Article Text

How have services for diabetes, eye, hearing and foot health been integrated for adults? Protocol for a scoping review
  1. Claire O'Shea1,2,
  2. Alehandrea Manuel3,
  3. Braden Te Ao3,
  4. Pushkar Raj Silwal1,
  5. Matire Harwood4,
  6. Rinki Murphy5,
  7. Jacqueline Ramke1,6
  1. 1School of Optometry and Vision Science, University of Auckland, Auckland, New Zealand
  2. 2Waikato Regional Diabetes Service, Health New Zealand - Te Whatu Ora, Hamilton, New Zealand
  3. 3School of Population Health, University of Auckland, Auckland, New Zealand
  4. 4General Practice and Primary Health Care, University of Auckland, Auckland, New Zealand
  5. 5Department of Medicine - Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand
  6. 6International Centre for Eye Health, London School of Hygiene & Tropical Medicine, London, UK
  1. Correspondence to Claire O'Shea; claire.o'shea{at}


Introduction The global population is ageing, and by 2050, there will be almost 2.1 billion people over the age of 60 years. This ageing population means conditions such as diabetes are on the increase, as well as other conditions associated with ageing (and/or diabetes), including those that cause vision impairment, hearing impairment or foot problems. The aim of this scoping review is to identify the extent of the literature describing integration of services for adults of two or more of diabetes, eye, hearing or foot services.

Methods and analysis The main database searches are of Medline and Embase, conducted by an information specialist, without language restrictions, for studies published from 1 January 2000 describing the integration of services for two or more of diabetes, eye, hearing and foot health in the private or public sector and at the primary or secondary level of care, primarily targeted to adults aged ≥40 years. A grey literature search will focus on websites of key organisations. Reference lists of all included articles will be reviewed to identify further studies. Screening and data extraction will be undertaken by two reviewers independently and any discrepancies will be resolved by discussion. We will use tables, maps and text to summarise the included studies and findings, including where studies were undertaken, which services tended to be integrated, in which sector and level of the health system, targeting which population groups and whether they were considered effective.

Ethics and dissemination As our review will be based on published data, ethical approval will not be sought. This review is part of a project in Aotearoa New Zealand that aims to improve access to services for adults with diabetes or eye, hearing or foot conditions. The findings will be published in a peer-reviewed journal and presented at relevant conferences.

  • Audiology
  • General diabetes
  • Diabetic neuropathy
  • Diabetic retinopathy
  • Health Services
  • Health Equity

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  • This study aims to provide a comprehensive review of integrated care for adults of two or more of diabetes, eye, hearing or foot services.

  • The search is implemented by an experienced information specialist, with screening, study selection and data extraction undertaken by two investigators independently.

  • A potential limitation could be a small number of publications identified that report integration of these services.


By 2030, it is estimated that the number of people aged 60 years and older globally will be 1.4 billion, and by 2050, it will be close to 2.1 billion.1 Many countries have committed to strategies that promote healthy ageing and maximise quality of life and well-being for people as they age. Diabetes tends to be a condition included in these strategies, partially due to its large and growing magnitude, which is projected to increase to 643 million people globally by 2030.1 2 Conditions that are less often explicitly included in healthy ageing strategies are those causing vision impairment, hearing impairment and foot problems. This is despite the large extent of these conditions among older adults. For example, 75% of the estimated 1.1 billion people with vision impairment and 62% of the estimated 1.6 billion people with hearing impairment are over the age of 50 years, while an estimated 105 million older adults live with peripheral neuropathy.3–5

Diabetes and sensory impairments—including vision impairment, hearing impairment and peripheral neuropathy—often occur together.6–9 For example, diabetes complications include diabetic retinopathy (damaged blood vessels at the back of the eye) which is a major cause of vision impairment and peripheral neuropathy (nerve damage in the legs and feet).8 Furthermore, the co-occurrence of hearing impairment and vision impairment (commonly referred to as ‘dual sensory impairment’) is receiving increasing attention, particularly among older adults.10 11 These sensory impairments also contribute to a higher risk of dementia, depression and falls in older people.10–12 Fortunately, many of the causes of vision impairment, hearing impairment and foot problems can be prevented—or progression delayed—if detected early and timely treatment is initiated. Therefore, strengthening services for sensory impairment in conjunction with diabetes services would enhance healthy ageing strategies.

