Addressing cataract in rural Malawi: the Nkhoma Eye Programme

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Author:

1.       William H, DeanCBM Ophthalmologist: Nkhoma Eye Hospital, Nkhoma, Malawi.

2.       Justin C Sherwin, Ophthalmology Registrar: Royal Victorian Eye and Ear Hospital, Melbourne, Australia.

3.       Ephraim Kambewa, Ophthalmic Clinical Officer Cataract

4.       Nick H Metcalfe, CBM Ophthalmologist: Nkhoma Eye

Malawi has four main eye care centres for its population of 14.8 million. The eye unit based at Nkhoma Eye Hospital opened in 1955, and CBM has been supporting it since 1977. The hospital is the home of the Nkhoma Eye Programme (NEP), which was started as a VISION 2020 district programme in 2000. In cooperation with the Malawi Ministry of Health (MOH) and other, non-governmental, organisations, the programme provides eye care services in central-western and centraleastern Malawi (population 4.5 million). Cataract operations are performed by an ophthalmologist and a clinical officer who trained as a cataract surgeon. In 1999, the prevalence of blindness (visual acuity [VA]<3/60 in the best eye) in people aged 40 years or older in Nkhoma was estimated at 3.7%, of which 62% was due to cataract.1 Only one in seven people who were blind from cataract and living within 10 miles of Nkhoma had been operated on. A survey conducted seven years later, in 2006, estimated the prevalence of blindness at 1.3%2, of which 36% was due to cataract.3 By then, four out of every five people who were blind from cataract and living within 10 miles of Nkhoma had been operated on. Here, we discuss the strategies that led to improved management of cataract.

Case finding

Since 2003, NEP has been involved in the screening of over 30,000 people per year for cataract. Only 5% of people self refer. NEP uses three methods for case finding.

• Three community member, employed by NEP, run daily clinics to screen for cataracts in designated districts and villages (25% of case finding).

• Eight mobile eye clinics, run by NEP, visit villages in the catchment area according to a well-publicised schedule (35% of case finding).

• NEP cooperates closely with the Malawi Council of the Handicapped (MACOHA), whose community-based health care workers assist with case finding (30-40% of case finding).

Quality of surgery

Since 2004, all operations have been performed using a suture less technique. The quality of surgery is high, and all outcomes are prospectively monitored. Approximately 90% of operations result in a good outcome (VA≥6/18) following correction. Less than 2% have a poor outcome (VA<6/60).

Increased surgical output

The number of cataract operations performed per year has risen from just over 400 in 1999 to over 4,000 in both 2008 and 2009 – a ten-fold increase in ten years. There also have been significant increases in cataract surgical output since the initiation of VISION 2020 program in two districts in East Africa (Kwale in Kenya, and Kilimanjoro in Tanzania). Similarities between Nkhoma Patients waiting for surgery at Nkhoma and these districts include:

• assistance with transport

• free examinations

• close links between the hospital and community services

• minimal waiting times before surgery.

Additional factors at NEP include:

• active case finding

• training of ophthalmic clinical officers to perform cataract surgery

• surgical outreach

• infrastructure development

• Support from national and international partners

• Patient satisfaction with post-operative outcomes and rehabilitation, which has led to a good reputation in the community

• Strong links with traditional authorities, village headmen and chiefs who assist in mobilising their communities, selecting volunteers and promoting our services. One Nkhoma ophthalmologist and the MACOHA coordinator have permanent positions on the National Committee for the Prevention of Blindness (NCPB). Cooperation with the MOH and other stakeholders ensures that limited resources are maximised. The NEP and MACOHA are fully integrated into the Malawi National VISION 2020 plan.

NEP has improved its eye care services over the last decade. An emphasis on continual improvement and the development of trained ophthalmic staff will help to ensure sustainability in eye care delivery in the future.

Opinion:

This article is very great. Ten years of Malawi Nkhoma Eye Program (NEP) program conducted in Malawi is a good example how the longterm program can be sustainable and reach success. One point that we can underlined was the increasing number of cataract surgery which reach ten folds after ten years of programme implementation. However, NEP is maintaning its continous improvement. The points which support the success of NEP program was very comprehensif, as mentioned above in the article.

