Assessing eye health knowledge and practices amongst primary health care nurses in a rural district, South Africa  

Study setting

Alfred Nzo District Municipality (AND) is the smallest of eight districts in the Eastern Cape province of South Africa. With 867 864 inhabitants (12.2% of the province’s population),¹⁷ AND is one of the most densely populated districts in the province. With a density of 81 people/ km².¹⁷ AND is also the most impoverished, rural, and underdeveloped district in the province, coupled with a high unemployment rate.¹⁸ The district has four local municipalities, with 74 PHC clinics. To contrast, this is a higher density than Umkhanyakude District, in the neighbouring KwaZulu-Natal province, which is also rural with 625 846 inhabitants, and a density of 49 people/km².¹⁹

Study design

A cross-sectional study was conducted in 28 randomly selected Primary Health care clinics (PHCC) within the AND. A sample size was calculated using the single population proportion formula,²⁰ where significance was at the 95% confidence level and 5% degree of precision. A figure of 50% was used for the expected knowledge base. District office registers, reporting on staff numbers and clinic contact details, were obtained from the AND office to ascertain a population size. These were approximately ten years old and confirmed a nursing workforce of 935 nurses in the PHCC within the district. There was no available updated version that accounted for deaths, retirements, and resignations. Factors such as retirement, deceased employees, and transfers away from the district, promotions, unfilled vacant posts, and the like were reasons given by clinic supervisors for actual staffing numbers being approximately 50% of that which had been anticipated according to the registers. To establish a more accurate sample size, the Principal Investigator (PI) telephonically communicated with the heads of each clinic, making appointments in advance to visit them for stakeholder engagement in preparation for data collection. On arrival at the clinics, it was apparent that the actual staffing was approximately 50% of that which had been anticipated according to the registers. As such, the population (N) was adjusted to 50% of 935 where N = 466.

Using the single population proportion formula, the minimum sample size calculation used was:

z (for a confidence level of 95%, standard normal distribution) = 1.96

d (acceptable/tolerated margin of error of 5%) = 0.05

p (if no prevalence/prior study the proportion is set at 50%) = 0.50

N (population size) = 466

The recommended sample size was calculated, and a 5% error margin was further added to the sample size to produce a required minimum sample size (n) of 211.

Stratified random sampling was applied across the district to ensure even representation of the various municipalities. Proportioning of participants was applied to match the distribution of clinics in the various municipalities. Participant numbers were 35% (n = 70) from Mbizana, 15% (n = 30) from Ntabankulu, 35% (n = 70) from Mzimvubu and the remaining 15% (n = 30) from Matatiele (15%).

Data collection, processing and analysis

The Principal Investigator (PI) contacted the heads of each clinic again, making appointments in advance to visit them for data collection purposes. Low staff numbers were found at most sites due absenteeism (due to quarantine or contact tracing guidelines resulting from the COVID-19 pandemic), leave and illness. From the available workforce, the PI addressed the staff in their common room to inform them of study aims and voluntary participation, only the consenting PHC staff were enrolled in the study. Furthermore, some PHC staff members who had been enrolled, ultimately did not participate, citing the high numbers of patients that were still waiting to be seen during business hours. The final number of participants who were enrolled in the study was 200. Willingness of voluntary participation was confirmed by signing of the consent forms by each willing participant.

The contents of the data collection tool were informed by various primary eye health service documents and screening guidelines for ocular health in South Africa, Nigeria, Uganda and a few other African countries.⁵ Data collection tools from previous studies that had assessed primary eye care skills amongst nurses and community health workers within sub-Saharan Africa (SSA) were also used to compile the final questionnaire that was used in this study.²¹ After completion, the comprehensive questionnaire was piloted on 20 PHC nurses in another province, where input for improvement was requested and given. None of the original questions were removed, instead the wording was simplified in some for ease of understanding. After modification, the PI finalised the tool for use in the study. The tool was divided into three sections: Part 1 - demographic data; Parts 2 & 3 - knowledge of different eye health professions and identification of common eye conditions using coloured pictures and brief descriptions of defining symptoms, and Part 4 focused on practices through task observation of the participants by the PI who sat as a patient for all the participants when they performed the task. Participants were provided with a distance and near tumbling E chart and a tape measure for distance measurement. Here the PI scored each participant on their ability to perform a visual acuity measurement and thereafter record the findings. A marking guide was derived and used for this evaluation ( Table 1), and participants were considered to be competent if they obtained a minimum score of seven out of ten (70%).

