DIAGNOSTIC AND THERAPEUTIC CHALLENGES
Year : 2017 | Volume
: 29 | Issue : 2 | Page : 121--130
Vision screening at schools: Strategies and challenges
Department of Ophthalmology, Little Flower Hospital and Research Centre, Angamaly, Kerala, India
Nellikunnath House, Pudukad, Thrissur - 680 301, Kerala
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Sathyan S. Vision screening at schools: Strategies and challenges.Kerala J Ophthalmol 2017;29:121-130
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Sathyan S. Vision screening at schools: Strategies and challenges. Kerala J Ophthalmol [serial online] 2017 [cited 2020 Jan 23 ];29:121-130
Available from: http://www.kjophthal.com/text.asp?2017/29/2/121/212768
A Different” Clinical Query
Dr. Sanitha Sathyan
Early detection and treatment of childhood ocular problems has a huge role in eliminating avoidable causes of visual impairment in our country. Conventionally, this is accomplished through school screening programs, which are quite popular in most parts of India. However, the traditional systems of school screening raise issues related to efficiency of screening, cost-effectiveness, adherence to compliance postscreening, etc. Innovative strategies and revision of protocols based on evidence from the field have a long way to go in ensuring the sustainability of existing school screening programs. Due to the high priority of refractive errors and school screening camps toward elimination of childhood visual impairment, this clinical query section focuses on this issue, from a public health perspective.
Dr. Rahul Ali, MS, MPH, MBA, Country Director, ORBIS India
Dr. Parikshit Gogate, MS, FRCS, M. Sc (Community Eye Health), Dr. Gogates' Eye Clinic, Pune
Dr. Asim Sil, Medical Director, Vivekananda Mission Asram Netra Niramay Niketan, Midnapur, West Bengal
Dr. Srinivas Marmamula, M. Sc (Community Eye Health), PhD, Gullapalli Pratibha Rao International Centre for Advancement of Rural Eye Care, LV Prasad Eye Institute, Hyderabad
Ms. N. Anuradha, BS (Opt), FBDO, Faculty and Vision Screening Co-ordinator, Elite School of Optometry, Sankara Netralaya, Chennai
Mr. R. Meenakshi Sundaram, MHM, Senior Manager – Outreach, Aravind Eye Care System (AECS) and Ms. R. Dhivya, MBA, LAICO-AECS
What Is the Current Role of School Screening Camps in India?
Dr. Rahul Ali
Vision and learning are closely related to each other and school is the first formal space for learning. Since 80% of what a child learns is visual, in case, they have a problem she/he suffers not only from poor vision but also faces critical setbacks in development. When children have difficulty in seeing clearly, be it the blackboard or their books, it hampers their ability to learn in the classroom with their peers. These children run the risk of being labeled as poor performers, uninterested, naughty, etc., for no real fault of theirs. Often they are isolated by their peers during games, sports, or other cocurricular activities in the school as well as in their community.
School-age children constitute a particularly vulnerable group because of the high prevalence of refractive error – myopia, hypermetropia, and astigmatism. When refractive errors are left uncorrected or when the correction is inadequate, they can cause severe visual impairment and even blindness. Refractive errors may not be addressed for a variety of reasons, including lack of awareness by the individual or their family, children not realizing that they are not seeing clearly, limited availability, or affordability of refractive services including glasses and cultural stigma that discourage the use of glasses.
Therefore, the key role of school eye health programs is to identify children with eye problems as early as possible and provide quality treatment on time. School eye health programs also help increase awareness among children, teachers, and school staff as well as parents about the importance of eye health and need for preventive or regular eye examinations. Timely intervention contributes to the improved participation of children within the school system– both academics as well as cocurricular activities helping them realize their full potential.
In India, eye screenings for schoolchildren are largely done by school teachers trained either under the National Programme for Control of Blindness (NPCB) or by the outreach teams of not-for-profit eye hospitals. Most schools, however, do not consider eye screening important enough to formally include as part of their annual academic calendar.
