Sustaining remote‐area programs: retinal camera use by Aboriginal health workers and nurses in a Kimberley partnership

Abstract

Objective: To describe how a novel program of diabetic retinopathy screening was conceived, refined and sustained in a remote region over 10 years, and to evaluate its activities and outcomes. Design: Program description; analysis of regional screening database; audit of electronic client registers of Aboriginal community controlled health services (ACCHSs). Setting and participants: 1318 Aboriginal and 271 non‐Aboriginal individuals who underwent retinal screening in the 5 years to September 2004 in the Kimberley region of north‐west Australia; 11 758 regular local Aboriginal clients of Kimberley ACCHSs as at January 2005. Main outcome measures: Characteristics of clients and camera operators, prevalence of retinopathy, photograph quality, screening intervals and coverage. Results: Among Aboriginal clients, 21% had diabetic retinopathy: 19% with non‐proliferative retinopathy, 1.2% with proliferative retinopathy, and 2.8% with maculopathy. Corresponding figures for non‐Aboriginal clients were 11%, 11%, 0 and 0.4%, respectively. Photograph quality was generally high, and better for non‐Aboriginal clients, younger Aboriginal clients and from 2002 (when mydriatic use became universal). Quality was not related to operator qualifications, certification or experience. Of 718 regular Aboriginal clients with diabetes on local ACCHS databases, 48% had a record of retinal screening within the previous 18 months, and 65% within the previous 30 months. Conclusions: Screening for diabetic retinopathy performed locally by Aboriginal health workers and nurses with fundus cameras can be successfully sustained with regional support. Formal certification appears unnecessary. Data sharing across services, client recall and point‐of‐care prompts generated by electronic information systems, together with policies making primary care providers responsible for care coordination, support appropriate timely screening.

Prevalence of self-reported diabetes and diabetic retinopathy in indigenous Australians: the National Indigenous Eye Health Survey

“…Very few studies have estimated prevalence of diabetic retinopathy among indigenous population in Australia and varying prevalence of retinopathy has been reported, ranging from 18% to 23%, lower than the prevalence of 30% we found 11,12,28,29 . This may reflect a bias in those with diabetes who participated in the survey and an overestimation of diabetes due to self‐reported measures.…”

“…Very few studies have estimated prevalence of diabetic retinopathy among indigenous population in Australia and varying prevalence of retinopathy has been reported, ranging from 18% to 23%, lower than the prevalence of 30% we found. 11,12,28,29 This may reflect a bias in those with diabetes who participated in the survey and an overestimation of diabetes due to self-reported measures. The prevalence of retinopathy is also influenced by other factors such as age, sociodemographic, and genetic factors, how diabetes is defined, and the methods used to detect and classify retinopathy.…”

“…The indigenous Australians are at higher risk for diabetic retinopathy (18–44%) because of their high prevalence of diabetes 11,12 . However, no current national data are available except for a few regional studies 13,14 .…”

“…10 The indigenous Australians are at higher risk for diabetic retinopathy (18-44%) because of their high prevalence of diabetes. 11,12 However, no current national data are available except for a few regional studies. 13,14 The true prevalence of eye disease and the areas of greatest need are not known and this has hampered the planning of effective eye care services for indigenous Australians.…”

Clinical trials in a remote Aboriginal setting: lessons from the BOABS smoking cessation study

“…Whilst new programs delivered by enthusiastic outsiders can provide short-term benefits to Indigenous Australians, once staff leave these programs often lose momentum [13]. Thus, recruiting, supporting, training and employing local Aboriginal and Torres Strait Islander people is one of the central elements in the provision of sustainable Indigenous health programs, especially in remote areas [14]. Such complexity also applies to research projects and cautionary reports have been published on the difficulties of conducting RCTs in ACCHSs settings [15,16].…”