A National Programme for Control of Blindness was launched in India in 1976. As part of the programme, primary-care physicians were sensitised to strategies for blindness control and community eye health to help them play a more proactive role in control of blindness. It was felt that this would encourage blindness control activities in the country. During their medical training, students are generally exposed to ophthalmology for a period of 4- 6 weeks, with insufficient exposure to primary eye care and principles of community eye health. Therefore, most medical students are not confident enough to tackle eye diseases in rural areas.
Generally, primary-care physicians feel that undergraduate ophthalmology training is not adequate. Therefore, reorientation to common eye problems and their management was emphasised so as to integrate primary eye-care services with the general health services at the periphery. This communication presents the evaluation of the trainees and the training module developed for use at this centre, during 1997 - 2000.
Materials and Methods
A three-day training programme was conducted for primary-care physicians at Dr. Rajendra Prasad Centre for Ophthalmic Sciences, New Delhi. Medical officers (primary-care physicians) working at Government-run Community Health Centres (CHC) and Primary Health Centres (PHC) were invited to participate in the training workshops. A CHC is equipped with 30 beds and caters to a population of 100,000, while a PHC provides basic health services and caters to a population of 30,000 in rural areas. 865 physician participants drawn from 9 states in North India (Jammu and Kashmir, Himachal Pradesh, Punjab, Haryana, Delhi, Uttar Pradesh, Rajasthan, Madhya Pradesh and Gujarat) were trained in 26 such workshops conducted between November 1997 and August 2000.
A training module was designed based on recommendations by an expert group. The module was then piloted in two training workshops and based on the feedback, a final module was prepared. Group exercises were modified from time to time to make the case studies more contemporary, in line with recent advances in management of eye diseases. The core elements of the training workshops remained unchanged throughout the training. A judicious mix of lecture discussions and demonstrations, peer discussions, exercises, games, jigsaw puzzles, video films and slide shows were used to convey the importance of community eye care. The planning and implementation of eye care services were discussed. Emphasis was on achieving a high level of interaction [Table - 1].
The knowledge level of trainees was evaluated before and after the course. Formats contained three questions related to magnitude of blindness in India, the most common causes of blindness in India and district level activities under the National Programme for Control of Blindness (NPCB). The trainees were asked to fill the pre-course evaluation formats to give the trainers some idea of their current knowledge and this would help the trainers plan some of the sessions. This was done to minimise the potential bias in learning that could have crept in, since some of the trainees could otherwise have guessed that there would be a post-course evaluation with the same three questions. In such a case, the learning process would then have a bias towards internalisation of knowledge relevant to these three questions.
Correct responses were assigned a score of 1 while wrong responses were scored zero. Cumulative scores for all three items were calculated. Trainees were also given a concurrent evaluation format in which they were asked to grade each session on a five-point scale (1-Very poor; 2-Poor; 3-Satisfactory; 4-Good; 5- Very Good/Excellent). The evaluation was done under four heads - Presentation style, Content of session, Usefulness/ Relevance of session to their job performance and Time allocated to each session. A cumulative score was assigned by pooling all the scores and mean values were generated.
To compare whether knowledge levels before and after the course were similar and whether the curriculum was uniformly covered in all training workshops, the workshops were categorised into two groups (a) Early - 6 workshops held in the first 18 months; (b) Late - workshops held in the subsequent 18 months. To analyse the effect of number of trainees per workshop, the workshops were classified as Low density (- 15 participants); Appropriate density (16 - 30 participants), and High density (> 30 participants).
All the three evaluations were completely anonymous, and participants were specifically directed not to mention their names. Consequently, it was possible to compare only group scores and not paired individual scores across the workshops. Data was entered into an Excel spreadsheet and transferred for analysis to Stata version 6.0 using Stat Transfer 6.0. Data was analyzed using Stata 6.0 software. Chi-square and t-test were used to test for significance.
A total of 772 of 865 (89.25%) participants submitted the pre-course evaluation forms, 748 (86.47%) returned the filled concurrent evaluation forms and 601 (69.48%) submitted the completed post-course evaluation forms. Most participants were aware of the commonest causes of blindness in India prior to the training sessions [Table - 2]. However, knowledge of the magnitude of blindness as well as district-level blindness control activities was poor. Knowledge on all parameters was significantly better at post-course evaluation [Table - 3]. Only 28.89% respondents had a cumulative score ž 2 at the pre-course evaluation, and this increased to 76.04% at post-course evaluation. This difference was statistically significant (P < 0.000001). Mean cumulative scores also increased significantly between the pre - and post - evaluation (P < 0.000001) [Table - 2]. Significant differences were observed when workshops were stratified into those conducted early (initial 18 months) and those conducted later (later 18 months) (P < 0.000001).
