Eye health indicators for universal health coverage: results of a global expert prioritisation process

Introduction

In its recent World Report on Vision, the WHO called for an updated approach to monitor eye health as part of universal health coverage (UHC). This project sought to develop a consensus among eye health experts from all world regions to produce a menu of indicators for countries to monitor eye health within UHC.

Methods

We reviewed the literature to create a long-list of indicators aligned to the conceptual framework for monitoring outlined in WHO’s World Report on Vision. We recruited a panel of 72 global eye health experts (40% women) to participate in a two-round, online prioritisation exercise. Two-hundred indicators were presented in Round 1 and participants prioritised each on a 4-point Likert scale. The highest-ranked 95 were presented in Round 2 and were (1) scored against four criteria (feasible, actionable, reliable and internationally comparable) and (2) ranked according to their suitability as a ‘core’ indicator for collection by all countries. The top 30 indicators ranked by these two parameters were then used as the basis for the steering group to develop a final menu.

Results

The menu consists of 22 indicators, including 7 core indicators, that represent important concepts in eye health for 2020 and beyond, and are considered feasible, actionable, reliable and internationally comparable.

Conclusion

We believe this list can inform the development of new national eye health monitoring frameworks, monitor progress on key challenges to eye health and be considered in broader UHC monitoring indices at national and international levels.

Community‐based rehabilitation for people with physical and mental disabilities in low‐ and middle‐income countries

This is a protocol for a Cochrane Review (Intervention). The objectives are as follows:

To assess the effectiveness and cost‐effectiveness of community‐based rehabilitation for people with physical and mental disabilities in low‐ and middle‐income countries.

Statistical analysis plan for the family-led rehabilitation after stroke in India (ATTEND) trial: A multicenter randomized controlled trial of a new model of stroke rehabilitation compared to usual care

Background

In low- and middle-income countries, few patients receive organized rehabilitation after stroke, yet the burden of chronic diseases such as stroke is increasing in these countries. Affordable models of effective rehabilitation could have a major impact. The ATTEND trial is evaluating a family-led caregiver delivered rehabilitation program after stroke.

Objective

To publish the detailed statistical analysis plan for the ATTEND trial prior to trial unblinding.

Methods

Based upon the published registration and protocol, the blinded steering committee and management team, led by the trial statistician, have developed a statistical analysis plan. The plan has been informed by the chosen outcome measures, the data collection forms and knowledge of key baseline data.

Results

The resulting statistical analysis plan is consistent with best practice and will allow open and transparent reporting.

Conclusions

Publication of the trial statistical analysis plan reduces potential bias in trial reporting, and clearly outlines pre-specified analyses.

Clinical Trial Registrations

India CTRI/2013/04/003557; Australian New Zealand Clinical Trials Registry ACTRN1261000078752; Universal Trial Number U1111-1138-6707.

Prevalence and risk factors for diabetes and diabetic retinopathy: results from the Nigeria national blindness and visual impairment survey

BACKGROUND

In Nigeria, urbanisation and increasing life expectancy are likely to increase the incidence of non-communicable diseases. As the epidemic of diabetes matures, visual loss from diabetic retinopathy (DR) will increase unless mechanisms for early detection and treatment improve, and health systems respond to the growing burden of non-communicable diseases.

METHODS

A nationally-representative population-based sample of 13,591 participants aged ≥40 years selected by multistage-stratified-cluster-random-sampling with probability-proportional-to-size procedures were examined in 305 clusters in Nigeria between January 2005 to June 2007. All were asked about history of diabetes and underwent basic eye examination. Visual acuity (VA) was measured using logMAR E-chart. Participants with VA<6/12 and/or DR detected underwent detailed eye examination including dilated retinal examination and retinal photography. Systematic sampling of 1-in-7 gave a subsample (n=1759) examined in detail regardless of VA; and had random blood glucose (RBG) testing. Images were graded by Moorfields Eye Hospital Reading Centre. Participants were defined as having diabetes if they were previously diagnosed or RBG>11.1mmol/l or had DR. Data in the subsample were used to estimate the prevalence and to analyse risk factors for diabetes and DR using multivariable logistic regression. Additional information on the types of DR was obtained from participants not in the subsample.

