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Sustainable English language teacher development at scale : lessons from Bangladesh
This text offers a thorough and comprehensive review of the lessons learnt from the award-winning 'English in Action' English language teacher development programme, which ran in government primary and secondary schools across Bangladesh from 2008 to 2017. Over the course of nine years the Programme involved 51,000 teachers and 20 million school students, demonstrably raising standards of teachers' classroom practice and students' English language attainment. The 16 chapters explore the programme in detail, looking at both the successes and the challenges encountered throughout its course, including the strategies used to address the challenges.
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Prevalence and causes of blindness and vision impairment among people 50 years and older in Nepal: A national Rapid Assessment of Avoidable Blindness survey
To determine the prevalence and causes of blindness and vision impairment among people 50 years and older in Nepal.
We conducted seven provincial-level Rapid Assessment of Avoidable Blindness (RAAB) cross-sectional, population-based surveys between 2018-2021. Provincial prevalence estimates were weighted to give nationally representative estimates. Sampling, enumeration, and examination of the population 50 years and older were done at the province level following standard RAAB protocol.
Across seven surveys, we enrolled 33,228 individuals, of whom 32,565 were examined (response rate 98%). Females (n = 17,935) made up 55% of the sample. The age-sex-province weighted national prevalence of blindness (better eye presenting visual acuity <3/60) was 1.1% (95% confidence interval [CI] 1.0-1.2%), and any vision impairment <6/12 was 20.7% (95% CI 19.9-21.5%). The prevalence of blindness was higher in women than men (1.3% [95% CI 1.1-1.5%] vs 0.9% [95% CI 0.7-1.0%]). Age-sex weighted blindness prevalence was highest in Lumbini Province (1.8% [95% CI 1.3-2.2%]) and lowest in Bagmati Province (0.7% [95% CI 0.4-0.9%]) and Sudurpaschim Province (0.7% [95% CI 0.4-0.9%]). Cataract (65.2%) was the leading cause of blindness in our sample, followed by corneal opacity (6.4%), glaucoma (5.8%) and age-related macular degeneration (5.3%). Other posterior segment diseases accounted for 8.4% of cases. Cataract was also the leading cause of severe vision impairment (83.9%) and moderate vision impairment (66.8%), while refractive error was the leading cause of mild vision impairment (66.5%).
The prevalence of blindness was higher among women than men and varied by province. The Lumbini and Madesh Provinces in the Terai (plains) region had higher prevalence of blindness than elsewhere. Cataract was the leading cause of blindness, severe vision impairment and moderate vision impairment while refractive error was the leading cause of mild vision impairment.
Journal Article
Barriers to cataract surgeries as perceived by visually impaired 50 years and older cataract blind participants of Nepal survey for rapid assessment of avoidable blindness
To identify the main barriers and determinants to cataract surgery as perceived by 50 years and older Nepali people with severe visual impairment & blind due to cataracts.
This was part of the Rapid Assessment for Avoidable Blindness (RAAB), held in all provinces of Nepal from 2018 to 2021. Cataract blindness was defined as a person having the best-corrected vision, < 6/60 in the better eye, and an unoperated cataract, which was the principal cause of visual disability. The participants were interviewed using a pretested questionnaire with seven known barriers. The demographic information was correlated with the barrier score.
We surveyed 718 cataract blind. Two-thirds of the participants were females. Four in ten were aged 50-59 years. The main barriers perceived were 'need is not felt' (237; 33%), cost associated with surgery (218; 30%), lack of access (93; 13%), fear of surgery (88; 12%), nobody to accompany (40; 6%), unaware of surgery (18; 3%), and treatment denied (24; 3%). The barriers were not significantly different in females than in males. (P = 0.85). The provincial variations of barriers were significant. (P < 0.001). High cost was a perceived barrier in all provinces except Gandaki. Access to treatment was a barrier in the Gandaki province (38%). One in four participants in the Madhesh and Bagmati provinces feared surgery. Nearly half of the cataract blind in the Madhesh and Lumbini province did not feel 'need for restoring vision'.
To improve cataract surgery uptake, identified barriers, like lack of awareness, low visual need, and high cost must be addressed. The strategies could be devised according to provincial barriers but similar to both genders and all 50 years and older cataract blind. Offering low-cost cataract surgery, financial assistance and health promotion to improve awareness and remove fear were recommended.
