BARRIERS TO SCREENING FOR DIABETIC RETINOPATHY: THE ROLE OF PRIMARY CARE PROVIDERS by Sarah Gayse BScN, University of Northern British Columbia, 2010 PROJECT SUBMITTED IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF MASTER OF SCIENCE IN NURSING: FAMILY NURSE PRACTITIONER UNIVERSITY OF NORTHERN BRITISH COLUMBIA March 2021 © Sarah Gayse, 2021 Running Head: FNP PROJECT ii Abstract Diabetes is a serious health concern that affects millions of people world-wide. The comorbidities and complications of diabetes are complex and require awareness within the healthcare system. Diabetic retinopathy affects a significant number of patients living with diabetes. Early detection through screening is recognized as the standard of care, in order to assess and monitor for diabetic retinopathy progression. Unfortunately, screening services are not always accessed, especially within the suggested time frames and frequencies. Currently there is limited data regarding the barriers that exist for individuals to access these crucial screening services. An integrative literature review approach was conducted to answer the research question: What strategies can nurse practitioners in the primary care setting use to promote screening for people living with diabetes to reduce their risk and progression to blindness from diabetic retinopathy? Four themes emerged from the findings which provided insight into determinants that affect diabetic retinopathy screening adherence: structural barriers to care, socioeconomic conditions, emotional barriers to accessing healthcare, and knowledge deficits. Discussion of three recommendations for primary care practice focus on: reassessing screening methods and intervals, activity sharing, and providing education. Implications for future research to enhance patient care are outlined. Keywords: primary care practice, nurse practitioners, diabetic retinopathy screening strategies and services, economic and emotional factors effecting diabetic retinopathy, access to care, integrated review method. Running Head: FNP PROJECT iii Table of Contents Abstract ii List of Tables and Figures vi Acknowledgements & Dedication vii Glossary of Terms viii Chapter 1: Introduction 1 Project Purpose 1 Chapter 2: Background 5 Diabetes 5 Diabetic Retinopathy 6 Practice Guidelines 7 Assessment 7 Screening Recommendations 8 Frequency of Screening 9 Screening Methods 10 Major Risk Factors 11 Glycemic Control 12 Dyslipidemia 13 Hypertension 13 Physical Activity 14 Health Behavioural Change 14 Primary Care Providers Role 16 Chapter 3: Research Methods Literature Search 18 19 Preliminary Search 19 Primary Search Strategies 20 Inclusion and Exclusion Criteria 22 Running Head: FNP PROJECT Secondary Search Strategies Data Evaluation and Analysis Chapter 4: Findings iv 23 24 25 Structural Barriers to Care 26 Environmental Factors 26 Healthcare Provider Availability 27 Socioeconomic Conditions 29 Personal Financial Barriers 30 Educational Background 31 Psychological Barriers to Accessing Healthcare 31 Patient-Provider Communication 31 Building Trust and Relationships 32 Family Support 33 Fear of Negative Outcomes 34 Knowledge Deficits Education on Screening Importance and Outcomes Chapter 5: Discussion 34 35 36 Theme One: Structural Barriers to Care 36 Theme Two: Socioeconomic Conditions 37 Theme Three: Psychological Barriers to Accessing Healthcare 39 Theme Four: Knowledge Deficits 41 Recommendations for Practice 41 Screening Methods and Intervals 42 Screening Intervals 43 Teleophthalmology 44 Activity Sharing 45 Running Head: FNP PROJECT Providing Education v 45 Knowledge Translation 46 Limitations and Future Research 47 Conclusion 48 References 49 Appendices 52 Appendix A: Search Strategy 55 Appendix B: Literature Review Matrix 56 Appendix C: Data comparison 66 Running Head: FNP PROJECT vi List of Tables and Figures Table 1: Search Terms Used in Databases to Extract Articles for Review Table 2: Search Strategies Used for the Database Search Table 3: Inclusion and Exclusion Criteria for the Literature Diagram 1: Concept Map Diagram 2: Key Notes to Consider in Practice Related to Diabetic Retinopathy Screening Adherence Diagram 3: Current Recommendations for Screening for Retinopathy Running Head: FNP PROJECT vii Acknowledgements I would like to express my gratitude to my advisory committee members, Dr. Sylvia Barton and Ms. Lauren Irving, for their guidance and contributions to this capstone project. Thank you to Saulteau First Nations for your full support and confidence in my success, to Laurie Gayse for endless love and encouragement, to Braxton and Benson for always giving me a reason to move forward, and to all my friends (you know who you are) for always giving me a reason to laugh throughout the chaos. Dedication In loving memory of David Gayse. Running Head: FNP PROJECT viii Glossary of Terms Diabetes Mellitus: a heterogeneous metabolic disorder which is characterized by the presence of hyperglycemia due to impairment of insulin secretion, defective insulin action or both (Punthakee, Goldenberg & Katz, 2018). Diabetic Retinopathy: Microvascular complication of diabetes involving the retina which causes the retinal blood vessels to bleed or leak fluid resulting in visual impairment, and potentially vision loss. Gestational Diabetes: glucose intolerance that is first recognized or begins during pregnancy. Glycemic Control: Maintaining optimal glucose control to reduce the risks of microvascular complications. Nurse Practitioner: a registered nurse who has obtained advanced knowledge to practice autonomously through successful completion of graduate studies. Competencies gained include health management, ordering and interpreting diagnostic tests, diagnoses and treatment, and promoting disease prevention and health promotion (Canadian Nurses Association [CNA], 2010). Primary Care: a sector of health services that provide holistic patient care for health promotion, disease prevention, and management by a health care provider. Primary Care Provider: a healthcare provider, usually a physician or nurse practitioner, who is responsible for providing primary health care to a patient over an extended period. Primary Health Care: a framework for healthcare services that includes primary care and addresses a full scope of holistic healthcare needs to promote positive health outcomes. Type 1 Diabetes: occurs when the pancreas is unable to produce insulin as a result of pancreatic beta cell destruction with consequent insulin deficiency. This includes cases which are due to an autoimmune process and those which the etiology of beta cell destruction is not known (Punthakee, Goldenberg & Katz, 2018). Running Head: FNP PROJECT ix Type 2 Diabetes: occurs when the pancreas secretion is defective and does not produce enough insulin or when the body does not effectively use the insulin that is produced (Punthakee, Goldenberg & Katz, 2018). Note: For the purposes of this paper, the terms health care provider, primary care provider, and nurse practitioner are used interchangeably. Running Head: FNP PROJECT 1 Chapter 1: Introduction Diabetes mellitus is a significant health concern, affecting over two million individuals in Canada (Harris, et al., 2011). One notable complication of diabetes is diabetic retinopathy, which affects 25.4% of people living with diabetes (Pires et al., 2015). Ultimately, if the disease and its co-morbidities are not monitored, progression remains unknown and untreated. Early detection and monitoring of the disease progression are necessary, with the goal to implement intervention and treatment in deterring the onset of retinopathy induced blindness (Agarwal, et al., 2014). Barriers to obtaining essential healthcare screening services is a concern that requires acknowledgement. This necessitates the assessment of situations that may affect an individual’s ability or willingness to access diabetic retinopathy screening. Project Purpose The purpose of this integrated literature review was to answer the following question: What strategies can nurse practitioners in the primary care setting use to promote screening for people living with diabetes to reduce their risk and progression to blindness from diabetic retinopathy? Researchers often notice problems in their professional or personal experiences that they feel require further investigation, in order to generate solutions (Malagon-Maldonado, 2014). The topic selection of this integrative literature review stemmed from both my personal and professional experiences. While working as the director of health and as a registered nurse in a rural First Nations community, I observe the health disparities of people firsthand. As such, I am invested in finding effective solutions to health challenges that result in improved health outcomes. The World Health Organization (2020) has found that the global prevalence of diabetes mellitus type 1 and type 2 in adults over 18 years of age has increased from 4.7% in 1980 to 8.5% in 2014. This increasing trend in new diagnoses of diabetes continues to Running Head: FNP PROJECT 2 significantly impact patient quality of life, causing physiological changes that contribute to a host of adverse outcomes, such as diabetic retinopathy; and increased dependence on the healthcare system. Through my nursing administrative and clinical work, I discovered that many patients who frequently presented with an initial diagnosis of diabetes had limited follow-up of other services. Often, there were no relevant interventions established and limited alterations in therapeutic management since the time of diagnosis. I observed hesitancy from many patients to pursue further appointments with their primary care providers. This resulted in barriers for these patients to adequately benefit from the implementation of preventative measures that could halt or mitigate the progression of their diabetes. Through my experiences, I gained a recognition of the missed opportunities in caring for people living with diabetes, of the disconnects within primary healthcare chronic disease management, and of the lapse of early screening and detection that can prevent complications associated with diabetes. As someone who lives in a rural community with limited healthcare services, I understand that it can be difficult to access specialized health services, or even to have a permanently established, consistent primary care provider. My immediate family member was someone who lived with type 1 diabetes and suffered from vision loss due to diabetic retinopathy. We had to travel eight hours for any form of treatment options. It resulted in him sustaining irreversible blindness at the age of 25. Had he been screened earlier, the outcome most likely would have been more favourable. Looking back, the ultimate solution would have been to increase his access to healthcare. Despite technological advances in the healthcare system, access to healthcare remains elusive to various populations (WHO, 2020). A review of the existing literature that pertains to barriers and access to healthcare by people living with diabetes provided insight into the relevant gaps they face in accessing needed health care services. By Running Head: FNP PROJECT 3 developing a deeper understanding of the available literature regarding access to healthcare, I chose, specifically, to gain a perspective on the barriers that individuals face with accessing appropriate screening methods for diabetic retinopathy. In addition to effective glycemic control, screening is globally recognized as a key intervention for health promotion with respect to diabetes care (WHO, 2020). It is essential that screening is introduced and maintained, in order to avoid the serious consequences of diabetic retinopathy. Although there are clear diabetes management guidelines in Canada, which suggest retinal screening as a preventative measure for the progression of diabetic retinopathy (Diabetes Canada, 2018), there is limited guidance on how to remove barriers to screening for patients living with diabetes. As primary care providers, the nurse practitioner role affords an opportunity for nurses to reach vulnerable populations and improve chronic disease management. Nurse practitioners are advocates for their patients and for their health issues, with the end goal of political and community support for a particular health program or goal (Watson, 2008). Recognizing where the gaps in accessing care exist, is the first step for nurse practitioners in finding effective solutions to bridging these gaps. Furthermore, by recognizing access barriers that may be present for populations