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Delivering a mobile outreach DR service

Rationale, context, resources & challenges to consider when considering developing a mobile outreach DR service.
Setting up a mobile outreach diabetic retinopathy service is a viable option in settings where - diabetes is a public health problem, - there is a lack of awareness locally about diabetes-related eye complications, - there is a lack of available diabetic retinopathy services, - and those services that do exist are not reaching the entire population, that is accessibility is an issue, There are other patient-related barriers to care, for example, affordability is an issue. To reduce vision impairment and blindness from diabetic retinopathy in the target population, a mobile service must have several key components. Planning and promoting the service. One, find people with diabetic retinopathy by targeting local diabetes clinics, patient support groups, pharmacies or other forums.
Two, create awareness about diabetic eye disease amongst people with diabetes, local health providers, and policymakers, for example, by giving health talks, distributing educational materials, using DR ambassadors, training health workers, or advocating with local stakeholders. Three, establish a clear timetable of activities which are implemented regularly and use a team approach to service provision. Deliver a range of clinical services. Four, establish early detection of DR through screening services. Five, provide timely, relevant treatment or referral of patients who can’t be treated at the mobile service. And six, establish a follow-up service, such as repeat screening or follow-up after treatment. Finally, maintain quality. Number seven, monitor services and share the data with policymakers.
This data includes indicators such as numbers of people with diabetes examined, the proportion of people detected with visual impairment or blindness from diabetic retinopathy, the proportion of people with sight-threatening diabetic retinopathy, and the number of laser treatments done. In 2011, Dr. Kibata established a mobile diabetic retinopathy service in Kenya which he continues to manage today. In the next part of this video, he shares some of his learning with Dr. Nyawira Mwangi from the Kenya Medical Training College.
Nyawira: So let’s say you have a typical patient. How is the situation regarding access to services for that patient.
Kibata: So if you took a typical Kenyan diabetic service, they’ll probably will need to spend a whole day at a hospital. They have to travel long distances. So that’s the first problem. Once they finally reach the hospital, there may not be doctors. And so they are not very sure that they’re going to get all that service on that same day. They’ll probably be seen by a clinical officer or a nurse who then has to refer them to a second or third tier hospital. So that’s an additional trip.
When you look at the opportunity cost of this poor patient who probably earns his living or her living from daily payments from picking tea or doing that, it’s very, very expensive on them. And it disincentivises them, because of just the amount of lost revenue and lost time. And to cap the whole situation is finally, when they get the service provider, the service provider probably will not provide the service, because there is no laser, there is no that, there is no this. And so the patient is asking themselves, if they haven’t lost their sight by then, they probably still have good sight. And so they’re asking, why am I going through all this, and yet I can see.
And this is the context that we face day by day on the patient side.
Nyawira: So how would a mobile service address these barriers?
Kibata: So the whole idea of a mobile service is to then leap through all these barriers, barriers of availability, barriers of the skill, barriers of the equipment needed, barriers of distance. And so the good thing about diabetic eye disease is that the patient is first of all diabetic. And therefore, there is a point of care. There must be, unless the patient is not accessing or going to a diabetic clinic. There is a diabetic clinic along this health care chain. So that provides us with a point of care. And so what we want to do is say, well, since we have a point of care, we can then go and reach the patient there. And that’s the mobility bit.
The mobility bit is not on the patient. The mobility bit is on the provider. And that must be very clear, that you must be prepared to do the mobility, plus the equipment and whatever else is needed. And that is what we did. We said, look, we know that in every government hospital, they’re seeing 100 patients, probably, a day. And so if we are present, at that point, on that day, we can screen 100 patients on that day. That’s how the mobility or mobile service helps.
Nyawira: How did you mobilise the resources for this?
Kibata: So the way I did it is, to commit funding from the clinic which was already existing, that was one. There was a clear commitment on my part that we were going to run this service. But we also engaged potential donors. One of the people who we engaged was World Diabetic Foundation. And World Diabetic Foundation was able to fund the outreach truck that we used as a service provider, which had the lasers. And we designed it so that we could be able to give the interventions we needed at whatever point. We could go to a market. And if we see the diabetics there, we’d be able to provide service.
We also got a bit of a cost recovery from the patient, but that is very, very minor. But we did not want it to be absolutely free, because there’s also this problem where if everything is free, people don’t take it seriously. But we funded that programme ourselves, largely.
Nyawira: What about your team? You have to train them.
Kibata: So that was the initial barrier for us, developing the team. Remember, I was the one who wanted to do this. Other people didn’t know. So we had to get a driver who was willing, first of all, to drive those long distances and who was willing to multitask. We had to get a nurse and train them to do all the things that needed to be done, the visual acuity, the pressures. We had to get a clinic officer who we had to train to be able to examine the fundus and know what they’re seeing. So I had to develop a team that I was confident about.
And it actually took me almost a year before I could let that team go on their own. Now, that was a barrier for me, because where we were, we did not have existing staff. But where you have existing staff, it may not be a big barrier. The good thing is that because the patients come early, they want the service to start early. Two, we make sure that a month in advance, four weeks in advance, all the sites we are going to visit have been mapped. The people know we are going there. The patients know we are going there. All the stakeholders know a month in advance when we’ll be going there.
And in every centre that we go, we make sure we leave when we are coming next. We don’t go back and then start telling them. On that day we leave there, they know when we are coming next. We will arrive. We’ll do the registration of the patients. We’ll do the vision. We’ll do the eye pressures. We’ll do a blood pressure. And we will do a blood sugar. And we will dilate all the patients. Once we dilate, the clinic office usually will have a look. And all the normals will be declared normal and sent away. All the ones that have pathology– and then I will look at those who need a review by the ophthalmologist. That was how it ran initially.
After some time, the clinical officer became so good that he’s able to do a complete fundoscopy. And once we identify the people who need intervention from several visits, we then give them a central date where we then now come with a truck and the lasers and the avastins and all that needs to happen. And we intervene. So that now, when the truck comes, it’s coming to offer a service to prescreened patients. And we are coming knowing we are going to give 10 injections, we have 10 lasers, because we really know from the four visits how many people actually need interventions. We had to do that, because I was that only one at that point able to offer the interventions.
And I had to use my time wisely. But ideally, we should offer the service at the same sitting. Screen, whoever needs laser is taken to the truck, and the laser is offered.
Nyawira: So we do screening. We do treatment. We also do education and follow-up?
Kibata: Yes. So in this screening, especially the hospital-based screening where we are screening in the diabetic clinic, we would ask the nurse that the health education, we would give it. So we would give a health education on diabetic eye disease. Where we are running in a dispensary or a church setting or in the diabetic support group meeting, we do the health talk ourselves. What we did is, we got a big flip charts that have diabetic eye disease in the various stages. And we would show them what it looks like. We had eye models. We would show them what it looked like. But that was very, very important.
But what really made the difference is when we got a blind diabetic patient who was a teacher to join us in the health talk. He used to give the health talk. We found that to be amazing. I think they identify with it. He was very passionate. It wasn’t some foreign concept. Here was a man who was their age, talking their language, explaining to them how you went blind. That was a game changer for us, getting a blind diabetic ambassador to do the health talk. It really, really, really resonates with them.
In summary, a mobile diabetic retinopathy service must be considered when people with diabetes face challenges in accessing DR screening and treatment. The success of a mobile service is underpinned by good awareness amongst the population and providers about the need for it. To deliver successful outcomes and achieve long-term impact, a mobile DR service must - have a trained team, - provide both screening and treatment as close to the target population as possible, - monitor and maintain the quality of service provision, - achieve long-term acceptance by involving key stakeholders from the health system and the population, - and consider the long-term management of the service before it starts.
58 year old teacher Dora has come to the mobile DR service because she heard about its scheduled visit at the local health centre. She has recently noticed some vision loss which she initially attributed to getting old and needing glasses. Dora has been on insulin for type 2 diabetes and hydrochlorothiazide for hypertension for 7 years. During this period, she has had multiple emergency admissions to hospital with out of control diabetes. She does not monitor her blood sugars regularly but her last HbA1C test about 6 months ago was 11%.
This is Dora’s first eye examination since she was diagnosed with diabetes. She is distressed and worried. She never knew that diabetes could affect her sight. Her vision is found to be 6/60 in both eyes and does not improve with pinhole test. The fundus examination reveals she has severe pre-proliferative diabetic retinopathy and early cataracts.

