Assessment of Optometrists’ Knowledge, Skills and Practice on Cataract: A Case Study from Kisumu County, Western Kenya

Background: Cataract is a major contributor to avoidable blindness in the world and greatly impact negatively on the quality of life. The prevalence of blindness in Kenya is estimated at 0.7% with cataract contributing 43%. Optometrists being the primary eye care providers for cataract patients, they are well placed to assess and refer cataract patients. Though there is no data on optometrist knowledge, skill and practice on cataract in Kisumu, Kenya. Methods: A cross-sectional study design was used. The study was conducted from June 2019 to August 219 using self-administered questionnaire. We collected basic socio-demographic characteristics and investigated participants’ knowledge, skills and practice on cataract. The primary outcome measures were the proportions of participants who identied the questions related to knowledge, skills and practice on cataract. Chi-square analysis was performed to look at the association between demographic and practice, knowledge and skills. Results: A total of 49 optometrists were interviewed with a male to female ratio of 2:1, mean age of 30.4(72%) years and mean duration of practice of one to ten years. Majority of the optometrists had good knowledge on various aspects of cataract. Like 98% had a good knowledge on the types of cataract. Based on skills, 75.5% could diagnose cataract correctly. However, 57.1% could not identify nuclear cataract. Practice among the optometrists was largely low in the sense that, 61.2% of optometrists did not screen patients aged 40 years and above for cataract. Almost half of the optometrists, 52.6% did a routine eye examination but did not know the importance of examining the crystalline lens for patient above 40 years.


Introduction
Cataract can be described as a group of eye diseases characterized by clouding of the eye lens due to lens body degeneration and deposits of protein on the natural lens of the eye Dandona & Dandona, (2006). Decreased visual acuity is an associated symptom of cataract, but its absence or presence does not preclude cataract. Worldwide cataract is the leading cause of blindness. According to World Health Organization WHO, (2012) model on blindness, cataract accounts for 6.7 million people being blind as a result of the disease. Cataract affects more than 70 million people worldwide Reutens, (2016). In Africa, America and Hispania it is 6-8 times more prevalent than in Caucasians, while Asians account for less than 10% of all clinical subtypes of the disease WHO, (2012). In Kenya, with a population of 47 million, avoidable blindness account for 0.7% with cataract contributing 43% and a projection of an increase by Page 3/14 2050Census, (2019. Though cataract is treatable, early detection and treatment can assist in avoiding serious reduced visual acuity even after a surgical intervention. Cataract has been shown to impacts negatively on the quality of life and may in uence daily activities such as driving, walking and economic activities Vision & News, (1960). Though cataract is treatable through surgical interventions optometrists are crucial in making diagnosis to allow the ophthalmologists carry more operations to reduce the burden Wilson, (2014). In Kenya, optometrists are the rst line providers of eye care services and they have the responsibility to conduct a comprehensive examination for all patients. The national strategic plan for avoidable blindness of 2014-2018 established that optometrists should work closely with ophthalmologists in delivery of eye care services in Kenya Ministry of Health, (2014). Therefore, their knowledge is signi cant in cataract management, hence need for assessment.
Cataract is clinically and genetically heterogeneous and includes several different forms Bourne et al., (2012). Each of these forms has diverse causes and severities. It is subdivided on the basis of anatomy of the lens and age of onset (congenital, juvenile and adult). Among the different subtypes of cataract nuclear cataract occurs most frequently and accounts for more than 50% of all cases of the disease Elston & Johnson, (2008). Similarly, cortical cataract is responsible for 0.01-0.04% of blind people worldwide. Sub-capsular cataract is normally rare but it is the most frequent form of cataract in infants, with more than 80% of cases observed within the rst year of life Zhu, (2017). It affects both eyes in 60-80% of cases, and usually more males 65% are affected as compared to females 35% Arbor, (2018).
Training of optometrists in Kenya is at bachelor level and diploma and the scope of training is different in the sense that the diploma holders are inclined towards optics only. The prevalence of cataract may rise if coordination between optometrists and ophthalmologists is not tightened. This is possible because majority of patients are examined by optometrists and if they do not refer these patients to ophthalmologists then the burden will rise. Hence, there is a need for skills of optometrists to be assessed.
A study by Phil & Hd, (2013) in India on assessment of outcomes of referrals of cataract patients.
Optometrists referred patients from the community hospitals and their private clinics to hospitals with specialist consultant ophthalmologist. The ophthalmologists who reviewed all the patients, found a substantial proportion of patients referred (n=2505) presumed to have cataract. Nearly half (n=1148) (45.8%) had no evidence of cataract, with only 510(20.4%) patients con rmed with cataract. Most probably the ophthalmologists had not informed the optometrists on the visual acuity score where surgery is performed. The Kenya Ophthalmic Division view optometry to be more of optics of the eye and this has brought confusion in de ning the roles of optometrists in the eye care. In developed countries like United States, the roles of optometrists are clearly de ned Sokoto et al., (2018). Optometrists are suppose to view all cases and evaluate the ones beyond their scope of practice for referral Polack & Kuper, (2017). In Kisumu, Kenya there is limited evidence in the literature about the optometrist's practice on cataract. Furthermore, cataract care presents major challenges because if a surgical intervention is not sought at the right time, a person's vision progresses to blindness. Therefore this study was to evaluate optometrist's knowledge, skills and practice on cataract in Kisumu, Kenya.

