Research

  • Opportunistic screening for obesity among hospital attendees
  • Outcome assessment on ENT kit distribution to health facilities at grass root level for continuity of care.
  • Ear and Hearing Care; Current practice & Future Challenges
  • Pattern of ear diseases in hilly and plain areas of Nepal
  • Otological morbidity among preschool children in Bhaktapur
  • Effect of impacted cerumen on hearing status
  • Knowledge, Attitude and Practice (KAP) on Eye Health
  • Ocular Manifestations in Children with Intellectual Disability
  • Optical Needs of Students with Low Vision
  • Barriers to Access of Eye Care and Education by BVI Children
  • Causes of Blindness in Children
  • Barriers to Education and Development of BVI Children enrolled to schools
  • Educational Status of BVI Children Studying in Integrated / Inclusive Schools of Nepal
  • Estimates of the Number of Blind and Visually Impaired Children
  • Inequity in Eye Health Care: A Comprehensive Study of Women's Access to Eye Care in Nepal
  • Health Inequity: A Generational Issue? Lessons From Eye Care Sector

Opportunistic screening for obesity among hospital attendees

-Rajan Shrestha
Recognizing increasing threat presented by diabetes, hypertension and primary open angle glaucoma to public health, CHEERS has initiated a screening program for patients and their escorts visiting CHEERS.
Among 9,805 individuals above the age of 35 years who attended the screening clinic at CHEERS, 35 % individuals had raised blood pressure. Obesity based on Body Mass Index (BMI) is present in 24% and based on Weight Height Ratio (WtHR) is in 42%. Seven percent subjects had raised intraocular pressure in either eye. Nearly 12 % were found to have raised blood sugar level. The screening has helped in the early diagnosis, treatment and raising awareness about these non-communicable diseases especially on those Pre-hypertensive (42%) and Overweight (16%) people who are at greater risk and who can be helped in preventing or slowing down full-fledged diseases.

Outcome assessment on ENT kit distribution to health facilities at grass root level for continuity of care.

-Samjhana Ghimire
Remote rural health camps for direct service delivery and building capacity of health workers through training and supply of equipment are twin pillars of BPEF's strategy to ensure continued service provision to needy people in remote rural areas. Commencing its first service in 2013 CHEERS has conducted 35 such camps in the different parts of Nepal.
Building capacity of health system for ear care is key priority in view of the high prevalence of ear diseases, hearing impairment and lack of services for them. For this purpose, in addition to training health workers they are also provided with ENT Kit. Till date, 144 ENT kits have been distributed. We undertook a questionnaire survey to assess their utilization by health workers.
Among 36 randomly selected out of 144, 29 (81%) ENT kits were functioning, 11% were not functioning and remaining 6% were destroyed during devastating earthquake leaving behind only the metallic syringe functioning. These facilities were examining 5 to 75 ENT patients per month. Unavailability of a replacing battery was the major self-reported problem.
With adequate support, grass root health workers do play a key role in making services available in peripheral areas.

Ear and Hearing Care; Current practice & Future Challenges

Sanjib Upadhyay
Children's Hospital for Eye ENT and Rehabilitation Services, Manahara, Bhaktapur, Nepal

