Needs and views on eye health and women's empowerment and theory of change map: implication on the development of a women-targeted eyecare programme for older Zanzibari craftswomen.

OBJECTIVES: To assess needs and views regarding eye health and empowerment from craftswomen's perspectives to develop a theory of change (ToC) for a women-targeted eyecare programme. MATERIAL AND METHODS: Eighteen stakeholders participated in a 2-day consultation workshop in Zanzibar. The composition was (1) 15 women and 3 men; (2) Unguja (n=8), Pemba (n=6) and Tanzania mainland (n=4) and (3) craftswomen (n=14) and governmental stakeholders (n=4). Thematic analysis determined the craftswomen's needs and views regarding eye health and empowerment and subsequently inputs, activities, outputs, outcomes and impact to develop the programme's initial ToC. In refining the initial ToC, we used insights from a qualitative study suggesting that improved near vision is perceived by craftswomen as a potential source of empowerment across economic, psychological, social, political and educational dimensions. RESULTS: The eye conditions experienced by the craftswomen were eye irritation caused by foreign bodies, the need for near spectacles and other eye morbidities. They were advised by the cooperatives to visit eye health centres for treatment. The main barriers to accessing services were inaccessibility and unaffordability of eye services and a lack of eye health knowledge and practices. Nineteen subthemes on women empowerment (economic n=4, social n=4, psychological n=6, education n=2 and political n=3) were obtained. We created a ToC on how investing in improving craftswomen near vision could achieve empowerment. CONCLUSION: The participants provided insights into their needs and how they would like the eyecare programme to be implemented and how they see they could be empowered in the process.

Willingness to pay for diabetic retinopathy screening in Qujiang District, rural Guangdong, southern China: a cross-sectional study.

OBJECTIVE: To determine willingness to pay for a diabetic retinopathy screening, and its determinants, among people with diabetes mellitus in Qujiang District of Shaoguan City, rural Guangdong, southern China. DESIGN: This cross-sectional study was conducted through a large-scale screening programme in 2019. We randomly selected 575 (21.5%) among 2677 people over 18 years old with known diabetes who attended the screening. Participants elected to pay nothing or RMB10-RMB120 (US$1.6-US$18.8), in RMB10 intervals, displayed on printed cards. One trained interviewer collected all the data. SETTING: Ten primary health centres in Qujiang District of Shaoguan City, Guangdong. PARTICIPANTS: 545 from the 575 randomly selected people (94.8%) agreed to participate in the study. OUTCOME MEASURES: Proportion of participants willing to pay anything for screening, mean amount they were willing to pay and determinants of these figures. RESULTS: Among 545 participants (mean age 64.6 years (SD±10.4), 40.7% men), 327 (60.0%) were willing to pay something for screening, of whom 273 (83.5%) would pay RMB10-RMB30 (US$1.6-US$4.7). People living in rural areas and those from lower-income families were more likely to be willing to pay anything, while men, urban residents and those covered by employer-linked insurance were willing to pay larger sums (p<0.05 for all). CONCLUSION: Nearly two-thirds of participants were willing to pay for screening in this screening programme organised at the primary care level in rural China. This finding offers the potential that such activities can be sustained and scaled up through user fees.

Effectiveness of community outreach screening for glaucoma in improving equity and access to eye care in Nigeria.

PURPOSE: To determine the effectiveness of community outreach screening for glaucoma in improving equity and access to eye care in Nigeria. METHODOLOGY: This was a prospective study in which two cohort of participants were recruited in Nigeria: 1 from 24 outreach screenings and another from consecutive patients presenting spontaneously to a tertiary eye clinic in Nigeria. Sociodemographic and clinical data were obtained from participants and compared. RESULTS: Our sample consisted of 120 patients with glaucoma or suspected glaucoma (6.38% of 1881 screenees) recruited from the 24 outreach screenings, and another 123 patients with glaucoma who presented spontaneously at the eye clinic. Participants from the screenings were significantly older (p=0.012), less educated (p<0.001), had lower incomes (p<0.001), lower glaucoma knowledge scores and were less aware of their glaucoma (both p<0.001) and were more likely to be dependent on relations and children (p=0.002) compared with clinic participants. Of the 120 patients identified at the screenings and referred to the clinic for definitive care, 39 (32.5%) presented at the clinic within 3 months. Reasons for poor uptake of referral services were lack of a felt need and lack of money for transportation. Considering only patients who accepted referral, they were still less educated (p<0.001), poorer (p=0.001) and less knowledgeable about glaucoma (p=0.003) than spontaneous clinic presenters. CONCLUSION: Outreach screening improved equity of access but its effects were somewhat reduced by poor uptake of referral care. Interventions such as free transportation and educational efforts may improve the uptake of referral services and maximise equity gains.

