Promising Model, Cheesy Title

To begin with a disclaimer: this is going to read a little like a research report, but hopefully it will help you understand the context of blindness prevention in Guangdong Province.

Back in 1997 the Zhongshan Ophthalmic Center (ZOC) carried out one of the first systematic blindness prevalence studies in rural Doumen County. They found two things. One, the prevalence of blindness and cataract was higher than was previously thought. Two, cataract surgical coverage was only 40%, and a majority of operated eyes remained blind. To address the problem of poor surgical skill, in 2001 the ZOC launched a project with funding from the Starr Foundation, training cataract surgeons at county-level hospitals. By 2008, the ZOC had trained 48 ophthalmic surgeons at 46 county hospitals. More importantly, a series of reports from the Study of Cataract Outcomes and Up-Take of Services (SCOUTS) confirmed that the transfer of surgical skills had been effective, with rural surgical results achieving PVA ≥ 0.3 in 83.4% of cases.

Despite this success, the CSR remained low in Guangdong. A recent country-wide survey found that cataract surgical coverage had only risen to 45% in Guangdong, and many partner county hospitals in the ZOC network were reporting low patient volumes. As a result, in 2010 a capacity building project was launched in 10 pilot county hospitals, in which screening teams from each hospital were trained to travel to township health centers, identify patients with potentially treatable cataract, and refer them to the county hospital for diagnosis and treatment.

After one year, the capacity building project has been effective in boosting the CSR of most of its partner county hospitals to around 800-900. But there is still room for improvement. Many hospitals are reporting hitting a “ceiling” in terms of surgical demand, despite epidemiological surveys that clearly indicate an existing backlog. There are three main reasons why the current CSR may be suboptimal:

1. Low screening turnout. Despite their success, temporary screening outreach camps are just that—temporary. A telling study published by India’s Aravind in 1999 revealed that when they first began carrying out screening camps, they could only reach 7% of the population in need.
2. Low patient awareness. Given the long-standing poor reputation of surgical skill in rural China, it may be the case that many patients are unaware of the training that rural surgeons in Guangdong have recently received. A 2009 study showed that knowledge and awareness are the two major barriers to cataract surgery acceptance.

3. Poor follow-up rates. Although Guangdong province has seen impressive surgical outcomes immediately after surgery, long-term outcomes are less optimistic. A 2007 study revealed that 80% of cataract patients have ocular comorbidities post-operatively, 90% of which can be treated if identified. Unfortunately, follow-up rates in rural Guangdong are poor, with only 30% of patients coming back within a week and almost none making the 1 month and 3 month deadlines. The failure to treat comorbidities post-operatively often results in the patient remaining blind or near-blind, which in turn decreases their faith in the quality of the surgery and negatively impacts attitudes of those around them.

The Screening and Extended Eye-care Referral (SEER) Project: A Grassroots Model of Blindness Prevention

(Okay, I know eye care is two words, but then the acronym wouldn’t be nearly as cheesy)

We think this kind of the model is the solution to address the three problems presented above. Through screening patients with poor vision and referring them to the county hospital, while providing basic patient education and monitoring patient follow-up, village health workers can fill a crucial gap in China’s current blindness prevention model.

Training is set to begin in July, stay tuned for pictures and initial results.