Publications by authors named "Covadonga Bascaran"

28 Publications

  • Page 1 of 1

Sex, gender, and retinoblastoma: analysis of 4351 patients from 153 countries.

Eye (Lond) 2021 Jul 16. Epub 2021 Jul 16.

International Centre for Eye Helath, London School of Hygiene & Tropical Medicine, London, UK.

Objective: To investigate in a large global sample of patients with retinoblastoma whether sex predilection exists for this childhood eye cancer.

Methods: A cross-sectional analysis including 4351 treatment-naive retinoblastoma patients from 153 countries who presented to 278 treatment centers across the world in 2017. The sex ratio (male/female) in the sample was compared to the sex ratio at birth by means of a two-sided proportions test at global level, country economic grouping, continent, and for selected countries.

Results: For the entire sample, the mean retinoblastoma sex ratio, 1.20, was higher than the weighted global sex ratio at birth, 1.07 (p < 0.001). Analysis at economic grouping, continent, and country-level demonstrated differences in the sex ratio in the sample compared to the ratio at birth in lower-middle-income countries (n = 1940), 1.23 vs. 1.07 (p = 0.019); Asia (n = 2276), 1.28 vs. 1.06 (p < 0.001); and India (n = 558), 1.52 vs. 1.11 (p = 0.008). Sensitivity analysis, excluding data from India, showed that differences remained significant for the remaining sample (χ = 6.925, corrected p = 0.025) and for Asia (χ = 5.084, corrected p = 0.036). Excluding data from Asia, differences for the remaining sample were nonsignificant (χ = 2.205, p = 0.14).

Conclusions: No proof of sex predilection in retinoblastoma was found in the present study, which is estimated to include over half of new retinoblastoma patients worldwide in 2017. A high male to female ratio in Asian countries, India in specific, which may have had an impact on global-level analysis, is likely due to gender discrimination in access to care in these countries, rather than a biological difference between sexes.
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http://dx.doi.org/10.1038/s41433-021-01675-yDOI Listing
July 2021

Situational analysis of diabetic retinopathy treatment Services in Ghana.

BMC Health Serv Res 2021 Jun 17;21(1):584. Epub 2021 Jun 17.

International Centre for Eye Health, London School of Hygiene and Tropical Medicine, London, UK.

Background: Although the equitable distribution of diabetic retinopathy (DR) services across Ghana remains paramount, there is currently a poor understanding of nationwide DR treatment services. This study aims to conduct a situation analysis of DR treatment services in Ghana and provide evidence on the breadth, coverage, workload, and gaps in service delivery for DR treatment.

Methods: A cross-sectional study was designed to identify health facilities which treat DR in Ghana from June 2018 to August 2018. Data were obtained from the facilities using a semi-structured questionnaire which included questions identifying human resources involved in DR treatment, location of health facilities with laser, vitreoretinal surgery and Anti-vascular endothelial growth factor therapy (Anti-VEGF) for DR treatment, service utilisation and workload at these facilities, and the average price of DR treatment in these facilities.

Results: Fourteen facilities offer DR treatment in Ghana; four in the public sector, seven in the private sector and three in the Christian Health Association of Ghana (CHAG) centres. There was a huge disparity in the distribution of facilities offering DR services, the eye care cadre, workload, and DR treatment service (retinal laser, Anti-VEGF, and vitreoretinal surgery). The retinal laser treatment price was independent of all variables (facility type, settings, regions, and National Health Insurance Scheme coverage). However, settings (p = 0.028) and geographical regions (p = 0.010) were significantly associated with anti-VEGF treatment price per eye.

Conclusion: Our results suggest a disproportionate distribution of DR services in Ghana. Hence, there should be a strategic development and implementation of an eye care plan to ensure the widespread provision of DR services to the disadvantaged population as we aim towards a disadvantaged population as we aim towards a universal health coverage.
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http://dx.doi.org/10.1186/s12913-021-06608-9DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8212523PMC
June 2021

Cataract Surgical Services in Palestine.

Ophthalmic Epidemiol 2021 Jun 13:1-9. Epub 2021 Jun 13.

London School of Hygiene and tropical medicine, London, UK.

: Cataract surgery, quantity and quality, is an indicator of ophthalmic care. A comprehensive assessment of cataract surgical services has never been carried out in Palestine, including West Bank, Gaza Strip and East Jerusalem. The objective of this study was to estimate the cataract surgical rate in 2015 to and to explore the modes of payment and referral systems.: A cross-sectional study conducted between June and August 2016. Medical Directors from Cataract Surgical Centres in Palestine were interviewed using a structured questionnaire to extract data on cataract output and surgical techniques. Additionally, data were collected on modes of payment for cataract services. The cataract surgical rate was calculated by dividing the total cataract output in 2015 by the estimated population of Palestine in millions.: In 2015, 9908 cataract surgeries were carried out in 22 centres. The cataract surgical rate was 2,117 operations per million population. Phacoemulsification was the most common technique (73.4%), however in government centres 67% were performed by extracapsular cataract extraction.In the Gaza Strip, 56.6% of cataract surgeries were operated at government centres, and 42.8% were operated at NGO centres while in West Bank, only 12% of cataract surgeries were operated at government centres, with two-thirds of cataracts diagnosed at governmental centres being referred to private and NGO centres. Seventy eight percent of cataract surgeries were funded by insurance, of which the government insurance scheme contributed 65%.: The cataract surgical rate in Palestine falls short of the required WHO target. The majority of cataract surgeries are funded by insurance.
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http://dx.doi.org/10.1080/09286586.2021.1923755DOI Listing
June 2021

Lag Time between Onset of First Symptom and Treatment of Retinoblastoma: An International Collaborative Study of 692 Patients from 10 Countries.

