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«PROJECT REPORT Candidate Number: 105692 MSc: Public Health for Eye Care Title: To evaluate VISION2020 Paediatric Ophthalmology links. Supervisor: Dr ...»

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PROJECT REPORT

Candidate Number: 105692

MSc: Public Health for Eye Care

Title: To evaluate VISION2020 Paediatric

Ophthalmology links.

Supervisor: Dr Hannah Kuper

Word Count: 9,993

Submitted in part fulfilment of the requirements for the degree of

MSc in Public Health for Eye Care

For Academic Year 2011-2012

Table of Contents

TABLE OF TABLES

TABLE OF FIGURES

ACKNOWLEDGEMENTS

ABBREVIATIONS

Abstract

BACKGROUND

AIM

NEED

METHODS

RESULTS

CONCLUSIONS

1 INTRODUCTION

2 RATIONALE

3 EPIDEMIOLOGY

3.1 DEFINITIONS

3.2 PREVALENCE

3.3 DISTRIBUTION

3.4 CAUSES

3.5 COMMON CAUSES:

3.5.1 Vitamin A deficiency

3.5.2 Ophthalmia Neonatorum

3.5.3 Congenital cataract

3.5.4 Infantile glaucoma

3.5.5 Retinopathy of prematurity

3.5.6 Teratogens

3.5.7 Uncorrected refractive error

3.5.8 Amblyopia

3.6 VISUAL DEVELOPMENT

3.7 PREVENTION

3.7.1 Childhood Blindness and Links

3.7.2 Control and Treatments

3.8 GAPS

3.9 HEALTH LINKS

3.10 PROGRAMMES

–  –  –

4 AIMS AND OBJECTIVES

4.1 AIM

4.2 OBJECTIVES:

5 METHODOLOGY

5.1 DATA GATHERING

5.2 QUESTIONNAIRES

5.2.1 Evaluation framework for the Questionnaire

5.3 INTERVIEWS

5.4 CASE STUDY: UK/BOTSWANA

5.5 ETHICS

6 RESULTS

6.1 LITERATURE REVIEW

6.2 SITUATION ANALYSIS

6.3 A CASE STUDY: ADDENBROOKE’S, CAMBRIDGE, UK AND PRINCESS MARINA, GABORONE, BOTSWANA... 27 6.4 QUESTIONNAIRES

6.5 QUESTIONNAIRE ANALYSIS

6.5.1 Situation Analysis

6.5.2 Effectiveness and Impact

6.6 INTERVIEWS

6.7 INTERVIEW ANALYSIS

6.8 RECOMMENDATIONS FOR STRENGTHENING AND MAINTENANCE OF LINKS

7 DISCUSSION

7.1 STRENGTHS OF THE STUDY

7.2 LIMITATIONS OF THE STUDY

8 CONCLUSION

9 RECOMMENDATIONS

9.1 MONITORING AND EVALUATION

9.2 TRAINING AND COMMUNICATION

9.3 PAEDIATRIC EYE CARE EMBEDDED IN HEALTH SYSTEMS

10 REFERENCES

11 APPENDICES

ii Table of Tables TABLE 1 SHOWING CATEGORIES OF BLINDNESS AND NUMBERS IN MILLIONS ACCORDING TO THE WHO (3)

TABLE 2: UNDER 5 MORTALITY RATE RELATED TO PREVALENCE OF CHILDHOOD BLINDNESS(5)

TABLE 3 CAUSES OF CHILDHOOD BLINDNESS RELATED TO COUNTRY STATUS (PER 1,000) (5)

TABLE 4 SHOWING THE STRUCTURE OF THE QUESTIONNAIRE

TABLE 5 EVALUATION FRAMEWORK FOR THE QUESTIONNAIRE

TABLE 6 TO SHOW ANALYSIS OF LINK DATA

TABLE 7 SHOWING RESPONSE RATE TO QUESTIONNAIRES SENT

TABLE 8 SHOWING DEMOGRAPHICS FROM QUESTIONNAIRE

TABLE 9 SHOWING GENRES INVOLVEMENT IN LINKS

TABLE 10 : TO SHOW THE CONNECTION BETWEEN THE QUESTIONNAIRES AND THE OBJECTIVES OF THE STUDY

TABLE 11 INTERVIEW INFORMATION

TABLE 12 SHOWING RECURRING RESPONSES AND TRENDS FORM INTERVIEWS

TABLE 13 SHOWING RECOMMENDATIONS FOR STRENGTHENING AND MAINTENANCE OF LINKS

Table of Figures FIGURE 1 GLOBAL CHILDHOOD BLINDNESS (8)

