Primary Health Care and Diabetic Retinopathy: Attitudes, barriers, and current screening practices among doctors in Fiji

Abstract

Diabetic retinopathy (DR) is the most common diabetic eye disease and a leading cause of blindness. The longer a person has diabetes, the greater the risk of developing DR. In countries, such as Fiji, where the prevalence of type 2 diabetes is at epidemic proportions, the risks and costs associated with undetected and treated DR are significant. To protect vision, people with diabetes should have regular comprehensive DR Screening. Previous research into barriers to regular eye examinations for people with diabetes mellitus (DM) in Fiji, suggest that primary healthcare providers play a critical role with respect to timely DR screening and treatment. The aim of this research was to gain an understanding of how DR is being managed in the primary healthcare setting in Fiji. This research was supported by the Fred Hollows Foundation and aligns with one of their primary goals; to increase the number of people diagnosed with DM receiving regular eye checks. Phase one of the research involved a review of existing national (Fiji) and international DR management guidelines. The content, presentation and quality of the guidelines were appraised using the Appraisal of Guidelines Research and Evaluation (AGREE) instrument. In addition, recommendations for frequency of DR screening were ascertained. In the second phase of the research, a survey of clinicians in primary care settings was undertaken to assess their attitudes and perceptions towards DR management. The findings of the guideline review revealed that initial DR screening should be conducted on diagnosis of DM, and on-going DR screening should be annually or biennially or with a decrease in VA. Antenatal DR screening should be conducted in the first trimester of pregnancy and all DR screening should at a minimum be conducted with dilated pupils. Appraisal of the guidelines reviewed using the AGREE instrument indicated a general lack of editorial independence in their development, and in many cases a lack of supporting information/research. The DR screening of the Fijian MoH DM guideline, was not consistent with international best practice. Specifically, the recommendations regarding when to conduct initial and antenatal DR screening were not clear, whilst on-going DR screening protocols were at a frequency now deemed to be sub-optimal on a cost-benefit basis. Results of the clinician survey indicated that the majority of clinicians perceived eye health and DR screening as an important consideration in the treatment of all patients with DM. A number of barriers were identified by the participants that may potentially impede optimal DR management. These barriers include: a lack of specific knowledge about DR, a lack of feedback from tertiary eye care providers regarding the management these patients receive, patient compliance, a lack of resources, and a sense of futility when treating complications of DM. Clinicians believe DR is a significant complication of DM. It is recommended that additional training is offered to clinicians in the primary healthcare setting in Fiji regarding the management of DR, and that the Fijian MoH DM guideline is revised with respect to DR management in line with international best practice. Future research is required to explore ways to raise clinicians’ and patients’ awareness regarding DR, and the importance of early detection.