Background: Diabetic retinopathy (DR) is a leading cause of visual impairment in India. Available evidence shows that there are more than 60 million persons with diabetes in India and that the number will increase to more than a 100 million by 2030. There is a paucity of data on the perceptions and practices of persons with diabetes and the available infrastructure and uptake of services for DR in India. Objectives: Assess perception of care and challenges faced in availing eye care services among persons with diabetics and generate evidence on available human resources, infrastructure, and service utilization for DR in India. Methods: The cross-sectional, hospital-based survey was conducted in eleven cities across 9 States in India. In each city, public and private providers of eye-care were identified. Both multispecialty and standalone facilities were included. Specially designed semi-open ended questionnaires were administered to the clients. Semi-structured interviews were administered to the service providers (both diabetic care physicians and eye care teams) and observational checklists were used to record findings of the assessment of facilities conducted by a dedicated team of research staff. Results: A total of 859 units were included in this study. This included 86 eye care and 73 diabetic care facilities, 376 persons with diabetes interviewed in the eye clinics and 288 persons with diabetes interviewed in the diabetic care facilities. Conclusions: The findings will have significant implications for the organization of services for persons with diabetes in India.

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Background: Diabetic retinopathy is a leading cause of visual impairment. Low awareness about the disease and inequitable distribution of care are major challenges in India. Objectives: Assess perception of care and challenges faced in availing care among diabetics. Materials and Methods: The cross-sectional, hospital based survey was conducted in eleven cities. In each city, public and private providers of eye-care were identified. Both multispecialty and standalone facilities were included. Specially designed semi-open ended questionnaires were administered to the clients. Results: 376 diabetics were interviewed in the eye clinics, of whom 62.8% (236) were selected from facilities in cities with a population of 7 million or more. The mean duration of known diabetes was 11.1 (±7.7) years. Half the respondents understood the meaning of adequate glycemic control and 45% reported that they had visual loss when they first presented to an eye facility. Facilities in smaller cities and those with higher educational status were found to be statistically significant predictors of self-reported good/adequate control of diabetes. The correct awareness of glycemic control was significantly high among attending privately-funded facilities and higher educational status. Self-monitoring of glycemic status at home was significantly associated with respondents from larger cities, privately-funded facilities, those who were better educated and reported longer duration of diabetes. Duration of diabetes (41%), poor glycemic control (39.4%) and age (20.7%) were identified as the leading causes of DR. The commonest challenges faced were lifestyle/behavior related. Conclusions: The findings have significant implications for the organization of diabetes services in India.

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Background: Available evidence from India shows that the control of diabetes is poor in majority of the population. This escalates the risk of complications. There is no systematic review to estimate the magnitude of diabetic retinopathy (DR) in India. Materials and Methods: A systematic literature search was carried out in Ovid Medline and EMBASE databases using Mesh and key search terms. Studies which reported the proportion of people with diabetes with DR in a representative community population were included. Two independent reviewers reviewed all the retrieved publications. Data were extracted using a predefined form. Review Manager software was used to perform meta-analysis to provide a pooled estimate. Studies included were assessed for methodological quality using selected items from the STROBE checklist. Results: Seven studies (1999–2014; n = 8315 persons with diabetes) were included in the review. In the meta-analysis, 14.9% (95% confidence interval [CI] 10.7–19.0%) of known diabetics aged ≥30 years and 18.1% (95% CI 14.8–21.4) among those aged ≥50 years had DR. Heterogeneity around this estimate ranged from I²= 79–87%. No linear trend was observed between age and the proportion with DR. The overall methodological quality of included studies was moderate. Conclusions: Early detection of DR is currently not prioritized in public health policies for noncommunicable diseases and blindness programs. Methodological issues in studies suggest that the proportion of diabetics with DR is underestimated in the Indian population. Future research should emphasize more robust methodology for assessing diabetes and DR status.

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Background: India has the second largest population of persons with diabetes and a significant proportion has poor glycemic control and inadequate awareness of management of diabetes. Objectives: Determine the level of awareness regarding management of diabetes and its complications and diabetic care practices in India. Methods: The cross-sectional, hospital-based survey was conducted in 11 cities where public and private providers of diabetic care were identified. At each diabetic care facility, 4–6 persons with diabetes were administered a structured questionnaire in the local language. Results: Two hundred and eighty-five persons with diabetes were interviewed. The mean duration since diagnosis of diabetes was 8.1 years (standard deviation ± 7.3). Half of the participants reported a family history of diabetes and 41.7% were hypertensive. Almost 62.1% stated that they received information on diabetes and its management through interpersonal channels. Family history (36.1%), increasing age (25.3%), and stress (22.8%) were the commonest causes of diabetes reported. Only 29.1% stated that they monitored their blood sugar levels at home using a glucometer. The commonest challenges reported in managing diabetes were dietary modifications (67.4%), compliance with medicines (20.5%), and cost of medicines (17.9%). Around 76.5% were aware of complications of diabetes. Kidney failure (79.8%), blindness/vision loss (79.3%), and heart attack (56.4%) were the commonest complications mentioned. Almost 67.7% of the respondents stated that they had had an eye examination earlier. Conclusions: The findings have significant implications for the organization of diabetes services in India for early detection and management of complications, including eye complications.

