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.

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.

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.

Measuring vision-specific quality of life among adults in Fiji.

PURPOSE: To evaluate an 18-item vision-specific quality-of-life questionnaire designed for use with adults in Fiji. METHODS: Participants in a population-based cross-sectional survey selected by multistage random sampling from those aged ≥40 years living on Fiji's main island had distance and near visual acuity measured. Those with presenting vision impairment (<6/18) and/or presbyopia (

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.

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.

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.

Clinical observations of biofouling on PEO coated silicone hydrogel contact lenses.

Silicone hydrogel contact lenses, which have been a major advance in the field of vision correction, require surface modification or coatings for comfort and biocompatibility. While current coatings show adequate clinical performance, advanced coatings may improve the biocompatibility of contact lenses further by reducing biofouling and related adverse clinical events. Here, we have produced coatings on Lotrafilcon A contact lenses by deposition of a thin film of allylamine plasma polymer (ALAPP) as a reactive interlayer for the high density grafting of poly(ethylene oxide) dialdehyde (PEO(ALD)(2)), which had previously shown complete resistance to protein adsorption in vitro. The performance of these contact lenses was evaluated in a controlled clinical study over 6h using Focus Night and Day (also known as Air Optix Night & Day) contact lenses as control lenses. Surface modified lenses were characterised by X-ray photoelectron spectroscopy (XPS) and atomic force microscopy (AFM) before and after wear. Clinical data showed a high level of biocompatibility of the PEO coated lenses equivalent to control lenses. Surface analysis of worn contact lenses demonstrated that the high density PEO coating is effective in reducing biofouling in vivo compared to control lenses, however small amounts of protein deposits were still detected on all worn contact lenses. This study highlights that elimination of biofouling in vivo can be much more demanding than in vitro and discusses issues that are important for the analysis of worn contact lenses as well as the design of improved contact lenses.

Stated and actual willingness to pay for spectacles in Timor-Leste.

PURPOSE: To conduct a survey of willingness to pay for ready-made spectacles in the low-resource country of Timor-Leste, and, uniquely, subsequent validation with actual payment information. METHODS: A systematic random sampling strategy was used to apply a binary with follow-up stated willingness to pay methodology. Findings were validated by comparing the amount declared willing to pay with the actual price paid at a subsequent visit. RESULTS: Of the 152 participants (96.2%; mean age 50.9 +/- 13.2 years; 50.0% female) agreeable to wearing spectacles if required, 84.9% were willing to pay for them, with 82.9% of these willing to pay at least United States dollars (USD) 0.10. By multivariate analysis, increasing age and owning fewer animals were significantly and independently associated with unwillingness to pay at least USD 0.10. Of the survey participants agreeable to wearing spectacles who attended a later visit (113/152; 74.3%; 53.1% female), the 80.5% who would benefit were offered spectacles, first for USD 1.00. If declined, this was revised to USD 0.10. If this was declined, the spectacles were dispensed, unknown to subsequent attendees, at no charge. The predictive value of stated willingness to pay at least USD 0.10 was 96.3%. CONCLUSIONS: Binary with follow-up stated willingness to pay with validation against actual payment was successfully applied to spectacles in Timor-Leste.

Education of eye health professionals to meet the needs of the Pacific.

Vision impairment has significant impact on quality of life and substantial economic consequences. Yet, in the Pacific Islands, as in other low resource settings, it is predominantly caused by chronic conditions that can be treated or prevented. A whole of health approach is required to rectify this, and must include an increase in workforce capacity, both in size and effectiveness, by providing competency-based education for eye care professionals. Training in curative clinical skills is not sufficient: broader competencies--including those for chronic conditions, issues of care quality, integration into the wider health care system, and commitment to professionalism and life-long learning--need to be addressed. Using current best practice approaches in education, and taking into consideration local needs, The Pacific Eye Institute, an initiative of The Fred Hollows Foundation New Zealand, aims to produce graduates with these core competencies who are capable of effectively and acceptably working in community or hospital settings to provide sustainable high quality, comprehensive eye care with ongoing desirable and consistent eye health outcomes.

Mid-level cadre providing eye care in the context of Vision 2020.

The contribution of the mid-level cadre of eye care providers is an essential component of the Vision 2020: The Right To Sight initiative, to eliminate avoidable blindness by 2020. However, for the past 20 years the functions of this cadre have not been definitively outlined, or universally accepted. Consequently, the competencies they require to provide high quality comprehensive eye care have not been established. This has had implications for both training programmes and the subsequent deployment of the graduates of these programmes. This paper examines, mainly through a review of World Health Organization (WHO) documentation, the progress that has been made in defining the role and outlining appropriately enabling training of this cadre of mid-level personnel. As a result of this analysis, recommendations are made concerning the development of this cadre to provide eye care in the context of Vision 2020: *Develop consistent and widely applicable nomenclature *Outline workplace functions and job descriptions, so that personnel can be categorised by their competencies and functions. *Develop curricula based on the competency requirements of job descriptions and that will prepare personnel for those jobs. *Establish and/or develop training centres, including those capable of training trainers. *Establish government recognition, resources, support, and evaluation and feedback systems to ensure that this mid-level cadre can implement their training, and have the opportunity of providing high quality eye care.

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.