Ophthalmic Clinical Officer Research Articles

Telemedicine integration into the eye health ecosystem in scaling of effective refractive error coverage in Kenya

This study explored the potential of telemedicine integration into the eye health ecosystem with an aim of scaling effective refractive error coverage in Kenya. This exploratory study was conducted telephonically and through online interviews with key opinion leaders, ophthalmologists, optometrists, ophthalmic clinical officers, optical technicians and beneficiaries of the optical technician’s services in rural areas. A telemedicine workflow was developed and validated based on the comments from the key opinion leaders using the Delphi technique. Quantitative and qualitative data were analysed using SPSS and NVivo Software respectively. All of the key opinion leaders agreed that telemedicine is relevant in the eye health ecosystem and recognition of primary vision technicians is critical for effective telemedicine integration. The reasons for the need of telemedicine integration were categorized into; good relationship, organized refractive error service delivery, convenience and availability and cost reduction. The possible factors influencing integration of telemedicine identified were categorized into cost, unwillingness, dominance, perception, lack of technical team, policies and network coverage. The limited human resources in the eye health ecosystem in developing countries cannot effectively deliver refractive error services to the growing population. Hence, integration of telemedicine and establishment of policies recognizing telemedicine are desirable to strengthen task shifting and scale effective refractive error coverage.

FACTORS CONTRIBUTING TO OPEN GLOBE INJURIES AMONG PATIENTS ATTENDING EYE CARE SERVICES AT MBALE REGIONAL REFERRAL HOSPITAL FROM AUGUST 2022 TO MARCH 2023. A CROSS-SECTIONAL STUDY.

Background Cases of open globe injuries are on the increase in various countries mainly as a result of occupation, accidents, and sharp instruments in children. Thus, this study determined the factors contributing to open globe eye injuries among patients attending the eye care services at Mbale Regional Referral Hospital. Methodology Used a cross-sectional design employing quantitative methods of data collection. 100 respondents who participated in the study were selected, where only patients with open globe injuries as well as caretakers were chosen among patients attending eye care services at MRRH. Results Regarding socio-demographic factors, the majority of the respondents (43%) who drank alcohol, (79%) agreed that open globe injuries are more common in children than adults, (52%) mentioned the cornea as the most affected part of the eye. According to individual-related factors, (70%) of the respondents agreed that social-economic status is associated with open globe injuries, (58%) said playing with sharp instruments/objects. Regarding environmental-related factors contributing to open globe injuries, the majority (47%) got injuries at home, (35%) said industry/construction jobs have high risks of open globe injuries. Conclusions Open globe injuries are more common at young age than the adults. Sharp objects like sticks are the most common cause of global injuries among individuals. The socioeconomic status of an individual is associated with global injuries Recommendations Health workers especially ophthalmologists, and ophthalmic clinical officers should sensitize the community and the whole public on risk factors, causes, and how to prevent global injuries. Parents should strictly monitor their children to prevent open globe injuries. Finally, industrial managers, construction engineers, and army commanding officers should procure protective gear and ensure that their workers take precautions like wearing protective gear while at work

MEDICAL-RELATED RISK FACTORS FOR AGE-RELATED MACULAR DEGENERATION AMONG PATIENTS ATTENDING EYE CARE CLINIC AT JINJA REGIONAL REFERRAL HOSPITAL. A CROSS-SECTIONAL STUDY.

Background: Patients with AIDS have an increased age-adjusted prevalence of intermediate-stage AMD compared with that found in a non-HIV-infected cohort evaluated with similar methods suggesting a potential risk that AIDs and other medical conditions could have towards Age-Related Macular Degeneration. The study aims to assess the medical-related risk factors for Age-Related Macular Degeneration. Methodology: A Cross-sectional descriptive study utilizing quantitative data collection methods. The study population comprised all patients receiving eye care services for Age-related Macular Degeneration conditions at the eye unit of Jinja Regional Referral Hospital for a period of 6 months from October 2022 to March 2023. Non-probability sampling was used to select 50 participants. Results: Half 25/50(50%) of the total number of respondents were between 61-70 years and the minority 02/50 (04 %) were 31-40 years. Most respondents 21/50 (42%) were peasants while 10/50 (20%) were Business personnel. The majority 18/50(36%) Strongly agreed that cataracts are a risk factor for Age-related Macular degeneration, followed by 17/50(34%) respondents who agreed. More respondents 39/50 (78%) indicated they had an intra-ocular surgery than 11/50(22%) respondents had not had an intra-ocular surgery. Most respondents 28/50 (56%) indicated they had a chronic disease while 22/50 (44%) respondents did not. A higher number of respondents 31/50(62%) were HIV Positive than 19/50(38%) who were found to be HIV negative. Conclusion: The medical-related risk factors for Age-related Macular Degeneration were having HIV/AIDs, chronic systemic diseases, Cataracts, and intra-ocular surgeries. Recommendations: Similarly, Health workers especially ophthalmologists and ophthalmic clinical officers should provide health education to the patients and the public and carry out regular outreach for eye vision screening.

