Training for primary and preventive eye care

0277-9536/83$3.00+ 0.00 Pergamon Press Ltd

SW. Sci. Med. Vol. 17, No. 22, PP. 1797-1808,1983 Printed in Great Britain

Section V: Manpower Development and Community Participation

TRAINING

FOR

PRIMARY

AND PREVENTIVE

VICTORIA M.

International

Eye Foundation,

EYE

CARE

SHEFFIELD

Kenya Rural Blindness Prevention Project, P.O. Box 55585, Nairobi, Kenya

Abstract-This paper discusses what health workers at various levels can be expected to do in providing eye care with regard to recognizing, managing and preventing common eye conditions. Three particular levels, Kenya’s ophthalmic clinical officer (secondary level), general clinical officers and nurses (firstreferral level) and primary health workers (primary level) will be discussed. Appropriate and effective training methods will be described especially with regard to curriculum content and resourses. Emphasis in caching is placed on the public health techniques already well understood by health workers and on the connection those techniques have to the prevention of blindness.

INTRODUCTION

When discussing Programmes for stated that: “An conditions should

primary eye care in its Guildeiines for the Prevention of Blindness. WHO appropriate service for common eye include suitable self-treatment when

indicated” [I]. Preventive eye care concerns the prevention of disease by the community itself. Most eye diseases can be prevented by simple individual and community activities in thefieldofpublic health and nutrition. Early treatment and/or appropriate referral in the early stages of infection or injury will decrease avoidable blindness. In Kenya. there are various levels of medical auxiliary personnel providing health care from the primary level to the secondary level 121.Very few provide any eye services at all. except for the specially trained ophthalmic medical auxiliaries. It is ‘the philosophy of the Kenya Rural Blindness Prevention Project (KRBPP) that all health workers should be able to provide primary and preventive eye care to all members of the community. National blindness prevention programs should eventually establish a program of education in primary and preventive eye care. Once an infrastructure of curative services is available in the peripheral areas. either through static clinics or mobile units providing for referral patients and supervision. general health workers (non-ophthalmic specialists) should be trained in the concepts of primary and preventive eye care. This paper is about appropriate strategies to achieve such goals.

ROLE OF MEDICAL AUXILIARIES IN KENYA Most developing countries do not have enough formally trained ophthalmologists to meet the needs of the people. especially in the rural areas. It is therefore necessary to train other cadres of health workers to provide eye services. Primq3

level-

Village Health Workers

A lot has been heard about this level of health worker. Sometimes described as village health workers.

village health helpers and neighborhood health workers. there are only a few such workers in practice. A number of community health projects have primary health workers as a component of their activities. These primary health workers are usually volunteers selected by their own neighborhoods to serve a group of anywhere from 50 to 1000 people. Most have little education. usually Standard (primary school) 4 or 6 to high school, Form 4. However. that education is usually not utilized in the rural areas and these people cannot be expected to perform at those levels. In some cases. the primary health workers are illiterate. However. this does not mean that they cannot be taught basic eye care and skills. Indeed. these are often the most enthusiastic students who perform practical activities the best of all. They can be male or female. young or old. but they must remain in the neighbourhood to be effective. The KRBPP has had experience in developing training materials [3] and teaching primary eye care to three successive classes of ‘village health helpers’ (VHH) in a Rural Health Project (Saradidi) in Siaya District. Western Kenya. over the last two and one half years. Each class has approx. 18 students. mostly women. with an average education level of Standard 5. The first class included two completely illiterate grandmothers who have proven to be outstanding in their understanding of common eye conditions. basic treatment. preventivemeasures and especially the practical skills. The performance of the VHHs in referring patients beforehand to the clinic is briefly discussed here. In Saradidi. the first group of. 18 Village Health Helpers (VHH) had been selected by their respective) homesteads and were known as Group A. In June of 1980. they were given a full-day’s session on Primary Eye Care and Blindness Prevention. The class was held outside with a table. benches and blackboard under a shade tree as the clinic building was not yet completed. No electricity is available, so large pictures and eye models were used instead of slides. Emphasis was placed on practical skills. In December 1980 Group A was given a brief review of clinical information and a test (see Appendix 1 for test). The group practiced measuring vision against 1797

1798

VICTORIA M. SHEFFIELD

making sure that each VHH knew the proper procedure and how to record the visions found. They were instructed to return to their homesteads, measure the vision of as many people as possible with eye complaints. Everyone with a vision of 6/18 (20/60 or 0.3-WHO standard) or worse in one or both eyes and/or an eye complaint was to be referred to the Saradidi clinic to be seen by an ophthalmologist. The clinic itself would prove to be a follow-up in seeing how many people attended, how many had been referred by VHH’s. how many were proper referrals with either poor vision and/or an eye complaint. and it would provide the opportunity to compare the accuracy of the visual acuity found by the VHH with the acuity found when the patient was retested by our professional staff. At the referral clinic a toal of 227 patients were seen in the clinic with 93 having been referred by VHH’s. A few came from villages with VHH’s but without a referral and the rest were from villages without VHH’s but had heard about the clinic. It is obvious that transportation is a severe limiting factor in having all the patients who should be seen able to travel to the clinic on one specific day. By carefully comparing the visions found by the VHH‘s with the visions found in the clinic of the 93 patients who were referred and attended. we were able to measure the accuracy of the visions measured by the VHH’s The visions were compared and categorized according to the standards used in our surveys. It was possible to compare the VHH’s referral vision with the clinic vision in 157 eyes. The referral visions matched the clinic visions by category in 111 eyes with 46 eyes not matching. However. most were only one category off. Of the 111. 73 had a visual acuity of 6/l 8 or better and were referred with refractive error. presbyopia or conjunctivitis. The other 38 had properly referred acuities of worse than 6/18. mostly with cataract (see Appendix 1). The results are very encouraging. The VHH’s can measure vision with a high degree of accuracy and refer the patients to the eye clinic as needed. They were very confident in their evaluations and understood well the procedures in the clinic. They were observant and interested while watching the specialists and demonstrated their understanding of their skills and knowledge in Primary Eye Care and Blindness Prevention activities. The project has also trained three successive classes of ‘village health workers’ (VHW) in primary eye care during their training sessions run by the Church of the Province of Kenya (CPK) in the highland part of Kenya. These VHWs are selected by their communities and the CPK. trained at the CPK mission training cetre in the area. The trained workers are supervised by the head tutor and staff of the training center. Each class includes approx. 30 trainees and their average level of education is Standard 7. Presently. KRBPP has begun training ‘neighbourhood health workers’ (NHW) at the KRBPP’s community health project in Meru in the north-central part of Kenya where all the Kenydn produced ‘Miraa’ (C~rha &Gs) is grown and processed for the local and export market. The crop is the mainstay of the economy in the region which has population of about

