Browsing by Author "Courtright, Paul"

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    Assessment of factors associated with diabetic retinopathy among diabetic patients in Zambia
    (2018) Kabaso, Kanasa; Geneau, Robert; Courtright, Paul
    Background: Diabetes Mellitus is an emerging public health problem in Africa. Evidence suggests that globalization, rapid urbanization and a nutritional transition have led to the rise in the prevalence of diabetes mellitus in Africa. Diabetic retinopathy is a common complication of diabetes mellitus that causes visual impairment and subsequent blindness. Early detection and prompt treatment can prevent blindness in up to 90% of patients. The common risk factors for diabetic retinopathy include hypertension, hyperglycemia and long duration of diabetes. Other risk factors include obesity, hyperlipidemia, smoking, puberty and pregnancy. There is limited data on diabetic retinopathy and its associated risk factors in Zambia. An understanding of these factors would help in the effective management of diabetic retinopathy. Methods: A secondary data analysis of data obtained from a hospital-based cross-sectional study of diabetic patients attending diabetic clinics in the Copperbelt Province in Zambia was carried out. All diabetic patients that attended the retinopathy-screening program between April 2012 and September 2012 were eligible for the primary study. The secondary data analysis was restricted to patients 18 years and older. Data analysis was carried out by R version 3.3.1. The characteristics of the study population were summarized using descriptive statistics. Univariate logistic regression analysis was used to select potential candidates for the multivariate regression model at p-value cutoff point ≤ 0.25 and variables of known clinical relevance were also included in the multivariable analysis. The final model fitness was checked using Hosmer and Lemeshow chi-square test. Finally, statistical significance was tested at P-value <0.05. Results: The prevalence of diabetic retinopathy was 19.4%. Multivariate analysis showed that the odds of diabetic retinopathy were significantly associated with age (OR =1.05: 95%Cl; 1.03-1.06), duration (OR=1.39: 95%Cl; 1.27-1.52), weight (OR =0.98: 95%Cl; 0.97-0.98), blood glucose (OR =1.04: 95Cl; 1.02-1.07) and systolic blood pressure (OR = 1.01: 95Cl; 1.00-1.02). Conclusion: Duration of diabetes, age, systolic blood pressure, weight and blood glucose levels were significantly associated with diabetic retinopathy in this study. More comprehensive population screening strategies and treatment programs addressing these risk factors should be put in place.
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    Barriers to cataract surgery in Africa: a systematic review
    (2016) Aboobaker, Shaheer; Courtright, Paul
    Background: Cataract remains the leading cause of blindness in Africa. We sought to review the available literature relating to barriers to cataract surgery in Africa. Methods: A review of the literature was undertaken using PubMed and Google Scholar using the search terms "barriers, cataract, Africa, cataract surgery, cataract surgical coverage (CSC), and Rapid Assessment of Avoidable Blindness (RAAB)". The review covered the period 1999-2014. Results: In RAABs, barriers related to awareness and access were more commonly reported than acceptance, while non -RAAB studies reported cost as the most commonly reported barrier. The few qualitative studies tended to report community and family dynamics with regard to barriers to cataract surgery. CSC was reported as lower in females in 88.2% of the studies. Conclusion: Studies of barriers to cataract surgery give variable responses. This may be due to the study context but also may be due to the type of data collection. It is likely that qualitative data will give a deeper understanding of the complex social, family, community, financial and gender issues relating to barriers to uptake of cataract surgery in Africa.