FIGURE 2 RELATIONSHIP BETWEEN HEALTH DEVELOPMENT INDEX AND UNDER-FIVE MORTALITY (24)

FIGURE 3 TO SHOW PREVALENCE OF THE SITE OF ABNORMALITY (5)

FIGURE 4 PRIMARY HEALTH CARE: THE 8 ESSENTIAL ELEMENTS (5)

FIGURE 5 TO SHOW THE STRUCTURE OF THE VISION2020 LINK HIERARCHY

FIGURE 6 UK AND AFRICA VISION2020 LINKS

FIGURE 7 AN OUTLINE OF THE MAIN STEPS IN THE VISION2020 LINKS MATCHING PROCESS

FIGURE 8 KEY ELEMENTS IN V2020 PAEDIATRIC LINKS (EXTRAPOLATED FROM THE LITERATURE)

iiiAcknowledgements

I would like to thank everyone who has supported me through the learning experiences of this year. Family and friends present and absent, near and far, old and new, colleagues in the UK and overseas; all have inspired me and provided invaluable motivation.

Too numerous to mention individually – I thank each and every one of you!

I am especially indebted to Dr Hannah Kuper for her reassurance, support and belief.

The value of her vast field experience and knowledge, as well as her inspirational mentoring has been instrumental in the realisation of this dissertation. Warm thanks also to Professor Clare Gilbert who guided me through the first few months of the course.

I would like to extend my sincere gratitude to Dr Daksha Patel for her tireless work in providing the best possible quality throughout the course, especially the excellence and calibre of the lecturers, national and international, many the absolute best in their field; it has been an honour to have learnt from their great wealth of experience and insight.

Sincere thanks to all who work at ICEH; their determination for global equality and fairness in the quest to provide sight for all has truly been inspiring. Their passion to this end will remain with me long after completion of the course.

Thank you to my classmates and friends for life, from whom I have learnt a so much about many things, much through our discussions of living and working in our various cultures. I am sincerely indebted to each of you for your enthusiasm, kindness and friendship.





I would like to dedicate this MSc dissertation to my father.

–  –  –

SMART Specific, measureable, achievable, realistic and time-bound SPROG Scottish Paediatric Ophthalmology Group THET Tropical Health and Educational Trust

–  –  –

Background Childhood blindness is a global issue, with an estimated 1.4 million blind children (1), the majority living in developing countries; predominantly in Asia and Africa. Vision loss in children can be treated and in many cases prevented. The VISION 2020 Links programme supports partnerships between the United Kingdom (UK) and overseas institutions, mostly in Africa. The programme promotes peer-learning and long-term support aiming to increase knowledge and capacity to all individuals involved and their working environments.

Aim To evaluate the effectiveness and impact of the Vision 2020 Links Programmes in Paediatric Ophthalmology.

Need To assess health links, measures of effectiveness and impact should be available to provide indicators for analysis, to present to funders and in order to appraise their effect.

Methods In order to evaluate the effectiveness of the VISION2020 links programmes a literature review was conducted to ascertain current opinions and trends; this included reviewing the grey and published literature and data from the VISION2020 coordinator. The study included data gathered in the form of structured questionnaires with link participants, semi structured interviews and a situation analysis.

Results The VISION20020 links are perceived by all contributors to be extremely beneficial and successful. Sharing of skills with partners and training has been well appreciated and it perceived that this has impact the delivery of paediatric eye health services. There is little quantitative data to support this as there are inconsistencies in reporting as well as the monitoring and evaluation of programmes.

Conclusions In order to strengthen VISON 2020 Paediatric ophthalmology links this study recommends more stringent monitoring and evaluation, sharing of resources for training and improved communication between links. Paediatric Eye Care must be highlighted across all health sectors and embedded in health systems for childhood blindness to be reduced in line with the aims of V2020.

vi 1 Introduction

The Tropical Health and Educational Trust (THET) define Health Links as:

“….. long‐term partnerships between UK health institutions and their counterparts in developing countries. The aim of Links is to improve health services in developing countries through the reciprocal exchange of skills, knowledge and experience between partners in the UK and those overseas.”(2) „VISION 2020: the Right to Sight‟ is a partnership between the World Health Organization (WHO) and the International Association for the Prevention of Blindness (IAPB) which was initiated in 2004 in response to the world‟s burden of blindness. 285 million people are visually impaired (i.e. vision below 6/60), 39 million are blind (i.e. below 3/60) and 246 million have low vision (i.e. below 6/18).(3) Surveys from 39 countries concluded that 43% of visual impairment is caused by uncorrected refractive error and 43% by cataract.(4) 80% of blindness is preventable and VISION 2020 aims to eliminate avoidable blindness by the year 2020.

