Knowledge, Attitude And Practice Of Ethiopian Paediatricians On Childhood Eye Diseases

Background: Eye examination and vision assessment are vital for the detection of conditions that result in blindness. Childhood blindness has serious impact on development, education and future employment opportunities for the affected child. Pediatrician’s knowledge about eye disease is important in preventing blindness by early diagnosis, proper treatment and identifying conditions requiring referral to the ophthalmologist to preserve or restore vision. The aim of this study was to assess knowledge, attitude and practice of Ethiopian pediatricians’ on childhood eye diseases. Methods: A cross-sectional descriptive study was done on 79 pediatricians working in various hospitals and clinics in Ethiopia. Participants were determined using convenient sampling technique. Data was collected using both closed and opened ended semi-structured questionnaires. Their responses were entered into EpiData 3.1 and transferred to Statistical Package for the Social Sciences (SPSS) version 21.0 software for analysis. Results: The ndings of the study showed that participants in this study had positive attitude (94.9%) towards childhood eye diseases, even though this was not reected in actual knowledge and practice. Poor knowledge and low practice in the context of positive attitude may be due to various barriers like inadequate training during undergraduate, lack ophthalmology attachment during pediatric residency and unavailability of ophthalmic equipment. Conclusions: Participants’ attitude towards childhood eye disease was positive, but their knowledge of eye diseases made their practice poor.


Background
Vision is an important sensory channel for the early development of attention and is likely to provide a unifying mechanism through which the information perceived through different sensory modalities can be organized and related (1). As a result, detecting visually impaired child and allowing getting correct and on time treatment has importance on child's growth and development.
It was estimated in 2010 that there are 19 million children (age 0-14) globally with visual impairment (VI) of whom 1.4 million were irreversibly blind (2). The causes of blindness in children vary widely from region to region, re ecting socioeconomic development, cultural practices, coverage of preventive measures (e.g. measles immunization), and access to appropriate eye care and optical services (3,4).
Corneal scarring due to vitamin A de ciency, measles infection, ophthalmia neonatorum, and the effects of harmful traditional eye remedies are the most common causes of VI in developing countries whereas cortical visual impairment (CVI), retinal disorders (including ROP), and disorders of the optic nerve are the main causes in developed countries. Retinopathy of prematurity (ROP) is an important cause of VI in children in middle-income countries and in urban centers of developing countries (4)(5)(6)(7)(8).
A blind child is more likely to live in socioeconomic deprivation, to be more frequently hospitalized during childhood and to die in childhood than a child not living with blindness. Of those who are blind, two-third lives in developing countries and up to 60% of such children die within 1 year of becoming blind (9,10).
Eye problems in Ethiopia are among the major public health challenges of the country and pose huge economic and social impact for affected individuals and to the society and the nation at large. Childhood blindness in Ethiopia is a considerable public health challenges which accounts for over 6% of the total blindness burden. A sight or life threatening ocular disorders, such as congenital cataract, corneal blindness, mainly as the result of measles and vitamin A de ciency, congenital eye anomalies, retinoblastoma and glaucoma, are common ocular morbidity in Ethiopia (11,12). Many of the causes are either preventable or treatable with early diagnosis and treatment. Pediatricians play an important role in preventing blindness in children through routine vision screening, routinely performed at well child visits.
Nevertheless, early detection and appropriate referral to an ophthalmologist largely depends on the pediatrician's knowledge, attitude and practice.
Study done to assess practices, attitudes, and perceived barriers toward pediatric vision screening among national pediatrician, the majority of respondents (67%) indicated that they did not begin formal visual acuity testing until age 3 or over. The most commonly reported barriers to screening were inadequate training (48%), time required for exam (42%) (13). A survey carried out in the state of Illinois USA by John and Sharon on compliance with requirement of vision 0screening by pediatricians showed that 60% of pediatricians tested visual acuity in children aged 5 years and above, while half of this group tested children 2 to 4 years old. The most common reasons for not testing visual acuity were inadequate time (42%), children too young (18%), or that screening would be done at school (18%) (14). Another survey on preschool vision screening in pediatric practice was conducted by Alex R. Kemper et al where a national sample of pediatricians was surveyed to evaluate preschool vision screening practices. The rate of acuity screening for 3-year-old children was low (35%), but increased for 4-(73%) and 5-year-old children (66%).
Common barriers to vision screening were that screening is too time-consuming (49%) and children are uncooperative (23%). In the same survey few pediatricians (3%) reported that screening is unnecessary because vision problems would be identi ed elsewhere (e.g., by the family) (15). A study done by Situma Peter Wanyama on Knowledge, attitude and practice (KAPs) of eye diseases in children among pediatricians in Kenya showed that 69.6% of participants had poor knowledge about eye diseases in children. Of the 69.6% of participants reported doing eye examination in children, only 43.5% do it as a routine part of every child's examination. The reasons reported by those who don't do eye examination (30.4%) were lack of enough time to do examination (39.5%) and not knowing how to do eye examination (31.6%) (16). Currently there is inadequate distribution of ophthalmologists and eye care worker in the regions of the country compared to pediatricians. In spite of the prominent role of pediatricians in prevention of childhood blindness, KAPs of these populations about childhood eye disease is not known in Ethiopia. Therefore, this study was conducted to assess the KAPs of Ethiopian pediatrician on childhood ocular illness.

