Low vision evaluation training in Nigeria: Time to improve human resource in developing countries

Abstract

Routine low vision care is a rarity in Nigeria and in most developing countries. The reason for the widespread apathy and lack of human resource development in this area is myriad. The Center for Vision, The Lens Rehabilitation Center for the Blind located in Portharcourt, Nigeria sought to correct this by working to revive interest and thus improve human resource available through provision of quality hands on training with world renowned scholars and faculty . Records of all who registered for two separate Low vision training courses at TLEC re(Hab) Nigeria between 2018 and 2019 were audited. Number of courses taught, participating faculty, gender and age distribution of trainees, previous training accessed by trainees, pretest scores and post test scores were compared. Numbers actually practicing low vision after 3 months of conclusion of the training and outcome of feedback questionnaires were also evaluated using a simple calculator. Fifty eyecare workers (42 in one day training and 8 over 2 weeks) with mean age of 33.6years and gender ratio of 1:2.3 were trained in two batches. There were 26 faculty available to teach both online and physically. Previous exposure to training was absent in the one day group while the two week group had just one. The courses taught were mainly on low vision evaluation(50% in the one day , 44.29% in the 2 week course) with additional courses on early intervention, rehabilitation of the blind and evaluation in special kids with additional problems. The hands on sessions were significantly better in the two week training with a third of the periods available dedicated to stepwise approach in low vision evaluation.

A comparison of pretest and post test scores showed there was an exponential improvement in understanding between the one day and the two week training of up to 50 % increase which reflected in the numbers able to refer appropriately and evaluate low vision patients in the country when the one day and 2 week groups were compared. There was a general consensus that the two week training was more preferred. Empowerment with relevant low vision charts and device equipment significantly improved the numbers still practicing 3 months after training ended when compared with those who were not given any by as much as 400%. In conclusion, low vision needs dedicated and well trained staff who compulsorily need to be empowered to function with provision of required equipment especially in developing countries where the majority of the need for low vision aids and assistive devices appear to be.

Keywords

Assistive devices developing countries low vision evaluation Nigeria TLEC (re)Hab training

Introduction

Routine low vision services is a rarity in Nigerian ophthalmic practice. Out of the approximately 400 practicing ophthalmologists (no published figures yet), just 3 are interested in offering low vision services. Similarly, of the over 4000 optometrists in Nigeria, less than 10 are offering any form of low vision care and even then in mostly rudimentary forms.

Ophthalmic care in developing countries is mainly centered around surgical, optical, and medical services and once any of these three ways through which vision can be preserved, treated, or improved upon is no longer successful and the patient slips into the low vision category, nothing else is consistently available that can be offered to the patient except in two centers in the entire country of Nigeria for low vision.

As much as 285 million are living with low vision worldwide (Bourne et al., 2013; Flaxman et al., 2017; International Agency for the Prevention of Blindness, n.d., 2012; Kempen et al., 2011; Resnikoff et al., 2004; Stevens et al., 2013) and up to 90% of these are living in developing countries like Nigeria (Flaxman et al., 2017; Stevens et al., 2013). Eighty million of these have permanent vision loss and can potentially benefit from low vision services (Pascolini & Mariotti, 2012; World Health Organization, 1992, 2007). Most of those with low vision are older people and the numbers will double over the next 20–30 years because of the aging population (World Health Organization, 1992). The number of children in need of low vision care worldwide is 6 million, and of these children, 4.8 million live in low- and middle-income countries (Binns et al., 2012; Corn et al., 2003; Dandona et al., 2002; Ferrell et al., 2011; Gilbert and Ellwein, 2008; World Health Organization, 1992, 2007).

On the contrary, there are up to 1 million people in Nigeria alone in need of such services (Rabiu et al., 2012). Therefore, setting up a sustainable training program in Nigeria is very much required and necessary. But despite this obvious need, in the face of apparent lack of interest, it has been a herculean task to attract people for training with just one training program going on in the southern part of Nigeria with some irregularity over the past two decades, and it seems even this may have fizzled out due to lack of sustained interest and possibly financial support was no longer available.

