Evaluation of the “10 Key Activities for Healthy Eyes in children”, Dar es

Salaam, TanzaniaDr Milka Mafwiri, Prof Clare Gilbert

ISGEO, Hyderabad, September 2012

Introduction

• Many childhood eye diseases are preventable ( corneal scaring), or treatable (eg cataract)

• Early identification and referral of children with eye conditions for tertiary eye care prevents amblyopia and irreversible blindness

• In 2002, WHO/Lions Sight First project identified 10 Key Activities (Messages) for Healthy eyes in Children (KAHE)

WHO’s 10 KAHEs for PHW Promote general child health and eye health:1. Give mothers vitamin A 200,000 I.U. immediately after delivery2. Promote breast feeding and good nutrition3. Immunize children against measles at 9 months and give vitamin A 100,000

I.U. Encourage second measles immunization 4. Any child with measles or malnutrition give vitamin A 100,000 IU (under 1

yr); 200,000 IU (1 yr+)5. Keep children’s faces cleanSpecific to eye health:6. Any child who cannot see well - refer to an eye care worker as soon as

possible7. Clean the eyes at birth. Apply antibiotic eye ointment8. Any child with a white pupil or other obvious abnormality - refer to an eye

care worker as soon as possible9. Any child with serious eye injury or red eye - refer to an eye care worker10.Do not put traditional eye medicines in the eyes

KAHEIt was recommended that KAHE be:• Implemented by primary health workers in countries that

have high a prevalence of blindness: SS Africa and S E Asia• Integrated into existing primary and/ community health

care services e.g. Reproductive Child Health (RCH) clinics, EPI, IMCI, and nutrition and vitamin A supplementation programs.

• However, to our knowledge no action was taken on any of the recommendations

Situation in Tanzania• In Tanzania children with eye

condition like cataract present late for management at tertiary centers, leading to poor visual outcome

• Health workers in RCH clinics are well placed to implement KAHE and thereby prevent blindness in children

Aim and objectives• To evaluate the implementation of WHO 10-KAHEs

for primary level staff by RCH workers in Dar-es Salaam

Specific objectives: To• Review the training curricular of RCH staff• Assess their knowledge and practices in childhood eye

care• Train RCH staff in childhood eye care• Determine the barriers to identification and referral of

children with eye problems faced by RCH staff• Compare the knowledge and practices of trained and

untrained RCH staff at one year

Methods: overviewMay – June 2010: • Development of education materials based on 10 KAHE• 15 RCH clinics selected in Dar: representative of the districts• 2 staff in each clinic selected to be part of the study• 2 supervisors identified• Pre-training assessment• One day training in 10-KAHE; given educational materials• Immediate post-training assessmentJuly 2010:• Evaluation of knowledge, attitudes and practicesJuly 2011:• 15 further RCH clinics identified; 30 staff selected• One year follow up evaluation of knowledge, attitudes and

practices • Compared with 30 staff in “new” RCH clinics• New RCH staff trained and given materials

Development of training materials-poster

• Different images that appropriately illustrated the 10-KAHEs were selected and incorporated into a poster. Images were collected from:– Photographs of patients attending eye and RCH

clinics in Dar-es-Salaam that were taken by a professional photographer

– NGOs image libraries, and – From the authors collection.

• The poster was pre-tested, colour printed on A-2 size and laminated.

Development of training materials-manual

• Same images used on the poster were made into a reference manual for RCH staff.

• Introductory page, anatomy of the eye, descriptions of each KAHE and their importance in preventing eye diseases and visual loss, treatment and referral guidelines, and contact numbers for tertiary eye centers. .

• Manuals were color printed on A5 paper, laminated and spiral bound

Poster: Kiswahili text

10 KAHEs training manual

Pre-training assessment to provide baseline data

• Observation:o health topics in posterso data collected in register

• Questionnaire administered to 30 selected RCH staff and 2 coordinators to assess knowledge and practices in relation to eye care:o eye diseases commonly seen in childreno how they manage themo topics covered during health education o referral practiceso picture recognition

Interviewing RCH staff

Using pictures to assess knowledge

This child has poor vision since birth. What condition does the child have?

What is the proper management of the condition.

Diagnosis= cataract.Management immediate

referral

One day training in 10-KAHEMethods:• Didactic teaching; discussion; visit to children’s eye

department; Topics covered: • Each KAHE. Emphasis• Identification, treatment of common eye diseases

and referral for secondary and tertiary care• Refer children with problems e.g. cataract, poor

vision, squint, serious trauma for tertiary care• Keep records of referred patientsEducational materials:• Poster and manual for each

RCH staff at end of training day

Post-training assessment at 3 weeks• Questionnaire re-administered:o knowledge, management of eye conditionso recognition of eye conditions on pictures

• Practices: daily activities at RCH:o growth monitoring, vitamin A supplementation,o immunization; Credes prophylaxis; health talks

• Observation:o use and display of educational materialso number of attended and referred children from registers

Post-training assessment at 1 year

• Same questionnaire administered to same 30 RCH staff

• Observation of practices• Display and use of 10 KAHE poster and manual• Number of referred patients from registers.• Mystery mothers

o attended RCH clinics to report health talk topicso report advice given by RCH staff after reporting having

a child at home with a “white spot in the eye”

Control group at 1 year

• Another group of 30 PHWs from 15 different RCH clinics in same geographical area were randomly selected

