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

Kalua et al. Human Resources for Health Skills of general health workers in primary eye care in Kenya, Malawi and Tanzania Khumbo Kalua 0 2 Michael Gichangi 1 Ernest Barassa 1 Edson Eliah 4 Susan Lewallen 3 4 Paul Courtright 3 4 0 Department of Ophthalmology, University of Malawi, College of Medicine , Blantyre , Malawi 1 Ministry of Health , Kenya 2 Blantyre Institute for Community Ophthalmology, Lions Sight First Eye Hospital , Blantyre , Malawi 3 Kilimanjaro Centre for Community Ophthalmology International, Division of Ophthalmology, University of Cape Town , South Africa 4 Kilimanjaro Centre for Community Ophthalmology Tanzania , PO Box 2265, Moshi , Tanzania 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. Contexte: En Afrique subsaharienne, les soins de la vue primaires comprennent habituellement le diagnostic, le traitement et l'aiguillage des problmes oculaires l'chelon le plus bas du systme de sant par des fournisseurs de soins de sant primaires qui reoivent une formation minimale en soins de la vue dans le cadre de leur formation gnrale. Nous avons entrepris cette tude dans le but d'valuer les connaissances en soins de la vue primaires et les comptences en ophtalmologie de ces fournisseurs ainsi que les facteurs y affrents dans des districts donns du Kenya, du Malawi et de la Tanzanie. Mthodes: Un questionnaire type (couvrant 26 lments) a t distribu aux fournisseurs de tous les tablissements de soins de sant primaires de deux districts de chacun des pays. Des donnes dmographiques ont t recueillies, et un examen visant mesurer le niveau de comptence des fournisseurs dans cinq tches cls (reconnaissance et gestion des cas de cataracte avance, de conjonctivite, de presbytie et de traumatisme grave, et mesure de l'acuit visuelle) a t administr. Rsultats: Au total, 343 fournisseurs ont particip l'tude (100 en Tanzanie, 107 au Kenya et 136 au Malawi). Le pourcentage de fournisseurs atteignant le seuil de comptence requis varie d'une tche l'autre : 55,7 % des fournisseurs sont suffisamment comptents pour reconnatre et grer les cas de cataracte avance, 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 - cas de traumatisme grave. Seuls 8,2 % des fournisseurs peuvent mesurer lacuit visuelle. Si lon combine tous les rsultats, neuf personnes seulement, soit 2,6 % des fournisseurs, atteignent le seuil de comptence dans les cinq tches. Conclusion: Les comptences en soins de la vue primaires actuelles des travailleurs de la sant sont insuffisantes, et une large proportion de ces travailleurs natteignent pas le seuil de comptence requis. Il est urgent de rvaluer les attentes en matire 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 could bring eye care closer to rural patients, and might be expected to contribute significantly to the prevention of blindness and visual impairment efforts. 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]. The curricula for PHCW in many African countries include PEC. The exact content varies, even within countries, and (...truncated)