Browsing by Author "Cook, Colin"

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    Acute Appendicitis in the Public and Private Sectors in Cape Town, South Africa
    (2014) Yang, Estin; Kahn, Delawir; Cook, Colin
    Compared to the Western world, the incidence of appendicitis is relatively low in South Africa, but with higher complication and rupture rates. Although there have been numerous studies published on appendicitis in South Africa, the literature is notably missing outcome data in the private sector. Therefore, this study aims to compare acute appendicitis in the public and private sectors in Cape Town, exploring patient characteristics, perforation rates, outcomes, and return to work.
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    Assessing the Knowledge and Practices regarding eye care and complications of Diabetes among Diabetic Patients 18 years and older, attending a tertiary Diabetic Clinic in Kampala, Uganda
    (2019) Hope, Mackline; Cook, Colin; Minnies, Deon
    Purpose The aim of this study was to audit the knowledge and practices regarding eye care and eye complications of diabetes mellitus (DM) among diabetic patients 18 years and above in Kampala, Uganda. Methods. A cross-sectional study was done to collect data on the demographics, level of awareness and practices of the 409 diabetic patients regarding eye care and eye complications of DM. Data collected was captured in EPIDATA version 3.1, exported to STATA version 15.0 for further management and analysis. Participants characteristics were summarized using summary statistics and graphs. Using a standard questionnaire, scores for knowledge and practice for diabetes; knowledge and practice on diabetic retinopathy were generated and in all the four scores aforesaid, participants were classified as having good or poor knowledge and practice1. Proportions of participants demonstrating good awareness and good practice were reported. Fishers and Pearson chi- square tests were used to test for associations between patient’s characteristics and knowledge and practice on DM. Bivariable and logistic regression analysis was performed and variables with a p-value of < 0.2 of the unadjusted odds ratio were further analyzed at multivariate logistic regression analysis to find out factors that significantly predict patient’s knowledge and practice on diabetes mellitus. Results. A total of 409 participants were interviewed in the study, majority were females 293 (71.6%) and mean age (SD) was 50 (12) years. A high proportion of participants 314 (76.9%) was aware that DM could affect the eyes but only 24 (5.9%) stated diabetic retinopathy as an eye complication in diabetic patients. Good knowledge about diabetes mellitus was demonstrated by 178 (43.5%) of the study participants. However, only 33.3% had good knowledge on eye care and diabetic retinopathy. It was determined that female diabetic patients and those who stayed with DM for 10 years and beyond were less likely to have good practice on DM compared to male patients and those who had been with DM for less than five years (OR, 95% CI: 0.58, 0.36-0.95, P=0.029: OR, 95% CI: 0.53, 0.32-0.87, P=0.011). It was also found that diabetic patients with good knowledge of DM were at least three times more likely to have good practice compared to those with the poor knowledge (OR, 95% CI: 3.2, 2.1 -4.8, P <0.001). Conclusion Lack of knowledge regarding the importance and need for periodic eye check-up for diabetic retinopathy was a significant finding in his study. Good knowledge on diabetes, gender and duration of DM had significant association with the patients practice patterns.
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    Audit of cataract surgery at Groote Schuur Hospital
    (2009) Motala, Mahommed Ismail; Cook, Colin; Meyer, Landon
    To report on the visual outcomes and complications of cataract surgery done at a South African training hospital. Literature review and retrospective observational study of all patients undergoing cataract surgery on the cataract surgery project lists during 2006. Follow-up occurred till last discharge visit. Primary outcome: Uncorrected visual acuity at the last visit of 6/6 - 6/18 visual acuity was achieved in 73.56% of the phacoemlusifaction group and in 65.77% of the scleral tunnel extracapsular cataract extraction group. (p=0.103). Secondary outcomes: Intraoperative complications were noted in 7.34% in the phacoemulsification group and in 12.87% of the scleral tunnel extracapsular cataract extraction group. (p=0.031). The posterior capsule rupture rate was 3.94% in the phacoemulsification group and 7.6% in the scleral tunnel extracapsular cataract extraction group. (p=0.066).