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Background: There is a paucity of information on the availability of services for diagnosis and management of diabetic retinopathy (DR) in India. Objectives: The study was undertaken to document existing healthcare infrastructure and practice patterns for managing DR. Methods: This cross-sectional study was conducted in 11 cities and included public and private eye care providers. Both multispecialty and stand-alone eye care facilities were included. Information was collected on the processes used in all steps of the program, from how diabetics were identified for screening through to policies about follow-up after treatment by administering a semistructured questionnaire and by using observational checklists. Results: A total of 86 eye units were included (31.4% multispecialty hospitals; 68.6% stand-alone clinics). The availability of a dedicated retina unit was reported by 68.6% (59) facilities. The mean number of outpatient consultations per year was 45,909 per responding facility, with nearly half being new registrations. A mean of 631 persons with sight-threatening-DR (ST-DR) were registered per year per facility. The commonest treatment for ST-DR was laser photocoagulation. Only 58% of the facilities reported having a full-time retina specialist on their rolls. More than half the eye care facilities (47; 54.6%) reported that their ophthalmologists would like further training in retina. Half (51.6%) of the facilities stated that they needed laser or surgical equipment. About 46.5% of the hospitals had a system to track patients needing treatment or for follow-up. Conclusions: The study highlighted existing gaps in service provision at eye care facilities in India.

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Background: The growing burden of avoidable blindness caused by diabetic retinopathy (DR) needs an effective and holistic policy that reflects mechanisms for early detection and treatment of DR to reduce the risk of blindness. Materials and Methods: We performed a comprehensive health policy review to highlight the existing systemic issues that enable policy translation and to assess whether India's policy architecture is geared to address the mounting challenge of DR. We used a keyword-based Internet search for documents available in the last 15 years. Two reviewers independently assessed retrieved policies and extracted contextual and program-oriented information and components delineated in national policy documents. Using a “descriptive analytical” method, the results were collated and summarized as per themes to present status quo, gaps, and recommendations for the future. Results: Lack of focus on building sustainable synergies that require well laid out mechanisms for collaboration within and outside the health sector and poor convergence between national health programs appears to be the weakest links across policy documents. Conclusions: To reasonably address the issues of consistency, comprehensiveness, clarity, context, connectedness, and sustainability, policies will have to rely more strongly on evidence from operational research to support decisions. There is a need to involve multiple stakeholders from multiple sectors, recognize contributions from not-for-profit sector and private health service providers, and finally bring about a nuanced holistic perspective that has a voice with implementable multiple sector actions.

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Background: There is a lack of information on the practice patterns and available human resources and services for screening for eye complications among persons with diabetes in India.Objectives: The study was undertaken to document existing health care infrastructure and practice patterns for managing diabetes and screening for eye complications. Methods: This cross-sectional, hospital-based survey was conducted in 11 cities where public and private diabetic care providers were identified. Both multispecialty and standalone diabetic care facilities were included. A semi-structured questionnaire was administered to senior representative(s) of each institution to evaluate parameters using the World Health Organization health systems framework. Results: We interviewed physicians in 73 hospitals (61.6% multispecialty hospitals; 38.4% standalone clinics). Less than a third reported having skilled personnel for direct ophthalmoscopy. About 74% had provision for glycated hemoglobin testing. Only a third had adequate vision charts. Printed protocols on management of diabetes were available only in 31.5% of the facilities. Only one in four facilities had a system for tracking diabetics. Half the facilities reported having access to records from the treating ophthalmologists. Direct observation of the services provided showed that reported figures in relation to availability of patient support services were overestimated by around 10%. Three fourths of the information sheets and half the glycemia monitoring cards contained information on the eye complications and the need for a regular eye examination. Conclusions: The study highlighted existing gaps in service provision at diabetic care centers in India.

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Context: There is a lack of evidence on the subjective aspects of the provider perspective regarding diabetes and its complications in India. Objectives: The study was undertaken to understand the providers' perspective on the delivery of health services for diabetes and its complications, specifically the eye complications in India. Settings and Design: Hospitals providing diabetic services in government and private sectors were selected in 11 of the largest cities in India, based on geographical distribution and size. Methods: Fifty-nine semi-structured interviews conducted with physicians providing diabetes care were analyzed all interviews were recorded, transcribed, and translated. Nvivo 10 software was used to code the transcripts. Thematic analysis was conducted to analyze the data. Results: The results are presented as key themes: “Challenges in managing diabetes patients,” “Current patient management practices,” and “Strengthening diabetic retinopathy (DR) services at the health systems level.” Diabetes affects people early across the social classes. Self-management was identified as an important prerequisite in controlling diabetes and its complications. Awareness level of hospital staff on DR was low. Advances in medical technology have an important role in effective management of DR. A team approach is required to provide comprehensive diabetic care. Conclusions: Sight-threatening DR is an impending public health challenge that needs a concerted effort to tackle it. A streamlined, multi-dimensional approach where all the stakeholders cooperate is important to strengthening services dealing with DR in the existing health care setup.

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