Availability of eye care infrastructure and human resources for managing diabetic retinopathy in the western province of Sri Lanka.

Purpose: Blindness and visual impairment due to diabetic retinopathy (DR) are avoidable by early screening and timely treatment. The western province of Sri Lanka has the highest prevalence of diabetes mellitus (18.6%) in the country. DR had been given less attention in services expansion because of lack of evidence. The aim of this study was to assess the availability of human resources (HR) and infrastructure for DR in eye care facilities. Methods: A cross-sectional survey was conducted in 51 health care institutions by administering a validated questionnaire schedule and through semi-structured interviews. The data on infrastructure, HR and level of training, and skills were collected during the site visits by observation, frequency counting, and interviewing. Key findings of the interviews were recorded using categorical responses. Data analysis was done using MS-Excel® and STATA/IC®-Version 2-13.0 packages. Results: The response rate of the survey was 84.3% (43/51). There were 40 board-certified ophthalmologists and 6 vitreo-retinal surgeons in the region, of whom 77.5% (31/40) were in Colombo district. The highest population-adjusted DR-related infrastructure ratios were recorded from Colombo district. Mid-level cadres such as medical officers' mean skill score of DR screening and treatment was low (0.37, 95% CI 0.32-0.40). Conclusion: There is no systematic DR screening program, and HR and infrastructure distribution was not aligned to the population need in the western province. Urgent attention should be paid to expand the service delivery and mid-level HR training for DR screening and treatment in this region.

A qualitative study on barriers and enablers to uptake of diabetic retinopathy screening by people with diabetes in the Western Province of Sri Lanka.

BACKGROUND: Blindness and visual impairment from diabetic retinopathy (DR) are avoidable through early detection and timely treatment. The Western Province of Sri Lanka has the highest prevalence of diabetes mellitus (DM) (18.6%) in the country. A situational analysis identified a significant gap in DR screening services (DRSS) uptake in this region. Barriers that hinder people with DM (PwDM) from attending DRSS are poorly understood. The purpose of this study is to understand the factors which influence the uptake of DRSS and follow-up to inform health promotion strategies and improve the uptake of these services. METHODS: Eleven focus group discussions (FGDs) were conducted with PwDM who presented to medical, general eye and vitreoretinal services in three public sector institutions (two tertiary and one secondary level) in the Western Province between October 2016 and March 2017. We enrolled six groups (four Sinhala speaking, two Tamil) of women and five groups (three Sinhala and two Tamil) of men representing ethnicity and gender. We performed a thematic analysis and described the main themes and subthemes using the socio-ecological model as a framework. RESULTS: We identified lack of knowledge of both the condition and the need for screening as key barriers to access DRSS. Socio-cultural factors in the family environment, economic reasons and institutional factors were also important barriers. Additional reasons include long waiting time at eye clinics and poor referrals exacerbated by the lack of a systematic DRSS. In addition, attitudes to DRSS such as fear of discomfort from the procedure and the need for accompaniment following mydriasis were also deterrents to follow-up screening. CONCLUSION: This study has shown that there are inter-related user, family, and institutional factors which affect the uptake of DRSS. Understanding how DR is conceptualised by PwDM in this region is essential to refine strategies to improve access to DRSS. Strategies to improve knowledge need to be more culturally acceptable and relevant to PwDM and their families, with increased availability of DRSS at convenient locations may increase timely uptake of screening.

Correction to: Systematic review and meta-analysis of diagnostic accuracy of detection of any level of diabetic retinopathy using digital retinal imaging.

Following publication of the original article [1], the authors reported an error in Fig. 4 in the PDF version. Figure 4 is the duplicate image of Fig. 3 and the correct figure is missing. The authors would like to apologize for this error. The correct figure is shown below.

Systematic review on barriers and enablers for access to diabetic retinopathy screening services in different income settings.

