Presbyopia Screening by Community Health Worker in Bangladesh: Implementation Research

Study context:

In aligning with the significant unmet need of presbyopia and prevalent eye care scenario of Bangladesh, BRAC- a multinational non-government organization (NGO), had been implementing a project titled 'Reading glass for improved livelihood (RGIL)' to provide eye care service to the people suffering from eye problems with special emphasis given to the near vision loss or presbyopia since 2006. The objective of this project was to provide access to vision screening and affordable eyeglasses to the people who combat diminished quality of life due to blurry up-close vision and to extend referral for people with other eye problems.

BRAC's Health Nutrition and Population Program (HNPP) Division is implementing this project in partnership with Vision Spring, USA. It has been an issue that whether program could use its existing Community Health Workers (CHW), (BRAC designated them as shasthya shebikas, here the investigators refer them as SS) instead of the assigned program organizers (BRAC designated, the investigators refer them as PO) who had been doing the job, for conducting screening and taking more leading role in selling glasses. In BRAC health program usually these SSs are expected to work six days a week, spending two hours each day for the household visits, covering around 250 Households (HHs) each month, and promote behaviour change communication on various health components. SSs are non-salaried staff with lower educational level, usually with eight years of schooling. During the initial stage on their job, they receive 16 days of basic training on basic preventive, promotive and curative health care, backed up by regular monthly refreshers training. POs usually had master level degree and were regular salaried staff of BRAC as field level worker. When hired by BRAC, they receive a six days basic health and management training to be able to work as a health worker in the community. This change of role shifting, if adopted means that program can easily ensure wider coverage within a short period as CHWs are more in numbers as well as have greater access in the community. Moreover presbyopia can easily and effectively be corrected by reading glasses and certified ophthalmologists are not necessarily required for the visual correction; a lay person with low literacy and appropriate training can prescribe reading glasses for the same. It was well-understood that organizing camp has its own limitation in regards to its coverage of whole population on a regular basis. Moreover, in order to sustain the reading glass program along with the camp, a system was warranted where trained workforce could screen and suggest eye glass during their routine community visit. It was therefore, an experimental study to assess the performance of different level of workforce to screen presbyopia cases, which was necessary to bring in any changes in the service delivery model to scale up throughout Bangladesh.

Eye camps were organized in each of the study sub-district with the aim to eliminate the vision problem faced by the presbyopic patients. Potential patients were encouraged to join camps and information on significance of the camp day, time and place of the camp, procedure of patients' registration, brief of diagnostic techniques, benefits of estimating of refractive error and offer to prescribe glasses only for presbyopia cases were largely disseminated throughout the whole community. Refraction were undertaken using E charts by the respective camp provider. Glasses were available to buy for the patients who required spectacles with a cost of around 2 USD on the spot and providers were instructed to counsel on glass use. These glasses were imported from the USA through Vision Spring, USA.

During the time of the intervention, USS were only employed in 20 sub districts where RGIL was being implemented by BRAC HNPP. To ensure USS recruitment in the study the investigators had to randomly select 6 sub-districts from these 20. Two sub districts were randomly assigned to one of the three arms through permuted-block randomization. Community people aged 35 or more, both male or female and having difficulty with near vision were invited for screening. Individuals having diagnosed eye diseases that require regular treatment and was not willing to participate in the study were excluded.