Cancers (Basel) 2021 Apr 19;13(8). Epub 2021 Apr 19.

Department of Ophthalmology, University of Washington, Seattle, WA 98195, USA.

Background: The relationship between lag time and outcomes in retinoblastoma (RB) is unclear. In this study, we aimed to study the effect of lag time between onset of symptoms and diagnosis of retinoblastoma (RB) in countries based on their national-income and analyse its effect on the outcomes.

Methods: We performed a prospective study of 692 patients from 11 RB centres in 10 countries from 1 January 2019 to 31 December 2019.

Results: The following factors were significantly different among different countries based on national-income level: age at diagnosis of RB ( = 0.001), distance from home to nearest primary healthcare centre ( = 0.03) and mean lag time between detection of first symptom to visit to RB treatment centre ( = 0.0007). After adjusting for country income, increased lag time between onset of symptoms and diagnosis of RB was associated with higher chances of an advanced tumour at presentation ( < 0.001), higher chances of high-risk histopathology features ( = 0.003), regional lymph node metastasis ( < 0.001), systemic metastasis ( < 0.001) and death ( < 0.001).

Conclusions: There is a significant difference in the lag time between onset of signs and symptoms and referral to an RB treatment centre among countries based on national income resulting in significant differences in the presenting features and clinical outcomes.
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http://dx.doi.org/10.3390/cancers13081956DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8073369PMC
April 2021

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

Syst Rev 2021 01 14;10(1):27. Epub 2021 Jan 14.

London School of Hygiene & Tropical Medicine, Keppel Street, London, WC1E 7HT, UK.

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.
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http://dx.doi.org/10.1186/s13643-020-01562-9DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7809874PMC
January 2021

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

Syst Rev 2021 01 4;10(1). Epub 2021 Jan 4.

London School of Hygiene & Tropical Medicine, Keppel Street, London, WC1E 7HT, UK.

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/ .
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http://dx.doi.org/10.1186/s13643-020-01553-wDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7780379PMC
January 2021

Assistive technology for visual impairment and trainers at schools for the blind in Delhi.

Assist Technol 2021 Jan 19:1-5. Epub 2021 Jan 19.

International Centre for Eye Health, Department of Clinical Research, London School of Hygiene and Tropical Medicine, London, UK.

The aim of the study was to assess the availability of assistive technology (AT) for visual impairment and trainers in schools for the blind in Delhi. A cross-sectional study was conducted in 22 of the 24 schools in Delhi. The headteacher of each school was asked about availability of 52 ATs divided into writing, reading, math, sciences, sports, mobility, and daily living, using a questionnaire. Information on availability of trainers was also collected. Of the 52 ATs, the most frequently available were Braille slate with stylus and abacus (>90% of schools), followed by Taylor frame, long cane and talking watch (80% to 90% of schools). Only 11 of 52 AT devices were available in 60% or more of the schools. Tactile-based ATs were more available than vision-based ATs. In the 22 schools, 63 trainers for reading & writing were available (80% of posts), 18 for sciences (59%), 25 for math (70%), and 11 for mobility (50% of posts). Except Braille slate and stylus, there is a huge shortage of AT in these schools. The educational needs and performance of students could be helped by developing and using a list of priority Assistive Products for example, the WHO AP list.
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http://dx.doi.org/10.1080/10400435.2020.1839144DOI Listing
January 2021

Travel burden and clinical presentation of retinoblastoma: analysis of 1024 patients from 43 African countries and 518 patients from 40 European countries.

Br J Ophthalmol 2020 Sep 15. Epub 2020 Sep 15.

Pediatric Oncology Unit, Hospital Universitario y Politécnico La Fe, Valencia, Spain.

Background: The travel distance from home to a treatment centre, which may impact the stage at diagnosis, has not been investigated for retinoblastoma, the most common childhood eye cancer. We aimed to investigate the travel burden and its impact on clinical presentation in a large sample of patients with retinoblastoma from Africa and Europe.

Methods: A cross-sectional analysis including 518 treatment-naïve patients with retinoblastoma residing in 40 European countries and 1024 treatment-naïve patients with retinoblastoma residing in 43 African countries.

Results: Capture rate was 42.2% of expected patients from Africa and 108.8% from Europe. African patients were older (95% CI -12.4 to -5.4, p<0.001), had fewer cases of familial retinoblastoma (95% CI 2.0 to 5.3, p<0.001) and presented with more advanced disease (95% CI 6.0 to 9.8, p<0.001); 43.4% and 15.4% of Africans had extraocular retinoblastoma and distant metastasis at the time of diagnosis, respectively, compared to 2.9% and 1.0% of the Europeans. To reach a retinoblastoma centre, European patients travelled 421.8 km compared to Africans who travelled 185.7 km (p<0.001). On regression analysis, lower-national income level, African residence and older age (p<0.001), but not travel distance (p=0.19), were risk factors for advanced disease.

Conclusions: Fewer than half the expected number of patients with retinoblastoma presented to African referral centres in 2017, suggesting poor awareness or other barriers to access. Despite the relatively shorter distance travelled by African patients, they presented with later-stage disease. Health education about retinoblastoma is needed for carers and health workers in Africa in order to increase capture rate and promote early referral.
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http://dx.doi.org/10.1136/bjophthalmol-2020-316613DOI Listing
September 2020

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 2020 16;6:102. Epub 2020 Jul 16.

London School of Hygiene and Tropical Medicine, London, UK.

Background: People living with diabetes can reduce their risk of vision loss from diabetic retinopathy by attending screening, which enables early detection and timely treatment. The aim of this pilot trial was to assess the feasibility of a full-scale cluster randomized controlled trial of an intervention to increase uptake of retinal examination in this population, as delivered within existing community-based diabetes support groups (DSGs).

