Participation of Smallholders in Agroforestry Agri-Environmental Scheme: A lesson from the rural Mount Kenya region

The likelihood of smallholder farmers not participating in agroforestry agri-environmental schemes and payments for ecosystem services (PES) may be due to limited farmland endowment and formal credit constraints. These deficits may lead to an ‘exclusive club’ of successful farmers, which are not necessarily poor, enjoying the benefits of agri-environmental schemes and PES although agrienvironmental schemes and PES have been devised as a means of fostering rural sustainable development and improving the livelihood of poor smallholder farmers. Smallholder farmers in parts of rural Kenya continue to enroll in ‘The International Small Group Tree Planting Programme’ (TIST), an agri-environmental scheme, promoting agroforestry, carbon sequestration and conservation agriculture (CA). The question remains if these farmers are really poor? This study examines factors that determine the participation of smallholder farmers in TIST in parts of rural Kenya. We use survey data compiled in 2013 on 210 randomly selected smallholder farmers from Embu, Meru and Nanyuki communities; the sample consists of TIST and non-TIST members. A random utility model and logit regression were used to test a set of non-monetary and monetary factors that influence participation in the TIST. The utility function is conceptualized to give non-monetary factors, particularly the common medium of communication in rural areas – formal and informal – a central role. Furthermore, we investigate other factors (incl. credit accessibility and interest rate) that reveal the nature of farmers participating in TIST. The findings suggest that spread of information via formal and informal networks is a major driver of participation in the TIST program. Furthermore, variables such credit constrains, age and labour supply positively correlate with TIST participation, while for education the opposite is true. It is important to mention that these correlations, although somewhat consistent, were all found to be weak. The results indicate that participation in the TIST program is not influenced by farm size; therefore we argue that the TIST scheme is NOT an ‘exclusive club’ comprising wealthy and successful farmers. Older farmers’ being more likely to join the TIST is an argument for their long- rather than widely assumed short-term planning horizon and a new contribution to the literature. Given the importance of poverty alleviation and climate smart agriculture in developing countries, sustainable policy should strengthening the social and human capital as well as informal networks in rural areas. Extension services should effectively communicate benefits to less educated and credit constrained farmers.

Rural communities and wind farms: a contingent valuation investigation

Using the contingent valuation method, this study investigates the preferences of local people for a wind farm that is planned in the Province of Rome. We estimate the reductions in their bimonthly electrical bills over a period of time that respondents are willing to accept as compensation for the installation of the wind farm. Our results suggest that respondents who perceive that the wind farm generates substantial negative impacts on landscape beauty ask higher reductions than others, while respondents who believe that the wind farm produces economic benefits for local communities ask lower reductions than others. Finally, we find that the demand for compensative measures is influenced particularly by socio-economic factors such as age and education.

An investigation of vision problems and the vision care system in Rural China

This paper examines the prevalence of vision problems and the accessibility to and quality of vision care in rural China. We obtained data from 4 sources: 1) the National Rural Vision Care Survey; 2) the Private Optometrists Survey; 3) the County Hospital Eye Care Survey; and 4) the Rural School Vision Care Survey. The data from each of the surveys were collected by the authors during 2012. Thirty-three percent of the rural population surveyed self-reported vision problems. Twenty-two percent of subjects surveyed had ever had a vision exam. Among those who self-reported having vision problems, 34% did not wear eyeglasses. Fifty-four percent of those with vision problems who had eyeglasses did not have a vision exam prior to receiving glasses. However, having a vision exam did not always guarantee access to quality vision care. Four channels of vision care service were assessed. The school vision examination program did not increase the usage rate of eyeglasses. Each county-hospital was staffed with three eye-doctors having one year of education beyond high school, serving more than 400,000 residents. Private optometrists often had low levels of education and professional certification. In conclusion, our findings shows that the vision care system in rural China is inadequate and ineffective in meeting the needs of the rural population sampled.

