Eye health promotion-oriented policy statements in various national and provincial health policy documents in South Africa

be the case even in South Africa. In view of these developments and conventional patterns of disease processes as well as challenges that are inherent in the developmental landscape of South Africa, all health disciplines, including Background: There are many fragmented public health policies that give directives towards various aspects of healthcare needs and implementation. However, none of these policies make specific reference to eye health promotion (EHP) as an enabler for individuals to take control of the determinants of their eye health (EH) needs. Aim: The current study sought to identify EHP messages in the various available policy documents at both national and provincial health department levels with a view to assessing awareness on the available gaps for the development of an integrated EHP policy in South Africa. Setting: The study used documents provided by the National Department of Health and those that were available online from various other provincial Departments of Health in the country. Methods: Content analysis of EH policies requested from the Directorate of Chronic Diseases, Disabilities and Geriatrics was conducted. Various other health policies that were enacted post-1994 and endorsed by the National and Provincial Departments of Health were also considered for analysis. Results: Twenty-four documents were considered for content analysis. The national guidelines on eye healthcare made reference to EH activities such as immunisation of children, vision screening of the elderly, vitamin A supplementation and maternal services to detect sexually transmitted diseases, amongst others. Of the 20 national and provincial health documents analysed, only four made reference to EH. None of these documents made any specific reference to EHP. Conclusion: Although four national guidelines contain content related to EHP, the fragmentation and lack of integration with other health policy documents may lead to eye healthcare messages not being prioritised for dissemination even where they are highly required. Also, public eye healthcare services in general will continue to lag behind as is the case in most provinces in South Africa.


Introduction
The Universal Eye Health: A Global Action Plan (2014-2019), articulated the essence of eliminating unwarranted cases of blindness through the participation of member states by developing and implementing favourable policies. 1 The importance of developing health policies that expedite and advocate for considerations for healthcare needs of people in the developing countries is of vital importance. These policies have to be implemented as part of the health systems that are aimed at improving the lives of individual community members in those countries. According to Han, 2 the 2000 World Health Report pointed out three fundamental objectives of health systems, namely improving the health of the populations they serve, responding to people's expectations and providing financial protection against costs because of illness. Unfortunately, health systems in developing countries are constantly exposed to challenges occurring as a result of epidemiological diversity and urbanisation within uneven but rapid economic growth in some instances. 3,4,5 Demographic changes, massive urbanisation, rural environments and the advent of unhealthy lifestyles have resulted in rapidly changing disease patterns on a global level since the industrial revolution of the 18th century, 6 and this appears to be the case even in South Africa. In view of these developments and conventional patterns of disease processes as well as challenges that are inherent in the developmental landscape of South Africa, all health disciplines, including http://www.avehjournal.org Open Access those that focus on eye care services should be considered in all health policy developments.
According to Bennett et al., 7 developing a strong health policy may influence health outcomes of the population. In support of this assertion, Filmer et al. 8 argued that although health policy development appears to focus on preventive versus curative services, there is a need to develop health policies that respond best to health priorities within the prevailing political, social and economic influences that impact health and service provisions. In agreement with this view, Jamison and Mosley's 9 arguments for strategies in health policy development have important implications. The authors postulated that whilst there is a need for health priority assessment on a national level, there is also a need to translate national health priorities to a local epidemiological context with consideration being given to the socio-cultural, administrative, economic and political impact on healthcare. It is, therefore, imperative that health policy strategies address issues on equity, efficiency, acceptability and sustainability within health service provision. 10,11 By extension, health issues that affect the delivery of eye care services should also be considered in policy development within the context of urban and rural communities. If this is done, the burden of eye diseases such as cataract, glaucoma and blinding uncorrected refractive errors that have already been widely reported by various scholars will be adequately addressed. Unfortunately, there appears to be no political will to incorporate eye healthcare in the primary health care (PHC) system in South Africa, with much needed services being pooled in hospitals rather than local clinics and community health centres (CHCs).
Interestingly, there is a worldwide increasing awareness that the underlying determinants of eye diseases are intricately influenced by those that also affect the well-being of individuals. 12,13 This refers to the social determinants of health which are directly linked to the environment within which affected individuals are born, grow and work. 14 It is therefore important that health policy development considers this very intricate relationship between the social determinants of health and eye health (EH) and the factors that link eye diseases to ill-health. Whilst health policy development is essentially considered a political process, this inter-relationship between EH and general health has important implications for eye health promotion (EHP) and implementation of policy directives in South Africa. The focus on EHP usually portrays government's commitment to incorporating EH into the PHC system of the country through a political process that this seemingly easy process has become. The narrative of optometrists performing certain clinical duties that are viewed to be in the domain of ophthalmologists gives credence to the politics of EHP and the non-existent policy. Therefore, this study sought to analyse various accessible health policy documents with a view to identifying statements that made specific reference to the importance of EHP in the country, which may cast a light on the determination of authorities to incorporate EH into PHC system in South Africa.