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    Evaluation of trichiasis surgeons' performance in selected trachoma endemic African countries
    (2021) Ofoegbu, Olubukola Oyinade; Geneau, Robert; Courtright, Paul; Minnies, Deon
    Purpose: Elimination of trachoma-related blindness requires addressing not only issues of trichiasis surgery availability and accessibility, but also quality. To improve surgeon performance, programmes undertake surgeon audits to identify surgeons needing re-training, reasons for poor outcomes, and actions to optimise surgical outcomes. This study aims to determine the frequency and associated factors of audits conducted in selected countries and factors associated with failed audits. Methods: A multicentric study was conducted as a secondary data analysis of surgeon audit results for eight African countries. Stata® was used to generate results for chi-square tests for association, odds ratio and 95% confidence intervals between independent samples for categorical variables and one-way ANOVA tests for continuous variables. Results: The study included 561 trichiasis surgeons and 193 (34.4%) had an audit. Dedicated eye care workers were more likely to have an audit (p<0.001) compared to general health workers. Among audited surgeons, 29 (15%) failed and were recommended for re-training. Surgeons using posterior lamellar tarsal rotation (PLTR) surgery (59.8%) and those trained more recently (mean 4.2 years) were more likely to pass the audit. Conclusion: Although surgeon audits are considered a routine part of programme activities in trachoma endemic countries, too few audits are being undertaken. Further research is needed to learn why surgeons practicing PLTR surgery and those trained more recently are more likely to pass their audit. To improve surgical outcomes, programmes must not only focus on surgical volume but carry out surgeon audits and use the audits to make programme decisions.
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    Global burden of trichiasis in women as compared to men: Findings from the Global Trachoma Mapping Project
    (2019) Moyo, George; Courtright, Paul; Geneau, Robert
    The secondary analysis undertaken for this MPH dissertation examines the global prevalence of trichiasis in relation to gender in trachoma endemic countries. Part A is the research protocol which outlines the background and the process of this research. This study is a population-based analytical study using data from the Global Trachoma Mapping Project (GTMP). GTMP was a standardized population-based trachoma prevalence survey undertaken to provide trachoma prevalence estimates. GTMP data was collected using the World Health Organisation–recommended population based prevalence survey methodology. Trachoma suspect district were identified for inclusion and multistage random sampling was used to sample households for examination of residents for clinical trachoma. Part B presents the background and highlights the importance of this research by exploring the existing theoretical and empirical literature relevant to the topic. It describes how trachoma is transmitted, its clinical manifestations, and the way it can lead to blindness. Results from previous studies on gender and trichiasis are presented. Part C presents the research project in a format suitable for journal submission. The background of this research project is summarized and the meta-analysis is conducted at the global level, at the country level, the regional level, the state level and at the EU level but all in accordance to prevalence of trichiasis in the EUs. The implications of the findings are discussed and limitations in interpretation presented.
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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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    Post-operative Trachomatous Trichiasis in Africa: a systematic review and online survey
    (2019) Mwangi, Grace Wangari; Courtright, Paul
    Background High incidence of post-operative trichiasis and other poor outcomes after surgery in most trachoma-endemic settings poses a major challenge to global elimination of trachoma. This systematic review aimed to assess the incidence of post-operative trichiasis and other poor outcomes of trichiasis surgery in Africa, based on findings of observational and interventional studies. Search methods We searched PubMed, Academic Search Premier, Africa-Wide Information, CINAHL and Health Source Nursing through EBSCOhost, Web of Science [all databases], and Cochrane Central Register of Controlled Trials for relevant studies on the subject. We also searched the reference lists of included studies to identify further potentially relevant studies. We included all observational and interventional studies that measured post-operative trichiasis as one of the primary outcomes. Only studies conducted in Africa were included in this review. Data collection and analysis Two reviewers independently screened the titles and abstracts, selected and assessed the articles for inclusion in this review. Any disagreements were resolved through discussion or by consulting a third reviewer. Where necessary, the corresponding authors of included studies were contacted to provide any missing data. Our primary outcome was post-operative trichiasis, which was defined as any eyelash touching the globe at different time points after surgery. Main results Thirty-five studies, including 12,943 participants, met the inclusion criteria. A number of the studies included in this review utilized the same data to measure the incidence of post-operative trichiasis and other poor outcomes over different follow-up periods. Overall, a review of the included studies revealed a pattern of high incidence of post-operative trichiasis and other poor outcomes ranging from 2.3 at 6 weeks to 65% at 7 years. This incidence varied by type of study design, surgical procedure and technique used as well as the follow up period among other factors.
