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«PROJECT REPORT Candidate Number: 100889 MSc: Community Eye Health Title: A pilot study to involve village based volunteers in integrated primary eye ...»

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Candidate Number: 100889

MSc: Community Eye Health

Title: A pilot study to involve village based volunteers in integrated primary eye care

services under National Rural Health Mission in India.

Supervisor: Dr. GVS Murthy

Word Count: 9315

Project Length: Standard

Submitted in part fulfillment of the requirements for the degree of MSc in Community Eye


For Academic Year 2010-11


It is my privilege to be a part of International Centre for Eye Health (ICEH), as a student of MSc Community Eye Health and researcher for this work. I am extremely thankful to my sponsors ―the Commonwealth Scholarship Commission UK― for granting me full sponsorship to pursue this MSc course.

I express my sincere respect to Prof. GVS Murthy for his kind support in mentoring and supervising this work from inception to the final write up. I have always cherished my association him. He has been a constant source of inspiration.

I would like to thank my teachers from ICEH especially Prof. Clare Gilbert who taught us skills for research in eye care. I am deeply obliged for her support during inception of this study. I would like to thank my course director Dr. Daksha Patel for the valuable guidance and study material for the research work during the course of study.

I thank my MSc batch mates specially Dr. Rajesh, Dr. Rohan and Dr. Valensha for their suggestions during the time of protocol development.

I am thankful to Dr. Praveen Garg CMO Gurgaon for kind permission to conduct study in Gurgaon. I would like to express my sincere thanks to Dr. Saryu Sharma, In-charge of ASHA training, Dr. Vijay Singhal, In-charge NRHM, Gurgaon, SMO of all CHCs and their staff for supporting our team in training and research work.

I would like to acknowledge the invaluable help of Dr. Noopur Gupta and Mr. Amit Bhardwaj, in all stages of this research work.

I enjoyed the enthusiasm and participation of all ASHAs in the training. It is their sincere and hard work that helped me to prove the objectives of my research work.

I am extremely thankful to Dr. Samiksha Singh for her help in statistical analysis. I am thankful to Mr. Mahesh for his help in data management.

Last but not the least I would like to thank my wife Shachi and children Prachi and Pravesh for their moral support during this research work.








1. Introduction and overview:

1. 1. Blindness and its burden

1.2 VISION 2020- Right to Sight

1.3 Primary Health Care and Primary Eye care:

1.4 National Rural Health Mission (NRHM)

1.5 Demographic profile of India, Haryana and Gurgaon

2. Rationale, Aims and Objectives

2.1 Rationale for the study

2.2 Aims and Objectives

3. Materials and methods:

3.1. Study area

3.2. Study Design

3.3 Study tools

3.4 Pre-training assessment of ASHA for knowledge on primary eye care:

3.5 Training of ASHA:

3.6: Post training Assessment of ASHA:

3.7 Data Analysis…………………………………………………………………………………………………….….22 3.8- Ethical approval

3.9 Budget:

4. Results:

4.1 Profile and knowledge score of already trained vertical eye care volunteers................. 26

4.2 Demographic profile of ASHA:

4.3. Pre-training Knowledge of ASHA

4.4. Assessment of the skills of ASHA

4.5. Factors affecting knowledge and skills:

4.6. Barriers faced by ASHAs in delivering primary eye care

5.0 Discussion

6.0 Limitations of the study:

7.0 Conclusion:

8.0 Recommendations:



Appendix 1: CARE

Appendix 2: Ethical approval AIIMS

Appendix 3: Participants information sheet.

Appendix 4: Permission from R.P.Centre

Appendix 5: Patient Information Sheet

Appendix 6: Consent form

Appendix 7: ASHA Self-Appraisal Card

Appendix 8: study tool

Appendix 9:Training schedule…………………………………………………………….………88 Appendix 10:Reporting format ASHA ……..……………………………………………..……...90 Appendix 11: Budget

Appendix 12: Vision screening card for school age children ………………………………….90 Appendix 13: Cataract screening card ……………………………………………………… …91 Appendix 14: Photographs …………………………………………………………………………92

–  –  –

PRI: Panchayati Raj Institutes ASHA: Accredited Social Health Activist NRHM: National Rural Health Mission WHO: World Health Organization IAPB: International Agency for Prevention of Blindness NPCB: National Programme for Control of Blindness PMOA: Paramedical Ophthalmic Assistant RCH: Reproductive and Child health ORS: Oral Rehydration Solution

–  –  –

Table 1.1 Prevalence of Blindness in India Table 1.

2 Primary eye care at community level Table 1.3: Key Primary health care activities of ASHA Table 3.1: Knowledge scores for various ocular conditions

Table 4.1: Recruitment of already trained vertical eye care volunteers:

Table 4.2: Demographic characteristics of already trained vertical eye care volunteers Table 4.

