Implementation of a large-scale school eye health program for Indian children

Background: School Eye Health programs are a common strategy to screen and manage eye conditions in children, but program outcomes may vary in ‘real-world’ contexts. Aim: This thesis investigates the implementation of a School Eye Health program, the Refractive Errors Among Children (REACH) which aims to provide refractive services in six nominated districts in five Indian states. Methods: Mixed methods were used. The program data (n=2,029,838 children; n=10,306 schools) from July 2016 to April 2019 comprised the quantitative, and semi-structured interviews with key stakeholders (n=114) constituted the qualitative data. Evaluation components investigated were: (1) coverage, (2) formulation and validation of program theories using realist approach, and (3) costs and cost-effectiveness relative to no program. Results: Of the children who attended the preliminary eye assessments, 143,340 (7.1%) screened positive and had a comprehensive examination. Of these, 42.4 % were provided with glasses. Using population estimates, the REACH program coverage ranged from 32.4% to 98.3% among the districts. Stakeholders cited that there were uncertainties around the accuracy of the database of children on roll and absenteeism of children to schools were barriers to access. Program theories for REACH were validated based on the program implementers’ viewpoints using a realist approach. Participation in co-design of the model of service delivery, community partnerships for the program implementation, integration of the quality control measures within the web-based data capturing system, and pre-determined program costs & targets were recognised as pathways that promoted transparency and successful implementation. From the service provider perspective, it costs US$1.0 per screening, US$ 3.0 for comprehensive refractive care, and US$ 5.9 for spectacles. The incremental cost-effectiveness ratios per quality-adjusted life-year varied with prevalence of refractive errors and therefore age with maximum cost-effectiveness for children 12 years and older. Stakeholders expressed the need for sustained funding as a concern for providing comprehensive services. Conclusion: School Eye Health programs are cost-effective when implemented at scale in India. While comprehensiveness of the program was valued, strategies tailored to the local circumstances are needed to promote continued care. The recommendations from this thesis can support future School Eye Health program implementation in countries such as India

Prevalence of refractive errors in children in India: a systematic review

Uncorrected refractive error is an avoidable cause of visual impairment which affects children in India. The objective of this review is to estimate the prevalence of refractive errors in children ≤ 15 years of age. The Preferred Reporting Items for Systematic Reviews and Meta‐Analyses guidelines were followed in this review. A detailed literature search was performed to include all population and school‐based studies published from India between January 1990 and January 2017, using the Cochrane Library, Medline and Embase. The quality of the included studies was assessed based on a critical appraisal tool developed for systematic reviews of prevalence studies. Four population‐based studies and eight school‐based studies were included. The overall prevalence of refractive error per 100 children was 8.0 (CI: 7.4–8.1) and in schools it was 10.8 (CI: 10.5–11.2). The population‐based prevalence of myopia, hyperopia (≥ +2.00 D) and astigmatism was 5.3 per cent, 4.0 per cent and 5.4 per cent, respectively. Combined refractive error and myopia alone were higher in urban areas compared to rural areas (odds ratio [OR]: 2.27 [CI: 2.09–2.45]) and (OR: 2.12 [CI: 1.79–2.50]), respectively. The prevalence of combined refractive errors and myopia alone in schools was higher among girls than boys (OR: 1.2 [CI: 1.1–1.3] and OR: 1.1 [CI: 1.1–1.2]), respectively. However, hyperopia was more prevalent among boys than girls in schools (OR: 2.1 [CI: 1.8–2.4]). Refractive error in children in India is a major public health problem and requires concerted efforts from various stakeholders including the health care workforce, education professionals and parents, to manage this issue

Measuring Coping in Parents of Children with Disabilities: A Rasch Model Approach

<div><p>Background</p><p>Parents of a child with disability must cope with greater demands than those living with a healthy child. Coping refers to a person’s cognitive or behavioral efforts to manage the demands of a stressful situation. The Coping Health Inventory for Parents (CHIP) is a well-recognized measure of coping among parents of chronically ill children and assesses different coping patterns using its three subscales. The purpose of this study was to provide further insights into the psychometric properties of the CHIP subscales in a sample of parents of children with disabilities.</p><p>Methods</p><p>In this cross-sectional study, 220 parents (mean age, 33.4 years; 85% mothers) caring for a child with disability enrolled in special schools as well as in mainstream schools completed the 45-item CHIP. Rasch analysis was applied to the CHIP data and the psychometric performance of each of the three subscales was tested. Subscale revision was performed in the context of Rasch analysis statistics.</p><p>Results</p><p>Response categories were not used as intended, necessitating combining categories, thereby reducing the number from 4 to 3. The subscale – ‘maintaining social support’ satisfied all the Rasch model expectations. Four item misfit the Rasch model in the subscale –maintaining family integration’, but their deletion resulted in a 15-item scale with items that fit the Rasch model well. The remaining subscale – ‘understanding the healthcare situation’ lacked adequate measurement precision (<2.0 logits).</p><p>Conclusions</p><p>The current Rasch analyses add to the evidence of measurement properties of the CHIP and show that the two of its subscales (one original and the other revised) have good psychometric properties and work well to measure coping patterns in parents of children with disabilities. However the third subscale is limited by its inadequate measurement precision and requires more items.</p></div

Overall performance of the CHIP Subscales in parents of children with disabilities.