Accuracy of rural refractionists in western China

Purpose. We assessed the prevalence and predictors of inaccurate refractive error among rural refractionists in western China. Methods. A subset of primary school children with visual acuity (VA) ≤6/12 in ≥1 eye, undergoing subjective refinement by local refractionists after cycloplegic autorefraction in an ongoing population-based study, received repeat refraction by university optometrists for quality control. Results. Among 502 children (mean age 10.5 years, 53.2% girls), independent predictors of poor (inaccurate by ≥1.0 diopter [D]) refraction by 21 rural practitioners (66.7% with high school or lower education) included hyperopia (odds ratio [OR], 4.2; 95% confidence interval [CI], 2.4-7.3, P < 0.001), astigmatism (OR = 3.8; 95% CI, 2.5-5.6; P < 0.001) and VA uncorrectable to >6/12 by the rural refractionist (OR = 4.7; 95% CI, 3.1-7.3; P = < 0.001). Among 201 children whose vision was uncorrectable in ≥1 eye by the rural refractionists, vision could be improved to >6/12 by the university optometrist in 110 (54.7%). We estimate vision could be so improved in 9.1% of all children refracted by these rural refractionists. A reason for inaccuracy in this setting is the erroneous tendency of rural refractionists to adjust instrument values for accommodation, even under cycloplegia. Conclusions. Rural refractionists in western China have little formal training and frequently fail to optimize VA among children, even when autorefractors are used. Training is needed emphasizing better use of automated refraction, particularly in children with astigmatism and hyperopia. © 2014 The Association for Research in Vision and Ophthalmology, Inc.

Attitudes of physicians, patients, and village health workers toward glaucoma and diabetic retinopathy in rural China:A focus group study

Objective: To understand the knowledge and attitudes of rural Chinese physicians, patients, and village health workers (VHWs) toward diabetic eye disease and glaucoma. Methods: Focus groups for each of the 3 stakeholders were conducted in 3 counties (9 groups). The focus groups were recorded, transcribed, and coded using specialized software. Responses to questions about barriers to compliance and interventions to remove these barriers were also ranked and scored. Results: Among 22 physicians, 23 patients, and 25 VHWs, knowledge about diabetic eye disease was generally good, but physicians and patients understood glaucoma only as an acutely symptomatic disease of relatively low prevalence. Physicians did not favor routine pupillary dilation to detect asymptomatic disease, expressing concerns about workflow and danger and inconvenience to patients. Providers believed that cost was the main barrier to patient compliance, whereas patients ranked poorly trained physicians as more important. All 3 stakeholder groups ranked financial interventions to improve compliance (eg, direct payment, lotteries, and contracts) low and preferred patient education and telephone contact by nurses. All the groups somewhat doubted the ability of VHWs to screen for eye disease accurately, but patients were generally willing to pay for VHW screening. The VHWs were uncertain about the value of eye care training but might accept it if accompanied by equipment. They did not rank payment for screening services as important. Conclusions: Misconceptions about glaucoma's asymptomatic nature and an unwillingness to routinely examine asymptomatic patients must be addressed in training programs. Home contact by nurses and patient education may be the most appropriate interventions to improve compliance.

Willingness to pay for cataract surgery in rural Southern China.

PURPOSE: To study willingness to pay for cataract surgery, and its associations, in Southern China. DESIGN: Cross-sectional willingness-to-pay interview incorporating elements of the open-ended and bidding formats. PARTICIPANTS: Three-hundred thirty-nine persons presenting for cataract screening in Yangjiang, China, with presenting visual acuity (VA) < or = 6/60 in either eye due to cataract. METHODS: Subjects underwent measurement of their VA and a willingness-to-pay interview. Age, gender, literacy, education, and annual income also were recorded. MAIN OUTCOME MEASURES: Maximum amount that the subjects would be willing to pay for cataract surgery. RESULTS: Among 325 (95.9%) subjects completing the interview, 169 (52.0%) were 70 years or older, 213 (65.5%) were women, and 217 (66.8%) had an annual income of <5000 renminbi (5000 = US 625 dollars). Eighty percent (n = 257) of participants were willing to pay something for surgery (mean, 442+/-444 renminbi [US 55 dollars+/-55]). In regression models, older subjects were willing to pay less (8 renminbi [US 1 dollar] per year of age; P = 0.01). Blind subjects were significantly more likely (odds ratio, 5.7; 95% confidence interval, 1.7-19.3) to pay anything for surgery, but would pay on average 255 renminbi (US 32 dollars) less (P = 0.004). Persons at the highest annual income level (>10,000 renminbi [US 1250 dollars]) would pay 50 dollars more for surgery than those at the lowest level (<5000 renminbi) (P = 0.0003). The current cost of surgery in this program is 500 renminbi (US 63 dollars). CONCLUSIONS: Sustainable programs will need to attract younger, more well-to-do persons with better vision, while still providing access to the neediest patients.

Spectacle acceptance among secondary school students in rural China: the Xichang Pediatric Refractive Error Study (X-PRES)--report 5.

