E-learning in medical education during COVID-19 pandemic: experiences of a research course at Kenya Medical Training College.

BACKGROUND: E-learning has been widely adopted as a teaching and learning approach in medical education internationally. However, its adoption in low- and middle-income countries is still at an infantile stage. The use of e-learning may help to overcome some of the barriers to access to quality education and provide flexible, low-cost, user-centred, and easily updated learning. To address the need for research education during the COVID-19 pandemic, we developed and implemented an e-learning course for students enrolled in higher diploma courses at the Kenya Medical Training College (KMTC). In this paper, we report our experience teaching the online research course in resource-constrained settings to enable other medical educators, students and institutions in similar settings to understand the most appropriate approaches to incorporating e-learning interventions. METHODS: This was a cross-sectional study that reviewed the experiences of learners and lecturers on a research course at Kenya Medical Training College. All higher diploma students admitted to the college in the 2020/21 academic year were invited to take part in the study. We also included all lecturers that were involved in the coordination and facilitation of the course. We analysed qualitative and quantitative data that were collected from the e-learning platform, an online course-evaluation form and reports from course lecturers. RESULTS: We enrolled 933 students on the online research course. These students had joined 44 higher diploma courses in 11 campuses of the college. The students struggled to complete synchronous e-learning activities on the e-learning platform. Only 53 and 45% of the students were able to complete the pretest and the posttest, respectively. Four themes were identified through a thematic analysis of qualitative data (1) Students gained research competencies (2) Students appreciated the use of diverse e-learning technologies (3) Students felt overwhelmed by the research course (4) Technological challenges reduce the effectiveness of online learning. CONCLUSION: Our results suggest that e-learning can be used to teach complex courses, such as research in resource-constrained settings. However, faculty should include more asynchronous e-learning activities to enhance teaching and learning and improve student experiences.

Evidence for national universal eye health plans.

Many low- and middle-income countries use national eye-care plans to guide efforts to strengthen eye-care services. The World Health Organization recognizes that evidence is essential to inform these plans. We assessed how evidence was incorporated in a sample of 28 national eye-care plans generated since the Universal eye health: a global action plan 2014-2019 was endorsed by the World Health Assembly in 2013. Most countries (26, 93%) cited estimates of the prevalence of blindness and 18 countries (64%) had set targets for the cataract surgical rate in their plan. Other evidence was rarely cited or used to set measurable targets. No country cited evidence from systematic reviews or solution-based research. This limited use of evidence reflects its low availability, but also highlights incomplete use of existing evidence. For example, despite sex-disaggregated data and cataract surgical coverage being available from surveys in 20 countries (71%), these data were reported in the eye health plans of only nine countries (32%). Only three countries established sex-disaggregated indicators and only one country had set a target for cataract surgical coverage for future monitoring. Countries almost universally recognized the need to strengthen health information systems and almost one-third planned to undertake operational or intervention research. Realistic strategies need to be identified and supported to translate these intentions into action. To gain insights into how a country can strengthen its evidence-informed approach to eye-care planning, we reflect on the process underway to develop Kenya's seventh national plan (2019-2023).

De nombreux pays à revenu faible et intermédiaire ont recours à des plans nationaux de santé oculaire pour guider les actions visant à renforcer les services d'ophtalmologie. L'Organisation mondiale de la Santé reconnaît qu'il est essentiel de disposer de données factuelles pour orienter ces plans. Nous avons évalué la manière dont ces données factuelles ont été intégrées à un échantillon de 28 plans nationaux de santé oculaire, élaborés depuis l'adoption par l'Assemblée Mondiale de la Santé, en 2013, du document Santé oculaire universelle: plan d'action mondial 2014­2019. La plupart des pays (26, soit 93%) ont indiqué utiliser des estimations de la prévalence de la cécité et 18 pays (64%) avaient fixé des objectifs relatifs au taux de chirurgie de la cataracte dans leur plan. D'autres types de données factuelles ont rarement été mentionnés ou utilisés pour définir des objectifs mesurables. Aucun pays n'a mentionné de données issues de revues systématiques ou de recherches fondées sur des solutions. Cette utilisation limitée des données factuelles reflète leur faible accessibilité, mais aussi l'usage incomplet des données existantes. Par exemple, bien que des enquêtes menées dans 20 pays (71%) donnent accès à des données ventilées par sexe et au taux de couverture de la chirurgie de la cataracte, seuls neuf pays (32%) ont reporté ces données dans leur plan de santé oculaire. Seuls trois pays ont mis en place des indicateurs ventilés par sexe et un seul a défini un objectif de couverture de la chirurgie de la cataracte pour en suivre l'évolution. La quasi-totalité des pays a reconnu qu'il était nécessaire de renforcer les systèmes d'information sanitaire et près d'un tiers prévoyait d'entreprendre des recherches opérationnelles ou interventionnelles. Il faudra définir et mettre en œuvre des stratégies réalistes pour passer de l'intention à l'action. Pour en savoir plus sur la manière dont un pays peut renforcer son approche d'élaboration de plans de santé oculaire à partir de données factuelles, nous nous intéressons à l'élaboration, en cours, du septième plan national du Kenya (2019­2023).

