With a health equity lens, University of Toronto researcher leads study focused on diabetes-related vision loss

The University of Toronto’s Aleksandra Stanimirovic is currently leading a study that, she says, underscores the reason she chose to become a health researcher as opposed to a physician.

The project focuses on a screening program for diabetic retinopathy – a complication of diabetes that can lead to blindness – among women from lower socio-economic groups.

She hopes her work will help affected women detect changes in their vision early so they can receive appropriate care.

“I thought as a clinician, my impact is somewhat limited to my patients, whereas with the research I’m doing now, for example, which is focused on policy change, my impact can be further reaching,” says Stanimirovic, now a post-doctoral researcher at the University of Toronto’s Institute of Health Policy, Management and Evaluation (IHPME) at the Dalla Lana School of Public Health.

“I can influence the outcomes not just of patients, but their caregivers and researchers.”

Stanimirovic, who is also a post-doctoral researcher in the Health System and Technology Evaluation Program at Toronto General Hospital Research Institute and a trainee in the Diabetes Action Canada CIHR SPOR Network, says early detection and treatment of diabetic retinopathy can prevent most vision loss. However, she notes there is an inverse relationship between screening, income and gender. Research shows, for instance, that women from lower socioeconomic groups are less likely to be screened for breast cancer and colon cancer.

Stanimirovic will study those who participated in a teleretina program, which provided diabetic retinopathy screening via a mobile clinic to users of the South Riverdale Community Health Centre in downtown Toronto between 2014 to 2019. The Toronto teleretina screening program was developed to address difficulties in getting vision checkups by Canadians with diabetes. It is geared toward low-income communities with a high prevalence of diabetes and low diabetic retinopathy screening rates.

A prior study led by Stanimirovic and her supervisor, Valeria Rac, showed the program was a more cost-effective way of screening than standard of care provided in disadvantaged communities. It cited prior research that found 37 per cent of those who participated in the program had never had an eye exam and 27 per cent of the screened cohort were diagnosed with diabetic retinopathy.

“When looking at women in lower socioeconomic groups, usually those with diabetes have multiple health conditions and very limited resources,” says Stanimirovic. “This impedes their opportunity to achieve health equity, which is access to health resources.

“There’s more than one factor that intersects to create this challenge of health inequity. These could be age, gender, ethnic background, etc. They all come together and create a condition of health inequity. The oppression doesn’t come from one factor; it comes from the intersectionality of all these factors that we call social determinants of health.”

Looking at the design, implementation and evaluation of health interventions with the intersectionality framework is important, says Rac, an assistant professor at IHPME. “I want to bring that lens for people to think through when they plan to implement a new program. What is the effect of that program with respect to equity and access to care on women, people from lower socioeconomic groups or people from certain cultures or racial backgrounds?

“We need to think comprehensively about this when we are bringing something new to the [health] system.”

Stanimirovic will examine how many people from the South Riverdale Community Health Centre – some of whom lack Ontario health insurance – were referred for screening, the number of people who had it done, and outcomes of screening. She will identify differences in referral and screening rates among men and women.

There is also a qualitative aspect to the study that involves speaking with patients, care providers and administrators of the teleretina program to gather feedback on what is working and how it can be improved.

By understanding the barriers and facilitators to screening, Stanimirovic hopes to develop engagement strategies that are more culturally appropriate for specific groups.

“We want to understand from those who identify as women: What are the barriers for getting screening? Is it because they’re taking care of kids? Maybe they’re not aware [the program] exists? Maybe they have competing priorities? We hope the thematic analysis will guide us in culturally reshaping this initiative,” says Stanimirovic. “Research has shown cultural components are critical in the success of community implementation.”

The aim, Stanimirovic says, is to increase rates of screening for diabetic retinopathy within the study population to detect changes in vision early so people can get the appropriate care. In Canada, more than three million people have diabetes; by 2025, that number will swell to five million.

“I don’t want to be [naïve] and think everybody’s going to get screened, but even small steps may improve their quality of life significantly,” Stanimirovic says. “I would like this to be an intervention that’s tailored to their needs and context, with the hope that it will improve their quality of care and quality of life.”

The research is supported by a trainee internship award from Diabetes Action Canada.

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