A Global Public Health Perspective: Facilitating Access to Assistive Technology.

SIGNIFICANCE: Clinicians should not overlook vulnerable populations with limited access to assistive technology (AT), the importance of collaboration in multidisciplinary teams, advocacy for enabling environments, and supportive health systems. Resources, a model of care, and recommendations can assist clinicians in contributing to changing attitudes, expanding knowledge, and improving the lives of many.The increasing availability of innovative advances in AT can immeasurably enhance the quality of life of people with disabilities. Clinicians will undoubtedly welcome the prospect of having cutting-edge AT available to prescribe to individuals who consult them. Arguably, though, the development of innovative strategies to improve access to AT, especially to underserved people "left behind," is equally urgent. Current efforts are inadequate, with millions of people with disabilities not being reached. Particularly at risk are women, children, and the elderly, as well as poorer people who live in resource-poor and remote areas, especially in low- and middle-income countries. Not only must physical access be facilitated, but also quality services must be available. Good-quality, affordable AT, which is appropriate and acceptable to the user, would ideally be provided by competent personnel, working in multidisciplinary teams, offering comprehensive, person-centered services, including rehabilitation, fully integrated into the various levels of the health system. Clinicians can contribute to improving access to quality services, participate in initiatives aiming to increase the knowledge of health personnel and the public, engage in advocacy to change attitudes, influence legislation, and raise awareness of universal health coverage-ultimately facilitating access to AT for all.

Evidence for integrating eye health into primary health care in Africa: a health systems strengthening approach.

BACKGROUND: The impact of unmet eye care needs in sub-Saharan Africa is compounded by barriers to accessing eye care, limited engagement with communities, a shortage of appropriately skilled health personnel, and inadequate support from health systems. The renewed focus on primary health care has led to support for greater integration of eye health into national health systems. The aim of this paper is to demonstrate available evidence of integration of eye health into primary health care in sub-Saharan Africa from a health systems strengthening perspective. METHODS: A scoping review method was used to gather and assess information from published literature, reviews, WHO policy documents and examples of eye and health care interventions in sub-Saharan Africa. Findings were compiled using a health systems strengthening framework. RESULTS: Limited information is available about eye health from a health systems strengthening approach. Particular components of the health systems framework lacking evidence are service delivery, equipment and supplies, financing, leadership and governance. There is some information to support interventions to strengthen human resources at all levels, partnerships and community participation; but little evidence showing their successful application to improve quality of care and access to comprehensive eye health services at the primary health level, and referral to other levels for specialist eye care. CONCLUSION: Evidence of integration of eye health into primary health care is currently weak, particularly when applying a health systems framework. A realignment of eye health in the primary health care agenda will require context specific planning and a holistic approach, with careful attention to each of the health system components and to the public health system as a whole. Documentation and evaluation of existing projects are required, as are pilot projects of systematic approaches to interventions and application of best practices. Multi-national research may provide guidance about how to scale up eye health interventions that are integrated into primary health systems.

Improving access to eye health services in rural Timor-Leste.

CONTEXT: Delivering eye health services to people in rural areas, especially in fragile, post-conflict countries, is a major challenge. This article reports on the implementation and evaluation of an innovative district-based outreach service. The main project partners were the Timor-Leste Ministry of Health and an international non-government organization, with assistance from a local non-government organization. ISSUE: An eye care nurse in Covalima District, a remote location 178 km from Timor-Leste's capital, Dili, was provided with a motor-bike for transport and regular support for outreach eye services to sub-district facilities. Data collected over the first year of operation were examined and included: services provided, spectacles dispensed, health promotion activities conducted and the cost of providing these. The project was also evaluated for its relevance, effectiveness, efficiency, impact and sustainability. LESSONS LEARNED: In the first 12 months, 55 outreach visits were conducted across the district's seven sub-districts during which 1405 people received vision screening, and 777 spectacles were dispensed. In addition to meeting the five evaluation criteria, compared with the hospital-based eye clinic the outreach service resulted in significantly greater gender equity among eye health service beneficiaries. This pilot project demonstrates what can be achieved when a Ministry of Health (central and district level) and non-government organizations (international and local) work in partnership to support a dedicated health care provider.

Population-based study of self-reported ocular trauma in Fiji.