Some success strategies in cataract management in rural area are:

1. The three most effective case finding strategies: Daily clinics to screen for cataracts in designated districts and villages, mobile eye clinics visit villages in the catchment area according to a well-publicised schedule, and cooperation with Malawi Council of the Handicapped (MACOHA), whose community-based health care workers assist with case finding.
2. The quality of surgery must be maintained. The operation established in Malawi was using suture less technique. Furthermore, all outcomes must be prospectively monitored.
3. Stretegy in increasing surgical output in patient management are: assistance with transport, free examinations, close links between the hospital and community services, minimal waiting times before surgery, active case finding, training of ophthalmic clinical officers to perform cataract surgery,surgical outreach, infrastructure development, Support from national and international partners, patient satisfaction with post-operative outcomes and rehabilitation, which has led to a good reputation in the community and strong links with traditional authorities, village headmen and chiefs who assist in mobilising their communities, selecting volunteers and promoting our services.

References

1 Eloff J, Foster A. Cataract surgical coverage: results of a population-based survey at Nkhoma, Malawi. Ophthalmic Epidemiol 2000;7(3):219-21.

2 Dean WH, Patel D, Sherwin JC, Metcalfe NH. Follow-up survey of cataract surgical coverage and barriers to cataract surgery at Nkhoma, Malawi. OphthalmicEpidemiol 2011;18(4):171-8.

3 Sherwin JC, Dean WH, Metcalfe NH. Causes of blindness at Nkhoma Eye Hospital, Malawi. Eur J Ophthalmol 2008;18(6):1002-6.

4 Lewallen S, Roberts H, Hall A, Onyange R, Temba M, Banzi J, et al. Increasing cataract surgery to meetVision 2020 targets; experience from two rural programmes in east Africa. Br J Ophthalmol 2005;89(10):1237-40.

The potential impact of a cataract surgery programme on the care of orphans and vulnerable children in Swaziland

J Pons, W Mapham, B Newsome, L Myer, R Anderson, P Courtright, C Cook

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Abstract

We aimed to evaluate the potential impact of a cataract surgery programme at the Good Shepherd Hospital, Siteki, Swaziland, on the care of orphans and vulnerable children in Swaziland. We studied consecutive patients aged 50 years and older undergoing surgery for age-related cataract who reported having children living in their household. Of 131 subjects recruited, 65 (49.6%) were the primary caregivers for the child(ren) in their household. Visual acuities measured 2 weeks after surgery significantly improved. Four weeks after surgery, there was a sizable increase in the proportions of subjects who were able to undertake self-care activities, attend to activities of daily living, undertake income-generating activities and care for children. Cataract surgery on elderly visually impaired patients has the potential to impact positively on the care of orphans and vulnerable children.

Reference:

J Pons, W Mapham, B Newsome, L Myer, R Anderson, P Courtright, C Cook, The potential impact of a cataract surgery programme on the care of orphans and vulnerable children in Swaziland S Afr Med J 2012;102:140-141. March 2012, Vol. 102, No. 3 SAMJ

Opinion:

This study is distinctive, because it broaden cataract management consideration. Cataract management outcome will affect patient quality of life. Patients capability of seeing again after cataract surgery will influence his/her particular population. An extraordinary example is stated in this study, where orphans care will be improved by cataract management of their grandparents.  Actually, Swaziland has the highest documented prevalence of HIV in the world, resulting in a large number of orphans whose grandparents provide care for them. In this study, half the subjects reported being the primary caregiver for the child(ren) living in their homes, despite being visually impaired from their cataract. Visual acuities and the range of activities they were able to perform, including child care activities and income-generating activities, significantly improved following surgery.

Indonesia is rich in its soacial culture and high population diversity among. So that in cataract management program, we should pay attention on prticular aspect closely correlated to specific comunity uniqueness. So, this article is broaden our insight in arranging program to be extensive correspond to multi dimentional aspect of specific population condition.   

             

Effectiveness and cost-effectiveness of an internet intervention for family caregivers of people with dementia: design of a randomized controlled trial

ABSTRACT

Background: The number of people with dementia is rising rapidly as a consequence of the greying of the world population. There is an urgent need to develop cost effective approaches that meet the needs of people with dementia and their family caregivers. Depression, feelings of burden and caregiver stress are common and serious health problems in these family caregivers. Different kinds of interventions are developed to prevent or reduce the negative psychological consequences of caregiving. The use of internet interventions is still very limited, although they may be a cost effective way to support family caregivers in an earlier stage and diminish their psychological distress in the short and longer run.

