This was a hospital based cross-sectional study conducted at the diabetic units of the Limbe and Buea Regional Hospitals Southwest Region of Cameroon.

The study population included adult diabetic male patient (>20 years) attending diabetic clinic at the Buea and Limbe Regional Hospital diagnosed with ED.

Sample size is calculated using the WHO-steps method.

$n=\frac{z^{2}p\left(1-p\right)}{d^2}$

where: n = minimum sample size, z = the standard normal variant at a confidence interval of 95% (standard value of 1.96), p = prevalence of ED among diabetic patients 41.5% [4] , d = the margin of error (0.05).

$n=\frac{{\left(1.96\right)}^2\left(0.41\right)\left(059\right)}{{(0.05)}^2}$

A total of 322 which is the minimum sample size were enrolled into the study, which were selected using a convenient sampling method.

Potential study participants were approached consecutively in the diabetology and in-patient units of the hospitals. The study’s purpose, procedure, risks and benefits were explained to each one in a language they best understood. An information notice about the study was given to the potential participant. They were allowed to ask any questions they had, after which they signed a consent form to participate in the study.

Eligible diabetic patients were invited to complete the structured self-administered questionnaire in the waiting hall. The questionnaire was made up of three parts; Sociodemographic, medical and biological characteristics, A validated questionnaire to assess erectile dysfunction (The International Index of Erectile Function (IIEF)) adopted from [11] and Part three which focused on the assessment on the quality of care sought, care received, effectiveness of care, barriers to care-seeking and rate of physician inquiry. All questionnaires were marked by chronological numbers to check for missing or no return cases. The number of patients approached, reason for exclusion, the number of refusals, and the number of questionnaires distributed and returned were recorded.

The quality of data was assured through a careful design of the questionnaire. Data collectors and supervisors were also trained on the purpose of the study, the detailed content of the questionnaire, the data collection procedure, participant selection, and the rights of study participants within the umbrella of research ethics. Supervisors checked the collected data for completeness and consistency throughout the data collection period.

Data obtained was analyzed using Stata and R version 3.5.3. The IIEF questionnaire which addresses and quantifies five domains: erection function, orgasmic (ejaculation) function, sexual desire (libido), intercourse satisfaction (ability to sustain intercourse), and overall satisfaction/premature ejaculation domains. It classifies individual sexual function domains into mild, moderate or severe form depending on scores. Prevalence was calculated by dividing the number of patients found to have ED (IIEF score ≤ 21) by the total number of patients sampled.

The type of care sought was calculated by getting the frequency of each care type (medical or non-medical) by those who sought care. Using Pearson’s chi-squared test, each care type was evaluated for association with ED improvement. Proportion of care-seekers was calculated by dividing the number of those sought care by the total number of men who experienced ED. Medical care-seeking behavior was then compared to patient awareness of diabetic ED and frequency of physician screening for any associations using chi-squared test. Barriers to care–seeking were calculated by tallying the reported reasons why those with ED had not sought care.

The ages of the 332 participants enrolled in the study ranged between 21 and 76 years, with a mean age of 55 years. Most participants (64.46%) were married and 75.30% of them were Christians. One third were retired (30.12%) while close to half (42.77%) of the participants earned over 100,000 CFA francs a month ( Table 1 ).

The majority of participants (290 participants, 87.35%) had type 2 DM ( Figure 1 ), with the duration of disease between 2 - 5 years being the most frequent. About a third of participants (31.07%) were on one or more other drugs such as anti-hypertensives, traditional therapy, highly active anti-retroviral drugs (HAART) or others (aspirin, statins, antacids) besides their routine anti-diabetic medications. 54.32% of participants had at least one chronic disease, with retinopathy and hypertension being the most frequent ( Table 2 ).

The majority of the participants were overweight (43.90%). 71.69% had normal blood pressure, 68.67% had elevated blood sugar and 64.55% had elevated glycated haemoglobin ( Table 3 ).

Of the 332 participants, 262 participants had ED i.e. reported an IIEF score of 21 or less, which correlates to prevalence of 78.92%, at a 95% confidence interval and within a 6.21% error margin ( Figure 2 ). Among those who had ED, the majority had mild to moderate ED, followed by mild, moderate then severe ED ( Figure 3 ).

Out of the 262 respondents with ED, only 98 (37.40%) had sought care for ED ( Figure 4 ).