Almost 6% of the world's population is hearing impaired; about 9% of them are children. Developing countries carry almost 2/3rd of the burden. More than 10 children per 1000 live births have severe to profound hearing loss. Hearing loss is the most common cause of moderate to severe disability and a leading cause of disability in low- and middle-income countries. About 60% of childhood hearing loss is preventable. Every day about 6 children are born deaf in Nepal; further every third child in school has an ear problem and every third of them has hearing impairment.
Nepal has 132 ENT surgeons (surgeon population ratio: 1 per 0.2 million) There are 35 health facilities where ENT services can be availed. Most of the services are located in urban areas thus a large population at grassroots is devoid of ENT services. Awareness of ear health is very poor among people in rural communities. Majority wait for ambulatory health services at their door steps
Any intervention provided between birth to 5 years (called critical period), normally has a better prognosis. Children's Hospital for Eye, ENT and Rehabilitation Services (CHEERS) is implementing two types of outdoor activities to identify children with hearing impairment:
1. School screening: Severe hearing impairment interferes with child's learning (12% of child's learning comes from hearing, interferes with child's earning potential when she/he is old enough to take up a job, retards cognitive development of brain, results in poor performance in school makes her/ him vulnerable to injury, stigmatised the child retreats from social activities (isolation) and loses self-confidence and self esteem. Objective of school screening program is to identify and refer children to tertiary care facilities for further management and raise awareness on ear health in the school community. A team of ENT surgeon, trained medical assistant, audiologist and hearing aid technician carry out school screening of up to 200 students per day.  Existing school health programs in Nepal, particularly the public/community schools have failed to be comprehensive.
2. Newborn hearing screening: Since hearing loss in infants is silent / hidden, greater emphasis should be given on early detection, reliable diagnosis and timely intervention. Objective of the newborn hearing screening should be to detect newborn with hearing problem and refer needy neonates to tertiary care centers for timely management. This is carried out at the birthing centers by a team of audiologist, trained medical assistant and staff nurse. Every day hearing screening of 15-20 neonates at risk is being done at Prasuti Griha by CHEERS.
One third of people above 65 years of age develop disabling hearing loss. CHEERS has outreach program to scale up ear health services to people from rural areas of Nepal. Surgical ear camps are organized to provide surgical services to people in need at their door steps. Health workers at grassroots are empowered to provide primary ear care services through training and providing basic ENT equipment. For young children who cannot be supported through medical, surgical or assistive means, CHEERS has its own enabling center where children are trained on basic skills of daily living before they are enrolled into the mainstream education system of the country.
Inadequate human resource and facilities to provide ear health services, low level of awareness among public, geographic difficulties to access services, uneven distribution of health facilities, expensive hearing aids and the unavailability of its maintenance are some of the challenges to make universal ear care possible in Nepal.

Pattern of ear diseases in hilly and plain areas of Nepal

-Luna Mathema, Chandan Baranwal, Sanjib Upadhyay
Children's Hospital for Eye ENT and Rehabilitation Services, Manahara, Bhaktapur, Nepal
 
Background:
Diseases affecting Ear, Nose and Throat are common problem in Nepal and carries significant workload to the clinician. Majority of these cases are treated by undertrained professionals in the rural areas.There is lack of hospital visits especially only for ear problem. even if they do, majority of these reach a pediatrician or a general practitioner. Poverty, lack of infrastructure, difficult geographical location and lack of knowledge are some of the major factors for not attending the medical facilities. Chronic suppurative otitis media (CSOM) is a major health problem throughout the developing countries. no nationwide statical data available on the prevalence of ENT diseases in Nepal. One study of BRINOS in collaboration with TUTH conducted in 1991shows that more than 50% of ear disease includes abnormal ear drum. Various studies have been conducted about ENT the disease prevalence of certain regions or hospital based, especially in pediatric population. 
 
Methods:
This was a cross sectional population based study. Twenty five mobile ENT camps were organized between 2014-2015; 18 in hilly areas and 7 in plain areas of Nepal. Villages with more than 5,000 population in the hilly areas and more than 8,000 population in the plain areas were selected purposively as camp sites. ENT surgeons, audiologists and community medical assistants were involved in the camp team. Camp at each site was held for 3 days. Free medicines, hearing aids or surgeries were provided to the needy.
Results:
A total of 11,791 patients; 7,851 from hilly and 3,940 from plain areas were examined at mobile ENT camps. Attendance of female was found to be more compared to that of male in both settings. The proportion of people with an ear disease was higher in plains (68%) than in the hills (61%). Impacted wax (42%) was seen to be the major problem in hilly areas, while infectious condition (43%) was more prevalent in plain areas. The proportion of children with an ear problem was found to be more in hilly areas than in the plain areas.
Conclusion:
Over two thirds of the camp attendants had an ear problem. Awareness of ear health among people from rural communities has to be raised so that they seek health services on time and adopt strategies to prevent disabling hearing impairment.

