PRISSM (Perfecting Refraction in India With Superior Service Models): A Cluster-randomized Controlled Trial of Three Models of School-based Spectacle Service Delivery in India

Background

Need: The leading cause of vision impairment among children in India, and in the world more widely, is an uncorrected refractive error (URE). For example, the population-based Refractive Error Studies in Children (RESC) studies found that 61% of vision impairment in rural children and 89% in urban children in India was due to URE and that as few as 10% of rural and 35% of urban children who need spectacles actually had them. The impact of this shortfall in service delivery is highlighted by recent randomized trials in Asia showing that provision of spectacles significantly improves children's educational outcomes, and the shortcoming in India is particularly important because India has the highest number children of any other country.

Potential impact: This trial has the potential to impact on at least two of the Sustainable Development Goals (SDG) of the United Nations. Although interventions to prevent myopia, such as topical anti-muscarinic therapy and increased time outdoors, show much promise, they are not yet ready for large-scale use. Until then, school vision programs remain the principle tool to address the problem of URE in India and elsewhere, and thereby improving children's access to high-quality education (SDG #4) and helping to address unequal access of girls to healthcare services affecting vision (SDG #5). In fact, the Indian government and many private entities are already taking a very active role in school vision screening. Since the onset of the Sarva Shiksha Abhiyan (Education for All) program in 2002, many millions of children have undergone school vision screening, but refraction and spectacles distribution has been limited and much more could be done to help. To sustain and expand these efforts, more cost-effective approaches are needed.

Problems with current models: Many non-governmental organization (NGO) and government spectacle distribution programs in India and elsewhere use school-based vision screening, refraction, and provision of spectacles. This is particularly true in poorer, rural or other under-served areas. The greatest strength of such programs is that they deliver refractive services and spectacles to a large proportion of children requiring them when school attendance rates are high. However, sustainability is problematic: these programs usually deliver spectacles for free, because their sale is not permitted in many schools. Further, this model is very demanding on resources, because refractionists must travel to numerous schools in their catchment area. Finally, it has been suggested that long-term compliance with spectacle wear may be higher when families make at least some contribution to spectacle costs, although evidence for this assertion is lacking.

Alternatively, other programs, particularly those in urban or better-served areas, may provide vision screening at schools, but then refer children and families failing to screen to a nearby facility for refraction and distribution or sale of spectacles. The strength of this model is that it is less demanding of resources (refractionists remain at their base facility rather than being directly involved in outreach screening) and spectacle sales at medical facilities are often more acceptable than sales in schools. Therefore, this model may be more sustainable. However, program experience and research have shown up to two-thirds of the referred children/families do not attend the facility that they are referred to.