200.000 people. The first class of 37 trainees has an average educational level of Standard 5. WHAT

THE VHW SHOULD

KNOW

AND

DO

Referrals The primary health worker is taught to refer: (I) vision that is worse and 6118 in one or both eyes; (2) any pupil that is not black: (3) any cornea that is not, clear; (4) all severe pain : and (5) all severe injuries. If the group is having trouble understanding the cornea and the pupil. it is explained that the eye has a white part and a black part. If there is a white mark on the black part (cornea1 ulcer. cataract. retinoblastoma). the patient must be sent to the health center. Many primary health workers are trained by medical missionaries or by outside agencies and funding is available to provide simple medicines. If this is so. the primary health workers can be taught to treat a patient who has red on the white part (and good vision) with tetracycline eye ointment three times a day for one week. However. preventive care receives the major emphasis. Promoting hygiene. sanitation. safety and encouraging nutritional foods that contain Vitamin A are activities that a primary health worker can be expected to do. Just referring patients with eye problems to the nearest health center prevents infections from getting worse. injuries from becomining complicated and people with white pupils from remaining blind simply for lack of referral. Teaching prevention here has a much wider scope. While the concerns are the same. these activities can have a major effect on a rural community which thus far has had no-one who was concerned about the community’s health. These primary health workers may prove to achieve the greatest results from teaching blindness prevention. What teaching resources are needed?

Visual aids are extremely valuable. If electricity and a projector are available. slides are very good and interesting. Pictures. photographs and simple diagrams are also good. Otherwise. a blackboard and chalk will suffice and often are still the best to have even with other aids. A plastic eye model which can be taken apart is excellent for teaching the parts of the eye. The IEF. Kenya. has developed a valuable teaching and reference aid called the Primary Eye Care Manual (PECM). It is an eight-page. card paper manual that describes the following (see Appendix 1) : (1) the meaning of Primary Eye Care (2) the role of the health worker in blindness prevention activities (3) eye conditions. their recognition. cause. treatment. and prevention (4) instruction on how to measure and record vision (5) diagrams showing the practical skills that the health worker should have. First-referral level-nurses

and general clinical officers

Enrolled community, and registered nurses and clinical ollicers in Kenya have many responsibilities. Besides staffing wards and clinics in provincial and district hospitals. they supervise health centers and

Training for primary and preventive eye care in rural areas. providing the only professional health care at the local level. The 16 Kenyan government and 4 mission ,nursing schools graduate approx. 650 nurses a year. All nursing students receive some lectures on the eye. The information usually deals with academic discussions of anatomy and physiology and then specific disease signs and symptoms. The tutor often reads from an ophthalmology text or assigns reading of a handout. Sometimes. if there is an ophthalmic clinical officer or surgeon in the area. he is invited to come and give a talk for an hour or so. However. because these specialists are so attuned to using ophthalmic terms and so often discuss what is irrelevant to the students. these sessions are sometimes completely useless. That is to say. the lectures should be suited to the student rather than to dispensaries

the lecturer. The KRBPP

has developed a curriculum and a 34page reference manual 141 with diagrams geared specifically to nurses and to the level of work they are expected to do. The KRBPP participated in the training of third and fouth year nursing students in a number of nursing schools. The sessions are practical providing useful’ information and skills that the students are likely to remember and use. General clinical officers serve virtually as junior physicians in the Kenya health system. In the provincial and district hospitals. they diagnose and treat the majority of patients coming for care and refer themore complicated patients to the physician. In the rural areas. they suprvise the larger health centers and dispensaries. provide training to mobile teams and often run mobile clinics themselves. In Kenya. clinical officer training usually begins after Forms 4 or 6 with a three-year genera1 medicine course held at the medical training center (M.T.C.) at either the Kenyatta National Hospital IK.N.H.) in Nairobi or at Nakuru. During this training. the third year trainees approx. 120. receive a 1O-14 hour course. (one-hour sessions per week) in ophthalmology. During the last seven years. the course has been taught by the KRBPP ophthalmologist. by invitation. at the Nakuru M.T.C. At the Nairobi M.T.C.. it has been taught by an ophthalmic clinical officer who is also a Registered Clinical Officer tutorwithaone-yeardiplomaineducation. TheKRBPP Field Training Specialist (FTS) has also participated in this training. As these trainees have little ophthalmic reference material available to them. the KRBPP has developed a 64-page teaching outline and reference manual 151 with diagrams geared specifically to the level of general clinical officers. Secondary level-ophthalmic

clinical ojkers

The most sophisticated level of health workers. other than ophthalmologists. providing curative eye services are Clinical Officers-Ophthalmic. They provide curative medical and surgical care in static clinics and mobile units. and are in fact the backbone of the ophthalmic program. In Kenya. the ophthalmic Clinical Officer is addressed formally as ‘Mister’ even though he is often called ‘Doctor’ and is thought of as such. Although these are not primary level health workers. blindness prevention programs must seek to establish and support the training of such people in

