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

Background: The integration of eye care services into the primary health-care (PHC) system and the accessibility and quality of eye health in the community is hugely dependent on available resources.Objective: The aim was to assess the resources available for eye care delivery in public PHC facilities in Obokun Local Government Area (LGA), Osun State, Nigeria.Methodology: This was a descriptive cross-sectional study of public PHC facilities and workers in Obokun LGA, Nigeria. A PHC facility checklist was used to obtain data on available infrastructure, material resources, primary eye care (PEC) services, and human resources during a tour and inspection of each facility. Further data on human resources were obtained with a semi-structured questionnaire administered to PHC workers. Data included information on the age, sex, cadre, duration of service, PEC practices, and training of PHC workers.Results: There were 4 (10.0%) primary health (PH) centres, 19 (47.5%) PH clinics and 17 (42.5%) health posts. The number and distribution of PHC facilities, material resources, and PEC services were below-recommended guidelines. There were 12 (11.2%) nurses, 4 (3.7%) community health officers, 19 (17.8%) community health extension workers (CHEWs), 7 (6.5%) health technicians, 8 (7.5%) junior CHEWs, and 57 (53.3%) health assistants. There was a sufficient number of PHC workers and community services to build capacity for PEC delivery.Conclusions: Resources were available for PEC in Obokun LGA; however, some were insufficient or unevenly distributed. Further training of PHC workers in PEC and the provision of the minimum required infrastructure and material resources are recommended.

Primary eye care is at the frontline in the elimination of the avoidable causes of blindness. Proficiency in the basic ophthalmic skills is a critical factor in the effective delivery of eye care services at the primary level of care. The aim of the study was to assess the ability of the primary health care workers to provide basic ophthalmic services at primary health care facilities. A semi-structured questionnaire was administered to 146 health providers in twelve primary health care facilities in Cross River State. Multi-stage random sampling technique was used in the selection of respondents for this study. The ability of the health providers to carry out visual acuity test and correctly identify cataract and conjunctivitis using pictures of eye conditions and patients complaints was also assessed and scored. Ethical approval was obtained from the ethics committee, Ministry of Health, Cross River State. Data were analysed using SPSS version 20.0.1. Majority of the participants could not perform the visual acuity test 126(86%). Their ability to correctly identify cataract and conjunctivitis were 78(53%) and 45(31%) respectively. Majority of those who showed the ability to perform some of the tests had previous training in primary eye care. The workers attributed the high failure rate/low score to lack of follow-up and inadequate duration of training on eye care, which was just for one day. The ophthalmic skills and knowledge of the primary health care providers were generally poor. This calls for a review of the strategy for the integration of primary eye care services into the existing primary health care system. Key words : primary, skills, eye care, assessment, ophthalmic

Primary Eye Care (PEC) provides the essential cares of the eyes and visual pathways at the Primary Health Care (PHC) level in order to prevent avoidable visual impairment and blindness. The aim of this study is to review the need for integration of PEC services into PHC in Nigeria healthcare system – with focus oF Delta State. A narrative review approach was used in evaluation of community needs, government and PHC facilities. Published literatures from around the world including in Sub-Saharan Africa and Nigeria was done through web search and Mendeley reference library. The evaluations show that there is ability and willingness to integrate PEC into PHC. Yet, there is observable mismatch in capacity vs. opportunity or a knowledge and attitude gap. In Delta State on Nigeria, there appears to be specialist Eye-care providers located in just 24% of the local government areas and absolutely none (zero %) at any PHC facility. In the rural communities, there is the barrier of affordances including problem of access, but the PHC staff can be equipped to provide basic services such as educational, preventive and referral services that non-governmental organisations have done. Therefore, integration of PEC into PHC at the community level is possible.