experiencing diabetes, theories may provide an understanding of the low incidence of early screening for diabetic retinopathy and of the responses required to increase screening. Barriers to accessing healthcare influence the appropriate utilization of services and whether health care outcomes are improved or not; thus, this review topic is most relevant for nurse practitioners in their care of people living with diabetes. Evidence-based nursing practice is typically acknowledged as having considerable potential to enhance the quality and delivery of nursing practice (Whall, Sinclair & Parahoo, Running Head: FNP PROJECT 4 2006); it is the use of the best evidence available to determine the most appropriate module of care for the target individual or group (Lohr, 2004). Healthcare practitioners must continually examine the best way to deliver care. Evidence-based practice brings relevant and accurate information into clinical practice, and is an effective method of transferring strong research evidence into practice settings (Lohr, 2004). Many nurse practitioners promote the integration of research and evidence into practice, with the aim of improving how advanced nurses practice, of optimizing patient care, and of enhancing the delivery of healthcare services (Harbman, et al., 2017). Using the best evidence available to assess the barriers, which individuals living with diabetes experience when trying to access diabetic retinopathy screening, will allow nursing practitioners to redesign care to be more effective, safe, and efficient. Running Head: FNP PROJECT 5 Chapter 2: Background In this chapter, I discuss the disease process of diabetes and diabetic retinopathy, and the associated outcomes. Following this, American and Canadian practice guidelines for diabetes are discussed, including frequency of screening and the types of screening available. Next, I provide an overview of major risk factors, which contribute to diabetic retinopathy. Finally, I present a discussion of behavior changes related to health outcomes and the role that primary care providers play in supporting patients living with diabetes and diabetic retinopathy. Diabetes Diabetes mellitus is known as a heterogeneous metabolic disorder. Type 1 diabetes is primarily a result of pancreatic beta cell destruction, consequently resulting in insulin deficiency (Punthakee, Goldenberg & Katz, 2018; Diabetes Canada, 2020). Often the pancreatic beta cell destruction is a result of an autoimmune process; however, there are cases where the etiology is unknown (Punthakee, Goldenberg & Katz, 2018; Diabetes Canada, 2020). Type 2 diabetes may include insulin resistance with insulin deficiency or a secretory defect with insulin resistance (Punthakee, Goldenberg & Katz, 2018; Diabetes Canada, 2020). Gestational diabetes refers to glucose intolerance during pregnancy. The prevalence of individuals with a confirmed diagnosis of type 1 or type 2 diabetes in Canada is 3,772,000 individuals (Diabetes Canada, 2020). Diabetes Canada (2020) estimates that from the years 2020 -2030, there will be a 30% increase in diabetes diagnoses among Canadians. Currently, the direct cost of diabetes to the healthcare system is $3.8 billion annually (Diabetes Canada, 2020). With the estimated 30% increase in diabetes cases, the impact on the healthcare system is considerable. Running Head: FNP PROJECT 6 Chronic hyperglycemia of diabetes is associated with long-term microvascular complications affecting the retina and multiple other systems, including the renal, nervous and cardiovascular systems. Specifically, I focus on diabetic retinopathy, a highly specific vascular complication of both type 1 and type 2 diabetes. The prevalence of diabetic retinopathy is strongly correlated with the duration of diabetes, and the level of glycemic control (Diabetes Canada, 2020). For the purposes of this integrated review, I focus on type 1 and type 2 diabetes, solely. Gestational diabetes is eliminated due to the added complexity surrounding pregnancy. Diabetic Retinopathy Diabetic retinopathy is caused by vascular changes in the retina. It results from either diabetes type 1 or type 2. There are three different categories of diabetic retinopathy (Altomare, Kherani & Lovshin, 2018; Diabetes Canada, 2020). The first category includes macular edema, which occurs at the macula and involves diffuse or focal vascular leakage (Altomare, Kherani & Lovshin, 2018; Diabetes Canada, 2020). The second category includes: microaneurysms, intraretinal hemorrhage, vascular tortuosity and vascular malformation; which all result from a progressive accumulation of microvascular changes. This form of retinopathy is considered “non-proliferative” and leads to “proliferative” retinopathy (Altomare, Kherani & Lovshin, 2018; Diabetes Canada, 2020). Proliferative retinopathy occurs when abnormal vessels form on the retina or the optic disc. The third category includes the occurrence of retinal capillary nonperfusion. This is where vascular closures are noted on the retina that ultimately result in blindness. There are no current treatments available for this form of retinopathy (Altomare, Kherani & Lovshin, 2018; Diabetes Canada, 2020). Running Head: FNP PROJECT 7 According to the World Health Organization (2015), diabetic retinopathy is the fifth leading cause of visual impairment and the fourth leading cause of blindness in the world. Out of the 285 million people worldwide with visual impairment, 4.2 million people are visually impaired due to diabetic retinopathy (WHO, 2015). It is the most common cause of legal blindness in people of working age (Altomare, Kherani & Lovshin, 2018; Diabetes Canada, 2020). The WHO (2015) recognizes that if the incidence rates of diabetes continue to rise, the consequences will result in an associated increase of diabetic retinopathy. Practice Guidelines Current practice guidelines provide evidence-based practice resources, which are meant to guide patient care. These guidelines are an asset for disease management. Diabetes is a complex disease that requires individualized care among patients. The current practice guidelines related to diabetes are intended to guide care through screenings and assessments, and pharmacological and non-pharmacological interventions, in order to reduce the burden of diabetes complications (American Diabetes Association, 2020; Punthakee, Goldenberg & Katz, 2018; Diabetes Canada, 2020). Assessment There are two avenues of assessing and managing diabetic retinopathy: glycemic control and screening(American Diabetes Association, 2020; Punthakee, Goldenberg & Katz, 2018; Diabetes Canada, 2020). Optimal glycemic control reduces the onset and progression of the microvascular complications of diabetes, including retinopathy (American Diabetes Association, 2020; Punthakee, Goldenberg & Katz, 2018; Diabetes Canada, 2020). The majority of patients who develop retinopathy present with no symptoms until proliferation is advanced (McCulloch, Running Head: FNP PROJECT 8 2019). At this stage, treatment may be ineffective, and ultimately result in permanent, irreversible vision loss (McCulloch, 2019). This makes early and frequent screening for retinopathy crucial. Screening Recommendations Screening for diabetic retinopathy has been shown to reduce the number of people who develop avoidable vision loss and irreversible blindness (McCulloch, 2019). Patients with proliferative diabetic retinopathy or macular edema may be asymptomatic until the damage is too advanced. Specific therapies such as laser photocoagulation and vascular endothelial growth factors (VEGF) inhibitors are found to be effective (McCulloch, 2019). Of note is that these therapies are highly beneficial in preventing vision loss, and much less so in reversing already diminished visual acuity (McCulloch, 2019). These facts provide strong support for the provision of retinopathy screening, in order to ensure early detection and appropriate referral for therapy (Diabetes Canada, 2020). Additionally, effective screening has shown to be a cost-effective method, as opposed to costs associated with vision loss. The price tag behind preventative eye care is significantly lower than the costs associated with the continual support and rehabilitation required, due to vision loss and blindness (Tapp, et al., 2015). When reviewing screening recommendations, there are several aspects of retinopathy to consider. These include the differences in incidence and prevalence of retinopathy found in both type 1 and type 2 diabetes, and the level of retinopathy that is occurring (Altomare, Kherani & Lovshin, 2018; Diabetes Canada, 2020). Running Head: FNP PROJECT 9 Frequency of Screening Both the American Diabetes Association (2020) and Diabetes Canada (2018) suggest that all individuals over the age of 15 years with type 1 diabetes should have retinal screening initiated within 5 years after diagnosis (Altomare, Kherani & Lovshin, 2018 ; Diabetes Canada, 2020). Screening, thereafter, depends on whether retinopathy is present or not. If there is no evidence of retinopathy, people with type 1 diabetes are rescreened annually (Diabetes Canada, 2020). If there continues to be no evidence of retinopathy for one or more annual eye exams, and the patient has good glycemic control, then the optometrist/ophthalmologist may consider screening every two years (American Diabetes Association, 2020). For people with type 2 diabetes in any age group, screening is to be initiated at the time of diagnosis. Subsequent screening, as with type 2 diabetes, is dependant on any presenting retinopathy. If retinopathy is not present, rescreening is advisable every 1 -2 years. Studies have shown that there is limited risk of developing retinopathy within three years after a normal eye examination in those with well-controlled type 2 diabetes (American Diabetes Association, 2020). In both type 1 and type 2 diabetes, if any stage of retinopathy is presented by the patient, referral to an ophthalmologist is paramount. Thereafter, subsequent dilated retinal examinations should be repeated annually, at minimum. However, if retinopathy is progressing or endangers vision, more frequent examinations will be advised (Diabetes Canada, 2020). This frequency depends on the stage and speed of advancement of retinopathy, as well as the level of glycemic control of the patient. Running Head: FNP PROJECT 10 Screening Methods Screening for diabetic retinopathy should be performed with only validated approaches and procedures (Diabetes Canada, 2020; American Diabetes Association, 2020). Different screening methods are used, based on the level of retinopathy present. Options for screening may include: dilated ophthalmoscopy, fundus imaging with preference to standard seven field or wide field imaging +/- macular optical coherence tomography, and potentially telehealth systems operated by ophthalmologists (Altomare, Kherani & Lovshin, 2018; Diabetes Canada, 2020). For sight-threatening diabetic retinopathy, including severe non-proliferative diabetic retinopathy, proliferative diabetic retinopathy or foveal threatening diabetic macular edema (DME) screening requires clinical evaluation and/or optical coherence tomography (Altomare, Kherani & Lovshin, 2018; Diabetes Canada, 2020). Retinal thickening and distance from the foveal centre in macular edema is assessed with optical coherence tomography technology (Diabetes Canada, 2020). Telemedicine programs are becoming more readily available in areas where ophthalmologists or optometrists may not be available. Telemedicine relies on high quality fundus photography, in order to identify and triage diabetic retinopathy (Diabetes Canada, 2020). The retinal imaging is electronically sent to the receiving party, where it should be then interpreted by an eye specialist. From there, the results should be documented and sent to the patient’s primary care provider and/or referring centre (American Diabetes Association, 2020). The benefits of telemedicine include: enhanced efficiency and reduced financial burden on both the patient and the health care system (American Diabetes Association, 2020). Potentially, retinal photography may enhance efficiency by reducing the use of ophthalmologists Running Head: FNP PROJECT 11 in routine examinations. This allows their expertise to be directed at more complex examinations and for providing treatments (American Diabetes Association, 2020). Furthermore, retinal photography may reduce costs of travel for the patient, and reduce hospital/clinic visits by making screening services more local and easily accessible. Although telemedicine