Barriers and enablers of primary eye care service provision in primary healthcare facilities in Rivers State: a qualitative approach

INTRODUCTION

Ocular morbidities poses a significant source of public health concern in Nigeria with resultant adverse effects on the development, quality of life, and socio-economic aspects of affected persons.^1-3 In addition to this problem, most of these morbidities and associated problems of blindness are actually preventable.^2,4,5 These problems have been linked to problems of poor access, inadequate skilled workforce, infrastructural and technical resources required to provide optimal eye care services to the populace.^6,7 The health workforce unavailability to provide such care especially in rural communities has indeed been pinpointed as a major barrier to the provision of these services.^6,8 It has thus been widely advocated for eye care to be integrated into PHC as a component of universal health coverage (UHC).⁶ This can immensely reduce the gap in inequitable access to eye health services as well as strengthen service delivery at all levels of healthcare.^6,9 PHC has been described to be in a good position to provide person-centred and community-based care which is required to reduce diseases and contribute to the reduction of the impact of diseases on individuals, and health systems.^6,7 Primary eye care (PEC), which involves enhancing referral processes and vision rehabilitation, preventing and treating conditions that may result in vision loss, and encouraging eye health, is an essential component of PHC.^6,10

For the provision of quality eye care to be possible, there needs to be the appropriate availability of infrastructure, equipment, equipment maintenance, and supplies.^6,8 This can be made possible through PEC, especially in areas experiencing inequitable distribution of these services.¹¹ The advantages of incorporating PEC into PHC can be experienced in every context, however, they become more pronounced when they are provided in rural or remote areas where inadequate manpower and infrastructure for eye care are being experienced.^9-11 To efficiently incorporate PEC, a robust PHC system is essential, as effectiveness of these services depends on the strength of the primary health structure it joins. However, Nigeria’s PHC system faces numerous challenges, including insufficient infrastructure, a lack of health personnel, being absent from work, and inadequate medical equipment. Additionally, weak government commitment to healthcare, conflicts, and poor prioritization of health systems have further weakened frontline health facilities. As a result, even though PHC services are available, the residents in Nigeria often underutilize them because of beliefs about insufficiency and bad quality.^6,12 For PEC to function effectively, it needs a comprehensive package of interventions, which includes eye health promotion, essential eye examination equipment, a steady supply of medications and consumables, established referral systems, supervision, medical records, funding, and strong commitment from stakeholders. Without addressing the entire package, PEC implementation risks being more rhetorical than practical.^6,8

Despite motivating factors of increase in proportion of persons having access to vital ocular surgical procedures, some level of government support, the availability of technical manpower to provide PEC services in urban areas, the equitable and effective provision of these services is faced with a number of challenges.¹² These include a gross inadequacy of government funding, lack of backing policies, inadequate facilities for areas covered, and the inability of available facilities to sustain eye care services due to inadequate political will. Other challenges included sustainability problems due to the inability to maintain skilled health personnel at the primary care level, lack of basic equipment, non-use of standard clinical management guidelines, as well as the issue of irregular hours of operation at the PHC facilities.⁶ In Rivers State, Nigeria, there are scant published studies assessing the factors affecting the provision of PEC services in PHC facilities. As long as ocular morbidities continue to occur in the State, the evidence generated from this research can be used to improve the provision of PEC services, thus, the need to conduct this study.^3-5 It was aimed at using a qualitative approach in exploring enablers and barriers affecting the provision of PEC services at PHC facilities in Rivers State.

METHODS

A qualitative study was conducted among 22 purposively selected PHC facility and unit heads using topic-guided in-depth and key informant interviews to collect data on the enablers and barriers of the capacity of the PHCs to provide PEC services. The study was conducted between February, 2024 - April, 2024. Two participants each were selected from the following purposively selected facilities including MPHC Eneka, MPHC Amadi Ama, MPHC Ozuoba, MPHC Rumuigbo, MPHC Rumuokwurusi, MPHC Omagwa, MPHC Mgbuoshimini, MPHC Igwuruta, MPHC Mgbundukwu, MPHC Churchill and MPHC Elekahia. Facility and unit heads who were present at the time of study were included in the study, and those who were on sick leave or annual leave or absent. And also those whose names were not on the duty roster were excluded from the study. The interview-guide was used to explore their views of the enabling and limiting factors affecting the provision of PEC services by the PHC facilities. A thematic or data saturation was therefore used to determine the sample size. Thematic saturation may be defined as the point in data collection where no additional information and cues are gotten, rather similar information is disseminated and collected, implying that an adequate sample size has been reached. The sample size was therefore 22 facility and unit heads, and respondents were selected according to their readiness to take part in the research. Analysis was done using NVivo software.