Methodology
Content analysis by means of a qualitative research approach was used for this study. The purpose of content analysis is to organise and elicit meaning from the document being analysed and draw realistic conclusions from it. 15 As a result, policies on EH were requested from the Directorate of Chronic Diseases, Disabilities and Geriatrics, after which national guidelines on the management of various eye healthcare conditions were provided. Also, national and provincial general health policies were sought in the websites of both the national and provincial health departments across all nine provinces of South Africa using Google search engine. Search words such as health promotion, eye health promotion and integrated eye health policy were used during the search for information. Only documents relevant to the purpose of the study were considered for analysis and interpretation. The criterion used in the selection of the health policy documents was that the document must have been produced by the Department of Health or endorsed by the Department of Health in South Africa. Also, only health documents produced in the post-apartheid era were considered for analysis. This was done to eliminate documents that might have had polarisation towards specific groups of people during apartheid than the ones that may be perceived to be more inclusive post-apartheid. Also, the type of EH promotional messages may have changed over time because of epidemiological transitions. The study received ethical approval from the University of South Africa's Department of Health Studies before commencement. Permission was also received from the National Department of Health to conduct the study throughout the country.

Eye health documents analysis
The research focused on specific evidence-based findings that have been proven to be capable of contributing towards improvements in community EH in a cost-effective manner.
To this end, the initial stage in EH policy analysis involved locating EHP elements in policy statements contained in the provided national guidelines on EH matters. Thereafter, the second stage sought and also examined the context in which EHP is expressed. The analysis process attempted to identify potential recipients of the programmes or interventions, human resources and levels of care and service provision. The third stage of the analysis process was to determine if there was a rational and scientific basis for the selection of EHP needs, priorities and strategies. The criteria for EH needs assessment looked at epidemiological prevalence, impact on health resources, community well-being, and whether health priorities or needs were localised or population-wide. Any possible proposals on EHP strategies and interventions were critically compared with the published evidence-based literature before inclusion.

General health policy analysis
The research developed a common set of criteria that was systematically applied to the documents analysed.
General health policy content analysis was also conducted in stages. The stages involved identification of statements on EHP in the general health policy documents. If EH or EHP was mentioned in policy statements, then the analytical process proceeded to determine if there was a rational or scientific basis to the selection of these strategies. If EH was not mentioned in policy documents, then the next stage would be to identify the provision for lifestyle induced risk factors. The analytical process attempted to determine if EHP could be incorporated into the lifestyle induced risk factor element in health policy documents.

Ethical considerations
The study received ethical clearance from the Research Ethics Committee of the Department of Health Studies at the University of South Africa before the commencement of the study (reference number: 45962545).

Results
A total of 24 documents from the national and provincial health departments were obtained for content analysis. Amongst these, four were guidelines on EH management protocols and the rest (20) were generic health policy documents. In order to understand the position and commitment of health authorities on matters of EHP, the following analysis was made.

