A narrative review of the knowledge, attitudes, and practices of healthcare professionals toward diabetic retinopathy

Abstract

Background:

Diabetic retinopathy (DR) is a leading cause of preventable vision loss worldwide. Early screening and diagnosis are critical in mitigating vision loss in patients with diabetes. This review aims to analyze existing research on healthcare professionals’ (HCPs) knowledge, attitudes, and practices regarding DR screening.

Methods:

A literature search was performed using four electronic databases: Medline, Google Scholar, Science Direct, and EBSCOhost. The search terms included synonyms connected by the Boolean operator “OR.” This search covered quantitative, qualitative, and mixed-methods research studies. The appraisal was done using the Joanna Briggs Institute’s critical tool. A total of 59 published articles were analyzed.

Results:

Forty-seven articles (79.7%) assessed knowledge of HCPs, 30 (50.8%) assessed attitudes, and 42 (71.2%) assessed practices related to DR screening and referrals. The studies reveal significant differences in knowledge, attitudes, and practices regarding DR among various HCPs. There was variation in levels of knowledge amongst various categories of HCPs, with nine studies reporting 100% knowledge of DR. Positive attitudes ranged from 13 to 100%. Similar variations were reported regarding practices, with many HCPs not screening patients for DR. Inadequate training, lack of screening resources like an ophthalmoscope, dilating eye drops, and being inundated with other responsibilities were common reasons for the gaps in knowledge and practices.

Conclusion:

Non-ophthalmic HCPs’ knowledge, attitudes, and practices (KAP) regarding DR screening were unsatisfactory. The HCPs with an ophthalmic background had varying levels of KAP regarding DR, with some having good knowledge and others having deficiencies in applying screening guidelines and providing patient education. Regular in-service training is needed, particularly for non-ophthalmic HCPs, and resources should be available for screening at the primary care level.

1 Introduction

Diabetes mellitus (DM) is one of the leading non-communicable diseases that contributes to significant morbidity and mortality worldwide (1). The global prevalence of DM is 10.5% impacting around 536.6 million persons, and is expected to increase by 12.2% (783.2 million people) (1). As with many other diseases, the prevalence of DM differs from region to region. As per the International Diabetes Federation, countries in the Middle East, such as Kuwait, Bahrain, Qatar, and Egypt in the North Africa region, report the highest diabetic prevalence at 16.2% (2). The high prevalence of DM in this region is also influenced by a genetic predisposition to insulin resistance among various ethnic groups (3). In North America and the Caribbean region, the prevalence of DM was 14%, followed by Southeast Asia (10%), Western Pacific (9.9%), Europe (9.2%), and South and Central America (8.2%) (2). The lowest prevalence rate of DM is observed in the African region (4.5%), particularly in other countries of Eastern Sub-Saharan, comprising Uganda, Kenya, Malawi, Tanzania, Ethiopia, and Rwanda, with limited published data for some areas, such as in rural areas of Tanzania and Ethiopia, due to an inadequate surveillance system (4).

Diabetic retinopathy (DR) is a prevalent complication of diabetes (5). This is a complex diabetic microvascular complication initiated by chronic hyperglycemia, causing metabolic abnormalities in the retina, including neurodegeneration and inflammation (5). The progression of DR starts with retinal blood vessel damage, then thickening of the basement membrane, loss of pericytes due to apoptosis induced by hyperglycemia weakening capillary walls leaking to microaneurysm formation, and disruption of endothelial function causing fluid to leak from capillaries or blockage in the capillaries leading to cotton-wool spots due to the hypoxia (6). Diabetic retinopathy risk factors are linked to inadequate glycaemic management, diabetes duration, age, nephropathy, high blood pressure, high levels of lipids, obesity, pregnancy, previous eye surgery, and smoking (7).

