Primary eye care in sub-Saharan African: do we have the evidence needed to scale up training and service delivery?

Contextual factors affecting integration of eye health into school health programme in Zanzibar: a qualitative health system research

BACKGROUND

Short-term school eye health programmes supported by external funders have sustainability issues. This study aimed to understand the contextual factors affecting integrating eye health into the school health programme.

METHODS

We elicited responses from 83 respondents, purposefully selected from the Ministry of Health (n = 7), Ministry of Education and Vocational Training (n = 7), hospitals/eye centres (n = 5), master trainers (4) and schools (n = 60) who participated in in-depth interviews. Their responses were analysed and grouped into contextual factors according to the WHO Consolidated Framework for Implementation Research: stakeholders/political, institutional, physical, cultural, delivery system and others. Themes were then generated, and quotations were presented to illustrate the findings.

RESULTS

The six contextual factors affecting the integration of eye health into the school eye health programme were i) Stakeholders/political (Good ministry coordination, defined departmental roles and resource mobilisation from multiple stakeholders; Good stakeholder synergies and address current gaps); ii) Institutional (Institutional coordination and adequate clinic space; Securing human and financial resources; Strategic advocacy for institutional resources); iii) Physical (Long travel distance to service points); vi) Cultural (low eye health awareness among parents, teachers and children); iv) Delivery system (Practical approach to increase screening coverage using teachers as screeners; Balance teachers' workload, increase screening sensitivity and follow up and; v) Others (Comprehensive training material and effective training delivery; Improved curriculum, teacher selection and supervision and incentives).

CONCLUSION

Integrated school eye health delivery is generally well-received by stakeholders in Zanzibar, with the caveat that investment is required to address the six contextual factors identified in the study.

Child eye health in Ethiopia: a mixed methods analysis of policy and commitment to action

BACKGROUND

Child eye health is a serious public health issue in Ethiopia, where children under the age of 15 account for over half of the population. Our aim was to review Ethiopian health policy and practice to reveal approaches and commitment to promotion and delivery of child eye health services.

METHODS

We conducted a mixed-methods situational analysis employing documentary analysis and key informant interview methods. Government publications touching on any element of child eye health were included. Key informants were eligible if they were leaders, authorities, researchers or clinicians involved in child health. Data was combined and analysed by narrative synthesis, using an adaptation of the Eye Care Situation Analysis Tool as a framework.

FINDINGS

Eleven documents developed by the Ministries of Health and Education were included and interviews with 14 key informants were conducted. A focus on child eye health was lacking in key health policy documents, demonstrated by limited allocation of funds, a shortage of human resources, and a subpar referral system across all levels of child eye care.

CONCLUSION

The study identified several gaps and limitations in child eye health in Ethiopia. There is a need for health policies that strengthen ownership, finance and partnerships for improved coordination, and collaboration with line ministries and other stakeholders to improve child eye health services in Ethiopia.

Use of the World Health Organization primary eye care protocol to investigate the ocular health status of school children in Rwanda

PURPOSE

To assess the ocular health status of primary and secondary schoolchildren in Rwanda and to explore the use of the World Health Organization (WHO) primary eye care screening protocol.

METHODS

This was a cross-sectional population-based study across 19 schools in Rwanda. Initial screening was carried out using the WHO screening protocol, whereby visual acuity was measured using a tumbling E Snellen chart (6/60 and 6/12). Abnormal ocular features were identified using a flashlight and history against a checklist. All children with abnormal screening were referred to an on-site ophthalmic clinic for full examination. Those who could not be treated on-site were referred to an ophthalmologist at a hospital for specialist care.

RESULTS

A total of 24,892 children underwent ocular health screening. Of those, 1,865 (7.5%) failed the primary screening; 658 (2.6%) were false positives (35.3% of those who failed screening), and 1,207 (4.8%) true positives. The most frequently observed ocular diagnoses were allergic conjunctivitis (3.11%) and strabismus (0.26%). Refractive error was very rare (0.18%).

CONCLUSIONS

The WHO primary eye care curriculum provides existing health personnel with an approach to school-based vision screening that uses a standardized checklist and low-cost resources. In our study cohort, results indicated a low frequency of refractive error; the overwhelming majority of ocular problems could be identified on visual inspection.

The social construction of genomics and genetic analysis in ocular diseases in Ibadan, South-western Nigeria

Genomics, an emerging field to improve public health practice, has potential benefits to understanding ocular diseases. This study explored the social construction of genomics in ocular diseases in the blind community in Ibadan, Nigeria, through two focus group discussions and twelve in-depth interview sessions conducted among people living with ocular disorders. The data were thematic and content-analysed. Although the participants had limited knowledge about ocular diseases, genomics, and their nexus, they maintained a positive attitude toward its potential benefits. This informed their willingness to participate in genomics testing for ocular diseases. The participants preferred saliva-based sample collection over blood-based, and expressed concern for the procedure and accrued benefits of genomics studies. Thus, public sensitisation about ocular diseases and client-centred genomics testing procedures should be engendered.

Human resource and governance challenges in the delivery of primary eye care: a mixed methods feasibility study in Nigeria

Background

To increase access to eye care, the World Health Organization’s Africa Region recently launched a primary eye care (PEC) package for sub-Saharan Africa. To determine the technical feasibility of implementing this package, the capacity of health systems at primary level needs to be assessed, to identify capacity gaps that would need to be addressed to deliver effective and sustainable PEC. This study reports on the human resource and governance challenges for delivering PEC in Anambra State, Nigeria.

