Report of Vision2020 Workshop on information needs to improve implementation of refractive error programs in India 20-25 March 2006 New Delhi, India Organized by: The International Centre for Eye Health, London, UK The Dr. RP Centre, All India Institute of Medical Sciences, Delhi, India Supported by: VISION2020 (support to courses) VISION2020 India
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nformation needs to improve implementation of refractive ... · 2) the magnitude and types of refractive errors in different age groups and populations 3) the impact of uncorrected
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Report of
Vision2020 Workshop on information needs to improve
implementation of refractive error programs in India
20-25 March 2006
New Delhi, India
Organized by:
The International Centre for Eye Health, London, UK The Dr. RP Centre, All India Institute of Medical Sciences, Delhi, India
Supported by:
VISION2020 (support to courses) VISION2020 India
Background: Correction of refractive errors (RE) is a priority of VISION2020 – the Right to Sight. However, there are many unanswered questions in relation to: 1) the causes 2) the magnitude and types of refractive errors in different age groups and populations 3) the impact of uncorrected REs on visual function, quality of life and income generating potential 4) the best ways of delivering RE services to those sectors of the community most in need. Purpose of the workshop: To identify gaps in the epidemiological, qualitative and operational research which limit the implementation of cost effective interventions for uncorrected REs, and to outline a programme of research which address some of these information gaps. Objectives of the workshop: The objective of the workshop was to identify gaps in information which need to be addressed for
the successful implementation of RE programs in India, and to design research studies which can provide scientifically valid evidence to improve implementation of such programs. This will ultimately help in devising effective strategies for the elimination of avoidable blindness and low vision in India.
Expected outcome: It was envisaged that at the end of the Workshop, up to 6 draft research proposals on RE would be designed for submission to funding agencies for financial support. Programme and participants: Please see Appendix 1 for details of the programme, and Appendix 2 for a list of participants
The programme was designed to give plenty of time for discussion and group work. The first 2 and a half days were spent in plenary sessions, with presentations which covered the following areas:
• Epidemiologic issues in RE
• Recent Studies on RE
• Operational issues in delivery of RE services • Service delivery approaches • Service delivery approaches for specific populations
• Qualitative research and evaluation of vision screening in children • Service Costing and Economic Implications • Activities and research of the international NGOs active in India in relation to RE services
At the end of the workshop participants were given a CD containing all the presentations.
Participants were carefully selected, bearing in mind the following:
• Geographical spread • Experience in service delivery
• Expertise in research (epidemiological; operational; qualitative; economic) • Representation from the non-government sector • Representation from VISION2020 India
• Representation from the government
Identifying priority problems that need to be addressed: Six groups each identified information gaps, and then prioritised the top 5 that need to be addressed
to improve the delivery of RE services. A smaller group then prioritised these problems into the top 7. The priority problems identified were as follows:
1) There is inadequate data on the prevalence and magnitude of RE in adults (including presbyopia), as well as coverage of spectacle wearing and the proportion of the need that could
be met by ready made glasses 2) There is a large unmet need for RE services particularly in rural areas, and there are different
approaches to delivering services for RE at the primary level. There is no evidence regarding
which model of delivering RE services is the most cost effective or sustainable. 3) Different school programmes are using different visual acuity cut-offs, and there is no evidence
regarding which is optimal from the perspectives of sensitivity and specificity, spectacle wearing
rates and other factors which influence efficiency. 4) There is no information on attitudes towards school eye health programs from the perspectives
of teachers and students, nor on the cost effectiveness and sustainability of different approaches
to delivering these programs 5) There is no information on the impact of uncorrected REs among adults of working age in terms
of quality of life (QOL), visual function, activities of daily living, or economic productivity. There is also no information on the impact of correcting significant RE on these variables.
6) There is very little information on community’s perceptions of visual impairment due to
uncorrected REs, nor on the factors which influence demand for RE services 7) There is no communication strategy for REs, and it is not known what health education materials
already exist, how they are perceived, and the impact they have on health seeking behaviour in
relation to REs.
Development of research protocols: Participants selected which group they wanted to work in, and spent the next 2 days working on a
research proposal. This was done using a standard template. After each presentation there was a lot of time for discussion and feedback, and some of the proposals need amending in light of this input.
