Visual health screening by schoolteachers in remote communities of Peru: implementation research

Ethnicity and refractive errors in Peruvian children aged 7-11 years: A five-year analysis of the Demographic and Health Survey

OBJECTIVE

To assess the association between ethnicity and self-reported refractive errors (REs) among Peruvian children aged 7-11 years.

MATERIALS AND METHODS

We conducted a cross-sectional study incorporating a secondary data analysis of 2017-2021 data from the Peruvian Demographic and Health Survey (DHS). REs and ethnicity were obtained from focal child's mother's report. Four outcomes were assessed: hyperopia, myopia, astigmatism and any RE. We included potential confounders, such as age, sex, wealth index, area of residence, region of origin, frequency of watching TV and watching screens at less than 30 cm distance. Generalised linear models with the Poisson family and log link function were used to calculate crude prevalence ratio and adjusted prevalence ratio (aPR) with 95% confidence intervals (95% CI).

RESULTS

Data from a total of 52,753 children were included. The prevalence of RE in children aged 7-11 years was 10.90% (95% CI 10.49-11.33), of which 5.19% were hyperopia, 3.35% myopia and 2.36% astigmatism. Those of the Aymara ethnicity were less likely to suffer from any RE and astigmatism (aPR = 0.68, 95% CI 0.46-0.99, p = 0.046; aPR = 0.70, 95% CI 0.53-0.92, p = 0.012, respectively), Members of Amazon groups were more likely to have hyperopia (aPR = 1.95, 95% CI 1.14-3.36, p = 0.015) and Quechuas were more likely to have myopia (aPR =1.29, 95% CI 1.02-1.62, p = 0.028), where all were compared to Mestizos.

CONCLUSION

About 1 in 10 Peruvian children suffer from a RE. The most frequent RE in this study was hyperopia. Ethnic differences were seen in the frequency of RE.

Development and validation of a novel questionnaire regarding vision screening among preschool teachers in Malaysia

AIM

To develop and evaluate the validity and reliability of a knowledge, attitude, and practice questionnaire related to vision screening (KAP-VST) among preschool teachers in Malaysia.

METHODS

The questionnaire was developed through a literature review and discussions with experts. Content and face validation were conducted by a panel of experts (n=10) and preschool teachers (n=10), respectively. A pilot study was conducted for construct validation (n=161) and test-retest reliability (n=60) of the newly developed questionnaire.

RESULTS

Based on the content and face validation, 71 items were generated, and 68 items were selected after exploratory factor analysis. The content validity index for items (I-CVI) score ranged from 0.8-1.0, and the content validity index for scale (S-CVI)/Ave was 0.99. Internal consistency was KR20=0.93 for knowledge, Cronbach's alpha=0.758 for attitude, and Cronbach's alpha=0.856 for practice.

CONCLUSION

The KAP-VST is a valid and reliable instrument for assessing knowledge, attitude, and practice in relation to vision screening among preschool teachers in Malaysia.

Effectiveness of a Recertification Vision Screening Training Module for Preschool Teachers

Background

Certified training must be provided for lay vision screeners prior to their conduct of a vision screening programme. However, the effectiveness of trained lay screeners does deteriorate over time. This study aims to evaluate the effectiveness of a recertification vision screening training module using the KieVision™ Preschool Vision Screening Kit for preschool teachers in Malaysia.

Methods

This was a randomised control trial. Fifty-nine preschool teachers previously enrolled in a Knowledge Transfer Programme were divided into a Study Group (n = 31) to receive recertification training and a Control Group (n = 28) to attend briefing sessions. Subjects was then asked to perform vision screening on 15 preschool children aged 4 years old-6 years old at their respective premises, then verified by optometrists after 2 weeks from the initial screening on the same children.

Results

A total of 894 children were screened, with the Study Group and Control Group screened 49.7% and 50.3%, respectively. There was higher validity in vision screening findings from the Study Group (sensitivity = 66.7%, positive predictive value (PPV) = 61.5%) compared to the Control Group (sensitivity = 36.0 %, PPV = 40.9%).

