Complex interventions to implement a diabetic retinopathy care pathway in the public health system in Kerala: the Nayanamritham study protocol

Introduction: Using a type 2 hybrid effectiveness-implementation design, we aim to pilot a diabetic retinopathy (DR) care pathway in the public health system in Kerala to understand how it can be scaled up to and sustained in the whole state. Methods and analysis: Currently, there is no systematic DR screening programme in Kerala. Our intervention is a teleophthalmology pathway for people with diabetes in the non-communicable disease registers in 16 family health centres. The planned implementation strategy of the pathway will be developed based on the discrete Expert Recommendations for Implementing Change taxonomy. We will use both quantitative data from a cross-sectional study and qualitative data obtained from structured interviews, surveys and group discussions with stakeholders to report the effectiveness of the DR care pathway and evaluation of the implementation strategy. We will use logistic regression models to assess crude associations DR and sight-threatening diabetic retinopathy and fractional polynomials to account for the form of continuous covariates to predict uptake of DR screening. The primary effectiveness outcome is the proportion of patients in the non-communicable disease register with diabetes screened for DR over 12 months. Other outcomes include cost-effectiveness, safety, efficiency, patient satisfaction, timeliness and equity. The outcomes of evaluation of the implementation strategies include acceptability, feasibility, adoption, appropriateness, fidelity, penetration, costs and sustainability. Addition of more family health centres during the staggered initial phase of the programme will be considered as a sign of acceptability and feasibility. In the long term, the state-wide adoption of the DR care pathway will be considered as a successful outcome of the Nayanamritham study. Ethics and dissemination: The study was approved by Indian Medical Research Council (2018-0551) dated 13 March 2019. Study findings will be disseminated through scientific publications and the report will inform adoption of the DR care pathway by Kerala state in future

Health and social exclusion in older age: evidence from Understanding Society, the UK household longitudinal study

Background Social exclusion of the elderly is a key policy focus but evidence on the processes linking health and social exclusion is hampered by the variety of ways that health is used in social exclusion research. We investigated longitudinal associations between health and social exclusion using an analytical framework that did not conflate them. Methods Data employed in this study came from 4 waves of Understanding Society, the UK Household Longitudinal Study 2009–2013. The sample comprised all adults who took part in all 4 waves, were 65 years or more in Wave 3, and had complete data on our variables of interest for each analysis. We used linear regression to model the relationship between Wave 2/3 social exclusion and Wave1–2 health transitions (N=4312) and logistic regression to model the relationship between Wave2/3 social exclusion and Wave 4 health states, conditional on Wave 3 health (N=4244). Results There was a dose–response relationship between poor health in Waves 1 and 2 and later social exclusion. Use of a car, mobile phone and the internet moderated the association between poor health and social exclusion. Given the health status in Wave 3, those who were more socially excluded had poorer outcomes on each of the three domains of health in Wave 4. Conclusions Use of the internet and technology protected older adults in poor health from social exclusion. Age-friendly hardware and software design might have public health benefits

Allergen immunotherapy for allergic rhinoconjunctivitis : a systematic review and meta-analysis

BACKGROUND: The European Academy of Allergy and Clinical Immunology (EAACI) is in the process of developing Guidelines on Allergen Immunotherapy (AIT) for Allergic Rhinoconjunctivitis. In order to inform the development of clinical recommendations, we undertook a systematic review to assess the effectiveness, cost-effectiveness and safety of AIT in the management of allergic rhinoconjunctivitis METHODS: We searched 15 international biomedical databases for published, in progress and unpublished evidence. Studies were independently screened by two reviewers against pre-defined eligibility criteria and critically appraised using established instruments. Our primary outcomes of interest were symptom, medication and combined symptom and medication scores. Secondary outcomes of interest included cost-effectiveness and safety. Data were descriptively summarized and then quantitatively synthesized using random-effects meta-analyses. RESULTS: We identified 5932 studies of which 160 studies satisfied our eligibility criteria. There was a substantial body of evidence demonstrating significant reductions in standardized mean differences (SMD) of symptom (SMD -0.53, 95%CI -0.63, -0.42), medication (SMD -0.37, 95%CI -0.49, -0.26) and combined symptom and medication (SMD -0.49, 95%CI -0.69, -0.30) scores whilst on treatment that were robust to pre-specified sensitivity analyses. There was in comparison a more modest body of evidence on effectiveness post-discontinuation of AIT, this suggesting a benefit in relation to symptom scores. CONCLUSIONS: AIT is effective in improving symptom, medication and combined symptom and medication scores in patients with allergic rhinoconjunctivitis whilst on treatment, and there is some evidence suggesting that these benefits are maintained in relation to symptom scores after discontinuation of therapy. This article is protected by copyright. All rights reserved