BACKGROUND: Diabetic retinopathy (DR) can lead to visual impairment and blindness if not detected and treated in time. Knowing the barriers/enablers in advance in contrasting different country income settings may accelerate development of a successful DR screening (DRS) program. This would be especially applicable in the low-income settings with the rising prevalence of DR. OBJECTIVES: The aim of this systematic review is to identify and contrast the barriers/enablers to DRS for different contexts using both consumers i.e., people with diabetes (PwDM) and provider perspectives and system level factors in different country income settings. METHODS: We searched MEDLINE, Embase, CENTRAL in the Cochrane Library from the databases start date to December 2018. We included the studies reported on barriers and enablers to access DRS services based at health care facilities. We categorised and synthesized themes related to the consumers (individuals), providers and the health systems (environment) as main dimensions according to the constructs of social cognitive theory, supported by the quantitative measures i.e., odds ratios as reported by each of the study authors. MAIN RESULTS: We included 77 studies primarily describing the barriers and enablers. Most of the studies were from high income settings (72.7%, 56/77) and cross sectional in design (76.6%, 59/77). From the perspectives of consumers, lack of knowledge, attitude, awareness and motivation were identified as major barriers. The enablers were fear of blindness, proximity of screening facility, experiences of vision loss and being concerned of eye complications. In providers' perspectives, lack of skilled human resources, training programs, infrastructure of retinal imaging and cost of services were the main barriers. Higher odds of uptake of DRS services was observed when PwDM were provided health education (odds ratio (OR) 4.3) and having knowledge on DR (OR range 1.3-19.7). CONCLUSION: Knowing the barriers to access DRS is a pre-requisite in development of a successful screening program. The awareness, knowledge and attitude of the consumers, availability of skilled human resources and infrastructure emerged as the major barriers to access to DRS in any income setting.

The Organization, Implementation, and Functioning of Dengue Surveillance in India-A Systematic Scoping Review.

Dengue´s re-emerging epidemiology poses a major global health threat. In India, dengue contributes significantly to the global communicable disease burden, and has been declared highly endemic. This study aims to identify and critically appraise India's dengue surveillance system. We conducted a systematic literature review, searching Medline, Web of Sciences, Global Health, and Indian Journals. We conducted a narrative synthesis and thematic analysis. Eighteen studies fulfilled eligibility. Organizationally, most studies referred to the National Vector Borne Disease Control Programme, primarily responsible for overall vector and disease control, as well as the Integrated Disease Surveillance Programme, responsible for reporting, outbreak identification, and integration. Surveillance implementation was mostly framed as passive, sentinel, and hospital-based. Reporting varies from weekly to monthly, flowing from primary healthcare centres to district and national authorities. Dengue confirmation is only recognized if conducted with government-distributed MAC-ELISA tests. The surveillance system predominantly relies on public reporting units. In terms of functioning, current surveillance seems to have improved dengue reporting as well the system's detection capacities. Emergency and outbreak responses are often described as timely; however, they are challenged by underreporting, weak data reliability, lack of private reporting, and system fragmentation. Concluding, India's dengue surveillance structure remains weak. Efforts to create an infrastructure of communication, cooperation, and integration are evident, however, not achieved yet.

Systematic review and meta-analysis of diagnostic accuracy of detection of any level of diabetic retinopathy using digital retinal imaging.

BACKGROUND: Visual impairment from diabetic retinopathy (DR) is an increasing global public health concern, which is preventable with screening and early treatment. Digital retinal imaging has become a preferred choice as it enables higher coverage of screening. The aim of this review is to evaluate how different characteristics of the DR screening (DRS) test impact on diagnostic test accuracy (DTA) and its relevance to a low-income setting. METHODS: We conducted a systematic literature search to identify clinic-based studies on DRS using digital retinal imaging of people with DM (PwDM). Summary estimates of different sub-groups were calculated using DTA values weighted according to the sample size. The DTA of each screening method was derived after exclusion of ungradable images and considering the eye as the unit of analysis. The meta-analysis included studies which measured DTA of detecting any level of DR. We also examined the effect on detection from using different combinations of retinal fields, pupil status, index test graders and setting. RESULTS: Six thousand six hundred forty-six titles and abstracts were retrieved, and data were extracted from 122 potentially eligible full reports. Twenty-six studies were included in the review, and 21 studies, mostly from high-income settings (18/21, 85.7%), were included in the meta-analysis. The highest sensitivity was observed in the mydriatic greater than two field strategy (92%, 95% CI 90-94%). The highest specificity was observed in greater than two field methods (94%, 95% CI 93-96%) where mydriasis did not affect specificity. Overall, there was no difference in sensitivity between non-mydriatic and mydriatic methods (86%, 95% CI 85-87) after exclusion of ungradable images. The highest DTA (sensitivity 90%, 95% CI 88-91%; specificity 95%, 95% CI 94-96%) was observed when screening was delivered at secondary/tertiary level clinics. CONCLUSIONS: Non-mydriatic two-field strategy could be a more pragmatic approach in starting DRS programmes for facility-based PwDM in low-income settings, with dilatation of the pupils of those who have ungradable images. There was insufficient evidence in primary studies to draw firm conclusions on how graders' background influences DTA. Conducting more context-specific DRS validation studies in low-income and non-ophthalmic settings can be recommended.

A Mixed-Method Study to Determine the Benefits of Periconceptional Folic Acid Supplementation and Effects of Folic Acid Deficiency in Mothers on Birth Outcomes.

