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.

Outreach screening to address demographic and economic barriers to diabetic retinopathy care in rural China.

IMPORTANCE: Poor access to existing care for diabetic retinopathy (DR) limits effectiveness of proven treatments. OBJECTIVES: We examined whether outreach screening in rural China improves equity of access. DESIGN, SETTING AND PARTICIPANTS: We compared prevalence of female sex, age > = 65 years, primary education or below, and requiring referral care for DR between three cohorts with diabetes examined for DR in neighboring areas of Guangdong, China: passive case detection at secondary-level hospitals (n = 193); persons screened during primary-level DR outreach (n = 182); and individuals with newly- or previously-diagnosed diabetes in a population survey (n = 579). The latter reflected the "ideal" reach of a screening program. RESULTS: Compared to the population cohort, passive case detection reached fewer women (50·8% vs. 62·3%, p = 0·006), older adults (37·8% vs. 51·3%, p < 0·001), and less-educated persons (39·9% vs. 89·6%, p < 0·001). Outreach screening, compared to passive case detection, improved representation of the elderly (49·5% vs. 37·8%, p = 0·03) and less-educated (70·3% vs. 39·9%, p<0·001). The proportion of women (59.8% vs 62.3%, P>0.300) and persons aged > = 65 years (49.5% vs 51.3%, p = 0.723) in the outreach screening and population cohorts did not differ significantly. Prevalence of requiring referral care for DR was significantly higher in the outreach screening cohort (28·0%) than the population (14·0%) and passive case detection cohorts (7·3%, p<0·001 for both). CONCLUSIONS AND RELEVANCE: Primary-level outreach screening improves access for the poorly-educated and elderly, and removes gender inequity in access to DR care in this setting, while also identifying more severely-affected patients than case finding in hospital.

Prevalence and service assessment of cataract in Tibetan areas of Sichuan Province, China: population-based study.

OBJECTIVES: To assess the prevalence of visual impairment (VI) and blindness (BL) due to cataract and cataract surgical outcomes in remote dispersed and high-altitude Tibetan areas of China. DESIGN AND SETTING: A cross-sectional study was conducted among people aged 50 and above in Tibetan Autonomous Prefecture of Kandze (TAPK), China, in 2017. The Rapid Assessment of Avoidable Blindness protocol was followed. PARTICIPANTS: Of 5000 eligible participants, 4764 were examined (response rate 95.3%). PRIMARY AND SECONDARY OUTCOME MEASURES: Cataract VI was defined as lens opacity at visual acuity (VA) levels of <3/60 (Blindness (BL)), ≥3/60 and <6/60 (severe visual impairment (SVI)), ≥6/60 and <6/18 (moderate visual impairment (MVI)), ≥6/18 and <6/12 (early visual impairment (EVI)). RESULTS: The estimated prevalence of cataract BL was 0.61% (95% CI 0.42 to 0.87). With best corrected VA, the estimated prevalence of SVI from cataract was 0.86% (95% CI 0.63 to 1.17); MVI was 2.39% (95% CI 2.00 to 2.87) and EVI was 5.21% (95% CI 4.61 to 5.87). Women in TAPK had a significantly higher prevalence of cataract BL (0.82%, 95% CI 0.54 to 2.15) than men (0.34%, 95% CI 0.16 to 0.70). Women had lower cataract surgical coverage (CSC) by eyes (60.8%, 95% CI 55.5 to 65.8) compared with men (70.1%; 95% CI 63.7 to 75.7). The prevalence of cataract BL was higher among Tibetan (2.28%; 95% CI 1.98 to 2.62) than Han Chinese (1.01%%; 95% CI 0.54% to 1.87%). Overall CSC by person with BL (by better eye) was 82.0% (95% CI 75.2 to 87.6). Among cataract-operated participants, 71.2% had VA equal to or better than 6/18. CONCLUSIONS: The study detected a low prevalence of VI and BL due to cataract with high CSC in the study area compared with many other places in China. Further actions should be taken to improve cataract surgical outcome.

Teachers' influence on purchase and wear of children's glasses in rural China: The PRICE study.