Methods

Design: This was a mixed methods feasibility study. A desk review of relevant Nigerian national health policy documents on both eye health and primary health care was conducted, and 48 primary health care facilities in Anambra state were surveyed. Data on human resource and governance in primary health facilities were collected using structured questionnaires and through observation with checklists. In-depth interviews were conducted with district supervisors and selected heads of facilities to explore the opportunities and challenges for the delivery of PEC in their facilities/districts. Data were analysed using the World Health Organization’s health system framework.

Results

A clear policy for PEC is lacking. Supervision was conducted at least quarterly in 54% of facilities and 56% of facilities did not use the standard clinical management guidelines. There were critical shortages of health workers with 82% of facilities working with less than 20% of the number recommended. Many facilities used volunteers and/or ad hoc workers to mitigate staff shortages.

Conclusion

Our study highlights the policy, governance and health workforce gaps that will need to be addressed to deliver PEC in Nigeria. Developing and implementing a specific policy for PEC is recommended. Implementation of existing national health policies may help address health workforce shortages at the primary health care level.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-021-07362-8.

Knowledge, Attitudes and Practices of Eye Health among Public Sector Eye Health Workers in South Africa

In South Africa, primary eye care is largely challenged in its organisational structure, availability of human and other resources, and clinical competency. These do meet the standard required by the National Department of Health. This study seeks to assess the levels of knowledge, attitudes, and practices on eye health amongst Human Resources for eye health (HReH) and their managers, as no study has assessed this previously. A cross-sectional study was conducted in 11 districts of a South African province. A total of 101 participants completed self-administered, close-ended, Likert-scaled questionnaires anonymously. Binary logistic regression analysis was conducted, and values of p < 0.05 were considered statistically significant. Most participants had adequate knowledge (81.6%), positive attitudes (69%), and satisfactory practices (73%) in eye health. HReH showed better knowledge than their managers (p < 0.01). Participants with a university degree, those aged 30-44 years, and those employed for <5 years showed a good attitude (p < 0.05) towards their work. Managers, who supervise and plan for eye health, were 99% less likely to practice adequately in eye health when compared with HReH (aOR = 0.012; p < 0.01). Practices in eye health were best amongst participants with an undergraduate degree, those aged 30-44 years (aOR = 2.603; p < 0.05), and participants with <5 years of employment (aOR = 26.600; p < 0.01). Knowledge, attitudes, and practices were found to be significantly moderately correlated with each other (p < 0.05). Eye health managers have poorer knowledge and practices of eye health than the HReH. A lack of direction is presented by the lack of adequately trained directorates for eye health. It is therefore recommended that policymakers review appointment requirements to ensure that adequately trained and qualified directorates be appointed to manage eye health in each district.

The Rising Burden of Diabetes-Related Blindness: A Case for Integration of Primary Eye Care into Primary Health Care in Eswatini

There is a rampant increase in diabetes prevalence globally. Sub-Saharan Africa (SSA) is projected to carry the largest burden of diabetes (34.2 million) by 2030. This will inevitably cause a parallel increase in diabetes-associated complications; with the predominant complications being blindness due to diabetic retinopathy and diabetic cataracts. Eye programs in developing countries remain inadequate, existing as stand-alone programs, focused on the provision of acute symptomatic care at secondary and tertiary health levels. Over 60% of people with undiagnosed diabetes report to eye care facilities with already advanced retinopathy. While vision loss due to cataracts is reversible, loss of vision from diabetic retinopathy is irreversible. Developing countries have in the last two decades been significantly impacted by infectious pandemics; with SSA countries committing over 80% of their health budgets towards infectious diseases. Consequently, non-communicable diseases and eye health have been neglected. This paper aimed to highlight the importance of strengthening primary health care services to prevent diabetes-related blindness. In SSA, where economies are strained by infectious disease, the projected rise in diabetes prevalence calls for an urgent need to reorganize health systems to focus on life-long preventative and integrated measures. However, research is critical in determining how best to integrate these without further weakening health systems.

Technical capacities needed to implement the WHO's primary eye care package for Africa: results of a Delphi process

OBJECTIVE

The aim of the study was to establish the technical capacities needed to deliver the WHO African Region's primary eye care package in primary healthcare facilities.

DESIGN

A two-round Delphi exercise was used to obtain expert consensus on the technical complexity of each component of the package and the technical capacities needed to deliver them using Gericke's framework of technical feasibility. The panel comprised nine eyecare experts in primary eyecare in sub-Saharan Africa. In each round panel members used a 4-point Likert scale to indicate their level of agreement. Consensus was predefined as ≥70% agreement on each statement. For round 1, statements on technical complexity were identified through a literature search of primary eyecare in sub-Saharan Africa from January 1980 to April 2018. Statements for which consensus was achieved were included in round 2, and the technical capacities were agreed.

RESULTS

Technical complexity statements were classified into four broad categories: intervention characteristics, delivery characteristics, government capacity requirements and usage characteristics. 34 of the 38 (89%) statements on health promotion and 40 of the 43 (93%) statements on facility case management were considered necessary technical capacities for implementation.

CONCLUSION

This study establishes the technical capacities needed to implement the WHO Africa Office primary eye care package, which may be generalisable to countries in sub-Saharan Africa.

The Technical Feasibility of Integrating Primary Eye Care Into Primary Health Care Systems in Nigeria: Protocol for a Mixed Methods Cross-Sectional Study

Background

Approximately 90% of the 253 million blind or visually impaired people worldwide live in low- and middle-income countries. Lack of access to eye care is why most people remain or become blind. The World Health Organization Regional Office for Africa (WHO-AFRO) recently launched a primary eye care (PEC) package for sub-Saharan Africa—the WHO-AFRO PEC package—for integration into the health system at the primary health care (PHC) level. This has the potential to increase access to eye care, but feasibility studies are needed to determine the extent to which the health system has the capacity to deliver the package in PHC facilities.

