Needs and views on eye health and women's empowerment and theory of change map: implication on the development of a women-targeted eyecare programme for older Zanzibari craftswomen.

OBJECTIVES: To assess needs and views regarding eye health and empowerment from craftswomen's perspectives to develop a theory of change (ToC) for a women-targeted eyecare programme. MATERIAL AND METHODS: Eighteen stakeholders participated in a 2-day consultation workshop in Zanzibar. The composition was (1) 15 women and 3 men; (2) Unguja (n=8), Pemba (n=6) and Tanzania mainland (n=4) and (3) craftswomen (n=14) and governmental stakeholders (n=4). Thematic analysis determined the craftswomen's needs and views regarding eye health and empowerment and subsequently inputs, activities, outputs, outcomes and impact to develop the programme's initial ToC. In refining the initial ToC, we used insights from a qualitative study suggesting that improved near vision is perceived by craftswomen as a potential source of empowerment across economic, psychological, social, political and educational dimensions. RESULTS: The eye conditions experienced by the craftswomen were eye irritation caused by foreign bodies, the need for near spectacles and other eye morbidities. They were advised by the cooperatives to visit eye health centres for treatment. The main barriers to accessing services were inaccessibility and unaffordability of eye services and a lack of eye health knowledge and practices. Nineteen subthemes on women empowerment (economic n=4, social n=4, psychological n=6, education n=2 and political n=3) were obtained. We created a ToC on how investing in improving craftswomen near vision could achieve empowerment. CONCLUSION: The participants provided insights into their needs and how they would like the eyecare programme to be implemented and how they see they could be empowered in the process.

Subjective Wellbeing, Work Performance and Lived Experience of Zanzibari Women Entrepreneurs with Uncorrected Functional Presbyopia: A Pre-Post Mixed-Methods Study.

PURPOSE: Uncorrected presbyopia has been shown to reduce Zanzibari women's quality of life. In this mixed-methods study, we examined the subjective wellbeing and self-reported work performance among older women entrepreneurs with functional presbyopia before and shortly after correction, and how poor vision at close distance affected their daily lives. METHODS: Women entrepreneurs underwent eye examination to identify those with uncorrected functional presbyopia. Their subjective wellbeing and work performance were both measured in Cantril's ladder. Ready-made glasses were then provided and 30 minutes to an hour later, their subjective wellbeing and work performance was remeasured. Twenty women entrepreneurs were interviewed to understand their lived experience with uncorrected presbyopia. RESULTS: Two-hundred-seventeen women entrepreneurs were included in the survey (mean age 51.6 years, SD 8.64). Women entrepreneurs had a mean subjective wellbeing score of 3.32 (SD 1.10) pre-correction and 5.99 (SD 1.13) post-correction (p < .001), and a mean self-rated current work performance score of 4.62 (SD 1.36) before correction and 5.47 (SD 1.35) post-correction (p < .001). One-hundred-and-ninety (87.6%) and 121 women entrepreneurs (55.8%) rated their current subjective wellbeing and work performance scores < 5, respectively. Around 1/4 of women entrepreneurs reported having severe difficulties with near tasks. CONCLUSION: Poor vision at a close distance caused by uncorrected functional presbyopia negatively affected economic, physical and psychosocial aspects of women entrepreneurs' lives. Subjective wellbeing and self-reported work productivity scores improved significantly shortly after presbyopia was corrected. More research with longer follow-up is needed to understand the full benefits of correcting presbyopia.

Refractive error, eye care needs and attitude towards spectacle wearing among older Zanzibari craftswomen and implications for developing women-targeted services: a cross-sectional study.

BACKGROUND: Aged Zanzibari women are in a disadvantaged position, having high demand for near-vision spectacles. Currently, there is no information on the eye health status of craftswomen, which makes planning a women-targeted project to deliver eye health services to older craftswomen in Zanzibar difficult. We assessed the prevalence of vision impairment, refractive error, presbyopia, effective spectacle coverage (distance and near) and attitude towards spectacle wearing among older Zanzibari craftswomen. METHODS AND ANALYSIS: This was a cross-sectional study. Unaided and presenting distance and near vision of craftswomen 35 years and older were assessed at the women's co-operatives. We determined the number of those with distance vision poorer than 6/12 and their causes (distance-vision impairment), the number of those with near vision poorer than N8 at 40 cm (presbyopia) and the number of those whose distance and/or near-vision needs were met adequately with their habitual spectacles (effective distance and near spectacle coverages). A piloted and validated questionnaire (15 statements) was used to determine their attitude towards spectacle wearing. RESULTS: In all, 263 craftswomen participated in the survey (mean age 52.1 years±9.4 years). The prevalence of distance vision impairment among the craftswomen was 29.7% (95% CI 24.2% to 35.6%), the primary cause being uncorrected refractive error (n=51, 65.4%), and none were corrected. The prevalence of presbyopia was 86.6% (95% CI 81.5% to 90.7%, n=231) and the effective near spectacle coverage was 0.99%. The craftswomen showed a positive attitude towards spectacle wearing (strongly agree or agree) based on 12 out of 15 statements. CONCLUSION: The high burden of vision impairment, uncorrected distance refractive error and presbyopia, and a positive attitude towards spectacle wearing among older craftswomen in Zanzibar indicated the need for women-targeted eye health programmes in low-resource settings.