Situation analysis on the integration of refractive error services provided by optometrists into the national health services in Kenya

IntroductionEven though the burden of uncorrected refractive error could potentially be addressed through innovative and cost-effective approaches, integration of the services into the National Health Services (NHS) is desirable. However, minimal information exists on the current situation warranting the need for evidence about the integration of refractive error service provided by optometrists into the national health services in Kenya.MethodsA situation analysis of the Kenyan refractive error services provided by optometrists within the NHS was undertaken based on access to service delivery, service coverage, and human resource. A strengths, weaknesses, opportunities, and threats analysis was undertaken based on the existent evidence to identify the core factors that could potentially facilitate or hinder the integration of refractive error services provided by optometrists within the National Health Services. The proportion of optometrists to be integrated in the NHS was estimated based on the minimum ratios recommended by the World Health Organization.ResultsA section of tertiary and secondary healthcare facilities in Kenya have specific services to address refractive errors within the NHS with most facilities lacking such services. Treatment of refractive error occurs at the level of eye care general services. There are 11,547 health facilities offering primary care services in Kenya. However, none of them offers refractive error services and only a section of facilities offering county health referral services provides eye care services which is limited to refraction without provision of spectacles. The existing workforce comprises of ophthalmologists, optometrists and ophthalmic clinical officers, together with nurses and other general paramedical assistants. Optometrists, ophthalmologists and ophthalmic clinical officers are allowed to undertake refraction. However, optometrists majorly practices in the private sector. Centralization of eye care services in urban areas, weak referral systems, and a shortage in the workforce per population was observed.ConclusionsThe Kenyan NHS should advocate for primary care and reorient the current hospital-based delivery approach for refractive error services. This is attributed to the fact that provision of refractive error services at primary care remains effective and efficient and could translate to early detection of other ocular conditions. The existing human resources in the eye health ecosystem in Kenya should maximize their efforts towards addressing uncorrected refractive error and optometrists should be integrated into the NHS.

PREVALENCE, INCIDENCES AND MANAGEMENT PRACTICES OF OPHTHALMIC EMERGENCIES; A CROSS-SECTIONAL STUDY IN JINJA REGIONAL REFERRAL HOSPITAL.

Introduction This study was aimed at establishing the prevalence of ophthalmic emergencies, determining the common incidences of ophthalmic emergencies, and establishing the common management practices of ophthalmic emergencies at Jinja Regional Referral Hospital. This study was carried out at the eye department of Jinja Regional Referral Hospital, Jinja City Busoga region Methodology It employed a descriptive cross-sectional study design that employed both qualitative and quantitative methods of data collection from a sample size of 100 using a self-administered questionnaire. Data was analyzed manually and presented in tables and figures. Results The study showed that 43(43%) of the respondents were 10-20 years old and 60(60%) of them were males. Most of the respondents affected 42(42%) were those who were working in industries, factories, and welding. The most common ophthalmic emergency incidences were open globe injuries 72(72%) and mostly corneal foreign bodies 42(42%). The common management options for ophthalmic emergencies present at JRRH were both topical and systemic antibiotics, anti-fungal anti-viral drugs depending on the cause of the illness; surgery; topical or systemic steroids to reduce inflammation in the eye; anti-glaucoma drugs to reduce IOPs and referral Conclusion The study concluded that the common age group affected by ophthalmic emergencies is 10-20 years and mostly males are affected and with those working, it was mostly welders, those working in industries, factories, and peasants. Recommendations The government, Ophthalmologists, ophthalmic clinical officers, and ophthalmic nurses should play their roles to address the challenges in service delivery to reduce ophthalmic emergencies or even avoid complications of ophthalmic emergencies

