Health Education Strategies Utilized by Two Unite For Sight Partners in Rural Ghana

Unite For Sight's partner eye clinics develop and implement health education strategies to eliminate patient barriers to care. This health education report was compiled by Unite For Sight Global Impact Fellow Page Crew.

Health Education by Crystal Eye Clinic

Crystal Eye Clinic is a private eye clinic located in Accra, Ghana, that serves a vast patient population throughout southern Ghana. This clinic offers ophthalmic exams and surgeries in Accra in addition to providing mobile outreach services for underserved communities in rural villages. Dr. Ernest Awiti, an optometrist at Crystal Eye Clinic, usually facilitates the outreach visits and often examines more than one hundred patients per visit, including children and adults. Patients are invited to the outreach, where they listen to a health education talk designed to introduce them to eye health education and the outreach process. Next, patients participate in a visual acuity assessment and receive an eye examination by an optometrist or ophthalmic nurse. Depending on the patient’s eye condition, he or she may receive medication, reading glasses, distance glasses, or be referred for further review by the ophthalmologist at Crystal Eye Clinic in Accra. In addition, patients who are diagnosed with cataracts or pterygium receive UFS-sponsored surgery at Crystal Eye Clinic.

The Crystal Eye Clinic practitioners utilize three main health education strategies to target rural populations in Ghana: stipended local community eye health workers, school presentations, and the health education talk presented at the beginning of every outreach. Local community eye health workers are community members who have expressed interest in serving their villages and are committed to encouraging patient participation in outreach and follow-up care. Sometimes these community eye health workers are appointed by the chief of the village in an effort to emphasize the importance of the outreach to the village and recognize community eye health workers as leaders. Having a prestigious appointment also facilitates trust between the community and the local eye health workers, which helps the eye clinic staff encourage attendance at outreach. Local community eye health workers are trained by an experienced Crystal Eye Clinic doctor or nurse at the clinic in Accra, where they learn basic eye health, primary eye care, and often observe cataract and pterygium surgeries in the operating room. Because local community eye health workers are educated about the technical processes of eye surgery and the importance of eye care, they serve as valuable community resources for patients who are referred for surgery. In addition, they receive practical eye care training and learn how to properly administer eye drops and assess patient visual acuity so that they can assist with outreaches.

The role of local community eye health workers is quite comprehensive. First, they advertise that the Crystal Eye Clinic mobile outreach team will be sponsoring a visit to their community. Community eye health workers will also identify people with eye problems and encourage them to attend the outreach. During outreach, the community eye health workers often assist Unite For Sight Global Impact Fellow volunteers with translation. After outreach has concluded, the community eye health workers hold a special session to counsel patients who are referred for cataract or pterygium surgeries. During this session, the community eye health workers reaffirm the patient’s decision to have surgery and discuss any residual concerns about the procedure. They also emphasize the importance of adhering to any pre-operative medication regimens and review the travel arrangements for surgery. The local community eye health workers are invaluable patient advocates who remain with the patients throughout the entire process of traveling to the clinic, having surgery, and returning to the village. In some cases, local community eye health workers assist in monitoring post-operative medication use in patients who are at increased risk for complications or may have trouble adjusting to a medication regimen. The local community eye health workers serve as an important liaison between the patients and the Crystal Eye Clinic staff and improve the clinic’s ability to reach underserved patients.

The Crystal Eye Clinic promotes eye health education among school-aged children by conducting health education talks at schools. This program targets children ages six to 14 and teaches them about eye anatomy and eye health at an age-appropriate level. The session also focuses on injury prevention and uses techniques such as playing games or acting out scenes to illustrate concepts related to eye health. Additionally, the health educators explain the dangers of using traditional medicine to treat eye problems. Often, the health educators will instruct teachers on how to identify children with common eye problems and where to refer these children for help. 