Unfortunately, health services that manage diabetes and sensory impairments are not accessible to all population groups equally. Subsequently, underserved groups—including Indigenous populations, people living in rural areas and people in areas of high deprivation—experience worse health outcomes compared with other population groups, including higher rates of avoidable causes of vision impairment, hearing impairment and diabetes complications.7 8 13 Reasons for this disparity are many and can include the prohibitive cost of reaching and/or using the service, the complexity of the health system making it difficult to navigate, or the reliance on family members or other carers for transport and other support.14 These access challenges can be exacerbated for older adults who experience several conditions, all requiring appointments with varying health providers.1

Integrated care has been defined in a range of ways but is widely considered to be a strategy to improve access to and outcomes of health services.15 We are embarking on a project in Aotearoa New Zealand to improve access to diabetes, eye, hearing and foot care for adults aged 40 years and above and we consider integration as a promising strategy to reduce the burden of care seeking among underserved population groups, including Māori and Pacific Peoples. To inform our approach, in this review, we aim to identify and summarise previous examples of integrated care for these conditions, as well as the benefits and challenges identified.

We will not limit our review based on the definition or type of integration described and will draw on the validated Project INTEGRATE framework16 to summarise the examples identified across the dimensions of person-centred care, clinical integration, professional integration, organisational integration, systemic integration, functional integration and normative integration.

Study objectives (research questions)

To meet our aim, we will attempt to answer the following questions:

  1. What is the extent of published evidence globally on efforts to integrate services for two or more of diabetes, eye, hearing or foot health?

  2. What are the characteristics of the integrated services?

  3. What are the benefits and challenges of integrated care highlighted by the authors in the identified publications?

  4. To what extent is equity considered in the integration activitivies described?

Methods and analysis

Protocol and registration

This scoping review protocol is reported according to the relevant items of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses for Scoping Reviews (PRISMA) guidelines (online supplemental annex 1).17 We have drawn on the methods outlined in the Joanna Briggs Institute Manual for Evidence Synthesis.18 The protocol was registered prospectively on Open Science Framework on 10 November 2023 (

Eligibility criteria

The review will include studies that describe the integration of services for two or more of diabetes, eye, hearing or foot health in the private or public sector and at the primary or secondary level of care. We will include studies regardless of the definition of integrated care used, however, integration must be described in the abstract using words such as integrating, combining or coordinating. We will exclude studies that only mention integrated care as a recommendation without it being a component of the study itself.

Studies will be included if they describe integration of health services targeted to adults aged 40 years and above, or to the entire population in any country. This age cut-off was chosen due to the high proportion of diabetes and sensory impairment that occurs among the population aged 50 years and above2–5 globally.

We chose 40 years instead of 50 years because in our context in Aotearoa New Zealand, Māori and Pacific Peoples tend to experience an earlier onset of conditions such as diabetes19 and cataract20 and often have a shorter life expectancy21 compared with New Zealand Europeans.

We will exclude studies that report outcomes exclusively for people under the age of 25 years as these are likely to include people enrolled in child and adolescent services which are commonly overseen by parents and/or caregivers, as well as the transition to adult services. We will also exclude studies exclusively focused on people aged 80 years and over as integration models may differ from those for the general adult population. Studies that focus on people receiving care in rest homes or aged-care facilities will also be excluded, as these services can differ substantially from those for older adults living in their own home environment.

Studies that will be included will be quantitative, qualitative or mixed methods of any study design (including pilot studies) that report primary data on integration of our health services of interest. Protocols, viewpoints, editorials and conference abstracts will be excluded. Systematic reviews will be excluded; however, the reference list will be screened to identify other potentially relevant studies. We will also share the list of included studies with field experts and ask them to suggest any other studies we should consider.

Studies to be included will be those published after 1 January 2000, where the full text is available. This date was chosen as we are most interested in recent examples of integration. There will be no language restrictions to the search. Every effort will be made to translate any non-English studies identified using Google Translate ( with verification by native speakers.

Search strategy

A search strategy was developed in consultation with an information specialist using a set of terms describing diabetes, eye, hearing and foot health, combined with terms describing integration of health services (online supplemental annex 2). The search was undertaken on Medline and Embase databases on 13 October 2023. Our intention is to complete the full scoping review by October 2024; if the timeline extends beyond this, we will update the search prior to completing the review.

The results will be downloaded into EndNote and then exported into Covidence systematic review software for screening ( The reference lists of all included articles will be examined to identify further relevant studies.