Ethics

Ethics approval was obtained for this study from the Health Research Ethics Committee of the Rivers State Hospital Management Board (permission number: RSHMB/RSHREC/2024/012). Permission to carry out the evaluation was obtained from the executive secretary and director planning, research and statistics of the Rivers State Primary Health Care Management Board (RSPHCMB) as well as the medical-officers-of-health and facility heads of the various PHC facilities in Rivers State.

Informed consent was also obtained from each respondent before conducting interviews and surveys, and their consent was also obtained for the recording of the interviews to be done. Also, the data collection tools were anonymized to ensure protection of the privacy of respondents and confidentiality of their responses.

Interview-guide for PEC

1) Position of health personnel interviewed? 2) What is your opinion on the readiness of this PHC to provide PEC to the Rivers State population (manpower, equipment, technical know-how, logistics, drugs)? 3) Have eye problems been treated in this facility before? 4) If yes to question 3 above, can you provide some details on the eye problems that have been treated in this facility in the past? 5) Are PEC services provided in your facility? 6) Were any challenges experienced during the course of providing these PEC services? 7) If yes, what were the challenges that were experienced? 8) Do you believe that the clients utilizing health care services in this facility will be willing to seek primary eye care here? 9) Are there specific examples you can provide to show the importance of the PEC initiative?

The interviews were recorded on a recording application on an android phone, were then transcribed and analysed using thematic content analysis.

In order to assure trustworthiness, we performed member checking by discussing early results with five participants to evaluate our interpretations in addition to returning transcripts to participants for verification. An audit trail of codebooks, memoranda, and documentation of analytical conclusions was used to show dependability. Rich contextual explanations of the study procedure, participants, and setting supported transferability. We saw researcher reflexivity and participation as contributing to the reliability and rigor of qualitative investigation rather than seeing subjectivity as prejudice.

RESULTS

Sociodemographic details of study participants

Among the 22 heads of facility that participated in this study, it was identified that their ages ranged between 38 and 54 years with a mean age of 44.8±4.4 years. In addition, 14 (63.6%) were females and 8 (36.4%) were males, and most were married 21 (95.5%). Also, 9 (40.9%) were nurses, 7 (31.8%) were community health officers, 5 (22.7%) were medical doctors, and there was a community health extension worker 1 (4.6%). These are shown in Table 1.

The themes and subthemes of the enablers and barriers confronting the provision of PEC services are shown in Table 2.

Enablers and barriers facing PEC service provision

The assessment of the enablers and barriers facing the provision of PEC services revealed subthemes of the enablers to include willingness and dedication of the workers to work, occasional provision of external support, as well as staff getting trained in specialized aspects of work to be done. Additionally, barriers identified to limit the provision of PEC services included shortage of manpower, poor technical skills for handling specialized equipment, drugs unavailability, lack of equipment and general logistics support from government to provide PEC services. The lack of government support was also cited as a barrier to providing PEC services.

Supporting quotes included the following:

Enabling factors

For the enabling factors favouring the provision of PEC services, the willingness to provide these services was coded as an enabling factor:

Participant 5: The primary health centre is prepared to offer primary eye care to the rivers state population. We have dedicated manpower, but lack essential equipment, technical expertise, logistical support, and adequate stocks of drugs.

Participant 6: Well, the people that we have around, the workers are willing to work, but the manpower is not enough, the equipment is not there.

Participant 8: In my job here, we're fully ready for eye care. We have few staff. More are needed.

Participant 12: Regarding the readiness of our primary health centre to offer primary eye care services to the rivers state population, there are some aspects to consider. Manpower-wise, we have limited personnel dedicated solely to eye care, but we do have some staff members trained in basic eye care procedures.

Another identified enabling factor was the availability of specially trained personnel needed for the provision of these services:

Participant 1: 100%. Because our doctor recently, he went for training, so he can carry out these services.

Participant 11: There are workers who are very ready, the workers are enough, no technical Know how people have not been properly trained. The doctor, I think will have primary knowledge in care of the eye but no equipment and no drugs.

Barriers limiting provision of services

Regarding the barriers coded to impact on PEC service delivery, the first was the shortage of the required manpower resources to provide these services as seen below:

Participant 15: There are several factors impacting our readiness to provide PEC to the Rivers State population. One significant challenge we face is a shortage of workforce. Currently, we only have five nurses working at this facility, and considering the high demand for our services, it's clear that we lack the necessary workforce to effectively deliver primary eye care.