RESULTS

In the subsample, 164 participants were excluded due to missing data; and 1,595 analysed. 52/1,595 had diabetes, a prevalence of 3.3% (95%CI 2.5-4.3%); and 25/52(48%) did not know. Media opacity in 8/52 precluded retinal examination. 9/44(20.5%) had DR. Higher prevalence of diabetes was associated with urban residence (Odds ratio [OR]1.87) and overweight/obesity (OR3.02/4.43 respectively). Although not statistically significant, DR was associated with hypertension (OR3.49) and RBG>15.0mmol/L (OR8.10). Persons with diabetes had 3 times greater odds of blindness. Of 11,832 other participants in the study sample, 175(1.5%) had history of diabetes; 28 had DR. Types of DR (total=37) included 10.8% proliferative, 51.4% macular oedema.

CONCLUSION

The age-adjusted prevalence of diabetes in Nigeria was 3.25% (95%CI 2.50-4.30) and over 10% of people with diabetes aged ≥40 years had sight-threatening-DR. These data will enable the development of better public health strategies for the control of diabetes and planning services for DR to prevent vision loss.

Challenges in developing competency-based training curriculum for food safety regulators in India

Context:

The Food Safety and Standards Act have redefined the roles and responsibilities of food regulatory workforce and calls for highly skilled human resources as it involves complex management procedures.

Aims:

1) Identify the competencies needed among the food regulatory workforce in India. 2) Develop a competency-based training curriculum for food safety regulators in the country. 3) Develop training materials for use to train the food regulatory workforce.

Settings and Design:

The Indian Institute of Public Health, Hyderabad, led the development of training curriculum on food safety with technical assistance from the Royal Society for Public Health, UK and the National Institute of Nutrition, India. The exercise was to facilitate the implementation of new Act by undertaking capacity building through a comprehensive training program.

Materials and Methods:

A competency-based training needs assessment was conducted before undertaking the development of the training materials.

Results:

The training program for Food Safety Officers was designed to comprise of five modules to include: Food science and technology, Food safety management systems, Food safety legislation, Enforcement of food safety regulations, and Administrative functions. Each module has a facilitator guide for the tutor and a handbook for the participant. Essentials of Food Hygiene-I (Basic level), II and III (Retail/ Catering/ Manufacturing) were primarily designed for training of food handlers and are part of essential reading for food safety regulators.

Conclusion:

The Food Safety and Standards Act calls for highly skilled human resources as it involves complex management procedures. Despite having developed a comprehensive competency-based training curriculum by joint efforts by the local, national, and international agencies, implementation remains a challenge in resource-limited setting.

The use of a newspaper insertion to promote DIY testing of vision in India

BACKGROUND

The mass media have the potential to motivate people to participate in self appraisal of their own health status. An innovative communication package was designed to help people to examine vision at home. The impact of publishing the "do it yourself" (DIY) kit in Indian newspapers was evaluated.

METHODS

A pretested bilingual vision testing kit was published in three newspapers. The kit comprised four tumbling Es corresponding to 6/12 line of Snellen's optotypes. Directions on using the kit were enclosed. 3 -7 days after publication of the kit, a telephone survey of newspaper readers was undertaken to evaluate the impact and cost effectiveness.

RESULTS

603 people were contacted over the telephone. 125 (20.73%) subscribed to the newspaper carrying the DIY insertion. 43.2% (54) noticed the insertion of which 88.89% (48) read the enclosed instructions carefully. 58.33% respondents felt sufficiently motivated to contact an ophthalmologist. Graduates had a 3.83 times higher probability of reading the communication insertion compared with others. Differences in relation to other demographic variables were not statistically significant.

CONCLUSIONS

Newspapers are an excellent medium for communicating self appraisal kits for vision testing. The medium is cost effective and has significant reach in the urban agglomerates of India.

A population-based eye survey of older adults in a rural district of Rajasthan: II. Outcomes of cataract surgery

PURPOSE

To assess the outcomes of cataract surgery in rural northwest India.