Modelling ready-made spectacle coverage for children and adults using a large global database.

BACKGROUND/AIMS: To model the suitability of conventional ready-made spectacles (RMS) and interchangeable-lens ready-made spectacles (IRMS) with reference to prescribing guidelines among children and adults using a large, global database and to introduce a web-based application for exploring the database with user-defined eligibility criteria. METHODS: Using refractive power and interpupillary distance data for near and distance spectacles prescribed to children and adults during OneSight clinics in 27 countries, from 2 January 2016 to 19 November 2019, we modelled the expected suitability of RMS and IRMS spectacle designs, compared with custom-made spectacles, according to published prescribing guidelines. RESULTS: Records of 18 782 presbyopic adult prescriptions, 70 619 distance adult prescriptions and 40 862 paediatric prescriptions were included. Globally, 58.7%-63.9% of adults could be corrected at distance with RMS, depending on the prescribing cut-off. For presbyopic adult prescriptions, coverage was 44.1%-60.9%. Among children, 51.8% were eligible for conventional RMS. Coverage for all groups was similar to the above for IRMS. The most common reason for ineligibility for RMS in all service groups was astigmatism, responsible for 27.2% of all ineligible adult distance prescriptions using the strictest cut-off, 31.4% of children's prescriptions and 28.0% of all adults near prescriptions globally. CONCLUSION: Despite their advantages in cost and convenience, coverage delivered by RMS is limited under current prescribing guidelines, particularly for children and presbyopic adults. Interchangeable designs do little to remediate this, despite extending coverage for anisometropia. Our free application allows users to estimate RMS coverage in specific target populations.

A pilot cost-benefit analysis of a children's spectacle reimbursement scheme: Evidence for Including children's spectacles in Mongolia's Social Health Insurance.

BACKGROUND AND AIM: Globally, 12.8 million children have vision impairment due to uncorrected refractive error (URE). In Mongolia, one in five children needs but do not have access to spectacles. This pilot cost-benefit analysis aims to estimate the net benefits of a children's spectacles reimbursement scheme in Mongolia. METHODS: A willingness-to-pay (WTP) survey using the contingent valuation method was administered to rural and urban Mongolia respondents. The survey assessed WTP in additional annual taxes for any child with refractive error to be provided government-subsidised spectacles. Net benefits were then calculated based on mean WTP (i.e. benefit) and cost of spectacles. RESULTS: The survey recruited 50 respondents (mean age 40.2 ± 9.86 years; 78.0% women; 100% response rate) from rural and urban Mongolia. Mean WTP was US$24.00 ± 5.15 (95% CI US$22.55 to 25.35). The average cost of a pair of spectacles in Mongolia is US$15.00. Subtracting the average cost of spectacles from mean WTP yielded a mean positive net benefit of US$9.00. CONCLUSION: A spectacle reimbursement scheme is potentially a cost-effective intervention to address childhood vision impairment due to URE in Mongolia. These preliminary findings support the proposal of the inclusion of children's spectacles into existing Social Health Insurance. A much larger random sample could be employed in future research to increase the precision and generalisability of findings.

A Review to Populate A Proposed Cost-Effectiveness Analysis of Glaucoma Screening in Sub-Saharan Africa.

