Ecological factors influencing patient adherence with diabetic eye screening in rural communities: a qualitative study

Abstract

Purpose : Diabetic retinopathy remains the leading cause of blindness among working-age U.S. adults—even though 90% of blindness is preventable with early screening and treatment—largely due to low screening rates. Teleophthalmology is an evidence-based form of diabetic eye screening that we hypothesized would be well-suited to rural populations. We sought to characterize environmental and psychosocial factors affecting patient adherence with yearly diabetic eye screening guidelines in a rural, multi-payer health system with an active teleophthalmology program.

Methods : We conducted individual interviews with 20 adult patients with type 2 diabetes and 9 primary care providers (PCPs) at Mile Bluff Medical Center in Mauston, WI. Both inductive and directed content analysis was performed on interview transcripts with the guidance of a qualitative methodologist.

Results : Patients had a mean age of 67 years (range 46-86) and 55% were male. PCPs were predominantly male (78%) and had been in practice for over 10 years (78%). Ecological factors influencing patient adherence with diabetic eye screening were categorized as environmental, social, and individual. Major structural and psychosocial themes included: limited access to and infrequent use of healthcare, long travel distances to obtain care, poverty and financial tradeoffs, trusting relationships with healthcare providers, family members’ struggles with diabetes, anxiety about diabetes complications, and the burden of diabetes management. We developed a model to understand the relationships between these factors adapted from the Ecological Model of Health.

Conclusions : Substantial barriers exist for rural patients that affect their ability to adhere with yearly diabetic eye screening. The prevalence of these themes can be measured in future quantitative surveys of rural health systems. Many studies emphasize patient education to increase adherence, but education alone fails to address major structural barriers in rural communities. Teleophthalmology may better address many environmental and psychosocial barriers by providing convenient access to specialists for diabetic eye screening at low-cost. Telemedicine programs may fill a crucial gap in patient barriers to diabetic eye screening in rural communities.

This is an abstract that was submitted for the 2018 ARVO Annual Meeting, held in Honolulu, Hawaii, April 29 - May 3, 2018.

 

Figure 1. Ecological Factors Influencing Rural Patient Adherence with Diabetic Eye Screening