Methods: All 16 DSGs in Kirinyaga county were invited to participate in the study. The first two groups recruited took part in the pilot trial. DSG members who met the eligibility criteria were recruited before the groups that were randomized to the two arms. In the intervention group, two peer educators were trained to deliver monthly DSG-based eye health education and individual telephone reminders to attend screening. The control group continued with usual DSG practice which is monthly meetings without eye health education. The recruitment team and outcome assessors were masked to the allocation. We documented the study processes to ascertain the feasibility, acceptability, and potential effectiveness of the intervention. Feasibility was assessed in terms of clarity of study procedures, recruitment and retention rates, level of acceptability, and rates of uptake of eye examination. We set the target feasibility criteria for continuation to the main study to be recruitment of 50 participants in the trial, 80% monthly follow-up rates for individuals, and no attrition of clusters.

Results: Of the 122 DSG members who were assessed for eligibility, 104 were recruited and followed up: 51 (intervention) and 53 (control) arm. The study procedures were well understood and easy to apply. We learnt the DSG meeting days were the best opportunities for recruitment. The study had a high acceptance rate (100% for clusters, 95% for participants) and high follow-up and retention rate (100% of those recruited). All clusters and participants were analysed. We observed that the rate of incidence of eye exam was about 6 times higher in the intervention arm as compared to the control arm. No adverse unexpected events were reported in either arm.

Conclusions: The study is feasible and acceptable in the study population. The results support the development of a full-scale cluster RCT, as the success criteria for the pilot were met.

Trial Registration: Pan African Clinical Trials Registry PACTR201707002430195 Registered on 25 July 2017.
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http://dx.doi.org/10.1186/s40814-020-00644-8DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7364632PMC
July 2020

Retinoblastoma presentation, treatment and outcome in a large referral centre in Tehran: a 10-year retrospective analysis.

Eye (Lond) 2021 02 4;35(2):575-583. Epub 2020 May 4.

MAHAK Hematology Oncology Research Center (MAHAK-HORC), MAHAK Hospital, Tehran, Iran.

Background/objectives: Early diagnosis, care and treatment of retinoblastoma is a challengeable issue for Iranian health system. This study was designed and conducted in a referral multidisciplinary centre in the capital city of Iran to evaluate management, care, prognosis and survival rates of paediatric patients with retinoblastoma.

Methods: In this retrospective study, a total number of 309 patients younger than 15 years, diagnosed with retinoblastoma, who referred for diagnosis and treatment to MAHAK's Pediatric Cancer Treatment and Research Center (MPCTRC) from 2007 to 2017 were evaluated. All data were analyzed via SPSS version 22 software in regard of parametric and non-parametric data. Survival rates were analyzed using the Kaplan-Meyer method.

Results: The mean age of patients was 20 months and the majority of patients (77%) had leukocoria as a common clinical symptom at the time of diagnosis. Primary treatment methods were systemic chemotherapy (94%), laser (35%) and primary enucleation (28%). Relapses occurred in nearly 42% of cases, and the median time from diagnosis to the first relapse was 9 months. At the time analyzing the data, 11% of patients died. Patients' 5-year OS and RFS rates were 79.6% and 41.5%, respectively.

Conclusion: Comparing results with other conducted studies identifies that the recurrence rate was high in our considered patients. Also, OS and RFS rates in our study were not as considerable as other reports. Screening methods, updating protocols and follow-up of patients may lead to improvements in survival rates of patients with retinoblastoma.
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http://dx.doi.org/10.1038/s41433-020-0907-zDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8027402PMC
February 2021

Barriers to using assistive technology among students with visual disability in schools for the blind in Delhi, India.

Disabil Rehabil Assist Technol 2020 Mar 27:1-5. Epub 2020 Mar 27.

Department of Clinical Research, International Centre for Eye Health, London School of Hygiene and Tropical Medicine, London, UK.

Students with visual loss may benefit from assistive technology (AT) for their educational activities. To understand the barriers faced in using ATs by students who have heard of ATs and reported needing them, but were not using (acquainted students), at schools for the blind in Delhi.: Two hundred and fifty students were selected randomly from ten schools for the blind in Delhi and screened for presenting and pinhole binocular distance vision using a modified 'E' chart and multiple pinhole occluder. Students were divided into two groups; 1/60 or better vision (likely to benefit from vision-based AT) and <1/60 vision, (likely to benefit from tactile/sound-based AT). Awareness of, and need for, ATs was investigated for each student with a questionnaire. Then information on barriers to using AT was obtained from students who knew about AT, felt they needed AT, but were not using them. This information was collected for a total of 42 ATs. The three most requested tactile/sound-based ATs for the 250 students were talking watch, Braille typewriter and audio format. The three most requested vision-based ATs in 69 (27.6%) students who had presenting or pinhole visual acuity less than 6/18 to 1/60 were near optical magnifiers, electronic magnifiers and large keyboard for computer. Non-availability of ATs in schools was the most common perceived barrier (43% of overall responses), followed by economic constraints (20% of responses). Non-availability or limited possession of ATs and financial constraints were the major barriers to use of ATs among students.IMPLICATION FOR REHABILITATIONStudents with visual disability face many challenges in accessing assistive technology for their education learning, especially in low middle-income countries.Non-availability and limited possession of assistive technology by schools for the blind are main barriers in the study.School authorities must recognize their responsibility to ensure assistive technology (academic and non-academic related, visual and non-visual based) are made accessible for their students with adequate quantity.Future studies should focus on all school age children in the community rather than focusing on school going children.
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http://dx.doi.org/10.1080/17483107.2020.1738566DOI Listing
March 2020

Global eye health and the sustainable development goals: protocol for a scoping review.

