Ordeal mechanisms, information, and the cost-effectiveness of strategies to provide subsidized eyeglasses

Approaches for delivery of refractive and optical care services in community and primary care settings

BACKGROUND

Uncorrected refractive error is a leading cause of vision impairment which, in most cases, can be managed with the appropriate spectacle correction. In 2021, the World Health Assembly endorsed a global target of a 40-percentage-point increase in effective coverage of refractive error by 2030. To achieve this global target, equitable access to refractive and optical services within community and primary care settings needs to be strengthened. This review will inform the development of technical guidance to support improvements in the testing and correction of refractive error among World Health Organization (WHO) member states.

OBJECTIVES

To determine the range of approaches for delivery of refractive and optical care services in community and primary care settings, and the methods employed for their evaluation.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase and Global Health databases, grey literature, and annual reports and websites of relevant organizations involved in eye-care delivery from January 2002 to November 2022 to identify approaches for refractive and optical service delivery.

SELECTION CRITERIA

We included observational and interventional studies, reviews, and reports from relevant organizations related to delivering refractive services and optical services for preschool and school-aged children and adults in community and primary care settings published between January 2002 and November 2022. We searched for studies and reports published within the last 20 years because vision impairment due to uncorrected refractive error has only recently become a public health and eye health priority, therefore we did not expect to find much relevant literature until after 2002.

DATA COLLECTION AND ANALYSIS

Two review authors screened titles, abstracts and full texts, and extracted data. We resolved any discrepancies through discussion. We synthesized data, and presented results as tables, figures, and case studies. This project was led by the World Health Organization (WHO) Vision and Eye Care Programme.

MAIN RESULTS

We identified 175 studies from searches of databases and grey literature, 146 records from company reports, and 81 records from website searches of relevant organizations that matched our inclusion criteria. Delivery approaches for refractive and optical services in community care included school-based, pharmacy, and outreach models, whereas primary care approaches comprised vision centre, health centre, and a combination of vision or health centre and door-to-door delivery. In community care, school-based and outreach approaches were predominant, while in primary care, a vision-centre approach was mainly used. In the WHO African region, the school-based and outreach approaches were mainly reported while, in the Americas, the outreach approach was mostly used. Very few approaches for service delivery were reported in the WHO Eastern Mediterranean region. Prominent gaps exist in the evaluation of the approaches, and few studies attempted to evaluate the approaches for delivery of refractive and optical care services.

AUTHORS' CONCLUSIONS

We comprehensively describe a range of approaches for delivery of refractive and optical services in community and primary care. Further evaluation of their effectiveness will better inform the application of these service-delivery approaches. The study outcomes will help guide WHO member states in strengthening refractive and optical services at community and primary care levels.

FUNDING

This scoping review was supported by the Vision and Eye care Programme, World Health Organization and ATscale Global Partnership.

REGISTRATION

The protocol of this scoping review was published in the Open Source Framework.

Exploring the Preferences of Parents of Children with Myopia in Rural China for Eye Care Services Under Privatization Policy: Evidence from a Discrete Choice Experiment

OBJECTIVES

This study aims to measure the preferences and valuations of parents of students with myopia parents for eye care service attributes in rural China, and to quantify the potential welfare impacts of privatization policy on children's eye care services.

METHODS

A discrete choice experiment was designed and implemented among a sample of parents of children with myopia in rural China. We randomly selected 350 participants from the list of subjects obtained from local town schools and family doctors using a random number table method. The participants were asked to choose between two hypothetical scenarios defined by five attributes: provider type, distance, price, lenses type, and refractionists' professional competencies. We estimate conditional logit and mixed logit models to approximate individual preferences for these attributes and estimate the welfare effects by calculating willingness to pay.

RESULTS

Respondents (n = 336) showed a significant preference for public providers of refractive error services, myopia control lenses, and professional refractionists (P < 0.01 for each). Consumer welfare losses due to a prohibition of the public provision of refractive error services could be compensated by improving the quality of products and services delivered by private providers. Lastly, both parent and child demographics and previous experience of eye care service consumption are important predictors of willingness to pay for refractive error services.