Due to poor internet connectivity issues, hard copies of the researcher-administered data collection tool were used. Each willing participant was individually invited into the tea room by the PI. The PI sat with one participant at a time, and guided on completion of the questionnaire. Where translation was requested, the PI assisted as he is conversant in the local language. After completion of the questionnaire, the PI asked the participants to measure distance and near visual acuity on him away from other staff members. Data was collected manually from all participants, captured onto Microsoft Excel, cleaned, coded, stored, and transferred to the R software for storage. Data were analysed descriptively for frequencies and chi-squared significance at the 95% confidence index.

Demographic and training information

A 95% response rate (n = 200) was achieved, and participants were from 28 of the 74 PHC facilities across AND. The majority of 172 (86.4%) were female. All participants were from the African race, where 96% spoke the IsiXhosa language, and the remaining 4% spoke IsiZulu. Of further concern, is the fact that the majority (93.5 %) have never been formally trained in eye care. Further demographic details have been detailed in Table 2.

None of the visited PHCC had a Snellen or other visual acuity (VA) chart or a penlight torch. The PI took his own equipment to the sites for assessment purposes. Additionally, none of the surveyed facilities across the district had a staff member responsible for ophthalmic care, and none of the facilities had a designated eye care consulting room. Only 35.5% of the participants affirmed that they understand the management and treatment protocols for eye health.

Knowledge of PHC nurses on different eye professionals ( Table 3).

Practices in the measurement of VA ( Table 4).

Knowledge and practices of different eye conditions and ocular pathologies ( Table 5).

Eye health knowledge

PHC workers are the first point of care for many rural South African communities and the first point of contact for health conditions in developing countries.²¹ There is an expected level of knowledge and skill that is required in order to provide effective management of eye conditions, and ensure that preventable blindness is addressed timeously.³³

Table 3 shows that almost half (46%) of the respondents did not know the basic roles and competencies of the different HReH, which indirectly affects their referral practices, as good knowledge of these would enable them to adequately triage ocular cases to the correct HReH. In knowing what the key roles of ophthalmologists, optometrists, opticians and ophthalmic nurses are, the referral of cases that could not be managed in the PHCC would be accurate with a reduced waiting period for the patient.

Knowledge of common eye conditions were also very weak. Similar results were found in Pakistan and Ethiopia, where poor knowledge of basic ocular conditions was noted amongst various health professionals.¹⁵ Reasons expressed for this poor knowledge was the fact that in their training, general practitioners spend a maximum of four weeks only in the ophthalmology rotation, which is a very short training period for one to gain sufficient knowledge and information on this area of healthcare.^34,35 Similarly, with nurse training in South Africa, there is no clinical component in ophthalmology or optometry, which is probably why the knowledge levels in this study were very poor. Previous studies have also shown that inadequate eye care knowledge, demonstrated by nurses, reduced their confidence in dealing with patients with eye problems.^35,36 Additionally, the clinical knowledge of basic ocular conditions, and leading causes of blindness and visual impairment were poorly identified and managed by the respondents in the AND.

Cataract is the leading cause of preventable blindness in SSA and the world, and an easily identifiable condition; however, approximately one quarter of the respondents identified it correctly. Worse still, the management of this condition was seen as urgent and immediate, which is inaccurate, and the cause of unnecessarily overloading referral transport and overloading an already strained system that could have given the ambulance space to a more deserving patient. This prevalence is significantly lower than that found in a similar study in Nepal where most PHC workers were able to identify a cataract accurately.³⁷ Similarly in other studies within African countries: Tanzania, Malawi, Kenya and Nigeria, PHC nurses were more knowledgeable in identifying and managing patients with cataract, VKC and glaucoma.^38,39 Foreign body sensations were the only condition that although not accurately identified, was managed adequately in this study. This was probably due to the discomfort, pain, and urgency that patients present with. In KwaZulu Natal Province, South Africa, knowledge regarding primary eye care was found to be relatively good amongst participants in PHCs within hospitals.¹⁵

This was probably due to the fact that hospitals employ ophthalmic nurses and optometrists in their primary care and outpatient departments. Unlike optometrists and ophthalmic nurses, most of the PHC nurses in this study were not HReH trained in eye health.

Poor knowledge and management of patients by PHC nurses are concerning factors as they marginalise patients in poor, rural communities, deter universal eye health access, and exacerbate the burden of disease. Clinic PHC nurses should be well-versed in eye care to protect patients, avoid ocular complications and adequately address ocular problems as this is all directly linked to visual impairment.⁴⁰ Health service managers should look to improving this as it has far-reaching effects on community wellbeing and general health.