How does a pair of near-vision spectacle correction empower older Zanzibari craftswomen?: A qualitative study on perception.

BACKGROUND: Studies have shown that correcting presbyopia among women could increase short-term income and quality of life. However, it is unclear whether these short-term outcomes translate to long-term empowerment. This is partly due to women's empowerment being under-studied in the eye health field. Hence, we attempted to understand Zanzibari craftswomen's perception of how near-vision spectacle correction could empower them. METHODS: Semi-structured interviews were conducted with 24 craftswomen with presbyopia (7 to 21 April 2022), identified from Zanzibari cooperatives using quota and heterogeneity sampling. We included a sample of tailors, beaders/weavers, and potters who were 40 years and older. Directed content analysis was performed on interview transcripts. RESULTS: Two themes and seven sub-themes emerged from the data. Craftswomen perceived that at the personal level, near-vision spectacle correction could improve their economic empowerment (better income and savings and buying things for themselves), psychological empowerment (more self-confidence and decision-making), political empowerment (taking up leadership roles), and educational empowerment (acquiring new skills). At a relational level, they perceived that near-vision spectacle correction could bring about economic empowerment (ability to buy things for the family), social empowerment (ability to participate in social activities), and educational empowerment (ability to educate other women). CONCLUSION: Older craftswomen perceived that correcting near vision could empower them at personal and relational levels that encompass economic, psychological, social, political and educational empowerment. The findings laid the foundation for future research into eye health and women's empowerment.

Survey of ophthalmologists-in-training in Eastern, Central and Southern Africa: A regional focus on ophthalmic surgical education.

Background: There are 2.7 ophthalmologists per million population in sub-Saharan Africa, and a need to train more. We sought to analyse current surgical training practice and experience of ophthalmologists to inform planning of training in Eastern, Central and Southern Africa. Methods: This was a cross-sectional survey. Potential participants included all current trainee and recent graduate ophthalmologists in the Eastern, Central and Southern African region. A link to a web-based questionnaire was sent to all heads of eye departments and training programme directors of ophthalmology training institutions in Eastern, Central and Southern Africa, who forwarded to all their trainees and recent graduates. Main outcome measures were quantitative and qualitative survey responses. Results: Responses were obtained from 124 (52%) trainees in the region. Overall level of satisfaction with ophthalmology training programmes was rated as 'somewhat satisfied' or 'very satisfied' by 72%. Most frequent intended career choice was general ophthalmology, with >75% planning to work in their home country post-graduation. A quarter stated a desire to mainly work in private practice. Only 28% of junior (first and second year) trainees felt surgically confident in manual small incision cataract surgery (SICS); this increased to 84% among senior trainees and recent graduates. The median number of cataract surgeries performed by junior trainees was zero. 57% of senior trainees were confident in performing an anterior vitrectomy. Only 29% of senior trainees and 64% of recent graduates were confident in trabeculectomy. The mean number of cataract procedures performed by senior trainees was 84 SICS (median 58) and 101 phacoemulsification (median 0). Conclusion: Satisfaction with post-graduate ophthalmology training in the region was fair. Most junior trainees experience limited cataract surgical training in the first two years. Focused efforts on certain aspects of surgical education should be made to ensure adequate opportunities are offered earlier on in ophthalmology training.

Mapping human resources for eye health in 21 countries of sub-Saharan Africa: current progress towards VISION 2020.

