Purpose: Uncorrected refractive errors are the leading cause of visual impairment in children, affecting children in all settings. The majority of refractive errors can be corrected with spectacles. High compliance with spectacle wear is required for children to realize the benefit, such as higher academic achievement. This review collates evidence on compliance with spectacle wear, factors which predict spectacle wear and reasons for non-compliance among schoolchildren.Methods: Literature searches were conducted on Medline, Embase, Global Health and the Cochrane Library. The date range was January 2000 to November 2017 and there were no language restrictions. The search retrieved a total of 1299 references, 522 duplicate records were removed leaving 777 references to assess. Twenty-five studies were included in the review.Results: Evidence suggests that greater severity of uncorrected refractive error and lower levels of uncorrected visual acuity are associated with higher levels of spectacle wear. Addressing socio-demographic reasons for non-compliance is complex as they are context specific. Evidence that children become less compliant with spectacle wear with increasing age is not consistent. Quantitative data indicate girls are more likely to be compliant with spectacles wear than boys, but qualitative studies highlight specific challenges faced by girls.Conclusion: There was considerable variation between studies in how spectacle compliance was defined, the time interval between dispensing the spectacles and assessment, and how compliance was assessed. There is need to standardize all aspects of the assessment of compliance. Further qualitative and quantitative studies are required in a range of settings to assess the biomedical and socio-demographic factors which affect spectacle wear compliance using standard definitions.
IMPORTANCE: Visual impairment from uncorrected refractive errors affects 12.8 million children globally. Spectacle correction is simple and cost-effective; however, low adherence to spectacle wear, which can occur in all income settings, limits visual potential. OBJECTIVE: To investigate predictors of spectacle wear and reasons for nonwear in students randomized to ready-made or custom-made spectacles. DESIGN, SETTING, AND PARTICIPANTS: In planned secondary objectives of a noninferiority randomized clinical trial, students aged 11 to 15 years who fulfilled eligibility criteria, which included improvement in vision with correction by at least 2 lines in the better eye, were recruited from government schools in Bangalore, India. Recruitment took place between January 12 and July 15, 2015, and analysis for the primary outcome occurred in August 2016. Data analysis for the secondary outcome was conducted in August 2018. Spectacle wear was assessed by masked observers at unannounced visits to schools 3 to 4 months after spectacles were distributed. Students not wearing their spectacles were asked an open-ended question to elicit reasons for nonwear. MAIN OUTCOMES AND MEASURES: Predictors of spectacle wear and reasons for nonwear. RESULTS: Of 460 students recruited and randomized (52.2% male; 46 students aged 11 to 12 years and 13 to 15 years in each trial arm), 78.7% (362 of 460) were traced at follow-up, and 25.4% (92 of 362) were not wearing their spectacles (no difference between trial arms). Poorer presenting visual acuity (VA) and improvement in VA with correction predicted spectacle wear. Students initially seen with an uncorrected VA less than 6/18 in the better eye were almost 3 times more likely to be wearing their spectacles than those with less than 6/9 to 6/12 (adjusted odds ratio, 2.84; 95% CI, 1.52-5.27). Improvement of VA with correction of 3 to 6 lines or more than 6 lines had adjusted odds ratios of 2.31 (95% CI, 1.19-4.50) and 2.57 (95% CI, 1.32-5.01), respectively, compared with an improvement of ...
