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.

Effect of providing free glasses on children's educational outcomes in China: cluster randomized controlled trial

Objective: To assess the effect of provision of free glasses on academic performance in rural Chinese children with myopia. Design: Cluster randomized, investigator masked, controlled trial.Setting 252 primary schools in two prefectures in western China, 2012-13. Participants: 3177 of 19 934 children in fourth and fifth grades (mean age 10.5 years) with visual acuity <6/12 in either eye without glasses correctable to >6/12 with glasses. 3052 (96.0%) completed the study.Interventions Children were randomized by school (84 schools per arm) to one of three interventions at the beginning of the school year: prescription for glasses only (control group), vouchers for free glasses at a local facility, or free glasses provided in class. Main outcome measures: Spectacle wear at endline examination and end of year score on a specially designed mathematics test, adjusted for baseline score and expressed in standard deviations. Results: Among 3177 eligible children, 1036 (32.6%) were randomized to control, 988 (31.1%) to vouchers, and 1153 (36.3%) to free glasses in class. All eligible children would benefit from glasses, but only 15% wore them at baseline. At closeout glasses wear was 41% (observed) and 68% (self reported) in the free glasses group, and 26% (observed) and 37% (self reported) in the controls. Effect on test score was 0.11 SD (95% confidence interval 0.01 to 0.21) when the free glasses group was compared with the control group. The adjusted effect of providing free glasses (0.10, 0.002 to 0.19) was greater than parental education (0.03, −0.04 to 0.09) or family wealth (0.01, −0.06 to 0.08). This difference between groups was significant, but was smaller than the prespecified 0.20 SD difference that the study was powered to detect. Conclusions: The provision of free glasses to Chinese children with myopia improves children’s performance on mathematics testing to a statistically significant degree, despite imperfect compliance, although the observed difference between groups was smaller than the study was originally designed to detect. Myopia is common and rarely corrected in this setting. Trial Registration: Current Controlled Trials ISRCTN03252665.

Determinants and heritability of intraocular pressure and cup-to-disc ratio in a defined older population.

PURPOSE:

To investigate the heritability of intraocular pressure (IOP) and cup-to-disc ratio (CDR) in an older well-defined population.

DESIGN:

Family-based cohort study.

PARTICIPANTS:

Through the population-based Salisbury Eye Evaluation study, we recruited 726 siblings (mean age, 74.7 years) in 284 sibships.

METHODS:

Intraocular pressure and CDR were measured bilaterally for all participants. The presence or absence of glaucoma was determined by a glaucoma specialist for all probands on the basis of visual field, optic nerve appearance, and history. The heritability of IOP was calculated as twice the residual between-sibling correlation of IOP using linear regression and generalized estimating equations after adjusting for age, gender, mean arterial pressure, race, self-reported diabetes status, and history of systemic steroid use. The heritability of CDR was calculated using the same model and adjustments as above, while also adjusting for IOP.

MAIN OUTCOME MEASURES:

Heritability and determinants of IOP and CDR, and impact of siblings' glaucoma status on IOP and CDR.

RESULTS:

We estimated the heritability to be 0.29 (95% confidence interval [CI], 0.12-0.46) for IOP and 0.56 (95% CI, 0.35-0.76) for CDR in this population. Mean IOP in siblings of glaucomatous probands was statistically significantly higher than in siblings of normal probands (mean difference, 1.02 mmHg; P = 0.017). The mean CDR in siblings of glaucomatous probands was 0.07 (or 19%) larger than in siblings of glaucoma suspect referrals (P = 0.045) and siblings of normal probands (P = 0.004).

CONCLUSIONS:

In this elderly population, we found CDR to be highly heritable and IOP to be moderately heritable. On average, siblings of glaucoma patients had higher IOPs and larger CDRs than siblings of nonglaucomatous probands.

Visual function and postoperative care after cataract surgery in rural China: study of cataract outcomes and up-take of services (SCOUTS) in the caring is hip project, report 2.

