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| ORIGINAL ARTICLE |
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| Year : 2022 | Volume
: 66
| Issue : 3 | Page : 282-286 |
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Effect of integrated people-centred eye care (IPEC) model on eye care seeking behaviour of community
Pallavi Shukla1, Praveen Vashist2, S Senjam Suraj3, Vivek Gupta3, Noopur Gupta4, Amit Bharadwaj5
1 Assistant Professor, Department of Preventive Oncology, All India Institute of Medical Sciences, New Delhi, India
2 Professor, Department of Community Ophthalmology, All India Institute of Medical Sciences, New Delhi, India
3 Additional Professor, Department of Community Ophthalmology, All India Institute of Medical Sciences, New Delhi, India
4 Additional Professor, Department of Ophthalmology, All India Institute of Medical Sciences, New Delhi, India
5 Research Officer, Department of Community Ophthalmology, All India Institute of Medical Sciences, New Delhi, India
| Date of Submission | 17-Jun-2021 |
| Date of Decision | 24-May-2022 |
| Date of Acceptance | 25-May-2022 |
| Date of Web Publication | 22-Sep-2022 |
Correspondence Address:
Praveen Vashist
788, Department of Community Ophthalmology, Dr. R P Centre, All India Institute of Medical Sciences, New Delhi - 110 029
India
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/ijph.ijph_1391_21
 Abstract | | |
Background: World report on vision makes integrated people-centered eye care as care model of choice. Integrating eye care with the existing public health system makes services available, accessible, affordable, and sustainable. Being from the community, Accredited Social Health Activists (ASHAs) are better suited to improve people's eye health-seeking behavior. Objectives: This study aims to assess the eye care-seeking behavior of community and to understand their response toward the approach of integrated vision centers (VC) with ASHA involvement. Methods: A cross-sectional descriptive study was conducted in South Delhi district where integrated VC were functional for more than a year. These centers were supervised by medical officer in-charge, under whom ophthalmic assistants, ASHAs, auxiliary nurse midwives, and pharmacist work. ASHAs were trained in community-based primary eye care. The community survey was conducted on eye health-seeking behavior and utilization of VC services. Descriptive statistics were used for data analysis. Results: Out of 1571 study participants, 998 reported any ophthalmic illness in family in the past 6 months as against 1302 who reported nonophthalmic illness in family. The majority (1461, 90%) were aware about integrated VC and half of them (748, 51.2%) visited it. Of them, 64.2% were motivated through ASHAs. ASHAs spread awareness about eye diseases, eye treatment facility, and referred patients from the community. The majority (93%) were happy with the integrated VC and 87.8% were happy with ASHAs. Conclusion: Integrated VC with ASHA engagement could pave the way for universal eye health. Understanding people's needs and engaging community would increase the demand for eye care.
Keywords: Accredited Social Health Activists, eye health-seeking behavior, integrated people-centered eye care, integrated vision centers
How to cite this article:
Shukla P, Vashist P, Suraj S S, Gupta V, Gupta N, Bharadwaj A. Effect of integrated people-centred eye care (IPEC) model on eye care seeking behaviour of community. Indian J Public Health 2022;66:282-6 |
How to cite this URL:
Shukla P, Vashist P, Suraj S S, Gupta V, Gupta N, Bharadwaj A. Effect of integrated people-centred eye care (IPEC) model on eye care seeking behaviour of community. Indian J Public Health [serial online] 2022 [cited 2023 Mar 26];66:282-6. Available from: https://www.ijph.in/text.asp?2022/66/3/282/356588 |
| Introduction | |  |
World report on vision (2019) aims at integrated people-centered eye care (IPEC) by engaging people and communities and integrating eye care into primary health care.[1],[2]
Visual impairment (>90%) in India is mostly avoidable.[3] Person-related barriers reduce the accessibility of eye care services.[4] Accredited Social Health Activists (ASHAs) could improve facilitation for primary eye care services. Few eye care institutes initiated the pyramidal model of eye care for the continuum of care.[5],[6] However, this verticality is resource-intensive for our country. Integration into the existing public health system would make eye care services accessible, affordable, and sustainable. Health and wellness centers also aim at such integration at the primary level.[7]
This study aimed to assess eye care-seeking behavior of the community and effect of ASHA training in primary eye care on vision center (VC) service utilization.
| Materials and Methods | | |
Study setting
The study was conducted in South Delhi district. Integrated VCs were set up within government-run primary-level health centers. It catered to eye health needs of nearly 50,000 people. It was manned by an ophthalmic assistant (OA) who provided basic ophthalmic examination including refraction facility and referral for serious ophthalmic conditions. These centers were supervised by medical officer in-charge, under whom OAs, ASHAs, auxiliary nurse midwives, and pharmacists worked. The OA was either from government side or provided by the base hospital, in case of shortage. One OA managed six VCs in a week on a rotation basis. The integrated VC was linked with secondary as well as tertiary level government hospitals in the district. The referral network was supplemented by providing referral services at the base hospital as well.
