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Community Eye Health J 2007;20(61): 7-15
MSc SUMMARIES
MSc Summaries
Prevalence
A survey of childhood blindness in three schools for the blind in Zambia
|
Grace Chipalo-Mutati |
Aim: To assess the causes and distribution of blindness in children in
three schools for the blind in Zambia, and to estimate the average cost
of primary education per child per year. The results of this study will be
used to develop baseline data for planning a nationwide intervention.
Methods: This was a descriptive, cross-sectional study with a
quantitative component, conducted in three schools for the blind in
Zambia. The World Health Organization Prevention of Blindness
childhood blindness proforma was used to collect data and a
questionnaire on cost was developed and administered to the head
teachers. The data were recorded in Excel and analysed in the Epi
InfoTM statistical software package, version 6.
Results: A total of 133 children were examined. The sex distribution
was 91 males (68.4%) and 42 females (31.6%), giving a male to
female ratio of 2.2:1. The age range was 6–24 years with a mean
age of 13.9 years. A total of 64.7% of the children were below
16 years of age. Whereas 1.5% of the children were found to have
no visual impairment, the majority (60.9%) were blind. The major
anatomical site for visual loss was the retina (30.8%). Oculocutaneous
albinism accounted for 68.3% of all visual loss affecting
the retina. Hereditary diseases (36.8%) were the most common
cause. Measles and vitamin A deficiency combined accounted for
65.2% of all causes due to childhood factors. A total of 60.2% of
children were blind from conditions that could have been avoided.
Fifty per cent of children changed visual status from blind to severely
visually impaired after refraction. Overall, 23.3% of children were
recommended for enrolment into mainstream education. The three
schools had unique features, which meant there was a wide
variation between them in the total yearly cost per pupil. It was
therefore not possible to determine a yearly cost per child that could
be used as a guide for the whole country.
Conclusion: If low vision aids are provided, a significant proportion
of visually impaired children can be given the same opportunities
and educational experiences as sighted children.
Using the key informant method to investigate childhood blindness related to vitamin A deficiency disorder in six rural sub-districts in Bangladesh
|
Lutful Husain |
Aim: This study was undertaken to assess the prevalence, causes,
and risk factors of childhood blindness related to vitamin A
deficiency disorder (VADD) in six rural sub-districts in Bangladesh.
Methods: The study was carried out in rural sub-districts of Kishoreganj
during June and July 2006. Risk factors of VADD-related childhood
blindness were explored in six rural sub-districts. The key informant
method of identifying blind children was used for the study. Key
informants are unpaid volunteers from the local community who
know their community very well. After receiving training from the field
team of the Child Sight Foundation, the key informants had two
weeks to identify blind children and motivate parents to bring the
child for an eye examination. A cross-sectional study design was
used to determine the prevalence and causes of childhood blindness
for the Kishoreganj district. A case-control study was carried out to explore the risk factors of VADD-related childhood blindness.
Results: Prevalence of childhood blindness in Kishoreganj was
found to be 1.03/1,000 children; 32.7% of all children with severe
visual impairment/blindness (SVI/BL) had lens disorders leading to
blindness. Corneal opacity was the cause of SVI/BL in 23.4% of the
study children. Thirty per cent of children were severely visually
impaired or blind due to hereditary diseases and 27.1% were
severely visually impaired or blind due to childhood factors. Overall,
37.8% children were severely visually impaired or blind due to
treatable eye conditions. Illiteracy of mother (odds ratio [OR]=2.45),
illiteracy of father (OR=1.74), mother’s disease in pregnancy
(OR=3.74), child not receiving vitamin A capsule during diarrhoea
(OR=5.01), and child not receiving vitamin A capsule during measles
(OR=3.88) appeared as significant risk factors for VADD-related
childhood blindness. The following were found to be significant
protective factors against vitamin A deficiency in children: child
immunised against measles (OR=0.10); colostrum given to child
(OR=0.15); child breastfed (OR=0.13); child given dark green leafy
vegetables (OR=0.01); child given meat/fish/eggs (OR=0.08); oil/fat
used in child’s food (OR=0.14); vitamin A capsule given to child in
last year (OR=0.31); vitamin A-rich food eaten during pregnancy
(OR=0.02); and antihelminthics given to child (OR=0.15).
Conclusion: A comprehensive and integrated programme is
needed to control the high prevalence of childhood blindness in the
Kishoreganj district. The control programme should include primary
prevention strategies for VADD-related blindness, strategies to
identify children with eye disease at an early age, and referral and
treatment of children with cataract. These programmes should take
a primary eye care approach to highlight the risk factors and
protective factors of VADD-related blindness in children.
Use of key informants in determining the magnitude and causes of childhood blindness in Chikwawa district, southern Malawi
|
Khumbo Kalua |
Background: Population-based studies to determine the
magnitude and causes of childhood blindness require very large
sample sizes and are very costly. Alternative methods such as the
key informant method (which is cheap and easy to use) have been
found to be as reliable as population-based studies in settings
where the population is very dense.
Aims: To determine the magnitude and causes of childhood
blindness in Chikwawa district, Malawi, using the key informant
method; to see how this method can be used in a setting of low
population density, where the population is widely dispersed.
Methods: Key informants are local people who know their
community well. They were randomly selected by the communities
themselves and trained for one day in techniques to identify
children in the community who are blind. Each key informant
covered on average 4–7 villages which were widely dispersed.
