Factors Influencing Eye Screening Adherence Among Latinx Patients With Diabetes: A Qualitative Study

Abstract

Purpose: Latinx populations have the highest rates of visual impairment and blindness of any ethnic group in the United States, with most cases of diabetic retinopathy remaining undiagnosed. We aimed to identify factors influencing adherence with diabetic eye screening in Latinx communities.

Methods: We conducted semistructured individual interviews with adult Latinx patients in Dane County, WI. Interviews were transcribed verbatim, translated from Spanish to English, and analyzed using QSR NVivo software. We performed both inductive open coding and deductive coding using the National Institute on Minority Health and Health Disparities Research Framework, as well as the Campbell and Egede Model.

Results: All participants (n = 20) self-identified as Latinx and were diagnosed with type 2 diabetes. The mean age was 61.5 years (range 33–79 years). Most participants were uninsured (60%), self-reported low or moderate health literacy (60%), and preferred to speak Spanish during their clinic appointments (75%). Individual-level barriers to diabetic eye screening included limited eye health literacy, lack of insurance coverage, and low self-efficacy with diabetes management. Health system-level facilitators included a recommendation to obtain eye screening from a primary care provider and the use of nonwritten forms of patient education. Community-level barriers included social isolation, concerns about inconveniencing others, machismo, and immigration status.

Conclusions: We identified several health system- and community-level factors, in addition to individual-level factors, influencing adherence with diabetic eye screening in Latinx communities.

Translational Relevance: Strategies addressing these factors may enhance the effectiveness of interventions to prevent blindness from diabetes and contribute to advancing health equity in Latinx communities.

Introduction

More than 50% of the Latinx population will develop diabetes in their lifetime, and among them, 34% will develop diabetic retinopathy.^1–3 Despite nearly all blindness from diabetes being avoidable with early detection and treatment, as many as 95% of diabetic retinopathy cases among Latinx patients remain undiagnosed because of low rates of yearly eye screening, as recommended by the American Diabetes Association.^4,5 The high prevalence of diabetic retinopathy contributes to vision loss in Latinx populations, which have the highest rates of visual impairment and blindness of any ethnic group in the United States.⁴ Thus there is an urgent need to increase diabetic eye screening in Latinx communities. 

Prior studies regarding Latinx eye health disparities have focused on individual-level factors.^6–10 Known individual-level factors influencing diabetic eye screening include limited eye health literacy, such as a lack of knowledge that vision loss from diabetes is preventable.^7,8 However, there is now increasing attention to assessing structural factors outside of those within the control of an individual patient.^11–13 Given the heterogeneity of the Latinx community (e.g., country of origin, literacy, acculturation, socioeconomic status), addressing health system- and environmental-level factors may be especially important for creating interventions generalizable across diverse Latinx populations to advance health equity.^10,14 This approach, known as “structural competency,” seeks to develop interventions that address cultural factors while also addressing structural socioeconomic and environmental influences.¹⁵ Notably, culturally-tailored and telehealth interventions for diabetes self-management education that address structural factors can significantly improve glycemic control among Latinx populations.^16,17 In this qualitative study, we conducted semistructured, individual interviews with Latinx patients with diabetes to identify and develop a deeper understanding of factors influencing adherence with eye screening, with the ultimate goal of developing structural interventions to prevent blindness in the Latinx community. 

Methods

Participant Recruitment and Research Setting

We recruited adults (18 years or older) with type 1 or type 2 diabetes who self-identified as Latinx/Hispanic to participate in semistructured, individual interviews to identify factors influencing adherence with diabetic eye screening. First, we developed a culturally-informed recruitment letter and flyer (both Spanish- and English-language versions) with input from the Latino Health Council of Dane County (a Latinx community stakeholder group in Dane County, WI), NewBridge Madison (a nonprofit organization serving older adults in Dane County, WI), and Access Community Health Centers (ACHC) (an urban, Federally Qualified Health Center in Dane County, WI that serves a large, Latinx population (41%)). Of note, this study was conducted prior to the introduction of teleophthalmology (i.e., telemedicine-based diabetic eye screening using retinal cameras in primary care clinics) at ACHC. Dane County's population is 6.9% Latinx/Hispanic.¹⁸ 