Study Rationale
I. With increasing prevalence of cataract in Kenya which can potentially outstrip the current capacity within hospital based cataract care, knowledge of optometrists of cataract management will be necessary.
II. No study has been done before in Kenya to assess the knowledge, skills and practice of optometrist on cataract.
III. The ndings of this study will inform on areas that need to be tackled by policy and necessitate for in house courses that will promote knowledge, skills and practice on cataract.

Methodology
The guideline for conducting a quantitative study proposed by Noyes et al., (2019) were followed to maintain scienti c quality and rigor. This was a prospective study in which respondents received the questionnaires face to face with the interviewer. The questionnaires were given to optometrists practicing The participants were recruited from the seven facilities from June 2019 to August 2019. The response rate was 100% and this was enhanced by maintaining constant contact between participants and the researcher at all time during the study period. Simple random sampling was used to recruit participants from respective clinics (n= 7) and demographics. Participant's recruitment was done through an invitation letter sent to the optometrists explaining what the study was all about and what the signi cance of the study was. An online random number calculator was used to generate the possible participants from the target population of 149 registered optometrists with the Optometrists Association of Kenya. Using standard normal deviate of 1.96; a conservative proportion of computer vision syndrome of 0.5 in the target population (given no previous knowledge, skills and practice reference in Kenya) were estimated to be well conversant with cataract and a level of accuracy required xed at 0.05; a sample size of 49 participants (using a base population of 149) was determined using formula (see Formula 1 in the Supplementary Files) After potential participants were identi ed, they consented and a copy of the signed consent was given to them. The questionnaires were given to the participants and they were given an option to seek clari cation in case of any di culty from the lead researcher. Seven research assistants who were optometrists were recruited to administer the questionnaires to the respondents. The research assistants were trained on research ethics and how the process was to run. The questionnaires consisted of closed ended questions worded in present tense aiming to explore the participant's knowledge, skills and practice on cataract. The questionnaire had been pre-tested during a pilot to asses for Cronbach's' reliability (assessed at level of 0.874, 0.929 and 0.926 for knowledge, skills and practice questionnaire respectively) and validity (assessed by performing a Pearson correlation coe cient and obtained 0.000<0.05, N=5).
Information collected included: socio demographic characteristics, knowledge of various aspects of cataract, their skills on cataract and practice on cataract management. The study had 16 structured questions broadly around respondent's demographic characteristics (3 questions), knowledge on cataract (4 questions), skills on cataract (7 questions) and practice on cataract (2 questions). The questions had two to three responses. One open ended question was on the reason for referral of cataract cases. The questionnaires took 20 minutes to complete with two to three responses of either aware, neutral or not aware on a three point Likert scale. A composite scale ranging from 20 to 100 was adopted with knowledge, skills and practice level categorized as: low (score of 20-40), medium (score of 41-79) and high/good (score of 80-100). The participants were to identify the type of cataract based on the photographic sent to them. The questionnaires were administered when participants were free and collected back each and every evening. Frequency distributions of all socio demographic characteristics and the proportion of participants who identi ed all items related to skills, knowledge and practice were calculated. A chi-square was used to calculate the association between demographic characteristic and knowledge, skills and practice. We conducted multiple logistic regression analysis to compare the knowledge, skills and practice with demographic characteristics. We calculated odds ratios (ORs) and 95% con dence intervals (CIs). Statistical Package for Social Sciences version 17 software was used to analyze the data. Values of p < 0.05 were considered statistically signi cant.

Demographic Characteristics
Males constituted 63.3% of the participants interviewed with females being 36.7%. The mean age of the participants was 30.4 (SD 6.9) with an age range of 25-36 years. The maximum year of practice of participants was ten years with a mean of 5.4 (SD 4.2).

Knowledge on Cataract
The majority of participants could correctly answer cataract knowledge questions. For example 61.2% could give the correct de nition of cataract; complication of cataract 47%; symptoms of cataract 93.6% and types of cataract 98.0%. But fewer were able to report on inability to read 12.2% as a complication of cataract; oaters as a symptom of cataract 4.1% and traumatic cataract 20.1%. (

Practice of Optometrists on Cataract
Majority of the respondents 61.2% did not examine all patients over 40 years for cataract. However, the 38.8% of the respondents who screened, only 47.4% knew the importance of screening while 52.6% just did the screening as a routine eye examination. Majority of participants (52.6%) admitted that they referred to a particular hospital due to availability of ophthalmologist followed by those with ophthalmology equipments at 39.5%. However, 2.6% did not refer patients (Figure 1.0).