Most people living in developing countries are fatalistic and quite accepting of most situations they find themselves in and if vision is failing, they tend to take it as an act of God and often do not seek help early. They are usually among the very poor who do not have enough resources to travel long distances to access these services and probably due to financial handicap were really not able to afford treatment in the first place. So uptake of low vision service is low due to lack of finances and distance. In everyday practice, the need for this skill is however apparent. Again the insufficient number of eyecare workers interested in this field due to the poor public perception has ensured that very few services are available (Chiang et al., 2011) and so the few functioning ones which are often located in the capitals often charge exorbitantly.

Low vision patients either won’t go due to their vision problem or end up traveling in the company of their caregiver who will have to make out time to take them (which usually means loss in work hours which leads to reduced earnings which negatively affects the individual assisting, the family unit, and the community at large), which tends to delay uptake (Chiang et al., 2011; Dandona et al., 2002).

The “developing” country system and unstable currency exchange rates do not allow for importation of good low vision aids in a regular manner and any locally made ones currently do not generally have very good finishing and are often rejected. Only one center in the north of Nigeria makes these and not in large enough quantities and is now gradually winding down due to poor patronage and distribution.

Since low vision care, along with uncorrected refractive errors, is one of the objectives of V2020 under disease control (Bourne et al., 2013; Flaxman et al., 2017; International Agency for the Prevention of Blindness, n.d., 2012; Pascolini & Mariotti, 2012; Resnikoff et al., 2004; Stevens et al., 2013; World Health Organization, 2007), helping to correct/improve vision has the potential to move someone from total dependence to at least some level of independence, which can make the whole difference in the family, the community, and in the psyche of the person involved.

To meet this objective, there must be enough low vision trained personnel, appropriate testing equipment, and appropriate low vision aids made available either for highly subsidized or free distribution (Dandona et al., 2002).

However this is not yet obtainable in most developing countries due to insufficient interest in the subject as a direct result of very few training centers (Chiang et al., 2011).

There was active training some time ago in a training center in the south south part of Nigeria which received considerable funding from nongovernmental organizations but probably due to unsustained effort, the training fizzled out, and it was observed that there was poor uptake of low vision services and of the considerable numbers trained, only very few still continued the practice. Why this happened was not clear.

This informed the setting up of a specialized center in Port Harcourt, The Lens Rehabilitation Center for the Blind and Severely Visually impaired (TLEC (re)Hab). This privately owned, not-for-profit nongovernmental body has been offering specialized low vision services for about 5 years at the time of writing this article, while developing capacity for training, sustained drive, and acquiring equipment appropriate for training eyecare workers to effectively evaluate the condition. This low vision facility is staffed by trained ophthalmic personnel and able to offer care for all categories of low vision.

This discussion is to chronicle the effects of the training programs established by this facility in expanding capacity and improving human resources in the absence of viable training programs in the country while trying to tackle these challenges and renewing interest in the field of low vision care through quality training and improved low vision service delivery.

Methods

The TLEC rehabilitation center for the blind and severely visually impaired (TLEC (re)Hab) is a registered not-for-profit nongovernmental organization established in 2015, which is affiliated to its parent eyecare delivery arm, The Lens Eye Clinic, Port Harcourt, an ophthalmic eyecare center committed to training and human resource development based in Port Harcourt, Rivers State, Nigeria.

The records of all low vision trainees who registered for two low vision training courses between 2018 and 2019 were audited. One was a 1-day training course held 8 September 2018 while the other was a 2-week course held between 28 January and 8 February 2019. The number of courses, number of faculties, the gender distribution of trainees, age, previous training in low vision, highest qualification attained, pretest scores for the 2-week training, and posttest scores were compared; number actually practicing low vision evaluation was also determined after 3 months of conclusion of the training. Feedback questionnaires were passed around at the end of each training and responses were reported. See Supplemental Appendices a and b. The data were compared where they were comparable and analyzed with the help of a statistician after filling in the information into an Excel sheet.

Results

Audit of first training

Forty-two trainees participated in a 1-day low vision crash course which was held Saturday, 8 September 2018. There were 12 males and 30 females with male: female ratio of 1:2.5. They came from all over Nigeria (Table 1).

Table 1.

Geopolitical Zone of origin of TLEC re(Hab) (2018) low vision course participants.