I799

order to improve the quality of eye services in the rural areas. After at least one year in the field. a general clinical officer can apply for specialty training in Ophthalmology. a course started in 1977. The one-year ophthalmology course is held at the Department 01. Ophthalmology of the Kenyatta National Hospital (K.N.H.) in Nairobi. The K.N.H. Department of Ophthalmology trains 7-I 1 ophthalmic clinical officers annually. male and female. with some being foreign students. The trainees receive instruction from staff ophthalmologists. usually under the apprenticeship method. Formal didactic lessons are given on specific subjects such as anatomy and physiology. strabismus and clinical diagnosis: but the greater emphasis is placed on practical skills and clinical experience. When these officers have successfully completed their course. they are able to examine patients using an ophthalmoscope and slit lamp. diagnose and treat most eye conditions. and refer the more difficult cases to the ophthalmologist. These clinical officers are trained to do minor external procedures such as entropion repair and excision of chalazion 161. An eight hour course on preventive opthalmology has been given to the trainees for the last three years. The curriculum deals specifically with the relationship of public health techniques such as hygiene. sanitation. safety and nutrition to blindness prevention 171. After completion of training. ideally. ophthalmic clinical officers should initially be assigned to a static clinic under the supervision of an ophthalmologist before taking an independent post. If they desire. and if they prove capable. some are trained to do intraocular surgery under supervision. A training program for such sophisticated eye health workers can be successful only with and through the support of the Ministry of Health. The program director can be supported by the government. an outside agency. or a mission organization. but the program must be coordinated through the Ministry of Health. Such a program must provide adequate sup portandsupervisionoftheseophthalmicclinicalofficers once they are assigned to the field.

TRAINING

Considerations hqfore training First-referral level health workers have great responsibility. often supervising a health center or dispensary. They are very busy with many patients to be seen besides performing their other general or administrative duties. Taking this into consideration. we must ask ourselves : (1) What are the common eye conditions that these people will see? (2) How much time will they have to spend with each patient? (3) What can they reasonably. not ideally. be expected to do? (4) What resources will they have available to them? In most of Africa. the common eye conditions are cataract. trachoma. coniunctivitis. nutritional disease and iniuries. The general health worker will have very little time to spend with each patient. Often. eye

1800

VICTORIA M. SHEFFIELD

patients are simply referred. without an attempt to diagnose and treat, to the nearest eye clinic which may be a long and expensive distance away. These general health workers need essential knowledge in order to manage an eye patient locally or to refer only if necessary. Although ophthalmology is known for its exotic electrical instruments. most common eye conditions can be recognized and managed with only eyes, brains and hands after some basic training. Remembering that health workers are always overburdened by the sheer numbers of patients. often with life-threatening ailments. it is imperative that the information they receive is basic and practical. They will not take the time to look up someting they learned once about an eye problem, and reference material is usually unavailable anyway. They will remember information they can use and practice. With practice comes experience and experience builds confidence and competence. Problems inherent in developing countries

There are many problems. both common and unique. in teaching in developing countries. ,There is the immense dilemma of greatest disease with least trained manpower and resources. Funding for blindness prevention programs is scarce. and with the great many health problems needing attention. eye care often gets little attention and support. Meeting these challenges requires dedication and hard work on the part of eye health workers at all levels. In the actual teaching situation, language can be a big problem. especially with different tribal languages and even dialects. Also, because. so much of medicine is in English and contains elaborate specific medical terms. the use of as few medical and ophthalmic terms as possibleis not only desirable but would also cut costs. Supplies are a major problem. Often even provincial hospitals will be without adequate eye medicines. There may not be post-operative cataract glasses available for aphakic patients. Many people need or want glasses. especially school children (because it is a sign that they can read), and they will insist on being referred to an eye clinic. Students often want the instructor to do something about the lack of supplies and may feel that it is not worth learning how to treat problems if they have nothing to treat them with. Perhaps the greatest problem is the lack of water. Women walk for miles for the amount of water that they can carry on their backs or heads. This is used for drinking, cooking, washing dishes and clothes, with none left for washing faces and hands. For the trainer who is training tutors how to teach health workers or is training health workers directly. expectations can be a real source of exasperation. It is also common for trainers to expect students to do what is taught and all will be well that is expecting too much. Often. certain students will answer our most difficult questions and we believe the entire class is thinking in the same way when in fact. most are not. Instruction must be aimed at the weakest students and. when teaching primary health workers. there are many areas where comprehension of concepts and skills will be extremely difficult. The bright ones will not get bored because eye training is new to them anyway. Our expectations for a Form 4 school leaver

are often far above what that person can actually absorb and learn. So much of the teaching becomes a process of constant encouragement and patience. With that. the students gain confidence and competence. A serious concern is that of the expectations of the community which the health worker serves. The community must understand the limitations of their health workers. especially the primary health workers. A patient with an eye infection may come to a primary health worker who has no medicine for treatment and then lose faith in him. People can come with severe injuries and expect to be treated by the primary health worker without having to go to a health center or hospital. Coordination with chiefs. sub-chiefs and village heads to discuss with the community what they can actually expect from their health workers must take place at some point early in the training project. How should the material he taught?

A lecture presentation is valuable to discuss blindness. its simple statistics and impact on the person and his community. In Kenya, where English is usually not the first language of workers, attention is paid to being clear and distinct. Very simple words are used. Repetition is not only acceptable. it is advisable; especially when a new word has been introduced. It is helpful to use as few ophthalmic terms as possible. Some. such as cornea. cannot be avoided; but it is neither necessary nor important for health workers to know or use specific ophthalmic terminology [8]. What should they be taught ?