An additional important component of Unite For Sight's program is the health education talk by Crystal Eye Clinic's ophthalmic nurses and optometrists. Presented at the start of each outreach, the health education talk lasts between 25 and 45 minutes, depending on the size of the outreach, and is designed to target rural populations living in southern Ghana. Often, rural communities have little or no eye health knowledge prior to an outreach visit. For many patients, it is their first time seeing an eye doctor, as local hospitals do not usually have an eye doctor on staff. Within these communities parents with children, elderly patients, illiterate patients, and patients with comorbidities such as diabetes or hypertension require special attention during the health education talk. Cultural beliefs are also an important consideration in the health education program, and the health educators tailor each session to the specific culture and speak in the local language, using translators as necessary. 

According to Dr. Awiti, rural communities tend to rely heavily on traditional medicine, while urban communities have greater exposure to western medicine. For this reason, it is extremely important to address traditional medicine when communicating with rural populations in Ghana. The dangers of traditional medicine can also be difficult to explain since patients have been exposed to traditional medicine used by their parents, grandparents, and other relatives whom they trust. In addition, some Ghanaians believe that diseases are spiritual consequences that require religious intervention, rather than medication, or that blindness is a normal part of aging and an act by God that does not require medical care. The local practitioners carefully consider these cultural beliefs when providing health education in rural Ghana.

Goals of the health education talk

  • Change patient perceptions about eye surgery to encourage eligible candidates to have surgery (cataract and pterygium surgery).
  • Encourage patients to adopt healthy behaviors to improve and maintain eye health.
  • Change patient perceptions regarding modern healthcare and orient patients to the healthcare system.

