Public health system integration of avoidable blindness screening and management, India.

In India, 73 million people have diabetes and 3.5 million infants are born preterm. Without timely screening, there is a risk of visual loss due to diabetic retinopathy and retinopathy of prematurity in these two groups, respectively. Both conditions are emerging causes of visual impairment in India but there is no public health programme for screening or management. Pilot projects were initiated in 2014 to integrate the screening and management of these conditions into existing public health systems, particularly in rural communities and their referral networks. The World Health Organization's health systems framework was used to develop the projects and strategies were developed with all stakeholders, including the government. Both projects involved hub-and-spoke models of care units around medical schools. For diabetic retinopathy, screening was established at primary health-care facilities and treatment was provided at district hospitals. For retinopathy of prematurity, screening was integrated into sick newborn care units at the district level and treatment facilities were improved at the closest publically funded medical schools. In the first two years, there were substantial improvements in awareness, screening, treatment and partnership between stakeholders, and changes in public health policy. By March 2018, diabetic retinopathy screening was established at 50 facilities in 10 states and treatment had been improved at 10 hospitals, whereas retinopathy of prematurity screening was established at 16 sick newborn care units in district hospital in four states and treatment had been improved at six medical schools. Advocacy within state governments was critical to the success of the initiative

Establishing peer support groups for diabetic retinopathy in India: Lessons learned and way ahead.

Purpose: Complications of diabetes mellitus (DM) are a public health problem globally. DM management entails medication and self-management. Peer support groups (PSGs) can improve self-management and promote healthy behavior. The objectives of this study were to design, establish, and evaluate two PSG models for people who had been screened for diabetic retinopathy to assess self-reported lifestyle changes, satisfaction with meetings and barriers to attendance. Methods: Peer groups were established using a pre-tested facilitator's guide in 11 locations in 3 states. Group members were oriented on diabetes management and lifestyle changes to improve control. Attendees' experiences were ascertained through semi-structured interviews and self-report. Data were analyzed using MS Excel 2017. Results: Eleven PSGs were established in 3 states, in 10 community health centers and one eye hospital. 53 sessions were held and 195 people attended on 740 occasions. Lifestyle changes most frequently reported between first and second visits were taking medication regularly and dietary modification. Attendance declined in the eye hospital group. 83% of CHCs members were satisfied or very satisfied compared with 37% of eye hospital (EH) members. The barriers included distance and lack of family support. Conclusion: PSGs held in CHCs were more sustainable than those in an eye hospital, and group members were more satisfied and more likely to report positive lifestyle changes. Findings were self-reported and hence a major limitation for the study. Further studies should focus on obtaining objective measures of control of diabetes and risk factors for diabetic retinopathy from members attending peer support groups in CHCs

Overview and project highlights of an initiative to integrate diabetic retinopathy screening and management in the public health system in India.

Purpose: Diabetes is a public health concern in India and diabetic retinopathy (DR) is an emerging cause of visual impairment and blindness. Approximately 3.35-4.55 million people with diabetes mellitus (PwDM) are at risk of vision-threatening DR (VTDR) in India. More than 2/3 of India's population resides in rural areas where penetration of modern medicine is mostly limited to the government public health system. Despite the increasing magnitude, there is no systematic screening for the complications of diabetes, including DR in the public health system. Therefore, a pilot project was initiated with the major objectives of management of DR at all levels of the government health system, initiating a comprehensive program for the detection of eye complications among PwDM at public health noncommunicable disease (NCD) clinics, augmenting the capacity of physicians, ophthalmologists and health support personnel and empowering carers/PwDM to control the risk of DR through increased awareness and self-management. Methods: A national task force (NTF) was constituted to oversee policy formulation and provide strategic direction. 10 districts were identified for implementation across 10 states. Protocols were developed to help implement training and service delivery. Results: Overall, 66,455 PwDM were screened and DR was detected in 16.2% (10,765) while VTDR was detected in 7.5%. 10.1% of those initially screened returned for the next annual assessment. There was a 7-fold increase in the number of PwDM screened and a 7.6-fold increase in the number of PwDM treated between 2016 and 2018. Conclusion: Services for detecting and managing DR can be successfully integrated into the existing public health system

Retinopathy of prematurity: Overview and highlights of an initiative to integrate prevention, screening, and management into the public health system in India.

Purpose: In India, more than 800 special newborn care units (SNCUs) have been established since 2008 in government facilities. More preterm infants are now surviving and blindness from retinopathy of prematurity (ROP) is increasing. The aim of the Queen Elizabeth Diamond Jubilee Trust's initiative (2012-1019) was to improve the quality of neonatal care and integrate ROP services into the government health system using expertise in the government and nongovernment sector in four states in a sustainable and scalable manner. Methods: State Ministries of Health were engaged and collaboration was established between three government programs (Ministry of Health and Family Welfare, Rashtriya Bal Swasthya Karyakram, and blindness prevention) and relevant professionals. Extensive training took place and equipment was provided. Implementation was guided by a multidisciplinary National Task Force and was monitored by state coordination committees. The Task Force appointed technical expert groups to support implementation through advocacy, information, education and communication materials, operational guidelines, a competency-based training curriculum, and an online database and website. Results: Twenty-two ophthalmologists in government facilities were trained to screen for ROP and nine to treat ROP. Almost 13,500 preterm infants were screened in 17 SNCUs and 86% of the 456 infants with sight-threatening ROP were treated. An educational resource using latest pedagogy based on key domain areas for best practices for small and preterm neonates including ROP has been developed and pilot tested and is being evaluated and scaled up. Conclusion: All four states are scaling up services or have plans to scale up, and several other states have started the initiatives

1800 121 2096 Diabeteshelp - A toll free helpline for people with diabetes.

People with diabetes mellitus require long-term care that is timely, patient-centered, community-based and sustainable. Any deficiency in care increases the risk of developing complications like Diabetic Retinopathy. Patients or their carers also have numerous questions and doubts during this long-period of care. This increases the pressure on health systems that are struggling with a lack of skilled human resources. One option is to provide counseling support using a dedicated helpline. Over the last five years a major initiative to tackle visual impairment due to diabetes was rolled out in India by the Public Health Foundation of India supported by the Queen Elizabeth Diamond Jubilee Trust, UK. One component of the initiative was establishing a toll-free helpline (1800 121 2096) to address the lack of awareness and to empower people with diabetes in Telangana and Andhra Pradesh states in India. Over a 1-year period, the helpline received 4406 calls, making a case for a national service for people with diabetes