Geopolitical zone	Numbers
South south	18 (42.8%)
South west	9 (21.4%)
South east	10 (23.8%)
North west	1 (2.4%)
North east	0 (0%)
North central	4 (9.5%)
Total	42 (100%)

The basic professional qualifications of the trainees ranged from ophthalmic nurse (n = 1, 2.38%), optometrist (n = 13, 30.95%), ophthalmology resident (n = 25, 59.53%), to ophthalmologist (n = 3, 7.14%). None had previous exposure to low vision training (Figure 1).

Figure 1.

Participants of first training in Nigerian low vision evaluation course (2018).

There were six faculty/instructors – three consultant ophthalmologists with training in low vision and rehabilitation of nonsighted, visually impaired and special children; one optometrist with training in computer adaptive skills; one special educator/counselor; and a legal practitioner. All were on ground except one of the ophthalmologists who spoke and helped review patients through SKYPE.

The number of lectures delivered were 20 in number over the 7 hour the didactic lectures were given from 8 am till 5 pm. There were two extra 1-hr periods for hands-on/practical sessions on live patients in two groups each in the course of the daylong training.

Questionnaires distributed following the lectures asked the following questions of the participants:

Was the time adequate to learn properly about low vision?

Answer: The time was not enough, it may be enough for a refresher course however: 35 out of 42 (87.5%)

Did you have enough hands-on?

Answer: I did not have enough time for hands-on. 39 out of 42 (97.5%)

What do you suggest about length of training?

Answer: Minimum timing should be at least 2–3 days. Ideal timing should be 2 weeks. 25 out of 30 responses

Would you be willing to attend a longer training?

Answer: Yes. 5 out of 40 (12.5%)

Would you have preferred a smaller group?

Answer: Yes. 42 out of 42 (100%)

Would you like to join a group on social media to learn more?

Answer: Yes 12, No 28 (42.8%)

Three of the six invited faculties handled low vision training (50%), two handled rehab and early intervention (33.3%), and one (16.7%) gave legal advice/information. Sixteen of the lectures were on and about low vision and its evaluation while 2 of the lectures were on rehabilitation of the blind and 1 each on early intervention and what the Nigerian law says about blind individuals and their rights (Figure 2).

Figure 2.

Lectures given in the first training in Nigerian low vision evaluation course.

Of those who attended this 1-day course, only one showed sustained interest at the end of 3 months post training and went ahead and attended the second longer course of 2 weeks duration. However, 76.1% (n = 32) of the trainees knew enough to be able to refer appropriately following this course based on the increased referral patterns following the training course.

Audit of second training

Subsequently, a 2-week intensive low vision evaluation course was held between 28 January and 8 February 2019 and was attended by eight trainees, three males and five females. Age range was from 24 to 45 years with mean of 33.6 years. There were three optometrists (37.5%), one Optometry extern (12.5%), and four ophthalmologists (50%) (Figure 3).

Figure 3.

Participants in second Nigerian low vision evaluation (2 weeks duration).

Only one participant had previous exposure to low vision training and was present during the previous year’s low vision 1-day crash course.

There were 20 faculty available drawn from all over the world (names in Supplemental Appendix) with 70 lectures delivered over the 2-week period and two 2-hr sessions of hands-on on a daily basis started from day 3 till day 14. Five of the faculty were Americans (33.3%), three were South African (20%), one from Ghana (6.7%) while the other six were Nigerians (40%).

All the lectures delivered by faculty who were non-Nigerian were given by Skype while the Nigerian faculty on ground ensured the course, especially the practical aspects, were running smoothly without disruption. Four of the faculty were ophthalmologists, eight were optometrists, four were teachers, three were visual impaired speakers/teachers, while a lecture prepared by a lawyer on what the law says and what it should say about the visually impaired was also delivered. Of the 70 lectures, 13 (18.57%) were on basic relevant ophthalmic education, 31 (44.29%) were on low vision, 4 (5.71%) were on early intervention while 14 (20%) were on rehabilitation of the blind, 6 (8.57%) were on counseling and understanding the psychology of the blind including testimonies of previously rehabilitated individuals while one each (1.43%) was on legal information documenting what the law currently says about the visually impaired and what it should say and school eye services (Figure 4).

Figure 4.

Range of lectures given during second Nigerian low vision evaluation course (2 weeks duration).

