Is India's policy framework geared for effective action on avoidable blindness from diabetes?

BACKGROUND

The growing burden of avoidable blindness caused by diabetic retinopathy (DR) needs an effective and holistic policy that reflects mechanisms for early detection and treatment of DR to reduce the risk of blindness.

MATERIALS AND METHODS

We performed a comprehensive health policy review to highlight the existing systemic issues that enable policy translation and to assess whether India's policy architecture is geared to address the mounting challenge of DR. We used a keyword-based Internet search for documents available in the last 15 years. Two reviewers independently assessed retrieved policies and extracted contextual and program-oriented information and components delineated in national policy documents. Using a "descriptive analytical" method, the results were collated and summarized as per themes to present status quo, gaps, and recommendations for the future.

RESULTS

Lack of focus on building sustainable synergies that require well laid out mechanisms for collaboration within and outside the health sector and poor convergence between national health programs appears to be the weakest links across policy documents.

CONCLUSIONS

To reasonably address the issues of consistency, comprehensiveness, clarity, context, connectedness, and sustainability, policies will have to rely more strongly on evidence from operational research to support decisions. There is a need to involve multiple stakeholders from multiple sectors, recognize contributions from not-for-profit sector and private health service providers, and finally bring about a nuanced holistic perspective that has a voice with implementable multiple sector actions.

Perceptions and practices related to diabetes reported by persons with diabetes attending diabetic care clinics: The India 11-city 9-state study

BACKGROUND

India has the second largest population of persons with diabetes and a significant proportion has poor glycemic control and inadequate awareness of management of diabetes.

OBJECTIVES

Determine the level of awareness regarding management of diabetes and its complications and diabetic care practices in India.

METHODS

The cross-sectional, hospital-based survey was conducted in 11 cities where public and private providers of diabetic care were identified. At each diabetic care facility, 4-6 persons with diabetes were administered a structured questionnaire in the local language.

RESULTS

Two hundred and eighty-five persons with diabetes were interviewed. The mean duration since diagnosis of diabetes was 8.1 years (standard deviation ± 7.3). Half of the participants reported a family history of diabetes and 41.7% were hypertensive. Almost 62.1% stated that they received information on diabetes and its management through interpersonal channels. Family history (36.1%), increasing age (25.3%), and stress (22.8%) were the commonest causes of diabetes reported. Only 29.1% stated that they monitored their blood sugar levels at home using a glucometer. The commonest challenges reported in managing diabetes were dietary modifications (67.4%), compliance with medicines (20.5%), and cost of medicines (17.9%). Around 76.5% were aware of complications of diabetes. Kidney failure (79.8%), blindness/vision loss (79.3%), and heart attack (56.4%) were the commonest complications mentioned. Almost 67.7% of the respondents stated that they had had an eye examination earlier.

CONCLUSIONS

The findings have significant implications for the organization of diabetes services in India for early detection and management of complications, including eye complications.

Human resources, patient load, and infrastructure at institutions providing diabetic care in India: The India 11-city 9-state study

BACKGROUND

There is a lack of information on the practice patterns and available human resources and services for screening for eye complications among persons with diabetes in India.

OBJECTIVES

The study was undertaken to document existing health care infrastructure and practice patterns for managing diabetes and screening for eye complications.

METHODS

This cross-sectional, hospital-based survey was conducted in 11 cities where public and private diabetic care providers were identified. Both multispecialty and standalone diabetic care facilities were included. A semi-structured questionnaire was administered to senior representative(s) of each institution to evaluate parameters using the World Health Organization health systems framework.

RESULTS

We interviewed physicians in 73 hospitals (61.6% multispecialty hospitals; 38.4% standalone clinics). Less than a third reported having skilled personnel for direct ophthalmoscopy. About 74% had provision for glycated hemoglobin testing. Only a third had adequate vision charts. Printed protocols on management of diabetes were available only in 31.5% of the facilities. Only one in four facilities had a system for tracking diabetics. Half the facilities reported having access to records from the treating ophthalmologists. Direct observation of the services provided showed that reported figures in relation to availability of patient support services were overestimated by around 10%. Three fourths of the information sheets and half the glycemia monitoring cards contained information on the eye complications and the need for a regular eye examination.

CONCLUSIONS

The study highlighted existing gaps in service provision at diabetic care centers in India.

Perception of care and barriers to treatment in individuals with diabetic retinopathy in India: 11-city 9-state study

BACKGROUND

Diabetic retinopathy is a leading cause of visual impairment. Low awareness about the disease and inequitable distribution of care are major challenges in India.

