Diabetic retinopathy screening: experiences from northern Tanzania

Assessing the barriers and facilitators of access to diabetic retinopathy screening in sub- Saharan Africa: a literature review

Diabetic retinopathy (DR) is the leading cause of blindness in working age adults. An increase in visual loss has been projected for sub-Saharan Africa (SSA) with the diabetes epidemic in the region. Screening is a cost-effective way to reduce this scourge, but adequate services are scarce. This review aims to evaluate the evidence on barriers and facilitators of access to DR screening with a view to making evidence-based recommendations for the development of effective and sustainable programmes in SSA. A systematic literature search of Africa-Wide Information, Embase, Cochrane library, Global Health, and Medline databases was done using diabetic retinopathy, screening, and Sub-Saharan Africa as concepts. Google Scholar was also searched to identify relevant literature. Studies were included if they were done in SSA and reported on barriers and/or facilitators of access to DR screening. The database search yielded 616 papers and google scholar yielded 9223 papers. Of these, 54 papers were assessed for eligibility and 18 met the inclusion criteria. These were appraised with appropriate checklists. Fourteen themes were synthesised. Most were supply challenges affecting all dimensions of access and the six components of the health systems building blocks. Several studies had poor methodologies, and this has implications for the evidence provided. The findings of this review show a weakness in the health systems suggesting this is the major indirect barrier to DR screening in SSA. Measures to strengthen the health system for DR screening is strongly recommended.

Establishing a screening programme for diabetic retinopathy in Kilimanjaro Region, Tanzania using intervention mapping

Background

The Kilimanjaro Diabetic Programme used the Intervention Mapping framework to develop a theory- and evidence-based diabetic retinopathy screening programme. A Working Committee of health care workers and stakeholders ensured community engagement and empowerment of the target audience.

Objectives

To deliver a culturally appropriate, sustainable, community supported health intervention, promoting eye health behaviour change, to prevent avoidable blindness.

Methods

The six steps of the Intervention Mapping protocol incorporated eight components: (1) a needs assessment of people with diabetes and health care workers (2) a clinical trial of diabetic retinopathy screening modes, (3) comic strips as a motivational strategy for diabetic retinopathy screening uptake, (4) health care worker education (5) an electronic database of people with diabetes (6) a self-carry diary (7) implementation of mobile diabetic retinopathy retinal screening (8) process and outcome programme evaluation.

Results

The programme eliminated barriers to diabetic retinopathy screening in Kilimanjaro Christian Medical Centre eye and diabetic clinics, placing a digital retinal screening camera in the diabetic clinic and a fast-track screening system in the eye clinic. Two comic strips and a diary provided information about self-management and record of medications, treatment, blood sugar and blood pressure at clinic visits. An annual rural health care worker education programme met requests for knowledge on treatment and care of diabetes, targeting prevention of diabetic retinopathy. Rural digital retinal screening was implemented. Rural diabetes clinics were initiated.

Conclusions

Intervention Mapping provided a systematic, iterative model to formulate and deliver an urban and rural diabetic retinopathy screening programme.

Trial registration number

ISRCTN31439939. Details available at https://www.isrctn.com/

A Human Serum-Based Enzyme-Free Continuous Glucose Monitoring Technique Using a Needle-Type Bio-Layer Interference Sensor

The incidence of diabetes is continually increasing, and by 2030, it is expected to have increased by 69% and 20% in underdeveloped and developed countries, respectively. Therefore, glucose sensors are likely to remain in high demand in medical device markets. For the current study, we developed a needle-type bio-layer interference (BLI) sensor that can continuously monitor glucose levels. Using dialysis procedures, we were able to obtain hypoglycemic samples from commercial human serum. These dialysis-derived samples, alongside samples of normal human serum were used to evaluate the utility of the sensor for the detection of the clinical interest range of glucose concentrations (70-200 mg/dL), revealing high system performance for a wide glycemic state range (45-500 mg/dL). Reversibility and reproducibility were also tested over a range of time spans. Combined with existing BLI system technology, this sensor holds great promise for use as a wearable online continuous glucose monitoring system for patients in a hospital setting.

A needs assessment of people living with diabetes and diabetic retinopathy

Background

The Kilimanjaro Diabetic Programme was initiated in response to the needs of people living with diabetes (PWLD) to identify barriers to uptake of screening for diabetic retinopathy, to improve management of diabetes, and establish an affordable, sustainable eye screening and treatment programme for diabetic retinopathy. Intervention Mapping was used as the framework for the needs assessment.

Methods

A mixed methods approach was used. Five psychometric measures, Diabetes Knowledge Questionnaire, Diabetes Health Beliefs, Self-Efficacy scale, Problem Areas in Diabetes scale, and Hopkins Scale Checklist-25 and a structured interview relating to self-efficacy, addressing disclosure of living with diabetes and life-style changes were used to triangulate the quantitative findings. These were administered to 26 PWLD presenting to rural district hospitals.

Results

The interviewees demonstrated low levels of perceived stigma regarding disclosure of living with diabetes and high levels of self-efficacy in raising community awareness of diabetes, seeking on going treatment from Western medicine over traditional healers and in seeking care on sick days. Self-efficacy was high for adjusting diet, although comprehensive dietary knowledge was poor. Negative emotions expressed at diagnosis, changes in life style and altered quality of life were reflected in high levels of anxiety and depression.

Conclusions

Low levels of stigma surrounding living with diabetes were linked to a desire to raise community awareness of diabetes, help others live with diabetes and to secure social support to access hospital services. Confusion over what constituted a healthy diet showed the importance of comprehensive, accessible diabetes education, essential to ensuring good glycaemic control, and preventing diabetic complications, including diabetic retinopathy. Low levels of self-efficacy along with high levels of anxiety and depression may have a negative impact on the uptake of screening for Diabetic Retinopathy. The findings of this needs assessment led to the planning and delivery of a comprehensive health intervention programme for PLWD in Kilimanjaro Region. The programme has provided them with support, resources, education, and screening for diabetic retinopathy at the regional hospital and at district level with mobile digital retinal cameras, an electronic diabetic database and computerised follow up to ensure continuity of care.