BACKGROUND: Evidence from high income countries shows mothers who are supplemented with folic acid in their periconceptional period and early pregnancy have significantly reduced adverse outcomes like birth defects. However, in India there is a paucity of data on association of birth defects and folic acid supplementation. We identified a few important questions to be answered using separate scientific methods and then planned to triangulate the information. OBJECTIVE: In this paper, we describe the protocol of our study that aims to determine the association of folic acid and pregnancy outcomes like neural tube defects (NTDs) and orofacial clefts (OFCs). We decided to fill the gaps in knowledge from India to determine public health consequences of folic acid deficiency and factors influencing dietary and periconceptional consumption of folic acid. METHODS: The proposed study will be carried out in five stages and will examine the questions related to folic acid deficiency across selected locations in South and North India. The study will be carried out over a period of 4 years through the hierarchical evidence-based approach. At first a systematic review was conducted to pool the current birth prevalence of NTDs and orofacial clefts OFCs in India. To investigate the population prevalence, we plan to use the key informant method to determine prevalence of NTDs and OFCs. To determine the normal serum estimates of folic acid, iron, and vitamin B12 among Indian women (15-35 years), we will conduct a population-based, cross-sectional study. We will further strengthen the evidence of association between OFCs and folic acid by conducting a hospital-based, case-control study across three locations of India. Lastly, using qualitative methods we will understand community and health workers perspective on factors that decide the intake of folic acid supplements. RESULTS: This study will provide evidence on the community prevalence of birth defects and prevalence folic acid and vitamin B12 deficiency in the community. The case-control study will help understand the association of folic acid deficiency with OFCs. CONCLUSIONS: The results from this study are intended to strengthen the evidence base in childhood disability for planning and policy initiatives.

Challenges in understanding the epidemiology of acquired brain injury in India.

An acquired brain injury (ABI) is an injury to the brain, which is not hereditary, congenital, degenerative, or induced by birth trauma. In India, rapid urbanization, economic growth and changes in lifestyle have led to a tremendous increase in the incidence of ABI, so much so that it is being referred to as a 'silent epidemic'. Unlike developed countries, there is no well-established system for collecting and managing information on various diseases in India. Thus it is a daunting task to obtain reliable information about acquired brain injury. In the course of conducting a systematic review on the epidemiology of ABI in India, we recognized several challenges which hampered our effort. Inadequate case definition, lack of centralized reporting mechanisms, lack of population based studies, absence of standardized survey protocols and inadequate mortality statistics are some of the major obstacles. Following a standard case definition, linking multiple hospital-based registries, initiating a state or nationwide population-based registry, conducting population-based studies that are methodologically robust and introducing centralized, standard reporting mechanisms for ABI, are some of the strategies that could help facilitate a thorough investigation into the epidemiology and understanding of ABI. This may help improve policies on prevention and management of acquired brain injury in India.

Reproductive health of women with and without disabilities in South India, the SIDE study (South India Disability Evidence) study: a case control study.

BACKGROUND: Evidence shows that women with disability have adverse pregnancy outcomes compared to those without a disability. There is a lack of published data on reproductive health of women with disability in India till date. The objective of the South India Disability Evidence (SIDE) Study was to compare reproductive health parameters including pregnancy experience, health access during pregnancy and type of delivery among women with disability compared to women with no disability. METHODS: The study was conducted in one district each in two States (Andhra Pradesh and Karnataka) in 2012. A case-control design was used to identify appropriate age and sex-matched controls for women with disability identified through a population-based survey. Trained key informants first listed women with disabilities who were then examined by a medical team to confirm the diagnosis. Trained research investigators administered questionnaire schedules to both groups of women to collect information on reproductive health and outcomes of any pregnancy experienced in the past two years. RESULTS: A total of 247 women with disability and 324 age-matched controls aged 15-45 years were recruited for the study. 87% of the women with disability had a physical disability. The mean age of women with disability was 29.86 against 29.71 years among women without a disability. A significantly lower proportion of women with disability experienced pregnancy (36.8%) compared to women without a disability (X (2) -16.02 P <0.001). The odds ratio for suffering from diabetes among women with disability compared to women without a disability was 19.3(95% CI: 1.2- 313.9), while it was 9.5 (95% CI: 2.2-40.8) for depression. A higher proportion of women without a disability (7.7%) compared to women with a disability (5.3%) reported a successful pregnancy in the past two years. There were no statistically significant differences between women with and without a disability with regard to utilization of antenatal care and pregnancy outcomes. CONCLUSIONS: The study provides evidence on some reproductive health parameters of women with disability in India for the first time ever. The findings will help in formulating policy and to develop specific interventions to improve pregnancy outcomes for women with disability in India.