ISGEO, Hyderabad, September 2012

1. Evaluation of the “10 Key Activities for Healthy Eyes in children”, Dar es Salaam, TanzaniaDr MilkaMafwiri, Prof Clare Gilbert ISGEO, Hyderabad, September 2012

2. 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)

3. WHO’s 10 KAHEs for PHW Promote general child health and eye health: • Give mothers vitamin A 200,000 I.U. immediately after delivery • Promote breast feeding and good nutrition • Immunize children against measles at 9 months and give vitamin A 100,000 I.U. Encourage second measles immunization • Any child with measles or malnutrition give vitamin A 100,000 IU (under 1 yr); 200,000 IU (1 yr+) • Keep children’s faces clean Specific to eye health: • Any child who cannot see well - refer to an eye care worker as soon as possible • Clean the eyes at birth. Apply antibiotic eye ointment • Any child with a white pupil or other obvious abnormality - refer to an eye care worker as soon as possible • Any child with serious eye injury or red eye - refer to an eye care worker • Do not put traditional eye medicines in the eyes

4. 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

5. 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

6. 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

7. 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

8. 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.

9. 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

10. Poster: Kiswahili text

11. 10 KAHEs training manual

13. Pre-training assessment to provide baseline data • Observation: • health topics in posters • data collected in register • Questionnaire administered to 30 selected RCH staff and 2 coordinators to assess knowledge and practices in relation to eye care: • eye diseases commonly seen in children • how they manage them • topics covered during health education • referral practices • picture recognition

14. Interviewing RCH staff

15. 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

16. 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

17. RCH staff at end of training day

18. Post-training assessment at 3 weeks • Questionnaire re-administered: • knowledge, management of eye conditions • recognition of eye conditions on pictures • Practices: daily activities at RCH: • growth monitoring, vitamin A supplementation, • immunization; Credes prophylaxis; health talks • Observation: • use and display of educational materials • number of attended and referred children from registers

19. 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 • attended RCH clinics to report health talk topics • report advice given by RCH staff after reporting having a child at home with a “white spot in the eye”

20. 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

21. 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

22. Study population Demographic and professional data

23. Results: trained vs controlKnowledge • Newborn conjunctivitis commonest condition • Trained staff were better able to: • describe the symptoms, diagnose and treat conjunctivitis than untrained staff (60.7% vs 30%, p=0.04.) • recognize conjunctivitis from an image than untrained staff (82.1% vs 33.3%) p<0.001 • Untrained staff lacked knowledge about childhood eye care • not know that vitamin A, measles immunization etc can prevent blindness in children • 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”.

24. Results: trained vs controlKnowledge • Trained staff were better able to: • Correctly recognize cataract from an image 60.7% vs 16.6%, p=0.01 • Name more conditions that affect eyes of children mean 3.2+/-1.3 vs 1 +/-1.0, p=0.00 • Name more options for management of eye conditions mean 2.16+/-1.0 vs 1.3 (+/- 1.0, p=0.01.) • Make management decisions and refer children with cataract and ocular trauma

25. 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: • give vitamin A to mothers: 100% vs 86.7%, p =0.03 • perform Crede’s prophylaxis : 57.1% vs 33.3%, p =0.1 • 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

26. 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 • enthusiastic about learning more • appreciated the poster and manual and proposed to distribute it to all RCH clinics • felt empowered to give eye health education to mothers • some loss of knowledge at one year Quote: “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.”

27. 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.”

28. Results: barriers and misconceptions about blinding eye diseases • Barriers towards implementation of 10-KAHE: • inadequate knowledge and supervision • lack of diagnostic equipments and eye drops • Misconceptions in the community: • spicy food during pregnancy causes a red eye (36%) • blindness in a child is due to eating clay (6%), curses (6%), eating eggs (3%) and witchcraft (3%)

29. Discussion • Pilot study has shown: • 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 • RCH staff are enthusiastic to learn • They appreciate and use posters and manual for reference and for health education. • RCH could form an entry point of PEC into PHC

30. 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 • MUHAS • Ifikara Health Institute • London School of Hygiene & Tropical Medicine • Sightsavers

31. Acknowledgements Pilot study was supported by • Task Force SIGHT and LIFE in 2010 and 2011 • Sightsavers Tanzania country office: printing materials Supervisor: • Prof Clare Gilbert and her LSHTM Sponsors for MSc studies at LSHTM: • Commonwealth scholarship committee • British Council For Prevention Of Blindness • LSTHM community: ICEH dedicated & inspiring teaching • Fellow students and my family

32. THANK YOU