Public Health

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Milante RR, Guo X, Neitzel AJ, Kretz AM, Mukherjee RM, Friedman DS, Repka MX, Collins ME. Analysis of vision screening failures in a school-based vision program (2016-19). J AAPOS 2021;Abstract
BACKGROUND: Vision screenings of a school-based program were conducted in state-mandated grades (pre-kindergarten [pre-K] or kindergarten [K], 1st and 8th grade), and nonmandated grades (2nd to 7th). METHODS: During school years 2016-19, 51,593 pre-K to 8th grade students from 123 Baltimore City Public Schools underwent vision screenings, with 85% of the schools qualifying for Free and Reduced Price Meals. Assessments included distance visual acuity, Spot photoscreening, stereopsis, and cover testing. Screening failures were analyzed by grade using aggregate data. Failure rates for mandated and nonmandated grades were compared using a logistic regression model, and visual acuity distributions were analyzed using individual data. RESULTS: Over the 3-year period, 17,414 (34%) of students failed vision screening. Failure rates by grade ranged from 28% to 38%. Children in kindergarten and 3rd grade and higher were statistically more likely to fail screening than those in 1st grade. Reduced visual acuity was the most common reason for failure (91%). Failure rates were significantly higher in nonmandated grades than in state-mandated testing grades (34.7% vs 32.5% [P < 0.001]). Mean visual acuity of all students who failed vision screening was 20/50 in the worse-seeing eye and was 20/40 in the better-seeing eye. CONCLUSIONS: One-third of students failed vision screening. High screening failure rates across all grades suggest that screening in select grade levels, as currently mandated in Maryland schools, is inadequate for detecting vision problems in the low-income communities served by this program.
Mitchell W, Bhatia R, Zebardast N. Retrospective cross-sectional analysis of the changes in marijuana use in the USA, 2005-2018. BMJ Open 2020;10(7):e037905.Abstract
OBJECTIVES: Understanding trends of marijuana use in the USA throughout a period of particularly high adoption of marijuana-legalisation, and understanding demographics most at risk of use, is important in evolving healthcare policy and intervention. This study analyses the demographic-specific changes in the prevalence of marijuana use in the USA between 2005 and 2018. DESIGN, SETTING AND PARTICIPANTS: A 14-year retrospective cross-sectional analysis of the National Health and Nutrition Examination Survey database, a publicly available biennially collected national survey, weighted to represent the entire US population. A total of 35 212 adults between 18 and 69 years old participated in the seven-cycles of surveys analysed (2005-2018). PRIMARY OUTCOME MEASURED: Lifetime use, first use before 18 years old, and past-year use of marijuana. RESULTS: The majority of adults reported ever using marijuana. While the overall prevalence of lifetime marijuana use remained stable (p=0.53), past-year use increased significantly between 2005 and 2018 (p<0.001) with highest rate of past-year use among younger age groups (p<0.001), males (p<0.001) and those with income below poverty level (p<0.001). Past-year use was the most common among non-Hispanic blacks, and less common among Hispanic/Mexican populations (p<0.002). Trends in past-year use increased among all age categories, males/females, all ethnicities, those with high school education/above, and those at all income levels (p<0.01 for all). CONCLUSIONS: While lifetime marijuana use remained stable, past-year use significantly increased between 2005 and 2018. While past-year use remained the most common in younger age groups, males, non-Hispanic blacks and those with lower income; increasing trends in past-year use were significant for all age, sex, race and income categories, and for those with high school education/above. With high adoption of marijuana-legalisation laws during this period, our results suggest an associated increase in past-year marijuana use.An accurate understanding of those most at risk can help to inform decisions of healthcare policy-makers and professionals, and facilitate a safe transition of changing marijuana legalisation and use in the USA.
