Community based case-finding and rehabilitation: detection of cataract patients and post-operative follow-up
The following recommendations are important for all those concerned with restoring sight to cataract patients and thus with getting these patients to attend an eye hospital.
Identifying patients, raising awareness and information
Remember that the patient may be blind!
Do not search for ‘blind people’ in order to find cataract patients but for those who are ‘older with poor vision’. Due to the usually slow process of becoming cataract blind, and adaptation to decreasing vision, cataract patients are often still quite active and so many do not consider them to be blind.
Most hospitals do not use enough ways of getting patients to the hospital. Patients and their families must be provided with the information required. This information can be passed on in different ways:
- Radio (which is often expensive).
- Through churches or other meeting places (ask for 10 minutes of the weekly sermon!).
- Through primary schools (there is virtually no primary school class without a pupil who has a cataract patient in his/her home. Collect names and addresses).
- Through local health units, projects, community activities, etc.
During all of these activities, use flyers, brochures and posters to get the required information across (see also 3 below).
he information provided by any of your ‘advertisements’ (radio-messages, flyers, brochures, posters) should be comprehensive enough to answer the following questions:
- How much will the cataract operation cost?
- How many days in hospital?
- Is a carer required to accompany the patient?
- Is food provided/available at the hospital? What is the cost? Should food be brought to the hospital?
- What does a cataract operation involve? Is it a safe procedure?
- What is the expected result?
- Will the patient need to come back later for follow-up? Will there be further costs?
Try to find out about the impact of all your cataract detection and ‘sensitization’ methods by asking patients at the hospital how they received the information to come for surgery. This will help you to invest more in cost-effective methods of promotion.
‘Reluctant’ cataract patients, i.e., cataract patients who still fail to present for surgery after having been invited several times, and after having been provided with all the needed information. Try to convince them by introducing them to post-operative patients from their neighbourhood or area. Also, try to discover the (real) reason why he/she has not appeared.
Do not spend too much time and money in getting a patient to the hospital within a full year after the first contact/information. ‘Money’ is commonly the reason for delays, but this is often available at certain periods of the year, for example, after harvesting. This is the time when a patient is encouraged to come for surgery.
For very poor families: offer alternatives in payment(or for reduced payment). There are good examples of family members searching for two other cataract patients (‘people with the same problem in their eyes’). When these patients attend the hospital and they give their names to the local CBR or PHC worker, then their own family member gets free or cheap surgery.
Do not forget: it is often the family that needs to be convinced, not the patient! Without the family, the patient cannot get to the hospital (she/he is blind) and also may not have money available (the ‘old person is taken care of’).
Post-operative community based follow-up of cataract patients
Train CRWs (or nurses, SDRWs) to explain the following to patients and family members:
1. How to use post-operative medicines and the length of treatment.
2. How to attach spectacles (as appropriate) to the ears.
3. How to clean spectacles.
4. Where to put spectacles in order to keep them safe
- a fixed place (otherwise they may be lost)
- where to place them at night.
5. What to do if spectacles are broken and the cost of replacement.
6. New vision exercises
- use the restored sight; expect to see and recognise people
- post-operative patients, without social care, may continue to live as a ‘blind’ person.
- encourage other people to involve the ex-patient
- collect water
- attend the market
- attend meetings, social activities, e.g., women groups.
It is recommended that the CRWs make up to 6 post-operative visits: week 1, week 2, week 3, week 4; month 2 + 1 visit.
Editorial Comment: In the programme described by Mr Vanneste, in Tanzania, a particular team member has the designation Survey-Detection-Referral Worker. The training and skills of the SDRW and the CRW have some similarity, with community based responsibilities, and so reference to the activities of SDRWs is included in the context of our theme on CBR.
Survey-Detection-Referral Workers (SDRWs)
What is a SDRW?
In the context of detection of cataract patients, it is a person who is attached to an Eye Unit (or a CBR/PHC programme collaborating with an Eye Unit) whose work is to sensitize and inform the community in general, and cataract patients and their families in particular, about cataract, i.e., about the possibility of cure at the Eye Unit. The SDRWs’s job is specifically to get as many patients as possible presenting themselves for surgery.
2. Good SDRWs are extremely cost-effective.
They will increase your budget by approximately 1-3%, but they may increase by 100-300% the number of cataract patients coming for surgery, which means that the Eye Unit becomes much more cost-effective.
3. Profile for selection of a SDRW: a ‘social worker’ type of person.
The communication skills of this person are more important than any academic degree. A trained social worker may not be comfortable in a 95% ‘field job’ with no obvious opportunity of promotion. Employ people who will be able to communicate well with community leaders and hospital staff, as well as with patients and their families.
4. Means of transport: motorbike (rural) or public transport (cities).
If possible, consider female workers. However, in rural areas, you might have to take on male SDRWs.
5. The training of SDRWs should include the following:
(i) Recording of visual acuity.
(ii) Identifying a normal, healthy eye.
(iii) Identifying cataract. Differences compared with corneal scars, etc.
(iv) Explanations about cataract. Provide information which might be useful when trying to encourage patients (and their families) to come for surgery.
(v) Understanding and recording findings (e.g., using a Cataract Detection Monitoring Document).
(vi) The activities and responsibilities of the Eye Unit and its staff.
(vii) Communication skills. How to meet with a family, i.e., how to introduce him/herself, the Eye Unit, etc. How (not) to explain about cataract.
(viii) During training, the SDRW should meet with at least 3 cataract patients before their surgery, should witness the operations, and take visual acuities after surgery.
6. Budget items to be considered:
(ii) Maintenance of a motorbike (petrol, oil, etc.).
(iii) Insurance for the person + motorbike or money for public transport.
(iv) Paper + access to a photocopier.
7. SDRWs need not have their own, personal office. They should be 95% of the time in the field.
8. His/her superior should be the ‘manager’ of the Eye Unit, preferably not the ophthalmologist, but the head nurse. The SDRWs should be recognised as members of the Eye Unit staff.
The most fruitful time for the SDRWs to achieve good results is to work during the weekend because that is when most social gatherings take place. These are ideal opportunities to reach many people. Churches, political and other social gatherings, etc. should be addressed.