Dr. Parikshit Gogate
School screening camps are done for various motives. Some philanthropists, doctors, optometrists, and service clubs do it because they want to do “something” for the society or for the children. While enthusiasm may be very high, the quality of examination is often questionable. Some are done because some activity needs to be done or for marketing purposes. It may be a one off screening camp, often limited to older children as they are easy to examine. Dispensing of spectacles is not a norm. Some insist that the parents need to buy spectacles from the organizers at a full or subsidized cost. However, many do the eye screening camp as they would examine in their clinic: distance near visual acuity, color vision examination, external ocular examination, ocular motility/orthoptic evaluation, and fundoscopy. They also dispense spectacles to those with a significant refractive error. Cycloplegic refraction is done where indicated. Published research shows that parents often do not purchase spectacles. Hence, giving them free or at a subsidized rate, at least to those with a significant refractive error, is needed.
Dr. Asim Sil
The school screening in India aims at detecting refractive error among schoolchildren (REACH). There are wide variations inside the country in its operations. In some region, it is effectively implemented; in some areas, it is just a ritual. This program has been in operation for decades but failed to create enough consciousness among parents.
Dr. M. Srinivas
Visual impairment affects a significant proportion of children in school age group, refractive error being the primary cause. Schools form a captive group where vision screening can be done to detect vision problems and provide glasses. In India, it is common to engage teachers for primary level vision screening schools. The NPCB in India recommends to engage female teachers, preferably those with spectacles for primary screening. Typically, the vision screening is conducted among the 10– 15-year age groups. However, younger children are also screened in few locations.
A typical training program for teachers includes vision screening (theory and practical session) and creating awareness about common eye conditions that affect children. The trained teachers will do the initial vision screening for all the children in their respective schools. Depending on the strength of the school, more than one teacher can be trained for primary screening. All the children who fail the screening test are referred for a more detailed eye examination which is typically done either by an ophthalmic assistant or an ophthalmologist. Those who need spectacles are provided with and those with more serious eye conditions are provided with service at higher centers. Our research has shown a large variability in diagnostic ability among teachers to pick-up children with visual impairment, whereas having dedicated field workers were more consistent in the detection of vision problems in these children. Vision screening in schoolchildren is carried out using a simple vision screening chart. The vision chart that is used by teachers corresponds to 6/9 optoypes. The chart has four optotypes and a child is considered to have successfully passed the test if three of the four optotypes are identified correctly. However, more recently 6/12 optotypes are recommended for primary level screening by trained school teachers.
Ms. N. Anuradha
Schoolchildren eye screening camps aim to detect vision impairment among children at an early stage and provide management. Vision impairment in children could have short-term implications such as loss of dependency, education, and employment opportunities. Long-term implication would include strabismus, amblyopia, and even blindness (Jose, Sachdeva). Early management of vision impairment would enhance the quality of life of children (Gilbert, Foster). Having identified the need for this early detection, NPCB included School eye screening as one of its key agenda since 1994. Identification of schools, training of school teachers in performing basic vision screening, provision of spectacles, and referral are the current activities of the school screening programs (Jose, Sachdeva).
According to 2011 census, 41% of children are Mr. R. Meenakshi Sundaram/Ms.R. Divya
School screening is the predominant strategy to screen for eye conditions among school-age children. These camps are usually initiated by either non-governmental organization (NGO) hospitals or by funding agencies such as Lions Clubs or Orbis who work with partner hospitals to implement the program. Government participation in this program has been more recent in some states where the Sarva Shiksha Abhiyan (SSA) programme included the provision of eye glasses for children. Children are a captive target group when approached through the school screening program and if done well can be a strong mechanism to ensure that childhood eye conditions are detected and managed in a timely manner. However, in this case, the quality of care delivered relies heavily on outside stakeholders to do their part well: school principals give the necessary priority, school teachers undergo the training and do the screening diligently, and parents understand the importance of eye care and encourage compliance among their children. Where this is not done well or not monitored, the programmed cannot claim to be truly effective.