Proposed task shifting integrated with telemedicine to address uncorrected refractive error in Kenya: Delphi study

BackgroundDeveloping countries such as Kenya still experience challenges around human resource to deliver refractive error services. However, given the burden of uncorrected refractive error, adoption of innovative and cost effective approaches is desirable. Hence this study intended to develop a task shifting framework integrated with telemedicine to potentially scale refractive error services.MethodsThis was an exploratory study conducted in four phases as follows: a scoping review of the scope of practice for ophthalmic workers in Kenya, an interview with key opinion leaders on the need for integration of public health approaches such as the vision corridors within the eye health ecosystem in Kenya and their knowledge on task shifting, and finally development and validation of a proposed task shifting framework through a Delphi technique. Purposive sampling was used to recruit key opinion leaders and data was collected via telephonic interviews. The qualitative data was analyzed thematically using NVivo Software, Version 11.ResultsThe scoping review showed that only optometrists, ophthalmologists and ophthalmic clinical officers are allowed to undertake refraction in Kenya. All of the key opinion leaders (100%) were aware of task shifting and agreed that it is suitable for adoption within the eye health ecosystem in Kenya. All of the key opinion leaders (100%) agreed that skills development for healthcare workers without prior training on eye health supervised by optometrists through telemedicine is desirable. Notwithstanding, all of the key opinion leaders (100%) agreed that integration of public health approaches such as the vision corridors across all levels of healthcare delivery channels and development of a self-assessment visual acuity tool is desirable. Finally all of the key opinion leaders (100%) agreed that task shifting is relevant for adoption within the eye health ecosystem in Kenya. The developed framework prioritized partnership, advocacy, skills development, establishment and equipping of refraction points. The proposed framework advocated for a telemedicine between professionals with conventional training and those with skills development.ConclusionTask shifting integrated with telemedicine could cost effectively scale refractive error service delivery. However, internal and external factors may hinder the success warranting the need for a multi-faceted interventions and a connection between planning and training to scale the uptake.

The diagnostic accuracy of diabetes retinopathy screening by ophthalmic clinical officers, ophthalmic nurses and county ophthalmologists against a retina specialist in 2 selected county referral hospitals, Kenya.

Diabetes is rapidly becoming a major cause of blindness among Kenyans, with the prevalence of any form of diabetes retinopathy (DR) ranging from 36% to 41%. Globally DR leads as a cause of vision loss in working age adults. In Kenya, specialized examinations are only available at national and some county referral hospitals through retina specialists, ophthalmologists or trained technicians. Thus, low coverage of retinal assessment and inadequate access to this service. An innovative DR fundus camera screening service run by ophthalmic nurses (ONs), ophthalmic clinical officers (OCOs) and county ophthalmologists was established since 2018. The purpose of this study was to investigate the diagnostic accuracy of DR digital retinal camera screening by ONs, OCOs and county ophthalmologist against that of a retina specialist measured by sensitivity and specificity as the primary outcomes. Cross sectional study conducted at 2 referral hospitals in Kenya. Using a Canon CR-2AF digital retinal camera patients with diabetes had a standard single shot of 45 degree view of the retina captured as image in each eye. This was graded for DR using the International Clinical Diabetic Retinopathy (ICDR) severity scale. All photos taken by the first graders (ON/OCO) were later assessed by the county hospital ophthalmologist who was blinded to their readings. The third grader (retina specialist) similarly was blinded to the readings of the first and second graders and assessed all the images from the 2 hospitals also using ICDR. A total of 308 patients with diabetes (median age 58 IQR 56-60, 53% female) were enrolled in the study. Sensitivity to identify any DR was (81.3%, 80.6%, and 81.54% for the OCO, ON and county ophthalmologist respectively). The corresponding specificities were 92.7%, 92.8% and 92.59%. Analysis of diagnostic accuracy of non-sight threatening DR against sight threatening DR revealed lower sensitivity for the three cadre groups although specificity remained high. In this study, ON and OCO with basic training in DR screening and photo grading performed screening of DR with high specificity. However, the sensitivity to detect sight threatening DR was generally low by all the cadres which may leave severe forms of DR undetected.

