Dr. PALLAVI SHUKLA, Dr. Praveen Vashist, Dr. Vivek Gupta, Dr. Suraj Singh Senjam
ASHAs available in communitycould be potential PEC workers. ASHA Training programme on PEC undertaken & evaluated in a district of Delhi
ASHAs selected randomly from a district imparted one day training on PEC & expected to refer patients to nearby Vision Centres (VC). Their knowledge and skill was assessed & after training and re-evaluated at 1 year. ASHAs asked to conduct vision screening of 40+ population in their areas. ASHA referral noted by Optometrist in VC. Focus Group Discussions (FGD) of ASHAs held to find barriers & facilitating factors in engaging ASHAs in PEC. Training evaluated using Kirkpatrick’s evaluation model for measuring reactions, learning, behaviour and results.
Mean knowledge score increased from 14.96 (+4.34) to 25.38 (+3.48) and sustained at 21.75 (+4.16) at 1yr. Increase in quarterly total OPD of > 200% which was sustained at 18.6% even after 6 months. ASHA FGDs conveyed ASHAs are willing to work for eye care for awareness generation and patient facilitation but were hesitant in vision screening.
ASHAs can be trained as PEC workers provided they have adequate support.
Key Words: ASHA, Primary eye care, Training, Kirkpatrick
As per the WHO estimates of 2010, there were 8 million blind in India and 63 million visually impaired.1 Nearly 80% of this visual impairment is avoidable. Universal Eye Health: Global Action Plan (2014-19) sets itself a Global Target of 25% reduction in prevalence of avoidable visual impairment by 2019 compared to the baseline prevalence of 2010.2The most important barrier in eliminating the avoidable blindness from India is unavailability and inaccessibility to eye care services.
Mechanisms need to be identified to supplement eye care services at primary level by task shifting approaches wherein the non-serious ophthalmic condition are managed at primary level by trained para medical ophthalmic assistants and non-specialist Medical Officers and only a smaller proportion of patients requiring operative or specialist services are referred to ophthalmic surgeons. In urban areas however, despite the supposed proximity of the urban poor to urban health facilities their access to them is severely restricted. Ineffective outreach and weak referral system also limits the access of urban poor to health care services.
In order to bridge this gap between community and services there is requirement of an educated workforce who are among the masses. They should be able to understand the felt and unfelt needs of the community and also aware about the accessibility of services and referral mechanism. Government of India made provisioning of one such worker, ASHA (Accredited Social Health Activist) in National Health Mission for every 1000 rural population and every 2000 urban vulnerable population.3 This workforce has been underutilized only as Maternal and Child Health worker, though they were put in place for all healthcare needs of the community.
The present study was conducted to engage ASHAs in primary eye care for awareness generation, identifying people with visual impairment, facilitating patients in seeking eye care services and keeping a record of visually impaired in their community. Kirkpatrick model was used to evaluate the training programme.4
Delhi city with a population of around 16.7 million is divided into 11 districts which are served by a tiered public health system.5The lowest level of public health facility includes dispensaries, MCH centres. Each dispensary/MCH centre has a Medical Officer and Auxiliary Nurse Midwives (ANMs). In areas populated by vulnerable populations, ASHAs are attached to these centres and they are named ASHA units. Each ASHA caters to a population of 2000-3000.
The study was conducted in district of South Delhi.There were 18 such ASHA units in South Delhi district, out of which 12 centres had the provision of vision centres where once a week optometrist used to provide refraction, eye screening and referral services.
This cross-sectional interventional study was undertaken as a part of an operational study of engaging ASHAs in primary eye care.
For sample size calculation, it was assumed that there would be 75% (p) increase in knowledge of ASHAs after training, absolute error margin of 15% (d), Design effect of 3 and 95% Confidence Level. Sample of 100 ASHAs was thus required. For recruiting 100 ASHAs, 7 ASHA units were selected randomly from those 12 centres which was had provision of vision centre. All ASHAs from those centres were included in the study.Written informed consent was taken from eligible ASHAs.