Muchos países con ingresos entre bajos y medios utilizan planes nacionales de atención oftalmológica para orientar los esfuerzos a fortalecer los servicios de atención oftalmológica. La Organización Mundial de la Salud reconoce que las pruebas son esenciales para informar a estos planes. Se evaluó cómo se incorporaron las pruebas en una muestra de 28 planes nacionales de atención oftalmológica generados desde que la Asamblea Mundial de la Salud aprobó Universal eye health: a global action plan 2014­2019 (Atención oftalmológica universal: un plan de acción mundial para 2014-2019) en 2013. La mayoría de los países (26, 93 %) citaron estimaciones de la prevalencia de la ceguera y 18 países (64 %) habían establecido metas para la tasa quirúrgica de cataratas en sus planes. Rara vez se citaron o utilizaron otras pruebas para establecer objetivos mensurables. Ningún país citó pruebas de revisiones sistemáticas o investigaciones basadas en soluciones. Este uso limitado de las pruebas refleja su baja disponibilidad, pero también destaca el uso incompleto de las pruebas existentes. Por ejemplo, a pesar de que los datos desglosados por sexo y la cobertura quirúrgica de cataratas están disponibles en las encuestas de 20 países (71 %), estos datos solo se reflejaron en los planes de atención oftalmológica de nueve países (32 %). Solo tres países establecieron indicadores desglosados por sexo y solo un país había establecido una meta para la cobertura quirúrgica de cataratas para el seguimiento futuro. Los países reconocieron casi universalmente la necesidad de fortalecer los sistemas de información sanitaria y casi un tercio tenía previsto realizar investigaciones operacionales o de intervención. Es necesario identificar y apoyar estrategias realistas para convertir estas intenciones en acciones. Para comprender mejor cómo un país puede fortalecer su enfoque basado en pruebas para la planificación de la atención oftalmológica, se ha analizado el proceso en curso para desarrollar el séptimo plan nacional en Kenia (2019-2023).

Effectiveness of peer support to increase uptake of retinal examination for diabetic retinopathy: study protocol for the DURE pragmatic cluster randomized clinical trial in Kirinyaga, Kenya.

BACKGROUND: All patients with diabetes are at risk of developing diabetic retinopathy (DR), a progressive and potentially blinding condition. Early treatment of DR prevents visual impairment and blindness. The natural history of DR is that it is asymptomatic until the advanced stages, thus annual retinal examination is recommended for early detection. Previous studies show that the uptake of regular retinal examination among people living with diabetes (PLWD) is low. In the Uptake of Retinal Examination in Diabetes (DURE) study, we will investigate the effectiveness of a complex intervention delivered within diabetes support groups to increase uptake of retinal examination. METHODS: The DURE study will be a two-arm pragmatic cluster randomized clinical trial in Kirinyaga County, Kenya. Diabetes support groups will be randomly assigned to either the intervention or usual care conditions in a 1:1 ratio. The participants will be 700 PLWD who are members of support groups in Kirinyaga. To reduce contamination, the unit of randomization will be the support group. Peer supporters in the intervention arm will receive training to deliver the intervention. The intervention will include monthly group education on DR and individual member reminders to take the eye examination. The effectiveness of this intervention plus usual care will be compared to usual care practices alone. Participant data will be collected at baseline. The primary outcome is the proportion of PLWD who take up the eye examination at six months. Secondary outcomes include the characteristics of participants and peer supporters associated with uptake of eye examination for DR. Intention-to-treat analysis will be used to evaluate the primary and secondary outcomes. DISCUSSION: Eye care programs need evidence of the effectiveness of peer supporter-led health education to improve attendance to retinal screening for the early detection of DR in an African setting. Given that the intervention combines standardization and flexibility, it has the potential to be adopted in other settings and to inform policies to promote DR screening. TRIAL REGISTRATION: Pan African Clinical Trial Registry PACTR201707002430195 , registered 25 July 2017, www.pactr.org.

