Process evaluation of a National Primary Eye Care Programme in Rwanda.

BACKGROUND: Visual 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. METHODS: We 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. RESULTS: Structured 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. CONCLUSIONS: A 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.

Outcomes of an elementary school-based vision screening program in North Carolina.

School nurses can play a key role in the detection of significant refractive error. The purpose of this study was to assess the impact of a statewide school nurse vision screening program by evaluating the outcomes of screening among first, third, and fifth graders in 10 schools in North Carolina during the 2009-2010 school year. Of the 2,726 children who were screened, 7.7% (n = 209) were abnormal, of which 89% (n = 186) were placed into a comprehensive database for follow-up. No documentation of any follow-up was available for 35% (n = 65) of these children. Of the 106 with complete eye examination data available, 54.7% (n = 58) had myopia, 22.6% (n = 24) had hyperopia, 11.3% (n = 12) had astigmatism, 1.9% (n = 2) had anisometropia, and 9.4% (n = 10) were normal. Even with incomplete follow-up, this screening activity led to identification of 3 cases for every 100 children screened, underscoring the importance of high-quality school-based vision screening programs.

Making sense of... photorefractive keratectomy.

The technique of photorefractive keratectomy (PRK) represents a major development in ophthalmology. Using lasers, PRK involves reshaping the cornea so that its refractive power is increased. Currently PRK can only be used to correct myopia and astigmatism, but hypermetropia may also be corrected by PRK in the near future.