To populate a proposed cost-effectiveness analysis of glaucoma screening in Sub-Saharan Africa (SSA).A complete search was conducted on PubMed, Medline and African Journals Online (AJOL) to obtain relevant published articles, which were included in this review. All relevant articles on prevalence of glaucoma in SSA and among other African-derived populations, severity of glaucoma, cost of diagnosis and management, clinical effectiveness of glaucoma screening and treatment and the different glaucoma screening strategies in SSA were reviewed.Population screening interventions for glaucoma may be considered as follows: standalone screening for glaucoma, screening for glaucoma during cataract outreach, and screening incorporated with diabetic retinopathy image review using tele-ophthalmology. Our review suggests that cost of glaucoma treatment is relatively low with cost of medical treatment ranging from USD 273 to USD 480 per year/patient and surgical treatment cost of USD 283 per patient as with other developing countries. Compliance with medication is moderate to good in about 50% of glaucoma patients. Prevalence of glaucoma is much higher in SSA and almost 50% of glaucoma patients are blind in at least one eye at presentation in clinics (without outreach screening). Our review suggests a moderate sensitivity and specificity in identifying glaucoma with basic equipment (direct ophthalmoscope, contact tonometer and frequency doubling technology) during outreach screening although about a third or fewer take up glaucoma services in clinics.Our review provides the necessary information to conduct a cost-effective analysis of glaucoma screening in SSA using the decision Markov model.

Is an integrated model of school eye health delivery more cost-effective than a vertical model? An implementation research in Zanzibar.

OBJECTIVE: To review and compare the cost-effectiveness of the integrated model (IM) and vertical model (VM) of school eye health programme in Zanzibar. METHODS AND ANALYSIS: This 6-month implementation research was conducted in four districts in Zanzibar. Nine and ten schools were recruited into the IM and VM, respectively. In the VM, teachers conducted eye health screening and education only while these eye health components were added to the existing school feeding programme (IM). The number of children aged 6-13 years old screened and identified was collected monthly. A review of project account records was conducted with 19 key informants. The actual costs were calculated for each cost categories, and costs per child screened and cost per child identified were compared between the two models. RESULTS: Screening coverage was 96% and 90% in the IM and VM with 297 children (69.5%) from the IM and 130 children (30.5%) from VM failed eye health screening. The 6-month eye health screening cost for VM and IM was US$6 728 and US$7 355. The cost per child screened for IM and VM was US$1.23 and US$1.31, and the cost per child identified was US$24.76 and US$51.75, respectively. CONCLUSION: Both models achieved high coverage of eye health screening with the IM being a more cost-effective school eye health delivery screening compared with VM with great opportunities for cost savings.

Prevalence of Refractive Error, Presbyopia, and Spectacle Coverage in Bogotá, Colombia: A Rapid Assessment of Refractive Error.

SIGNIFICANCE: Uncorrected refractive error is the leading cause of visual impairment; therefore, reducing its prevalence is important worldwide. For two decades, there has not been a comprehensive assessment of refractive error in Latin America. PURPOSE: The purpose of this study was to determine the current prevalence of refractive error, presbyopia, spectacle coverage, barriers to uptake refractive services, and spectacle correction in people 15 years and older in Bogotá, Colombia. METHODS: A cross-sectional community-based survey was conducted using 50 randomly selected clusters from 10 districts of Bogotá reflecting the socioeconomic status of the city. Respondents 15 years and older were interviewed and underwent standardized clinical eye examinations. Prevalence of uncorrected refractive error, spectacle coverage, and visual impairment were standardized to 2015 age-sex population distribution of Bogotá and further analyzed. RESULTS: A total of 2886 subjects (90% of 3206 eligible subjects) participated in the study; 39.1% were male and 60.9% were female in the age range of 15 to 96 years, with a median age of 46 years (interquartile range, 45 to 54 years). Age- and sex-standardized prevalence of visual impairment was 19.3% (95% confidence interval [CI], 17.8 to 20.8%). Prevalence of uncorrected refractive error was 12.5% (95% CI, 11.3 to 13.7%). Prevalence of presbyopia among participants 35 years and older was 55.2% (95% CI, 52.9 to 57.4%). Spectacle coverage was 50.9% for distance vision, and it was 33.9% for presbyopia. Main barrier to spectacle uptake was a limitation in affording spectacles because of economic factors (29.5%). CONCLUSIONS: This study provides a current estimate of refractive error using the Rapid Assessment of Refractive Error for Colombia and the Latin American region. The prevalence of uncorrected refractive error and presbyopia was high, and the barriers to spectacle uptake were higher in the lowest socioeconomic strata. The results obtained in the present study will help in making evidence-based decisions related to eye care service delivery in Colombia.