Training in eye care

Most of the participants in our study reported to have never had any eye health training. The very few who have received proper training had not had a refresher course. As a result, the majority of eye care cases were then referred, even those that could have been managed timeously and locally. There were poor management guidelines in place and no set referral criteria used. In agreement, previous studies reported inappropriate referral pathways in northern Nigeria³⁹ while, to the contrary, evidence reported a clear and precise referral pathway in India.⁴¹

This low number of trained PHC workers in PEC is in line with a study in Nigeria that found that not even one of the respondents had received training on PEC in their facility.⁴² On the contrary, in a similar study done in Kenya it was found that a much higher proportion (two thirds) of the participants in PHCC had received PEC training.³⁸ It stood to reason that the Kenyan study reported that almost all PHC workers provided adequate eye care with confidence, which could be cited as an example of competence overreaching as those that were not trained learned from the others and managed patients satisfactorily.^38,43 In this study, the extremely low number of PHC nurses who had received some form of eye health training could be linked to the basic nursing curriculum – which does not mention eye health – and lack of continued professional development in the nursing profession. The majority of those who had received training in eye care had never completed any refresher eye care training. In our study, only two of the respondents were ophthalmic nurses, and both were working as professional nurses due to a lack of specialised post funding at clinic level. To further exacerbate the problem is the fact that only three nursing colleges offer ophthalmic nurse specialisation training in the entire country. Some non-governmental organisations (NGO’s) like The Fred Hollows Foundation have tried to bridge this gap by offering some kind of eye care training for PHC workers; however, this has not been sustained leading to its eventual failure.

It is clear that nurse training needs to better embrace eye health training so as to effectively manage cases in the PHCC. Poor identification of leading causes of blindness and visual impairment, poor knowledge of HReH and poor management of eye health cases all point to much needed training and refresher training of nurses in eye health. This needs to be addressed with a view to providing eye health training.

Clinical skill observation and practice norms

The study results show that the ability to carry out a visual acuity assessment by the PHC workers in the AND is far below the expected level ( Table 4). A great majority of the participants did not meet the minimum competency levels of this clinical technique and scored less than 7/10 on assessment. Visual acuity is an important measure of visual function and is necessary for decision making with ophthalmic patients. Visual acuity is the most frequently performed measure of visual function in clinical practice and most people worldwide living with VI are living in low and middle-income countries.⁴⁴ Visual acuity measurements then ought to be routinely conducted with all patients visiting the PHC clinic.⁷ Inaccurate execution, as displayed by those in this study, further marginalises scholars and older patients who could have played a significant role in society had the visual impairment been assessed accurately, and visual assistive devices or treatment initiated for improved vision. Similarly in studies in Nepal and Eastern Africa, only 14% and 12.3% of the PHC workforce respectively could measure visual acuity.^7,37 Furthermore, the poor outcome in our study is also not surprising considering that none of the visited PHC clinics had a Snellen chart to measure patients’ visual acuity.

Limitations

The study location was in a deep rural area with an extremely poor roads network, making it difficult to reach the clinics on the extreme periphery of the region. Inclusion of these facilities may have added substantial information to the study. A general shortage in staffing was, however, noted in the clinics where staffing ranged from one PHC worker on duty, where the study could not be prioritised over patients that were waiting to be served. In PHCCs such as this, we were forced to help where we could and turn back as participation in the study was not possible. It would be beneficial for the study to be conducted in more districts to get a better understanding of the knowledge and practices of PHC nurses on a larger scale.

Implications of study

Data collected and analysed in the study sets a clear basis on the need for training and development of eye health knowledge in PHCC such as this one, more especially the ones in rural settings where local services are a dire need, due to financial limitations. It is imperative that training insitutions prioritise developing materials to meet this need and empower HReH in PHCC.

Recommendation

We recommend basic eye health training to be included in the nursing curriculum to equip PHC workers with the necessary skills to improve their role in VI. Refresher courses are recommended for staff in PHCC to ensure adequate skill levels in their clinics. Training materials should be provided in the local language to enhance the homogenous culture in this province. Secondly, there needs to be an establishment of guidelines and funnelling protocols for eye health cases. HReH posts must be created, funded, and filled for sufficient staffing and effective eye care.

Ethics approval

Written ethical clearance was obtained from UKZN BREC/00000663/2019 and gatekeeper permission was obtained from the DoH, Alfred Nzo District, and the DoH, Eastern Cape Province.