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/.

Developing comic strips promoting diabetic retinopathy screening in Kilimanjaro, Tanzania, using Intervention Mapping.

INTRODUCTION: Intervention Mapping is the protocol used by the Kilimanjaro Diabetic Programme to plan, develop, implement, and evaluate an evidence-based screening programme for diabetic retinopathy. Two comic strips were developed to deliver the message on the need for diabetic retinopathy screening. OBJECTIVES: The first objective was to develop a culturally appropriate and accessible health message to promote diabetic retinopathy screening for the target audience. The second objective was to deliver a motivational message to promote acceptance of diabetic retinopathy screening irrespective of past eye health behaviour. METHODS: A multi-method research design was used. Social cognitive theory provided the theoretical basis for the intervention, involving community participation to promote positive eye health behaviour. RESULTS: For the Draughts Comic Strip, Flesch-Kincaid readability was 75.7% and comprehension was 87.04%, and for the Soap Opera Comic Strip Flesch-Kincaid readability was 75.6% and comprehension was 86.54%. CONCLUSION: The development of the diabetic retinopathy comic strips was a positive health education strategy implemented during a clinical trial comparing methods of screening for diabetic retinopathy at the Kilimanjaro Christian Medical Centre Hospital. The level of comprehension of the comic strips by stakeholders indicated their understanding of the message. Patients enroled in the clinical trial requested the comic strips. No discarded comic strips were found in the clinic during the clinical trial. TRIAL REGISTRATION: Trial registration number: ISRCTN31439939. Details available at https://www.isrctn.com/ .

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.

Microbial keratitis in East Africa: why are the outcomes so poor?

PURPOSE: Microbial keratitis (MK) is a major cause of blindness in Africa. This study reports the epidemiology, causative organism, management and outcome of MK in people admitted to a large referral hospital in Northern Tanzania, and explores why the outcomes are so poor for this condition. METHODS: A retrospective review of all admissions for MK during a 27-month period. Information was collected on: demographics, history, examination, microbiology, treatment and outcome. RESULTS: A total of 170 patients with MK were identified. Presentation was often delayed (median 14 days), and more delayed if another health facility was visited first (median 21 days). Appropriate intensive antibiotic treatment was prescribed in 19% before admission. Lesions were often severe (41% >5mm). Filamentary fungi were detected in 25% of all specimens (51% of specimens with a positive result). At discharge, 66% of affected eyes had a visual acuity of less than 6/60. Perforations developed in 30% and evisceration was necessary in 8%. Perforation was associated with large lesions and visiting another health facility. HIV infection was diagnosed in 16% of individuals tested, which is approximately twice the prevalence found in the wider population. CONCLUSIONS: Microbial keratitis is a significant clinical problem in this region, which generally has a very poor outcome. Delayed presentation is a critical issue. Fungal keratitis is a prominent cause and there is an indication that HIV may increase susceptibility. Prompt recognition and appropriate treatment in primary/secondary health facilities and rapid referral when needed may reduce the burden of blindness from this disease.

Prevalence of cytomegalovirus retinitis in Tanzanians with low CD4 levels.

AIM: To determine the prevalence of cytomegalovirus virus (CMV) retinopathy among a consecutive group of Tanzanians with AIDS with CD4 count <100 cells/µl. METHODS: Patients with HIV infection with CD4 count <100 cells/µl presenting consecutively to infectious disease services at two hospitals were examined by indirect ophthalmoscopy with fully dilated pupils. Additional clinical information was collected by interview and from patient files. RESULTS: One-hundred and fifty patients with CD4 count <100 cells/µl were examined, of whom 74 had CD4 count <50 cells/µl; 129 patients (86%) were classified as WHO stage 3 or 4. Only two patients (1.3%; 95% CI 0 to 2.3%) had CMV retinitis. DISCUSSION: This study demonstrates that AIDS patients in Tanzania do survive into the stage of severe immunosuppression, and that even among this group CMV retinitis is very uncommon. This supports previous studies reporting low prevalence of CMV where CD4 counts were not available. Differences in immune response in AIDS patients in different settings may depend on environmental exposure to specific viruses early in life.