Evidence for integrating eye health into primary health care in Africa: a health systems strengthening approach

BACKGROUND: The impact of unmet eye care needs in sub-Saharan Africa is compounded by barriers to accessing eye care, limited engagement with communities, a shortage of appropriately skilled health personnel, and inadequate support from health systems. The renewed focus on primary health care has led to support for greater integration of eye health into national health systems. The aim of this paper is to demonstrate available evidence of integration of eye health into primary health care in sub-Saharan Africa from a health systems strengthening perspective. METHODS: A scoping review method was used to gather and assess information from published literature, reviews, WHO policy documents and examples of eye and health care interventions in sub-Saharan Africa. Findings were compiled using a health systems strengthening framework. RESULTS: Limited information is available about eye health from a health systems strengthening approach. Particular components of the health systems framework lacking evidence are service delivery, equipment and supplies, financing, leadership and governance. There is some information to support interventions to strengthen human resources at all levels, partnerships and community participation; but little evidence showing their successful application to improve quality of care and access to comprehensive eye health services at the primary health level, and referral to other levels for specialist eye care. CONCLUSION: Evidence of integration of eye health into primary health care is currently weak, particularly when applying a health systems framework. A realignment of eye health in the primary health care agenda will require context specific planning and a holistic approach, with careful attention to each of the health system components and to the public health system as a whole. Documentation and evaluation of existing projects are required, as are pilot projects of systematic approaches to interventions and application of best practices. Multi-national research may provide guidance about how to scale up eye health interventions that are integrated into primary health systems

Setting targets for human resources for eye health in sub-Saharan Africa: what evidence should be used?

With a global target set at reducing vision loss by 25% by the year 2019, sub-Saharan Africa with an estimated 4.8 million blind persons will require human resources for eye health (HReH) that need to be available, appropriately skilled, supported, and productive. Targets for HReH are useful for planning, monitoring, and resource mobilization, but they need to be updated and informed by evidence of effectiveness and efficiency. Supporting evidence should take into consideration (1) ever-changing disease-specific issues including the epidemiology, the complexity of diagnosis and treatment, and the technology needed for diagnosis and treatment of each condition; (2) the changing demands for vision-related services of an increasingly urbanized population; and (3) interconnected health system issues that affect productivity and quality. The existing targets for HReH and some of the existing strategies such as task shifting of cataract surgery and trichiasis surgery, as well as the scope of eye care interventions for primary eye care workers, will need to be re-evaluated and re-defined against such evidence or supported by new evidence

What Will Happen If We Do Nothing To Control Trachoma: Health Expectancies for Blinding Trachoma in Southern Sudan

Summary measures of population health attempt to express disease burden in terms of a common “currency” and are useful in establishing public health priorities. Disability adjusted life years (DALYs), a health gap measure, have previously been used to estimate burden due to trachoma; however, their methods and results have limitations. This study demonstrates the application of the health expectancies to estimate burden due to trachoma. The study illustrates the future burden associated with doing nothing to control trachoma in Southern Sudan: a substantial proportion of remaining life expectancy spent with trichiasis and low vision or blindness for both men and women, with a disproportionate burden falling on women. The results presented are intuitively meaningful for policy makers and a non-technical audience and compare favourably with other indicators such as mortality and incidence rates or DALYs, which are not generally easily understood. Unless action is taken by further delivery of trachoma control interventions, then populations in Southern Sudan can expect to spend a substantial proportion of their life with low vision or blindness due to trachoma

The Burden of Trachoma in Ayod County of Southern Sudan

Trachoma, a neglected tropical disease, is the leading cause of infectious blindness and is targeted for global elimination by the year 2020. We conducted a survey in Ayod County of Jonglei State, Southern Sudan, to determine whether blinding trachoma was a public health problem and to plan interventions to control this disease. We found the burden of trachoma in Ayod to be one of the most severe ever documented. Not only were adults affected by the advanced manifestations of the disease as is typical for older age groups, but young children were also affected. At least one person with clinical signs of trachoma was found in nearly every household, and 1 in 3 households had a person with severe blinding trachoma. Characteristics previously identified as risk factors were ubiquitous among surveyed households, but we were unable to identify why trachoma is so severe in this location. Surgical interventions are needed urgently to improve vision and prevent irreversible blindness in children and adults. Mass antibiotic distribution may alleviate current infections and transmission of trachoma may be reduced if communities adopt the behavior of face washing and safe disposal of human waste. Increasing access to improved water sources may not only improve hygiene but also reduce the spread of guinea worm and other water-borne diseases

Surgery versus epilation for the treatment of minor trichiasis in Ethiopia: a randomised controlled noninferiority trial.

Trachomatous trichiasis can cause corneal damage and visual impairment. WHO recommends surgery for all cases. However, in many regions surgical provision is inadequate and patients frequently decline. Self-epilation is common and was associated with comparable outcomes to surgery in nonrandomised studies for minor trichiasis (<six lashes touching eye). This trial investigated whether epilation is noninferior to surgery for managing minor trichiasis

Risk Factors for Ocular Chlamydia after Three Mass Azithromycin Distributions

Trachoma, which is the leading infectious cause of blindness worldwide, is caused by repeated ocular infection with Chlamydia trachomatis. Treatment for trachoma includes mass azithromycin treatments to the entire community. The World Health Organization recommends at least 3 rounds of annual mass antibiotic distributions in areas with trachoma, with further mass treatments based on the prevalence of trachoma. However, there are other options for communities that have received several rounds of treatment. For example, programs could continue antibiotic treatments only in those households most likely to have infected individuals. In this study, we performed trachoma monitoring on children from 12 Ethiopian communities one year after a third mass azithromycin treatment, and conducted a household survey at the same time. We found that children were more likely to be infected with ocular chlamydia if they had ocular inflammatory signs or ocular discharge, or if they had missed the preceding antibiotic treatment, had an infected sibling, or came from a larger community. These risk factors suggest that after mass azithromycin treatments, trachoma programs could consider continuing antibiotic distributions to households that have missed prior antibiotic distributions, in households with children who have the clinical signs of trachoma, and in larger communities

Tropical Data: Approach and Methodology as Applied to Trachoma Prevalence Surveys

PURPOSE: Population-based prevalence surveys are essential for decision-making on interventions to achieve trachoma elimination as a public health problem. This paper outlines the methodologies of Tropical Data, which supports work to undertake those surveys. METHODS: Tropical Data is a consortium of partners that supports health ministries worldwide to conduct globally standardised prevalence surveys that conform to World Health Organization recommendations. Founding principles are health ministry ownership, partnership and collaboration, and quality assurance and quality control at every step of the survey process. Support covers survey planning, survey design, training, electronic data collection and fieldwork, and data management, analysis and dissemination. Methods are adapted to meet local context and needs. Customisations, operational research and integration of other diseases into routine trachoma surveys have also been supported. RESULTS: Between 29th February 2016 and 24th April 2023, 3373 trachoma surveys across 50 countries have been supported, resulting in 10,818,502 people being examined for trachoma. CONCLUSION: This health ministry-led, standardised approach, with support from the start to the end of the survey process, has helped all trachoma elimination stakeholders to know where interventions are needed, where interventions can be stopped, and when elimination as a public health problem has been achieved. Flexibility to meet specific country contexts, adaptation to changes in global guidance and adjustments in response to user feedback have facilitated innovation in evidence-based methodologies, and supported health ministries to strive for global disease control targets

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/