There are three tasks for the health worker: (1) Recognize the problem (2) Treat or refer (3) Prevent the problem. Task No. I: recognize the problem. After the usual history questions such as duration and possible injury. the health worker examines the eye. As most problems affect the front. visible parts of the eye. the health worker can recognize what part is affected. To recognize an eye problem and to locate it. the health worker must know the visible parts of the eye. e.g. the cornea. the pupil. the partlconjunctiva and the eyelids. A simple diagram. practical demonstration by looking at each other’s eye. slides and/or an eye model that can be taken apart are valuable teaching aids depending on availability of such aids and of electricity. Four basic rules teach the health worker what a normal eye looks like: (1) The cornea should be cleur (2) The pupil should be black (3) The white partlconiunctiva should be white. (It is explained that the white part is not always completely white. But it should not be red or yellow) (4) The eyelids should open and close properly. Task No. 2: treat or refer. After the students determine what part of the eye has a problem or if the eye appears normal, they are taught to measure the patient’s vision. At this time in the session. the students measure and record the vision of each other. each taking a turn as both patient and examiner. They

Training

for primary

and preventive

are taught that vision of 6118 or better is considered normal. Vision worse than 6/l 8 in one or both eyes is an indication for referral of the patient to an eye clinic. The Landolt ‘C’ chart can be understood by both literate and illiterate people by explaining that it is a ‘boma’ or corral and the patient must point to the way out. The health workers must record the vision they find while practicing on each other as this exercise can often be confusing. Accepted practice is to write a large ‘V’ for vision followed by an ‘R’ for the right eye and an ‘L’ for the left eye. The vision fraction is then recorded. The KRBPP has revised their ‘C’ chart to include only the 6/6.6/9.6/l 8 and 6/60 lines. It was found that busy health workers did no have time to go through the exercise of measuring each line on the full chart or moving the patient forward. In any event. if the vision is worse than 6/l 8 in one eye or both eyes. the patient is referred to the eye clinic. Testing of hand movements and the recording of ‘HM’ is taught. However. ‘LP’ and ‘NLP’ are not discussed as light perception is difficult to quantify. and most health workers do not have a torch or batteries available. As most eye patients present with redness and discharge which is usually either conjunctivitis or early trachoma and the vision is better than 6/l& the health worker feels confident in treating these patients with plain antibiotic (tetracycline) eye ointment. If the cornea is affected or the pupil is not black. the vision is usually worse than 6118 and the patient will be referred. Loss of vision. severe injury and severe pain. as opposed to itching. are referred. Common eye conditions are discussed next. Although approaches to teaching vary, it must be remembered that these health workers should be able to recognize what part of the eye has a problem. its effect on vision. and how it should be managed. It is not necessary for them to know thedisease name and specific signs and symptoms. In fact. it is often found that a health worker can memorize and write down the signs. symptoms and treatment of a disease named in a test question. but cannot recognize that disease in a clinical setting. If slides or pictures are used. it is a valuable exercise to ask the class to recognize what part of the eye has the problem rather than showing a photograph and saying it is a cataract or trachoma. etc. The students then go through their four rules : (1) Is the cornea clear? (2) Is the pupil black? (3) Is the white particonjunctiva white? (4) Do the eyelids open and close properly? The students can often tell you whether the vision will be good or bad depending on where the problem is and thus begins to decide whether to treat or refer the patient. We begin with problems of the cornea. A comeal ulcer is shown. The students are told to recognize it. They must then measure the vision and management is usually antibiotic (Tetracycline) eye ointment and referral. A chemical bum is shown. The health worker learns of the injury from the history. Treatment by irrigation is discussed. A foreign body is shown. Foreign body removal is then discussed. For each condition. emphasis is placed on prevention of bhchxs. Early diagnosis and treatment for ulcers and safety measures to prevent injuries are stressed. It is

eye care

1801

valuable to teach these health workers how to make a simple protective eye shield out of hard paper or old X-ray film as well as appropriate first aid measures for patients with eye injuries. A group of sides or photographs can show a white pupil. One can show an old person with a cataract and one can show a child with either a congenital cataract or retinoblastoma. Specific disease names do not have to be given. but a person with a white pupil. mpccially a child. should be referred to the eye clinic immediately. Pictures showing problems with the white part can follow. Slides depicting simple conjunctivitis should be shown as this is what they will see most often. They understand that the vision is usually good. 6118 or better. and there is no severe pain. These patients can be treated with tetracycline eye ointment three times a day for one week. Good hygiene practices to prevent the spread of infection to others are emphasized. If they can recognize and treat simple conjunctivitis patients. they will save the patients the time and trouble in travelhng to the eye clinic. and save the eye specialist’s time for more complicated patients. Another good photograph to show is ‘foam’ on the white part. The history shows a malnourished person. usually a child. coming from an area with few vegetables or little food of any kind. The health worker is told that this patient must be treated with a capsule of Vitamin A. 200.000 I.U. or the eyes may get worse and the cornea might become white. They all understand what a white cornea means for a patient. Continual treatment with Vitamin A is costly and impractical. Health workers at all levels understand that a good diet is necessary for good health. They may even have heard that Vitamin A is good for the eyes. Now they understand why. Slides showing foods rich in Vitamin A are valuable. or a few such foods available in the area are presented in a kind of ‘show and tell’. Students should be reminded to consider availability. cost and cultural likes and dislikes when giving advice about diet. Finally. slides showing problems with the eyelids are presented. The main condition here is trachoma. Discussion of the progression of the disease is followed by an explanation of the treatment. As trachoma is so easily prevented. discussion in detail about hygiene and sanitation is appropriate here. A photograph showing a child with flies covering his face is dramatic. Washing the face daily. especially for children. is good practice. Sanitation measures to reduce flies. etc. proper construction and use of latrines. burning or burying of refuse. covering of foodstuffs. and keeping animals in a separate corral away from the home. emphasize public health concerns that they already know. The teacher must emphasize that some cultural changes in habit and customs are necessary for public health measures to work. At this point. the students practice evertinp each other’s upper eyelids in order to look for signs of trachoma. They then practice putting eye drops and ointment into each other’s eyes. By not only performing these skills on another person. but having them done on themselves. the participants can be more sensitive to the feelings of the patient. And more importantly. it helps remove some of the unique fears that people have about touching eyes. When demonstrating how to apply eye medicine it is

