Detecting Uncorrected Refractive Errors in children in India

Uncorrected refractive error (URE) is one of the most common forms of eye disorders that results in poor vision and has severe social and economic implications if uncorrected. A URE can simply be diagnosed, measured, and corrected with the aid of glasses, but for many in the developing world this simple correction method is not happening.

Global estimates indicate that more than 2.3 billion people in the world suffer from poor vision due to URE, of which 670 million people are considered visually impaired because they do not have access to corrective treatment such as glasses. Over the past decade, a series of studies using a survey methodology, referred to as Refractive Error Study in Children (RESC), were performed in populations with various ethnic origins and cultural settings. These studies confirmed that the prevalence of uncorrected refractive errors is considerably high for children in low-and-middle-income countries.

The current problem in India

The above study found that URE is the leading cause of vision impairment amongst children inIndia, with 61% of vision impairment in rural children and 89% in urban children in India being due to URE. It also highlighted that as few as 10% of rural and 35% of urban children needing glasses actually had them. Studies have also shown that URE in children causes up to 77% of blindness and severe visual impairment in India. School vision programmes remain the principal tool to address the problem of URE in India and elsewhere, and in doing so to improve children’s access to high-quality education. In fact, the Indian government are taking a very active role in school vision screening. Since the onset of the Sarva Shiksha Abhiyan (Education for All) programme in 2002, many millions of children have undergone school vision screening, but refraction and glasses distribution have been limited as currently it only delivers glasses to 18% of the estimated 4.1 million children needing them.

The above study found that URE is the leading cause of vision impairment amongst children inIndia, with 61% of vision impairment in rural children and 89% in urban children in India being due to URE. It also highlighted that as few as 10% of rural and 35% of urban children needing glasses actually had them. Studies have also shown that URE in children causes up to 77% of blindness and severe visual impairment in India. School vision programmes remain the principal tool to address the problem of URE in India and elsewhere, and in doing so to improve children’s access to high-quality education. In fact, the Indian government are taking a very active role in school vision screening. Since the onset of the Sarva Shiksha Abhiyan (Education for All) programme in 2002, many millions of children have undergone school vision screening, but refraction and glasses distribution have been limited as currently it only delivers glasses to 18% of the estimated 4.1 million children needing them.

How BCPB is supporting the best way to ensure children get and wear their glasses

In India, some glasses programmes screen and refract children and provide glasses all at schools (“School Model”). The strength of this model is that some children at school needing glasses get them. However, sustainability is poor, because glasses sales are not permitted in many schools. Furthermore, there may not be enough refractionists (a person trained to measure the refraction of the eye and to determine the proper corrective lenses), to cover all schools in an area. Other programmes provide vision screening at schools, but refer children failing screening to nearby facilities for refraction and distribution/sale of glasses (“Referral Model”). This model’s strengths are less demands on refractionists, and easier glasses sales. However, it is estimated that up to two thirds of children do not come to hospital for their follow up appointment after they have been referred.

Evidence in 2017 suggests that a variety of strategies which increase involvement of teachers in the screening  process (individual screening of each class by the classroom teacher, parent-teacher meetings,  SMS, phone call, or handwritten notes in the students diary from teachers to families who do not complete referrals) can significantly increase the proportion of families following up for care at an outside eye care facility. Using this evidence, the project BCPB is supporting in India will work with 10,000 children aged 11 to 15 at 69 public, private, rural and urban schools and will trial an “optimised” referral model of distribution of glasses, maximising teacher involvement. This will trial whether follow up rates are higher. It will also test to see whether an option to purchase “upgrade glasses” (glasses that have scratchproof coatings and designs selected to appeal to local children) will increase the likelihood of the child continuing to wear them – this will be checked at a three-month unannounced visit to the child’s school.

The difference this project will make

10,000 children will be screened for UREs and for those who have a URE or another eye disorder they will be referred to an eye health clinic for a follow up appointment.

An “Optimised Referral Model” with strong teacher involvement will double the current “Referral Model” of attendance of follow-up appointments and acceptance of glasses to two-thirds (currently estimated at only one-third of take up), making it more cost-effective than the “School Model”, which is currently unsustainable.

The establishment of a Continuum of Care through the leadership of three hospitals in the Orbis REACH network, all fully equipped to provide comprehensive services for children with more complex vision problems identified during screening. Care will be provided free if the family is unable to pay.

The project will also address a further aim in India’s government plans to improve gender and socio-economic equality in accessing healthcare, as school-based vision programmes help to redress inequalities by bringing services into the classroom, with 90% of Indian children now attending school.

As there is now a high attendance of girls in schools in India, the project will help redress Indian girls’ unequal healthcare access to eye care.

Project Update – Spring 2021

Results

A total of 166 schools with 63,212 children strength was included in the study at three study centers. Through this study we screened 60,711 children aged between 10 to 15 years and detected 3,005 (4.94%) cases of refractive error and 459 (0.75%) other conditions. Among the refractive errors 2,590 (86.19%) children were prescribed and received spectacles. Among the other conditions, 378 children (82.35%) received medical treatment and 81 (17.64%) surgical intervention. On the day of primary screening 2,501children were absent. A total of 5,014 children were eligible for the study after primary screening.

School Model:  In this model 21,787 children from 58 schools were completed primary screening and found 1,799 children eligible for the study. Among eligible children 1,737 (96.6%) children was screened for secondary examination. among eligible children screened 1,252 had refractive error and 1,110 (64%) prescribed glasses. During the follow-up and compliance, visit 700 children (63%) had spectacle compliance, meaning that 63% of children were found wearing spectacles on their faces at an un-announced follow-up at school 12 weeks after distribution of glasses.

Referral Model: In this model 20,490 children from 54 schools were completed primary screening and found 1,663 children eligible for the study. All the eligible children were referred to nearby Vision Centre/ secondary centre for refraction and delivery of free glasses, out of which only 206 (12.4%) reached the referral centre and 188 (91%) received spectacles. Among them, 147 (78.18%) of children were found wearing spectacles on their faces at an un-announced follow-up at school 12 weeks after distribution of glasses.

Referral Model + Cost Recovery:   In this model 18,434 children from 54 schools were completed primary screening and found 1,552 children eligible for the study. All the eligible children were referred to nearby Vision Centre/secondary centre for refraction and delivery of free glasses, out of which only 168 (10.8%) reached the referral centre and 157 (93%) received spectacles. Among them, 119 (75.8%) of children were found wearing spectacles on their faces at an un-announced follow-up at school 12 weeks after distribution of glasses.

COVID-19 impact on the PRISSM Study

Prior to the 24 March lockdown in India, data collection on screening, follow-up, and data related to cost effectiveness was completed from all the 162 schools (100%) from all three centers in different parts of India. Data on compliance was completed from 156 schools out of 162 (96.3%) from the 3 study centers. Due to the COVID lockdown, we could not complete the compliance study at 6 (3.7%) schools, and these schools remain closed at the present time.

Despite COVID and the India’s national wide lockdown, we have been successful in transmitting data from two out of three centers to data entry clerks using cell phone photos.

Cost effectiveness

Cost per child identified needing spectacles (program perspective), who gets and is still wearing them 8 to 12 weeks s later, compared between School, Referral and Referral + cost model.

ModelSpectacle (1) /Referral compliance (2 & 3) at 12 weeksCost per child received and wearing spectacle at 12 weeks
School63%$12.29                   
Referral12.4%$31.07
Referral + cost10.8%$32.93

The table above clearly shows that the far higher overall compliance rate among children in the School Screening Model that this will be the most cost-effective approach in this setting, contrary to our expectations.