Allied Health Professions: Reducing the risk of sight-threatening diabetic retinopathy in people of Asian origin in the UK, Nepal, India, Thailand and China

Prof Shahina Pardhan, Dr Raju Sapkota, Dr Georgina Nakafero, Prof Dingchang Zheng

ARU research on the prevalence of sight-threatening diabetic retinopathy (STR) has helped reduce the risk of blindness in people from Asian backgrounds in the UK, Nepal, India, Thailand and China.

The findings of Prof Pardhan and her team from the Vision and Eye Research Institute (VERI) led them to work with a range of stakeholders to improve health literacy and retinal screening uptake and promote healthier lifestyles. This has directly benefitted more than 110,000 individuals with diabetes.

The research team

Explore ARU researchers' original work via our open access repository, ARRO

Research summary

Diabetes affects 463 million people globally. Diabetic retinopathy, a serious complication of diabetes, is a leading cause of blindness, especially among people of Asian origin.

The risk of diabetic retinopathy increases significantly when diabetes is poorly controlled and/or when it is not detected early. Timely detection and treatment of diabetic retinopathy reduces the risk of blindness by 60–90%.

Prof Pardhan’s research in the UK found that South Asian diabetic patients have a higher incidence of STR, and develop it at a much younger age or shorter duration of diabetes than Caucasian patients.

This is because people of South Asian origin are less aware of diabetic complications, and the importance of good diabetic control and regular retinal screening. Difficulties accessing healthcare, poor self-help skills, and language barriers all contribute to this lack of health literacy.

Furthermore, most participants in the UK study were unaware of national diabetes education programmes. This suggests that such programmes are not culturally appropriate for different ethnicities, and therefore less effective.

In Nepal, Prof Pardhan and collaborators found that low health literacy and poor treatment compliance put diabetic patients at a higher risk of uncontrolled diabetes, and therefore an increased risk of blindness. These participants also tended to underestimate their blood sugar levels, and therefore overestimated how well-controlled their diabetes was.

Prof Pardhan's research in India found that while diabetic patients were generally aware of the need for regular exercise, only 55% undertook it. Most patients did not know what physical activity to undertake and for how long, and women were less likely than men to exercise regularly.

In China, Prof Pardhan found that diabetic patients also had a low level of awareness that poorly controlled diabetes and poor lifestyles could lead to blindness, and of the importance of regular retinal screening.

The majority of patients at an eye clinic only attended for the first time when retinopathy was well-advanced, making treatment difficult. These patients were also likely to underestimate their blood sugar levels and not exercise regularly.

Retina of a person with diabetic retinopathy

Summary of the impact

  • Helped develop and disseminate evidence-led, culturally and linguistically appropriate awareness and lifestyle interventions among diabetic people of Asian origin
  • Changed healthcare professionals’ patient care practices
  • Facilitated behaviour change and improved outcomes in more than 110,417 people in the UK, India, Nepal, China and Thailand
  • Increased uptake of retinopathy screening from 20-36% to 87-98% and reduced risk of blindness by 60-90%

Impact

Behaviour change through improved awareness of diabetic retinopathy screening in patients

UK

Prof Pardhan and her team used interviews on television and radio stations such as ITV Anglia, Salaam Radio (a Muslim community station), British Forces Broadcasting Service, Gurkha Radio, and Online Services (OS) Nepal to disseminate key information on diet, lifestyle, and the importance of retinal screening.

Prof Pardhan and her team at VERI worked with South Asian community groups, healthcare providers, physical activity instructors, dieticians, and people with diabetes to co-produce short video-based diabetic awareness programmes appropriate for people of Asian origin in the UK.

Recorded in Nepali, Hindi and Urdu, the programmes covered good diabetes control, dietary advice on Asian food, regular physical activity, and the importance of retinal screening.

The videos were disseminated jointly by Prof Pardhan and her team at the grassroots level at community centres, mosques, religious festivals and community gatherings.

