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.

Association between Visual Perception and Socioeconomic Status in Malaysian Preschool Children: Results from the Test of Visual Perceptual Skills-4.

Visual perception in children can be evaluated using the Test of Visual Perceptual Skills-4th edition (TVPS-4) with normative data developed for the U.S. population. It is widely used by healthcare practitioners in Malaysia, despite reports that children in Asia outperform their U.S. peers in visual perception assessment. We compared TVPS-4 scores among 72 Malaysian preschool children (mean age: 5.06 ± 0.11 years) with U.S. norms and investigated the association between socioeconomic factors and TVPS-4 scores. Malaysian preschoolers had significantly higher standard scores (116.60 ± 7.16) than the U.S. norms (100 ± 15; p < 0.001). They also had significantly higher scaled scores (between 12.57 ± 2.10 and 13.89 ± 2.54) than the U.S. norms (10 ± 3, all p < 0.001) for all subtests. Multiple linear regression analyses revealed that socioeconomic variables were not significant predictors for five visual perception subtests and the overall standard score. The visual form constancy score could be predicted by ethnicity (ß = -1.874, p = 0.03). The visual sequential memory score could be predicted by the father's employment status (ß = 2.399, p < 0.001), mother's employment status (ß = 1.303, p = 0.007), and low household income (ß = -1.430, p < 0.037). In conclusion, Malaysian preschoolers outperformed their U.S. peers in all TVPS-4 subtests. Socioeconomic variables were associated with visual form constancy and visual sequential memory, but not with the other five subtests or TVPS-4's overall standard scores.

Development of Knowledge, Attitude and Practice Questionnaire for age-related macular degeneration patients.

AIM: To develop and validate a questionnaire to evaluate knowledge, attitude and practice of patients diagnosed with age-related macular degeneration (AMD) who have undergone intravitreal injection treatment. METHODS: This study was conducted among patients diagnosed with AMD in Kuala Lumpur. The generation of the instrument included four phases which included item and domains development, content, face validity and exploratory factor analysis. Content validity and modified Kappa was used for validation of knowledge domain. Exploratory factor analysis was used for validation of both attitude and practice domains. Face validity was conducted in 12 patients, content validity was ascertained in 120 patients and test-retest reliability was determined in 39 patients with AMD. RESULTS: Content validity index (CVI) and modified kappa showed excellent values for most items in the knowledge domain with CVI for item (I-CVI) values between 0.78-1.0 and Kappa values of >0.74. The Kaiser-Meyer-Olkin (KMO) sampling adequacy showed acceptable scores of 0.70 and 0.75 for both attitude and practice domains respectively and Bartlett's Test of sphericity were significant (χ2 =0.00, P<0.001). Factor analysis resulted in five factors with thirty items for attitude domain and four factors with twenty items for practice domain. The Cronbach's alpha showed acceptable values for all items in knowledge, attitude and practice domain with values >0.70 and good test-retest reliability. The final version of the questionnaire consisted of 93 items from four sections consisting of demographic details, knowledge, attitude and practice. CONCLUSION: The findings of this validation and reliability study show that the developed questionnaire has a satisfactory psychometric property for measuring KAP of patients diagnosed with AMD undergoing intravitreal injection treatment.

Association between Socioeconomic Status and Vision Screening Outcomes among Preschool Children in Klang Valley, Malaysia: A Cross-Sectional Study.