Methods/design: A pragmatic randomized controlled trial is designed to evaluate the effectiveness and cost-effectiveness of ‘Mastery over Dementia’, an internet intervention for caregivers of people with dementia. The intervention aims at prevention and decrease of psychological distress, in particular depressive symptoms. The experimental condition consists of an internet course with 8 sessions and a booster session over a maximum period of 6 months guided by a psychologist. Caregivers in the comparison condition receive a minimal intervention. In addition to a pre and post measurement, an intermediate measurement will be conducted. In addition, there will be two follow-up measurements 3 and 6 months after post-treatment in the experimental group only. To study the effectiveness of the intervention, depressive symptoms are used as the primary outcome, whereas symptoms of anxiety, role overload and caregiver perceived stress are used as secondary outcomes. To study which caregivers profit most of the internet intervention, several variables that may modify the impact of the intervention are taken into account. Regarding the cost-effectiveness, an economic evaluation will be conducted from a societal perspective.

Discussion: This study will provide evidence about the effectiveness and cost-effectiveness of an internet intervention for caregivers. If both can be shown, this might set the stage for the development of a range of internet interventions in the field of caregiving for people with dementia. This is even more important because future generations of caregivers will be more familiar with the use of internet.

My Opinion:

This study try to design a RCT to evaluate the effectiveness and cost-effectiveness of an internet intervention for caregivers of people with dementia. In the background, this study stated that research has shown that particular types of interventions are effective.

Internet intervention could be an effective program because family caregivers may favor internet interventions instead of meeting in a group or meeting with a professional face-to-face, due to lack of time or preferences concerning privacy. Caregivers may also be unwilling to visit a mental health care institute for themselves because in their view they are not the ones who need help.

One of the main characteristics of effective interventions is a psychological rather than purely educational approach. That's from the content of the intervention given to the caregiver, stated by the author of this study design. 

One thing I see quiet good in this study is the economic analyses. This economic evaluation will involve both a costeffectiveness analysis (CEA) and a cost-utility analysis (CUA). From this analysis, it will be more clear to see if this kind of intervention will be cost effective or not.

Reference : https://www.researchgate.net/publication/280099823_Effectiveness_and_cost-effectiveness_of_an_internet_intervention_for_family_caregivers_of_people_with_dementia_design_of_a_randomized_controlled_trial

Mobile Health Clinics in the Era of Reform

Objectives: Despite the role of mobile clinics in delivering care to the full spectrum of at-risk populations, the collective impact of mobile clinics has never been assessed. This study characterizes the scope of the mobile clinic sector and its impact on access, costs, and quality. It explores the role of mobile clinics in the era of delivery reform and expanded insurance coverage. 
Study Design: A synthesis of observational data collected through Mobile Health Map and published literature related to mobile clinics.
Methods: Analysis of data from the Mobile Health Map Project, an online platform that aggregates data on mobile health clinics in the United States, supplemented by a comprehensive literature review.
Results: Mobile clinics represent an integral component of the healthcare system that serves vulnerable populations and promotes high-quality care at low cost. There are an estimated 1500 mobile clinics receiving 5 million visits nationwide per year. Mobile clinics improve access for vulnerable populations, bolster prevention and chronic disease management, and reduce costs. Expanded coverage and delivery reform increase opportunities for mobile clinics to partner with hospitals, health systems, and insurers to improve care and lower costs.
Conclusions: Mobile clinics have a critical role to play in providing high-quality, low-cost care to vulnerable populations. The postreform 
environment, with increasing accountability for 
population health management and expanded access among historically underserved populations, should strengthen the ability for mobile clinics to partner with hospitals, health systems, and payers to improve care and lower costs.

Opini:
Jurnal ini memberi tahu mengenai peranan mobile health clinic di United State. Pengumpulan data diperoleh dari Mobile health map project yang merupakan program online dari mobile health clinic di United State.
Dari jurnal ini didapatkan bahwa: 
Mobile clinics are an integral component of the healthcare system, serving vulnerable populations and promoting high-quality care at low cost.

