In this section, we share highlights from a discussion between Dr Nyawira Mwangi and Dr Kibata Githeko, ophthalmologist and vitreo-retinal surgeon who runs a mobile outreach DR service in Kenya. We discuss the need for mobile DR services and the process of implementing it. As you read this article, consider how you can maximize the return on investment.
Dr Nyawira: When is it necessary to set up a mobile DR service?
Dr Kibata: Setting up a mobile DR outreach service is an option, particularly when:
- Diabetes is a public health problem
- There is sub-optimal awareness about the eye complication among the people living with diabetes (PLWD), local health care providers or policy makers
- There is scarcity of resources for DR services, including trained health workers (availability)
- Current services are not reaching the entire population (accessibility)
- There are other patient-related barriers to care ( e.g affordability)
Dr Nyawira: What is involved in delivering a DR mobile outreach service?
Dr Kibata: The mobile service must have several components:
- Finding people with DR by targeting local diabetes clinics, patient support groups, pharmacy or other forums.
- Creating awareness about complication of diabetes in the eye . through health talks, distributing information education and communication (IEC) materials, using DR ambassadors, training health workers and advocacting with local stakeholders
- Health promotion to improve glycaemic control, lifestyle changes and regular monitoring of blood sugar
- Establish early detection of DR – through screening
- Timely relevant treatment or referral of patients for whom the service is not available at the mobile service
- Establishing a follow-up service such as repeat screening or follow up after treatment
Dr Nyawira: What outcomes should a mobile DR service achieve?
Dr Kibata For a mobile DR service to have an impact, it should aim to create a demand for the services and manage the supply of services through activities that
- Raise the awareness about Diabetic retinopathy and the importance of DR service.
- Provide both screening and treatment as an integral part of the service. There is no need to screen if there is no treatment.
- Maintain a regular timetable for services for continuity.
- Monitor the services and share the data, policy-makers. Such statistics would include: Numbers examined, the proportion of people with visual impairment and blindness from DR detected, the proportion with sight-threatening DR, and the number of laser treatments done.
Dr Nyawira: Tell us about your mobile DR service in Kenya
Dr Kibata: The mobile service in Kenya began running in 2011. We were already running a static service at UHEAL in Nairobi and we had examined the evidence on the prevalence of diabetes and diabetic retinopathy in Kenya. Building on this, we devised the mobile service as an integrated approach to address obstacles faced by patients in 5 targeted regions, all within a 200km radius from Nairobi.
We mapped the hospitals with diabetes clinics in these areas. We contacted the hospitals to obtain information on how often the clinics run in a week, the volume of patients and the distance to the facility. We then visited the clinics to engage with the PLWD, the health workers in diabetes and hypertension clinics as well as the hospital administration. Further, we visited diabetes support groups in the regions and policy makers at national level. We got buy-in from all the stakeholders.
Through partnership with the Ministry of Health, and through a grant from World Diabetes Federation, we acquired a truck, whose body was assembled locally according to our specifications. The truck has a mobile examination and treatment unit, which includes facilities for slit lamp examination, laser and intravitreal injections. There is also a waiting area with a tent and chairs, where health education is provided. The services are provided at agreed venues. The truck goes out weekly for screening, whereas treatment services are provided on a predetermined day at a central location in each region each month.
We later delinked the mobile service from the static clinic, and had a dedicated team to provide health education, patient education, screening, referral and follow-up components on a weekly outreach visit. This includes a driver, nurse, ophthalmic clinical officer and an administrator. These staff received intensive training to run the service. Treatment interventions for DR are provided by the ophthalmologist during the monthly treatment day. Patients who need services not provided at the mobile service are referred to the static clinic. Treatment cost was cheaper than the static clinic.
The service has relied on the support of patients and health care providers. Patients invite members of their support groups to attend. Patient representatives also act as ambassadors and give health talks to peers. Health workers, particularly senior nurses at the diabetes clinics, have been effective advocates for the service. They also refer patients with diabetes to the mobile unit, which increases efficiency.
The mobile service thus brings screening and treatment points very close to patients on a regular basis. It also works within the flow of existing diabetes services to avoid creating a disruption.
Dr Nyawira: What challenges have you encountered in the mobile service in Kenya?
Dr Kibata: We have encountered a number of constraints:
- The mobile service is labor-intensive. In order to be at the agreed venues on time, and to take care of the high volume of patients, we have had to leave Nairobi as early as 4am and return late in the night. This caused lots of fatigue on the day of outreach and subsequent days.
- The training investment required to maintain high quality in screening is very high
- Shortage of staff for the service, as it requires an especially trained and highly motivated workforce
- Technology challenges: the electronic database became corrupted; we did not have a fundus camera dedicated to the mobile service
- Patients may not afford the service and do not have insurance
- Some of the patients did not like the dilatation of the pupils for screening
- Patients who are not attending diabetes services and who are not members of support groups are difficult to reach
- The running costs of the mobile service are very high
- Dealing with the cataract challenge effectively remains a critical problem even in a DR service and is often a barrier to laser treatment.
- Sustainability of the program is affected by multiple logistical and health system obstacles
- Expectation that the intervention will improve vision and when it does not, then you have skepticism on the intervention.
Thank you Dr Kibata for sharing with us this experience.
Your take
Looking into the future, what do you think will be the key developments in mobile DR services?
What will the biggest challenges be?
How can you monitor the coverage of the target population for your screening program?
© Nyawira Mwangi
Control of Diabetic Retinopathy 