Components of the health education talk by the local eye doctors

  • Introduce Unite For Sight
    • Purpose of Unite For Sight: to eliminate preventable blindness.
    • Accomplishes this through fundraising to sponsor eye care.
    • Emphasize Unite For Sight’s status as a “non-profit” and “non-governmental” organization.
    • Explain the roles of volunteers in facilitating the outreach, donating eyeglasses, and fundraising to provide support for eye care and eye surgeries.
    • Discuss the primary activity of Unite For Sight in Ghana: sponsoring eye surgery.
  • The Basics of Cataract Surgery
    • Address the misconceptions and traditional beliefs regarding surgery:
      • The surgery does not involve removing the eyes and cutting them before putting the eyes back in the patient.
      • The surgery will not replace the patient’s eye with a cat’s eye.
      • The surgery is not extremely painful.
      • A relative cannot donate an eye to you.
      • Not everyone with poor vision needs surgery.
    • Explain how surgery is performed in basic terms.
      • Cataract surgery will clear the lens so the eye can see, like cleaning an eyeglasses lens or replacing the cloudy lenses of eyeglasses with clear lenses.
    • Ask patients in the audience who have had surgery to share their experiences.
    • Discuss the typical price of cataract surgery (50 – 80 Ghanaian Cedi, up to 200 Ghanaian Cedi) to establish the value and importance of surgery.
      • Explain that many patients in Ghana typically can’t afford the surgery so UFS sponsors surgeries and pays for post-operative medication, housing, and surgery.
    • Explain basic post-operative care.
      • The importance of using prescribed medications.
      • The importance of keeping the eye clean.
  • Eyeglasses
    • UFS volunteers donate eyeglasses.
    • Explain how eyeglasses work:
      • Purpose: to help a patient with poor vision see better.
      • There are two types of glasses: distance glasses and reading glasses.
        • As you get older, your eyes require reading glasses to see small print.
      • Eyeglasses do not change the size of the eyes.
    • Explain refractive error.
    • Show patients how to hold eyeglasses and how to take care of glasses so patients understand the value of the glasses.
    • Do not share glasses with friend or relatives.
    • Discuss the usual cost of eyeglasses outside of outreach to establish the value of the glasses. Explain that each patient can only purchase one pair of glasses and must take care of them.
    • Sunglasses help to prevent pterygium.
  • Medicines
    • Traditional herbal preparations are harmful for the eyes.
      • Only use medicines that have been prescribed by the doctor.
    • Even prescribed medicines can be harmful if they are used improperly.
      • It is extremely important to adhere to the doctor’s instructions for using any prescribed eye treatment.
      • Do not share medications, and only use medications exactly as prescribed. 
      • Do not refill medicines at the local pharmacy unless instructed to by the doctor.
    • Explain how to administer eye drops properly.
    • Explain how to understand a medication regimen (e.g. put one drop in both eyes three times daily).
      • Avoid harmful traditional eye practices including:
        • Squeezing the juice of Achempong leaves into your eye.
        • Applying palm oil, urine, cow milk, breast milk, hot banku, cocoa leaves, tomato juice, hot herbal mix, or pomade to your eye.
        • Using alcohol as cleaning agent for the eye.
        • Applying a homemade salt solution or seawater as a treatment for pain, redness, or blurred vision.
        • Using chloramphenicol to treat glaucoma or inflammatory eye conditions.
        • Couching: traditional practice to "treat" cataracts during which a metal tool is used to push the lens out of place.
  • The importance of a healthy diet
    • Foods to eat to maintain health include:
      • Vegetables: carrots, milk, beets, cabbage, green pepper, cucumber, lettuce
      • Fruits: oranges, paw paw, mangoes
      • Milk
      • Explain that “gaurine” (cassava flakes) does not cause blindness.
    • Diet information specific to children
  • Eye diseases that cause blindness:
    • Cataracts
      • Explanation of cataracts: use the lenses of eyeglasses as an analogy for the eye lens becoming cloudy.
      • Can be age-related, trauma-induced (especially farming injuries), or congenital.
      • Give another brief explanation of cataract surgery.
        • Reinforce the fact that the procedure replaces the lens and does not involve removing the eye.
        • Re-affirm the importance of post-operative follow-up visits and using medications properly.
    • Glaucoma
      • Irreversible condition characterized by high pressure in the eye.
        • High eye pressure is like high blood pressure.
        • High eye pressure damages the nerve in the eye.
      • Cannot be fixed with surgery.
      • Causes permanent blindness.
      • Family related.
        • Have your relatives examined if you are diagnosed.
      • There are no signs or symptoms until damage to the eye has already occurred.
      • Treatment includes daily eye drops that can be refilled at local pharmacies.
      • Some patients are eligible for a surgical procedure, but it does not improve vision like cataract surgery; it only stabilizes the eye pressure.
    • Emphasize the importance of regular eye exams even if the patient is not currently having problems, especially if the patient has a chronic disease like diabetes or hypertension.
      • At the first sign of an eye problem, seek help from a doctor or go to the hospital. Do not use traditional medicine.
      • Explain the symptoms of eye problems like pain, redness, or discharges coming from the eye. For example, if pus or a fluid discharge is coming out of the eye, this is not “the bad coming out of the eye”. This is a sign of a serious problem, which requires treatment by a physician.
  • Conclusion
    • Introduce the visual acuity chart and visual acuity testing.
    • Ask the audience for questions.
    • Explain that patients can always talk to the local community eye health worker with questions when outreach is over.

After the health education talk, the local eye doctor introduces the UFS volunteers, doctors, nurses, and local community eye health workers to the community, and patients are then directed to the start of the clinic process, beginning with patient registration.

Health Education by Charity Eye Clinic

Charity Eye Clinic in Kumasi, Ghana, provides eye health outreach services to various rural villages throughout the Ashanti Region of Ghana. Dr. Kate Gaisie, the optometrist at the clinic, believes that providing the health education talk at the beginning of outreach and utilizing local community eye health workers are the most effective health education strategies are. Often, local community eye health workers have had cataract or pterygium surgery, so they can share their experiences as former patients of Charity Eye Clinic and serve as valuable peer resources for patients who are referred for surgery. The primary roles of local community eye health workers, however, are to assist with clinic announcements and advertising for outreach visits and translate the health education talk when necessary.

