Author: Mapa Mudiyanselage Prabhath Piyasena (United Kingdom)
Co-authors: GVS Murthy, JLY Yip, C Gilbert, T Peto, I Gordon, S Kamalakannan
Purpose
Diabetes mellitus (DM) is one of the most prevalent non-communicable diseases which imposes a significant impact on health systems. Diabetic retinopathy is a common microvascular complication of the eyes caused by chronic hyperglycaemia. Blindness due to DR is common among the working age populations and it is becoming a global issue due to rising prevalence of DM. Knowing the barriers/enablers in advance in contrasting different country income settings may accelerate development of a successful DR screening (DRS) program. This would be especially applicable in the low-income settings with the rising prevalence of DR.
Setting/Venue
The current evidence provides information on barriers without considering the settings. However, barriers to access DRS are different in various country income levels and health systems. The overall aim of the review was to explore barriers to access DRS in various country income settings. The aim of this systematic review is to identify and contrast the barriers/enablers to DRS for different contexts using both consumers i.e., people with diabetes (PwDM) and provider perspectives and system level factors in different country income settings.
Methods
We searched MEDLINE, Embase, CENTRAL in the Cochrane Library from the databases start date to December 2018. We included the studies reported on barriers and enablers to access DRS services based at health care facilities. We defined access as all level of factors affecting the processes of DRS in a health care facility. We included the studies which have assessed barriers or enablers to access DRS by PwDM and challenges or incentives faced by providers in provision of screening services in current screening programs or at opportunistic screening. Two reviewers independently assessed the eligibility of inclusion by going through titles and abstracts of 16,388 articles after, importing them to an EndNote® library. We categorised and synthesized themes related to the consumers (individuals), providers and the health systems (environment) as main dimensions according to the constructs of social cognitive theory, supported by the quantitative measures i.e., odds ratios as reported by each of the study authors.
Results
The database search identified a total of 16,388 records and we assessed 127 full-texts. 77 studies were included in the review. The most prominent barriers to access DRS in low-income countries were lack of knowledge on DM eye complications, awareness about importance of eye examination and availability of eye clinics. Among providers, main challenges were lack of skilled human resources and lack of access to DR imaging and treatment infrastructure.Consumers’ barriers related to knowledge and awareness could be observed in the lower-middle countries as well. This was associated with poor general education and low functional health literacy. In provider perspectives scarce human resources and lack of training were the main challenges faced in upper-middle countries. In high income countries living alone, problems in mobility and multiple comorbidities were observed as the main barriers among the consumers. The main enablers were fear of blindness, proximity of screening facility, experiences of vision loss and being concerned of eye complications. Higher odds of uptake of DRS services was observed when PwDM were provided health education (odds ratio (OR) 4.3) and having knowledge on DR (OR range 1.3-19.7).
Conlusions
The evidence in this review clearly suggests that the barriers and enablers are different in each income setting. The most consistent barrier across different income settings was lack of knowledge and awareness on DR and DRS among the users. In providers point of view, lack of skilled human resources and screening infrastructure was the main barrier. Knowing the modifiable barriers in a specific context would be helpful to identify the risk groups early and to improve DRS uptake among institutional PwDM. A main recommendation of this review is to carry out an assessment of barriers and enablers in each context before implementing a DRS program. The consumer-based health educational interventions and provider-based skills and DRS infrastructure development would improve the access to DRS especially in low-income settings.
Financial Disclosure
None to disclose
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