Next, the recruitment letters and flyers were mailed by ACHC staff to a random sample of 480 patients with diabetes who self-identified as Latinx and obtained primary care in their health system. Recruitment flyers were also distributed directly to eligible patients by ACHC primary care providers and staff, as well as circulated in the local Latinx community by the Latino Health Council of Dane County and NewBridge Madison. A phone number was provided in the recruitment flyer for individuals to opt-in to participate in the study by calling the research team for more information and to confirm their eligibility. We continued to recruit participants until the sample size was sufficient to reach informational redundancy, in which no new information was obtained from additional interviews.¹⁹ 

Interviews

The English-language version of the semi-structured interview guide (Supplementary Material S1), in which the interviewer asks a series of open-ended questions to allow the interview participant to fully express themselves, was developed by adapting those used in our prior study on factors influencing adherence with diabetic eye screening in a predominantly non-Hispanic, white, rural patient population.²⁰ The Spanish-language version was translated by accredited professionals and revised for accuracy by native and heritage Spanish speakers (C.P., M.M.P, J.L.G.).Questions were designed to address the most relevant components from the National Institute on Minority Health and Health Disparities (NIMHD) Research Framework²¹ to capture participants’ perspectives on factors influencing adherence with diabetic eye screening. The NIHMD Research Framework is a hybrid of the National institute on Aging health disparities research framework and the socioecological model,^22,23 which represents the need to consider both biological and social determinants of health, as well as to recognize that these determinants may have both positive and negative impacts on health.²¹ The interview results from questions eliciting participants’ detailed perspectives on teleophthalmology, artificial intelligence–based image interpretation, and virtual care are reported in a separate study.⁴³ 

A written survey at the end of the interview was used to collect demographic information, including age, self-reported gender, race and ethnicity, country of heritage or origin, insurance status, diabetes type, duration of diabetes, diabetic eye screening adherence, highest level of education, self-reported English fluency, and self-reported health literacy using the Single Item Literacy Screener.²⁴ The zip code of the patient's home residence was used to calculate the Social Vulnerability Index (SVI) using U.S. Census data.^25,26 SVI assesses the vulnerability of communities based on 15 social factors, including poverty and access to transportation, on a scale of 0 to 1.0 (1.0 being the most vulnerable and 0.46 being the median SVI for the U.S. overall). 

Interviews were 45 to 60 minutes in duration and were conducted in the participants’ preferred language (i.e., either Spanish or English) from July to November 2022 either virtually or in-person at a community center in Madison, WI, owned by the University of Wisconsin–Madison. All interviews were conducted one-on-one by a bilingual English- and Spanish-speaking male Bachelor's-level research specialist (C.P.) with training in qualitative research and who self-identifies as Latino and Mexican-American. The interviewer took field notes during the interviews and let participants know that he had no specialized medical knowledge of diabetes or diabetic retinopathy. Participants were provided with $30 in compensation for their time and were offered coverage of transportation costs. 

Data Analysis

Interviews were audiorecorded, transcribed verbatim, professionally translated from Spanish to English, and analyzed using QSR NVivo software for Mac Version 1.7 (QSR International, Melbourne, Australia). We performed both inductive open coding and directed content analysis using the NIMHD Research Framework, as well as the Campbell and Egede Models.^21,27 The Campbell and Egede Model was developed based on a systematic review to identify barriers faced by inner-city African Americans for type 2 diabetes care, as well as to identify effective interventions/programs at the individual, community, and health system levels, through integration of the Brown model for socioeconomic position and health among persons with diabetes, the Chronic Care Model, and the NIMHD Research Framework.^21,28,29 Directed content analysis is a method used in qualitative research in which existing models can help identify and determine relationships between codes.³⁰ We began by analyzing the interview transcripts using inductive analysis to remain open to emerging themes. The research specialist (C.P.) performed independent open coding of the first five transcripts. Research team members then met with N.J., a PhD qualitative methodologist, to review these codes and agree on an initial coding framework. A second coding cycle was then performed by a research specialist (C.P.) to fit codes into an evolving collection of higher order categories. Operational definitions for each factor were determined using existing categories from the NIHMD Research Framework and the Campbell and Egede Model where applicable. The level of each factor identified (i.e., individual, health system or community-level) was based on their correspondence to the category most closely aligned within the NIHMD research framework and Campbell and Egede Model. 