There are two categories of diabetic retinopathy: non-proliferative and proliferative (5). Non-proliferative diabetic retinopathy (NPDR) is the initial progression stage of DR, and it is an asymptomatic stage characterized by the absence of neovascularization on the retinal sites (5). Proliferative DR (PDR) is the late stage of DR characterized by retinal neovascularization, usually with visual symptoms such as fluctuation of vision or reduced vision, seeing dark spots when looking in an open space due to hemorrhages in the vitreous space (8). Proliferative DR is considered a sight-threatening DR condition requiring urgent medical attention to prevent further vision loss or blindness (5). The healthcare professionals (HCPs) involved in the management of patients at risk for DR must understand the different stages and characteristics of DR so that appropriate interventions are offered promptly to prevent severe vision impairment or blindness. According to the epidemiological data from the global DR barometer, it has been observed that 28% of diabetic patients develop DR, while 42% develop diabetic macular edema (8). These findings emphasize the significance of early detection and treatment of eye issues related to diabetes (8).

In individuals between the ages of 20 and 70 in low- or middle-income countries, DR is the primary reason for blindness or moderate-to-severe vision impairments (1). Nearly 80% of adults, equating to 4.2 million adults, and 655,000 adults have some form of DR, which is more than twice in Mexican Americans and almost three times as common in African Americans (1). Globally, DR had a prevalence of 22.3% according to a 2021 systematic review (9). The prevalence of sight-threatening DR and clinically significant macular edema is 6.2% and 4.1%, respectively (9). Africa and North America have the largest prevalence of DR at 35.9% because of the growing diabetic population, while South and Central America have the smallest prevalence at 13.4% (9). According to a 2021 systematic review, the prevalence of DR in the Sub-Saharan African (SSA) region varies from 13 to 82%, while the sight-threatening DR ranges from 2.1% to 51.4% based on a systematic review reported in 2021 (10).

It is the responsibility of the HCPs managing a patient with diabetes to screen or refer the patient for screening for DR. Healthcare professionals’ knowledge, attitudes, and practices (KAP) of DR screening and referrals play a vital role in preventing vision impairment in people with diabetes. Late screening of patients with diabetes due to poor referral systems can lead to permanent vision impairment or blindness (7). While problems within the healthcare system may lead to delays in the diagnoses and management of patients, a lack of awareness among HCPs regarding the significance of DR screening can also be an important contributory factor (11). Alarmingly, over 37% of diabetic patients globally suffer from DR because of delays in referring them for an eye screening (8).

After critically analyzing the literature discussed, screening for DR appears to be sub-optimal, and there is therefore a need to document the gaps in the existing practices of HCPs regarding DR screening. Whilst previous reviews have looked at the general complications of DM (12), this is the first narrative review to focus specifically on DR. We aimed to evaluate and summarize the key findings of published studies that have investigated knowledge, attitudes, and practices of HCPs regarding DR. This review will offer important insights and strategies to strengthen DR screening. Additional advantages include supporting ongoing training to improve healthcare providers’ comprehension of DR screening and referral procedures. This is especially important for non-ophthalmic providers.

2 Method and materials

2.1 Literature search strategies and eligibility

Before commencing the literature search, the strategy and eligibility for inclusion and exclusion criteria for a review were developed. A systematic search was done to identify published articles on the KAPs of HCPs about DR. Five electronic databases were searched, including Medline (via the PubMed and Ovid interfaces), Google Scholar, Scopus, Science Direct, and EBSCOhost. We used the “building blocks” approach, often used in reviews, to create thorough search strategies. We organized search terms into categories representing different HCPs involved in treating patients with diabetes (including those impacted by DR). We also broadened the search terms by including synonyms and using the Boolean operators to connect them. The keywords include “knowledge OR attitude OR practice, diabetic retinopathy OR diabetic complications, healthcare professionals OR workers OR providers OR physicians OR nurses OR doctors OR general practitioners OR optometrists OR ophthalmologists.” The search was restricted to articles from earlier research studies from 1996 to 2023. Table 1 presents the components of the criteria for inclusion and exclusion.