Methods
This cross sectional descriptive study was done on 79 pediatricians working in various hospitals and clinics in Ethiopia using convenience sampling after ethical clearance was obtained from the Ethical Review Committee of Jimma University. Data was collected using both closed and opened ended structured questionnaire during Ethiopian Pediatric Society (EPS) annual conference held on February 6-8, 2019 after adequate orientation was given for all data collectors. The study participants were informed about the study and requested to sign a written consent. Only those study participants who were agreed and signed the informed consent were included. The collected data was checked for completeness, coded and entered into EpiData version 3.1 and exported to SPSS version 21. For descriptive statistics; frequency, percentage, mean, range and standard deviation were used. The overall KAPs of the study participants were analyzed in details and presented by using tables. The Chi-square test was used to test the association between different variables and a P-value of < 0.05 was interpreted as statistically signi cant.
Categorization of participants' knowledge and practice was according to bloom's cut off points into good (> 80%), moderate (60-80%) and poor (< 60%). The sections assessing attitude of the respondents regarding childhood eye diseases was categorized into positive statements and negative statements by using Likert's scale. The scores were vary from 11-55 and all individual answers were summed up for total scores. The scores were classi ed into 3 levels: Positive attitudes 44-55 scores (80%-100%); Neutral attitudes 33-43 scores (60%-80%) and Negative attitudes < 33 scores (< 60%).
The following operational de nitions were used in this study:

Results
Of the total of 123 pediatricians who were contacted and reminded 79 returned complete answers, a response rate of 64.22%. The respondents included 45 males (57.0%) and 34 females (43.0%). The mean age was 37.82 (SD 9.80) years, range 26-66 years. The mean duration of practice were 8.24 (SD 8.2) years, range 1-33 years. A majority were government practice (72.15%) and currently practicing in specialized hospital (70.88%).     (14.16). This could be possibly because of unavailability of visual acuity chart in most of pediatric department The most common reasons cited by those who reported they don't do eye examination (13.90%) were not adequately trained. On practice of retinoblastoma suspicious 74.7% of respondents said that they immediately refer to ophthalmologist. The others 21.5% order CT-scan and 3.8% order ultrasonography. It needs further study on this particular question what characteristics suggest retinoblastoma on those imaging modalities.
The ndings of our study showed that participants in this study had positive attitude (94.9%) towards childhood eye diseases (it was compared to study done in Kenya) (16). Logistic regression assessing the association between the attitudes and socio-demographic factors had no statistically signi cant association with attitude against childhood eye disease.

Conclusion
In conclusion, the study demonstrated that even though the pediatrician had actual poor knowledge and low practice, they had high level of interest to improve their knowledge and practice on childhood eye diseases like diagnosing and managing ophthalmic problems, uses of ophthalmic medication and simple diagnostic instruments. Therefore, pediatrics and child health departments' needs to include pediatrics ophthalmology course attachment in to residency curriculum. In addition, the institution should make available important ophthalmic equipment such as visual acuity chart and direct ophthalmoscopy.

Strength and limitation of the study
This study is the rst to evaluate the knowledge, practices and attitudes toward eye diseases in children among pediatrician in Ethiopia. We addressed a previously neglected issue to nd ways in overcoming of childhood blindness that challenge developing world including Ethiopia Our study was not without limitation. These limitations included: Many unanswered questions, especially the open-ended questions which were di cult to analysis and interpret, and a few published studies on this speci c topic with which to compare the ndings and give conclusion.