Importance: Uncorrected refractive errors are the most common cause of visual impairment in children despite correction being highly cost-effective. Objective: To determine whether less expensive ready-made spectacles produce rates of spectacle wear at 3 to 4 months comparable to those of more expensive custom-made spectacles among eligible school-aged children. Design, Setting, and Participants: This noninferiority, double-masked, randomized clinical trial recruited children aged 11 to 15 years from January 12 through July 31, 2015, from government schools in urban and periurban areas surrounding Bangalore, India. Follow-up occurred from August 1 through September 31, 2015. Participants met the following eligibility criteria for ready-made spectacles: failed vision screening at the 6/9 level in each eye; refraction was indicated; acuity improved with correction by 2 or more lines in the better-seeing eye; the corrected acuity with the spherical equivalent was not more than 1 line less than with full correction; anisometropia measured less than 1.0 diopter; and an appropriate frame was available. Interventions: Eligible children were randomized to ready-made or custom-made spectacles. Main Outcomes and Measures: Proportion of children wearing their spectacles at unannounced visits 3 to 4 months after the intervention. Results: Of 23 345 children aged 11 to 15 years who underwent screening, 694 had visual acuity of less than 6/9 in both eyes, and 535 underwent assessment for eligibility. A total of 460 children (227 female [49.3%] and 233 male [50.7%]; mean [SD] age, 13.4 [1.3] years) were eligible for ready-made spectacles (2.0% undergoing screening and 86.0% undergoing assessment) and were randomized to ready-made (n = 232) or custom-made (n = 228) spectacles. Follow-up rates at 3 to 4 months were similar (184 [79.3%] in the ready-made group and 178 [78.1%] in the custom-made group). Rates of spectacle wear in the 2 arms were similar among 139 of 184 children (75.5%) in the ready-made arm and 131 of 178 children (73.6%) in the custom-made arm (risk difference, 1.8%; 95% CI, -7.1% to 10.8%). Conclusions and Relevance: 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. These findings suggest that ready-made spectacles could substantially reduce costs for school-based eye health programs in India without compromising spectacle wear, at least in the short term. Trial Registration: isrctn.com Identifier: ISRCTN14715120.
BACKGROUND: Uncorrected refractive errors are the commonest cause of visual impairment in children, with myopia being the most frequent type. Myopia usually starts around 9 years of age and progresses throughout adolescence. Hyperopia usually affects younger children, and astigmatism affects all age groups. Many children have a combination of myopia and astigmatism. To correct refractive errors, the type and degree of refractive error are measured and appropriate corrective lenses prescribed and dispensed in the spectacle frame of choice. Custom spectacles (that is, with the correction specifically required for that individual) are required if astigmatism is present, and/or the refractive error differs between eyes. Spectacles without astigmatic correction and where the refractive error is the same in both eyes are straightforward to dispense. These are known as 'ready-made' spectacles. High-quality spectacles of this type can be produced in high volume at an extremely low cost. Although spectacle correction improves visual function, a high proportion of children do not wear their spectacles for a variety of reasons. The aim of this study is to compare spectacle wear at 3-4 months amongst school children aged 11 to 15 years who have significant, simple uncorrected refractive error randomised to ready-made or custom spectacles of equivalent quality, and to evaluate cost savings to programmes. The study will take place in urban and semi-urban government schools in Bangalore, India. The hypothesis is that similar proportions of children randomised to ready-made or custom spectacles will be wearing their spectacles at 3-4 months. METHODS/DESIGN: The trial is a randomised, non-inferiority, double masked clinical trial of children with simple uncorrected refractive errors. After screening, children will be randomised to ready-made or custom spectacles. Children will choose their preferred frame design. After 3-4 months the children will be followed up to assess spectacle wear. DISCUSSION: Ready-made spectacles have benefits for providers as well as parents and children, as a wide range of prescriptions and frame types can be taken to schools and dispensed immediately. In contrast, custom spectacles have to be individually made up in optical laboratories, and taken back to the school and given to the correct child. TRIAL REGISTRATION: ISRCTN14715120 (Controlled-Trials.com) Date registered: 04 February 2015.
