ORIGINAL CLINICAL STUDY
Diabetes and Diabetic Retinopathy Management in East Africa: Knowledge, Attitudes, and Practices of Hospital Staff in Kenya David G. Kupitz, MD,* Eva Fenwick, BA,Þ K. H. Martin Kollmann, MD,þ Frank G. Holz, MD,* and Robert P. Finger, MD*Þ
Purpose: Good diabetes mellitus (DM) and diabetic retinopathy (DR) management depends largely on involved medical staff, prompting us to investigate knowledge, attitudes, and practices about DM and DR at a tertiary referral center in Kenya. Design: The design for this study is exploratory qualitative using semistructured interviews. Methods: Data from eye and diabetes clinic staff were collected until thematic saturation was reached, transcribed, and iteratively analyzed for relevant themes based on the constant comparative method. Results: Among 46 participants (mean age, 38 years; 54% females), most were physicians (n = 25, 54%), followed by nurses (n = 14, 30%) and clinical officers (n = 6, 13%). Diabetes mellitus and DR were seen as urgent health problems (n = 42, 91%), and regular ophthalmic screening of diabetic patients was universally recommended. Two thirds (n = 32, 70%) were unaware of DM and DR management guidelines at the hospital. Participants identified training of staff in diagnosing (n = 30, 65%), efficient detection and referral of diabetic patients (n = 24, 52%), and improved outreach services (n = 14, 30%) as most pressing areas of need. Communication among hospital departments was found to be suboptimal. Reported barriers to good DR management were lack of retinal laser treatment and costs. Conclusions: Management outcomes for DM and DR may be improved by implementing integrated service provision, direct ophthalmological involvement in diabetic clinics, endorsement and effective distribution of guidelines, an increase in screening capacity, and the introduction of ongoing medical education covering DM and DR. Key Words: diabetes mellitus, diabetic retinopathy, Africa, KAP (knowledge, attitudes, practice), screening (Asia-Pac J Ophthalmol 2014;3: 271Y276)
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he prevalence of type 2 diabetes mellitus (DM) is projected to increase substantially over the coming decades worldwide, rising from 2.8% in 2000 to 4.4% in 20301 leading to the number of people with diabetes increasing from 284.6 million in 2010 to 438.4 million in 2030.2 Long-standing diabetes leads to a number of severe complications, mainly affecting the kidneys, the cardiovascular system, the eyes, and various aspects
From the *Department of Ophthalmology, University of Bonn, Bonn, Germany; †Centre for Eye Research Australia, The Royal Victorian Eye and Ear Hospital, University of Melbourne, Melbourne, Australia; and ‡Department of Ophthalmology, University of Nairobi, Nairobi, Kenya. Received for publication April 26, 2013; accepted August 5, 2013. The authors have no funding or conflicts of interest to declare. Reprints: Robert P. Finger, MD, Department of Ophthalmology, University of Bonn, Ernst-Abbe-Str. 2, 53127 Bonn, Germany. E-mail: robertfi[email protected]. Copyright * 2013 by Asia Pacific Academy of Ophthalmology ISSN: 2162-0989 DOI: 10.1097/APO.0b013e3182a83bfa
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of the nervous system.3 After 15 years of living with diabetes, approximately 2% of people become blind, and about 10% develop severe visual impairment due to ocular complications.4 Largely because of demographic and lifestyle changes, subSaharan Africa will be affected by a particularly steep increase in prevalence of DM during the coming years and decades.1,2,5 This is likely leading to a higher incidence and prevalence of ocular complications of DM, such as diabetic retinopathy (DR),5 which is already a leading cause of blindness in people of working age in developed countries. In the United States, for instance, DR at 17% is the leading cause of new cases of legal blindness in adults aged 20 to 74 years,6 and its prevalence in adults aged 40 years and older is 3.4%.7 Furthermore, current trends of increasing DM prevalence have led to declining vision in middle-aged persons in the United States.8 In sub-Saharan Africa, the contribution of DR to the overall prevalence of blindness is unknown, but DR affects 16% to 55% of people with DM depending on the duration and glycemic control, with some 21% to 25% of people with newly diagnosed type 2 DM presenting with retinopathy.9 Health care services in Africa have largely not kept pace with this growing challenge,10 and few interventions have focused on DR management and prevention of visual impairment.11 The Vision 2020 Action Plan 2006Y2011 has recognized DR as a priority eye disease. It emphasizes the need for highly organized health care systems, well-trained personnel, and adequate equipment.12 Against this background, the knowledge, attitudes, and practices (KAP) of medical and eye care staff are particularly important because these health professionals directly affect management outcomes at the interface between scientific theory and clinical practice. In developing countries, several studies have shed light on patients’ KAP regarding DM and DR.13Y17 However, only a few studies have examined general practitioners’ knowledge of diabetic eye disease,18Y21 and to the authors’ knowledge, no study has assessed KAP of eye and diabetes care providers in Africa. A KAP survey is a representative study of a specific population used to investigate health behavior, and today they are widely used to gain information on health-seeking practices by collecting information on what is known, believed, and done in relation to a particular topic.22 KAP surveys commonly have a simple design, yield quantifiable data, are easy to interpret, and allow for a concise presentation of results and generalizability of small sample results to a wider population as well as cross-cultural comparability. To make a KAP more comprehensive, it has been suggested to include qualitative methods, such as focus group discussions and in-depth interviews to better reflect the survey’s context.23 Therefore, we conducted a KAP survey enhanced with indepth interviews regarding DM and DR management among the staff at a Kenyan tertiary referral hospital. The main objectives of the study were to explore the staff’s current KAP, to identify problems and shortcomings, and to formulate
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recommendations for improvements in KAP and thus DM and DR management.
MATERIALS AND METHODS The study was set at the Kenyatta National Hospital (KNH) in Nairobi, the capital of Kenya. Kenyatta National Hospital is the largest national referral, teaching, and research hospital in the country.
Study Sample Participants worked in the Departments of Internal Medicine or Ophthalmology at KNH. All were involved in the management of diabetic patients, mostly through outpatient clinics. Staff groups included physicians (diabetologists and ophthalmologists, including registrars in training), clinical officers, nurses, patient educators, and nutritionists. Because it is usual in qualitative studies, the sample size estimate was based on the researchers’ judgment of informational representation24 and was set at 50 to allow for all relevant professions to be included in sufficient numbers, yield a comprehensive picture of the current situation, and minimize redundancy of information. A convenience sampling approach was used, whereby eligible staff present at the respective clinics and willing to be interviewed were recruited. Ethical approval for the study was obtained from the ethics and research committee of the KNH. Every participant gave written informed consent before the interview. The study adhered to the tenets of the Declaration of Helsinki.
Data Collection Data were collected using semistructured interviews by a trained interviewer (D.G.K.). The interviews were guided by a set of open-ended questions developed from a literature review and input from local ophthalmologists and diabetologists. Topics covered included knowledge about DM and its ocular complications; attitudes toward management of diabetic patients,
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colleagues, and the efficacy of the health care system; and current DM and DR management practices at the hospital. The format allowed for additional questions and topics to be covered as they arose over the course of the interview. In addition, participants were asked to rate 16 statements regarding DM and DR management on a 5-point Likert scale from strongly agree to strongly disagree (Table 1). Questions and statements were adapted from existing questionnaires25 and complemented by additional questions relevant to the study objective. Face-toface interviews lasted for about 30 to 45 minutes and were conducted in English using a separate room at the respective outpatient clinic to allow for privacy.