BACKGROUND: To characterize causes, risk factors and outcomes for ocular trauma among adults aged ≥40 years in Fiji. DESIGN: Population-based cross-sectional survey; multistage cluster random sampling. PARTICIPANTS: 1381 (= 73.0% participation); eight provinces on Viti Levu. METHODS: Interview-based questionnaire. Visual acuity measurement. Dilated ocular examination. MAIN OUTCOME MEASURES: Circumstances, management and consequences of self-reported ocular trauma. RESULTS: Of participants, 20.6% recalled ocular trauma: being Melanesian (P < 0.001) and male (P < 0.001) were predictive. Age at injury was ≤15 years for 13.0%: 78.4% occurred at home; 72.4% caused by sharp objects. For injury at >15 years: 38.5% occurred inside the home, most by sharp objects (51.6%) and domestic violence (28.4%); agricultural activities caused 20.6% of injuries; non-agricultural workplace incidents caused 16.2%, with chemicals responsible for 27.5% of these; public alcohol consumption was associated with 13.8% of injuries, mostly by assault (91.2%). Conventional medical services were the primary source of care for 47.2% of injured participants: 61.9% attended on injury day. For trauma: sample prevalence of vision impairment in at least one eye was 1.7% (95% confidence interval 1.1-2.4%), and 0.1% (95% confidence interval 0.02-0.5) for bilateral blindness. Injury at ≤15 years (P = 0.008) and at the workplace (P = 0.044) were predictive of ongoing vision impairment. Of visually impaired eyes, 36% had corneal opacity that may have been caused by relatively minor trauma. CONCLUSIONS: Ophthalmic service strengthening (including minor corneal trauma management) and specific injury prevention strategies (including behaviour change education and advocacy for legislation) are required to decrease the ocular trauma burden in Fiji.

The impact of reduced distance and near vision on the quality of life of adults in Timor-Leste.

PURPOSE: To determine the independent, relative, and combined impact of reduced distance and near vision on the vision-specific quality of life (VS QOL) of adults in Timor-Leste. DESIGN: A population-based cross-sectional eye health survey was conducted in urban and rural areas in Timor-Leste. PARTICIPANTS: Participants were 40 years or older. Those with better eye presenting distance vision worse than 6/18, and every third participant with 6/18 or better vision, completed the VS QOL questionnaire: in total 704 of the 1414 participants. METHODS: Distance and near visual acuities were measured and eye health was assessed. The VS QOL questionnaire administered by interview was analyzed using Rasch analysis, univariate analysis, and linear regression to determine associations between VS QOL, demographic factors, and levels of visual impairment. MAIN OUTCOME MEASURES: The Timor-Leste VS QOL questionnaire results. RESULTS: Rasch analysis confirmed that for participants both with and without visual impairment, the Timor-Leste VS QOL questionnaire provided a valid and reliable measure, was unidimensional, and had appropriate response categories. There was a consistent pattern of deterioration in VS QOL as vision worsened: for each category of distance- and near-vision impairment, there was an independent and significant change in Timor-Leste VS QOL scores between no visual impairment and either mild, moderate, or severe impairment (P < 0.05). Combined distance- and near-vision impairment was associated with a greater impact on VS QOL than categories separately, the impact of severe distance- and near-vision impairment being the greatest and clinically significant: -3.05 (95% confidence interval [CI], -3.60 to -2.49; P<0.05; and 95% CI, <-1.0). Distance vision (37.2%) contributed relatively more than near vision (4.7%) to the total variance in VS QOL (41.9%). Older people, those not married, not literate, and rural dwellers had significantly worse Timor-Leste VS QOL scores (P < 0.05). CONCLUSIONS: This study provides evidence of independent dose-response relationships between distance- and near-vision impairment and poorer VS QOL. Distance-vision impairment had a relatively larger impact on VS QOL than near-vision impairment. Combined distance- and near-vision impairment was associated with a greater impact on VS QOL compared with the independent impact of distance- or near-vision impairment at similar levels.

Monitoring and evaluation of refractive error and presbyopia for Vision 2020.

PURPOSE: To develop output and outcome indicators for the correction of refractive error and presbyopia to a level comparable with those advocated by Vision 2020 for cataract. METHODS: World Health Organization, Vision 2020 and published eye care intervention literature were searched to find evidence of best practice. This information was used to construct a suite of indicators for monitoring the correction of refractive error and presbyopia. RESULTS: Indicators for the monitoring and evaluation of refractive error and presbyopia correction were proposed, addressing refraction and spectacle dispensing outputs and rates, and refractive error correction and presbyopia correction coverage. CONCLUSION: Using data collection that should be occurring in everyday clinical practice, the proposed indicators would provide more comprehensive information than those currently suggested by Vision 2020. As such, they would be more useful in the monitoring and evaluation of the correction of refractive error and presbyopia in the context of Vision 2020.