As part of an operational research study on ASHA involvement in eye care, 100 ASHAs from seven integrated VCs were given one-day training in community-based primary eye care.[8] They were made aware about various eye conditions, especially those which were common avoidable causes of visual impairment such as cataract, refractive error, and diabetic retinopathy. Apart from disease identification, they were also sensitized about referral mechanisms for those conditions. They were also trained in identifying visually impaired adults using 6/18 Snellen's optotype.
Study design
It was a cross-sectional descriptive study.
Study area
The study was conducted in South Delhi district.
Study population
Comprised people aged 40 years and above residing in ASHA areas of South Delhi district.
Sample size
A total of 1500 individuals aged ≥40 years were enrolled in the study. It was part of an operational research study on ASHA involvement in eye care, sample size was calculated based on the assumption of the proportion of visually impaired individuals that could be identified by ASHA workers.
Sampling
To make it representative of each ASHA, 15 households were selected through systematic random sampling from each of 100 ASHA areas.
The first household was selected randomly using the spinning bottle technique. From there, every 27th house was selected (sampling interval = 27, each ASHA area had nearly 400–420 households, and nearly 15 households were selected for each ASHA). The households were enumerated, and members informed about the eye survey to be done the next day. In case any house was found locked, a slip was left on their door.
The next day, all available individuals in the enumerated household were interviewed. In case, there was still no response from locked houses on the day of interview, they were replaced by adjacent households.
Inclusion criteria
Individuals aged ≥40 years who gave their valid written informed consent for survey and resided in the area for ≥6 months.
Exclusion criteria
Those who were severely ill and nonresponsive were excluded from the survey. Those who were unavailable for the survey on enumeration day and at the time of interview were excluded from the study.
Study tools
A semi-structured, pretested interview schedule was used to collect data. It constituted questions on eye care-seeking behavior of the community, perception of the community toward eye care facility, their level of satisfaction toward ASHA, and awareness about ASHA engagement in eye care.
Data were also obtained from integrated VC records.
Study period
The community survey commenced 6 months after ASHA training in community-based primary eye care. It took approximately 1 year to complete the survey.
Data analysis
Descriptive statistics using proportions and percentages were used for analysis. Paired t-test used to compare the pretraining and posttraining VC attendance.
Parameters studied
The parameters assessed in the study were health-seeking behavior for nonophthalmic illness, awareness about eye diseases and eye care facilities, performance of ASHA in community related to eye care, and level of satisfaction in community related to VC and ASHAs.
Ethical considerations
Procedures were in accordance with the Helsinki Declaration of 1975 (revised in 2000). Ethical approval for the study was obtained from the institute's ethics committee. Written informed consent was obtained from each participant.
| Results | | |
From seven integrated VCs, 102 ASHAs were enrolled for the study. In all, 1571 people (almost 15 from each ASHA area) aged ≥ 40 years were enrolled for the community survey.
Health-seeking behavior of community survey participants
Compared to 1302 (82.9%) individuals who reported anyone from the family having nonophthalmic illnesses in the past 6 months, 998 (63.5%) reported any of their family members to be suffering from any ophthalmic illness. Similar proportion sought care from government facilities for nonophthalmic sickness 760 (45.4%) as well as for ophthalmic illness 446 (42.7%). For nonophthalmic illness, 46.5% of individuals sought private doctors but for ophthalmic illness, they rarely visited private facilities, rather they relied on over-the-counter drugs from chemists (39.1%). Out of those who sought eye care, 110 (10.5%) were benefitted through eye camps organized by nongovernmental and charitable hospitals [Table 1]. | Table 1: Health-seeking behavior of people participating in the community survey
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Awareness in community about vision center
Individuals who were interviewed came from catchment areas of enrolled ASHAs. All enrolled ASHA areas were attached to one or the other VCs operating once a week in existing government dispensary. Awareness of individuals regarding these VCs was assessed through a set of questions. The majority of individuals (1461 [90%]) were aware about the presence of government dispensary in the vicinity. However, only 748 (51.2%) were aware that eye check-up facility (VC) was also available on a weekly basis in the same dispensary. Among those 748 people who were aware about VC, nearly half (371) had visited dispensary for eye care. ASHAs were an important resource in popularizing VCs and nearly two-thirds of people who had availed eye care services from these integrated VCs were facilitated through ASHAs [Figure 1]. | Figure 1: Awareness and eye care seeking assessed through the community survey. ASHAs: Accredited Social Health Activists, OPD: Outpatient department
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Awareness in community about Accredited Social Health Activists' involvement in eye care
Out of 1571 enrolled individuals, 1504 knew ASHA of their area. Among those who knew ASHA of their area, 500 (33.2%) people knew about integrated VC started in the government dispensary. In the community survey, it was found that ASHAs informed 18.4% respondents about certain eye diseases like cataract and refractive error. ASHAs were allotted a task to conduct vision screening of 40 years and older individuals in their community, but only 8.8% of individuals confirmed that their vision was screened by ASHAs. However, ASHAs did refer 387 (25.7%) individuals to VC but most of these referrals (258, 66.7%) were without screening and only based on symptoms described by the individuals.