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    Cataract surgery and non-attendance: RCT to determine the effect of a SMS reminder system and financial impact in a developing country
    (2017) Malherbe, Lodewicus Francois; Cook, Colin
    AIMS: Missed cataract surgical appointments are an important cause of inefficiency, with delays in appropriate treatment, loss of continuity of care, and wasted resources. This study was conducted to determine if an SMS reminder system will reduce the failure to attend (FTA) rate by our patients who are booked for cataract surgery. METHODS: A randomised controlled trial was conducted at Groote Schuur Hospital between June 2015 and June 2016. Eligible patients were randomised into one of two study groups: either the "NO reminder control group "or the "SMS reminder intervention group". Patients in the SMS reminder group were entered into a secure web platform from which the automated SMS reminder system dispatched an SMS reminder one month, four days and one day pre-operatively between 10am and 12am. The message contained the following: "Dear "Mr/Mrs name", this is to confirm your cataract surgery at Groote Schuur Hospital, booked for "date". Please phone 021 404 3541 if any queries." RESULTS: 234 patients were enrolled into this study, and 15 patients were excluded. Of the remaining 219 patients, 111 were randomised into the NO reminder group (control) and 108 into the SMS reminder group (intervention). SMS reminders reduced the FTA rate by 52.6% from 11.7% to 5.6% (p=0.11). Transport problems were identified as the most common reason for non-attendance. CONCLUSION: An SMS reminder system aids in the reduction of non-attendance for booked cataract surgery. With an estimated cost of only 54 cents for three SMS reminders, this affordable intervention results in an improved efficiency of clinical service delivery.
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    Cataract surgical services in Madagascar
    (2018) Ndaule, Eric; Kello, Amir Bedri; Cook, Colin
    Objective: The main purpose of this study was to evaluate cataract surgical services in Madagascar to help guide the national eye health program. Methods: A retrospective study that used cataract surgical data collected between January 1st and December 31st, 2012 in 8 regional capitals (districts) of Madagascar. 1072 cataract operated eyes from 8 regional capitals supported by Kilimanjaro Centre for Community Ophthalmology (KCCO) satellite centers were analysed. Results: The study findings demonstrated a borderline post-operative visual acuity outcome after 24 hours but showed visual improvements 4 weeks after follow up. Males were more likely to have cataract surgeries compared to females. The cataract surgery rate (CSR) was 1467 in 8 regional capitals of Madagascar. Conclusion: This study demonstrated unequal distribution of cataract surgical services in Madagascar. Therefore, the findings of this study could be used to advocate for equitable provision of cataract surgery across all regions in Madagascar.
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    Clinical profile, causes, and outcomes of optic neuritis at Groote Schuur Hospital
    (2016) Mustak, Sayeed-Hamzah; Cook, Colin
    Objective: To determine the clinical profile, causes and response to corticosteroid therapy in patients admitted and treated for optic neuritis at a tertiary hospital in Cape Town, South Africa. Methods: A retrospective case review was conducted of 117 patients admitted to Groote Schuur Hospital and treated for optic neuritis between January 2002 and December 2012. Inclusion criteria were based on clinical findings of acute optic nerve dysfunction with or without optic disc swelling. Demographic information, clinical presentation, course of illness, investigations performed and visual outcomes at discharge and at three month follow up were collected. Data analysis was performed using STATA version 10.0. Results: 60 of 117 patients (51%) had an identifiable secondary cause for optic neuritis. Of the 57 patients with idiopathic optic neuritis only 14 had features of "typical optic neuritis" associated with demyelinating disease. HIV and syphilis accounted for 62% of secondary causes of optic neuritis. Presenting visual acuity of hand movements (HM) or worse and absence of pain with extra ocular movement were associated with poorer final visual outcomes in the idiopathic optic neuritis group. Conclusion: Optic neuritis in our patients, as elsewhere in Africa,tends to be atypical in presentation, with a high proportion of patients having an identifiable, most commonly infectious, cause.These patients thus require more extensive investigation in order to identify possible causes which may influence management. In settings with a high HIV prevalence, HIV and syphilis testing should form part of the routine first line investigations for patients with optic neuritis.Secondary optic neuritis and idiopathic atypical optic neuritis carry a poorer prognosis than typical demyelinating optic neuritis.