OBJECTIVE:

To study the postoperative visual function and uptake of refraction and second-eye surgery among persons undergoing cataract surgery in rural China.

METHODS:

Self-reported visual function was measured 10 to 14 months after surgery. Subjects with improvement of 2 or more lines with refraction were offered glasses, and those with significant cataract were offered second-eye surgery.

RESULTS:

Among 313 eligible subjects, 242 (77%) could be contacted; 176 (73%) of those contacted were examined. Interviewed subjects had a mean +/- SD age of 69.9 +/- 10.2 years, and 63.6% were female. The mean +/- SD visual function score was 88.4 +/- 12.3, higher than previously reported for cataract programs in rural China and significantly (P = .03) correlated with presenting vision. Forty-two percent of subjects had spectacles, more than half being reading glasses. Though 87% of subjects' vision improved with refraction, only 35% accepted prescriptions, the most common reason for refusal being lack of perceived need. Second-eye surgery was accepted by a total of 48% (85 of 176) of patients, cost being the biggest reason for refusal.

CONCLUSIONS:

Visual function was high in this cohort. Potential benefit of refraction and second-eye surgery was substantial, but uptake of services was modest. Programs to improve service uptake should focus on reading glasses and cost-reduction strategies such as tiered pricing.

Visual disability, visual function, and myopia among rural chinese secondary school children: the Xichang Pediatric Refractive Error Study (X-PRES)--report 1.

PURPOSE: To evaluate visual acuity, visual function, and prevalence of refractive error among Chinese secondary-school children in a cross-sectional school-based study. METHODS: Uncorrected, presenting, and best corrected visual acuity, cycloplegic autorefraction with refinement, and self-reported visual function were assessed in a random, cluster sample of rural secondary school students in Xichang, China. RESULTS: Among the 1892 subjects (97.3% of the consenting children, 84.7% of the total sample), mean age was 14.7 +/- 0.8 years, 51.2% were female, and 26.4% were wearing glasses. The proportion of children with uncorrected, presenting, and corrected visual disability (< or = 6/12 in the better eye) was 41.2%, 19.3%, and 0.5%, respectively. Myopia < -0.5, < -2.0, and < -6.0 D in both eyes was present in 62.3%, 31.1%, and 1.9% of the subjects, respectively. Among the children with visual disability when tested without correction, 98.7% was due to refractive error, while only 53.8% (414/770) of these children had appropriate correction. The girls had significantly (P < 0.001) more presenting visual disability and myopia < -2.0 D than did the boys. More myopic refractive error was associated with worse self-reported visual function (ANOVA trend test, P < 0.001). CONCLUSIONS: Visual disability in this population was common, highly correctable, and frequently uncorrected. The impact of refractive error on self-reported visual function was significant. Strategies and studies to understand and remove barriers to spectacle wear are needed.

Impact of posterior subcapsular opacification on vision and visual function among subjects undergoing cataract surgery in rural China: Study of Cataract Outcomes and Up-Take of Services (SCOUTS) in the Caring is Hip Project, report 5.