BACKGROUND: Development of human resources for eye health (HReH) is a major focus of the Global Action Plan 2014 to 2019 to reduce the prevalence of avoidable visual impairment by 25% by the year 2019. The eye health workforce is thought to be much smaller in sub-Saharan Africa than in other regions of the world but data to support this for policy-making is scarce. We collected HReH and cataract surgeries data from 21 countries in sub-Sahara to estimate progress towards key suggested population-based VISION 2020 HReH indicators and cataract surgery rates (CSR) in 2011. METHODS: Routinely collected data on practitioner and surgery numbers in 2011 was requested from national eye care coordinators via electronic questionnaires. Telephone and e-mail discussions were used to determine data collection strategies that fit the national context and to verify reported data quality. Information was collected on six practitioner cadres: ophthalmologists, cataract surgeons, ophthalmic clinical officers, ophthalmic nurses, optometrists and 'mid-level refractionists' and combined with publicly available population data to calculate practitioner to population ratios and CSRs. Associations with development characteristics were conducted using Wilcoxon rank sum tests and Spearman rank correlations. RESULTS: HReH data was not easily available. A minority of countries had achieved the suggested VISION 2020 targets in 2011; five countries for ophthalmologists/cataract surgeons, four for ophthalmic nurses/clinical officers and two for CSR. All countries were below target for optometrists, even when other cadres who perform refractions as a primary duty were considered. The regional (sample) ratio for surgeons (ophthalmologists and cataract surgeons) was 2.9 per million population, 5.5 for ophthalmic clinical officers and nurses, 3.7 for optometrists and other refractionists, and 515 for CSR. A positive correlation between GDP and CSR as well as many practitioner ratios was observed (CSR P = 0.0042, ophthalmologists P = 0.0034, cataract surgeons, ophthalmic nurses and optometrists 0.1 > P > 0.05). CONCLUSIONS: With only a minority of countries in our sample having reached suggested ophthalmic cadre targets and none having reached targets for refractionists in 2011, substantially more targeted investment in HReH may be needed for VISION 2020 aims to be achieved in sub-Saharan Africa.

Trends and implications for achieving VISION 2020 human resources for eye health targets in 16 countries of sub-Saharan Africa by the year 2020.

BACKGROUND: Development of human resources for eye health (HReH) is a major global eye health strategy to reduce the prevalence of avoidable visual impairment by the year 2020. Building on our previous analysis of current progress towards key HReH indicators and cataract surgery rates (CSRs), we predicted future indicator achievement among 16 countries of sub-Saharan Africa by 2020. METHODS: Surgical and HReH data were collected from national eye care programme coordinators on six practitioner cadres: ophthalmologists, cataract surgeons, ophthalmic clinical officers, ophthalmic nurses, optometrists and 'mid-level refractionists' and combined them with publicly available population data to calculate practitioner-to-population ratios and CSRs. Data on workforce entry and exit (2008 to 2010) was used to project practitioner population and CSR growth between 2011 and 2020 in relation to projected growth in the general population. Associations between indicator progress and the presence of a non-physician cataract surgeon cadre were also explored using Wilcoxon rank sum tests and Spearman rank correlations. RESULTS: In our 16-country sample, practitioner per million population ratios are predicted to increase slightly for surgeons (ophthalmologists/cataract surgeons, from 3.1 in 2011 to 3.4 in 2020) and ophthalmic nurses/clinical officers (5.8 to 6.8) but remain low for refractionists (including optometrists, at 3.6 in 2011 and 2020). Among countries that have not already achieved target indicators, however, practitioner growth will be insufficient for any additional countries to reach the surgeon and refractionist targets by year 2020. Without further strategy change and investment, even after 2020, surgeon growth is only expected to sufficiently outpace general population growth to reach the target in one country. For nurses, two additional countries will achieve the target while one will fall below it. In 2011, high surgeon practitioner ratios were associated with high CSR, regardless of the type of surgeon employed. The cataract surgeon workforce is growing proportionately faster than the ophthalmologist. CONCLUSIONS: The HReH workforce is not growing fast enough to achieve global eye health targets in most of the sub-Saharan countries we surveyed by 2020. Countries seeking to make rapid progress to improve CSR could prioritise investment in training new cataract surgeons over ophthalmologists and improving surgical output efficiency.

Evidence for integrating eye health into primary health care in Africa: a health systems strengthening approach.

BACKGROUND: The impact of unmet eye care needs in sub-Saharan Africa is compounded by barriers to accessing eye care, limited engagement with communities, a shortage of appropriately skilled health personnel, and inadequate support from health systems. The renewed focus on primary health care has led to support for greater integration of eye health into national health systems. The aim of this paper is to demonstrate available evidence of integration of eye health into primary health care in sub-Saharan Africa from a health systems strengthening perspective. METHODS: A scoping review method was used to gather and assess information from published literature, reviews, WHO policy documents and examples of eye and health care interventions in sub-Saharan Africa. Findings were compiled using a health systems strengthening framework. RESULTS: Limited information is available about eye health from a health systems strengthening approach. Particular components of the health systems framework lacking evidence are service delivery, equipment and supplies, financing, leadership and governance. There is some information to support interventions to strengthen human resources at all levels, partnerships and community participation; but little evidence showing their successful application to improve quality of care and access to comprehensive eye health services at the primary health level, and referral to other levels for specialist eye care. CONCLUSION: Evidence of integration of eye health into primary health care is currently weak, particularly when applying a health systems framework. A realignment of eye health in the primary health care agenda will require context specific planning and a holistic approach, with careful attention to each of the health system components and to the public health system as a whole. Documentation and evaluation of existing projects are required, as are pilot projects of systematic approaches to interventions and application of best practices. Multi-national research may provide guidance about how to scale up eye health interventions that are integrated into primary health systems.