BMJ Open 2020 03 18;10(3):e035789. Epub 2020 Mar 18.

London School of Hygiene and Tropical Medicine, International Centre for Eye Health, London, UK.

Introduction: In 2015, most governments of the world committed to achieving 17 sustainable development goals (SDGs) by the year 2030. Efforts to improve eye health contribute to the advancement of several SDGs, including those not exclusively health-related. This scoping review will summarise the nature and extent of the published literature that demonstrates a link between improved eye health and advancement of the SDGs.

Methods And Analysis: Searches will be conducted in MEDLINE, Embase and Global Health for published, peer-reviewed manuscripts, with no time period, language or geographic limits. All intervention and observational studies will be included if they report a link between a change in eye health and (1) an outcome related to one of the SDGs or (2) an element on a pathway between eye health and an SDG (eg, productivity). Two investigators will independently screen titles and abstracts, followed by full-text screening of potentially relevant articles. Reference lists of all included articles will be examined to identify further potentially relevant studies. Conflicts between the two independent investigators will be discussed and resolved with a third investigator. For included articles, data regarding publication characteristics, study details and SDG-related outcomes will be extracted. Results will be synthesised by mapping the extracted data to a logic model, which will be refined through an iterative process during data synthesis.

Ethics And Dissemination: As this scoping review will only include published data, ethics approval will not be sought. The findings of the review will be published in an open-access, peer-reviewed journal. A summary of the results will be developed for website posting, stakeholder meetings and inclusion in the ongoing Lancet Global Health Commission on Global Eye Health.
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http://dx.doi.org/10.1136/bmjopen-2019-035789DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7202701PMC
March 2020

Global Retinoblastoma Presentation and Analysis by National Income Level.

JAMA Oncol 2020 05;6(5):685-695

Imam Hussein Cancer Center, Karbala, Iraq.

Importance: Early diagnosis of retinoblastoma, the most common intraocular cancer, can save both a child's life and vision. However, anecdotal evidence suggests that many children across the world are diagnosed late. To our knowledge, the clinical presentation of retinoblastoma has never been assessed on a global scale.

Objectives: To report the retinoblastoma stage at diagnosis in patients across the world during a single year, to investigate associations between clinical variables and national income level, and to investigate risk factors for advanced disease at diagnosis.

Design, Setting, And Participants: A total of 278 retinoblastoma treatment centers were recruited from June 2017 through December 2018 to participate in a cross-sectional analysis of treatment-naive patients with retinoblastoma who were diagnosed in 2017.

Main Outcomes And Measures: Age at presentation, proportion of familial history of retinoblastoma, and tumor stage and metastasis.

Results: The cohort included 4351 new patients from 153 countries; the median age at diagnosis was 30.5 (interquartile range, 18.3-45.9) months, and 1976 patients (45.4%) were female. Most patients (n = 3685 [84.7%]) were from low- and middle-income countries (LMICs). Globally, the most common indication for referral was leukocoria (n = 2638 [62.8%]), followed by strabismus (n = 429 [10.2%]) and proptosis (n = 309 [7.4%]). Patients from high-income countries (HICs) were diagnosed at a median age of 14.1 months, with 656 of 666 (98.5%) patients having intraocular retinoblastoma and 2 (0.3%) having metastasis. Patients from low-income countries were diagnosed at a median age of 30.5 months, with 256 of 521 (49.1%) having extraocular retinoblastoma and 94 of 498 (18.9%) having metastasis. Lower national income level was associated with older presentation age, higher proportion of locally advanced disease and distant metastasis, and smaller proportion of familial history of retinoblastoma. Advanced disease at diagnosis was more common in LMICs even after adjusting for age (odds ratio for low-income countries vs upper-middle-income countries and HICs, 17.92 [95% CI, 12.94-24.80], and for lower-middle-income countries vs upper-middle-income countries and HICs, 5.74 [95% CI, 4.30-7.68]).

Conclusions And Relevance: This study is estimated to have included more than half of all new retinoblastoma cases worldwide in 2017. Children from LMICs, where the main global retinoblastoma burden lies, presented at an older age with more advanced disease and demonstrated a smaller proportion of familial history of retinoblastoma, likely because many do not reach a childbearing age. Given that retinoblastoma is curable, these data are concerning and mandate intervention at national and international levels. Further studies are needed to investigate factors, other than age at presentation, that may be associated with advanced disease in LMICs.
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http://dx.doi.org/10.1001/jamaoncol.2019.6716DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7047856PMC
May 2020

Peer-support to increase uptake of screening for diabetic retinopathy: process evaluation of the DURE cluster randomized trial.

Trop Med Health 2020 6;48. Epub 2020 Jan 6.

1London School of Hygiene and Tropical Medicine, London, England.

Background: There is limited evidence on how implementation of peer support interventions influences effectiveness, particularly for individuals with diabetes. We conducted a cluster randomized controlled trial to compare the effectiveness of a peer-led health education package versus usual care to increase uptake of screening for diabetic retinopathy (DR).

Methods: Our process evaluation used a mixed-method design to investigate the recruitment and retention, reach, dose, fidelity, acceptability, and context of implementation, and was guided by the Consolidated Framework for Implementation Research (CFIR). We reviewed trial documents, conducted semi-structured interviews with key informants ( = 10) and conducted four focus group discussions with participants in both arms of the trial. Three analysts undertook CFIR theory-driven content analysis of the qualitative data. Quantitative data was analyzed to provide descriptive statistics relevant to the objectives of the process evaluation.