Data Analysis The interviews were recorded as audio files and subsequently transcribed. The transcript from each interview was iteratively analyzed for relevant themes and categories using an inductive analytical approach based on the constant comparative method. This approach allows broad themes to be developed from the raw data, which are constantly modified and refined based on new ideas emerging from the analysis.26,27 The qualitative software program QSR NVivo 2.0 (QSR International Pty Ltd, Australia) was used to systematically code the transcripts. A second researcher also reviewed the data using this method, and any discrepancies were resolved through discussion. This method of analysis produces a clear audit trail, which maximizes the reliability and objectivity of the conclusions. The Preferred Practice Patterns for DR management of the American Academy of Ophthalmology16 were used as reference guideline to assess the level of knowledge and reported practice patterns.
RESULTS Sample Characteristics Between October and December 2009, a total of 46 participants were interviewed. A further 4 staff members declined
TABLE 1. Responses to Attitude Statements (in Percent of Participants, n = 46) Agree, %
Statement 1. DR is a common health problem. 2. More uneducated people have diabetes than those who are educated. 3. Diabetics are more likely to develop eye problems than nondiabetic patients. 4. As long as the diabetes is kept under control, there is no need to worry about diabetic complications. 5. Screening for retinopathy is necessary among diabetic patients. 6. All diabetic patients must be referred to ophthalmologists. 7. If diabetes is treated early on, damage due to DR can be prevented. 8. Referring the diabetic patient to an ophthalmologist can prevent DR. 9. If the doctor has told the diabetic patient to come for regular follow-up, the patient will come. 10. Diabetic patients are knowledgeable about their disease. 11. Diabetic patients themselves are mainly responsible for their eye health. 12. DR is sufficiently covered in the curriculum during my studies. 13. I receive enough continuous education on DR. 14. Diabetic services are allotted with a sufficient budget in the hospital. 15. The use of mobile DR screening vans would be helpful. 16. The use of trained photographic readers of retinal images would be helpful.
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Disagree, % Undecided, Strongly Moderately % Moderately Strongly 56 7 78
35 13 9
2 4 4
7 28 4
48 4
15
24
2
20
39
100 78 54 33 30
17 37 28 46
2 2 2
4 7 15 15
22 7
7 17 22 15 4 67 57
48 24 35 17 22 22 33
9 2 7 4 30 4 9
26 39 22 37 26 2
11 17 15 26 17 4 2
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Knowledge, Attitudes, and Practices in DM and DR
participation. Mean age T standard deviation of participants was 38 T 8 years, and half of the sample (n = 25, 54%) were female. Participants were mostly physicians (n = 25, 54%); a third (n = 14, 30%) were nurses, 13% (n = 6) clinical officers, and 1 nutritionist. Two thirds (n = 30, 65%) of participants worked in the Department of Ophthalmology and one third (n = 16, 35%) in the Department of Internal Medicine (ie, the diabetic outpatient department). Demographic characteristics are summarized in Table 2.
random or fasting blood glucose levels, medical history, and HbA1c levels if available (depending on laboratory supply) at the KNH and elsewhere. Twenty-five interviewees (50%) reported personally examining diabetic patients for DR. Among the 20 participants who did not screen patients for DR, 30% (n = 6) said they had received some form of training in fundoscopy but did not routinely practice it. Most medical outpatient clinic (MOPC) staff (n = 11, 69%) reported a lack of diagnostic ophthalmic equipment at their clinic.
Basic Diabetes Knowledge
Diabetic Retinopathy Screening and Referral
Diabetes mellitus prevalence in Kenya was estimated by participants to range from 0.03% to 80% of the total population. The current reported prevalence estimate is 4.2%,28 and just over one third (n = 17, 38%) of participants’ estimates were within a 3% range of this figure. Virtually, all (98%) reported the prevalence to be increasing. Ocular complications caused by DM were known by all participants with 87% (n = 40) mentioning DR, whereas the remaining 13% (n = 6) mentioned either retinal problems, bleeding vessels, or retinal detachment. Most participants were aware of poor blood glucose control as a risk factor for the development of DR (n = 43, 93%). Less frequently mentioned were hypertension (n = 24, 52%) and hyperlipidemia (n = 5, 11%). When asked about presentation and symptoms of DR, 96% (n = 44) mentioned poor, reduced, or blurred vision, whereas only 28% (n = 13) knew that the condition is typically asymptomatic in its early stages.
All participants agreed upon the importance of DR screening in diabetic patients; however, only half believed that ocular checkups could prevent visual impairment from DR (n = 28, 61%). Most participants mentioned the need for additional DR screening methods, such as mobile screening vans and remote assessment of photographic retinal pictures by trained graders (both n = 41, 89%), to improve the quality of the diagnosis and the capacity of the current services. Frequently mentioned problems in relation to DR screening were lack of outreach services or mobile clinics in rural Kenyan areas (n = 14, 30%), late diagnosis of DM in most patients (n = 14, 30%), and lack of public awareness of the problem (n = 14, 30%). Eleven participants (24%) suggested a comprehensive DM center with an integrated eye component or the presence of an ophthalmologist and basic ophthalmic equipment at DM clinics as possible solutions. Nine participants (20%) knew the recommended referral time for an ocular checkup for type 1 diabetic patients (5 years after diagnosis or at the age of 11 years, whichever occurs first29). Most (n = 40, 87%) knew that type 2 diabetic patients should be referred for an eye examination immediately after diagnosis. Among nonophthalmic health care personnel, the majority (75%) interviewed referred diabetic patients for eye checkups immediately after diagnosis and were aware of the importance of regular eye checkups. Although 88% (n = 14) of the staff at the medical outpatient department stated that every newly diagnosed diabetic patients should be referred for an ocular checkup, only two thirds (n = 10) believed that referrals were seen to completion. Among the eye clinic staff, less than half (n = 14) felt that all newly diagnosed diabetic patients were referred for screening. Around a third of all participants (n = 12, 26%) reported that only diabetic patients with eye complaints were referred for an ocular checkup. An unknown but significant proportion of patients were believed to be ‘‘lost on the way’’ to the eye clinic after referral from the medical outpatient clinic. Overall, lack of early referral of diabetic patients to an
‘‘They appear to be on the rise, and that may not be an actual increment; it may just be that more people are becoming aware and are now presenting. On the other hand, our diets are changing; they are becoming more westernized, and that may be influencing how many people are actually developing the diabetes. So I think they are increasing for those 2 reasons’’ (Int. 41, registrar ophthalmology).
