Evaluating the eye care delivery performance of one-year trained vision technicians for rural eye care in the developing world

Abstract

This thesis describes an evaluation of the eye care delivery performances of Vision Technicians (VTs) assessing their diagnostic and spectacle prescribing performance, management decisions, job satisfaction and confidence, as well as patient satisfaction at the LV Prasad Eye Institute's vision centres (VCs) in India.

A pilot study was conducted in a tertiary setting to validate and adapt the research instruments. A 'Gold Standard Optometrist' (GSO), who had been calibrated against ophthalmologists and an optometrist, was used to assess the clinical performance of VTs.

The eye examination results and management plan for 328 patients examined by 24 VTs in 24 VCs were compared with those of the selected GSO. Job satisfaction and job confidence questionnaires were administered to the 24 participant VTs, while patient satisfaction surveys were administered to 259 patients visiting the VCs.

VTs demonstrated reasonably high sensitivity in detecting refractive error (83.0%) and significant ocular pathology (77.4%); however disease diagnostic accuracy was low (61.6%). The accuracy of identifying conditions of the crystalline lens was high (76.2%), demonstrating good agreement (k=0.72). In contrast, the VTs' sensitivity in detecting posterior segment conditions was low (18.5%). However, the majority (78.4%) of referral decisions were warranted because decisions were often based on non-improvement in visual acuity with spectacles. VTs' spectacle prescriptions were accurate 76% of the time for mean spherical equivalent and 65% of the time for astigmatism. One-third of high refractive error cases were undetected.

VTs overall had positive satisfaction towards their job. This indicates that they are a motivated workforce and more likely to remain in the job. Importantly, the services provided by VTs were also well received by the community, with over 80% expressing satisfaction.

With the advantages of reduced training costs, reasonably competent clinical ability in addressing the two most common global cause of vision impairment (i.e. refractive error and cataract), positive satisfaction towards their job and highly satisfied community with the service received, one-year trained VTs can be considered a useful cadre for rural eye care.

The performance measurement framework with a 'gold standard practitioner' for evaluating the clinical performances presented in this thesis could also be useful for assessing the performance of other eye care personnel, and health workers in other health areas.