Cost and Expected Visual Effect of Interventions to Improve Follow-up After Cataract Surgery: Prospective Review of Early Cataract Outcomes and Grading (PRECOG) Study.

IMPORTANCE: Some experts recommend increasing low rates of follow-up after cataract surgery in low- and middle-income countries using various interventions. However, little is known about the cost and effect of such interventions. OBJECTIVE: To examine whether promoting follow-up after cataract surgery creates economic value. DESIGN, SETTING, AND PARTICIPANTS: The Prospective Review of Early Cataract Outcomes and Grading (PRECOG) is a cohort study with data from patients undergoing cataract surgery from January 19, 2010, to April 18, 2012. Final follow-up was completed on August 10, 2012. Data were collected before surgery, at discharge, and at follow-up at least 40 days after surgery from 27 centers in 8 countries in Asia, Africa, and Latin America. Each center enrolled 40 to 120 consecutive patients undergoing cataract surgery. If patients did not return to the hospital for the follow-up visit, hospitals could use telephone calls or transportation subsidies to increase follow-up rate. Data were analyzed from December 2013 to January 2016. MAIN OUTCOMES AND MEASURES: Cost of interventions (telephone calls and transportation subsidies) to increase follow-up at least 40 days after surgery, visual acuity (VA) in the eye undergoing cataract surgery, presence of complications, patient and facility costs per visit, and willingness to pay for treatment or glasses if needed. The maximum incremental cost of improving VA in 1 patient (incremental cost-effect ratio [ICER]) was calculated for spontaneous follow-up (compared with no follow-up) and follow-up with the telephone and transportation interventions. Expected ICERs were estimated including only those patients willing to pay. RESULTS: Among 2487 patients (1068 men [42.9%]; 1405 women [56.5%]; 14 missing [0.6%]; mean [SD] age, 68.4 [11.3] years), 2316 (93.1%) received follow-up, of whom 369 (16.0%) were seen in an outside facility or home and were in the cost-effectiveness analysis as unable to follow up. A grand mean (a mean of means of the different countries) of 56.3% of patients needed glasses, of whom 56.9% were willing to pay, and 1.6% had treatable complications, of whom 39.4% were willing to pay. Maximum proportions with improved VA (and corresponding ICERs) were 0.08 for no follow-up, 0.45 ($151.56) for spontaneous follow-up, 0.53 ($164.46) for a telephone intervention, and 0.53 ($133.07) for a transportation intervention. These results were most sensitive to the cost of follow-up. Expected proportions (ICERs) were 0.08, 0.27 ($232.69), 0.30 ($456.22), and 0.30 ($206.47), respectively. CONCLUSIONS AND RELEVANCE: Most patients benefiting from follow-up after cataract surgery returned spontaneously when requested at discharge. Use of telephone calls or transportation subsidies to increase follow-up in low- and middle-income countries may not be cost-effective.

How Do Patients Choose Their Spectacles in the Public Sector of South Africa?

PURPOSE: This study was designed to understand the profiles of the patients who attended and chose to purchase spectacles from the public sector eye clinics in KwaZulu Natal, South Africa. Furthermore, we wished to explore patients' perceptions of the spectacle frames on offer and to understand the motivation of the patients in selecting their spectacle frames. METHODS: This descriptive study consented 674 patients from seven eye clinics in KwaZulu Natal. Each was interviewed using a questionnaire containing open-ended, close-ended questions and questions with a Likert-scale response. RESULTS: Females comprised 68.4% of the study population. The majority of participants had not completed secondary school or had no schooling (78.9%), were unemployed (70.9%), and earned less than R2000 per month or did not have any form of income (89.2%). Of the 670 who chose to buy spectacles from the eye clinics, 79.4% indicated that this was convenient (79.4%) and 23.0% said that they were motivated in their decision because they liked the available frames. More than 95% of participants rated the design, quality, and price as good to excellent. Factors influencing their decisions included design, recommendations from staff, and quality. Those who bought the spectacles from the budget range were prepared to pay more for the next pair of spectacles, whereas almost all reported that they would return to the same eye clinic for their next pair of spectacles and that they would recommend relatives and friends to the clinic. CONCLUSIONS: The results from the study indicate that there is high acceptance by patients of the range of spectacles offered in public sector eye clinics with specific suggestions to improve it. Increased understanding of the perceptions and motivations in spectacle choice will help inform planning and procurement decisions in supplying the needs of the patients and broadening the patient base.