1802

VICTORIA M. SHEFFIELD

a good time to stop for a moment and mention the dangerous effects of steroids. Without going into detail about mechanisms. etc., one can-name those eye medicines in the country that contain steroid and stress that they must not be used without the authority of an eye specialist. Steroid-containing eye medicines can make an infection worse. cause a white pupil. and delay healing of an ulcer. These things they have learned about. It is enough and not necessary to confuse them by adding that steroids can also precipitate glaucoma. The subject of glaucoma is always an exasperating one. To more sophisticated health workers such as third-year clinical officer trainees. glaucoma may be something that can be explained with some satisfaction. However. it is always confusing and unnecessary to explain glaucoma to any other levels of health workers. As patients with severe eye pain and/or vision worse than 6118 in one or both eyes should be referred. we hope that many glaucoma patients will be picked up that way. Until a method of effective mass screening is developed. it is futile to try to teach health workers about the disease. There are patients who will come to see the health worker complaining about their vision. One particular group is school children. The health workers are instructed to ask the history questions. examine the eyes which usually appear to be normal, and then, of course. measure the vision. If the vision is worse than 6118 in one or both eyes. the patient will be referred to the eye clinic for evaluation. If the vision is 6/18 or better in both eyes. the discomfort is probably due to poor reading habits or to anxiety about studies. School children must often do chores after school until it is dark. It is then when they find time to read. The health worker can advise three things: (I) use good light on the reading material. e.g. a paraffin lantern or electric light if available (2) do not hold the book too close to your eyes (3) rest your eyes for 15 minutes after each one half hour of reading. Task No. 3: prevent the problem. Prevention has been discussed as each condition was presented. A review of public health problems reminds health workers that hygiene and sanitation. safety. and good nutrition are not only activities of primary health care. but also of primary rye care. Thus. general clinical officers and nurses have learned the visible parts of the eye. how diseases affect those parts and the prevention of eye diseases. They have learned four practical skills e.g. measuring vision. everting eyelids. applying eye medicines. and making a protective eye shield. This approach of defining the three tasks---is used for teaching at both the primary and first--referral levels. The IEF staff has also developed training manuals and teaching outlines to be used by trainers when talking to the following groups: (I ) general clinical ohicers (2) nursing students (3) village health workers (4) primary school students (5) maternal and child health (Family Planning for mothers and their under fives) (6) chiefs barazas (meetings with the community) (7) agricultural fairs

(8) provincial seminar participants (9) district seminar participants (IO) rural health training centers. Copies of the indexes of the two manuals for general clinical officers and nursing students and village health workers have been given before. The subjects discussed in the teaching outlines so the other three groups are : Primary school students-Healthy eyes. tired eyes. nutrition. hygiene and sanitation. and eye safety. MCH/FP mothers and their under fives-Healthy eyes. nutrition. hygiene. and eye safety. Chiefs barazas-Healthy eyes vs blind eyes. nutrition. hygiene. and safety. Agricultural fairs-Leading causes of blindness in Kenya. nutrition. hygiene. and eye safety. Training materials Also. IEF/Kenya has developed the Red Eye Chart which shows various conditions causing an acute red eye in both photograph and diagram form. and also describes the condition and its treatment. This chart is available at cost of printing and postage from the IEF in Nairobi. Visual aids are available from the World Health Organization in Geneva. the Foundation for Teaching Aids at Low Cost (TALC) in London. and agencies such as the International Eye Foundation in Bethesda. Maryland. U.S.A. and Nairobi. Kenya. and Helen Keller International in New York. U.S.A. 19. 101. For everting eyelids, a pencil or cotton-tipped stick is adequate. Eye drops and eye ointment are necessary to practice applying medicines. Some hard paper such as a file folder. a pair of scissors and some tape (strapping) are needed to practice making an eye shield paper. tape and cotton-tipped sticks used by the trainer should be the same as what will be available to the health worker in hs work. IN-SERVICE TRAINING

Kenya is divided into eight provinces. Seven of these are rural: the eighth province consists of the Nairobi metropolitan area. Each province is divided into districts. which are further sub-divided into divisions. locations. and sub-locations. In the seven rural provinces there are a total of 39 districts. The health system follows political divisions. Each province has a large general hospital. and there are smaller district hospitals in each district. with health centers and dispensaries distributed on a divisional/locational basis. In-service training and disgemination of eye health care through seminars have been conducted since 1981. The targets have been first the administrative cadres of the province and second the rural health workers in the province. Provincial seminars The staff of the KRBPP has. over the past two years. conducted seminars on primary eye care and blindness prevention in six of the seven provinces in Kenya. A half-&y provincial seminar is held first in the provincial capital. The participants are provincial level leaders from various ministries such as health. agriculture. water development. public works. etc. The discussions center on policy planning and the need

1803

Training for primary and preventive eye care for a cooperative effort in preventing avoidable blindness. Blindness and its personal and socioeconomic effects on the family. community and country are discussed. A brief presentation with slides describes the leading causes of blindness and their prevention. The seminar ends with discussion about interaction between all ministries with support for blindness prevention activities from the highest levels. District seminars The full-day district seminars are then held in each district in the province. Up to 60 participants are present. These are all district level health leaders such as the hospital matron. public health officer. nutritionist. and dispensary and health center in-charges. etc. The objective of the district seminar is to train health workers how to recognize eye problems. to be able to determine whether a patient should be treated locally or referred. and then understand how these eye problems can be prevented. The seminar is usually opened by the Medical Officer of Health. who serves as the in-charge of the district hospital. The seminar organizers are introduced and then each participant stands and introduces himself or herself. These introductions are very important in making the group feel at ease and feel willing to participate in discussions. A statement is made as to why the participants have been invited to the seminar. i.e. learn how to recognize. treat or refer and prevent eye problems. The seminar has two components: (1) a lecture that includes slides (or a flip chart depending on the availability of electricity). and (2) a practical skills session. To perform the first task of recognizing the problem. the participants are taught the visible parts of the eye using the previously mentioned four rules. They are then taught and practice measuring vision to determine the seriousness of the problem and whether to treat or give primary care and refer. The slide session discusses problems with the cornea. pupil. white part/conjunctiva and eyelids. During the discussion of trachoma. they practice everting eyelids and applying drops and ointment on each other. At the end of the session, they are taught how to use the Red Eye Chart. It is difficult to determine how many people actually go back to their units and practice primary eye care. However. we have found that the seminars certainly serve a promotive service in creating an awareness about eye disease and its prevention. Orientation,for