Otological morbidity among preschool children in Bhaktapur

Baranwal Chandan, Upadhyay Sanjib, Mathema Luna, Bomjan Balram, Gnyawali Subodh
Children's Hospital for Eye ENT and Rehabilitation Services, Manahara, Bhaktapur, Nepal
 
Abstract
Background:
About 32 million children in the world have disabling hearing loss. The prevalence of disabling hearing loss in children is greatest in South Asia (2.4%), Asia Pacific (2%) and Sub-Saharan Africa (1.9%). Major proportion of childhood hearing impairment in developing countries is secondary to preventable or modifiable causes.  Even mild degree of hearing impairment affects proper development and learning of children.
Methodology:
This was a purposive cross sectional study. All children from selected preschools in Bhaktapur were screened by trained community medical assistants through school visits. Head light and otoscope were used to examine external ear and tympanic membrane. OAE and tympanometer  were used to screen their hearing potential. Those who had an ear problem were referred to tertiary level ENT hospital where detailed evaluation and management was done by ENT surgeons and audiologists.
Results:
A total of 11,378 children from 110 preschools were screened for their ear health. About 85% of the schools were private run. Among a total of 5,183 referred children, 534 (10.3%) attended the hospital. Among those who attended, 439 (82.2%) actually had an ear problem. Wax was prevalent among the majority (48.1%) of the children followed by OME (13.5%) and ETD (8.4%). Infectious conditions (CSOM TT, ASOM) were found to be more common in children reporting from public schools and those of lower age group (< 5 years).
Conclusion:
Children should be screened for their ear problems at the youngest possible age. Low level of attendance to hospital by referred children indicates the need of raising awareness among parents and teachers.

EFFECT OF IMPACTED CERUMEN ON HEARING STATUS

 -Sushil Gaire, Luna Mathema, Ujeli Maharjan, Chandan Baranwal, Sanjib Upadhyay, Rajan Shrestha
Children's Hospital for Eye ENT and Rehabilitation Services, Manahara, Bhaktapur, Nepal
 
abstract
 
BACKGROUND:
Deafness and hearing impairment are major causes of disability in developing countries. World Health Organization (WHO) has pointed out that much deafness and hearing impairment is avoidable or remediable. Prevalence of Wax Impactation was found to be 62% in Nepal. This study was carried out to find the severity of hearing loss due to wax impaction and to evaluate the effect of cerumen removal in reversing hearing impairment among children.
METHODS:
The design was a pre-test/post-test static-group comparison. Children aged 5-16 years attending ENT outpatient department of CHEERS and diagnosed to have impacted wax in either ear during one year study period were enrolled.  Hearing test was done using an audiometer. Wax solvent were prescribed to dissolve wax and ear canal irrigation was performed after a week. Hearing test was repeated after the procedure. Pure Tone Audiometry (PTA) threshold for each ear with wax impaction was determined at 250Hz, 500Hz, 1KHz, 2KHz, 4KHz and 8KHz by air conduction. Bone conduction measurements were also obtained at 500Hz, 1KHz, 2KHz and 4KHz.
RESULTS:
A total of 180 children were enrolled. Out of 360 ears, 256 (71%) (M: F=1.8:1) had impacted wax on which our study was based upon.  Among them 150 (59%) had hearing loss. About 76 % ears (n=150) had mild while 24 % (n=150) had moderate hearing loss. Conductive hearing loss was found in 97 % (n=150) ears and mixed hearing loss was found in 3% (n=150) ears due to super-imposed sensorineural component. Hearing loss was found in 5% (n=222) after wax removal.
CONCLUSION:
Wax impaction is a relatively common cause of hearing loss, usually of the mild conductive type. Wax removal is highly effective in restoring hearing in children with wax impaction. Timely screening and appropriate management should be done to prevent further ear complications. 

Knowledge, Attitude and Practice (KAP) on Eye Health

  1. KAP of care takers of children at household

    535 care takers of children at household in 12 distircts were interviewed to know their KAP on eye health. The study showed almost 20% of the people at household to be unaware of eye diseases. Awareness was found low when people were less educated. Only 74% of the people knew that eye health services were available in their local health facilities while 60% preferred seeking services from health facilities when needed. The major barrier for people not seeking services from health facilities was due to monetary reasons. The major source of information for availability of eye health services in the community was from the neighbor. Walking distance to the nearest health facility however was reported to be more than 3 hours by 8% respondents.