Mitchell W, Marmamula S, Zebardast N, Ng W, Locascio JJ, Kumbam T, Brahmanandam S, Barrenkala NR. Psychometric validation techniques applied to the IND-VFQ-33 visual function questionnaire: the Hyderabad ocular morbidity in the elderly study (HOMES). BMC Med Res Methodol 2021;21(1):26.Abstract
BACKGROUND: Over 2 billion people suffer from vision impairment or blindness globally, and access to validated visual measurement tools in imperative in accurately describing and managing the burden of eye disease. The present study applies contemporary psychometric validation techniques to the widely used 33-item Indian Visual Function Questionnaire (IND-VFQ-33). METHODS: We first estimated the polychoric correlation between each pair of items. Next, an unrotated and oblique Promax rotated factor analysis, item response theory (IRT, using a graded response model (GRM)), and differential item functioning (DIF) testing were applied to the IND-VFQ-33. We subsequently propose a validated IND-VFQ-33 questionnaire after psychometric testing, data reduction, and adjustment. RESULTS: Exploratory unrotated factor analysis identified two factors; one with a particularly high eigenvalue (18.1) and a second with a lower eigenvalue still above our threshold (1.1). A subsequent oblique Promax factor rotation was undertaken for a 2-factor solution, revealing two moderately correlated factors (+ 0.68) with clinically discrete item loadings onto either Factor 1 (21 items; collectively labelled "daily activities") or Factor 2 (5 items; collectively labelled "bright lights"). IRT confirmed high item discrimination for all remaining items with good separation between difficulty thresholds. We found significant DIF on depression for six items in Factor 1 (all uniform DIF, except item 21 (non-uniform DIF) with no substantive difference in beta thresholds for any item and no substantive difference in expected individual or sum score, by depression at baseline. For Factor 2, only one item demonstrated significant uniform DIF on gender, similarly without major differences in beta thresholds or expected total score between gender at baseline. Consequently, no further item recalibration or reduction was undertaken after IRT and DIF analysis. CONCLUSION: Applying IRT and DIF validation techniques to the IND-VFQ-33 identified 2 discrete factors with 26 uniquely-loading items, clinically representative of difficulty performing daily activities and experiencing difficulty due to bright lights/glare respectively. The proposed modified scale may be useful in evaluating symptomatic disease progression or response to treatment in an Indian population.
Mitchell W, Hassall M, Henderson T. Updating the model of eye care for Aboriginal populations in remote Central Australia. Clin Exp Ophthalmol 2020;48(9):1299-1306.Abstract
Eye disease is the third-highest contributor towards health inequality for Aboriginal Australians. Understanding how the Central Australian ophthalmology service addresses complexities of remote eye care is crucial in understanding how expansion can meet current and future needs. The present study analyses findings from the MEDLINE database and Governmental reports, and descriptive information from stakeholders in Central Australia and the Australian Department of Health. We describe the current Central Australian ophthalmology model at three levels; (a) the healthcare service level (specialized primary care, local/outreach optometry and ophthalmology services, and intensive extended surgical weeks), (b) the community level (local community staff, clinics and initiatives, and eye "champions" and mutual support), and (c) the healthcare system level (federal and state government, and private funding). We conclude that building full-time specialist availability, and system-wide approaches to increase patient utilisation, will facilitate overcoming barriers of remoteness, and create enduring improvements in Central Australian eye care and health-inequality.
Mudie LI, Guo X, Slavin RE, Madden N, Wolf R, Owoeye J, Friedman DS, Repka MX, Collins ME. Baltimore Reading and Eye Disease Study: vision outcomes of school-based eye care. Can J Ophthalmol 2022;57(1):36-40.Abstract
OBJECTIVE: There are unmet needs for refractive correction in the pediatric population, especially in high-poverty communities. We reported the impact of refractive correction on vision outcomes over a 2-year follow-up in the Baltimore Reading and Eye Disease Study. DESIGN: Prospective, school-based cohort study. PARTICIPANTS: Students of second and third grades who were prescribed glasses during baseline assessment. METHODS: We conducted baseline eye exams in 12 Baltimore public schools during the fall of school year 2014-15 with follow-up visits in the spring of school year 2014-15 (first follow-up) and school year 2015-16 (second follow-up). Visual acuity (VA) was measured at distance and near with correction. Refractive status was determined based on the eye with the larger refractive error and categorized as myopia, hyperopia, and astigmatism. MAIN OUTCOME MEASURES: VA in better-seeing and worse-seeing eye at first and second follow-up, and acuity improvement from baseline. RESULTS: In the 206 students (84% African American) who completed the first follow-up, both distance (from 0.14 ± 0.20 to 0.05 ± 0.10 logMAR) and near presenting VA (from 0.08 ± 0.16 to 0.03 ± 0.06 logMAR) improved from the baseline assessment; children with more severe hyperopia showed improvement in near VA by 0.05 ± 0.16 logMAR. Children who were prescribed glasses through a school-based research study had improved vision, which was sustained into the following school year. CONCLUSIONS: Many second and third graders in Baltimore Schools needed refractive correction and benefited from provision of glasses with sustained vision improvement over the 2-year observation.
