Patient, family member, and health care provider perspective on barriers and facilitators to diabetic retinopathy screening in Thailand: A qualitative study

PLOS ONE · 15 authors, 4 centres

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TL;DR

This qualitative study in Thailand identified low awareness of diabetic retinopathy (DR) among patients and family members, with major barriers to screening including long waiting times, financial issues, and lack of accompaniment. Family support varied widely, and even with insurance coverage, some patients did not attend appointments. The findings highlight the need for improved patient education, shared decision-making, and involvement of family members and non-physician clinicians to increase DR screening uptake.

Full summary

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**Background:** Diabetic retinopathy (DR) is a leading cause of preventable blindness, yet screening rates remain suboptimal globally. In Thailand, less than 50% of diabetic patients undergo annual DR screening. This qualitative study aimed to investigate factors influencing DR screening in Thailand and identify barriers to follow-up compliance from the perspectives of patients, family members, and health care providers (HCPs).

**Methods:** A descriptive qualitative study was conducted between August and December 2019. A total of 15 focus group discussions (FGDs) were held across five DR outpatient clinics in different regions of Thailand (north, northeast, west, central, and south). Each FGD comprised 5–12 participants, with three distinct stakeholder groups: diabetic patients (n=47), their family members (n=41), and HCPs (n=34). Patients were eligible if they were ≥18 years with type 1 or 2 diabetes; exclusion criteria included no light perception, being unwell, or having physical/mental disability. HCPs had ≥5 years of experience with diabetic patients. The mean age of patients was 57.61±12.95 years, with a mean diabetes duration of 9.23±9.49 years. Family members had a mean age of 49.60±13.84 years. HCPs had a mean age of 41.55±9.45 years and mean experience of 17.10±11.16 years. FGDs lasted 45–60 minutes, were conducted in Thai, audio-recorded, transcribed verbatim, and translated into English. Thematic analysis using a framework analytical approach was employed to identify key themes.

**Key Results:** Five major themes emerged: knowledge of diabetes, behaviors of DM care, awareness about DR, barriers to DR screening, and suggestions to improve attendance. - **Knowledge of diabetes:** Most patients were diagnosed after experiencing symptoms (e.g., exhaustion, frequent urination, foot numbness). Only a few were diagnosed during routine check-ups or incidentally at eye exams. Seven patients worried about symptoms like polyuria and fatigue; others accepted the disease. One patient was aware that diabetes could affect eyes and kidneys. Family members expressed fear of death, blindness, and amputation. - **Behaviors of DM care:** Many patients preferred lifestyle changes over medication alone. Family support varied: some provided blood sugar monitors, reminded about appointments, and helped with diet; others struggled with stubborn patients. HCPs noted two patient categories: those who understood and attended follow-ups, and those who did not and blamed themselves. - **Awareness about DR:** Awareness was low. Participants could not distinguish DR from glaucoma. Most knew DR was linked to blood sugar, but only a few knew it could cause vision loss. Only two patients knew about laser treatment and injections. Family members also had limited knowledge; only four knew that damaged blood vessels cause blurry vision and blindness. HCPs reported that patients often adopted strict diet control only before appointments and used traditional herbs. - **Barriers to DR screening:** Major barriers included lack of ophthalmologists, long waiting times, financial constraints, transportation problems, absence of accompanying persons, and ignorance of DR screening. Even with insurance coverage, some patients failed to attend. Some only came when medications ran out. Anxiety, depression, and family bereavements also played a role. - **Suggestions:** Patients preferred reminder systems (phone calls 2–3 days before appointments). Family members suggested community education camps and screening at primary care centers. HCPs recommended coordination with sub-district administrative organizations and village health volunteers, at least 30 minutes of consultation time, and follow-up for missed appointments within a week.

**Clinical Implications:** The study underscores the need for improved patient education about the asymptomatic nature of diabetes and DR, shared decision-making, and involvement of family members and non-physician clinicians (e.g., diabetes nurses, educators) to encourage regular screening. Policymakers should address deterrents like long waiting times and financial issues, and leverage universal health coverage schemes to improve access. The findings can inform strategies to increase DR screening uptake in Thailand and similar settings.

STUDY TYPE

other

SPECIALTY

ophthalmology

SUMMARISED BY

AI pipeline

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100% · A

ORIGINAL PAPER

PMC10399890

Patient, family member, and health care provider perspective on barriers and facilitators to diabetic retinopathy screening in Thailand: A qualitative study

PLOS ONE

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ABSTRACT

Abstract Objectives Diabetic retinopathy (DR) can cause significant visual impairment which can be largely avoided by early detection through proper screening and treatment. People with DR face a number of challenges from early detection to treatment. The aim of this study was to investigate factors that influence DR screening in Thailand and to identify barriers to follow-up compliance from patient, family member, and health care provider (HCP) perspectives. Methods A total of 15 focus group discussions (FGDs) were held, each with five to twelve participants. There were three distinct stakeholders: diabetic patients (n = 47) presenting to a diabetic retinopathy clinic in Thailand, their family members (n = 41), and health care providers (n = 34). All focus group conversations were transcribed verbatim. Thematic analysis was used to examine textual material. Results Different themes emerged from the FGD on knowledge about diabetes, self-care behaviors of diabetes mellitus (DM), awareness about DR, barriers to DR screening, and the suggested solutions to address those barriers. Data showed lower knowledge and awareness about diabetes and DR in both patients and family members. Long waiting times, financial issues, and lack of a person to accompany appointments were identified as the major deterrents for attending DR screening. Family support for patients was found to vary widely, with some patients reporting to have received adequate support while others reported having received minimal support. Even though insurance covered the cost of attending diabetes/DR screening program, some patients did not show up for their appointments. Conclusion Patients need to be well-informed about the asymptomatic nature of diabetes and DR. Communication at the patient level and shared decision-making with HCPs are essential. Family members and non-physician clinicians (such as diabetes nurses, diabetes educators, physician assistants) who work in the field of diabetes play a vital role in encouraging patients to attend diabetes and DR follow-ups visits regularly.

CITATION EXPORT

Geetha Kumar, Saranya Velu, Shahina Pardhan et al.. Patient, family member, and health care provider perspective on barriers and facilitators to diabetic retinopathy screening in Thailand: A qualitative study. PLOS ONE. (2023). https://doi.org/10.1371/journal.pone.0289618

AUTHORS

15 · 4 CENTRES

Geetha Kumar, Saranya Velu, Shahina Pardhan, Raju Sapkota, Paisan Ruamviboonsuk, Mongkol Tadarati, Peranut Chotcomwongse, Variya Nganthavee, Warisara Pattanapongpaiboon, Rajiv Raman, Chulaporn Limwattananon, Pracheth Raghuveer, Pracheth Raghuveer, Pracheth Raghuveer, Pracheth Raghuveer

1Shri Bhagwan Mahavir Vitreoretinal Services, Sankara Nethralaya, Chennai, Tamil Nadu, India
2Vision and Eye Research Institute, School of Medicine, Anglia Ruskin University, Cambridge, United Kingdom
3Department of Ophthalmology, Rajavithi Hospital, Bangkok, Thailand
4Kasturba Medical College Mangalore, Manipal Academy of Higher Education, INDIA