DESIGN

Population-based, cross-sectional study.

PARTICIPANTS

A total of 549 cataract-operated persons (723 operated eyes).

METHODS

Cluster sampling was used in randomly selecting a cross-sectional sample of persons 50 years of age or older for visual acuity measurement, refraction, and slit-lamp and direct ophthalmoscope examination early in 1999. Those operated on for cataract were queried as to the date and place of surgery. The principal cause of reduced vision was identified for all examined eyes with presenting visual acuity worse than 6/18.

MAIN OUTCOME MEASURES

Presenting and best-corrected visual acuity and cause of vision loss.

RESULTS

Presenting visual acuity was less than 6/60 in the better eye in 33.7% of cataract-operated persons and greater than or equal to 6/18 in both eyes in 8.2%; 31.7% were bilaterally operated on. Of cataract-operated eyes, 44.1% initially had visual acuity less than 6/60 and 31.5% greater than or equal to 6/18; with best correction, the corresponding percentages were 14.0% and 61.5%. Intracapsular cataract extraction was used in 92% of cases, and 66% had been operated on in surgery camps. Surgical complications were common and a major cause of vision impairment. In multiple logistic regression modeling, female gender and residence in a rural area were associated negatively with both presenting and best-corrected visual acuity outcomes, and surgery conducted before 1990 was associated negatively with best-corrected visual acuity. Place of surgery and subject schooling were not associated with vision outcomes.

CONCLUSIONS

Cataract surgery subjects in rural areas of India that are without adequately equipped facilities and skilled surgeons, and lack of availability of intraocular lenses, are not realizing the full sight-restoring potential of modern-day surgery. Emphasis on the quality of cataract surgery outcomes must be increased to keep pace with that being given to increasing surgical volume.

A population-based eye survey of older adults in a rural district of Rajasthan: I. Central vision impairment, blindness, and cataract surgery

PURPOSE

To assess the prevalence of central vision blindness and cataract surgery in older adults in rural northwest India.

DESIGN

Population-based, cross-sectional study.

PARTICIPANTS

A total of 4284 examined persons 50 years of age or older.

METHODS

A random selection of village-based clusters was used to identify a population sample in the predominantly rural Bharatpur district of Rajasthan. Eligible subjects in the 25 selected clusters were enumerated through a door-to-door household survey and invited to village sites for visual acuity testing and eye examination early in 1999. The principal cause of reduced central vision was identified for eyes that had visual acuity worse than 6/18. Independent replicate testing for quality assurance monitoring took place in participants with reduced vision and in a sample of those with normal vision in five of the study clusters.

MAIN OUTCOME MEASURES

Presenting and best-corrected visual acuity and lens status.

RESULTS

A total of 4728 eligible persons in 2821 households were enumerated, and 4284 (90.6%) were examined. The prevalence of presenting and best-corrected visual acuity worse than 6/60 in both eyes was 11.9% (95% confidence interval: 10.0%-13.9%) and 6.1% (95% CI: 4.7%-7.4%), respectively. Presenting blindness was associated with increasing age, female gender, lack of schooling, and rural residence. Cataract was the principal cause of blindness in one or both eyes in 67.5% of blind persons, with uncorrected aphakia and other refractive error affecting 18.4% in at least one eye. The prevalence of cataract surgery was 12.8% (95% CI: 11.6%-14.0%), with an estimated 65.7% of the cataract blind operated on; low surgical coverage was associated with lack of schooling.

CONCLUSIONS

Blindness, particularly blindness because of cataract, continues to be a significant problem among the elderly living in remote areas of rural northwest India. Increased attention should be given to reaching women and the illiterate.