Altogether, the programmes have reached 15 South Asian communities across the UK with a joint membership of over 15,150.

Nepal

In 2018, Prof Pardhan and her team, alongside a range of stakeholders in Nepal including representatives of The Diabetes and Endocrinology Association of Nepal (DEAN) and the Nepal Health Research Council, diabetic patients, and healthcare providers, developed a geographically and culturally appropriate training programme.

The Nepalese Association of Optometrists are disseminating the programme via outreach activities to 50 villages in all seven provinces of Nepal. The Diabetes Thyroid and Endocrine Care Centre, one of the two major diabetic centres in Pokhara, Nepal’s second largest city, also rolled out the programme to all newly diagnosed diabetic patients attending its clinics.

By the end of 2020, the training had benefited 28,356 patients, of whom 89% requested retinal screening compared to 28% prior to the training.

Preliminary data from a randomised clinical trial in joint collaboration between Gandaki Medical College and Prof Pardhan’s team showed that 98% of patients in the intervention group requested a diabetic retinal check within three months, compared to 36% in the control group.

India

Since 2018, the training program developed by Pardhan and her team has been delivered to all newly diagnosed patients with diabetes attending Kurseong subdivisional hospital, which historically had a retinal screening uptake as low as 20%.

Between January 2018 and May 2020, the programme reached 26,556 patients, 88% of whom subsequently requested retinal screening.

Changes in patient care by healthcare professionals

Nepal

Prof Pardhan’s input into an evidence-based approach has helped doctors at the largest eye hospital in Pokhara, which has a catchment area covering 25% of the total land area of Nepal and provides comprehensive eye care services to a population of 3 million people, to improve patient care for those needing surgery.

Doctors at the hospital started to actively follow up on patients with diabetes, particularly targeting patients with a higher risk of blindness.

This has improved the health of 87% of patients who are most at risk of going blind.

India

VERI’s research collaboration with Sankara Nethralaya Hospital in Chennai led to innovative approaches to improving patient attendance.

The hospital, which treats 17,000 patients with STR every year, now uses text messages to encourage patients to attend clinics, and offers a bespoke one-to-one counselling service for patients with SRT to explain the importance of regular attendance and treatment.

This has improved attendance and reduced risk of blindness in 90% of all their patients with SRT.

China

VERI’s research collaboration with the Second Affiliated Hospital of Zhejiang University led to new strategies to address high levels of diabetic blindness in patients attending its eye clinics.

The hospital, which is the second largest in Hangzhou and serves 600,000 outpatients, now distributes the first ever leaflet about preventing diabetic retinopathy written in Chinese to patients attending its diabetic clinic. It also started to offer a programme of retinal screening at the point of diagnosis and sends regular reminders to its diabetic patients.

The hospital reports that this has already reduced the risk of diabetic blindness.

Thailand

Prof Pardhan’s research has informed Rajavthi Hospital, Bangkok’s strategies to address the low uptake of Thailand’s national retinal screening programme.

Eyecare staff from screening centres in Thailand attended diabetic retinopathy training in India to upgrade their skills in order to address the barriers that have led to the low levels of retinal screening among patients in Thailand.

United Nations Sustainable Development Goals

We have mapped our REF 2021 impact case studies against the United Nations' Sustainable Development Goals (SDGs).

The 17 SDGs, adopted by all UN Member States in 2015, are an urgent call for action. They recognise that ending poverty and other deprivations must go hand-in-hand with strategies that improve health and education, reduce inequality, and spur economic growth – all while tackling climate change and working to preserve our oceans and forests.

This case study is mapped to SDG 3: Ensure healthy lives and promote well-being for all at all ages, target 3.4.

See also

Read the full REF 2021 impact case study for UoA 03: Reducing the risk of sight-threatening diabetic retinopathy in people of Asian origin in the UK, Nepal, India, Thailand and China (PDF)

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