*3.2. Analysis of Practices*

Table 5 shows the frequency distribution of practice-related statements. It was found that almost all the participants (95%) prioritise prevention of blindness programmes. More than two-thirds (71%) reported that their spectacle service has a satisfactory turnaround time. Another 70% disagreed that their administration (drug stock/frame stock/IOL stock) is efficiently managed by our ward clerk/s, and 67% indicated that they do not perform noncontact tonometry on all patients. Overall, about three-quarters (73.27%) of the participants were well acquainted with practices on eye health.

Using binary logistic regression, there were statistically significant associations in every category assessed (Table 6). Management were 99% less likely to practice properly towards eye health when compared with RHeH (aOR = 0.012; *p* < 0.01). The Participants Qualified with Certificates and Grade 12 were 92% less likely and participants with postgraduate qualifications were 89% (aOR = 0.106; *p* < 0.01) less likely to know practices related to eye health when compared with participants having a university degree. With regards to age, the middle age group (30–44 years) were about three times more likely to have the best information on practices within the eye clinics (aOR = 2.603; *p* < 0.05) when compared with the >44 years age group. Having <5 years of experience were 27 times more likely to practice properly than those having more than 27 years of experience (aOR = 26.600; *p* < 0.01).


**Table 5.** Practices towards eye health by eye health workers (%).

**Table 6.** Association between practices and demographic variables.


Spearman's correlation (Table 7) test found significant moderate positive correlation exists between knowledge, attitudes, and practices among the participants.


**Table 7.** Spearman's correlation test output.

Correlation is significant at the 0.01 level (2-tailed).

#### **4. Discussion**

The study aimed to determine the levels of knowledge, attitudes, and practices of eye health care workers and their supervisors towards eye health. Knowledge, attitude, and practice (KAP) surveys are useful in public health planning, as they collect focused, essential information that is useful in guiding public health programmes [30].

### *4.1. Knowledge on Eye Health*

Good knowledge of health is always associated with satisfactory health behaviours and outcome [30]. Therefore, understanding the correlates of good eye health through knowledge leads to improved eye care in a society [31]. The present study found a good level of knowledge among the participants. The study also found that eye health managers had poorer knowledge than the HReH that they supervise. Similarly, other studies conducted in South Africa and Swaziland reported poor knowledge of eye health management, factors attributed to the absence of policies and guidelines on eye health [32,33]. Authors reported a lack of eye health knowledge amongst general practitioners and attributed this to their short training period in this area of healthcare [34]. Other studies that reported reasons for poor knowledge in eye health said that it was due to the fact that it was not a critical "life or death" issue, a lack of adequately trained personnel, a shortage of refresher courses, and that focusing on it would unnecessarily add to their already high workload [35,36]. A recent Ethiopian study found poor knowledge among paediatricians of eye diseases [37].

In this study, education levels were significantly associated with knowledge levels. This finding is similar to that of other studies conducted elsewhere [33,38,39]. These studies showed a correlation between eye health knowledge, age, and the respondents' education level [31,38]. On the contrary, another study showed no correlation between knowledge of eye health and education level or age [40]. As a result, regardless of how qualified another physician was in another area of health such as orthopaedics, paediatrics, or even general health practice, their knowledge was still poor when it came to eye health. Considering that medical officers and specialists initially qualify as medical doctors, their reported minimal exposure to ocular health in their training is a possible reason for their poor knowledge. As they also spend a few weeks in their ophthalmology block, they do not learn much in this area of health care and as such have poor knowledge in it [39–41].

#### *4.2. Attitudes towards Eye Health*

Health workers who have positive attitudes are more likely to follow standard procedures and apply themselves to their duties, whereas those with negative attitudes would not do the same [42]. In this study, the majority of the participants had positive attitudes regarding eye health. It was also found that the youngest participants had the most negative attitudes. The possible explanation for this is that the youngest participants generally came from the safe and sheltered environment of an academic institution, where there were systems and clear protocols. They had since entered a system that does not have clear processes and guidelines, no dedicated directorate, and no easily available supervision. In addition to the working environment, they generally did not have the basic equipment that they required to perform their basic tasks [24,43]. In realising this, they did not have an understanding supervisor who would realise that urgent procurement of basic equipment was a critical enabler for them to perform their duties. As a result, they found themselves lost. The reality of their internal managers not being trained in eye health, and being incapable of providing clinical guidance and support, might be part of the reason for their negative attitude towards it. In another study, HReH attitudes were far more favourable amongst themselves when they were discussing task sharing as opposed to when they were discussing it with management [44]. A recent study conducted among paediatricians in Jordan reported satisfactory attitudes regarding eye health and disorders [45].