Of the 98 who had sought care, 84 (85.71%) had sought principally medical care, while 14 (14.29%) had sought non-medical care. The type of care each finally received was grouped into four to aid analysis. Respondents either received All Medical Care (glycemic control, specific ED medications and psychosexual counseling), Some Medical Care (either glycemic control, specific ED medications or counseling), Hybrid Care (received both medical and non-medical care) or non-medical Care ( Table 4 ).

Respondents who had correct knowledge of ED as a diabetic complication were more likely to seek medical care, as well as those who were regularly screened for ED by their healthcare provider (χ² = 57.27, p = 0.0021) ( Table 5 ).

Most of the respondents (164 respondents, 85.71%) had not sought care for ED, even though they experienced it. Fear of stigma, ignorance of health information and health misinformation were the leading barriers that prevented patients with ED from seeking care ( Table 6 ).

Of the 332 participants in the study population, about half had never been screened for diabetic ED during routine follow-up visits to their healthcare provider ( Table 7 ). Physicians were more likely to screen younger patients ( Figure 5 ) and those who had previously sought care for ED. Almost all the patients (92.68%) said they would like their providers to inquire about ED ( Table 8 ).

ED is a diabetic complication affecting sexual, reproductive, physical, mental health and overall quality of life. In this study, we sought to determine the prevalence of ED among diabetic patients and the type of care sought, within the population of diabetic patients who attend the Limbe and Buea Regional hospital of the 332 participants enrolled in our study, 262 (78.92%) had ED. This prevalence was within the reported global range of 30% - 90%. The high value is similar to the results of other studies carried out in Ethiopia, Nigeria, Iran and other parts of the world [4] [5] [11] [12] . It is however lower than the 95% prevalence recorded by Kemp et al. [6] in South Africa. This difference could be because the latter carried out their study at a tertiary hospital, more likely to have patients with advanced complications of the disease. Also, their population was predominantly older (mean age = 62 years) compared to ours (mean age = 55 years).

Concerning the differential types of ED according to severity, our study revealed that the majority of men with ED had mild-moderate and mild disease, while the minority had moderate and severe ED. This corroborates the findings of Seid et al. [5] but is opposite to what Kemp et al. [8] reported. In the latter’s study, the majority of diabetic men with ED had severe ED. The fact that the latter’s study population was dominated by older participants could equally explain this difference.

Our study identified a low proportion of ED patients who sought care. This was the same result reported by Seid et al. [5] . The barriers to care-seeking were health ignorance (i.e. respondents were not aware that ED was a diabetic complication, or knew it was but thought it incurable), health misinformation (respondents said ED is not a diabetic complication) and fear of stigma. Stigma was more likely a preventive factor among younger patients, while health ignorance and misinformation where the barriers to care-seeking amongst older respondents, according to our study.

Rahaman et al. [7] reported similar levels of knowledge of diabetic ED (50%) among a diabetic population in Iran and identified that poor knowledge of DM and its complications had a negative effect on care seeking behaviours; because patients neither knew how to identify the problem, associate it with a cause or know how and where to seek proper treatment. This was reflected by our study, in that, patients who had correct information on diabetic ED were more likely to seek medical care (the recommended standard of care), over non-medical care for their symptoms.

Sexual health issues have been widely reported to be associated with a high degree of stigma because they are sensitive, requiring high confidentiality and zero judgement from the healthcare team. In the cases where patients are not confident in the team to demonstrate these ethics, stigma will prevent them from seeking care hence prolonging the burden of the disease.

Another aspect of care analyzed by our study was physician-initiated care; the rate, the trends and the influence on care-seeking behaviour. Over half of the respondents (56%) had never been screened for diabetic ED by their healthcare provider. Similar results were reported by Berradi et al. [11] . In our setting, possible explanations for this could be low health provider/patient ratios, which decrease the time and efficacy of the service available to each patient by their healthcare provider. The sensitivity of the issue could also account for physician reluctance.

Our study revealed a directly proportional relationship between physician screening and positive care-seeking behaviour. It also revealed that physicians have a higher tendency to screen younger patients over older ones, even though ED is known to be more prevalent in the old. This could be because they judge sexual function to be a more dire need (reproductive needs, higher demand for partner satisfaction) in a younger patient than in an older one.

Even though they reported that it wasn’t the case, almost all respondents wanted their healthcare providers to regularly ask them about ED symptoms during follow up visits and consultations, revealing that physician screening can be practiced as an affective and patient-friendly method to identify diabetic ED, giving room for prompt management and better QoL in these patients.