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Population need for primary eye care in Rwanda: A national survey.

ABSTRACT: BACKGROUND:Universal access to Primary Eye Care (PEC) is a key global initiative to reduce and prevent avoidable causes of visual impairment (VI). PEC can address minor eye conditions, simple forms of uncorrected refractive error (URE) and create a referral pathway for specialist eye care, thus offering a potential solution to a lack of eye health specialists in low-income countries. However, there is little information on the population need for PEC, including prevalence of URE in all ages in Sub-Saharan Africa. METHODS:A national survey was conducted of people aged 7 and over in Rwanda in September-December 2016. Participants were selected through two-stage probability proportional to size sampling and compact segment sampling. VI (visual acuity<6/12) was assessed using Portable Eye Examination Kit (PEEK); URE was detected using a pinhole and presbyopia using local near vision test. We also used validated questionnaires to collect socio-demographic and minor eye symptoms information. Prevalence estimates for VI, URE and need for PEC (URE, presbyopia with good distance vision, need for referrals and minor eye conditions) were age and sex standardized to the Rwandan population. Associations between age, sex, socio-economic status and the key outcomes were examined using logistic regression. RESULTS:4618 participants were examined and interviewed out of 5361 enumerated (86% response rate). The adjusted population prevalence of VI was 3.7% (95%CI = 3.0-4.5%), URE was 2.2% (95%CI = 1.7-2.8%) and overall need for PEC was 34.0% (95%CI = 31.8-36.4%). Women and older people were more likely to need PEC and require a referral. CONCLUSIONS:Nearly a third of the population in Rwanda has the potential to benefit from PEC, with greater need identified in older people and women. Universal access to PEC can address unmet eye health needs and public health planning needs to ensure equitable access to older people and women.

SUBMITTER: Bright T

PROVIDER: S-EPMC5929506 | biostudies-literature | 2018

REPOSITORIES: biostudies-literature

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Population need for primary eye care in Rwanda: A national survey.

Bright Tess T Kuper Hannah H Macleod David D Musendo David D Irunga Peter P Yip Jennifer L Y JLY

PloS one 20180501 5

<h4>Background</h4>Universal access to Primary Eye Care (PEC) is a key global initiative to reduce and prevent avoidable causes of visual impairment (VI). PEC can address minor eye conditions, simple forms of uncorrected refractive error (URE) and create a referral pathway for specialist eye care, thus offering a potential solution to a lack of eye health specialists in low-income countries. However, there is little information on the population need for PEC, including prevalence of URE in all a ...[more]

PMID: 29715288

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Project description:BackgroundVisual impairment is a global public health problem, with an estimated 285 million affected globally, of which 43% are due to refractive error. A lack of specialist eye care in low and middle-income countries indicates a new model of care would support a task-shifting model and address this urgent need. We describe the features and results of the process evaluation of a national primary eye care (PEC) programme in Rwanda.MethodsWe used the Medical Research Council process evaluation framework to examine the implementation of the PEC programme, and to determine enablers and challenges to implementation. The process evaluation uses a mixed methods approach, drawing on results from several sources including a survey of 574 attendees at 50 PEC clinics, structured clinical observations of 30 PEC nurses, in-depth interviews with 19 key stakeholders, documentary review and a participatory process evaluation workshop with key stakeholders to review collated evidence and contextualize the results.ResultsStructured clinical assessment indicated that the PEC provided is consistent with the PEC curriculum, with over 90% of the clinical examination processes conducted correctly. In 4 years, programme monitoring data showed that nearly a million PEC eye examinations had been conducted in every health centre in Rwanda, with 2707 nurses trained. The development of the eye health system was an important enabler in the implementation of PEC, where political support allowed key developments such as inclusion of eye-drops on the essential medicines list, the inclusion of PEC on insurance benefits, the integration of PEC indicators on the health management information systems and integration of the PEC curriculum into the general nursing school curriculum. Challenges included high turnover of primary care nurses, lack of clarity and communication on the future funding of the programme, competing priorities for the health sector and sustained supervision to assure quality of care.ConclusionsA model of a national primary eye care programme is presented, with service delivery to all areas in Rwanda. Key learning from this evaluation is the importance of strengthening the eye health care system, together with a strong focus on training primary care nurses using a PEC curriculum.