Identified children were examined by the ophthalmologist to confirm
the diagnosis.
Results: A group of 44 key informants was selected and trained.
There were more female (80%) than male (20%) key informants.
The key informants correctly identified 37 children who were blind in
196 villages (86% of the expected number from the area). The
prevalence of childhood blindness was found to be 0.09%. Cataract
was found to be the most common cause (35%) of childhood
blindness, followed by corneal scarring (22%).
Conclusion: The key informant method was found to be cheap
and useful in identifying children who are blind, even in areas
where the population is widely dispersed. We recommend that
this method be used to identify children who are blind in other
districts of Malawi and where population-based surveys cannot
be conducted.
A national survey of visual impairment in Botswana
|
Oathokwa Nkomazana |
Aims: To estimate the prevalence and determine the causes of
visual impairment in people aged 50 years and older in Botswana,
and to assess cataract surgical services in the country.
Methods: Multi-stage cluster randomised sampling with probability
proportional to size was used to select a cross-sectional, nationally
representative sample of 2,662 adults aged 50 years and older.
Demographic details were collected for each of the subjects. This
was followed by measurement of distance visual acuity. The
crystalline lenses of all the subjects were examined for cataract. All
those whose vision did not improve to 6/18 with pinhole had their
pupils dilated with a short-acting mydriatic and their fundus
examined. Subjects with vision <6/60 due to cataract were asked
why they had not had surgery. Blindness was defined as vision <3/60
in the better eye with available correction and visual impairment as
vision <6/18 in the better eye with available correction. The
convention used by the World Health Organization, of assigning the
major cause to the disorder most amenable to treatment, was used
for those with more than one disorder causing visual impairment.
Results: A total of 2,127 eligible subjects were examined (79.9%
response rate) from 55 clusters. Of those, 130 were blind. The age and
sex-standardised prevalence of blindness was calculated to be
3.69% (95% confidence interval [CI] 2.38–5.00%). A total of 56 had
severe visual impairment (age- and sex-standardised prevalence of
1.69%, 95% CI 1.04–2.33%). The main causes of blindness were
cataract (46.9%), diabetic retinopathy (20.0%), non-trachomatous
corneal opacities (13.1%), and trachoma (6.2%). Cataract was also
the main cause of both severe (58.9%) and moderate (40.2%)
visual impairment. Refractive errors were responsible for 38.5% of
moderate visual impairment. In total, 55 (37%) of the eyes had best
corrected vision <6/60 after cataract surgery. The age- and sex-standardised
cataract surgical coverage for vision <3/60 was
66.5% for persons and 40.9% for eyes. For both blind and severely
visually impaired people, the main reason given for not seeking
surgery for cataract was lack of awareness of the presence of
cataract. For those who were bilaterally blind, this was followed by
lack of escort and cost of surgery. For those who were blind in one
eye, fear of the operation ranked second, followed by lack of escort
and the cost of surgery.
Conclusion: There are an estimated 6,370 adults aged 50 years
and older who are blind in Botswana. The majority of them are blind
from operable cataract. There is a need to provide high-volume,
high-quality, efficient and accessible cataract surgical services in
Botswana to address cataract blindness. Strategies also need to be
developed to combat blindness secondary to corneal scarring and
diabetic retinopathy.
Prevalence of blindness and low vision in Sawah Kulon village, Purwakarta district, West Java, Indonesia
|
Nina Ratnaningsh |
Background: In order to provide comprehensive eye care in a
district, it is important to determine the prevalence and causes of
visual impairment. Studies done in various parts of the world have
identified a large proportion of treatable causes of blindness in
people aged 40 years and older.
Aim: To conduct the first study to assess the prevalence of blindness
and low vision in Sawah Kulon, Purwakarta district, West Java,
Indonesia, where there is a primary health care centre.
Methods: Census data were used to design the survey. A
sample size of 1,102 people aged 40 years and older was
calculated for this district. Enumeration and door-to-door visual
acuity examinations were performed for all persons aged 40 years
and older. Further eye examinations were conducted by an ophthalmologist
on people with visual acuity <6/18. Differences in the
prevalence of blindness associated with age group, sex, and
economic status were explored using stratified analyses.
Results: Blindness and low vision were found in 1.67% and
6.05% of the sample, respectively. Blindness and low vision
increased significantly with increasing age; these conditions were
also twice as high in females as in males. They were higher in
people with lower income, although this was not statistically
significant. Cataract was the principal cause of low vision
(70.7% of people) and blindness (62.5% of people). Refractive
error was responsible for 20.7% of blindness and 25.0% of
low vision.
Conclusion: These data will be valuable in planning appropriate
services in this district. People with lower income have poorer
access to services and local health services need to be developed
appropriately.
Diabetic retinopathy: analysing the Pakistan survey and evaluating local resources
|
Aurangzeb Shaikh |
Aims: To estimate the prevalence of diabetic retinopathy (DR) in
adults in Pakistan, to estimate the current service facilities for DR
treatment in the province of Sindh, and to compare the current
infrastructure with similar data collected in 1998 in order to provide
evidence that can be used for provincial planning of diabetic eye
services in Sindh.
Methods: The data of the recent Pakistan National Blindness and
Visual Impairment Survey were analysed to calculate the prevalence
of DR and to identify risk factors. Statistical methods used to assess
association between the variables included summary statistics,
simple cross-tabulation, and Mantel-Haenzel odds ratios (OR).