Diagnosis and management of keratoconus by eye care practitioners in Kenya

BackgroundTo explore current eye care practice in keratoconus diagnosis and management in Kenya.MethodsAn online questionnaire was distributed to ophthalmic clinical officers (OCO) and optometrists.ResultsA total of 203 responses were received from 52 OCOs and 151 optometrists with a response rate of 24.4% and 53.5% respectively. The majority reported having access to retinoscopes (88.5%; p = 0.48) and slit lamps (76.7; p = 0.14). Few practitioners had access to a corneal topographer (13.5%; p = 0.08) and rigid contact lens (CL) fitting sets (OCOs 5.8%, optometrists 33.8%; p < 0.01). One-third did not feel that retinoscopy (38.7%; p = 0.21), slit lamp findings (30.3%; p = 0.10) and corneal topography (36.6%; p = 0.39) are important investigations in keratoconus diagnosis. Corneal topography was not recommended in two-thirds of patients (59.0%; p = 0.33) with vernal keratoconjunctivitis (VKC). The majority counselled against eye rubbing in mild (73.6%; p = 0.90) VKC, 52.9% in moderate (p = 0.40) and 43.6% in severe (p = 0.24) cases. The majority prescribed spectacles in mild (90.2%; p = 0.95), 29% (p = 0.97) in moderate and 1.9% (p = 0.05) in severe cases. When the binocular best corrected visual acuity (BCVA) with spectacles was ≤ 6/18, 76.9% of OCOs and 58.9% of optometrists referred for CLs (p = 0.02). When binocular BCVA with CLs dropped to ≤ 6/18, 83.7% (p = 0.18) referred to the ophthalmologist for surgical intervention. Few OCOs fitted rigid CLs (15.4% OCOs, 51.0% optometrists; p = 0.01), majority referred to optometrists (82.7% OCOs, 43.7% optometrists; p < 0.01). Progression was monitored in 70.1% (p = 0.11) of mild, 50.9% (p = 0.54) moderate and 25.3% (p = 0.31) advanced cases. Few OCOs (15.4%) performed corneal cross-linking (CXL). A few respondents (5.4%; p = 0.13) did not know when to refer keratoconus patients for CXL. Co-management with ophthalmologists was reported by 58.0% (p = 0.06) of respondents.ConclusionThe results of this study highlight the need to map services for keratoconus patients, review current curricula and continuous education priorities for mid-level ophthalmic workers, develop guidelines for the diagnosis and management of keratoconus and improve interdisciplinary collaboration.

Training Needs Assessment for a Bachelor of Science Program in Eye Care at the University of Rwanda

BackgroundThe University of Rwanda, established the Ophthalmology Department in 2004 to train Ophthalmic Clinical Officers (OCO). A proposal was developed towards upgrading the qualification level of the OCOs training at the University of Rwanda.AimThis study aimed to assess the need to upgrade the qualification of ophthalmic clinical officers to improve eye health services in Rwanda.MethodologyA descriptive cross-sectional study was conducted among 87 participants comprised of ophthalmic clinical officers, eye health development stakeholders, and employers in Rwanda selected purposively. Data analysis was performed using SPSS version 16.ResultsThe results showed that 77% of participants in the stakeholders group and 51.4% in the OCOs group were males. About 97% (n= 34) of the OCO responded “Yes” to the questions “Do you think some of the weaknesses related to quality practice are related to the level of training?” and “Does your qualification have any effect to your professional development?” Furthermore, 85% had never been promoted at any employment position, 100 % (n=35) alumni and 84 % (n=22) stakeholders agreed that there is a need for bachelor’s degree program.ConclusionThe need for developing new programs in ophthalmology including a Bachelor of Science degree program for OCOs was evident.Rwanda J Med Health Sci 2021;4(3):357-365

How far would you travel to consult a rural Ugandan eye specialist? A cross-sectional study

Aims: Blindness and visual impairment are major public health concerns. However there is only 1 ophthalmologist per million individuals in Africa. Hence, individuals must travel long distances to see an eye specialist leading to reduced uptake of eye care services. The aims were to review patients’ demographics and geographical distribution, and conditions diagnosed at a rural eye clinic in Uganda. Methods: The ophthalmic clinical officer made handwritten records of attendees at the once-weekly morning clinic over a 14-week period. Data, including demographics, town of residence and diagnoses, were collated and analyzed. Results: During the study period, 273 participants attended the clinic (96 males, 177 females). On average, 19.5 patients were seen in the clinic per week. Patient ages’ ranged from 3 days to 89 years old (mean age=32.5 y). The commonest diagnoses were allergic conjunctivitis (9.9%), bacterial conjunctivitis (9.2%), pterygium (8.8%), presbyopia (8.8%), and blunt trauma (5.9%). Patients lived an average distance of 25.1 km from the clinic, with 23.0% living &gt;30 km away. Conclusion: The wide geographical distribution of attendees at the Ugandan eye clinic supports earlier research that these clinics are sparsely distributed requiring individuals to travel long distances to seek eye care services.