rural health training centers

Tutors in the six rural health training centers (RHTC) provide instruction to continuing generations of health unit teams (HUT’s). Each team consists of a clinical officer. nurse. public health technician. a clerk and a driver. Approximately seven teams attend each three-month session in each RHTC and there are three sessions per year in each RHTC: i.e. approx. 105 people per RHTC per year. The teams come from different dispensaries and health centers. and provide static and mobile services in their areas. The sessions provide continuing education and up-dating. on medical practices. such as immunization. MCHiFP services. nutrition. etc. In the past. eye care was either

not included. or a local eye specialist was asked to come and give a talk for an hour or so in one day. In June. 1982. the KRBPP invited all the tutors to attend a week-long seminar to develop their own curriculum for teaching primary eye care and blindness prevention to the HUTS. Twenty-nine tutors representing five of the six RHTCs. were able to attend. The tutors were divided into five groups and each was given a subject: cornea. pupil. white part/con,iunctiva. eyelids and vision problems. Each group defined the tasks to be taught to be able to recognize. manage and prevent problems with each subject. They also listed resources needed to ieach these tasks. A copy of the curriculum draft with some editing and a copy of the student manual written from the content section of the curriculum follows. One of the resources requested was a flip chart because slide prqiectors and even electricity are rarely available. A 3%page flip chart has been designed and printed with financial support from the Royal Commonwealth Society For the Blind. It is designed to accompany the curriculum and includes diagrams of the specific condition being taught. We have. so far. attended eye sessions taught entirely by the tutors at three RHTCs. Each didactic session was followed by a practical session with the HUT members measuring vision. taking histories and treating eye patients. It was originally thought that the curriculum was too complicated and would need revision. However. after seeing it taught by the tutors. they seemed comfortable and quite successful with it. Some tutors have expressed a real satisfaction in being able to teach a specialty which includes specific practical skills. Also. they have expressed pride in having designed the curriculum themselves. and we believe that this is a key factor in the tutor’s acceptance and success with it.

PRIMARY HUT CURRICULUM

EYE CARE: TEACHER’S GUIDE

For the trainers of health workers. training on the prevention of blindness should stress six tasks their trainees should be able to perform. These are: (1) Taking a history (2) Examining the eye (3) Testing the vision (4) Making a diagnosis (5) Managing the problem (6) Preventing the problems. For each task. the guidelines indicate the : Content Teaching/learning activities Resources needed Evaluation method.

REFERENCES 1.

World Health Organization. Guidelines_for Pro~rammes for the Prevention of Blindness. p. 20. World Health Organization. Geneva. 1979. 2. Meaders. R. H. .Eye health care delivery systems. Unpublished. 1982. 3. International Eye Foundation. Primary eye care and blindness prevention for village health workers. Unpublished. 1981.

VICTORIAM. SHEFFIELD

1804 4. International 5. 6. 7. 8.

Eye Foundation. Ophthalmology for nurses. Unpublished. 1981. International Eye Foundation. Ophthalmology for general clinical officers. Unnublished. 198 1. international Eye Foundation. Maiyeu na Modooku. Unpublished. 198 1. International Eye Foundation. Public health course for clinical officers/ophthalmology. Unpublished. 1980. Savage F. and Godwin P. Controlling your language: making English clear. Trans. R. Sot. trap Med. H_vg. 75. No. 4. 1981.

9. World Health Organization. 1211 Geneva 27. Switzerland. 10. Sources of Teaching Aids: (a) Foundation for Teaching Aids at Low Cost (TALC). Institute of Child Health. 30 Guilford Street. London WClN LEH. U.K.: (bl International Eye Foundation. 7801 Norfolk Avenue. Bethesda. MD 20814. U.S.A.: (c) Helen Keller International. Inc.. 15 West 16th Street. New York. NY 10011. U.S.A.; (d) International Eye Foundation. P.O. Box 55585. Nairobi. Kenya.

APPENDIX

1

NAME

TEST PRIMARY Instructions:

Read the questions choose.

FOR VILLAGE EYE CARE

carefully

HEALTH

WORKERS

AND BLINDNESS

and choose

the best answer.

PREVENTION

Circle the letter in front of the answer

I. The purpose of the eye is to 2. The front window of the eye is the cornea. It should be: a. clear b. white c. black 3. The lens is inside the eyeball behind the pupil. The pupil should be: a. white b. red c. black 4. When there is a cataract in the lens. the pupil looks: a. black b. white or grey c. red 5. If the white part (conjunctiva) of the eye is infected. it will look: a. red b. the same as when it is not infected c. very dry 6. The eyelids protect the eyeball. They should: a. never “blink” b. open and close properly c. stay open when you are sleeping 7. Some signs of an eye infection are: a. cataract b. the need for glasses c. a red eye with pus running out 8. If a patient has an eye infection. he will say that he has: a. burning and itching in his eyes b. no pain c. a cataract 9. If the patient has a white mark on his cornea. he should: a. go to the eye specialist immediately b. wear his glasses c. not worry about it if it is not red IO. If a person does not see well. you must measure his vision. You can use the ‘C’ Chart a. the patient must stand 6 paces from the chart b. the chart must not face the sun or the light c. the patient must open both eyes to see the chart 11, When you measure the vision. you should always: a. test the right eye first b. test with both eyes open c. press hard when covering the eye 12. You can tell the patient that each ‘C’ is: a. easy to see and that if he cannot see them. he is going blind b. a boma and he must point to the way out c. easier to see if he has cataracts 13. If the patient cannot see even the big ‘C’. you must move him: a. further back from the chart b. 3 paces to the side c. 3 paces from the chart and test him again

and:

