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Journal of Racial and Ethnic Health Disparities

, Volume 6, Issue 6, pp 1244–1249 | Cite as

Barriers to and Facilitators of Diabetic Retinopathy Screening Utilization in a High-Risk Population

  • Elizabeth Fairless
  • Kristen NwanyanwuEmail author
Article

Abstract

Background

Diabetic retinopathy (DR) is among the leading causes of vision loss in the USA, yet an estimated 50% of patients with diabetes do not receive recommended annual screening eye exams. Patients with diabetes and low socioeconomic status or who are racial/ethnic minorities are at increased risk for vision loss.

Methods

Qualitative interviews were conducted with 24 patients with diabetes at a federally qualified community health center in an urban area regarding factors influencing their use of screening. The interviews were recorded, transcribed, and analyzed line by line to identify themes. The themes were organized in a theoretical framework of factors influencing receipt of screening.

Results

The median age of participants was 57.5 (range 44–73). Ten participants identified as female and 14 as male. Participants identified as Black (14), White (4), Hispanic (3), and other/no answer (3). Twenty-three had health insurance. Twenty-three had received an eye exam within in the past year, and 17 reported that they receive eye exams at least yearly. Four hundred fifteen comments were analyzed, and 22 concepts were identified under 7 broader themes and two overarching categories of individual and structural factors. Themes included vision status, competing concerns, emotional context, resource availability, in-clinic experience, cues to action, and knowledge about diabetes.

Conclusions

The factors that influence diabetic retinopathy screening utilization are complex. Visual symptoms and the need for glasses are important facilitators of screening. Many patients lack knowledge about diabetic retinopathy and the utility of preventative eye care. New strategies for engaging high-risk populations are necessary.

Keywords

Diabetic retinopathy Health disparities Qualitative research Diabetes Diabetic eye screening Ophthalmology 

Notes

Acknowledgments

We would like to thank the participants for giving their time and sharing their experiences, the Cornell Scott Hill Health Center for accommodating us, and the Yale Center for Research and Engagement for their insight into the greater New Haven community.

Data Access, Responsibility, and Analysis

Both authors E.F. and K.N. had full access to all the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.

Author Contributions

Author E.F. collected, analyzed, and interpreted the data and prepared the article. Author K.N. conceived and designed the study, interpreted the data, and provided critical revision of the article.

Funding

This work was financially supported by the National Center for Advancing Translational Science (CTSA Grant Number UL1 TR001863) and National Institute of Diabetes and Digestive and Kidney Diseases (Award Number T35DK104689).

Compliance with Ethical Standards

Conflict of Interest

The authors declare that they have no conflicts of interest.

Disclaimer

The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.