Objective

Our objective is to assess the technical feasibility of integrating the WHO-AFRO PEC package in PHC facilities in Nigeria.

Methods

This study has several components, which include (1) a literature review of PEC in sub-Saharan Africa, (2) a Delphi exercise to reach consensus among experts regarding the technical complexity of the WHO-AFRO PEC package and the capacities needed to deliver it in PHC facilities, (3) development of PEC technical capacity assessment tools, and (4) data collection, including facility surveys and semistructured interviews with PHC staff and their supervisors and village health workers to determine the capacities available to deliver PEC in PHC facilities. Analysis will identify opportunities and the capacity gaps that need to be addressed to deliver PEC.

Results

Consensus was reached among experts regarding the technical complexity of the WHO-AFRO PEC package and the capacities needed to deliver it as part of PHC. Quantitative tools (ie, structured questionnaires, in-depth interviews, and observation checklists) and topic guides based on agreed-upon technical capacities have been developed and relevant stakeholders have been identified. Surveys in 48 PHC facilities and interviews with health professionals and supervisors have been undertaken. Capacity gaps are being analyzed.

Conclusions

This study will determine the capacity of PHC centers to deliver the WHO-AFRO PEC package as an integral part of the health system in Nigeria, with identification of capacity gaps. Although capacity assessments have to be context specific, the tools and findings will assist policy makers and health planners in Nigeria and similar settings, who are considering implementing the package, in making informed choices.

International Registered Report Identifier (IRRID)

DERR1-10.2196/17263

Primary Eye Care in Eastern Nepal

Purpose: Vision 2020 and the Global Action Plan 2013-2019 prioritise primary eye care (PEC) as an important component of reducing avoidable blindness. Studies in sub-Saharan Africa have demonstrated that current PEC provision is poor. There has been no evaluation of the current practice of PEC among primary health care workers (PHCWs) in Nepal.Methods: A mixed methods descriptive cross-sectional study with semi-structured interviews and focus group discussions (FGDs) was carried out in Eastern Nepal. Government employed PHCWs working at health posts in three districts were invited to take part in a PEC knowledge and skills assessment. Each health post was assessed for ophthalmic equipment and medications. Three focus group discussions and eight semi-structured interviews were carried out with community ophthalmic assistants, PHCWs and a district health manager.Results: 107 PHCWs in 35 health posts took part in the quantitative study. Only 8.4% had received eye care training. 27.1% PHCWs could diagnose a corneal ulcer, 83.2% conjunctivitis, 75.7% cataract and 54.2% ophthalmia neonatorum. Only 14.0% could measure visual acuity, and 5.7% of HPs had a vision chart. Ophthalmic assistants described their concern for the low level of PEC at health posts. PHCWs were keen to receive training and highlighted the need for greater government support in the provision of eye care services.Conclusion: PEC knowledge and skills among PHCWs in eastern Nepal is inadequate to provide quality PEC services. There is a pressing need for PEC training in the region, provision of ophthalmic equipment and greater government support for eye care.

Accuracy of Trained Community-based Rehabilitation Volunteers in Identification and Appropriate Referral of Adults with Perceived Visual Disability in an Urban-slum Setting in Southern India

PURPOSE

The integration of primary eyecare into existing primary healthcare systems requires simple yet effective tools that do not overburden the grass-root level worker. The objective of this study was to test the accuracy of a questionnaire-based tool administered by trained community-based rehabilitation volunteers (CBRVs) in identifying persons with visual disability, proportions accessing referral pathway and barriers to uptake of eyecare services.

METHODS

CBRVs working in the urban-slum service area of a teaching hospital were trained in administering a questionnaire-based tool derived from the World Health Organization (WHO) "Training in the community for people with disabilities" to a responsible adult member of the household. Post-training, they screened and referred adults with perceived visual problems. This tool was tested against two reference standards: (i) history of visual disability elicited by ophthalmologist; (ii) pre-set visual acuity and diagnosis criteria.

RESULTS

Ten CBRVs screened 950 individuals of whom 805 (84.7%) were examined by an optometrist and ophthalmologist. Sensitivity and specificity of this method were 75% (95% CI 72-78%), 95.8% (95% CI 94-98%) respectively, using history and 60.2% (95% CI 57-63%), 91.8% (95% CI 90-94%) using clinical criteria as reference standard. Referral pathway was used by 91/221 (41.2%) referred individuals. The commonest barriers to accessing eye care were 'did not feel the need' (32.2%) and 'busy with work/household responsibilities' (30.2%).

CONCLUSIONS

This questionnaire-based tool administered by grass-root level health workers to a responsible adult member of the family may be a promising screening method for identification and appropriate referral of persons with visual disability in the community.

Process evaluation of a National Primary Eye Care Programme in Rwanda

Background

Visual impairment is a global public health problem, with an estimated 285 million affected globally, of which 43% are due to refractive error. A lack of specialist eye care in low and middle-income countries indicates a new model of care would support a task-shifting model and address this urgent need. We describe the features and results of the process evaluation of a national primary eye care (PEC) programme in Rwanda.

Methods

We used the Medical Research Council process evaluation framework to examine the implementation of the PEC programme, and to determine enablers and challenges to implementation. The process evaluation uses a mixed methods approach, drawing on results from several sources including a survey of 574 attendees at 50 PEC clinics, structured clinical observations of 30 PEC nurses, in-depth interviews with 19 key stakeholders, documentary review and a participatory process evaluation workshop with key stakeholders to review collated evidence and contextualize the results.

