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F1000Research

2046-1402

F1000 Research Limited

London, UK

10.12688/f1000research.159132.1

Research Article

Articles

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

[version 1; peer review: 3 approved with reservations]

Flatela

Lwandile

Data Curation Formal Analysis Investigation Methodology Project Administration Resources Software Validation Visualization Writing – Original Draft Preparation 1 Xulu-Kasaba

Zamadonda N

Conceptualization Data Curation Formal Analysis Methodology Resources Software Supervision Validation Visualization Writing – Original Draft Preparation Writing – Review & Editing https://orcid.org/0000-0003-2729-8639 a 1 1Optometry, University of KwaZulu-Natal College of Health Sciences, Durban, KwaZulu-Natal, 4001, South Africa

a XulukasabaZ@ukzn.ac.za

No competing interests were disclosed.

18 12 2024

2024

1530

25 11 2024

2024

This is an open access article distributed under the terms of the Creative Commons Attribution Licence, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Background

The burden of visual impairment and avoidable blindness has been attributed to the shortage and poor distribution of adequately trained eye care personnel. In the district health system, primary health care (PHC) nurses are the first point of contact for eye care patients. To provide adequate eye care, the nurses in PHC clinics apply their knowledge on basic eye health to ensure best practices and management for patients that present at their clinics. Anecdotal evidence regarding the knowledge and practices of these PHC professionals is scarce. The purpose of this study was to evaluate PHC nurses’ knowledge and practices on eye health.

Methods

A quantitative, cross-sectional study was conducted in a rural district of the Eastern Cape Province in South Africa. Stratified random sampling was used to select 28 from the 74 PHC clinics in the district. A researcher-administered questionnaire using a 5-point likert scale with options strongly disagree, disagree, neutral, agree and strongly agree, was developed, piloted and finalised for this study. The tool had four sections: demographic information, knowledge of eye health, practices on evaluating visual function and identification and management of presenting eye conditions. Data were collected, captured onto MSXcel, cleaned, coded and analysed descriptively, and for Chi-squared significance at 95%, using R statistical software.

Results

From 200 responses, 86.4% (n=172) were females of the African race. Most (93.5%, n=187) had never undergone formal training in eye care. Only 28% (n=56) correctly identified a mature cataract while 28% (n=56) correctly identified signs of glaucoma; the global leading causes of preventable blindness. A total of 94% (n=188) failed to accurately measure visual acuity on a patient.

Conclusions

PHC nurses showed poor knowledge and practices of common eye conditions. There is an urgent need for eye health training for PHC nurses, and the clear management protocols on eye care.

Visual impairment Primary health care Primary eye care Nurses Eye health Primary health care clinics knowledge and practices rural eye health

The author(s) declared that no grants were involved in supporting this work.

Introduction

Visual Impairment (VI) remains a major public health concern that continues to rise. ¹ Globally, an estimated 596 million people have reduced vision at distance, while more than 500 million suffer from uncorrected near vision. ² According to the World Health Organisation (WHO), 80% of all VI is preventable, while 90% is found in low-to-middle income countries (LMIC). ³ It is further estimated that 76% of moderate and severe VI cases in southern Sub-Saharan Africa (SSA) are caused by cataract, glaucoma and uncorrected refractive error (URE). ^{3,
4} Of further concern are the dire socio-economic consequences of VI suffered by the affected individuals. ⁵

Primary eye care (PEC) is one of the pillars of primary health care (PHC) recommended by the WHO. ⁶ PEC involves eye health promotion, treatment of simple eye diseases, and identification and prompt treatment of persons needing eye care ⁶; all areas that are pivotal in preventing blindness and VI. Poor and rural populations bear the burden of VI and its consequences as resources are skewed against these communities. ⁴ Amongst other challenges, poor access to clinics with eye health services, weak infrastructure, and a shortage of human resources amplify the burden of VI in LMIC. ^{7–
10} Blanchet et al emphasise that poor integration of eye health services into the health systems and scarcity of eye health policies in LMICs have a negative contribution towards achieving improvement in visual health. ¹¹ This would further impede the attainment of the third Sustainable Development Goal centred on good health and vision. ¹²

In South Africa’s district health system (DHS), the majority of patients needing PEC initially present themselves at PHC centres. ¹³ The level of care provided has been described as inadequate in relation to community needs, and inferior to the standard prescribed by the National Department of Health (NDoH). ^{14,
15} As PHC workers are the first point of contact with patients, they are tasked with providing PEC to the communities in which they are based. To adequately deliver PEC services, PHC providers are tasked with the responsibility of identifying, managing and referring patients accordingly and timeously. ⁷ There is a dearth of evidence evaluating their knowledge and practices in basic eye care services in the rural areas of SSA countries such as South Africa. ¹⁶ This study aimed to assess PHC nurses’ knowledge and practices in PEC in order to evaluate how eye patients are being managed in PHC clinics within the district and other similar rural contexts.