Management Diagnostics Participants reported that most patients presenting to the diabetes outpatient clinic had already been diagnosed with DM elsewhere and were referred. Participants believed that presence of DM and DM control were usually assessed by
TABLE 2. Personal Characteristics of the Sample
Age, y Sex, n (%) Profession, n (%)
Male Female Physician Nurse Clinical officer Nutritionist
Work experience (since graduation), y
Total Sample (n = 46)
Department of Ophthalmology (n = 30)
38.2 21 (45.7) 25 (54.3) Consultants, 7 (15.2) Residents, 18 (39.1) 14 (30.4) 6 (13.0) 1 (2.2) 10.4
37.2 15 (50.0) 15 (50.0) Consultants, 3 (10.0) Residents, 15 (50.0) 8 (26.7) 4 (13.3)
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9.8
Department of Internal Medicine (n = 16) 40.1 6 (37.5) 10 (62.5) Consultants, 4 (25.0) Residents, 3 (18.8) 6 (43.8) 2 (12.5) 1 (6.3) 11.4
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ophthalmologist was identified as a problem by half of participants (n = 24, 52%). ‘‘There’s no system for booking the patient, because we just tell the patient to go, ‘you should be at the eye unit by 7:30.’ We don’t know whether they are seen or not, and we don’t know whether they are the eleventh or thirteenth (referring to the maximum number of 10 patients screened every Friday), you see? And that going and coming can give us a lost opportunity. Because somebody will get tired from time spent waiting’’ (Int. 12, clinical officer, Diabetes Clinic).
Treatment Most participants understood the importance of good longterm blood glucose control (n = 35, 76%). Laser treatment of DR was known by most participants (n = 40, 87%). Half (n = 14, 47%) of the staff working at the Department of Ophthalmology could correctly describe clinical indicators for different types of retinal laser treatment. Additional treatment options such as vitreoretinal surgery and the intravitreal injections were cited by 50% (n = 23) and 39% (n = 18), respectively. In contrast, 13% (n = 6) could not describe any specific ocular treatment of DR. Most participants advocated ophthalmological follow-up every year (n = 31, 67%) or every 6 months (n = 11, 24%) for patients without manifestations of DR. Only 1 participant knew about the diabetes-related goals laid out in the National Strategic Plan for Eye Care in Kenya.30 One additional interviewee was aware of the plan, but not of the diabetes-related content. Frequently mentioned barriers to accessing DR services were unaffordable treatment and medication costs (n = 21, 46%). When asked when they would refer a patient for DR treatment (eg, laser), ophthalmologists and ophthalmic clinical officers (n = 22) most frequently stated proliferative DR (n = 9, 41%) and macular edema (n = 7, 32%). Severe nonproliferative DR was also mentioned (n = 5, 23%), whereas 9% (n = 2) would refer any patient with DR. Just less than half of ophthalmologists and registrars (n = 8, 44%) had experience using retinal laser, and most participants (n = 32, 70%) were unaware of any treatment guidelines. ‘‘I think the policy here is [I] the ones who have complaints, are the ones who are referred to the ophthalmologists. But the others who do not have vision symptoms; I don’t think I’d refer them’’ (registrar internal medicine).
Management Responsibilities When asked to evaluate the statement, ‘‘Diabetic patients themselves are mainly responsible for their eye health,’’ 41% (n = 19) agreed, whereas 57% (n = 26) disagreed (Table 1). When asked in an open-ended question who is responsible for a diabetic patient’s eye health, 39% (n = 18) stated that the main responsibility rested with the patient, whereas 41% (n = 19) assumed a more equally distributed responsibility between the patient and their medical service provider. In contrast, diabetes clinic staff assigned more responsibility to the patient. Half of the participants (n = 25, 54%) agreed with the statement that diabetic patients are generally knowledgeable about their disease, whereas 37% (n = 17) disagreed (Table 1).
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Infrastructure Equipment Lack of equipment at the hospital was cited as a major impediment to the detection and management of DM and DR, including glucometers and other blood glucose testing equipment (n = 10, 22%), retinal lasers (n = 20, 43%), and direct ophthalmoscopes (n = 11, 24%). In addition, not having any access to diagnostic equipment or testing facilities (including HbA1c testing and basic ophthalmic equipment) was mentioned by 15% (n = 7).
Training and Staff Two thirds of participants (n = 30, 65%) suggested a need to improve staff training in DM and DR management and diagnosis and 41% (n = 19) in DR treatment. Several participants mentioned a need to consider training of staff other than ophthalmologists for services, such as screening, fundoscopy, retinal angiography, and retinal laser. When rating their own training, over half (n = 26, 57%) believed that DM and DR are sufficiently covered in their curriculum, whereas 37% (n = 17) wished for more in-depth coverage. Continuing medical education (CME) about DM and DR was identified as lacking by most participants (n = 29, 63%). Although nearly half (n = 21, 46%) had received some diabetes-related CME within the past 12 months, only 17% (n = 8) had participated in CME activities that at least partly covered DR. ‘‘I think every group should have a session with a consultant. So that they go to say ‘this is how we do FLA (fluorescein angiography),’ for example, 1 session and then from there continue with your peers’’ (Int. 41, registrar ophthalmology).
Communication The only form of patient-related communication between the Departments of Ophthalmology and Internal Medicine was the use of a common file or a common consultation form (mentioned by 70%, n = 32). Several participants reported a complete absence of any communication between the 2 departments (n = 7, 15%). One participant suggested on improving the comprehensibility of ophthalmological reports for medical outpatient clinic staff (eg, to decrease abbreviations) and to make the transfer of information between ophthalmologists and the medical outpatient clinic more efficient.