is an excellent option, they do not replace comprehensive eye exams, which ideally are performed at least initially and then based on an eye care specialist’s recommendation, afterwards (American Diabetes Association, 2020). If any evidence of diabetic retinopathy is present, it is recommended that the patient be urgently referred to an ophthalmologist (Diabetes Canada, 2020). As previously mentioned, retinopathy screening strategies are necessary, in order to identify treatable disease and to reduce the risk of blindness. Potential treatment options include: intraocular injectable pharmaceuticals, laser therapy, and microsurgical treatments. These treatments, alone or in combination, have been found effective in the prevention of vision loss due to diabetic retinopathy. Effective screening, thorough assessments, and prompt referrals are crucial to prevent treatable vision loss (Altomare, Kherani & Lovshin, 2018; Diabetes Canada, 2020). Major Risk Factors Modifiable risk factors can be described as specific agents, which may increase or decrease a person’s risk of developing a specific disease (Mancini, Hegele & Leiter, 2018; Diabetes Canada, 2020). These agents are considered modifiable, because they can be changed, thus altering their outcomes. Of note is that the modifiable risk factors being identified are those that affect a person’s risk of developing vascular complications of diabetes, leading to Running Head: FNP PROJECT 12 retinopathy. Diabetes is known to be associated with a high risk of vascular disease. Aggressive management of all vascular risk factors, including dyslipidemia, glycemic control, and hypertension, is, therefore, necessary in individuals with diabetes (Mancini, Hegele & Leiter, 2018; Diabetes Canada, 2020). Poor glycemic control, dyslipidemia, and hypertension are discussed as modifiable risk factors that will alter outcomes of diabetes. When managed effectively, each of these factors may reduce diabetes related complications. Glycemic Control One of the most notable risk factors for effective management of diabetes is optimal glycemic control. Evidence has shown that improved glycemic control reduces the risk of microvascular complications of diabetes, including retinopathy (Imran, Agarwal, Bajaj, & Ross, 2018; Diabetes Canada, 2020). There are varying guidelines available for glycated hemoglobin A1C levels, but most of the current Canadian literature indicates that A1C levels of greater than 7.0% are associated with a significant increase in diabetes related complications. Establishing adequate glucose control by lowering the A1C value to below 7.0%, demonstrates profound benefit for microvascular complications in both type 1 and 2 diabetes (Imran, Agarwal, Bajaj, & Ross, 2018; Diabetes Canada, 2020). This is especially accurate if the A1C is controlled early in the disease, with limited episodes of hypoglycemia and hyperglycemia. Variability in glucose levels should be monitored, and the approach should be aimed at stabilization. This may involve more tightly controlled values of an A1C less than 6.5% in people who are newly diagnosed with diabetes and have longer life expectancy; targets of A1C of <8.5% may be advisable for those with limited life expectancy and repeated episodes of hyper or hypoglycemia (Imran, Agarwal, Bajaj, & Ross, 2018; Diabetes Canada, 2020). This situation requires more intensive review and Running Head: FNP PROJECT 13 individualized care planning, as such complications from diabetes, including retinopathy, arise with inadequate glycemic control. Dyslipidemia As previously mentioned, diabetes is linked to a high risk of vascular complications, making aggressive management of all risk factors, including dyslipidemia, crucial. It is commonly found that diabetic patients have hypertriglyceridemia (hyper-TG), low high-density lipoprotein cholesterol (HDL), and normal plasma concentrations of low-density lipoprotein cholesterol (LDL) (Mancini, Hegele & Leiter, 2018; Diabetes Canada, 2020). Regardless of the actual risk calculation, the majority of individuals with a duration of diabetes of over 15 years, or with concomitant vascular disease, should undergo lipid lowering therapy (Mancini, Hegele & Leiter, 2018; Diabetes Canada, 2020). The full management of dyslipidemia includes: frequent intervals of lipid profile monitoring, lipid-lowering therapy, and health lifestyle behaviours; regimes tailored to individual needs. Hypertension In the Diabetes Canada Guidelines, Tobe, et al. (2018) explains that various studies have shown a strong association between elevated systolic and diastolic blood pressure, and vascular complications in those living with diabetes. Intensive blood pressure control has benefits of preventing cardiovascular complications, potentially even higher than the benefits of glycemic control (Tobe, et al., 2018; Diabetes Canada, 2020). With cardiovascular disease being the highest link to deaths in diabetic individuals, targeted blood pressure control is essential. Diabetes Canada (2020) recommends that the treatment of hypertension should aim to achieve a systolic blood pressure of <130 mmHg and diastolic BP of <80 mmHg. Treatment options Running Head: FNP PROJECT 14 include: ACE inhibitors, ARBs, dihydropyridine CCBs, and thiazide/thiazide-like diuretics (Tobe, et al., 2018; Diabetes Canada, 2020). If single, standard dose therapy does not achieve targeted blood pressure levels, additional anti-hypertensives should be used (Tobe, et al., 2018; Diabetes Canada, 2020). Physical Activity Physical activity has been identified as a consequential modifiable risk factor for diabetes. Regular physical activity is known to reduce the risk of diabetes and elevated glucose levels, and to promote overall health improvements related to energy levels, weight control, and obesity prevention. There is a strong linkage between obesity and diabetes prevalence (WHO, 2015). Praidou, Harris, Niakas and Labiris (2016) found that there is a significant negative correlation between physical activity and diabetic retinopathy severity. This finding allows for the recommendation that patients with diabetic retinopathy need be educated on the benefits of physical activity and healthy weight management. A lack of physical activity and obesity are associated with more critical retinopathy levels in patients living with diabetes (Praidou, Harris, Niakas & Labiris, 2016). Health Behavioral Change When discussing factors that influence diabetic retinopathy, it is important to consider behaviors that can contribute to desired change. This type of change can stem from various levels of a system. This may include the individual, an organization, a community, and a population. Each of these levels can be interrelated and impact one another in various ways (Tombor & Michie, 2017). Tombor and Michie (2017) suggest that interventions are found to be the most effective when they are aimed at reaching several levels simultaneously and consistently. There Running Head: FNP PROJECT 15 were several recommendations that were identified through evidence-based reports. Several recommendations include: · Improving knowledge about the impacts of a person’s behavior on their health, · Providing personal relevance to what health behavior changes would mean to the person, · Promoting positive affective attitudes towards behavioral change, · Increasing the positive descriptive norms in society, · Improving the positive subjective norms in society, · Promoting the personal and moral norms of behavioral change, · Promoting self-efficacy for behavioral changes, · Intention and goal setting with follow-through plans, · Creating behavioral contracts to improve accountability, · Increasing awareness of social influences, and · Measures to prevent relapse and to cope with difficult situations (Tombor & Michie, 2017). Despite the high risk of persons living with diabetes developing retinopathy complications, a high number of people are unaware of the prevention strategies available, and the risks that developing retinopathy carries (Cavan, et al., 2017). Strategies to promote diabetic Running Head: FNP PROJECT 16 retinopathy screening behaviors may provide an increased awareness of how primary care providers can guide patients into positive behavioral change, in order to enhance their health. Primary Care Provider’s Role Diabetes is a complex disease with multiple comorbidities. It is strongly advised that individuals living with diabetes require a team approach to their medical care. This type of care may include, but is not limited to, physicians, nurse practitioners, registered nurses, dietitians, pharmacists, and mental health professionals; all of whom offer access within primary care clinics. Primary care providers often work in a collaborative and integrated team approach, in order to ensure the patient receives efficient coordination and management of chronic conditions (American Diabetes Association, 2003). It is essentially the first contact within the health care system for patients, and referrals to higher levels of care are provided through them as needed. Managing diabetes and preventing irreversible blindness from diabetic retinopathy is critical. This outcome requires cooperation from both the primary care provider and the specialists concerned with patients experiencing diabetic retinopathy. Although this situation seems like an indisputable fact, it is not always a consistent practice within healthcare systems (WHO, 2015). Promoting the prevention and management of diabetic retinopathy in primary care requires a patient-centered approach; one that includes collaboration in the decision-making process between patients and their primary care providers. Primary care providers must understand the value of considering ways to promote retinopathy preventative behaviors in patients experiencing diabetes. They must also realize that, in order to implement behavioral change in patients, it is essential to assess situations which may affect their capacity to access Running Head: FNP PROJECT diabetic retinopathy screening. Thus, barriers to screening for diabetic retinopathy, and the role of primary care providers, became the focus of my integrated literature review. 17 Running Head: FNP PROJECT 18 Chapter 3: Research Methods Conducting an integrated literature review provides a process by which to synthesize major research studies that are relevant to a research question (Whittemore & Knafl, 2005). Reviewing literature to summarize findings is a method that provides a more comprehensive understanding of an issue or area of concern. The method used to review existing literature can work to either strengthen or weaken research evidence. Therefore, it is important for clinicians to conduct reviews that can provide validity and reliability information related to their outcomes. Three common methods for conducting literature reviews include: systematic reviews, narrative reviews, and integrative reviews. This project focuses on the implementation of an integrative review. An integrative review summarizes past empirical or theoretical literature, in order to provide a more comprehensive understanding of a particular phenomenon (Broome, 1993). An integrative review uses a more flexible approach than a systematic review, in that it allows for diverse, peer-reviewed research studies (i.e. experimental and non-experimental) to be incorporated. For an integrative review to be credible, it must be comprehensive, allowing for a fuller understanding of an issue or concern (Whittemore & Knafl, 2005). Integrative reviews have the potential to build nursing science, inform research and practice, and produce evidenceinformed policy initiatives (Whittemore & Knafl, 2005). It is an approach that places value in having a valid and reliable process for summarizing the literature, while including diverse research such as non-experimental evidence. Thus, an integrative literature review was conducted to reveal strategies which nurse practitioners can use in the primary care setting, in order to: 1) promote screening for patients living with diabetes, and 2) reduce their risk and progression to blindness from diabetic retinopathy. This project has substantially added to my Running Head: FNP PROJECT 19 understanding of the purposes of research methods related to qualitative, quantitative, and mixed methods research; specifically, through an analysis and synthesis of a specific set of articles that formed the basis of my integrated literature review. Literature Search Preliminary Search Searching for literature that is current, relevant, peer-reviewed, and of the