AIM: To study the effect of posterior capsular opacification (PCO) on vision and visual function in patients undergoing cataract surgery in rural China, and to compare this with the effect of refractive error. METHODS: Patients undergoing cataract surgery in at least one eye by local surgeons in a rural setting between 8 August and 31 December 2005 were examined with slit lamp grading of PCO 10-14 months after surgery. Subjects with any PCO associated with best-corrected visual acuity of 6/7.5 or worse, or with grade 2+ or worse PCO without visual decrement, were offered YAG laser capsulotomy. Vision and self-reported visual function were assessed, and various demographic and clinical factors potentially associated with PCO were recorded. RESULTS: Of 313 patients operated on within the study window, 239 (76%) could be contacted by telephone; study examinations were performed on 176 (74%). Examined subjects had a mean (SD) age of 69.4 (10.5) years, 116 (67%) were female, and 149 (86%) had been blind (presenting visual acuity < or = 6/60) in the operated eye before surgery. PCO of grade 1 or above was present in 34 of 204 operated eyes (16.7%). Those with PCO had significantly worse presenting vision (p = 0.007) but not visual function (p>0.3) than those without PCO. Women had a significantly higher prevalence of PCO (20.9%) than did men (8.6%, p<0.05). Of 19 eyes undergoing capsulotomy with best-corrected visual acuity measured the next day, 13 (68%) improved by one or more lines, and seven (37%) improved by two or more lines. Despite a higher uptake of capsulotomy (95%) as opposed to refraction (35%) in this cohort, the yield in terms of eyes with poor presenting visual acuity (< 6/18) that could be improved was higher for refraction (26% = 9/35) than for capsulotomy (9% = 3/35). CONCLUSION: The prevalence of PCO and impact on vision and visual function in this cohort was modest 1 year after surgery. However, PCO prevalence increases with time. Follow-up of this cohort is underway to determine the effectiveness of this early intervention in identifying and treating subjects who will eventually experience clinically significant PCO.

Prevalence and determinants of spectacle nonwear among rural Chinese secondary schoolchildren: the Xichang Pediatric Refractive Error Study Report 3.

OBJECTIVE: To study spectacle wear among rural Chinese children. METHODS: Visual acuity, refraction, spectacle wear, and visual function were measured. RESULTS: Among 1892 subjects (84.7% of the sample), the mean (SD) age was 14.7 (0.8) years. Among 948 children (50.1%) potentially benefiting from spectacle wear, 368 (38.8%) did not own them. Among 580 children owning spectacles, 17.9% did not wear them at school. Among 476 children wearing spectacles, 25.0% had prescriptions that could not improve their visual acuity to better than 6/12. Therefore, 62.3% (591 of 948) of children needing spectacles did not benefit from appropriate correction. Children not owning and not wearing spectacles had better self-reported visual function but worse visual acuity at initial examination than children wearing spectacles and had a mean (SD) refractive error of -2.06 (1.15) diopter (D) and -2.78 (1.32) D, respectively. Girls (P < .001) and older children (P = .03) were more likely to be wearing their spectacles. A common reason for nonwear (17.0%) was the belief that spectacles weaken the eyes. Among children without spectacles, 79.3% said their families would pay for them (mean, US $15). CONCLUSIONS: Although half of the children could benefit from spectacle wear, 62.3% were not wearing appropriate correction. These children have significant uncorrected refractive errors. There is potential to support programs through spectacle sales.

Waiting time for cataract surgery and its influence on patient attitudes.

PURPOSE:

To characterize willingness to pay for private operations and preferred waiting time among patients awaiting cataract surgery in Hong Kong.

METHODS:

This was a cross-sectional survey. Subjects randomly selected from cataract surgical waiting lists in Hong Kong (n = 467) underwent a telephone interview based on a structured, validated questionnaire. Data were collected on private insurance coverage, preferred waiting time, amount willing to pay for surgery, and self-reported visual function and health status.

RESULTS:

Among 300 subjects completing the interview, 144 (48.2%) were 76 years of age or older, 177 (59%) were women, and mean time waiting for surgery was 17 +/- 15 months. Among 220 subjects (73.3%) willing to pay anything for surgery, the mean amount was US$552 +/- 443. With adjustment for age, education, and monthly household income, subjects willing to pay anything were less willing to wait 12 months for surgery (OR = 4.34; P = 0.002), more likely to know someone having had cataract surgery (OR = 2.20; P = 0.03), and more likely to use their own savings to pay for the surgery (OR = 2.21; P = 0.04). Subjects considering private cataract surgery, knowing people who have had cataract surgery, using nongovernment sources to pay for surgery, and having lower visual function were willing to pay more.

CONCLUSIONS:

Many patients wait significant periods for cataract surgery in Hong Kong, and are willing to pay substantial amounts for private operations. These results may have implications for other countries with cataract waiting lists.

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.

