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

Courtright, Paul; Seneadza, Asiwome; Mathenge, Wanjiku; Eliah, Edson; Lewallen, Susan

doi:10.1179/136485910x12743554760225

Cited by 47 publications

(60 citation statements)

References 22 publications

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“…A detailed review by Courtright et al [13] identified only five articles providing information on the effectiveness of general primary health care workers in practicing primary eye care. Steinkuller, in 1987, commented on the results of PEC training for general health care workers in South Africa, Tanzania, Kenya, and Malawi [14].…”

Section: Introductionmentioning

confidence: 99%

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

Kalua

Gichangi

Barassa

et al. 2014

BMC Health Serv Res

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BackgroundKnowledge 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.MethodsThis 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.ResultsAll 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.ConclusionThe 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.

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Section: Introductionmentioning

confidence: 99%

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

Kalua

Gichangi

Barassa

et al. 2014

BMC Health Serv Res

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“…In spite of this, there is persistent enthusiasm for the concept of providing eye services (diagnosis, treatment, and referral) at the most basic level of the health system by general PHCW in Africa [6]. PEC may be considered an example of “task shifting” from more specialized workers (dealing only with eye conditions) to less specialized.…”

Section: Introductionmentioning

confidence: 99%

“…The concept of PEC became very popular with non-governmental organizations and it is frequently cited at meetings as a critical piece of the eye health services in developing countries. The lack of evidence for its benefits as practised, however, has been documented [6]. …”

Section: Introductionmentioning

confidence: 99%

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

et al. 2014

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BackgroundPrimary 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.MethodsA 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.ResultsThree-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.ConclusionThe 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.

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“…In an effort to overcome this, primary eye care (PEC) as an integral part of primary health care (PHC) has been recommended as a key strategy. PEC means different things in different parts of the world [3]. In settings with more resources, “primary eye care” refers to services delivered by nurses and health assistants who are trained for and work more or less exclusively in eye care, such as ophthalmic clinical officers or ophthalmic nurses and assistants.…”

Section: Introductionmentioning

confidence: 99%

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

Andriamanjato

Mathenge²,

Kalua

et al. 2014

Hum Resour Health

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BackgroundThe 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.MethodsSpecialized 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.ResultsSensitivities 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.ConclusionsIn 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.

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

Cited by 47 publications

References 22 publications

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

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

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

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

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