Methods 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/ km ². 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/km ². 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: n = Z 2 p ( 1 − p ) d 2 1 + Z 2 p ( 1 − p ) Nd 2

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%).

Table 1. Scoring guide for VA assessment.

Task	Points awarded for correct practice	Points awarded for incorrect answer
Distance from VA chart	2	0
Accurate instructions to patient	1	0
Ensuring sufficient lighting	1	0
Monocular execution of assessment	2	0
Seating patient and chart at the same height	1	0
Correct near VA target distance	1	0
Accurate recording of distance and near VA	2	0

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.

Results 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.

Table 2. Demographic information and professional training characteristics.

Characteristic	Frequency (n)	Percentage (%)
Age (in years)
1. <30	27	13.5
2. 30-39	48	24
3. 40-49	68	34
4. 50-59	24	12
5. >60	33	16.5
Job Title/Category
1. Professional nurse	154	77
2. Enrolled nurse	15	7.5
3. Enrolled nursing assistant	29	14.5
4. Ophthalmic nurse	2	1.0
Highest qualification
1. Basic 1 or 2 years nursing training	43	21.5
2. Nursing Diploma/Nursing Degree/Post basic qualification	157	78.5
Duration of Service (in years)
1. 0 – 5	79	40
2. 6 – 15	78	39
3. 16 – 25	26	13
4. >25	17	8
Trained in Eye care
1. No	187	93.5
2. Yes	13	6.5
Institutions where staff were trained in eye health
1. Public Tertiary institution	4	2
2. NGO	4	2
3. DoH	5	2.5
4. I was never trained on eye health	187	93.5
Completed refresher eye care training
1. No	195	97.5
2. Yes	5	2.5
Refresher eye care training frequency
1. Every two years	1	0.5
2. Annually	2	1
3. Other	2	1
4. Never	195	97.5

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).

Table 3. Basic knowledge on roles of different Human resources for eye health (HReH).

Knowledge analysis
	Disagree	Agree
I know the different types of eye health professionals (p = 0.322)	46%	54%
Optometrists are mainly trained in cutting lenses ( p < 0.001)	35%	65%
Ophthalmic Nurses train for a further 2 years (after basic nursing training) to qualify and practice in that role ( p = 0.024)	42%	58%
Ophthalmic Nurses are best suited to work in PHC settings ( p < 0.001)	28%	72%
Optometrists are best suited to only work in tertiary settings ( p < 0.001)	32%	68%
Ophthalmologists are best trained in refraction and low vision services ( p = 0.024)	42%	58%

Practices in the measurement of VA ( Table 4).

Table 4. Showing participants’ scores on VA measurement.

Practice analysis
Total score achieved	% of scores	Nr of participants who achieved scores	Final outcome summarised
10	0.0%	0	6% passed
9	1.0%	2
8	1.5%	3
7	3.5%	7
6	11.5%	23	94% failed
5	22.5%	45
4	30.5%	61
3	15.5%	31
2	14.0%	28
1	0.0%	0
0	0.0%	0

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

Table 5. Showing levels of identification of conditions (from coloured pictures) and management thereof. Knowledge practices and case management with common visual conditions.

Knowledge and practical analysis
Agreement responses by participants are recorded below	KNOWLEDGE (CORRECTLY IDENTIFIED)		PRACTICE (CORRECT MANAGEMENT)
	%	P-VALUE	%	P-VALUE
CATARACT
K: Accurate identification of mature cataract from coloured picture.	28	<0.001
P: A patient with (a mature cataract) must be transferred to hospital urgently.			26	<0.001
UVEITIS
K: Accurate identification of uveitis from coloured picture and symptom description.	16	<0.001
P: A patient with (uveitis) needs an urgent referral.			32	<0.001
VERNAL KERATOCONJUNCTIVITIS (VKC)
K: Accurate identification of VKC picture and case history.	20	<0.001
P: A patient with VKC cannot be managed in the clinic and should be referred urgently to a hospital.			24	<0.001
PRIMARY OPEN ANGLE GLAUCOMA
K: Accurate identification of glaucoma from description of throbbing eye pain, family history and visual field loss.	28	<0.001
P: This patient (with glaucoma) does not need any referral; they need to be monitored yearly.			40	0.016
PRESBYOPIA
K: Accurate identification from symptoms and case history.	60	0.007
P: Accurate management based on case history and symptoms.			42	<0.001
CORNEAL FOREIGN BODY
K: Accurate identification based on coloured picture and case history.	25	0.007
P: Good management and urgent referral based on case history and symptoms.			25	<0.001

