A Qualitative Assessment of Low Vision Care Among Optometric Practitioners in Sub-Saharan Africa Using a Health Systems Framework

Study Design

A framework-guided qualitative study with phenomenological and case study elements using a semi-structured interview was employed in this study to explore the perspectives of optometrists engaged in LVCR across five countries in Sub-Saharan Africa. The adopted approach helped to gain in-depth insights into the experiences, challenges and other factors in the provision of low vision care and rehabilitation services that were essential in evaluating the WHO health systems framework. The Semi-structured interview helped to maintain consistency in the interviews and ensured all components of the health systems building blocks were sufficiently interrogated.

Inclusion and Exclusion Criteria

The population that were targeted for this study were registered optometrists who were providing low vision care within their respective countries. The practitioners were required to provide a range of services including identifying, examining and prescribing vision aids and/or vision rehabilitation to patients with irreversible vision loss. Persons receiving care should have low vision or moderate to severe visual impairment (MSVI) with a visual acuity range from 6/18 to 3/60 in the better seeing eye. Participants who practiced LVCR but where not optometrist were excluded from the study.

Sampling of Countries

Low vision practitioners in five sub-Saharan African countries were recruited for this study. The countries that were included were selected using stratified random sampling. Three out of the four regional blocks; western, eastern and southern Africa, were randomly selected with central Africa being the only region which was not included. Countries that used English as their official language were selected within each regional block. Countries that had more than one optometry program with at least one of them awarding university level undergraduate degrees and had graduated at least three cohorts of students at the time of the study were considered. Based on these criteria, the eligible countries were Ghana, Nigeria, South Africa, Malawi and Kenya. Table 1 shows the countries selected with their respective population and number of optometrist.^31,32 It also shows a range of economic states from low income to upper middle income based on world bank data. ³³

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Table 1.

Characteristics of Countries Included in the Study.

Country	Number of optometrist	Population	Economy category	Number of optometry institutions
Ghana	406	33 787 914	Lower middle income	2
Kenya	580	55 339 003	Lower middle income	2
Malawi	77	21 104 483	Low income	2
Nigeria	5716	227 882 945	Lower middle income	14
South Africa	4040	63 212 384	Upper middle income	4

Practitioner Recruitment and Data Collection

A prior relationship was not established between the researcher and the participants before recruitment. The optometry association in each country was contacted to help identify low vision practitioners and optometrists involved in LVCR. The practitioners participated in one-on-one in-depth interviews relating to the state of low vision care in their respective countries. A snowball sampling approach was used to recruit practitioners for the study. Since previous studies have documented few low vision practitioners across sub-Saharan Africa,^34,35 a sample of 25 low vision practitioners with five from each country was expected. These practitioners were contacted and interviewed through phone calls, emails and video conferencing platforms based on their preferences. The date, time and medium for the interview were selected by the respondents. All the interviews were conducted by one member of the research team (CHA) to ensure consistency and reliability in the interview process. However, due to inherent differences in each country, some countries did not have enough participants to meet the minimum expected sample and this caused the interviews to end when all available respondents were interviewed. Secondly, based on the core indicators for the health systems framework no new information emerged after the second to third interview in each country. Three practitioners (one from Ghana and two from South Africa) were unable to respond to the request to be interviewed after initially agreeing to partake in the study. None of them gave a reason for declining the interview.

Modified Health Systems Framework

The WHO health systems framework was modified and used to guide data collection in this study. The original framework has six blocks which are: governance and leadership, health service delivery, human resource, health information, essential medicines and financing. The modified framework that was used omitted the health information block as this requires a review of national health information systems. The essential medicine block was modified to read low vision aids and technology as this was more applicable to this study.

The following indicators were used to measure the five blocks:

The interview guide was generated based on the indicators stated under each block. The guide was pre-tested on about 2% of the expected study sample. The results of the pre-testing was used to modify the guide. The length of the guide was reduced from 48 questions to 22, this helped to shorten the time for the interviews to an average of 45 minutes per participants.