Visual outcomes after cataract surgery and cataract surgical coverage in India

Visual outcomes of 2369 cataract operated persons(3655 eyes) across seven major Indian states were assessed in 1998. This is the largest ever study over the past decade in the country. 9.54 per cent of the examined population had undergone operation for cataract in one or both eyes. Intra-capsular cataract extraction was the commonest surgical modality adopted (91.62%). Intraocular lens implants resulted in better visual outcomes with 71.4 per cent of such patients achieving a good visual outcome (> or = 6/18 in operated eyes). Visual outcome was also good if ICCE operated patients were provided good quality aphakic spectacles. There were no gender differentials in surgical uptake rates. The risk of poor postsurgical visual outcome was strongly associated by type of surgery (Adjusted OR for ICCE-2.78; 95% CI: 1.41-5.49) and the non-availability or poor quality aphakic spectacles (Adjusted OR for poor/no spectacles 4.59-95% CI: 3.53-5.97). Duration since surgery and the source of surgery did not influence visual outcomes. Half the cataract blind remained unoperated in the study population.

Rapid assessment of cataract blindness in India

28,055 persons aged 50 yrs+ from seven states in India were surveyed by a rapid assessment technique for cataract blindness. The prevalence of bilateral blindness (vision < 6/60 in the better eye) was 11.68 percent (95% C.I. 10.54-12.81). The age-gender adjusted blindness prevalence rate was 11.04 percent (95% C.I. 11.033-11.044). Age and occupational status were associated with blindness prevalence. Cataract was the commonest cause of low vision and blindness in this population. Respondents aged 60-69 years had a 2.74 times higher risk, while those aged 70 years+ had a 4.86 times higher risk of being blind, compared to those 50-59 years. Productively employed individuals had lowest blindness rates. Blindness rates were five times higher among respondents who were not working and two times higher among those engaged solely in household activities. The prevalence of cataract was 43.32 percent (95% C.I. 41.14-45.50) among those aged 50+ years. The prevalence increased with increasing age. Gender did not influence the prevalence of cataract in the present survey. Extrapolating from the present survey, it is estimated that 11.9 million blind people (vision < 6/60 in the better eye) in India are in urgent need of cataract surgery.

Qualitative research in ophthalmic sciences

Qualitative research was the preserve of social scientists before making inroads into medical sciences, as the medical fraternity was wedded to evidence-based medicine. Qualitative research methods are now being increasingly used in medicine. The goal of qualitative research is to help in the understanding of social phenomenon in their natural settings. These methods help to unravel mysteries relating to complex human interactions and to study the role of human behaviour in health and disease. Recent evidence points to the complementary roles of qualitative and quantitative methods in medical research. Qualitative methods include observations, interviews, focus groups, projective techniques, analysis of personal documents and accounts, sorting and ranking, and case studies. This communication describes the application of qualitative methods in ophthalmic research.

Risk factors for pediatric presumed microbial keratitis: a case-control study

PURPOSE

To evaluate risk factors for pediatric presumed microbial keratitis and to describe the clinical picture, microbiologic spectrum, treatment modalities, posttreatment sequelae, and visual outcome in cases of pediatric presumed microbial keratitis.

METHODS

A case-control study design was used to identify the risk factors associated with pediatric presumed microbial keratitis. Fifty cases of fresh corneal ulceration aged 12 years or younger were compared with 50 controls. The study variables included were age, gender, immunization status, nutritional status (weight for height), and socioeconomic status. The clinical presentation of the cases with corneal ulceration, microbiologic spectrum, and treatment modalities also were evaluated. All the cases were followed up for a minimum of 3 months, and the posttreatment sequelae and visual outcome were analyzed.

RESULTS

The mean (+/- standard deviation) age of children with corneal ulceration and controls was 4.8 (+/-3.8) years and 5.1 (+/-2.8) years, respectively. Incomplete immunization status (AOR [95% confidence interval (CI)], 1.34 [0.62-2.9]) and poor nutritional status [AOR (95% CI) 1.06 (0.68-1.6)] were not found to be the predictors of corneal ulceration. Lower socioeconomic status was significantly associated with the occurrence of corneal ulceration [AOR (95% CI) 1.52 (1.1-2.3)]. Corneal trauma (38%) and systemic illness (24%) were the most often associated predisposing factors. Seventy percent of the cases were culture positive. Staphylococcus (70%) species was the most frequently isolated, followed by Pseudomonas aeruginosa (10%). Fungi were isolated in five eyes. Postresolution visual acuity at 3 months could be recorded only in 31 eyes and a visual acuity of 6/18 or better was achieved in 22% of these cases.

