title: Reasons for poor follow-up of diabetic retinopathy patients after screening in Tanzania: a cross-sectional study.
abstract: BACKGROUND
  Diabetes is an emerging public health problem in sub-Saharan Africa. Diabetic retinopathy is the commonest microvascular complication of diabetes and is a leading cause of blindness, mainly in adults of working age. Follow-up is crucial to the effective management of diabetic retinopathy, however, follow-up rates are often poor in sub-Saharan Africa. The aim of this study was to assess the proportion of patients not presenting for follow-up and the reasons for poor follow-up of diabetic patients after screening for retinopathy in Kilimanjaro Region of Tanzania.
  
  
  METHODS
  All diabetic patients referred to a tertiary ophthalmology hospital after screening for retinopathy in 2012 were eligible for inclusion in the study. A randomly selected group of patients from the community-based diabetic retinopathy screening register were identified; among this group, follow-up was assessed. Interviews were conducted within this group to inform on the reasons for poor follow-up.
  
  
  RESULTS
  Among the 203 patients interviewed in the study 50 patients (24.6 %) attended the recommended referral appointment and 153 (75.4 %) did not. Financial reasons were self-reported by 35.3 % of those who did not attend the follow-up appointment as the reason for non-attendance. Multiple logistic regression analysis showed that the patient report of the clarity of the referral process (p = 0.014) and the patient report of whether a healthcare worker told the patient that diabetic retinopathy could be treated (p = 0.005) were independently associated with attendance at a follow-up appointment. Income per month was not associated with attendance at a follow-up appointment on multivariate analysis.
  
  
  CONCLUSIONS
  Financial factors are commonly cited as the reason for non-compliance with follow-up recommendations. However, the reasons for poor compliance are likely to be more complicated. This study highlights the importance of health system factors. Improving the clarity of the referral process and frequent reminders to patients that diabetic retinopathy can be treated are practical strategies that should be incorporated into screening programmes to increase attendance at subsequent follow-up appointments. The results from this study are applicable to other screening programmes as well as those for diabetic retinopathy.
authors.affiliation: Kilimanjaro Christian Medical University College, Faculty of Nursing, Moshi, Tanzania.
authors.forename: Christina
authors.initials: C
authors.lastname: Mtuya
authors.affiliation: Eye Department, Kilimanjaro Christian Medical Centre, Moshi, Tanzania. crcleland87@gmail.com.
authors.forename: Charles R
authors.initials: CR
authors.lastname: Cleland
authors.affiliation: Eye Department, Kilimanjaro Christian Medical Centre, Moshi, Tanzania.|International Centre for Eye Health, Faculty of Infectious & Tropical Diseases, London School of Hygiene & Tropical Medicine, London, UK.
authors.forename: Heiko
authors.initials: H
authors.lastname: Philippin
authors.affiliation: Kilimanjaro Christian Medical University College, Faculty of Nursing, Moshi, Tanzania.
authors.forename: Kidayi
authors.initials: K
authors.lastname: Paulo
authors.affiliation: Kilimanjaro Christian Medical University College, Faculty of Nursing, Moshi, Tanzania.
authors.forename: Bernard
authors.initials: B
authors.lastname: Njau
authors.affiliation: Eye Department, Kilimanjaro Christian Medical Centre, Moshi, Tanzania.
authors.forename: William U
authors.initials: WU
authors.lastname: Makupa
authors.affiliation: Department of Work & Social Psychology, University Maastricht, Faculty of Psychology and Neuroscience, P.O. Box 616, 6200 MD, Maastricht, The Netherlands.
authors.forename: Claudette
authors.initials: C
authors.lastname: Hall
authors.affiliation: Newcastle Eye Hospital Research Foundation, 182 Christo Road, Waratah, NSW, 2289, Australia.
authors.forename: Anthony
authors.initials: A
authors.lastname: Hall
authors.affiliation: Kilimanjaro Centre for Community Ophthalmology, Division of Ophthalmology, University of Cape Town, Cape Town, South Africa.
authors.forename: Paul
authors.initials: P
authors.lastname: Courtright
authors.affiliation: Kilimanjaro Christian Medical University College, Faculty of Nursing, Moshi, Tanzania.
authors.forename: Declare
authors.initials: D
authors.lastname: Mushi
mesh_terms: D000328:Adult; D000359:Aftercare; D000368:Aged; D000369:Aged, 80 and over; D001294:Attitude to Health; D003430:Cross-Sectional Studies; D003930:Diabetic Retinopathy / Q000175:diagnosis*; D005260:Female; D006297:Health Services Accessibility; D006801:Humans; D007348:Insurance, Health; D016015:Logistic Models; D008297:Male; D008403:Mass Screening / Q000706:statistics & numerical data*; D008875:Middle Aged; D010349:Patient Compliance / Q000523:psychology / Q000706:statistics & numerical data*; D012959:Socioeconomic Factors; D013636:Tanzania
keywords: Africa; Diabetic retinopathy; Follow-up; Screening