Funding: G.F.K. received funding to undertake a master's degree from the British Council for the Prevention of Blindness, the Commonwealth Scholarships Commission UK, and the University of Rwanda (UR). Data collection was funded by the Travel Trust Fund at the London School of Hygiene and Tropical Medicine. J.R. was a Commonwealth Rutherford Fellow, funded by the UK government through the Commonwealth Scholarship Commission in the UK. J.R.'s position at the University of Auckland is funded by the Buchanan Charitable Foundation, New Zealand. ; The aim of this study was to investigate barriers and enablers associated with the uptake of cataract surgery in Rwanda, where financial protection is almost universally available. This was a hospital-based cross-sectional study where potential participants were adults aged >18 years who accepted an appointment for cataract surgery during the study period (May-July 2019). Information was collected from hospital records and a semi-structured questionnaire was used for data collection. Of the 297 people with surgery appointments, 221 (74.4%) were recruited into the study, 126 (57.0%) of whom had attended their appointment. People more likely to attend their surgical appointment were literate, had fewer than 8 children, had poorer visual acuity, had access to a telephone in the family, received a specific date to attend their appointment, received a reminder, and reported no difficulties walking (95% significance level, p < 0.05). The most commonly reported barriers were insufficient information about the appointment (n = 40/68, 58.8%) and prohibitive indirect costs (n = 29/68, 42.6%). This study suggests that clear communication of appointment information and a subsequent reminder, together with additional support for people with limited mobility, are strategies that could improve uptake of cataract surgery in Rwanda. ; Publisher PDF ; Peer reviewed
Purpose: Uncorrected refractive error is the leading cause of visual impairment in children. Many countries, including India, implement school eye health programmes involving vision screening and provision of free spectacles. This is costly for governments/organisations involved. This analysis estimates potential cost-savings if ready-made spectacles, in addition to traditional custom-made spectacles, are available for dispensing in school eye health programmes.Methods: An economic evaluation was conducted alongside a randomised controlled trial comparing spectacle wear of ready-made spectacles versus custom-made spectacles for children aged 11-15 years in schools in India. A cost-minimisation approach was used to calculate cost-savings of a 'ready-made spectacles available' programme compared with a 'custom-made spectacles only' school programme. The analysis was from a service provider perspective. Main outcomes: cost-saving per child needing spectacles and cost-saving per 1000 children screened.Results: The prevalence of uncorrected refractive error was 2.23%, and 86% of children were eligible for ready-made spectacles. The cost per child needing spectacles in a custom-made spectacles only programme was USD$26.91, and in a ready-made spectacles available programme was $11.15, producing a 58.6% cost-saving per child needing spectacles of $15.76. Considering the total cost of the eye health programme, this equated to a 15.1% cost-saving per 1000 children screened of $361. Results were robust to multivariate sensitivity analyses.Conclusion: Our study is the first to demonstrate the significant cost-saving potential of ready-made spectacles in school eye health programmes for uncorrected refractive error compared with custom-made spectacles alone. This has substantial economic benefits for national/international programmes.
BACKGROUND: Uncorrected refractive errors are the commonest cause of visual loss in children despite spectacle correction being highly cost-effective. Many affected children do not benefit from correction as a high proportion do not wear their spectacles. Reasons for non-wear include parental attitudes, overprescribing and children being teased/bullied. Most school programmes do not provide health education for affected children, their peers, teachers or parents. The Portable Eye Examination Kit (Peek) will be used in this study. Peek has applications for measuring visual acuity with software for data entry and sending automated messages to inform providers and parents. Peek also has an application which simulates the visual blur of uncorrected refractive error (SightSim). The hypothesis is that higher proportion of children with uncorrected refractive errors in schools allocated to the Peek educational package will wear their spectacles 3-4 months after they are dispensed, and a higher proportion of children identified with other eye conditions will access services, compared with schools receiving standard school screening. METHODS/DESIGN: Cluster randomized, double-masked trial of children with and without uncorrected refractive errors or other eye conditions. Government schools in Hyderabad, India will be allocated to intervention (Peek) or comparator (standard programme) arms before vision screening. In the intervention arm Peek will be used for vision screening, SightSim images will be used in classroom teaching and will be taken home by children, and voice messages will be sent to parents of children requiring spectacles or referral. In both arms the same criteria for recruitment, prescribing and dispensing spectacles will be used. After 3-4 months children dispensed spectacles will be followed up to assess spectacle wear, and uptake of referrals will be ascertained. The cost of developing and delivering the Peek package will be assessed. The cost per child wearing their spectacles or accessing services will be compared. DISCUSSION: Educating parents, teachers and children about refractive errors and the importance of wearing spectacles has the potential to increase spectacle wear amongst children. Innovative, potentially scalable mobile technology (Peek) will be used to screen, provide health education, track spectacle wear and adherence to follow-up amongst children referred. TRIAL REGISTRATION: Controlled-Trials.com, ISRCTN78134921 . Registered on 29 June 2016.