Two community ophthalmologists from the department of
ophthalmology at Dow University of Health and Sciences (Karachi)
collected information about available infrastructure and human
resources from all government tertiary centres and non-government
hospitals which had treatment facilities for DR. This was performed
under supervision of the provincial co-ordinator of the prevention
and control of blindness programme in Sindh. Relevant information
was collected using a data collection form based on one developed in a previous study. This allowed comparisons within Sindh province
to be made. Additional data on the availability of fundus fluorescein
angiography (FFA) were collected.
Results: A total of 17,311 adults (aged 30 and older) were
enumerated for the survey. Among the 16,507 subjects examined,
660 diabetic patients were identified. Of these, 101 (15.3%)
exhibited evidence of DR. The overall prevalence of diabetes was
4% and the overall prevalence of DR was 0.6%. The odds ratio (OR)
of DR was higher in adult diabetic subjects living in urban areas (OR
2.7, 95% confidence interval [CI] 1.08–4.1) compared to those
living in rural areas. The risk was also higher in hypertensive (OR
2.77, 95% CI 1.0–4.1) and obese (body mass index >30) participants
(OR 2.2, 95% CI 1.7–4.2). Government sector hospitals
provided better diabetic eye care services in terms of diagnosis
(100% had diagnostic facilities) and treatment (85% had functional
laser facilities), compared to the situation in 1998 (when only 50%
had functional lasers). Twenty per cent of government tertiary
centres and 50% of non-government hospitals had FFA capability.
We found the same picture as in 1998 regarding vitreo-retinal
surgical facilities.
Conclusion: The burden of blindness due to diabetic retinopathy
can be reduced by good planning. Equal distribution of resources
among the rural and urban areas must be targeted to obtain a
comprehensive diabetic eye care programme. There has been some
training of human resources for the management of DR, but it
needs to be improved. Further research regarding the affordability of
the service is required.
Rapid assessment of avoidable blindness in Kunming, China
|
Min Wu |
Background: According to global estimates by the World Health
Organization (WHO), there were 141 million people with visual
impairment in 2002 and cataract was then the leading cause of
blindness. A national survey of China in 1987 suggested that the
prevalence of blindness (as defined by the WHO) was 0.42% for
all ages.
Aim: To evaluate the prevalence and causes of visual impairment
in people aged 50 and older in Kunming, China.
Methods: A population-based cross-sectional study was
conducted using multi-stage cluster sampling (including probability
proportional to size, compacted segment and non-compacted
segment sampling) to select 46 clusters of 60 individuals, each
over 50 years of age. The standardised protocol for rapid
assessment of avoidable blindness (RAAB) was used to identify
people with visual impairment (VI) and ophthalmic examination
was used to determine the main cause of VI. The RAAB software
package and STATA 9 software were used to enter and analyse data.
Results: A total of 2,588 people from the sample of 2,760 were
examined. Age- and sex-standardised prevalence of blindness
(available corrected visual acuity <3/60 in the better eye) was
2.7%. It was 2.3% for severe visual impairment (SVI) and 7.2% for
VI. The main causes of blindness were cataract (63.2%), other
corneal scarring (14.7%), and glaucoma (7.4%). In total, 84.2% of
blindness was avoidable, including cataract, other corneal scarring,
uncorrected aphakia, and surgical complications. Cost was the
most common barrier to cataract surgery. Cataract surgical
coverage (CSC) in persons with best corrected visual acuity <3/60
was 58.9%. Cataract operations had a good outcome (visual acuity
≥6/18) in 43% of operated eyes.
Conclusion: The prevalence of blindness in Kunming is relatively
high. The leading cause of blindness, SVI, and VI is still cataract.
CSC is quite low and the outcome of cataract surgery is poor in the
survey area.
Prevalence and perceptions
Prevalence of diabetic retinopathy and barriers to uptake of eye care services by diabetic patients at the Social Security Institute Central Hospital in Asunción, Paraguay
|
Miriam Rafaela Cano |
Aims: To estimate the prevalence of diabetic retinopathy (DR)
among patients at the endocrinology department of the Social
Security Institute (IPS) Central Hospital, Paraguay, and to explore
the health-seeking behaviour of diabetic patients.
Methods: We randomly selected 307 patients from all diabetic
patients attending the endocrinology clinic in order to establish the
presence or absence of DR. Systemic and ophthalmic data were
collected using questionnaires. DR was classified according to international
disease severity scales for clinical diabetic retinopathy and
diabetic macular oedema. Blindness and visual impairment were
measured according to the grading system of the World Health
Organization. Two focus groups, one comprising patients with visual
impairment due to DR and another comprising diabetic patients
with normal vision, were identified through purposive sampling.
Patient behaviour with regards to seeking health care was explored
in both groups. Quantitative data were analysed using EpiData and
Stata, and a thematic framework was developed for the qualitative
analysis.
Results: Of the 307 diabetic patients examined, 113 (36.8%) were
male and 194 (63.2%) were female. A total of 304 (99%) patients
had type-2 diabetes and three had type-1 diabetes (0.9 %). Eighty-nine
patients (29%) had some level of visual impairment. Of these,
16 were blind, a prevalence of 5.2% (blindness from all causes).