PURPOSE: To assess determinants of spectacle acceptance and use among rural Chinese children. METHODS: Children with uncorrected acuity < or = 6/12 in either eye and whose presenting vision could be improved > or = 2 lines with refraction were identified from a school-based sample of 1892 students. Information on obtaining glasses and the benefits of spectacles was provided to children, families, and teachers. Purchase of new spectacles and reasons for nonpurchase were assessed by direct inspection and interview 3 months later. RESULTS: Among 674 (35.6%) children requiring spectacles (mean age, 14.7 +/- 0.8 years), 597 (88.6%) were followed up. Among 339 children with no glasses at baseline, 30.7% purchased spectacles, whereas 43.2% of 258 children with inaccurate glasses replaced them. Most (70%) subjects paid US$13 to $26. Among children with bilateral vision < or = 6/18, 45.6% bought glasses. In multivariate models, presenting vision < 6/12 (P < 0.009), refractive error < -2.0 D (P < 0.001), and amount willing to pay for glasses (P = 0.01) were predictors of purchase. Reasons for nonpurchase included satisfaction with current vision (78% of those with glasses at baseline, 49% of those without), concerns over price or parental refusal (18%), and fear glasses would weaken the eyes (13%). Only 26% of children stated that they usually wore their new glasses. CONCLUSIONS: Many families in rural China will pay for glasses, though spectacle acceptance was < 50%, even among children with poor vision. Acceptance could be improved by price reduction, education showing that glasses will not harm the eyes, and parent-focused interventions.

Associations between near work, outdoor activity, and myopia among adolescent students in rural China: the Xichang Pediatric Refractive Error Study report no. 2.

OBJECTIVE:

To study the associations between near work, outdoor activity, and myopia among children attending secondary school in rural China.

METHODS:

Among a random cluster sample of 1892 children in Xichang, China, subjects with an uncorrected acuity of 6/12 or less in either eye (n = 984) and a 25% sample of children with normal vision (n = 248) underwent measurement of refractive error. Subjects were administered a questionnaire on parental education, time spent outdoors, and weekly time spent engaged in and preferred working distance for a variety of near-work activities.

RESULTS:

Among 1232 children with refraction data, 998 (81.0%) completed the near-work survey. Their mean age was 14.6 years (SD, 0.8 years), 55.6% were girls, and 83.1% had myopia of -0.5 diopters or less (more myopia) in both eyes. Time and diopter-hours spent on near activities did not differ between children with and without myopia. In regression models, time spent on near activities and time outdoors were unassociated with myopia, adjusting for age, sex, and parental education.

CONCLUSIONS:

These and other recent results raise some doubts about the association between near work and myopia. Additional efforts to identify other environmental factors associated with myopia risk and that may be amenable to intervention are warranted.

Impact of cataract screening outreach in rural China.

PURPOSE: To examine differences between patients with cataract detected during screening and presenting to clinic in rural China. METHODS: Subjects were recruited from 27 screenings and an eye clinic in the same town. All had pinhole-corrected vision < or =6/18 in > or =1 eye due to ophthalmologist-diagnosed cataract. Subjects were administered a previously validated questionnaire on barriers to surgery in four areas: knowledge (K), perceptions of quality (Q), transportation (T), and cost (C). RESULTS: Screening group (SG; n = 120) and clinic group (CG; n = 120) participants did not differ from eligible, examined screening and clinic patients respectively in age, gender, or vision. SG participants were significantly more likely to be female (P = 0.002) and had a smaller housing area and less education (P < 0.001 for both) than those in the CG. Those in the CG were more likely to be blind (habitual VA < or = 6/60) in the better-seeing eye (P = 0.05) and more willing to undergo and pay for cataract surgery (P < 0.001 for both) than SG. In logistic regression models, SG subjects had significantly lower quality scores (P < 0.001) and better habitual vision (P = 0.02) than did CG participants, and SG subjects who agreed to cataract surgery (78.3%) had significantly higher knowledge scores (P < 0.001) than those who refused. DISCUSSION: Screening outreach has the potential to ameliorate disparities in access to cataract surgery in rural China, as it appears more likely to detect patients with cataract with gender-related, economic, educational, and attitudinal barriers to surgery. However, education may be needed to convince screening subjects to undergo surgery.

Height, stunting, and refractive error among rural Chinese schoolchildren: the See Well to Learn Well project.