Experience of income inequality over the life-course and health in early old age

Background and aims: The inequality hypothesis states that area-level income inequality causes a change in the psychosocial environment which is consequently detrimental for people’s health. Previous studies in this area have provided mixed support for this hypothesis, particularly among older people. However, the majority of previous studies have failed to adequately account for people’s past experience of inequality over the course of their lives. This project aimed to address this gap in the literature by determining whether and how older people’s past exposure to inequality was related to their subsequent health. Hypotheses: Based on the previous literature, the primary hypotheses of this project were a) that experiencing higher levels of inequality over the life-course should be related to worse subsequent health, b) that inequality experienced during any stage of the life-course should be detrimental for later health, c) that this effect should be mediated by other individual and country-level factors and d) that experience of inequality should be detrimental for health in multiple domains. Data and methods: The project utilised data on the health and circumstances of older people from three large surveys, covering over 60,000 people in 16 countries. Current health was assessed in relation to a) accumulated experience of inequality and b) experience of inequality during three specific periods of the life-course. These associations were tested separately for nine health outcomes, including both subjective and objective measures. Results: The project results demonstrated a significant and robust negative association between life-course experience of inequality and older people’s subsequent physical health, as indicated by objectively measured grip strength and peak flow rate. However, this association was not found for the other seven study outcomes. The project also found only mixed evidence that the associations between inequality and the objectively measured outcomes were mediated by the hypothesised individual and country-level factors.EThOS - Electronic Theses Online ServiceGBUnited Kingdo

Burden of Diabetic Retinopathy amongst People with Diabetes Attending Primary Care in Kerala: Nayanamritham Project

Background: The burden of diabetic retinopathy (DR) in people attending the public health sector in India is unclear. Thirty percent of the population in India is reliant on public healthcare. This study aimed to estimate the prevalence of DR and its risk factors in people with diabetes in the non-communicable disease registers who were attending the family health centres (FHCs) in the Thiruvananthapuram district in Kerala. Methods: This cross-sectional study was conducted over 12 months in 2019 within the framework of a pilot district-wide teleophthalmology DR screening programme. The age- and gender-adjusted prevalence of any DR and sight-threatening DR (STDR) in the whole sample, considering socio-demography, lifestyle and known clinical risk groups, are reported. Results: A total of 4527 out of 5307 (85.3%) screened in the FHCs had gradable retinal images in at least one eye. The age and gender standardised prevalence for any DR was 17.4% (95% CI 15.1, 19.7), and STDR was 3.3% (95% CI 2.1, 4.5). Ages 41–70 years, males, longer diabetes duration, hyperglycaemia and hypertension, insulin users and lower socio-economic status were associated with both DR outcomes. Conclusions: The burden of DR and its risk factors in this study highlights the need to implement DR screening programs within primary care to reduce health inequality

Promoting recruitment of minority ethnic groups into research: qualitative study exploring the views of South Asian people with asthma

Background We sought to understand the barriers and facilitators to participation in research from the perspectives of South Asian people with asthma. Methods Eight focus groups were conducted in the preferred language of participants. Sampling was purposeful to ensure inclusion of males and females from differing ethnic, linguistic and religious backgrounds. Results The forming of trusting relationships was described as pivotal to the successful recruitment of minority ethnic groups into research; personalized approaches were likely to be better received than more impersonal written approaches. Notable barriers to participation included: the stigma of being labelled with asthma; concerns surrounding participation in pharmaceutical trials; major time or travel commitments and a failure to show respect by not making information available in minority ethnic languages. Flexibility, in terms of timing, location and respecting of cultural and religious sensitivities around gender segregation, together with the offer of incentives, were highlighted as key factors to promote participation. Conclusions The barriers to recruitment are largely surmountable, but these will necessitate the use of resource intensive and more personalized approaches than are commonly employed for the White European origin population. Our proposed model to enhance recruitment is likely to have transferability beyond the field of asthm

Estimating the costs of blindness and moderate to severe visual impairment among people with diabetes in India

Objectives This study provides an estimate of the annual cost of blindness and moderate to severe visual impairment (MSVI) among people with diabetes aged 40 years and above in India in the year 2019.Design A cost of illness study.Setting India.Participants People with diabetes aged 40 years and above in India in the year 2019.Primary and secondary outcome measures Estimates are provided for the total costs of screening for most common vision-threatening eye conditions, treatment of these conditions, economic activity lost by these people and their family carers whose ability to work is affected, and loss of quality of life experienced by people with diabetes and blindness or MSVI.Results It is estimated that for people with diabetes aged 40 years or above, annual screening followed by eye examination where required would cost around 42.3 billion Indian rupees (INR) (4230 crores) per year; treating sight problems around 2.87 billion INR (287 crores) per year if 20% of those needing treatment receive it; and lost economic activity around 472 billion INR (47 200 crores). Moreover, 2.86 million (0.286 crores) quality-adjusted life years (QALYs) are lost annually due to blindness and MSVI. The estimate of lost production is highly sensitive to the proportion of people with MSVI able to work and how their output compares with that of a person with no visual impairment.Conclusions This is the first study to estimate the cost of blindness and MSVI for people aged 40 years and over with diabetes in India. The annual cost to the Indian economy is substantial. This cost will be expected to fall if a successful screening and treatment plan is introduced in India. Further work is suggested using more robust data, when available, to estimate the loss of productivity and loss of QALYs, as this would be worthwhile