that you

Training

for primary

and preventive

eye care

1805

14. If he still cannot see even the biggest ‘C’. you should : a. ask him to go back 6 paces from the chart and try again b. ask him if he can see your hand moving c. ask him to look with both eyes 15. When recording the vision. the FIRST number is: a. the number of paces that the patient stood away from the chart b. the number of ‘C’s’ that he could see clearly c. the vision in the right eye 16. The SECOND number: a. tells the vision in the left eye b. tells how far he stood from the chart c. tells the line d.the smallest ‘C’s’ that the patient could see 17. If a person has taka taka or dudu in his eye. you should: a. tell him to try to rub it out b. try to wash it out with fresh. clean water c. try to pick it out with a small. sharp stick 18. If there is a cut in the eyeball or the eyelid : a. You must put a protective shield over the eye and send him to the eye specialist immediately b. put ointment in the eye c. wash the eye with clear water 19. If you see blood behind the cornea. you should: a. test the vision only b. put a protective shield over the eye and send him to the eye specialist immediately c. tell him to press on the eye to stop the bleeding 20. If the person has spilled OMO or chemicals in his eyes you must: a. wash them immediately with fresh. clean water for a/ Ieusr 15 minutes. b. put protective eye shields over the eyes c. test his vision first then wash the eyes with water for a few minutes 21. The first primary health care worker is: a. doctor b. mother c. nurse 22. If a mother brings her newborn baby to you and the baby’s eyes are red. very swollen and full of pus. you should: a. wash the eyes. then test the vision b. patch the eyes for a week c. wash the baby’s eyes with clean water. apply penicillin eye drops or tetracycline eye ointment and send the baby and the mother and father to the clinic for treatment because they have gonorrhea 23. A patient with early trachoma will have bright red blood vessels and white snots underneath the unner evelid. To find these signs of trachoma. you must: a. turn the upper eyelid and look for these signs b. wash the eyes out and patch them for a week c. test the vision and send him to the eye specialist 24. If a patient has EARLY signs of trachoma. you should: a. test the vision b. give him tetracycline eye ointment in his eyes ever day for 3 weeks c. try to remove the white spots with a cotton swab 25. After touching a patient with any eye infection. you should always: a. wash your hands well with soap and water b. put a patch over the infected eye for 3 days c. measure his vision and record it in the chart 26. Trachoma and other eye infections: a. are spread very easily by using the same towel and washcloth for all of the members of the family b. are not spread by flies c. are not common in areas where there is poor sanitation and poor waste disposal 27. The eyes need special vitamins (Vitamin A) and protein for good health. A person will get enough Vitamin A if he eats the following foods every day: a. ugali and cereals b. green. leafy vegetables. yellow fruits and milk c. fanta and a lot of bread 28. A person who keeps himself clean will not get many diseases. Which of these are good health habits: a. washmg your face and hands at least twice a day. Washing the hands always before eating and after visiting the choo b. sharing the same towel and washcloth c. keeping the animals in the home and you find that his vision is worse than 619. and he does NOT have an eye 29. If a school child cannot see the blackboard infection. you should : a. tell him to eat food with Vitamin A to improve his vision b. give him tetracycline ointment in both eyes for a week c. send him to see the eye specialist because he may need glasses 30. Eye drops and eye ointment should be put into: a. the lower eyelid b. the upper eyelid c. the eye patch

1806

VICTORIA

Ke.v 1 see

6b

2a 3c 4b 5a

11 12 13 14 15

?C

8a 9a 10 a

M.

SHEFFIELD

a b c b a

16 17 18 19 20

c b a b a

21 22 23 24 25

b c a b a

26 27 28 29 30

a b a c a

APPENDIX 2 Condition

Recognized by

IA. Trachoma 1B. Trachoma with eye lashes touching cornea 2. Conjunctivitis 3. Conjunctivitis of the newborn . 4. Allergic conjunctivitis 5. Comeal ulcer 6. Vitamin A malnutrition 7A. Eye injury 76. Foreign body 8. Eye strain

Caused by

Follicles and scarring of both inner upper eyelids (see red eye chart) Intumed upper lids with eye lashes touching cornea (see red eye chart) Red conjunctiva sometimes with pus (see red eye chart) Pus in eyes of newborn

Trachoma infection

Red itching eyes (see red eye chart) Red eye. especially around cornea. or white spot on cornea (see red eye chart) Night blindness. comeal dryness. Bitot’s spots History of injury: swollen eyelids. hyphema. red painful eye. comeal laceration (see red eye chart) Red. painful eye with particle on cornea or under eyelid (see red eye chart) Normal vision and complaint of pain when reading

Allergy Bacteria or virus

Scarring in Bacteria Bacteria:

upper eyelids

and viruses often gonorrhea

Poor diet Injury blunt or sharp Small particle on cornea or under eyelids Too much reading

Prevented by

Treated by Tetracycline 1% eye ointment 3 times daily for 3 weeks or tetracycline 3% eye ointment once daily for 3 weeks Surgery-refer to eye clinic Tetracycline lo/, eye ointment 3 times daily x 7 days (1) Careful. frequent cleaning of eyes, (2) local and systemic antibiotics. (3) REFER INFANT AND PARENTS TO CLINIC 0.5% Zinc sulphate eye drops 2 times daily. for 2 weeks Tetracycline 1% eye ointmmt 3 times daily for 7 days. If no improvement in 3 days. refer to eye clinic (1) 200.000 I.U. Vitamin A capsule. (2) refer to eye clinic. (3) nutrition education Measure vision ; if vision is normal. place shield on eye and see patient refer to eye clinic. DO NOT PUT MEDICINE IN EYE Remove with cotton-tipped stick; tetracycline eye ointmmt and patch. If difficult to remove. refer immediately to eye clinic Education : if no improvement refer to eye clinic

Good hygiene Good hygiene Good hygiene Antibiotic eye ointment in both eyes at birth Nothing Good hygiene Good diet: green. leafy vegetables. yellow fruits and vegetables. milk and eggs Safety measures and education Use of goggles and eye protection when at work Proper light and proper reading habit