Over 25 million people in sub-Saharan Africa are blind or visually impaired, the majority from avoidable causes. Health promotion and disease prevention are important strategies for eye health, through good governance, health literacy and increasing access to eye care services. To increase equity in access for eyecare services, the World Health Organization Africa Region developed a package of interventions for primary eye care, which includes health promotion. The aim of this study was to assess the capacity of the primary healthcare system to deliver health promotion for eye care in Nigeria. Mixed methods were used during a survey of 48 government-owned primary health care facilities in Anambra state, Nigeria: interviews with district health supervisors, facility staff and village health workers, and a desk review of policy documents for primary health care and eye care in Nigeria. Findings were benchmarked against the capacities needed to deliver health promotion agreed through a Delphi exercise and were analysed using the World Health Organization’s health system building blocks. Eye health promotion policies exist but are fragmented across different national health policies. Health promotion activities focussed on “mobilising” community members to access care provided in facilities, particularly for women of childbearing age and young children, and health education was limited. Only one in ten facilities engaged the elderly and a fifth delivered health promotion for eye care. Health promotion activities were supervised in 43.2% of facilities and transport to remote areas was limited. A robust eye health promotion strategy needs to be included in the National Eye Health Policy. The scope of existing health promotion will need to expand to include eye conditions and different age groups. Increasing eye health literacy should be emphasized. Governance, training health workers in eye health promotion, educational materials, and transport to visit communities will also be needed.

In 2020, an estimated 596 million people worldwide had distance vision impairment and a further 510 million had uncorrected near vision impairment.1 Most of these people live in low-income and middle-income countries (LMIC). Eye health is also affected by conditions that do not, at least initially, impair vision. Although these conditions are not currently included in global prevalence estimates, they contribute substantially to the unmet need for eye health services. Vision is important for many aspects of life, and vision impairment can profoundly affect individuals, families, and society. Eye health touches all lives, either directly or indirectly, through its impact on those close to us. The year 2020 marks the culmination of the global initiative to eliminate avoidable blindness, VISION 2020: The Right to Sight (appendix 1 p 7). This initiative provided the framework for national programmes to address eye health over the past 20 years. In 2019, WHO published the World report on vision,2 which was endorsed by the 73rd World Health Assembly in 2020. The report and resolution call for the advancing of eye health as an integral part of universal health coverage, by implementation of integrated people-centred eye care, following the approach outlined in a broader health services framework.3 The Lancet Global Health Commission on Global Eye Health contends that eye health should be part of the mainstream agenda to achieve universal health coverage and sustainable development. We define eye health as the state in which vision, ocular health, and functional ability are maximised, thereby contributing to overall health and wellbeing, social inclusion, and quality of life. Eye health can be considered both a process and an outcome. We define eye care services as those that contribute to any of vision, ocular health, or functional ability being maximised. This report broadly divides into two halves. First, we present evidence for the importance of eye health, supporting the case for urgent action. Second, looking beyond 2020, we examine approaches to enable delivery of eye health services within universal health coverage. In section 1 we summarise the visual system, vision impairment, and common conditions. In section 2, we synthesise several reviews done by the Commission on the relevance of eye health to the Sustainable Development Goals (SDGs), as well as its impact on quality of life, general health, and mortality. In section 3, we describe the magnitude and causes of vision impairment in 2020 and projected global and regional trends. We explore service needs of people with non-vision impairing eye conditions. We propose a more standardised approach to reporting population-based eye health surveys and examine the disability weights applied to vision impairment. In section 4, we summarise findings from a systematic review of eye health economics, identifying important areas for future work. We present a new estimate of global lost productivity associated with vision impairment for 2020, and an analysis of the cost-effectiveness ratios for cataract surgery and refractive error services. In section 5, we outline a bibliometric analysis of eye health research since 2000, and report a global Grand Challenges project, highlighting crucial issues for concerted research and action. Lastly, we address the question of how health systems can practically advance towards delivering high quality integrated people-centred eye care within universal health coverage.2 We argue that business as usual will be insufficient, as evidenced by new analysis of effective cataract surgical coverage data. We examine service delivery components: primary eye care and integration with general health services, workforce strengthening, financing, health information systems, indicators, advocacy, and approaches to increase quality and equity. The development of global eye health This Commission views global eye health through the global health framework articulated by Koplan and colleagues.4 Eye health started with an understanding of the anatomy, physiology, diseases of the eye, and the development of clinical ophthalmology, the medical and surgical discipline for diagnosis and treatment of eye diseases. From the mid-20th century onwards (figure 1), there have been major technological advances in microsurgical techniques for cataract and other conditions, and equipment for diagnosis and treatment of major non-communicable eye diseases, resulting in more effective interventions. There has been an enormous demographic transition, with ageing populations and epidemiological changes from infectious diseases and towards non-communicable diseases, requiring accessible and affordable eye services with long-term follow-up. The increase in demand, emphasis on better quality, and higher cost of more sophisticated diagnostic and treatment services is requiring an increase in resources, which presents enormous public health challenges. Open in a separate window Figure 1 The development of global eye health Blue circles indicate major global developments. Red circles indicate major treatments and programmatic developments. WHA=World Health Assembly. IAPB=International Agency for the Prevention of Blindness. RAAB=Rapid Assessment of Avoidable Blindness. RACSS=Rapid Assessment of Cataract Surgical Services.