Background: Vision screening programmes' outcomes are routinely used to report the prevalence of vision anomalies in children. However, the association between vision screening outcomes and the children's socioeconomic status remains underexplored. This cross-sectional study determined the association between socioeconomic and birth status with vision screening outcomes in a sample of children in Klang Valley. Methods: Total 411 children (mean age: 5.49 ± 0.47 years old) attending preschools were selected via stratified cluster sampling. Habitual distance visual acuity, near visual acuity, and stereoacuity were measured. The fail criteria were distance visual acuity ≥ 0.3 logarithm of the Minimum Angle of Resolution (logMAR), near visual acuity ≥ 0.4 logMAR or stereoacuity ≥ 300 arcsec. Socioeconomic and birth history data were obtained using parent-report questionnaires. The association between socioeconomic factors and screening outcomes were determined with binary logistic regression. Results: Sixty-two children (15.1%) failed the screening, with a significantly higher failure rate for Bumiputera children (16.34%) compared to non-Bumiputera children (4.08%) (χ 2 (1, 410) = 5.21; P = 0.024). After adjusting for confounders, Bumiputera children were four times more likely to fail vision screening (OR: 4.54; 95% confidence intervals [CI]: 1.07, 17.76; P = 0.044). Other socioeconomic factors were not significant predictors for failing vision screening. Conclusion: Preschool children's ethnicity is associated with vision screening outcomes. Bumiputera children are more likely to fail vision screening than their non-Bumiputera peers.

Association between reduced visual-motor integration performance and socioeconomic factors among preschool children in Malaysia: A cross-sectional study.

Visual-motor integration (VMI) is related to children's academic performance and school readiness. VMI scores measured using the Beery-Bucktenicka Developmental Test of Visual-Motor Integration (Beery-VMI) can differ due to differences in cultural and socioeconomic backgrounds. This study compared the VMI scores of Malaysian preschoolers with the corresponding US norms and determined the association between their VMI scores and socioeconomic factors. A cross-sectional study was conducted among 435 preschoolers (mean age: 5.95±0.47 years; age range: 5.08-6.83 years) from randomly selected public and private preschools. VMI scores were measured using Beery-VMI in the preschools' classrooms. Information on the socioeconomic characteristics of the preschoolers was obtained using a parent-report questionnaire. One sample t-test was used to compare their VMI scores with the corresponding US norms. Multivariate logistic regression models were used to explore the influence of socioeconomic factors on the preschoolers' VMI scores. Overall, Malaysian preschoolers' VMI performance was similar to the US standardized norms (p>0.05). Children from low-income families were twice likely to obtain lower than average VMI scores than those from higher-income families (OR = 2.47, 95%CI 1.05, 5.86). Children enrolled at public preschools were more likely to obtain a lower than average VMI score than those who enrolled at private preschools (OR = 2.60, 95%CI 1.12, 6.06). Children who started preschool at the age of six were more likely to obtain lower than average VMI scores than those who started at an earlier age (OR = 4.66, 95%CI 1.97, 11.04). Low maternal education level was also associated with lower than average VMI score (OR = 2.60, 95%CI 1.12, 6.06). Malaysian preschoolers' Beery-VMI performance compared well to their US counterparts. Some socioeconomic factors were associated with reduced VMI scores. Those from disadvantaged socioeconomic backgrounds are more likely to have reduced VMI performance, potentially adversely affecting their school readiness, cognitive performance, and future academic achievements.

Do reduced visual acuity and refractive error affect classroom performance?

The role of visual acuity and refractive errors in the academic performance of children is controversial due to the variable quality of the research in this area and the mixed findings reported. This review aims to provide clarity by reviewing and critiquing relevant peer-reviewed publications and also summarises what is known regarding the visual demands of modern classroom environments. The outcomes of this review suggest that while a number of studies have investigated the role of vision in relation to children's academic performances, the veracity of the evidence obtained from the majority of these studies is undermined by methodological limitations. Comparisons between studies are constrained by differences in experimental designs, instrumentation and sample characteristics. Despite these limitations, the weight of evidence suggests there is an association between academic performance and both visual acuity and refractive error in children. However, well-designed experimental studies are necessary to further understand the relationship between these parameters.

Visual demands in modern Australian primary school classrooms.