Analysis of an international collaboration for capacity building of human resources for eye care: case study of the college-college VISION 2020 LINK.

BACKGROUND: There is an extreme health workforce shortage in Eastern, Central, and Southern Africa. Shortage of eye care workers impedes effective implementation of prevention of blindness programs. The World Health Organization has identified education, partnership, leadership, financing, and policy as intertwined interventions that are critical to resolving this crisis on the long term. CASE PRESENTATION: The VISION 2020 LINK between the College of Ophthalmology of Eastern, Central, and Southern Africa and the Royal College of Ophthalmologists in the United Kingdom aims to increase the quantity and quality of eye care training in East, Central, and Southern Africa through a focus on five strategic areas: fellowship examination for ophthalmologists, training the trainers, curriculum development for residents in ophthalmology and ophthalmic clinical officers, continuous professional development (CPD), and mentoring program for young ophthalmologists. This study examined how education and partnership can be linked to improve eye care, through an evaluation of this north-south link based on its own targets and established frameworks to guide north-south links. METHODS: An exploratory qualitative case study design was used. Twenty-nine link representatives were recruited through purposive sampling and snowballing. Face-to-face interviews were conducted using a semi-structured interview schedule that incorporated the components of a successful link from an existing framework. Documents pertaining to the link were also examined. Thematic analysis was used for data analysis. RESULTS: The findings revealed that the perception to the contribution of the link to eye care in the region is generally positive. Process indicators showed that the targets in three strategic objectives of the link have been achieved. Framework-based evaluation also showed that the link is successful. Mutual learning and development of friendships were the most commonly identified success factors. Inadequate awareness of the link by college members is a key challenge. CONCLUSION: The study concludes that the link is active and evolving and has achieved most of its targets. Further developments should be directed to influence health system strengthening in Eastern, Central, and Southern Africa more strategically. The study recommends expansion of the scope of collaboration to involve multiple health system building blocks.

Eye Health Integration in Southern and Eastern Africa: A Scoping Review.

Integrated health systems are deemed necessary for the attainment of universal health coverage, and the East, Central, and Southern Africa Health Community (ECSA-HC) recently passed a resolution to endorse the integration of eye health into the wider health system. This review presents the current state of integration of eye health systems in the region. Eight hundred and twelve articles between 1946 and 2020 were identified from four electronic databases that were searched. Article selection and data charting were done by two reviewers independently. Thirty articles met the eligibility criteria and were included in the narrative synthesis. Majority were observational studies (60%) and from Tanzania (43%). No explicit definition of integration was found. Eye health was prioritized at national level in some countries but failed to cascade to the lower levels. Eye health system integration was commonly viewed in terms of service delivery and was targeted at the primary level. Eye care data documentation was inadequate. Workforce integration efforts were focused on training general health-care cadres and communities to create a multidisciplinary team but with some concerns on quality of services. Government funding for eye care was limited. The findings show eye health system integration in the ECSA-HC region has been in progress for about four decades and is focused on the inclusion of eye health services into other health-care programs. Integration of comprehensive eye care into all the health system building blocks, particularly financial integration, needs to be given greater emphasis in the ECSA-HC.

Travel time to cataract surgical services in Kenya, Malawi and Rwanda: demonstrating a standardised indicator of physical access to cataract surgery.