Journal Article
Effective cataract surgical and refractive error coverages in the state of Qatar
Purpose
To evaluate the progress in Qatar’s eye care since 2009, focusing on effective cataract surgical and refractive error coverages, leading to enhanced eye health strategies and action plans.
Methods
A modified Rapid Assessment of Avoidable Blindness (RAAB) survey was employed using multi-stage sampling in all persons 50 years and older in Qatar. The study focused on uncorrected refractive errors, cataract surgery coverage and effectiveness, and visual acuity assessment.
Results
There were 339 individuals out of 3,206 examined participants who underwent cataract surgery, out of which 66.1% of 559 operated eyes obtained good post-operative outcomes (presenting visual acuity ≥ 6/12). Age -sex - adjusted eCSC for a cataract surgical threshold < 6/12 was 61.2% (95%CI 54.9–67.4). A poor post-operative outcome (presenting visual acuity < 6/60) was observed in 9.3% of all operated eyes, lower than the 14.9% reported in 2009. Cataract surgical coverage at the 6/18 threshold showed good coverage (94%) improving since 2009 (87%). Effective refractive coverage (eREC) was 74.3% (95%CI 70.9–77.7). Effective coverage of both services was lower among Qatari women compared to other population groups.
Conclusion
Qatar’s CSC improved since the 2009 RAAB, but there are disparities in effective coverage based on gender and nationality. WHO set a global target to achieve a 30%-point increase in eCSC and a 40%-point increase in eREC by 2030; accordingly, Qatar’s targets should be 91.2% and 100% retrospectively by 2030. To meet these targets, efforts are needed to improve the quality of cataract surgery and access to refractive correction.
Journal Article
Estimating the need for diabetic retinopathy services in north India: evidence from a population-based survey in the catchment population of an eye care provider in central Uttar Pradesh
ObjectiveThe aim of this study was to assess the prevalence of diabetic retinopathy (DR) and retina screening coverage among people with diabetes in the catchment area of a high-volume eye care organisation in north India.DesignA population-based cross-sectional study using Rapid Assessment of Avoidable Blindness survey, including the DR module.SettingA customised rural district in the catchment of Dr Shroff’s Charity Eye Hospital in Uttar Pradesh in north India.Participants4095 people of age 50 years and above were enrolled using a two-staged cluster sampling, 3867 (94.4%) participated; 2167 (52.9%) were women. 3803 of 4095 (92.9%) participants were assessed for diabetes. People with already diagnosed diabetes and anyone with a random blood glucose ≥200 mg/dL were offered dilated fundus examination.Primary and secondary outcomesPrimary and secondary outcomes were the prevalence of DR and screening coverage for DR, respectively.ResultsThe prevalence of diabetes was 7.0% (95% CI 5.9% to 8.0%). 50.2% of all people with diabetes were newly detected. The prevalence of any DR among people with diabetes who consented to dilated pupillary examination was 22.8% (51 of 224), (95% CI 18.2% to 27.3%). 5.8% (13/224) of people with diabetes were found to have sight-threatening DR and only 15.4% (2/13) had received treatment. 84.8% of people with previously diagnosed diabetes had never had their eyes tested for DR; this was significantly higher in women (90.2% vs 76.0%, respectively, p<0.001). 76% of people with previously diagnosed diabetes had poorly controlled diabetes; this was significantly higher for those on non-allopathic treatment (p<0.01). The odds of DR were higher with duration of diabetes >10 years and poor glycaemic control (OR of 1.8 and 1.6, respectively), but this was not found to be statistically significant.ConclusionThe prevalence of DR in this predominantly rural setting was found to be higher than the national average. Coverage of retinal screening and treatment was found to be very low. Working with general health providers to increase detection of people with diabetes and leveraging vision centres to improve DR screening coverage is needed in this region.
Journal Article
Rationale and feasibility of a combined rapid assessment of avoidable blindness and hearing loss protocol
This study has two main objectives: 1) to assess the value of combining the rapid assessment of avoidable blindness (RAAB) and the recently developed rapid assessment of hearing loss (RAHL) based on existing population-based data from Cameroon andIndia; 2) to test the feasibility of a combined RAAB-RAHL protocol.