Results

Structured clinical assessment indicated that the PEC provided is consistent with the PEC curriculum, with over 90% of the clinical examination processes conducted correctly. In 4 years, programme monitoring data showed that nearly a million PEC eye examinations had been conducted in every health centre in Rwanda, with 2707 nurses trained. The development of the eye health system was an important enabler in the implementation of PEC, where political support allowed key developments such as inclusion of eye-drops on the essential medicines list, the inclusion of PEC on insurance benefits, the integration of PEC indicators on the health management information systems and integration of the PEC curriculum into the general nursing school curriculum. Challenges included high turnover of primary care nurses, lack of clarity and communication on the future funding of the programme, competing priorities for the health sector and sustained supervision to assure quality of care.

Conclusions

A model of a national primary eye care programme is presented, with service delivery to all areas in Rwanda. Key learning from this evaluation is the importance of strengthening the eye health care system, together with a strong focus on training primary care nurses using a PEC curriculum.

Electronic supplementary material

The online version of this article (10.1186/s12913-018-3718-1) contains supplementary material, which is available to authorized users.

Barriers and incentives for conducting research amongst the ophthalmologists in Sub-Sahara Africa

Background

Research is a critical component amongst the strategies to improve health outcomes of any country. The role of research assumes greater importance in Africa as it carries a larger share of the global burden of diseases, blindness, and low vision. “Vision 2020- the Right to Sight” is a WHO-IAPB collaborated initiative aiming to eliminate preventable blindness by the year 2020. High quality research in eye care is imperative for the initiative to succeed, however, there is a dearth of research in eye care in sub-Saharan Africa in general and specifically in the Eastern, Central, and Southern African (ECSA) region. Identifying the barriers that hamper research in this region is an important step towards the elimination of preventable blindness.

Methods

A structured questionnaire using the SurveyMonkey program was sent to ophthalmologists in the ECSA region and South Africa through their respective regional professional bodies.

Results

Lack of funding, inadequate time and poor research knowledge were the main research barriers while the ability to improve eye health care through research was the main incentive for conducting research. The response rate for South Africa was low, restricting comparisons with other ECSA countries.

Conclusion

The barriers mainly center on financial, human and administrative infrastructure and resources. In spite of the barriers, ophthalmologists in the study region are enthusiastic in research aiming to increase evidence—based knowledge to improve eye health care in line with the goals of “Vision 2020- the Right to Sight” initiative.

Task sharing: Development of evidence-based co-management strategy model for screening, detection, and management of diabetic retinopathy

BACKGROUND

The number of adults with diabetes is increasing worldwide and also the number of people with diabetic retinopathy (DR), a major complication of diabetes. Task sharing in eye care for people with diabetes could address the shortage in the number of ophthalmologists and increase access to eye care services. This study investigated the opinion of eye care professionals for a checklist of tasks, which are involved in DR management, to be possibly shared by optometrists and mid-level eye and health care workers with ophthalmologists.

METHODS

The study used a purposive sampling technique. All available eye and health care workers from five selected hospitals in two provinces in Pakistan were recruited. A cross-sectional survey was conducted to investigate the potential roles of various cadres in eye care delivery for people with diabetes.

RESULTS

Ninety-six (79%) participants including doctors (n = 56), optometrists (n = 29), and mid-level eye care workers (n = 11) responded to the survey. Two-thirds of the participants suggested mid-level eye care workers, while 88.5% stated that lady health workers could provide education and health promotion to people with diabetes. Most of the participants (88.5%) suggested that optometrists could share the task of dilated ophthalmoscopy with ophthalmologists for detection of DR and make referrals to ophthalmologists if needed. Ophthalmologists remained the recommended cadre to undertake the eye examinations of patients with proliferative DR and diabetic macular edema.

CONCLUSION

This research provided an insight on how task sharing in DR management can be implemented by optimizing the roles of eye care workers.

Incorporating primary eye care into primary health care: Piloting a perceived visual disability questionnaire based model in rural southern India - An observational study

Purpose:

Over 20% of the world's visually impaired and blind populations live in India. Integration of primary eye care (PEC) into existing primary health care by trained personnel could address access-related barriers. We piloted an unreported, modified WHO disability questionnaire-based model for community health workers (CHWs) to screen and refer persons with perceived visual impairment instead of the traditional visual acuity model. The objective of the study was (1) to determine the prevalence of perceived visual impairment, rate of follow-up postreferral, distribution of ocular morbidity, visual impairment, and proportion of appropriate referrals and (2) to compare results of this intervention with those of existing services.

Methods:

CHWs were trained in administering a questionnaire for identification and referral of persons with perceived visual impairment in 7 rural villages and 22 tribal hamlets from the institutional database. In this cross-sectional study, patients screened and referred to PEC services from September 2014 to March 2015 underwent comprehensive ocular examination by an optometrist and ophthalmologist. Data collected from their records were analyzed retrospectively.

Results:

Of 18,534 individuals screened, 3082 (16.64%, 95% confidence interval: 16.06–17.14) complained of perceived visual impairment and were referred; 463 (15%) of these followed up for examination. Correct referrals were noted in 452 (97.6%) cases. Cataract (52.3%) and refractive error (15.8%) were the most common morbidities. There was a 39.6% increase in uptake of eye care services from baseline.

Conclusion:

The questionnaire-based screening tool administered by CHWs can lead to appropriate identification and referral of persons with ocular morbidity impacting uptake of eye care services.