Developing a competency-based curriculum for eye care managers in Sub-Saharan Africa.

INTRODUCTION: There are insufficient healthcare providers to supply eye care services to the millions of people living with visual impairment in developing countries. Eye care providers may supply more efficient and effective services if supported by skilled managers. To help produce skilled managers, appropriate competencies for eye care managers in Sub-Saharan Africa were included in the curriculum for the Postgraduate Diploma in Community Eye Health course (PGDCEH) at the University of Cape Town. METHODS: The competencies were developed from information from course-development consultations with Sub-Saharan ophthalmologists, and heads and managers of eye care programs; minutes of curriculum planning meetings; and the competencies and skills required by general, eye and public health managers. The competencies were mapped onto the PGDCEH curriculum. RESULTS: The core expectations for eye care managers were in keeping with accepted generic management competencies and skills. Additional competencies (eg population/public health) were commensurate with those for medical and population-based clinical management, medical education and public health. Broader aspects of eye care (eg patient-centered care) were also incorporated. CONCLUSIONS: Competencies for eye care managers in Sub-Saharan Africa were developed using participatory and multidisciplinary approaches to enhance context-appropriateness. Identifying these ensures that the PGDCEH learning content reflects the actual skills required, provides clarity about learning outcomes, and forms the basis for student assessment. Further, job descriptions and workplace performance evaluation of graduates can be based on these. Ongoing evaluation of the PGDCEH implementation and outcomes will provide feedback to make improvements to the course.

Eye care in Timor-Leste: a population-based study of utilization and barriers.

BACKGROUND: To determine utilization of Western-style conventional health services for eye problems in Timor-Leste, and barriers to seeking that care. METHODS: An interview-based questionnaire was administered as part of a population-based cross-sectional survey of 50 clusters (urban and rural) of 30 people aged > or =40 years. RESULTS: Of 1470 people enumerated, 1414 were examined (96.2%). A total of 1293 (91.4%) reported at least one previous or present eye problem, mostly (88.6%) blurred/poor vision, for near and/or distance. Men (OR 1.6, 95% CI 1.1-2.3), literates (OR 2.1, 95% CI 1.4-3.5), urban dwellers (OR 4.1, 95% CI 2.6-6.4) and those in paid employment compared with being a farmer (OR 3.0, 95% CI 1.5-5.9) were more likely to have reported a problem. A total of 858 (66.4%) sought Western-style care for its remedy. Non-utilization was associated with being illiterate (OR 3.7, 95% CI 2.9-4.8), a rural dweller (OR 3.8, 95% CI 3.0-4.9), unemployed (OR 1.6, 95% CI 1.1-2.2) or a farmer (OR 5.2, 95% CI 3.5-7.6) compared with being in paid employment, having moderately impaired compared with non-impaired near vision (OR 1.4, 95% CI 1.1-1.8), and red/itchy/painful eyes compared with blurred vision (OR 2.3, 95% CI 1.6-3.2), but not age, gender or poor distance vision. Lack of awareness of service availability was the most frequent reason for not seeking treatment (32.9%), especially for rural respondents. Attitudinal reasons were also prevalent (32.5%), with social (11.8%), economic (11.5%) and service-related (9.0%) issues less so. CONCLUSIONS: If eye health is to improve in Timor-Leste, there must be better appreciation of it, and increased availability, accessibility and awareness of services.

Public sector refraction and spectacle dispensing in low-resource countries of the Western Pacific.

BACKGROUND: Given that uncorrected refractive error is a frequent cause of vision impairment, and that there is a high unmet need for spectacles, an appraisal of public sector arrangements for the correction of refractive error was conducted in eight Pacific Island countries. METHODS: Mixed methods (questionnaire and semi-structured interviews) were used to collect information from eye care personnel (from Fiji, Papua New Guinea, Solomon Islands, Vanuatu, Cook Islands, Samoa, Tonga and Tuvalu) attending a regional eye health workshop in 2005. RESULTS: Fiji, Tonga and Vanuatu had Vision 2020 eye care plans that included refraction services, but not spectacle provision. There was wide variation in public sector spectacle dispensing services, but, except in Samoa, ready-made spectacles and a full cost recovery pricing strategy were the mainstay. There were no systems for the registration of personnel, nor guidelines for clinical or systems management. The refraction staff to population ratio varied considerably. Solomon Islands, Tuvalu and Vanuatu had the best coverage by services, either fixed or outreach. Most services had little promotional activity or community engagement. CONCLUSIONS: To be successful, it would seem that public sector refraction services should answer a real and perceived need, fit within prevailing policy and legislation, value, train, retain and equip employees, be well managed, be accessible and affordable, be responsive to consumers, and provide ongoing good quality outcomes. To this end, a checklist to aid the initiation and maintenance of refraction and spectacle systems in low-resource countries has been constructed.