A secondary data analysis of population-based disability surveys in India and Cameroon (in 2013-2014) was conducted, focussing on people aged 50+. Hearing impairment (HI) was defined as pure tone average of ≥41dB (better ear).Visual impairment (VI) was defined as presenting visual acuity of <6/18 (better eye). The relationship between HI and VI was examined. The feasibility of a combined RAAB-RAHL survey was assessed within a RAHL conducted among adults aged 50+ in Malawi in 2018. Outcomes included: time taken, costs, number of people examined in a day, and qualitative feedback from participants and field teams.
The prevalence of combined VI and HI among people aged 50+ was 4.4% (95% confidence interval (CI) 3.0, 6.4) in India and 4.8% (95%CI 3.0, 8.0) in Cameroon. Among participants with VI, approximately a third in India (29.3%) and Cameroon (35.1%) also had HI. A quarter of participants in India (25.4%) and Cameroon (26.9%) who had HI also had VI. In Malawi, the total time taken to complete both RAAB and RAHL assessments was approximately 27 minutes per participant. It was feasible to complete 30 participants per day for a team of four people. The estimated cost of a combined RAAB-RAHL approach in comparison to two separate impairment surveys is up to 37% less depending on the method of combination.
The substantial overlap between VI and HI supports a combined rapid survey of the two impairments. The pilot study of a combined RAAB-RAHL survey demonstrates feasibility and lower cost compared to conducting two standalone impairment surveys. A combined RAAB-RAHL approach could maximize limited resources to increase prevalence data for both vision and hearing impairment.
Journal Article
What is the coverage of retina screening services for people with diabetes? Protocol for a systematic review and meta-analysis
IntroductionDiabetic retinopathy is a leading cause of vision impairment globally. Vision loss from diabetic retinopathy can generally be prevented by early detection and timely treatment. The WHO included a measure of service access for diabetic retinopathy as a core indicator in the Eye Care Indicator Menu launched in 2022: retina screening coverage for people with diabetes. The aim of this review is to provide a comprehensive global and regional summary of the available information on retina screening coverage for people with diabetes.Methods and analysisA search will be conducted in five databases without language restrictions for studies from any country reporting retina screening coverage for adults with any type of diabetes at the national or subnational level using data collected since 1 January 2000 until the search date. We will also seek reports and coverage statistics from government websites of all WHO member states. Two investigators will independently screen studies, extract relevant data and assess risk of bias of included studies. The results of the review will be reported using the Preferred Reporting Items for Systematic Review and Meta-Analysis guideline. We will summarise the range of coverage definitions reported across included studies and present the median retina screening coverage in WHO regions and by World Bank country income level. Depending on the availability of data, we will conduct meta-analysis to assess disparities in retina screening coverage for people with diabetes by factors in the PROGRESS framework (Place of residence, Race/ethnicity/culture/language, Occupation, Gender/sex, Religion, Education, Socioeconomic status and Social capital).Ethics and disseminationThis review will only include published data thus no ethical approval will be sought. The findings of this review will be published in a peer-reviewed journal and presented at relevant conferences.Protocol registration numberOSF registration 17/10/2023: https://osf.io/k5p69.
Journal Article
Population-based rapid assessment of avoidable blindness survey in Sohag governorate in Egypt
ObjectivesTo determine the prevalence and causes of blindness and vision impairment, and the coverage and quality of cataract surgical services, among population aged 50 years and older in Sohag governorate in Egypt.DesignA population-based cross-sectional survey using two-stage cluster random sampling following the rapid assessment of avoidable blindness methodology.SettingA community-based survey conducted by six teams of ophthalmologists, assistants and local guides. Enrolment and examination were door-to-door in selected clusters.ParticipantsUsing 2016 census data, 68 population units were randomly selected as clusters (of 60 people) with probability proportionate to population size. Anyone aged 50 years and older, residing in a non-institutional setting in a cluster for at least 6 months, was eligible to participate.Primary and secondary outcome measuresThe prevalence and causes of blindness and vision impairment. Secondary outcomes were CSC and effectiveness and participant-reported barriers to cataract surgery.ResultsOf 4078 participants enrolled, 4033 (98.9%) were examined. The age-adjusted and sex-adjusted prevalence of blindness, severe vision impairment and moderate vision impairment were 5.9% (95% CI 4.8% to 6.9%), 4.7% (95% CI 3.8% to 5.7%) and 18.9% (95% CI 16.8% to 21.0%), respectively. Cataract caused most of blindness (41.6%), followed by non-trachomatous corneal opacity (15.7%) and posterior segment diseases (14.5%). Cataract surgical coverage (CSC) for persons for visual acuity <3/60 was 86.8%, the proportion of cataract surgeries with poor visual outcome was 29.5% and effective CSC (eCSC) was 44.9%. eCSC was lower in women than men. The most frequently reported barrier to surgery was cost (51.5%).ConclusionsThe prevalence of blindness in Sohag governorate is higher than districts in other middle-income countries in the region. CSC was high; however, women suffer worse quality-corrected CSC than men. The quality of cataract surgery needs to be addressed, while health system strengthening across government and private settings could alleviate financial barriers.