best evidence may be one of the most difficult aspects of implementing evidence-based practice. It can be time consuming and difficult for researchers to even find a place to start. Deciding which question to pursue, which database to use, which filters to implement, and which key terms to determine will be effective is only the beginning. Some basics of effective searching include: having a carefully defined clinical question, choosing key search terms, adding synonyms, truncating or wildcarding if needed, and using Boolean operations (Hoffmann, Bennett & Del Mar, 2010). A broad initial search of existing literature was conducted within Google Scholar to provide guidance for the literature search. By evaluating key terms and medical subject heading (MeSH) terms used in the available articles, relevant themes emerged to support the research topic. A concept map is presented in Diagram 1 that was used to guide the research question, to determine the focus, and to select key strategies for conducting the research (integrated literature review). Running Head: FNP PROJECT 20 Diagram 1 Concept Map Research Question Diabetic Retinopathy Vision Loss Blindness Nurse Pracitioner Visual Impairment Primary Care Provider Clinician Barriers to Screening Georgraphic Economic Social Primary Search Strategies Keywords and MeSH terms were searched within CINAHL, PubMed, Medline (Ovid), Medline (Full Text), and PsychINFO. Table 1 depicts the search terms used in each database. Within these databases, the search terms were used and combined with the Boolean terms “AND” and “OR”, when required. Refer to Table 2 for the search strategies. Running Head: FNP PROJECT 21 Table 1 Search Terms Used in Databases to Extract Articles for Review PubMed Medline (Full Text) PsychINFO CINAHL Medline (Ovid) Nurse Practitioner (NP) NP NP NP NP Primary Care Provider (PCP) PCP PCP PCP PCP GP GP General Practitioner (GP) Diabetic Retinopathy (DR) DR DR DR DR Retinopathy Retinopathy Retinopathy Retinopathy Retinopathy Vision Loss Vision Loss Vision Loss Vision Loss Vision Loss Blindness Blindness Barriers to Barriers to Screening Screening Blindness Barriers to Screening Barriers to Screening Table 2 Search Strategy Used for Database Searches Search Search Terms #1 “Nurse Practitioner” OR “Primary Care Provider” OR “General Pracitioner” #2 “Diabetic Retinopathy” OR “Retinopathy” OR “Vision Loss” OR “Blindness” #3 #1 AND #2 #4 “Barriers to Screening” #5 #3 AND #4 Running Head: FNP PROJECT 22 Inclusion and Exclusion Criteria Eligibility criteria were created to identify relevant literature, which looked at the barriers that may exist to accessing diabetic retinopathy screening. The inclusion and exclusion criteria are presented in Table 3. Table 3 Inclusion and Exclusion Criteria for the Literature Inclusion Criteria Study was published in English Exclusion Criteria Study focused on youth (<18) or older adults (>65) Population of study was adults (18-65) Study focused on other complications of diabetes Study focused on barriers to services Study focused on methods of screening Study addresses diabetic retinopathy Study was published between the years 2009 – 2019 For articles to be included within the integrated review, the study had to be published between the years 2009-2019. This was to ensure all literature was current and relevant to practice. Also included were those articles published in English. Articles that focused exclusively on specific ethnic backgrounds were eliminated, because of the specific focus and lack of universal use to the general Canadian population. The general adult population was used, as youth and elderly populations may face challenges which are unique to their age. There were a Running Head: FNP PROJECT 23 vast number of studies outlining various methods of screening; thus I determined that articles must address the barriers to accessing this screening, but not focus on what the specific details of screening methods were, and not focus on a comparison of screening methods, specifically. Also, all articles had to focus on the barriers to accessing services for retinopathy screening, in order to ensure the focus of the integrated review remained relevant to the review research question. Articles that discussed populations with other specific complications of diabetes, such as kidney disease and neuropathy, were excluded, in order to deter from the focus on retinopathy screening. Diabetes is a complex care disease that has numerous complications. It was important for me to address only one of these complications; thus proceeding with a project of manageable scope by which to focus my specific research question. Secondary Search Strategies The process following the application of inclusion and exclusion criteria, previously defined, resulted in the cumulative search yielding 221 articles. Once duplicates were removed, there was a total of 90 articles to screen. Not all key words are found in the title of research articles; however, the search engines utilized organizes papers with three sets of terms, and one will always include the health condition of interest (Higgins & Green, 2011). Therefore, in my review, diabetic retinopathy, screening, and barriers were the terms selected. This screen yielded 60 results, which was then further interpreted using the inclusion and exclusion criteria (refer to Table 3). This left 15 articles for full review. Once the search was further customized to include articles with full-text available and to exclude those without, the remainder resulted in 13 articles. These 13 full-text articles were vigorously evaluated and reduced to a final total of eight Running Head: FNP PROJECT 24 articles, which were used for the analysis and synthesis of my integrated literature review (refer to Appendix A: Search Strategy). Data Evaluation and Analysis Whitemoore and Knalf (2005) note that an integrative literature review requires exceptional analyses of the literature. Appendix B: Literature Review Matrix – Preliminary Studies presents a display of the information that was retrieved from each of the eight selected articles. The headings of the review matrix include: 1) study overview, 2) research approach and sample, 3) strengths and limitations, and 4) key findings and themes. From this information, I was able to synthesize across all eight articles, the dominant themes. Appendix C: Data Comparison, Similar and Contradictory Ways Data is Presented illustrates a comparison guide between the eight articles, in order to create an awareness of similarities and differences between articles. The column headings display the data collection methods and research approaches for each article. Data collection methods varied within the literature to include: 1) systematic reviews, 2) interviews, 3) literature reviews, and 4) crosssectional studies. All eight peer-reviewed articles used a qualitative approach to determine the views of people who experienced barriers to accessing care. It is important that the condensed matrix data be validated, in order to create resolutions that form a thorough understanding of the findings from this literature review. As such, an integration of the findings into four themes are discussed, next. Running Head: FNP PROJECT 25 Chapter 4: Findings In this chapter, an integration of the literature review findings into four themes is discussed. Through the comprehensive search that was previously described, eight articles were identified to address strategies which nurse practitioners can utilize within the primary care setting, in order to promote screening for people living with diabetes and to reduce their risk and progression to blindness from diabetic retinopathy. The specific articles included: two systematic reviews, three qualitative studies, two literature reviews, and one cross sectional study. Four themes emerged through the data analysis process, which provided insight into promoting screening for diabetic retinopathy within primary care. These themes included: 1) structural barriers to care, 2) socioeconomic conditions, 3) emotional barriers to accessing healthcare, and 4) knowledge deficits. The articles in this review were selected to effectively respond to the research question: What strategies can nurse practitioners in the primary care setting use to promote screening for people living with diabetes to reduce their risks and progression to blindness from diabetic retinopathy? The articles focus on specific screening recommendations, methods of screening, and frequency of screening, while considering major risk factors for developing and advancing diabetic retinopathy. Each of the selected articles also address strategies and methods of health behavioural change whether at the individual, organizational, community, or population level; and how primary care providers can play a role in these changes. The subsequent sections discuss each of the four themes. Running Head: FNP PROJECT 26 Structural Barriers Common barriers were noted across the eight articles related to structural barriers for accessing diabetic retinopathy screening (Graham‐Rowe, et al., 2018; Hipwell, et al., 2014; Lindenmeyer, 2014; Liu, et al., 2018; Shah, et al., 2018). This included: 1) environmental factors, such as travel distance required to access screening services, and 2) healthcare provider availability, which affects long wait times for specialty services for diabetic retinopathy screening. Environmental Factors Rural populations face multiple barriers to accessing retinopathy screening, including long transportation requirements and multiple barriers related to accessing healthcare services (Graham‐Rowe, et al., 2018; Hipwell, et al., 2014; Lindenmeyer, 2014; Liu, et al., 2018). The literature emphasized that transportation modes and access barriers must be considered when promoting retinal screening. Travelling to and from appointments was found to be the largest issue for rural patients. Through the multi-perspective interviews, Hipwell (2014) found that the proximity of screening from a patient’s home may affect their screening uptake. The inconvenience of distance to screening locations deters many patients from attending their screening appointments. While patients in more central urban locations have access to public transportation or minimal travel time, those living in rural or remote areas have several barriers to consider. The long travel times may require hotel stays, expensive fuel purchases, time away from work, and potentially time away from children or family to accommodate the appointments (Graham‐Rowe, et al., 2018). This could result in, not only being an inconvenience but expensive as well. Running Head: FNP PROJECT 27 Once patients are at their appointments, a routine part of their testing includes mydriasis drops. Patients are advised not to drive after the drops, due to photosensitivity and blurred vision (Hipwell, et al., 2014; Lindenmeyer, 2014). Both Lindenmeyer (2014) and Hipwell (2014) found in their studies that the transportation required after mydriasis drops was a significant barrier in navigating a return home. Some patients have the option to be driven by another person; however, this is not always practical for all patients. Lindenmeyer’s (2014) study found that staff at the retinal screening clinics claimed that it was common for patients to ignore the warning not to drive. Reducing inconvenience related to the environmental factors for those living with diabetes may promote more effective screening attendance. In a systematic review, GrahamRowe (2018) found two studies that supported mobile screening units as a possible method for bridging the barriers to accessing screening. Mobile screening units were found to be associated with higher attendance when compared to screening appointments at urban optometry clinics (Graham‐Rowe, et al., 2018). Healthcare Provider Availability Difficulty related to health primary care provider availability, specifically specialist services related to retinopathy screening, was another common theme found within the literature (Graham‐Rowe, et al., 2018; Hipwell, et al., 2014; Lindenmeyer, 2014; Liu, et al., 2018; Shah, et al., 2018). In Liu, et al.’s (2018) study, the limited availability of specialist services has encouraged the uptake of services to be utilized less frequently, on a “as needed basis”. This leaves appointment times reserved for urgent/emergent care, which ultimately results in longer wait times. Thus, patients tend to avoid utilizing these services for preventative care, and often Running Head: FNP PROJECT 28 end up with irreversible retinal damage as a