It is essential to close to the treatment pathway:
Those who need glasses should be able to procure them – this is a common practice to provide free or subsidized glasses that encourages uptakeThose receiving glasses should wear them as instructed – several studies report spectacle wear compliance is reported to be poor across the countryThose referred to higher levels of care – again the uptake of the referral is reported to be very poorThose requiring further investigations or procedures – here, the uptake is poor and there are several other barriers which the original school screening program may not have planned for.
First, it is important to begin to monitor and review indicators that measure the above performance.
Even when done well, we need to realize that this cannot be a one-episode event for a particular school. It is evident that children found to have an eye problem should have regular, long-term reexamination and management. However, regular engagement of schools on an ongoing basis is not a common practice.
As per the guidelines of NPCB, the government schools have to be served by the PHC-based ophthalmic assistants in terms of training to the teachers and final examination and delivering glasses. Glasses dispensing can be done through the District Programme Manager. The grant is also allocated by District Health Society. As per the Five-Year Plan, 9 lakhs is budgeted for schoolchildren glasses for the whole country per year. SSA Teachers are added with responsibility of regular school teachers for preliminary assessment in some areas. In some places, the SSA Teachers act like Trainer of Trainees.
What Are the Major Obstacles Met With during Community Screening for Visual Problems in Children?
Dr. Rahul Ali
In the case of schools, obtaining permissions from the district/school authorities for holding an eye screening activity is a major challenge; school authorities often feel that the screening program interferes with their regular academic calendar and does not add value to the school or to the childrenHigh absenteeism in some schools poses a major challenge for the screening team to cover the entire school in a single visitMany young children who need glasses require cycloplegic refraction before a final prescription can be given. The act of having to put drops in their eyes and the resultant effect of having a dilated pupil for some time thereafter can make children reluctant from getting the examination and parents or school authorities from giving permissions for the examination. In addition, in certain regions of the country, government authorities have rules preventing instillation of any drops in the eye in the school premises. This forces the team to refer these children to the vision center or the base hospital for a cyclopegic refraction resulting in many dropoutsExisting myths around blindness and visual impairment prevalent in the community act as barriers in uptake of screening and resultant treatment including glassesPrevious bad experiences with quacks or traditional healers can increase skepticism toward accepting any eye health service providedThere is limited demand for services as often the community still does not consider eye care a health priority.
Dr. Parikshit Gogate
The major problem is that teachers and parents do not feel that refractive errors, or visual problems, in children are a priority. Spectacles are something for the mature of the elderly. An eye examination is often considered a waste of time and resources. This is changing, especially in urban areas. Furthermore, many schools do not have a place where a proper eye place screening (with its distance and illumination requirements) can be done. The screening camp is considered a distraction to normal academic activities and often an extra burden to the teachers. Teachers in government schools are already burdened with considerable nonacademic tasks.
Dr. Asim Sil
Low awareness level about eye problems in children among the communityLengthy process of permission for school screeningIn West Bengal, issues related to sickness of children after consumption of deworming medication have created a negative impact among school teachersEnsuring service to children including timely supply of spectacles.
Dr. M. Srinivas
One of the main challenges for undertaking a school screening is getting approval from competent authorities at different levels. This is often a time-consuming and long-drawn process. It is also not uncommon for the school to deny participation in these programs. This happens more often in private schools in urban locations. Lack of time and availability of teachers is the most commonly quoted reason for their nonparticipation.
The results of the screening largely depend on the motivation levels of the teachers in conducting vision screening in their schools after receiving their training. It also depends on the importance given to this exercise by the school head master/principal. It is still not know as what factors make a teacher a good vision screener. While some school authorities view vision screening process as an important “value addition” that school can provide to their children, some consider this as routine activity that just needs to be done.
Maintaining quality standards across the schools is another challenge. Reporting of results of the screening from school authorities is also very important so that the data from various schools can be compiled and services can be provided when needed. Especially in government schools, in rural areas, regular attendance of students can be an important issue. This can be overcome by prior announcement of the vision screening dates and also by doing the vision screening exercise on multiple days over a span of 2 weeks.
