Barriers to and enablers of diabetic retinopathy screening attendance: a systematic review of published and grey literature

Diabet Med. 2018 Oct;35(10):1308-1319. doi: 10.1111/dme.13686. Epub 2018 Jun 6.


Aims: To identify and synthesize studies reporting modifiable barriers/enablers associated with retinopathy screening attendance in people with Type 1 or Type 2 diabetes, and to identify those most likely to influence attendance.

Methods: We searched MEDLINE, EMBASE, PsycINFO, Cochrane Library and the 'grey literature' for quantitative and qualitative studies to February 2017. Data (i.e. participant quotations, interpretive summaries, survey results) reporting barriers/enablers were extracted and deductively coded into domains from the Theoretical Domains Framework; with domains representing categories of theoretical barriers/enablers proposed to mediate behaviour change. Inductive thematic analysis was conducted within domains to describe the role each domain plays in facilitating or hindering screening attendance. Domains that were more frequently coded and for which more themes were generated were judged more likely to influence attendance.

Results: Sixty-nine primary studies were included. We identified six theoretical domains ['environmental context and resources' (75% of included studies), 'social influences' (51%), 'knowledge' (51%), 'memory, attention, decision processes' (50%), 'beliefs about consequences' (38%) and 'emotions' (33%)] as the key mediators of diabetic retinopathy screening attendance. Examples of barriers populating these domains included inaccurate diabetic registers and confusion between routine eye care and retinopathy screening. Recommendations by healthcare professionals and community-level media coverage acted as enablers.

Conclusions: Across a variety of contexts, we found common barriers to and enablers of retinopathy screening that could be targeted in interventions aiming to increase screening attendance.

Publication types

  • Research Support, N.I.H., Extramural
  • Systematic Review

MeSH terms

  • Attitude of Health Personnel
  • Communication Barriers*
  • Diabetes Mellitus, Type 2 / complications
  • Diabetes Mellitus, Type 2 / psychology
  • Diabetic Retinopathy / diagnosis*
  • Diabetic Retinopathy / epidemiology
  • Diabetic Retinopathy / psychology
  • Gray Literature / statistics & numerical data
  • Guideline Adherence
  • Health Knowledge, Attitudes, Practice*
  • Humans
  • Patient Participation*
  • Professional Role