Results: The trial had positive implementation outcomes, 100% retention of clusters and 96% retention for participants, 83% adherence to delivery of content of group talks (fidelity), and 78% attendance (reach) to at least 50% (3/6) of the group talks (dose). The data revealed that intervention characteristics, outer setting, inner setting, individual characteristics, and process (all the constructs of CFIR) influenced the implementation. There were more facilitators than barriers to the implementation. Facilitators included the relative advantage of the intervention compared with current practice (intervention characteristics); awareness of the growing prioritization of diabetes in the national health policy framework (outer setting); tension for change due to the realization of the vulnerability to vision loss from DR (inner setting); a strong collective sense of accountability of peer supporters to implement the intervention (individual characteristics); and regular feedback on the progress with implementation (process). Potential barriers included the need to queue at the eye clinic (intervention characteristic), travel inconveniences (inner setting), and socio-political disruption (outer setting).

Conclusions: The intervention was implemented with high retention, reach, fidelity, and dose. The CFIR provided a valuable framework for evaluating contextual factors that influenced implementation and helped to understand what adaptations may be needed during scale up.

Trial Registration: Pan African Clinical Trials Registry: PACTR201707002430195 registered 15 July 2017.
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http://dx.doi.org/10.1186/s41182-019-0188-zDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6945600PMC
January 2020

Awareness, utilization and barriers in accessing assistive technology among young patients attending a low vision rehabilitation clinic of a tertiary eye care centre in Delhi.

Indian J Ophthalmol 2019 10;67(10):1548-1554

Department of Community Ophthalmology, Dr. Rajendra Prasad Centre for Ophthalmic Sciences, All India Institute of Medical Sciences, New Delhi, India.

Purpose: People with visual disability need assistive technology to improve their body functioning and performance. The purpose of the present study was to understand the awareness, use and barriers in accessing the assistive technology among young patients attending visual rehabilitation clinic of a tertiary eye care hospital in Delhi.

Methods: A cross-sectional study was conducted on consecutively recruited patients registered for the first time in visual rehabilitation clinic of the community ophthalmology department of the tertiary eye centre during June and July 2018. A study tool consisting of 42 assistive technologies was developed. Patients were screened for distance visual acuity both presenting and binocular pinhole vision using an 'E' chart with two optotype (6/18, 6/60).

Results: 85 patients (69.4% male) were enrolled from the VR clinic. 83.5% of the patients had a best corrected binocular vision acuity <6/18 to 1/60. There was good awareness of only 2 of the 42 devices (>67% of the participants): near optical magnifiers, walking long canes. There was moderate awareness of 10 devices (34-66% of the participants) and poor awareness of the rest (<33%). Likewise, participants reported moderate usage of 3 out of the 42 devices and poor usage of the remaining devices. Non-availability of devices was the most frequently reported barrier in the study.

Conclusion: The awareness and utilization of assistive technologies for visual disability was poor in patients attending visual rehabilitation clinic. Hospitals could procure assistive technologies and introduce strategies to improve awareness as well as promote utilization.
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http://dx.doi.org/10.4103/ijo.IJO_197_19DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6786185PMC
October 2019

Impact of a 10-Year Eye Care Program in Sokoto, Nigeria: Changing Pattern of Prevalence and Causes of Blindness and Visual Impairment.

Middle East Afr J Ophthalmol 2019 Apr-Jun;26(2):101-106. Epub 2019 Aug 26.

Clinical Research Department, International Centre for Eye Health, London School of Hygiene and Tropical Medicine, London, United Kingdom.

Background: This study was undertaken to ascertain the current magnitude and causes of blindness and visual impairment in persons aged 50 years and over and to assess the impact of a 10-year eye care program in Sokoto State, Nigeria.

Methods: A rapid assessment of avoidable blindness (RAAB) survey (in persons 50 years and over) was conducted in 2016. Participants were selected in Wurno health zone using a two-stage cluster randomized sampling with probability proportional to size. Operational definitions were based on RAAB and World Health Organization eye examination record definitions. Eye care program documents were reviewed and data from a baseline survey undertaken in 2005 were reanalyzed.

Results: A response of 89.1% (2405 of 2700 participants) was obtained in the 2016 survey. With available correction, the unadjusted prevalence of blindness was 7.7% (95% confidence interval [CI]: 6.4, 8.9). The odds of blindness were 1.8 times higher in females than males (95% CI: 1.3, 2.4; < 0.001). Major causes of blindness were cataract (48.9%) corneal disease (20.1%), glaucoma (10.3%), and uncorrected refractive error/aphakia (8.7%). The age- and sex-adjusted prevalence of blindness has declined from 11.6% (95% CI: 7.4, 17.0) in 2005 to 6.8% (95% CI: 5.6, 8.0%) in 2016.

Conclusion: The blindness prevalence is high, and the major causes are avoidable in the health zone. The findings suggest that investments in the program over the last 10 years might have led to almost a halving in the prevalence of blindness in th e population. However, the small sample size of persons 50+ years from Wurno zone in the 2005 survey necessitate caution when comparing the 2005 and the 2016 surveys.
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http://dx.doi.org/10.4103/meajo.MEAJO_113_17DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6737780PMC
November 2019

Assistive technology for students with visual disability in schools for the blind in Delhi.

Disabil Rehabil Assist Technol 2020 08 23;15(6):663-669. Epub 2019 Apr 23.

Department of Community Ophthalmology, Dr. Rajendra Prasad Centre for Ophthalmic Sciences, All India Institute of Medical Sciences, New Delhi, India.

