Dr Nyawira Mwangi
Researcher at the International Centre for Eye Health | Educator at Kenya Medical Training College | Public eye health specialist | Passionate for strengthening heath systems for Diabetic Retinopathy
Location Nairobi, Kenya
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Dr Nyawira Mwangi made a comment
Thank you everyone for participating on the course. Looking forward to reading your comments on what you have learnt.
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Absolutely @IsrarMuhammad. In your current role - how will you approach this? What would be your next steps?
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Good to have you on the course @benicdegraft-johnson. Yes as a nutritionist you can contribute significantly to the control of visual impairment and blindness associated with diabetes.
Good patient counseling is an important pillar in this endeavor. -
Health data is an area that needs a lot of attention - especially regarding integration, accuracy, completeness and access to the data.
In the DR-NET LINKS program, we have some examples of shared data between diabetes services and eye care services in the same hospital, but this is still not shared across hospitals. -
Dr Nyawira Mwangi made a comment
Very important issue for Diabetic Retinopathy programs - the need to manage cataract in patients with diabetic retinopathy
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Thank you @IsrarMuhammad. How can we know that we are using a holistic approach? Any suggestions?
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Looking out for your reflections on these questions:
'As you watch, reflect on your own setting. Is there a guideline on call and recall intervals available or a system in place already? If not, how could one be set up? What are the main challenges that are, or are likely to be, encountered in managing a call and recall system in your setting?' -
Thank you @FadyAlDakkan. Do you know if the DR service in your area collects data on patient satisfaction?
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Dr Nyawira Mwangi made a comment
Welcome to week 4. A good point of reflection is the level of availability of treatment services in your setup. Are the services uniformly available and accessible?
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Dr Nyawira Mwangi made a comment
What screening tests are available in your setting? What is your experience with using them?
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Glad that we have a chance to reflect on the implications of the sensitivity and specificity of DR screening tests. What are the reasons why you prefer a test with high sensitivity (in an instant where you have to place a value between sensitivity and specificity)?
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Absolutely correct @RecivallSalongcay. Thank you for highlighting these points.
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Good to have you on the course @BernadetteFord. Thank you for pointing out that a referral is necessary but not sufficient to ensure the patients get to a screening service. The system may not be easy to navigate and there are many steps that may be obstacles.
Any thoughts on how we can overcome these challenges? -
Dr Nyawira Mwangi made a comment
Do you have a DR screening program? What methods of screening are available in your setting? We would love to hear about your screening program.
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Dr Nyawira Mwangi made a comment
Welcome to week 2, where we begin to discuss the organization of services for DR, such as screening services
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How often do people with diabetes in your setting visit the diabetes clinic? And what proportion of them access and utilize diabetes eye care services?
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Please share your comments or any literature on the prevalence of diabetes or DR in your setting or in other settings. Why would it differ by setting?
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In which of these aspects of prevention might you play a role?
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We would love to hear your reflections on this aspect:
'As you watch, consider how incidence data guides the development of appropriate prevention strategies for DR generally and within your setting.' -
At what stage do you see most of your patients? In my context, most patients present with sight-threatening disease.
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Dr Nyawira Mwangi made a comment
Very good outline of the clinical presentations of DR at the eye clinic (in the video). What is your experience with these?
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The vitreous has important functions, but it does not regenerate, therefore various vitreous substitutes have been used.
This article discuss this need for substitutes in more detail: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4458642/ -
Correct especially now that we know that visual impairment and blindness due to diabetes can be prevented with these interventions.
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Quite right @SamiraKhalilova. The case definition will have an impact on the measures of disease and the need for appropriate responses to control the disease.
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Thank you @SvenAretz and @LajosCsincsik for sharing these articles. A very good way to prompt conversations on the technology for retinal examination that has been used at various times and in various places. And how the health sector can make decisions on the infrastructure required. In the section on screening, we will discuss this more.
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Thank you @JoanaRodrigues. How about the practice outside the clinical setting? Is self-monitoring of blood glucose at home feasible after discharge from the hospital?
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Dr Nyawira Mwangi made a comment
Welcome everyone, greetings from Nairobi, Kenya. Nyawira
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Dr Nyawira Mwangi made a comment
Is this your first online course? Or the first course on FutureLearn? We would love to know.
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Dr Nyawira Mwangi made a comment
Welcome to the course, we are delighted that you have joined. The course will empower you to participate in the control of diabetes-related visual impairment and blindness. The COVID-19 pandemic has been described as having a potentially devastating impact on the services for diabetes eye disease, so this is a very crucial course at this time. Looking forward...
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Quite right @JadaanLeticia. It is necessary to increase the proportion of the population that has insurance coverage and also ensure that these treatments are covered in the insurance packages.
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@SitumaPW This is an important clinical question that has generated lots of interest in the clinical and research community. One paper posits that in future we may have more bilateral injections, given the need to reduce the treatment burden for patients and other considerations:...
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@dinsukhladwa Well done!!!
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Dr Nyawira Mwangi made a comment
Well done for completing the course, and for weighing in with your comments in each step. Best wishes as you make use of the learning.