Background: Uncorrected refractive errors can be corrected by spectacles which improve visual functioning, academic performance and quality of life. However, spectacle wear can be low due to teasing/bullying, parental disapproval and no perceived benefit.Hypothesis: higher proportion of children with uncorrected refractive errors in the schools allocated to the intervention will wear their spectacles 3-4 months after they are dispensed. Methods: A superiority, cluster-randomised controlled trial was undertaken in 50 government schools in Hyderabad, India using a superiority margin of 20%. Schools were the unit of randomization. Schools were randomized to intervention or a standard school programme. The same clinical procedures were followed in both arms and free spectacles were delivered to schools. Children 11-15 years with a presenting Snellen visual acuity of <6/9.5 in one or both eyes whose binocular acuity improved by ≥2 lines were recruited.In the intervention arm, classroom health education was delivered before vision screening using printed images which mimic the visual blur of uncorrected refractive error (PeekSim). Children requiring spectacles selected one image to give their parents who were also sent automated voice messages in the local language through Peek. The primary outcome was spectacle wear at 3-4 months, assessed by masked field workers at unannounced school visits. www.controlled-trials.com ISRCTN78134921 Registered on 29 June 2016. Findings: 701 children were prescribed spectacles (intervention arm: 376, control arm: 325). 535/701 (80%) were assessed at 3-4 months: intervention arm: 291/352 (82.7%); standard arm: 244/314 (77.7%). Spectacle wear was 156/291 (53.6%) in the intervention arm and 129/244 (52.9%) in the standard arm, a difference of 0.7% (95% confidence interval (CI), -0.08, 0.09). amongst the 291 (78%) parents contacted, only 13.9% had received the child delivered PeekSim image, 70.3% received the voice messages and 97.2% understood them. Interpretation: Spectacle wear was similar in both arms of the trial, one explanation being that health education for parents was not fully received. Health education messages to create behaviour change need to be targeted at the recipient and influencers in an appropriate, acceptable and accessible medium. Funding: USAID (Childhood Blindness Programme), Seeing is Believing Innovation Fund and the Vision Impact Institute.
BACKGROUND: Uncorrected refractive errors can be corrected by spectacles which improve visual functioning, academic performance and quality of life. However, spectacle wear can be low due to teasing/bullying, parental disapproval and no perceived benefit. Hypothesis: higher proportion of children with uncorrected refractive errors in the schools allocated to the intervention will wear their spectacles 3–4 months after they are dispensed. METHODS: A superiority, cluster-randomised controlled trial was undertaken in 50 government schools in Hyderabad, India using a superiority margin of 20%. Schools were the unit of randomization. Schools were randomized to intervention or a standard school programme. The same clinical procedures were followed in both arms and free spectacles were delivered to schools. Children 11–15 years with a presenting Snellen visual acuity of <6/9.5 in one or both eyes whose binocular acuity improved by ≥2 lines were recruited. In the intervention arm, classroom health education was delivered before vision screening using printed images which mimic the visual blur of uncorrected refractive error (PeekSim). Children requiring spectacles selected one image to give their parents who were also sent automated voice messages in the local language through Peek. The primary outcome was spectacle wear at 3–4 months, assessed by masked field workers at unannounced school visits. www.controlled-trials.com ISRCTN78134921 Registered on 29 June 2016 FINDINGS: 701 children were prescribed spectacles (intervention arm: 376, control arm: 325). 535/701 (80%) were assessed at 3–4 months: intervention arm: 291/352 (82.7%); standard arm: 244/314 (77.7%). Spectacle wear was 156/291 (53.6%) in the intervention arm and 129/244 (52.9%) in the standard arm, a difference of 0.7% (95% confidence interval (CI), -0.08, 0.09). amongst the 291 (78%) parents contacted, only 13.9% had received the child delivered PeekSim image, 70.3% received the voice messages and 97.2% understood them. INTERPRETATION: Spectacle wear was ...