DR accounted for 33% of visual impairment and 43.8% of blindness.
The overall prevalence of blindness from DR was 2.28%, while
149 patients (48.53%) had some level of DR. Diabetic macular
oedema was present in 88 patients (28.7%). Proliferative DR was present in 26 of all patients (8.5%). The risk of getting DR was on
average 1.9 times higher for every five years a patient had suffered
from diabetes. Associations with other risk factors such as high
blood pressure, body mass index, or HbA1c level were not significant
in this study. The most important issues raised by the qualitative
study included a general lack of awareness about diabetes and its
possible complications, denial of the disease, and fear of going
blind once DR had become established.
Conclusion: Findings from the study in the IPS Central Hospital in
Paraguay suggest that diabetic retinopathy is an important public
health problem. We highly recommend that a systematic screening
programme be implemented to diagnose and treat DR earlier. Some
of the issues encountered in the qualitative part of the study
included lack of awareness about the serious complications of
diabetes and difficulty coping with or accepting the disease. These
results call for an urgent improvement of health education and
promotion, as well as the provision of social services to patients.
Genetic eye diseases and genetic counselling services in Egypt
|
Ahmed Gomaa |
Background: Available data suggest that two-thirds of childhood
blindness in the Middle East is due to genetic diseases (with a
prevalence ranging from 47% in Tunisia to 86% in Kuwait) and that
autosomal recessive disorders, attributed to high rates of consanguineous
marriage (between blood relatives), are common.
Consanguineous marriage is common in Egypt (40%) and genetic
eye diseases are assumed to cause at least half of all cases of
childhood blindness. Genetic counselling services have been
recommended by the World Health Organization as a potential
control measure, but these services have not been evaluated with
respect to eye diseases in children.
Aims: To assess the availability and level of use of genetic
counselling services in Egypt, to evaluate parents’ attitudes towards
and satisfaction with these services, and to assess ethno-cultural
beliefs about the causes of genetic disorders.
Methods: In-depth interviews were carried out in Egypt with
consumers of the service (the parents of affected children) and
service providers (ophthalmologists and geneticists).
Results: There are no guidelines for referral to genetic counselling
services, and referral by ophthalmologists is affected by their
personal experiences and research activities. The parents of
affected children interviewed were satisfied with the service
provided and the geneticists interviewed were qualified and highly
skilled. However, services are insufficient and there are long waiting
lists. The main barriers to service uptake were lack of motivation by
parents, cost, long waiting lists, distance, and lack of awareness
among doctors. Many parents attributed the condition of their child
to the will of Allah, while doctors thought consanguinity to be the
cause. Parents’ perceptions of the term ‘genetic disease’ varied, but
the majority understood it to mean a condition inherited within the
family. The main motivation for seeking advice was to discover the
risk of having another affected child. Parents were compliant with
doctors’ advice, but they often found it difficult to understand the
level of risk. Abortion is prohibited in Islam and mothers were often
blamed, even by other women, for their child’s blindness. The
possible consequences of genetic diseases were reported as
divorce, husband taking another wife, social stigma, having no more
children, and financial difficulties.
Conclusion: Genetic eye diseases are prevalent in Egypt, where
they are due to high rates of consanguineous marriages. Genetic
counselling services have the potential to reduce the prevalence of
genetic disorders, but education and community support are
needed to maximise the efficiency of such programmes.
Visual impairment in leprosy patients in northern Viet Nam
|
Nguyen Huu Le |
Background: The visual impairment suffered by leprosy
patients is an additional health burden often overlooked by health
service providers. The prevalence of visual impairment and
blindness is higher among leprosy patients than in the wider
population, and it occurs as a complication of the disease or as
part of the ageing process. Various studies have found that the
prevalence of visual impairment is about 15% in patients who have
had leprosy for less than 10 years, increasing to 40% in those who
have had leprosy for 15 years or more. Eye care services in leprosaria
are often neglected or under-utilised by patients. It is
necessary to know the prevalence and causes of visual impairment
and blindness, and to investigate existing eye care practices, in
order to improve utilisation of eye care services and to allocate
appropriate resources.
Methods: One of the largest and oldest leprosy villages in northern
Viet Nam was selected for this study. All the residents of this
leprosarium (all of whom have leprosy) were invited to participate
and examined for visual impairment and blindness. Patients who
would have benefited from eye surgery, but who had not taken it up,
were interviewed about their reasons. Responses were recorded on
the questionnaire.
Results: A total of 403 patients were seen at the leprosarium. The
prevalence of blindness was 9.9% and that of visual impairment,
24.1%. Cataract was the most common cause of blindness
(57.5%) and of visual impairment (83.5%). Corneal opacity, from
exposure keratitis (15%) and trachoma (12%), was the second
most common cause of blindness. Cataract surgical coverage was
42.9%, trichiasis surgical coverage was 50%, and lagophthalmos
surgical coverage was only 7.9%. Lack of awareness about
treatment was the main reason given for not seeking treatment.
Conclusion: The prevalence of visual impairment and blindness in
leprosy patients is very high and, at present, patients’ eye care
needs are not being met. There should be an urgent, comprehensive
blindness prevention programme for leprosy patients.
There is a need for better collaboration between leprosy control and
blindness prevention programmes.