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Nahum AS, Vongsachang H, Friedman DS, Collins ME. Parental Trust in School-Based Health Care: A Systematic Review. J Sch Health 2022;92(1):79-91.Abstract
BACKGROUND: Health care delivery in schools is a frequently adopted approach to reduce health care inequalities. Lack of parental trust has been identified as impacting participation in school-based health care programs (SBHPs). The aim of our systematic review is to outline themes related to parental trust in SBHPs. METHODS: We searched MEDLINE, Embase, CINHAL, ERIC, PsycInfo, and Web of Science for articles published between 1969 and 2019. Eligible studies (1) were peer-reviewed primary research articles; (2) were school-based health interventions or screening programs; (3) included parental trust data; and (4) were carried out on schoolchildren from pre-K to grade 12. Study location, data collection date, number of participants, demographics, intervention type, study aim and methodology, and all trust themes mentioned, were extracted. Studies were critically appraised using the CASP checklist for qualitative research. RESULTS: We identified 9 themes related to parental trust in SBHPs: (1) safety; (2) effectiveness; (3) health professionals' training and credentials; (4) communication; (5) confidentiality; (6) providers; (7) government, authorities, and health service; (8) the pharmaceutical industry; and (9) research and data sharing. CONCLUSIONS: The themes identified provide a framework for examining trust in SBHPs, and may guide the development of interventions to increase trust and engagement in SBHPs.
Naidoo K, Kempen JH, Gichuhi S, Braithwaite T, Casson RJ, Cicinelli MV, Das A, Flaxman SR, Jonas JB, Keeffe JE, Leasher J, Limburg H, Pesudovs K, Resnikoff S, Silvester AJ, Tahhan N, Taylor HR, Wong TY, Bourne RRA, of the of Study VLEGGBD. Prevalence and causes of vision loss in sub-Saharan Africa in 2015: magnitude, temporal trends and projections. Br J Ophthalmol 2020;104(12):1658-1668.Abstract
BACKGROUND: This study aimed to assess the prevalence and causes of vision loss in sub-Saharan Africa (SSA) in 2015, compared with prior years, and to estimate expected values for 2020. METHODS: A systematic review and meta-analysis assessed the prevalence of blindness (presenting distance visual acuity <3/60 in the better eye), moderate and severe vision impairment (MSVI; presenting distance visual acuity <6/18 but ≥3/60) and mild vision impairment (MVI; presenting distance visual acuity <6/12 and ≥6/18), and also near vision impairment (
Neitzel AJ, Wolf B, Guo X, Shakarchi AF, Madden NA, Repka MX, Friedman DS, Collins ME. Effect of a Randomized Interventional School-Based Vision Program on Academic Performance of Students in Grades 3 to 7: A Cluster Randomized Clinical Trial. JAMA Ophthalmol 2021;139(10):1104-1114.Abstract
Importance: Uncorrected refractive error in school-aged children may affect learning. Objective: To assess the effect of a school-based vision program on academic achievement among students in grades 3 to 7. Design, Setting, and Participants: This cluster randomized clinical trial was conducted in Baltimore City Public Schools during school years from 2016 to 2019 among 2304 students in grades 3 to 7 who received eye examinations and eyeglasses. Intervention: Participating schools were randomized 1:1:1 to receive eye examinations and eyeglasses during 1 of 3 school years (2016-2017, 2017-2018, and 2018-2019). Main Outcomes and Measures: The primary outcome was 1-year intervention impact, measured by effect size (ES), defined as the difference in score on an academic test (i-Ready or Partnership for Assessment of Readiness for College and Careers tests on reading and mathematics) between intervention and control groups measured in SD units, comparing cohort 1 (intervention) with cohorts 2 and 3 (control) at the end of program year 1 and comparing cohort 2 (intervention) with cohort 3 (control) at the end of program year 2. The secondary outcome was 2-year intervention impact, comparing ES in cohort 1 (intervention) with cohort 3 (control) at the end of program year 2. Hierarchical linear modeling was used to assess the impact of the intervention. Analysis was performed on an intention-to-treat basis. Results: Among the 2304 students included in the study, 1260 (54.7%) were girls, with a mean (SD) age of 9.4 (1.4) years. The analysis included 964 students (41 schools) in cohort 1, 775 students (41 schools) in cohort 2, and 565 students (38 schools) in cohort 3. There were 1789 Black students (77.6%), 388 Latinx students (16.8%), and 406 students in special education (17.6%). There was an overall 1-year positive impact (ES, 0.09; P = .02) as assessed by the i-Ready reading test during school year 2016-2017. Positive impact was also observed among female students (ES, 0.15; P < .001), those in special education (ES, 0.25; P < .001), and students who performed in the lowest quartile at baseline (ES, 0.28; P < .001) on i-Ready reading and among students in elementary grades on i-Ready mathematics (ES, 0.03; P < .001) during school year 2016-2017. The intervention did not show a sustained impact at 2 years or on Partnership for Assessment of Readiness for College and Careers testing. Conclusions and Relevance: Students in grades 3 to 7 who received eyeglasses through a school-based vision program achieved better reading scores. Students had improved academic achievement over 1 year; however, a sustained impact was not observed after 2 years. Trial Registration: The Registry of Efficacy and Effectiveness Studies Identifier: 1573.1v1.