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    Relationship between the prevalence of trachomatous inflammation in children (age 1-9years) and the prevalence of trichiasis in adults (age 15years and above) at a presumed steady state
    (2017) Antwi-Adjei, Ellen K; Courtright, Paul; Geneau, Robert
    Background: Trachoma is the leading cause of infectious eye disease that leads to blindness. Continuous re-infection by the bacteria, Chlamydia trachomatis, leads to scarring of the cornea and subsequently to blindness. It is commonly found in the poorest and remotest part of Africa, Asia, Latin America and Mid-east, where hygienic conditions are also poorer. The Alliance for the Global Elimination of Blinding Trachoma by the year 2020 (GET 2020) was launched by World Health Organization (WHO) with the main aim of eliminating trachoma as a public health problem globally by year 2020. The Alliance funded Sightsavers, as part of the strategy to meet this target, to set up the Global Trachoma Mapping Project (GTMP) which was to map all endemic places for intervention through a population-based prevalence survey. There are five main signs of the disease and the number of people affected by each sign explains the magnitude and the intervention needed in that population. WHO recommends the active trachoma survey in children age 1-9 years and the blinding signs in adults' age 15 years and above. More researches, that establish quicker means of intervention for the endemic trachoma areas, are needed using the GTMP data in order to meet the year 2020 target. Methods: Baseline data from the Global Trachoma Mapping Project (GTMP) was used as a secondary dataset for this research. All eligible regions in Ethiopia were included. The GTMP teams conducted surveys in seven regions. All age groups were included, but for the purpose of planning, the study assessed TF in children age 1-9 years and TT in adults age 15 years and above. The prevalence of TF in children and TT in adults are indicators for programme decision making for intervention and establishing the relationship between them would aid in the intervention. The relationship if established could help in planning the extent of intervention needed in a given population. Data on sanitation and hygiene as well as altitude, which were collected as part of GTMP, were assessed to determine if they contributed to relationship between TF and TT. Results: The study included a total of 282,558 individuals living in 174 evaluation units from seven regions of Ethiopia, among whom 256,587 gave consent to be examined. This study found a significant relationship between the prevalence of TF in children and the prevalence of TT in adults when analysis is done at the evaluation unit level (correlation rho, 0.59; p-value <0.0001). Hence, 59% of the prevalence of TT in adults can be explained for by the presence of TF in children. Sub-group analysis showed that the correlation persisted at the regional level. Conclusion: A better understanding of the relationship between the prevalence of TF and the prevalence of TT together with the factors influencing this association using this large dataset may aid in prioritization of districts for intervention and has implications for global activities for the elimination of trachoma.
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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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    Skills of general health workers in primary eye care in Kenya, Malawi and Tanzania
    (BioMed Central Ltd, 2014) Kalua, Khumbo; Gichangi, Michael; Barassa, Ernest; Eliah, Edson; Lewallen, Susan; Courtright, Paul
    BACKGROUND:Primary eye care (PEC) in sub-Saharan Africa usually means the diagnosis, treatment, and referral of eye conditions at the most basic level of the health system by primary health care workers (PHCWs), who receive minimal training in eye care as part of their curricula. We undertook this study with the aim to evaluate basic PEC knowledge and ophthalmologic skills of PHCWs, as well as the factors associated with these in selected districts in Kenya, Malawi, and Tanzania. METHODS: A standardized (26 items) questionnaire was administered to PHCWs in all primary health care (PHC) facilities of 2 districts in each country. Demographic information was collected and an examination aimed to measure competency in 5 key areas (recognition and management of advanced cataract, conjunctivitis, presbyopia, and severe trauma plus demonstrated ability to measure visual acuity) was administered. RESULTS: Three-hundred-forty-three PHCWs were enrolled (100, 107, and 136 in Tanzania, Kenya, and Malawi, respectively). The competency scores of PHCW varied by area, with 55.7%, 61.2%, 31.2%, and 66.1% scoring at the competency level in advanced cataract, conjunctivitis, presbyopia, and trauma, respectively. Only 8.2% could measure visual acuity. Combining all scores, only 9 (2.6%) demonstrated competence in all areas. CONCLUSION: The current skills of health workers in PEC are low, with a large per cent below the basic competency level. There is an urgent need to reconsider the expectations of PEC and the content of training.
