Mixed methods study protocol for combining stakeholder-led rapid evaluation with near real-time continuous registry data to facilitate evaluations of quality of care in intensive care units [version 1; peer review: awaiting peer review]

BACKGROUND: Improved access to healthcare in low- and middle-income countries (LMICs) has not equated to improved health outcomes. Absence or unsustained quality of care is partly to blame. Improving outcomes in intensive care units (ICUs) requires delivery of complex interventions by multiple specialties working in concert, and the simultaneous prevention of avoidable harms associated with the illness and the treatment interventions. Therefore, successful design and implementation of improvement interventions requires understanding of the behavioural, organisational, and external factors that determine care delivery and the likelihood of achieving sustained improvement. We aim to identify care processes that contribute to suboptimal clinical outcomes in ICUs located in LMICs and to establish barriers and enablers for improving the care processes. METHODS: Using rapid evaluation methods, we will use four data collection methods: 1) registry embedded indicators to assess quality of care processes and their associated outcomes; 2) process mapping to provide a preliminary framework to understand gaps between current and desired care practices; 3) structured observations of processes of interest identified from the process mapping and; 4) focus group discussions with stakeholders to identify barriers and enablers influencing the gap between current and desired care practices. We will also collect self-assessments of readiness for quality improvement. Data collection and analysis will be performed in parallel and through an iterative process across eight countries: Kenya, India, Malaysia, Nepal, Pakistan, South Africa, Uganda and Vietnam. CONCLUSIONS: The results of our study will provide essential information on where and how care processes can be improved to facilitate better quality of care to critically ill patients in LMICs; thus, reduce preventable mortality and morbidity in ICUs. Furthermore, understanding the rapid evaluation methods that will be used for this study will allow other researchers and healthcare professionals to carry out similar research in ICUs and other health services

Spectacle compliance among adolescents in Southern India: Perspectives of service providers

Purpose: Compliance to spectacle wear is vital to elimination of avoidable blindness among schoolchildren. This study aims to understand the barriers to compliance and strategies to overcome the barriers from the perspectives of the service providers of the school vision-screening model. Methods: A snapshot qualitative study using focus group discussions (FGDs) was conducted among the service providers including eye care professionals (ECPs) and social workers that are part of the school screening program. Sessions were audio recorded and transcribed. Themes were formed following inductive coding using a conceptual framework. Results: Out of the three FGDs, two were with ECPs and one with social workers. Four subthemes identified under the barriers were poor awareness, spectacle-related, psychosocial, and financial barriers. Unique barriers according to the service providers included nonuse of spectacles by asymptomatic children, children with unilateral refractive errors and those with emmetropic parents. Service providers also brought out parent's feelings of guilt, doubts about their children's impaired vision, the negative self-image among children, and difficulties in obtaining funding to support the costs of screening. Solutions that emerged included the personal visit of professionals for spectacle distribution and counseling parents, demonstration of improvement in vision for activities that were difficult for the children without spectacles and rewarding, and role modeling of compliant children. Conclusion: This study had identified unique barriers and solutions from the perspectives of the service providers. The suggested strategies would aid in an effective schoolchildren vision screening practice to enhance compliance to spectacle wear

Environmental factors in school classrooms: How they influence visual task demand on children.

BackgroundThe key visual factors in a classroom environment include the legibility, angle subtended at the eye, illumination, contrast, and colour of the visual task. The study evaluated the visual environmental factors in the school classrooms.Materials and methodsThe distance Visual Acuity (VA) demand was evaluated based on the size of visual task i.e. the smallest size of chalkboard writing and its viewing distance. The environmental factors which can have an effect on the visibility in classrooms such as illuminance on the chalkboard and at student's desk, chalkboard contrast, light sources and the student's perception of their classroom visual environment were measured. To quantify the distance VA demand and to compare with a standard high contrast VA chart measure, a validation of the measurements was performed by chalkboard simulation experiment. The "acuity reserve" to be included to the measured distance VA demand was evaluated.ResultsWe included twenty-nine classrooms of eight schools. The median distance VA threshold demand was 0.28 logMAR(0.25,0.45). The median illuminance on front desk position and chalkboard contrast was 130 lux(92,208) and 40(36,50) respectively with 62% classrooms having low illumination (ConclusionThe study findings highlight the increased visual task demand in school classrooms and the need for appropriate seating arrangements in classrooms based on the visual acuity of children. The study emphasises regular audit of the classroom environment along with the school eye screening

Efficacy of vision therapy in children with learning disability and associated binocular vision anomalies

