Research Paper: GIVING SIGHT TO SCHOOL CHILDREN IN ZAMBIA
Researcher: Joseph S Munsanje, Sightsavers -Zambia Office
Funding Agency: Optometrist Giving Sight (OGS)
Cost of the study: $100,000
1.0 Background
Zambia is a landlocked Country located in Southern Africa with a population of
12million people. The country is ranked 165 out of 177 countries on the United
Nations Human Development Index (Human Development Report 2007/2008,
Zambia). According to government statistics, nearly 67% of the population lives
in abject poverty, meaning basics such as food, clothing and shelter are
inadequate for the larger majority of Zambians.
In the health sector, Zambia has been implementing the National Health
Strategic Plan 2006-2010 whose vision is “to provide Zambians with equity of
access to cost effective quality health care as close to the family as
possible”(National Health Strategic Plan 2006-2010). Eye diseases are the 5th
highest cause of patient visitation to hospitals in Zambia. This is due to the fact
that nearly 3million Zambians suffer from ocular morbidity, the majority of who
suffer from refractive errors and low vision.
In the National Eye Health Strategic Plan 2007-2011, uncorrected refractive
errors have been identified as the most common cause of visual impairment in
Zambia. The problem apart from affecting more adults, also affects school going
children especially the age group 11-15 thereby reducing their school attendance
and sometimes contributing to school drop out. This research was aimed at
establishing the prevalence of refractive errors among school going children
aged 11-15 in 5 districts of Southern Province of Zambia. The study further
identified correctional services against uncorrected refractive errors that could
improve child school attendance.
2.0 Problem Statement
Zambia’s education progression has been embedded in a policy document of
1996 namely “Educating our Future”. The policy guided the Education Strategic
Plan 2003-2007 and the National Implementation Framework (NIF) 2008-2010.
The key thrusts for the Zambia Education Policy and implementation are Access
and Participation, Quality and Relevance, Efficiency, Effectiveness and Equity.
The Ministry of Education is now organized along the lines of Education services,
standard and Curriculum; and Administration and Planning. Inclusive schooling
falls under the directorate of specialized education Services. Teaching and
learning services are provided through Provincial Education offices and District
Education Boards at district level.
Based on the above policy framework, Zambia increased its enrolment rate for
grade one to 130.98% in 2009, however; completion has remained low at
21.96% for grade 1-12. It is therefore clear that Zambia may attain the MDG 1
indicator on enrolment but will fail to attain the progression and completion
indicators.
The education of Children with Disabilities (CWD) in Zambia is guaranteed
through two policy frameworks. The 1996 Education Policy that provides for
“Inclusive Education” and appropriate education for each child, and the Zambia
Disabilities Act of 1996 that provides for Government penalties to any education
institution that refuses to enroll a disabled child based on disability. The Ministry
of Education indicated that CWD constitute 5.1% of its enrolment for grades 1-9,
and 1.58% of its enrolment for grades 10-12. This clearly shows a very high
dropout rate and very low progression rate for children with disabilities thereby
posing a question on what could be some of the causes for the high drop out.
Could visual impairment be one of the causes and what could be done to
improve this situation?
3.0 Research Questions:
The Key questions that guided the study were:
1. What is the existing establishment for schools in Zambia that could
support the control of Refractive Errors and Low Vision?
2. Can the school system be adapted to screen for refractive errors among
school children
3. What are the sight needs of children with refractive errors and low vision
Zambia?
4. What is the prevalence of refractive e errors and low vision in Zambia?
5. Can existing refractive Errors and Low Vision needs be corrected
6. Does correction of refractive errors and low vision improve child school
attendance and subsequently performance?
4.0 Methodology
A mapping exercise was undertaken to identify the number of schools in the five
study districts namely Monze, Choma, Kalomo, Intezhitezhi and Namwala. Data
was collected on the number of children aged 11-15 in schools across the
districts. Once this data was collected; it was then set as target numbers for the
school screening exercise.
A team of seven Ophthalmic Clinical Officers and Ophthalmic Nurses supervised
by an Ophthalmologist and the Provincial Education Standards OfficerLivingstone was assembled and trained in Training Teachers to screen for
Refractive Errors and Low Vision using E-Chart with a cut off point of 6/9. Once
complete with the ToT, Two teachers were invited from each school for training
on screening for Refractive. The teachers were trained within their localities,
using a format in which the districts were demarcated into Zones and schools
grouped according accordingly by DEBS office. Teachers from schools falling
within one zone were then assembled at a central location and the training
administered. After the training, the teachers were given a literate E-Chart to go
and screen all children aged 11-15, and any other children and teachers with
sight problems in their respective schools and submit reports to District
Ophthalmic personnel. The teachers undertook the task and submitted registers
of all pupils’ screened with a note on those pupils requiring refraction.
Sightsavers Zambia contracted two optometrists from Pakistan to conduct the
refractions on the booked pupils. The Optometrists were temporarily registered
with the Medical Council of Zambia (MCZ) in line with local legislation. In
addition, an Ophthalmologist from the University Teaching Hospital (UTH), which
is Zambia’s highest referral hospital was contracted to provide supervisory
services to the Optometrists. The contract with the local Ophthalmologist was
also done to comply with local legislation( for visiting Optometrists to be
supervised) as well as ensure that the ground work was laid for proper follow up
of cases that required services not related to refractive errors. The refractions
commenced on 22nd July 2009 and were completed on 8th October, 2009.
5.0 Key Findings
5. 1 Responsiveness of the School System to learning of Children with
Disabilities (Visual Impairment).
Education officials at the Province and the district levels were involved right from
the beginning. They provided all the statistical data for the calculation of targets
for teachers to be trained per district and number of children expected to be
screened in each district. The Planning workshops involved them in mapping
exercise for zoning their respective districts and clustering the schools into