The pretest scores of the trainees was average of 27% with a range of 17%–34%. The posttest scores average for all trainees was 64% with a range of 38%–80%. This showed an improvement by 250% (Figure 5).

Figure 5.

Comparison of pretest and posttest scores of trainees during 2 weeks Nigerian low vision evaluation course.

Two (25%) of the trainees scored the least in the post test. The questions mainly asked in the course of the post training evaluation/assessment questionnaires were as follows:

Do you think the course duration was sufficient?

Answer: Yes. 8 out of 8

How long do you suggest?

Answer: 2 weeks is fine. 7 out of 8

What could have been better?

Answer: More variety in the food. (1 out of 8) The instructor could have completed a full examination first then allow the trainees to start examining afterward on their own. Instead bits and pieces of the examination were shown at various times and then they were expected to put it all together. 2 out of 8

Did you have enough hands-on?

Answer: Yes. 6 out of 8

What would have been ideal in terms of hands-on?

Answer: We were all given basic low vision kits but we took them home on the first day. We could have left them behind and taken them on the last day to be able to use them. So we had to keep waiting for one another to finish using the center’s equipment before we were able to use them.

Any other advice/message about staff and faculty? Lectures were enjoyed. It has been a productive time.

Answer: Lectures were all enjoyed. It was a productive time.

The numbers actually practicing low vision had increased from zero in the second set of trainees to five out of eight, 3 months after the course ended.

Discussion

Training in low vision is extremely important. Since VISION 2020 was launched in 1999, the primary objective was to promote “A world in which nobody is needlessly visually impaired, where those with unavoidable vision loss can achieve their full potential” (Bourne et al., 2013; International Agency for the Prevention of Blindness, n.d., 2012; Stevens et al., 2013). Therefore, strenuous efforts have since been made from that period to train eyecare workers who will ensure that this objective is met (Chiang et al., 2011). This is to avoid the consequences of low vision, which include a child’s ability to pursue education and an adult’s ability for gainful employment, higher risk of death, risk of falls, difficulties with daily living and increased dependence (Binns et al., 2012; Corn et al., 2003; Ferrell et al., 2011; World Health Organization, 2001). Management of low vision through the provision of good quality services which are scalable, adaptable, cost-effective, and responsive to the population is a VISION 2020 priority (International Agency for the Prevention of Blindness, n.d., 2012) However, the training has been observed to be lopsided as most eyecare workers despite extensive knowledge in preventive and therapeutic eyecare still find it difficult to help a patient who has lost some vision to maximize that vision to improve quality of life (Chiang et al., 2011).

To correct this, in 2006, VISION 2020 stakeholders developed an action plan to include visual impairment particularly caused by uncorrected refractive error. Since then, the World Health Assembly (WHA) has reinforced this with action plans over the years. The most recent one is called Universal Eye Health: Global Action Plan 2014–2019 (GAP) (accessed 25 March 2019) (Flaxman et al., 2017; World Health Organization, 2007), which aims to reduce the prevalence of avoidable visual impairment by 25% by 2019.

Recognition of those who can have potential improvement in vision-related tasks following visual impairment is critical and this is not deeply taught in most ophthalmic residency training programs (Chiang et al., 2011). Therefore, since 89% of visually impaired people live in developing countries (Flaxman et al., 2017; International Agency for the Prevention of Blindness, n.d., 2012; Kempen, 2011; Pascolini & Mariotti, 2012; Resnikoff et al., 2004), the onus is on developing countries to develop their own training programs to handle this challenge.

Who can?

Almost any eyecare worker can be trained to evaluate patients who have low vision at its simplest. Therefore, due to the relative fewer numbers of the higher cadre of eyecare workers, even nurses and community health workers can be trained in order to quickly bridge the gap. Thus, this training course allowed the training to be accessed by a nurse participant and plans to organize one targeted especially for them and community health workers. This will further help bring the service closer to the people who actually require it. There is little targeted training as far as known in sub-Saharan Africa, but there is one in Tanzania (Kishiki & Courtwright, 2012) and another in the pipeline organized by the African Council of Optometry (2019) and Brien Holden Institute.