Smartphone-Guided Algorithms for Use by Community Volunteers to Screen and Refer People With Eye Problems in Trans Nzoia County, Kenya: Development and Validation Study

BackgroundThe provision of eye care services is currently insufficient to meet the requirements of eye care. Many people remain unnecessarily visually impaired or at risk of becoming so because of treatable or preventable eye conditions. A lack of access and awareness of services is, in large part, a key barrier to handle this unmet need.ObjectiveThis study aimed to assess whether utilizing novel smartphone-based clinical algorithms can task-shift eye screening to community volunteers (CVs) to accurately identify and refer patients to primary eye care services. In particular, we developed the Peek Community Screening app and assessed its validity in making referral decisions for patients with eye problems.MethodsWe developed a smartphone-based clinical algorithm (the Peek Community Screening app) using age, distance vision, near vision, and pain as referral criteria. We then compared CVs’ referral decisions using this app with those made by an experienced ophthalmic clinical officer (OCO), which was the reference standard. The same participants were assessed by a trained CV using the app and by an OCO using standard outreach equipment. The outcome was the proportion of all decisions that were correct when compared with that of the OCO.ResultsThe required sensitivity and specificity for the Peek Community Screening app were achieved after seven iterations. In the seventh iteration, the OCO identified referable eye problems in 65.9% (378/574) of the participants. CVs correctly identified 344 of 378 (sensitivity 91.0%; 95% CI 87.7%-93.7%) of the cases and correctly identified 153 of 196 (specificity 78.1%; 95% CI 71.6%-83.6%) cases as not having a referable eye problem. The positive predictive value was 88.9% (95% CI 85.3%-91.8%), and the negative predictive value was 81.8% (95% CI 75.5%-87.1%).ConclusionsDevelopment of such an algorithm is feasible; however, it requires considerable effort and resources. CVs can accurately use the Peek Community Screening app to identify and refer people with eye problems. An iterative design process is necessary to ensure validity in the local context.

The management of microbial keratitis within Uganda’s primary health system: a situational analysis

Background: Microbial keratitis (MK) frequently leads to sight-loss, especially when the infection is severe and/or appropriate treatment is delayed. The primary health system as an entry point plays a central role in facilitating and directing patient access to appropriate care. The purpose of this study was to describe the capacity of primary health centres in Uganda in managing MK. Methods: We carried out a rigorous assessment of primary health centres and mid-cadre training schools in South Western Uganda. Through interviews, checklists and a picture quiz, we assessed capacity and knowledge of MK management. In addition, we interviewed the heads of all the mid-cadre training schools to determine the level of eye health training provided in their curricula. Results: In total, 163 health facilities and 16 training schools were enrolled. Of the health facilities, only 6% had an Ophthalmic Clinical Officer. Only 12% of the health workers could make a diagnosis of MK based on the clinical signs in the picture quiz. Although 35% of the facilities had a microscope, none reported doing corneal scraping. None of the facilities had a stock of the recommended first line treatment options for MK (ciprofloxacin and natamycin eye drops). Among the training schools, 15/16 had an eye health component in the curriculum. However, the majority (56%) of tutors had no formal expertise in eye health. In 14/16 schools, students spent an average of two weeks in an eye unit. Conclusions: Knowledge among health workers and capacity of health facilities in diagnosis and management of MK was low. Training for eye health within mid-cadre training schools was inadequate. More is needed to close these gaps in training and capacity.

The management of microbial keratitis within Uganda's primary health system: a situational analysis.