Strengthening primary eye care in South Africa: An assessment of services and prospective evaluation of a health systems support package

Visual impairment is a significant public health concern, particularly in low- and middle-income countries where eye care is predominantly provided at the primary healthcare (PHC) level, known as primary eye care. This study aimed to perform an evaluation of primary eye care services in three districts of South Africa and to assess whether an ophthalmic health system strengthening (HSS) package could improve these services. Baseline surveys were conducted in Cape Winelands District, Johannesburg Health District and Mopani District at 14, 25 and 36 PHC facilities, respectively. Thereafter, the HSS package, comprising group training, individual mentoring, stakeholder engagement and resource provision, was implemented in 20 intervention sites in Mopani District, with the remaining 16 Mopani facilities serving as control sites. At baseline, less than half the facilities in Johannesburg and Mopani had dedicated eye care personnel or sufficient space to measure visual acuity. Although visual acuity charts were available in most facilities, <50% assessed patients at the correct distance. Median score for availability of nine essential drugs was <70%. Referral criteria knowledge was highest in Cape Winelands and Johannesburg, with poor clinical knowledge across all districts. Several HSS interventions produced successful outcomes: compared to control sites there was a significant increase in the proportion of intervention sites with eye care personnel and resources such as visual acuity charts (p = 0.02 and <0.01, respectively). However, engaging with district pharmacists did not improve availability of essential drugs (p = 0.47). Referral criteria knowledge improved significantly in intervention sites (p<0.01) but there was no improvement in clinical knowledge (p = 0.76). Primary eye care in South Africa faces multiple challenges with regard to organisation of care, resource availability and clinical competence. The HSS package successfully improved some aspects of this care, but further development is warranted together with debate regarding the positioning of eye services at PHC level.

Population need for primary eye care in Rwanda: A national survey

Background

Universal access to Primary Eye Care (PEC) is a key global initiative to reduce and prevent avoidable causes of visual impairment (VI). PEC can address minor eye conditions, simple forms of uncorrected refractive error (URE) and create a referral pathway for specialist eye care, thus offering a potential solution to a lack of eye health specialists in low-income countries. However, there is little information on the population need for PEC, including prevalence of URE in all ages in Sub-Saharan Africa.

Methods

A national survey was conducted of people aged 7 and over in Rwanda in September-December 2016. Participants were selected through two-stage probability proportional to size sampling and compact segment sampling. VI (visual acuity<6/12) was assessed using Portable Eye Examination Kit (PEEK); URE was detected using a pinhole and presbyopia using local near vision test. We also used validated questionnaires to collect socio-demographic and minor eye symptoms information. Prevalence estimates for VI, URE and need for PEC (URE, presbyopia with good distance vision, need for referrals and minor eye conditions) were age and sex standardized to the Rwandan population. Associations between age, sex, socio-economic status and the key outcomes were examined using logistic regression.

Results

4618 participants were examined and interviewed out of 5361 enumerated (86% response rate). The adjusted population prevalence of VI was 3.7% (95%CI = 3.0–4.5%), URE was 2.2% (95%CI = 1.7–2.8%) and overall need for PEC was 34.0% (95%CI = 31.8–36.4%). Women and older people were more likely to need PEC and require a referral.

Conclusions

Nearly a third of the population in Rwanda has the potential to benefit from PEC, with greater need identified in older people and women. Universal access to PEC can address unmet eye health needs and public health planning needs to ensure equitable access to older people and women.

Integration of eye health into primary care services in Tanzania: a qualitative investigation of experiences in two districts

BACKGROUND

Visual impairment is a public health problem in sub-Saharan Africa, affecting nearly 5% of the population. Efforts to combat avoidable causes have been hampered by weak health systems and little evidence exists to suggest what interventions may be effective to improve the situation. Despite this, there are calls to promote some specific interventions, one of which being the closer integration of eye health services into health systems, often focusing on training primary health workers to deliver basic eye health services. This study seeks to understand how eye health services are delivered by primary health workers who have received training and what constraints remain to effective service provision.

METHODS

This was a qualitative investigation into the experiences of 20 primary health workers trained in primary eye care and eight key informants working within specialist eye health services or regional and district health management positions in two districts in Tanzania.

RESULTS

Despite feeling confident in their own eye care skills, most primary health workers felt constrained in the services they could provide to their communities by insufficient resources needed for diagnosis and treatment, and by lack of systematic supportive supervision to their work. Specialist ophthalmic staff were aware of this issue, although for the most part they felt it was not within their capacity to remedy and that it fell within the remit of general health managers. Many participants discussed the low support to eye health from the national government, evidenced through the lack of dedicated funding to the area and traditional reliance on outside funds including international charities.

CONCLUSIONS

Although training of primary health workers is useful, it is recognised that is not sufficient to address the burden of eye health disease present in rural communities in Tanzania. It is likely that broader engagement with the general health system, and most likely with the private sector, will be necessary to improve the coverage of eye health care to remote and poor communities such as those in Morogoro. Further investment is needed to develop innovative approaches to delivering eye health services, including preventative, curative and rehabilitative services.

Circumventing 'free care' and 'shouting louder': using a health systems approach to study eye health system sustainability in government and mission facilities of north-west Tanzania

Background

Little is known about the contributions of faith-based organisations (FBOs) to health systems in Africa. In the specialist area of eye health, international and domestic Christian FBOs have been important contributors as service providers and donors, but they are also commonly critiqued as having developed eye health systems parallel to government structures which are unsustainable.