• There are an estimated 1500 mobile clinics, receiving 5 million or more annual visits nationwide.

• Mobile clinics improve access for vulnerable populations, bolster prevention and chronic disease management, and reduce costs.

• Expanded coverage and delivery reform increase opportunities for mobile clinics to partner with hospitals, health systems, and insurers to improve care and lower costs.

Referensi:

1. http://www.ajmc.com/journals/issue/2014/2014-vol20-n3/mobile-health-clinics-in-the-era-of-reform/P-1

http://www.ajmc.com/journals/issue/2014/2014-vol20-n3/mobile-health-clinics-in-the-era-of-reform/P-1#sthash.UbDkeXsL.dpuf

Community-based approach for prevention and control of dengue hemorrhagic fever in Kanchanaburi Province, Thailand

full article

Manirat Therawiwat1, Wijitr Fungladda2, Jaranit Kaewkungwal2, Nirat Imamee1 and Allan Steckler3 

 

Abstract

An action research design was conducted in two villages of Mueang District, Kanchanaburi Province to assess the effectiveness of a community-based approach program. Knowledge, perceived susceptibility, self-efficacy, and regular larval survey behavior were measured for program outputs. Container Index (CI), House Index (HI), and Breteau Index (BI) were used to confirm program outcomes. Key community stakeholders in the experimental village were identified and empowered through active learning in the village. Monthly meetings with the key stakeholders were used to share experiences learned, to reflect on the program outputs and outcomes as well as to plan for the next cycle of program activities. The program was quite successful. Knowledge, perception, self-efficacy, and larval survey practices in the experimental group were significantly higher than before the experiment, and higher than the comparison group. CI, HI, and BI were decreased sharply to better than the national target. Community status as community leaders was the best predictor for larval survey behavior at the first survey. Participating in the study program activities was the best predictor at the end of the program. The results from this study suggest that the dengue hemorrhagic fever (DHF) prevention and control program at the sub-district health level should be more proactive and emphasized at the village level. Monitoring the disease control program outputs and outcomes should be performed regularly during monthly meetings. Finally, local health officers need to be empowered for these matters  

OPINION

Efforts to control Aedes mosquitoes have been redirected from local health services at the provincial level to community-based control using village health volunteers. Efforts have not been effective and DHF is still a major health problem in all areas of the country. The one cost-effective measure that provides effective disease control over the long run is involving the persons who are responsible for creating or tolerating Aedes aegypti larval habitats in the local community environment in control or elimination of those habitats. They will learn that it is in their best interest to participate with other members of their community to create community ownership of their program (Gubler and Clark, 1996).  

the community-based empowerment program that allowed the key community stakeholders to actively participate in continuing education activities starting from conducting a community survey, identifying the problem, planning, action and observation, reflection, and re-planning with the sub-district health officers and researcher. Representatives of each household developed the control or elimination of mosquito breeding places and weekly larval survey activities with the assistance of the key stakeholders of that village zone. The activities at the household level were more specific to each household context, specifically the mosquito breeding places. The activities were also developed around the basic concept of the problem solving process. In this case, the activities were started from mapping of possible breeding places of mosquitoes in and around the house, identification of the breeding places, identification of possible solutions, implementation the selected solutions, monitoring and evaluation of the implementation outcomes through regular larval surveys. Besides these activities, the learning experiences of each key community stakeholder were shared and discussed in a monthly meeting in the village. The experiences were used as the inputs for project activities monitoring and re-planning.

Empowering key community stakeholders through active participation in on going activities played a great role in program success. Working for DHF prevention and control in the village as a partnership among primary, secondary, and tertiary stakeholders was also crucial.

 

Building and analyzing an innovative community-centered dengue-ecosystem management intervention in Yogyakarta, Indonesia

full article

Susilowati Tana*1 , SittiRahmah Umniyati2 , Max Petzold3 , Axel Kroeger4,5, Johannes Sommerfeld4

ABSTRACT

Background and Objectives: Dengue is an important public health problem in Yogyakarta city, Indonesia. The aim of this study was to build an innovative community-centered dengue-ecosystem management intervention in the city and to assess the process and results. 