It is essential to understand the strategies and processes which are deployed currently across the Assistive Technology (AT) space toward measuring innovation. The main aim of this paper is to identify functional innovation strategies and processes which are being or can be deployed in the AT space to increase access to AT globally. We conducted a scoping review of innovation strategies and processes in peer-reviewed literature databases and complemented this by identifying case studies demonstrating innovation strategies. The review includes WHO world region, publication year, AT type and a sector analysis against the Systems-Market for Assistive and Related Technologies Framework. We analyzed the case studies and interviews using thematic analysis. We included 91 papers out of 3,127 after review along with 72 case studies. Our results showed that product innovations were more prevalent than provision or supply innovations across papers and case studies. Case studies yielded two themes: open innovation (OI); radical and disruptive innovation. Financial instruments which encourage OI are needed and we recommend pursuing OI for AT innovation. Embedding AT within larger societal missions will be key to success governments and investors need to understand what AT is and their translational socioeconomic value.
Eye health and vision have widespread and profound implications for many aspects of life, health, sustainable development, and the economy. Yet nowadays, many people, families, and populations continue to suffer the consequences of poor access to high-quality, affordable eye care, leading to vision impairment and blindness. In 2020, an estimated 596 million people had distance vision impairment worldwide, of whom 43 million were blind. Another 510 million people had uncorrected near vision impairment, simply because of not having reading spectacles. A large proportion of those affected (90%), live in low-income and middle-income countries (LMICs). However, encouragingly, more than 90% of people with vision impairment have a preventable or treatable cause with existing highly cost-effective interventions. Eye conditions affect all stages of life, with young children and older people being particularly affected. Crucially, women, rural populations, and ethnic minority groups are more likely to have vision impairment, and this pervasive inequality needs to be addressed. By 2050, population ageing, growth, and urbanisation might lead to an estimated 895 million people with distance vision impairment, of whom 61 million will be blind. Action to prioritise eye health is needed now. This Commission defines eye health as maximised vision, ocular health, and functional ability, thereby contributing to overall health and wellbeing, social inclusion, and quality of life. Eye health is essential to achieve many of the Sustainable Development Goals (SDGs). Poor eye health and impaired vision have a negative effect on quality of life and restrict equitable access to and achievement in education and the workplace. Vision loss has substantial financial implications for affected individuals, families, and communities. Although high-quality data for global economic estimates are scarce, particularly for LMICs, conservative assessments based on the latest prevalence figures for 2020 suggest that annual global productivity loss from vision impairment is approximately US$410·7 billion purchasing power parity. Vision impairment reduces mobility, affects mental wellbeing, exacerbates risk of dementia, increases likelihood of falls and road traffic crashes, increases the need for social care, and ultimately leads to higher mortality rates. By contrast, vision facilitates many daily life activities, enables better educational outcomes, and increases work productivity, reducing inequality. An increasing amount of evidence shows the potential for vision to advance the SDGs, by contributing towards poverty reduction, zero hunger, good health and wellbeing, quality education, gender equality, and decent work. Eye health is a global public priority, transforming lives in both poor and wealthy communities. Therefore, eye health needs to be reframed as a development as well as a health issue and given greater prominence within the global development and health agendas. Vision loss has many causes that require promotional, preventive, treatment, and rehabilitative interventions. Cataract, uncorrected refractive error, glaucoma, age-related macular degeneration, and diabetic retinopathy are responsible for most global vision impairment. Research has identified treatments to reduce or eliminate blindness from all these conditions; the priority is to deliver treatments where they are most needed. Proven eye care interventions, such as cataract surgery and spectacle provision, are among the most cost-effective in all of health care. Greater financial investment is needed so that millions of people living with unnecessary vision impairment and blindness can benefit from these interventions. Lessons from the past three decades give hope that this