Visual impairment and blindness pose a significant and growing public health threat in Nigeria. Over 1.6 million Nigerians are visually impaired or blind, with more than 80% of these cases being preventable and treatable. The risk for ocular morbidities is expected to increase due to rapid population growth, an aging population, and the rising burden of noncommunicable diseases. Despite efforts to improve eye health services, universal eye health remains elusive, with 35% of Nigerians unable to access eye care in primary healthcare (PHC) facilities. Many Nigerians instead turn to traditional and alternative medicine for primary eye care (PEC), which can worsen their outcomes. This article highlights the potential of the country's PHC system to address these challenges, emphasizing the importance of PEC as an integral part of PHC. The article discusses the various challenges faced by PHC workers in delivering eye care services in Nigeria, focusing on financing, training, leadership, and policies for eye care. It also provides a set of comprehensive recommendations aimed at overcoming these challenges, including improved leadership and policy implementation, optimized financing, strengthened collaborations and partnerships, enhanced education and training, and effective human resource management systems. We emphasize the importance of holistic and strategic efforts to bolster the PHC workforce's capacity to provide universal eye healthcare in Nigeria, ultimately improving access to high‐quality eye care services for all.

BackgroundApproximately 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.ObjectiveOur objective is to assess the technical feasibility of integrating the WHO-AFRO PEC package in PHC facilities in Nigeria.MethodsThis 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.ResultsConsensus 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.ConclusionsThis 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

BackgroundTo 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.MethodsDesign: 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.ResultsA 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.ConclusionOur 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.

Vision impairment and blindness are major public health challenges, especially in low- and middle-income countries. Although the prevalence of blindness in India has reduced considerably, untreated cataract still remains a public health challenge. The World Report on Vision (2019) emphasizes the need to make eye care an integral aspect of universal health coverage and incorporate integrated people-centred eye care in health systems. (1) To describe the setup of an Integrated Primary Eye Care model. (2) To describe the pattern of ocular morbidity among patients attending the primary healthcare clinics across four states in India. Retrospective observational study describing the primary eye care services delivered across four states in India between August 2019 and March 2020. The de-identified secondary data were analyzed for the pattern of ocular morbidity. Seven thousand and twenty-four patients availed the eye care services across the four primary care clinics. Majority of the patients were female (54.7%), most patients belonged to the age groups of 45-60 years (33.2%) and 30-45 years (32.3%). Elderly patients of both genders had equal access to the eye care services. The common presenting complaints were diminished vision (83.1%), redness (9.5%), and pain (6.4%). Uncorrected presbyopia (35%), refractive error (32.8%), and cataract (12.8%) were the commonly observed ocular morbidities. Integration of primary eye care into primary health care can improve access to eye care services, especially for vulnerable population such as elderly and women, who otherwise face several challenges to access eye care services.

