Diabetic Retinopathy in Kenya: assessment of services and interventions to improve access

Background

The majority of the estimated 420 million people living with diabetes (PLWD) reside in low and middle income countries. An estimated 35% of PLWD have diabetic retinopathy (DR) and 10% have vision threatening retinopathy requiring urgent treatment. There is high unmet need for DR services in many of these countries, which highlights the need to strengthen health systems. The purpose of this PhD is to provide evidence on the factors and interventions for promoting access and utilisation of services for DR. We focused on Kenya, which has adopted Universal Health Coverage (UHC) as a target for 2030. The specific objectives were to: i) To synthesise the literature on the magnitude, needs and priorities for diabetic retinopathy services.  ii)To conduct an assessment of the health system for PLWD and diabetic retinopathy in Kenya;  iii) To use the evidence from the literature and evidence from the health system assessment as a platform for health system strengthening; and iv) To develop and  test an intervention through a randomized clinical trial  to improve uptake of eye care services for PLWD in Kenya.

Methods

The first objective was achieved through a literature review. For the second objective, a health system assessment for diabetes and DR was conducted, based on the World Health Organization’s framework for health systems building blocks and the tracer condition approach. For the third objective, as part of health system strengthening, national guidelines for DR and a short online course for health care workers were developed. For the fourth objective, using the evidence from the health system assessment, we designed and implemented a two arm (1:1) pragmatic cluster randomized controlled trial to test whether a peer supporter led package of interventions can increase uptake of DR screening among members of diabetes support groups who have never had screening. The primary outcome measure was attendance at DR screening in the 14 clusters and 734 participants followed up over six months.

Results

A review of the literature on the epidemiology and interventions for diabetes and DR, identified that the key roles of health systems in reducing incidence of DR-related blindness are: (1) control of diabetes (2) early detection of DR and (3) appropriate treatment of DR. However, most of the available evidence is from high-income countries. The health system assessment for diabetes and DR in Kenya identified a high unmet need for DR screening, and uptake of screening was the bottleneck to entry to DR services. The main barriers were lack of referral and inadequate knowledge of diabetes eye health. The results of the cluster-randomized trial indicate that the peer-led interventions are acceptable and reach the population most vulnerable to DR. One in two of the participants in the intervention arm compared to one in ten in the control arm attended DR screening. We also found that the most of the effect occurs within the first month of the intervention.

Conclusions

This thesis provides information about how the health systems can be strengthened through the development of national DR guidelines and online training programmes to improve eye services for PLWD. The uptake of DR screening by PLWD can be significantly increased through a community based intervention utilising diabetes support groups and peer supporters, which can lead to earlier diagnosis of DR and the prevention of blindness.

Acknowledgements and funding

Funded by the Queen Elizabeth Diamond Jubilee Trust – through the Commonwealth Eye Health Consortium

Associated materials 

  1. Thesis: ‘Diabetic Retinopathy in Kenya: assessment of services and interventions to improve access’
  2. National guidelines for the screening and management of diabetic retinopathy in Kenya
  3. An online course on control of diabetic retinopathy

Associated publications (full list of publications and if open access link to PDFs)

  1. Mwangi, N., Macleod, D., Gichuhi, S. et al. Predictors of uptake of eye examination in people living with diabetes mellitus in three counties of Kenya. Trop Med Health 45, 41 (2017). https://doi.org/10.1186/s41182-017-0080-7
  2. Mwangi, N., Ng’ang’a, M., Gakuo, E. et al. 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. BMC Public Health 18, 871 (2018). https://doi.org/10.1186/s12889-018-5761-6
  3. Mwangi, N., Bascaran, C., Ng’ang’a, M. et al. 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. Pilot Feasibility Stud 6, 102 (2020). https://doi.org/10.1186/s40814-020-00644-8
  4. Mwangi, N., Bascaran, C., Ramke, J. et al. Peer-support to increase uptake of screening for diabetic retinopathy: process evaluation of the DURE cluster randomized trial. Trop Med Health 48, 1 (2020). https://doi.org/10.1186/s41182-019-0188-z
  5. Mwangi, N., Gachago, M., Gichangi, M. et al. Adapting clinical practice guidelines for diabetic retinopathy in Kenya: process and outputs. Implementation Sci 13, 81 (2018). https://doi.org/10.1186/s13012-018-0773-2
  6. Nyawira M, Muchai G, Gichangi M, Gichuhi S, Githeko K, Atieno J, Karimurio J, Kibachio J, Ngugi N, Nyaga P, Nyamori J, Zindamoyen ANM, Bascaran C, Foster A, for the Technical Working Group. Clinical guidelines for diabetic retinopathy in Kenya: an executive summary of the recommendations. Journal of Ophthalmology of Eastern Central and Southern Africa. 2017 (PDF attached)

Associated publication:

  1. Nyawira Mwangi , Covadonga Bascaran , Jacqueline Ramke , Lawrence Muthami , Stephen Gichuhi  , Mathew Kipturgo , Lucy Manyara , David Macleod , Consuela Moorman  , Allen Foster Rationale for integration of services for diabetes mellitus and diabetic retinopathy in Kenya.
  2. Nyawira Mwangi, MSc, Covadonga Bascaran, Jacqueline Ramke, Mathew Kipturgo, Min Kim, Mark Ng’ang’a, Stephen Gichuhi, David Macleod, Consuela Moorman, Lawrence Muthami, Michael Gichangi, Allen Foster. Increasing attendance at screening for diabetic retinopathy: results of the DURE cluster-randomized trial in Kenya.

Specific contacts

PI: Nyawira Mwangi (Nyawira.Mwangi@alumni.lshtm.ac.uk)

Supervisors: Allen Foster (Allen.Foster@lshtm.ac.uk), Covadonga Bascaran, (Covadonga.Bascaran@lshtm.ac.uk), Lawrence Muthami (lmuthami@kemri.org)