Rationale for integration of services for diabetes mellitus and diabetic retinopathy in Kenya.

BACKGROUND: Good diabetes mellitus (diabetes) and diabetic retinopathy (DR) management depends on the strength of the health system, prompting us to conduct a health system assessment for diabetes and DR in Kenya. We used diabetes and DR as tracer conditions to assess the strengths and weaknesses in the health system, and potential interventions to strengthen the health system. In this paper, we report on the need and relevance of integration to strengthen diabetes and DR care. This theme emerged from the health system assessment. METHODS: Using a mixed methods study design, we collected data from service providers in diabetes clinics and eye clinics in three counties, from key informants at national and county level, and from documents review. RESULTS: There is interest in integration of diabetes and DR services to address discontinuity of care. We report the findings describing the context of integration, why integration is a goal and how these services can be integrated. We use the results to develop a conceptual framework for implementation. CONCLUSIONS: The principal rationale for integrated service provision is to address service gaps and to prevent complications of diabetes and DR. The stakeholder interest and the existing infrastructure can be leveraged to improve these health outcomes.

Feasibility of a cluster randomized controlled trial on the effectiveness of peer-led health education interventions to increase uptake of retinal examination for diabetic retinopathy in Kirinyaga, Kenya: a pilot trial.

BACKGROUND: People living with diabetes can reduce their risk of vision loss from diabetic retinopathy by attending screening, which enables early detection and timely treatment. The aim of this pilot trial was to assess the feasibility of a full-scale cluster randomized controlled trial of an intervention to increase uptake of retinal examination in this population, as delivered within existing community-based diabetes support groups (DSGs). METHODS: All 16 DSGs in Kirinyaga county were invited to participate in the study. The first two groups recruited took part in the pilot trial. DSG members who met the eligibility criteria were recruited before the groups that were randomized to the two arms. In the intervention group, two peer educators were trained to deliver monthly DSG-based eye health education and individual telephone reminders to attend screening. The control group continued with usual DSG practice which is monthly meetings without eye health education. The recruitment team and outcome assessors were masked to the allocation. We documented the study processes to ascertain the feasibility, acceptability, and potential effectiveness of the intervention. Feasibility was assessed in terms of clarity of study procedures, recruitment and retention rates, level of acceptability, and rates of uptake of eye examination. We set the target feasibility criteria for continuation to the main study to be recruitment of 50 participants in the trial, 80% monthly follow-up rates for individuals, and no attrition of clusters. RESULTS: Of the 122 DSG members who were assessed for eligibility, 104 were recruited and followed up: 51 (intervention) and 53 (control) arm. The study procedures were well understood and easy to apply. We learnt the DSG meeting days were the best opportunities for recruitment. The study had a high acceptance rate (100% for clusters, 95% for participants) and high follow-up and retention rate (100% of those recruited). All clusters and participants were analysed. We observed that the rate of incidence of eye exam was about 6 times higher in the intervention arm as compared to the control arm. No adverse unexpected events were reported in either arm. CONCLUSIONS: The study is feasible and acceptable in the study population. The results support the development of a full-scale cluster RCT, as the success criteria for the pilot were met. TRIAL REGISTRATION: Pan African Clinical Trials Registry PACTR201707002430195 Registered on 25 July 2017.

Peer-support to increase uptake of screening for diabetic retinopathy: process evaluation of the DURE cluster randomized trial.

BACKGROUND: There is limited evidence on how implementation of peer support interventions influences effectiveness, particularly for individuals with diabetes. We conducted a cluster randomized controlled trial to compare the effectiveness of a peer-led health education package versus usual care to increase uptake of screening for diabetic retinopathy (DR). METHODS: Our process evaluation used a mixed-method design to investigate the recruitment and retention, reach, dose, fidelity, acceptability, and context of implementation, and was guided by the Consolidated Framework for Implementation Research (CFIR). We reviewed trial documents, conducted semi-structured interviews with key informants (n = 10) and conducted four focus group discussions with participants in both arms of the trial. Three analysts undertook CFIR theory-driven content analysis of the qualitative data. Quantitative data was analyzed to provide descriptive statistics relevant to the objectives of the process evaluation. RESULTS: The trial had positive implementation outcomes, 100% retention of clusters and 96% retention for participants, 83% adherence to delivery of content of group talks (fidelity), and 78% attendance (reach) to at least 50% (3/6) of the group talks (dose). The data revealed that intervention characteristics, outer setting, inner setting, individual characteristics, and process (all the constructs of CFIR) influenced the implementation. There were more facilitators than barriers to the implementation. Facilitators included the relative advantage of the intervention compared with current practice (intervention characteristics); awareness of the growing prioritization of diabetes in the national health policy framework (outer setting); tension for change due to the realization of the vulnerability to vision loss from DR (inner setting); a strong collective sense of accountability of peer supporters to implement the intervention (individual characteristics); and regular feedback on the progress with implementation (process). Potential barriers included the need to queue at the eye clinic (intervention characteristic), travel inconveniences (inner setting), and socio-political disruption (outer setting). CONCLUSIONS: The intervention was implemented with high retention, reach, fidelity, and dose. The CFIR provided a valuable framework for evaluating contextual factors that influenced implementation and helped to understand what adaptations may be needed during scale up. TRIAL REGISTRATION: Pan African Clinical Trials Registry: PACTR201707002430195 registered 15 July 2017.

Attitudes of nursing staff towards computerisation: a case of two hospitals in Nairobi, Kenya.

BACKGROUND: The health sector is faced with constant changes as new approaches to tackle illnesses are unveiled through research. Information, communication and technology have greatly transformed healthcare practice the world over. Nursing is continually exposed to a variety of changes. Variables including age, educational level, years worked in nursing, computer knowledge and experience have been found to influence the attitudes of nurses towards computerisation. The purpose of the study was to determine the attitudes of nurses towards the use of computers and the factors that influence these attitudes. METHODS: This cross sectional descriptive study was conducted among staff nurses working at one public hospital (Kenyatta National Hospital, (KNH) and one private hospital (Aga Khan University Hospital (AKUH). A convenience sample of 200 nurses filled the questionnaires. Data was collected using the modified Nurses' Attitudes Towards Computerisation (NATC) questionnaire. RESULTS: Nurses had a favorable attitude towards computerisation. Non-users had a significantly higher attitude score compared to the users (p = 0.0274). Statistically significant associations were observed with age (p = 0.039), level of education (p = 0.025), duration of exposure to computers (p = 0.025) and attitudes towards computerisation. CONCLUSION: Generally, nurses have positive attitudes towards computerisation.This information is important for the planning and implementation of computerisation in the hospital as suggested in other studies.