Principal Investigators for the proposals are Dr. Clare Gilbert and Dr. G V S Murthy
The following is a summary of the 7 research proposals
Group 1: Title:
National population based prevalence survey of refractive errors in adults aged >16 years
Study design: Cross sectional epidemiological study
Multi centre: Yes
Objectives: To determine the: • Prevalence and causes of visual impairment in the population above the age of
15 years • Prevalence of presbyopia • Spectacle Coverage and unmet need
• Access to eye care services among population with refractive error
Time frame: 3 years
Facilitator: Dr G V S Murthy
Contact person Dr. Asim Sil
Other group participants:
Dr. R.R.Sudhir Dr. Nitin Batra
Ms Neena John Mr. M.Srinivas
Group 2: Title:
Societal perspectives and a comparison of sustainability and cost effectiveness of different service delivery models at primary levels for
refractive errors
Study design: Cross Cutting (Economic, operational (org/non-formal), operational, QOL. VF) in rural and urban settings.
Multi centre: Yes
Objectives: • To understand the community perspective of need for refractive error service
provision at primary level. • To determine the community perspective of available RE services at primary level.
• To compare in terms of Cost-Effectiveness the 3 most common models of RE service delivery at primary level in Rural & Urban underprivileged locations.
• To identify the factors for sustainability (Technical, Managerial, Financial &
Leadership) of the compared models in Rural and Urban Area. • To disseminate and publish study results for aiding in advocacy and policymaking.
Time frame: 3 years
Facilitator: Dr. K.Vishwanath
Contact person Dr. B.R.Shamanna
Other group participants:
Ms. Leena Bhanot Mrs Gunawathy Fernandez Ms Archana Bora Mr. Anand Sudhan
Group 3a: Title:
Optimum visual acuity standards for school eye health programmes in India
Study design: Operational research
Multi centre: Yes
Objectives: To explore different visual acuity screening criteria in vision testing programmes for children aged 11-15 years (i.e. to compare the current criteria of <6/9 in one or both eyes with a) <6/9 tested binocularly b) <6/12 in one or both eyes c) <6/12 tested binocularly) With respect to:
• sensitivity and specificity
• spectacle wearing rates • number and nature of eye disease missed using binocular vision testing • the range and type of spectacles needed for the programme
Time frame: 2 years
Facilitator: Dr. Clare Gilbert
Contact person Dr. H. Kishore
Other group participants:
Dr. Jatin Shah Dr. Chandrashekar Shetty
Dr. Gagandeep Singh Dr. Gautam Bhaduri Dr SKD Thakur
Dr Deepak Bagga
Dr. Arun Kumar Arora Dr. Anand S.Vaijwade
Dr. Elizabeth Joseph Dr. G.V.Rao Ms Lakshmi Shinde
Dr. Pankaj Bhattacharya
Group 3b: Title:
Evaluation and comparison of the impact and cost-effectiveness of two vision screening programmes in primary and secondary schools in rural and urban South India
Study design: Operational research
Multi centre: Yes
Objectives: To assess the: • Impact of school screening on the prevalence of presenting visual impairment in
school students: by primary/ secondary school, by private/government school, sex, by cause, by caste
• Cost-effectiveness of school screening in different settings (urban vs. rural; government vs. private)
• Spectacles use (urban vs. rural; government vs. private; sex; primary vs. secondary; by refractive error, by presenting VA; caste
• Attitude towards spectacles • School performance before and after spectacles provision
Time frame: 3 years
Facilitator: Dr. Susanne Wedner
Contact person Dr. S. Sujatha
Other group participants:
Mrs. K.Mani Mala Mr. Barry Lester
Group 4:
Title:
Impact of correcting RE in person aged 16 and above on economic
productivity and QOL in India
Study design: Operational research
Multi centre: Yes
Objectives: • To develop and validate the an Indian Refractive Error Quality of Life Questionnaire (IND-RE-QOL) for individuals aged 16 and above
• To assess the impact of correcting refractive error on QOL • To assess the impact of correcting refractive error on economic productivity
Time frame: 3.5 years
Facilitator: Dr. Sanjeev Gupta
Contact person Dr. Kuldeep Dole
Other group participants:
Mr. V.Vijay Kumar Dr. V.R.Venkataraman
Group 5: Title:
A qualitative study using Participatory Rural Appraisal (PRA) as the basis of Community perception of visual needs, services and eye health seeking behaviour in India
Study design: Qualitative research
Multi centre: Yes
Objectives: To determine the following: • Community perceptions of visual needs and visual disability in daily life • Community definitions of normal and abnormal vision, visual function and the
near vision loss • Understand eye health seeking behaviour of the community (where, when and
to whom to go) • Community perceptions on services , providers and use of glasses • Perceptions of the community on relevance and role of traditional methods of
treatment in eye care • Prioritisation of visual needs in community by the level of visual loss and among
other health needs • Prioritisation of visual needs in community in relation to other health needs • Difference in age groups, gender, profession, geographical areas,
socioeconomic strata • Acceptable services in relation to cost, satisfaction and time frame
Time frame: 16 months
Facilitator: Dr. Hannah Faal
Contact person Dr. Uday Gajiwala
Other group
participants:
Mr. P.K.M.Swamy
Dr. Sara Varughese Mr. Aruneesh Singh
Mr. Krishna Kumar
Dr. Anil Tara Dr. Shashank Patel
Group 6: Title:
The impact of information and education through communication on visual impairment due to refractive errors in India.