Analysis

All interviews were audio-recorded and transcribed verbatim to ensure accuracy. Thematic analysis was conducted following Braun and Clarke’s six-phase framework ³⁶ with the aid of QDA miner 5.0 software to support organization and coding of the data. The coding was done by CHA who is a male academic with expertise in LVCR and has prior experience with qualitative studies. The six phases involved familiarization with the data, coding, generating initial themes, reviewing themes, defining and naming themes, and producing the report. Coding consistency was maintained through periodic checks by authors DVS and NR to ensure alignment with the research study. The themes and sub-themes were therefore grounded in the data, reflecting both individual perspectives and broader trends relevant to low vision care in the region. Additionally, demographic data for each practitioner, including gender, years of experience, and low vision specific qualifications, were collected and summarized.

Ethical Considerations

Ethical approval for the study was obtained from the Human and Social Sciences Research Ethics Committee of the University of KwaZulu-Natal(HSSREC/00004324/2022). The study adhered strictly to the tenets of the Declaration of Helsinki on studies involving human subjects. Before participation, all individuals were provided with an information sheet outlining the study objectives, procedures, potential risks, and benefits. Sufficient time was allowed for practitioners to ask questions and discuss any concerns. Each practitioner then signed an informed consent form, affirming their voluntary participation and understanding of the research purpose, confidentiality measures, and their right to withdraw at any time without penalty. Furthermore, at the beginning of each interview practitioners were requested to affirm their agreement to participate in the study and provided approval for the interviews to be recorded.

Policies Governing Low Vision Care and Rehabilitation LVCR

The practitioners were not aware of current national policy documents that specifically governed low vision practice and development. However, some practitioners reported being aware of national eye health policies

For now, I don’t know of any such policies. So the only policy I know is a general policy about eye health. But one specific for low vision, I don’t think I’m aware about that for now. Maybe it might be there, but I don’t think I have seen or read something about that. (N2, Male)

A practitioner indicated that the current policy being implemented was from an initiative within the facility in which he practices rather than the government and this has improved detection of children with low vision and aided in proper placement of these children in schools.

There was no policy through the government. However, through a non-governmental organization [name redacted for the ensure anonymity], we have conducted several meetings with the Ministry of Disability, in Malawi. Up to now, the only policy that has come up, is the admission policy to Schools for the Blind. They say any child, before being admitted to the School for the Blind, they have to go through low vision therapist for assessments before going to (the) school. Otherwise, we don’t have any other policy as far as low vision is concerned, in Malawi (M1, Male)

The perceived absence of a policy framework for low vision practice and development had negative consequences for patients as practitioners expressed in the following comment:

We don’t have anything that deals with low vision, partial sightedness, or any vision disability and not having that, has had a ripple effect. We have a Department of Social Development where people with disabilities get care. They get grants, for instance, a social grant to assist them, obviously, especially when they’re not working. But even this Department of Social Development does not have standards for defining vision impairment, low vision, legal blindness. They don’t have it. The reason I’m saying that is, I will have two clients with similar vision function and I will write a recommendation and one will be granted a social development grant and (the other) one will be rejected. . . (SA1, Male)

Coordination of LVCR Activities

Most low vision practitioners were not aware of any coordinating or supervisory body responsible for coordinating low vision care within the country.

In an attempt to identify a possible coordinating body one practitioner indicated that the closest body was the Directorate of Eye Care in the region.

I think it is the director of eye care in the province. But they don’t coordinate as such. The coordination is limited to the compilation of statistics through the monthly reports. Incidentally, we told them (directorate of eye care) that, look, we want to start a low vision clinic. We took it upon ourselves to do that. They did not come to us to say, we want you to start this. No, it’s us who did that. (SA2, Female)

Another practitioner ascribed a coordinating role to the blind union within the country as they were responsible for distributing low vision aids.