Cataract surgical outcomes, visual function and quality of life in four rural districts in Vietnam.

BACKGROUND: To evaluate cataract surgical outcomes in four rural districts of Ha Tinh Province, Vietnam. DESIGN: Cross-sectional study. PARTICIPANTS: Post-cataract surgery patients sampled randomly from facilities in four rural districts of Ha Tinh Province >3 months after surgery. MAIN OUTCOME MEASURES: Postoperative visual acuity (VA), visual function and quality of life. RESULTS: Among 412 patients, the mean age was 74.5 ± 9.4 years, 67% (276) were female, and 377 (91.5%) received intraocular lenses (IOL). Nearly two-thirds of patients had no postoperative visits after discharge. Postoperatively, more than 40% of eyes had presenting VA <6/18, while 20% remained <6/60. The mean self-reported visual function and quality of life for all patients were 68.7 ± 23.8 and 73.8 ± 21.6, respectively. Most patients (89.5%) were satisfied with surgery and the majority (94.4%) would recommend surgery to others. One-third of patients paid ≥$US50 for surgery. In multiple regression modelling, older age (P < 0.01), intraoperative complications (P < 0.01) and failure to receive an IOL (P < 0.01) were associated with postoperative VA <6/60. CONCLUSION: Satisfaction with surgery was high, and many patients were willing to pay for their operations. Poor visual outcomes were common; however, and better surgical training is needed to reduce complications and their impact on visual outcomes. More intensive postoperative follow-up may also be beneficial. © 2011 The Authors. Clinical and Experimental Ophthalmology © 2011 Royal Australian and New Zealand College of Ophthalmologists.

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.

Use of eye care services among diabetic patients in urban Indonesia.

OBJECTIVES:

To assess the use of eye care and its predictors among diabetic patients in Indonesia.

METHODS:

Diabetic patients aged 18 years and older were recruited consecutively from a university clinic and 2 community clinics in Jakarta, Indonesia. Information obtained by questionnaire and record review included demographic and socioeconomic status, knowledge about diabetic retinopathy, and ocular and medical history. The main outcome was self-reported or record history of an eye examination by an eye care professional with dilation of the pupil within the preceding year.

RESULTS:

Among 196 participants (mean [SD] age, 58.4 [9.4] years; 61.5% female), 166 (84.7%) had not undergone ocular examination in the last year, including 100 of 119 patients (84.0%) at the university clinic. Fewer than half (82 of 166 [49.4%]) of all patients reported being told of the need for eye examinations by their physician. In regression analyses, factors associated with having an eye examination were higher diabetic retinopathy knowledge score (odds ratio = 1.52; P = .01) and years since being diagnosed as having diabetes (odds ratio = 1.71 for third vs first tertile; P = .02). Education, income, health insurance status, and diagnosis of diabetic retinopathy were not predictive of examination. The most common reasons given by subjects for not having had eye examinations concerned lack of knowledge about the need for care (97 of 160 subjects [60.6%]), while financial barriers were cited by only 22 of 160 subjects (13.8%).

CONCLUSION:

The low proportion of diabetic subjects receiving recommended annual eye examinations in Indonesia might be improved through patient and physician education.

Ophthalmology. 2011 Dec;118(12):2343-50. doi: 10.1016/j.ophtha.2011.06.016. Epub 2011 Sep 1. Randomized, controlled trial of an educational intervention to promote spectacle use in rural China: the see well to learn well study.