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Dr Nyawira Mwangi replied to Perpetual Forson
Certainly - look out for Step 4.5 @PerpetualForson
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You can learn more on grading by registering on the DR grading course whose the link provided above. Have fun!
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Dr Nyawira Mwangi made a comment
Hello everyone. What will you do at the end of this course to contribute to development or improvement of the DR services? Let's share our action points.
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It is evident from the comments that many facilities do not have a call and recall system in place. If this is your experience, two quick questions for you:
1. Do you have a database of the patients with diabetes?
2. Do you keep a record of the patient's contact information (such as telephone) and return dates for review, and is this information easily... -
@MavisBadu, good reflection. What steps would you start with?
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Good to hear of this success in your service @JUDITHBOATENGADIASE
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Thanks for reflecting on this @SisiliaR. In week 3, step 3.4, we will revisit this and I look forward to reading any additional reflections on you may have on this.
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Dr Nyawira Mwangi made a comment
This paper may provide additional inspiration as you consider what you can do with the evidence from the situation analysis: https://tropmedhealth.biomedcentral.com/articles/10.1186/s41182-019-0160-y
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Thanks for sharing your experience and the strategies that would improve the patient experience of treatment @AnnePatterson. As you have pointed out, the prospect of laser and anti-VEGF injections may cause anxiety / fear: - of pain, of keeping the eye open during the procedure, or losing vision, etc. This is important information to include in discussions...
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Thanks @HannahBeharrell for this input, which highlights the need for patient-centered services. This will be discussed in section 3.3.
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Quite right @ROSEMARYATAKORA. Step 1.18 discussed these requirements
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@RitaAkuoko Absolutely!
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If you are interested in finding evidence on diagnostic test accuracy as it relates to DR, this paper may provide some inspiration https://systematicreviewsjournal.biomedcentral.com/articles/10.1186/s13643-018-0846-y
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From the comments, it seems that there is a lack of national or other local guidelines in most settings. The ICO guidelines are used in some settings, and you can download this document from the link above. A number of African countries (such as Ghana) are in the process of developing the DR guidelines and documenting the process of developing the guidelines....
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@FuseiniSulemana I have been privileged to be involved in the development of the Ghana national DR guidelines, we expect the document will be produced and disseminated soon.
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Dr Nyawira Mwangi made a comment
An important point to note - it is important to have access to treatment services (either at the facility or in a referral service), before starting a screening service. This is to enable patients screened and found to have vision-threatening DR to access treatment. Hence it is important to reflect on step 1.
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Thanks for sharing your reflections on this @RajendraAhya. The lens functions best at low physiologic levels of oxygen, even though it is exposed to a broad spectrum of oxygen levels in the fluids around it (and this may lead to oxidative damage which increases the risk for conditions such as cataract). The lens and the fluids around it also contain...
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Dr Nyawira Mwangi made a comment
Welcome everyone to week 2. Screening for diabetic retinopathy is an important strategy for control of DR. How should we use it? Share your thoughts as you go through the content.
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Dr Nyawira Mwangi made a comment
Well done for completing week 1. Glad that many of you found the course interesting. Remember that you can download the resources if you need to. Keep up the enthusiasm.
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Thank you for highlighting this important point on health financing and data @GodwinKunafa. How can professional associations help to address these gaps?
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Reading the responses, I notice a lot of resource challenges. What about other challenges, such as patients experiencing difficulty navigating the referral systems, even within the same health facility?
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As you think about global challenges for diabetic eye disease, you may find this paper interesting https://www.thelancet.com/journals/langlo/article/PIIS2214-109X(19)30450-4/fulltext
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Many of the comments recognize the need for awareness creation, lifestyle change and investment in research. What steps can you take today in this direction?
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@AnnePatterson you certainly have lots of knowledge that is very useful. You are quite right that we need to give emphasis to 'how' to achieve the target glucose level, BP, cholesterol and other measures. Many times service providers concentrate on the 'what'.
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@EvelynEmeliaAnsah @VivianTakyiwa @LucianusNuoseg @AGOTSEJOSHUAKOMLA Apart from lack of awareness/education, what is the role of other barriers such as resource constraints or lack of clinical guidelines in your facility/region?
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@JadaanLeticia you have raised a very important point - a large proportion of the patients are undiagnosed. What are some strategies that can be used to reduce this?
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@JulesHarrison @OnyekachiJaneIreka There is some evidence that showing the patients their own retinal images is a powerful and convincing tool for education. Do you have any experience with this?
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@RusselElaineDiaz quite right - the fact that the images can be stored and retrieved for reference is an important advantage of photographic methods.
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@SampsonYalley quite right. What approaches can be used to encourage adoption of these aspects of a healthy lifestyle?
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Yes, this is interesting research @AGOTSEJOSHUAKOMLA. We look forward to reading the outcomes of the research.
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Good to hear you found if useful @AnnePatterson. Any thoughts on current gaps in knowledge that require further research?
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@RejoiceAbilla thank you for pointing out the importance of self-management. Who is primarily responsible for educating a newly- diagnosed patient and family in your setting?