DISCUSSION Using an exploratory KAP approach enhanced by qualitative components related to DM and DR of hospital staff at a tertiary referral center in Kenya, we found the basic knowledge of DM and DR diagnoses and treatment to be good. In contrast, criteria for referral for treatment of ocular complications of DM were less well understood. Screening capacity for DM and even more so DR at the tertiary referral center were deemed insufficient by both diabetic and ophthalmic staff, and a need for outreach screening in rural areas to detect DR was emphasized. A lack of communication among the medical service providers involved in diabetic patient care was identified as a major barrier to efficient service delivery. Both, ophthalmic and nonophthalmic health professionals were aware of the need for immediate referrals for eye checkups after diagnosis. Key diagnostic and treatment equipment for DM and DR were reported to be lacking, * 2013 Asia Pacific Academy of Ophthalmology
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and participants stated that they would like to receive more continuing medical education regarding DM and DR management. Our finding of good levels of DM- and DR-related knowledge contrasts markedly with findings in other developing countries such as Oman where a study found that only 38% of physicians involved in diabetes care knew that the retina should be examined in diabetic patients.19 Similarly, in the current study, all participants understood the need to refer newly diagnosed type 2 diabetic patients for ocular checkups compared with only 36.5% of clinicians working in medical outpatient departments across Kenya reported in another study.31 At present, DR screening is not systematically performed in diabetes clinics at KNH. Few internal medicine registrars or diabetologists have the necessary skills or equipment to perform fundoscopy. Other studies conducted in developing countries have reported similar findings with, for example, only 1.3% of general practitioners performing ophthalmoscopy in South India.18 Even in a high-resource setting like Canada, 70% of general practitioners and 78% of internal medicine registrars did not feel competent to detect DR.32 Moreover, another study found that even under ideal circumstances (ie, dilated pupils and dark room), physicians other than ophthalmologists tended to miss instances of DR requiring treatment in half, whereas ophthalmologists missed only 4% of cases.33 These findings emphasize the need for adequate training and the importance of clinical experience in screening for and detecting DR. However, they also call into question the performance of DR screening by nonophthalmic personnel despite this being a practical way to address the medical staff shortages in developing countries such as Kenya. The current DR screening practice at KNH was felt to be inadequate by participants in terms of capacity (ie, an imbalance among too few staff, too little infrastructure, and too many persons in need of services). An integrated approach involving ophthalmic personnel present and actively screening for DR during diabetic clinics was favored by the medical staff interviewed in this study. Such an integrated approach to DR screening may be useful in the African context, especially at centers where patients travel long distances to attend clinics, which often last the whole day.11 In addition to on-site screening, outreach screening was suggested to service remote rural regions in Kenya. Outreach screening is an effective alternative to on-site specialist examination and has considerable potential to prevent vision loss in resource-poor settings.34 Our study showed that outreach screening and innovative screening techniques, such as mobile screening vans and trained graders of retinal images, were strongly supported concepts among staff. Communication and patient referral at the KNH was reported to be suboptimal, and a number of patients were described as being lost ‘‘in transit’’ in their journey from the diabetic clinic to the eye clinic. A recent study in Tanzania showed that in a comparable setting, only 47% of referred diabetic patients who did not have an eye examination in the past year turned up at the eye clinic even after having been counseled about potential vision loss due to delayed treatment.11 More detailed investigation of the current communication, referral, and follow-up systems at the KNH could lead to substantial improvement of service outcomes at the study hospital and other comparable service units in Africa. The strengths of this study include the use of KNH as the study setting, as it is one of the largest tertiary referral centers in Kenya and indeed in Africa. Moreover, the broad participant group and the relatively large sample size of this qualitative study strengthen our findings. To our knowledge, KAP on DM and DR management from the service provider’s perspective have not been investigated in any African country, despite * 2013 Asia Pacific Academy of Ophthalmology
Knowledge, Attitudes, and Practices in DM and DR
extensive KAP studies having been conducted in family planning and human immunodeficiency virus/acquired immunodeficiency syndrome. Semistructured interviews are excellent means to collect data in an exploratory study.35 However, asking staff to report on practices at their own place of work may cause bias thus limiting the accuracy of the findings. Moreover, as participants were aware of the study’s background and thus more likely to mention ocular complications of DM, the results may be biased in this way. It is also possible that questions pertaining to active knowledge (eg, enumeration of symptoms) may not always fully reflect a person’s entire understanding of a topic. Nevertheless, because an interview setting is comparable with a patient consultation, this approach was felt to be reflective of the day-to-day application of knowledge in the participants’ work environment. Further limitations of our study are the qualitative, exploratory approach, and the fact that statistical inferences cannot be drawn from our data. However, exploratory studies are useful for gaining depth and breadth of information, and the results can inform larger, quantitative investigations. In conclusion, although basic awareness and knowledge of DM and DR and its management were good, certain gaps are apparent, especially with regard to recommended referral and management practices. Ophthalmic infrastructure, screening procedures for DR, outreach services, referral practices, and ongoing education in DM and DR for medical staff proved to be the major areas in need of improvement. To improve DM and DR management services in Kenya in the short term, effective introduction of management guidelines and improved and ongoing CME for staff are recommended. In the long term, provision of sufficient infrastructure and staff capacity are vital to cope with the increasing prevalence of DM and its complications in Kenya. ACKNOWLEDGMENT The investigators thank all participating staff at the Kenyatta National Hospital in Nairobi. The study was supported by the Georg and Hanne Zimmermann Foundation (Georg und Hanne Zimmermann Stiftung).
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22. Manderson L, Aaby P. An epidemic in the field? Rapid assessment procedures and health research. Soc Sci Med. 1992;35:839Y850. 23. Launiala A. How much can a KAP survey tell us about people’s knowledge, attitudes and practices? Some observations from medical anthropology research on malaria in pregnancy in Malawi. Anthropology Matters. 2009;11:1Y13. 24. Cottrell RR, McKenzie JF. Health Promotion and Education Research Methods. 2nd ed. Sudbury, MA: Jones & Bartlett Learning; 2010. 25. Kaliaperumal K. Diabetic Retinopathy Knowledge, Attitude and Practice Study Protocol. Madurai, India: Aravind Eye Care System; 2004. 26. Rice P, Ezzy D. Qualitative research methods: a health focus. Oxford, United Kingdom: Oxford University Press; 1999.
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16. Silva VB, Temporini ER, Moreira Filho Dde C, et al. Treatment of diabetic retinopathy: patients’ perceptions in Rio Claro (Sa˜o Paulo State)VBrazil. Arq Bras Oftalmol. 2005;68:363Y368. 17. Yan X, Liu T, Gruber L, et al. Attitudes of physicians, patients, and village health workers toward glaucoma and diabetic retinopathy in rural China: a focus group study. Arch Ophthalmol. 2012;130:761Y770. 18. Raman R, Paul P, Padmajakumari R, et al. Knowledge and attitude of general practitioners towards diabetic retinopathy practice in South India. Community Eye Health. 2006;19:13Y14. 19. Khandekar R, Shah S, Al Lawatti J. Retinal examination of diabetic patients: knowledge, attitudes and practices of physicians in Oman. East Mediterr Health J. 2008;14:850Y857. 20. Muecke J, Newland H, Ryan P, et al. Awareness of diabetic eye disease among general practitioners and diabetic patients in Yangon, Myanmar. Clin Experiment Ophthalmol. 2008;36:265Y273. 21. Preti RC, Saraiva F, Junior JA, et al. How much information do medical practitioners and endocrinologists have about diabetic retinopathy? Clinics (Sao Paulo). 2007;62:273Y278.
29. American Academy of Ophthalmology Retina Panel. Preferred Practice Pattern Guidelines. Diabetic Retinopathy. San Francisco, CA: American Academy of Ophthalmology; 2008. 30. Health KMO. National Strategic Plan for Eye Care in Kenya 2005Y2010. Nairobi, Kenya: Ministry of Health; 2005. 31. Ekuwam DN. Situation Analysis of Diabetic Retinopathy Services in Kenya. Nairobi, Kenya: University of Nairobi; 2008. 32. Delorme C, Boisjoly HM, Baillargeon L, et al. Screening for diabetic retinopathy. Do family physicians know the Canadian guidelines? Can Fam Physician. 1998;44:1473Y1479. 33. Sussman EJ, Tsiaras WG, Soper KA. Diagnosis of diabetic eye disease. JAMA. 1982;247:3231Y3234. 34. Bragge P, Gruen RL, Chau M, et al. Screening for presence or absence of diabetic retinopathy: a meta-analysis. Arch Ophthalmol. 2011;129:435Y444. 35. Brenner M, Brown J, Canter D. The Research Interview, Uses and Approaches. London, United Kingdom: Academic Press; 1985.