OBJECTIVE: To test an educational intervention promoting the purchase of spectacles among Chinese children. DESIGN: Randomized, controlled trial. PARTICIPANTS: Children in years 1 and 2 of all 20 junior and senior high schools (ages 12-17 years) in 3 rural townships in Guangdong, China. METHODS: Children underwent visual acuity (VA) testing, and parents of participants with presenting VA worse than 6/12 in either eye improving by more than 2 lines with cycloplegic refraction were recommended to purchase glasses. Children at 10 randomly selected schools received a lecture, video, and classroom demonstration promoting spectacle purchase. MAIN OUTCOME MEASURES: Self-reported purchase of spectacles (primary outcome) and observed wear or possession of newly purchased glasses (secondary outcome) at follow-up examinations (mean, 219 ± 87 days after the baseline visit). RESULTS: Among 15 404 eligible children, examinations were completed for 6379 (74.6%) at intervention schools and 5044 (73.6%) at control schools. Spectacles were recommended for 2236 (35.1%) children at intervention schools and for 2212 (43.9%) at control schools. Of these, 417 (25.7%) intervention schools children and 537 (34.0%, P = 0.45) control schools children reported buying glasses. Predictors of purchase in regression models included female gender (P = 0.02), worse uncorrected VA (P < 0.001), and higher absolute value of refractive error (P = 0.001). Neither the rate of self-reported purchase of glasses or observed wear or possession of newly purchased glasses differed between control schools and intervention schools in mixed-effect logistic regression models. Among children not purchasing glasses, 21.7% had better-eye VA of worse than 6/18. CONCLUSIONS: An intervention based on extensive pilot testing and focus groups in the area failed to promote spectacle purchase or wear. The high burden of remaining uncorrected poor vision underscores the need to develop better interventions. FINANCIAL DISCLOSURE(S): The author(s) have no proprietary or commercial interest in any materials discussed in this article.

Reliability of reports of childhood trauma in bipolar disorder: A test–retest study over 18 months

This study aimed to explore the reliability of self-reported trauma histories in a population with a diagnosis of Bipolar Disorder using the Childhood Trauma Questionnaire. Previous studies in other populations suggest high reliability of trauma histories over time and it was postulated that a similar high reliability would be demonstrated in this population. Thirty-nine patients with a confirmed diagnosis (DSM-IV criteria) were followed-up and re-administered the Childhood Trauma Questionnaire after 18 months. Cohen's kappa scores and intraclass correlations suggest reasonable test-retest reliability over the 18-month time period of the study for all types of childhood abuse, namely emotional, physical, sexual, and physical abuse and emotional neglect. Intraclass correlations ranged from r = .50 to (sexual abuse) to r = .96 (physical abuse). Cohen's kappas ranged from .44 (sexual abuse) to .76 (physical abuse). Retrospective reports of childhood trauma can be seen as reliable and are in keeping with results found with other mental health populations.

Intentions Toward Physical Activity and Resting Behavior in Pregnant Women: Using the Theory of Planned Behavior Framework in a Cross-Sectional Study

BACKGROUND: Pregnant women are recommended to 1) perform daily moderate-intensity physical activity and 2) limit the amount of sedentary time. Many women do not meet these recommendations. Reduced physical activity and increased sedentary behavior may result from women actively intending to rest during pregnancy. The Theory of Planned Behavior (TPB) has been used to assess attitudes (e.g., positive/negative beliefs), subjective norms (e.g., perception of others' views), perceived behavioral control (PBC) (e.g., self-efficacy), and intention toward exercising while pregnant but has not been applied to aspects pertaining to resting during pregnancy.

METHODS: Pregnant women (n = 345) completed a cross-sectional questionnaire that included two TPB Questionnaires where the target behaviors were 1) being physically active and 2) resting. Bootstrapped paired t tests, ANOVA, and linear hierarchal regression analyses were performed to identify predictors of intentions and whether intentions toward the two behaviors varied at different stages of pregnancy.

RESULTS: As women progressed in their pregnancy, their attitude, PBC, and intention toward being physically active all significantly declined. A positive attitude, subjective norms, and intention toward resting all significantly increased with the advancing trimester. Self-reported health conditions predicted lower intention for physical activity but not for resting.

DISCUSSION: The significantly inverse relationship between physical activity and resting across time suggests that women feel they should focus on one behavior at the expense of the other. Finding that women generally do not perceive these behaviors as mutually compatible has implications in strategizing as to how to encourage women to be active during pregnancy.