ASHAs informed people about integrated VC in the vicinity; they even facilitated and helped people who had accessibility issues to reach the VC/base hospital to avail eye care services. In the community survey, 64 (4.3%) individuals informed that they received such support from ASHAs.
Community satisfaction toward integrated vision centers facility
Of 371 people who had visited integrated VC at the dispensary, 345 (93.0%) were happy with services and 26 (7%) were not happy. Individuals were asked an open-ended question on what parameters were they satisfied with the eye care facility. The first reason that they gave for their satisfaction or dissatisfaction was recorded. Most people were happy with eye care services because it was in vicinity (47.2%) or was free of cost (31.6%). People who were not satisfied with services quoted unavailability of eye medicine and spectacle as a major deterrent [Table 2]. | Table 2: Reason for satisfaction with vision center and Accredited Social Health Activists of the surveyed area
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Community satisfaction toward Accredited Social Health Activists
Out of all those who knew ASHA of their area (1504), only 1380 (91.8%) responded to the question “Are you happy with ASHA.” The remaining 124 ambivalent replies were excluded from the result. Of all those who answered this question, all the reasons for their satisfaction and dissatisfaction were noted down. Out of all those who knew the ASHA of their area, the majority (1321, 87.8%) were happy/satisfied with her performance. The main reasons for their satisfaction were, ASHAs had a good rapport with the community (46.6%), they took good care of pregnant ladies and children (32.6%), and provided information on health issues (22.8%). Out of 59 dissatisfied individuals, 43 (74.1%) stated that ASHA did not provide sufficient information while 16 (27.6%) complained that they did not visit often [Table 2].
Utilization of eye care services at the integrated vision center
The records from all seven VCs were assessed for 1 year. In the quarter before ASHA training, the baseline outpatient department (OPD) of the VC was 3240. In the quarter immediately after ASHA training, the OPD shot up by nearly 40% with greater increase observed among females (40.2%) than in males (35.9%). The same trend continued even after 6 months of training. After 9 months of training, there was a slight reduction [Figure 2]. | Figure 2: Gender-wise OPD trend of all seven vision centers from 3 months before to 9 months after training. OPD: Outpatient department
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The monthly average OPD increased from 1136 at baseline to 1404 (23.6%) after training. This increase was variable across centers and ranged from 4% to 69.4%.
| Discussion | | |
This study was an approach to achieve universal eye health through integrated VC and people-centric eye care. It was conducted to assess the eye health-seeking behavior of the community and to understand community response toward this approach to identify gaps in the delivery of primary eye care.
Among the studied households, 90% reported nonophthalmic sickness in the past 6 months; however, only two-thirds perceived any ophthalmic illness in family in the same duration. The way people perceive their health status determines the way they seek to care for it.[9] Lesser demand for eye care reflects that eye health is lesser prioritized. In another study from Delhi on awareness and eye health-seeking practices for cataract, it was found that although 90% of people knew about this most common avoidable blinding condition, hardly 42% were aware about its symptoms and only 40% knew surgery was the treatment of choice.[10] People usually do not seek primary care for the eye until they suffer from painful eye, emergency eye conditions, or sudden loss of vision. Reasons could be unavailability, inaccessibility, or lack of awareness.