Methods

In this study, we use a health systems approach (quarterly interviews, a participatory sustainability analysis exercise and a social network analysis) to describe the strategies used by eye care practitioners in four hospitals of north-west Tanzania to navigate the government, church mission and donor rules that govern eye services delivery there.

Results

Practitioners in this region felt eye care was systemically neglected by government and therefore was ‘all under the NGOs’, but support from international donors was also precarious. Practitioners therefore adopted four main strategies to improve the sustainability of their services: (1) maintain ‘sustainability funds’ to retain financial autonomy over income; (2) avoid granting government user fee exemptions to elderly patients who are the majority of service users; (3) expand or contract outreach services as financial circumstances change; and (4) access peer support for problem-solving and advocacy. Mission-based eye teams had greater freedom to increase their income from user fees by not implementing government policies for ‘free care’. Teams in all hospitals, however, found similar strategies to manage their programmes even when their management structures were unique, suggesting the importance of informal rules shared through a peer network in governing eye care in this pluralistic health system.

Conclusions

Health systems research can generate new evidence on the social dynamics that cross public and private sectors within a local health system. In this area of Tanzania, Christian FBOs’ investments are important, not only in terms of the population health outcomes achieved by teams they support, but also in the diversity of organisational models they contribute to in the wider eye health system, which facilitates innovation.

Electronic supplementary material

The online version of this article (doi:10.1186/s12961-016-0137-9) contains supplementary material, which is available to authorized users.

Setting targets for human resources for eye health in sub-Saharan Africa: what evidence should be used?

With a global target set at reducing vision loss by 25% by the year 2019, sub-Saharan Africa with an estimated 4.8 million blind persons will require human resources for eye health (HReH) that need to be available, appropriately skilled, supported, and productive. Targets for HReH are useful for planning, monitoring, and resource mobilization, but they need to be updated and informed by evidence of effectiveness and efficiency. Supporting evidence should take into consideration (1) ever-changing disease-specific issues including the epidemiology, the complexity of diagnosis and treatment, and the technology needed for diagnosis and treatment of each condition; (2) the changing demands for vision-related services of an increasingly urbanized population; and (3) interconnected health system issues that affect productivity and quality. The existing targets for HReH and some of the existing strategies such as task shifting of cataract surgery and trichiasis surgery, as well as the scope of eye care interventions for primary eye care workers, will need to be re-evaluated and re-defined against such evidence or supported by new evidence.

Knowledge and practice of primary eye care among primary healthcare workers in northern Nigeria

OBJECTIVE

To assess knowledge and practice of primary eye care among primary healthcare workers known as community health extension workers in Funtua district of Nigeria.

METHODS

Cross-sectional mixed method study among health workers employed in government-owned primary healthcare facilities. Quantitative data were obtained using self-administered questionnaires and checklists, while qualitative data by modified Delphi technique, role plays and observation. A score of 1 was given for each correct answer, while a total score of ≥60% was considered 'good'.

RESULTS

Eighty three of 88 health workers participated (94%) in the questionnaire survey; while 16 of them were selected for the qualitative survey. Good scores regarding the knowledge of common eye diseases were obtained by 68.7%, but only 26.4% of them could identify their most important features. Participants could undertake 3 of 5 steps in visual acuity testing. Skills in recognising common eye diseases and their management were weak; while practice was often not according to the guidelines.

CONCLUSION

Community health extension workers displayed good knowledge of common eye diseases. Areas of weakness are recognition and interpretation of eye signs, and practice rarely follows the guidelines. Preventive medicine was neglected; community health extension workers require practical retraining and supervision to achieve integration of primary eye care into primary healthcare services.

Ocular morbidity and health seeking behaviour in Kwara state, Nigeria: implications for delivery of eye care services

BACKGROUND

There is currently limited information as to which conditions are most prevalent in communities in developing countries. This makes effective planning of eye services difficult.

METHODS

3,899 eligible individuals were recruited and examined in a cross-sectional survey in Asa Local Government Area, Nigeria. Those who self-reported an ocular morbidity were also asked about their health-seeking behaviour. Health records of local facilities were reviewed to collect information on those presenting with ocular morbidities.

RESULTS

25.2% (95% CI: 22.0-28.6) had an ocular morbidity in at least one eye. Leading causes were presbyopia and conditions affecting the lens and conjunctiva. The odds of having an ocular morbidity increased with age and lower educational attainment. 10.1% (7.7-13.0) self-reported ocular morbidity; 48.6% (40.4-56.8) of them reported seeking treatment. At the facility level, 344 patients presented with an ocular morbidity over one month, the most common conditions were red (26.3%) or itchy (20.8%) eyes.

CONCLUSION

Ocular morbidities, including many non vision impairing conditions, were prevalent with a quarter of the population affected. The delivery of eye care services needs to be tailored in order to address this need and ensure delivery in a cost-effective and sustainable manner.

Ocular infections in sub-Saharan Africa in the context of high HIV prevalence

Healthy eyes and good vision are important determinants of populations' health across the globe. Sub-Saharan Africa is affected by simultaneous epidemics of ocular infections and human immunodeficiency virus (HIV). Ocular infection and its complications, along with cataract and ocular trauma, are common conditions in this region with great impact on daily life. In this review, we discuss the epidemiology, clinical manifestations and microbial aetiology of the most important infectious ocular conditions in sub-Saharan Africa: conjunctivitis, keratitis and uveitis. We focus specifically on the potential association of these infections with HIV infection, including immune recovery uveitis. Finally, challenges and opportunities for clinical management are discussed, and recommendations made to improve care in this neglected but very important clinical field.