consequence (Liu, et al., 2018). Graham-Rowe, et al. (2018) found similar results, and added that long wait times on the day of the patient’s appointment, insufficient scheduling notice, and inability to get an appointment in a timely manner, were problematic and led to a general avoidance of these essential screening appointments. Another point considered was the problem of food abstinence for people living with diabetes, because of long wait times for their appointments (Graham‐Rowe, et al., 2018). Shah, et al. (2018) produced similar results, and suggest activity sharing to create opportunities for patients to obtain coordinated, continuous, and high-quality preventative eye care. Activity sharing may potentially optimize the roles of existing healthcare workers to eliminate barriers related to a lack of specialists or long appointment wait times. There are opportunities for optometrists, refractionists, ophthalmic technicians, diabetes educators, nurses, and family physicians to fulfil specific activities related to diabetic retinopathy screening (Shah, et al., 2018). Hipwell, et al. (2014) suggest a proactive approach to the coordination of care, which involves patients, primary care settings, and screening programs. However, it was noted that leaving patients to coordinate their own appointments and care may potentially give the impression that retinopathy screening is viewed as a low priority (Hipwell, et al., 2014). Tele-ophthalmology is suggested within the literature as a potential strategy to addressing barriers related to specialty health care provider availability. By utilizing the technology available with tele-ophthalmology, mid-level healthcare workers can take images of the retina and forward them to a tertiary eye care facility, in order for them to be assessed by specialists and to have a management plan developed based on these images (Shah, et al., 2018). Ultimately, this could reduce the requirement of patient appointments in a higher-level care Running Head: FNP PROJECT 29 facility, potentially expedite the screening process, and reduce wait times as a result (Shah, et al., 2018). Thus, based on these considerations related to structural barriers, there is an excellent opportunity for nurse practitioners to deliver services that would result in reducing strain on the healthcare system. With a lack of healthcare providers, specifically specialist availability, and an increasing number of patients presenting with diabetes, annually, nurse practitioners are well positioned to provide the necessary primary care services to those living with diabetes in a timely and comprehensive manner. Socioeconomic Conditions The World Health Organization (2020) defines the social determinants of health as nonmedical factors that influence health outcomes. These are understood as the socioeconomic conditions that a person is born into and lives with on a daily basis. Social determinants of health include: 1) income, 2) education, 3) employment and job insecurity, 4) food insecurity, 5) housing, 6) early childhood development, 7) social inclusion, and 8) access to health services (WHO, 2020). A person’s low socioeconomic position is linked to their tendency to experience poor health conditions (WHO, 2020). The three socioeconomic conditions that are discussed in this section include: 1) income, 2) education, and 3) employment, all of which influence personal financial status and that may have an impact on people living with diabetes accessing healthcare services (Graham‐Rowe, et al., 2018; Hipwell, et al., 2014; Liu, et al., 2018; Shah, et al., 2018). Of note in this literature review is the insight that personal financial barriers, as well as the patient’s educational background, are important factors that contribute to retinopathy screening uptake. Running Head: FNP PROJECT 30 Personal Financial Barriers Through the qualitative, semi-structured interview process, Liu, et al., (2018) found that patients had reported several challenges related to socioeconomic barriers, including specific financial limitations. First, the cost of healthcare services was found to be a major concern for patients (Shah, et al., 2018); diabetes is expensive to manage without health insurance. Further, retinopathy screening requires financial commitments that may not be widely recognized; often patients are required to choose between their healthcare costs and daily living expenses (Liu, et al., 2018). Hipwell, et al. (2014) found that patients who admitted to not regularly attending their appointments for screening, explained that it was primarily due to competing work commitments and to needing to take time for postoperative recuperation. It is often difficult for patients to take time off work to attend regular screening programs. In addition, patients who are self-employed or casual employees lose income when they must take time off work to attend appointments (Graham‐Rowe, et al., 2018). Further constraints include: 1) family responsibilities, such as paying for childcare; 2) finding adequate childcare; and 3) other family commitments that may act as barriers against taking time away for screening appointments (Graham‐Rowe, et al., 2018). Patients living with diabetes often have multiple comorbidities, in addition to their primary diagnosis of diabetes. These health challenges require the patient’s time, energy, and resources, in order to address the management of multiple health conditions, concurrently; thus leading the patient to focus primarily on acute medical issues, as opposed to preventive care. Eventually, it becomes a consistent trend in the patient’s life that they are only obtaining health services for severe symptoms, rather than for preventive care as well, such as diabetic retinopathy screening. Running Head: FNP PROJECT 31 Educational Background Liu, et al. (2018) revealed that patients who had limited educational backgrounds felt this had a negative impact on their health literacy. Limited health literacy compromises the patient’s understanding of their health condition and creates challenges related to following diabetes management guidelines. It was found that patients experienced frustration, due to a lack of understanding of how to manage their diabetes; and often the diabetes education they did receive left them unclear and unable to make informed decisions about their health (Liu, et al., 2018). Psychological Barriers to Accessing Healthcare Psychological barriers to accessing healthcare services became a theme within the reviewed literature. Psychological barriers were associated with impeding or not supporting individual uptake of diabetic retinopathy screening protocols. The most prevalent components related to psychological barriers included: 1) patient-provider communication, 2) building trust and relationships, 3) family support, and 4) fear of negative outcomes. Patient-Provider Communication The necessity for effective patient-provider communication was a recurring theme found in the literature. It was most thoroughly highlighted by Graham-Rowe, et al (2018); when a patient is initially diagnosed with diabetes, thorough communication of the potential risks, outcomes, and measures for screening must be discussed. Poor communication techniques exhibited by the health care provider in relationship with the patient can result as a substantial barrier that prevents the transfer of essential information to the patient. Language and communication style is also noted as a barrier (Graham‐Rowe, et al., 2018). If the patient and provider share a different first language, for instance, misunderstandings can easily occur. Running Head: FNP PROJECT 32 Furthermore, if the provider communicates using complex medical terminology, the patient will potentially be left unclear about their diagnosis or management plan. It may be overwhelming or intimidating for patients to ask for clarification while speaking to their healthcare provider. Graham-Rowe, et al. (2018) provide suggestions for overcoming these patient-provider communication barriers within the healthcare system. This may include providing access to interpreters or cultural navigators/workers. By having family members or a support person be present during their appointments, such an arrangement may facilitate conversation, may provide support to the patient to ask questions, and may encourage an exchange of different perspectives related to the topic being discussed. Building Trust and Relationships Many of the reviewed articles commented on the effects of building trust and relationship between individuals and healthcare providers within the context of medical systems (Graham‐ Rowe, et al., 2018; Hipwell, et al., 2014; Shah, et al., 2018). The authors explained how people often struggled with finding a sense of comfort and support, resulting in ineffective trust and relationship building with their care providers; and how ultimately, this affects the patient’s satisfaction with the encounter that can result in a decision not to participate in the screening program (Graham‐Rowe, et al., 2018; Shah, et al., 2018). Once a person developed a perception of being discriminated within the healthcare system, there was a strong association of them exhibiting longer time periods between screening visits. However, also highlighted were many individuals who experienced validation and motivation during their interactions with providers as they accessed screening services, especially when given the time to discuss screening recommendations with their healthcare provider (Graham‐Rowe, et al., 2018). Running Head: FNP PROJECT 33 Family Support The presence of positive family support was associated with improved preventative behaviours demonstrated by patients living with diabetes; while its absence was a barrier (Graham‐Rowe, et al., 2018). Family support was described to include: 1) assistance with transportation to appointments, 2) repeated encouragement, and 3) timely appointment reminders (Graham‐Rowe, et al., 2018). In some cases, family support came from first-hand experience of a family member who was living with diabetes; thus potentially providing a context of experience for all family members to observe the negative consequences of ineffective diabetes control, themselves. Although this could act as an enabler in the sense of “what not to do”, it could also cause significant fear regarding potential outcomes for other family members’ trajectory of diabetes and associated challenges. Lui, et al. (2018) noted that fear motivated some patients to seek regular retinopathy screening to prevent these potential undesirable outcomes. However, it was also found that participants in Lui, et al.’s (2018) study reported that seeing family members with these severe complications often resulted in patients avoiding screening, due to fear of receiving unfavourable news about their health. Furthermore, it was indicated that patients struggled with negative judgements from family (or friends) regarding their commitment and adherence to the recommended diabetes management guidelines; feelings of frustration were commonly reported. Participants often felt as though their daily choices, such as exercise and diet, were judged harshly when their behaviours were not in alignment with the guidelines (Liu, et al., 2018). The experience of being monitored and judged created an atmosphere of social stigmatization, which was found to contribute to low self -esteem and to feeling that they were incapable of adhering to the health recommendations (Liu, et al., 2018). Running Head: FNP PROJECT 34 Fear of Negative Outcomes The literature revealed that the notion of fear related to diabetes has a significant influence on the daily lives of these patients (Graham‐Rowe, et al., 2018; Liu, et al., 2018). Of note, is that the emotional impact of diabetes described here is a more generalized version of that which was discussed in the previous family support section. As mentioned, for some of the patients the fear of vision loss was found to be a strong incentive to attend screening. However, the fear of being given bad news with a diagnosis of diabetic retinopathy was found to be a barrier to being screened (Graham‐Rowe, et al., 2018). Both Graham‐Rowe, et al. (2018) and Liu, et al. (2018) found that the negativity that surrounds poorly controlled diabetes related directly to feelings of failure, guilt, fear, and anger. Non-adherent behaviours often caused internalized negative feelings and a self-identification of being “bad” or “naughty”. The literature indicates that this negativity led to a lack of confidence in patients’ ability to