In our study, nearly half of the people visited government facility as the first point of health care for nonophthalmic as well as ophthalmic illness including eye emergencies (45% and 43%, respectively). A study from South India among asthma and chronic obstructive pulmonary disease patients also reported that half of the patients sought initial treatment from government facility.[11] There was another group of patients who were ready to pay to compensate for their time and wage loss. This group approached private doctors/traditional healer whoever was in their vicinity and more approachable. However, for eye care, they hardly sought care from the private sector. Perhaps more public–private partnership in this area could improve the primary eye care situation of community. They preferred over-the-counter (OTC) drugs from chemists. Reasons could be many, people do not consider ophthalmic diseases serious enough to seek help from a professional or there is an absolute lack of awareness about ophthalmic conditions and facilities which provide eye care. There is also a complete lack of knowledge about the serious ill effects of OTC prescriptions. There are various studies which have reported problems of drug resistance and steroid-induced glaucoma due to OTC prescriptions.[12],[13] Around 10% of people sought eye care through camps organized by government/ Non-government organization (NGO)/private hospitals. Such camps although an outreach activity, do not provide sustainability.
One of the key strategies for IPEC is to strengthen primary eye care by integrating it into primary health care. That involves providing promotive, preventive, and curative services at all levels of health care. The study tried to focus on this strategy by integrating primary eye care services into the existing public health system and ensuring a smooth referral linkages. When a representative survey was conducted in this study, it was found that more than 90% of people were aware about the presence of a government dispensary in vicinity but only 51.2% were aware that an eye care facility existed within the government dispensary. Maybe because these services had started only a year before and were available on a weekly basis. For people to seek eye care services, it was important that first they are made aware about the common eye diseases and how it can be managed easily if detected early. As rightly shared by an article from Africa, for effective utilization of eye care services by people, it is a must that they be made aware about eye diseases, treatment facilities, and cost involved in procedures.[14]
The most promising finding of the study was that although integrated VCs were functioning before ASHA training, source of information about integrated VCs was mostly ASHAs (64.2%).
A study on review of factors emphasizes that the prevention of visual impairment worldwide is largely influenced by the availability, accessibility, and affordability of eye care services.[15] In our study, we tried to minimize these barriers by providing integrated VC at the level of primary health centers. People were happy that services were in vicinity and completely free of cost. Even referral services were either free or subsidized at government rate.
The assessment of level of patient satisfaction toward any health-care facility is one of the yardsticks to measure the quality of care provided. In one of the studies from Andhra Pradesh, three components from VC model: location and accessibility of VC and vision technician services were responsible for a 61.5% cumulative variance of patient satisfaction.[16] Our study differed with Andhra Pradesh study in one important aspect that in our integrated VC, there was no provision of spectacle. Most of the people were happy with services but the lack of spectacles was a deterrent.
A study from Andhra Pradesh highlights that person-related barriers were more common than service-related barriers.[4] To bring about attitudinal/behavioral change among individuals, there was a need for community participation. Another barrier to eye care utilization is a lack of awareness.[17] The purpose of training ASHAs and involving them in eye care was to minimize these person-related barriers. Engaging ASHAs was again an adaptation of the key strategy of the world vision report to empower and engage people in the community. Since ASHAs belong to the same community where they work, they can reach out to all households in the community and make people aware about eye health promotion and prevention of blinding or visually impaired conditions. Around half the people claim to have a good rapport with ASHAs. This rapport could help in demand generation and facilitating patients to eye care facilities. Since ASHAs are incentive-based volunteers, providing them specific incentives in eye care, especially vision screening, would improve their engagement in eye care. The discussions with ASHA did highlight the fact that without incentives, they lost direction and were distracted.
The output of ASHA engagement could be seen through VC records. There was a significant increase in mean OPD after ASHA training in eye care.
Since the National Programme for Control of Blindness and Visual Impairment comes under the umbrella of the National Health Mission, the services can be better coordinated at grassroot and primary level. The provision of eye care services at the health and wellness centers level (primary level of the public health system) is also in sync with the WHO strategies of coordinating services within and across sectors and creating an enabling environment.[18] There are various health programs which have a common target population such as programs for the elderly, noncommunicable diseases, and that on blindness control. Engaging the same grass-root worker and utilizing the same referral channel would streamline the process and reduce duplication of efforts.
| Conclusion | | |
Integrated VCs with engagement of ASHAs or community volunteers in primary eye care and facilitation of patients to eye care services could pave the way for achieving universal eye health. Understanding people's needs and engaging them would increase the demand for eye care and help in mitigating the prevailing inequalities. Integration of eye care services at all levels of the public health system would make services universally available across regions and sustainable. Through our pilot study, we tried to implement the WHO's recent model of IPEC for the first time in India.
Financial support and sponsorship
Sightsavers India, Delhi Government Health Department.
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2]
[Table 1], [Table 2]
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