Consistency was ensured by the principal investigator (Y.L.), who dual-coded every fifth transcript. Throughout the analysis process, codes were iteratively reviewed by the entire research team, which met regularly to discuss and refine the first- and second-order analytical categories pertinent to understanding factors influencing adherence with diabetic eye screening in the Latinx community. Members of the University of Wisconsin (UW) Institute of Clinical and Translational Research-Community Academic Partnership Qualitative Research Group also reviewed subsets of the interview data and coding methods. 

To enhance rigor, we performed member-checking by reviewing and facilitating an in-depth discussion of the results of our analysis with a subset of patient interview participants and community stakeholders (i.e., patients [n = 3] and Latinx community members [n = 3]) in two separate one-hour meetings.³¹ We recruited community stakeholders from NewBridge Madison to participate in member-checking by inviting their feedback during their usual monthly virtual meeting. This group has a long-standing working relationship with our research team in serving as community stakeholders who provide feedback on our research projects. For the meetings with the subset of interviewees and the community stakeholders, the interviewer (C.P.) facilitated a discussion in Spanish using a PowerPoint presentation that summarized our main findings with supportive example quotes. Participants in these member-checking meetings added further nuance to our analysis and judged our interpretation of the interview data to be accurate and complete, as well as provided their perspectives on the most important barriers and facilitators. Our report of this study followed the Consolidated Criteria for Reporting Qualitative Research.³² We also performed a t-test and Fisher's exact test to compare demographic characteristics between interview participants and all patients who were mailed the interview recruitment materials by Access Community Health Center's clinical staff. 

Ethics/Institutional Review Board Review

The UW-Madison Health Sciences Institutional Review Board determined that this interview research met criteria for exemption. The interviewer (C.P.) obtained verbal consent from all participants following the guidance of the Institutional Review Board. All research activities were conducted in accordance with the Declaration of Helsinki. 

Results

Patient Characteristics

There were 22 Latinx patients with diabetes who contacted the research team in response to the recruitment flyer. Among these individuals, two did not attend an interview despite two or more rescheduling attempts. All interview participants (n = 20) self-identified as Latinx/Hispanic adults and had a diagnosis of type 2 diabetes (Table 1). The mean age was 59.8 years (range 33–79 years). Most were female (60%, n = 12) and of Mexican origin or heritage (60%, n = 12). The majority of participants were uninsured (60%, n = 12), self-reported low or moderate health literacy (60%, n = 12), and preferred to speak Spanish during their clinic appointments (75%, n = 15). In addition, most self-reported that their English fluency was either “not at all” or “not very well” (55%, n = 11). A minority of participants (30%, n = 6) self-reported adherence with diabetic eye screening within the past year. The group of patients who were mailed the invitation letter were slightly younger overall than our patient interview participants, but their demographic characteristics did not otherwise differ with respect to gender, type 2 diabetes prevalence, insurance status, and preference for speaking Spanish at clinic visits (Supplementary Table S2). 

Table 1.

 

Demographics of Patient Interview Participants (n = 20)

 

Most interviews were conducted in Spanish (85%, n = 17) and in-person (90%, n = 18). Most participants (90%, n = 18) had no prior relationship with the research team, but two (10%) were acquainted with the interviewer (C.P.) from his prior work with the Latino Health Council of Dane County on increasing COVID-19 vaccination rates in the Latinx community. A total of 20 patient interviews were conducted as informational redundancy was reached in which no new factors were identified (Supplementary Fig. S3). 