Study design: Qualitative and operational
Multi centre: Yes
Objectives: • To identify and collate available material and methods of health education regarding refractive errors in India.
• To develop and test (if necessary) IEC material on refractive errors.
• To develop marketing strategies for each target audience. • To assess the impact of health education about refractive errors on increasing
spectacle uptake.
Time frame: 4 years
Facilitator: Dr. Praveen Vashist
Contact person Dr. Noela Prasad
Other group participants:
Mr. Rajiv Williams Dr. Manish Sharma
Next steps:
• Two page concept notes to be drawn up by the contact person of each group with inputs from other members of the Group, to include the following: o Title
o Background, which summarises what is known, what is not known, and the rationale for the study
o Study design o Objectives of the study o Outline of methods
o Collaborating centres o Plan of activities o Budget
• Concept notes to be sent to Dr GVS Murthy by the end of April 2006 • The concept notes will then be sent to international eye NGDOs, Ministry of Health & family
Welfare, Govt. of India and other research funding agencies.
• Once the concept note is accepted, a full proposal will be prepared with the inputs from the members of the Group and will be submitted to a specific agency for support.
• Dr Clare Gilbert and Dr G V S Murthy will visit the identified research partners in India to assess the research ‘preparedness’ of the different institutions.
Appendix 1: Programme
Day 1 Monday March 20th
0900-
1030
Registration and Inaugural Session
GVS Murthy, C Gilbert;
H. Faal; Dr Ghose, Mr
PKM Swamy
1100-
1300
PLENARY: Epidemiologic issues in RE
ICMR Support for medical research in India
Description of refractive errors (RE) Defining coverage and unmet need
Methods of assessment of RE including rapid appraisal Global magnitude of uncorrected refractive errors
Risk factors for RE
Progression of RE- need for follow up
Chair: Dr. S.Ghose / Mr. R.D.Thulasiraj
Dr. R.S.Dhaliwal
Dr. Vijaylakshmi Dr. Hannah Faal
Dr. GVS Murthy Dr. Clare Gilbert
Dr. Manish Sharma
Dr. Susanne Wedner
1345-
1515
PLENARY: Recent Studies on RE
Refractive errors in secondary school children in Tanzania
Methodology and findings of refractive error surveys in children in India Prevalence of RE among the aged in India
Rapid assessment of RE in Gujarat- Methodology and Relevance Association of Childhood Myopia with family characteristics
Data on spectacle use in India
Follow Up of children after spectacle correction in South India
Chair: Dr. Hannah Faal/ Dr. Ramani Dr. Susanne Wedner
Dr. Clare Gilbert Mr. R.D.Thulasiraj
Dr G. Uday Ms Neena John
Dr. Kuldeep Dole
Ms Mani Mala
1545-
1715
PLENARY: Operational issues in delivery of RE services
Setting priorities for RE services
Advocacy for RE in health programs Compliance with spectacles - evidence and need for follow up studies
Frequency of replacing glasses among children and adults Norms for establishing a quality RE service Technology initiatives for affordable spectacles
IEC approaches for augmenting RE services uptake
Chair: Dr. R.S.Dhaliwal /Dr. B.R.Shamanna Clare Gilbert
Hannah Faal Suzanne Wedner
GVS Murthy Dr. Vijayalakshmi Mr. Krishna Kumar
Dr. Noela Prasad
Day 2 Tuesday 21st March
0900-
1030
PLENARY: Service delivery approaches:
Integrating RE services in primary care in urban slums
Using community volunteers for dispensing glasses Integrating RE services into CBR projects
Vision Centres: augmenting RE services, utilization & appropriate referral
Making spectacles affordable Involving trained Optometrists in RE service delivery
Bringing self-styled practitioners on board
Chair: Clare Gilbert/ Dr. Gautam Bhaduri Dr. Praveen Vashist
Dr. B. Shamanna Dr. Asim Sil
Mr. Anand Sudhan
Dr. Hannah Faal Mrs Laksmi Shinde
Mr. Srinivas
1100-1300
PLENARY: Service delivery approaches for specific populations:
Govt. of India’s vision for child’s right to sight
LCIF supported Project on school screening in Mumbai What constitutes an optimal school screening program
Plan International support to comprehensive eye care programs
Opportunistic screening strategies for industry etc. How sensitive is vision testing in children?
