Non-Adherence to Diabetes Complications Screening in a Multi-Ethnic Asian Population: Protocol for a Mixed-Methods Prospective Study (Preprint)

Yearly screening for microvascular complications of diabetes mellitus (DM), namely diabetic retinopathy (DR), diabetic nephropathy (DN), and diabetic foot complications (DFC), is recommended to reduce their incidence, and delay or prevent their progression. Poor adherence to screening is common, but prospective data on the magnitude and predictors of nonadherence to DR, DN, and DFC screening in Singapore are unavailable. The Understanding Non-Adherence to Diabetes Complications Screening study aims to determine the rates, predictors, and clinical and economic impact of nonadherence to diabetic complications screening in patients with type 2 diabetes in Singapore. The study describes the methodology and participants' baseline characteristics that may be associated with nonadherence to DM complications screening. In this prospective, mixed methods, clinic-based study, patients who underwent DR, DN, or DFC screening and were offered an annual rescreening appointment, were recruited from 6 primary care centers. Patients' sociodemographic, medical, clinical, and patient-reported characteristics were recorded at baseline. Nonadherence to DR, DN, or DFC screening is defined as not attending the annual rescreening appointment within 4 months of the scheduled rescreening date. Adherence and clinical data will be recorded at 16 months post enrollment. Additionally, selected participants and health care professionals will undergo qualitative interviews to elicit barriers or facilitators of adherence to rescreening. Ethical approval was obtained in November 2016. Study enrollment commenced across the 6 sites between June 2018 and February 2019, and baseline data collection ended at all sites in January 2020. 974 eligible patients (2123 screenings; median age of 61.0, IQR 55.0-67.0 years; male: 515, 52.9%; Chinese: 624, 64.1%) consented and completed the baseline assessment. Of these, 734 (75.4%), 603 (61.9%), and 786 (80.7%) attended DR, DN, and DFC screening, respectively. Most (n=793, 81.4%) attended more than 1 complication screening on the same day; had received secondary or lower education (n=701, 71.9%); had hypertension (n=711, 73.4%) and dyslipidemia (n=828, 85.1%); and 43.1% (n=419) were obese (BMI>27.5 kg/m2). Median DM duration and hemoglobin A1c levels were 6.3 (IQR 3.0-12.0) years and 6.9% (6.4%-7.6%), respectively. Over half (n=532, 55.1%) had not received prior DM education. Furthermore, participants reported low levels of diabetes-related self-efficacy (median 1.4, IQR 1.0-3.9 out of 5). At baseline, we have successfully enrolled almost 1000 patients with type 2 diabetes scheduled for annual DR, DN, or DFC rescreening, and potential predictors of nonadherence to rescreening were systematically collected. Follow-up phases will focus on establishing the rates and associated modifiable predictors of nonadherence to DR, DN, or DFC rescreening, which may inform program initiatives. DERR1-10.2196/63253.