**1. Introduction**

Visual impairment is a serious public health problem globally. It is estimated that 253 million people worldwide are affected by visual impairment. In Sub-Saharan Africa (SSA), 22 million people are blind or visually impaired mainly from avoidable causes such as cataracts and uncorrected refractive errors [1]. Over 100 million adults in SSA are estimated to have near visual impairment [1]. Blindness from avoidable causes is said to have increased in all four regions of SSA in the past decade [2]. The age-standardised prevalence of blindness (>50 years) was found to be 5.1% in western and 4.3% in eastern SSA [1]. The disproportionate burden of visual impairment in low-and-middle-income countries (LMIC) compared to high-income countries was observed to be a direct cause of socioeconomic factors, poor health systems and concomitant human immunodeficiency virus (HIV), and tuberculosis epidemics [3–7]. The World Health Organization's 2014–2019 global action plan (GAP) for universal eye health aimed to reduce avoidable vision loss, thereby curbing the quality-of-life limitations and economic demands associated with visual disabilities [8–10].

**Citation:** Xulu-Kasaba, Z.; Mashige, K.; Naidoo, K. Knowledge, Attitudes and Practices of Eye Health among Public Sector Eye Health Workers in South Africa. *Int. J. Environ. Res. Public Health* **2021**, *18*, 12513. https:// doi.org/10.3390/ijerph182312513

Academic Editors: Roberto Alonso González Lezcano, Francesco Nocera and Rosa Giuseppina Caponetto

Received: 5 November 2021 Accepted: 22 November 2021 Published: 27 November 2021

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1

The World Health Organisation (WHO) has recommended that primary eye care (PEC) be included in primary healthcare (PHC) as a strategy to increase sustainability and access to ocular health services [11,12]. To effectively control visual impairment, the WHO highlighted the importance of accessible eye care services and called on member states to secure the inclusion of PEC within PHC, as previously recommended by the International centre for eye health [8,13]. Many challenges such as lack of agreement on the scope of PEC and lack of clear guidelines on the technical eye-related skills required by PHC workers were reported as challenges for the effective implementation of PEC in SSA. These affect the extent of training, supervision, and the type of equipment and consumables required [14].

In South Africa, PEC is mainly provided at the PHC level, but if need arises, patients are referred to higher-level institutions. The country does not have a dedicated directorate for eye health, nor does it have an integrated eye health promotional policy [15]. This results in inadequate eye care services, similar to other African countries [16,17]. Challenges in the South African eye care programme include insufficient human resources, unaffordable or unavailable medication, unsatisfactory programme evaluation and inadequate service coverage for Vitamin A supplementation, vision assessments, spectacle provision, cataract surgery, and screening for eye complications in patients with diabetes [18–23]. In addition, coordination between the different levels of the eye health system is lacking, with poor communication, a complex referral system and problems transporting patients to specialised services [19].

Studies from South Africa have reported on the prevalence of visual loss/visual impairment in different districts/provinces [24–27]. Another study performed an evaluation of primary eye care services in three districts of South Africa to assess whether an ophthalmic health system strengthening (HSS) package could improve these services [28]. The study concluded that primary eye care in South Africa faces multiple challenges with regard to the organisation of care, and clinical competency [28]. Training of all cadres of eye health was said to be crucial if the goals of VISION 2020 were to be attained, and universal access to ocular health achieved [29]. Very little is known about the knowledge, attitudes, and practices of eye health care workers and their supervisors towards eye health. Therefore, this study aimed to establish the level of knowledge, attitudes, and practices of eye health amongst HReH and their supervisors/managers. In this study, participants were tasked with responding to questions on the definitions of the different HReH, their roles in their work, resources needed in eye health, and challenges that exist in eye health daily. Policies guiding HReH work were also included in the questions.

Based on the responses, study findings will assist in clarifying the levels to which management and HReH each understand staffing roles and needs within the province, leading to possible interventions needed for optimal service provision. This study will also inform policymakers, healthcare administrators, and eye care professionals on areas that need attention in public health policies, further promoting efficient and equitable allocation of resources to alleviate the burden of vision loss in South Africa.

### **2. Methods**

A cross-sectional study was conducted in the 56 eye clinics and 11 district offices in the province of KwaZulu-Natal, South Africa. The population for the study comprised two levels of managers, district office-based NCD coordinators and medical managers, who manage HReH within the various HCFs. Included HReH were Optometrists, Ophthalmologists, Ophthalmic Medical Officers (OMOs), and Ophthalmic Nurses, as well as an administrator, working in the various eye clinics.