BackgroundA major human resources for health challenge for Nigeria is ensuring the availability and retention of adequate competent health workers in the right mix to provide health care particularly at primary health care facilities in remote and rural communities. This study applied the Workload Indicators of Staffing Need (WISN) method to determine the numbers of nurses, midwives, community health officers (CHOs), community health extension workers (CHEWs), and junior community health extension workers (JCHEWs) required to cope with health care service delivery at primary health care facilities in Cross River State; compare workloads of different cadres at selected health facilities, and identify facilities with highest workload pressure.MethodsCross River State in Nigeria has 18 local governments, 196 wards, and an estimated population of over three million people. We used the WISN method to estimate the numbers of nurses/midwives, CHOs/CHEWs, and JCHEWs required to cope with the workload in the 196 ward-level primary health care facilities.FindingsBasic services provided by nurses/midwives, and CHOs/CHEWs were typical of the primary health care level. They are antenatal care, routine immunization, child welfare clinic, family planning, treatment of minor ailments, assisted and normal deliveries, postnatal care, emergencies, care of tuberculosis patients, and referrals. Findings show that available nurses/midwives for the 196 PHC facilities were 79, and the calculated requirement was 209, WISN ratio of 0.4 and difference of − 130; the existing number of CHOs/CHEWs was 808, the calculated requirement was 1,258, WISN ratio of 0.6, with a difference of − 450; and the number of existing JCHEWs was 258, the calculated requirement was 203, WISN ratio of 1.3 with a difference of 55. Cross River State had only 40% of required nurses and midwives; and 60% of CHOs/ CHEWs needed to provide health services in the ward-level PHC facilities.ConclusionThe findings from this study indicated marked shortages of needed health workforce particularly nurses and midwives at the primary level of care; and overlap in some of the tasks performed by nurses/midwives, CHO/CHEWs, and JCHEWs.

BackgroundA recent survey of avoidable blindness in Varamin District, Iran, identified moderately high levels of visual impairment (10%) and blindness (1.5%) in people >50 years. This study aimed to define current provision, identify gaps and suggest practical solutions for improving eye health services in this area.MethodsThe World Health Organization (WHO) framework for analyzing health systems has several key components: service delivery, health workforce, information system, medical products and technologies, financing, and governance. We used this structure to investigate the strengths and weaknesses of the eye health system in Varamin. All public and private eye care facilities and a random selection of primary health care (PHC) units were assessed using semi-structured researcher-administered questionnaires.ResultsVaramin has 16 ophthalmic clinics, including two secondary hospitals that provide cataract surgery. There were ten ophthalmologists (1:68,000 population), two ophthalmic nurses and five optometrists working in Varamin district. There were no eye care social or community workers, ophthalmic counsellors, low vision rehabilitation staff. Although the Vision 2020 target for ophthalmologists has been met, numbers of other eye care staff were insufficient. The majority of patients travel to Tehran for surgery. The recent survey identified cataract as the leading cause of blindness, despite the availability of surgical services in the district and high health insurance coverage. Poor awareness is a major barrier. No units had a written blindness prevention plan, formal referral pathways or sufficient eye health promotion activities. Only one of the PHC units referred people with diabetes for retinal examination. There is partial integration between eye care services and the general health system particularly for prevention of childhood blindness: chemo-prophylaxis for ophthalmia neonatorum, school vision tests, measles immunization and Vitamin A supplementation.ConclusionsThis analysis demonstrated the need for better integration between eye care services and the general health system, local planning for prevention of blindness, an information system, a better staff mix and health education to increase community awareness and service uptake. There is the capacity to deliver far more surgery locally. All aspects of a health system need to be developed to deliver comprehensive and efficient eye care.

Introduction:Visual impairment is a critical issue in low- and middle-income countries (LMICs), where unmet eye care needs are significant. The WHO’s 2019 World Report on Vision recommends integrating primary eye care (PEC) into primary healthcare (PHC). This study evaluates the integration of PEC into PHC within County-wide Tight Medical Alliances (CTMAs) in rural China.Methods:From 2021 to 2023, we implemented the Eye CARE Model, focusing on Capacity building, Awareness raising, and Referral system Establishment (CARE). We used the Medical Research Council (MRC) process evaluation framework and a quasi-experimental difference-in-differences (DID) method to assess the impact on eye care utilization in three pilot counties in Yunnan Province.Results:The Eye CARE Model increased primary and secondary eye care visits by 76 and 52 per 10,000 people, respectively. It also improved community-based eye health education and established a three-tiered referral system. The intervention had high fidelity and reach, supported by local government and CTMAs, though challenges in sustaining incentives and integrating PEC indicators into health systems were noted.Conclusions:The Eye CARE Model successfully increased eye care utilization and demonstrated the feasibility of integrating PEC into PHC in rural China, emphasizing the importance of contextual factors in LMICs.

