A Feasibility Study to Develop an Integrated Diabetic Retinopathy Screening Programme in the Western Province of Sri Lanka

Background: Diabetic retinopathy (DR) is a common microvascular complication of diabetes mellitus which can lead to sight loss, if not detected and treated in time. Objectives: This study aimed to assess the feasibility of integrating DR screening (DRS) services into free public sector health care in Sri Lanka. The objectives were to identify barriers to access DRS, to determine the most appropriate DRS modality and to assess acceptability of a health educational intervention (HEI). Methods: The study was conducted using mixed methods. The barriers were assessed through systematic literature search and qualitative studies. A systematic literature review and meta-analysis was conducted to assess the diagnostic accuracy of DRS using digital retinal imaging. Based on the results of the formative stages, a local context specific DRS modality was defined and validated at a tertiary level medical clinic by trained physician graders. Finally, a HEI was adapted and acceptability was assessed using participatory approach. Results: The formative studies revealed that lack of knowledge and awareness on DR, lack of skilled human resources and DRS imaging infrastructure as the main barriers. In the meta-analysis, highest sensitivity was observed in mydriatic more than two field strategy (92%, 95% CI 90-94%). In the validation study, sensitivity of the defined referable DR was 88.7% for grader 1 and 92.5% for grader 2, using mydriatic imaging. The specificity was 94.9% for grader 1 and 96.4% for grader 2. The overall acceptability of the HEI material was satisfactory. Conclusions: Knowing the barriers to access DRS is a pre-requisite in development of a DRS program. Non-mydriatic 2-field strategy is a more pragmatic approach in implementing DRS programs in low income non-ophthalmic settings, with dilatation of pupils of those who have ungradable images. The process of adapting HEI was not simply translation into local language, instead a tailored approach for the local context.