2.2 Article selection

Following an in-depth search, all retrieved articles were entered into Mendeley 2.110.0 software (2024 Elsevier, Mendeley Ltd., London). The identified duplicates were removed using the duplicates command. Relevant articles were selected in three phases. In phases 1 and 2, the titles and abstracts of articles were screened by the first author (KDM) with the help of two colleagues working in the same organization as KDM, and irrelevant articles were excluded. In phase 3, the full-text manuscripts were carefully assessed. The articles of studies that met pre-defined inclusion criteria in Table 1 were selected. KDM decided to include relevant studies, but the disagreements were discussed to reach a consensus.

2.3 Data extraction and quality assessment

KDM carefully assessed the title and abstract of each study, and data related to the topic were extracted. The quality assessment was done using two Joanna Briggs Institute’s (JBI) critical appraisal tools for methodological appropriateness, including analytic methods, with one revised version containing 8 items for analytical cross-sectional studies, and another containing 10 items for qualitative studies (13). In this review, the level of quality was assessed based on the elements of methodological appropriateness from the JBI critical appraisal tool, with the results included in Supplementary Tables 1 and 2. The quality assessment scores employed for a review include methodologically strong (with <2 missing criteria), moderate (with 2–3 missing criteria), and weak (with >2) (14).

3 Results

3.1 Identification of studies

The initial search identified a total of 237 articles. Following the exclusion of 31 duplicates, the titles, and abstracts of 206 articles of published studies underwent a screening process to identify published articles relevant to this review. Subsequently, 123 articles were excluded based on the pre-defined inclusion criteria (Table 1). In addition, 24 articles were excluded after reviewing the full-text manuscripts as the focus was on the treatment of DR. Finally, 59 published studies were included and analyzed in this review. A summary of the literature search and selection stages has been provided in Figure 1.

Figure 1

3.2 Summary of included studies

The studies included originated from all six World Health Organization (WHO) regions, with the majority (n = 23) being from the Eastern Mediterranean region, followed by 11 from the African region and 10 from the Western Pacific region (Figure 2). There were only three studies that were conducted in the Americas and European regions. In terms of individual countries, 16 studies were conducted in Saudi Arabia, followed by seven in India (15–73). The study settings included public and private healthcare sectors, and the study populations included various categories of HCPs who manage diabetes and DR. The sample sizes ranged from eight HCPs to 710 physicians.

Figure 2

3.3 Study quality

The reviewed studies in this analysis were characterized by clearly defined objectives and the use of the appropriately selected methodologies, as determined through evaluation with the Joanna Briggs Institute’s (JBI) critical appraisal tool (13, 74–76). Thirty-six quantitative studies demonstrated a moderate JBI quality level (16–26, 28–32, 34, 35, 37–41, 43–47, 49, 52–54, 58, 60, 62, 63, 65, 66, 68, 70, 71). The other 18 showed a strong level in Supplementary Table 1 (15, 27, 29, 30, 33, 36, 42, 44, 48, 51, 55, 57, 59, 61, 64, 65, 69, 72). Three qualitative studies demonstrated moderate levels of quality assessment (56, 67, 73), and one showed a strong JBI quality assessment (Supplementary Table 2) (50).

3.4 Categories of healthcare professionals

The HCPs included in this review are primary healthcare nurses, primary care physicians (general practitioners or family physicians, and internists), ophthalmic care professionals (ophthalmologists, optometrists, and ophthalmic nurses), medical residents, diabetologists, dietitians, laboratory scientists, physical therapists, general nursing personnel (professional registered nurses, and staff nurses), paramedical personnel, and other clinical officers involved in the management of diabetes (Table 2). Some of the included studies used the terms “medical practitioner,” “medical officer,” and “physicians” interchangeably when referring to the doctors (17, 19, 20, 22, 24, 25, 28, 29, 32, 40, 41, 50, 52, 53, 61, 66, 69, 73). This review presents all HCPs as described in their respective articles.