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    Corneal endothelial cells provide evidence of accelerated cellular senescence associated with HIV infection: a case-control study
    (Public Library of Science, 2013) Pathai, Sophia; Lawn, Stephen D; Shiels, Paul G; Weiss, Helen A; Cook, Colin; Wood, Robin; Gilbert, Clare E
    BACKGROUND: Cellular senescence may be a key factor in HIV-related premature biological aging. We assessed features of the corneal endothelium that are known to be associated with biological aging, and cellular senescence markers in HIV-infected adults. METHODS: Case-control study of 242 HIV-infected adults and 249 matched controls. Using specular microscopy, the corneal endothelium was assessed for features of aging (low endothelial cell density [ECD], high variation in cell size, and low hexagonality index). Data were analysed by multivariable regression. CDKN2A expression (a cell senescence mediator) was measured in peripheral blood leukocytes and 8-hydroxy-2′-deoxyguanosine (8-OHDG; an oxidative DNA damage marker) levels were measured in plasma. RESULTS: The median age of both groups was 40 years. Among HIV-infected adults, 88% were receiving antiretroviral therapy (ART); their median CD4 count was 468 cells/µL. HIV infection was associated with increased odds of variation in cell size (OR = 1.67; 95% CI: 1.00-2.78, p = 0.04). Among HIV-infected participants, low ECD was independently associated with current CD4 count <200 cells/µL (OR = 2.77; 95%CI: 1.12-6.81, p = 0.03). In participants on ART with undetectable viral load, CDKN2A expression and 8-OHDG levels were higher in those with accelerated aging, as reflected by lower ECD. CONCLUSIONS: The corneal endothelium shows features consistent with HIV-related accelerated senescence, especially among those with poor immune recovery.
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    Key informants for peadiatric eye disease case finding in Madagascar
    (2019) Chimeziri, Anderson; Courtright, Paul; Cook, Colin
    As at 2014, 19 million children aged < 16 years were visually impaired, 1.4 million of these children were blind and needed visual rehabilitation interventions. Surveys, mostly utilizing key informants (KI), have suggested that the prevalence of blindness in children in Sub Saharan Africa ranges between 2 -8 per 10,000 children. Childhood eye disease is rare and conditions are difficult to detect; thus, surveys to estimate the prevalence of blindness requires rigorous, costly and difficult methods to obtain reasonable estimates among children. Key informant programs, which engage the community in case finding, have been shown to be a reasonable alternative to large scale surveys and were used in Madagascar in 2014 by four regional eye care programmes. I propose to analyse the data generated from the programmes to quantify the prevalence of eye conditions among children and how the KIs performed. Method: The analysis will use data collected in a cross sectional approach. Statistical analysis will be conducted using Stata (15.0) statistical software. Data from all of the KI registers will be pooled and overall magnitude estimates calculated. KI productivity and sub-group analyses will include assessment of demographic characteristics of the children and the KI by age and sex. Ethical approval will be provided by the UCT Health Research and Ethics Committee and the Madagascar Ministry of Health. Discussion: The results from this study will help child eye health programmes to determine how best to use KI to better serve children with vision loss, and guide in the provision of eye services for children care.
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    Outreach cataract surgery services: how good are their outcomes?