Conclusion

Teachers who received recertification training were more competent in detecting children's vision impairment using KieVision™ Preschool Vision Screening Kit. Thus, timely recertification training should be emphasised to ensure sustainable consistency and reliability of vision screening programmes conducted by lay vision screeners.

Integrated people-centered eye care: A scoping review on engaging communities in eye care in low- and middle-income settings

BACKGROUND

Community engagement has been endorsed as a key strategy to achieving integrated people-centered eye care that enables people and communities to receive a full spectrum of eye care across their life-course. Understanding the ways communities are engaged in eye care, to what degree participation is achieved, and the factors associated with intervention implementation is currently limited.

OBJECTIVE

The scoping review aimed to assess how community engagement is approached and implemented in eye care interventions in low- and middle-income countries, and to identify the barriers and facilitators associated with intervention implementation.

METHODS

Searches were conducted across five databases for peer-reviewed research on eye care interventions engaging communities published in the last ten years (January 2011 to September 2021). Studies were screened, reviewed and appraised according to Cochrane Rapid Reviews methodology. A hybrid deductive-inductive iterative analysis approach was used.

RESULTS

Of 4315 potential studies screened, 73 were included in the review. Studies were conducted across 28 countries and 55 targeted populations across more than one life-course stage. A variety of community actors were engaged in implementation, in four main domains of eye care: health promotion and education; drug and supplement distribution and immunization campaigns; surveillance, screening and detection activities; and referral and pathway navigation. With the approaches and level of participation, the majority of studies were community-based and at best, involved communities, respectively. Involving community actors alone does not guarantee community trust and therefore can impact eye care uptake. Community actors can be integrated into eye care programs, although with varying success. Using volunteers highlighted sustainability issues with maintaining motivation and involvement when resources are limited.

CONCLUSION

This scoping review provides researchers and policy makers contextual evidence on the breadth of eye care interventions and the factors to be considered when engaging and empowering communities in integrated people-centered eye care programs.

Correlation and agreement between the Mohindra and cycloplegic retinoscopy techniques in children

PURPOSE

As an objective technique to assess refractive status, retinoscopy is particularly useful in children. The Mohindra technique (RM) is an alternative for those patients not good candidates for cycloplegic retinoscopy (RC). The aim of the present research was to compare both techniques and to determine the correlation and agreement of their measurements.

MATERIAL AND METHODS

A total of 47 boys and girls of ages ranging from 3 to 11 years old were included in the study. Cycloplegic (cyclopentolate 1%) and Mohindra retinoscopy were conducted in both eyes, and refraction was also assessed with an autorefractometre (AR). The results from the three techniques were compared and a correction factor between RM and RC was calculated.

RESULTS

Statistically significant differences were found between RM and RC (median of -0.42 D; p < 0.001) and between RM and AR (median of -0.42 D; p = 0.008), but not between RC and AR (median of 0.00 D; p = 0.758). A strong correlation was found between RM and RC (rho = 0.846; p < 0.001), although the Bland-Altman test revealed a larger difference between these techniques in patients with larger hyperopic refractive errors, with a correction factor of RC = 1.15 RM + 0.42.

CONCLUSIONS

The Mohindra technique may be considered a valid alternative to cycloplegic retinoscopy in patients of young age, with a good correlation between both techniques, albeit less agreement in patients with high hyperopic refractions.

Implementation of paediatric vision screening in urban and rural areas in Cluj County, Romania

BACKGROUND

In 2018 and 2019, paediatric vision screening was implemented in Cluj County, Romania, where universal paediatric vision screening does not yet exist. We report on the preparation and the first year of implementation.

METHODS

Objectives, target population and screening protocol were defined. In cities, children were screened by kindergarten nurses. In rural areas, kindergartens have no nurses and children were screened by family doctors' nurses, initially at the doctors' offices, later also in rural kindergartens. CME-accredited training courses and treatment pathways were organised. Implementation was assessed through on-site observations, interviews, questionnaires and analysis of screening results of referred children.