3- Mean PEC knowledge score of the trained primary eye care volunteers Table 4.4: Demographic characteristics of ASHA Table 4.5: Demographic characteristics of respondent and non-respondent ASHA Table 4.6: Pre and post training mean score for the knowledge of ASHA on blindness Table 4.7: Pre and post training mean score for the knowledge of ASHA - on Cataract Table 4.8: Pre and post training mean score for the knowledge of ASHA - on Glaucoma Table 4.8: Pre and post training mean score for the knowledge of ASHA - on GlaucomaRefractive error Table 4.10: Pre and post training mean score for the knowledge of ASHA - on DR Table 4.11: Pre and post training mean score for the knowledge of ASHA on eye Injury Table 4.12: Pre and post training mean score for the knowledge on conjunctivitis Table 4.13: Pre and post training mean score for knowledge on Vitamin A deficiency Table 4.14 Pre and post training mean Knowledge score for respective eye diseases Table 4.15: Assessment of the skills of ASHA in Primary eye care Table 4.16: Participation in PEC activities after the training programme Table 4.17: Factors affecting Knowledge ASHA after training Table 4.18: Factors affecting Skills of ASHA post-training Table 4.19: Barriers faced by ASHAs in performing activities for identification of patients


Fig 1.1: Conditions requiring primary eye care for prevention of blindness Fig-3.2: Health services in district Gurgaon












APPENDIX 11: BUDGET SHEET Appendix 12: Vision screening card for school age children Appendix 13: Cataract screening card Appendix 14: Photographs



Primary eye care services are essential for common ocular morbidities and elimination of avoidable blindness. Primary eye care is important in India due to a high population burden, lack of awareness and poor access to eye care services in rural areas. Government of India launched National Rural Health Mission, an integrated programme for health care in rural areas.

Under this programme, village level health volunteer called ―Accredited Social Health Activist‖ (ASHA) have been recruited for every thousand population. Around one million ASHAs are now involved in primary health care mainly in MCH care practices. Early detection and treatment of blinding eye conditions and ocular morbidity will facilitate a reduction in magnitude of blindness if these volunteers can also be utilized in primary eye care at the community level.

Aim and objectives:

Primary objective of the current study was to develop a training curriculum for ASHA in ―Primary Eye Care‖ and to assess the change in their knowledge and skills after the training.


The training curriculum and study tools were developed after interviewing the previously trained primary eye care volunteers who were already involved in delivering primary eye care. ASHA were assessed for their knowledge in Primary eye care using a semi-structured questionnaire. A total of 69 ASHA were trained and they were reassessed for their knowledge and skills after two weeks.

Results Training resulted in significant gain in the knowledge of ASHA in primary eye care (from mean score of 31.2 to 81.4). Most ASHA could satisfactorily perform the skills (mean score 72.4 out of

100) learnt in primary eye care. Some difficulties were reported in record maintenance. After training, ASHA participated in various primary eye care activities in their area.

Conclusions and recommendations ASHA can effectively participate in community level primary eye care if supported with availability of eye care service. Performance based incentives should be included for ASHAs in facilitating cataract surgery and providing spectacles. Government of India should take steps for training of ASHA in primary eye care all over the country.


1. 1. Blindness and its burden

1.1.1 Global Burden of Blindness:

It is estimated that globally there are 39 million blind people (presenting visual acuity (VA) 3/60) (WHO) and another 246 million people have moderate to severe visual impairment (presenting VA 6/18).1The South East Asian region including India is the worst affected, with 12 million blind and 90.5 million visually impaired people, 80% of which is avoidable. 1It is estimated that cataract and glaucoma are major causes of blindness whereas uncorrected refractive error is the major cause of visual impairment in this region.1When compared to previous estimates of blindness by WHO,2the overall prevalence of blindness has reduced.

1.1.2 Blindness in India In past 40 years four major national level surveys have been conducted in India. The prevalence of blindness has shown declining trends in last 20 years. (Table 1.1)

–  –  –

1.1.3. Causes of Blindness and Visual Impairment in India:

RAAB survey (2006-07)6 showed cataract was still the single most important cause of blindness being responsible for 72% of blindness in the country. Refractive error is one of the most common causes of visual impairment and the second leading cause of blindness in India (19.6%)5. 39.3 million people are visually impaired due to uncorrected refractive error in India.8 Nearly 7% of children in the 5 to 15 years age group have myopia; most of them remain unrecognized and underserved.9 The emerging scenario in the developing world suggests that diabetes and blindness secondary to diabetic retinopathy may soon be a major problem in this part of the world as well.10 It is estimated that number of diabetics will increase from 19 million to 57 million from 1995 to 202511.Glaucoma is another important emerging cause of blindness in India responsible for around 5.8% of blindness.5 In the Aravind Comprehensive Eye Diseases study in South India, the prevalence of glaucoma in 40+ was estimated to be 2.6% for primary open angle glaucoma and 1.7% for primary angle closure glaucoma.12 Corneal blindness is another important cause of avoidable blindness with prevalence of at least one eye blindness of 0.66% in southern India.13

1.2 VISION 2020- Right to Sight Vision 2020 Right to Sight is a global initiative launched by WHO and IAPB envisaged for elimination of avoidable blindness. The key strategies are human resources development, strengthening of existing eye care infrastructure and control of conditions responsible for avoidable blindness. These were cataract, trachoma, onchocerciasis, childhood blindness, refractive error and low vision. India has also included elimination of blindness due to glaucoma and diabetic retinopathy under Vision2020 Right to Sight India plan.

1.3 Primary Health Care and Primary Eye care Primary health care (PHC) is defined as ―essential health care based on practical, scientifically sound and socially acceptable methods and technology made universally acceptable to individuals and families in the community through their full participation and at a cost that the community and the country can afford to maintain at every stage of their development in the

spirit of self-determination‖.14 There are eight key elements of PHC:

 Health education for preventing and controlling prevailing health problems.

 Promotion of food supply & proper nutrition.

 Adequate supply of safe water & basic sanitation.

 MCH care, including family planning.

 Immunization against infective diseases.

 Prevention and control of locally endemic diseases.

 Appropriate treatment of common diseases & injuries.

 Provision of essential drugs.

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