Individual-Level Factors

Individual-level barriers to diabetic eye screening included sociodemographic and behavioral factors, such as limited eye health literacy, belief in God's will, poverty/financial tradeoffs, and lack of health insurance coverage (Table 2). Although many participants reported fear of blindness and loss of autonomy, many did not know that eye screening could prevent vision loss, and some assumed that they could wait to seek eye care until they developed visual symptoms from diabetes. There were also common misconceptions that wearing glasses would make one's vision worse and that diabetic eye disease could be treated with glasses. Even in cases when participants endorsed an awareness of diabetes care guidelines, several expressed a lack of self-efficacy in following these guidelines. A few expressed fatalistic beliefs that complications from diabetes, such as blindness, are inevitable, and thus any actions to prevent such outcomes are futile. 

Table 2.

 

Individual-Level Factors

 

Similarly, a commonly cited factor that could serve as both a barrier and a facilitator for diabetic eye screening was a belief in God's will. Some participants viewed their belief in God's will as a justification for not seeking care. These participants stated their belief that the fate of their health is in God's hands, rather than within their own control. This deference to external forces further reinforced participants’ low self-efficacy and fatalism with regard to healthcare. In contrast, others expressed that seeking and obtaining care was following the will of God, manifested through the care they receive from their healthcare team or support from their family members, who are put in their path by God. Yet many participants expressed the belief that individuals are solely responsible for their own health and that external support from their family, physicians, healthcare, and community organizations should not be fully relied upon, given that such support is neither common nor guaranteed. Thus self-reliance was emphasized as having an important role because patients must take the initiative to obtain guideline-concordant diabetes care. Overall, the most important individual-level factor cited in our member-checking meetings was the financial aspect of diabetic eye screening, which was perceived as being too expensive for low-income Latinx communities, especially for those who lacked health insurance. 

Health System-Level Factors

Health system-level factors consisted of those related to access to care, patient education, patient outreach, and relationships between patients and healthcare providers (Table 3). Participants reported significant challenges in scheduling eye clinic appointments because of limited appointment availability and long wait times (i.e., several months). They reported that facilitators included financial support and incentive programs for eye screening, as well as having access to technologically-advanced eye screening in the primary care clinic (i.e., teleophthalmology). 

Table 3.

 

Health System-Level Factors

 

With regard to patient outreach, many participants indicated that they would appreciate the opportunity to receive diabetes education outside of their clinic visits (e.g., diabetes self-management education provided through community-based outreach programs) but perceived financial constraints, specifically lack of insurance, to be a major barrier. Similarly, participants expressed the desire for greater diversity in education methods, preferring hands-on, video- and image-based education, because of their difficulties with understanding written patient education materials. Other facilitators related to patient outreach included having social workers help support basic needs (i.e., food, housing, transportation, etc.) and receiving reminders from their primary care and eye clinics about diabetic eye screening. 

Related to patient-provider relationships, all participants endorsed that they would obtain diabetic eye screening if recommended by their healthcare provider. In addition, participants indicated that they trusted doctors in general to provide them with high-quality care and recommendations to improve their health. Furthermore, having strong emotional support from their provider was critical in supporting some participants to achieve positive health outcomes. Community stakeholders found that having a very high level of emotional support from a healthcare provider was unusual and should not be expected by patients. However, they agreed with participants that providers who had a culturally-appropriate bedside manner and spoke Spanish are more effective in influencing patients to adhere with diabetes care guidelines, such as eye screening. Participants also noted that while Spanish interpreters are very helpful, they pose several limitations for patients compared to the ability to communicate directly with a healthcare provider in Spanish. 

Community-Level Factors

Community-level factors included those relating to community resources, societal structure, social functioning, and geography/politics (Table 4). Barriers to diabetic eye screening included limited transportation and a lack of awareness of existing community resources, particularly those that provide financial assistance for or offer free diabetic eye screening, as well as financial assistance for diabetes medications and general diabetes care. Participants also noted being relatively isolated from other Latinx community members, which made it more difficult to learn about community resources. Many participants voiced concerns about being a nuisance or inconveniencing others because of their health needs. This concern extended to choosing not to reschedule a missed eye clinic appointment to avoid being “a bother” to others. Other participants described how diabetes made them feel excluded from their family and friends, for example due to the inability to share the same food at meals because of their diabetic dietary restrictions. Participants considered family support to be very important for managing their diabetes, and that educating a patient's family members about diabetes should be an important component of patient education. Thus concerns about inconveniencing others and a lack of social connections were barriers to obtaining guideline-concordant diabetes care, such as for eye screening. 