Locating eye health promotion statements in eye health policy documents
The Directorate of Chronic Diseases, Disabilities and Geriatrics in which EHP activities were planned provided the following guidelines which were their only documents on EH in general:

National guideline on prevention of blindness in South Africa
The national guideline on prevention of blindness in South Africa is a document that focuses on the prevention of avoidable blindness as a component of the VISION 2020 global initiative. It focuses on the prevention of diseases and has set out four levels of prevention which may be interpreted as a strategy for EHP. Its analysis was done in line with the questions and evidence as shown in Table 1.

National guideline on the management and control of eye conditions at primary level
The objectives of this guideline are to effectively manage eye conditions at primary level thereby limiting complications and potential blindness. It further seeks to apply costeffective interventions and accessibility to eye care for persons with eye disease/problems. In order to determine its relevance and focus to EHP, the questions and evidence as presented in Table 2 were recorded.

National guideline on refractive error screening for persons 60 years and older
The objectives of this guideline include the identification, referral and provision of services for the targeted adults who may benefit from refractive correction by provision of screening services, provision of refractive services, provision of cost-effective correction devices, establishment of appropriate referral channels and establishment of estimates of refractive errors needs for the targeted population. The focus on EHP promotion is shown in Table 3.

National guideline on cataract surgery
The objectives of these guidelines include to correct blindness and impaired vision, to reduce the economic burden to the individual, family and community and to improve the quality of life of the individual. The focus on EHP is shown in Table 4.

Locating eye health promotion related messages in other health documents National and provincial health policy analysis
The national documents that were analysed include, amongst others, the constitution of the Republic of South Africa, National School Health policy and Integrated Nutrition Programme. The rest of the documents are as shown in Table 5