    (2019) Nieder-Heitmann, Norman; Cook, Colin
    Background Cataracts are the main cause of blindness worldwide. Cataract blindness is reversible with surgery, a procedure which is well recognized for its clinical and cost effectiveness. Several approaches are used to reduce the cataract burden. They include a “reach out” approach, a “reach in” approach and a combination of the two. The Aravind Eye Care System in India, performing over 250 0000 cataract surgeries annually, exclusively utilizes the “reach in” approach. In neighbouring Nepal, with its large rural population residing in mountainous areas, outreach services still play an essential role in addressing cataract blindness. In South Africa, there are several non-governmental cataract surgery services utilizing the “reach out” approach. Objectives The primary objective of this study is to investigate the visual outcomes of a nongovernmental organization providing outreach cataract surgery services (referred to as the “Outreach Service” from now on) in South Africa. This was done by directly comparing them to the visual outcomes obtained at a permanent hospital-based cataract surgery service. The secondary objective is to compare the visual outcomes in both these settings to the recommended day one postoperative visual acuities as set out by the WHO. Methods A retrospective comparison was made of the day one postoperative visual acuities of patients who underwent cataract surgery during outreaches conducted by the Outreach Service and the day one postoperative visual acuity of patients who were operated on at Groote Schuur Hospital. The study period was from July 2014 to December 2014. Results A total of 1067 cases from the Outreach Service and 584 cases from Groote Schuur Hospital were included in the study. The patients who underwent surgery at Groote Schuur Hospital had significantly better day one visual acuities (Pearson chi square test, p< 0.0001). The day one visual acuity in cases performed during outreaches also did not fulfil the minimum day one visual acuity as set out by the World Health Organization (WHO). Conclusion Despite its limitations, our study does raise concerns about the quality of cataract surgery performed on these outreaches. Our recommendation is that non-governmental outreach cataract surgery services should audit their four to six-week visual outcomes. Should they still not meet the WHO’s criteria, the necessary steps should be taken to identify and rectify the reasons for these poor outcomes. Ultimately, South Africa should strive towards establishing more permanent eye care centres.
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    The prevalence and determinants of diabetic retinopathy in Botswana: Findings from a screening programme
    (2017) Omari, Nuru Said; Cook, Colin; Nkomazana, Oathokwa
    Background: The International Diabetes Federation estimates that the number of adults with diabetes in Africa will increase by 98% by the year 2030. The importance of diabetic retinopathy as a cause of blindness has increased because of longevity and a decline in the other preventable causes of blindness in developing countries. Retinopathy diagnosed early, followed closely, and treated timeously with retinal laser therapy, prevents blinding retinopathy. The objective of the study is to determine the prevalence of Diabetic Retinopathy, its determinants and the acceptability as well as accessibility of the screening service by patients. Methods: The study is a cross-sectional study conducted at Gaborone diabetic retinopathy screening clinic. Convenience sampling was used where every eligible patient that arrived for DR screening and had consented was included in the study. Basic descriptive statistics of the study sample were reported and a multivariate analysis was performed with DR as the outcome of interest. Results: A total of 220 participants attended the clinic between 12th of January and 6th of February 2015. The mean age of the participants was 55.96 (p=0.32) years and females comprised the majority 65.45% (n= 144, p=0.33)) of participants. A fifth of the participants (n=43, p=0.67) felt they had poor knowledge of diabetes and 25.91% (n=57, p=0.96) stated they did not understand the purpose of screening. Only 63.64% (n=140, p=0.46) reported to always being compliant with their medication and compliance did not differ significantly between those who had retinopathy and those who did not. Traditional medicine use was reported in 16.36% of the participants (n=36, p=0.33). Diabetic Retinopathy was found in 31.82% (n=70) of the population and of those, 3 participants (1.36%) had referable DR. Maculopathy was found in 21.82% (n=48) of participants. Increasing household number and years living with DM were the only variables found to have a significant association with development of diabetic retinopathy. Conclusion: The prevalence of diabetic retinopathy has increased in our population compared to previous studies. The number of Diabetics attending the DR screening service in Gaborone has also increased but continuous diabetes health education cannot be over emphasized. Incorporation of local cultural values into the overall management of the disease is the best way to increase patient compliance.