BACKGROUND: The visual demands of modern classrooms are poorly understood yet are relevant in determining the levels of visual function required to perform optimally within this environment. METHODS: Thirty-three Year 5 and 6 classrooms from eight south-east Queensland schools were included. Classroom activities undertaken during a full school day (9 am to 3 pm) were observed and a range of measurements recorded, including classroom environment (physical dimensions, illumination levels), text size and contrast of learning materials, habitual working distances (distance and estimated for near) and time spent performing various classroom tasks. These measures were used to calculate demand-related minimum criteria for distance and near visual acuity, contrast and sustained use of accommodation and vergence. RESULTS: The visual acuity demands for distance and near were 0.33 ± 0.13 and 0.72 ± 0.09 logMAR, respectively (using habitual viewing distances and smallest target sizes) or 0.33 ± 0.09 logMAR assuming a 2.5 times acuity reserve for sustained near tasks. The mean contrast levels of learning materials at distance and near were greater than 70 per cent. Near tasks (47 per cent) dominated the academic tasks performed in the classroom followed by distance (29 per cent), distance to near (15 per cent) and computer-based (nine per cent). On average, children engaged in continuous near fixation for 23 ± 5 minutes at a time and during distance-near tasks performed fixation changes 10 ± 1 times per minute. The mean estimated habitual near working distance was 23 ± 1 cm (4.38 ± 0.24 D accommodative demand) and the vergence demand was 0.86 ± 0.07(Δ) at distance and 21.94 ± 1.09(Δ) at near assuming an average pupillary distance of 56 mm. CONCLUSIONS: Relatively high levels of visual acuity, contrast demand and sustained accommodative-convergence responses are required to meet the requirements of modern classroom environments. These findings provide an evidence base to inform prescribing guidelines and develop paediatric vision screening protocols and referral criteria.

Simulated astigmatism impairs academic-related performance in children.

PURPOSE: Astigmatism is an important refractive condition in children. However, the functional impact of uncorrected astigmatism in this population is not well established, particularly with regard to academic performance. This study investigated the impact of simulated bilateral astigmatism on academic-related tasks before and after sustained near work in children. METHODS: Twenty visually normal children (mean age: 10.8 ± 0.7 years; six males and 14 females) completed a range of standardised academic-related tests with and without 1.50 D of simulated bilateral astigmatism (with both academic-related tests and the visual condition administered in a randomised order). The simulated astigmatism was induced using a positive cylindrical lens while maintaining a plano spherical equivalent. Performance was assessed before and after 20 min of sustained near work, during two separate testing sessions. Academic-related measures included a standardised reading test (the Neale Analysis of Reading Ability), visual information processing tests (Coding and Symbol Search subtests from the Wechsler Intelligence Scale for Children) and a reading-related eye movement test (the Developmental Eye Movement test). Each participant was systematically assigned either with-the-rule (WTR, axis 180°) or against-the-rule (ATR, axis 90°) simulated astigmatism to evaluate the influence of axis orientation on any decrements in performance. RESULTS: Reading, visual information processing and reading-related eye movement performance were all significantly impaired by both simulated bilateral astigmatism (p < 0.001) and sustained near work (p < 0.001), however, there was no significant interaction between these factors (p > 0.05). Simulated astigmatism led to a reduction of between 5% and 12% in performance across the academic-related outcome measures, but there was no significant effect of the axis (WTR or ATR) of astigmatism (p > 0.05). CONCLUSION: Simulated bilateral astigmatism impaired children's performance on a range of academic-related outcome measures irrespective of the orientation of the astigmatism. These findings have implications for the clinical management of non-amblyogenic levels of astigmatism in relation to academic performance in children. Correction of low to moderate levels of astigmatism may improve the functional performance of children in the classroom.

Impact of simulated hyperopia on academic-related performance in children.