Methods: For describing the baseline situation, entomological surveys and household surveys were carried out in six randomly selected neighborhoods in Yogyakarta city, documents were analyzed and different stakeholders involved in dengue control and environmental management were interviewed. Then a community-centered dengue-ecosystem management intervention was built up in two of the neighborhoods (Demangan and Giwangan) whereas two neighborhoods served as controls with no intervention (Tahunan and Bener). Six months after the intervention follow up surveys (household interviews and entomological) were conducted as well as focus group discussions and key informant interviews. 

Findings: The intervention results included: better community knowledge, attitude and practices in dengue prevention; increased household and community participation; improved partnership including a variety of stakeholders with prospects for sustainability; vector control efforts refocused on environmental and health issues; increased community ownership of dengue vector management including broader community development activities such as solid waste management and recycling.

Conclusion: The community-centred approach needs a lot of effort at the beginning but has better prospects for sustainability than the vertical ‘‘top-down’’ approach.

OPINION

In this article shown that in-depth interviews with city government officers showed the following: Although there are defined community structures with leaders, volunteers and assemblies (forums) the 3M campaign (see introduction) is often not implemented by community members and is therefore limited in scope. The community sees dengue control as a government responsibility, and has limited knowledge about mosquito breeding places. The most common community education programme is to show banners and distribute leaflets at community health centres and district health offices but such one-way communication is not very effective and is limited in coverage. These promotion efforts have resulted in increased community knowledge about dengue vector control but not in improved behavior concerning source reduction.
Outcomes of the intervention included: increased community knowledge, attitude and practices in dengue prevention; increased household and community participation; prospects for sustainability and continued partnership; routine community vector control efforts refocused on environmental and health issues.
It can be seen that the community-centred multistakeholder approach needs more efforts at the beginning but has better prospects for sustainability than the vertical ‘‘top–down’’ approach, which achieves high coverage levels at the start but needs a maintained effort on the side of the public control services.

Bringing Breakfast to Our Students A Program to Increase School Breakfast Participation

Abstract

The relationship between breakfast consumption and academic success has been extensively studied over the past 30 years. Despite the wide availability of school breakfast programs and the preponderance of evidence that breakfast consumption has positive effects on a student’s ability to learn and function in the school setting, many students do not eat breakfast. A survey of students at a large Midwestern high school identified the main barriers to breakfast consumption as not having enough time in the morning to eat and not feeling hungry before school. A program that included extending breakfast cafeteria hours and providing a mobile cart that served a complete school breakfast during students’ morning study hall classes was implemented. By the end of the school year, average daily school breakfast participation increased by more than 400%. In a student survey conducted 6 months after implementation of the program, more than a quarter of the students reported purchasing food from the cart.

Opini

Pada jurnal ini, kita dapat mengetahui evaluasi penerapan program sarapan sekolah di Midwestern High School yaitu alasan mengapa siswa enggan sarapan di pagi hari, yaitu :

1.      Anak tidak memiliki cukup waktu untuk sarapan pagi hari

2.      Anak merasa tidak lapar sebelum ia berangkat ke sekolah

Setelah dilakukan evaluasi, sekolah menerapkan program sarapan di sekolah berupa :

1.      Merubah jam buka pada kantin di sekolah, lebih pagi

2.      Menyediakan mobile cart yang melayani sarapan selama siswa menjalani morning study hall classes

Melalui penerapan program ini, didapatkan adanya signifikansi peningkatan sarapan di sekolah hingga 400%.

Pada jurnal ini, kita dapat mengetahui bahwa pada siswa sekolah menengah yang sudah merasa perlu sarapan pagi, mereka bisa menjalankan program sarapan pagi di sekolah secara mandiri tanpa dibuatkan program khusus untuk semua anak pada waktu yang ditentukan. Program sarapan di sekolah secara mandiri ini juga dapat memberikan variasi menu makanan pada siswa yang sesuai dengan keinginannya. Selain keuntungan yang diperoleh, ada juga sisi negatif yang mungkin muncul akibat ketidaksamaan yang terjadi yaitu : level ekonomi keluarga yang bervariasi dan sulitnya mengontrol nilai gizi atas asupan makanan yang dikonsumsi.

References

http://jsn.sagepub.com/content/29/4/263.full.pdf