zones. In addition, by participating in the discussions as well as attending all the
teacher training workshops, the authorities were found to be adequately
supportive of learning for children with visual impairment. This is evidenced by
the support and collaboration that they provided to the study, which ultimately
assumed the status of a joint research with the Ministry of Education. It is also
the Education Authorities at the district who were compiling the lists of the
screened children from the schools and passing them on to the district
Ophthalmic staff for refraction services.
5. 2 Adapting the School System to sustainably screen children against
uncorrected refractive errors.
The study trained a total of 512 teachers from 510 schools. All the refraction
teams were accompanied by district education officials whilst trained teachers
moved with the children from their schools to the refraction centres. With the
training of teachers and the experience they have had from this exercise; the
Ministry of Education is now adequately aware of the problem of uncorrected
refractive errors and low vision among children including the possible solutions or
referral channels. Most teachers confessed that they used to think that some of
the children were dull; when in fact these children had uncorrected refractive
errors or low vision. This is a very positive development not only for the child but
the entire community. Table 1 below shows the number of Teachers trained.
Table 1. Number of teachers trained by district
District
No schools No Schools No
Teachers No.
in existing turned up
targeted/Invited Teachers
trained
Itezhitezhi
52
38
60
45
Namawala
38
37
43
46
Monze
98
108
120
120
Choma
178
171
195
177
Kalomo
134
114
134
124
Totals
500
468
552
512
%
Teachers
trained
75%
107%
100%
91%
93%
93%
5.3 Sight Needs of Children Screened
A total of 56,296 children were screened from 510 schools out of the estimated 112,208
leaving a total of 55,912. This represents a reach rate of 50.1%. The actual lay out of the
screening data is as follows:
Table 2. Screening Results by district.
VA cutoff
Estimated Enrollment in
schools
No. of schools
Screened
Booked
N
%
Monze
<6/9
26,342
108
12,927
1,570
12.1%
Choma
<6/9
35,015
171
19,488
1,306
6.7%
Namwala
<6/9
11,504
37
6,328
766
12.1%
Itezhitezhi
<6/9
7,475
38
2,984
655
22.0%
Kalomo
<6/12
31,872
156
14,569
1,282
8.8%
112,208
510
56,296
5,579
9.9%
Total:
There was a remarkable difference between the numbers screened and the estimated targets. In review of the study with
the Ministry of Education officials; it was discovered that the estimated numbers of children in the schools are based on
grade one enrolment rate of 73% of the child population. The enrolment numbers reduce as the years go; meaning that by
the time the children reach ages 11-15; many would have dropped out. The schools unfortunately maintain the high
enrolments rates because their funding from the Ministry is based on the number of children at the school. The screening
exercise was in this case an eye opener to the Ministry since the children are not there despite them being estimated to
be there by the Ministry of Education.
Some logistical hurdles were experienced during the screening exercise. These included teachers expectations such as
payment for the screening exercise and when this was not forthcoming, reduced on their commitment to the exercise.
Other factors are absenteeism and logistical troubles to do with the road network and accessibility of schools.
5. 4 Prevalence of Uncorrected Refractive Errors among children aged 11-15 years
Despite not reaching the target pupil numbers for screening, a total of 5, 579 pupils were booked for refraction services
out of the 56,296 screened by teachers thereby requiring further examinations by the optometrists. As could be seen from
Table 3 below, 4,727 of these children received a refraction service from the team of optometrists representing 85%
coverage of the total number of pupils who were booked. However, a larger number of these were not prescribed with
optical devices as their conditions were established not be a result of refractive error. Instead they were treated for various
conditions with appropriate eye medication or referral. Out of the number refracted, 1,364 were prescribed with glasses
repreting a prevalence rate of 3% uncorrected refractive errors among screened children
Table 3: Number of Children refracted by District
VA
cutoff
Enrolled
in
schools
No. of
schools
Screened
Booked
Refracted
N
%
N
%
Prescribed
Glasses given to date
Yes
No
Monze
<6/9
26,342
108
12,927
1,570
12.1%
1,517
96.6%
386
25.4%
217
56.22%
169
43.78%
Choma
<6/9
35,015
171
19,488
1,306
6.7%
1,199
91.8%
267
22.3%
161
60.30%
106
39.70%
Namwala
<6/9
11,504
37
6,328
766
12.1%
668
87.2%
226
33.8%
117
51.77%
109
48.23%
Itezhitezhi
<6/9
7,475
38
2,984
655
22.0%
372
56.8%
143
38.4%
17
11.89%
126
88.11%
Kalomo
<6/12
31,872
156
14,569
1,282
8.8%
971
75.7%
500
51.5%
334
66.80%
166
33.20%
112,208
510
56,296
5,579
9.9%
4,727
84.7%
1,522
32.2%
846
55.58%
676
44.42%
Total:
5.5 Correction of Refractive Errors found with children with uncorrected refractive errors in Southern Province
A Total of 846 (55.58%) children received their glasses and demonstrated that uncorrected refractive errors can be corrected
locally using glasses and other low vision devices. Manufacturing and distribution of glasses as per prescriptions for each child
was contracted to two optical labs in Lusaka for fitting of lenses; whilst all frames were ordered well in advance from the global
Resource Centre in Durban by Sightsavers. Another 25 pupils out of the estimated 300 received low vision assessments and Low
Vision Aids are being ordered for them. Table 4 below shows the statistics.
Table 4: A complete spreadsheet of statistics including glasses given and follow up action required.
VA
cutoff
Enrolled
in
schools
No. of
schools
Screened
Booked
Refracted
N
%
N
%
Prescribed
Glasses given
Yes
No
Monze
<6/9
26,342
108
12,927
1,570
12.1%
1,517
96.6%
386
25.4%
217
56.22%
169
43.78%
Choma
<6/9
35,015
171
19,488
1,306
6.7%
1,199
91.8%
267
22.3%
161
60.30%
106
39.70%
Namwala
<6/9
11,504
37
6,328
766
12.1%
668
87.2%
226
33.8%
117
51.77%
109
48.23%
Itezhitezhi
<6/9
7,475
38
2,984
655
22.0%
372
56.8%
143
38.4%
17
11.89%
126
88.11%
Kalomo
<6/12
31,872
156
14,569
1,282
8.8%
971
75.7%
500
51.5%
334
66.80%
166
33.20%
112,208
510
56,296
5,579
9.9%
4,727
84.7%
1,522
32.2%
846
55.58%
676
44.42%
Total:
Wearing rates at 3 months
follow up*
Wearing Wearin
Traced N
%
5.6 Improvement of school attendance and performance due to corrected refraction
Most pupils and teachers who received their glasses immediately testified on significant improvement of their vision and
functional capability. However on school attendance and performance by some of the pupils that immediately received
their glasses; this question is needs further evidence from follow up of these children to prove the improvement. This is
yet to happen and maybe reported in 2011 after the activity is undertaken.
6.0 Conclusion

