Piloting targeted glaucoma screening: experiences of eye care services in Ganjam district, Odisha state, India

The number of patients with visual impairment and blindness from glaucoma is rapidly increasing with wide-ranging impacts for individuals and societies. However, the disease often goes undiagnosed for a long time, especially in low- and middle-income countries where healthcare services are limited. This paper presents the results of a pilot programme, which integrated targeted glaucoma screenings of people aged ≥40 y in community-based eye care services in the Ganjam district of Odisha state, India.

Using routine programme data, descriptive statistics were produced for the characteristics of patients participating in the screening programme and the rate and uptake of glaucoma referrals. Bivariate analysis was used to examine associations between patient characteristics, clinical risk factors and glaucoma diagnosis.

Out of 23 356 individuals aged ≥40 y screened for glaucoma over a period of 18 mo, 2219 (9.5%) were referred and 2031 presented for further examination. Among them, almost half (n=968, 48%) were diagnosed with glaucoma, representing a screening to diagnosis conversion rate of 4.14% (95% CI 3.9 to 4.4%). A positive diagnosis of glaucoma among suspects was associated with female sex, age >60 y, visual impairment, vertical cap-to-disc ratio ≥0.6:1, intraocular pressure ≥30 mmHg and shallow anterior chamber (p<0.001).

The importance of targeted screening for glaucoma using simple referral criteria to identify patients at high risk of vision loss who can benefit from treatment is critical to slow the progression of the disease and the prevention of blindness. Further studies assessing costs of the targeted screening, the role of technology in improving programme effectiveness and efficiency and the longer term compliance with treatment are needed to support glaucoma policy frameworks, guidelines and clinical practice.

Artificial intelligence for early diagnosis of lung cancer through incidental nodule detection in low- and middle-income countries-acceleration during the COVID-19 pandemic but here to stay

Although the coronavirus disease of 2019 (COVID-19) pandemic had profound pernicious effects, it revealed deficiencies in health systems, particularly among low- and middle-income countries (LMICs). With increasing uncertainty in healthcare, existing unmet needs such as poor outcomes of lung cancer (LC) patients in LMICs, mainly due to late stages at diagnosis, have been challenging-necessitating a shift in focus for judicious health resource utilization. Leveraging artificial intelligence (AI) for screening large volumes of pulmonary images performed for noncancerous reasons, such as health checks, immigration, tuberculosis screening, or other lung conditions, including but not limited to COVID-19, can facilitate easy and early identification of incidental pulmonary nodules (IPNs), which otherwise could have been missed. AI can review every chest X-ray or computed tomography scan through a trained pair of eyes, thus strengthening the infrastructure and enhancing capabilities of manpower for interpreting images in LMICs for streamlining accurate and early identification of IPNs. AI can be a catalyst for driving LC screening with enhanced efficiency, particularly in primary care settings, for timely referral and adequate management of coincidental IPN. AI can facilitate shift in the stage of LC diagnosis for improving survival, thus fostering optimal health-resource utilization and sustainable healthcare systems resilient to crisis. This article highlights the challenges for organized LC screening in LMICs and describes unique opportunities for leveraging AI. We present pilot initiatives from Asia, Latin America, and Russia illustrating AI-supported IPN identification from routine imaging to facilitate early diagnosis of LC at a potentially curable stage.

Effect of Door-to-Door Screening and Awareness Generation Activities in the Catchment Areas of Vision Centers on Service Use: Protocol for a Randomized Experimental Study

A vision center (VC) is a significant eye care service model to strengthen primary eye care services. VCs have been set up at the block level, covering a population of 150,000-250,000 in rural areas in North India. Inadequate use by rural communities is a major challenge to sustainability of these VCs. This not only reduces the community’s vision improvement potential but also impacts self-sustainability and limits expansion of services in rural areas. The current literature reports a lack of awareness regarding eye diseases and the need for care, social stigmas, low priority being given to eye problems, prevailing gender discrimination, cost, and dependence on caregivers as factors preventing the use of primary eye care.

Our organization is planning an awareness-cum-engagement intervention—door-to-door basic eye checkup and visual acuity screening in VCs coverage areas—to connect with the community and improve the rational use of VCs.

In this randomized, parallel-group experimental study, we will select 2 VCs each for the intervention arm and the control arm from among poor, low-performing VCs (ie, walk-in of ≤10 patients/day) in our 2 operational regions (Vrindavan, Mathura District, and Mohammadi, Kheri District) of Uttar Pradesh. Intervention will include door-to-door screening and awareness generation in 8-12 villages surrounding the VCs, and control VCs will follow existing practices of awareness generation through community activities and health talks. Data will be collected from each VC for 4 months of intervention. Primary outcomes will be an increase in the number of walk-in patients, spectacle advise and uptake, referral and uptake for cataract and specialty surgery, and operational expenses. Secondary outcomes will be uptake of refraction correction and referrals for cataract and other eye conditions. Differences in the number of walk-in patients, referrals, uptake of services, and cost involved will be analyzed.