3.5 Methods of assessing healthcare professionals’ knowledge, attitudes, and practices

Fifty-three of the 59 studies used a cross-sectional design (15–49, 51–54, 57–66, 68–72, 77–87), five were descriptive qualitative studies (50, 55, 56, 67, 73), and one study employed a mixed-methods approach (28). Fifty-one studies used self-administered structured interview questionnaires with closed-ended questions (15–27, 29, 30, 32–42, 44–46, 49, 51–60, 62–68, 70–72, 77–79, 81–88). Five studies used semi-structured questionnaires with closed and open-ended questions (28, 50, 55, 61, 69), and three studies used unstructured questionnaires (56, 67, 73). The studies employed various methods to gather data, such as paper-based, telephone, and online surveys, and focus group discussions (FGDs) for qualitative research (15–73, 85). Twenty-three studies assessed knowledge, attitudes, and practices (17, 18, 21–24, 28, 31, 32, 39, 40, 43, 53, 57, 58, 61, 63–66, 69, 70, 72, 85), three assessed knowledge and attitudes (25, 37, 52), five assessed knowledge, and practices (20, 26, 29, 59, 62), and one study assessed attitudes and practices toward DR (71). Fourteen studies assessed knowledge only, 10 of which used structured questionnaires comprising “yes/no/I do not know” responses (27, 35, 36, 41, 42, 46–48, 50, 51), one used a questionnaire with “almost never/sometimes/often/almost always/refer somewhere” responses (60), and four were focus group discussions (55, 56, 67, 73). Two studies assessed attitudes only with one study using a structured questionnaire with a 5-point Likert scale (1 = strongly agree, 2 = agree, 3 = neutral, 4 = disagree, 5 = strongly disagree) (30) and the other used a questionnaire with “yes/no/I do not know/not sure” responses (45). Nine studies assessed practices only with seven using questionnaires with “yes/no/I do not know” responses (15, 16, 33, 34, 38, 44, 68), one using a questionnaire with “very confident/not confident/never learn to perform” responses (54), and another one used a questionnaire with 5-point Likert scale responses (49).

3.6 Healthcare professionals’ knowledge of diabetic retinopathy

Of the 59 studies, 47 (79.7%) assessed the knowledge of DR among different categories of HCPs. Most studies (over 90%) utilized a common set of DR knowledge-related questions (17–29, 31, 32, 35–37, 39–43, 46–48, 50–53, 55–67, 69, 70, 72, 73, 85). These questions encompassed various aspects of diabetes and its impact on the retina. Topics included the knowledge of DR prevalence among individuals affected by diabetes, the effects caused by complicated diabetes on vision, eye complications linked to diabetes, the preferred method for evaluating DR in different resource settings, progressive stages of DR with their respective clinical manifestations, and the risk factors were linked to a rapid progression of DR. These risk factors encompass the age, pregnancy, duration of diabetes, body weight, control of blood glucose levels, retinal conditions, hypertension, hyperlipidemia, and renal diseases (17–29, 31, 32, 35–37, 39–43, 46–48, 50–53, 55–67, 69, 70, 72, 73, 85). The knowledge about DR varied among different categories of the HCPs involved in diabetic care, including those providing DR screening services. Most HCPs (93.8%) were aware that diabetes can cause eye damage, leading to irreversible vision impairment or loss.

Nine of the 48 studies reported that 100% of HCPs had a good knowledge of DR, and these studies were from Nigeria, South Africa, the UK, India, Thailand, Kenya, Saudi Arabia, Fiji, and China (65–67, 69, 73). A study conducted in Southern India among 200 paramedical personnel reported that only 2.5% of the 200 paramedical personnel knew about DR. Low proportion was attributed to insufficient educational materials on DR for this category of HCPs (63). In Northwestern Nigeria, 63.2% of the 105 physicians knew the effective method for prolonging the onset and progression of DR (17). In the Canary Islands, the results showed that 68.4% of the 165 sampled PHC nurses knew how to differentiate normal retinal images or photographs from the affected ones (42).

