Diabetic retinopathy screening barriers among Palestinian primary health care patients: a qualitative study

Incidence and risk factors of retinopathy of prematurity in Palestine: a retrospective cohort study, 2024

BACKGROUND

Retinopathy of prematurity (ROP) is a major, yet preventable, cause of childhood blindness. This study aimed to determine the incidence in Palestine and the risk factors for ROP development.

METHODS

We conducted a retrospective cohort study involving 520 preterm infants born between January 2020 and December 2023 in 7 major Palestinian Neonatal Intensive Care Units (NICUs) who were screened for ROP. We examined a range of clinical variables from medical records to explore their relationship with the development of the disease.

RESULTS

The incidence of ROP and severe type 1 ROP was 42.9% and 8.8%, respectively. Many risk factors were significant in univariate analysis, such as respiratory distress syndrome (RDS), the duration of mechanical ventilation, the number of blood transfusions needed, and the need for supplemental oxygen at 28 days. However, only lower gestational age (OR, 10.4; 95% CI, 3.66-29.9; p < 0.001), lower birth weight (OR, 2.5; 95% CI, 1.3-4.7; p = 0.006), lower postmenstrual age at the time of diagnosis, and multiple gestations were significant in multivariate analysis.

CONCLUSION

ROP is a significant problem in Palestine, with a relatively higher incidence than in neighboring countries. Considering the statistically significant variables in the clinical practice will prevent missing severe cases that may progress to blindness.

Predictive factors for adherence to intravitreal anti-vascular endothelial growth factor therapy in Palestinian patients with diabetic retinopathy, retinal vein occlusion, and age-related macular degeneration: a retrospective cohort study

BACKGROUND

The burden of retinal vascular and degenerative diseases on patients and healthcare systems can be significant if patients do not complete scheduled intravitreal injections. This study aimed to identify the factors that influence adherence with follow-up injections in patients with diabetic retinopathy, age-related macular degeneration, and retinal vein occlusion receiving intravitreal injections of anti-vascular endothelial growth factor treatment.

METHODS

This study utilized data from patients who received intravitreal anti-vascular endothelial growth factor injections between 2022 and 2023 at An-Najah National University Hospital. Patient information, such as demographic information, number of injections administered, and details of follow-up visits, was obtained from the hospital's electronic records. When electronic records lacked certain information, patients or their relatives were contacted to provide the missing data. Data entry and analysis were performed using chi-square tests and the Statistical Package for Social Sciences. A p-value ≤ 0.05 indicated statistical significance.

RESULTS

A total of 107 patients, 43 (40.2%) were adherent, while 64 (59.8%) were non-adherent. Sex was significantly associated with adherence (P = 0.035), with females more likely to adhere. Planned number of injections correlated with adherence (P = 0.004), as those receiving fewer injections were more adherent. Cost problems negatively impacted adherence (P = 0.016), with non-adherent patients more frequently reporting financial barriers. Positive patient expectations for vision improvement were strongly associated with adherence (P = 0.003). Mobility problems influenced adherence (P = 0.049), as those without mobility issues adhered more. Physical assistance from relatives significantly improved adherence (P = 0.036). Factors not significantly influencing adherence included comorbidities, education level, and insurance status.

CONCLUSION

Our study revealed that 60% of patients did not adhere to intravitreal anti-vascular endothelial growth factor treatment injections. Factors influencing adherence included the planned number of injections, cost problems, indication for injections, sex, need for physical assistance, and mobility problems. It is crucial to increase awareness of these factors to prevent complications such as blindness. Raising awareness could lead to improved adherence rates, better treatment outcomes, and positive impacts on patient and community health.

Prevalence of vision impairment, diabetic retinopathy and disability in adults 50+ in the occupied Palestinian territories