Participant 16: I believe there are some aspects that need improvement. While there may be manpower available, additional training and resources are required to enhance the technical know-how and ensure adequate equipment and logistics.

Participant 19: Manpower is lacking, as we have only a small team of nurses, and training is needed to enhance our capacity.

Participant 22: We have one eye doctor which is not enough manpower. We just started giving eye care not long ago. More people know we offer this, so we need more staff.

The workers were also of the opinion that they lacked the proper technical skills needed to provide PEC services:

Participant 7: Eye is not something you just do, you need to have a doctor that knows about the eyes, so that the person that will check the people’s eyes to know what is there, you cannot just bring somebody to see, to come and do test somebody’s eye that does not know anything about, there should be an optician around to make sure. when it comes to eye Care

Participant 9: We’re really not in good shape for handling eye care. Don’t have close to enough trained people who know eyes, or the right tools and machines and medications to test vision and treat issues. It's lacking big time, but with the provision of all you mentioned I think we will be ready.

Participant 20: Equipment for eye care is insufficient, and technical know-how in this area is limited.

The unavailability of logistics support was also cited as a potential barrier to the PEC service delivery.

Participant 17: Eye problems have been addressed to some extent in the past. We have had a private individual providing eye care services here. However, this setup is not government-supported, and we believe that having government-backed initiatives would greatly enhance our ability to address eye care needs comprehensively.

Participant 21: Logistics and availability of drugs for eye care are also challenging.

The unavailability of required equipment and training to use the equipment was also a problem facing the effective provision of these services as seen in the following quotes.

Participant 13: We don’t have any equipment, but if we have, this facility is big enough to take any kind of health care services here, we have space, we have wards, and all the rest, so we need facilities and there is no technical knowledge, people don't know about it here, there is nobody trained in this facility that can do it right now.

Participant 2: In my job here, we're very ready for eye care. We have few staff. More equipment, drugs and trainings are needed.

Participant 14: Equipment-wise, while we do have some basic tools and instruments, we may lack some specialized equipment needed for comprehensive eye examinations.

Participant 22: We have the doctors and the nurses here. I believe we have the capacity to run that kind of care here. we do have the doctor here. The equipment is not enough.

In addition, without the required drugs needed for the treatment of ocular morbidities, it would be difficult to fully render the necessary eye care to the populace. This is seen in the following quotes:

Participant 3: When it comes to eye care, people are enough? But we don't have eye department here. So, no equipment, we have no equipment. The technical know-how nothing. The logistics No. Drugs? No. Like, these are the only two drugs we have, eye drugs, apart from this I don't have any other knowledge.

Participant 4: While there are some manpower, equipment, and technical know-how, the adequacy of these resources is unclear. The availability of drugs could also be a concern.

Participant 18: Additionally, there might be a need to ensure a consistent supply of drugs essential for eye care services. Asides that we are very ready.

Finally, having poor government support can severely limit the provision of these services to a populace, as shown by the following quote:

Participant 10: Eye problems have been addressed to some extent in the past. We have had a private individual providing eye care services here. However, this setup is not government-supported, and we believe that having government-backed initiatives would greatly enhance our ability to address eye care needs comprehensively.

DISCUSSION

This study has been able to show enabling and limiting factors affecting the PEC services in Rivers State. The enabling factors included the willingness of staff to provide these services as well as the availability of specially trained personnel needed for the provision of these services. Barriers identified to limit the delivery of PEC services included the shortage of the required manpower resources to provide these services, the lack of proper technical skills needed to provide PEC services and unavailable equipment and training to use the equipment. Poor drug supply, inadequate logistics support and the absence of the required government support for PEC services were also identified. These enablers and problems have also been identified by other studies as being potential factors affecting the effective PEC services delivery. In one of such studies, an identified enabling factor encouraging PEC services delivery was the availability of technical manpower to provide PEC services.¹² Barriers identified by other studies that corroborate the present study findings have also included a gross inadequacy of government funding, lack of backing policies, inadequate facilities for areas covered, the inability of available facilities to sustain eye care services due to insufficient government support, and the lack of basic equipment.^6,8,11