Comparing within early and late workshops, the difference in knowledge of magnitude of blindness was not significant at pre course evaluation, though there was a difference in scores achieved by the two groups in the other parameters [Table - 3]. At post-course evaluation, a significant difference was seen in scores achieved on magnitude of blindness and in overall cumulative scores, between the two groups of workshops.
In the pre-course evaluation there were significant differences between three categories of workshops (low density, appropriate density and high density workshops). However, at post-course, there were no significant differences. The gradient of increase in knowledge (reflected by proportion of correct responses to each subject) was related to level of knowledge before the workshops. Groups scoring less at pre-course evaluation showed more improvement at post-course evaluation.
Trainees were also asked to evaluate the sessions using a five-point scale. Trainees evaluated sessions on presentation style and content, relevance of sessions to their job situation and the time allocated or utilised for each session [Table - 4]. Sessions recording high scores included those on diabetic retinopathy, overview and magnitude of blindness, organisation of eye camps, principles of management, need for community eye health, training auxilaries in eye care, Information, Education and Communication (IEC) activities, school vision screening programmes, community assessment and intervention and primary eye care. This was seen consistently in relation to presentation, content and relevance. Time allocated was observed to be insufficient by nearly half the trainees, in respect of all sessions. Glaucoma and vitamin-A deficiency were given low scores on relevance, even though vitamin-A deficiency control is predominantly a primary care intervention.
Interactive sessions were appreciated more. Sessions using games, puzzles, exercises and audiovisual support like video films were also appreciated more.
Participants graded most training sessions as excellent in terms of presentation, except in relation to glaucoma and vitamin-A deficiency programs [Table - 5]. The mean scores were consistently high for presentation, content and relevance. However, time allocation/utilisation scored lower mean values in most sessions. Cumulative mean values were highest for the management game, eye camp organisation, diabetic retinopathy and cataract [Table - 6]. Cumulative mean scores assigned by trainees in the early and late training workshops were also compared. Significant differences were observed in grading on need for community eye health, vitamin-A deficiency, diabetic retinopathy, and community interventions [Table - 6]. Scores were analysed and compared based on number of participants per workshop. It was observed that differences between workshops with -15 trainees and those with 16 - 30 trainees were significant only for the management game. The differences between workshops with > 30 trainees and those with 16 - 30 trainees were significant only in eye infections and trauma. Results indicate an overall consistency in delivering the training module irrespective of the time of the workshops or the number of participants in a workshop. Overall, faculty fatigue did not seem to significantly affect the training, even though the entire program was conducted over a three-year period. However, differences were observed in a few subject areas.
The post-course evaluation response rate (607, 69.48%) was lower by 20% compared to the pre-course evaluation (772, 89.25%). It is difficult to decide if the non-respondents were those who did not benefit, or if they were evenly distributed. As the trainees were asked not to write their names on the evaluation forms, it is likely that even those who did not benefit would have completed the post-course evaluation formats.
Comparison of pre and post-course evaluations showed that there was significant improvement in knowledge at the end of the workshops. It has generally been perceived that rural doctors are slow to access new technologies and that they would need training. It was felt that training primary care physicians at well-equipped tertiary care institutions would offer excellent exposure to the latest technology in eye-care. This will act as an enabling motivator for doctors. Though it would be easier to train doctors nearer their place of work, the advantage of the environment of a leading eye care institution would be lost.
Many primary care physicians are not sufficiently equipped to perform a number of important procedures. Moreover, skills acquired may deteriorate over time and lead to diminished competence. Continuing Medical Education (CME) programmes can help tremendously in such situations. Studies have also shown that CME programmes, in addition to updating professional skills, also help in reducing physicians’ job stress and dissatisfaction. In India, where opportunities for professional advancement are limited, these types of CMEs are essential.
Clinical competencies are assessed mainly by knowledge tests. Studies in other medical disciplines have earlier shown that knowledge gained during CME programmes reflects changes in competence and practices. However, some studies have observed that improved competence may not always lead to changes in performance because practical problems and organisational and social barriers may limit the application.
The immediate benefit of training in Community Eye Health was therefore evident in the present study. However, it is not possible to comment on how long this effect will be sustained. CME programme in diabetes practice guidelines observed that impact declined after one year. If this is true, it is important to develop follow-up training capsules, for direct training or distance learning to maintain a long-term impact. This will ensure the increased participation of primary-care physicians in eye-care activities and help the country reduce the load of avoidable blindness in a more effective and efficient manner. Most importantly, it is clear that closely monitored training programmes at well-equipped health care institutions can help motivate doctors working in rural areas to perform better. The capability of such institutions to train health professionals in a consistent and uniform manner should be exploited if the quality of health care in developing countries is to improve.
Source of Support:
Conflict of Interest:
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