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    Retinal arterioles narrow with increasing duration of anti-retroviral therapy in HIV infection: a novel estimator of vascular risk in HIV?
    (Public Library of Science, 2012) Pathai, Sophia; Weiss, Helen A; Lawn, Stephen D; Peto, Tunde; D'Costa, Leris M; Cook, Colin; Wong, Tien Y; Gilbert, Clare E
    Objectives HIV infection is associated with an increased risk of age-related morbidity mediated by immune dysfunction, atherosclerosis and inflammation. Changes in retinal vessel calibre may reflect cumulative structural damage arising from these mechanisms. The relationship of retinal vessel calibre with clinical and demographic characteristics was investigated in a population of HIV-infected individuals in South Africa. METHODS: Case-control study of 491 adults ≥30 years, composed of 242 HIV-infected adults and 249 age- and gender-matched HIV-negative controls. Retinal vessel calibre was measured using computer-assisted techniques to determine mean arteriolar and venular diameters of each eye. RESULTS: The median age was 40 years (IQR: 35-48 years). Among HIV-infected adults, 87.1% were receiving highly active antiretroviral therapy (HAART) (median duration, 58 months), their median CD4 count was 468 cells/µL, and 84.3% had undetectable plasma viral load. Unadjusted mean retinal arteriolar diameters were 163.67±17.69 µm in cases and 161.34±17.38 µm in controls (p = 0.15). Unadjusted mean venular diameters were 267.77±18.21 µm in cases and 270.81±18.98 µm in controls (p = 0.07). Age modified the effect of retinal arteriolar and venular diameters in relation to HIV status, with a tendency towards narrower retinal diameters in HIV cases but not in controls. Among cases, retinal arteriolar diameters narrowed with increasing duration of HAART, independently of age (167.83 µm <3 years of HAART vs. 158.89 µm >6 years, p-trend = 0.02), and with a HIV viral load >10,000 copies/mL while on HAART (p = 0.05). HIV-related venular changes were not detected. CONCLUSIONS: Narrowing of retinal arteriolar diameters is associated with HAART duration and viral load, and may reflect heightened inflammatory and pro-atherogenic states of the systemic vasculature. Measurement of retinal vascular calibre could be an innovative non-invasive method of estimating vascular risk in HIV-infected individuals.
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    Retinal nerve fibre layer thickness and contrast sensitivity in HIV-infected individuals in South Africa: a case-control study
    (Public Library of Science, 2013) Pathai, Sophia; Lawn, Stephen D; Weiss, Helen A; Cook, Colin; Bekker, Linda-Gail; Gilbert, Clare E
    BACKGROUND: Antiretroviral treatment (ART) has altered the spectrum of HIV-related eye disease, resulting in a lower prevalence of retinal opportunistic infections (OIs). However, abnormalities in visual function have been reported in HIV-infected individuals despite effective viral suppression and the absence of retinal OIs. These changes may be mediated by an HIV-associated 'neuroretinal disorder', characterized by changes in the retinal nerve fibre layer (RNFL). HIV infection may also be associated with accelerated biological aging. The aim of this study was to investigate the relationships between contrast sensitivity, RNFL thickness, HIV infection and frailty in South African adults. METHODS: Case-control study of 225 HIV-infected individuals without retinal OIs and 203 gender/age-matched HIV-seronegative individuals. Peri-papillary RNFL thickness was determined with spectral domain optical coherence tomography in four quadrants. CS was measured using a Pelli-Robson chart. Frailty was assessed using standard criteria. Multivariable linear and logistic regression were used to assess associations between HIV status and RNFL/CS and frailty. RESULTS: The median age of both groups was similar (41.2 vs. 41.9 years, p = 0.37). 88% of HIV-infected individuals were receiving ART and their median CD4 count was 468 cells/μl. Adjusted CS score was lower in HIV-infected participants compared to HIV-seronegative individuals (1.76 vs. 1.82, p = 0.002). Independent predictors of poor CS in the HIV-infected group were positive frailty status and current HIV viral load >2 log copies/ml. Lower CS score was also associated with thin temporal RNFL in HIV-infected individuals (p = 0.04). Superior quadrant RNFL thickness was greatest in ART-naïve participants relative to the HIV-uninfected group (p-trend = 0.04). Longer ART duration was associated with thinning of inferior and nasal RNFL quadrants (p-trend = 0.03 and 0.04, respectively). CONCLUSIONS: Contrast sensitivity is reduced in HIV-infected individuals and functionally associated with frailty and unsuppressed viraemia. This may reflect structural changes in the RNFL that are evident despite the absence of OIs.