Evaluation of the first 5 years of a national eye health programme in Vanuatu.

PURPOSE: To evaluate against its objectives the achievements of the first 5 years of a national eye health programme in Vanuatu. METHODS: Programme clinical activity data were collated from surgical logs, clinic and outreach reports, and patient register books. Cataract surgical outcomes were retrieved from monitoring software. Programme annual reports provided information about management, infrastructure improvements, equipment supplied, repaired or replaced, the supply and use of consumables, and human resource development and deployment. Costs were determined from project budgets and acquittals. RESULTS: The programme promoted eye health, including through the integration of eye care into existing health services; established adequate facilities, at referral hospitals, provincial hospitals and rural health clinics, with equipment and manpower to provide eye care appropriate to the location; established a primary eye care programme; strengthened cataract services, although its effect on any cataract backlog is unknown; developed a diabetic eye disease diagnosis and treatment service, but its reach and effectiveness are unknown; provided accessible comprehensive eye care, but its effect on the prevalence of vision impairment is unknown; and established medical records and data collection systems, but these need more attention. DISCUSSION: This programme achieved much. However, the evaluation highlighted the limitations of inadequate project design and that, without addressing further human resource development and the Ministry of Health's wavering financial commitment, there are potential risks to ongoing services. That revenue generating capacity was not incorporated into this programme may prove to be a flaw that will limit ongoing access to eye care, especially in rural areas.

Spectacles in Fiji: need, acquisition, use and willingness to pay.

BACKGROUND: Little information is available regarding the perceived need, previous acquisition, use and willingness to pay for spectacles in Fiji, on which to base spectacle provision services. METHODS: Using a rapid appraisal technique, semi-structured interviews were conducted with 174 urban and rural households in Fiji's Central Province to assist in planning eye-care services. RESULTS: Problems with distance and/or near vision comprised 85.8 per cent of reported eye problems and started between the ages of 40 and 64 years for 54.8 per cent of people surveyed. Of these vision problems, no treatment was sought for 24.2 per cent and of the remainder, spectacles were the treatment for 65.5 per cent. At least one person in 51.7 per cent of households previously or currently used spectacles, and 90 per cent of these reported using them for near tasks. Spectacle usage occurred in more urban (61.8 per cent) than rural (47.1 per cent) households. The majority (54.0 per cent) were willing to pay over FJD10 for spectacles in the future, although more rural (21.8 per cent) than urban (7.3 per cent) households were willing to pay less than FJD10 (USD 4.70). Where spectacles had been received at no cost in the past, 89.5 per cent were prepared to pay FJD10 or more for these in the future. CONCLUSIONS: Given the high number of reported visual problems, it should be a priority to construct a sustainable spectacle system for Fiji. This will require further consultation with the community and government but it should be possible to design a system responsive to the financial and other needs of urban and rural Fijians.

Prevalence and causes of blindness and low vision in Timor-Leste.

AIM: To estimate the prevalence and causes of blindness and low vision in people aged > or = 40 years in Timor-Leste. METHOD: A population-based cross-sectional survey using multistage cluster random sampling to identify 50 clusters of 30 people. A cause of vision loss was determined for each eye presenting with visual acuity worse than 6/18. RESULTS: Of 1470 people enumerated, 1414 (96.2%) were examined. The age, gender and domicile-adjusted prevalence of functional blindness (presenting vision worse than 6/60 in the better eye) was 7.4% (95% CI 6.1 to 8.8), and for blindness at 3/60 was 4.1% (95% CI 3.1 to 5.1). The adjusted prevalence for low vision (better eye presenting vision of 6/60 or better, but worse than 6/18) was 17.7% (95% CI 15.7 to 19.7). Gender was not a risk factor for blindness or low vision, but increasing age, illiteracy, subsistence farming, unemployment and rural domicile were risk factors for both. Cataract was the commonest cause of blindness (72.9%) and an important cause of low vision (17.8%). Uncorrected refractive error caused 81.3% of low vision. CONCLUSION: Strategies that make good-quality cataract and refractive error services available, affordable and accessible, especially in rural areas, will have the greatest impact on vision impairment.