Chair: Mr G V Rao/ Dr. Vijayalakshmi Dr. R.Jose
Dr. Jatin Shah Clare Gilbert
Ms. N. Abraham, PLAN
Dr. Anil Tara Dr G V S Murthy
1345-
1515
PLENARY: Qualitative research and evaluation of vision screening
in children:
Community perceptions and gender issues in spectacle use
Need for refractive correction in a population Designing quality of life instruments to monitor impact
Available research on quality of life instruments
Barriers to uptake of RE services Evaluation of school screening program in India
Chair: Mr. PKM Swamy/ Dr. K.Vishwanath Susanne Wedner
R.D.Thulasiraj Vijay Kumar
GVS Murthy
Dr. Ramani Asim Sil
1545-1715
PLENARY: Service Costing and Economic Implications
The need for costing of RE services Costing of services at Vision Centre level
Costing of services at secondary level institutions Costing of school eye screening programs
Economic implications of RE services
Measuring cost effectiveness of RE services
Chair: Dr C Shetty/ Dr A Tara
C Gilbert Mr.Anand Sudhan
R.D.Thulasiraj GVS Murthy
Dr B Shamanna
K. Anand
Day 3 Wednesday 22nd March
0900-
1045
NGO support for RE services research
ORBIS Plan for RE research
SSI plan for RE research CBM plan for RE research
LCIF plan for RE research SCOJO Foundation support for RE research
Vision 2020 India Forum activities for RE services
Chair: Dr Asim Sil/ Dr GVS Muthy
Mr G V Rao
Ms Elizabeth Kurien Dr Sara Varughese
Dr C.S.Shetty Mr. Aruneesh Singh
Mr PKM Swamy
1100 - 1300
GROUP WORK SESSION 1: Identifying research areas to improve implementation of RE programs in India in relation to Epidemiologic
Research, Economic implications including costing of RE services, Operational Research and Service delivery - organized sector, Operational
Research and Service delivery - non formal sector, Qualitative research,
QOL, VF
Moderators: Dr. Sanjeev Gupta
Dr Shamanna Dr Hannah Faal
Dr Clare Gilbert
Dr Suzanne Wedner Dr GVS Murthy
1345-1515
PRESENTATION AND DISCUSSION FROM SESSION 1:
Group rapporteurs
Chair: Clare Gilbert/ Hannah Faal
1545-
1715
PLENARY: Identification of research priorities for India for RE services
and sources of funding
Chair: Clare Gilbert/ Hannah Faal
Day 5 Friday 24th March
All morning
GROUP WORK SESSION 2: CONTINUED
After-
noon
PLENARY SESSION:
Presentation of protocols by Groups 1-4, with discussion
Moderators: C. Gilbert,
H Faal
Day 4 Thursday 23rd March
All day GROUP WORK SESSION 2: Preparation of protocols for 7 research studies
Resource Persons: H. Faal; C. Gilbert; S. Wedner; GVS Murthy; Dr.K. Vishwanath; Dr S
Gupta; Dr Praveen Vashist
Day 6 Saturday 25th March
900 -1030
PLENARY SESSION: Presentation of protocols by Groups 5 and 6, with discussion
Chair: Dr. Faal/ Dr Praveen Vashist
1030 -
1300
WRAP UP SESSION:
Identification of institutions to undertake research Conclusions and recommendations
40. Mr. PKM Swamy National Executive Director VISION 2020: The Right to Sight –INDIA, National Secretariat, # 805, R-Block, New Rajinder Nagar, New Delhi -110 060
47. Dr . R.R. Sudhir HOD Dept of Preventive Ophthalmology and Associate Consultant Cornea Services, Sankara Nethralaya, Medical Research Foundation, 18 College Road, Chennai: 600 006