3.7 Attitudes of healthcare professionals toward diabetic retinopathy

Thirty-two studies that evaluated the attitudes of HCPs toward DR screening and referrals utilized common items in the Likert scale format (17, 18, 21–23, 28, 30, 39, 57, 65, 70–72). Some of these items reflected beliefs such as eye examinations are not within the realm of responsibility for the general healthcare providers or primary care physicians, eye-related problems are time-consuming, addressing diabetic retinopathy in an outpatient clinic setting is impractical, and performing fundoscopy without periodic in-service training is not valuable.

The proportion of HCPs with a positive attitude toward DR ranged from 13.2 to 100%. Notably, four studies conducted in Yemen, two in Indonesia, and Pakistan reported that 100% of all HCPs exhibited positive attitudes toward DR screening, including prevention (30, 39, 58, 69). These studies revealed that HCPs demonstrated commendable attitudes toward DR by prioritizing DR screening in diabetic patients. Additionally, HCPs in these studies received specialized training on DR, comprehended its psychological impact, respected the autonomy of diabetic patients, and emphasized the significance of stringent blood glucose control (30, 39, 58, 69). Conversely, a study in Saudi Arabia among 99 primary care physicians (PCPs), revealed that only 13.2% had positive attitudes toward DR (52). The study reported that PCPs believed that well-trained HCPs (the ophthalmologists, optometrists, and ophthalmic nurses) should conduct DR screening, including diagnosing and managing individuals affected by DR effectively, as opposed to the general PCPs, like GPs, family physicians, internists, and other non-ophthalmic practitioners involved in the management of diabetes.

3.8 Healthcare professionals’ practices of diabetic retinopathy

Forty studies used items such as screening for DR among all diabetes patients irrespective of the type, whether a patient was symptomatic, and adherence to standardized diabetic eye screening schedules and referral guidelines. Only 4.3% of Indonesia’s 92 general practitioners (GPs) had followed the DR referral and screening protocols effectively (58). This low proportion of GPs was mainly due to the lack of comprehensive vision testing, the unavailability of vision acuity testing charts and ophthalmic medical technology such as ophthalmoscopes for a basic fundoscopic examination, and an underdeveloped referral system (58). The practice of performing fundoscopy varied among PHC nurses and ophthalmic care practitioners (such as optometrists, ophthalmologists, and ophthalmic nurses) in eight studies conducted across five different regions, including Saudi Arabia, the USA, India, Australia, and South Africa (15, 16, 33, 44, 47, 54, 69, 71). Two South African studies conducted in the eThekwini municipality and the Waterburg and Capricorn Districts reported that all PHC nurses did not implement DR screening programs due to a lack of appropriate skills to perform screening procedures for DR, being busy with other responsibilities, staff shortage, and proactively referring them to ophthalmologists for eye examinations, regardless of visual symptoms (15, 16). In these two studies, 43% of 42 PHC nurses in eThekwini and all PHC nurses in the Waterburg and Capricorn districts only perform case history taking, including referring patients with diabetes to ophthalmic nurses (15, 16).

4 Discussion

This narrative review found variations in HCPs’ knowledge, attitudes, and practices regarding diabetic retinopathy (DR). While these disparities may have been due to the differences in tools, settings, and research methodologies, some commonalities were noted. Not unexpectedly, the educational background of HCPs plays a crucial role; those who received specialized training in ophthalmic care, such as ophthalmologists, optometrists, and ophthalmic nurses, typically scored higher across all three domains than other categories of HCPs in three WHO regions, namely Africa, the Americas, and South East Asia (15, 16, 44, 47, 55, 56, 69, 72). Primary care physicians (PCPs) and general practitioners (GPs) demonstrated a good knowledge of DR occurring due to prolonged hyperglycemia and when to screen patients diagnosed with diabetes in the Eastern Mediterranean, South East Asia, and European regions (22–24, 29, 50, 52, 62, 66, 70).

