methodology, supervisor, ensured data quality and integrity. MMB prepared and revised the manuscript. All authors approved the revised manuscript.

Corresponding author

Correspondence to Matiyas Mamo Bekele.

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Competing interests

The authors declare no competing interests.

Ethics approval and consent to participate

The study was conducted in accordance with 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, and permission was secured from the medical director of Adare General Hospital. The study purpose was explained to each participant, and written informed consent was obtained. Participants were informed of their right to withdraw at any time, and confidentiality was maintained by excluding personal identifiers from all data collection instruments.

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Tegegn, M.T., Alimaw, Y.A., Bekele, M.M. et al. Near visual impairment and its associated factors among adult diabetic patients at Adare General Hospital, Southern Ethiopia. Sci Rep 15, 40094 (2025). https://doi.org/10.1038/s41598-025-23965-1

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