The WHO views the control of blindness in children to be a top priority within the VSION2020: Right to Sight programme.(5) It is estimated that 1.4 million children are blind, predominantly from middle-income and low-income countries, the majority of whom live in the poorest regions of Africa and Asia.(1, 6) Untreated these children face a lifetime of blindness in front of them which is estimated to be 75 million blind-years.(7) In different regions, there are marked differences in the causes of paediatric blindness, attributed in many instances to socio-economic factors.(8) Accurate economic adjustments do not exist for the calculation of DALY‟s (Disability adjusted Life years) or HALY‟s (Health adjusted Life years) with regards to child blindness but this is an important future economic consideration in view of the far reaching life-long impact.(9, 10) In developing countries 50% of the population are children younger than 15 years of age; 5% of worldwide blindness is in this age group.(8) It is estimated that 50% of children die within two years of becoming blind and in many cases from preventable causes – this is a significant public health issue. (11) It has been argued that aid and assistance globally from developed countries to developing and under developed nations is of questionable value in the long term. Are developed nations actually supporting change or assisting development or in fact are we in fact fuelling the reverse?(12) We cannot assume as the giver of support that we know the best and/or the most appropriate way to deliver support. The „need‟ must be identified by the partner to satisfy short and long term needs and the inevitable success that accompanies this.

(12) Is the contribution of aid and donations towards developing country settings actually contributing towards economic growth and a public benefit?(13) It is therefore the aim of this dissertation to evaluate the strengths, weaknesses‟ and contributions within Paediatric Ophthalmology VISION2020 Link Partnerships, as well as discussing recommendations to contribute to positively enhancing the programmes.

2 Rationale The VISION2020 Links programme was established in 1999 as part of an initiative by the WHO and the IAPB. In 2002 United Nations Millennium Development project highlighted the importance of collaborative global working across health sectors to support and encourage improved health status in the developing world, in order to eliminate avoidable blindness.

V2020 develops partnerships between the UK and overseas links, predominantly in Africa.

The Needs Assessments process of the programme identifies the necessity for development in children‟s eye care services and therefore Paediatric Ophthalmology is included as part of the programme, in the effort to impact the prevalence of childhood blindness to reduce it from 0.75/1,000 to 0.4/1,000 by 2020. (11) The V2020 coordinators are aiming to achieve effective and positive outcomes through realising the aims and objectives of the Links programme. Paediatric Ophthalmology Link leads, staff from the UK and link partners have given many hours voluntarily, to develop their projects through visits, collaborative working and training. The aim is that effectiveness is impacted through training, development of knowledge and collaborative working. Human resource development is not only limited to training but extends to support and to translate knowledge into effective practise.(14) The dissertation aims to evaluate the VISION2020 Paediatric Links programme‟s effectiveness, with special reference to training, and to recommend how the programme‟s effectiveness and impact may be enhanced in the future.

3 Epidemiology 3.1 Definitions The UNICEF definition of a „child‟ is an individual under the age of 16 years, although WHO considers less than 14 years to be a „child‟.

Table 1 showing categories of blindness and numbers in millions according to the WHO (3)

–  –  –

3.2 Prevalence As childhood blindness is relatively rare, it is difficult to calculate and measure prevalence accurately, large sample sizes and large longitudinal studies are required to achieve this.(15). The association with the country‟s infant mortality is a proxy measure of childhood blindness prevalence; it is highest in Africa and Asia, where the child population is also high. 75% of blind children live in developing countries, and of these, over 40% of cases are preventable. These include measles, vitamin A deficiency, prematurity and genetic syndromes.(16) Blindness may also be directly related to mortality; a child blind before their second birthday has a 50% chance of surviving to their fifth birthday. (5) The causes of child blindness may also cause of death. Childhood Blindness leads to the equivalent of 75 million „blind years‟, based on present figures, which has significant economic impact and presents as a major public health challenge.(17)

3.3 Distribution

Childhood blindness is strongly linked with malnutrition, poverty, poor sanitation and hygiene, illiteracy and poor access to health services. (18) The data available indicates the large divide and differences in prevalence between the wealthiest and poorest countries – up to a difference of ten times; 0.1/1000 children (0-15 years) in wealthy countries to 1.1/1000 children in the poorest. (19) The highest prevalence is in South-east Asia and Africa. (17)

–  –  –



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