PURPOSE: To investigate the impact of simulated hyperopia and sustained near work on children's ability to perform a range of academic-related tasks. METHODS: Fifteen visually normal children (mean [±SD] age, 10.9 [±0.8] years; 10 male and 5 female) were recruited. Performance on a range of standardized academic-related outcome measures was assessed with and without 2.50 diopters of simulated bilateral hyperopia (administered in a randomized order), before and after 20 minutes of sustained near work, at two separate testing sessions. Academic-related measures included a standardized reading test (the Neale Analysis of Reading Ability), visual information processing tests (the Coding and Symbol Search subtests from the Wechsler Intelligence Scale for Children), and a reading-related eye movement test (the Developmental Eye Movement test). RESULTS: Simulated bilateral hyperopia and sustained near work each independently impaired reading, visual information processing, and reading-related eye movement performance (p < 0.001). A significant interaction was also demonstrated between these factors (p < 0.05), with the greatest decrement in performance observed when simulated hyperopia was combined with sustained near work. This combination resulted in performance reductions of between 5 and 24% across the range of academic-related measures. A significant moderate correlation was also found between the change in horizontal near heterophoria and the change in several of the academic-related outcome measures, after the addition of simulated hyperopia. CONCLUSIONS: A relatively low level of simulated bilateral hyperopia impaired children's performance on a range of academic-related outcome measures, with sustained near work further exacerbating this effect. Further investigations are required to determine the impact of correcting low levels of hyperopia on academic performance in children.

Simulated hyperopic anisometropia and reading, visual information processing, and reading-related eye movement performance in children.

PURPOSE: This study investigated the impact of simulated hyperopic anisometropia and sustained near work on performance of academic-related measures in children. METHODS: Participants included 16 children (mean age: 11.1 ± 0.8 years) with minimal refractive error. Academic-related outcome measures included a reading test (Neale Analysis of Reading Ability), visual information-processing tests (Coding and Symbol Search subtests from the Wechsler Intelligence Scale for Children), and a reading-related eye movement test (Developmental Eye Movement test). Performance was assessed with and without 0.75 diopters of simulated monocular hyperopic defocus (administered in a randomized order), before and after 20 minutes of sustained near work. Unilateral hyperopic defocus was systematically assigned to either the dominant or nondominant sighting eye to evaluate the impact of ocular dominance on any performance decrements. RESULTS: Simulated hyperopic anisometropia and sustained near work both independently reduced performance on all of the outcome measures (P < 0.001). A significant interaction was also observed between simulated anisometropia and near work (P < 0.05), with the greatest decrement in performance observed during simulated anisometropia in combination with sustained near work. Laterality of the refractive error simulation (ocular dominance) did not significantly influence the outcome measures (P > 0.05). A reduction of up to 12% in performance was observed across the range of academic-related measures following sustained near work undertaken during the anisometropic simulation. CONCLUSIONS: Simulated hyperopic anisometropia significantly impaired academic-related performance, particularly in combination with sustained near work. The impact of uncorrected habitual anisometropia on academic-related performance in children requires further investigation.

Heredity factor in myopia development among a sample in Klang Valley, Malaysia.

BACKGROUND: Development of myopia among young children is often contributed to the refractive status of the parents. This study was conducted to determine whether myopia can be inherited across the generation among a sample in the Klang Valley. Three generations involved are: G1 (grandparents), G2 (parents) and G3 (children). METHODS: Sixty-two families were screened and forty families were selected to participate in this study. The inclusion criterion is having at least one myopic member in any of the three generations. Subjects (G2) were first asked to fill up a questionnaire form before their refractive status was determined by clinical examination that provided acuity of 6/6 or better. Refractive status of G1 was determined using information from the questionnaire while for G2 and G3 through clinical examination. RESULTS: Generally, the prevalence of myopia is seen to increase throughout the generations from G1 being the lowest (25.6%) to G3 being the highest (41.1%). Strong genetic influence can be found between G1 and G2 as majority of myopes in G2 is when both parents were myopic. However, although the prevalence of myopia increased from G2 to G3, there was no strong genetical influence. Majority of subjects in G3 were non-myopes when both their parents were myopic. CONCLUSION: Parental history accounts for a limited proportion of variance in myopia development.