Association between Demographic Characteristics and Knowledge on Cataract
There was a good knowledge among participants aged 25-30 years 77.4% as compared to those aged 31-36 years 226%. Based on the duration of practice, participants who had practiced for less than 5

Association between Demographic Characteristics and Practice
On practice, proportion of participants who had practiced for less than ve years and between six to nine years was the same 35.7%. However, there was no statistically signi cant difference on the quali cation of the participants and those who had practiced for more than ten years (p=0.202, p=0.494) respectively.

Discussions
Cataract in Kenya, just like in other country in sub-Saharan Africa remains a devastating condition. It is the leading cause of avoidable blindness worldwide, with nearly 50-90% true cataract patients remaining undiagnosed Ubah, Isawumi, & Adeoti, (2013). With these gures it is obvious that in Kenya; where there is lack of strong institutional capacity for cataract; care can be a big challenge. This study recruited forty nine optometrists working in Kenya and sought to assess knowledge, skills and practice on cataract. The results ascertained that cataract is treatable surgically and depending on the scope of practice, optometrists are well placed to diagnose and refer. However, with the current situation of optometry in Kenya, the burden of cataract will highly affect the quality of life.
With regard to knowledge of optometrists on cataract, the study ndings established that 61.2% of the forty nine optometrists knew the correct de nition of cataract. They possessed knowledge on the various types of cataract, symptoms of cataract and complications of cataract. This is a clear implication that optometry training in Kenya has not narrowed only on optics of the eye but pathology has been incorporated in the training. In this study, 95.9% of 49 optometrists knew of the ocular complications of cataract. There was a signi cant relationship between good cataract knowledge, age and duration of practice. Optometrists that had practiced for less than ve years were associated with good knowledge on cataract. This high percentage of awareness about conditions associated with or complications of cataract is important as it would positively motivate optometrist in an effort to detect early and refer patients to ophthalmologists. There was a statistically signi cant association between age and duration of practice of optometrist with knowledge on cataract. Better knowledge among young optometrist could be explained by the fact that they recently graduated from school. There was no statistically signi cant association between the level of quali cation with good knowledge, skills and practice on cataract. This could be explained by the fact that the only difference in training between optometrist and optometry technologist is duration of training but the syllabus is the same. This study established that despite the good level of knowledge among the optometrist, there exists a gap in skills in interpretation of type of cataract. The good knowledge of optometrists on cataract will only be signi cant if they put it on practice.
On assessment of skills and practice among optometrists on diagnosis, treatment of cataract, the study found that 75.5% of participant's diagnosed cataract based on reduced visual acuity. This is comparable to what was found in a study at Light house eye hospital by Shahsuvaryan, (2016)  In this study, 61.2% of optometrists did not screen patients age 40years and above who attended eye clinics. This was possible because optometrists nd it hard to relate with optometrist and as a results they don't see the need of referring cataract patients to the ophthalmologists, hence they major on optics. However, we also established that 52.6% of the optometrists who screened were not aware of what they were looking for. This is similar to a study by (Krishna, 2014) who found that even though 50% of optometrists screened patients above 40years, they were not aware of increased sensitivity to light as symptoms of cataract. The lack of screening awareness is probably attributed to lack of interest in pathology of the eye with a lot of interest in optics. In the Kenyan context, optometrists' roles are confusing as they are capable of performing most procedures in relation to their scope of training. However, the Ophthalmic Division requires the optometrists to only do refraction. So this translate that the burden of cataract may rise in Kenya as the rst line eye care providers who meet majority of the patients are inclined towards optics. Hence, the Ophthalmic Division should streamline funds in management of eye care services and ensure that they restructure the roles of optometrists. The possible reason for the low skills among optometrists is attributed to lack of interest by the practitioners due to the division frustrations.
This study has some limitations: rstly, there are more than 300 optometrists in Kenya although only 149 are registered with Optometrists Association of Kenya. The sample size would have been larger if the author would have included all optometrists, however being that they are not interested in joining the association for reasons best known to them, accessing their email addresses proved futile. At the same time, Ophthalmic Division does not allow unregistered optometrists to engage in any activity. Secondly, as the respondents were only optometrists, the view of the Ophthalmic Division was not included in the study. Getting the opinion of stakeholders would have better the study. Future studies to be conducted should include the Ophthalmic Division, ophthalmologists in Kenya to con rm the study ndings. Figure 1 Reasons for Referral

Supplementary Files
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