The Use of Key Informant Method for Identifying Children with Blindness and Severe Visual Impairment in Developing Countries.

PURPOSE: An estimated 19 million children are visually impaired; of these, 1.4 million are irreversibly blind. A key challenge is to identify them early in life to benefit maximally from visual rehabilitation, and/or treatment. This aggregative review and structured literature analysis summarizes evidence of what it is about the key informant (KI) approach that works to identify children with blindness or severe visual impairment (B/SVI) in the community (for whom, to what extent, in what circumstances, in what respect, how and why). METHODS: Peer-reviewed (PubMed, hand search) and grey literature (Google, World Health Organization website, academic theses, direct requests) were included, and methods and criteria used for identification, productivity (number of children referred per KI), accuracy of referrals (positive predictive value, PPV), age of children with B/SVI, KI definition, sex, information about cost and comparisons aggregated. RESULTS: We included 31 documents describing 22 unique KI programs. Mostly KIs identified children with B/SVI in 1-3 weeks, i.e. "campaign mode." In 60%, KIs were community volunteers, others formal health sector workers (FHSW). Around 0.02-1.56 children per KI (median = 0.25) were successfully recruited. PPV ranged from 12 to 66%. In two studies comparing FHSWs and community KIs, the latter were 8 and 10 times more productive. CONCLUSION: KIs working in campaign mode may provide an effective approach to identifying children with B/SVI in communities. Including identification of ocular problems and/or other impairments has been recommended. Research on factors that influence effectiveness and on whether KIs continue to contribute could inform programs.

Awareness and use of eye care services in Fiji.

PURPOSE: To determine the awareness, use, and barriers to use of eye services in Fiji's Central Province. METHODS: A cross-sectional survey study design with random clusters of households was used. Semi-structured interviews were conducted (152 females and 22 males). For 267 household members, presenting distance and near visual acuities were measured, and the perception of and satisfaction with their vision were recorded. RESULTS: Most (86%; 150/174) respondents were aware of at least one conventional eye care service. However, only 66% (121/183) of household members with previous eye problems had consulted one of these; the proportion was even lower for those in the older age groups (p < 0.01). Rural dwellers expressed satisfaction with their vision, despite being more likely to regard it as limiting their activities and being less likely to seek conventional care. A higher proportion of females were reported to have (or have had) eye problems (60:40) and were found to have bilateral visual impairment (60:40). Despite this, females and males attended the hospital eye clinic (47:53) or sought treatment from conventional services (51:49) nearly equally. The reasons given for not seeking conventional care were "fatalistic attitude" ("did not bother", "could manage", or accepted the condition: 57%), expense (12%), and fear (8%). CONCLUSION: Central Province Fijians, particularly the old, rural, and female, under-utilise conventional eye care services. As in developing countries elsewhere, fatalistic attitudes to visual impairment are a significant contributor to this. To improve eye health, planning and implementation of eye care services must overcome under-utilisation by addressing local barriers to uptake through community participation in education and affirmative action.

Diurnal variation of corneal sensitivity and thickness.

PURPOSE: To measure the diurnal variation of central corneal sensitivity and thickness over 24 hours. METHODS: A noncontact pneumatic esthesiometer to measure central corneal sensitivity and an optical pachymeter to measure central corneal thickness were used on 20 noncontact lens wearers. These measurements were performed at 22:00 before 8 hours of sleep and on the following day on eye opening and at hourly intervals between 7:00 and 22:00. RESULTS: Central corneal sensitivity varied by 35% over the 24 hours. Sensitivity was significantly lower by 17.1 +/- 2.1% on eye opening and recovered to the level of the previous night after 4 hours. Corneal sensitivity continued to increase throughout the day but was not significantly higher. Central corneal thickness varied by 3.9% over the 24 hours. The mean overnight corneal swelling was 2.9 +/- 0.31%, and 2 hours after eye opening, the cornea had deswelled to the same thickness as the previous night. The cornea thinned further throughout the day, but there were no statistically significant differences between the values after 14:00. There was a high correlation between corneal sensitivity and thickness over time (r = 0.8; p < 0.05). DISCUSSION: Corneal sensitivity correlated with corneal thickness: both were higher on awakening and then decreased and remained below the levels measured the previous night. This may be due to physiological and/or environmental factors. The lack of significant differences between the values after 14:00 suggests that baseline may be measured at any time from 7 hours after eye opening.