Assessing resources
Situation analysis of human resources in eye care in Afghanistan
|
Roya Husainzada |
Background: The lack of adequately trained eye care personnel in
low- and middle-income countries has been identified as a factor in
the persistence of avoidable blindness. This situation is even more
acute in fragile states, such as Afghanistan, where governments lack
the capacity to manage public resources and deliver basic services,
and are unable to protect and support poor and vulnerable groups.
Aims: To undertake a situation analysis of human resources in eye
care in Afghanistan by assessing the number, qualifications, and
distribution (geographical and by type of practice) of ophthalmologists,
ophthalmic paramedical staff, and other ophthalmic personnel; and
to assess the number and distribution (geographical and by
category) of training institutions for eye care personnel.
Methods: The study was carried out between July and August 2006
in all provinces that had eye care centres and institutes. Data were
collected from all private, government (public and army), and non-governmental
organisation (NGO) eye care centres, as well as from
training institutes for eye care personnel. This was done by visiting
most of the centres and using electronic communication.
Results: The total number of eye care personnel in the country was
441. Out of these, 118 (26.8%) were ophthalmologists, 197 (44.7%)
were ophthalmic paramedics (of which 103 were mid-level
ophthalmic personnel), and 126 (28.5%) were other ophthalmic
personnel. The ratio of ophthalmologists to population was
1:200,000 and that of mid-level ophthalmic personnel was
1:229,126. A total of 384 eye care personnel (87%) worked in
urban areas and 57 (13%) worked in rural areas. Amongst them,
29 worked in the private sector (6.5%), 60 in the public sector
(14%), 148 in NGOs (33.5%), 118 (43%) in mixed organisations
(government and NGOs), and 15 in the army (3%). There were no
eye sub-specialists or paediatric ophthalmologists. A total of 74 eye
doctors were medical officers (62%) and there were just four
community ophthalmologists. Of the ophthalmic paramedics,
103 were mid-level ophthalmic personnel (ophthalmic technicians
and nurses, refractionists, and optometrists). There were five eye
care training institutions in the country.
Conclusion: The human resources presently available in
Afghanistan are inadequate, not only in quantity but also in quality.
Eye care personnel are poorly distributed, with serious shortages in
rural and peripheral areas. Most eye care personnel worked in
government centres and NGOs. There were very few eye care
training institutions, most of which were run by NGOs.
A situation analysis to provide information for developing a screening and treatment programme for retinopathy of prematurity in Sri Lanka
|
Umme H Rawoof |
Background: Sri Lanka is a lower-middle-income country with very
good health indicators and services for premature babies. However,
the expansion of intensive neonatal care units (NCUs) is leading to
greater survival of premature babies and more blindness from retinopathy
of prematurity (ROP).
Aim: To collect information on policies regarding neonatal care,
current service provision and facilities for premature babies, and to
assess current programmes for ROP. This information will be useful
for planning a national ROP programme.
Methods: Hospitals with NCUs were visited in three provinces. Data
were collected on infrastructure, personnel, policies regarding ventilation
and oxygen administration, and survival of premature babies
(from hospitals and the Ministry of Health). Data on ROP screening
policies and the number of babies examined and treated were
collected from ophthalmic units where possible.
Results: There are approximately 340,000 births annually, 17% of
which are premature (defined as birth weight [BW] <2,500 g).
There are no data on the proportion of babies with BW <1,500 g.
Survival of babies with BW <1,000 g is 51%; it is over 75% for
babies with BW of 1,000–1,500 g. Continuous monitoring of oxygen
is not possible in all NCUs and alarms are often not adequately set
up. Equipment is not equally distributed among provinces. Screening
for ROP is not well organised and babies are often examined outside
the NCU. The incidence of pre-threshold and threshold ROP ranged
from 34.8% to 46.8%, and that of stage 4/5 was 1.3% in one NCU.
Data collection is inconsistent.
Conclusion: Survival rates are relatively good in babies most at risk
of ROP. Rates of ROP are high, which may be due to inadequate
oxygen monitoring. Current ROP programmes need to be better
organised, with standard screening criteria, examination methods,
indications for treatment, and data collection. Long-term follow-up
and referral systems for rehabilitation also need to be planned.
Assessing human resource needs for prevention of blindness in Association of Southeast Asian Nations (ASEAN) countries: identifying the gaps
|
Pg Hj Md Khairol Asmiee Bin Pg Hj Sabtu |
Aim: To obtain an overview of the current human resource needs in
eye care for the prevention of blindness in the member countries of
the Association of Southeast Asian Nations (ASEAN): Brunei
Darussalam, Cambodia, Indonesia, Lao People’s Democratic Republic,
Malaysia, Myanmar, Philippines, Singapore, Thailand, and Viet Nam.
We identified the different levels of eye care personnel, their numbers
and distribution, and the training capacity for them in the region.
Methods: A mail-based questionnaire survey was used. Participants
were recruited using the ‘snowballing’ technique, whereby one
subject gives the researcher the name of another subject, who in
turn provides the name of a third, and so on (Vogt, 1999), based on
predetermined criteria. The specially designed questionnaire was
pre-tested before distribution to assess its validity. Various channels
were used to distribute it and participants were provided with several options to respond, including a web questionnaire. Ethical approval
was obtained from the London School of Hygiene and Tropical
Medicine ethics committee prior to conducting the survey.
Participants were provided with information sheets about the survey
before their informed consent was sought.