prevent diabetes complications, which subsequently was a barrier to accessing screening services (Liu, et al., 2018). Knowledge Deficits The knowledge base of people living with diabetes related to the education provided to them from their health care provider, became a theme within the reviewed literature. Personal knowledge of screening outcomes and risks were associated with facilitating or inhibiting individual behaviours related to retinopathy prevention. A critical component regarding the health beliefs of patients living with diabetes is that, it is essential they receive education from their health care provider on the importance of adhering to recommendations of screening, as well as of potential negative outcomes should recommendations for screening be dismissed. Running Head: FNP PROJECT 35 Education on Screening Importance and Outcomes Within the literature, participant knowledge regarding retinopathy became a predictor of screening adherence. In Lindenmeyer’s study (2014), those with a more thorough understanding of retinopathy were more influenced to attend diabetic eye screening. Unfortunately, it became apparent in the literature that many patients lack knowledge in diabetic retinopathy screening and the associated outcomes (Graham‐Rowe, et al., 2018; Hipwell, et al., 2014; Shah, et al., 2018). Graham‐Rowe, et al. (2018) found that several studies reported that this lack of knowledge resulted in a barrier to screening attendance. Understanding how diabetes affects vision was found to be a crucial motivating factor in screening uptake. It was also found that some patients were not aware of the difference between diabetic retinopathy screening and routine eye tests at optometry clinics. This resulted in patients falsely believing that they had attended screening (Graham‐Rowe, et al., 2018; Hipwell, et al., 2014). The literature further revealed that, although primary care providers understand the importance of patient education, several were not willing to make the link between diabetes and blindness from retinopathy clear, in an attempt to not cause panic in their patients (Graham‐ Rowe, et al., 2018). Furthermore, education is time consuming and primary care providers may find it difficult to allow sufficient patient time to be dedicated to education. Shah, et al. (2018) found that education was an area that could benefit from activity sharing; directing retinopathy screening education to nurses and diabetes educators to ensure knowledge was being extended to patients. Running Head: FNP PROJECT 36 Chapter 5: Discussion Through this integrated literature review, four themes were identified, which may influence uptake and attendance of diabetic retinopathy screening. These themes include: 1) structural barriers to accessing specialized screening services, 2) socioeconomic conditions, which influence an individual’s ease of accessing care, 3) emotional aspects of a retinopathy diagnosis, and 4) educational aspects of screening. Through evidence-based practice, nurse practitioners provide consistent, safe care to patients. Evidence-based practice reduces variations in clinical practice, promotes consistency in patient care, and leads to higher quality of care and patient safety (CNA, 2021). The literature review findings can influence the practice of nurse practitioners by ensuring they are aware of barriers that may stand between a patient and their willingness to access diabetic retinopathy screening. Next, the findings are discussed in the context of primary care, with recommendations for primary care professionals’ clinical practice. Educational recommendations are highlighted to aid in influencing future practice. This section concludes with a brief discussion of study limitations and recommendations for future research. Theme One: Structural Barriers to Care Screening for diabetic retinopathy is a specialized service that requires advanced technology and screening by ophthalmology specialists, or other high level eye care professionals. These services tend to be available in tertiary care centres located in urban areas. The literature revealed multiple structural barriers that patient’s face to accessing these resources. Recognizing that it may be difficult for patients to travel from rural areas to larger centres is an important aspect of care that must be considered. Primary care providers need to be Running Head: FNP PROJECT 37 mindful that inconvenient travel distances can have an influence on an individual’s daily life, as well as influence a patient’s tendency to attend screening appointments (Graham‐Rowe, et al., 2018; Hipwell, et al., 2014; Lindenmeyer, 2014; Liu, et al., 2018). The costs associated with long distance travel may also impact an individual’s ability to attend screening altogether. Regardless of an individual’s location from a testing centre, the barrier of transportation still exists. A routine part of testing includes installing mydriasis drops, which cause visual impairments that result in the inability to drive, afterwards (Hipwell, et al., 2014; Lindenmeyer, 2014). Patients may not have family or friends to drive them home, the money to pay for a taxi, or the means for other forms of transportation. This could result in high-risk behaviours, such as disregarding the advice to not drive, or attempting to be transported in an unsafe manner. With all transportation issues aside, the availability of specialty care providers for retinopathy screening remains an ongoing concern (Graham‐Rowe, et al., 2018; Hipwell, et al., 2014; Lindenmeyer, 2014; Liu, et al., 2018; Shah, et al., 2018). Due to high demand and limited specialist services routinely available, individuals tend to have a difficult time obtaining the necessary care in a convenient time frame. Thus, extended wait times negatively influence screening uptake, and preventative screening is often resorted to as a low priority. This results in retinopathy services being set aside until an urgent situation arises, which can sometimes be irreversible (Liu, et al., 2018). Theme Two: Socioeconomic Conditions The social determinants of health are defined by the World Health Organization as nonmedical conditions, which influence health outcomes (WHO, 2021). The recognized social determinants of health include: 1) income and social protection, 2) education, 3) unemployment Running Head: FNP PROJECT 38 and job insecurity, 4) working life conditions, 5) food insecurity, 6) housing, 7) basic amenities, 8) the environment, 9) early childhood development, 10) social inclusion and non-discrimination, 11) structural conflict, and 12) access to affordable health services of decent quality (WHO, 2021). These determinants can influence health equity in positive and negative ways; the lower the socioeconomic position of an individual, the worse the health outcomes (WHO, 2021). It is necessary for primary care providers to acknowledge the influence that these determinants may have on a patient’s care. They are determinants that should be included in the assessment and intervention choices for a patient (CNA, 2021). The socioeconomic conditions which are addressed in the literature include: income, education, and employment (Graham‐Rowe, et al., 2018; Hipwell, et al., 2014; Liu, et al., 2018; Shah, et al., 2018). Personal finances in low-moderate income individuals are found to contribute to poorer health outcomes. This includes: 1) the cost of diabetes management, such as blood glucose testing strips, 2) medication, and 3) eating a specialized diet. Furthermore, attending screening appointments have associated costs with travel, as mentioned earlier, such as hotels and fuel; while taking into account potential lost wages from time off of work and various other financial responsibilities. Those with low incomes may be forced to choose their health over other financial obligations, such as their monthly utility bills and food purchase expenses (Graham‐Rowe, et al., 2018). Education is another social determinant of health that was noted across the literature. People with lower education levels often had difficulty understanding how to appropriately manage their diabetes (Liu, et al., 2018). The higher the education level, the better is the health literacy. It is important for primary care providers to assess a patient’s education level and degree of understanding. This allows for health education and diabetes management to be delivered at Running Head: FNP PROJECT 39 the individual’s level of learning, in order to ensure the information is clear and concise; contributing to better health outcomes. Thus, the findings discussed above related to socioeconomic conditions provide an opportunity for reflection on the nurse practitioner role. Nurse practitioners should be mindful of their patient’s income, education, and employment status. By providing connections to other health care providers, such as social workers who may offer financial assistance, nursing practitioners can work with other health professionals to ensure patients benefit from optimizing needed assistance. Theme Three: Psychological Barriers to Accessing Healthcare Psychological factors of patient care may be unintentionally overlooked by primary care providers. With busy schedules and the need to provide medical assessments, information, and planning in a timely manner, a patient’s emotional wellbeing may seem less significant. However, the choices a patient makes may have a profound emotional component behind it. The literature revealed that psychological barriers had a strong link to the person’s willingness to seek diabetic retinopathy screening. Poor patient-provider communication causes stress and anxiety in patients. If their health needs are not discussed, concerns may be overlooked by both the patient and the provider. From the initial diagnosis, a patient should be provided with information regarding the complexity of diabetes and the risks associated with poor diabetes management (Graham‐Rowe, et al., 2018). If the primary care provider does not communicate with their patient effectively, poor health outcomes for the patient may result. Communication barriers may include communication style, such as the use of medical jargon and language or cultural barriers (Graham‐Rowe, et al., 2018). Running Head: FNP PROJECT 40 Another psychological aspect of patient-provider communication is trust. If a patient does not trust their primary care provider, they will be less likely to engage in discussions with them, take their medical advice, or return for future appointments; all of which will negatively affect the patient’s care (Graham‐Rowe, et al., 2018; Hipwell, et al., 2014; Shah, et al., 2018). The literature clearly highlighted that when a patient feels supported by their provider, they are more likely to access future services and be receptive to receiving crucial medical advice (Graham‐ Rowe, et al., 2018). The literature also revealed a positive association between family support and improved utilization of preventative screening services. Graham‐Rowe, et al. (2018) reported that participants may have witnessed members of their family having to live with managing diabetes. These experiences often provided insight and action that transferred over into managing their own diabetes. Fear was found to be a strong psychological barrier associated with diabetes. The literature addressed this as both a barrier and an enabler experienced by patients and their ability to access screening. The fear of going blind due to diabetic retinopathy was posed as a motivating factor to attend screening. In contrast, the literature revealed that the fear of negative outcomes caused anxiety in patients with diabetes; therefore, desire to access screening was emotionally hindered (Graham‐Rowe, et al., 2018). Other emotional aspects included the experience of stigma related to poor diabetes management, as non-compliance in diabetes management may lead to a patient being negatively labelled. This can lead to patients experiencing and feeling guilt, anger and failure in their ability to manage their chronic disease (Graham‐Rowe, et al., 2018; Liu, et al., 2018). Running Head: FNP PROJECT 41 Theme Four: Knowledge Deficits A person’s knowledge and understanding of diabetes, retinopathy, and associated risks was a significant theme found across the focused literature. It was acknowledged that patients were more likely to adhere to recommendations when they received better education from their primary care providers, especially related to the risks and benefits of screening. In contrast, the literature revealed that many individuals had