BACKGROUND: Travel time can be used to assess health services accessibility by reflecting the proximity of services to the people they serve. We aimed to demonstrate an indicator of physical access to cataract surgery and identify subnational locations where people were more at risk of not accessing cataract surgery. METHODS: We used an open-access inventory of public health facilities plus key informants in Kenya, Malawi and Rwanda to compile a geocoded inventory of cataract facilities. For each country, gridded estimates of the population aged ≥ 50 years and a travel-time friction surface were combined and a least-cost-path algorithm applied to estimate the shortest travel time between each grid and the nearest cataract facility. We categorised continuous travel time by 1-, 2- and 3 h thresholds and calculated the proportion of the population in each category. RESULTS: At the national level, the proportion of the population aged ≥ 50 years within 2 h travel time to permanent cataract surgical services was 97.2% in Rwanda (n = 10 facilities), 93.5% in Kenya (n = 74 facilities) and 92.0% in Malawi (n = 6 facilities); this reduced to 77.5%, 84.1% and 52.4% within 1 h, respectively. The least densely populated subnational regions had the poorest access to cataract facilities in Malawi (0.0%) and Kenya (1.9%). CONCLUSION: We demonstrated an indicator of access that reflects the distribution of the population at risk of age-related cataract and identifies regions that could benefit from more accessible services. This indicator provides additional demand-side context for eye health planning and supports WHO's goal of advancing integrated people-centred eye care.

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.

International collaboration for the development of clinical guidelines in low and middle-income countries: case study on the development of a national framework and clinical guidelines for diabetic retinopathy in Ghana.

BACKGROUND: Diabetic retinopathy is a leading cause of blindness in many countries across the world. Ghana has seen a rise in diabetic retinopathy and is working on various strategies to prevent blindness. Clinical guidelines are seen as a promising strategy for improving quality and reducing cost of care. Little is known about the processes of collaborative guideline development in the African context. METHODS: This case study discusses the process of developing clinical guidelines for diabetic retinopathy in Ghana via a collaboration with the Kenya team that had previously developed guidelines for Kenya. RESULTS: The main lesson learnt was the ability to overcome challenges. The main output achieved was the draft national framework, guidelines and training slides on the guidelines. CONCLUSION: Horizontal international collaboration can aid development of clinical guidelines.

Advancing the Sustainable Development Goals through improving eye health: a scoping review.

UN member states have committed to achieving the Sustainable Development Goals (SDGs) by 2030. This Review examines the published evidence on how improving eye health can contribute to advancing the SDGs (beyond SDG 3). We identified 29 studies that showed direct benefits from providing eye health services on SDGs related to one or more of poverty (SDGs 1, 2, and 8), education (SDG 4), equality (SDGs 5 and 10), and sustainable cities (SDG 11). The eye health services included cataract surgery, free cataract screening, provision of spectacles, trichiasis surgery, rehabilitation services, and rural community eye health volunteers. These findings provide a comprehensive perspective on the direct links between eye health services and advancing the SDGs. In addition, eye health services likely have indirect effects on multiple SDGs, mediated through one of the direct effects. Finally, there are additional plausible links to other SDGs, for which evidence has not yet been established.

Grand Challenges in global eye health: a global prioritisation process using Delphi method.

BACKGROUND: We undertook a Grand Challenges in Global Eye Health prioritisation exercise to identify the key issues that must be addressed to improve eye health in the context of an ageing population, to eliminate persistent inequities in health-care access, and to mitigate widespread resource limitations. METHODS: Drawing on methods used in previous Grand Challenges studies, we used a multi-step recruitment strategy to assemble a diverse panel of individuals from a range of disciplines relevant to global eye health from all regions globally to participate in a three-round, online, Delphi-like, prioritisation process to nominate and rank challenges in global eye health. Through this process, we developed both global and regional priority lists. FINDINGS: Between Sept 1 and Dec 12, 2019, 470 individuals complete round 1 of the process, of whom 336 completed all three rounds (round 2 between Feb 26 and March 18, 2020, and round 3 between April 2 and April 25, 2020) 156 (46%) of 336 were women, 180 (54%) were men. The proportion of participants who worked in each region ranged from 104 (31%) in sub-Saharan Africa to 21 (6%) in central Europe, eastern Europe, and in central Asia. Of 85 unique challenges identified after round 1, 16 challenges were prioritised at the global level; six focused on detection and treatment of conditions (cataract, refractive error, glaucoma, diabetic retinopathy, services for children and screening for early detection), two focused on addressing shortages in human resource capacity, five on other health service and policy factors (including strengthening policies, integration, health information systems, and budget allocation), and three on improving access to care and promoting equity. INTERPRETATION: This list of Grand Challenges serves as a starting point for immediate action by funders to guide investment in research and innovation in eye health. It challenges researchers, clinicians, and policy makers to build collaborations to address specific challenges. FUNDING: The Queen Elizabeth Diamond Jubilee Trust, Moorfields Eye Charity, National Institute for Health Research Moorfields Biomedical Research Centre, Wellcome Trust, Sightsavers, The Fred Hollows Foundation, The Seva Foundation, British Council for the Prevention of Blindness, and Christian Blind Mission. TRANSLATIONS: For the French, Spanish, Chinese, Portuguese, Arabic and Persian translations of the abstract see Supplementary Materials section.