Those who had recently started working in eye health had the most positive attitude compared to those who had been working for more than 15 years. Evidence has shown that even though financial remuneration drives employees, it does not compare to the attainment of certain personal goals, either by progression or vertical promotion [46,47]. Intrinsic drivers include promotion and more responsibility within the employment context, driving better performance, self-actualisation, and job satisfaction in an employee [47,48]. The fulfilment that comes with greater responsibility and decision making often drives millennials (those up to age 40) to work hard as they value climbing the corporate ladder [46,47]. As this is lacking in some areas of HReH employment within DoH, it lowers the employee drive and nurtures a negative attitude towards work. Further to this, the lack of professional support and understanding is a challenge within these eye clinics. Most respondents in this study (78.2%) did not feel that their working space was sufficient for eye health professionals to work in. This is further supported by the majority (89.1%) of respondents who agreed that if directorates want to see positive outputs, they need to provide resources in the eye clinics. Sithole conducted a study among the Directorate Managers and found that there were no guidelines on eye screening, eye protection, and basic eye care [32]. Since the management group generally had a slightly older population, with a long service period, their negative attitude was largely due to a lack of ocular guidelines. They further did not have any ocular directorate at a senior level to look to for guidance, possibly resulting in a negative attitude, and shifted their focus more to their familiar health areas such as geriatrics and NCD [32].

#### *4.3. Practices towards Eye Health*

Overall, participants were practicing satisfactorily towards eye health. Almost all the participants confirmed that their eye clinics/districts prioritised blindness prevention in their daily practice. This shows that in light of their working circumstances, these eye health workers still aim to practice the highest level of clinical care in their workplaces. Two-thirds (67%) of the participants indicated that eye clinics did not perform tonometry or fundus examinations due to a lack of equipment, showing that the lack of understanding and prioritising of eye health has severe consequences. Another South African study reported that the conventional practice in hospitals is for trainees to perform cataract surgery under the supervision of consultants, and evaluation of the progress in ophthalmic surgical training was essentially an apprenticeship model [47]. To improve cataract surgical outcomes in Africa, "improved training of surgeons" was ranked as the top priority [49,50].

Both managers and HReH were clear about the severe shortage of basic equipment in the eye clinics, as well as the inefficient spectacle supply chain. Furthermore, the replacement of dysfunctional and old equipment is not honoured or prioritised by managers. Another study reported similar findings indicating that South Africa's primary eye health services lack the organisation and resources to address the leading causes of visual impairment, namely uncorrected refractive error and cataract [23,51,52]. Resource constraints, both human and equipment, are common inhibitors to the delivery of ocular services in African countries [17,52,53]. The shortage of these resources impedes basic practices aimed to ensure the prevention of blindness and PEC. The WHO states that an efficient supply chain and the availability of medicines, and medical devices, are crucial contents in their framework of health systems, to ensure health systems strengthening [8]. This will continue to be unsuccessful if these issues persist as they impede the practices of HReH.

Future studies should seek to include financiers and supply chain managers in public health services, in an effort to understand the details involved in the financing of eye health overall. This will add valuable information and provide further context on the issues raised in this study.

#### **5. Conclusions**

The overall knowledge, attitudes and practices on eye health were satisfactory among the participants but differed significantly between managers and HReH. It is evident that an appropriate eye health professional should be appointed as part of management at both operational and directorate levels. Resources, both human and equipment, would need to be better allocated by knowledgeable professionals for improvement of clinical practice and eye health services overall. There is a need to review the current management structure, as HReH currently work under difficult conditions.

Despite adding new information to the body of existing knowledge, the limitation of this study was the exclusion of supply chain and finance personnel, who could have given context to the issues that were raised by respondents.

The appointment of a sufficiently trained directorate to manage eye health in each district would be beneficial to eye health and prevention of blindness strategies. This will further ensure that an efficient eye health workforce is placed and managed through optimal governance, resulting in improved eye health outcomes and better service delivery to the communities within the province.

**Supplementary Materials:** The following are available online at https://www.mdpi.com/1660-460 1/18/23/12513/s1, Table S1: Validation of questionnaire.

**Author Contributions:** Z.X.-K. conceptualised the study and prepared the manuscript, K.M. and K.N. supervised the study and reviewed the manuscript. All authors have read and agreed to the published version of the manuscript.

**Funding:** The authors thank the UKZN University Capacity Development Programme for funding the study.

**Institutional Review Board Statement:** The study was conducted according to the guidelines of the Declaration of Helsinki and approved by the Biomedical Review Ethics Committee of the University of KwaZulu-Natal (BE155/19 on 19 May 2019).

**Informed Consent Statement:** Informed consent was obtained from all participants involved in the study.

**Data Availability Statement:** Data are included in the manuscript.

**Acknowledgments:** The authors thank the HReH in the KZN eye clinics and their managers both in the hospitals and at the various district offices for their participation in this study.

**Conflicts of Interest:** The authors declare that they have no competing interest or financial relationships that could have influenced the writing of this manuscript.

#### **References**