This training institution has put in place programs to train eyecare workers with the target to include all cadres of eyecare workers and also target ophthalmic residents in training. Currently, their training programs for both colleges of West African and National postgraduate medical college do not include anything on low vision and rehabilitation of the visually impaired. This low vision training is about the only one in West Africa still running (other prior programs stopped a few years ago for obscure reasons) and aims to ensure those who pass through have a good grasp of the techniques employed in evaluating these patients and know which devices will best help a low vision patient. Other training programs in other parts of the world have a similar objective like the National Eye Health Programs (NEHEP, n.d.) of the National Eye Institute.

Ideal length of training

Even though the time for the 1-day course was not enough (as almost 90% expressed), a good number conceded that an extra day or two would have made a lot of difference, especially in terms of hands-on. Although a lot more material was crammed into the time available, most residents who wanted to attend had time to spare for only the 1-day training program, probably because their specialist training is intensive and time-bound, leaving little time for longer specialized trainings. Very few were ready to make out time to attend longer trainings. This reflected in the fact that none of the residents signed up for the 2-week training. In comparison, there were relatively more consultants attending the 2-week training course. Possibly because they had more time as their training was already completed and could now take time to learn certain aspects of interest to a much deeper level.

The general consensus for both sets of trainees however was that 2 weeks was just ideal for all training and hands-on to be completed and well assimilated. This relatively fewer numbers of eyecare workers who turned up for training when compared with the number of ophthalmologists in the country (probably up to 600, exact number not known but not less than 500, since not all register to attend national conferences) is probably evidence of the reduced interest in this field but at the same time one can also say it may indicate renewed/awakened interest in this uncommon area compared with the very little recorded activity in this area from previous experience over the past decades. This cannot be compared to large numbers that have been attending clinical ophthalmology training programs which have been organized and regularly attended since 1988 as observed by Otuka and Ubah (2015). When examining the proportion of those who attend this training and those who attend clinical ophthalmology and community ophthalmology training sessions, both of which are relatively well developed and well attended due to its greater demand, the fact that many patients may require low vision evaluation in order to improve their quality of life should inform that more attention needs to be given to training in this area with regular organization of low vision training.

Proportion practicing 3 months after training

This audit showed that after the 1-day training course, two showed sustained interest in low vision and one signed up for the 2-week training course. This may possibly indicate the inadequate nature of the 1-day session. Most of those who attended the initial 1-day course were not able to practice due to the limited understanding of the subject and little time to deeply explain the calculations required. Only one had previous exposure to low vision training having previously attended a 2-week course elsewhere. All others never had any prior exposure. However, up to three-quarters were able to have heightened awareness and properly refer patients who could benefit from low vision care. This in itself is a commendable outcome as more people who could potentially use vision to execute a task were pointed in the right direction. In the second course which was for 2 weeks, six out of eight were able to confidently practice low vision evaluation and five had actually taken steps to do so on a consistent basis by asking us to help them set up a moderately equipped low vision clinic alongside their regular eyecare services. This has increased the pool of low vision workers in Nigeria by 100%.

Participating faculty

More faculty participated in the 2-week training compared to the 1-day to a proportion of 1:3.3. The numbers of teaching/special education (1:7) and optometry faculty were also higher (1:8). This was not surprising as the course had traditionally been dominated by optometrists and with more time given for details, more faculty who were already working over the years in this field had an opportunity to reproduce themselves. Orbis faculty also participated by giving live lectures online to the trainees. The Internet was fully utilized to minimize cost of organizing the training sessions. The recent great improvement in Internet services in Nigeria contributed greatly to this as the sessions were quite clear with very good audio and was as interactive as though the lecturer on Skype was on ground locally.

Courses taught

The courses taught were carefully selected to maximize the relatively short time available for the 1-day course and allow the curious and serious minded to have an idea of how patients with low vision can be helped to see better. Due to time constraints, there were only 20 lectures in the 1-day training in 15- to 20-min didactic segments while there were at least 70 lectures during the 2-week training which were carefully delivered and digested by the trainees in a much more sedate manner for maximum understanding. There were also informal sessions of discussions between trainees and trainers where areas that were not so clear were discussed for clearer understanding.