Effectiveness of task-shifting for the detection of diabetic retinopathy in low- and middle-income countries: a rapid review protocol.

BACKGROUND: Diabetic retinopathy is the most common ocular complication of diabetes and a cause of vision loss in adults. Diabetic retinopathy screening leading to early identification of the disease followed by timely treatment, can prevent vision loss in people living with diabetes. A key barrier to the implementation of screening services in low- and middle-income countries is the low number of ophthalmologists per million population. Interventions that shift screening to non-ophthalmology cadres have been implemented in programmes in low- and middle-income countries and are routinely used in high-income countries. The aim of this rapid review is to summarise the published literature reporting the effectiveness of task-shifting interventions for the detection of diabetic retinopathy by non-ophthalmologists in low- and middle-income countries. METHODS: We will search MEDLINE, Embase, Global Health and Cochrane Register of Studies for studies reporting task-shifting interventions for diabetic retinopathy detection. The review will include studies published in the last 10 years in the English language. We will include any interventional or observational comparative study measuring outcomes in terms of participation or access to diabetic retinopathy detection services (uptake) and quality of diabetic retinopathy detection services (detection, severity, diagnostic accuracy). For included studies, cost-effectiveness of the task-shifting intervention will also be presented. Two reviewers will screen search results independently. The risk of bias assessment and data extraction will be carried out by one reviewer with verification of 10% of the papers by a second reviewer. The results will be synthesised narratively. DISCUSSION: Differences in health systems organization, structure and resources will determine the need and success of task-shifting interventions for DR screening. The review will examine how these interventions have been used and/or tested in LMICs. The results will be of interest to policy makers and programme managers tasked with designing and implementing services to prevent and manage diabetes and its complications in similar settings. SYSTEMATIC REVIEW REGISTRATION: OSF: https://osf.io/dfhg6/ .

Effectiveness of interventions to increase uptake and completion of treatment for diabetic retinopathy in low- and middle-income countries: a rapid review protocol.

BACKGROUND: Vision loss due to diabetic retinopathy can largely be prevented or delayed through treatment. Patients with vision-threatening diabetic retinopathy are typically offered laser or intravitreal injections which often require more than one treatment cycle. However, treatment is not always initiated, or it is not completed, resulting in poor visual outcomes. Interventions aimed at improving the uptake or completion of treatment for diabetic retinopathy can potentially help prevent or delay visual loss in people with diabetes. METHODS: We will search MEDLINE, Embase, Global Health and Cochrane Register of Studies for studies reporting interventions to improve the uptake of treatment for diabetic retinopathy (DR) and/or diabetic macular oedema (DMO), compared with usual care, in adults with diabetes. The review will include studies published in the last 20 years in the English language. We will include any study design that measured any of the following outcomes in relation to treatment uptake and completion for DR and/or DMO: (1) proportion of patients initiating treatment for DR and/or DMO among those to whom it is recommended, (2) proportion of patients completing treatment for DR and/or DMO among those to whom it is recommended, (3) proportion of patients completing treatment for DR and/or DMO among those initiating treatment and (4) number and proportion of DR and/or DMO rounds of treatment completed per patient, as dictated by the treatment protocol. For included studies, we will also report any measures of cost-effectiveness when available. Two reviewers will screen search results independently. Risk of bias assessment will be done by two reviewers, and data extraction will be done by one reviewer with verification of 10% of the papers by a second reviewer. The results will be synthesised narratively. DISCUSSION: This rapid review aims to identify and synthesise the peer-reviewed literature on the effectiveness of interventions to increase uptake and completion of treatment for DR and/or DMO in LMICs. The rapid review methodology was chosen in order to rapidly synthesise the available evidence to support programme implementers and policy-makers in designing evidence-based health programmes and public health policy and inform the allocation of resources. SYSTEMATIC REVIEW REGISTRATION: OSF osf.io/h5wgr.