The implications of the enablers identified in the present study are of immense importance in the PEC service delivery. When there is the presence of a team of willing and well-trained staff members, they would be more enthusiastic and dedicated to their roles as healthcare personnel. This also creates a positive and welcoming environment for clients seeking eye care services as the healthcare personnel are more motivated to provide patient-centred care, which inadvertently promotes better health outcomes among clients.^9,11 In addition, having staff that are trained in the necessary technical and specialized areas needed in the use of primary eye care equipment is crucial for the provision of quality eye care services. This is because the staff are now able to conduct thorough eye assessments, accurately diagnose various eye conditions based on presenting symptoms, and develop individualized treatment plans for clients.^12,13 Furthermore, well-trained staff can provide valuable education to clients on preventive eye health measures, the significance of routine ocular examinations, and the proper use of eyewear or contact lenses. This empowers clients with knowledge and guidance that is needed to promote proactive eye health practices and enhance early detection of eye problems.^6,13,14

The barriers limiting the provision of eye care services identified in this study also have their own implications on PEC services in Rivers State. Firstly, considering the unavailability of necessary equipment to provide PEC services, there is no way high-quality eye care can be provided considering that healthcare personnel will be unable to make accurate diagnosis.¹⁵ Unavailability of such equipment can lead to misdiagnosis or delayed diagnosis of eye conditions, which exposes the patient to the danger of experiencing preventable ocular morbidities.^8,11 Also, the unavailability of the necessary equipment implies that advanced treatments and surgeries such as cataract surgeries, cannot be performed on those who need them. This could result in the deterioration of the patient’s condition with negative impacts on the quality of life.^9,13 When these equipment and facilities are not equitably distributed, there is the possibility of having high patient volumes in the few PHC facilities that have the necessary equipment, resulting in long waiting times and potentially discouraging clients from seeking timely care.¹⁵ Manpower inadequacies can also have severe effects on the effective provision of PEC services considering that some eye care services may not be provided at all, or they may be provided by less qualified or trained individuals, increasing the risk of poor outcomes.^11,15 Also, there would be fewer clinics and extended travel times for clients, particularly those residing in rural areas. This can deter individuals from seeking necessary eye care and resort to the use of non-conventional forms of care including the use of herbal mixtures, self-care and so on.⁸ When there is an insufficiency of the required eye care professionals, there would also be the problem of increased workloads for the available staff, resulting in overworking them, problems of burnout, decreased morale, and lower quality of care.⁹ Maintaining continuous patient follow-up and management which are essential for chronic eye conditions like glaucoma and diabetic retinopathy, also becomes difficult.⁶

It is crucial to note that availability of essential drugs is vital for the provision of optimal PEC services. A limited drug supply can result in inconsistent treatment, with clients being unable to access necessary medications regularly, resulting in worsening eye conditions and complications. The unavailability of specific drugs can also force doctors to prescribe alternative medications that may not be as effective or have more side effects, leading to poor patient compliance.¹⁵ Limited supply of the necessary drugs could also result in prices of the drugs increasing and making it difficult for clients, especially those from low-income backgrounds, to afford necessary medications. This inadvertently results in poor patient compliance as well, and the likelihood of worsening of the patient’s condition.^8,15 The support of the government in strengthening the health system for the effective provision of PEC is also crucial for the provision of these services. Effective eye care requires strong policies and advocacy. Poor government support often results in weak policies, limited national eye health strategies, and inadequate incorporation of eye care into overall healthcare systems.^6,9 In addition, the absence of sufficient government support, limits primary eye care programs usually due to inadequate funding which leads to a lack of resources needed for essential services, outreach programs, and community education.⁶ Without government support, there are fewer opportunities for education and professional development for eye care professionals, resulting in a workforce that may not be adequately prepared to provide eye treatment for the populace. Also, eye care services in rural and underserved areas can become limited without the necessary government support. This increases the risk of untreated eye conditions, leading to preventable blindness and visual impairment.⁸

This study addresses a relevant topic about a critical gap in health care with regards to barriers and enablers of PEC services provision in primary health care facilities. It aligns well with WHO and UEHC which ensures all people have access to quality, comprehensive eye care-preventive, curative, and rehabilitative- without financial hardship. While this study has a strong public health impact as discussion links the findings to reducing visual impairment and preventable blindness among the populace, and the need for improved integrated eye care across PHC facilities, it was however, limited, because of the small sample size that inhibited generalizability. We therefore recommend future studies to incorporate quantitative component which will allow for inferential statistical analyses, in assessing the association between the various variables.

CONCLUSION

PEC services provision in Rivers State though having factors that enables its availability, is still faced with a number of challenges that can severely limit it. These include the shortage of the required manpower resources, the lack of proper technical skills needed to provide the services, unavailable equipment and training, poor drug supply, inadequate logistics support and the absence of the required government support.