Results: Seven out of ten countries responded. The result of the
study shows that there is, to varying degrees, a shortage and
maldistribution of ophthalmologists in some ASEAN member
countries, particularly in Indonesia and CMLV countries (Cambodia,
Myanmar, Lao People’s Democratic Republic, and Viet Nam), where
the burden of blindness is significantly higher. Furthermore, the
integration of primary eye care into mainstream primary health care
is incomplete. At secondary and tertiary level, the shortage of
ophthalmologists has been supplemented by the use of mid-level
eye personnel. However, their impact in addressing cataract (the
main cause of blindness in the region) is restricted, as their roles are
limited to carrying out basic eye tests, history-taking, and instrument
care. Local training facilities are available for most levels of eye care
workers, but questions about their quality and capacity remain
unanswered. The working conditions of ophthalmologists in the
ASEAN region are reasonable, and ophthalmologists are supported
by professional and regulatory bodies. However, career structures
for mid-level personnel are not available in all member countries.
Conclusion: In order to meet current needs, especially in countries
with a high burden of blindness, there is an urgent need to address
the shortage and maldistribution of ophthalmologists. Career
structure and deployment CHK of mid-level eye personnel need to be
addressed and aligned to meet current eye care needs. The ASEAN
region has the capacity to address its eye care needs and should do
so through capacity building and service delivery programmes.
Situation analysis of human resources for eye care in the North West Province of Cameroon
|
Henry Nkumbe |
Aim: To provide comprehensive information on existing human
resources for the provision of comprehensive eye care services in
the North West Province of Cameroon.
Methods: Quantitative data were collected using a pre-tested
questionnaire administered to all consenting eye care workers in
the North West Province. Data on service outputs were obtained
using a checklist and other available documents. Qualitative data
were collected by means of semi-structured interviews administered
to staff of eye units, primary level eye care workers, and visual
rehabilitation workers.
Results: The North West Province, which has a population of
2.1 million, had 9 eye units, 3 ophthalmologists, 21 ophthalmic
paramedics, 47 community-based rehabilitation workers trained in
primary eye care, and 8 ophthalmic paramedic students. There were
also 19 special education teachers in two schools for the blind. In
addition, the province had 3,131 community-directed distributors
of ivermectin. The duration and type of ophthalmic training of
ophthalmic paramedics, as well as their educational backgrounds,
were very diverse. Close to 90% of the staff in the eye units were
employed by mission hospitals and the distribution of human
resources in the province was grossly unequal. The cataract surgical
rate had increased by 35% between 2002 and 2005, to a total of
414 per year. The coverage of refractive services and the number of
patients consulted per outreach had remained constant during the
same period, at less than 1% and at 30 patients, respectively. The
main barriers to the provision and uptake of eye care services were
lack of human resources, poor collaboration among stakeholders,
cost of services, and patient beliefs.
Conclusion: The number, distribution, mix of skills, and output of
eye care workers in the North West Province are inadequate. At
provincial level, it would be desirable to have a committee for the
prevention of blindness. It would be worthwhile to research consumer
perceptions and barriers to the uptake of eye care services. At
national level, an action plan, advocacy, and funding for in-country
training of different levels of eye care personnel should be considered.
Evaluating interventions/programmes
Evaluation of the SAFE strategy for preventing trachomatous visual impairment in the Enemor and Ener District of Ethiopia
|
Aga Assegid |
Background: Although the SAFE strategy (Surgery, Antibiotics, Face
washing, Environmental change) is increasingly implemented to
control trachoma, its operational effectiveness is not well known.
Aim: To evaluate the implementation of the SAFE strategy in a
trachoma control programme area in the context of VISION 2020.
Methods: A cross-sectional trachoma survey, focus group discussions,
and routine data analysis were undertaken in July 2006 in the
Enamor and Ener District of southern Ethiopia. Using multi-stage
cluster sampling with probability proportionate to size and compact
segment sampling methods, 544 households were selected from a
population of 110,000. Individuals were examined for signs of
trachoma and visual impairment, and the heads of two-thirds of
households were interviewed about risk factors.
Results: Of the 2,510 people enumerated, 2,637 (95%) were
examined. The prevalence of trichiasis (TT) in people older than
14 was 9.04% (95% confidence interval [CI] 7.4–10.6%). Trachoma
was responsible for 13% of visual impairment in people older than
40. Follicular trachoma (TF) in children aged one to nine was 33.1%
(95% CI 29.4–37.1%), while 56.1% (95% CI 52.7–59.5%) had clean
faces. The percentage of households using latrines was 74.4%
(95% CI 69.9–78.87%). The themes that emerged from discussions
included distance and fear as barriers to surgery, appreciation of
antibiotics, “quest for water” and “education with legal enforcement’
in terms of facial and environmental hygiene. A minimum of US $18
per person was invested on SAFE over five years. Although active
trachoma and visual impairment were moderately reduced as compared to baseline estimates and projections (40% for active
trachoma and 25% for visual impairment), the programme was not
adequate to control trichiasis.
Conclusion: The SAFE strategy may be effective when implemented
for a longer duration, to an adequate extent, and with
concurrent development programmes. SAFE should be routinely
evaluated in order to improve its implementation. Further investigation
of its socio-economic impact is recommended.