CONCLUSION

Corneal ulceration in pediatric age group in India is associated with poverty.

Monitoring visual outcome of cataract surgery in India

Two simple methods of assessing visual outcome following cataract surgery were evaluated in India. The first used data obtained from standardized patient records of cataract surgery. The second used data from population-based rapid epidemiological assessments. Analysis of 4168 hospital and eye camp records showed that, with the available standard correction, a good outcome (visual acuity > or = 6/18) was achieved in 37.8%, a borderline outcome (visual acuity 6/246-6/60) in 45.6% and a poor outcome (visual acuity 6/60) in 16.6% of instances. Of 2401 aphakic/pseudophakic eyes examined in a cross-sectional population-based study, outcome was good in 43.5% and poor in 26.4%. For 776 eyes examined in a similar study in a different state, outcome was good in 49.9% and poor in 23.9%. These assessments indicate that outcome with available correction was poor in 15-25% of eyes following cataract surgery. Visual outcome is likely to improve when better correction for aphakia can be provided. Further assessment of the causes of poor visual outcome is needed. The visual outcome following cataract surgery could be monitored on a regular basis by ophthalmologists, using either of the methods evaluated, an exercise which in itself is likely to improve the outcome of surgery. When the proportion of poor outcomes is high (> 10%) further investigation into the causes is warranted.

Cost of vitamin A and iron supplementation to "at risk" population

This is a cost descriptive study which estimates the cost of providing iron and vitamin A supplementation through the primary health care system in India. The norms for the primary health care workers were taken as per national norms. The costs included the proportionate cost of the building, workers' salary and the cost of the supplements. The total cost of providing iron supplementation through the PHC was estimated at Rs. 43,800. The cost per beneficiary for adult folifer was Rs. 3.60, for paediatric folifer was Rs. 2.90 and for syrup folifer, it was Rs. 15.50. The overall cost of providing iron and folic acid supplements to the "at risk" population was estimated as Rs 4.40 per beneficiary per year. The cost of vitamin A supplementation to under three through the PHC system was estimated at Rs. 3.20 per beneficiary per year. Both iron as well as vitamin A supplementation through the PHC system appear to be low cost interventions.

Sex difference in age at onset of schizophrenia: discrepant findings from India

Consecutive male (n=100) and female (n=100) DSM-IV schizophrenics newly registered for treatment in a large psychiatric hospital were examined with regard to age at onset of the first psychotic symptom. Age at onset of the first psychotic symptom did not differ between the sexes regardless of whether schizophrenia was diagnosed by DSM-IV or by several alternative systems. Age at onset defined by other criteria, namely age at first contact with a physician, and age at first admission for psychiatric care, also did not show any differences between the sexes. Survival analysis of subjects having a documented date of birth revealed a female preponderance at younger ages. A higher positive symptom score predicted older age at onset of the first psychotic symptom in the total sample. These findings call into question the universality of the traditional view of a younger age at onset of schizophrenia among males. Tentative neurodevelopmental and cultural explanations are presented to explain why there is no sex difference in age at onset of schizophrenia in India.

Industrial ocular morbidity in a north Indian town

A study on industrial ocular morbidity was carried out in 6 industrial establishments at Saharanpur. The mean age of the respondents was 35.3 years. 58.2% were regular floor staff. 10.6% professed suffering from an industrial ocular injury. 60% of these injuries were sustained by ocular metallic trauma. 51.9% complained of ocular symptoms at the time of the survey. The frequency of ocular complaints increased with age. The point prevalence of ocular morbidity was 746.03/1000 industrial workers. Refractive errors were the commonest ocular condition (56.7%) observed, followed by Trachoma (32.6%). The highest prevalence of morbidity was recorded among workers above 44 years. Clerical and managerial personnel had higher prevalence compared to other jobs. Only 3.6% of the floor workers were using protective devices while on the job.