To understand the awareness and utilization of assistive technology in students at schools for the blind in Delhi. A cross sectional study was conducted among 250 students selected randomly from 10 blind schools in Delhi. Binocular distance presenting and pinhole vision acuity were assessed using Snellen "E" chart and a multiple pinhole occluder. Students were also interviewed using a questionnaire about 42 assistive devices to understand their awareness and use. Male participants were 72.8%. Of the total, 27.6% students had best corrected visual acuity <6/18 to 1/60, and the rest had <1/60 vision. The awareness about tactile and sound-based technology was good among students: Braille books (98%), Braille slate and stylus (99.2%), handheld audio recorders (77.6%) and screen readers (77.2%). Good awareness was reported for abacus (88.8%), walking long canes (94.4%) and smart cane (89.6%), audible balls (96%), Braille chess (82.8%) and talking watch (98%). Among the students with <6/18 to 1/60 vision, the awareness of visual based technology ranged from 0.8% (typoscope) to 43.6% (video magnifiers). Braille technology was used for reading by 96.4% (books) and for writing by 96.8% (Braille slate and stylus) irrespective of visual status. Other devices were poorly used ranging from nil (typoscope) to 55% (screen readers). The use of math and science learning devices was poor (<20%). Walking canes were used by 59% of students whereas 87.2% students used audible ball for games. The results showed that majority of students used tactile based technology irrespective of visual status.Implications for rehabilitationStudents with visual disability need assistive technology for a wide range of activities including academic learning.Students in schools for the blind who have binocular best corrected vision acuity of 1/60 or better should be encouraged to use visual based assistive technology instead of tactile based.Students with binocular best corrected vision acuity less than1/60 should be encouraged to use other available tactile and sound-based assistive technologies as well as Braille books and Braille slate and stylus for their academic activities including maths and sciences.Teachers should be trained in the use of various assistive technologies for reading, writing, maths, sciences, sports, mobility and activities of daily living.
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http://dx.doi.org/10.1080/17483107.2019.1604829DOI Listing
August 2020

Spectacle Compliance and Its Determinants in a School Vision Screening Pilot in Botswana.

Ophthalmic Epidemiol 2019 04 9;26(2):109-116. Epub 2018 Oct 9.

a Department of Clinical Research, Faculty of Infectious and Tropical Diseases , London School of Hygiene & Tropical Medicine , London , UK.

Purpose: The effectiveness of school eye health programmes relies on many factors, including compliance with spectacle wear. The objectives of this study were to determine spectacle compliance in a school vision screening pilot programme in Botswana, and investigate factors predictive of compliance.

Methods: The study was an observational, cross-sectional follow-up of a pilot school screening programme. Unannounced compliance checks were completed after 3-4 months in a convenience sample of 19 schools. Sex, age, school level, visual acuity, and refractive error were analysed using logistic regression to investigate factors predictive of compliance.

Findings: Compliance data were recorded for 193/286 (67.5%) children; 62.2% were female and the median age was 15 years (interquartile range 12-17 years). 60.1% of the sample were compliant with spectacle wear. Girls were more likely to be compliant than boys (adjusted odds ratio (aOR) = 2.32, 95% confidence interval (CI) 1.03-5.27). Children at primary and junior secondary school were more likely to be complaint than senior secondary school children (aOR = 16.96, 95% CI 5.60-51.39; and aOR = 3.39, 95% CI 1.39-8.22, respectively). Children with binocular uncorrected visual acuity (UCVA) of 6/7.5 to 6/12 were 2.76 (95% CI1.05-7.23) times more likely to be compliant than children with binocular UCVA of 6/6.

Conclusion: Compliance was higher in Botswana than previous African studies; however, improvement in this area would increase the effectiveness of the programme. Further investigation into barriers to spectacle wear affecting boys and older children is warranted. A prescribing protocol to avoid low prescriptions - especially where binocular UCVA is 6/6 - is desirable.
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http://dx.doi.org/10.1080/09286586.2018.1523441DOI Listing
April 2019

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 2018 07 13;18(1):871. Epub 2018 Jul 13.

International Centre for Eye Health, London School of Hygiene and Tropical Medicine, Keppel Street, WC1E 7HT, London, UK.

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.
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http://dx.doi.org/10.1186/s12889-018-5761-6DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6044026PMC
July 2018

Adapting clinical practice guidelines for diabetic retinopathy in Kenya: process and outputs.

Implement Sci 2018 06 15;13(1):81. Epub 2018 Jun 15.

London School of Hygiene and Tropical Medicine, London, UK.

Background: The use of clinical practice guidelines envisages augmenting quality and best practice in clinical outcomes. Generic guidelines that are not adapted for local use often fail to produce these outcomes. Adaptation is a systematic and rigorous process that should maintain the quality and validity of the guideline, while making it more usable by the targeted users. Diverse skills are required for the task of adaptation. Although adapting a guideline is not a guarantee that it will be implemented, adaptation may improve acceptance and adherence to its recommendations.

Methods: We describe the process used to adapt clinical guidelines for diabetic retinopathy in Kenya, using validated tools and manuals. A technical working group consisting of volunteers provided leadership.

Results: The process was intensive and required more time than anticipated. Flexibility in the process and concurrent health system activities contributed to the success of the adaptation. The outputs from the adaptation include the guidelines in different formats, point of care instruments, as well as tools for training, monitoring, quality assurance and patient education.

Conclusion: Guideline adaptation is applicable and feasible at the national level in Kenya. However, it is labor- and time -intensive. It presents a valuable opportunity to develop several additional outputs that are useful at the point of care.
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http://dx.doi.org/10.1186/s13012-018-0773-2DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6003001PMC
June 2018

Trends in cataract surgical rate and resource utilisation in Egypt.

Ophthalmic Epidemiol 2018 Oct - Dec;25(5-6):351-357. Epub 2018 Jun 8.

b International Centre for Eye Health, Department of Clinical Research, Faculty of Infectious and Tropical Diseases , London School of Hygiene and Tropical Medicine , UK.

