Understanding non-adherence to diabetes complications screening in a multi-ethnic Asian population using a mixed-methods design: protocol and baseline participant profile (Preprint)

BACKGROUND Yearly screening for microvascular complications of diabetes mellitus (DM), namely retinopathy (DR), nephropathy (DN), and foot complications (DFC), is recommended to reduce their incidence, and delay or prevent their progression. However, poor adherence to screening is common, but prospective data on the magnitude and predictors of non-adherence to DR, DN and DFC screening in Singapore are unavailable. OBJECTIVE The Understanding Non-Adherence to Diabetes Complications Screening (UNADS) study aims to determine the rates, predictors, clinical and economic impact of non-adherence to diabetic complications screening in patients with type 2 diabetes (T2DM) in Singapore. We describe the study methodology and participants’ baseline characteristics that may be associated with non-adherence to DM complications screening. METHODS In this prospective, mixed-methods, clinic-based study, patients who underwent DR, DN, and/or DFC screening and were offered an annual rescreening appointment, were recruited from six primary care centres. Patients’ sociodemographic, medical, clinical, and patient-reported characteristics were recorded at baseline. Non-adherence to DR/DN/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-enrolment. Additionally, selected participants and healthcare professionals will undergo qualitative interviews to elicit barriers/facilitators of adherence to rescreening. RESULTS 974 eligible patients (2,123 screenings, median [IQR] age 61.0 [55.0-67.0] years, 52.9% male, 64.1% Chinese) consented and completed the baseline assessment. Of these, 75.4%, 61.9%, and 80.7% attended DR, DN and DFC screening, respectively. Most (81.4%) attended >1 complication screening on the same day; had received secondary or lower education (71.9%); had hypertension (73.4%) and dyslipidemia (85.1%); and 43.1% were obese (BMI>27.5 kg/m2). Median DM duration and HbA1c levels were 6.3 years and 6.9%, respectively. Over half (55.1%) had not received prior DM education. Furthermore, participants reported low levels of diabetes-related self-efficacy (1.4 [IQR 1.0-3.9] out of 5). CONCLUSIONS At baseline, we have successfully enrolled almost 1000 patients with T2DM scheduled for annual DR/DN/DFC rescreening, and potential predictors of non-adherence to rescreening were systematically collected. Ongoing follow-up phases will focus on establishing the rates and associated modifiable predictors of non-adherence to DR/DN/DFC rescreening, which may inform programme initiatives.