challenge can be met. Between 1990 and 2020, the age-standardised global prevalence of blindness fell by 28·5%. Since the 1990s, prevalence of major infectious causes of blindness—onchocerciasis and trachoma—have declined substantially. Hope remains that by 2030, the transmission of onchocerciasis will be interrupted, and trachoma will be eliminated as a public health problem in every country worldwide. However, the ageing population has led to a higher crude prevalence of age-related causes of blindness, and thus an increased total number of people with blindness in some regions. Despite this progress, business as usual will not keep pace with the demographic trends of an ageing global population or address the inequities that persist in each country. New threats to eye health are emerging, including the worldwide increase in diabetic retinopathy, high myopia, retinopathy of prematurity, and chronic eye diseases of ageing such as glaucoma and age-related macular degeneration. With the projected increase in such conditions and their associated vision loss over the coming decades, urgent action is needed to develop innovative treatments and deliver services at a greater scale than previously achieved. Good eye health at the community and national level has been marginalised as a luxury available to only wealthy or urban areas. Eye health needs to be urgently brought into the mainstream of national health and development policy, planning, financing, and action. The challenge is to develop and deliver comprehensive eye health services (promotion, prevention, treatment, rehabilitation) that address the full range of eye conditions within the context of universal health coverage. Accessing services should not bring the risk of falling into poverty and services should be of high quality, as envisaged by the WHO framework for health-care quality: effective, safe, people-centred, timely, equitable, integrated, and efficient. To this framework we add the need for services to be environmentally sustainable. Universal health coverage is not universal without eye care. Multiple obstacles need to be overcome to achieve universal coverage for eye health. Important issues include complex barriers to availability and access to quality services, cost, major shortages and maldistribution of well-trained personnel, and lack of suitable, well maintained equipment and consumables. These issues are particularly widespread in LMICs, but also occur in underserved communities in high-income countries. Strong partnerships need to be formed with natural allies working in areas affected by eye health, such as non-communicable diseases, neglected tropical diseases, healthy ageing, children's services, education, disability, and rehabilitation. The eye health sector has traditionally focused on treatment and rehabilitation, and underused health promotion and prevention strategies to lessen the impact of eye disease and reduce inequality. Solving these problems will depend on solutions established from high quality evidence that can guide more effective implementation at scale. Evidence-based approaches will need to address existing deficiencies in the supply and demand. Strategic investments in discovery research, harnessing new findings from diverse fields, and implementation research to guide effective scale up are needed globally. Encouragingly, developments in telemedicine, mobile health, artificial intelligence, and distance learning could potentially enable eye care professionals to deliver higher quality care that is more plentiful, equitable, and cost-effective. This Commission did a Grand Challenges in Global Eye Health prioritisation exercise to highlight key areas for concerted research and action. This exercise has identified a broad set of challenges spanning the fields of epidemiology, health systems, diagnostics, therapeutics, and implementation. The most compelling of these issues, picked from among 3400 suggestions proposed by 336 people from 118 countries, can help to frame the future research agenda for global eye health. In this Commission, we harness lessons learned from over two decades, present the growing evidence for the life-transforming impact of eye care, and provide a thorough understanding of rapid developments in the field. This report was created through a broad consultation involving experts within and outside the eye care sector to help inform governments and other stakeholders about the path forward for eye health beyond 2020, to further the SDGs (including universal health coverage), and work towards a world without avoidable vision loss. The next few years are a crucial time for the global eye health community and its partners in health care, government, and other sectors to consider the successes and challenges encountered in the past two decades, and at the same time to chart a way forward for the upcoming decades. Moving forward requires building on the strong foundation laid by WHO and partners in VISION 2020 with renewed impetus to ultimately deliver high quality universal eye health care for all.