A randomised controlled trial to investigate effects of enhanced supervision on primary eye care services at health centres in Kenya, Malawi and Tanzania

Background

Knowledge and skills of primary health care workers (PHCWs) in primary eye care have been demonstrated to be inadequate in several districts of Kenya, Malawi, and Tanzania. We tested whether enhanced supervision, focused on improving practical skills over two years, would raise the scores of these workers on a test of basic knowledge and skills.

Methods

This was a randomised controlled trial. All primary health care (PHC) facilities within two districts of each country were enrolled and randomly assigned by district (Kenya, Malawi) or by health care facility (Tanzania) to receive quarterly skills-based supervision by a district eye coordinator or to continue existing routine supervision. At baseline, a test of basic knowledge and skills in five key areas was administered to PHCWs, and visual acuity (VA) charts and working torches were provided. After two years the test was administered again. Changes in test scores were compared between the intervention (enhanced supervision) and the non-intervention (routine supervision) facilities.

Results

All 137 facilities in the six districts were enrolled including 343 PHCWs. At baseline, no facility had a visual acuity chart and 18 (13%) had a working torch; the average total skills scores were 6.04 and 6.38 (maximum of 12) in the non-intervention and the intervention facilities, respectively. After two years, 16 intervention facilities (23.2%) had a visual acuity chart correctly placed and 19 (27.5%) had a working torch, compared to 4 (5.9%) and 6 (8.8%), respectively, in the routine supervision facilities. At the facility level, the change in overall test scores was +1.84 points in the intervention sites compared to +0.42 points in the non-intervention sites (p<0.001). Staff turnover included about 75% of the staff by the end of the study.

Conclusion

The improvements in the enhanced supervision facilities were very modest and of questionable clinical significance. The low impact of the intervention may be due to the high turnover of PHCWs or high absenteeism. A better understanding of the quality of eye care at PHC facilities and influencing factors are urgently needed before continuing to invest resources in the scale up of this model of task shifting in Africa.

Skills of general health workers in primary eye care in Kenya, Malawi and Tanzania

BACKGROUND

Primary eye care (PEC) in sub-Saharan Africa usually means the diagnosis, treatment, and referral of eye conditions at the most basic level of the health system by primary health care workers (PHCWs), who receive minimal training in eye care as part of their curricula. We undertook this study with the aim to evaluate basic PEC knowledge and ophthalmologic skills of PHCWs, as well as the factors associated with these in selected districts in Kenya, Malawi, and Tanzania.

METHODS

A standardized (26 items) questionnaire was administered to PHCWs in all primary health care (PHC) facilities of 2 districts in each country. Demographic information was collected and an examination aimed to measure competency in 5 key areas (recognition and management of advanced cataract, conjunctivitis, presbyopia, and severe trauma plus demonstrated ability to measure visual acuity) was administered.

RESULTS

Three-hundred-forty-three PHCWs were enrolled (100, 107, and 136 in Tanzania, Kenya, and Malawi, respectively). The competency scores of PHCW varied by area, with 55.7%, 61.2%, 31.2%, and 66.1% scoring at the competency level in advanced cataract, conjunctivitis, presbyopia, and trauma, respectively. Only 8.2% could measure visual acuity. Combining all scores, only 9 (2.6%) demonstrated competence in all areas.

CONCLUSION

The current skills of health workers in PEC are low, with a large per cent below the basic competency level. There is an urgent need to reconsider the expectations of PEC and the content of training.

Task shifting in primary eye care: how sensitive and specific are common signs and symptoms to predict conditions requiring referral to specialist eye personnel?

BACKGROUND

The inclusion of primary eye care (PEC) in the scope of services provided by general primary health care (PHC) workers is a 'task shifting' strategy to help increase access to eye care in Africa. PEC training, in theory, teaches PHC workers to recognize specific symptoms and signs and to treat or refer according to these. We tested the sensitivity of these symptoms and signs at identifying significant eye pathology.

METHODS

Specialized eye care personnel in three African countries evaluated specific symptoms and signs, using a torch alone, in patients who presented to eye clinics. Following this, they conducted a more thorough examination necessary to make a definite diagnosis and manage the patient. The sensitivities and specificities of the symptoms and signs for identifying eyes with conditions requiring referral or threatening sight were calculated.

RESULTS

Sensitivities of individual symptoms and signs to detect sight threatening pathology ranged from 6.0% to 55.1%; specificities ranged from 8.6 to 98.9. Using a combination of symptoms or signs increased the sensitivity to 80.8 but specificity was 53.2.

CONCLUSIONS

In this study, the sensitivity and specificity of commonly used symptoms and signs were too low to be useful in guiding PHC workers to accurately identify and refer patients with eye complaints. This raises the question of whether this task shifting strategy is likely to contribute to reducing visual loss or to providing an acceptable quality service.

Primary eye care skills scores for health workers in routine and enhanced supervision settings

INTRODUCTION

Primary health care in Tanzania is provided at two types of health units, the dispensary and the health centre. Theoretically, primary health workers (with knowledge of primary eye care [PEC]) are ideally placed to identify people in need of eye care services. In Tanzania, they are expected to be able to identify, treat, or correctly refer a number of eye conditions including cataract, trauma, presbyopia, and the 'red eye'. They are also expected to be able to measure visual acuity correctly and to educate the community about prevention.

OBJECTIVES

The objective was to determine the effect of enhanced supervision of health workers on PEC knowledge and skills in Kilimanjaro Region, Tanzania.

STUDY DESIGN

This was a quasi-experimental, cluster randomized intervention study of an enhanced supervisory method compared to a routine supervisory method; 36 dispensaries were randomly allocated into the two groups.

