Task-shifting eye care to ophthalmic community health officers (OCHO) in Sierra Leone: A qualitative study

Topical review: Task shifting and the recruitment and retention of eye health workers in underserved areas

Many populations experience difficulty accessing eye care, especially in rural areas. Implementing workforce recruitment and retention strategies, as well as task shifting through widening scope of practice, can improve eye care accessibility. This article provides novel evidence on the compatibility of these strategies aimed at enhancing ophthalmic workforce recruitment, retention, and efficacy.

PURPOSE

The global burden of blindness is unequally distributed, affects rural areas more, and is frequently associated with limited access to eye care. The World Health Organization has specified both task shifting and increasing human resources for eye health as instruments to improve access to eye care in underserved areas. However, it is uncertain whether these two instruments are sufficiently compatible to provide positive synergic effects. To address this uncertainty, we conducted a structured literature review and synthesized relevant evidence relating to task shifting, workforce recruitment, retention, and eye care. Twenty-three studies from across the globe were analyzed and grouped into three categories: studies exploring recruitment and retention in human resources for eye health in general, studies discussing the relationship between task shifting and recruitment or retention of health workers in general, and studies specifically discussing task shifting and recruitment or retention in eye care workers.

FINDINGS

Our findings demonstrate that incentives are effective for initiating task shifting and improving recruitment and retention in rural areas with a stronger effect noted in midlevel eye care professionals and trainees. Incentives can take various forms, e.g., financial and nonfinancial. The consideration of context-specific motivational factors is essential when designing strategies to facilitate task shifting and to improve recruitment and retention.

Proposed task shifting integrated with telemedicine to address uncorrected refractive error in Kenya: Delphi study

BACKGROUND

Developing countries such as Kenya still experience challenges around human resource to deliver refractive error services. However, given the burden of uncorrected refractive error, adoption of innovative and cost effective approaches is desirable. Hence this study intended to develop a task shifting framework integrated with telemedicine to potentially scale refractive error services.

METHODS

This was an exploratory study conducted in four phases as follows: a scoping review of the scope of practice for ophthalmic workers in Kenya, an interview with key opinion leaders on the need for integration of public health approaches such as the vision corridors within the eye health ecosystem in Kenya and their knowledge on task shifting, and finally development and validation of a proposed task shifting framework through a Delphi technique. Purposive sampling was used to recruit key opinion leaders and data was collected via telephonic interviews. The qualitative data was analyzed thematically using NVivo Software, Version 11.

RESULTS

The scoping review showed that only optometrists, ophthalmologists and ophthalmic clinical officers are allowed to undertake refraction in Kenya. All of the key opinion leaders (100%) were aware of task shifting and agreed that it is suitable for adoption within the eye health ecosystem in Kenya. All of the key opinion leaders (100%) agreed that skills development for healthcare workers without prior training on eye health supervised by optometrists through telemedicine is desirable. Notwithstanding, all of the key opinion leaders (100%) agreed that integration of public health approaches such as the vision corridors across all levels of healthcare delivery channels and development of a self-assessment visual acuity tool is desirable. Finally all of the key opinion leaders (100%) agreed that task shifting is relevant for adoption within the eye health ecosystem in Kenya. The developed framework prioritized partnership, advocacy, skills development, establishment and equipping of refraction points. The proposed framework advocated for a telemedicine between professionals with conventional training and those with skills development.

CONCLUSION

Task shifting integrated with telemedicine could cost effectively scale refractive error service delivery. However, internal and external factors may hinder the success warranting the need for a multi-faceted interventions and a connection between planning and training to scale the uptake.

Task Shifting and Task Sharing to Strengthen the Surgical Workforce in Sub-Saharan Africa: A Systematic Review of the Existing Literature

BACKGROUND

A major constraint to surgical care delivery in low-resource settings is inadequate workforce availability. Surgical task shifting (TShifting) and task sharing (TSharing), in which non-surgeon clinicians (NSCs) are trained to perform select surgical procedures, have been proposed as one solution. However, patterns of safety and efficacy of surgical TShifting/TSharing are not well-established. This study aims to summarize the current literature and assess clinical outcomes and impact of surgical TShifting/TSharing in sub-Saharan Africa.