IMPORTANCE: Uncorrected refractive error causes 90% of poor vision among Chinese children. BACKGROUND: Little is known about teachers' influence on children's glasses wear. DESIGN: Cohort study. PARTICIPANTS: Children at 138 randomly selected primary schools in Guangdong and Yunnan provinces, China, with uncorrected visual acuity (VA) ≤6/12 in either eye correctable to >6/12 in both eyes, and their teachers. METHODS: Teachers and children underwent VA testing and completed questionnaires about spectacles use and attitudes towards children's vision. MAIN OUTCOME MEASURES: Children's acceptance of free glasses, spectacle purchase and wear. RESULTS: A total of 882 children (mean age 10.6 years, 45.5% boys) and 276 teachers (mean age 37.9 years, 67.8% female) participated. Among teachers, 20.4% (56/275) believed glasses worsened children's vision, 68.4% (188/275) felt eye exercises prevented myopia, 55.0% (151/275) thought children with modest myopia should not wear glasses and 93.1% (256/275) encouraged children to obtain glasses. Teacher factors associated with children's glasses-related behaviour included believing glasses harm children's vision (decreased purchase, univariate model: relative risk [RR] 0.65, 95% CI 0.43, 0.98, P < 0.05); supporting children's classroom glasses wear (increased glasses wear, univariate model: RR 2.20, 95% CI 1.23, 3.95, P < 0.01); and advising children to obtain glasses (increased free glasses acceptance, multivariate model: RR 2.74, 95% CI 1.29, 5.84, P < 0.01; increased wear, univariate model: RR 2.93, 95% CI 1.45, 5.90, P < 0.01), but not teacher's ownership/wear of glasses. CONCLUSIONS AND RELEVANCE: Though teachers had limited knowledge about children's vision, they influenced children's glasses acceptance.

Blindness and eye disease in a Tibetan region of China: findings from a Rapid Assessment of Avoidable Blindness survey.

INTRODUCTION: The only population-based survey of blindness and visual impairment of a Tibetan population was conducted in the Tibet Autonomous Region in 1999. METHODS AND ANALYSIS: The Rapid Assessment of Avoidable Blindness methodology was used to conduct a survey of Kandze Tibetan Autonomous Prefecture, Sichuan Province of China in the Fall 2017. Using the 2010 census, 100 clusters of 50 participants aged 50 years or older were randomly sampled using probability proportionate to size. RESULTS: Among the 5000 people enumerated, 4763 were examined (95.3% response). The age-adjusted and sex-adjusted prevalence of blindness, severe visual impairment, moderate visual impairment and early visual impairment (EVI) were 1.6% (95% CI: 1.08 to 2.38)), 0.9% (95% CI:0.7 to 1.5), 5.1% (95% CI:4.4 to 5.7), and 7.45% (95% CI:6.67 to 8.2), respectively. The prevalence of blindness among Tibetans was significantly higher than that among Han Chinese (2.2% (95% CI:1.8 to 2.6) and 0.6 (95% CI:0.2 to 1.7), respectively, p<0.05). Women bore a significant excess burden of EVI compared with men (8.5% (95% CI:7.5 to 9.6) and 6.1% (95% CI:5.1 to 7.2), respectively, p<0.05). Cataract was the primary cause of blindness (39.4%) followed by macular degeneration (10.6%) and corneal opacity (5.3%). CONCLUSION: Blindness and visual impairment in Kandze Tibetan Autonomous Prefecture is substantially less than an earlier study of a Tibetan region and now resembles other regions of China. About 58% of blindness and 67% of SVIwere avoidable, primarily by providing cataract services. Eighty-three percent of EVI was avoidable by providing refractice services throughout the region.

A Mobile Phone Informational Reminder to Improve Eye Care Adherence Among Diabetic Patients in Rural China: A Randomized Controlled Trial.

