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

Kalua et al. Human Resources for Health 2014, 12(Suppl 1):S2 http://www.human-resources-health.com/content/12/S1/S2 RESEARCH Open Access Skills of general health workers in primary eye care in Kenya, Malawi and Tanzania Khumbo Kalua1,2*, Michael Gichangi3, Ernest Barassa3, Edson Eliah4, Susan Lewallen4,5, Paul Courtright4,5 Abstract Background: Primary eye care (PEC) in sub-Saharan Africa usually means the diagnosis, treatment, and referral of eye conditions at the most basic level of the health system by primary health care workers (PHCWs), who receive minimal training in eye care as part of their curricula. We undertook this study with the aim to evaluate basic PEC knowledge and ophthalmologic skills of PHCWs, as well as the factors associated with these in selected districts in Kenya, Malawi, and Tanzania. Methods: A standardized (26 items) questionnaire was administered to PHCWs in all primary health care (PHC) facilities of 2 districts in each country. Demographic information was collected and an examination aimed to measure competency in 5 key areas (recognition and management of advanced cataract, conjunctivitis, presbyopia, and severe trauma plus demonstrated ability to measure visual acuity) was administered. Results: Three-hundred-forty-three PHCWs were enrolled (100, 107, and 136 in Tanzania, Kenya, and Malawi, respectively). The competency scores of PHCW varied by area, with 55.7%, 61.2%, 31.2%, and 66.1% scoring at the competency level in advanced cataract, conjunctivitis, presbyopia, and trauma, respectively. Only 8.2% could measure visual acuity. Combining all scores, only 9 (2.6%) demonstrated competence in all areas. Conclusion: The current skills of health workers in PEC are low, with a large per cent below the basic competency level. There is an urgent need to reconsider the expectations of PEC and the content of training. Résumé Contexte: En Afrique subsaharienne, les soins de la vue primaires comprennent habituellement le diagnostic, le traitement et l’aiguillage des problèmes oculaires à l’échelon le plus bas du système de santé par des fournisseurs de soins de santé primaires qui reçoivent une formation minimale en soins de la vue dans le cadre de leur formation générale. Nous avons entrepris cette étude dans le but d’évaluer les connaissances en soins de la vue primaires et les compétences en ophtalmologie de ces fournisseurs ainsi que les facteurs y afférents dans des districts donnés du Kenya, du Malawi et de la Tanzanie. Méthodes: Un questionnaire type (couvrant 26 éléments) a été distribué aux fournisseurs de tous les établissements de soins de santé primaires de deux districts de chacun des pays. Des données démographiques ont été recueillies, et un examen visant à mesurer le niveau de compétence des fournisseurs dans cinq tâches clés (reconnaissance et gestion des cas de cataracte avancée, de conjonctivite, de presbytie et de traumatisme grave, et mesure de l’acuité visuelle) a été administré. Résultats: Au total, 343 fournisseurs ont participé à l’étude (100 en Tanzanie, 107 au Kenya et 136 au Malawi). Le pourcentage de fournisseurs atteignant le seuil de compétence requis varie d’une tâche à l’autre : 55,7 % des fournisseurs sont suffisamment compétents pour reconnaître et gérer les cas de cataracte avancée, et ce pourcentage est de 61,2 % pour les cas de conjonctivite, de 31,2 % pour les cas de presbytie et de 66,1 % pour les * Correspondence: 1 Department of Ophthalmology, University of Malawi, College of Medicine, Blantyre, Malawi Full list of author information is available at the end of the article © 2014 Kalua et al; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. The Creative Commons Public Domain Dedication waiver (http:// creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Kalua et al. Human Resources for Health 2014, 12(Suppl 1):S2 http://www.human-resources-health.com/content/12/S1/S2 Page 2 of 6 cas de traumatisme grave. Seuls 8,2 % des fournisseurs peuvent mesurer l’acuité visuelle. Si l’on combine tous les résultats, neuf personnes seulement, soit 2,6 % des fournisseurs, atteignent le seuil de compétence dans les cinq tâches. Conclusion: Les compétences en soins de la vue primaires actuelles des travailleurs de la santé sont insuffisantes, et une large proportion de ces travailleurs n’atteignent pas le seuil de compétence requis. Il est urgent de réévaluer les attentes en matière de soins de la vue primaires et le contenu de la formation. Background There is a growing body of literature documenting problems in the quality of care in primary health care (PHC) systems in eastern Africa. Murray and Frenk state that most deficiencies in quality of care result from gaps in knowledge or the inappropriate applications of available technology rather than a lack of resources [1]. Gilson and others note serious weaknesses in the quality of PHC in Tanzania [2]. A study there of 502 cases at 62 facilities documented the fact that primary health care workers (PHCW) failed to use standard guidelines in treating about half of severely ill children [3]. With respect to the delivery of eye care, problems have also been documented in the management of urgent eye conditions in PHC facilities [4]. Recently, a pilot study in Tanzania tested knowledge of priority eye conditions among PHCW and found it inadequate to deal with those [5]. 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. The concept of PEC was born after Alma Ata when it was noted that some of the tenets of primary health care could have an impact on reducing two important causes of blindness in developing countries: vitamin A deficiencyrelated corneal disease and trachoma. Tetracycline eye ointment was included in the basic medicines recommended at the PHC facility to treat the latter. The scope of PEC started to expand when it was noted that general PHCW, with minimal or no equipment, could probably be taught to recognize a white pupil (advanced cataract) and a red eye (which may indicate a number of different problems, some vision threatening and some self-limited) [7]. With the additional skill of measuring visual acuity (VA, a critical indicator of the health of an eye, comparable to vital signs in general medicine) it was assumed that many important eye conditions could be recognized, treated, or referred appropriately at the PHC level. If this were true, it co (...truncated)