PURPOSE: To evaluate the hypothesis that changes in nutritional status could be partly responsible for observed increases in myopia prevalence among Chinese children. DESIGN: Cross-sectional cohort study. METHODS: Rural Chinese secondary school children participating in a study of interventions to promote spectacle use were randomly sampled (20% of children with uncorrected vision >6/12 bilaterally, and 100% of remaining children) and underwent cycloplegic refraction with subjective refinement and measurement of height and weight. Stunting was defined according to the World Health Organization standard population. RESULTS: Among 3226 children in the sample, 2905 (90.0%) took part. Among 1477 children undergoing refraction, 1371 (92.8%) had height and weight measurements. These children had a mean age of 14.5 +/- 1.4 years, 59.8% were girls, and mean spherical equivalent refraction was -1.93 +/- 1.82 diopters. Stunting was present in 87 children (6.4%). While height was inversely associated with refractive error (RE) (taller children were more myopic) among boys (r = -0.147, P = .001), this disappeared when adjusting for age, and no such association was observed among girls. Neither girls nor boys with stunting differed significantly in refraction from children without stunting, and neither stunting nor height was associated with RE when adjusting for age, height, and parental education. The power of this study to have detected a 0.75 diopters difference in RE between children with and without stunting was 0.96. CONCLUSION: Results from this cross-sectional study are not consistent with the hypothesis that nutritional status is a determinant of RE in this setting.

Use of eye care services among diabetic patients in urban and rural China.

OBJECTIVE: To assess the use of eye care and its predictors among diabetic patients in China. DESIGN: Cross-sectional, clinic-based study. PARTICIPANTS: Diabetic patients 18 years of age or older were recruited consecutively from an urban tertiary and community hospitals and from a rural clinic in Guangdong, China. METHODS: Information obtained by questionnaire and chart review included: demographic and socioeconomic status, knowledge about diabetic retinopathy (DR), and ocular and medical history. MAIN OUTCOME MEASURES: Self-reported or chart history of an eye examination ever or within the preceding 12 months. RESULTS: The participation rate among 889 eligible subjects was 92.7%. Among 824 participants (mean age, 62.6+/-12.9 years; 58.8% female), 550 (66.7%) had not been examined in the last year as recommended by the American Academy of Ophthalmology, and 356 (43.2%) had never been examined. For the rural hospital, these figures were 81.1% and 68.7%, respectively. In regression analyses, factors associated with having an eye examination in the last year were: attendance at urban hospitals (odds ratio [OR], 3.46 [P<0.001] and 1.76 [P = 0.021] for the tertiary and community hospitals, respectively, compared with the rural clinic), higher DR knowledge score (OR, 1.24; P = 0.001), greater concern about vision loss (OR, 1.22; P = 0.007), and recommendation of regular eye examinations by the provider (OR, 2.36; P = 0.011). Predictors of ever having an eye examination were similar. Monthly income and health insurance status were not predictive of being examined. CONCLUSIONS: These results suggest that the low proportion of diabetic receiving recommended annual eye examinations in China may be improved through patient and physician education. Copyright © 2010 American Academy of Ophthalmology. Published by Elsevier Inc. All rights reserved.

Presbyopia and near-vision impairment in rural northern China.

PURPOSE: Presbyopia limits activities of daily living, but population-based data from rural China are scarce. METHODS: A population-based, cross-sectional study was conducted in 2009 among all persons aged 40+ years in a rural area near Shenyang, China. Distance and near VA were measured using logMAR E charts. Individuals with pinhole-corrected distance vision ≥20/63 underwent detailed eye examination and near refraction. RESULTS: A total of 1008 (91.5%) respondents were examined (mean age, 58.4 ± 10.7 years for men, 56.8 ± 9.89 years for women). Women and older subjects were more likely to participate. The prevalence of functional presbyopia (near vision <20/50 [N8] improved by ≥1 line with correction) was 67.3% (95% confidence interval [CI], 64.30%-70.09%), increasing from 27.6% at 40 to 49 years of age to 81.8% at 60 to 69 years. Multivariate analysis showed that older age (P < 0.001), but not gender or education, was significantly associated with a higher risk of presbyopia. Self-reported presbyopic spectacle correction coverage was 51.5%. In multivariate logistic regression models, worse presenting near vision (P = 0.013) and higher required spherical equivalent power (P < 0.001) were associated with having correction, while age, gender, education, and distance vision were unassociated. Major barriers reported by persons without near correction included poor quality of available glasses (33.1%) and lack of awareness of the condition and its treatment (28.8%). CONCLUSIONS: Presbyopia is highly prevalent in rural China, and nearly half of affected persons have no access to correction. Interventions should focus on education and improvement in the quality of refractive services.