Ms. N. Anuradha
Success of any health program lies in the acceptance and compliance to the management provided. In school eye screening, the program is generally completed with the provision of spectacles. However, studies from India report compliance to spectacle wear up to 30% only (Gogate et al.). There are various barriers identified for poor compliance to spectacle wear that could be categorized as (a) physical barriers including scars on the nose, poor style of the spectacle frames, and lack of choice to children on spectacle frames, (b) psychological barriers including adolescents feeling discriminated and set apart, fears of injury to eyes, and (c) societal barriers like lack of parental involvement and negative attitudes of society toward those wearing spectacles (Anuradha et al.). It is essential that region specific barriers are understood, and interventions that would improve spectacle wear are planned accordingly.
Apart from uncorrected refractive errors, other ocular conditions such as squint, ptosis, and cataract need immediate referral and management as these conditions could leave long-term implications on children. These referrals are yet to become an integral part of the school eye screening. Literature reports that parents seek care for children only when the problem is obvious and persistent like the presence of redness (Balasubramaniam et al.). Overcoming logistical difficulties in planning visit to hospital and improving awareness about these conditions are important.
Follow-up for ensuring compliance to spectacle wear and referral must be made a part of all the school screening programs to truly combat blindness among children. Recent population-based studies worldwide provide evidence for the high prevalence of nonstrabismic binocular vision anomaly (NSBVA) ranging between 28% and 32% among schoolchildren (Wajuhian et al.; Jang et al.). The prevalence of NSBVA among schoolchildren between 7 and 17 years of age in South India has been reported to be as high as 30.8% (Hussaindeen et al., 2016; article in press). This high percentage of NSBVA suggests the need for routine screening for these anomalies among schoolchildren in the community. They also state that accommodative and vergence dysfunctions can significantly impair the reading performance of a child, especially after the third grade due to the increasing visual demands of the child.
The color vision anomalies and color vision defects affect around 8% of males. Screening of schoolchildren for color vision defects, especially boys, would help in identifying those with the problem. Since few of the career choices refrain from selecting children with color vision defects, this initiative would help them plan their career accordingly. Counseling the children and parents would help plan their future.
Mr. R. Meenakshi Sundaram/Ms. R. Divya
As per the budget and availability of Paramedical Ophthalmic Assistants, the program cannot be done in all the government and government-aided schools. The NGO eye hospitals are not permitted to do similar kind of training and screening camps in government and government-aided schools as the national level scheme exists. Obtaining official permission to conduct teachers training program becomes a big challenge in many places. Unfortunately, more schoolchildren neither served by the PMOAs nor by NGOs.
Unfortunately, the children who are advised for glasses are not delivered on time in government schools. It is delivered after a long time in some places.
Even, the NGO eye hospitals deliver the glasses and not monitored or followed up to ensure the usage rate after a month. It is not done as a standard protocol. As mentioned above, the usage rate is very low for many reasons.
As mentioned above, the children who have other eye problems like strabismus are not continuously monitored as we give our focus to glaucoma/retina kind of patients. These obstacles can be addressed and rectified by developing a system and trained technical workforce. These are the challenges.
How To Tackle The Issue Of Noncompliance To Spectacles And Amblyopia Therapy From A Public Health Point Of View?
Dr. Rahul Ali
The issues of noncompliance with spectacle wear and amblyopia therapy has been a long-standing challenge in school eye health programs. A few ways to tackle noncompliance of spectacles are as follows:
Involve parents throughout the entire process
Before school screening – announcement and discussions during the parent– teacher meeting in schools circulate information to the parents through the childrenDuring school screening – involve parents as volunteers on the day of the screeningAfter school screening: counsel the parent, teacher, and child about the benefits of glasses, why and how one should use them and take care of them, etc., while dispensing glasses
Make children an integral part of school eye health activities – involve them as volunteers, information disseminators, tell stories, organize street plays, and play videos or cartoons on eye screening and spectacles useEnsure that a variety of spectacle models (frames) are available and allow children to choose their own frames. The chances of a child wearing glasses that they have chosen for themselves are a lot higher than a child simply receiving a standard pair of “free glasses”Create a mechanism by which minor adjustments can be made on-site when glasses are delivered to the children. This will ensure that the glasses fit well and are comfortable for the child to wearDevelop a mechanism for peer learning in schools and the community to ensure regular use and maintenance of the spectacles. This also reduces bullying and teasing of the children wearing spectacles.