Key: K - Knowledge, P – Practices.

Discussion

This study sought to evaluate PEC knowledge amongst the PHC nurses in AND, and further assess the current practices and protocols that are used in managing eye care cases. As most patients initially present at PHCC for their health concerns, including eye health, it is critical to assess the knowledge and practices of nurses that manage the larger population at those health facilities.

In our study the most common cadre of staff that participated were professional nurses of the female gender aged 41 to 50 years of age. This finding is similar to studies in Nigeria and other parts of South Africa, where most participants were females in the same age grouping. ^{7,
22} The female bias is to be expected as the nursing profession was a predominantly female career option, and viewed as an extension of the domestic role played by women in homes and other sectors of society. ^{23,
24} Additionally, its common traits of caregiving and nurturing also align nursing more with female social gender roles than male gender roles. Similarly, the age range of most participants is within the most common labour force in South Africa, as evidenced by Statistics South Africa in their reports. ²⁵ An overwhelming majority of the participants had a service record of 15 years, meaning that they had a fairly good idea of the PHC environment, with another two decades of service prior to their retirement. As such, they were within their earlier years of service and were still amenable to learning and skill development for the betterment of their careers.

It is satisfactory to learn that the majority of the participants were trained and qualified as professional nurses. The AND fares well in this regard as the South African Nursing Council (SANC) distribution report shows that the Eastern Cape province has an average of 61 % of the nursing staff trained as professional nurses, ²⁶ one of the higher prevalence’s in the country. This could be attributed to the many nurse training facilities that exist in the Eastern Cape Province and is a positive case for general public health in the communities they serve. The fact that all the participants spoke isiXhosa, the local language in the province was an indicator of a homogenous culture of the participants. In light of this, it will benefit learning if refresher courses use training material in this language. ²⁷ Previous evidence has affirmed that medical learning is positively enhanced when a mother tongue or native language is used. ²⁶

Of significant concern, however, is the markéd shortage of Human Resources for Eye Health (HReH) in the PHCC, which was confirmed by the far ‘lower-than-expected’ numbers of study participants on arrival at the clinics. Staffing numbers at PHCCs were less than half of the numbers confirmed by the regulating office, and some clinics had a single nursing professional on duty for the day, tasked with seeing to the general and eye care of the entire community. Health professional shortages are a serious concern in Africa, worsened by the “brain drain”, or exodus of experienced HReH from poorer countries to economically affluent first world countries. ²⁸ This further exacerbates prevailing health system challenges and worsens the burden of disease in poorly resourced and underdeveloped African countries. Professional nurses are amongst the highest numbers of trained health professionals that are known to have left South Africa in search of improved working conditions, better staffing and financial rewards offered by first world economies. ²⁹ In communities such as the AND, this shortage is a reality that further marginalises the population, and impedes the delivery of basic eye care in their clinics.

The fact that nearly none of the employees at the PHCCs had undergone eye health training further intensifies the severe staffing deficit. The number of participants was lessened by the fact that the original sample size was incorrect, owing to poor record keeping. In many health sectors, it has been argued that good record keeping is associated with appropriate standards of nursing, improved patient care, and swift reaction in the instance of emerging legal issues. ^{30–
32} It is imperative that this be improved for clear, transparent data and reporting in the future. In this study, this was seen as a significant part of the dire issues that add to the barriers to the delivery of adequate eye care to communities in the AND. Policymakers who use the staffing numbers that the district office has are under the impression that the district’s PHCC are well staffed, which is contrary to the reality of the situation on the ground. Consequently, this insufficient staffing worsens the burden of diseases, increases VI and the prevalence of avoidable blindness, and negates the achievement of universal health coverage through reduced service delivery, realised due to staffing shortages. The district needs to improve its staffing of eye clinics and its record keeping to ensure accessibility of sufficient eye care. Better access to eye care will further ensure improved learning opportunities for children through the school health system, improved employability opportunities for young adults, and subsequently reduced levels of poverty in this region.