  2. KAP of care takers of children attending eye camps

    456 care takers of children attending eye camps in 12 districts of Nepal were interviewed to know their KAP on eye health. Almost 20% of the caretakers of children attending eye camps were not aware of any eye diseases among children. Those who were found aware, were aware mostly on night blindness and red eyes. Almost 45 % of the respondents had no idea if they had eye health services at their local health facilities even though they preferred up taking services from health facilities. No knowledge on availability of eye health services was found to be the major barrier for the respondents not seeking appropriate eye health services.

  3. KAP of Female Community Health Volunteers

    209 FCHV's from 12 districts were interviewed to know their KAP on eye health. Almost 20% of the Female Community Health Volunteers were found not to be aware of any eye diseases. Those who were aware had heard on night blindness and red eyes only. Cataract, glaucoma and many other blinding conditions were not known to most of the FCHV’s. Despite their recommendation to visit health facilities in need 2% FCHV’s reported that people in their community still visited traditional healers for eye health problems. Barrier they reported on community peoples behalf for not up taking services from health facilities was due to monetary reasons.

  4. KAP of teachers

    23 teachers from 14 districts were given self administered questionnaire to know their KAP on eye health. More than half of the teachers were found to be aware on night blindness and diminished vision. Even among the teachers 8% were not aware where they got eye health services. Ways to prevent eye diseases was not known to 2.5% teachers.

Ocular Manifestations in Children with Intellectual Disability

Background: Intellectual disability is the most common developmental disability. Up to three percent or almost 200 million people of the world’s population have intellectual disabilities. Intellectual disability is a disability characterized by significant limitations both in intellectual functioning and in adaptive behaviour. Visual and ocular defects are more common in people with intellectual disabilities than in general population. Our study aims to assess the prevalence of ocular diseases and visual defects among intellectually disabled children enrolled in the special schools/daycare centers.

Methods: One hundred and fifty seven children with intellectual disabilities (93 boys and 64 girls) in special schools/daycare centers of Kathmandu aged 3 years to 18 years underwent detailed ophthalmologic examination. Cycloplegic refraction was done in all subjects in two eyes separately. Visual acuity was assessed with Preferential looking chart, Kay Picture chart and Snellen’s chart. Binocular function was assessed with cover test, Hirschberg or Bruckner test. Contrast sensitivity was assessed with Hiding Heidi low contrast ‘face’ test. Accommodative lag was measured by using Monocular Estimation Method. The anterior and posterior segment evaluation was done with the torch light and direct ophthalmoscope.

Results: Among the 157 children, 50.3% had refractive error with astigmatism being the most common type (21.01%). Strabismus was detected in 17.2% of the subjects (exotropia in 8.92% and esotropia in 8.28%). The mean log contrast sensitivity value (1.81 + 0.17 log units) was found to be within normal limits. Significant lag of accommodation was found in 61% of the children. 45.2% of the children had significant anterior and/or posterior segment findings. The major anterior segment findings were conjunctivitis, nasolacrimal duct obstruction, blepharitis, chalazion and keratoconus with the major posterior segment findings of glaucoma suspect, retinitis pigmentosa and myopic fundus. 

Conclusion: Visual defects are highly prevalent in the group of children with intellectual disabilities and are mostly correctable. Detailed ophthalmic examination must be done in these children including consideration of accommodation and contrast sensitivity.

Optical Needs of Students with Low Vision

Purpose. To identify the optical needs of students with low vision studying in the integrated schools for the blind in Nepal.

Methods. A total of 779 blind and vision-impaired students studying in 67 integrated schools for the blind across Nepal were examined using the World Health Organization/Prevention of Blindness Eye Examination Record for Children with Blindness and Low Vision. Glasses and low-vision devices were provided to the students with low vision who showed improvement in visual acuity up to a level that was considered sufficient for classroom learning. Follow-up on the use and maintenance of device provided was done after a year.

