School-based vision screening in Quetta, Pakistan: a qualitative study of experiences of teachers and eye care providers

Abstract

Background Visual impairment in children is a significant public health problem affecting millions of children globally. Many eye problems experienced by children can be easily diagnosed and treated. We conducted a qualitative study with teachers and optometrists involved in a school-based vision screening programme in Quetta district of Pakistan to explore their experiences of training, vision screening and referrals and to identify factors impacting on the effectiveness of the programme. Methods Between April 2018 and June 2018, we conducted semi-structured in-depth interviews with 14 teachers from eight purposefully selected schools with high rates of inaccurate (false positive) referrals. Interviews were also conducted with three optometrists from a not-for profit private eye care hospital that had trained the teachers. Interviews were audio recorded and professionally transcribed. NVIVO software version 12 was used to code and thematically analyze the data. Results Findings suggest that the importance of school-based vision screening was well understood and appreciated by the teachers and optometrists. Most participants felt that there was a strong level of support for the vision screening programme within the participating schools. However, there were a number of operational issues undermining the quality of screening. Eight teachers felt that the duration of the training was insufficient; the training was rushed; six teachers said that the procedures were not sufficiently explained, and the teachers had no time to practice. The screening protocol was not always followed by the teachers. Additionally, many teachers reported being overburdened with other work, which affected both their levels of participation in the training and the time they spent on the screening. Conclusions School-based vision screening by teachers is a cost-effective strategy to detect and treat children’s vision impairment early on. In the programme reviewed here however, a significant number of teachers over referred children to ophthalmic services, overwhelming their capacity and undermining the efficiency of the approach. To maximise the effectiveness and efficiency of school-based screening, future initiatives should give sufficient attention to the duration of the teacher training, experience of trainers, support supervision, refresher trainings, regular use of the screening guidelines, and the workload and motivation of those trained.

Integrated people-centered eye care: A scoping review on engaging communities in eye care in low- and middle-income settings

“…Training teachers to screen children in India led to an increased sense of responsibility and knowledge of eye care [ 24 ]. However, when training was too basic or limited, teachers in Pakistan reported being confused about the processes [ 84 ]. Simplified training and use of resources (e.g.…”

“…In other contexts, non-financial incentives had facilitated involvement in screening and detection interventions including access to no cost eye examination for teachers [ 23 ], vision screening training among teachers leading to ‘train the trainer’ opportunities [ 24 ], and t-shirts and certificates for key informants in detecting children needing eye surgery in Tanzania [ 76 ]. Gender-based aspects of screening and detection included: localized knowledge of female community health volunteers in Nepal, and key informants in India, leading to easier identification of visually impaired children and provision of low vision aids [ 73 , 74 ]; understanding the need for gender segregated school-based vision screening in Pakistan [ 84 ]; and awareness of gender bias in Nepal, Uganda, and Malawi among female community health workers facilitated access to eye care for girls through advocacy and parent engagement [ 73 ].…”

Assessing the prevalence of refractive errors and accuracy of vision screening by schoolteachers in Liberia

“…Low specificity in these pilots was largely related to insufficient teacher training and supervision, poor motivation and incorrect screening procedures. 20 In other programmes that reported the sensitivity and specificity of teacher screening, results varied greatly. For instance, in Port Harcourt in Nigeria, a study of vision screening in primary schools showed a sensitivity of 53.3% and a specificity of 94.6% (PVA <6/18).…”

“…The reasons behind these variations have not yet been fully explored but most attribute these to teachers’ interests and motivations to conduct vision screening. For example, Bechange et al 20 found that in Pakistan, while some teachers were highly motivated and diligent in following the screening protocol, others could not clearly recall the procedure, reported incorrect use of the E chart and, in a few cases, delegated their screening task to older students.…”

“…Various strategies have been recommended to improve teacher screening performance, including refresher training, 20 having standardised protocols, 44 involving all (rather than selected) teachers in the vision screening 45 and motivating teachers through financial incentives. 23 , 46 However, similar to other studies, 16 our analysis by school suggests that inaccurate screening is a localized problem determined by commitment, skills and practices of individual teachers rather than the quality of the programme as a whole.…”