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 Nigeria ³⁹ 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.

Conclusion

Most of the nurses in this district are females within a suitable working age, who speak the local language spoken by patients in that district. This study showed that the PHC nurses in the Alfred Nzo region had inadequate eye health knowledge on HReH and basic eye conditions that are leading causes of visual impairment and blindness globally. This has a grave impact on the treatment, referral and management of treatable and preventable visual impairment conditions in the region. PHC nurses in this area did not know how to measure visual acuity. Most nurses were never trained in eye health. None of the clinics visited had a Snellen chart for visual acuity measurement. There were no basic guidelines and referral protocols that could be referred to for eye conditions. Eye health is clearly not prioritised in this district. Health managers need to prioritise eye health, specifically PEC, and seek to train nurses in order to provide adequate universal eye health within the communities they work.

Declarations 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.

Consent to participate

Informed written consent was obtained from all participants included in the study.

Author contributions

Detailed contributions from the authors have been tabled in Table 6 below.

Table 6. Authors’ contributions.

Area of contribution	Contributor
Conceptualisation	ZXK
Data curation	LBF & ZXK
Formal analysis	LBF & ZXK
Funding acquisition	No funding was received.
Investigation	LBF
Methodology	LBF & ZXK
Project administration	LBF
Resources	LBF & ZXK
Software	LBF & ZXK
Supervision	ZXK
Validation	LBF & ZXK
Visualization	LBF & ZXK
Writing – original draft preparation	LBF & ZXK
Writing – review & editing	ZXK
LBF – Lwandile B Flatela
ZXK – Zamadonda Xulu-Kasaba

Ethical considerations

Following ethical clearance by the Biomedical Research Ethics Committee (BREC/00000663/2019) at the University of KwaZulu-Natal in May 2020, and gatekeeper permission by the Eastern Cape Department of Health (DoH), data collection was delayed by the national lockdown imposed by the COVID-19 pandemic. When restrictions were lifted, re-certification was obtained, and data collected from February to June 2021.

Data availability statement Underlying data

Data in the form of questionnaire response spreadsheets and ethical permissions is available on Zenodo underproject name “Assessing eye health knowledge and practices amongst primary health care nurses in a rural district, South Africa” at https://doi.org/10.5281/zenodo.14150666.

Extended data

All extended data is available under the terms of the Creative Commons Zero “No rights reserved” data waiver (CC0 1.0 Public domain dedication). Access to this dataset requires registration with an IEEE account, which is free.

Acknowledgments

The authors would like to thank all the participants who voluntarily agreed to participate and give valuable information to make this study successful.

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10.5256/f1000research.174818.r397069

Reviewer response for version 1

Tousignant

Benoit

1 Referee https://orcid.org/0000-0002-0395-5027 1University of Montreal, Montreal, Canada

Competing interests: No competing interests were disclosed.

22 8 2025

2025

This is an open access peer review report distributed under the terms of the Creative Commons Attribution Licence, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

recommendation

approve-with-reservations

The authors present an interesting study on the knowledge and practice levels of primary care nurses with regard to eye care in rural South Africa. Some revisions are required to strengthen the manuscript.

- "African race" is used throughout abstract and manuscript. consider reviewing and referring to specific South African ethnicities of the participants, rather than a too general term

- references should include WHO World report on vision (2019), in addition to refs 1-5

- instead of ref 6, use WHO Eye care competency framework. Adapt and rephrase manuscript accordingly, using wording form that document.

- In Study design, when first mentioning the PI, include that person's initials in parentheses

- Data collection: 2nd line, missing word: "...at most sites due TO absenteeism"

- a copy of the questionnaire is required

- methods should specify how analysis was made with Likert: how were neutral responses handled?

- Results section generally: the text should briefly report highlights of results and then refer to Tables 3-4-5 for the complete results.

- Tables 3 and 5: add note to say which stat test the p-values refer to (chi-square?)

- methods (relating to results presented in Table 5: include example of cataract (or other condition) pictures used to test knowledge and practice? how were these pictures or knowledge items selected, and by whom?

- manuscript would benefit from a deeper analysis, including additional analyses such as looking at associations between % of correct knowledge and age, sex, type of institution, job title, duration of service. Use non-parametric tests as need if cell counts are below 5. Repeat these analyses for % of correct practice. Report carefully, given the small numbers of certain cells/subgroups.