OBJECTIVES

Assess perception of care and challenges faced in availing care among diabetics.

MATERIALS AND METHODS

The cross-sectional, hospital based survey was conducted in eleven cities. In each city, public and private providers of eye-care were identified. Both multispecialty and standalone facilities were included. Specially designed semi-open ended questionnaires were administered to the clients.

RESULTS

376 diabetics were interviewed in the eye clinics, of whom 62.8% (236) were selected from facilities in cities with a population of 7 million or more. The mean duration of known diabetes was 11.1 (±7.7) years. Half the respondents understood the meaning of adequate glycemic control and 45% reported that they had visual loss when they first presented to an eye facility. Facilities in smaller cities and those with higher educational status were found to be statistically significant predictors of self-reported good/adequate control of diabetes. The correct awareness of glycemic control was significantly high among attending privately-funded facilities and higher educational status. Self-monitoring of glycemic status at home was significantly associated with respondents from larger cities, privately-funded facilities, those who were better educated and reported longer duration of diabetes. Duration of diabetes (41%), poor glycemic control (39.4%) and age (20.7%) were identified as the leading causes of DR. The commonest challenges faced were lifestyle/behavior related.

CONCLUSIONS

The findings have significant implications for the organization of diabetes services in India.

Prevalence of blindness and visual impairment in Nigeria: the National Blindness and Visual Impairment Study

PURPOSE

To determine the prevalence of blindness and visual impairment among adults aged > or = 40 years in Nigeria.

METHODS

Multistage, stratified, cluster random sampling with probability proportional to size procedures was used to identify a cross-sectional nationally representative sample of 15,027 persons > or = 40 years of age from all 36 states in Nigeria and the Federal Capital Territory. Distance visual acuity (VA) was measured with a reduced logMAR tumbling-E chart at 4 and 1 m. Presenting and best corrected visual acuities were recorded. Autorefraction was performed in all examined adults. Clinical evaluations included examination under dilation for those with presenting vision < 6/12 in either eye.

RESULTS

In the study, 15,122 persons aged > or = 40 years were enumerated and 13,599 (89.9%) examined. Prevalence of blindness (< 20/400 in the better eye) and severe visual impairment (< 20/200-20/400; presenting vision) was 4.2% (95% confidence interval [CI]: 3.8%-4.6%) and 1.5% (95% CI: 1.3%-1.7%), respectively. Blindness was associated with increasing age, being female, poor literacy, and residence in the North. Participants residing in the South West had the lowest prevalence while those in the North East had the highest prevalence of blindness. It is estimated that 4.25 million adults aged > or = 40 years have moderate to severe visual impairment or blindness (< 20/63 in the better eye).

CONCLUSIONS

There is a high prevalence of blindness and severe visual impairment among those aged > or = 40 years in Nigeria. Significant differences exist between the geopolitical zones and emphasis should be on ensuring eye services across Nigeria, which means that planning at the regional level is necessary.

The Nigerian national blindness and visual impairment survey: Rationale, objectives and detailed methodology

Background

Despite having the largest population in Africa, Nigeria has no accurate population based data to plan and evaluate eye care services. A national survey was undertaken to estimate the prevalence and determine the major causes of blindness and low vision. This paper presents the detailed methodology used during the survey.

Methods

A nationally representative sample of persons aged 40 years and above was selected. Children aged 10–15 years and individuals aged <10 or 16–39 years with visual impairment were also included if they lived in households with an eligible adult. All participants had their height, weight, and blood pressure measured followed by assessment of presenting visual acuity, refractokeratomery, A-scan ultrasonography, visual fields and best corrected visual acuity. Anterior and posterior segments of each eye were examined with a torch and direct ophthalmoscope. Participants with visual acuity of < = 6/12 in one or both eyes underwent detailed examination including applanation tonometry, dilated slit lamp biomicroscopy, lens grading and fundus photography. All those who had undergone cataract surgery were refracted and best corrected vision recorded. Causes of visual impairment by eye and for the individual were determined using a clinical algorithm recommended by the World Health Organization. In addition, 1 in 7 adults also underwent a complete work up as described for those with vision < = 6/12 for constructing a normative data base for Nigerians.

Discussion

The field work for the study was completed in 30 months over the period 2005–2007 and covered 305 clusters across the entire country. Concurrently persons 40+ years were examined to form a normative data base. Analysis of the data is currently underway.

Conclusion

The methodology used was robust and adequate to provide estimates on the prevalence and causes of blindness in Nigeria. The survey would also provide information on barriers to accessing services, quality of life of visually impaired individuals and also provide normative data for Nigerian eyes.