Decreasing delay in pediatric g y p presentation to CEHTF Fortunate Shija Asiwome Seneadza Susan Lewallen Susan Lewallen Chileshe Mboni Chileshe Mboni Paul Courtright Gerald Msukwa Ariel Phiri Tionenji Ng’ongola
KCCO in brief • Established in 2001 in Moshi, TZ • Work throughout eastern Africa • Leading technical agency for d h l f paediatric eye disease in Africa: courses, research & publications courses, research & publications Pic buliding
Sites for current study
How do we get from here… to here? Identify early Provide high Ensure proper and refer quality surgery follow up This requires a program
Background ‐ why this study? • Evidence from schools for blind for blind • Previous AED project indicated that trainin indicated that training PHCW alone was not effective effective • Interest in expanding pediatric programs requires information on costs
1. Document delay & reasons Objectives Objectives for delay in presentation to 3 CEHTF 2. Measure knowledge and skills of MCH workers at recognizing and referring childhood cataract 3. Test whether training & supervision will increase supervision will increase referrals by MCH workers 4 Estimate cost of establishing 4. Estimate cost of establishing CEHTF in Africa
Study design ‐ objective #1 ‐ explaining delay in presentation l i i d l i t ti Standardized interviews with caretakers presenting to CEHTF with significant surgical with significant surgical problem • cataract, glaucoma, cataract, glaucoma, squint, RB, orbital tumour • • who recognized who recognized problem • steps taken to access service • barriers encountered
Study design ‐ objective #2 ‐ what do MCH workers know and practice? k k d ? • Administered a simple test and questionnaire to MCH • Administered a simple test and questionnaire to MCH workers from 1 district each site
Study design ‐ objective #3 ‐ will trained & supervised MCH workers make more i d MCH k k referrals? • 1 day training on recognizing and referring children • Regular phone contact from CEHTF, monitor referrals and compare to neighboring district
Preliminary results… Preliminary results…
Number of children with selected d diagnoses admitted over 6 months d d h Malawi Tanzania Zambia total Congenital cataract 51 30 28 109 Developmental cataract Developmental cataract 21 21 6 6 3 3 30 30 Congenital glaucoma 16 8 5 29 Squint 1 3 17 21 Retinoblastoma 8 3 7 18 Secondary glaucoma 0 3 0 3 Orbital tumour 1 0 1 2 Total 98 53 61 212
Months of delay from recognition at home to arrival at CEHTF (means, 95% CI) h l Initial delay y 2’dary delay y y Total (1 st contact ‐ (recognition ‐ delay 1 st contact) CEHTF (mos) C Congenital cataract i l 17 (10 23) 17 (10 ‐ 23) 19 (13 24 ) 19 (13 ‐ 24 ) 36 (28 43) 36 (28 ‐ 43) (109) Developmental Developmental 12 (4 20) 12 (4 ‐ 20) 16 (9 ‐ 24 ) 16 (9 24 ) 29 (18 40) 29 (18 ‐ 40) cataract (30) Congenital glaucoma Congenital glaucoma 1 (0 ‐ 3) 1 (0 3) 8 (0 ‐ 15) 8 (0 15) 9 (2 ‐ 16) 9 (2 16) (29) Squint (21) q ( ) 3 (0 ‐ 7) ( ) 27 (14 ‐ 41) ( ) 30 (17 ‐ 43) ( ) Retinoblastoma (18) 2 (1 ‐ 3) 10 (6 ‐ 15) 12 (8 ‐ 17)
Cataract: months of delay from recognition at home to arrival at CEHTF i i h i l CEHTF (means, 95% CI) Initial delay 2’dary delay Total delay % > 12 (1 st contact ‐ (recognition ‐ months 1 st contact) 1 st ) CEHTF CEHTF Malawi 19 (10 ‐ 28) 19 (12 ‐ 26) 38 (28 ‐ 47) 57 (n=72) ( ) Tanzania 18 (8 ‐ 28) 18 (11 ‐ 24) 36 (24 ‐ 47) 64 (n 36) (n=36) Zambia 7 (2 ‐ 11) 18 (10 ‐ 26) 25 (18 ‐ 33) 59 (n=31) (n=31)
Cataract: reasons for delay Cataract: reasons for delay Tanzania Zambia Rx’d by primary health worker 4 5 No money/transportation 10 13 Didn’t recognize problem/think serious 10 8 Multiple diseases in child 3 0 Didn’t know where to go Didn t know where to go 0 0 4 4 Other 4 1
How many hours from home is the CEHTF? vel who trav % w
No association found between h hours to CEHTF and delay t CEHTF d d l
Health workers’ knowledge ‐ pre training Mentioned cataract as cataract as possible diagnosis g Malawi 21/48=44% 2/25=8% Tanzania 20/38=53% Zambia
Health workers' knowledge: at what age ( (months) can a child have eye surgery? h ) h ld h
Health workers’ knowledge ‐ pre training Mentioned scar as possible diagnosis Malawi 34/55=62% Tanzania 2/25=8% Zambia 13/38=38%
Did health workers (pre training) examine the eyes of children at immunization? h f hild i i i ? always some ‐ never y if mother asks How many y times have a torch Malawi 9 42 1 5 5/52=9% (17%) ( %) ( (81%) %) ( %) (2%) (10%) ( %) Tanzania 5 15 1 4 5/25=20% (20%) (20%) (60%) (60%) (4%) (4%) (16%) (16%) Zambia 2 28 7 1 3/38=8% (5%) (74%) (18%) (3%)
Did training help increase referrals? Did training help increase referrals? Comparison between referrals from trained and untrained districts d d d d Country Referrals from Referrals from trained districts non trained districts Malawi 15 12 Tanzania 10 2
Discussion • Preliminary data indicate that we are still not getting kids in early enough. This issue is equally important as training and equipping CEHTF • Delay occurs both before and after contact with health system • Existing MCH workers have very limited skills and knowledge ‐ can they help if better trained & supervised?? • A variety of different methods will be needed and we A i f diff h d ill b d d d need evidence for which work and which do not in different settings different settings
Still to do • Continue collecting data on children through end of the year • Longer follow up on the referrals ‐ ongoing for g p g g next year to see whether the training actually improved referrals p • Complete analysis of costs – data have been collected collected • Advocacy to be discussed
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