PARTICIPANTS

Health workers based at government dispensaries in Mwanga District.

DATA COLLECTION

Participants were interviewed pre and post intervention and the information was recorded using a standardized pretested questionnaire.

RESULTS

Mean scores of knowledge in healthcare workers was higher in the intervention group (score = 6.43, 80.4% improvement) compared to the non-intervention group (score = 4.71, 58.9% improvement). The ability to describe and demonstrate vision testing was better (score = 1.8) in the enhanced supervision group compared to the routine supervision group (score = 0.88, P = 0.03). There was a high level of attrition (24%) within one year from the time of baseline survey, especially amongst clinical officers (44%).

CONCLUSION

During the pilot study, enhanced supervision improved PEC knowledge and skills of health workers compared to health workers with routine supervision.

RECOMMENDATIONS

Training in PEC needs revision to become more practicum-based. There is need to revise supervision guidelines (to be skills-based) and the supervision skills of district eye coordinators (DECs) need to be enhanced. There is a huge need to improve governance (accountability and rule of law) of health staff.

Using key informants to estimate prevalence of severe visual impairment and blindness in children in Cross River State, Nigeria

PURPOSE

To assess the prevalence and causes of childhood blindness in Cross River State, Nigeria, using the key informant (KI) method.

METHODS

KIs were selected and trained and requested to bring children to identified facilities 2 weeks after training for examination by a specialist team. Visual acuity and cause of impaired acuity were assessed. Children at a Cross River State school for the blind were also assessed. An estimated prevalence of childhood blindness and severe visual impairment (BL/SVI) in the Cross River State was calculated.

RESULTS

A total of 742 KIs were included. The prevalence of BL/SVI in Cross River State was estimated to be 0.09-0.22 per 1,000 children. The three most common anatomic causes are lens related (35%), whole globe (19.4%), and corneal (15.7%), most of which are avoidable.

CONCLUSIONS

The prevalence of childhood BL/SVI in Cross River State was somewhat lower than expected but similar to other recent reports from Africa. Lens-related causes were the most common. KIs performed well, ensuring that many children in need of eye services were examined.

Evidence for integrating eye health into primary health care in Africa: a health systems strengthening approach

Background

The impact of unmet eye care needs in sub-Saharan Africa is compounded by barriers to accessing eye care, limited engagement with communities, a shortage of appropriately skilled health personnel, and inadequate support from health systems. The renewed focus on primary health care has led to support for greater integration of eye health into national health systems. The aim of this paper is to demonstrate available evidence of integration of eye health into primary health care in sub-Saharan Africa from a health systems strengthening perspective.

Methods

A scoping review method was used to gather and assess information from published literature, reviews, WHO policy documents and examples of eye and health care interventions in sub-Saharan Africa. Findings were compiled using a health systems strengthening framework.

Results

Limited information is available about eye health from a health systems strengthening approach. Particular components of the health systems framework lacking evidence are service delivery, equipment and supplies, financing, leadership and governance. There is some information to support interventions to strengthen human resources at all levels, partnerships and community participation; but little evidence showing their successful application to improve quality of care and access to comprehensive eye health services at the primary health level, and referral to other levels for specialist eye care.

Conclusion

Evidence of integration of eye health into primary health care is currently weak, particularly when applying a health systems framework. A realignment of eye health in the primary health care agenda will require context specific planning and a holistic approach, with careful attention to each of the health system components and to the public health system as a whole. Documentation and evaluation of existing projects are required, as are pilot projects of systematic approaches to interventions and application of best practices. Multi-national research may provide guidance about how to scale up eye health interventions that are integrated into primary health systems.

Using primary health care (PHC) workers and key informants for community based detection of blindness in children in Southern Malawi

BACKGROUND

There is great interest in providing primary eye care (PEC) through integration into primary health care (PHC). However, there is little evidence of the productivity of PHC workers in offering primary eye care after training and integration, and there is need to compare their effectiveness to alternative methods. The current study compared the effectiveness of trained Health Surveillance Assistants (HSAs) versus trained volunteer Key Informants (KIs) in identifying blind children in southern Malawi.

METHODS

A cluster community based study was conducted in Mulanje district, population 435 753. Six clusters each with a population of approximately 70 000 to 80 000, 42% of whom were children were identified and randomly allocated to either HSA or KI training. From each cluster 20 HSAs or 20 KIs were selected for training. Training emphasized the causes of blindness in children and their management, and how to identify and list children suspected of being blind. HSAs and KIs used multiple methods (door to door, school screening, health education talks, village announcements, etc.) to identify children. Using the World Health Organization (WHO) estimates (eight blind children per 10 000 children); approximately 144 to 162 blind children were expected in the chosen clusters. Listed children were brought to a centre within the community where they were examined by an ophthalmologist and findings recorded using the WHO form for examining blindness in children.

RESULTS

A total of 59 HSAs and 64 KIs were trained. HSAs identified five children of whom two were confirmed as blind (one blind child per 29.5 HSAs trained). On the other hand, the KIs identified a total of 158 children of whom 20 were confirmed blind (one blind child per 3.2 KIs trained). More blind boys than girls were identified (77.3% versus 22.7%) respectively.

CONCLUSION

Key Informants were much better at identifying blind children than HSAs, even though both groups identified far fewer blind children compared with WHO estimates. HSAs reported lack of time as a major constraint in identifying blind children. Based on these findings using HSAs for identifying blind children would not be successful in Malawi. Gender differences need to be addressed in all childhood blindness programs to counteract the imbalance.