Adoption of a comprehensive approach to strengthen screening of diabetic retinopathy in low- and middle-income nations

Dear Editor, Diabetic retinopathy (DR) is one of the complications of uncontrolled diabetes and has been ranked as a common cause of preventable blindness worldwide.[1] Considering that the majority of people with diabetes are from low- and middle-income nations, the public health significance of DR in these nations is immense.[1] The findings of a multicentric community-based screening reported the national prevalence of DR as 12.5% among people aged ≥40 years, while there was no significant difference in the prevalence between urban and rural areas, justifying the extensive nature of the condition.[2] It is an alarming observation that despite the rising burden of the condition, many low- and middle-income nations lack national-level DR screening programs.[1] Screening for DR has been recognized as the need of the hour, as the results of a study done in Saudi Arabia revealed that almost 33% of diabetic patients eventually develop DR.[3] The purpose of the current article is to identify the potential barriers in the effective implementation of screening services for DR and propose strategies for strengthening screening services at the community level. The presence of a wide range of barriers in low- and middle-income nations has not permitted the effective implementation of screening services for DR.[1–3] At the health system level, lack of specialized equipment (like fundus camera, etc.), shortage of trained personnel (especially at primary care level), and poor linkage between primary care providers and specialists have immensely contributed to delays in diagnosis and treatment.[2,4] From the financial perspective, high out-of-pocket expenditures on screening and treatment and limited health insurance coverage have not helped people to come forward and avail services, even if available.[5] Poor accessibility to screening facilities or lack of teleophthalmology services in remote and rural settings has also emerged as a major concern.[2,6] In addition, low awareness among individuals with diabetes about the risk of DR, the need for regular eye examinations, and the presence of fear or misinformation can also reduce patient compliance.[5] Finally, the absence of a national screening program in these nations and poor integration with existing noncommunicable disease initiatives at the primary level have also influenced the reach or utilization of screening services.[2,5] Acknowledging the magnitude of DR, and the merits attributed to early screening, there is a definite need to strengthen screening services in low- and middle-income nations.[1,2,5–8] The interventions begin with public awareness and community engagement to educate diabetic patients about the importance of regular eye screening and the facilities available in healthcare establishments.[7] These awareness activities can be conducted with the help of community health workers as well as via different modes of mass media, including social media for wider reach.[7] These awareness activities must be supplemented with the strengthening of health systems, including integrating DR screening in routine diabetes care offered at primary health centers and training nonophthalmic health workers (such as nurses and outreach workers) to conduct basic eye examinations to manage the shortage of trained personnel.[5,8] Moreover, a much-awaited initiative is to include DR screening into existing noncommunicable diseases initiative, as this will improve coordination and financial support.[1] Further, we must formulate standard protocol for screening, including periodicity, risk stratification, and referral pathways to avoid delay in the initiation of required treatment.[1,5] Efforts should be taken to offer these screening services either free or at subsidized costs to people from lower socioeconomic classes, and in this regard, options to implement public–private partnerships must be explored.[5] To neutralize the concern of geographical inaccessibility, teleophthalmology services can be initiated in underserved settings, and the option of mobile screening units can also be evaluated.[6] For the benefit of primary care providers, training programs can be organized to facilitate recognition of early signs and immediate referral of patients.[5,6] Finally, the screening coverage and treatment outcome can be monitored to evaluate the program, and these records can be used to improve accountability and for research purposes.[2,9] In conclusion, DR is a preventable cause of blindness, which is on the rise in low- and middle-income nations. The need of the hour is to adopt a multifaceted approach, targeting strengthening healthcare infrastructure, enhancing public awareness, and integrating DR screening into primary health care. Data availability statement The literature pertaining to the article can be made available at request by contacting Saurabh RamBihariLal Shrivastava at [email protected] on reasonable request. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.

Abstract licence: CC BY-NC-SA

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   Systematic review on barriers and enablers for access to diabetic retinopathy screening services in different income settings · 2019

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