Is the work clearly and accurately presented and does it cite the current literature?

Partly

If applicable, is the statistical analysis and its interpretation appropriate?

Partly

Are all the source data underlying the results available to ensure full reproducibility?

Is the study design appropriate and is the work technically sound?

Partly

Are the conclusions drawn adequately supported by the results?

Partly

Are sufficient details of methods and analysis provided to allow replication by others?

Partly

Reviewer Expertise:

Eye care, public health, Global health

I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard, however I have significant reservations, as outlined above.

Xulu-Kasaba

Zamadonda

Optometry, University of KwaZulu-Natal - Westville Campus, Durban, KwaZulu-Natal, South Africa

Competing interests: No competing interests were disclosed.

17 1 2026

No.

Query

Response to Query

- In Study design, when first mentioning the PI, include that person's initials in parentheses

Initials of the PI have been included with the first mention.

- "African race" is used throughout abstract and manuscript. consider reviewing and referring to specific South African ethnicities of the participants, rather than a too general term

- references should include WHO World report on vision (2019), in addition to refs 1-5

- instead of ref 6, use WHO Eye care competency framework. Adapt and rephrase manuscript accordingly, using wording form that document.

African is the least offensive term that is agreeable with ethnic people in Africa generally. This is why it was preferred in relation to “Blacks”. Other terms would have been tribalistic, which is a contentious issue now in South Africa. As such, “African” was the best option.

Ref 2 (2021) contains updated data from the World report on vision (2019). We opted to use the latest available values.

- Data collection: 2nd line, missing word: "...at most sites due TO absenteeism"

Thank you, corrected.

- a copy of the questionnaire is required

At the end of the manuscript, under “Data availability statement” there is a link that leads to a repository with the questionnaire and other data for the study. The journal asks that it be placed in this online repository.

- methods should specify how analysis was made with Likert: how were neutral responses handled?

Thank you, this has been addressed with the addition of a paragraph detailing it at the end of the methods section.

- Results section generally: the text should briefly report highlights of results and then refer to Tables 3-4-5 for the complete results.

Noted, thank you.

- Tables 3 and 5: add note to say which stat test the p-values refer to (chi-square?)

Noted and addressed.

As detailed under “Data collection, processing and analysis”, the tool was developed using various primary health guidelines and screening documents. Coloured pictures were selected from those documents by the researchers in the study. These are all in the suppository and available for anyone to see. Next to each picture was a statement on naming the condition e.g. this is a mature cataract accompanied by the 5 category Likert Scale, then there would be a second question e.g. It requires an immediate transfer to a hospital, with the respondent indicating again from Strongly agree to disagree.

Tables 3, 4 and 5 have given most of the suggested information. Associations relating to gender, type of institution and job title became redundant when we tried them due to the fact that almost 100% of the participants shared the same characteristics e.g. all were females, working at the same type of institution with the same job title. Otherwise, thank you for the input, it is worth remembering for future data analysis and discussion.

10.5256/f1000research.174818.r402133

Reviewer response for version 1

Chaturvedi

Sakshi

1 Referee https://orcid.org/0000-0002-4979-3430 1Banasthali Vidyapith, Rajasthan, India

Competing interests: No competing interests were disclosed.

18 8 2025

2025

recommendation

approve-with-reservations

The study falls short in addressing nurses' knowledge of eye health, a critical area that directly influences the quality and timeliness of patient care. Without establishing this foundational context, the introduction misses an opportunity to highlight the broader implications of inadequate ocular awareness among nursing professionals. Furthermore, the tools used to assess knowledge and practices appear to lack sufficient validation, raising concerns about the reliability and interpretability of the results. The sampling technique is also vaguely described, with limited information on how participants were selected or whether the sample is representative factors that are essential for ensuring methodological rigor and generalizability.

Is the work clearly and accurately presented and does it cite the current literature?

Partly

If applicable, is the statistical analysis and its interpretation appropriate?

Partly

Are all the source data underlying the results available to ensure full reproducibility?

Yes

Is the study design appropriate and is the work technically sound?

Yes

Are the conclusions drawn adequately supported by the results?

Yes

Are sufficient details of methods and analysis provided to allow replication by others?