PURPOSE: To determine whether short message service (SMS) reminders improve adherence to scheduled ocular examinations among patients with diabetes in rural China. DESIGN: Randomized controlled trial. METHODS: This study enrolled consecutive patients with diabetes scheduled for eye examinations at 5 hospitals in low-income areas of Guangdong, China from March 1, 2015 to May 31, 2016. Participants were randomized (1:1) to receive automated SMS reminders containing information about diabetic retinopathy (DR) 1 week and 3 days prior to scheduled eye appointments (Intervention) or to appointments without reminders (Control). Regression models following intention-to-treat principles were used to estimate the association between the main outcome (attendance within ± 1 week of scheduled visit) and membership in the Intervention group, with and without adjustment for other potential predictors of follow-up. Secondary outcomes included change in DR knowledge score (1, worst; 5, best) and endline satisfaction with care (3, worst; 15, best). RESULTS: Among 233 patients, 119 (51.1%) were randomized to Intervention (age 59.7 ± 11.3 years, 52.1% men) and 114 (48.9%) to Control (58.7 ± 9.50 years, 49.1% men). All participants provided data for the main study outcome. Attendance at scheduled appointments for the Intervention group (51/119, [42.9%]) was significantly higher than for Controls (16/114, [14.0%], between-group difference 28.8% [95% confidence interval (CI) 17.9%, 39.8%], P < .001). Factors associated with attendance in multiple regression models included Intervention group membership (Relative Risk [RR] 3.04, 95% CI, 1.73-5.33, P < .001) and baseline DR knowledge (RR 1.47, 95% CI 1.21-1.78, P < .001). Improvement in Satisfaction (mean difference 1.08, 95% CI 0.70-1.46, P < .001) and DR knowledge (mean difference 1.30, 95% CI 0.96-1.63, P < .001) were significantly higher for the Intervention group. Total cost of the intervention was US$5.40/person. CONCLUSION: Low-cost SMS informational reminders significantly improved adherence to, knowledge about, and satisfaction with care. Additional interventions are needed to further improve adherence.

Cluster-randomized controlled trial of the effects of free glasses on purchase of children's glasses in China: The PRICE (Potentiating Rural Investment in Children's Eyecare) study.

BACKGROUND: Offering free glasses can be important to increase children's wear. We sought to assess whether "Upgrade glasses" could avoid reduced glasses sales when offering free glasses to children in China. METHODS: In this cluster-randomized, controlled trial, children with uncorrected visual acuity (VA)< = 6/12 in either eye correctable to >6/12 in both eyes at 138 randomly-selected primary schools in 9 counties in Guangdong and Yunnan provinces, China, were randomized by school to one of four groups: glasses prescription only (Control); Free Glasses; Free Glasses + offer of $15 Upgrade Glasses; Free Glasses + offer of $30 Upgrade Glasses. Spectacle purchase (main outcome) was assessed 6 months after randomization. RESULTS: Among 10,234 children screened, 882 (8.62%, mean age 10.6 years, 45.5% boys) were eligible and randomized: 257 (29.1%) at 37 schools to Control; 253 (28.7%) at 32 schools to Free Glasses; 187 (21.2%) at 31 schools to Free Glasses + $15 Upgrade; and 185 (21.0%) at 27 schools to Free Glasses +$30 Upgrade. Baseline ownership among these children needing glasses was 11.8% (104/882), and 867 (98.3%) children completed follow-up. Glasses purchase was significantly less likely when free glasses were given: Control: 59/250 = 23.6%; Free glasses: 32/252 = 12.7%, P = 0.010. Offering Upgrade Glasses eliminated this difference: Free + $15 Upgrade: 39/183 = 21.3%, multiple regression relative risk (RR) 0.90 (0.56-1.43), P = 0.65; Free + $30 Upgrade: 38/182 = 20.9%, RR 0.91 (0.59, 1.42), P = 0.69. CONCLUSIONS: Upgrade glasses can prevent reductions in glasses purchase when free spectacles are provided, providing important program income. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT02231606. Registered on 31 August 2014.

The Impact of Multimedia Education on Uptake of Comprehensive Eye Examinations in Rural China: A Randomized, Controlled Trial.