Background: Microbial keratitis (MK) frequently leads to sight-loss, especially when the infection is severe and/or appropriate treatment is delayed. The primary health system as an entry point plays a central role in facilitating and directing patient access to appropriate care. The purpose of this study was to describe the capacity of primary health centres in Uganda in managing MK. Methods: We carried out a rigorous assessment of primary health centres and mid-cadre training schools in South Western Uganda. Through interviews, checklists and a picture quiz, we assessed capacity and knowledge of MK management. In addition, we interviewed the heads of all the mid-cadre training schools to determine the level of eye health training provided in their curricula. Results: In total, 163 health facilities and 16 training schools were enrolled. Of the health facilities, only 6% had an Ophthalmic Clinical Officer. Only 12% of the health workers could make a diagnosis of MK based on the clinical signs in the picture quiz. Although 35% of the facilities had a microscope, none reported doing corneal scraping. None of the facilities had a stock of the recommended first line treatment options for MK (ciprofloxacin and natamycin eye drops). Among the training schools, 15/16 had an eye health component in the curriculum. However, the majority (56%) of tutors had no formal expertise in eye health. In 14/16 schools, students spent an average of two weeks in an eye unit. Conclusions: Knowledge among health workers and capacity of health facilities in diagnosis and management of MK was low. Training for eye health within mid-cadre training schools was inadequate. More is needed to close these gaps in training and capacity.

Prevalence of Trachoma in Northern Benin: Results from 11 Population-Based Prevalence Surveys Covering 26 Districts

ABSTRACTAims: We sought to evaluate trachoma prevalence in all suspected-endemic areas of Benin.Methods: We conducted population-based surveys covering 26 districts grouped into 11 evaluation units (EUs), using a two-stage, systematic and random, cluster sampling design powered at EU level. In each EU, 23 villages were systematically selected with population proportional to size; 30 households were selected from each village using compact segment sampling. In selected households, we examined all consenting residents aged one year or above for trichiasis, trachomatous inflammation – follicular (TF), and trachomatous inflammation – intense. We calculated the EU-level backlog of trichiasis and delineated the ophthalmic workforce in each EU using local interviews and telephone surveys.Results: At EU-level, the TF prevalence in 1–9-year-olds ranged from 1.9 to 24.0%, with four EUs (incorporating eight districts) demonstrating prevalences ≥5%. The prevalence of trichiasis in adults aged 15+ years ranged from 0.1 to 1.9%. In nine EUs (incorporating 19 districts), the trichiasis prevalence in adults was ≥0.2%. An estimated 11,457 people have trichiasis in an area served by eight ophthalmic clinical officers.Conclusion: In northern Benin, over 8000 people need surgery or other interventions for trichiasis to reach the trichiasis elimination threshold prevalence in each EU, and just over one million people need a combination of antibiotics, facial cleanliness and environmental improvement for the purposes of trachoma’s elimination as a public health problem. The current distribution of ophthalmic clinical officers does not match surgical needs.

Analysis of an international collaboration for capacity building of human resources for eye care: case study of the college-college VISION 2020 LINK

BackgroundThere is an extreme health workforce shortage in Eastern, Central, and Southern Africa. Shortage of eye care workers impedes effective implementation of prevention of blindness programs. The World Health Organization has identified education, partnership, leadership, financing, and policy as intertwined interventions that are critical to resolving this crisis on the long term.Case presentationThe VISION 2020 LINK between the College of Ophthalmology of Eastern, Central, and Southern Africa and the Royal College of Ophthalmologists in the United Kingdom aims to increase the quantity and quality of eye care training in East, Central, and Southern Africa through a focus on five strategic areas: fellowship examination for ophthalmologists, training the trainers, curriculum development for residents in ophthalmology and ophthalmic clinical officers, continuous professional development (CPD), and mentoring program for young ophthalmologists. This study examined how education and partnership can be linked to improve eye care, through an evaluation of this north-south link based on its own targets and established frameworks to guide north-south links.MethodsAn exploratory qualitative case study design was used. Twenty-nine link representatives were recruited through purposive sampling and snowballing. Face-to-face interviews were conducted using a semi-structured interview schedule that incorporated the components of a successful link from an existing framework. Documents pertaining to the link were also examined. Thematic analysis was used for data analysis.ResultsThe findings revealed that the perception to the contribution of the link to eye care in the region is generally positive. Process indicators showed that the targets in three strategic objectives of the link have been achieved. Framework-based evaluation also showed that the link is successful. Mutual learning and development of friendships were the most commonly identified success factors. Inadequate awareness of the link by college members is a key challenge.ConclusionThe study concludes that the link is active and evolving and has achieved most of its targets. Further developments should be directed to influence health system strengthening in Eastern, Central, and Southern Africa more strategically. The study recommends expansion of the scope of collaboration to involve multiple health system building blocks.