Yes

Reviewer Expertise:

Nursing research , Public health , Nursing education

References 1

: Need to Educate Student Nurses for Eye Care: A Descriptive Analysis of Student Nurses’ eye health literacy. International Journal of Nursing Education .2023;15(4) : 10.37506/ijone.v15i4.20043 52-58

10.37506/ijone.v15i4.20043

Xulu-Kasaba

Zamadonda

Optometry, University of KwaZulu-Natal - Westville Campus, Durban, KwaZulu-Natal, South Africa

Competing interests: No competing interests were disclosed.

17 1 2026

This is what the study sought to assess, the knowledge of nurses on eye health and their practices. As such, it was not possible to discuss what the study was trying to assess in the introduction. This is why the knowledge is discussed under the Discussion section, after results had been obtained.

Furthermore, the tools used to assess knowledge and practices appear to lack sufficient validation, raising concerns about the reliability and interpretability of the results.

Albeit not statistically validated, all tools were piloted in another province as stated in the Methodology section under “Data collection, processing and analysis”. Through this process, amendments were made, the tool refined and finalised for the study.

10.5256/f1000research.174818.r361697

Reviewer response for version 1

Bowen

Michael

1 Referee https://orcid.org/0000-0002-4818-9450 1The College of Optometrists, London, England, UK

Competing interests: No competing interests were disclosed.

4 2 2025

2025

recommendation

approve-with-reservations

Study Setting section: It would be useful to include details of the number of Primary Health Care clinics in KwaZulu-Natal, which is used as the comparison province to the study province.

The use of "AND" as the acronym for Alfred Nzo District Municipality is potentially odd for readers less familiar with this acronym. For may English speakers AND looks like a capitalized "and". It might be helpful to change to using "ANDM" as the acronym.

Study Design section: in this section there is a statement that "a figure of 50% was used for the knowledge base" - this is somewhat unclear. Does this mean that respondents were assumed (for the purposes of the power calculations) to be likely to answer 50% of the questions correctly? This would benefit from some clarification.

Results section: Table 3 is titled "Basic knowledge on roles of different Human resources for eye health (HReH)" however, it is not clear that the data being reported relate to an objective assessment of knowledge. Several of the questions for which response data are reported here are reporting participants view of their own knowledge. It would be preferable to re-title and ensure that there is some text added to clarify the nature of these data. They are still of interest - but need to be accurately described.

The methods section mentions a 5 point Likert scale - it is not clear from any of the tables which data were derived from these questions. Ideally a copy of the questionnaire used should be included as an annex or within supplementary materials. It is slightly difficult to review the paper without seeing the questionnaire.

Table 5 - this table reports data relating to participants ability to correctly identify eye health conditions from photographs. It was not clear from the methods section whether these photographs had been tested by a group of eye health professionals (such as optometrists / ophthalmologists) to provide a base-line for the rate at which qualified eye health professionals were able to correctly identify the conditions from the images. This is important as it provides some validation that the images are 'good enough' representations of the conditions in question. It would be helpful to share some of the images used in the paper or as supplementary material.

Table 5 - It is not clear from the table or the text in the results section whether the data relating to the %ages of participants who made the correct management responses relate to the whole group or just to those who were able to correctly identify the condition. This is important to the interpretation of these data, so would be helpful to make this clear. For example, for Uveitis, if 16% of the participants correctly identified it as Uveitis, but only 32% of those who correctly identified it knew that it needed an urgent referral, that provides different insights than if if 16% correctly identified the Uveitis, but 32% of all the participants knew it needed an urgent referral. In the latter case, even though they didn't know what the condition was an additional 16% of participants knew that it needed urgent referral.

Table 5 - Primary Open Angle Glaucoma - it is unclear from the table, or from the information available elsewhere in the paper, what information was actually given to participants to test their ability to identify POAG and how the information given would lead to the correct management being no referral - monitor yearly. The information summarised in the table suggests that 'throbbing eye pain' was one of the symptoms offered to participants, which does not necessarily suggest stable POAG or OHT. It is also unclear how any of the PHC's in the study would be able to safely monitor OHT or stable POAG, given their lack of equipment. This question and the associated data need to be reviewed by the authors and their inclusion in the final paper considered carefully.

Discussion section:

Page 7, paragraph 3: "...one of the higher prevalence's" (a) if prevalences is to be used, the apostrophe needs to be removed; (b) I am not sure that it is helpful to use "prevalences" in reference to the number of qualified nurses in the work force in a region. I would suggest editing this to read: "....one of the higher proportions of qualified to unqualified nurses in the country."