ASHAs were trained incommunity based Primary Eye Care using a Standardized Training Module.6 The training module for volunteers which was developed during WHO-SEARO workshop was used.One day training wasconducted for each centre using the module, movie on primary eye care and role plays.
ASHAs were given hands-on training in screening vision of individuals aged 40 years and above using two “E” charts of 6/60 and 6/18 optotypes. ASHAs were provided a training kit comprising of measuring ribbon, screening cards, referral slips and training module.
Knowledge assessment on Primary eye care of ASHAs was done using pre-tested questionnaire thrice, prior to training, immediately after training and an year after training. Their skill in vision screening was assessed immediately after training and an year later in their respective field practice areas. Vision screening skill of ASHAs was labelled as satisfactory/ unsatisfactory based on four essential criteria: accurate distance estimation, correct card positioning & tumbling, measuring each eye at least four times and recording the vision. If at least three out of four times person responded correctly the direction of “E”, his vision for that cut off in that eye was assumed to be “normal”.
After training ASHAs were given 3- 4 months to conduct vision screening of all 40 plus population of their area using 6/60 and 6/18 cut offs. Apart from vision screening, ASHAs could indicate in referral slips if the person was having Diabetes, diagnosed Glaucoma, symptoms of Presbyopia (near vision difficulties after 40 years of age) or any other eye condition. ASHAs were at the liberty of referring anyone to the dispensary with eye trouble or vision problems irrespective of their age or gender.
In the vision centres, optometrist examined patients and kept a record of those who came with ASHA referral slip.
Focus group discussions (FGD) were held with ASHAs of all these 7 centres. Total of 5 FGDs were held. Each FGD lasted for 40-50 minutes and had 10-12 participants. FGDs were held after 6 months of primary eye care training. The FGD were tape-recorded and content was transcribed.
Pre and post comparisons in knowledge scores were done using paired t-test. For qualitative analysis of FGDs, the transcripts were coded. The codes were merged and patterns identified to generate themes. From the themes, a theory was framed. The analysis of qualitative data was done using Atlas.ti (version 7)
Using Kirkpatricks model the entire training programme was evaluated into 4 segments:
- Reaction: Measures how trainees reacted to training and what were the shortcomings.
- Learning: Measures objectively the effect of training on their knowledge.
- Behaviour: Measures the change in behaviour of trainee because of training.
- Measurable outcomes of training (Result).
Total 102 ASHAs were recruited for the study from 7 centres. Mean age of ASHA was 37.5 years ranging from 22 to 56 years. Majority (77.5%) of them had completed education above class 10th. Mostly were currently married (95.1%) and lived in a nuclear family (66.7%). [Table 1]
Reaction: Reaction of ASHA towards this training programme was assessed through FGD. ASHAs were quite satisfied with the training provided to them in eye care. They said it enhanced their knowledge. It made them more confident in talking about eye care in community. It helped in enhancing their image in community beyond just “Maternal and Child Health” worker. They were able to counsel patients better and bring them to dispensary for check-up. ASHAs gained knowledge about diseases like Cataract, Glaucoma, effect of Diabetes on eyes, Presbyopia and Conjunctivitis. Regarding vision screening, they were happy to learn about it but found it difficult to do it all by themselves without support and said that they were benefitted by the supportive supervision provided to them in this programme. ASHAs also recommended that this training should be repeated at frequent intervals of say 6-12 months.
Learning: In order to assess the learning achieved by ASHAs through this training, knowledge assessment was done using a pre-tested questionnaire. The sustained increase in knowledge was seen after 1 year using the same questionnaire. [Table 2]
Immediately after training, there was improvement in knowledge related to all sections. It was only after training that many of them became aware about certain aspects and retained this knowledge even after an year like blindness causes (42.2%, 89.2% and 60.8%), type of vision loss in cataract (53.9%, 83.3% & 79.4%), when should cataract be operated (68.6%, 97.1% & 79.4%), post-operative care of eyes(35.3-84.3%, 58.8-95.1 & 55.9-93.1%), long term medication in Glaucoma and its advantage 67.7%, 84.3% & 81.4%), symptoms of refractive error and its management (41.2%, 81.4% & 74.5%), part of eye which got affected by DR (15.7%, 87.3% & 76.5%) and led to blindness (60.8%, 79.4% & 85.%) symptoms of conjunctivitis (59.8%, 88.2% & 92.2%), its mode of transmission (85.3%, 98.0 & 97.1%) and using an open eye vial for not more than 15-30 days (39.2%, 93.1% & 72.6%).