Table 4.

 

Community-Level Factors

 

One participant acknowledged that Latin-American masculinity expectations, or machismo, was a barrier to obtaining diabetic eye care. He reported that he was unwilling to seek care even when encouraged to do so by other family members because he considers himself the “head of the household,” and thus he should not be told what to do by his partner or kids. Although community stakeholders agreed that there is a prevalent “macho mentality” that leads some Latino men to refuse to see a doctor, they also believed that socioeconomic considerations played a bigger role. Specifically, they noted that because men are traditional breadwinners for their families, men often don't have as much time to see a doctor because of work obligations and will avoid taking the time off work needed to adequately address their health problems because of the financial cost of taking unpaid leave. The community stakeholders noted that single working mothers also faced similar barriers. 

Finally, some participants shared that their immigration status was a major barrier to obtaining care because of their ineligibility for health insurance and fear of legal consequences from revealing their immigration status to healthcare organizations that make them vulnerable to being reported to immigration officials. 

Discussion

In this qualitative interview study among Latinx patients with diabetes, we identified individual-, health system-, and community-level factors influencing adherence with eye screening. Individual-level barriers included limited eye health literacy, lack of insurance coverage, and low self-efficacy with diabetes management. Health system-level facilitators included a recommendation to obtain eye screening from a primary care provider and the use of non-written forms of patient education. Community-level barriers included social isolation, concerns about inconveniencing others, machismo, and immigration status. Our results highlight the critical importance of moving beyond solely patient-level interventions, such as patient education, to also developing structural interventions related to health system- and community-level factors to increase diabetic eye screening adherence and advance eye health equity in Latinx communities. 

Prior qualitative studies regarding factors influencing patient adherence with diabetic eye screening have identified knowledge, cost, access to care, transportation, competing concerns (i.e., work and childcare), having multiple health problems, psychosocial issues, service integration between primary care and eye care, as well as healthcare provider communication, knowledge, and cultural competency to be both barriers and facilitators.^33,34 A prior qualitative study comparing factors influencing diabetic eye screening adherence between English- and Spanish-speaking insured patients at Kaiser Permanente found that nonadherent patients were more likely to believe that patients’ individual beliefs and attitudes (i.e., fatalism regarding vision loss from diabetes and a belief that screening isn't necessary if one's vision is good) contribute to their nonadherence with diabetic eye screening.⁹ Our study extends and enriches the existing literature by providing more detailed and nuanced aspects of these factors for Latinx patients, including differing interpretations regarding a belief in God's will, an emphasis on self-reliance, and concerns about inconveniencing others, social exclusion and isolation, immigration status, the role of machismo, as well as relationships and communication with healthcare providers. 

Our study significantly adds to the literature by identifying and providing an in-depth understanding of the complexity underlying many specific patient beliefs and attitudes, such as a belief in God's will and the lack of need for eye screening. These beliefs could be manifested either by nonadherence and low self-efficacy reinforced by a belief in surrendering one's health outcomes to external forces or manifested by adherence because of the belief that the support provided by one's family and healthcare team was put in place by external forces. However, the belief in God's will was also juxtaposed with a common belief that self-reliance⁹ in healthcare is essential because of participants’ strong desire to avoid inconveniencing others, which prevented Latinx patients from asking for help with transportation or appointment scheduling. In addition, although it has been previously reported that nonadherent patients often believe that there is “no need” for diabetic eye screening,⁷ our participants expressed a willingness to have diabetic eye screening, but only once symptoms developed or if recommended by their primary care provider. Our findings suggest that by leveraging the recommendation of the primary care provider and through partnerships with trusted community groups, including faith-based organizations, to provide community-based health education, it may be possible to address some of the barriers posed by patient beliefs and attitudes to increase diabetic eye screening in Latinx communities. 