Amblyopia has to be diagnosed at the hospital after a comprehensive examination. Hence, diagnosis and treatment is restricted to the hospital spaces rather than integration into the outreach efforts in the community. However, a similar approach as that of spectacle compliance is applicable to this too – awareness, parental involvement, child-friendly eye patches, mechanism for peer learning, etc.
Dr. Pariksit Gogate
The parents and teachers need to be educated that the children need to wear/use their spectacles on a regular basis so that they see well that their visual system develops and that it would improve their learning outcomes. The child should be counseled too. It would help him not only read and write better but also see the television more clearly and allow him to drive later. It may be linked to whatever he thinks is his/her future career (engine driver, pilot, or a doctor). The limited window period available to treat amblyopia should be explained too. Our research shows that if children are allowed to choose their spectacle frames, they are more likely to wear them (like their dresses). Furthermore, attractive, colorful, and light frames go a long way. Research, from Mexico, China, and Pune, India, shows that girls, younger children, and these from small towns and villages are more compliant with spectacles.
Dr. Asim Sil
More awareness creation in an effective way
Counseling parentsPrescribing glass only for significant refractive errorAvoiding uniform design of frames for all children, giving them a choice to select framesQuality spectacles, unbreakable plastic lenses.
Dr. M. Srinivas
The correction of refractive errors not only entails prescription of spectacles but also appropriates dispensing and then the continuous use of spectacles by the children. Poor compliance to spectacles use has been reported from several studies. Understanding the reasons will enable us to address them, as the reasons could vary considerably across different regions. The reasons could range from personal to family to social or societal regions. Apart from this, there may be reasons associated with the provision of service and dispensing protocols.
If the spectacles are dispensed for small magnitude of refractive errors that is unlikely to cause visual impairment, then children may not feel the need of using spectacles as they will not find any benefit of using spectacles. This may be more common if the refractive error is unilateral. Children tend to have their preferences for the spectacle frame that they wear. Involving children in selection of frames can motivate them to wear spectacles. Having a good collection of frames for the children to choose from instead of standard set of frames often leads to a better compliance. Most programs tend to have a fixed set of frames for dispensing and this may be detrimental to long-term spectacles compliance. Furthermore, the quality of lens and the spectacle frames is equally important. It is suggested that all the children who need spectacles should be dispensed with CR-39 lens and preferably in a shell frame. If spectacles are broken too soon due to poor quality issues, then credibility and benefit of the school eye health program may be at stake. Furthermore, spectacles should be dispensed as soon as possible. If there is a large gap between the refraction and actual dispensing of spectacles which is often seen in some programs, then spectacle compliance may not be good. In some situation, children might have moved out of schools or refractive errors might have changed in occasional cases.
Spectacles use among children may be a social stigma, especially girls in certain families. The spectacles are often seen as symbol of defective eyes and serious eye problems. Educating parents on the need for spectacles with a clear emphasis on the benefits the child may have with the use of spectacles will lead to better spectacle compliance in children. Teacher's role should not only be restricted to vision screening but also should ensure that children get services needed and use the spectacles on a regular basis. Generating awareness among the community at large on refractive errors and the benefits of using spectacles can help in ensuring better compliance among children. This is where the media has a huge role to play for a long-term public health measure.
Ms. N. Anuradha
Noncompliance to spectacle wear means that uncorrected refractive errors remain still a burden. Interventions to improve compliance should be part of any school screening program. Since there are many barriers identified from various reports, solutions to overcome these barriers should also aim at targeting these identified barriers.