"A city will be sterile if its citizens do not say what should be said." V Arthur SM Lim
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Diabetes and Diabetic Retinopathy Management in East Africa: Knowledge, Attitudes, and Practices of Hospital Staff in Kenya David G. Kupitz, MD,* Eva Fenwick, BA,Þ K. H. Martin Kollmann, MD,þ Frank G. Holz, MD,* and Robert P. Finger, MD*Þ
Purpose: Good diabetes mellitus (DM) and diabetic retinopathy (DR) management depends largely on involved medical staff, prompting us to investigate knowledge, attitudes, and practices about DM and DR at a tertiary referral center in Kenya. Design: The design for this study is exploratory qualitative using semistructured interviews. Methods: Data from eye and diabetes clinic staff were collected until thematic saturation was reached, transcribed, and iteratively analyzed for relevant themes based on the constant comparative method. Results: Among 46 participants (mean age, 38 years; 54% females), most were physicians (n = 25, 54%), followed by nurses (n = 14, 30%) and clinical officers (n = 6, 13%). Diabetes mellitus and DR were seen as urgent health problems (n = 42, 91%), and regular ophthalmic screening of diabetic patients was universally recommended. Two thirds (n = 32, 70%) were unaware of DM and DR management guidelines at the hospital. Participants identified training of staff in diagnosing (n = 30, 65%), efficient detection and referral of diabetic patients (n = 24, 52%), and improved outreach services (n = 14, 30%) as most pressing areas of need. Communication among hospital departments was found to be suboptimal. Reported barriers to good DR management were lack of retinal laser treatment and costs. Conclusions: Management outcomes for DM and DR may be improved by implementing integrated service provision, direct ophthalmological involvement in diabetic clinics, endorsement and effective distribution of guidelines, an increase in screening capacity, and the introduction of ongoing medical education covering DM and DR. Key Words: diabetes mellitus, diabetic retinopathy, Africa, KAP (knowledge, attitudes, practice), screening (Asia-Pac J Ophthalmol 2014;3: 271Y276)
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he prevalence of type 2 diabetes mellitus (DM) is projected to increase substantially over the coming decades worldwide, rising from 2.8% in 2000 to 4.4% in 20301 leading to the number of people with diabetes increasing from 284.6 million in 2010 to 438.4 million in 2030.2 Long-standing diabetes leads to a number of severe complications, mainly affecting the kidneys, the cardiovascular system, the eyes, and various aspects
From the *Department of Ophthalmology, University of Bonn, Bonn, Germany; †Centre for Eye Research Australia, The Royal Victorian Eye and Ear Hospital, University of Melbourne, Melbourne, Australia; and ‡Department of Ophthalmology, University of Nairobi, Nairobi, Kenya. Received for publication April 26, 2013; accepted August 5, 2013. The authors have no funding or conflicts of interest to declare. Reprints: Robert P. Finger, MD, Department of Ophthalmology, University of Bonn, Ernst-Abbe-Str. 2, 53127 Bonn, Germany. E-mail: robertfi[email protected]. Copyright * 2013 by Asia Pacific Academy of Ophthalmology ISSN: 2162-0989 DOI: 10.1097/APO.0b013e3182a83bfa
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of the nervous system.3 After 15 years of living with diabetes, approximately 2% of people become blind, and about 10% develop severe visual impairment due to ocular complications.4 Largely because of demographic and lifestyle changes, subSaharan Africa will be affected by a particularly steep increase in prevalence of DM during the coming years and decades.1,2,5 This is likely leading to a higher incidence and prevalence of ocular complications of DM, such as diabetic retinopathy (DR),5 which is already a leading cause of blindness in people of working age in developed countries. In the United States, for instance, DR at 17% is the leading cause of new cases of legal blindness in adults aged 20 to 74 years,6 and its prevalence in adults aged 40 years and older is 3.4%.7 Furthermore, current trends of increasing DM prevalence have led to declining vision in middle-aged persons in the United States.8 In sub-Saharan Africa, the contribution of DR to the overall prevalence of blindness is unknown, but DR affects 16% to 55% of people with DM depending on the duration and glycemic control, with some 21% to 25% of people with newly diagnosed type 2 DM presenting with retinopathy.9 Health care services in Africa have largely not kept pace with this growing challenge,10 and few interventions have focused on DR management and prevention of visual impairment.11 The Vision 2020 Action Plan 2006Y2011 has recognized DR as a priority eye disease. It emphasizes the need for highly organized health care systems, well-trained personnel, and adequate equipment.12 Against this background, the knowledge, attitudes, and practices (KAP) of medical and eye care staff are particularly important because these health professionals directly affect management outcomes at the interface between scientific theory and clinical practice. In developing countries, several studies have shed light on patients’ KAP regarding DM and DR.13Y17 However, only a few studies have examined general practitioners’ knowledge of diabetic eye disease,18Y21 and to the authors’ knowledge, no study has assessed KAP of eye and diabetes care providers in Africa. A KAP survey is a representative study of a specific population used to investigate health behavior, and today they are widely used to gain information on health-seeking practices by collecting information on what is known, believed, and done in relation to a particular topic.22 KAP surveys commonly have a simple design, yield quantifiable data, are easy to interpret, and allow for a concise presentation of results and generalizability of small sample results to a wider population as well as cross-cultural comparability. To make a KAP more comprehensive, it has been suggested to include qualitative methods, such as focus group discussions and in-depth interviews to better reflect the survey’s context.23 Therefore, we conducted a KAP survey enhanced with indepth interviews regarding DM and DR management among the staff at a Kenyan tertiary referral hospital. The main objectives of the study were to explore the staff’s current KAP, to identify problems and shortcomings, and to formulate
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recommendations for improvements in KAP and thus DM and DR management.
MATERIALS AND METHODS The study was set at the Kenyatta National Hospital (KNH) in Nairobi, the capital of Kenya. Kenyatta National Hospital is the largest national referral, teaching, and research hospital in the country.
Study Sample Participants worked in the Departments of Internal Medicine or Ophthalmology at KNH. All were involved in the management of diabetic patients, mostly through outpatient clinics. Staff groups included physicians (diabetologists and ophthalmologists, including registrars in training), clinical officers, nurses, patient educators, and nutritionists. Because it is usual in qualitative studies, the sample size estimate was based on the researchers’ judgment of informational representation24 and was set at 50 to allow for all relevant professions to be included in sufficient numbers, yield a comprehensive picture of the current situation, and minimize redundancy of information. A convenience sampling approach was used, whereby eligible staff present at the respective clinics and willing to be interviewed were recruited. Ethical approval for the study was obtained from the ethics and research committee of the KNH. Every participant gave written informed consent before the interview. The study adhered to the tenets of the Declaration of Helsinki.
Data Collection Data were collected using semistructured interviews by a trained interviewer (D.G.K.). The interviews were guided by a set of open-ended questions developed from a literature review and input from local ophthalmologists and diabetologists. Topics covered included knowledge about DM and its ocular complications; attitudes toward management of diabetic patients,
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colleagues, and the efficacy of the health care system; and current DM and DR management practices at the hospital. The format allowed for additional questions and topics to be covered as they arose over the course of the interview. In addition, participants were asked to rate 16 statements regarding DM and DR management on a 5-point Likert scale from strongly agree to strongly disagree (Table 1). Questions and statements were adapted from existing questionnaires25 and complemented by additional questions relevant to the study objective. Face-toface interviews lasted for about 30 to 45 minutes and were conducted in English using a separate room at the respective outpatient clinic to allow for privacy.