Results. Almost 78% of students studying in the integrated schools for the blind were not actually blind; they had low vision. Five students were found to be wrongly enrolled. Avoidable causes of blindness were responsible for 41% of all blindness. Among 224 students who had visual acuity 1/60 or better, distance vision could be improved in 18.7% whereas near vision could be improved in 41.1% students. Optical intervention provided improved vision in 48.2% of students who were learning braille. Only 34.8% students were found to be using the devices regularly after assessment 1 year later; the most common causes for nonuse were damage or misplacement of the device.

Conclusions. A high proportion of students with low vision in integrated schools could benefit from optical intervention. A system of comprehensive eye examination at the time of school enrollment would allow students with low vision to use their available vision to the fullest, encourage print reading over braille, ensure appropriate placement, and promote timely adoption and proper usage of optical device.

Full Article

Barriers to Access of Eye Care and Education by BVI Children

  1. KAP of care takers of children at household

    535 care takers of children at household in 12 distircts were interviewed to know their KAP on eye health. The study showed almost 20% of the people at household to be unaware of eye diseases. Awareness was found low when people were less educated. Only 74% of the people knew that eye health services were available in their local health facilities while 60% preferred seeking services from health facilities when needed. The major barrier for people not seeking services from health facilities was due to monetary reasons. The major source of information for availability of eye health services in the community was from the neighbor. Walking distance to the nearest health facility however was reported to be more than 3 hours by 8% respondents.

  2. KAP of care takers of children attending eye camps

    456 care takers of children attending eye camps in 12 districts of Nepal were interviewed to know their KAP on eye health. Almost 20% of the caretakers of children attending eye camps were not aware of any eye diseases among children. Those who were found aware, were aware mostly on night blindness and red eyes. Almost 45 % of the respondents had no idea if they had eye health services at their local health facilities even though they preferred up taking services from health facilities. No knowledge on availability of eye health services was found to be the major barrier for the respondents not seeking appropriate eye health services.

  3. KAP of Female Community Health Volunteers

    209 FCHV's from 12 districts were interviewed to know their KAP on eye health. Almost 20% of the Female Community Health Volunteers were found not to be aware of any eye diseases. Those who were aware had heard on night blindness and red eyes only. Cataract, glaucoma and many other blinding conditions were not known to most of the FCHV’s. Despite their recommendation to visit health facilities in need 2% FCHV’s reported that people in their community still visited traditional healers for eye health problems. Barrier they reported on community peoples behalf for not up taking services from health facilities was due to monetary reasons.

  4. KAP of teachers

    23 teachers from 14 districts were given self administered questionnaire to know their KAP on eye health. More than half of the teachers were found to be aware on night blindness and diminished vision. Even among the teachers 8% were not aware where they got eye health services. Ways to prevent eye diseases was not known to 2.5% teachers.

Causes of Blindness in Children

Purpose: To identify the causes of blindness and visual impairment among students in integrated schools for the blind in Nepal.

Methods: A total of 778 students from all 67 integrated schools for the blind in Nepal were examined using the World Health Organization/Prevention of Blindness Eye Examination Record for Children with Blindness and Low Vision during the study period of 3 years.

Results: Among 831 students enrolled in the schools, 778 (93.6%) participated in the study. Mean age of students examined was 13.7 years, and the male to female ratio was 1.4:1. Among the students examined, 85.9% were blind, 10% had severe visual impairment and 4.1% were visually impaired. The cornea (22.8%) was the most common anatomical site of visual impairment, its most frequent cause being vitamin A deficiency, followed by the retina (18.4%) and lens (17.6%). Hereditary and childhood factors were responsible for visual loss in 27.9% and 22.0% of students, respectively. Etiology could not be determined in 46% of cases. Overall, 40.9% of students had avoidable causes of visual loss. Vision could be improved to a level better than 6/60 in 3.6% of students refracted.

Conclusion: More than one third of students were visually impaired for potentially avoidable reasons, indicating lack of eye health awareness and eye care services in the community. The cause of visual impairment remained unknown in a large number of students, which indicates the need for introduction of modern diagnostic tools.