There were however certain points which ASHAs forgot after an year like the part of eye getting affected with cataract (9.8%, 82.4% & 28.4%), frequency of retinal examination required for diabetics (2.9%, 78.4% & 6.9%). Surprisingly one myth was strongly impinged on ASHAs mind that conjunctivitis could be transmitted by looking into each other’s eyes (25.5%, 86.3% & 22.6%). [Table 2]
There was significant change in knowledge (69.7%) in all sections immediately after training. When scores after one year were compared with the pre-training scores, again there was a significant increase (45.4%). [Table 3]
Their skill in vision screening was assessed immediately after training and after one year in their field practice area. Immediately after training 45 (44.1%) ASHAs could conduct vision screening and recording satisfactorily while after one year only 36 (35.3%) could do it satisfactorily. Most of them committed error in recording, but were able to correctly measure distance, position and four times tumble the card and made the person cover one eye correctly.
Behaviour of ASHA towards this programme was assessed through FGD. ASHAs were enquired about vision screening and their contribution to primary eye care. ASHA reported following hurdles while conducting vision screening in community like they were unable to screen males on account of purdah, inability to screen vision of working community as they were unavailable most of the time, urban localities were so ountered was that they were engaged in multiple activities and were forced to do the work which was considered important by ANMs and MOICs. ASHAs being incentive based, they requested for incentive for vision screening. They had willingness to work for eye care but hesitated in conducting vision screening. They had developed a good rapport with the community and were able to spread awareness about common eye diseases and eye care facilities available. They also assisted patients in facilitating them in availing eye care services.
Measurable Outcome (Result):
Last aspect of Kirkpatrick model was to find out measurable output of training programme.
Secondary data was taken from vision centre records. Output before training was compared with that afterwards. There was more than 200% increase in quarterly OPD immediately after training and even after 6 months this increase was sustained at 18.6%. Among males there was 336% increase in quarterly OPD after training which was retained at 7% after 6 months. Among females there was 211% increase in quarterly OPD immediately after training and even after 6 months this increase was sustained at 20.8%. [Figure 1]
Reaction of ASHA towards this training is positive. They showed interest in training programme. This is also obvious from the fact that almost all the ASHAs of the designated centres attended training and undertook evaluation tests even at one year. There were minimum dropouts even when there was no incentive given to them for training.
ASHAs showed a significant increase in knowledge immediately after training which was sustained even after an year. There is another study conducted on ASHA training though on a different concept, newborn care. It was seen in that study that knowledge increased more after three months and not immediately, signifying that people learn more by doing.7
Another study from South India a similar study was conducted to evaluate the training of hypertension for ASHAs showed that there was an increase from baseline after training which further increased after 3 months.8
ASHAs felt that one day training was not enough for them and that they required refresher training at frequent intervals because they are engaged in multiple activities, so their attention diverts. Till date there are not many studies conducted to understand the role of ASHA workers in eye care. In one study conducted in Ranpur taluka of Ahmedabad district, 40 ASHAs were able to identify 434 people with vision less than 6/60.9
There are many examples from across globe where primary level workers are utilized for primary eye care as well. This is perhaps the best system where there is integration of eye care services at all levels of public health system. There is a study from Tanzania eye health is integrated into primary care services.10
In Malawi primary health care workers were used to detect childhood blindness.11
Through Kirkpatrick model we are able to say that ASHAs can be trained effectively in community based primary eye care which predominantly takes care of awareness generation in community and facilitating patients to seek eye care services. [Figure 2]
- S.P.Mariotti, D. Pascolini. Global estimates of visual impairment: 2010. Br J Ophthalmol. 2012 May;96(5):614‐8.