• Underwent the same assessment as those who had been trained earlier

• Afterwards they too were trained in 10-KAHE and given a poster and manual

Data management

• Data were entered on Epi Info software• Comparisons were made in knowledge and

practices between the trained group of 2010: – at 3 weeks and at one year after training– and the control group of 2011

• Chi squire test were performed to compare the differences

Demographic and professional data

Characteristics Trained group n=30 Control group n=30 p

CO Nurses All CO Nurses All

Mean age (sd) 38.3 (8.1) 47.5 (6.7) 42.9 (8.7) 45.4 (8.5) 45.4 (7.6) 45.3 (7.9) 0.4

Mean yrs @ clinic 3.1 (1.4) 4.9 (2.4) 4.0 (2.9) 5 (4.6) 6.3 (5.5) 5.6( 5.10

Female 9 15 24 (80.0) 8 15 23 (76.6)

Male 6 0 6 (20) 7 0 7 (23.3) 0.6

Qualification year

1979-89 2 2 4 (13.3) 3 6 9 (30)

1990-99 4 7 11 (36.6) 2 2 4 (13.3)

2000-09 9 6 15 (50.0) 10 7 17 (56.6) 0.3

Trained in eye care 13 12 23 (76.6) 11 12 23 (76.6)

Not trained 2 3 5 (23.4) 4 3 7 (23.4)

Study population

Results: trained vs controlKnowledge

• Newborn conjunctivitis commonest condition • Trained staff were better able to:

o describe the symptoms, diagnose and treat conjunctivitis than untrained staff (60.7% vs 30%, p=0.04.)

o recognize conjunctivitis from an image than untrained staff (82.1% vs 33.3%) p<0.001

• Untrained staff lacked knowledge about childhood eye careo not know that vitamin A, measles immunization etc can

prevent blindness in childreno Quote: I used to counsel mothers to exclusively breast feed ….,

but I did not know that it prevents eye diseases.…. now I feel more confident talking to mothers about it”.

• Trained staff were better able to:o Correctly recognize cataract from an image

60.7% vs 16.6%, p=0.01o Name more conditions that affect eyes of children

mean 3.2+/-1.3 vs 1 +/-1.0, p=0.00o Name more options for management of eye

conditionsmean 2.16+/-1.0 vs 1.3 (+/- 1.0, p=0.01.)

o Make management decisions and refer children with cataract and ocular trauma

Results: trained vs controlKnowledge

Results: trained vs controlPractices

• All monitored growth, immunized children against measles and other diseases, gave vitamin A supplements to children and delivered health education.

• Trained staff were more likely to:o give vitamin A to mothers: 100% vs 86.7%, p =0.03 o perform Crede’s prophylaxis : 57.1% vs 33.3%, p =0.1 o give eye health education: 100% vs 56.7%, p < 0.0001

• Untrained staff: Ocular prophylaxis of the newborn was not performed- conjunctivitis common

• Eye related health education was not delivered.• No eye related educational materials in RCHs• Better supervision and supplies would assist their work

Results: General• Basic training curricular deficient in child eye care• None of RCH staff had refresher training in eye care.• Clinics lacked educational materials on eye health• RCH staff

o enthusiastic about learning moreo appreciated the poster and manual and proposed to

distribute it to all RCH clinicso felt empowered to give eye health education to mothers o some loss of knowledge at one yearQuote: “These days I frequently see adults with destroyed corneas

and in- turned eyelashes just like in the pictures! ….before the training, I never knew what was wrong with all these people. Oh, I feel like calling a big meeting to give a lecture…. I advice them to go to hospital.”

Quotes“Mothers and other patients crowd around it [poster], reading and asking us questions. They show a lot of concern for their children. They compare the appearances on the pictures and ask questions about themselves and their children.”

“This simple manual is good for reference.....First we look at the poster then consult the manual for further information”

“ ….when we came back from training, our colleagues wanted to know everything ……. All seven photocopied the manual for their reference.”

Results: barriers and misconceptions about blinding eye diseases

• Barriers towards implementation of 10-KAHE:o inadequate knowledge and supervisiono lack of diagnostic equipments and eye drops

• Misconceptions in the community:o spicy food during pregnancy causes a red eye (36%)

o blindness in a child is due to eating clay (6%), curses (6%), eating eggs (3%) and witchcraft (3%)

Discussion• Pilot study has shown:

o 10 KAHE that impact on general health are routinely implemented in RCHs in Dar es Salaam, while those that are related to eye health are not

o RCH staff are enthusiastic to learno They appreciate and use posters and manual for

reference and for health education.• RCH could form an entry point of PEC into PHC

Next stepsNext phase (being undertaken):• Review of policy; health system; service delivery in

relation to RCH in two districts in Morogorro region• Modification of materials so more in line with IMCI;

advocate for adoption by WHO and MoHThen:• Cluster randomized trial• Collaboration between o MUHASo Ifikara Health Instituteo London School of Hygiene & Tropical Medicineo Sightsavers

Acknowledgements

Pilot study was supported byo Task Force SIGHT and LIFE in 2010 and 2011o Sightsavers Tanzania country office: printing materials

Supervisor: o Prof Clare Gilbert and her LSHTM

Sponsors for MSc studies at LSHTM:o Commonwealth scholarship committeeo British Council For Prevention Of Blindness

• LSTHM community: ICEH dedicated & inspiring teaching• Fellow students and my family

THANK YOU