The Rapid Assessment of Avoidable Blindness methodology is a population-based survey of vision impairment among the population 50 and above, with optional modules on diabetes, diabetic retinopathy and disability. The first Rapid Assessment of Avoidable Blindness study in the occupied Palestinian territories (oPt) was conducted in 2008. Prevalence of blindness (50+) was 3.4%. 80% of blindness was avoidable. Between July 2018 and April 2019, we completed a nationally-representative follow up survey in oPt using the Rapid Assessment of Avoidable Blindness methodology including the optional modules. We tested distance visual acuity (presenting and pinhole) using a bespoke mobile data collection application. 4223 Palestinians aged 50 years and above were enumerated, of whom 3847 participated (response rate 91.1%). Prevalence of any vision impairment (presenting vision impairment <6/12 in the better seeing eye), blindness (<3/60), severe vision impairment (<6/60 but ≥3/60), moderate vision impairment (<6/18 but ≥6/60) and mild vision impairment (<6/12 but ≥6/18) were 25.8% (95% confidence interval [CI] 23.8-27.8%), 2.6% (1.9-3.2%), 1.4% (1.0-1.8%), 10.2% (9.1-11.2%) and 11.6% (10.3-12.8%), respectively. Avoidable causes of poor vision accounted for 82.4% of blindness, 83.3% of severe vision impairment, 82.0% of moderate vision impairment and 90.2% of mild vision impairment. Diabetes prevalence (reported or suspected based on random blood glucose ≥200 milligrams/decilitre) was 33.8% (32.1-35.5). Half of diabetes participants had diabetic retinopathy and/or maculopathy. Prevalence of disability (reported functional limitations) was 23.8% (21.0-26.5), and higher in women than men. The prevalence of vision impairment and blindness in oPt compared with 2008 was similar. Prevalence of diabetes, diabetic retinopathy and disability were all high, highlighting key areas for public health prioritization among older adults in oPt.

Present and future screening programs for diabetic retinopathy: a narrative review

Diabetes is a prevalent global concern, with an estimated 12% of the global adult population affected by 2045. Diabetic retinopathy (DR), a sight-threatening complication, has spurred diverse screening approaches worldwide due to advances in DR knowledge, rapid technological developments in retinal imaging and variations in healthcare resources.Many high income countries have fully implemented or are on the verge of completing a national Diabetic Eye Screening Programme (DESP). Although there have been some improvements in DR screening in Africa, Asia, and American countries further progress is needed. In low-income countries, only one out of 29, partially implemented a DESP, while 21 out of 50 lower-middle-income countries have started the DR policy cycle. Among upper-middle-income countries, a third of 59 nations have advanced in DR agenda-setting, with five having a comprehensive national DESP and 11 in the early stages of implementation.Many nations use 2-4 fields fundus images, proven effective with 80-98% sensitivity and 86-100% specificity compared to the traditional seven-field evaluation for DR. A cell phone based screening with a hand held retinal camera presents a potential low-cost alternative as imaging device. While this method in low-resource settings may not entirely match the sensitivity and specificity of seven-field stereoscopic photography, positive outcomes are observed.Individualized DR screening intervals are the standard in many high-resource nations. In countries that lacks a national DESP and resources, screening are more sporadic, i.e. screening intervals are not evidence-based and often less frequently, which can lead to late recognition of treatment required DR.The rising global prevalence of DR poses an economic challenge to nationwide screening programs AI-algorithms have showed high sensitivity and specificity for detection of DR and could provide a promising solution for the future screening burden.In summary, this narrative review enlightens on the epidemiology of DR and the necessity for effective DR screening programs. Worldwide evolution in existing approaches for DR screening has showed promising results but has also revealed limitations. Technological advancements, such as handheld imaging devices, tele ophthalmology and artificial intelligence enhance cost-effectiveness, but also the accessibility of DR screening in countries with low resources or where distance to or a shortage of ophthalmologists exists.

'I don`t need an eye check-up'. A qualitative study using a behavioural model to understand treatment-seeking behaviour of patients with sight threatening diabetic retinopathy (STDR) in India

Diabetic Retinopathy (DR) affects about 27% of patients with diabetes globally. According to the World Health Organization (WHO), DR is responsible for37 million cases of blindness worldwide. The SMART India study (October 2020-August 2021) documented the prevalence of diabetes, and DR in people40 years and above across ten Indian states and one Union Territory by conducting community screening. About 90% of people with sight threatening diabetic retinopathy (STDR) were referred from this screening study to eye hospitals for management, but failed to attend. This qualitative study, a component of the SMART India study, explored perceptions of referred patients regarding their susceptibility to eye related problems in diabetes and the benefits/barriers to seeking care. Perceived barriers from the viewpoint of ophthalmologists were also explored. Guided by the Health Beliefs Model (HBM), 20 semi structured interviews were carried out with consenting patients diagnosed with STDR. They included nine patients who had sought care recruited from eight eye hospitals across different states in India and eleven patients who did not seek care. Eleven ophthalmologists also participated. Four themes of analysis based on the HBM were, understanding of DR and its treatment, perceptions about susceptibility and severity, perceived barriers, perceived benefits and cues to action. Findings revealed poor understanding of the effects of diabetes on the eye contributing to low risk perception. Prohibitive costs of treatment, difficulties in accessing care services and poor social support were major barriers to seeking care. Ophthalmologists acknowledged that the absence of symptoms and the slow progressive nature of the disease deluded patients into thinking that they were fine. The study attests to the need for greater health literacy around diabetes, DR and STDR; for making treatment more affordable and accessible and for the development of effective patient education and communication strategies towards increasing compliance.