A grey literature search will seek eligible reports published since 1 January 2000 from websites of the WHO, the International Agency for the Prevention of Blindness, the WHO network of collaborating centres and organisations for ear and hearing care and the International Working Group on the Diabetic Foot. The terms used will be [“eye” or “hearing” or “foot”] AND [“integrated care” or “integration” or “coordinated care”]. Potentially eligible reports will be added to Covidence for screening.

Study selection

Study selection will take place using Covidence. All titles and abstracts identified during the literature search will be screened by two reviewers independently to identify potentially relevant studies. Any conflicts will be discussed and resolved with a third reviewer. The full text of these potentially relevant studies will be assessed by two reviewers independently to establish eligibility for inclusion in the review, and reasons for exclusion will be assigned by each reviewer. Any conflicts will be discussed and resolved with a third reviewer. A PRISMA flow diagram will be completed to summarise the study selection process.

Data charting process

A custom data charting form will be developed in Covidence. The form will be piloted by three reviewers on two reports and required amendments made. Each included study will then be charted independently by two of the reviewers and any discrepancies will be resolved by discussion; a third reviewer will be consulted if necessary. Authors of included studies will be contacted in the case of unclear information; three attempts of contact will be made by email.

Data items

The following data items will be collected during the data charting process:

  1. Publication characteristics: title, year of publication, study design, country of study, study setting.

  2. Characteristics of the services:

    1. Services integrated (diabetes, eye, hearing, foot health).

    2. Health sector (public/private/third party-non-profit organisation).

    3. Level of the health system (primary/secondary/tertiary).

    4. Target population (age, ethnicity, socioeconomic status, place of residence (urban/rural)).

  3. Characteristics of integrated care:

    1. Description of the integration activity.

    2. Any description or measure of effectiveness of the integration.

    3. Any benefits or challenges of integration expressed by study authors.

  4. Health equity consideration

    1. Population groups targeted with integration activity (according to the PROGRESS Framework22: place of residence, race/ethnicity/culture/language, occupation, gender/sex, religion, education, socioeconomic status and social capital).

    2. Description of differential outcomes of integration activity across population groups (ie, did integration promote equity).

    3. Any factors that aided (facilitators) or inhibited (barriers) the achievement of equity in integrated care expressed by study authors.

Synthesis of results

The description of the integration for each study will be used to categorise the integration to one or more items of the Project INTEGRATE framework (online supplemental annex 3).16

We will use tables, maps and text to summarise the included studies, with a focus on findings specific to adults aged ≥40 years. This will include a summary of where studies have been undertaken, which services tend to be integrated, in which sector and level of the health system, targeting which population groups. We will also summarise the type of integration activity using the 40 items and corresponding seven dimensions of the Project INTEGRATE framework.16 We will summarise how the effectiveness of integration was assessed, the extent to which authors considered the integration effective and the benefits and challenges they report. Finally, we will report the extent to which equity is considered, the population groups targeted with integration activities, and key facilitators and barriers to achieving equity in integrated care. Collectively, this summary will highlight the common forms of integration between services for diabetes, eye, hearing and foot health, where it has commonly occurred, whether it promotes equity and key lessons learnt.

Patient and public involvement


Ethics and dissemination

As our review will only include published data, ethical approval will not be sought.

This review is part of a project in Aotearoa New Zealand that aims to improve access to, and outcomes of, services for adults with diabetes or eye, hearing, or foot conditions. We will draw on the integration examples identified in the review as we consider options to evaluate how services for diabetes and eye, hearing and foot health may be integrated for adults in Aotearoa New Zealand. As such, our hope is that the findings of this review will be beneficial for those individuals living with one or more of these conditions, as well as health professionals, health service managers and policy-makers who are responsible for such care in Aotearoa New Zealand and elsewhere.

The findings will be published in a peer-reviewed journal and presented at relevant conferences as well as policy dialogues.

Ethics statements

Patient consent for publication


We acknowledge Iris Gordon, who constructed the search.


Supplementary materials


  • Contributors JR conceived the idea for the review. CO'S drafted and revised the protocol with suggestions from AM, BTA, PRS, MH, RM and JR.

  • Funding This review is supported with funding from the Health Research Council of New Zealand (Grant No: 22-151). PRS is supported by a Buchanan Charitable Foundation Postdoctoral Fellowship (Grant No: N/A).

  • Competing interests None declared.

  • Patient and public involvement Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.