Same paragraph: With reference to the participants mainly speaking isiXhosa, it would be useful to readers to include some information about the population in that region - was the percentage of isiXhosa speakers among the participant sample representative of the rates of isiXhosa speakers in the population of ANDM?

Page 8, paragraph 2: the second sentence in this paragraph is confusing: "The number of participants was lessened by the fact that the original sample size was incorrect, owing to poor record keeping". This is not really correct. The original population size was incorrect due to the records of nursing staff being inaccurate. While this error could have led to an incorrect sample size being calculated, the investigators took appropriate measures to establish a more reliable / accurate estimate of the population size, and thus were able to derive a more reliable sample size. However, since it appears that the authors intention in this section is to address the concerning lack of accurate records for nursing staff numbers, I would suggest simply rewording this along the lines of: "The challenges encountered by the research team in this project in seeking to establish a reliable estimate of the total number of nursing staff employed within PHCs across ANDM are noteworthy. The initial population number provided was nearly double the final population established by the researchers."

In the same paragraph the sentence: "Consequently, this insufficient staffing worsens the burden of diseases, increases VI and the prevalence of avoidable blindness..." while likely to be true, for a research paper it is slightly hyperbolic. It would be preferable to reword along the lines of: "The very low levels of PHC staff seems likely to contribute to increased levels of VI and preventable sight loss / blindness, and potentially a worse burden of disease across the province, as it is hard to see how such low levels of PHC staffing would fail to lead to reduced service delivery / access to care. These low staffing levels are likely to make it much harder to achieve universal health coverage in a meaningful way."

Page 8 - Eye health knowledge section: First paragraph, final sentence "...that preventable blindness is addressed timeously." "Timeously" should be replace by "in a timely way".

Second paragraph of Page 8 - "Table 3 shows..." in this this paragraph the authors suggest that the poor awareness of the various eye health professions' roles "...indirectly affects referral practices...". It is not clear how the data from this research supports this assertion. If this is not a direct finding of the research. For example - was there an analysis of the data that showed that those who incorrectly identified the competencies and roles of the different eye health professionals performed less well on the questions relating to making correct management decisions where these related to referral? In any case, lower knowledge in this area seems highly likely to directly affect referral practices - this could be offered as an observation if there is not a specific analysis to support this as a "finding" per se.

Third paragraph in this section, starting with "Knowledge of common eye conditions..." in this first sentence "were" needs to be replaced with "was".

Page 8, final paragraph: I am not sure it is helpful to refer to the "prevalence" of a poor capacity of participants to correctly identify cataract - this should be reworded along the lines of: "The low level of knowledge of cataract in this study is significantly lower than..."

Same paragraph - the grammar in the sentence on Foreign body sensations is a little odd - suggest rewording along the lines of: "'Foreign body sensations' was the only condition which, although not correctly identified by the majority of participants, produced appropriate management responses from an acceptable proportion of participants".

Training in eye care section: it is unfortunate that the analyses of the data reported here do no include any analysis of whether the nurses who HAD received some eye health training did in fact perform better on the identification and management tasks, as well as on the awareness and perception of other eye health professions competencies. While the numbers who received training may have been too small to support a fully reliable sub-group analysis, this seems too important a question not to at least investigate to some extent, even if in reporting the low numbers in the "with training" group had to be raised as a cautionary factor.

The reference to "There were poor management guidelines in place and no set referral criteria used" appears to introduce / refer to data or information not reported earlier in the paper. It would certainly be interesting to have seen data relating to the management guidelines used in the PHCs that participated in the study, as well as they referral criteria for those sites. Without data, this assertion lacks the impact it could have otherwise.

Second paragraph in this section: the sentence starting: "It stood to reason that the Kenyan study...." this sentence is somewhat muddled in the section "...which could be cited as an example of competence overreaching as those that were not trained learned from the others and managed patients satisfactorily." I think that the authors mean that the Kenyan study could be cited as an example of where the training of some staff lead to improved performance by all the staff due to the untrained staff learning from those who had received training - if this is the case, that sentence would benefit from rewording.