insufficient knowledge of diabetic retinopathy screening and of potential associated outcomes by not accessing screening; significant knowledge deficits influencing screening participation (Graham‐Rowe, et al., 2018; Hipwell, et al., 2014; Shah, et al., 2018). Importantly, having a clear understanding of diabetic retinopathy is an enabling influence in the utilization of screening services. It became evident in the reviewed literature that providers need to understand the importance of patient education; however, there was hesitancy on their part to provide comprehensive education to their patients This was partly due to the belief that it may cause more stress and fear in patients if the risks associated with retinopathy were explained in detail (Graham‐Rowe, et al., 2018). Additionally, the tedious work of educating patients does not always fit ideally into the provider’s scheduled day. It may be more beneficial to refer patients to other members of the healthcare team, in order to have them dedicate time to patient education (Shah, et al., 2018). Recommendations for Practice Diagram 2 highlights the key points drawn from the four thematic findings of the literature review that nurse practitioners in practice need to consider in relation to diabetic retinopathy screening adherence. Based on these findings, three recommended strategies were Running Head: FNP PROJECT 42 identified to improve diabetic retinopathy screening adherence, and include: 1) screening methods and intervals, 2) activity sharing, and 3) providing education. These strategies can be incorporated into daily nurse practitioner practice to improve patient care. Diagram 2: Key Notes to Consider in Practice Related to Diabetic Retinopathy Screening Adherence Address Structural Barriers to Care · Environmental Factors · Provider Availability Consider Socioeconomic Conditions · Personal Financial Barriers · Educational Background Approach Emotional Barriers to Accessing Healthcare · Patient-provider communication · Building Trust and Relationships · Family Support · Fear of Negative Judgement Increase Knowledge · Education on Screening · Importance and Outcomes Screening Methods and Intervals The findings provided insight into understanding potential alterations in screening methods and screening intervals. The Diabetes Canada Clinical Practice Guidelines Expert Committee (Altomare, Kherani & Lovshin, 2018) on screening are provided below in Diagram 3: Current Recommendations for Screening for Retinopathy; recommendations intended to promote increased and better retinopathy screening in patients living with diabetes. Diagram 3: Current Recommendations for Screening for Retinopathy When to initiate screening · Type 1 diabetes: 5 years after diagnosis in all individuals ≥15 years · Type 2 diabetes: children, adolescents and adults at diagnosis Running Head: FNP PROJECT 43 Diagram 3: Current Recommendations for Screening for Retinopathy Screening methods · 7-standard field, stereoscopic-colour fundus photography with interpretation by a trained reader (gold standard) · Direct ophthalmoscopy or indirect slit-lamp fundoscopy through dilated pupil · Digital fundus photography If retinopathy is present · Diagnose retinopathy severity and establish appropriate monitoring intervals (1 year or less) · Treat sight-threatening retinopathy with laser, pharmacological or surgical therapy · Review glycemic, BP and lipid control, and adjust therapy to reach targets as per guidelines* · Screen for other diabetes complications If retinopathy is not present · Type 1 diabetes: rescreen annually · Type 2 diabetes: rescreen every 1 to 2 years · Review glycemic, BP and lipid control, and adjust therapy to reach targets as per guidelines* · Screen for other diabetes complications (Altomare, Kherani & Lovshin, 2018). Screening Intervals Based on the above recommendations, suggested screening intervals are for one year or less if retinopathy is present. If retinopathy is not present, intervals of one year for individuals living with type 1 diabetes, and intervals of 1-2 years for individuals living with type 2 diabetes, are suggested (Altomare, Kherani & Lovshin, 2018). The literature also provided insight on screening intervals. It was found that patients were struggling to adhere to the high demand of annual screening intervals, especially if there were no concerns found with their vision. Scanlon (2017) provided evidence to support lengthening screening intervals to two years for low risk Running Head: FNP PROJECT 44 groups. The criteria to follow for such group include: 1) two screening episodes with individualised risk factor data, 2) two screening episodes with no retinopathy, and 3) one screening episode with individualised risk factor data (Scanlon, 2017). This flexibility in screening intervals may help relieve some of the challenges related to barriers accessing screening services. Teleophthalmology Further screening recommendations were made within the reviewed literature that promoted access to diabetic retinopathy screening services, which pertained to screening methods as opposed to screening intervals. The screening recommendations highlighted the above suggested 7-standard field, stereoscopic-colour fundus photography with interpretation by a trained reader as the gold standard of care. Direct ophthalmoscopy or indirect slit-lamp fundoscopy through a dilated pupil and digital fundus photography are other listed screening methods (Altomare, Kherani & Lovshin, 2018). These services are typically provided by an ophthalmologist in a specialty eye care centre, and most often located in urban areas with extended wait times. The findings within the literature review highlighted teleophthalmology and mobile screening services as resources, in order to eliminate travel barriers and to lessen wait times. These resources can help to reduce the inconveniences associated with physically accessing retinal screening services, and consequently result in higher screening attendance (Graham‐ Rowe, et al., 2018). With technological advances in medicine, intermediate healthcare workers can be educated to take retinal images and send them for review by specialists. The management Running Head: FNP PROJECT 45 plan can then be determined by this evidence and discussed with the patient at the distance screening site (Shah, et al., 2018). Activity Sharing Activity sharing is an excellent option to consider, as revealed in the findings (Shah, et al., 2018), providing the opportunity for existing healthcare workers to perform functions that will benefit both healthcare providers and patients. This method of care allows for specialists to delegate certain activities related to retinopathy screening, in order to allow for better optimization of their time and skills. It also results in lessening other obstacles related to specialist availability and burnout. Furthermore, it enables patients to have easier access to care, by having a wider range of options for accessing care providers; thus potentially eliminating lengthy appointment wait times. Shah, et al. (2018) noted that opportunities for activity sharing between care providers, such as optometrists, refractionists, ophthalmic technicians, diabetes educators, nurses, and family physicians, exist. These options should be reviewed within primary care, and primary care providers should ensure that their skills are being fully applied within their scope of practice. This may also involve collaboration with retinopathy specialists or other care providers, with the goal of developing a patient-centred approach that includes how retinopathy screening activities may be shared. Providing Education Diabetes Canada (2018), the American Diabetes Association (2020), and other various clinical resource guidelines provide rigorous tools for diabetes management. Educational tools are widely accessible. The concern within the literature is not about finding appropriate Running Head: FNP PROJECT 46 education for patients, it is rather that the method by which education is delivered to the patient is not always optimum. It is crucial for nurse practitioners to recognize that effective communication is a key component of any method in providing useful information to patients. If a language barrier exists, for instance, nurse practitioners need to take the time to provide interpreters, cultural coordinators, or liaisons for the patient (Graham-Rowe, et al., 2018). Busy provider schedules may not allow the time for thorough patient education. In this case, it is suggested that other members of the health care team be used to provide focused education, such as nurses or diabetic educators (Shah, et al., 2018). In addition, encouraging patients to have a support person present during their appointments may ease anxieties, and potentially promote open discussions. If education is provided to both the patient and their support person, they may feel more supported and reassured in executing their management plan. The nurse practitioner role is well suited for patient education, as they possess broad clinical content knowledge as well as the expertise to engage in quality education with patients. Knowledge Translation Knowledge translation in healthcare research is the process, by which research is synthesized, disseminated, and applied to improve its efficiency of health outcomes, patient care, and quality of life (Visintini, 2014). It involves taking the findings from research and applying them to ‘real-life’ practical scenarios. Knowledge translation is important because it bridges the knowledge-to-action gaps that exist from the collection of research to the application of research. By providing realistic recommendations of knowledge translation, it allows for the research to inform the health policy-making processes in Canada, both at the individual and system levels to create change (Visintini, 2014). Running Head: FNP PROJECT 47 Through this integrative literature review, the focus was on which strategies a nurse pracitioner can use in the primary care setting to promote screening for people living with diabetes to reduce their risk and progression to blindness from diabetic retinopathy was discussed, and recommendations for practice were identified. This review has the potential to improve the methods by which primary care practitioners assess and screen for diabetic retinopathy. The recommendation for activity sharing should be applied in primary care practices to ensure that all patients with diabetes have a full team of healthcare workers following their concerns. This would allow for screening promotion to be implemented at various levels within the healthcare system and potentially decrease some of the barriers identified in this review. Limitations and Future Research This section addresses the various limitations and strengths of the integrative literature review, followed by advisement of future research that may be beneficial for diabetic retinopathy screening within primary care. The integrative literature review findings had various limitations, including the selection of research participants. Within the literature selected, most primary studies used convenience sampling or hand-selection of participants, highlighting a risk for researcher bias. Furthermore, a literature review is an objective look at research, and includes summaries and analyses that come from a single researcher opinion. Others may read the same literature and have different interpretations of the findings. Although the findings from the literature provided insight into the barriers that may exist for patients needing to access diabetic retinopathy screening services, a gap presented was the shortage of articles that addressed nurse practitioners in practice. It would be beneficial for future research to focus on how primary care providers can enhance their role, in order to address the Running Head: FNP PROJECT 48 screening barriers that exist for people living with diabetes. Bridging the gap between existing barriers, recommendations for change, and the effectiveness of this change exceeds the limits of this paper. However, future research may provide clearer insight into approaches that facilitate change within primary care, in order to address and eliminate existing barriers to screening. The concept of eliminating barriers to care is intricate, but future research would be beneficial to the quality enhancement of patient care in this area. Conclusion Access to care is a broad concept used to describe the ability to obtain needed medical services (Wilson, Kratzke & Hoxmeier, 2012). There are various determinants that affect access to care. The literature has revealed some of the current barriers related to accessing diabetic retinopathy healthcare screening services. Recognizing where barriers exist in accessing care is a crucial first step toward finding effective solutions, in order to bridge these gaps within primary care practice. Once barriers are defined, future considerations related to potential adjustments may be used to develop solutions to specific access barriers, directing more effective patient care, appropriate treatment, and positive outcomes. Furthermore, by recognizing access barriers that may be present in people living with diabetes, nurse practitioner practices may be improved by implementing strategies that can be used to promote screening, in order to reduce patient risk and progression to blindness from diabetic retinopathy. Thus, the four themes that emerged as findings (structural barriers to care, socioeconomic conditions, emotional barriers to accessing healthcare, and knowledge deficits), and three associated recommendations (reassessing screening methods and intervals, activity sharing, and providing education), confirm that understanding barriers to screening for diabetic retinopathy is a practice area of importance, and worthy of further research to improve patient outcomes. Running Head: FNP PROJECT 49 References Agarwal, P., Jindal, A., Saini, V., & Jindal, S. (2014). Advances in diabetic retinopathy. Indian Journal Of Endocrinology And Metabolism, 18(6), 772. Altomare, F., Kherani, A. & Lovshin, J. 