Positive attitudes of HCPs are important in the success of screening programs for DR. Healthcare professionals with a positive disposition toward DR screening were more likely to refer diabetic patients for DR screening (8, 28, 39, 45). A combination of adequate knowledge and appropriate training on screening for DR has been shown to positively influence attitudes (45, 69). It is crucial for all HCPs, regardless of their specialty, to be familiar with the global protocols for DR screening and understand that they have a responsibility to either screen or refer diabetic patients for eye-related issues.

As with knowledge, the practice of referring diabetic patients for DR screening varied among different categories of HCPs across all six regions. Poor practice was related to either insufficient resources or a lack of expertise. Non-ophthalmic trained nurses did not have the practical skills needed to perform basic eye examinations. Research has shown that training of non-ophthalmic HCPs in DR screening can be effective in improving early detection and appropriate referral of patients (89, 90). Foundational training for non-ophthalmic HCPs at the first point of care should be a priority area in all healthcare settings serving diabetic patients. This training should include fundamental skills such as visual acuity testing, ophthalmoscopy or fundoscopy, and being aware of DR referral guidelines.

The lack of resources such as ophthalmoscopes and dilating eye drops also contributed to poor practices in some settings, especially amongst general practitioners. Interestingly, this finding was not restricted to studies from low and middle-income regions, such as Africa and the Eastern Mediterranean region, but also reported in studies from Europe and America (17, 18, 22, 44, 53). Furthermore, some HCPs reported having too many other responsibilities that resulted in insufficient screening for DR in patients with diabetes (21, 37). These gaps result in many patients not being screened or referred for screening. Implementing educational measures is crucial for improving DR screening processes and developing an effective referral network to ophthalmologists or optometrists for comprehensive eye examinations for all diabetic patients.

The use of more sophisticated medical technology, such as artificial intelligence fundus imaging and optical coherence tomography, has enhanced screening for DR. While this review did not focus on how screening was done, it must be noted that the use of these technologies may enable earlier and more accurate detection and timely treatment. These technologies are powered by automated retinal image analysis, which is also suitable for non-dilated pupils for fundoscopy to save time during DR screening.

This review has some limitations. It was limited to non-experimental research on HCPs’ knowledge, attitudes, and practices toward DR screening and referrals. The literature search was confined to electronic data sources. The review exhibited susceptibility to publication bias, as studies that yielded statistically significant results were more likely to be published, potentially distorting the overall findings. The study design and sampling methodologies may have influenced the validity of the findings. The results of studies that used non-random sampling or had low response rates may not reflect the KAP of all HCPs in that setting. Furthermore, practice was self-reported, including non-random samples, and this is likely to differ from the actual KAP. The heterogeneity of studies and samples poses a challenge in synthesizing the findings of the review. Whilst these limitations significantly influence the conclusions drawn from the reviewed articles, this review still has value in identifying the gaps in existing KAP amongst HCPs across regions.

5 Conclusion

There are important gaps in the knowledge, attitudes, and practices regarding DR screening among HCPs, particularly non-ophthalmic-trained HCPs. These HCPs have limited knowledge of the risk factors, early signs, and progression stages of DR, and attitudes that reflect that DR screening should be the responsibility of ophthalmic-trained HCPs only. Screening for DR was poorly practiced. The common reasons for these gaps were inadequate training, insufficient screening resources, and a high workload. Regular in-service training is needed to enhance screening and timely referrals, particularly for non-ophthalmic professionals. It is imperative that, even at the level of primary healthcare, appropriate resources are available so that patients at risk of DR can be screened and referred appropriately to reduce the burden of visual impairment and blindness due to DR.

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