Quality of life and near vision impairment due to functional presbyopia among rural Chinese adults.

PURPOSE: To evaluate the impact of near-vision impairment on visual functioning and quality of life in a rural adult population in Shenyang, northern China. METHODS: A population-based, cross-sectional study was conducted among persons aged 40+ years, during which functional presbyopia (correctable presenting near vision < 20/50 [N8] at 40 cm) was assessed. Near-vision-related quality of life and spectacle usage questionnaires were administered by trained interviewers to determine the degree of self-rated difficulty with near tasks. RESULTS: A total of 1008 respondents (91.5% of 1102 eligible persons) were examined, and 776 (78%) of completed the questionnaires (mean age, 57.0 ± 10.2 years; 63.3% women). Near-vision spectacle wearers obtained their spectacles primarily from markets (74.5%) and optical shops (21.7%), and only 1.14% from eye clinics. Among 538 (69.3%) persons with functional presbyopia, self-rated overall (distance and near) vision was worse (P < 0.001) and difficulty with activities of daily living greater (P < 0.001) than among nonpresbyopes. Odds of reporting any difficulty with daily tasks remained higher (OR = 2.32; P < 0.001) for presbyopes after adjustment for age, sex, education and distance vision. Compared to persons without presbyopia, presbyopic persons were more likely to report diminished accomplishment due to vision (P = 0.01, adjusted for age, sex, education, and distance vision.) CONCLUSIONS: Difficulties with activities of daily living and resulting social impediments are common due to presbyopia in this setting. Most spectacle wearers with presbyopia in rural China obtain near correction from sources that do not provide comprehensive vision care.

Prevention of Cataract Blindness in Rural China.

China has undergone dramatic economic and social reforms during last 30 years, leading to a notably higher level of living standards and health care access for Chinese citizens. However, China's cataract surgical rate of 780 cases/y per million population trails Asian neighbors with lower income levels such as India and Vietnam. Eye care providers and patients encounter many barriers in gaining access to one another.Hands-on training programs conducted by international nongovernmental organizations and the government have helped to increase the number of qualified cataract surgeons in rural area, but establishing a residency training system that produces ophthalmologists capable of performing independent surgery is the only sustainable way to meet the increasing demand for surgery from an aging population. The New Rural Cooperative Medical System has successfully reduced the financial burden of cataract surgery for the rural population; however, reimbursement for outpatient treatment of leading eye diseases is needed.Community outreach screening combined with education is essential in rural areas' increased demand for surgery. Methods to optimize the yield from such screening must still be devised and proven, however. Improvements in the hospital administration and management structure are also needed to improve the efficiency of China's rural hospitals in delivering high-quality, low-cost cataract surgical services.

Preoperative characteristics and compliance with follow-up after trabeculectomy surgery in rural southern China

Purpose: To evaluate preoperative characteristics and follow-up in rural China after trabeculectomy, the primary treatment for glaucoma there. Methods: Patients undergoing trabeculectomy at 14 rural hospitals in Guangdong and Guangxi Provinces and their doctors completed questionnaires concerning clinical and sociodemographic information, transportation, and knowledge and attitudes about glaucoma. Follow-up after surgery was assessed as cumulative score (1 week: 10 points, 2 weeks: 7 points, 1 month: 5 points). Results Among 212 eligible patients, mean preoperative presenting acuity in the operative eye was 6/120, with 61.3% (n=130) blind (≤6/60). Follow-up rates were 60.8% (129/212), 75.9% (161/212) and 26.9% (57/212) at 1 week, 2 weeks and 1 month, respectively. Patient predictors of poor follow-up included elementary education or less (OR=0.37, 95% CI 0.20 to 0.70, p=0.002), believing follow-up was not important (OR=0.62, 95% CI 0.41 to 0.94, p=0.02), lack of an accompanying person (OR=0.14, 95% CI 0.07 to 0.29, p<0.001), family annual income <US$800 (OR=0.28, 95% CI 0.11 to 0.72, p=0.008) and not requiring removal of scleral flap sutures postoperatively (OR=0.11, 95% CI 0.06 to 0.22, p<0.001). Age, sex, employment, travel distance/time/costs, patient preoperative clinical factors and physician factors were unassociated with follow-up. Conclusions: Follow-up after 2 weeks was inadequate to provide optimal clinical care, and surgery is being applied too late to avoid blindness in the majority of patients. Earlier surgery, support for return visits and better explanations of the importance of follow-up are needed. Directing all patients to return for possible scleral flap suture removal may be a valid strategy to improve follow-up.