Discussion
Eye health promotion is an important aspect of any action plan that seeks to address causative factors of various forms of visual impairment and blindness. The national guidelines on various ways of addressing visual ailments by members of the public should be considered as an important baseline in policy development. Although none of these documents make mention of EHP specifically, or reference to issues such as health education, immunisation, safety promotion and maternal services in the national guideline on prevention of blindness in South Africa has a direct contribution to issues of EHP. For example, a study by Khanna 16 highlighted the importance of health education through school health integrated programmes that target school-going children. In this study, the author made reference to the Indian government by way of acknowledging the commitment made by recognising the importance of EH care programmes within the schools. Similarly, the South African government has also recognised the importance of integrated school health programmes that encompass early childhood vision screening programmes in the primary schools. 17 Furthermore, the guideline considers immunisation as an important initiative for eliminating unwarranted causes of visual impairment and blindness and this has also been integrated in the school health programmes. This is a commendable initiative as causes of blindness, especially amongst children, can be prevented through immunisation programmes against measles and vitamin A supplementation that can assist in the eradication of diseases such as exophthalmia and corneal scarring that may lead to avoidable blindness.
Vitamin A supplementation has also been mentioned in the second guideline on the management and control of eye conditions at primary level with a view to alerting eye healthcare practitioners on the need for this control measure in the prevention of childhood blindness. Undiagnosed and uncorrected causes of visual impairment in childhood can negatively affect the development of vision and cause learners to have low academic success or even quit  school before graduation. 18 Malik et al. 19 recommended various key activities to promote good EH, especially in children, these are shown in Table 7. 18 The guideline also makes reference to the importance of maternal health services as an important strategy in the elimination of EH diseases. Notably, ophthalmic neonatorum affects children in the first few weeks after birth and this infection is usually contracted during delivery, 20 and such a disease can be avoided when precautionary measures are taken during maternal health services. Although maternal health services are freely available for expectant mothers in South Africa, there appears to be those who do not use these services, thus putting the life of the new born at risk of developing infectious diseases. 21,22 There is therefore a need for creating awareness about the need for antenatal care services amongst expectant mothers in order to avoid any possible EH problems when a child is born.
Another important element mentioned in the national guideline on prevention of blindness in South Africa is the promotion of eye safety. Although there are no educational and preventive programmes on eye protection especially in industries that have the propensity to cause irreversible eye damage, 23 workplace eye injuries remain a common occurrence in South Africa. 24 Eye protection awareness campaigns should be initiated by relevant authorities across South Africa to eliminate avoidable eye injuries that may cause irreversible blindness.
The World Health Organisation (WHO) promotes the washing of faces in the global initiative to eliminate trachoma through the Surgery, Antibiotics, Facial cleanliness and Environmental improvements (SAFE) strategy by the year 2020. 25 This strategy advocates for the use of antibiotics for treating trachoma, management of trichiasis through surgery, considerations for environmental improvements through the provision of sanitation and clean water in the household as well as facial cleanliness for reducing transmissions. 26,27 Although the disease was prevalent in the early eighties in the former northern Transvaal region (now Limpopo Province) of South Africa, affecting mostly children, 28 it is now widely believed that the disease has been eliminated in South Africa. However, it remains a leading infectious disease that cause blindness amongst children and adults in most parts of the world including the African continent. 29 Notably, the second guideline refers to issues of personal hygiene, which is a contributory factor in the contraction of trachoma. Therefore, face washing should be promoted at all times, especially during these times of Corona Virus 2019 disease .
Although the prevalence of the uncorrected refractive error was found to be relatively low amongst South Africans, 30 an earlier study that examined 4890 school-going children found that 63.6% of the 91 eyes examined had reduced vision. 31 Another study conducted in three communities amongst individuals aged 16-74 years in the Western Cape Province revealed that 30.8% of the participants had refractive error. 32 This shows that there is a need for vision screening programmes for early detection of any eye conditions that may cause visual impairment or blindness if left unattended. Therefore, the activities of vision screening, refraction services and provision of spectacles mentioned in the guideline on refractive errors screening for persons 60 years and older may be considered to be efforts for effective EHP for this age group. However, vision screening exercises for this age group should also focus on other eye diseases that cause visual impairment and blindness  amongst the elderly for timeous intervention. In a study by Maake and Oduntan 33 on the prevalence and causes of visual impairment amongst patients seen at Khensani Hospital in Giyani, it was found that cataract (34.1%) and glaucoma (31.7%) were the leading causes of blindness whilst uncorrected refractive errors (56.7%) were the leading cause of low vision. That the last guideline makes reference to cataract surgery, and advertising such services to those who need them can be considered an important EHP message. As alluded to in a study by Khoza et al., 34 which was a survey on the prevalence of cataract in the selected communities of the Limpopo Province, such references to cataract surgery as mentioned in the guideline on cataract surgery should be supported by improved accessibility to cataract surgery services. Barriers to accessibility to cataract surgery are a major contributory factor to the scourge of blindness because of cataract.
In other documents that were found on the websites of the national and provincial departments of health that made mention to EH, the focus was mainly on vision screening as an important message for health promotion. Upon analysis, these documents revealed that the aspects of good health cannot just be imposed on individuals, but involvement in the determinants of their health is of paramount importance. According to DiClemente and Kaczynski, 35 understanding human behaviour is such a daunting challenge to an extent that if one is to implement the directives of the Ottawa Charter 16 for effective EH, there is a need to fully understand the theoretical models that can better predict the impact and outcomes of any intervention strategies. One such example is the ecological approach and models that provide a comprehensive framework for understanding human behaviour 36 by studying levels of behavioural influence including psychological underpinnings, social and cultural beliefs, as well as their physical environment.

Conclusion
The content of the national guidelines on aspects of eye healthcare management in South Africa makes reference to important issues that relate to EHP in the country. Although there is still no integrated policy on EHP, statements such as face washing, immunisation, vision screening and cataract referrals make these documents to be important reference material for EHP initiatives in the country. In line with the directives of the Ottawa Charter, it was expected that there would be integration of EHP initiatives with most documents from the social sector cluster, however, this is not the case at both national and provincial levels as there appears to be no integration except at elementary school level where the policy on school health makes reference to such an integration. This further strengthens the call for the completion of the process of finalising the development of a stand-alone policy on eye healthcare that will ensure uniformity of EHP messages across all the provinces in South Africa.