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@MUHAMMOD-RABIUSALIHU please do that
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@MonicaDanikuu The course will run over the next four weeks
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Dr Nyawira Mwangi made a comment
So glad you have joined this exciting course! We get to explore diabetic eye disease - from diabetes to diabetic retinopathy, from epidemiology to screening and treatment. We'll learn how to apply the knowledge to solve the complex challenges related to diabetes-related visual impairment. I look forward to reading and discussing your fantastic ideas in the...
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@Dr.MiriamCano Thank you
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Thank you @MARIASFAKIANAKI - well discussed.
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Dr Nyawira Mwangi made a comment
How might you use the essential list for diabetic retinopathy?
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Has anyone been involved in an assessment of the health system for diabetic retinopathy? What were your findings?
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Quite right @INNOCENTMAFUNGA - AI missed the aspect of human communication
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For the human resources, do we have different cadres of health workers participating in service delivery for DR in different countries and levels of care?
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Excellent @SohMbuyeeMacpella. What indicators might be useful and feasible at present?
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Dr Nyawira Mwangi made a comment
Do share the strategies that you have used to establish or strengthen links between diabetes and eye care services
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Quite right @JorgeGerardoMoralesNavarro . In some settings there are self-care educators in eye clinics, and diabetes educators in diabetes clinics. Quite helpful with patient education.
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Thank you @SohMbuyeeMacpella for the insight about the use of multi-dose treatment and the advantage on cost. Did the multidose treatment otherwise work well? Any issues with storage of avastin? Any effect on the frequency of infections, such as endophthalmitis?
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Thank you for raising these important issues - especially social and economic determinants of the use of services for diabetes and DR @JorgeGerardoMoralesNavarro. I am sure similar experiences would be reported in multiple settings. I invite comments from other learners regarding stigma as it relates to diabetes and eye care services.
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Dr Nyawira Mwangi made a comment
Welcome to Week 3, in which we look at some practicals aspects of screening. How do they relate to your experience? Please share this with us.
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Thank you @JorgeGerardoMoralesNavarro. How do the NGOs work- do they provide service delivery (run their own health facilities) or what are the main roles that they play? Are they international or local NGOs?
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9.2% of the 1.12 million adults will need screening.
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Dr Nyawira Mwangi made a comment
Please include your suggestions: In what ways might the rich information obtained from the situation analysis be useful?
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@CHIAEliasnyanyo this would be the quizzes? If you encounter a similar problem, do let us know the specific quiz and question.
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@JorgeGerardoMoralesNavarro There are 1.12 million adults in Ormo. Of these, 9.2% (of the 1.12 million) have diabetes and hence all of those will need screening for retinopathy. Of those adults with diabetes, it is estimated that 10% will need treatment.
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Dr Nyawira Mwangi replied to Pratyush Dhakal
Good to hear of your experience with handheld cameras @PratyushDhakal. Please share more on this. Who conducts the screening? How do they reach the rural population? What do you do for those found to require a retina specialist?
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Indeed this is a major barrier to access in settings where patients have to pay for services out of pocket. To find a sustainable strategy, stakeholders in diabetes and eye care services, including the community, will need to be engaged.
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Dr Nyawira Mwangi replied to MARIA SFAKIANAKI
Thank you for sharing this @MARIASFAKIANAKI - and glad to see that the screening program also includes health promotion and referral, which are important but often neglected services.
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Dr Nyawira Mwangi made a comment
Do clinicians and patients actually adhere to the guidelines used in your set-up? Would love to hear your experience.
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How might a public-private partnership (PPP) be implemented in this setting? Is there goodwill for this @INNOCENTMAFUNGA? There is growing recognition that Universal Health Coverage and other targets may not be achieved without PPPs. However the type and the implementation of PPPs would be unique to each setting.
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Best wishes as you mobilize these resources @PATRICKPAUL
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@JudyKaragania thank you for raising this important point - where should the camera be located - is it in the diabetes clinic or in the eye clinic (if you have to prioritize)?
For insights from the Kenyatta National Hospital DR screening program, see ... -
I concur @NicolaJames, the use of AI is likely to have an important role in DR screening, though there are pros and cons to it. This paper may be of interest: https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2703944
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Quite right @INNOCENTMAFUNGA - beyond providing proof that the technology works, its important to consider how the investment in the technology will solve or aggravate gaps in health care.
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Thank you @SohMbuyeeMacpella @CHIAEliasnyanyo. No easy solution - we need the human resources, and also technology such as telemedicine and artificial intelligence in the hands of the staff may be helpful..
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@SohMbuyeeMacpella thank you for sharing this experience of services being interrupted during crisis - with infrastructural, human resource and service delivery constraints. I would be interested to know how your thoughts about what should be done first to begin to re-establish the program in this context. Where should be the starting point?
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True @Dr.MiriamCano, it would be unethical to establish screening services if treatment services are not available
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Good summary @LOVEDAYNDUBUISI. Do you think type 1 diabetes is associated with high mortality from other complications, likely before the patients get to visit an eye clinic? Could this be part of the reason why the data is sparse?
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@StèveRobertEBANAMVOGO is this more common for women known to have diabetes who get pregnant or women who develop diabetes in pregnancy?