Cataract related blindness in India & its social implications

The prevalence of blindness in India is 14.9 per 1000. Eighty per cent of this blindness is due to cataract alone. Most of the cataract blinds in the country are in the rural areas while the surgical service delivery network is concentrated in the urban areas. Thus a large proportion of patients in the rural areas continue to remain blind. This situation has many social implications. There is loss of productivity, breakdown of interpersonal relationships, depressive manifestations, loss of self esteem and most patients lead an isolated humiliating life. Patients lack information on the available services and continue to remain blind for years even after being diagnosed as operable. This is unfortunate because cataract surgery is one of the most cost effective health interventions known and most operated patients, irrespective of the surgical technique, are immensely satisfied with the level of visual rehabilitation after surgery.

A study of ocular morbidity among elderly population in a rural area of central India

A cross-sectional study was conducted in five randomly selected villages in Wardha district of Maharashtra state to study the magnitude and factors related to the prevalence of ocular diseases among the elderly population. A total of 903 persons above 50 years were screened. The prevalence of low vision was 32% while that of blindness was 12.2%. Ocular morbidity rate was 1.21 lesions per elderly person and it increased significantly with increasing age (p < 0.001). Ocular diseases were found to be more prevalent among males, low socio-economic status group and landless labourers (p < 0.001). There was a high prevalence of refractive errors (40.8%), cataract (40.4%), aphakia (11.1%) followed by pterygium (5.2%), glaucoma (3.1%) and corneal opacities (3%). Prevalence of diseases of the lens and iris increased significantly with increasing age (p < 0.001). There is a need to evolve strategies for reducing the burden of ocular diseases and improve geriatric eye health under the existing infrastructure of health care delivery in our country.

Community-based investigation of an outbreak of acute viral conjunctivitis in urban slums

Nine hundred and sixteen people from 143 randomly selected households were included in this community-based investigation of an outbreak of acute viral conjunctivitis in urban slum communities of Delhi in 1994. During the 2-weeks recall period, 456 (49.8%) had conjunctivitis and 229 (25%) were symptomatic at the time of this investigation. Overall, females had a higher attack rate than males (P < 0.05). The attack rate increased with age (P < 0.001). A total of 61.6% of the conjunctival swabs were antigen positive as evidenced by indirect immunofluorescence assay. Viruses could be isolated from 30.3% of the samples processed. Out of these, 70% were identified as Coxsackie A 24 and 30% as EV 70.

A follow-up study on visual outcome after camp-based intracapsular cataract extraction

The visual outcome of 164 intracapsular cataract extractions (ICCE) performed in 158 patients at an eye-camp was evaluated. 93.3% had a preoperative visual acuity of less than 3/60. On the 4th/5th post-operative day, 39.3% had a visual acuity between 6/18 and 6/36; 84.7% had vision better than 3/60. Six weeks post-operatively, 44.1% had visual acuity better than 6/18 and a total of 84.1% better than 3/60. The vision of 40.7% improved between the 4th/5th post-operative day and the follow-up visit at 6 weeks. 46.4% of patients had post-operative corrected visual acuity better than 6/18, 24.3% had vision between 6/18 and 6/36, and a total of 84.3% had vision better than 3/60. The patients' satisfaction in terms of improvement in mobility and ability to do housework at 6 weeks after the operation correlated better with the improvement in vision in terms of the number of Snellen's lines than with the actual post-operative visual acuity.

Assessment of cataract surgery in rural India. Visual acuity outcome

A socio-epidemiological assessment of what happens to the visual outcome after camp-based intracapsular cataract extraction was conducted in 6 villages and periurban areas in North India. 120 patients (143 eyes) were included in the study. The mean age at cataract extraction was 64.39 (range 33-83 years). 44.7% of the operated eyes obtained a good vision ( > or = 6/18) while 39.9% had low vision (6/24-3/60). The duration since the cataract extraction was seen to influence visual outcome. 70% of the respondents were satisfied with the surgical outcome. 76% of those with unilateral aphakia and 8.3% of those with bilateral aphakia were regularly using spectacles. 58.3% were satisfied with the spectacles. Dissatisfaction was generally due to lack of visual improvement. The major benefits accruing to the patients were improved personal activity, increased mobility and recognition of family members. It is our opinion that camp-based intracapsular cataract extraction with aphakic correction is still an important alternative in rural India.