Project description:BackgroundA substantial fraction of dizzy patients are assessed by neurologists and ear-nose-throat (ENT) physicians. With the differential diagnosis being broad and often different specialties involved, we aimed to assess the interaction with generalists from the specialists' perspective to identify limitations and needs and to define strategies for improvement in patient care and education by the specialist.MethodsOne hundred eleven board-certified neurologists (n = 62) and ENT physicians (n = 49) working in Switzerland participated in an online survey. Here, we focused on limitations faced in the diagnostic workup and treatment of the dizzy patient and potential strategies to improve the standard of care and the interaction between generalists and specialists. Descriptive statistical analyses were performed. We hypothesized that those specialists applying modern concepts in history-taking and bedside examination techniques reach a specific diagnosis more often and request fewer referrals.ResultsSpecialists indicated higher confidence in reaching a specific diagnosis for patients presenting with acute dizziness than episodic/chronic dizziness (80% vs. 60%) at the first consultation. Knowledge of the timing-and-trigger concept [odds ratio (OR) = 0.81 (0.67-0.98), p = 0.034], as well as of subtle oculomotor/vestibular signs [OR = 0.80 (0.68-0.94), p = 0.007] was predictive of the self-reported probability of reaching a specific diagnosis in patients with episodic/chronic dizziness, while no such differences were observed in the care of acutely dizzy patients. Further referrals of acutely dizzy patients were significantly higher in neurologists than in ENT physicians (17% vs. 10%, p < 0.001) and in specialists located in the Latin part of Switzerland [OR = 2.84 (1.63-4.93), p < 0.001], while this was not the case for patients with episodic/chronic dizziness. Identified unmet needs included regular communication between physicians (27%/53%; always/often true) and sufficiently detailed information on the previous workup from the referrals (27%/53%). Specialists expressed most interest in hands-on courses/workshops, webinars, and practical guidelines for education.ConclusionIn our survey, bedside state-of-the-art assessments were key in reducing the fraction of unclear dizzy cases. Several gaps were identified that should be addressed. Specifically, referring physicians should provide more comprehensive details regarding urgency, prior diagnostics, and treatment. Specifically, when promoting the knowledge of neurologists and ENT physicians, this should be preferentially done by offering a combination of hands-on courses and webinars.

Project description:ImportanceUnderstanding eye care use over time is essential to estimate continued unmet health care needs and help guide future public health priorities.ObjectiveTo update trends in using eye care and affording eyeglasses in the United States.Design, setting, and participantsThis analysis of data from the US National Health Interview Survey included adults 18 years and older from 9 annual cross-sectional population-based samples ranging in size from 21 781 to 36 697 participants from 2008 to 2016. Data were analyzed from August 2017 to February 2018.ExposuresVisual impairment, defined as self-reported difficulty seeing despite wearing eyeglasses.Main outcomes and measuresOutcome measures included visits to an eye care professional and inability to afford eyeglasses when needed in the past year. Survey logistic regression, adjusted for age, sex, race/ethnicity, visual impairment status, education, employment, general health, poverty-income ratio, and vision insurance, was used to examine associations between survey year and eye care outcomes.ResultsAnalyses included 9 annual cross-sectional population-based samples pooled from 2008 to 2016, ranging in size from 21 781 to 36 697 participants aged 18 years or older. Compared with 2008, greater proportions of the US population were 65 years or older, Hispanic, or Asian in 2016. There was a significant trend for eye care use and difficulty affording eyeglasses from 2008 to 2016. In fully adjusted models, Americans were less likely to use eye care in 2014 compared with 2008 (odds ratio [OR], 0.90; 99.9% CI, 0.82-0.98; P < .001). Compared with 2008, Americans were also less likely to report difficulty affording eyeglasses from 2014 onwards (2014: OR, 0.82; 99.9% CI, 0.69-0.97; P < .001; 2015: OR, 0.81; 99.9% CI, 0.69-0.96; P < .001; 2016: OR, 0.70; 99.9% CI, 0.59-0.82; P < .001). After adjusting for all covariates, including survey year, those with visual impairment compared with those without were more likely to use eye care (OR, 1.54; 99.9% CI, 1.45-1.65; P < .001) but had greater difficulty affording eyeglasses (OR, 3.86; 99.9% CI, 0.58-0.72; P < .001). Women were also more likely to use eye care (OR, 1.42; 99.9% CI, 1.37-1.48; P < .001) and report difficulty affording eyeglasses (OR, 1.68; 99.9% CI, 1.56-1.81; P < .001) compared with men. Compared with non-Hispanic white individuals, black, Asian, and Hispanic individuals were less likely to use eye care, and Asian and black individuals were less likely to have difficulty affording eyeglasses.Conclusions and relevanceThese data indicate decreased difficulty affording eyeglasses among Americans from 2014 to 2016, possibly related to economic recovery and health care reform. However, the findings suggest women and racial/ethnic minorities are more likely to have lower use of eye care or inability to afford eyeglasses.

Project description:Background and objectives: Although primary care clinicians provide >60% of U.S. asthma care, no nationally representative study has examined variation in adherence among primary care groups to four cornerstone domains of the Expert Panel Report-3 asthma guidelines: assessment/monitoring, patient education, environmental assessment, and medications. We used the 2012 National Asthma Survey of Physicians: National Ambulatory Medical Care Survey to compare adherence by family/general medicine practitioners (FM/GM), internists, pediatricians and Community Health Center mid-level clinicians (CHC). Methods: Adherence was self-reported (n = 1355 clinicians). Adjusted odds of almost always adhering to each recommendation (≥75% of the time) were estimated controlling for clinician/practice characteristics, and agreement and self-efficacy with guideline recommendations. Results: A higher percentage of pediatricians adhered to most assessment/monitoring recommendations compared to FM/GM and other groups (e.g. 71.6% [SE 4.0] almost always assessed daytime symptoms versus 50.6% [SE 5.1]-51.1% [SE 5.8], t-test p < 0.05) but low percentages from all groups almost always performed spirometry (6.8% [SE 2.0]-16.8% [SE 4.7]). Pediatricians were more likely to provide asthma action/treatment plans than FM/GM and internists. Internists were more likely to assess school/work triggers than pediatricians and CHC (environmental assessment). All groups prescribed inhaled corticosteroids for daily control (84.0% [SE 3.7]-90.7% [SE 2.5]) (medications). In adjusted analyses, pediatric specialty, high self-efficacy and frequent specialist referral were associated with high adherence. Conclusions: Pediatricians were more likely to report high adherence than other clinicians. Self- efficacy and frequent referral were also associated with adherence. Adherence was higher for history-taking recommendations and lower for recommendations involving patient education, equipment and expertise.