Recommendations

The Rivers State government needs to make a stronger commitment to driving the availability of quality PEC services for the Rivers State populace. This can be achieved through the formulation of policies to promote the provision of these services, as well as implementing a strategic framework for tackling ocular morbidities in the State. This framework should be able to ensure adequate funding for PEC programs and interventions, the provision of the necessary manpower, equipment, technical resources as well as the steady supply of medications and consumables that will enhance the effective provision of eye care services at the PHC level.

The PHC management board should also ensure the provision of regular in-service training and retraining of PHC personnel to be able to deliver the required eye care services to the populace.

In addition to these, the PHC management team should establish an effective referral/feedback systems to ensure unfettered access to quality care at all levels when needed.

ACKNOWLEDGEMENTS

The authors wish to thank Benson Ephraim-Emmanuel, for his advice and technical assistance.

Funding: No funding sources

Conflict of interest: None declared

Ethical approval: The study was approved by the Institutional Ethics Committee of the Rivers State Hospital Management Board (permission number: RSHMB/RSHREC/2024/012)

REFERENCES

1. 1. Moyegbone JE, Nwose EU, Anowa EI, Clarke A, Odoko JO, Agege EA. Prevalence of visual impairment among primary and secondary school children in Delta State, Nigeria. World Health. 2020;7(10):4171-9.
2. 2. Abdull MM, Sivasubramaniam S, Murthy GV, Gilbert C, Abubakar T, Ezelum C, et al. Causes of blindness and visual impairment in Nigeria: the Nigeria national blindness and visual impairment survey. Investig Ophthalmol Vis Sci. 2009;50(9):4114-20.
3. 3. Anyiam FE, Chinawa NE, Nathaniel GI, Wajuihian SO. Preliminary findings of ocular morbidity in participants attending ophthalmic outreach services in rural Nigeria. Niger Del Med. 2017;2:13-8.
4. 4. Chinawa NE, Odogu VK, Ezeh EI, Anyiam FE. ocular morbidity pattern and presentation among residence of a semi-urban community in Rivers State, Nigeria. Asian J Med Health. 2020;18(8):14-20.
5. 5. Chukwuka IO, Chinawa EN, Ejele IO. Ocular morbidity pattern in Abonnema, Akuku-Toru local government area of Rivers state. Ann Biomed Sci. 2017;16:217-30.
6. 6. Koce FG, Randhawa G, Ochieng B. A qualitative study of health care providers’ perceptions and experiences of patients bypassing primary healthcare facilities: a focus from Nigeria. J Glob Health Rep. 2020 Jul 27;4.
7. 7. Ogunyemi AO, Balogun MR, Ojo AE, Welch SB, Onasanya OO, Yesufu VO, et al. Barriers and facilitators to the delivery of age-friendly health services in primary health care centres in southwest, Nigeria: a qualitative study. PLoS One. 2024;19(3):e0288574.
8. 8. Eze CC, Eze BI, Chuka-Okosa CM, Okoloagu N. Assessment of resources for primary eye care delivery in a rural area, South East Nigeria. Niger J Ophthalmol. 2020;28(2):49-56.
9. 9. Yasmin S, Schmidt E. Primary eye care: opportunities for health system strengthening and improved access to services. Int Health. 2022;14:i37-40.
10. 10. Bainaboina G. A short communication on primary eye. Qual Prim Care. 2020;28:2020.
11. 11. Du Toit R, Faal HB, Etya’ale D, Wiafe B, Mason I, Graham R, et al. Evidence for integrating eye health into primary health care in Africa: a health systems strengthening approach. BMC Health Serv Res. 2013;13(1):102.
12. 12. Aghaji AE, Gilbert C, Ihebuzor N, Faal H. Strengths, challenges and opportunities of implementing primary eye care in Nigeria. BMJ Glob Health. 2018;3(6).
13. 13. John D, Shanbhag D. Our experience of utilizing community‑based health assistants in delivering primary eye care services in a resource‑poor setting of Rural Bengaluru, Karnataka, South India. J Fam Med Prim Care. 2017;6:691-2.
14. 14. Ministry of Health and Family Welfare M. Eye Care at Health and Wellness Centres: Part of Comprehensive Primary Health Care. Operational Guidelines. 2020.
15. 15. Jolley E, Mafwiri M, Hunter J, Schmidt E. Integration of eye health into primary care services in Tanzania: a qualitative investigation of experiences in two districts. BMC Health Serv Res. 2017;17(1):823.