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    Retinopathy of prematurity screening criteria and work load implications at Tygerberg Children's Hospital, South Africa: A cross-sectional study
    (2016) Visser-Kift, Elsimé; Myer, Landon; Freeman, Nicola; Cook, Colin
    High-income country ROP Screening guidelines are not appropriate for middle-income countries and screening requirements may vary even between units within one city. This study aimed to determine optimal ROP screening criteria, and its workload implications, for Tygerberg Children's Hospital (TCH), South Africa. Methods This cross-sectional study included premature infants screened for ROP, at TCH (1 January 2009 to 31 December 2014). Logistic regression for prediction and classification were performed. Predictors were birth weight (BW) and gestational age (GA). Endpoints were clinically significant ROP (CSROP) and Type 1 ROP (T1ROP).
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    School Vision Screening Programs In Reducingchildren With Uncorrected Refractive Error In Low And Middle-income Countries (Lmic)(Systematic Review)
    (2019) Abraham, Opare; Abdullahi, Leila H.; Minnes, Deon; Cook, Colin
    Background: The prevalence of uncorrected refractive error among school-age children is on the rise with a detrimental effect on academic performance and socio-economic status of those affected. School vision screening appears to be an effective way of identifying children with uncorrected refractive error so early intervention can be made. Despite the increasing popularity of school vision screening programs in recent times, there is a lot of debate on its effectiveness in reducing the proportion of children with uncorrected refractive error in the long term especially in settings where resources are limited. Objective: To assess the effectiveness of school vision screening programs in reducing children with uncorrected refractive error in LMIC. Search Methods: To identify studies suitable for this systematic review, a comprehensive and systematic search strategy was employed. We searched various databases and the search was restricted to articles published in English. We included RCTs, cross-sectional studies, case-control studies, and cohort studies. Participants included school children who had undergone vision screening as part of school vision screening programs in the LMIC setting and found to have a refractive error. Two independent reviewers screened the result of the search output and performed a full-text review of the search result to identify papers that met the pre-defined inclusion criteria. Data extraction and risk of bias assessment for the included studies was performed by the two independent reviewers and discrepancies were resolved by consensus and through consultation. The certainty of the evidence was assessed using the GRADE approach. Main Result: We found thirty relevant studies conducted in ten different countries that answered our review questions. Our review showed that school vision screening may be effective in reducing the proportion of children with an uncorrected refractive error by 81% (95% CI: 77%; 84%, moderate certainty evidence), 24% (95% CI: 13%; 35%, moderate certainty evidence,) and 20% (95% CI: 18%; 22%, moderate certainty evidence) at two, six, and more than six months respectively after its introduction. Our review also suggest that school vision screening may be effective in achieving 54% (95% CI: 25%; 100%, moderate certainty evidence), 57% (95% CI:46%; 70%, low certainty evidence), 38% (95% CI: 29%; 51%, moderate certainty evidence) and 41% (95% CI: 24%; 68%, low certainty evidence) level of spectacle wear compliance among school children at less than three months, at three months, at six months and at more than six months respectively after its introduction. Our review further found moderate to high certainty evidence indicating that school vision screening together with the provision of spectacles may be relatively cost-effective, safe and has a positive impact on the academic performance of children. Conclusion: Result of this review shows that school vision screening together with the provision of spectacle may be a safe and cost-effective way of reducing the proportion of children with uncorrected refractive error with a long-term positive impact on academic performance of children. Most of the studies included in this review were however conducted in Asia and the applicability of this finding to countries in other regions especially those outside the LMIC circle is not clear.