Clinical skill and observation and practice norms: the first sentence in this section seems potentially problematic. Since this research did not compare 'community / primary care nurses' generally in South Africa or elsewhere with the PHC nursing staff, it seems perhaps unreasonable to expect them to know how to do even a basic refraction examination, especially since almost none of them have had any eye health training either in their training to qualification or post-qualification. How are the research team defining "the expected level"? When and where was this level established / agreed and how was it communicated to nursing or leadership staff in the PHC system within ANDM? I think it would be preferable to reword the first two sentences for this section along the lines of:

"The study highlighted that current nursing staff within the ANDM PHC system lack the ability to carry out a basic visual acuity assessment, which should be a core requirement for the PHC clinics to be able to provide. Our data showed that the majority of participants in this study scored 6/10 or less on this clinical technique for assessing visual acuity."

Within the recommendations section it would be helpful to consider adding something about establishing clear referral guidelines and pathways (which the authors mention earlier in the text) and developing and providing all PHC clinics with eye health diagnostic guides and management guidance. It would seem feasible for an "eye health pack" to be developed, to include Snellen (or even LogMAR) and tumbling E charts, tape measures, occluders, vision assessment check lists (perhaps as posters for display for ease of staff use) and so on.

Is the work clearly and accurately presented and does it cite the current literature?

Partly

If applicable, is the statistical analysis and its interpretation appropriate?

Yes

Are all the source data underlying the results available to ensure full reproducibility?

Is the study design appropriate and is the work technically sound?

Partly

Are the conclusions drawn adequately supported by the results?

Partly

Are sufficient details of methods and analysis provided to allow replication by others?

Partly

Reviewer Expertise:

Optometry, Eye health, Survey Design and analysis, Psychology,

Xulu-Kasaba

Zamadonda

Optometry, University of KwaZulu-Natal - Westville Campus, Durban, KwaZulu-Natal, South Africa

Competing interests: No competing interests were disclosed.

17 1 2026

1. It would be useful to include details of the number of Primary Health Care clinics in KwaZulu-Natal, which is used as the comparison province to the study province.

KwaZulu-Natal is a province whilst Alfred Nzo District is part of a province. As such, it would be incorrect to relate the two. This is why a district that is similar in its socio-economic status was used as a comparison to the district of the study.

2. The use of "AND" as the acronym for Alfred Nzo District Municipality is potentially odd for readers less familiar with this acronym. For may English speakers AND looks like a capitalized "and". It might be helpful to change to using "ANDM" as the acronym.

Makes sense, this has been considered .

This was an error. It has been corrected under data analysis.

The rationale behind this question simply relates accurate knowledge resulting in relevant referral and triage, which has been explained in the discussion. Knowing the main role of an Ophthalmologist (surgery) and an Optometrist (vision correction), for example, means that one would know that a patient with a cataract needs to be referred to an ophthalmologist as the only correction in that instance is surgery. One would have to establish the participants’ own knowledge.

A new paragraph has been added in the methodology to improve on the Likert scale. Furthermore, please see the bottom of the manuscript where data is being declared. The journal requested that this be placed in a zenodo repository space. The zenodo link is provided in that section, and the questionnaires are all availed there for perusal and review.

In the methods section we included information stating that the images were taken from documents already used within the Departments and in their training manuals. Further to this, the images were supplied in high resolution colour (as you will see in the questionnaire). As such, we believe that the quality was sufficient for the study. All of this has been supplied as supplementary material in the repository.

All the results report on the entire group. Example, if 16% reported uveitis correctly and 32% thought it needed urgent referral it means that there is a 16% participant population that would still refer for urgent attention even though they do not know that this is uveitis. As this picture was accompanied by the definition of pain, the respondents might have concluded that even though the condition was not identified correctly, the symptom of pain warranted an urgent referral.

Noted with thanks. Please take a look at the data collection tool for clarity with the actual data given.

Discussion section:

Thank you, these errors have been corrected. The revised version suggests that some of the nurses are not qualified, which would be an incorrect statement.

In the sentence that states that most participants spoke IsiXhosa, we later expressed that in that province IsiXhosa is the main language. As such, this would support representivity of the data.

Thank you, this has been amended.

Thank you this was amended.

Page 8 - Eye health knowledge section: First paragraph, final sentence "...that preventable blindness is addressed timeously." "Timeously" should be replace by "in a timely way".

This was addressed above when explaining why nurses needed to know the main roles of different HReH.

Third paragraph in this section, starting with "Knowledge of common eye conditions..." in this first sentence "were" needs to be replaced with "was".

Amended, thank you.

Duly noted and amended where applicable.

All noted and addressed where necessary in the revised manuscript. Other input is valuable and is most appreciated.

Added suggestions as per recommendation.