Structured Counselling and Regular Telephonic follow up to improve Referral flow and compliance in Nepal for Diabetic Retinopathy(SCREEN-D Study): a randomised controlled trial.

BACKGROUND: Diabetic Retinopathy (DR) is an emerging public health issue, leading to severe visual impairment or blindness. Early identification and prompt treatment play a key role in achieving good visual outcomes. The objective of the study was to estimate the effectiveness of SCREEN package on improving referral compliance from peripheral centres to a tertiary eye centre in Nepal. METHODS: In this facility-based cluster-randomized trial, ten out of 19 referring centres of the tertiary eye care centre in Lumbini zone, Nepal were randomized into intervention and control groups. A SCREEN packagewereprovided as intervention for DR patients who require advanced treatment in the tertiary centres and was compared with the current practice of the control arm, where structured counselling and follow-up mechanism are absent. Compliance was estimated by a weekly follow-up between the referring centre and the referred hospital. RESULTS: We recruited 302 participantsof whom 153 were in the intervention arm. The mean age of the participants was 57.8 years (Standard deviation [SD]±11.7 years). With implementation of SCREEN package71.2% (n=109) in the intervention group and 42.9% (n=64) in the control group were compliant till three months of follow-up (Difference 28.3%, 95% CI: 17.6- 39.0, p<0.05). Compliance was 43% (n=66) with counselling alone, and 66% (n=103) with first telephonic follow-up in the intervention arm. The mean duration to reach the referral centre was 14.7 days (SD± 9.4 days) and 18.2 days (SD± 9.1 days) in the intervention and the control arm, respectively (Difference 3.5 days, 95% CI: 0.7 to 6.4 days). CONCLUSIONS: Counselling& follow-up to patients is the key factor to improve the utilization of the health services by patients with DR. Health systems must be strengthened by optimizing the existing referral structure in Nepal. TRIAL REGISTRATION: ClinicalTrials.gov Protocol Registration and Results System, ClinicalTrials.gov Identifier: NCT04834648 , 08/04/2021.

Eye-glasses wear compliance following school-based visual acuity screening in Nepal: a comparative study.

INTRODUCTION: Eye-glasses wear compliance is found to be low among children in school-based eye screening programs who are provided spectacles free of charge. METHODS: Thirty-six schools from school visual acuity screening program in Nepal were randomly selected to receive no follow-up (standard) or follow-up by an optometry team at 3 months. In the intervention group (that received the follow-up), ophthalmic personal made unannounced visits to the schools at 3 months to determine spectacle compliance .Direct examination to determine compliance with spectacle wear 6 months was done. The primary reason for noncompliance from a list of possibilities was identified using a questionnaire. RESULTS: Among 297 (145 control and 152 intervention) students that received glasses in the 36 schools, 128/152 (84%) were available for examination at 3 months in the intervention group. A total of 216/297 (73%) students were available for examination at 6 months (73 % and 72% of the control and intervention groups, respectively). Within the intervention group, 51% of children at 3 months and 57% at 6 months were wearing glasses during the unannounced visits. The main source of refractive error was myopia. Out of 66 children with astigmatism, 24 (36%) were wearing glasses. There was no statistically significant difference in compliance (p=0.85) between private and public schools, but compliance correlated better with the educational status of careers. CONCLUSION: A follow-up visit to the school by eye care personnel did not improve spectacle wear compliance among children .Other factors may also be responsible for poor compliance.

Childhood blindness and visual impairment in the Narayani Zone of Nepal: a population-based survey.

Purpose: To estimate the prevalence and causes of blindness (BL), severe visual impairment (SVI), moderate visual impairment (ModVI) and mild visual impairment (MildVI) in children in Narayani Zone, Nepal. Methods: In 2017, 100 population clusters within the Narayani Zone of Nepal were selected using RAAB software. Children (aged 0-15 years) suspected of having visual problems were identified using Key Informants (KIs) and school teachers and were referred for ophthalmologic examination. Eye care staff actively sought children who failed to present for examination. Causes of BL/SVI/ModVI/MildVI were categorized using standard World Health Organization definitions. Results: Of 76,588 children selected, 72,900 (95%) were screened. Of 2,158 children referred for examination, 1,322 were referred by teachers and 836 by KIs. A total of 1,617 (75%) children received a detailed examination, of whom 128 children [65 girls (51%)] mean age of 9.4 (± 4.1 years) were confirmed to have BL 7 (5.5%), SVI 16 (12.5%), ModVI 19 (15%) or MildVI 86 (67%). The combined prevalence of BL/SVI/ModVI/MildVI was 175/100,000 (95% CI 172-178/100,000); BL/SVI/ModVI was 55/100,000 (95% CI 53-57/100,000) and the combined BL/SVI estimate was 30/100,000 (95% CI 29-31/100,000). The leading causes of BL/SVI/MVI were refractive error 23 (55%) and whole globe disorders 5 (12%). Total avoidable causes were 31 (74%). Conclusion: The prevalence of BL/SVI/ModVI among children in Narayani Zone was moderate and included a high proportion of avoidable and treatable cases. Pediatric ophthalmic services need improvement, mainly refractive error correction in rural areas of Nepal.

Interventions to improve utilization of cataract surgical services by girls: Case studies from Asia and Africa.

PURPOSE: Gender and blindness initiatives continue to make eye care personnel aware of the service utilization inequity strongly favouring men, yet interventions to reduce that inequity, particularly for girls, are under developed. METHODS: This descriptive study gathered quantitative data on the degree of gender equity at five Child Eye Health Tertiary Facilities (CEHTFs) in Asia and Africa and conducted in-depth interviews with eye care personnel to assess their strategies and capacity to reduce gender inequity. Cataract surgery was utilized to assess the degree of inequity and success of interventions to reduce inequity in case finding, service utilization, and follow-up. RESULTS: CEHTF administrative data showed significant gender inequity in cataract surgical services favouring boys in all settings. CEHTFs actively seek children through community and school-based outreach, yet do not have initiatives to reduce gender inequity. Little gender inequity was found among children receiving surgical and follow-up care, although two out of three children were boys. CEHTF staff, despite being aware, offered no effective means to reduce gender inequity involving cataract surgical services. Interventions that successfully increased service utilization by girls came from individual cases, involving extraordinary effort by a single eye care programme person. CONCLUSION: Community-based case finders such as Anganwadi workers in India, Female Community Health Volunteers (FCHVs) in Nepal, and Key Informants (KIs) in Africa are necessary to identify children in need of cataract services, but insufficient to increase service utilization by girls. Secondary, often extra-ordinary community-based interventions by eye care personnel are needed in all settings.