References

  1. 1.
    Centers for Disease Control and Prevention. National Diabetes Statistics Report, 2017. Atlanta, GA: Centers for Disease Control and Prevention, US Department of Health and Human Services; 2017.Google Scholar
  2. 2.
    Saaddine JB, Honeycutt AA, Narayan KMV, Zhang X, Klein R, Boyle JP. Projection of diabetic retinopathy and other major eye diseases among people with diabetes mellitus: United States, 2005-2050. Arch Ophthalmol. 2008;126:1740–7.CrossRefGoogle Scholar
  3. 3.
    Wong TY, Cheung CMG, Larsen M, Sharma S, Simó R. Diabetic retinopathy. Nat Rev Dis Primers. 2016;2:16012.CrossRefGoogle Scholar
  4. 4.
    Schoenfeld ER, Greene JM, Wu SY, Leske MC. Patterns of adherence to diabetes vision care guidelines: baseline findings from the diabetic retinopathy awareness program. Ophthalmology. 2001;108:563–71.CrossRefGoogle Scholar
  5. 5.
    IDF Diabetes Atlast, 8th Edition [Internet]. 8th ed. Internal Diabetes Federation; 2017. Available from: www.diabetesatlas.org.
  6. 6.
    Bachmann MO, Eachus J, Hopper CD, Davey Smith G, Propper C, Pearson NJ, et al. Socio-economic inequalities in diabetes complications, control, attitudes and health service use: a cross-sectional study. Diabet Med. 2003;20:921–9.CrossRefGoogle Scholar
  7. 7.
    Harris MI, Klein R, Cowie CC, Rowland M, Byrd-Holt DD. Is the risk of diabetic retinopathy greater in non-Hispanic Blacks and Mexican Americans than in non-Hispanic Whites with type 2 diabetes?: a U.S. population study. Diabetes Care. 1998;21:1230–5.CrossRefGoogle Scholar
  8. 8.
    Elam AR, Lee PP. High-risk populations for vision loss and eye care underutilization: a review of the literature and ideas on moving forward. Surv Ophthalmol. 2013;58:348–58.CrossRefGoogle Scholar
  9. 9.
    Preferred practice pattern: diabetic retinopathy [Internet]. American Academy of Ophthalmology. 2014 Updated 2017. Available from: www.aao.org/ppp.
  10. 10.
    Fathy C, Patel S, Jr PS, Kohanim S. Disparities in adherence to screening guidelines for diabetic retinopathy in the United States: a comprehensive review and guide for future directions. Semin Ophthalmol. 2016;31:364–77.CrossRefGoogle Scholar
  11. 11.
    Shi Q, Zhao Y, Fonseca V, Krousel-Wood M, Shi L. Racial disparity of eye examinations among the U.S. working-age population with diabetes: 2002–2009. Diabetes Care. 2014;37:1321–8.CrossRefGoogle Scholar
  12. 12.
    Lu Y, Serpas L, Genter P, Mehranbod C, Campa D, Ipp E. Disparities in diabetic retinopathy screening rates within minority populations: differences in reported screening rates among African American and Hispanic patients. Diabetes Care. 2016;39:e31–2.CrossRefGoogle Scholar
  13. 13.
    Dumser SM, Ratcliffe SJ, Langdon DR, Murphy KM, Lipman TH. Racial disparities in screening for diabetic retinopathy in youth with type 1 diabetes. Diabetes Res Clin Pract. 2013;101:e3–5.CrossRefGoogle Scholar
  14. 14.
    Baker RS, Bazargan M, Bazargan-Hejazi S, Calderón JL. Access to vision care in an urban low-income multiethnic population. Ophthalmic Epidemiol. 2005;12:1–12.CrossRefGoogle Scholar
  15. 15.
    Elam AR, Lee PP. Barriers to and suggestions on improving utilization of eye care in high-risk individuals: focus group results. Int Sch Res Notices [Internet]. 2014 [cited 2018 Apr 9];2014. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4897391/.
  16. 16.
    Alexander RL, Miller NA, Cotch MF, Janiszewski R. Factors that influence the receipt of eye care. Am J Health Behav. 2008;32:547–56.CrossRefGoogle Scholar
  17. 17.
    Curry L, Nunez-Smith M. Mixed Methods in Health Sciences Research: A Practical Primer. 1st ed. Thousand Oaks, CA: SAGE Publications; 2014.Google Scholar
  18. 18.
    Cornell Scott Hill Health Corporation Fact Sheet [Internet]. 2017 [cited 2018 Apr 9]. Available from: https://www.cornellscott.org/documents/resources/FactSheet.pdf.
  19. 19.
    Evers J, Boer F de. The Qualitative Interview: Art and Skill. 1st ed. The Hague: Eleven International Publishing; 2012.Google Scholar
  20. 20.
    Glaser BG, Strauss AL. The discovery of grounded theory: strategies for qualitative research. reprint. Chicago: Aldine; 1967.Google Scholar
  21. 21.
    McLeroy KR, Bibeau D, Steckler A, Glanz K. An ecological perspective on health promotion programs. Health Educ Q. 1988;15:351–77.CrossRefGoogle Scholar
  22. 22.
    Richard L, Gauvin L, Raine K. Ecological models revisited: their uses and evolution in health promotion over two decades. Annu Rev Public Health. 2011;32:307–26.CrossRefGoogle Scholar
  23. 23.
    Becker MH. The health belief model and personal health behavior. Thorofare: Slack; 1974.Google Scholar
  24. 24.
    Janz NK, Becker MH. The health belief model: a decade later. Health Educ Q. 1984;11:1–47.CrossRefGoogle Scholar
  25. 25.
    Puent BD, Nichols KK. Patients’ perspectives on noncompliance with diabetic retinopathy standard of care guidelines. Optometry. 2004;75:709–16.CrossRefGoogle Scholar
  26. 26.
    Fisher MD, Rajput Y, Gu T, Singer JR, Marshall AR, Ryu S, et al. Evaluating adherence to dilated eye examination recommendations among patients with diabetes, combined with patient and provider perspectives. Am Health Drug Benefits. 2016;9:385–93.PubMedPubMedCentralGoogle Scholar
  27. 27.
    Shi L, Wu H, Dong J, Jiang K, Lu X, Shi J. Telemedicine for detecting diabetic retinopathy: a systematic review and meta-analysis. Br J Ophthalmol. 2015;99:823–31.CrossRefGoogle Scholar
  28. 28.
    Owsley C, McGwin G, Lee DJ, Lam BL, Friedman DS, Gower EW, et al. Diabetes eye screening in urban settings serving minority populations: detection of diabetic retinopathy and other ocular findings using telemedicine. JAMA Ophthalmol. 2015;133:174–81.CrossRefGoogle Scholar
  29. 29.
    Zimmer-Galler IE, Kimura AE, Gupta S. Diabetic retinopathy screening and the use of telemedicine. Curr Opin Ophthalmol. 2015;26:167–72.CrossRefGoogle Scholar
  30. 30.
    Jani PD, Forbes L, Choudhury A, Preisser JS, Viera AJ, Garg S. Evaluation of diabetic retinal screening and factors for ophthalmology referral in a telemedicine network. JAMA Ophthalmol. 2017;135:706–14.CrossRefGoogle Scholar
  31. 31.
    Singh RP, Scott IU. Using EHR tools to optimize ophthalmologic outcomes in patients with diabetes. Retina Today [Internet]. 2016 [cited 2018 Jun 28]; Available from: http://retinatoday.com/2016/09/using-ehr-tools-to-optimize-ophthalmologic-outcomes-in-patients-with-diabetes/.
  32. 32.
    Proser M, Shin P. The role of community health centers in responding to disparities in visual health. Optometry. 2008;79:564–75.CrossRefGoogle Scholar
  33. 33.
    Policy statement: improving access to vision care in community health centers [Internet]. American Public Health Association; 2009 Nov. Report No.: 200910. Available from: https://www.apha.org/policies-and-advocacy/public-health-policy-statements/policy-database/2014/07/31/08/14/improving-access-to-vision-care-in-community-health-centers
  34. 34.
    Shin P, Finnegan B. Assessing the need for on-site eye care professionals in community health centers [Internet]. Washington, D.C.: The George Washington University School of Public Health and Health Services; 2009 Feb p. 1–23. Report No.: 22. Available from: https://hsrc.himmelfarb.gwu.edu/sphhs_policy_briefs/22. Accessed 8 Apr 2018.

Copyright information

© W. Montague Cobb-NMA Health Institute 2019

Authors and Affiliations

  1. 1.Yale School of MedicineNew HavenUSA
  2. 2.Department of Ophthalmology and Visual ScienceYale School of MedicineNew HavenUSA

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