Project description:Timely outreach to individuals in an advanced stage of illness offers opportunities to exercise decision control over health care. Predictive models built using Electronic health record (EHR) data are being explored as a way to anticipate such need with enough lead time for patient engagement. Prior studies have focused on hospitalized patients, who typically have more data available for predicting care needs. It is unclear if prediction driven outreach is feasible in the primary care setting. In this study, we apply predictive modeling to the primary care population of a large, regional health system and systematically examine the impact of technical choices, such as requiring a minimum number of health care encounters (data density requirements) and aggregating diagnosis codes using Clinical Classifications Software (CCS) groupings to reduce dimensionality, on model performance in terms of discrimination and positive predictive value. We assembled a cohort of 349,667 primary care patients between 65 and 90?years of age who sought care from Sutter Health between July 1, 2011 and June 30, 2014, of whom 2.1% died during the study period. EHR data comprising demographics, encounters, orders, and diagnoses for each patient from a 12?month observation window prior to the point when a prediction is made were extracted. L1 regularized logistic regression and gradient boosted tree models were fit to training data and tuned by cross validation. Model performance in predicting one year mortality was assessed using held-out test patients. Our experiments systematically varied three factors: model type, diagnosis coding, and data density requirements. We found substantial, consistent benefit from using gradient boosting vs logistic regression (mean AUROC over all other technical choices of 84.8% vs 80.7% respectively). There was no benefit from aggregation of ICD codes into CCS code groups (mean AUROC over all other technical choices of 82.9% vs 82.6% respectively). Likewise increasing data density requirements did not affect discrimination (mean AUROC over other technical choices ranged from 82.5% to 83%). We also examine model performance as a function of lead time, which is the interval between death and when a prediction was made. In subgroup analysis by lead time, mean AUROC over all other choices ranged from 87.9% for patients who died within 0 to 3?months to 83.6% for those who died 9 to 12?months after prediction time.

Project description:BackgroundAlthough quality postnatal care (PNC) is a known significant intervention for curbing maternal and newborn morbidity and mortality, it is underutilized in most developing countries including Rwanda. Thus, it is crucial to identify factors that facilitate or occlude receipt of adequate PNC. This study aimed at assessing the prevalence of adequate PNC content and the associated factors in Rwanda.MethodsWe used weighted data from the Rwanda Demographic and Health Survey (RDHS) of 2020, comprising of 4456 women aged 15-49 years, who were selected using multistage sampling. Adequate PNC was considered if a woman had received all of the five components; having the cord examined, temperature of the baby measured, counselling on newborn danger signs, counselling on breastfeeding and having an observed breastfeeding session. We, then, conducted multivariable logistic regression to explore the associated factors, using SPSS version 25.ResultsOut of the 4456 women, 1974 (44.3, 95% confidence interval (CI): 43.0-45.9) had received all the PNC components. Having no radio exposure (adjusted odds ratio (AOR) =1.41, 95% CI: 1.18-1.68), visited by a fieldworker (AOR = 1.35, 95% CI: 1.16-1.57), no big problem with distance to a health facility (AOR = 1.50, 95% CI:1.24-1.81), and residing in the Southern region (AOR = 1.75, 95% CI: 1.42-2.15) were associated with higher odds of adequate PNC compared to their respective counterparts. However, having no exposure to newspapers/magazines (AOR = 0.74, 95% CI: 0.61-0.89), parity of less than 2 (AOR = 0.67, 95% CI: 0.51-0.86), being a working mother (AOR = 0.73, 95% CI: 0.62-0.85), no big problem with permission to seek healthcare (AOR = 0.54, 95% CI: 0.36-0.82), antenatal care (ANC) frequency of less than 4 times (AOR = 0.79, 95% CI: 0.62-0.85), inadequate ANC quality (AOR = 0.56, 95% CI: 0.46-0.68), and getting ANC in a public facility (AOR = 0.57, 95% CI: 0.38-0.85) were associated with lower odds of adequate PNC.ConclusionsLess than half of the mothers in Rwanda had received adequate PNC, and this was associated with various factors. The results, thus, suggested context-specific evidence for consideration when rethinking policies to improve adequate PNC, including a need for intensified PNC education and counselling during ANC visits, continued medical education and training of PNC providers, and strengthening of maternal leave policies for working mothers.

Dataset Information

Population need for primary eye care in Rwanda: A national survey.

Publications

Population need for primary eye care in Rwanda: A national survey.

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