Mapping human resources for eye health in 21 countries of sub-Saharan Africa: current progress towards VISION 2020.

BackgroundDevelopment of human resources for eye health (HReH) is a major focus of the Global Action Plan 2014 to 2019 to reduce the prevalence of avoidable visual impairment by 25% by the year 2019. The eye health workforce is thought to be much smaller in sub-Saharan Africa than in other regions of the world but data to support this for policy-making is scarce. We collected HReH and cataract surgeries data from 21 countries in sub-Sahara to estimate progress towards key suggested population-based VISION 2020 HReH indicators and cataract surgery rates (CSR) in 2011.MethodsRoutinely collected data on practitioner and surgery numbers in 2011 was requested from national eye care coordinators via electronic questionnaires. Telephone and e-mail discussions were used to determine data collection strategies that fit the national context and to verify reported data quality. Information was collected on six practitioner cadres: ophthalmologists, cataract surgeons, ophthalmic clinical officers, ophthalmic nurses, optometrists and ‘mid-level refractionists’ and combined with publicly available population data to calculate practitioner to population ratios and CSRs. Associations with development characteristics were conducted using Wilcoxon rank sum tests and Spearman rank correlations.ResultsHReH data was not easily available. A minority of countries had achieved the suggested VISION 2020 targets in 2011; five countries for ophthalmologists/cataract surgeons, four for ophthalmic nurses/clinical officers and two for CSR. All countries were below target for optometrists, even when other cadres who perform refractions as a primary duty were considered. The regional (sample) ratio for surgeons (ophthalmologists and cataract surgeons) was 2.9 per million population, 5.5 for ophthalmic clinical officers and nurses, 3.7 for optometrists and other refractionists, and 515 for CSR. A positive correlation between GDP and CSR as well as many practitioner ratios was observed (CSR P = 0.0042, ophthalmologists P = 0.0034, cataract surgeons, ophthalmic nurses and optometrists 0.1 > P > 0.05).ConclusionsWith only a minority of countries in our sample having reached suggested ophthalmic cadre targets and none having reached targets for refractionists in 2011, substantially more targeted investment in HReH may be needed for VISION 2020 aims to be achieved in sub-Saharan Africa.

Trends and implications for achieving VISION 2020 human resources for eye health targets in 16 countries of sub-Saharan Africa by the year 2020.

BackgroundDevelopment of human resources for eye health (HReH) is a major global eye health strategy to reduce the prevalence of avoidable visual impairment by the year 2020. Building on our previous analysis of current progress towards key HReH indicators and cataract surgery rates (CSRs), we predicted future indicator achievement among 16 countries of sub-Saharan Africa by 2020.MethodsSurgical and HReH data were collected from national eye care programme coordinators on six practitioner cadres: ophthalmologists, cataract surgeons, ophthalmic clinical officers, ophthalmic nurses, optometrists and ‘mid-level refractionists’ and combined them with publicly available population data to calculate practitioner-to-population ratios and CSRs. Data on workforce entry and exit (2008 to 2010) was used to project practitioner population and CSR growth between 2011 and 2020 in relation to projected growth in the general population. Associations between indicator progress and the presence of a non-physician cataract surgeon cadre were also explored using Wilcoxon rank sum tests and Spearman rank correlations.ResultsIn our 16-country sample, practitioner per million population ratios are predicted to increase slightly for surgeons (ophthalmologists/cataract surgeons, from 3.1 in 2011 to 3.4 in 2020) and ophthalmic nurses/clinical officers (5.8 to 6.8) but remain low for refractionists (including optometrists, at 3.6 in 2011 and 2020). Among countries that have not already achieved target indicators, however, practitioner growth will be insufficient for any additional countries to reach the surgeon and refractionist targets by year 2020. Without further strategy change and investment, even after 2020, surgeon growth is only expected to sufficiently outpace general population growth to reach the target in one country. For nurses, two additional countries will achieve the target while one will fall below it. In 2011, high surgeon practitioner ratios were associated with high CSR, regardless of the type of surgeon employed. The cataract surgeon workforce is growing proportionately faster than the ophthalmologist.ConclusionsThe HReH workforce is not growing fast enough to achieve global eye health targets in most of the sub-Saharan countries we surveyed by 2020. Countries seeking to make rapid progress to improve CSR could prioritise investment in training new cataract surgeons over ophthalmologists and improving surgical output efficiency.