Childhood visual impairment is an important public health concern considering the social, emotional and economic consequences. Lack of access to eye care services contributes to this growing problem. Therefore, integrating primary eye care into existing primary healthcare would facilitate improved access to equitable, effective and affordable eye care services, particularly for children. The study assessed the provision of primary paediatric eye care services in health facilities in the Ashanti region of Ghana. The study was conducted at the primary health facilities in the Ashanti region of Ghana. Stratified random sampling was used to select 145 health facilities in this descriptive study. The eye care professionals in these facilities completed a questionnaire concerning primary eye care services for children. Data were analysed using descriptive and inferential statistics. Eye care services were available in 131 (90%) of the health facilities resourced with essential eye equipment. Refraction services were provided by 129 (98.5%) despite limited coverage by the national health insurance scheme. More than 80% of participants lacked continuing education and 59% had poor awareness of management guideline. Barriers identified included lack of specialised equipment and inadequate resources. The study highlights disparities in the provision of child eye care services among the health facilities in the Ashanti region of Ghana.Contribution:This study provides useful information to inform policy on targeted interventions for child eye care services to ensure accessible, equitable and comprehensive services.

Background: To improve access to comprehensive eye health services within the community, an intervention study that sought to integrate primary eye care (PEC) into existing primary health care (PHC) services, namely Community-based Health Planning and Services (CHPS), was conducted. Aim: To improve access to eye health at community level. Setting: The study was conducted in Northern, Eastern and Western Regions of Ghana. Methods: The study was a cross-sectional exploratory study, which employed both qualitative and quantitative methods. It used multistage cluster randomised sample design. The study involved a household survey, observation, focus group discussions (FGDs), in-depth interviews (IDIs) and informal discussions and case narratives. Results: The findings of the baseline survey covered information on the eye health knowledge, and health-seeking behaviours at community level. Out of the total 1760 people interviewed, 52.5% were women. The educational level of the respondents was low, 35.7% had no education and only 3% had tertiary education. All the study communities, including 67% of survey respondents, said eye disease was the third most common health problem. Overall knowledge about specific diseases was low. Only 3% and 5% of respondents mentioned trachoma and glaucoma, respectively, as a cause of blindness. All community members tended to either seek help from the practitioner closest to them or else alternate between different practitioners. Conclusion: The study showed that eye disease was a common health problem in all the communities. The community members desired eye care services manned by trained personnel close to them. Using CHPS appeared to be an option that can greatly improve access to eye care services in Ghana.

Background: The equitable distribution of a skilled health workforce is critical to health service delivery, and Kaduna state has taken significant steps to revamp the primary health care system to ensure access to health care for its populace. However, some of these investments are yet to yield the desired outcomes due to workforce shortages and inequitable distribution of those available. Methods: A Workload Indicator for Staffing Need study was conducted at the primary health care level in Kaduna state. The study focused on estimating staffing requirements; Nurse/Midwife and Community Health Worker practitioners; Community Health Officer, Community Health Extension Worker and Junior Community Health Extension Worker, in all government prioritized primary health care facilities. Ten focal primary health care facilities in Kaduna North Local Government Area were included in the study. Results: Findings revealed a shortage of Nurses/Midwives and Community Health Workers across the study facilities. For the Nurse/Midwife staffing category, 9/10 PHCs have a Workload Indicator for Staffing Need ratio < 1; indicating that the number of staff in the Nurse/Midwife category is insufficient to cope with the workload. In two of the ten primary health care facilities, there is an excess in the number of CHWs available; a Workload Indicator for Staffing Need ratio > 1 was calculated. Conclusions: The Workload Indicator for Staffing Need study highlights the staffing needs in government prioritized primary health care facilities in Kaduna state. This evidence establishes the basis for the application of an evidence-based approach to determining staffing needs across the primary health care sector in the State, to guide workforce planning strategies and future investments in the health sector. The World Health Organisation Workload Indicator for Staffing Need tool is useful in estimating staffing needs required to cope with workload pressures, particularly in a resources-constrained environment like Kaduna State.