You should be able to recognize and refer the following conditions Condition 1. Cataract 2. Comeal scarring 3. White pupil in infant or child 4. Unexplained vision loss 5. Severe eye pain 6. Severe injury

Recognized by Decreased vision. white ouoil Kite scar on cornea

Caused by

Treated by

Old age or injury REFER TO EYE CLINIC Old infection. injury or malnutrition

White pupil in infant or child Cataract or tumor

NO EYE MEDICINE

Vision worse than 6/18 in one Disease inside the eyeball ‘or both eyes History of injury and loss of vision (see red eye chart)

REFER TO EYE CLINIC IMMEDIATELY

1807

Training for primary and preventive eye care

The The The The

CORNEA should be CLEAR PUPIL should be BLACK WHITE PART should be WHlTE EYELIDS should OPEN AND CLOSE PROPERLY

NEVER USE OINTMENTS OR DROPS CONTAINING STEROIDS ATROPINE UNLESS ORDERED BY EYE SPECIALIST

OR

APPENDIX 3 PRIMARY

EYE

CARE

AND BLINDNESS PREVENTION HEALTH WORKERS

G. Tumor in a baby or child H. Nutritional eye disease

CONTENT

COURSE

FOR VILLAGE

I. INTRODUCTION

IV. INJURY A. On the outside of the eyeball B. Cuts C. Foreign body D. Bums

II. PARTS OF THE EYE A. Cornea B. Pupil C. Lens D. White part E. Eyelids III.

A. B. C. D. E. F.

V. NEED FOR GLASSES VI. SAFETY

EYE DISEASES

Cataract Trachoma Conjunvititis Conjunctivities in the newborn

VIII. EXAMINING

Comeal Stye

IX. PRACTICAL

VII. HYGIENE AND SANITATION THE EYE

ulcer

SKILLS

APPENDIX 4 OPHTHALMOLOGY COURSE

V. TRAUMA A. Non-penetrating (blunt) 1. Black eye 2. Hyphema 3. Cornea1 abrasion 4. Traumatic cataract B. Penetrating (sharp) 1. Eyelid laceration 2. Conjunctival laceration 3. Comeal/scleral laceration 4. Rupture of the eyeball C. Foreign body D. Bums

CONTENT

I. INTRODUCTION II. ANATOMY AND PHYSIOLOGY A. Cornea B. Anterior chamber

C. D. E. G. H. I. J.

Iris Pupil Lens . Vitreous Retina Sclera Conjunctiva Extra-ocular muscles

K.

Eyelids

F.

III. LEADING CAUSES A. Cataract B. Trachoma C. Glaucoma

D.

OF BLINDNESS

B. C. D. E. F. G. H. I.

IN KENYA

Cornea1 scarring from disease and trauma

IV. OTHER COMMON EYE DISORDERS A. Conjunctivitis Ophthalmia neonatorum Cornea1 ulcers Retinobiastoma Hordeolum (stye) Chalazion Pingueculum Pterygium Nutritonal blindness

FOR NURSES

VI. REFRACTIVE ERRORS A. Definition B. Types 1. Myopia 2. Hyperopia 3. Astigmatism 4. Presbyopia C. Athenopia VII. PHARMACOLOGY VIII. SAFETY IX. HYGIENE

AND SANITATION

X. EXAMINATION IX. PRACTICAL GLOSSARY

OF THE PATIENT

SKILLS

1808

VICTORIA

M.

SHEFFIELD

APPENDIX

OPHTHALMOLOGY COURSE I. INTRODUCTION

FOR GENERAL

CONTENT

with Statistical Maps

II. ANATOMY A. Anterior segment B. Posterior segment C. Conjunctiva D. Extra-ocular muscles E. Eyelids and lashes F. Lacrimal system G. Bony orbit III. PHYSIOLOGY A. Cornea B. Anterior chamber angle C. Aqueous humor D. Iris E. Ciliary body ’ F. Pupil G. Lens H. Vitreous body 1. Retina J. Choroid K. Sclera L. Conjunctiva M. Eyelids IV. EXAMINATION V. PRACTICAL VI. REFRACTIVE A. B.

C.

OF THE PATIENT

SKILLS ERRORS

Definition Types 1. Myopia 2. Hyperopia 3. Astigmatism 4. Presbyopia Asthenopia

VII. LEADING CAUSES OF BLINDNESS IN KENYA A. Cataract B. Trachoma C. Glaucoma D. Comeal scarring from disease and trauma VIII. COMMON EYE DISORDERS A. Nutritional eye disease B. Conjunctivitis C. Ophthalmia neonatorum D. Comeal ulcers E. Senile macular degeneration (SMDl

5

CLINICAL

2. Fractures of the orbigal bones 3. Hyphema 4. Comeal abrasion . 5. Traumatic cataract B. Penetrating I, Eyelid lacerations 2. Conjunctival lacerations 3. Comeal/scleral lacerations 4. Rupture of the eyeball 5. Traumatic eviscerationienulceation C. Foreign body 1. Extra-ocular 2. Intra-ocular D. Bums I. Thermal 2. Chemical 3. Inra-red light 4. Ultraviolet light X. TUMORS A. Eyelids 1. Hordeolum (stye) 2. Chalazion 3. Molluscum contagiosum 4. Basal cell epithelioma 5. Squamous cell carinoma XII. NEURO-OPHTHALMOLOGY A. Visual pathways B. Visual fields C. Pupils 1. Perrla 2. Mydriasis 3. Miosis 4. Anisocoria D. Neuro-physiology of strabismus XIV. HYGIENE AND SANITATION XV. SAFETY XVI. A. B. C. D. E. F. G. H. I.

PHARMACOLOGY Safety note Mydriatics Miotics Anti-bacterial agents Steroids Fluorescein strips Topical anesthetics Chloroquine Drug sensitivities

GLOSSARY IX. TRAUMA A. Non-penetrating I. Black eye

OFFICERS

BIBLIOGRAPHY