Exploring Factors Influencing Diabetic Retinopathy Screening Uptake: A Systematic Review and Meta-Synthesis

Abstract

Context: Diabetic retinopathy (DR) is a leading cause of preventable vision loss among people with diabetes. This study synthesized qualitative evidence on barriers and facilitators to the uptake of DR screening in primary care. Evidence Acquisition: A systematic review and thematic meta-synthesis of qualitative studies was conducted in accordance with PRISMA guidelines and registered with PROSPERO. Seven databases were searched from inception to April 2026. Study quality was assessed using the Critical Appraisal Skills Programme (CASP) Qualitative Checklist, and confidence in the findings was evaluated using GRADE-CERQual. Data were synthesized using thematic synthesis. Results: A total of 37 studies involving 1,117 participants (n = 1,024 patients, n = 93 healthcare professionals) from 11 countries were included. Thematic synthesis of first- and second-order constructs generated 128 initial codes, which were organized into 14 descriptive themes and subsequently abstracted into five analytical themes: (1) knowledge, risk perception, and health beliefs; (2) psychological and emotional factors; (3) social and cultural influences; (4) structural, logistical, and economic barriers; and (5) health system and organizational factors. Key barriers included limited awareness, low perceived risk, fear, financial and transportation challenges, and restricted access to services. Key facilitators included provider recommendations, family support, recall systems, integrated care, teleophthalmology, and artificial intelligence (AI)-assisted retinal screening. Findings were interpreted post hoc through the lens of the Health Belief Model, although several systemic factors extended beyond its individual-level constructs. Discussion: DR screening uptake is influenced by interrelated individual, social, structural, and health system factors. Improving participation requires multifaceted approaches that combine patient education, provider engagement, organized screening systems, integrated care, and technology-enabled services to reduce preventable vision loss. Confidence in these findings is moderate, reflecting the consistency and breadth of the qualitative evidence, although it is primarily based on studies conducted in high-income countries.