RESULTS

Out of 12,795 eligible four- and five-year-old children, 7,876 were screened in 2018. In the cities, kindergarten nurses screened most children without difficulties. In Cluj-Napoca 1.62x the average annual birth rate was screened and in the small cities 1.64x. In the rural areas, however, nurses of family doctors screened only 0.49x the birth rate. In 51 out of 75 rural communes, no screening took place in the first year. Of 118 rural family doctors' nurses, 51 had followed the course and 26 screened children. They screened only 41 children per nurse, on average, as compared to 80 in the small cities and 100 in Cluj-Napoca. Screening at rural kindergartens met with limited success. These are attended by few children because of low population density, parents working abroad or children being kept at home in case of bad weather and road conditions.

CONCLUSIONS

Three times fewer children were screened in rural areas as compared to urban areas. Kindergartens in rural areas are too small to employ nurses and family doctors' nurses do not have easy access to many children and have competing healthcare priorities: there are 1.5x as many family doctors in urban areas as compared to rural areas. For nationwide scaling-up of vision screening, nurses should be enabled to screen a sufficient number of children in rural areas.

School-based vision screening in Quetta, Pakistan: a qualitative study of experiences of teachers and eye care providers

Background

Visual impairment in children is a significant public health problem affecting millions of children globally. Many eye problems experienced by children can be easily diagnosed and treated. We conducted a qualitative study with teachers and optometrists involved in a school-based vision screening programme in Quetta district of Pakistan to explore their experiences of training, vision screening and referrals and to identify factors impacting on the effectiveness of the programme.

Methods

Between April 2018 and June 2018, we conducted semi-structured in-depth interviews with 14 teachers from eight purposefully selected schools with high rates of inaccurate (false positive) referrals. Interviews were also conducted with three optometrists from a not-for profit private eye care hospital that had trained the teachers. Interviews were audio recorded and professionally transcribed. NVIVO software version 12 was used to code and thematically analyze the data.

Results

Findings suggest that the importance of school-based vision screening was well understood and appreciated by the teachers and optometrists. Most participants felt that there was a strong level of support for the vision screening programme within the participating schools. However, there were a number of operational issues undermining the quality of screening. Eight teachers felt that the duration of the training was insufficient; the training was rushed; six teachers said that the procedures were not sufficiently explained, and the teachers had no time to practice. The screening protocol was not always followed by the teachers. Additionally, many teachers reported being overburdened with other work, which affected both their levels of participation in the training and the time they spent on the screening.

Conclusions

School-based vision screening by teachers is a cost-effective strategy to detect and treat children’s vision impairment early on. In the programme reviewed here however, a significant number of teachers over referred children to ophthalmic services, overwhelming their capacity and undermining the efficiency of the approach. To maximise the effectiveness and efficiency of school-based screening, future initiatives should give sufficient attention to the duration of the teacher training, experience of trainers, support supervision, refresher trainings, regular use of the screening guidelines, and the workload and motivation of those trained.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-021-10404-9.

Socioeconomic inequality in the global burden of refraction disorders: results from the Global Burden of Diseases Study 2017

PURPOSE

To explore socioeconomic inequality in global burden of refraction disorders using disability-adjusted life years (DALYs).

METHODS

World Bank categorical and national DALY numbers, crude rates and age-standardized rates caused by refraction disorders between 1990 and 2017 were obtained. Gini coefficient and concentration index were computed to assess trends in global health inequality in refraction disorders burden.

RESULTS

Lower middle-income countries had the highest burden of refraction disorders and greatest decline in age-standardized DALY rates of 15.9% (171.0 in 1990; 143.8 in 2017), followed by upper middle-income countries, with a 9.7% decline (103.7 in 1990; 93.7 in 2017). High-income countries had the lowest age-standardized DALY rates (70.4 in 1990; 65.7 in 2017), while low-income countries had the lowest DALY numbers. Between-country inequality decreased, with Gini coefficient declining from 0.203 in 1990 to 0.184 in 2017. Socioeconomic-associated inequality also decreased, with concentration index changing from -0.060 in 1990 to -0.041 in 2017. Small peaks of DALY numbers and crude rates occurred in the age group of 5-9 years in countries with different income levels. An earlier occurrence of high peaks of DALY estimates in older adults had been observed in countries with lower income.