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Ramke J, Evans JR, Habtamu E, Mwangi N, Silva JC, Swenor BK, Congdon N, Faal HB, Foster A, Friedman DS, Gichuhi S, Jonas JB, Khaw PT, Kyari F, Murthy GVS, Wang N, Wong TY, Wormald R, Yusufu M, Taylor H, Resnikoff S, West SK, Burton MJ, in study group GCGEH. Grand Challenges in global eye health: a global prioritisation process using Delphi method. Lancet Healthy Longev 2022;3(1):e31-e41.Abstract
Background: We undertook a Grand Challenges in Global Eye Health prioritisation exercise to identify the key issues that must be addressed to improve eye health in the context of an ageing population, to eliminate persistent inequities in health-care access, and to mitigate widespread resource limitations. Methods: Drawing on methods used in previous Grand Challenges studies, we used a multi-step recruitment strategy to assemble a diverse panel of individuals from a range of disciplines relevant to global eye health from all regions globally to participate in a three-round, online, Delphi-like, prioritisation process to nominate and rank challenges in global eye health. Through this process, we developed both global and regional priority lists. Findings: Between Sept 1 and Dec 12, 2019, 470 individuals complete round 1 of the process, of whom 336 completed all three rounds (round 2 between Feb 26 and March 18, 2020, and round 3 between April 2 and April 25, 2020) 156 (46%) of 336 were women, 180 (54%) were men. The proportion of participants who worked in each region ranged from 104 (31%) in sub-Saharan Africa to 21 (6%) in central Europe, eastern Europe, and in central Asia. Of 85 unique challenges identified after round 1, 16 challenges were prioritised at the global level; six focused on detection and treatment of conditions (cataract, refractive error, glaucoma, diabetic retinopathy, services for children and screening for early detection), two focused on addressing shortages in human resource capacity, five on other health service and policy factors (including strengthening policies, integration, health information systems, and budget allocation), and three on improving access to care and promoting equity. Interpretation: This list of Grand Challenges serves as a starting point for immediate action by funders to guide investment in research and innovation in eye health. It challenges researchers, clinicians, and policy makers to build collaborations to address specific challenges. Funding: The Queen Elizabeth Diamond Jubilee Trust, Moorfields Eye Charity, National Institute for Health Research Moorfields Biomedical Research Centre, Wellcome Trust, Sightsavers, The Fred Hollows Foundation, The Seva Foundation, British Council for the Prevention of Blindness, and Christian Blind Mission. Translations: For the French, Spanish, Chinese, Portuguese, Arabic and Persian translations of the abstract see Supplementary Materials section.
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Singh T, Ichhpujani P, Singh RB. First Line of Defense in COVID-19: Masks in Clinical Practice. Asia Pac J Public Health 2020;:1010539520979928.Abstract
The current evidence suggests that masks are efficacious in limiting the transmission of severe acute respiratory syndrome coronavirus 2 (SARS-CoV2). Although cloth masks are effective in outdoor environments, there is a consensus about the requirement of N95 masks or respirators when working in close proximity to patients who may be asymptomatic carriers, specifically in ophthalmology clinics, where slit-lamp examinations, noncontact tonometry, and other procedures place the physicians and patients in close proximity with each other. In this report, we review the available evidence regarding the efficacy of different types of masks in clinical practice in ophthalmology.