Background work involved planning of interventions and selection of VCs has been completed. Participant recruitment has begun and is currently in progress.

Through this study, we will analyze whether our door-to-door intervention is effective in increasing the number of visits to a VC and, thus, overall sustainability. We will also study the cost-effectiveness of this intervention to recommend its scalability.

Dataset evaluating the treatment timeliness of cervical cancer in Zambia

Cervical cancer is the fourth most common cancer diagnosed among women globally. Effective screening routines and early detection are vital in reducing its disease burden and mortality. Several factors can influence the timely detection and treatment of cervical cancer, especially in low middle-income countries where the burden of this disease is highest. The data presented in this paper relates to the research article “Cervical cancer diagnosis and treatment delays in the developing world: Evidence from a hospital-based study in Zambia”. The raw and analysed data include the studied patients’ social demographic factors, clinical data concerning the stage and histological subtype of cancer, dates at which the various activities within the cancer treatment pathway occurred and delays to definitive treatment of cervical cancer at Zambia’s only cancer treatment facility. Detailing delays to the treatment of cervical cancer allows recognition of specific points in the cancer treatment pathway requiring intervention to effectively improve cancer care and reduce the morbidity and mortality associated with the disease.

Cervical cancer diagnosis and treatment delays in the developing world: Evidence from a hospital-based study in Zambia

Expedited diagnostic processes for all suspected cervical cancer cases remain essential in the effort to improve clinical outcomes of the disease. However, in some developing countries like Zambia, there is paucity of data that assesses factors influencing diagnostic and treatment turnaround time (TAT) and other metrics vital for quality cancer care. We conducted a retrospective hospital-based study at the Cancer Diseases Hospital (CDH) for cervical cancer cases presenting to the facility between January 2014 and December 2018. Descriptive statistics were used to summarize demographic characteristics while a generalized linear model of the negative binomial was used to assess determinants of overall TAT. Our study included 2121 patient case files. The median age was 49 years (IQR: ±17) and most patients (n=634, 31%) were aged between 41–50 years. The International Federation of Gynaecology and Obstetrics (FIGO) Cancer stage II (n =941, 48%) was the most prevalent while stage IV (n=103, 5.2%) was the least. The average diagnostic TAT in public laboratories was 1.48 (95%CI: 1.21–1.81) times longer than in private laboratories. Furthermore, referral delay was 55 days (IQR: 24–152) and the overall TAT (oTAT) was 110 days (IQR: 62–204). The age of the patient, HIV status, stage of cancer and histological subtype did not influence oTAT while marital status influenced oTAT. The observed longer oTAT may increase irreversible adverse health outcomes among cervical cancer patients. There is a need to improve cancer care in Zambia through improved health expenditure especially in public health facilities.

Primary care and pulmonary physicians’ knowledge and practice concerning screening for lung cancer in Lebanon, a middle‐income country

Screening for lung cancer with low‐dose computed tomography (LDCT) was shown to reduce lung cancer incidence and overall mortality, and it has been recently included in international guidelines. Despite the rising burden of lung cancer in low and middle‐income countries (LMICs) such as Lebanon, little is known about what primary care physicians or pulmonologists know and think about LDCT as a screening procedure for lung cancer, and if they recommend it.

Evaluate the knowledge about LDCT and implementation of international guidelines for lung cancer screening among Lebanese primary care physicians (PCPs) and pulmonary specialists.

PCPs and PUs based in Lebanon were surveyed concerning knowledge and practices related to lung cancer screening by self‐administered paper questionnaires.

73.8% of PCPs and 60.7% of pulmonary specialists recognized LDCT as an effective tool for lung cancer screening, with 63.6% of PCPs and 71% of pulmonary specialists having used it for screening. However, only 23.4% of PCPs and 14.5% of pulmonary specialists recognized the eligibility criteria for screening. Chest X‐ray was recognized as ineffective by only 55.8% of PCPs and 40.7% of pulmonary specialists; indeed, 30.2% of PCPs and 46% of pulmonary specialists continue using it for screening. The majority have initiated a discussion about the risks and benefits of lung cancer screening.

PCPs and pulmonary specialists are initiating discussions and ordering LDCT for lung cancer screening. However, a significant proportion of both specialties are still using a non‐recommended screening tool (chest x‐ray); only few PCPs and pulmonary specialists recognized the population at risk for which screening is recommended. Targeted provider education is needed to close the knowledge gap and promote proper implementation of guidelines for lung cancer screening.

The challenges of implementing low-dose computed tomography for lung cancer screening in low- and middle-income countries

Lung cancer accounts for an alarming human and economic burden in low- and middle-income countries (LMICs). Recent landmark trials from high-income countries (HICs) by demonstrating that low-dose computed tomography (LDCT) screening effectively reduces lung cancer mortality have engendered enthusiasm for this approach. Here we examine the effectiveness and affordability of LDCT screening from the viewpoint of LMICs. We consider resource-restricted perspectives and discuss implementation challenges and strategies to enhance the feasibility and cost-effectiveness of LDCT screening in LMICs.