- Global Action Plan | International Agency for the Prevention of Blindness[Internet]. London(GB): The International Agency for the Prevention of Blindness (IAPB); [Cited 2016 Apr 28]. Available from : www.iapb.org/advocacy/who-action-plan
- ASHAChapter 2014-15-Delhi State Health Mission.[Internet]. Delhi[IN]: National Health Mission; 2013 Dec 31 [Cited on 2016 May 17]. Available from:http://dshm.delhi.gov.in/pdf%5CASHA_Material%5CASHAPIP&ROP%5CASHA%20PIP%20%202014-15%20(8).pdf
- The Kirkpatrick Model- Kirkpatrick Partners. Available from: https://www.kirkpatrickpartners.com/Our-Philosophy/The-Kirkpatrick-Model Delhi (NCT)| Districts of India. Available from: http://districts.nic.in/districts.php?sid=DL
- Manual on training of trainers for volunteers in primary eye care. Module conceived and developed vide APW no. SEA-2015-B7-APW-0002 between Dr R P Centre for Ophthalmic Sciences, AIIMS and World Health Organization, SEA Region. (Unpublished)
- Stalin P, Krishnan A, Rai SK and Agarwal RK. ASHA’s involvement in newborn care: A feasibility study. Indian Pediatrics. Vol 48. November 2011.
- Abdel-All M, Thrift AG, Riddell M, Thankappan KRT, Mini GK, Chow CK et al. Evaluation of a training program of hypertension for Accredited Social Health Activists (ASHA) in rural India. BMC Health Serv Res.2018 May 2;18(1):320.
- Soni P, Bhatt S and Gupta P. Role of ASHA (Accredited Social Health Activist) Worker in Screening for Low Vision at the Grass Root Level. International Journal of Recent Trends in Science and Technology. 2014. Volume 9(3): 358-360
- Jolley E, Mafwiri M, Hunter J, Schmidt E. Integration of eye health into primary care services in Tanzania: a qualitative investigation of experiences in two districts. BMC Health Services Research. 2017;17:823.
- Kalua K, Ng’ongola RT, Mbewe F, Gilbert C. Using primary health care (PHC) workers and key informants for community based detection of blindness in children in Southern Malawi. Human Resources for Health. 2012;10:37.
Tables and Figures
Table 1: Demographic profile of recruited ASHAs N=102
|Demographic Variables||Frequency||Percentage||Demographic Variables||Frequency||Percentage|
|Education Of ASHA||Type of family of ASHA|
|Marital Status of ASHA||Distance of ASHA area from Centre|
|Currently Married||97||95.1||< 1 km||45||44.1|
|No. of children of ASHAs||>5 km||1||1.0|
Table 2: Knowledge assessment on primary eye care
|Questions on knowledge assessment of ASHAs regarding primary eye care||Number of ASHAs conforming the right choice|
|One year later
|Definition of Blindness as per NPCB||1||28 (27.5)||66 (64.7)||56 (54.9)|
|Which glass is removed while taking distance vision?||1||1 (1.0)||47 (46.1)||22 (21.6)|
|In which age blindness is common?||1||85 (83.3)||95 (93.1)||85 (83.3)|
|Most important cause of Blindness in India||1||43 (42.2)||91 (89.2)||62 (60.8)|
|Other important causes||1||69 (67.7)||89 (87.3)||91 (89.2)|
|Type of vision deficit in cataract||1||55 (53.9)||85 (83.3)||81 (79.4)|
|Part of the eye affected by cataract||1||10 (9.8)||84 (82.4)||29 (28.4)|