Full Article

Barriers to Education and Development of BVI Children enrolled to schools

A study of 770 children studying in 55 schools in 35 districts of Nepal conducted by BP Eye Foundation in partnership with Tribhuwan University, IOM, BPKLCOS and ICEVI has reported the status of education of BVI children to be sub-optimal for the following reasons:

  • no system of appropriate assessment at the time of school admission is in place,
  • many children have been taught Braille instead of teaching them to use prints using residual vision,
  • there is insufficient number of Resource Teachers
  • resource rooms for BVI children are not well equipped
  • teachers are not paid well, resulting in lack of motivation
  • there is poor financial support from the parents sometimes because of poverty and at other times because of negative attitude.

Despite expanded State support in recent years, the integrated/inclusive schools remain grossly under-resourced. Managerial inefficiency and lack of coordination among concerned stake holders makes an already bad situation even worse.

Educational Status of BVI Children Studying in Integrated / Inclusive Schools of Nepal

Just as there is paucity of accurate data on number of blind children and their service needs, there is a similar gap in accurate information about the number of children who need to be in schools and are not there yet. Ministry of Education data indicate that about 5,000 children have been enrolled in schools (MoE Flash Report-1, 2006- 2007). However, our assessment of children in 55 integrated / inclusive schools supported by Ministry of Education have shown that most schools have less than half the claimed number. By a conservative estimate, between 20,000 to 25,000 blind children are still out of school (EFAVI National Task Force 2009). While enrollment is low, dropout rates are reported to be high.

Estimates of the Number of Blind and Visually Impaired Children

Data on prevalence of childhood blindness are important for policy formulation and program implementation. The number of Blind and Visually Impaired (BVI) children reported by different stakeholders show great variation. BPEF in partnership with International Council for Education of Vision Impaired (ICEVI) and Ministry of Education’s EFAVI Task force, Nepal Netra Jyoti Sangh and Tilganga Institute of Ophthalmology organized a consultative meeting to determine the number as accurately as possible. Employing the currently available information and after making certain assumptions and allowances for possible error, all stakeholders agreed that there were 30,240 blind children and at least 3 times as many children (90,720) with low vision in Nepal in 2009.

Inequity in Eye Health Care: A Comprehensive Study of Women's Access to Eye Care in Nepal

NGEHG's study of 2.45 million service users from 16 Eye Hospitals; 142,457 service users from Eye Camps and 28,640 people in a community based survey has generated possibly world’s largest database on gender and eye health. The number of female and male attending the hospital was found to be almost similar - 1,223,499 for male and 1,230,359 for female. The number of cataract surgery was 180,352 (male) and 181,711 (female). However, given the fact that blindness in women is twice as common as in male, it clearly emerges out that one third of needy women have failed to utilize the existing eye care services. Although utilization of eye camp services by women was slightly better the gap between the need and actual utilization did not change significantly. Rapid Assessment of Avoidable Blindness (RAAB) showed that blindness was higher among females in all zones except Lumbini zone. When women were visited at their homes, blindness was found to be 1.4 to 3.8 times more common in women than men.

Health Inequity: A Generational Issue? Lessons From Eye Care Sector

Nepal Gender and Eye Health Group (NGEHG) is a multi disciplinary and multi institutional consortium led by BPEF to study eye health inequity in Nepal. In a study of 2,453,858 individuals accessing eye care services in 16 hospitals in the 3 years under observation, the group reported that only 326,841 children utilized eye care services. This is less than 14 percent of the total service users, although children constitute 40 percent of Nepal’s population. When access is an issue for children in general, no wonder then, it is even greater problem for a girl child as the findings of the survey show. For a total number of 326,841 children seen during 3 years there were 171,686 boys and 155,155 girls. The rates of underutilization of services are even higher for girls and the gap is wider than seen in adult patient population. A girl child is therefore, doubly disadvantaged, first for being a child and then being a girl. Girls in Terai are reported to suffer even greater exclusion than their peers in the hills.

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Our story is twenty five years old. My inspiration is as new as it was then. Of the Board of Trustees, Mr Anang Man Serchan, Dr. Laxmi Narayan Prasad and Dr. Nabin Chandra Rai ...

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B.P. Eye Foundation
Lokanthali, Bhaktapur, Nepal
+977 01-5182505, 5182135
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