A mobile diabetic retinopathy (DR) service is a public health strategy to provide targeted screening and other services to people with diabetes who live in different locations. A mobile DR service is essential in many places to maximise available resources and extend the reach of the service.

Key features of a mobile DR service

A mobile DR services needs to:

  • Provide a high quality service under all conditions
  • Provide a reliable and regular service to gain the support and confidence of local health providers and the population being served
  • Monitor data to keep track of the services being provided and the resources needed.

Important considerations for a mobile DR service

Before starting the service it is important to consider at the local level:

  • The evidence on the need for DR services in this setting
  • The current DR screening practices and guidelines
  • The activities to be carried out and outcomes to be achieved
  • Which locations to target, and how often
  • The local stakeholders that need to be involved
  • The values, beliefs and social customs in the target population
  • The resources that are needed including funding
  • The expectations for return on investment (ROI)
  • If there are potential conflicts with existing health services or service regulations
  • How will the service be coordinated and monitored
  • When the service could be stopped.

In the video on this step, we explore the key components of a mobile DR service and hear from Dr Kibata Githeko, who in 2011 established a DR mobile service in Kenya which he continues to manage today. He shares some of his learning with Dr Nyawira Mwangi from the Kenya Medical Training College.

Key components of a mobile DR service

As you go through this step, reflect on the factors that may affect the implementation and sustainability of a mobile DR service, within your setting or in Ormo (our hypothetical case study). At the planning stage, should we also consider when to stop mobile services at a particular location? If yes, what evidence would you use to guide the decision on when to stop?

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Diabetic Eye Disease: Building Capacity To Prevent Blindness

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