Frames that are provided free in the screening programs lack appeal, forcing children to discontinue its use. Measurements for individual children are important for a well-fitting frame to relieve children of discomfort rather than bulk ordering. Parents are not informed of their children's visual or refractive status, and they also seem to lack awareness about the need for spectacles. Literature refers to well-fitting, trendy frames of adolescents' choice, involvement of parents in the screening program, and interesting awareness sessions to tackle these barriers (Anuradha et al.).
Since refractive errors are not life-threatening, there are no mass campaigns on emphasizing the use of spectacles. However, considering the effect spectacles have on the quality of life of children, such steps are essential. It is also essential to bring about a behavioral change in the attitude of society and its members toward spectacle wear with the help of media.
With a significant number of children to be screened, effective strategies to reach out to the children are reported such as rapid assessment strategies (Marmamula et al.) and single day screening strategies (Anuradha et al.). Such models should be effectively utilized in the screening strategies.
Mr. R. Meenakshi Sundaram/Ms. R. Divya
The school teachers and parents can be motivated to increase the compliance rate. In many places, the training for school teachers is perceived as a burden. The management is not realizing the need for such kind of training and focusing the academic activities. The training exposure gives an ownership among the teachers. Teachers can easily influence the parents for better compliance.
How Can You Make School Eye Screening More Child-Friendly and Acceptable?
Dr. Rahul Ali
Although it is challenging to create a child-friendly environment within the community especially in the rural areas, there are ways to use local resources to develop an enabling environment to facilitate screening.
Children (age group 5– 10 years)
Deploying female vision screeners/taking support of class teacher(s)Avoiding the using of white coat (apron) by the eye health professionals because children often get intimidatedCreating an ambience that can interest children such as placing toys and distributing colorful balloonsDistributing comics as well as playing videos or cartoons on eye health during the screening program to playfully engage with the children on a seemingly serious subject like eye health.
Children (above 10 years)
Storytelling by the class teacher on eye screening. This will help prepare them for the upcoming screening activityDistributing comics as well as playing videos or cartoons on eye health during the screening program to playfully engage with the children on a seemingly serious subject like eye healthDisplaying popular public figures or cartoon characters wearing spectaclesMaking children responsible for some of the activities during the screening camp.
Dr. Parikshit Gogate
Make the child a participant in the eye screening program rather than just a recipient. Explain them what we are going to do and why are we doing it. How long it would take and what would it lead to (a pair of spectacles or further evaluation in an eye clinic). Schedule the activity when the children and teachers have time. Not during their busy period or near examinations. Enlist the benefits of a good visual acuity to teachers and children.
Dr. Asim Sil
Engaging children in the process in different locally appropriate way
Developing friendly relations with school teachersHorizontal networking with other agencies working for children.
Dr. M. Srinivas
If school screening is perceived as an important activity by the school authorities and teachers participate in the process activity, children tend to follow the suit. It should be conducted in “play-way” manner without compromising on the quality. Then, the children will participate more actively. If it is perceived by the children as “eye examination” to detect eye problems and thus they may become nervous and uncomfortable. This is where their favorite teacher can help! If someone who is considered as a strict teacher is doing the screening, then the children may get scared to get themselves examined and may also give inappropriate responses during vision screening test.
Ms. N. Anuradha
School eye screening initiatives should be planned with unique activities so that all the stakeholders of the screening including children, parents, teachers, eye care professionals, and other volunteers are made part of this program.
Vision ambassadors training program
A unique program to raise awareness makes children a part of the screening program enhancing their involvement is proposed. As a team, this group of volunteers under the supervision of teachers would also follow-up children for compliance.
Prizes in the prayer session from the school headmaster to students for compliance to spectacle wear and compliance trophy to schools that had maximum proportion of compliance could motivate children and the school authorities.
Providing choice of frames to children by introducing trendy colorful spectacle frames.
On occasions like Children's day and World Sight day, unique competitions on eye care awareness and events such as human chain and rally would ensure participation of all the children in the school. This would also aim in other children understanding the need for spectacles and overcoming teasing, a predominant barrier for spectacle compliance.