Where do persons with blindness caused by cataracts in rural areas of India seek treatment and why?

The utilization of eye care facilities by patients with a cataract was evaluated among 240 patients selected from eye care camps that were conducted by our center. Of the patients, 52.9% had visited previous eye care camps, while 19.2% consulted private ophthalmologists. Easy accessibility, reputation of a facility, competence of its staff, free service, and nearby facilities were the major reasons that were cited by patients for utilization of service facilities. Distance, monetary constraints, and a lack of professional trust, escorts, and the perception about the seriousness of their ocular condition were the main reasons that patients were not motivated to use such service facilities. Statistically significant differences were observed when past utilization of eye care camps was related to age, marital status, and source of income.

A community-based evaluation of eyesight and spectacle use after intracapsular cataract extraction in northern India

The visual outcome and extent of aphakic spectacle use at community level was evaluated in 177 patients who underwent ICCE in peripheral camps. In 16.9%, both eyes were operated. The mean age at cataract surgery was 63 years (range 33-82 years). After surgery, 79.7% had better vision; 72.3% were extremely satisfied with the surgical outcome. Of those with improved or similar vision, 81.9% were regularly using aphakic spectacles. Free aphakic spectacles after surgery were received by 57.6%. Broken spectacles was the most common cause for not using or intermittently using spectacles. The major benefits to patients were the ability to undertake personal activities, improved mobility and recognition of family members, friends and cattle.

Epidemiological aspects of visual impairment above 50 years in a rural area

A cross-sectional survey was conducted in 5 villages in central India to find out the extent, causes and epidemiological factors for visual impairment among 903 individuals aged above 50 years; 44.3% of them were visually impaired (29.4% with low vision and 14.9% blind). Age-specific visual impairment increased at a rate of 13.2% with each decade of advancing age. Landless labourers suffered more from visual impairment than other occupational groups (p < 0.05). Socioeconomic and literacy status of the population did not significantly influence the prevalence of visual impairment. Major causes of visual impairment were cataract (48.5%), refractive errors (24.5%), age-related macular degeneration (10%), glaucoma (6.8%), and others (10.2%). In view of the high prevalence of visual impairment among the elderly individuals, it is necessary to intensify our efforts in motivating them for early detection and treatment.

Cost analysis of eye camps and camp-based cataract surgery

BACKGROUND

Although cataract accounts for half the blindness in the world, the resources available are not sufficient to meet the existing need for operations. The most effective low cost cataract surgery is probably performed in community camps.

METHODS

We estimated the costs incurred in performing cataract operations in makeshift comprehensive eye care camps. Both the capital and recurrent inputs were costed at current market rates.

RESULTS

Rupees 1,508,600 (US$ 47,100) was spent on conducting 17 camps during April 1992 to March 1993. Recurrent inputs were responsible for 83% of the total costs. Sixty per cent of the recurrent inputs were borne by non-governmental organizations. The total capital expenditure was borne by the mobile ophthalmic units. Food and drugs for patients (40%), and staff salaries and allowances (35%) were the major recurrent expenditure, while 60% of the capital expenditure was accounted for by vehicles. The unit cost of cataract surgery was Rs 772 (US$ 23).

CONCLUSIONS

We suggest that comprehensive eye camps are cost-effective.

Evaluation of an innovative school eye health educational mode

An innovative mode of using school children as health educators for transmitting messages on eye health care in the school environment was evaluated. Fifty children were evaluated at baseline and immediately after the educational session. A significant change in cognitive aspects of eye care was demonstrated (p < 0.001). Knowledge on vitamin A related aspects and childhood ocular trauma improved substantially compared to all other aspects of eye care.

