Page 168 - DISINVESTMENT AND IMPLEMENTATION OF VISION SCREENING TESTS BASED ON THEIR EFFECTIVENESS

CHAPTER 8
there are no gynaecologists, was very low and it was difficult to reach women in isolated areas. This study found that employing a mobile screening unit in rural areas was an efficient solution to the issues encountered in rural areas.23
To address the issues encountered in the rural areas – that are discussed in greater detail in Additional file 11 – the screening protocol was adapted during the second year. We will report on the results of these adaptations in the future.
Referral to diagnostic assessment and treatment was also more difficult in rural areas: an ophthalmologist’s report was entered in the database for 21% of referred children screened in Cluj-Napoca, 16% in small cities and 11% in rural areas. Because of the low number of diagnostic reports entered in the database, the quality of the referrals was difficult to assess. While there are indications that screeners learned quickly – referral rates went down after initially being higher than expected – there are also indications the protocol was not always correctly followed and there were large differences in referral rates between screeners. Outliers among screeners, including four nurses who each examined 86 or more children but did not refer a single child, suggest that, in hindsight, quality assurance was inadequate and screeners should have been more closely supervised.
Inequitable access to screening is a common issue in preventive health care24 and a consistent finding across various screening programmes is that participation is lowest among the most socially deprived,25 even though economic barriers are not the most important impediments.26
Many barriers encountered in the rural areas in Cluj County were also found in a study of barriers to participation in school vision screening in Chicago and Baltimore: challenges with the consent forms, including the collection of paper forms, language and literacy barriers, difficulties in raising parental awareness of the programme and attitudes towards vision and eye care such as low prioritisation of eye care and not believing their child needs glasses.27 This would suggest that the problems encountered in rural areas are, at least in part, not due to intrinsic characteristics of the rural areas. This would be consistent with findings in rural health research.28
CONCLUSIONS
When implementing vision screening in a country where almost half the population lives in rural areas, it is paramount to address this disparity in order to avoid inequity in the provision of preventive health care.
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