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.

Impact of spectacles wear on uncorrected visual acuity among urban migrant primary school children in China: a cluster-randomised clinical trial.

OBJECTIVE: To estimate the effect of providing free spectacles on uncorrected visual acuity (VA) among urban migrant Chinese school children. DESIGN: Exploratory analysis from a parallel cluster-randomised clinical trial. METHODS: After baseline survey and VA screening, eligible children were randomised by school to receive one of the two interventions: free glasses and a teacher incentive (tablet computer if ≥80% of children given glasses were wearing them on un-announced examination) (treatment group) or glasses prescription and letter to parents (control group). The primary outcome was uncorrected logarithm of the minimal angle of resolution (LogMAR) VA at study closeout, adjusted for baseline uncorrected VA. RESULTS: Among 4376 randomly selected children, 728 (16.6%, mean age 10.9 years, 51.0% boys) at 94 schools failed VA screening and met eligibility criteria. Of these, 358 children (49.2%) at 47 schools were randomised to treatment and 370 children (50.8%) at 47 schools to control. Among these, 679 children (93.3%) completed follow-up and underwent analysis. Spectacle wear in the treatment and control groups was 68.3% and 29.3% (p<0.001), respectively. Uncorrected final VA for eyes of treatment children was significantly better than control children, adjusting only for baseline VA (difference of 0.039 LogMAR units, 95% CI: 0.008, 0.070, equivalent to 0.39 lines, p=0.014) or baseline VA and other baseline factors (0.040 LogMAR units, 95% CI 0.007 to 0.074, equivalent to 0.40 lines, p=0.020). CONCLUSION: We found no evidence that spectacles wear worsens children's uncorrected VA among urban migrant Chinese school children.

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.

Prevalence of refractive error, presbyopia, and unmet need of spectacle coverage in a northern district of Bangladesh: Rapid Assessment of Refractive Error study.

PURPOSE: To determine the prevalence of refractive error (RE), presbyopia, spectacle coverage, and barriers to uptake optical services in Bangladesh. METHOD: Rapid assessment of refractive error (RARE) study following the RARE protocol was conducted in a northern district (i.e., Sirajganj) of Bangladesh (January 2010-December 2012). People aged 15-49 years were selected, and eligible participants had habitual distance and near visual acuity (VA) measured and ocular examinations were performed in those with VA<6/18. Those with phakic eyes with VA <6/18, but improving to ≥6/18 with pinhole or optical correction, were considered as RE and people aged ≥35 years with binocular unaided near vision of

The situation of low vision services in Papua New Guinea: an exploratory study.

BACKGROUND: The aim of this study was to investigate the current situation of low vision services and barriers to low vision service delivery in Papua New Guinea (PNG). METHODS: An exploratory study was undertaken to assess the situation of available services, human resources, training, equipment and assistive devices, supportive policies, needs of people with low vision and community attitudes toward people with low vision. In-depth interviews with 50 key informants were conducted in-country. Key informants included eye-care practitioners (n = 13), special education teachers (n = 10), community-based rehabilitation workers (n = 3), other stakeholders providing disability-related services (n = 8), and people with low vision (n = 14) and their family members (n = 2). Interview transcripts were analysed inductively and deductively using thematic analysis. RESULTS: Barriers were identified at systems and community levels. The barriers at the systems level were: low vision not a priority area for eye care and rehabilitation programs, limited availability of low vision services, trained personnel and low vision devices; low vision not included in training programs of eye-care practitioners and lack of awareness of available referral services among service providers. The barriers identified at the community level were lack of awareness of services, distance, costs and limited transport to access services and negative community attitudes. CONCLUSION: This study has identified barriers from the perspectives of different stakeholders, including service providers and people with low vision and their families. Knowledge of these barriers can now guide the development of future low vision services in PNG.

Population Prevalence of Need for Spectacles and Spectacle Ownership Among Urban Migrant Children in Eastern China.