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Global Journal of Health Science, 4(6), 23 Running Head: FNP PROJECT 55 Appendices Appendix A: Search Strategy discussing modifiable barriers and enablers to Lorencatto, Lawrenson, Burr, Grimshaw, Ivers & Francis (2018) screening attendance enablers of diabetic retinopathy competing demands, lack of support, and analysis were thoroughly analysis combination allowed comprehensive coverage of literature systematic review of published and grey literature No declared competing interests identified Practical implications for practice emotional support, negative emotions) lack of trust in care providers, lack of (difficult patient-provider communication, 3) Provide a sense of comfort and support attendance) community networks to promote and recommendations, media, and awareness (health care provider education 2) Increase screening importance appointment scheduling issues) with diabetes (transportation, other Search methods, data extraction defined 1) Reduce any inconveniences for those & Themes Key Findings 56 Strengths Strengths & Limitations Deductive coding and inductive search. the literature 6 databases for review utilizing Systematic Sample Approach & Research attendance: A screening retinopathy Barriers to and diabetic Establish studies Study Overview Graham‐Rowe, Information Literature Appendix B: Literature Review Matrix - Primary Studies Running Head: FNP PROJECT This study aims to examine the patient, health care providers, and screening Lindenmeyer, Stratton, Gadsby, O'Hare & Scanlon (2014) Study Overview Hipwell, Sturt, Information Literature interview qualitative sectional perspective cross Multi- Sample Approach & Research outcomes, retinal screening vs routine eye screening) qualitative/quantitative, patient/practitioner perspectives, 1. Proactive coordination of care & Themes: levels, and locations) modes, ethnicities, socioeconomic coordinate their own appointments and strategy (diverse service delivery screening programs: leaving patients to Utilized a well-rounded sampling involving patients, primary care and Strengths Strengths & Limitations result in skewed opinions care provider perspectives, could included patient perspectives, not Majority of literature reviewed in bias Hand selected article may result Limitations Key Findings (highlight screening importance and literature (grey/published, all contexts/models) 4) Message content improvement 57 Included extensive range of Running Head: FNP PROJECT searched includes the Cochrane effectiveness of quality improvement interventions which may Lorencatto, Burr, Bunce, Francis & Grimshaw (2018) Databases Review to assess the Graham-Rowe, Intervention This review aims Sample Approach & Lawrenson, Information Research Study Overview 24 professionals Literature experiences experiences of & non-regular), screeners) how these staff and patients’ patients (regular screening usage screening and interview study of N=62; 38 screening retinopathy qualitative GP practices; (15 PCC & 9 diabetic and anguish: A 9 participating diabetic retinopathy influence experiences with Attitudes, access technicians’ inconvenient location far from home, 2. Barriers to screening include importance of retinopathy screening care may undermine the perception of the 58 healthcare professionals or the healthcare system relate to significant improvements risk of bias for most of the bias domains of trials to be at low or unclear 2. QI interventions targeting patients, compared to usual care ’Risk of bias’ assessment via Cochrane EPOC found majority 1. Screening attendance increased by 12% & Themes Key Findings screening compared to diabetic retinopathy retinal photography at optometry practices 3. Patients were unclear about routine navigation to home after mydriasis drops Strengths Strengths & Limitations Small sample size researcher bias Purposive sampling- may result in level of ease of making appointments and Limitations methods and analysis Clear descriptions of research Running Head: FNP PROJECT High variety of study locations increase the study strength Embase, PsycINFO, Web of Science, screening attendance. for diabetic retinopathy Median duration of follow-up= 12 months- potentially not long enough follow up period to obtain adequate data OpenGrey, the ISRCTN, ClinicalTrials.go v, and the WHO into Review did data entry review authors One of the extracted data. independently authors Two review ICTRP Limitations Health, ProQuest Family engines and RCTs MEDLINE, retinopathy increase attendance screening Utilized a wide variety of search Library, increase diabetic Interventions to Running Head: FNP PROJECT to usual care without QI interventions in retinopathy screening when compared 59 study is to identify factors Hipwell, Stratton, Al-Athamneh, that contribute to The goal of this Study Overview Lindenmeyer, Sturt, Information Literature patients, care interviews of Semistructured Sample Approach & Research RCT n=66 2013. between 1988- published Studies GRADE. evidence using certainty of rated them. They both author checked the other review Manager 5 and 2. Contacting patients services Interview questions are clearly defined 1. Communication with screening & Themes Key Findings Strengths Strengths & Limitations Running Head: FNP PROJECT 60 retinopathy (2014) to identify contextual Shiyanbola, Swearingen,Carlson (2018) affect patient , Jacobson & Smith factors which This study aims Liu, Zupan, Information Literature study Study Overview providers at Mile patients and care interviews with Semistructured Sample Approach & Research programs screening from 3 regional 61 travel required for screening, transportation barriers methods and analysis 1. Environmental factors: long distance & Themes Key Findings 8. Transportation and ease of access 7. Diversity of ethnicity and language 6. Level of deprivation (location) 5. Perception of non attenders 4. Focus on newly diagnosed patients services 3. Integrating screening with other health Clear descriptions of research Strengths Strengths & Limitations factors. screening: A 9 GP practices screening uptake diabetic retinopathy qualitative case identify high/low Small sample size researcher bias patients' uptake of case-based Purposive sampling- may result in Limitations Utilized diverse practice areas analysis to patients primary care Comparative screeners providers, and practices on by diabetic Influence of screening uptake high or low Gadsby & Scanlon Running Head: FNP PROJECT screening guidelines in rural areas with diabetic eye screening in rural communities: A since 2000 using Zetoc that patients in lower risk groups may be Screening intervals for diabetic retinopathy and screened for literature review reviews evidence Scanlon (2017) Ongoing Sample Approach & Research Subject titles are vast and relevant availability allows for a wide range of data Literature review over 17 years Strengths Strengths & Limitations criteria to assess individual risk factors years for low risk groups if they follow 1. Intervals should be lengthened to 2 & Themes Key Findings burdens, limited educational background issues over preventative, financial analysis difficulty addressing multiple health emotional aspects of living with diabetes, 3. Individual factors: demographics, care providers negative judgement from others, trust with conditions- prioritizing acute medical study: may results in bias One rural hospital utilized for Small sample size Limitations fear r/t seeing other family members ill, 2. Social factors: patient relationships, 62 Inductive data of health ecological model framework: Interview Centre Bluff Medical This article Information Literature Study Overview retinopathy patient adherence qualitative study annual Factors influencing adherence to Running Head: FNP PROJECT eye care to prevent vision loss r/t N=96 participants from 5 provinces; 2 professionals’ opinions on retinopathy management and task share with other care (2018) Task sharing: Development of evidence‐based co‐ management hospitals coordinated, continuous and high-quality technique review eye care screening pertaining to diabetic retinopathy provided focused questions Semi-structured questionnaire from participants (79%) retinopathy ensure that patients with diabetes have optimize the roles of eye care workers to Harper & Keeffe Moderately high response rate sampling 1. Task sharing has the potential to & Themes Key Findings this study was to Strengths Strengths & Limitations Ormsby, Islam, Purposive Sample Approach & Research standard areas were assessed of diabetes care- only high May not be applicable to all areas The purpose of Study Overview in the review guidelines Shah, Noor, Information Literature national programs were included annual Limitations towards screening and level of attendance coverage- both regional and intervals that the reviewed 2. Further studies need to be conducted on how this will affect patient behaviour less frequent care 26 articles 63 Articles had good population retinopathy at implications for Running Head: FNP PROJECT consider any implications for public health strategies and policies photography screening programs to prevent vision loss from diabetic retinopathy in rural Australia: A review and urban programs and Assessed both remote and urban Embase screening Retinal process are clearly defined PubMed and retinopathy n=12 from 1996-2013 Studies obtained 3. Retinal photography is a cost effective screening strategy recorded electronically retinopathy photography when screening for diabetic 2. There is a positive impact of retinal highly effective retinopathy screening have proven to be designed to determine the effectiveness of 1. 17 years worth of research studies & Themes Key Findings 64 articles that may not have been Potential for missing some Limitations specs Australia- not limited in location The article search and selection & Taylor (2015) using Medline, effectiveness of Fredericks, Jackson Literature review Strengths Strengths & Limitations To assess the Sample Approach & Research to other population groups/areas. Tapp, Svoboda, Information Literature diabetic retinopathy Study Overview ophthalmologist detection, and management of Focused population group in study working with screening, Pakistan. May not be applicable Limitations Cross sectional providers strategy model for Running Head: FNP PROJECT reporting key findings Studies were inconsistent in Running Head: FNP PROJECT 65 --- Graham‐Rowe, et al., 2018; Lawrenson, et al., 2018 Liu, et al., 2018; Lindenmeyer, et al., 2014; Mixed-methods Systematic Review Interviews Study Cross-Sectional Review Literature --- Quantitative Shah, et al., 2018 Tapp, et al., 2015; Scanlon, 2017 Hipwell, et al., 2014 --- Qualitative Data Collection 66 --- --- --- --- --- --- Scanlon, 2017; Lawrenson, et al., 2018 Graham‐Rowe, et al., 2018; Tapp, et al., 2015; Shah, et al., 2018; Liu, et al., 2018; Lindenmeyer, et al., 2014; Hipwell, et al., 2014; Research Approach Appendix C: Data Comparison - Similar and Contradictory Ways Data is Presented Running Head: FNP PROJECT