|Is there any medical management for cataract?||1||87 (85.3)||95 (93.1)||94 (92.2)|
|When should cataract be operated?||1||70 (68.6)||99 (97.1)||81 (79.4)|
|Best season for cataract surgery||1||70 (68.6)||98 (96.1)||95 (93.1)|
|Post op care: cleaning eyes regularly||1||78 (76.5)||97 (95.1)||95 (93.1)|
|Post op care: correct method of lying down||1||47 (46.1)||71 (69.6)||76 (74.5)|
|Post op care: lifting weights||1||66 (64.7)||73 (71.6)||79 (77.5)|
|Post op care: follow ups||1||86 (84.3)||96 (94.1)||95 (93.1)|
|Post op care: taking bath||1||36 (35.3)||60 (58.8)||57 (55.9)|
|Advice to known Glaucoma cases: regular and long term use of glaucoma medication||1||39 (38.2)||68 (66.7)||61 (59.8)|
|Advice to known Glaucoma: screening of family members||1||46 (45.1)||92 (90.2)||56 (54.9)|
|Regular Glaucoma medication preventsfurther deterioration of vision||1||69 (67.7)||86 (84.3)||83 (81.4)|
|IV. Refractive Error|
|Correct Diagnosis of the patient in case scenario||1||42 (41.2)||83 (81.4)||76 (74.5)|
|RE treatment: Spectacles||1||71 (69.6)||88 (86.3)||86 (84.3)|
|RE treatment: Surgery/Lasik||1||14 (13.7)||19 (18.6)||6 (5.9)|
|RE Treatment: Contact lens||1||11 (10.8)||26 (25.5)||9 (8.8)|
|Types of Refractive Errors||1||22 (21.6)||79 (77.5)||59 (57.8)|
|Can Near/Far Sightedness occur together in one eye?||1||28 (27.5)||80 (78.4)||67 (65.7)|
|V. Diabetic Retinopathy|
|Part of eye mostly affected in diabetes||1||16 (15.7)||89 (87.3)||78 (76.5)|
|Can Diabetes lead to blindness?||1||62 (60.8)||81 (79.4)||87 (85.3)|
|Frequency of retinal examination in known diabetics||1||3 (2.9)||80 (78.4)||7 (6.9)|
|VI. General Eye Care|
|Can conjunctivitis spread from one person to another by looking into each other’s eyes?||1||26 (25.5)||88 (86.3)||23 (22.6)|
|Three important symptoms of conjunctivitis?||1||61 (59.8)||90 (88.2)||94 (92.2)|
|Which among the following can keep eyes healthy?||1||85 (83.3)||100 (98.0)||99 (97.1)|
|An open eye vial can be used within 15-30 days||1||40 (39.2)||95 (93.1)||74 (72.6)|
|At what distance will you check for blindness?||1||60 (58.8)||99 (97.1)||96 (94.1)|
Table 3: Change in knowledge immediately after training and an year later.
|P-value||After one year of Training
|Section I: Blindness||5||2.22 (0.90)||3.80 (1.04)||<0.001||3.10 (1.22)||<0.001|
|Section II: Cataract||10||5.93 (1.92)||8.41 (1.56)||<0.001||7.67 (1.37)||<0.001|
|Section III: Glaucoma||3||1.51 (0.84)||2.41 (0.68)||<0.001||1.96 (0.86)||<0.001|
|Section IV: Refractive Error||6||1.84 (1.36)||3.68 (1.05)||<0.001||3.56 (1.74)||<0.001|
|Section V: Diabetic Retinopathy||3||0.79 (0.72)||2.45 (0.78)||<0.001||1.69 (0.66)||<0.001|
|Section VI: General Eye Care||5||2.67 (1.23)||4.63 (0.64)||<0.001||3.78 (0.82)||<0.001|
|Total Score||32||14.96 (4.34)||25.38 (3.48)||<0.001||21.75 (4.16)||<0.001|
Figure 1: Trend in patients visiting vision centres who are referred by ASHA
*1st: 3 months Before training 2nd: within 3 months of training 3rd: 3-6 months after training 4th: after an year
Figure 2: Evaluation of ASHA training programme on Primary Eye Care