The health education seminar begins with introductions of the Unite For Sight volunteers, local community eye health workers, and clinic staff facilitating the outreach. According to Dr. Gaisie, when addressing adults living in rural settings in the Ashanti Region, it is important to describe the services provided by Unite For Sight, explain how the normal eye works, and provide information about cataracts and glaucoma. Like Dr. Awiti at Crystal Eye Clinic, Dr. Gaisie believes that traditional medicine is an important issue that must be addressed in each presentation. Common cultural principles create barriers to eye care, such as believing that eye problems are a normal part of aging, that eye problems they should not be treated since visual impairments are created by God, or that the eyes are removed during cataract surgery. According to Dr. Gaisie, these beliefs are common throughout Ghana and are not unique to rural populations. Thus, the health education talk is a vital tool to provide public health outreach and to encourage patients to seek eye care.

Components of the health education talk by Charity Eye Clinic's optometrist

  • Introduction of Unite For Sight (UFS) and volunteers.
  • Explanation of how the eyes produce vision:
    • Light travels into the eyes.
    • The brain and the eyes work together. If you cannot see, it could be due to a problem with your eyes or a problem with your nerves connecting your eyes to your brain.
    • During surgery, the doctor will not remove the eyes because this would interrupt the eye-brain connection necessary for sight.
  • Unite For Sight helps patients in Ghana receive eye care.
    • Discuss the expensive cost of surgery to establish the value of the service that UFS provides.
    • If a patient needs cataract surgery, UFS will sponsor the surgery.
    • UFS will also pay for the cost of post-operative medications, room and board for surgery patients in Kumasi, and provide free sunglasses to take home.
  • Eye diseases
    • Cataracts: (supplements talk with enlarged photograph showing an eye with cataract).
    • Use an analogy to explain cataracts:
      • Cataracts are like having dust on eyeglasses. The doctor needs to wipe the dust that covers the surface of the glasses; this way light can enter the eye to produce vision. Using medication alone will not correct the problem; this would be equivalent to pouring water on dusty eyeglasses. Cataract surgery is similar to washing the dust off the eyes.
      • Cataracts are like a closed door that doesn’t allow light to pass through. Surgery is equivalent to opening the door for light to be able to pass through.
    • Cataracts can be caused by aging, chemical burns, trauma, or congenital development.
    • Cataract surgery may not help all patients with blindness, especially if the patient has a retina problem (e.g. age-related macular degeneration), diabetes, or hypertension.
      • Ask patients to do a self-assessment:
      • Do you urinate more than 3 times per night? If yes, patient should see a doctor to check for diabetes. This patient is not currently eligible for surgery.
      • Do you have a recurring headache in the back of your head? If yes, patient should see a doctor to check for hypertension. This patient is not currently eligible for surgery.
    • Couching is a poor treatment choice for cataracts.
      • Use the analogy of the eye as an egg. The egg requires a yolk, like the eye requires a lens to see, but if you separate the yolk from the white of the egg, the egg is spoiled, just like an eye would spoil from couching.
    • Pterygium: (supplements talk with enlarged photograph showing an eye with pterygium)
      • Pterygium can be caused by exposure to dust, sun, and smoke.
      • Produces characteristic outgrowth of the white part of the eye (the conjunctiva) to the black part of the eye (the pupil).
        • This growth does not allow light to pass through the pupil, which is essential for vision.
        • Pterygium is like pulling a curtain across the eye.
      • Surgery can correct pterygium by removing the conjunctiva growth.
      • It is important to seek treatment early, before the pterygium severely limits vision.
    • Glaucoma:
      • Glaucoma is an eye disease characterized by having high pressure, like hypertension, in the eyes.
        • Describe eye anatomy: There is water (aqueous humor) in the eye. The inflow of water should match the outflow of the water to result in a specific quantity of water in the eye. If the inflow does not match the outflow, the result is an increase in eye pressure.
