Evidence to improve the Efficiency and Effectiveness of School Eye Health Programmes

Background: Uncorrected refractive errors (uRE) are the commonest cause of visual loss in children, accounting for 90-95% of visual impairment. Myopia is the commonest form, which usually starts around the age of 9 to 11 years, progressing in severity throughout adolescence. Hypermetropia is more common in younger children, and usually resolves by around 10 years of age. Astigmatism affects all age groups and does not change over time. Myopia is far more common in Asian children, particularly in South East Asia, and all types of refractive errors are less common in African children. There is emerging evidence of the impact of correcting REs in children in terms of school performance, and spectacle correction improves quality of life and visual functioning. Many countries have programmes for uncorrected refractive errors among schoolchildren. However, approaches vary and subsequent spectacle wear can be very low. Over-prescribing may be a factor as protocols are rarely used. Other barriers to spectacle wear include being teased, no perceived benefit and beliefs about causation. There have been only two trials of interventions to improve spectacle wear: an education intervention of students in China and a trial of free vs low cost spectacles in Tanzania. Another trial has been undertaken in China to assess the utility of ready-made spectacles (i.e. same prescription without astigmatic correction in both eyes), which are less expensive to make and easier to dispense. This trial found that ready-made spectacles were suitable for over 90% of children who needed spectacles, but cost savings to programmes was not analysed. Aim: The overall aim of this project is to provide evidence which could be used to improve the efficiency and effectiveness of school eye health programs for uREs in India. The project entails two randomized trials, each of which focus on a specific research question, based on reported reasons why children do not wear their spectacles: one trial addresses the cost of spectacles the other addresses negative attitudes towards spectacle wear by parents and peers. Objectives: The project has two broad objectives; to reduce the cost and improve the efficiency of school programs for uREs by assessing the utility of ready-made spectacles, and to assess whether novel health education interventions delivered by a mobile phone application (Peek) increase spectacle wearing rates in children. Methods: The objectives were addressed in two randomized clinical trials. Trial 1: The utility and cost saving of ready-made vs custom spectacles in a noninferiority, randomized trial of eligible children aged 11-15 years. Trial 2: The effectiveness of interventions delivered by mobile phone applications (Peek) on spectacle wear in a cluster randomized clinical trial of eligible children aged 11-15 years. The mobile phone app included images generated by PeekSim, which mimic the visual blur experienced by children with uREs which were used to educate parents, teachers, normally sighted children and children with uREs, with voice message reminders to parents about the benefits of spectacle wear. Results: Trial 1 86.0% of children undergoing assessment were eligible for ready-made spectacles. Rates of spectacle wear in the two arms were similar i.e., 139/184 children (75.5%) in the ready-made arm and 131/178 children (73.6%) in the custom-made arm (risk difference, 1.8%; 95%CI, −7.1%to 10.8%). Cost minimisation analysis was approximately USD 2,120.00 (range 3,054-840.00) per 100 children needing spectacles. Trial 2 701 children were prescribed spectacles (Peek arm: 376, control arm: 325). 535/701 (80%) were assessed at 3-4 months: Peek arm: 291/352 (82.7%); standard arm: 244/314 (77.7%). Spectacle wear was 156/291 (53.6%) in the Peek arm and 129/244 (52.9%) in the standard arm, a difference of 0.7%. Among the 292 (78%) parents contacted, only 13.9% had received the PeekSim image, 70.3% received the voice message and 97.2% understood it. Conclusions: Trial 1: Most children were eligible for ready-made spectacles, and the proportion wearing ready-made spectacles was not inferior to the proportion wearing custom-made spectacles at 3 to 4 months. The cost analysis suggests that ready-made spectacles can substantially reduce costs for school eye health programs in India without compromising spectacle wear, at least in the short term. Implications Use of ready-made spectacles in the delivery of school eye health programmes have the potential to increase the efficiency of a programme. Trial 2: Spectacle wear was similar in both arms of the trial, one explanation being that health education for parents was not delivered as intended. Implications Health education messages to create behaviour change need to be appropriate and use an acceptable and accessible medium.