Prevalence of refractive error, presbyopia and spectacle coverage in Kahama District, Tanzania: a rapid assessment of refractive error.

BACKGROUND: In Tanzania, the prevalence of refractive error and presbyopia have not been comprehensively assessed, limiting appropriate planning and implementation of delivery of vision care. This study sought to determine the prevalence of refractive error and presbyopia, spectacle coverage and the barriers to uptake of refractive services in people aged 15 years and older in the Kahama district of Tanzania. METHODS: A cross-sectional community-based survey was conducted using 54 randomly selected clusters. Respondents 15 years and older were interviewed and underwent standardised clinical eye examinations. Uncorrected refractive error (URE) was defined as presenting vision worse than 6/12 that could be corrected to better than 6/12 using a pinhole. Spectacle coverage was defined as the proportion of need that was met (those that improved from unaided vision with their own spectacle correction). RESULTS: A total of 3,230 subjects (99.75 per cent of 3,240 eligible) participated in the study with 57.2 per cent males and the median age of participants was 35 years (inter-quartile range, 24 to 49). The prevalence of visual impairment was 10.4 per cent (95% CI 9.4 to 11.4) and was lower in those who had completed their primary school education (odds ratio (OR) 0.54, 95% CI: 0.40 to 0.72) and highest in subjects 40 years and older (OR 3.17, 95% CI: 2.14 to 4.70) and farmers (OR 8.57 95% CI: 2.27 to 32.43). Refractive error prevalence was 7.5 per cent (95% CI: 6.65 to 8.54) and this was highest in participants over 40 years (OR 1.60, 95% CI: 1.14 to 2.25) and in students (OR 3.64, 95% CI: 1.35 to 9.86). Prevalence of presbyopia was 46.5 per cent (773/1,663, 95% CI: 44.34 to 48.75). Spectacle coverage for refractive error and presbyopia was 1.69% (95% CI: 0 to 3.29) and 0.42% (95% CI: 0 to 1.26), respectively. CONCLUSION: Uncorrected refractive error is a public health challenge in the Kahama district and sustainable service delivery and health promotion efforts are needed.

Prevalence of refractive error and spectacle coverage in Zoba Ma'ekel Eritrea: a rapid assessment of refractive error.

PURPOSE: To determine the prevalence of refractive error and spectacle coverage in Zoba Ma'ekel, Eritrea in order to assist in planning for refractive services and blindness prevention strategies. METHODS: A community-based cross-sectional study using multistage cluster sampling was conducted. A total of 3200 participants aged 15-50 years were enumerated and examined using the Rapid Assessment of Refractive Error (RARE) protocol. RESULTS: The response rate was 99.1%. The prevalence of refractive error was 6.4% (95% confidence interval [CI], 5.6-7.2%). Spectacle coverage for refractive error was 22.2% (95% CI 16.7-28.5%). It was higher among males than females (Fisher's exact test, p = 0.028), and highest in those who had completed secondary school (48.6%, 95% CI 31.9-65.6%) and those who resided in Asmara (Fisher's exact test, p < 0.002). The prevalence of presbyopia was 32.9% (95% CI 30.3-35.7%) with 94.9% correctable. Spectacle use for presbyopia was 9.9% (95% CI 7.2-13.4%), which was lowest in those with no formal schooling but highest in those who had completed secondary school (χ(2) test, p < 0.001) and those persons who resided in Asmara (Fisher's exact test, p < 0.001). Respondents expressed different barriers to uptake of services. A total of 128 subjects were aware of the problem but did not feel the need for consultation while 83 subjects stated they could not afford the cost of examination and spectacles. CONCLUSION: The study provides helpful findings to assist with the development of appropriate refractive service planning in Zoba Ma'ekel. Uncorrected refractive error is of public health importance and prompt measures are needed to address the problem.