Initially, it was left for the Kenya Society for the Blind. They were the ones the government has put as the resource centres where if you need any low vision device, educational materials, you get through them, but it’s really not working (K1, Male)

Data Availability

Data on low vision care seemed to be a major challenge in Sub-Saharan Africa. In some countries, the current prevalence of low vision was not available.

Actually, in terms of statistics, in Malawi, so far, we don’t have statistics of how many people have low vision, apart from the study that we are doing within our organisation. It’s only the number in blind schools that we collect (M1, Male)

This lack of data has an influence on the plan the country would have for the development of LVCR.

Again, I think the last prevalence study of any vision thing that happened in the province was undertaken around 2006, 2007, somewhere there. The question is, do we have a plan? It’s very important. Because we need to have evidence of, you know, prevalence and all those things, the RAAB [Rapid Assessment of Avoidable Blindness] studies and all that. But we don’t have at the moment that deals with the actual numbers. Either looking at those that present in the facility or taking the study out into the communities. At the moment, we don’t have such. (SA1, Male)

One practitioner indicated that the method of reporting information from the country did not provide information specifically on low vision activities. Another described his frustration in trying to modify the reporting format to include data on LVCR.

WHO has decided that in South Africa, there are two [indicators], the number of cataract operations done to prevent blindness, and the number of glasses you have prescribed. So, the information that is sent by us as a country to WHO talks to those two key performance indicators. (SA2, Female)

I have tried to smuggle low vision into our strategy. But when it goes to the province, it doesn’t conform with the provincial indicator for our facility. So, it keeps getting kicked out. So, I think the issue now is more on the indicators that we use as a facility because I can do my monthly reporting, but it doesn’t reflect on any strategic platform that low vision is being practiced. (SA1, Male)

Coverage and Distribution of Low Vision Care Centres

The practitioners noted that the coverage of low vision care was low and ascribed this to the low number of practitioners involved in low vision care in relation to the population that needed to be served.

The coverage is still poor when we talk about low vision in Nigeria because Nigeria has a population of over 200 and something million people and the low vision specialists we have, I can tell you, I don’t think we are up to 100. In Edo state alone, which is one of the major states, the low vision specialists here are not up to; let me count, not up to 5. In Lagos too, I don’t think there are up to 10 low vision specialists in Lagos state. In Abuja, same thing. So, in the whole country, I don’t think we have more up to 100 low vision specialists. (N2, Male)

Another practitioner associated the low coverage with the negative experiences of potential low vision practitioners during their first few encounters with patients.

This is because the other optometrist I work with, I ask them, why are you not doing the low vision? Even though you have received training, you know, some time ago a workshop was organized. They even have their certificates. But they don’t do it. So the response I had was, Doc (Doctor), the outcome, most of them, the outcome is no good. It’s time-wasting, time-consuming. The patient will come and they will feel so emotional towards you. Meanwhile, there are other clients you need to attend to. So I think the care in this country is very low, very low because they feel as soon as they identify the condition, they just push the person away. (G2, Male)

Poor remuneration and lack of standardized training were also identified as contributing factors for the poor coverage and distribution of low vision practicing optometrists.

Brien Holden has been having this crash program so by now we should have had every square inch of this country covered by an optometrist who practices low vision but in terms of actualization that’s not yet forthcoming. Like I said they come and do their workshop they go back and they forget about everything they are not interested in practicing because low vision doesn’t fetch money as I said the clients are mainly people from poor backgrounds, so it doesn’t fetch money. In Ghana, there should be a dedicated centre where people can go and have adequate training in low vision and I think that would be the basis of sustainability. (G4, Male)

During the interviews, most practitioners were not able to mention more than three centres that provided low vision care. Distribution was a challenge as some regions in some countries did not have even one centre or low vision practitioner.

