Interventions to improve school-based eye-care services in low- and middle-income countries: a systematic review

Methodological quality of the review: Medium confidence

Author: Anthea M Burnett, Aryati Yashadhana, Ling Lee, Nina Serova, Daveena Braina & Kovin Naidoo

Region: 13 countries

Sector: Eye care service delivery

Subsector: Improving school-based eye-care services

Equity focus: No

Study population: Children

Type of programme: School based

Review type: Other review

Quantitative synthesis method: Systematic review

Qualitative synthesis method: Not applicable

Background: Vision impairment and blindness in children can have negative consequences on their health, education and prospects, which in turn can affect the nation’s broader economic prosperity. Globally, an estimated 19 million children are blind or vision impaired, with the majority of vision impairment being preventable or treatable. School-based eye-care interventions have the potential to provide high-quality and cost-effective services that allow the early detection of eye diseases and prevention of blindness, particularly for children living in remote locations. Identifying methods of improving and strengthening school-based eye-care interventions, particularly in low and middle income countries, is therefore important.

Objectives: The aim of this study was to review interventions improving eye-care services for school children in low and middle income countries.

Main findings: 48 describing school-based eye-care interventions were included in this review. Identified articles were from 13 countries spanning five World Health Organization (WHO) regions, including Africa (eight studies), the Americas (10 studies), the Eastern Mediterranean (one study), South-East Asia (18 studies) and the Western Pacific (11 studies). Availability of school-based eye-care interventions: Overarching factors in the provision of successful school-based eye-care interventions included communication between health services and schools, the willingness of schools to schedule sufficient time while minimising impact, and the support of principals, staff and parents.

School-based eye-care resources: Studies reported that the lack of facilities and tools, such as appropriate charts for vision screening, was a potential barrier to implementing school-based eye-care programmes. The supply of low-cost spectacles was identified as increasing spectacle acceptance. However, other studies reported that spectacle acceptance may be low with free or low-cost spectacles, which can be linked to parental concerns of poor quality.

Health plans and policies: A key policy-based facilitator to the prioritisation of child eye-care is uptake and execution of a national eye-care plan, and the inclusion of eye-care in school health policy. An example from a trachoma intervention in Tanzanian schools outlined that, while elimination of trachoma was prioritised in health policies, it also needed to be incorporated into education curriculums if progress was to be made. Since achieving shared responsibility of the monitoring and execution of policies targeting eye health is considered important in the success of school-based eye-care interventions in low and middle income countries, partnerships between ministries and non-governmental or private organisations are considered crucial.

Accessibility of economic and physical accessibility: The cost of spectacles for children was identified as a significant barrier in many settings. Factors associated with a higher willingness to pay for spectacles included previous or current ownership of spectacles, regular spectacle wear, a recognised need for spectacles or an understanding that vision improves with spectacles. An additional economic factor that was reported to influence the demand of parents or guardians for eye-care services and spectacles was the loss of daily wages due to a lack of a carer to accompany children to additional appointments. Information accessibility: Studies have identified misconceptions regarding the causes and treatment of eye disease and vision impairment as a significant barrier.

Acceptability: Cultural appropriateness, the perspectives of children, parents, eye-care specialists, teachers and the broader community all affect the success of school-based eye-care interventions. Any intervention must be culturally appropriate, as long-standing cultural practices can have a stronger influence than national health policy. Spectacle compliance: Support networks within schools, including health promotion interventions, teacher training and curriculum-based eye health education, were key in correcting negative perceptions regarding spectacles or eye care.

Quality of trained teachers as screeners: There are inherent benefits in using teachers to conduct initial screening, as compared with visiting eye-care specialists, particularly in terms of cost-effectiveness. Financial incentives may encourage teachers to participate and were shown to increase spectacle compliance through additional teacher motivation.

Authors conclude that the provision of school-based eye-care programmes has great potential to reduce ocular morbidity and developmental delays caused by childhood vision impairment and blindness. Policy-based support, while also attempting to reduce misconceptions and stigma among children and their parents, is crucial for continued access.

Methodology: Inclusion criteria consisted of studies which: i) evaluated the delivery of a school-based eye-care programme through vision screening, refractive services or health promotion activities; ii) reported the evaluation results as either spectacle compliance rates, quality of vision screening processes, quality of vision screening personnel, or changes in knowledge or attitudes due to health promotion; or iii) provided other quantitative or qualitative results from follow-up evaluations of school-based eye-care interventions. Authors included cross-sectional epidemiological surveys, prospective observational studies, qualitative studies, economic evaluations and randomised controlled trials.

Literature search was performed on the online databases CINAHL, Embase, ERIC, Medline, ProQuest, PubMed and Web of Science for articles published between January 2000 and May 2018. No language restrictions were placed on the search, but since search terms were in English, we only retrieved English abstracts. We imported citations into Covidence software (Veritas Health Innovation, Melbourne, Australia), where two authors independently reviewed titles and abstracts. Two independent reviewers then appraised study quality using the Mixed Methods Appraisal Tool (v-2011, McGill University, Montreal, Canada. Authors analysed the extracted data qualitatively using NVivo 11 (QSR International, Melbourne, Australia). Thematic deductive coding was applied to identify the a priori themes from the availability, accessibility, acceptability and quality conceptual framework.

Applicability/external validity: Not discussed.

Geographic focus: Not discussed.

Summary of quality assessment:

Medium confidence was attributed to the conclusions about the effects of this review’s findings. Although authors used appropriate methods to analyse the findings of included studies, authors did not conduct thorough searches of the literature to ensure that all potentially relevant studies were identified. In addition, authors restricted the search period from January 2000 and May 2018, and data extraction of included studies was done by one reviewer only.

Publication Source:

Burnett AM, Yashadhana A, Lee L, Serova N, Brain D, Naidoo K. Interventions to improve school-based eye-care services in low-and middle-income countries: a systematic review. Bull World Health Organ. 2018 Oct 1; 96(10): 682–694D.