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    Task shifting for cataract surgery in eastern Africa: productivity and attrition of non-physician cataract surgeons in Kenya, Malawi and Tanzania
    (BioMed Central Ltd, 2014) Eliah, Edson; Lewallen, Susan; Kalua, Khumbo; Courtright, Paul; Gichangi, Michael; Bassett, Ken
    BACKGROUND:This project examined the surgical productivity and attrition of non-physician cataract surgeons (NPCSs) in Tanzania, Malawi, and Kenya. METHODS: Baseline (2008-9) data on training, support, and productivity (annual cataract surgery rate) were collected from officially trained NPCSs using mailed questionnaires followed by telephone interviews. Telephone interviews were used to collect follow-up data annually on productivity and semi-annually on attrition. A detailed telephone interview was conducted if a surgeon left his/her post. Data were entered into and analysed using STATA. RESULTS: Among the 135 NPCSs, 129 were enrolled in the study (Kenya 88, Tanzania 38, and Malawi 3) mean age 42 years; average time since completing training 6.6 years. Employment was in District 44%, Regional 24% or mission/ private 32% hospitals. Small incision cataract surgery was practiced by 38% of the NPCSs. The mean cataract surgery rate was 188/year, median 76 (range 0-1700). For 39 (31%) NPCSs their surgical rate was more than 200/year. Approximately 22% in Kenya and 25% in Tanzania had years where the cataract surgical rate was zero. About 11% of the surgeons had no support staff.Factors significantly associated with increased productivity were: 1) located at a regional or private/mission hospital compared to a district hospital (OR = 8.26; 95 % CI 2.89 - 23.81); 2) 3 or more nurses in the eye unit (OR = 8.69; 95% CI 3.27-23.15); 3) 3 or more cataract surgical sets (OR = 3.26; 95% CI 1.48-7.16); 4) a separate eye theatre (OR = 5.41; 95% CI 2.15-13.65); 5) a surgical outreach program (OR = 4.44; 95% CI 1.88-10.52); and 6) providing transport for patients to hospital (OR = 6.39; 95% CI 2.62-15.59). The associations were similar for baseline and follow-up assessments. Attrition during the 3 years occurred in 13 surgeons (10.3%) and was due to retirement or promotion to administration. CONCLUSIONS: High quality training is necessary but not sufficient to result in cataract surgical activity that meets population needs and maintains surgical skill. Needed are supporting institutions and staff, functioning equipment and programs to recruit and transport patients.
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    Task shifting in primary eye care: how sensitive and specific are common signs and symptoms to predict conditions requiring referral to specialist eye personnel?
    (BioMed Central Ltd, 2014) Andriamanjato, Hery; Mathenge, Wanjiku; Kalua, Khumbo; Courtright, Paul; Lewallen, Susan
    BACKGROUND:The inclusion of primary eye care (PEC) in the scope of services provided by general primary health care (PHC) workers is a 'task shifting' strategy to help increase access to eye care in Africa. PEC training, in theory, teaches PHC workers to recognize specific symptoms and signs and to treat or refer according to these. We tested the sensitivity of these symptoms and signs at identifying significant eye pathology. METHODS: Specialized eye care personnel in three African countries evaluated specific symptoms and signs, using a torch alone, in patients who presented to eye clinics. Following this, they conducted a more thorough examination necessary to make a definite diagnosis and manage the patient. The sensitivities and specificities of the symptoms and signs for identifying eyes with conditions requiring referral or threatening sight were calculated. RESULTS: Sensitivities of individual symptoms and signs to detect sight threatening pathology ranged from 6.0% to 55.1%; specificities ranged from 8.6 to 98.9. Using a combination of symptoms or signs increased the sensitivity to 80.8 but specificity was 53.2. CONCLUSIONS: In this study, the sensitivity and specificity of commonly used symptoms and signs were too low to be useful in guiding PHC workers to accurately identify and refer patients with eye complaints. This raises the question of whether this task shifting strategy is likely to contribute to reducing visual loss or to providing an acceptable quality service.