So far, I know, Blantyre is the main one, and another one at Queen’s. There’s Nkoma, In Lilongwe we also tried to establish another one, that was at the Central Hospital. Okay. But the challenge is that most of the optometrists are not really interested in low vision. So far, I can say, it’s only, you know, Blantyre, Nkoma and Queens low vision centres so far. (M2, Female)

Integration of Low Vision Service into the Public Health Care System

Most of the practitioners interviewed worked in public health facilities that were funded by the government. However, the low vision clinics were not separate units as they were part of the general services provided in the facility. Therefore, even though low vision services were provided they were not considered low vision centres.

I think in Nigeria, what we have is a general clinic. We don’t have a sub-section that has low vision. So, for now, we don’t have a low vision centre. (N2, Male)

Low Vision Clinic Schedule and Equipment

Practitioners provided general optometric care in their facilities and dedicated specific days that they provided LVCR services. In most cases, one day within the week was dedicated to low vision care and very few patients were booked.

I do general optometry. Then, I also have my low vision clinic in which I see my low vision patients once a week. I don’t book too much patients in the clinic. At least, maximum I book is three. But I prefer to have two because of the time I need to spend with the patients. (N2, Male)

A practitioner indicated that though he has a specific day for providing low vision service, he sometimes needs to compromise and provide care on other days as patients travel very long distances and some do not have the financial resources to return for the specific day dedicated to LVCR services.

So low vision days over here are Wednesdays. However, people come from different parts of the country. Some from Northern region, Volta region with a referral note. They don’t have, they don’t have anyone to contact. I’ve received a number of a good number of low vision cases on the other dates, which I still attend to them. As I mentioned, some are coming from far, far places, Volta Region and the others. So, they will be like, uh, look, I have to go back. Coming back, um, next week or the day you are giving me, won’t be that easy for me. (G2, Male)

The basic equipment needed to examine patients was not a challenge to most practitioners. A practitioner expressed his view on this in the context of the limitations posed by the economic environment.

We are in Africa. Equipment and gadgets we need are wide and varied. I would just say that we have the basics. We don’t have enough. That’s the humble truth. If there’s something like a humble truth or the honest truth. (N3, Female)

In places where equipment was unavailable practitioners used their personal kits even though they worked in a government funded facility.

. . . we do not have the low vision equipment. But by God’s grace, when I was in LV Prasad, because of the interest I had, I managed to buy the low vision kit for myself and that was the primary low vision kit I bought for myself. But post LV Prasad, I have managed to acquire one or two other things. So now, I use my own equipment to assist patients. (G3, Female)

The Low Vision Practitioner

There were varied responses from practitioners on what they believed should be the definition of a low vision practitioner. One perspective was that an optometrist is equipped with the necessary skills to provide LVCR services.

When you come out of university, you are a low vision practitioner. When you come out into the practice world and actually work, you can choose to use your low vision, or not to use your low vision. You don’t have to do another course to become a low vision practitioner. So, to answer your question, every optometrist is a low vision practitioner; because they’re coming out of university qualified in low vision if they choose to do; that depends on the individual (SA4, Male)

Other practitioners described the need for additional training and certification to provide LVCR services.

a low vision practitioner is someone who’s got an optometry degree and has gone for further training to become a certified low vision practitioner (N3, Female)

In Kenya, optometrists are not officially recognized as low vision practitioners. Ophthalmic clinical officers are trained and certified to become low vision care practitioners.

Officially by the government is the OCO (Ophthalmic clinical officers), it’s all a tricky question because the government does not actually recognise optometrists. But as much as I’m working in a government setting, still an OCO will be in a position to even recommend who is legally blind. (K1, Male)

Motivation to Practice LVCR

The motivation to practice LVCR revolved around two things:

. . . a need for relevance and opportunity to be able to serve the undeserved in the facility where I work. (N3, Female)

The majority of practitioners made their final decisions based on the needs of the facility while others were encouraged by colleagues to pursue a career in the low vision sub-specialty

. . . along the line, I moved to Ocular Health because it was something I had interest in. But, an ophthalmologist, where I work, I told him that I was interested in Ocular Health. And he now said, no, no. He said, why don’t you think about going to low vision? That’s where most people are not really interested in. Go there and try and create a name. Or try and create something for yourself. And distinguish yourself among other professionals. (N2, Male)

I think I’m one person whose interests are really stimulated by the need that I see in my workplace. When I start seeing quite a number of people in need of something that I know we have the capability to do, and that I can assist them with, then even if it was never my favourite subject, but I find myself having the responsibility to establish those services so that we can cater for that group of people. (SA3, Female)

Facilities that are equipped and provide low vision care serve as a catalyst for practicing optometrists to develop an interest in low vision.