Hands-on sessions: Patients were invited through fliers, radio adverts, and notices on social media on different platforms and a mixed multitude of those with low vision and those with blindness category requiring rehabilitation were seen by the trainees. Initial demonstrations of each step was shown as much as possible and then groups of two trainees were given a patient, thereafter each trainee was given a patient to evaluate and all entries were made in a log book given for that purpose which was graded at the end of the course. However, for the first course, only group demonstration was possible due to the limited time and larger number of trainees. Information is better passed when there are fewer numbers and hands-on was allowed after a demonstration of a step is made. This may have affected the numbers of those able to evaluate patients afterward compared with the second course.

Pretest and posttest scores: Before anything was taught, all trainees were given a pretest and at the very end before departure, the same set of questions were given to them to determine their gain in knowledge. In between, they were also tested midway on two other aspects – their workbook detailing the cases they evaluated and another test evaluating their knowledge midway into the training just after the first week was completed. The distinct improvement of 250% between the pre- and post-test scores was gratifying to the trainees and faculties alike. This indicates that a large number can be safely and effectively trained in low vision evaluation in as short a time as 2 weeks. This, if properly harnessed can help rapidly increase the human resource available to help patients in developing countries where such skills are not widely available in the shortest possible time.

Empowering the trainee

Training is only complete when demonstrations are made and the trainee is equipped with what was used to train him in order to give out assistive devices appropriately. All trainees of the 2-week course were given a 28 item basic low vision kit to help them in their new practice. Probably the fastest way for newly acquired skills to dissipate is to teach a new skill and not empower the trainee by providing the basic equipment required for that purpose. The basic materials specially put together by TLEC rehab tutors can be used to examine a patient who has low vision and include the early treatment for diabetic retinopathy and low vision resource center charts for distance and near vision evaluation, sample telescopes, magnifiers of different strengths, filters, occluders, pen torch, typical sample forms for low vision evaluation and early intervention, and so on. In comparison, the first set of trainees who were not given any kit were not able to practice low vision at all. This says a lot about the effect of empowering a trainee and how skills obtained after training can easily be lost if materials required are not provided hand in hand.

Three months after

Five out of 8 (62.5%) of the participants started low vision clinics in their centers immediately, with assistance from TLEC rehab which helped bring the total number of trained low vision workers in Nigeria to 12 altogether from an original number of just 7 functional specialists in the country. One other trainee in the north is working on reviving a moribund low vision center into a functional one. This is a significant improvement and we plan to train more and regularly too (Figure 6).

Figure 6.

Map of Nigeria.

Challenges

In attempting to equip these clinics, it has been extremely difficult to source for suitable charts and low vision assistive devices like telescopes and magnifiers, and so on. All local optical and ophthalmic suppliers in Nigeria were checked to see if they had any, but despite the increased demand which followed the trainings, it has been difficult to get devices to give patients. A similar experience was observed by Nyankerh et al. (2019). This is likely to create challenges for the next batch of trainees who will require similar materials to set up their own clinics and may rapidly develop into a major crisis if steps are not taken quickly.

Conclusion

It is possible to generate interest in low vision care if training is simplified and made down to earth. Success in skill transfer is better if equipment is given to trainees to ensure they are able to practice immediately after they return to their base. Follow-up by trainers is essential to help them along through the initial teething problems till they are confident of their abilities. However, sourcing for devices may now be the new hurdle to surmount as there is no resource center within Nigeria or across Africa. We may have to look inwards and possibly apply local technology or advocate for duty free importation. It is now apparent in the spirit of universal health coverage which advocates easy access, that rather than depending on a distant resource center (the known one being in Hong Kong), such a regional low vision resource center is urgently required here in Nigeria for local production/supplies of high-quality devices in order to better serve low vision patients and those requiring rehabilitation at reduced costs in sub-Saharan Africa to sustain the low vision care/training. Research into ways and means this can be achieved locally will be looked into by the Foundation with possible collaboration by willing organizations.

Supplemental Material

Basic_low_vision_kit – Supplemental material for Low vision evaluation training in Nigeria: Time to improve human resource in developing countries

Supplemental material, Basic_low_vision_kit for Low vision evaluation training in Nigeria: Time to improve human resource in developing countries by Adedayo Adio, Charles Bekibele, David Lewerenz and Linda Lawrence in The British Journal of Visual Impairment

Footnotes

Declaration of conflicting interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

ORCID iD

Adedayo Adio

Supplemental material

Supplemental material for this article is available online.

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