Data Analysis The interviews were recorded as audio files and subsequently transcribed. The transcript from each interview was iteratively analyzed for relevant themes and categories using an inductive analytical approach based on the constant comparative method. This approach allows broad themes to be developed from the raw data, which are constantly modified and refined based on new ideas emerging from the analysis.26,27 The qualitative software program QSR NVivo 2.0 (QSR International Pty Ltd, Australia) was used to systematically code the transcripts. A second researcher also reviewed the data using this method, and any discrepancies were resolved through discussion. This method of analysis produces a clear audit trail, which maximizes the reliability and objectivity of the conclusions. The Preferred Practice Patterns for DR management of the American Academy of Ophthalmology16 were used as reference guideline to assess the level of knowledge and reported practice patterns.
RESULTS Sample Characteristics Between October and December 2009, a total of 46 participants were interviewed. A further 4 staff members declined
TABLE 1. Responses to Attitude Statements (in Percent of Participants, n = 46) Agree, %
Statement 1. DR is a common health problem. 2. More uneducated people have diabetes than those who are educated. 3. Diabetics are more likely to develop eye problems than nondiabetic patients. 4. As long as the diabetes is kept under control, there is no need to worry about diabetic complications. 5. Screening for retinopathy is necessary among diabetic patients. 6. All diabetic patients must be referred to ophthalmologists. 7. If diabetes is treated early on, damage due to DR can be prevented. 8. Referring the diabetic patient to an ophthalmologist can prevent DR. 9. If the doctor has told the diabetic patient to come for regular follow-up, the patient will come. 10. Diabetic patients are knowledgeable about their disease. 11. Diabetic patients themselves are mainly responsible for their eye health. 12. DR is sufficiently covered in the curriculum during my studies. 13. I receive enough continuous education on DR. 14. Diabetic services are allotted with a sufficient budget in the hospital. 15. The use of mobile DR screening vans would be helpful. 16. The use of trained photographic readers of retinal images would be helpful.
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Disagree, % Undecided, Strongly Moderately % Moderately Strongly 56 7 78
35 13 9
2 4 4
7 28 4
48 4
15
24
2
20
39
100 78 54 33 30
17 37 28 46
2 2 2
4 7 15 15
22 7
7 17 22 15 4 67 57
48 24 35 17 22 22 33
9 2 7 4 30 4 9
26 39 22 37 26 2
11 17 15 26 17 4 2
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Knowledge, Attitudes, and Practices in DM and DR
participation. Mean age T standard deviation of participants was 38 T 8 years, and half of the sample (n = 25, 54%) were female. Participants were mostly physicians (n = 25, 54%); a third (n = 14, 30%) were nurses, 13% (n = 6) clinical officers, and 1 nutritionist. Two thirds (n = 30, 65%) of participants worked in the Department of Ophthalmology and one third (n = 16, 35%) in the Department of Internal Medicine (ie, the diabetic outpatient department). Demographic characteristics are summarized in Table 2.
random or fasting blood glucose levels, medical history, and HbA1c levels if available (depending on laboratory supply) at the KNH and elsewhere. Twenty-five interviewees (50%) reported personally examining diabetic patients for DR. Among the 20 participants who did not screen patients for DR, 30% (n = 6) said they had received some form of training in fundoscopy but did not routinely practice it. Most medical outpatient clinic (MOPC) staff (n = 11, 69%) reported a lack of diagnostic ophthalmic equipment at their clinic.
Basic Diabetes Knowledge
Diabetic Retinopathy Screening and Referral
Diabetes mellitus prevalence in Kenya was estimated by participants to range from 0.03% to 80% of the total population. The current reported prevalence estimate is 4.2%,28 and just over one third (n = 17, 38%) of participants’ estimates were within a 3% range of this figure. Virtually, all (98%) reported the prevalence to be increasing. Ocular complications caused by DM were known by all participants with 87% (n = 40) mentioning DR, whereas the remaining 13% (n = 6) mentioned either retinal problems, bleeding vessels, or retinal detachment. Most participants were aware of poor blood glucose control as a risk factor for the development of DR (n = 43, 93%). Less frequently mentioned were hypertension (n = 24, 52%) and hyperlipidemia (n = 5, 11%). When asked about presentation and symptoms of DR, 96% (n = 44) mentioned poor, reduced, or blurred vision, whereas only 28% (n = 13) knew that the condition is typically asymptomatic in its early stages.
All participants agreed upon the importance of DR screening in diabetic patients; however, only half believed that ocular checkups could prevent visual impairment from DR (n = 28, 61%). Most participants mentioned the need for additional DR screening methods, such as mobile screening vans and remote assessment of photographic retinal pictures by trained graders (both n = 41, 89%), to improve the quality of the diagnosis and the capacity of the current services. Frequently mentioned problems in relation to DR screening were lack of outreach services or mobile clinics in rural Kenyan areas (n = 14, 30%), late diagnosis of DM in most patients (n = 14, 30%), and lack of public awareness of the problem (n = 14, 30%). Eleven participants (24%) suggested a comprehensive DM center with an integrated eye component or the presence of an ophthalmologist and basic ophthalmic equipment at DM clinics as possible solutions. Nine participants (20%) knew the recommended referral time for an ocular checkup for type 1 diabetic patients (5 years after diagnosis or at the age of 11 years, whichever occurs first29). Most (n = 40, 87%) knew that type 2 diabetic patients should be referred for an eye examination immediately after diagnosis. Among nonophthalmic health care personnel, the majority (75%) interviewed referred diabetic patients for eye checkups immediately after diagnosis and were aware of the importance of regular eye checkups. Although 88% (n = 14) of the staff at the medical outpatient department stated that every newly diagnosed diabetic patients should be referred for an ocular checkup, only two thirds (n = 10) believed that referrals were seen to completion. Among the eye clinic staff, less than half (n = 14) felt that all newly diagnosed diabetic patients were referred for screening. Around a third of all participants (n = 12, 26%) reported that only diabetic patients with eye complaints were referred for an ocular checkup. An unknown but significant proportion of patients were believed to be ‘‘lost on the way’’ to the eye clinic after referral from the medical outpatient clinic. Overall, lack of early referral of diabetic patients to an
‘‘They appear to be on the rise, and that may not be an actual increment; it may just be that more people are becoming aware and are now presenting. On the other hand, our diets are changing; they are becoming more westernized, and that may be influencing how many people are actually developing the diabetes. So I think they are increasing for those 2 reasons’’ (Int. 41, registrar ophthalmology).
Management Diagnostics Participants reported that most patients presenting to the diabetes outpatient clinic had already been diagnosed with DM elsewhere and were referred. Participants believed that presence of DM and DM control were usually assessed by
TABLE 2. Personal Characteristics of the Sample
Age, y Sex, n (%) Profession, n (%)
Male Female Physician Nurse Clinical officer Nutritionist
Work experience (since graduation), y
Total Sample (n = 46)
Department of Ophthalmology (n = 30)
38.2 21 (45.7) 25 (54.3) Consultants, 7 (15.2) Residents, 18 (39.1) 14 (30.4) 6 (13.0) 1 (2.2) 10.4
37.2 15 (50.0) 15 (50.0) Consultants, 3 (10.0) Residents, 15 (50.0) 8 (26.7) 4 (13.3)
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9.8
Department of Internal Medicine (n = 16) 40.1 6 (37.5) 10 (62.5) Consultants, 4 (25.0) Residents, 3 (18.8) 6 (43.8) 2 (12.5) 1 (6.3) 11.4
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ophthalmologist was identified as a problem by half of participants (n = 24, 52%). ‘‘There’s no system for booking the patient, because we just tell the patient to go, ‘you should be at the eye unit by 7:30.’ We don’t know whether they are seen or not, and we don’t know whether they are the eleventh or thirteenth (referring to the maximum number of 10 patients screened every Friday), you see? And that going and coming can give us a lost opportunity. Because somebody will get tired from time spent waiting’’ (Int. 12, clinical officer, Diabetes Clinic).