I was motivated when I worked at one of the federal health institutions here. The ophthalmologists in that part of the country didn’t really have any low vision services. So when I saw the need, I discussed with them and they encouraged me. They’ve got low vision aids that they didn’t know how to use. So, I have something to start with if I actually went for training. So, it was the need that I saw in that special health institution that spurred me to go for a low vision specific qualification. (N5, Male)

Practitioners were divided about the role of undergraduate education in their decisions to practice LVCR. Whilst some believed it made a significant contribution others felt it was woefully inadequate.

I would classify it as just a sketchy training on low vision. That’s what I would describe my undergraduate knowledge of low vision to be [foundational]. Sadly, the emphasis was not really on low vision. We had it as a course, it was not in-depth enough you know. And so I couldn’t really, although I knew what low vision was all about, but it was not deep enough to know about it to be able to see low vision patients. (N4, Male)

I think I still refer to all that I studied on campus. Yeah. So the training was very good, I must say. It was really, really very good. It was under the late Prof. Oduntun. So, he really gave us much on that. And yeah, it stuck since then. (SA3, Female)

Recognition of the Low Vision Practitioner

It emerged that in all the countries even in Nigeria where there was a residency program, low vision practitioners were not given any recognition by state agencies and did not get additional benefits in terms of remuneration or promotion. The situation was worse in Kenya where they were still trying to get optometry as a cadre to be recognized and employed by the Ministry of Health even though they have been graduating optometrists since 2012.

There are no such benefits. You become, low vision specialist, you work like a general optometrist, on top of that, as part of your duty, you are also involved in, a low vision assessment without any incentives. (M1, Male)

In Kenya, the optometrists started in 2012. That was the first time they graduated. And still up to date, the government is not employing optometrists who are actually supposed to be in charge of low vision (K1, Male)

Training and Recruitment of Low Vision Practitioners

The general view of all the practitioners was that there were insufficient low vision practitioners in their countries. Furthermore, there was no active approach to recruiting future practitioners either. Most of the practitioners had not seen any advertisements for low vision practitioners throughout their careers. In all instances, they were employed as optometrists and largely through their personal initiatives acquired the additional skills to provide LVCR services for their patients.

I haven’t heard any advertisement concerning a low vision practitioner. I haven’t heard any facility looking for a low vision practitioner. (GI, Male)

I’m employed as an optometrist in my facility, I have to create the awareness that I have got this exposure and this training and I can offer this (low vision) service. (N3, Female)

The most often adopted approach to increase the number of low vision practitioners has been sporadic short-term training courses. The irregular nature of these training courses failed to provide a continuous supply of low vision practitioners. Therefore, it is seen as a temporary solution and a more sustainable one is needed. However, the practitioners believed that such training courses have their place and are needed to help fill the wide human resource gap in low vision practice.

It’s about eye care. It’s about the people. It’s not about the practitioners. People need to see. People need to read. And then you can count the number of optometrists who are practicing this low vision. We are very few. (G1, Male)

These two weeks of training I told you of, they have been having intakes. But sadly, I don’t get to see the products of these training coming up to like practice and see patients. . . But since we need more hands to be on deck, we are not discouraging anyone. Even people that go for the two weeks. You know, we are trying as much as possible to create the awareness. At least even if they are not able to review, they are able to identify and screen. They are able to refer. So, it is all part of the work. (N4, Male)