Interesting awareness sessions: special sessions through cartoons, small movies, skit, science projects should be executed so that the sessions are of interest to the children.
Mr. R. Meenakshi Sundaram/Ms. R. Divya
Compared to school screening, other strategies are not as effective in reaching out to children, especially those who are under 5 years of age and children who are out of school. Reaching the younger-aged children becomes essential for early detection of cataracts and other eye defects to prevent the onset of amblyopia. The Anganwadi system is one way of effectively reaching this age group. However, both school screening and Anganwadi screening do not ensure complete coverage or regular access for children to receive eye care. As providers, we tend to organize the outreach efforts in convenient areas and larger schools to ensure efficiency. However, the schools and communities in smaller rural areas that are harder to reach out to are left out with a thought that it is these that need this service the most.
For this, it is necessary for us to provide eye care available at locations that are convenient to the community. Primary eye care facilities can play a significant role in addressing this need. They can be equipped for basic eye screening and detection of common pediatric eye conditions. These centers can also encourage their communities to ensure that the children are brought in for routine eye examinations as many of these conditions are not self-reported. These centers can be the conduit for providing ongoing continuous care.
First of all, there is no clarity or not educated regarding the magnitude of eye care needs in the pediatric age. We predict that 0.008% of children may have childhood blindness. We are used to target a number of persons to attend community eye screening with various eye problems which cannot be done for pediatric eye screening camp. The defect rate is very low. Anganwadi workers are the key link persons. They have to be trained like school teachers to do a kind of preliminary assessment, and the children can be mobilized for a specially arranged pediatric camp or nearby primary eye care center or hospital. Again a formal instruction has to be issued by government authority to get buy in from Anganwadi workers otherwise it would be difficult. Furthermore, the workforce to screen pediatric eye problems has to be strengthened and increased.
What Are Your Suggestions For Improving The Current Model Of School Eye Screening In India?
Dr. Rahul Ali
School eye screening is nothing new to us and there are several models of school eye health programs currently operational across the country. Most models employ teachers as the first point of contact, i.e., the person who conducts the primary screening of the schoolchildren. This is efficient considering the huge cohort that needs to undergo screening. However, the teachers' training should be standardized, and a robust quality assurance mechanism should be put in place to ensure consistent and accurate outcomes to minimize both false positives and false negatives.
Most school-based programs end with the distribution of spectacles and there is no mechanism to determine whether children who are given spectacles are using them or not. Hence, there is no opportunity to identify the challenges or barriers for compliance. The REACH program, a school eye health program of Orbis in India, has built into the process a compliance check at 3 months after giving glasses and an annual follow-up mechanism within the program to address this concern. This approach has provided the screening teams not only with an opportunity to evaluate the success of the intervention but also a chance to identify any specific reason for noncompliance as well as a mechanism for dealing with repair or replacement in case of minor problems or breakage of the glasses that were provided earlier. Annual follow-up also helps create a formal relationship between the eye health provider and the school which creates an opportunity for continuity of care.
Another challenge encountered by the most outreach programs – school eye health programs are no exception – is an easy and efficient way of capturing data. School screening programs deployed across the length and breadth of our country for decades should have by now provided us a wealth of information and insights. However, the absence of efficient data management system to capture and manage this large volume of data did not exist and this has been a missed opportunity. To that end, Orbis has developed a bespoke software, REACHSoft, to support the planning, implementation, and management (including monitoring and evaluation) of the REACH program. From the first basic step of scheduling a visit to a school, ReachSoft supports every step of the planning process – collecting the student database, scheduling planning and service delivery activities, and collecting data at the individual student level during the actual service delivery – primary screening, detailed examination, spectacle dispensing, and referral management including monitoring progress as well as generating reports aiding the management of the program. While, better data management and real-time monitoring facilitate the smooth implementation of the program; going forward, we feel the huge data set which will be developed by the end of the program can help in research as well as the development of evidence-based recommendations for improving future programs.