Treatment Most participants understood the importance of good longterm blood glucose control (n = 35, 76%). Laser treatment of DR was known by most participants (n = 40, 87%). Half (n = 14, 47%) of the staff working at the Department of Ophthalmology could correctly describe clinical indicators for different types of retinal laser treatment. Additional treatment options such as vitreoretinal surgery and the intravitreal injections were cited by 50% (n = 23) and 39% (n = 18), respectively. In contrast, 13% (n = 6) could not describe any specific ocular treatment of DR. Most participants advocated ophthalmological follow-up every year (n = 31, 67%) or every 6 months (n = 11, 24%) for patients without manifestations of DR. Only 1 participant knew about the diabetes-related goals laid out in the National Strategic Plan for Eye Care in Kenya.30 One additional interviewee was aware of the plan, but not of the diabetes-related content. Frequently mentioned barriers to accessing DR services were unaffordable treatment and medication costs (n = 21, 46%). When asked when they would refer a patient for DR treatment (eg, laser), ophthalmologists and ophthalmic clinical officers (n = 22) most frequently stated proliferative DR (n = 9, 41%) and macular edema (n = 7, 32%). Severe nonproliferative DR was also mentioned (n = 5, 23%), whereas 9% (n = 2) would refer any patient with DR. Just less than half of ophthalmologists and registrars (n = 8, 44%) had experience using retinal laser, and most participants (n = 32, 70%) were unaware of any treatment guidelines. ‘‘I think the policy here is [I] the ones who have complaints, are the ones who are referred to the ophthalmologists. But the others who do not have vision symptoms; I don’t think I’d refer them’’ (registrar internal medicine).
Management Responsibilities When asked to evaluate the statement, ‘‘Diabetic patients themselves are mainly responsible for their eye health,’’ 41% (n = 19) agreed, whereas 57% (n = 26) disagreed (Table 1). When asked in an open-ended question who is responsible for a diabetic patient’s eye health, 39% (n = 18) stated that the main responsibility rested with the patient, whereas 41% (n = 19) assumed a more equally distributed responsibility between the patient and their medical service provider. In contrast, diabetes clinic staff assigned more responsibility to the patient. Half of the participants (n = 25, 54%) agreed with the statement that diabetic patients are generally knowledgeable about their disease, whereas 37% (n = 17) disagreed (Table 1).
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Infrastructure Equipment Lack of equipment at the hospital was cited as a major impediment to the detection and management of DM and DR, including glucometers and other blood glucose testing equipment (n = 10, 22%), retinal lasers (n = 20, 43%), and direct ophthalmoscopes (n = 11, 24%). In addition, not having any access to diagnostic equipment or testing facilities (including HbA1c testing and basic ophthalmic equipment) was mentioned by 15% (n = 7).
Training and Staff Two thirds of participants (n = 30, 65%) suggested a need to improve staff training in DM and DR management and diagnosis and 41% (n = 19) in DR treatment. Several participants mentioned a need to consider training of staff other than ophthalmologists for services, such as screening, fundoscopy, retinal angiography, and retinal laser. When rating their own training, over half (n = 26, 57%) believed that DM and DR are sufficiently covered in their curriculum, whereas 37% (n = 17) wished for more in-depth coverage. Continuing medical education (CME) about DM and DR was identified as lacking by most participants (n = 29, 63%). Although nearly half (n = 21, 46%) had received some diabetes-related CME within the past 12 months, only 17% (n = 8) had participated in CME activities that at least partly covered DR. ‘‘I think every group should have a session with a consultant. So that they go to say ‘this is how we do FLA (fluorescein angiography),’ for example, 1 session and then from there continue with your peers’’ (Int. 41, registrar ophthalmology).
Communication The only form of patient-related communication between the Departments of Ophthalmology and Internal Medicine was the use of a common file or a common consultation form (mentioned by 70%, n = 32). Several participants reported a complete absence of any communication between the 2 departments (n = 7, 15%). One participant suggested on improving the comprehensibility of ophthalmological reports for medical outpatient clinic staff (eg, to decrease abbreviations) and to make the transfer of information between ophthalmologists and the medical outpatient clinic more efficient.
DISCUSSION Using an exploratory KAP approach enhanced by qualitative components related to DM and DR of hospital staff at a tertiary referral center in Kenya, we found the basic knowledge of DM and DR diagnoses and treatment to be good. In contrast, criteria for referral for treatment of ocular complications of DM were less well understood. Screening capacity for DM and even more so DR at the tertiary referral center were deemed insufficient by both diabetic and ophthalmic staff, and a need for outreach screening in rural areas to detect DR was emphasized. A lack of communication among the medical service providers involved in diabetic patient care was identified as a major barrier to efficient service delivery. Both, ophthalmic and nonophthalmic health professionals were aware of the need for immediate referrals for eye checkups after diagnosis. Key diagnostic and treatment equipment for DM and DR were reported to be lacking, * 2013 Asia Pacific Academy of Ophthalmology
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and participants stated that they would like to receive more continuing medical education regarding DM and DR management. Our finding of good levels of DM- and DR-related knowledge contrasts markedly with findings in other developing countries such as Oman where a study found that only 38% of physicians involved in diabetes care knew that the retina should be examined in diabetic patients.19 Similarly, in the current study, all participants understood the need to refer newly diagnosed type 2 diabetic patients for ocular checkups compared with only 36.5% of clinicians working in medical outpatient departments across Kenya reported in another study.31 At present, DR screening is not systematically performed in diabetes clinics at KNH. Few internal medicine registrars or diabetologists have the necessary skills or equipment to perform fundoscopy. Other studies conducted in developing countries have reported similar findings with, for example, only 1.3% of general practitioners performing ophthalmoscopy in South India.18 Even in a high-resource setting like Canada, 70% of general practitioners and 78% of internal medicine registrars did not feel competent to detect DR.32 Moreover, another study found that even under ideal circumstances (ie, dilated pupils and dark room), physicians other than ophthalmologists tended to miss instances of DR requiring treatment in half, whereas ophthalmologists missed only 4% of cases.33 These findings emphasize the need for adequate training and the importance of clinical experience in screening for and detecting DR. However, they also call into question the performance of DR screening by nonophthalmic personnel despite this being a practical way to address the medical staff shortages in developing countries such as Kenya. The current DR screening practice at KNH was felt to be inadequate by participants in terms of capacity (ie, an imbalance among too few staff, too little infrastructure, and too many persons in need of services). An integrated approach involving ophthalmic personnel present and actively screening for DR during diabetic clinics was favored by the medical staff interviewed in this