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    Setting targets for human resources for eye health in sub-Saharan Africa: what evidence should be used?
    (BioMed Central, 2016) Courtright, Paul; Mathenge, Wanjiku; Kello, Amir B; Cook, Colin; Kalua, Khumbo; Lewallen, Susan
    With a global target set at reducing vision loss by 25% by the year 2019, sub-Saharan Africa with an estimated 4.8 million blind persons will require human resources for eye health (HReH) that need to be available, appropriately skilled, supported, and productive. Targets for HReH are useful for planning, monitoring, and resource mobilization, but they need to be updated and informed by evidence of effectiveness and efficiency. Supporting evidence should take into consideration (1) ever-changing disease-specific issues including the epidemiology, the complexity of diagnosis and treatment, and the technology needed for diagnosis and treatment of each condition; (2) the changing demands for vision-related services of an increasingly urbanized population; and (3) interconnected health system issues that affect productivity and quality. The existing targets for HReH and some of the existing strategies such as task shifting of cataract surgery and trichiasis surgery, as well as the scope of eye care interventions for primary eye care workers, will need to be re-evaluated and re-defined against such evidence or supported by new evidence.
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    “The graduates of the Postgraduate Diploma in Community Eye Health: how do they manage?”
    (2020) Minnies, Deon; Reid, Steve; Cook, Colin; Hartman, Nadia
    The Postgraduate Diploma in Community Eye Health (PgDCEH) has been offered at the University of Cape Town, South Africa since 2009 to develop management capacity in support of the delivery of effective and efficient eye care services in sub-Saharan Africa. We investigated how graduates applied the PgDCEH-acquired management competencies and the factors that enabled or constrained them to apply these competencies. A multiple case study design was used, employing mixed methods of data collection and analysis. Data collection comprised of a questionnaire survey, in-depth interviews and review of various supporting documents, including assignments submitted by students. Twenty-six of the 34 students who graduated from 2009 to 2014 submitted completed questionnaires. Of these, 15 purposively selected graduates and their secondary key informants participated in in-depth interviews. We found that the PgDCEH elicited some positive effects on the graduates, especially in their ability to perform management tasks and the level of confidence they have in their abilities. There were some personal achievements, but no significant programme improvements were observed. This study provided evidence that the PgDCEH as a health system strengthening intervention struggled to generate the anticipated response of improved eye care programme performance. Personal motivation, suitability of the training and opportunity to apply were the main factors determining how graduates apply management competencies. The utilization of the project management approach, a greater focus on health system maintenance and attention to the dynamic of change in people's lives are critical determinants of success in eye health programmes. The research also highlighted the importance of health care workers' personal motives and motivations as drivers of success and achievement on programme level, and that line management support, supervision and proper performance management are required to attain this. This research broadened understanding of how PgDCEH graduates interact with their work environment and uncovered ways to improve the design and delivery of management training for eye health workers in the future. Revision of the criteria for selection, strengthening focus on leadership, project and relationship management topics, and integrating the training into health professions' education programmes may substantially improve the impact of health management education. The study concluded that the constituent elements of the health system are not inanimate objects, as commonly portrayed, but people, who are connected in intimate, complex and multi-dimensional ways through communication, relationships and team dynamics to deliver health outcomes.