title: Assessment of public health services for diabetes mellitus and diabetic retinopathy during the COVID-19 pandemic in the State of Hidalgo, Mexico.
Creators: name: Martinez-Juarez, LA
Publisher: name: London School of Hygiene & Tropical Medicine
Year: 2022

description: Background: Diabetes mellitus (DM) is a metabolic disease characterized by high levels of blood sugar, which affect different organs, including the eyes. Diabetic retinopathy (DR) is a complication of diabetes which can lead to vision loss. Mexico has one of the highest prevalence of DM in the world. The management of DM and DR requires a health system prepared to prevent, diagnose, and offer timely treatment to the population that requires it. This remains important during the COVID-19 pandemic, which is a threat to the delivery of all health services. Aims: To assess the public health system for DR services in the state of Hidalgo, identify the constraints resulting from COVID-19, and provide recommendations to maintain and strengthen the health system to prevent blindness and the delivery of comprehensive eye care services for persons living with diabetes. Methods: This work follows a mixed-method descriptive study design. First, the current and future magnitude of DM and DR in Mexico and Hidalgo was estimated, in addition, available data on clinical service delivery for diabetes mellitus and diabetic retinopathy in Hidalgo in the period before the Covid-19 epidemic and during the epidemic were collated. Then, 13 key stakeholders from the public health sector in Mexico and the State of Hidalgo related to the development and implementation of policies and strategies for DM and DR were interviewed to assess the service provision for DM and DR through a tool for the assessment of diabetic retinopathy and diabetes management system (TADDS). They were also asked to identify the constraints on health providers resulting from the COVID-19 pandemic in delivering services to persons living with DM and DR. Finally, the major constraints to improve the eye care services were identified in order to provide recommendations and a policy brief for the Minister of Health in Hidalgo. Results: Hidalgo with a population of approximately 3 million has an estimated 272,000 people living with diabetes of which approximately 90,000 are expected to have diabetic retinopathy and 21,000 require treatment for sight threatening retinopathy. Responses to 41 questions from the TADDS instrument were analysed. The main constraints to the provision of DM / DR services were identified as a limited public health education programme about diabetes mellitus and limited health education of PLWD about DR. The primary health centres do not have the required personnel, equipment and essential consumables / medicines for prevention, diagnosis, and control of patients with DM, and the identification of those with DR. The specialist endocrinology and eye health services are only available in the State capital with no effective referral system between primary health centres and specialist eye health centre. There is an inadequate screening and treatment service for DR throughout the State. Questions to identify the constraints on health providers resulting from the COVID-19 pandemic yielded 28 thematic nodes identifying delivery constraints due to the pandemic, and 40 thematic nodes providing possible solutions. The qualitative analysis of the interviews revealed that the COVID-19 pandemic has reduced the health personnel and other resources available in primary health centres and secondary hospitals for DM/DR care. Eight recommendations were identified for improving services to PLWD and seven for the provision of eye health services during and after the pandemic. Conclusions: This study has shown that DM is a national health priority in Mexico, for which health promotion, preventive and therapeutic measures are inadequate. DR is not currently recognised as a priority in available health policies, or by operational clinical guidelines across the continuum of DM/DR care. In the state of Hidalgo those DM and DR services that are present have been severely reduced by the COVID epidemic. As requested by the Hidalgo health authority, a policy brief and specific recommendations are provided based on this study.