Transcript ALUMIN WEEK

Evaluation of the “10 Key Activities for
Healthy Eyes in children”, Dar es
Salaam, Tanzania
Dr 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 delivery
2. Promote breast feeding and good nutrition
3. 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 clean
Specific to eye health:
6. Any child who cannot see well - refer to an eye care worker as soon as
possible
7. Clean the eyes at birth. Apply antibiotic eye ointment
8. Any child with a white pupil or other obvious abnormality - refer to an eye
care worker as soon as possible
9. Any child with serious eye injury or red eye - refer to an eye care worker
10. Do not put traditional eye medicines in the eyes
KAHE
It 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: overview
May – 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 assessment
July 2010:
• Evaluation of knowledge, attitudes and practices
July 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 materialsposter
• 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 materialsmanual
• 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 posters
o 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 children
o how they manage them
o topics covered during health education
o referral practices
o 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-KAHE
Methods:
• 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 patients
Educational 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 conditions
o 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 materials
o 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 topics
o 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
Study population
Characteristics
Trained group n=30
CO
Nurses
All
Control group n=30
CO
Nurses
All
Mean age (sd)
38.3 (8.1) 47.5 (6.7)
42.9 (8.7)
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)
2
2
4 (13.3)
3
6
9 (30)
4
7
11 (36.6)
2
2
4 (13.3)
9
6
15 (50.0)
10
7
17 (56.6)
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)
45.4 (8.5) 45.4 (7.6)
p
45.3 (7.9)
0.4
0.6
Qualification year
1979-89
1990-99
Demographic and professional data
2000-09
0.3
Results: trained vs control
Knowledge
• 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 care
o not know that vitamin A, measles immunization etc can
prevent blindness in children
o 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”.
Results: trained vs control
Knowledge
• Trained staff were better able to:
o Correctly recognize cataract from an image
60.7% vs 16.6%, p=0.01
o Name more conditions that affect eyes of children
mean 3.2+/-1.3 vs 1 +/-1.0, p=0.00
o Name more options for management of eye
conditions
mean 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 control
Practices
• 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 more
o appreciated the poster and manual and proposed to
distribute it to all RCH clinics
o felt empowered to give eye health education to mothers
o some loss of knowledge at one year
Quote: “These days I frequently see adults with destroyed corneas and inturned 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 supervision
o 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 learn
o They appreciate and use posters and manual for
reference and for health education.
• RCH could form an entry point of PEC into PHC
Next steps
Next 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 MoH
Then:
• Cluster randomized trial
• Collaboration between
o
o
o
o
MUHAS
Ifikara Health Institute
London School of Hygiene & Tropical Medicine
Sightsavers
Acknowledgements
Pilot study was supported by
o Task Force SIGHT and LIFE in 2010 and 2011
o Sightsavers Tanzania country office: printing materials
Supervisor:
o Prof Clare Gilbert and her LSHTM
Sponsors for MSc studies at LSHTM:
o Commonwealth scholarship committee
o British Council For Prevention Of Blindness
• LSTHM community: ICEH dedicated & inspiring teaching
• Fellow students and my family
THANK YOU