Complex interventions to implement a diabetic retinopathy care pathway in the public health system in Kerala: the Nayanamritham study protocol.

INTRODUCTION: Using a type 2 hybrid effectiveness-implementation design, we aim to pilot a diabetic retinopathy (DR) care pathway in the public health system in Kerala to understand how it can be scaled up to and sustained in the whole state. METHODS AND ANALYSIS: Currently, there is no systematic DR screening programme in Kerala. Our intervention is a teleophthalmology pathway for people with diabetes in the non-communicable disease registers in 16 family health centres. The planned implementation strategy of the pathway will be developed based on the discrete Expert Recommendations for Implementing Change taxonomy. We will use both quantitative data from a cross-sectional study and qualitative data obtained from structured interviews, surveys and group discussions with stakeholders to report the effectiveness of the DR care pathway and evaluation of the implementation strategy.We will use logistic regression models to assess crude associations DR and sight-threatening diabetic retinopathy and fractional polynomials to account for the form of continuous covariates to predict uptake of DR screening. The primary effectiveness outcome is the proportion of patients in the non-communicable disease register with diabetes screened for DR over 12 months. Other outcomes include cost-effectiveness, safety, efficiency, patient satisfaction, timeliness and equity. The outcomes of evaluation of the implementation strategies include acceptability, feasibility, adoption, appropriateness, fidelity, penetration, costs and sustainability. Addition of more family health centres during the staggered initial phase of the programme will be considered as a sign of acceptability and feasibility. In the long term, the state-wide adoption of the DR care pathway will be considered as a successful outcome of the Nayanamritham study. ETHICS AND DISSEMINATION: The study was approved by Indian Medical Research Council (2018-0551) dated 13 March 2019. Study findings will be disseminated through scientific publications and the report will inform adoption of the DR care pathway by Kerala state in future. TRIAL REGISTRATION NUMBER: ISRCTN28942696.

Burden of Diabetic Retinopathy amongst People with Diabetes Attending Primary Care in Kerala: Nayanamritham Project.

BACKGROUND: The burden of diabetic retinopathy (DR) in people attending the public health sector in India is unclear. Thirty percent of the population in India is reliant on public healthcare. This study aimed to estimate the prevalence of DR and its risk factors in people with diabetes in the non-communicable disease registers who were attending the family health centres (FHCs) in the Thiruvananthapuram district in Kerala. METHODS: This cross-sectional study was conducted over 12 months in 2019 within the framework of a pilot district-wide teleophthalmology DR screening programme. The age- and gender-adjusted prevalence of any DR and sight-threatening DR (STDR) in the whole sample, considering socio-demography, lifestyle and known clinical risk groups, are reported. RESULTS: A total of 4527 out of 5307 (85.3%) screened in the FHCs had gradable retinal images in at least one eye. The age and gender standardised prevalence for any DR was 17.4% (95% CI 15.1, 19.7), and STDR was 3.3% (95% CI 2.1, 4.5). Ages 41-70 years, males, longer diabetes duration, hyperglycaemia and hypertension, insulin users and lower socio-economic status were associated with both DR outcomes. CONCLUSIONS: The burden of DR and its risk factors in this study highlights the need to implement DR screening programs within primary care to reduce health inequality.

Geriatric club attached to a primary care hospital as an effort to physically, socially, and mentally engage elderly: A case study from Kerala, India.

INTRODUCTION: Ageing leads to physiological, social and mental changes. The case study shares experiences about the development and evolution of a 'geriatric club' attached to a primary health centre in Kerala, India and the early outcomes noticed among the members of the geriatric club. PROCESS: This club, established three years before, has become an ongoing self-sustainable organisation helping senior citizens to socialise with their peers. Meeting on a regular day every week at the health centre, with programs varying from discussions on health issues to entertainments like music, dance, festival celebration and film shows, the club has become part of all elderly patients in and around the health centre. OUTCOME: Outcome of the club was looked qualitatively and quantitatively through Focus Group Discussions and before and after comparison of Mini Mental Status Examination Scores and Geriatric Depression Scale scores of elderly club members. FGDs concluded that members were benefitted through participation in the club and the club activities helped them to get engaged physically, mentally and socially. Mean GDS scores of the participants decreased from baseline [5.43, SE 0.76] to after six months [5.20, SE 0.74] (P 0.006). Mean MMSE scores showed improvement from baseline [22.26, SE 0.69] to after six months [24.80, SE 0.81] (P 0.001). CONCLUSION: Geriatric social clubs attached to primary health care hospitals with suitable contextual adaptations can engage elderly patients physically, mentally and socially. It is hypothesised that such activities can have positive impact on depression and cognitive improvement.