Finding community solutions to improve access and acceptance of cataract surgery, optical correction and follow up in children in Malawi

Background: Late presentation to the hospital and poor post-operative follow-up after cataract surgery are associated with complications which compromise visual recovery and perpetuate disability among children with cataract. The objectives of the study were to understand the social, psychological and physical consequences of blindness in families, to understand why some parents with blind children access services and others do not, and to explore factors related to decision making within families that prevent access to health care services. Methodology: A mixed methodology quantitative and qualitative community study of blindness in children conducted in southern Malawi to compare “Doers”: families with blind children from the same communities who had attended cataract surgical services with “Non-doers” versus families with blind children from the same communities who had not attended services. Individual, family, community socio-cultural and economic characteristics and other qualitative data on knowledge, perceptions, and beliefs were recorded and analyzed thematically, based on grounded theory. Results: A total of 53 in-depth interviews of parents;21 in-depth interviews of children;15 focus group discussions with community members;62 children’s clinical eye examinations, and 4 case studies were conducted over the study period. Doer families were likely to have a reliable source of income, have better housing and live closer to health centres than non-doer families. Visual acuity among doers was better than non-doers. Conclusion: This research has highlighted reasons why some families who have children with cataract are likely to be delayed to seek surgical intervention. Comprehensive counseling modules targeting such families need to be developed to increase acceptance and access to children’s cataract surgical services.

Three-year follow up of primary health care workers trained in identification of blind and visual impaired children in Malawi

Background: Control of blindness in children is one of the priorities of VISION 2020. Early detection of children needing eye services is essential to achieve maximum visual recovery. Even though training primary (community) Health care workers (PHC) should play an important role in early identification of children, it is not known how many of these workers leave after being trained, and whether those who remain continuing identifying children in the long term. The objectives of the study were to determine the attrition of primary health workers over a 3-year period after training, and to assess their knowledge and skills on cataract in children in southern Malawi. Methods: This was a cohort study that followed primary health care workers (health surveillance assistants) over a 3-year period from 2008 to 2011 and reassessed their attrition rates, knowledge and skills on cataract in children. Results: Among the 59 HSAs that were originally trained in 2008, 54 (92%) were interviewed and were found to be still working in the health sector. Knowledge regarding cataract blindness in children remained constant over the 3-year period, however, only two HSAs had reported identifying and referring children. Conclusion: Despite attrition among primary health care workers being low, only a few actually identify cataract children in the communities after being trained. Other innovative ways are needed to identify prevalent and incident cases in Malawi, as the use of HSAs is unlikely to be successful in addressing blindness in children.

Scaling up of trachoma mapping in Salima District, Central Malawi

Background: A number of suspected endemic districts with Trachoma have not been mapped in Malawi, and this contributes to delays for scaling up trachoma control activities. Objectives: To determine the prevalence of trachoma and associated risk factors in one of the suspected endemic districts (Salima District) in central Malawi and to generate information to guide policy decisions. Methods: A population-based survey conducted in randomly selected clusters in Salima District (population 418,672), centralMalawi. Children aged 1-9 years and adults aged 15 and above were assessed for clinical signs of trachoma. Results: In total, 884 households were enumerated within 36 clusters. A total of 2765 persons were examined for ocular signs of trachoma. The prevalence of trachomatous inflammation, follicular (TF) among children aged 1-9 years was 17.1% (95% CI 14.9-19.4). The prevalence of trachoma trichiasis (TT) in women aged 15 years and above was 1.3% (CI 0.7-2.3), while the prevalence in men was zero. The presence of a dirty face and lack of sanitation were significantly associated with trachoma follicular (P < 0.001). Conclusion: Prevalence rate of trachoma follicles (TF) in Central Malawi exceeds the WHO guidelines for the intervention with mass antibiotic distribution (TF > 10%), and warrants the trachoma SAFE (Surgery, Antibiotics, Face washing and Environmental hygiene) control strategy to be undertaken in Salima District.