Does Training Clinic Nurses to Test Pinhole Visual Acuity as a Screen for Glaucoma Increase Glaucoma Referrals to Eye Care Professionals? A Pilot Study in Malawi

Purpose: To test whether general nurses, trained in screening for glaucoma, can increase the number of glaucoma cases seen by eye-care professionals in a rural setting in Africa.Methods: In two districts in Malawi, 87 clinic nurses and two ophthalmic clinical officers were trained in case detection and referral of patients with suspect glaucoma. Data were collected on the number of patients screened and referred over a 12-month period. The clinic nurses and ophthalmic clinical officers received supportive supervision four times during the period and interviews were used to elicit their perspectives on the training and referral procedures.Results: The 87 nurses screened 294 people (mean 3.4 per nurse) and referred 147 (50%) of them. Of the 147 referred, 56 (38%) were seen by the ophthalmic clinical officers who referred 15 (27%) to the ophthalmologist. Only two people were seen by the ophthalmologist. Testing visual acuity in people over 40 years of age was not seen as a priority by primary level clinic nurses. Nurses reported that cost and distance were barriers precluding attendance by patients at the next level. Women were two times less likely to be referred. About one quarter of patients who were offered surgery refused. Fewer than half the patients who had surgery attend for follow-up.Conclusions: Training general nurses to screen for and refer suspect glaucoma cases did not lead to increased glaucoma service delivery. Other strategies to identify high risk patients need to be tested.

Primary eye care in Rwanda: gender of service providers and other factors associated with effective service delivery

To assess factors associated with high output of recently trained medical personnel in Rwanda. Nurses and village health workers (VHW) from all health centres in Rubavu district were included. Data were collected during focus group discussions and through one-to-one interviews. Follow-up interviews were carried out in January 2009. There was a wide range from none to all VHW referring people to a health centre. VHW brought more people to the health centre if there was a visiting ophthalmic clinical officer from the Eye Unit offering free screening. VHW output varied; male VHW brought 66.7% of patients identified (regardless of the sex of the health centre nurse), while female VHW brought 5.2 times as many people if the health centre nurse was male compared to if the nurse was female. Changes in training curriculum and support and supervision of health workers trained in primary eye care (PEC) are likely to lead to improved outputs. Information efforts should reinforce that male and female nurses have the same training and skills in PEC.

Presbyopic Spectacle Coverage, Willingness to Pay for Near Correction, and the Impact of Correcting Uncorrected Presbyopia in Adults in Zanzibar, East Africa

To assess presbyopic spectacle coverage, willingness to pay, and the impact of correcting uncorrected presbyopia in individuals 40 years of age and older in Zanzibar and whether assessment of presbyopia can be incorporated into Rapid Assessment of Blindness (RAAB) surveys. A cross-sectional, population-based survey of presbyopia was incorporated into a RAAB survey. The sample size of 400 included individuals older than 50 years (from RAAB survey) and those 40 to 50 years old (from the same household) who had a corrected visual acuity (VA) of at least 6/18 in either eye. An Ophthalmic Clinical Officer (OCO) administered visual function (VF) and quality of life (QOL) questionnaires followed by clinical assessment by an optometrist. Participants requiring a simple near addition were dispensed free readymade spectacles. The same team traced participants 6 months later and readministered the questionnaires. Those requiring new spectacles had their near VA measured and were given spectacles. Three hundred eighty-one participants were examined. The prevalence of presbyopia was 89.2% (340/381) and spectacle coverage was only 17.6%. Barriers to accessing services included spectacles not being a priority and lack of money. At follow-up, 175 (93.6%) of 187 participants given spectacles still had them. Mean satisfaction was high at 89.5%. The mean amount participants were willing to pay for spectacles had increased from 2.17 USD at baseline to 3.14 USD at follow-up. The impact of correcting presbyopia on VF produced an effect size of 2.90 and effect sizes ranging from 1.15 to 3.90 for mean QoL scores. This study highlights the value of correcting presbyopia from the community perspective and the necessity of providing affordable, quality, and accessible near spectacles at the primary health level.