Evaluation of cataract surgical outcomes in Cicendo Eye Hospital, Bandung, West Java, Indonesia
|
Mayang Rini |
Aims: Cicendo Eye Hospital is a referral hospital in West Java
Province. Every year, the hospital performs about three thousand
cataract operations on average. However, cataract surgical outcome
has not been evaluated. Outcome is an important indicator for
monitoring the progress of the hospital’s cataract surgical services
towards the goals of VISION 2020.
Methods: This was a prospective observational study of all consecutive,
age-related cataract operations booked on the elective list at
the hospital from 1 April 2006 to 31 June 2006. Data were
collected by means of a standardised computer cataract surgery
outcome record form. Pre-operative visual status was recorded and
the post-operative visual outcomes were measured at one day and
one month after surgery. Analysis was done to identify the risk
factors for poor outcome.
Results: A total of 443 patients were operated on. The mean age was
63 years and 52% of all patients were male. Using the WHO definition,
26.6% were blind pre-operatively and 72.69% of all eyes operated
had visual acuity <3/60. Most of the operations were extracapsular
extractions with intraocular implantation. One day after surgery,
42.44% of eyes achieved a visual outcome better than 6/18. At one
month, this was the case for 76.08% of eyes. A poor outcome of less
than 3/60 was seen in 11 cases (2.48%) at one month after surgery.
Intra- and post-operative complications were seen in 10.84% of all
cases, mainly due to vitreous loss (66.67%). Intra-operative complications,
systemic diseases present before the operation, and
associated eye diseases were significant risk factors for poor outcome.
Conclusion: At one month after surgery, visual outcome of the
operated eye almost attained WHO criteria for available correction.
The most significant risk factor for poor outcome was intra-operative
complications, which could be minimised by improving skills and
taking due care during operations.
An evaluation of eye health promotion activities to increase the use of eye care services in the Kilimanjaro VISION 2020 Direct Referral Site programme
|
Joseph Banzi
|
Aims: To assess community awareness about the Kilimanjaro
VISION 2020 Direct Referral Site (DRS) eye care programme in
Tanzania and the effectiveness of promotion strategies to increase
the use of eye care services, and to solicit ideas on how these activities
can be improved.
Methods: Quantitative methods were used to analyse secondary
data (30,019 patient records collected at the point of service
between January 2003 and June 2006) about how patients
received information about the Kilimanjaro VISION 2020 DRS
programme. Additionally, 75 interviews were conducted at markets,
mosques, and churches in the districts of Same, Mwanga, and Hai
to complement the retrospective data. Qualitative methods were
used to collect perceptions about eye diseases and about the
programme from patients, the community, and health facility
personnel. Fifteen semi-structured interviews were conducted with
patients and families of operated and non-operated cataract
patients. Focus group discussions with community leaders and
health facility workers involved a total of 47 participants. Purposive
non-probability sampling was used to select participants. The
sample included a roughly equal balance of men and women.
Results: The quantitative analysis of existing data revealed that
most respondents (39.3%) had received information from churches
or mosques. The second most frequently mentioned source of information
was posters (25.4% of responses), followed by radio,
medical personnel, other sources, and village leaders. The qualitative
analysis showed a high level of awareness about eye
diseases, with cataract emerging as the most commonly recognised
eye problem. Some people were aware that an operation was the
treatment for cataract, but there was limited understanding
amongst the community and health facility workers of what the
operation entailed. However, patients who had undergone the
operation were able to give quite detailed accounts. The conceptions
held by community members provided useful entry points for future
promotional work. One community member suggested that “the
word upasuaji (operation) gives a bad impression, meaning to cut
the eye.” Suggestions from others included explaining the operation
in terms of cleaning of the eye, removing the cataract, or correcting
the eye. Many people in the DRS areas were able to describe in
detail how the programme worked and what services were provided.
However, users wanted more clarity, particularly about the costs of
surgery. Health facility workers were both aware of and involved in
the promotional activities. The community perceived the DRS
programme as providing an affordable service close to home which
included transportation to hospital. People reported that the eye
health promotion activities had helped to dispel fear about surgery.
There were, however, a few comments about how the programme
had become too “business-like,” not allowing enough time for
detailed examination. Opinions about how best to communicate the
DRS programme emphasised multiple-method approaches, and
suggested improvements to the posters, greater use of interpersonal
channels, more time for promotional activities in the build-up
before a DRS visit, and the use of loudspeakers.
Conclusion: Promotional activities have created awareness,
encouraged the use of eye care services, provided opportunities for
facility workers and community members to participate, and
fostered positive attitudes towards the DRS programme. There is
room for improvement: we can increase the reach of promotional
activities, perfect the posters, ensure greater clarity on the issue of
fees for services, and build interpersonal channels to encourage
more two-way communication with users.
Cataract surgical outcome and genderspecific barriers to cataract services in Tilganga Eye Centre and its outreach microsurgical eye clinics in Nepal
|
Reeta Gurung |
Aims: To evaluate the cataract surgical outcome in Tilganga Eye
Centre (TEC) and its outreach microsurgical eye clinic, to determine
the barriers to patient uptake of cataract services in both urban
(TEC) and rural (outreach clinic) settings, and to explore genderspecific
health care-seeking behaviour.
Methods: The records of 562 patients who had undergone cataract
surgery in the hospital from 1 January 2006 to 30 June 2006 and of
178 patients treated by the outreach clinics were analysed. Surgical outcomes were measured using the OUTCOME software package. An
open‑ended questionnaire was used to interview 80 cataract patients
with visual acuity <6/60 (38 in hospital, 42 in outreach clinics), in
order to explore possible gender-specific barriers to cataract surgery.