Purpose: To describe cataract services in Egypt and explore resources and practices in public and private sectors.

Methods: The study was conducted between June and August 2015. All facilities in the country providing cataract services were contacted to obtain information on surgeries performed in 2014. Hospitals performing eye surgery in Quena, Sharkia, and Fayoum regions were visited and a questionnaire on resources for cataract surgery was completed.

Results: Cataract surgery was offered in the public sector by 64 government and 16 university teaching hospitals and in the private sector by 101 hospitals. Over 90% of all facilities in the country contacted participated in the study. In 2014, the national cataract surgical rate (CSR) was 3674 varying in governorates from 7579 in Ismailia to 402 in Suez. The private sector performed 70% of cataract surgeries. Analysis of three regions showed an 11.7% increase in cataract output between 2010 and 2014. The average number of cataract surgeries per unit in 2014 was 2272 in private, 1633 in university, and 824 in government hospitals. Private hospitals had 60% of human resources for eye care. Phacoemulsification was the surgical technique in 85.6% of private, 72.1% of university, and 41% of government hospitals. Reasons explaining the differences in output between public and private sectors were the lack of trainers, supervisors, and incentives.

Conclusion: The private sector provides most of the cataract services in Egypt, resulting in inadequate services for the poor. There is a 15-fold variation in CSR between the best and least served regions. The public sector could increase cataract output by improving training, supervision, and incentives.
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http://dx.doi.org/10.1080/09286586.2018.1481983DOI Listing
March 2019

Predictors of uptake of eye examination in people living with diabetes mellitus in three counties of Kenya.

Trop Med Health 2017 21;45:41. Epub 2017 Dec 21.

London School of Hygiene and Tropical Medicine, London, UK.

Background: Diabetic retinopathy (DR) is a significant public health concern that is potentially blinding. Clinical practice guidelines recommend annual eye examination of patients with diabetes for early detection of DR. Our aim was to identify the demand-side factors that influence uptake of eye examination among patients already utilizing diabetes services in three counties of Kenya.

Methods: We designed a clinic based cross-sectional study and used three-stage sampling to select three counties, nine diabetes clinics in these counties and 270 patients with diabetes attending these clinics. We interviewed the participants using a structured questionnaire. The two outcomes of interest were 'eye examination in the last 12 months' and 'eye examination ever'. The exposure variables were the characteristics of participants living with diabetes.

Results: The participants had a mean age of 53.3 years (SD 14.1) and an average interval of 4 months between visits to the diabetes clinic. Only 25.6% of participants had ever had an eye examination in their lifetime, while 13.3% had it in the preceding year. The independent predictors of uptake were referral by diabetes services, patient knowledge of diabetes eye complications, comorbid hypertension and urban or semi-urban residence.

Conclusions: We conclude that access to retinal examination for DR is low in all three counties. An intervention that increases the knowledge of patients with diabetes about eye complications and promotes referral of patients with diabetes for eye examination may improve access to annual eye examination for DR.
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http://dx.doi.org/10.1186/s41182-017-0080-7DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5740562PMC
December 2017

Changing patterns of cataract services in North-West Nigeria: 2005-2016.

PLoS One 2017 17;12(8):e0183421. Epub 2017 Aug 17.

Clinical Research Department, International Centre for Eye Health, London School of Hygiene & Tropical Medicine, London, United Kingdom.

Purpose: This study was conducted to assess the impact of the eye care programme on cataract blindness and cataract surgical services in Sokoto, Nigeria over a 12 year period 2005-2016.

Methods: Data from the 2005 population based cross-sectional study of blindness in Sokoto state was re-analysed to obtain baseline estimates of the prevalence of cataract blindness and cataract surgical coverage for persons 50 years and over in Wurno health zone. A population based survey of a representative sample of persons 50 years and over in Wurno health zone was conducted in July 2016. Data on eye health workforce, infrastructure and cataract surgical services between 2005 and 2016 were analysed from relevant documents.

Results: In 2005 the unadjusted prevalence of bilateral cataract blindness (<3/60) in people 50 years and over in Wurno health zone was 5.6% (95% CI: 3.1, 10.1). By 2016 this had fallen to 2.1% (95% CI 1.5%, 2.7%), with the age-sex adjusted prevalence being 1.9% (95% CI 1.3%, 2.5%). The CSC for persons with visual acuity <3/60, <6/60, <6/18 for Wurno health zone was 9.1%, 7.1% and 5.5% respectively in 2005 and this had increased to 67.3%, 62.1% and 34.7% respectively in 2016. The CSR in Sokoto state increased from 272 (1005 operations) in 2006, to 596 (2799 operations) in 2014. In the 2005 survey, couching (a procedure used by traditional practitioners to dislocate the lens into the vitreous cavity) accounted for 87.5% of all cataract interventions, compared to 45.8% in the 2016 survey participants. In 2016 18% of eyes having a cataract operation with IOL implantation had a presenting visual acuity of <6/60 (poor outcome) with the main causes being postoperative complications (53%) and uncorrected refractive error (29%).

Conclusion: Between 2005 and 2016 there was a doubling in cataract surgical rate, a 7 times increase in cataract surgical coverage (<3/60), and a decrease in cataract blindness and the proportion of eyes being couched. However, there remains a high prevalence of un-operated cataract in 2016 indicating a need to further improve access to affordable and good quality cataract surgical services.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0183421PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5560675PMC
October 2017

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

Hum Resour Health 2017 03 14;15(1):22. Epub 2017 Mar 14.

International Centre for Eye Health, London School of Hygiene & Tropical Medicine, Keppel Street, London, WC1E 7HT, United Kingdom.