        • Refer to eye diagram to show anatomy of normal eye and the location of the increased pressure in relation to the optic nerve.
      • Glaucoma is a hereditary condition; it is not contagious. 
        • If you are diagnosed with glaucoma, your relatives should also be assessed.
        • If a relative has glaucoma you should be assessed.
          • Perform a glaucoma check at age 25. If no glaucoma at this time, have a check-up once per year until age 40.
          • Perform a glaucoma check at age 40. If no glaucoma at this time, have a check-up twice per year.
      • Surgery for glaucoma does not restore sight and medications do not restore sight.
        • The purpose of glaucoma medications is to stabilize the eye pressure and prevent further damage.
      • Unfortunately, signs and symptoms of glaucoma only appear at a late stage in the disease.
      • If you have glaucoma, you need to have an eye exam to check your eye pressure every month for the rest of your life.
  • How to take care of your eyes:
    • Chemical burns: Treat a chemical burn by flushing the eyes with clean water.
    • Diet is very important.
      • Increase dietary intake of Vitamin A by eating cabbage, carrots, and cocoa yam leaves.
      • Discuss how to prepare cocoa yam leaves so as not to lose nutrients through cooking (i.e. boil cocoa yam leaves in water and use the water while cooking to retain nutrients).
    • Having regular eye exams is very important. Many people in Ghana do not see an eye doctor until there is a problem. The eye is like a window to the whole body and can help doctors detect other diseases like diabetes or hypertension.
  • Traditional medicines:
    • Explain that traditional medicine “melts the eye,” is an “enemy of the eye,” or “destroys the eye”.
    • Using traditional medicine can result in a cloudy cornea or expand a corneal ulcer.
    • Do not try to self-treat a red eye; seek care from an eye doctor.
    • Do not share medications with other people. Do not use other people’s medications.
      • Share example to illustrate the dangers in sharing medicine:  If a person complains of symptoms of nausea and vomiting, this can result in three separate diagnoses: malaria, typhoid fever, or pregnancy. These diagnoses have different medical indications even though they share common symptoms. Likewise, similar eye symptoms of itching or pain can indicate different medical conditions and may require different treatments.
  • Cataract surgery
    • It is important to do surgery in the earlier stages of cataracts (as soon as you are eligible) before your eyes become totally blind.
    • Cataracts will get worse and it will be difficult to have to rely on children and relatives to care for you.
    • Unite For Sight is a great opportunity to treat cataracts because they offer to pay for all of your surgery expenses.
    • If surgery will not help your eye condition, the eye doctor will tell you this and you will not have surgery.
  • Eye Drop Demonstration
    • Two Unite For Sight volunteers perform the demonstration of how to properly use eye drops and eye ointment. One volunteer acts as the caregiver, the other acts as the patient.
      • First, clean your hands.
      • For first time use of eye drop bottle: Remove the cap from the eye drop bottle then replace the cap to puncture the eye drop dispenser.
      • Do not touch the tip of the eye drop applicator with your hand.
      • Do not put the eye drop bottle cover in your pocket or on the floor where it will get dirty.
      • Pull the lower eyelid down to make a pocket.
      • Apply one drop.
      • Close your eyelid gently and press your index finger to the inside corner of your eye (to close proximal lacrimal duct) for 30 seconds.
      • Wait 5 minutes before applying a second medication (drop or ointment).
    • To apply ointment:
      • Pull the lower eyelid down to make a pocket.
      • Apply the ointment by squeezing the tube applicator from the inside corner of the eye pocket to the outside corner.
      • Avoid “Meate”, which means using a finger to spread the ointment.
  • Question and Answer session
    • Encourage patients to ask general questions to facilitate the discussion.
    • Briefly explain how the visual acuity assessment is performed using the E chart.
    • After the health education talk, the practitioner directs patients to the start of the clinic process, beginning with patient registration.