Evaluation of vitamin A status by conjunctival impression cytology among school aged population

Conjunctival impression cytology was used to determine the extent of preclinical and clinical vitamin A deficiency in school children aged 8-13 years. Nearly 23% of the examined children had an abnormal cytology reflecting a poor vitamin A status. The differences in cytology results were not significantly affected by either age or sex.

Sociobiologic factors influencing low birth weight at a rural project hospital

The incidence of low birth weight (less than or equal to 2500 g) was 38.9% among 2292 singleton live births at a rural project hospital in Haryana. Only 7.0% of the newborns weighed 2000 g or less. Female babies had a higher incidence of low birth weight. Other factors considered were maternal age, parity and literacy and father's literacy. Young mothers (less than 20 years) had a higher incidence of low birth weight. Similarly parents who were illiterate or educated to below the primary grade also had a higher incidence of low birth weight. The maximum percentage of low birth weight was seen in the primiparous mothers. An increase of low birth weight was also seen after the 4th parity. The best outcome was at para 4.

Knowledge, attitude and practices regarding acute respiratory infections

One hundred and six mothers in a rural area were interviewed to determine as to how they recognise pneumonia in children, what therapies they practice with mild acute respiratory illnesses and pneumonias and the feeding practices they adopt. Most mothers recognised pneumonia by noticing fast respiratory rate and difficulty in breathing. More severe cases were recognised by these signs among a higher percentage of mothers. As regards management of mild ARI episodes, more than half the mothers preferred not to give any treatment or use only home remedies. In pneumonias, a majority of them preferred to consult a qualified doctor. Nearly a third of them were of the opinion that they would take the child to hospital if the disease was severe. Regarding feeding practices, most of them stated that they would continue feeding, fluids and breast feeds. Only 10% desired to stop and another 15% would decrease the amounts.

Effect of educational intervention on defaecation habits in an Indian urban slum

The defaecation habits of 172 adults before and after a cholera epidemic in New Delhi in 1988 were investigated. Intensive educational activities were undertaken during the epidemic. A community latrine facility was constructed in this area in February 1988. A greater proportion of females than males were found to be exclusively using the latrines at both rounds of the investigation. A statistically significant relationship with age was observed (P less than 0.001), while literacy was not found to exert a statistically significant effect. Difference in usage habits were more marked in the second round of the investigation. Cost and distance were the main reasons cited for non-utilization of latrines. 91.4% of respondents stated that they had faced some problem in using latrines. Most children were found to be defaecating in the open around the dwelling units at both rounds of the investigation.

Vitamin A intake and vitamin A deficiency in rural children

The prevalence of vitamin A deficiency was estimated in 366 rural children in the age group of 1 to 15 years. In a systematically selected subsample of 90 children, the dietary intake of vitamin A was assessed. The prevalence of vitamin A deficiency signs ranged from 24.1 to 34.8%. The adequacy of dietary intake of vitamin A ranged from 8 to 12% when compared with the recommended dietary allowance. The dietary intake of children with and without vitamin A deficiency was not different (p greater than 0.05). The main source of beta carotene in the diet was cereals accounting for 47.9% of the total beta carotene intake.

Knowledge of mothers regarding immunization in a high coverage area--need for strengthening health education

One hundred mothers of 'fully' immunized 12-24 month old children were administered a schedule to elicit knowledge regarding immunization. The mean age of the mothers was 27.05 years. Knowledge regarding vaccine availability was good, except in case of measles. A much lower proportion were aware of correct doses and intervals. Only DPT was reported to produce side-effects by a majority. The hypothesis that in a high coverage area, mothers would be armed with more specific immunization information was not borne out.

Socio-biological determinants of birth weight

A study on a few selected socio-biological determinants of birth weight was conducted at a rural project hospital in Haryana. Records of 2292 singleton live births over a period of two years (1985-1987) were analysed, by bivariate and multivariate methods. The mean birth weight of the infants was 2715 g (S.D. 453). Mean birth weight of male infants was 92 g more than female infants. Literacy levels of both parents, maternal age, parity, place of residence and antenatal care were found to have significant influence on the birthweight. Multiple regression showed that maternal age, maternal literacy and place of residence had minimal influence on the birth weight compared to other factors.