CONCLUSION

Middle-income countries are more burdened with refraction disorders but have achieved great progress in the last few decades. The global health improvement in refraction disorders has been accompanied by narrowing inequality. Older adults in lower income countries tend to suffer from refraction disorders at an earlier age, compared with older adults in higher income countries.

Interventions to improve school-based eye-care services in low- and middle-income countries: a systematic review

Objective

To review interventions improving eye-care services for schoolchildren in low- and middle-income countries.

Methods

We searched online databases (CINAHL, Embase®, ERIC, MEDLINE®, ProQuest, PubMed® and Web of Science^TM) for articles published between January 2000 and May 2018. Eligible studies evaluated the delivery of school-based eye-care programmes, reporting results in terms of spectacle compliance rates, quality of screening or attitude changes. We considered studies to be ineligible if no follow-up data were reported. Two authors screened titles, abstracts and full-text articles, and we extracted data from eligible full-text articles using the availability, accessibility, acceptability and quality rights-based conceptual framework.

Findings

Of 24 559 publications screened, 48 articles from 13 countries met the inclusion criteria. Factors involved in the successful provision of school-based eye-care interventions included communication between health services and schools, the willingness of schools to schedule sufficient time, and the support of principals, staff and parents. Several studies found that where the numbers of eye-care specialists are insufficient, training teachers in vision screening enables the provision of a good-quality and cost–effective service. As well as the cost of spectacles, barriers to seeking eye-care included poor literacy, misconceptions and lack of eye health knowledge among parents.

Conclusion

The provision of school-based eye-care programmes has great potential to reduce ocular morbidity and developmental delays caused by childhood vision impairment and blindness. Policy-based support, while also attempting to reduce misconceptions and stigma among children and their parents, is crucial for continued access.

Validation of Peek Acuity application in pediatric screening programs in Paraguay

AIM

To validate the Peek Acuity mobile phone application in pediatric populations and compare its utility, both economic and diagnostic, against conventional screening methods using a pediatric ophthalmologist examination as the gold standard.

METHODS

A cohort of 393 subjects from Fernando de la Mora, Paraguay (ages 6-16y) were enrolled in the study. Subjects were randomly assigned a starting screening modality among: Peek Acuity, a single line of tumbling E optotypes set at 20/40, and Spot Vision Screener. Once completing the first screening modality, the subjects completed the two remaining techniques. Referral criteria were established based on the most current American Association of Pediatric Ophthalmology and Strabismus (AAPOS) recommendations: 20/40 for Peek Acuity and the tumbling E, and refractive error detection for the Spot Vision Screener. Subjects that failed to achieve the cut-off for any of the three screening techniques or subjects that passed the screening but were randomly selected to perform a comprehensive eye exam to determine the false negative rate, were evaluated by a pediatric ophthalmologist. This evaluation was considered the gold standard, and included vision assessment by a Snellen chart, strabismus evaluation, and cycloplegic refraction with dilated fundoscopy.

RESULTS

We obtained 48% sensitivity, 83% specificity, 43% positive predictive value, and 86% negative predictive value for Peek Acuity's ability to refer compared to evaluation by a pediatric ophthalmologist, failing to achieve a desired sensitivity for implementation. Peek Acuity trended to overestimate the subject's visual acuity, providing a higher visual acuity that would not indicate referral for a comprehensive eye examination. However, its high specificity accurately predicted a significant number of children who did not need further evaluation. When comparing the three screening methods, no single screening modality outperformed the others. Peek Acuity represented a technology that was economically feasible compared to other screening modalities in low income settings, due to the prevalence of cell phone use.

CONCLUSION

Peek Acuity represents an efficient tool that has potential for implementation in school screenings with different strategies aimed at pediatric populations due to its low cost and high specificity. An increase in sensitivity would improve detection of children with refractive errors.