PURPOSE: To study the effect of multimedia education on acceptance of comprehensive eye examinations (CEEs), critical for detecting glaucoma and diabetic eye disease, among rural Chinese patients using a randomized, controlled design. METHODS: Patients aged ≥40 years were recruited from 52 routine clinic sessions (26 intervention, 26 control) conducted at seven rural hospitals in Guangdong, China. Subjects answered demographic questionnaires, were tested on knowledge about CEEs and chronic eye disease, and were told the cost of examination (range US$0-8). At intervention sessions, subjects were cluster-randomized to view a 10-minute video on the value of CEEs and retested. Control subjects were not retested. Trial outcomes were acceptance of CEEs (primary outcome) and final knowledge scores (secondary outcome). RESULTS: At baseline, >70% (p = 0.70) of both intervention (n = 241, 61.2 ± 12.3 years) and control (n = 218, 58.4 ± 11.7 years) subjects answered no knowledge questions correctly, but mean scores on the test (maximum 5 points) increased by 1.39 (standard deviation 0.12) points (p < 0.001) after viewing the video. Intervention (73.0%) and control (72.9%) subjects did not differ in acceptance of CEEs (p > 0.50). In mixed-effect logistic regression models, acceptance of CEEs was associated with availability of free CEEs (odds ratio 18.3, 95% confidence interval 1.32-253.0), but not group assignment or knowledge score. Acceptance was 97.5% (79/81) when free exams were offered. CONCLUSIONS: Education increased knowledge about but not acceptance of CEEs, which was generally high. Making CEEs free could further increase acceptance.

Cataract surgical outcomes from a large-scale micro-surgical campaign in China.

PURPOSE: To assess cataract surgical outcomes during the Jiangxi Provincial Government's "Brightness and Smile Initiative" (BSI) in South East China during May 2009 to July 2010. METHOD: This cross sectional combined with retrospective study included 1157 cataract surgical patients (1254 eyes) recruited from six counties in Jiangxi during the initiative. Patient information before surgery and at discharge was obtained from hospitals' case records. Patient follow-up eye examinations were conducted during field visits in the autumn of 2010. Fifteen months after the initiative started, study subjects were examined by provincial ophthalmologists using a Snellen visual chart, portable slit lamp, torch and ophthalmoscope. The World Health Organization (WHO) cataract surgical outcome monitoring tally sheet and the outcome categories good (visual acuity, VA, ≥ 0.3 (6/18)), borderline (VA <0.3 but ≥ 0.1 (6/60)) and poor (VA < 0.1) were used for data collection and analysis. RESULTS: A total of 99.7% of operated patients had intraocular lenses implanted. The percentage of eyes with good outcomes (presenting VA) at follow-up was low (49.6%), while the borderline and poor outcome rates were high (34.1% and 16.3%, respectively), in comparison to WHO recommendations. There was a significant outcome difference at follow-up (p < 0.01) between eyes operated by county surgeons trained by an International Non-Government Organization and those operated on by other visiting surgeons. CONCLUSIONS: This study documented a low rate of good cataract surgical outcomes from the BSI in Jiangxi. The quality of cataract surgery should be improved further in the province.

Rapid assessment of avoidable blindness in three counties, Jiangxi Province, China.

BACKGROUND: A survey was undertaken in 2007 to assess the prevalence and causes of blindness and visual impairment in people aged ≥ 50 years in three different counties in Jiangxi, South East China (Gao'an, Xin'gan and Wan'zai). The counties were purposively selected to assess the impact of established non-governmental organisation activities in two counties (Gao'an and Xin'gan) compared with a third county (Wan'zai) without such a programme. METHODS: Clusters of 50 people aged ≥ 50 years were sampled with a probability proportional to the size of the population. Because of differences in expected prevalence and resources available for conducting the surveys, the total sample size varied from 4699 in Gao'an (94.0% response rate) to 3834 in Xin'gan (95.9%) and 2861 (95.4%) in Wan'zai. Households within clusters were selected through random walk sampling. Visual acuity (VA) was measured with a tumbling 'E' chart. Ophthalmologists examined people with VA< 6/18 in either eye. RESULTS: The prevalence of blindness (VA< 3/60 in the better eye with available correction) was similar in Gao'an (1.5%, 95% CI 1.1% to 1.8%), Xin'gan (1.8%, 1.4% to 2.2%) and Wan'zai (1.6%, 1.2% to 2.1%), and the prevalence of visual impairment (VA< 6/18 and ≥ 6/60) was approximately fourfold higher. Cataract was the leading cause of blindness in each of the three counties, while uncorrected refractive error was the dominant cause of visual impairment. The majority of blindness was avoidable in Gao'an (84.3%), Xin'gan (71.0%) and Wan'zai (71.7%). CONCLUSIONS: The prevalence of blindness in the three counties in Jiangxi, China was lower than expected, yet most of the blindness and visual impairment was avoidable, indicating that the prevalence could be reduced further through adequate programme planning and implementation.