CONCLUSIONS

The privatization policy on children's eye care services would not cater to the preferences of rural consumers, inevitably leading to welfare losses. However, reduced consumer welfare could be compensated by improving the quality of products and service delivery from private providers. These results could help inform strategies to improve and reduce inequities in access to high-quality eye care services in rural China.

Time's ticking! Effects of deadline on the utilization of health services: Evidence from a cluster-randomized controlled trial

The low utilization of health services in rural areas is an essential factor affecting the health level of rural residents. Based on insights from behavioral economics, this study evaluates the average treatment effect of imposing a deadline on vision-care vouchers (i.e., the voucher-deadline intervention) on the utilization of health services. Using the vision health as a case study, a non-masked cluster-randomized controlled trial was conducted in 13 rural schools of a county in Shaanxi Province of China during 2018-2019. Among 1270 baseline sample students with myopia, 610 students from 6 schools were randomly assigned to receive vouchers with no deadline (i.e., the Control group), and 660 students from 7 schools to receive vouchers with a 30-day deadline (i.e., the Deadline group). The results showed that the voucher-deadline intervention significantly improved the vision-center visiting rate by 13.2 percentage points within 30 days and shortened the interval between visits (i.e., increased timeliness) by 18.7 days. In comparison, the vision-center visiting rate and the interval between visits among the control group were 16.7% and 30.5 days, respectively. However, considering a longer time frame (6 months), we found that intervention only shifted students' utilization to before the voucher expires without improving overall utilization rate. The loss aversion and time pressure induced by the voucher deadline are possible explanations for the treatment effects. This study suggests insights from behavioral economics can enhance the design of public health programs to improve the utilization and the cost-effectiveness of health-service programs. TRIAL REGISTRATION: isrctn.org Identifier ISRCTN03252665.

Myopia and Depression among Middle School Students in China-Is There a Mediating Role for Wearing Eyeglasses?

Compared with non-myopic students, myopic students face more barriers to learning (e.g., inability to see the blackboard clearly) and socializing (e.g., being victims of teasing, social exclusion and violence), which may lead to increased stress, anxiety and frustration. The high prevalence of myopia and depression among school-age children naturally raises a question of great policy relevance: are myopic students more vulnerable to mental health problems such as depression? This paper sheds some light on this question by analyzing data from the China Education Panel Survey, a large-scale survey of China's middle school students. Our analysis first quantifies the association between myopia and sample students' depression status (measured by the widely adopted CES-D scale) adjusted for potential confounding factors. We then explore whether the myopia-depression relationship is mediated by wearing eyeglasses, a cost-effective means of vision correction. Based on data on 19,299 middle school students, our analysis reveals that myopic students scored 0.12 standard deviations higher on the CES-D scale than their non-myopic counterparts. The adverse effect of myopia is more severe for relatively disadvantaged students: older students (who are more likely to suffer from both myopia and depression), lower-performing students and students from poorer families. Further medication analysis shows that wearing eyeglasses suppresses the myopia-depression relationship but cannot completely offset the adverse effect of myopia.

Effect of Eyeglasses on Student Academic Performance: What Matters? Evidence from a Randomized Controlled Trial in China

Although eyeglasses have been considered a cost-effective way to combat myopia, the empirical evidence of its impacts on improving learning outcomes is inconsistent. This paper provides empirical evidence examining the effect of providing eyeglasses on academic performance between provinces with a different economic level in western China. Overall, we find a significant impact in Intention-to-Treat analysis and a large and significant local average treatment effect of providing free eyeglasses to students in the poor province but not in the other. The difference in impact between the two provinces is not a matter of experimental design, implementation, or partial compliance. Instead, we find that the lack of impact in the wealthier provinces is mainly due to less blackboard usage in class and wealthier households. Our study found that providing free eyeglasses to disadvantaged groups boosted their academic performance more than to their counterparts.