Notably, there is an increasingly recognized need to view eye health disparities through a multilevel lens and to develop interventions that address interactions between individuals and their environment.^7,35 Following the Campbell and Egede Model, individual-level factors can be a result of the patient's environment or can themselves shape the patient's interaction with the environment.²⁷ Thus solely examining individual factors fails to consider the interaction of those factors with the healthcare system and community environment, which serves as the focus of our study. For example, participants often described being unable or afraid to seek financial assistance with healthcare because of their immigration status, a community-level barrier. Thus interventions targeting financial barriers to eye screening should make clear that financial assistance will be provided for eye screening to patients regardless of immigration status, while providing screening at significantly lower cost (e.g., using teleophthalmology) and enhancing patient outreach to overcome logistical barriers to eye care.³⁶ It was also notable that although there are a substantial number of local Latinx organizations that facilitate healthcare services in Dane County, WI, a significant number of participants were unaware of such resources. This may also be related to the social isolation from the Latinx community reported by participants, which may be more common given the relatively small Latinx population locally (6.9%). Thus enhancing awareness of community-level resources could also serve as an important strategy for increasing diabetic eye screening in Latinx communities, particularly in areas with relatively smaller Latinx populations. 

Our findings related to individual factors influencing diabetic eye screening among Latinx patients with diabetes agree with those from prior studies that major barriers to diabetic eye screening include financial concerns and limited health literacy, with 65% of Hispanic adults having basic or below basic health literacy.^6–9,37 To address these barriers, possible health system-level interventions endorsed by community stakeholders included providing financial support and incentives (e.g., provision of diabetic eye screening for free or at reduced cost to low-income patients, financial bonuses from health insurers to patients who obtain diabetic eye screening, etc.), leveraging the recommendation of the primary care provider (e.g., providing providers with suggested scripts or training on motivational interviewing to encourage patients to obtain diabetic eye screening), providing teleophthalmology conveniently in the primary care clinic, use of non-written patient education methods (e.g., patient testimonials in video format displayed on electronic tablets or on waiting room television screens), providing diabetes education outside of the clinic (e.g., presentations at community centers, faith-based organizations, and health fairs), training healthcare providers on culturally appropriate patient-provider communication, and increasing the number of Spanish-speaking healthcare providers through workforce diversification initiatives. Future studies are needed to test these suggested strategies to determine which are most effective for increasing diabetic eye screening among Latinx patients. 

It is important to consider the heterogeneity of beliefs within communities, particularly for Latinx populations, which are often comprised of a variety of different national origins.¹⁰ However, cultural factors that appeared consistently in our study include a strong preference for culturally appropriate communication and Spanish speaking providers.^8,38 More specifically, participants expressed a lack of trust in physicians from whom they perceived lack of interest in getting to know them as a person. In contrast, participants valued having healthcare providers who seemed invested in their holistic wellbeing and provided emotional support, including inquiring about personal factors that may be influencing their adherence with diabetes care guidelines. Furthermore, participants who preferred to use Spanish at their clinic visits expressed frustration because of a variety of shortcomings from the use of Spanish interpreters compared to being able to communicate directly with Spanish-speaking healthcare providers. By improving patient/provider communication, healthcare teams can more effectively address the needs of Latinx patients with diabetes, such as by leveraging familial support and eliciting potential barriers related to social determinants of health to connect patients with social workers to assist with overcoming those barriers. 