Purpose: To report the frequency of binocular vision (BV) anomalies in children with specific learning disorders (SLD) and to assess the efficacy of vision therapy (VT) in children with a non-strabismic binocular vision anomaly (NSBVA). Methods: The study was carried out at a centre for learning disability (LD). Comprehensive eye examination and binocular vision assessment was carried out for 94 children (mean (SD) age: 15 (2.2) years) diagnosed with specific learning disorder. BV assessment was done for children with best corrected visual acuity of ≥6/9 – N6, cooperative for examination and free from any ocular pathology. For children with a diagnosis of NSBVA (n = 46), 24 children were randomized to VT and no intervention was provided to the other 22 children who served as experimental controls. At the end of 10 sessions of vision therapy, BV assessment was performed for both the intervention and non-intervention groups. Results: Binocular vision anomalies were found in 59 children (62.8%) among which 22% (n = 13) had strabismic binocular vision anomalies (SBVA) and 78% (n = 46) had a NSBVA. Accommodative infacility (AIF) was the commonest of the NSBVA and found in 67%, followed by convergence insufficiency (CI) in 25%. Post-vision therapy, the intervention group showed significant improvement in all the BV parameters (Wilcoxon signed rank test, p < 0.05) except negative fusional vergence. Conclusion: Children with specific learning disorders have a high frequency of binocular vision disorders and vision therapy plays a significant role in improving the BV parameters. Children with SLD should be screened for BV anomalies as it could potentially be an added hindrance to the reading difficulty in this special population

Do school classrooms meet the visual requirements of children and recommended vision standards?

<div><p>Background</p><p>Visual demands of school children tend to vary with diverse classroom environments. The study aimed to evaluate the distance and near Visual Acuity (VA) demand in Indian school classrooms and their comparison with the recommended vision standards.</p><p>Materials and methods</p><p>The distance and near VA demands were assessed in 33 classrooms (grades 4 to 12) of eight schools. The VA threshold demand relied on the smallest size of distance and near visual task material and viewing distance. The logMAR equivalents of minimum VA demand at specific seating positions (desk) and among different grades were evaluated. The near threshold was converted into actual near VA demand by including the acuity reserve. The existing dimensions of chalkboard and classroom, gross area in a classroom per student and class size in all the measured classrooms were compared to the government recommended standards.</p><p>Results</p><p>In 33 classrooms assessed (35±10 students per room), the average distance and near logMAR VA threshold demand was 0.31±0.17 and 0.44±0.14 respectively. The mean distance VA demand (minimum) in front desk position was 0.56±0.18 logMAR. Increased distance threshold demand (logMAR range -0.06, 0.19) was noted in 7 classrooms (21%). The mean VA demand in grades 4 to 8 and grades 9 to 12 was 0.35±0.16 and 0.24±0.16 logMAR respectively and the difference was not statistically significant (p = 0.055). The distance from board to front desk was greater than the recommended standard of 2.2m in 27 classrooms (82%). The other measured parameters were noted to be different from the proposed standards in majority of the classrooms.</p><p>Conclusion</p><p>The study suggests the inclusion of task demand assessment in school vision screening protocol to provide relevant guidance to school authorities. These findings can serve as evidence to accommodate children with mild to moderate visual impairment in the regular classrooms.</p></div

Categorization of desk positions and the minimum and average distance visual acuity demand (Mean±SD (range)) at different desk positions in 33 classrooms.

<p>Categorization of desk positions and the minimum and average distance visual acuity demand (Mean±SD (range)) at different desk positions in 33 classrooms.</p

Comparison of variables in measured 33 classrooms to the Indian Government standard recommendations.

<p>Comparison of variables in measured 33 classrooms to the Indian Government standard recommendations.</p

Are children with low vision adapted to the visual environment in classrooms of mainstream schools?

Purpose: The study aimed to evaluate the classroom environment of children with low vision and provide recommendations to reduce visual stress, with focus on mainstream schooling. Methods: The medical records of 110 children (5–17 years) seen in low vision clinic during 1 year period (2015) at a tertiary care center in south India were extracted. The visual function levels of children were compared to the details of their classroom environment. The study evaluated and recommended the chalkboard visual task size and viewing distance required for children with mild, moderate, and severe visual impairment (VI). Results: The major causes of low vision based on the site of abnormality and etiology were retinal (80%) and hereditary (67%) conditions, respectively, in children with mild (n = 18), moderate (n = 72), and severe (n = 20) VI. Many of the children (72%) had difficulty in viewing chalkboard and common strategies used for better visibility included copying from friends (47%) and going closer to chalkboard (42%). To view the chalkboard with reduced visual stress, a child with mild VI can be seated at a maximum distance of 4.3 m from the chalkboard, with the minimum size of visual task (height of lowercase letter writing on chalkboard) recommended to be 3 cm. For 3/60–6/60 range, the maximum viewing distance with the visual task size of 4 cm is recommended to be 85 cm to 1.7 m. Conclusion: Simple modifications of the visual task size and seating arrangements can aid children with low vision with better visibility of chalkboard and reduced visual stress to manage in mainstream schools

Box plot representing the comparison of minimum distance visual acuity demand at different desk positions (front, middle and last row) between grades 4 to 8 and grades 9 to 12.

<p>Box plot representing the comparison of minimum distance visual acuity demand at different desk positions (front, middle and last row) between grades 4 to 8 and grades 9 to 12.</p

Average letter size, viewing distance and visual acuity demand, and comparison between different grades (grade 4 to 8 and grade 9 to 12 group) and schools (n = 8) in 33 classrooms.

<p>Average letter size, viewing distance and visual acuity demand, and comparison between different grades (grade 4 to 8 and grade 9 to 12 group) and schools (n = 8) in 33 classrooms.</p