Healthy Eyes in Schools: An evaluation of a school and community-based intervention to promote eye health in rural Timor-Leste

Abstract

Objective: To assess whether there was an improvement in the knowledge, attitudes and practices of students after the Healthy Eyes in Schools Project intervention and to complete a process evaluation to inform future implementation of health promotion interventions. Design: A descriptive, mixed-methods design was used, including questionnaires and interviews. Setting: Four primary schools in Aileu District, Timor-Leste. Local teachers received training and resources to implement nine lessons about eye health. The intervention was supported in two schools by the concurrent creation of school gardens and improvements to the water and sanitation, where required. Method: Students from classes 5 and 6 participated: 384 students aged 10–17 years (median = 12 years, inter-quartile range = 12–13 years) completed the baseline knowledge, attitudes and practices survey and 237 students participated in a follow-up survey. Interviews with teachers, students and parents informed the process evaluation. Results: The intervention was associated with an improvement in eye health knowledge and some attitudes and practices of students. Attitudes about the capabilities of blind children and adults did not change. The teachers’ attitude and support from principals and an international non-governmental organisation appeared to be key factors in the successful implementation of the Healthy Eyes in Schools Project. The limited eye health in the existing curriculum, limited parent participation and access to healthy food may have influenced the effectiveness of the Healthy Eyes in Schools Project intervention. Conclusion: A number of benefits appeared to be associated with the inclusion of eye health topics in school health and hygiene education in Timor-Leste. Concurrent development of a supportive environment appeared to enable this initiative. The results of this evaluation can be used to advocate to the Ministries of Education and Health and other education stakeholders for the inclusion of eye health in the health and hygiene curriculum.

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

“…Inappropriate or overprescribing of spectacles was identified in studies from India and Mexico, 26 , 43 suggesting that the prescribing of spectacles for moderate vision impairment should be balanced with cost and willingness to pay 43 . 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 minimizing impact, 52 , 63 and the support of principals, staff and parents 23 , 28 , 29 …”

“…A key policy-based facilitator to the prioritization of child eye-care is uptake and execution of a national eye-care plan, 50 , 53 , 61 and the inclusion of eye-care in school health policy 28 , 29 , 50 , 55 , 58 . Studies assessing the feasibility of school-based eye-care interventions, such as the targeting of trachoma in the United Republic of Tanzania, 58 vision screening in Peru, 30 South Africa 29 and Thailand, 56 and the provision of free spectacles in China, 39 noted that success was dependent on multidisciplinary support from health and education ministries.…”

“…Studies assessing the feasibility of school-based eye-care interventions, such as the targeting of trachoma in the United Republic of Tanzania, 58 vision screening in Peru, 30 South Africa 29 and Thailand, 56 and the provision of free spectacles in China, 39 noted that success was dependent on multidisciplinary support from health and education ministries. The level of collaboration between ministries may either facilitate 20 , 28 , 30 , 58 or inhibit 62 the coordination and success of interventions at the school level. An example from a trachoma intervention in Tanzanian schools outlined that, while elimination of trachoma was prioritized in health policies, it also needed to be incorporated into education curriculums if progress was to be made 58 .…”

“…Poor literacy, lack of awareness of eye health and misconceptions among parents were all reported as having an impact on seeking care, age of presentation and treatment choices for children 28 , 56 , 64 . A prominent misunderstanding regarding the wearing of spectacles is that they weaken or harm the eyes, resulting in the reluctance of parents to obtain them 36 , 45 , 48 , 65 , 66 …”

“…However, girls, children with higher maternal education and children with poorer visual acuity at presentation were generally more likely to be wearing spectacles at follow-up. Many studies 28 , 33 , 36 , 37 , 41 , 43 , 45 , 48 , 56 , 64 , 66 reported that children’s experiences or perspectives of wearing spectacles were linked to stigma and discrimination, or included verbal 36 , 37 , 48 , 56 or physical abuse 43 . In Timor-Leste, 18.1% (43/237) of children surveyed believed that vision-impaired people could not attend school 28 .…”