Journal Article
Socioeconomic position and eye health outcomes: identifying inequality in rapid population-based surveys
ObjectiveMonitoring health outcomes disaggregated by socioeconomic position (SEP) is crucial to ensure no one is left behind in efforts to achieve universal health coverage. In eye health planning, rapid population surveys are most commonly implemented; these need an SEP measure that is feasible to collect within the constraints of a streamlined examination protocol. We aimed to assess whether each of four SEP measures identified inequality—an underserved group or socioeconomic gradient—in key eye health outcomes.DesignPopulation-based cross-sectional survey.ParticipantsA subset of 4020 adults 50 years and older from a nationally representative sample of 9188 adults aged 35 years and older in The Gambia.Outcome measuresBlindness (presenting visual acuity (PVA) <3/60), any vision impairment (VI) (PVA <6/12), cataract surgical coverage (CSC) and effective cataract surgical coverage (eCSC) at two operable cataract thresholds (<6/12 and <6/60) analysed by one objective asset-based measure (EquityTool) and three subjective measures of relative SEP (a self-reported economic ladder question and self-reported household food adequacy and income sufficiency).ResultsSubjective household food adequacy and income sufficiency demonstrated a socioeconomic gradient (queuing pattern) in point estimates of any VI and CSC and eCSC at both operable cataract thresholds. Any VI, CSC <6/60 and eCSC <6/60 were worse among people who reported inadequate household food compared with those with just adequate food. Any VI and CSC <6/60 were worse among people who reported not enough household income compared with those with just enough income. Neither the subjective economic ladder question nor the objective asset-wealth measure demonstrated any socioeconomic gradient or pattern of inequality in any of the eye health outcomes.ConclusionWe recommend pilot-testing self-reported food adequacy and income sufficiency as SEP variables in vision and eye health surveys in other locations, including assessing the acceptability, reliability and repeatability of each question.
Journal Article
On-call transthoracic echocardiographic interpretation by first year cardiology fellows: comparison with attending cardiologists
Background
Transthoracic echocardiograms (TTE) performed and interpreted by cardiology fellows during off-duty hours are critical to patient care, however limited data exist on their interpretive accuracy. Our aims were to determine the discordance rate between TTEs performed and interpreted by cardiology fellows and National Board of Echocardiography certified attending cardiologists and to identify factors associated with discordance.
Methods
Consecutive on-call TTEs acquired and interpreted by 1st year cardiology fellows over 4.6 years at an academic center were prospectively evaluated by attending cardiologists. Fellow interpretations were classified as concordant or discordant with the attending interpretation. We assessed the association of patient, imaging and fellow characteristics with discordance.
Results
A total of 777 TTE interpretations (730 patients) were performed/interpreted by 40 first year fellows and overread by 13 attendings. The most common indications were assessment of left ventricular function (40.9%) and pericardial effusion (37.3%). There was a major or minor discordance in 4.1 and 17.4% of studies, respectively with 42.1% of disagreements occurring in assessment of left ventricular size and function. The indication to assess left ventricular function [OR 2.19, 95% CI (1.32, 3.62),
P
= 0.002 vs. pericardial effusion] and greater duration of echocardiographic image acquisition (OR 1.02, 95% CI 1.01, 1.03,
P
= 0.004) were independently associated with overall discordance.
Conclusions
In this large prospective study we found that attending cardiologists disagreed with 1 in 5 fellow TTE interpretations. Standardized tools for evaluation of echocardiograms performed by fellows are needed to ensure quality of training and patient safety.
Journal Article