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.
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http://dx.doi.org/10.1186/s12960-017-0196-1DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5348790PMC
March 2017

A tool for planning retinoblastoma services in sub-Saharan Africa.

Pediatr Blood Cancer 2017 04 3;64(4). Epub 2016 Nov 3.

International Centre for Eye Health, London School of Hygiene and Tropical Medicine, London, UK.

Background: Cancer care remains inadequate in low-middle income countries (LMICs). Children with cancer have 80% chance of surviving in high-income countries compared to 20% in LMICs. Retinoblastoma (RB), an aggressive eye cancer of childhood and top childhood cancer in sub-Saharan Africa (SSA), has a low survival rate, due to a delay in diagnosis and abandonment of treatment. The purpose of this study is to provide a tool for planning human resources required to manage RB in SSA.

Procedure: Online tool was developed with 19 modifiable fields and 23 estimates. Routine data were used to populate modifiable fields: population, birthrate, infant mortality rate, and total fertility rate. Values were held constant: frequency, 1:17,000; familial cases, 8%; unilateral RB, 74%; extraocular disease, 70%; and survival postextraocular treatment, 10%.

Results: One thousand twenty-three RB incident and familial cases are estimated each year across Ethiopia, Ghana, Malawi, Nigeria, Tanzania, Uganda, Zambia, and Zimbabwe: 75 familial, 700 unilateral, 717 extraocular disease, and 645 palliative. Nigeria represents 431 cases and Zimbabwe 33 cases. Over the eight countries, a total of 41,558 patient visits are estimated each year consisting of unilateral enucleation, follow-up visits, intensive treatment, and familial screening, with a total of 2,802 prosthetic eyes being required each year.

Conclusions: In the absence of data, estimates are essential for planning countrywide medical services. More attention is needed around planning for services from the Ministry level including emphasis on building multidisciplinary teams for diseases such as RB, including countrywide database and integrated clinical practice guidelines among all levels of care.
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http://dx.doi.org/10.1002/pbc.26296DOI Listing
April 2017

Visual health screening by schoolteachers in remote communities of Peru: implementation research.

Bull World Health Organ 2016 Sep 21;94(9):652-659. Epub 2016 Jun 21.

Universidad Peruana Los Andes, Lima, Peru .

Objective: To describe the adaptation and scaling-up of an intervention to improve the visual health of children in the Apurimac region, Peru.

Methods: In a pilot screening programme in 2009-2010, 26 schoolteachers were trained to detect and refer visual acuity problems in schoolchildren in one district in Apurimac. To scale-up the intervention, lessons learnt from the pilot were used to design strategies for: (i) strengthening multisector partnerships; (ii) promoting the engagement and participation of teachers and (iii) increasing children's attendance at referral eye clinics. Implementation began in February 2015 in two out of eight provinces of Apurimac, including hard-to-reach communities. We made an observational study of the processes and outcomes of adapting and scaling-up the intervention. Qualitative and quantitative analyses were made of data collected from March 2015 to January 2016 from programme documents, routine reports and structured evaluation questionnaires completed by teachers.

Findings: Partnerships were expanded after sharing the results of the pilot phase. Training was completed by 355 teachers and directors in both provinces, belonging to 315 schools distributed in 24 districts. Teachers' appraisal of the training achieved high positive scores. Outreach eye clinics and subsidies for glasses were provided for poorer families. Data from six districts showed that attendance at the eye clinic increased from 66% (45/68 children referred) in the pilot phase to 92% (237/259) in the implementation phase.

Conclusion: Adaptation to the local context allowed the scaling-up of an intervention to improve visual health in children and enhanced the equity of the programme.
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http://dx.doi.org/10.2471/BLT.15.163634DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5034634PMC
September 2016

Human resources for refraction services in Central Nepal.

Clin Exp Optom 2015 Jul 5;98(4):335-41. Epub 2015 May 5.

International Centre for Eye Health, London School of Hygiene and Tropical Medicine, Keppel Street, London, UK.

Background: Uncorrected refractive error is a public health problem globally and in Nepal. Planning of refraction services is hampered by a paucity of data. This study was conducted to determine availability and distribution of human resources for refraction, their efficiency, the type and extent of their training; the current service provision of refraction services and the unmet need in human resources for refraction in Central Nepal.

Methods: This was a descriptive cross-sectional study. All refraction facilities in the Central Region were identified through an Internet search and interviews of key informants from the professional bodies and parent organisations of primary eye centres. A stratified simple random sampling technique was used to select 50 per cent of refraction facilities. The selected facilities were visited for primary data collection. Face-to-face interviews were conducted with the managers and the refractionists available in the facilities using a semi-structured questionnaire.

Results: Data was collected in 29 centres. All the managers (n=29; response rate 100 per cent) and 50 refractionists (Response rate 65.8 per cent) were interviewed. Optometrists and ophthalmic assistants were the main providers of refraction services (n=70, 92.11 per cent). They were unevenly distributed across the region, highly concentrated around urban areas. The median number of refractions per refractionist per year was 3,600 (IQR: 2,400 - 6,000). Interviewed refractionists stated that clients' knowledge, attitude and practice related factors such as lack of awareness of the need for refraction services and/or availability of existing services were the major barriers to the output of refraction services. The total number of refractions carried out in the Central Region per year was 653,176. An additional 170 refractionists would be needed to meet the unmet need of 1,323,234 refractions.

Conclusion: The study findings demand a major effort to develop appropriately trained personnel when planning refraction services in the Central Region and in Nepal as a whole. The equitable distribution of the refractionists, their community-outreach services and awareness raising activities should be emphasised.
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July 2015
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