BACKGROUND

In 2010, the prevalence of Diabetes Mellitus (DM) in Palestine in the age group 25-64 years was 12.7%. This number is predicted to reach 20.8% in 2020 and 23.4% in 2030. In 2015, the prevalence of diagnosed DM among the refugee population aged 40 years or older served by the United Nations Refugees and Works Agency (UNRWA) was 12.2% in the Gaza Strip and 13.9% in the West Bank. These rates were higher than in any other region served by the UNRWA. The prevalence of diabetic retinopathy (DR) among 376 type 2 DM patients in Ramallah clinics in the West Bank in 2012 was 36.7%; one third had never had their eyes examined.

St John Eye Hospital Group (SJEHG) is the only charitable provider of expert eye care in Palestine. It conducted a screening program of 36,796 DM patients in 39 clinics in the West Bank between 2012 and 2015, and found the prevalence of DR in this population to be 31.5%. A total of 2,390 DR cases received laser treatment, 955 cases received Avastin injections, 317 cases underwent phaco eye surgery, and 77 underwent vitrectomy.

The number of DM patients served by UNRWA in the Gaza Strip in 2016 was 42,000 across 22 clinics. There are only two ophthalmologists caring for these patients. As a result, DR management has not been adequate. SJEHG is leading the development and implementation of a comprehensive and integrated model of care for diabetes-related eye disease in the Gaza Strip, with the overall goal to ensure that a care pathway for DR is available, accessible, and affordable for poor and marginalised populations.

AIMS

The aims of the research presented here are to provide evidence on the effectiveness of selected components of the model of care for eye health in persons with DM and to inform appropriate replication and sustainable implementation of equitable services in Gaza and elsewhere in the region in the future.

METHODS

A mixed-method approach will be used to assess the effectiveness of selected components of the model of care. This will include: (i) repeated cross-sectional surveys and (ii) qualitative data collection to assess knowledge, attitudes, and practices (KAP) relating to DM and DR among DM patients and those caring for them before and after awareness generation activities; (iii) qualitative research to investigate acceptability and satisfaction with the model of care and to develop recommendation of sustained implementation; (iv) observations to investigate impact of the model of care on practice and facilities at UNRWA clinics; and (v) and the assessment of the positive and negative predictive value of DR screening and referral performed by newly trained allied ophthalmic healthcare professionals using hand held digital cameras, compared to assessment of DR carried out by ophthalmologists.

Notably, this project will also include a health economics research component, which will focus on the cost-effectiveness of the model of care and will result in the development of a sustainable financing model to promote sustainability of care and equitable access to care across the population of Gaza.
Participants will include a sample of DM patients who present at any of the 22 UNWRA clinics in Gaza, as well as all health care professionals caring for them.

RESULTS

The KAP surveys of DM patients and health providers, part of the health economics evaluation, and the results of the comparative study between the assessment of DR done by the newly trained allied ophthalmic personnel and the assessment done by the ophthalmologists will be completed by October 2017. The results of these surveys will be presented at the congress.

DISCUSSION

DM and DR are significant health problems in Palestine. DR management was not adequate at UNRWA clinics in Gaza due to lack of qualified human resources. For the first time, a comprehensive and integrated model of care for DM-related eye disease will be implemented in Gaza, Palestine. The research presented here will provide evidence on the (cost) effectiveness of key components of this model of care, as well as recommendations for improvement, scale-up and sustainability of the model of care in the future.

Assessing an integrated, comprehensive, and equitable model of care for diabetes-related eye disease in Gaza/Palestine