METHODS

A two-tiered systematic, PRISMA-adherent literature review of surgical TShifting/TSharing in sub-Saharan Africa was conducted. Collected data included healthcare settings; types of surgeries performed; attitudes toward NSCs; and categories, training, capacity, clinical outcomes, safety, retention, cost-effectiveness, and supervision of NSCs. A random effects meta-analysis of morbidity and mortality rates between NSCs and surgeons was conducted.

RESULTS

Among the 659 abstracts screened, 31 studies met inclusion criteria and were integrated in the final analysis. Eighteen studies (58%) report on the capacity and aptitude of NSCs, 16 (52%) on clinical outcomes and safety, and seven (23%) on attitudes. NSCs performed 1999 (61%) of 3304 total surgical cases studied. The most common operations reported were hernia repair (n = 12, 57%), acute abdominal (n = 12, 57%), and orthopedic procedures (n = 6, 29%). No differences were found between NSC and surgeon case morbidity [315 (16%) vs. 224 (17%); p > 0.05] and mortality [44 (2.2%) vs. 33 (2.5%); p > 0.05] rates.

CONCLUSION

NSCs are increasingly performing surgical tasks in regions of sub-Saharan Africa deficient in trained surgeons and appear to have non-inferior safety outcomes in select programs.

Integrating eye care in low-income and middle-income settings: a scoping review

OBJECTIVES

Integrated people-centred eye care has been recommended as a strategic framework for reducing global vision impairment and blindness. The extent to which eye care has integrated with other services has not been widely reported. We aimed to investigate approaches to integrating eye care service delivery with other systems in low resource settings, and identify factors associated with integration.

DESIGN

Rapid scoping review based on Cochrane Rapid Review and Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines.

DATA SOURCES

MEDLINE, Embase, Web of Science, Scopus and Cochrane Library databases were searched in September 2021.

ELIGIBILITY CRITERIA

Papers with interventions involving eye care or preventative eye care integrated into other health systems, peer-reviewed in English, conducted in low-income or middle-income countries, and published between January 2011 and September 2021 were included.

DATA EXTRACTION AND SYNTHESIS

Two independent reviewers screened, quality appraised and coded included papers. A deductive-inductive iterative analysis approach was used with a focus on integrating service delivery.

RESULTS

The search identified 3889 potential papers, of which 24 were included. Twenty papers incorporated more than one intervention type (promotion, prevention and/or treatment), but none included rehabilitation. Most articles involved human resources development yet rarely appeared to be people-centred. The level of integration was associated with building relationships and enhancing service coordination. Integrating human resources was challenged by the need for ongoing support and worker retention. In primary care settings, workers were often already at full capacity, had competing priorities, varying capabilities and limited motivation. Additional barriers included inadequate referral and information systems, poor supply chain management and procurement practices and finite financing.

CONCLUSION

Integrating eye care into low resource health systems is a challenging task, compounded by resource limitations, competing priorities and ongoing support needs. This review highlighted a need for people-centred approaches to future interventions, and further investigation into integrating vision rehabilitation services.

Primary eye care: opportunities for health system strengthening and improved access to services

Primary eye care (PEC) is a vital component of primary healthcare (PHC) and is the cornerstone for the progress towards universal eye health coverage. While the concept of PEC is not new, with the increased focus of the global eye-health agenda on equity and people-centred care, it is critical to review experiences of delivering PEC in low- and middle-income countries and to identify common lessons learnt. This commentary builds on the available evidence and focuses specifically on three recently published evaluations of PEC in Sightsavers-supported programmes in Tanzania, Sierra Leone and Pakistan. It argues that systems thinking is critical in the delivery of PEC interventions, as only this approach can ensure that the integration of PEC into PHC is delivered in a comprehensive, coherent and sustainable way.