Subburaman G-BB, Kempen JH, Durairaj S, Balakrishnan V, Valaguru V, Namperumalsamy VP, Thulasiraj RD, Gupta S. Making the decision to donate eyes: Perspectives from the families of the deceased in Madurai, India. Indian J Ophthalmol 2020;68(10):2094-2098.Abstract
Purpose: To identify factors affecting family members' decision whether to donate eye organs. Methods: A community-based case-control study based on in-home interviews with families of deceased individuals who had or had not donated eye organs, in Madurai district, Tamil Nadu, India. Data collected were knowledge and awareness of eye donations, whether the deceased individual had expressed or pledged willingness to donate, and family members' attitudes and willingness to donate their own eye organs. Results: Seventy-six families of donors and 256 families of non-donors completed the survey. Multivariable analysis showed that the following variables were significantly associated with a donation: age, whether the deceased had registered for eye donation, pre-expressed willingness of deceased to donate, whether family members personally know beneficiaries of eye donations, and higher score on a scale evaluating knowledge and awareness about eye donation. The majority of donors' families (71%) had been encouraged by someone to donate. Among non-donor families, a substantially larger fraction (52.8%) indicated they would have donated had someone reminded or encouraged them to do so, in comparison with those who indicated lack of awareness or knowledge (14.5%). Conclusion: Community programs are likely to be effective if they encourage individuals to pledge their eyes or express their willingness to donate their eyes to family members in advance of death; they increase public awareness of the value of eye donation. A friend, family member, neighbor or counselor approaching bereaved families and having a dialogue about eye donation would substantially increase the probability of a decision to donate.
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Ung L, Jonas JB, Lietman TM, Chodosh J. COVID-19 and the Unfinished Agenda of VISION 2020. Am J Ophthalmol 2021;224:30-35.Abstract
PURPOSE: To critically evaluate the potential impact of the coronavirus disease (COVID-19) pandemic on global ophthalmology and VISION 2020. DESIGN: Perspective supplemented with epidemiologic insights from available online databases. METHODS: We extracted data from the Global Vision Database (2017) and Global Burden of Disease Study (2017) to highlight temporal trends in global blindness since 1990, and provide a narrative overview of how COVID-19 may derail progress toward the goals of VISION 2020. RESULTS: Over 2 decades of VISION 2020 advocacy and program implementation have culminated in a universal reduction of combined age-standardized prevalence of moderate-to-severe vision impairment (MSVI) across all world regions since 1990. Between 1990 and 2017, low-income countries observed large reductions in the age-standardized prevalence per 100,000 persons of vitamin A deficiency (25,155 to 19,187), undercorrected refractive disorders (2,286 to 2,040), cataract (1,846 to 1,690), onchocerciasis (5,577 to 2,871), trachoma (506 to 159), and leprosy (36 to 26). Despite these reductions, crude projections suggest that more than 700 million persons will experience MSVI or blindness by 2050, principally owing to our growing and ageing global population. CONCLUSIONS: Despite the many resounding successes of VISION 2020, the burden of global blindness and vision impairment is set to reach historic levels in the coming years. The impact of COVID-19, while yet to be fully determined, now threatens the hard-fought gains of global ophthalmology. The postpandemic years will require renewed effort and focus on vision advocacy and expanding eye care services worldwide.
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Zheng Q, Jones FK, Leavitt SV, Ung L, Labrique AB, Peters DH, Lee EC, Azman AS, Azman AS. HIT-COVID, a global database tracking public health interventions to COVID-19. Sci Data 2020;7(1):286.Abstract
The COVID-19 pandemic has sparked unprecedented public health and social measures (PHSM) by national and local governments, including border restrictions, school closures, mandatory facemask use and stay at home orders. Quantifying the effectiveness of these interventions in reducing disease transmission is key to rational policy making in response to the current and future pandemics. In order to estimate the effectiveness of these interventions, detailed descriptions of their timelines, scale and scope are needed. The Health Intervention Tracking for COVID-19 (HIT-COVID) is a curated and standardized global database that catalogues the implementation and relaxation of COVID-19 related PHSM. With a team of over 200 volunteer contributors, we assembled policy timelines for a range of key PHSM aimed at reducing COVID-19 risk for the national and first administrative levels (e.g. provinces and states) globally, including details such as the degree of implementation and targeted populations. We continue to maintain and adapt this database to the changing COVID-19 landscape so it can serve as a resource for researchers and policymakers alike.

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