I started wearing glasses when I was 10. I remember having difficulty seeing things at distance, including the teaching board in class. I also used to have difficulty recognizing people across the room, and watching television. Thirty years on I often reflect on how my life would be different if my vision was not corrected. Given that 80% of learning is visual, being unable to see at distance would have no doubt affected my educational performance.
My experience is not unique. According to a report by the Education Commission, up to 10% of children in developing countries may suffer from poor vision. And around nine in 10 of these cases are due to uncorrected refractive error (URE), a condition in which the eye does not focus correctly when looking at distance or near, resulting in blurred vision. URE can be addressed through an eye examination, including a refraction, or measuring the power of the eye, and eyeglasses.
I was lucky to grow up in a high resource setting where I was able to get comprehensive eye care. This early exposure may have shaped my own decision to become an optometrist specializing in public health.
A global problem with a simple solution
URE is the leading cause of global visual impairment. According to a recent Lancet article there are 124 million people unable to see clearly at distance. Nineteen millions of those with poor vision are children. Yet the solution to URE is straightforward and cost-effective, including a refraction by a trained professional and a pair of quality and affordable eyeglasses.
Yet despite this, there are several challenges. In particular, a lack of trained people to screen, examine the eye and the absence of good quality, affordable eyeglasses. Two-thirds of ophthalmologists and optometrists in sub-Saharan Africa are located in capital cities. There are issues with demand, meaning children, parents, and teachers are sometimes unaware of the benefits of wearing eyeglasses, in some cases, believing they actually weaken the eye.
In addition, there is stigma. In India, girls can feel pressure not to wear glasses for fear of it impacting their chance of getting married. Cost can also be a barrier as eye care and eyeglasses are often expensive. It can be prohibitively costly for a parent to pull a child out of school to travel to a clinic for screening and treatment and purchase eyeglasses.
School vision screening programs have been developed to address many of these issues. But sometimes interventions are uncoordinated, ad hoc, non-standardized, and unsustainable. The lack of coordination occurs between organizations carrying out the screening and the ministries of health and education. In addition, the screening event is often a one-time activity, based on external funding. There is a lack of standardization in terms of what ages should be screened, by whom, how often, and the point at which a child be given a pair of eyeglasses. There is also the issue of ensuring a child wears glasses in the classroom.
Taking screening into school
To address these issues, Sightsavers with Partnership for Child Development (PCD) and the World Bank implemented a School Health Integrated Program (SHIP), supported by a grant from GPE. SHIP’s objectives were to raise awareness and build the capacity of governments to implement school health initiatives, and to demonstrate how schools can be used as a platform to deliver health using two model interventions: vision screening and deworming. The intervention was piloted in four focus countries: Cambodia, Ethiopia, Ghana, and Senegal.
The project was implemented in phases:
- Joint planning between ministries of education and health to build capacity and prioritize school health and nutrition while identifying locations and schools for screening.
- Next, a cascading program of training aimed at embedding and spreading expertise among teachers in schools. Additionally, teachers were provided with resources to carry out screening, including manuals and a simplified vision screener so screening could take place in schools.
- Once screened, students who failed the test were referred to a mobile refraction unit, under the ministry of Health, providing eyeglasses at no cost. Students who required further examination were referred to the closest eye unit. In addition, teachers who took part in the screening were also screened and given glasses as needed.
The project used a standardized system of guidelines developed in collaboration between Sightsavers, Brien Holden Vision Institute, and the International Center for Eye Health at the London School of Hygiene and Tropical Medicine. These guidelines outline the use of teachers to screen, simplified vision screening and prescribing protocols.
The project trained 476 teachers in 158 school; reached 57,434 children with vision screening; dewormed 47,106 children; and dispensed 1,017 pairs of eyeglasses.
Lessons to make school-based vision programs successful
Through the project we learned that a number of factors helped to make school eye health programs successful, including:
- Schools can be used as an effective platform for health delivery
- Collaboration between ministry of Education and ministry of Health is vital
- Integrated school-level activities must be easy for teachers to implement
- These initiatives must be aligned with existing policies, systems and infrastructure to support ownership & sustainability