The unexpected frontline detectors of poor vision

BARCELONA — Teachers are on the frontlines of education, battling with books and blackboards to ensure inclusive and equitable quality education for all, while simultaneously touching other critical Sustainable Development Goals. But some NGOs think teachers can have an even bigger role — as frontline detectors of poor health, particularly poor eye health.

Eighty percent of what a child learns is processed through their visual system. When it comes to vision impairment in children aged 5-15, an estimated 12.8 million cases are due to uncorrected or inadequately corrected refractive errors, which can be easily rectified with glasses.

But with a scarcity of trained health workers, it’s not always easy to get children the visual exams they need. That’s where teachers come in.

“If you know the situation in Africa, if you know the situation in most developing countries, none of the countries have enough health care workers who could do this screening. If you look at the overall need — the 700 million children who need vision screening — and you look at the scarcity of eye care or other health care, I don't think there's any other way to actually provide this service,” said Hasan Minto, global programs director at Our Children’s Vision and chair of the International Agency for the Prevention of Blindness’ work group on school eye health.

“Eye health services are far too often a neglected part of child health interventions at the expense of a student’s potential,” he said.

IAPB, Unite for Sight, Sightsavers, and Partnership for Child Development are just some organizations who see teachers as a solution to reducing the number of people forced to live with a vision impairment — a figure that currently stands at 1.3 billion, 80 percent of which is avoidable.

How it works

Minto, who is based in Pakistan, explained that the Brien Holden Vision Institute — co-founder of Our Children’s Vision — has trained over 20,000 teachers since 2012 across East Africa, China, Vietnam, Pakistan, and India via a standardized one-day training. “They are taught to do an external eye exam looking for signs of an unhealthy eye — if there is red eye, discharge, a cataract or squint — and if a child has a learning disability.”

IAPB has also adopted a set of guidelines — developed by Our Children’s Vision, the Brien Holden Vision Institute, Sightsavers International, and London School of Hygiene and Tropical Medicine — which ensures teachers in low- to middle-income countries have a standardized level of skills to address their students’ vision and eye health needs.

The School Health Integrated Programming initiative — developed and implemented by the Partnership for Child Development and Sightsavers with funding from the Global Partnership for Education — has also trained teachers in Cambodia, Ethiopia, Senegal, Liberia, and Ghana to be aware of major eye conditions affecting their region and to carry out simple physical eye examinations.

“This dramatically reduced the numbers of children in a school that needed to be tested by a medical professional, thus improving both capacity and coverage,” said Lesley Drake, executive director of PCD. The SHIP initiative then works with the eye care units of the district hospitals to assess cases referred by teachers, reducing the amount of time children, who would otherwise have to spend time in a hospital, miss school.

Dr. Priya Morjaria, research fellow at the International Centre for Eye Health at the London School of Hygiene & Tropical Medicine and global technical lead at Peek Vision, said the follow-up services are vital. “That’s one of the principles of any screening program: no screening without a service.”

However, access to services beyond the initial school screening can pose a challenge. “If you want that child seen, the teacher might inform the parent somehow and the parent then needs to take the child somewhere. It may mean they're not able to go to work that day or they don't have the financial means to take the child,” Morjaria said, adding that access to treatment has to be thought of at the onset of any school screening programs.

For example, Unite for Sight works with local clinics on outreach programs in rural areas of Ghana, India, and Honduras to ensure that once community members, including teachers, have identified people with potential vision or eye health issues, they are seen at the monthly outreach clinic for corrective measures.

“I think that it's so important to identify within particular communities the best way to eliminate barriers to care, and schools typically have such a great role and ability to do that,” said Jennifer Staple-Clark, Unite For Sight’s founder and CEO. “We have had many children sent to us because the teachers are the ones to have identified and told the parents, ‘you should go get eye care for your child.’”

The benefits of school screening

Aside from the reduction of time families need to spend travelling to a clinic for eye care, the streamlining of services for local clinics, and increased access to eye health for lower-income communities, screening can be the difference between receiving an education and not.

“One child was seen as being unable to learn and it turned out that he had bilateral cataracts and was unable to see,” Staple-Clark said, explaining that as a result this child had been held back in school.

Oftentimes, children with poor vision are mistakenly believed to have a learning disability or seen as unable to learn — a misdiagnosis that has severe implications. The implementation of teacher-led screening can help rectify this.

This cross-sectoral approach to health care could also have monetary benefits. “The ‘integrated’ element is now understood globally to be a cost-effective way to maximize the impact of interventions and, overarchingly, as a significant contributor to a country’s investment in human capital,” PCD’s Drake said.

Advice for replication

Minto explained that while other NGOs working on vision should train teachers on vision screening and basic eye health, working in silos does not yield positive results: “If an NGO sends teachers for training and expects them to perform, usually you don’t get good results.”

“But if you work with the health and educations system and involve the ministry of education as a partner and work with district education officers who then communicate this to the schools, it then becomes part of the education,” Minto explained. The best system to follow would include two trained teachers per school who report to the district and bring eye care teams to schools to provide corrective services, according to Minto.

Drake emphasized the importance of adequate training so teachers do not “raise false alarms,” adding that it is important to ensure an initiative offers a comprehensive package of eye health education and sensitization for the entire community.

While standardization of training and processes are a benefit, a cookie-cutter approach to school screening isn’t always going to be successful. Contexts have to be considered, Morjaria said, explaining that the model works well in Kenya, but in India, it is not as sustainable because teachers are overburdened and female teachers are often not allowed to travel into other schools to do screenings.

“You have to take into account what's the norm in these places, how will these teachers be incentivized, and will they get permission to do this. There’s a lot of factors to take into consideration.”

Devex, with financial support from our partner Essilor, is exploring challenges, solutions, and innovations in eye care and vision. Visit the Focus on: Vision page for more.

Update, Feb. 28, 2019: This article has been updated to clarify the Global Partnership for Education.