<p>CHIP- Coping Health Inventory for Parents.</p><p>* Misfitting items were deleted iteratively and the final 15-item revised version is only shown here. See text for details (results section).</p><p>Overall performance of the CHIP Subscales in parents of children with disabilities.</p

Person-item map for the Rasch-revised 15-item ‘maintaining family integration, co-operation, and an optimistic definition of the situation’ subscale of the Coping Health Inventory for Parents (n = 220).

<p>Participants are located on the left of the dashed line (represented by ‘x’) and participants with better coping ability are located at the top of the map. Items (i.e., coping patterns) are on the right of the dashed line with those considered to be least helpful located toward the top of the map. Each ‘x’ and “.” represent two and one participants respectively. Alongside each item is also indicated its abridged description and number as in the 45-item original CHIP. The complete description of items can be found in <a href="http://www.plosone.org/article/info:doi/10.1371/journal.pone.0118189#pone.0118189.t002" target="_blank">Table 2</a> in the text. M, mean; S, 1 SD from the mean; T, 2 SD from the mean.</p

The patient health questionnaire-9: validation among patients with glaucoma.

BACKGROUND: Depression and anxiety are two common normal responses to a chronic disease such as glaucoma. This study analysed the measurement properties of the depression screening instrument - Patient Health Questionnaire-9 (PHQ-9) using Rasch analysis to determine if it can be used as a measure. METHODS: In this hospital-based cross-sectional study, the PHQ-9 was administered to primary glaucoma adults attending a glaucoma clinic of a tertiary eye care centre, South India. All patients underwent a comprehensive clinical evaluation. Patient demographics and sub-type of glaucoma were abstracted from the medical record. Rasch analysis was used to investigate the following properties of the PHQ-9: behaviour of the response categories, measurement precision (assessed using person separation reliability, PSR; minimum recommended value 0.80), unidimensionality (assessed using item fit [0.7-1.3] and principal components analysis of residuals), and targeting. RESULTS: 198 patients (mean age ± standard deviation  = 59.83±12.34 years; 67% male) were included. The native PHQ-9 did not fit the Rasch model. The response categories showed disordered thresholds which became ordered after category reorganization. Measurement precision was below acceptable limits (0.62) and targeting was sub-optimal (-1.27 logits). Four items misfit that were deleted iteratively following which a set of five items fit the Rasch model. However measurement precision failed to improve and targeting worsened further (-1.62 logits). CONCLUSIONS: The PHQ-9, in its present form, provides suboptimal assessment of depression in patients with glaucoma in India. Therefore, there is a need to develop a new depression instrument for our glaucoma population. A superior strategy would be to use the item bank for depression but this will also need to be validated in glaucoma patients before deciding its utility

Prevalence of refractive errors, uncorrected refractive error, and presbyopia in adults in India: A systematic review

Purpose: The objective of this review is to estimate the prevalence of refractive errors, uncorrected refractive error (URE), and uncorrected presbyopia in adults aged ≥30 years in India. Methods: The Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines were followed. A detailed literature search was performed to include all studies published from India from the year 1990 using the Cochrane Library, Medline, and Embase. Refractive error was defined by >0.50 D ametropia. URE was defined by presenting visual acuity (PVA) worse than 6/18 improving with pinhole or spectacle correction, and uncorrected presbyopia by near vision <N8 improving with correction in the absence of distance URE. Results: Fifteen studies were included from South India, one each from Western and Central India, and one study covered 15 states across India. The prevalence of RE of at least 0.50 D of spherical equivalent ametropia was 53.1% [(95% confidence interval (CI): 37.2–68.5), of which myopia and hyperopia was 27.7% and 22.9%, respectively. The prevalence of URE was 10.2% (95% CI: 6.9–14.8), but heterogeneity in these estimates was very high. The prevalence of uncorrected presbyopia was 33% (95% CI: 19.1–51.0). Conclusion: This review highlights the magnitude of refractive errors among adults in India. More studies are needed using standard methods in regions where there is a lack of information on UREs. Programs delivering spectacles for adults in India will need to primarily focus on reading glasses to correct presbyopia along with spectacles for hyperopia and myopia

Item content of the Patient-Health Questionnaire-9.

<p>^*Framing question for all above items – “Over the last 2 weeks, how often have you been bothered by any of the following”.</p><p>Response options for all the above items: not at all (0), several days (1), more than half the days (2), nearly every day (3).</p

Item calibration (location) and fit statistics for the five items of the Patient Health Questionnaire.

<p>Item calibration (location) and fit statistics for the five items of the Patient Health Questionnaire.</p