Our study had many strengths, including incorporating input from Latinx community stakeholders from the initial design of our study through data analysis, having Latinx researchers on our study team, and including a large proportion of participants who were uninsured (60%) and self-reported nonadherence with diabetic eye screening (70%)—groups who are often under-represented in research. However, our study also had a few limitations. We did not have access to the medical records of interview participants and thus cannot confirm their adherence with diabetic eye screening. However, in our prior study assessing patient self-reported adherence with diabetic eye screening among rural patients (who are also known to have low health literacy), we found that patients were much more likely to report being adherent with diabetic eye screening when they were actually nonadherent (∼30%), than vice versa (<10%) (unpublished data).³⁶ In addition, the high prevalence of self-reported nonadherence with diabetic eye screening in our study (70%) is consistent with the high prevalence of not having an eye exam with the past 12 months (75%) among participants in the Los Angeles Latino Eye Study.³⁹ Thus we believe that the large proportion of participants in this study (70%) who self-reported being non-adherent with diabetic eye screening were most likely actually nonadherent. Furthermore, we did not design this study to assess differences in factors influencing diabetic eye screening based on SVI or self-reported adherence with diabetic eye screening. However, there were no clear differences noted in participant responses based on SVI or self-reported adherence with diabetic eye screening. This is consistent with literature that has found that patients who are adherent and those who are nonadherent with diabetic eye screening report similar barriers.⁴⁰ 

With regard to the generalizability of our findings, although we did not purposely exclude individuals with type 1 diabetes, all participants had type 2 diabetes, which is consistent with its greater prevalence (95% of the U.S. diabetes population has type 2 rather than type 1 diabetes).⁴¹ Participants were also predominantly Mexican in origin and heritage, consistent with the demographics of Latinx populations in Wisconsin.⁴² Furthermore, most participants obtained care from a single Federally Qualified Health Center highly regarded by the local Latinx community, which is relatively small (comprising only 6.9% of the population of Dane County) compared to that of the overall U.S. population (18.9%). Thus our findings may not be generalizable to Latinx communities from different countries of origin, those obtaining care from other health systems, or those living in areas with larger Latinx populations. However, the consistency in findings between our study and those conducted among Latinx populations in many other regions of the United States is reassuring of their validity and generalizability. A future national, survey-based study including a wide variety of Latinx populations would be helpful to better assess the generalizability of our findings and which characteristics may be associated with specific factors influencing diabetic eye screening in Latinx populations. 

In conclusion, we identified several health system- and community-level factors, in addition to individual factors, influencing adherence with diabetic eye screening in Latinx communities. Strategies addressing these factors may enhance the effectiveness of interventions to prevent blindness from diabetes and contribute to advancing health equity in Latinx communities. 

Acknowledgments

The authors gratefully acknowledge the contributions from the study participants, Latino Health Council of Dane County, NewBridge Madison, and Access Community Health Centers, Madison, WI for their partnership in the development and distribution of interview participant recruitment materials, as well in the design, conduct, and analysis of data for this study. We also acknowledge the University of Wisconsin Institute of Clinical and Translational Research-Community Academic Partnership Qualitative Research Group for their input on the data analysis and the NIH/NEI Implementation of Teleophthalmology in Rural Health Systems (I-TRUST) Study Data and Safety Monitoring Committee (DSMC) for their helpful feedback on the manuscript. This study was presented as a poster presentation at the Association for Research in Vision and Ophthalmology Annual Meeting on April 26th, 2023, in New Orleans, LA. 

Supported by NIH/NEI UG1 EY032446-02S1 Diversity Supplement (Liu), NIH/NEI UG1 EY032446 (Liu), University of Wisconsin Shapiro Summer Research Program (Hoang), University of Wisconsin Rural and Urban Scholars in Community Health (UW RUSCH) (Garcia), NIH/NIA K99 AG076966-01 (Mora Pinzón), and NIH/NEI K23 EY030911-04 (Channa). It was also supported in part by the Clinical and Translational Science Award (CTSA) program, through the NIH National Center for Advancing Translational Sciences (NCATS), grant UL1TR002373 and an Unrestricted Grant from Research to Prevent Blindness, Inc. to the UW-Madison Department of Ophthalmology and Visual Sciences. The funders had no influence on the design or results of the study. The content is solely the responsibility of the authors and does not necessarily represent the official views of the NIH. 

Disclosure: C. Pelayo, None; M. Mora Pinzón, None; L.J. Lock, None; C. Fowlkes, None; C.L. Stevens, None; J. Hoang, None; J.L. Garcia, None; N.A. Jacobson, None; R. Channa, None; Y. Liu, None