IMPORTANCE: The number of urban migrants in China is 300 million and is increasing rapidly in response to government policies. Urban migrants have poor access to health care, but little is known about rates of correction of refractive error among migrant children. This is of particular significance in light of recent evidence demonstrating the educational impact of providing children with spectacles. OBJECTIVE: To measure prevalence of spectacle need and ownership among Chinese migrant children. DESIGN, SETTING, AND PARTICIPANTS: Population-based, cross-sectional study among children who failed vision testing (uncorrected visual acuity ≤6/12 in either eye) between September 15 and 30, 2013, at 94 randomly selected primary schools in predominantly migrant communities in Shanghai, Suzhou, and Wuxi, China. MAIN OUTCOMES AND MEASURES: Refractive error by cycloplegic refraction; spectacle ownership, defined as producing glasses at school, having been told to bring them; and needing glasses, defined as uncorrected visual acuity of 6/12 or less correctable to greater than 6/12 in either eye, with myopia of -0.5 diopters (D) or less, hyperopia of +2.0 D or greater, or astigmatism of 0.75 D or greater in both eyes. RESULTS: Among 4409 children, 4376 (99.3%) completed vision screening (mean [SD] age, 11.0 [0.81] years; 55.3% boys; 4225 [96.5%] migrant and 151 [3.5%] local). Among 1204 children failing vision testing (total, 27.5%; 1147 migrant children [27.1%] vs 57 local children [37.7%]; P = .003), 850 (70.6%) completed refraction. Spectacle ownership in migrant children needing glasses (147 of 640 children [23.0%]) was less than among local children (12 of 34 children [35.3%]) (odds ratio = 0.55; 95% CI, 0.32-0.95; P = .03). Having uncorrected visual acuity less than 6/18 in both eyes was associated positively with baseline spectacle ownership (odds ratio = 5.73; 95% CI, 3.81-8.62; P < .001), but parental education and family wealth were not. CONCLUSIONS AND RELEVANCE: Among urban migrant children, there was a high prevalence of need for spectacles and a very low rate of spectacle ownership. Spectacle distribution programs are needed specifically targeting migrant children.

Impact of Free Glasses and a Teacher Incentive on Children's Use of Eyeglasses: A Cluster-Randomized Controlled Trial.

PURPOSE: To study the effect of free glasses combined with teacher incentives on in-school glasses wear among Chinese urban migrant children. DESIGN: Cluster-randomized controlled trial. METHODS: Children with visual acuity (VA) ≤6/12 in either eye owing to refractive error in 94 randomly chosen primary schools underwent randomization by school to receive free glasses, education on their use, and a teacher incentive (Intervention), or glasses prescriptions only (Control). Intervention group teachers received a tablet computer if ≥80% of children given glasses wore them during unannounced visits 6 weeks and 6 months (main outcome) after intervention. RESULTS: Among 4376 children, 728 (16.7%, mean age 10.9 years, 51.0% boys) met enrollment criteria and were randomly allocated, 358 (49.2%, 47 schools) to Intervention and 370 (50.8%, 47 schools) to Control. Among these, 693 children (95.2%) completed the study and underwent analysis. Spectacle wear was significantly higher at 6 months among Intervention children (Observed [main outcome]: 68.3% vs 23.9%, adjusted odds ratio [OR] = 11.5, 95% confidence interval [CI] 5.91-22.5, P < .001; Self-reported: 90.6% vs 32.1%, OR = 43.7, 95% CI = 21.7-88.5, P < .001). Other predictors of observed wear at 6 months included baseline spectacle wear (P < .001), uncorrected VA <6/18 (P = .01), and parental spectacle wear (P = .02). The 6-month observed wear rate was only 41% among similar-aged children provided free glasses in our previous trial without teacher incentives. CONCLUSIONS: Free spectacles and teacher incentives maintain classroom wear in the large majority of children needing glasses over a school year. Low wear among Control children demonstrates the need for interventions.

The Berkeley Rudimentary Vision Test.