This was an operations research in which external expertise and resources were needed. The study proved quite
expensive given the operational interventions.

The study demonstrated that the school system can be harnessed to support the education of children with visual
impairment and improve both enrollment and retention rates in schools.

Approximately 3% of the children screened had some degree of refractive errors. From a quick review of the raw data
it appears that many children had prescriptions which improved their visual acuity thereby likely to improve their school
attendance, self esteem and school performance.

The main barrier to the development of services for refractive error in the country is a lack of trained personnel. This is
an area that is calling for support in terms of student scholarships and training materials for the Optometry training
programme in the country.

Close collaboration between the Ministry of Education and Health can improve education outcomes, including
participation of children with disabilities in learning.
7.0 Recommendations:

Need for collaboration between Ministries of Education and Health to improve learning outcomes

The project revealed additional benefits as over 18 teachers had their vision corrected and improved through glasses

Learning from this study; school health services should clearly include eye health in their curriculum

The eye health sector should use teachers for screening as this is sustainable and improves the skill and knowledge of
teachers including understanding the pupils who may be poorly performing due to uncorrected refractive errors

Optical laboratories need to be developed across the country to provide acceptable affordable and comfortable
spectacles.

Ownership of school health should lie with the education authorities and adequately supported by eye health
providers.

All children with disabilities must have a proper ophthalmic assessment, with measurement of visual function, including
visual acuity at 6/12, so that those who have the potential to benefit from surgery and/or optical and/or low vision
services can be identified and managed accordingly.

Referral relationships must be built between the schools and the primary health system(Primary Health Care) to help
attain quick attention to the children