study. Such an integrated approach to DR screening may be useful in the African context, especially at centers where patients travel long distances to attend clinics, which often last the whole day.11 In addition to on-site screening, outreach screening was suggested to service remote rural regions in Kenya. Outreach screening is an effective alternative to on-site specialist examination and has considerable potential to prevent vision loss in resource-poor settings.34 Our study showed that outreach screening and innovative screening techniques, such as mobile screening vans and trained graders of retinal images, were strongly supported concepts among staff. Communication and patient referral at the KNH was reported to be suboptimal, and a number of patients were described as being lost ‘‘in transit’’ in their journey from the diabetic clinic to the eye clinic. A recent study in Tanzania showed that in a comparable setting, only 47% of referred diabetic patients who did not have an eye examination in the past year turned up at the eye clinic even after having been counseled about potential vision loss due to delayed treatment.11 More detailed investigation of the current communication, referral, and follow-up systems at the KNH could lead to substantial improvement of service outcomes at the study hospital and other comparable service units in Africa. The strengths of this study include the use of KNH as the study setting, as it is one of the largest tertiary referral centers in Kenya and indeed in Africa. Moreover, the broad participant group and the relatively large sample size of this qualitative study strengthen our findings. To our knowledge, KAP on DM and DR management from the service provider’s perspective have not been investigated in any African country, despite * 2013 Asia Pacific Academy of Ophthalmology
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extensive KAP studies having been conducted in family planning and human immunodeficiency virus/acquired immunodeficiency syndrome. Semistructured interviews are excellent means to collect data in an exploratory study.35 However, asking staff to report on practices at their own place of work may cause bias thus limiting the accuracy of the findings. Moreover, as participants were aware of the study’s background and thus more likely to mention ocular complications of DM, the results may be biased in this way. It is also possible that questions pertaining to active knowledge (eg, enumeration of symptoms) may not always fully reflect a person’s entire understanding of a topic. Nevertheless, because an interview setting is comparable with a patient consultation, this approach was felt to be reflective of the day-to-day application of knowledge in the participants’ work environment. Further limitations of our study are the qualitative, exploratory approach, and the fact that statistical inferences cannot be drawn from our data. However, exploratory studies are useful for gaining depth and breadth of information, and the results can inform larger, quantitative investigations. In conclusion, although basic awareness and knowledge of DM and DR and its management were good, certain gaps are apparent, especially with regard to recommended referral and management practices. Ophthalmic infrastructure, screening procedures for DR, outreach services, referral practices, and ongoing education in DM and DR for medical staff proved to be the major areas in need of improvement. To improve DM and DR management services in Kenya in the short term, effective introduction of management guidelines and improved and ongoing CME for staff are recommended. In the long term, provision of sufficient infrastructure and staff capacity are vital to cope with the increasing prevalence of DM and its complications in Kenya. ACKNOWLEDGMENT The investigators thank all participating staff at the Kenyatta National Hospital in Nairobi. The study was supported by the Georg and Hanne Zimmermann Foundation (Georg und Hanne Zimmermann Stiftung).
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10. Gning S, Thiam M, Fall F, et al. Diabetes mellitus in sub-Saharan Africa: epidemiological aspects and management issues. Med Trop (Mars). 2007;67:607Y611. 11. Mumba M, Hall A, Lewallen S. Compliance with eye screening examinations among diabetic patients at a Tanzanian referral hospital. Ophthalmic Epidemiol. 2007;14:306Y310. 12. World Health Organization. Vision 2020VThe Right to Sight. Action Plan 2006Y2011. Geneva, Switzerland: Global Initiative for the Elimination of Avoidable Blindness. World Health Organization; 2007. 13. Rani P, Raman R, Subramani S, et al. Knowledge of diabetes and diabetic retinopathy among rural populations in India, and the influence of knowledge of diabetic retinopathy on attitude and practice. Rural Remote Health. 2008;8:838.
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22. Manderson L, Aaby P. An epidemic in the field? Rapid assessment procedures and health research. Soc Sci Med. 1992;35:839Y850. 23. Launiala A. How much can a KAP survey tell us about people’s knowledge, attitudes and practices? Some observations from medical anthropology research on malaria in pregnancy in Malawi. Anthropology Matters. 2009;11:1Y13. 24. Cottrell RR, McKenzie JF. Health Promotion and Education Research Methods. 2nd ed. Sudbury, MA: Jones & Bartlett Learning; 2010. 25. Kaliaperumal K. Diabetic Retinopathy Knowledge, Attitude and Practice Study Protocol. Madurai, India: Aravind Eye Care System; 2004. 26. Rice P, Ezzy D. Qualitative research methods: a health focus. Oxford, United Kingdom: Oxford University Press; 1999.
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16. Silva VB, Temporini ER, Moreira Filho Dde C, et al. Treatment of diabetic retinopathy: patients’ perceptions in Rio Claro (Sa˜o Paulo State)VBrazil. Arq Bras Oftalmol. 2005;68:363Y368. 17. Yan X, Liu T, Gruber L, et al. Attitudes of physicians, patients, and village health workers toward glaucoma and diabetic retinopathy in rural China: a focus group study. Arch Ophthalmol. 2012;130:761Y770. 18. Raman R, Paul P, Padmajakumari R, et al. Knowledge and attitude of general practitioners towards diabetic retinopathy practice in South India. Community Eye Health. 2006;19:13Y14. 19. Khandekar R, Shah S, Al Lawatti J. Retinal examination of diabetic patients: knowledge, attitudes and practices of physicians in Oman. East Mediterr Health J. 2008;14:850Y857. 20. Muecke J, Newland H, Ryan P, et al. Awareness of diabetic eye disease among general practitioners and diabetic patients in Yangon, Myanmar. Clin Experiment Ophthalmol. 2008;36:265Y273. 21. Preti RC, Saraiva F, Junior JA, et al. How much information do medical practitioners and endocrinologists have about diabetic retinopathy? Clinics (Sao Paulo). 2007;62:273Y278.
29. American Academy of Ophthalmology Retina Panel. Preferred Practice Pattern Guidelines. Diabetic Retinopathy. San Francisco, CA: American Academy of Ophthalmology; 2008. 30. Health KMO. National Strategic Plan for Eye Care in Kenya 2005Y2010. Nairobi, Kenya: Ministry of Health; 2005. 31. Ekuwam DN. Situation Analysis of Diabetic Retinopathy Services in Kenya. Nairobi, Kenya: University of Nairobi; 2008. 32. Delorme C, Boisjoly HM, Baillargeon L, et al. Screening for diabetic retinopathy. Do family physicians know the Canadian guidelines? Can Fam Physician. 1998;44:1473Y1479. 33. Sussman EJ, Tsiaras WG, Soper KA. Diagnosis of diabetic eye disease. JAMA. 1982;247:3231Y3234. 34. Bragge P, Gruen RL, Chau M, et al. Screening for presence or absence of diabetic retinopathy: a meta-analysis. Arch Ophthalmol. 2011;129:435Y444. 35. Brenner M, Brown J, Canter D. The Research Interview, Uses and Approaches. London, United Kingdom: Academic Press; 1985.
"A city will be sterile if its citizens do not say what should be said." V Arthur SM Lim
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