Evaluation of multi-level barriers and facilitators in a large diabetic retinopathy screening program in federally qualified health centers: a qualitative study

Ana Bastos de Carvalho, S. Lee Ware, Tamara Belcher, Franceska Mehmeti, Eric B. Higgins, Rob Sprang, Cody Williams, Jamie L. Studts, Christina R. Studts

Research output: Contribution to journalArticlepeer-review

6 Scopus citations


Background: Recommended annual diabetic retinopathy (DR) screening for people with diabetes has low rates in the USA, especially in underserved populations. Telemedicine DR screening (TDRS) in primary care clinics could expand access and increase adherence. Despite this potential, studies have observed high variability in TDRS rates among clinics and over time, highlighting the need for implementation supports. Previous studies of determinants of TDRS focus on patients’ perspectives, with few studies targeting upstream multi-level barriers and facilitators. Addressing this gap, this qualitative study aimed to identify and evaluate multi-level perceived determinants of TDRS in Federally Qualified Health Centers (FQHCs), to inform the development of targeted implementation strategies. Methods: We developed a theory-based semi-structured interview tool based on the Consolidated Framework for Implementation Research (CFIR). We conducted 22 key informant interviews with professionals involved in TDRS (administrators, clinicians, staff). The interviews were audio-recorded and transcribed verbatim. Reported barriers and facilitators were organized into emergent themes and classified according to CFIR constructs. Constructs influencing TDRS implementation were rated for each study site and compared across sites by the investigators. Results: Professionals identified 21 main barriers and facilitators under twelve constructs of the five CFIR domains. Several identified themes were novel, whereas others corroborated previous findings in the literature (e.g., lack of time and human resources, presence of a champion). Of the 21 identified themes, 13 were classified under the CFIR’s Inner Setting domain, specifically under the constructs Compatibility and Available Resources. Themes under the Outer Setting domain (constructs External Incentives and Cost) were primarily perceived by administrators, whereas themes in other domains were perceived across all professional categories. Two Inner Setting (Leadership Engagement, Goals and Feedback) and two Process (Champion, Engaging) constructs were found to strongly distinguish sites with high versus low TDRS performance. Conclusions: This study classified barriers and facilitators to TDRS as perceived by administrators, clinicians, and staff in FQHCs, then identified CFIR constructs that distinguished high- and low-performance clinics. Implementation strategies such as academic detailing and collection and communication of program data and successes to leadership; engaging of stakeholders through involvement in implementation planning; and appointment of intervention champions may therefore improve TDRS implementation and sustainment in resource-constrained settings.

Original languageEnglish
Article number54
JournalImplementation Science Communications
Issue number1
StatePublished - Dec 2021

Bibliographical note

Funding Information:
This study was funded by NCATS UL1TR001998, the University of Kentucky College of Medicine Institutional Physician Scientist Career Development Program; the Diabetes Research Center at Washington University in St. Louis of the National Institutes of Health under award number P30DK020579; and the Cincinnati Eye Institute Foundation Ignite Award (2019 Ed). The content is solely the responsibility of the authors and does not necessarily represent the official views of any funders.

Publisher Copyright:
© 2021, The Author(s).


  • Barriers and facilitators
  • Diabetes care
  • Federally Qualified Health Centers
  • Implementation
  • Multi-level factors
  • Primary care
  • Professionals
  • Screening

ASJC Scopus subject areas

  • Health Policy
  • Health Informatics
  • Public Health, Environmental and Occupational Health


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