Last, but not the least in any way, a crucial aspect which has to be built into any social or public health intervention to make it sustainable is a strong mechanism to effectively engage and communicate with the stakeholders involved. It is important to first understand the ground reality before attempting to bring about any behavior change. A tool which helps to so this would be a knowledge, attitude, and practice (KAP) study among children, their parents, teachers, service providers, and other relevant stakeholder in the intervention area before intervention. An insight into their current level of knowledge of refractive error, its causes, and treatment; their attitude toward usage of glasses as well as their general eye health-seeking behavior will help to develop a robust communication plan to be deployed in parallel with the service delivery to empower stakeholders with the right information which will make them receptive and accepting of the treatments provided. For example, within the REACH Program, Orbis has conducted a similar KAP survey in five states and will be using these findings to develop customized, locally relevant communication material to increase awareness and generate demand for refractive error services.
Dr. Parikshit Gogate
The eye screening should be standardized: distance, illumination for distance, and near vision. Color vision, orthoptic evaluation, external ocular examination, and if needed fundoscopy should be made a part of the examination. Ensure that, all children are screened and nobody is left out. Make a separate visit for the absentees and those left out in the first visit. Do not prescribe and/or dispense spectacles to children with a small refractive error like − 0.5 or less. It only adds to parents' anxiety and results in noncompliance. Ensure that the screening is linked to dispensing of spectacles, at least to those who cannot afford it and those with a significant refractive error. Otherwise, we have just given the child a piece of paper and increased her/his and her/his parent's anxiety. Educate the children, teachers, and parents the importance of wearing spectacles and the benefits that improved visual acuity shall bring.
Dr. Asim Sil
Revising the protocol based on evidenceLearning from successful models – mostly related to operationsImproving coordination between different stakeholders in both government and nongovernment sectors.
Dr. M. Srinivas
The following suggestions can improve and positively impact school eye screening programs
Use of 6/12 optotypes instead of 6/9 optotypesInvolving children and parents in frame selection can often lead to better spectacles complianceSpectacles should be delivered to children within a maximum period of 2 weeksThe programs should actively involve class teachers who can ensure that children use the spectacles in the schoolsSpectacles should be with robust frame and CR-39 lenses so that they last longer in the hands of childrenShould do follow-up examination among the children dispensed with spectacles to understand the spectacle compliance on a long-term basisTaking school authorities on board before starting the vision screening programs will help in ensuring them accept the programHaving a dedicated day every year for school vision screening will be helpful.
Ms. N. Anuradha
Follow-up should be made an integral part of the school eye screening to gauge complianceReferral for other ocular conditions should be made out of the screening programRegion-specific barriers for compliance to spectacle wear and referral should be identifiedUpgradation in the screening protocol periodically to cater to all aspects of vision impairment among childrenScreening programs should impart interventions to improve compliance ensuring true elimination of avoidable blindness.
Mr. R. Meenakshi Sundaram/Ms. R. Divya
Given the important role of teachers in ensuring the quality of the screening as well as ensuring uptake and compliance to the treatment advised, it is essential that providers put effort into ensuring that they are properly engaged. A recent study has observed the impact of training and engaging “all class teachers” of a school rather than the traditional process of having only a small number of teachers trained to screen the entire school strength. This way, the teachers had less students to screen and it was their own students whom they knew well and could pick out behavioral signs that could indicate defective vision, better than the general screening teachers. Furthermore, these teachers were more willing to take ownership of the uptake and compliance to the treatment advised.
Even though this is being a part of national eye health program, it is not given exclusive focus like cataract and other specialty problems. It should be developed as exclusive program in the 5-Year Plan with defined criteria. An elaborate description has been made for recurrent grant in aid scheme and nonrecurrent grant in aid schemes. There are criteria for participation by any NGO eye hospital in India. At the same time, schoolchildren scheme is not given a structure, focus, etc. Result of that, this program is not viewed as an important scheme and ignored in an intangible way.
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Conflicts of interest
There are no conflicts of interest.