Building capacity for diabetic eye screening and management in low-middle income countries
: A mixed-methods approach

Student thesis: Doctoral ThesisDoctor of Philosophy


Worldwide, the burden of diabetes mellitus (DM) and its complications are becoming a major public health concern, particularly in low-middle income countries (LMICs), where 80% of people with DM (PwDM) reside. The main sight-threatening complication of DM is diabetic retinopathy (DR). Early detection through diabetic eye screening (DESPs) is fundamental to reduce the risk of avoidable DR-related blindness or visual impairment. Since the introduction of systematic DESPs in high-income countries such as the UK, DR is no longer the leading cause of blindness among working age adults. The main aim of this thesis is to enable capacity building for DESPs in LMICs, focusing on two low-resource settings, Vietnam and Bangladesh.

Identifying gaps in national level DR policies and planning in LMICs is crucial to inform and enact DR policies. A mixed methods approach (quantitative and qualitative analyses) was used to evaluate the feasibility of DESPs in Bangladesh and Vietnam, and enabling capacity building in both settings was key.

Gaps in DR policy processes and DESP implementation in LMICs exist, especially in low-income countries. To build capacity for DESPs in Vietnam nurses were trained to perform DR screening and grading; however, their diagnostic test accuracy was low, demanding further exploration and evaluation. The think-aloud study assessed the decision-making processes of novice and expert DR graders to improve DR training protocols in Vietnam. Compared to novices, expert graders were more likely to systematically grader fundus images and use all available grading tools, such as the red-free filter to view more discrete signs of DR. Furthermore, high costs and distance to hospitals were two main barriers to DR screening and treatment uptake in Bangladesh and Vietnam; therefore, intervention strategies to improve uptake are necessary.

To ensure DESPs are sustainable, fully integrated and universally accessible, careful planning, development and evaluation are required.
Date of AwardJul 2021
Original languageEnglish
Awarding Institution
  • Queen's University Belfast
SponsorsUlverscroft Foundation
SupervisorNathan Congdon (Supervisor), Tunde Peto (Supervisor) & Lynne Lohfeld (Supervisor)


  • Diabetes
  • eye screening
  • diabetes eye screening program

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