Designing for Health Accessibility: Case Studies of Human-Centered Design to Improve Access to Cervical Cancer Screening

Our world faces immense challenges in global health and equity. There continue to be huge disparities in access to health care across geographies, despite the massive strides that have been made to address health issues. In this dissertation, I explore the role of human-centered design to improve global health access and reduce disparities. Human-centered design, a cross-disciplinary creative problem-solving approach, has been applied and studied in both academic research and practice, but its role in improving global health access remains poorly understood.

In this dissertation, I present research on designing for health accessibility in the context of one particular disease: cervical cancer. Every year, 300,000 women around the world die of cervical cancer and ninety percent of these deaths occur in low- and middle-income countries. Cervical cancer is an illustrative example of the global disparities in access to health care, given that cervical cancer is preventable and the majority of global cervical cancer mortality is in low- and middle-income countries.

My research examines the work of two organizations that created unique solutions to improve access to cervical cancer screening in India and Nicaragua. I develop case studies of each organization grounded in ethnographic fieldwork, including over 250 hours of observation and 15 interviews over two years. Through these case studies, I show how early efforts to understand the barriers inhibiting cervical cancer screening access allow design practitioners to create novel and feasible ways to address these barriers. This demonstrates the importance of design practitioners considering multiple dimensions of accessibility, including availability, physical accessibility, accommodation, affordability, and acceptability, while conducting design research in order to improve the potential impact of their ideas and prototypes. Overall, this dissertation establishes the foundation of a new paradigm to “design for accessibility” that can inspire further application and research across sectors to address the many social equity and accessibility challenges facing our world.

Investigating the use of ultrasonography for the antenatal diagnosis of structural congenital anomalies in low-income and middle-income countries: a systematic review

Background: Congenital anomalies are the fifth leading cause of under-5 mortality globally. The greatest burden is faced by those in low/middle-income countries (LMICs), where over 95% of deaths occur. Many of these deaths may be preventable through antenatal diagnosis and early intervention. This systematic literature review investigates the use of antenatal ultrasound to diagnose congenital anomalies and improve the health outcomes of infants in LMICs.

Methods: A systematic literature review was conducted using three search strings: (1) structural congenital anomalies; (2) LMICs; and (3) antenatal diagnosis. The search was conducted on the following databases: Medline, Embase, PubMed and the Cochrane Library. Title, abstract and full-text screening was undertaken in duplicate by two reviewers independently. Consensus among the wider authorship was sought for discrepancies. The primary analysis focused on the availability and effectiveness of antenatal ultrasound for diagnosing structural congenital anomalies. Secondary outcomes included neonatal morbidity and mortality, termination rates, referral rates for further antenatal care and training level of the ultrasonographer. Relevant policy data were sought.

Results: The search produced 4062 articles; 97 were included in the review. The median percentage of women receiving an antenatal ultrasound examination was 50.0% in African studies and 90.7% in Asian studies (range 6.8%-98.8%). Median detection rates were: 16.7% Africa, 34.3% South America, 34.7% Asia and 47.3% Europe (range 0%-100%). The training level of the ultrasound provider may affect detection rates. Four articles compared morbidity and mortality outcomes, with inconclusive results. Significant variations in termination rates were found (0%-98.3%). No articles addressed referral rates.

Conclusion: Antenatal detection of congenital anomalies remains highly variable across LMICs and is particularly low in sub-Saharan Africa. Further research is required to investigate the role of antenatal diagnosis for improving survival from congenital anomalies in LMICs.

Evaluation of Portable Tablet-Based Audiometry in a South Indian Population

While a comprehensive booth audiogram is the gold standard for diagnosis of hearing loss, access to this may not be available in remote and low resource settings. The aims of this study were to validate a tablet-based audiometer in a tertiary medical center in India and explore its capacity in improving access to hearing healthcare. Subjects presenting to Ear–Nose–Throat clinics for conventional booth audiometry testing were recruited for subsequent tablet-based audiometric testing. Testing with the tablet was conducted in a non-sound-treated hospital clinic room. Bilateral air and bone conduction hearing threshold data from 250 through 4000 Hz were validated against conventional booth audiometry. In addition, a small feasibility study was conducted in rural clinics. 70 participants (37 adults and 33 children between the ages 5–18) were assessed. 69% were male, with a mean age of 29.7 years. Sensitivity and specificity for the tablet were 89% (95% CI 80–94%) and 70% (95% CI 56–82%), respectively. While median differences in air conduction thresholds between conventional and tablet audiograms showed statistical significance at 250, 500, and 1000 Hz (p < 0.001), the threshold results of the tablet audiometer were within 5 dB of the conventional audiogram and not clinically significant. Ten patients were successfully screened in rural clinics with tablet audiometry. Tablet portable audiometry is a valid tool for air and bone conduction threshold assessment outside of conventional sound booths. It can accurately identify hearing impairment and offers a screening tool for hearing loss in low resource settings.