PURPOSE: Very poor visual acuity often cannot be measured with letter charts even at close viewing distances. The Berkeley Rudimentary Vision Test (BRVT) was developed as a simple test to extend the range of visual acuity measurement beyond the limits of letter charts by systematically simplifying the visual task and using close viewing distances to achieve large angular sizes. The test has three pairs of hinged cards, 25 cm square. One card-pair has four single tumbling E (STE) optotypes at sizes 100 M, 63 M, 40 M, and 25 M. Another card-pair has four grating acuity (GA) targets at sizes 200 M, 125 M, 80 M, and 50 M. The third card-pair has a test of white field projection (WFP) and a test of black white discrimination (BWD). As a demonstration of feasibility, a population of subjects with severe visual impairment was tested with the BRVT. METHODS: Adults with severe visual impairments from a wide variety of causes were recruited from three different rehabilitation programs. Vision measurements were made on 54 eyes from 37 subjects; test administration times were measured. RESULTS: For this population, letter chart visual acuity could be measured on 24 eyes. Measurements of visual acuity for STE targets were made for 18 eyes and with GA targets, for two eyes. Five eyes had WFP, and one had BWD. Four had light perception only. The median testing time with the BRVT was 2.5 min. DISCUSSION: The BRVT extends the range of visual acuity up to logMAR = 2.60 (20/8000) for STEs, to logMAR = 2.90 (20/16,000) for gratings and includes the WFP and BWD tests. CONCLUSIONS: The BRVT is a simple and efficient test of spatial vision that, with 13 increments, extends the range of measurement from the limits of the letter chart up to light perception.

The challenge of uncorrected refractive error: driving the agenda of the Durban Declaration on refractive error and service development.

The purpose of this article is to highlight the challenge of uncorrected refractive error globally, as well as to discuss recent advocacy successes and innovative programs designed to address the need for broader refractive error service development, particularly in developing countries. The World Health Organization's VISION 2020: The Right to Sight program first posed the challenge to national governments to give priority to strategies and resources targeted towards avoidable causes of blindness and visual impairment, so that these unnecessary forms of blindness or visual impairment can be eliminated globally by the year 2020. The blindness prevention community is challenged to increase in scale its initiatives, which support the attainment of VISION 2020: The Right to Sight goals primarily and the United Nation's Millennium Development Goals indirectly. The Durban Declaration on Refractive Error and Service Development was the outcome of a meeting of eye-care professionals, researchers, governments, civil society and industry in March 2007 and still stands as a guiding document to the blindness prevention community for the elimination of avoidable blindness due to uncorrected refractive error.

Prevalence and causes of functional low vision and implications for services: the Pakistan National Blindness and Visual Impairment Survey.

PURPOSE: To determine the prevalence and causes of functional low vision (FLV) and total blindness and to estimate the assessment needs for low-vision services in Pakistan. METHODS: Multistage, cluster random sampling was used to select a nationally representative sample of adults (age, > or =30 years). Participants underwent visual acuity measurement and detailed ophthalmic examination. Functional low vision was defined as a corrected visual acuity in the better eye of less than 6/18 to more than no perception of light (NPL) in individuals with untreatable causes of visual loss. Total blindness was defined as NPL in both eyes. Needs assessments were categorized into three groups: optical services, nonoptical/environmental interventions, and rehabilitation. RESULTS: A sample of 16,507 adults (95.3% response rate) was examined. The standardized prevalence of FLV and total blindness were 1.7% (95% CI: 1.5%-1.9%) and 0.2% (95% CI: 0.1%-0.2%), respectively. More than 90% of those with FLV were illiterate and 35.3% were of working age (i.e., <60 years). An estimated 727,000 (586,000-891,000) adults in Pakistan had FLV. Retinal conditions were the commonest cause in urban populations (39.8% vs. 26.5% rural) compared with corneal opacity in rural areas (38.0% vs. 25.5% urban). It was estimated that 565,000 adults require assessment for optical services, 735,000 for nonoptical interventions, and 424,000 for rehabilitation. CONCLUSIONS: As VISION 2020 enters its second 5-year phase, the provision of low-vision services and their integration into national eyecare programs is a priority. In Pakistan, planning must take account of the magnitude along with the demographic and educational characteristics of those affected.