Results: At discharge from the hospital, 69.9% of patients
presented with visual acuity (VA) >6/18 and 78% presented with
best corrected visual acuity (BCVA) >6/18. At the three-week
follow-up, 79.4% presented with VA >6/18. On providing them with
best correction, VA was >6/18 in 93.2%. A total of 50 (8.9%)
presented with VA <6/60 at discharge. At three-week follow-up,
2.8% presented with VA <6/60, which improved to 2.4% when best
corrected. At discharge from the outreach clinic, 79.2% of patients
presented with VA >6/18 and 85.5% presented with BCVA >6/18.
At the three-week follow-up, 72.8% presented with VA >6/18.
When best corrected, VA was >6/18 in 93.6%. A total of 16 (9%)
presented with VA <6/60 at discharge. At three-week follow-up,
5.8% presented with VA <6/60, which improved to 2.6% when best
corrected. The rate of complications was 7.8% in the hospital and
6.7% in the outreach clinics. The causes of poor outcome were
surgical complications and case selection in the hospital, and
refractive error (p=0.02) and case selection in the outreach clinics.
Urban women chose to seek cataract services later, as they felt able
to cope with their deteriorating vision, whereas rural women gave
the long distance to services as the main reason for postponing
surgery. For urban and rural men, the main barriers were cost and
the lack of someone to accompany them.
Conclusion: Good visual outcome can be achieved in outreach
clinics if strict protocols are followed. Operative complications and
the rate of poor vision are not significantly different in both settings,
despite the differences in environment. To bridge the barriers
presented by distance and a lack of money, it is possible to carry out
operations with good outcomes closer to rural communities.
Cost
Cost analysis of cataract services by eye care providers in Nigeria
|
Shuaib Ayoola Oke |
Aim: To determine and compare cost-effectiveness of cataract
services in different eye care settings in Nigeria.
Methods: The study was conducted in three eye care facilities in
the states of Lagos and Ogun in Nigeria between January and
December 2005. Patient records were retrieved from three eye
hospitals: a private hospital, a government hospital, and an NGO
hospital. Recruitment criteria included all bilaterally blind cataract
patients above the age of 40 with visual acuity (VA) <6/60 on the
Snellen visual acuity chart who had undergone cataract operations
in one eye. Twenty to thirty per cent of the operated patients were
traced to their homes and interviewed to determine their visionrelated
quality of life, using an adapted version of the Indian vision
function questionnaire, the IND-VFQ33. Cost data included provider
and patient costs. Major outcome measures were cost-effectiveness
ratios, restoration of good vision post-operatively, gain in utility and
quality-adjusted life years (QALYs) post-operatively, change in visionrelated
quality of life, and patient satisfaction.
Results: Within the period of the study, 350 cataract operations
were performed in the private hospital, 53 in the government
hospital, and 543 in the NGO hospital. Among the patients who
were bilaterally blind, 60 were in the private hospital (17%), 15 were
in the government hospital (28%), and 147 were in the NGO
hospital (27%). The mean age was 66.59 years (standard deviation
0.50). The unit cost of cataract surgery was highest in the
government hospital (US $2,734), while good sight restoration
(VA ≥6/18) was highest in the private hospital. The NGO hospital was
the most cost-effective, at US $224 per QALY gained. Patient
satisfaction was greatest for the private hospital and lowest for the
government hospital.
Conclusion: Although cataract surgery in the private and NGO eye
care sectors in Nigeria falls within an acceptable range of cost-effectiveness,
there is an urgent need to reduce unit cost. Cost
outlay, output and outcome of cataract surgery need to be reviewed
in the government sector.
Comparing the cost-effectiveness of school eye screening versus a primary eye care model to provide refractive error services for children in India
|
Barry A Lester |
Aim: To compare the cost-effectiveness of school eye screening
(SES) for refractive errors with a primary eye care (PEC) model that
provides comprehensive eye care, including refractive services, to
children of school age.
Methods: Retrospective data from SES and PEC clinics in Delhi
slums for 2005–2006 were examined. Children who had been
dispensed spectacles through both models over 12 months were
surveyed. Visual acuity with and without spectacles was measured
and the children’s spectacle-wearing behaviour was evaluated. The
quality-adjusted life years (QALYs) gained were calculated using
utility analysis for each model and were compared.
Results: The SES model was more cost-effective than the PEC
model in all areas. In the SES model, the cost to examine a child
was US $0.64, the cost to examine and dispense spectacles was
US $12.13, and the undiscounted cost per QALY was US $18.11.
In the PEC model the cost of examining a child was US $3.10, the
cost of examining and dispensing spectacles was US $25.58, and
the undiscounted cost per QALY was US $45.42. The correlation of
spectacles prescribed to spectacles manufactured was excellent in
both models, with a combined correlation of 98%. The sensitivity of
teachers screening for vision impairment was 100%, while their
specificity was 59.8%.
Conclusion: School eye screening in India is a highly cost-effective
method of correcting visual impairment due to refractive errors in
school-age children and should be expanded where possible. As
not all children can be examined through school screening,
comprehensive eye care clinics play an important role in the
correction of refractive errors, but at a higher cost.