Purposive sampling was used to identify 196 role-players within eye health in KwaZulu-Natal, a total population of 174 HReH and 22 Managers. Due to this sample size being relatively small, a sample size calculation was deemed to be irrelevant. In an attempt to obtain a saturated sample, the PI contacted all the eye clinics and made arrangements to personally visit each institution so as to ensure a saturated sample. Of the 196 eye health workers, 91 were either on leave, ill, occupied by other work, or unavailable for other

reasons. The remaining 105 employees who were available all accepted the invitation to take part in the study. Ultimately, 101 eye health workers returned the self-administered, completed questionnaire after the allocated 20 min time frame, yielding a response rate of 96.2%.

The questionnaire comprised four sections. The first section of the questionnaire contained demographic information such as age, race, district, role in eye health, period of service, and highest level of qualification. The second, third, and fourth sections of the questionnaire comprised ten statements for each section to determine participants' knowledge, attitudes, and practices on eye health. All the statements were 5-point Likert type with the categories ranging from "Strongly Disagree" to "Strongly Agree".

The questionnaire was pretested among 10 HReH members who had resigned from the public sector eye clinics within two years prior to the commencement of this study. They responded to the questions and gave comments on the questionnaire. Amendments were made wherever needed, and the tool was modified and validated for this study. The Cronbach alpha scores were 0.72 for knowledge, 0.85 for attitude, and 0.84 for practices (Table S1).

Ethical clearance for the study was granted by the University of KwaZulu-Natal (BE155/19) and the Department of Health Research Ethics Committee. Anonymity and confidentiality were maintained at all times. Participation in the study was voluntary.

Data were cleaned, coded, captured, and analysed using SPSS version 25. The Likert scale responses were condensed to elicit binary responses. Where the correct response was an agreement, "Strongly agree and Agree" were accepted as favourable responses while "Neutral, Disagree and Strongly disagree" were considered to be unfavourable. Similarly, where the correct response was a disagreement, "Strongly Disagree" and "Disagree" were accepted as favourable responses while "neutral", "I don't know", "Agree" and "Strongly Agree" were rejected as unfavourable responses. Participants who correctly answered a minimum of 75% of the questions were considered to have adequate knowledge, a positive attitude, and satisfactory practicing skills.

#### **3. Results**

Most of the study participants were Africans (91%). About half (44.6%) were aged between 30 and 44 years, and HReH contributed 76.2% of the responses (Table 1). The highest qualification levels amongst the participants were a university degree (48.5%), a post-basic diploma in ophthalmic nursing (20.8%), a postgraduate degree (17.8%), a diploma (6.9%), and those with a grade 12 or a certificate for a short course were 6% were 6% of the study population.



#### *3.1. Analysis of Knowledge*

Table 2 shows a summary of the responses related to knowledge regarding eye health. Results show that the majority of the participants answered correctly to most of the statements. It was found that almost all the participants (95%) knew which eye health services were provided in their hospitals. An overwhelming majority of the participants agreed that

an Ophthalmic Nurse provides the role of performing eye screening and assisting in theatre (83%), and an Optometrist is central in performing refraction and low vision services (87%), respectively. About two-thirds (65%) of the participants disagreed that an Optometrist is the HReH performs general primary eye health. Overall, 82% of the participants had good knowledge regarding eye health.


**Table 2.** Frequency distribution of responses related to knowledge regarding eye health.

D = Disagree, N = Neutral, A = Agree.

Table 3 shows the results from binary logistic regression analysis to determine the significant factors for having good knowledge. According to binary logistic regression analysis, HReH were 14 times more likely to have better knowledge (aOR = 14.21; *p* < 0.01) than their managers. Participants having a certificate qualification were 98% less likely to have good knowledge (aOR = 0.02; *p* < 0.05) compared to those with a higher level of education (a university degree and a postgraduate qualification). Respondents in the middle-aged (30–44) group were 12 times more likely to have better knowledge (aOR = 12.02; *p* < 0.01) than those in the oldest age group (>44 years).

**Table 3.** Logistic regression output for having good knowledge.



Figure 1 reports the frequency distribution of the statements regarding attitudes towards eye health. It was found that most of the participants showed positive attitudes towards eye health. For example, 90% of the participants thought that Glaucoma, Diabetic Retinopathy, and Uncorrected Refractive Error should be treated as priority areas of care, and eye health is not about cataract surgery, which should be known to the directorate. Just over half of the participants agreed that the prevention of blindness should be prioritised, as most blinding conditions are preventable. Overall, 69% of the participants showed positive attitudes towards eye health.

**Figure 1.** Summary of responses related to attitude towards eye health.

Binary logistic regression analysis (Table 4) showed that participants who were <30 years old were 94% less likely to have positive attitudes when compared with participants >44 years (aOR = 0.06; *p* < 0.05). It was found that participants working <5 years and between 5 and 10 years were 30 times and 17 times more likely to have positive attitudes towards eye health when compared with participants having >25 years of experience. No other variables were found to be significantly associated with positive attitudes regarding eye health (*p* > 0.05).


**Table 4.** Association between attitude and demographic variables.
