Childhood visual impairment causes and barriers to accessing eye care: A suggested approach for Africa

Background Childhood vision impairment (VI) has a significantly harmful effect on both health and social outcomes. Aim To assess the causes of childhood VI, to determine obstacles to accessing eye care services and to develop a strategy for the childhood eye care system in African nations. Method This systematic review was conducted by searching several online databases, including; Scopus, PubMed, ProQuest, Web of Science, Google Scholar, Ebsco and Medline. They focussed on articles available between 2003 and 2023. These studies were conducted to evaluate the causes of childhood VI and to assess obstacles to accessing eye care services in African countries. Results The main causes of childhood VI in African nations can be avoided with timely diagnosis and an appropriate management strategy. The leading obstacles to accessing childhood eye care services were a lack of availability, accessibility and affordability. In addition to these barriers, we found that there are concerns with quality of services, primary health care system, geographic barriers, incorrect health beliefs, inappropriate parental perception, a lack of knowledge, attitudes and inadequate practices related to paediatric eye care. Conclusion The main causes of childhood VI were uncorrected refractive error (RE), amblyopia, cataract and corneal opacities that can be avoided with timely diagnosis and an appropriate management strategy. While the main obstacles to accessing childhood eye care services were a lack of availability, accessibility, affordability and healthcare system. Contribution The recommended strategy for childhood eye-care services includes models for delivery and training.


Introduction
Childhood visual impairment (VI) can significantly impact child development, negatively affecting their quality of life. 1,2The World Health Organization (WHO) reported that good vision plays a major role in the growth of children and teenagers. 3Globally, the prevalence of childhood VI varies depending on socioeconomic status, ranging from low in affluent areas to high in extremely poor ones. 4,5,6,7The results of Yekta et al.'s systematic review in 2022 indicated that the global prevalence of childhood VI, based on uncorrected visual acuity (UCVA), was 7.26%, in which the African region reported the highest prevalence of childhood blindness. 8Several studies reported that the prevalence of VI in school-aged children in various African countries is noteworthy; for example, a study in South Africa reported a prevalence rate of 2.15%, 9 while another study in Sudan found a prevalence rate of 5.5%. 10In addition, a study in Ethiopia found a prevalence rate of 9.5%. 11e main causes of childhood VI vary significantly and are influenced by factors like socioeconomic status and access to basic eye care services. 12,13,14However, almost 80% of these causes are avoidable with early diagnosis and treatment. 5,6,7,8,9,10,11,12,13,14,15,16Uncorrected refractive errors (REs) were the leading cause of childhood VI, followed by amblyopia and congenital cataract. 8,16dentifying affected children within the community is crucial because it impacts on the demand for services and the effectiveness of school programme screening.Early detection of affected children helps reduce the global burden of childhood VI and enhances public health outcomes. 17,18egular check-ups, along with access to primary, secondary and tertiary eye care, are important for the prevention of avoidable childhood blindness and VI among school-age children. 13stacles to access eye care services for children are wideranging and encompass factors that hinder children from obtaining these services, ultimately leading to negative consequences for both service distribution and access. 19nfortunately, eye care services for the children in many African nations lack infrastructure, equipment, resources and qualified professionals.
The current workforce on the African continent is insufficient, with most countries falling short of the WHO recommended ratio of eye care professionals to population. 20,21Furthermore, the primary obstacles to obtaining eye care services for young children in Africa are cost and unavailability. 22Thus, the current systematic review was performed to assess the causes of childhood VI and to determine obstacles to accessing eye care in order to develop an approach for the childhood eye care system in African countries.

Search plan and selection criteria
The current review was performed in compliance with the guidelines established by PRISMA 2020. 23The authors conducted a comprehensive search of several online databases, such as PubMed, Web of Science, ProQuest, Scopus, Medline and Google Scholar for studies published between 2003 and 2023.The articles included in this systematic review were evaluated to assess the causes of VI in children and to determine barriers to the availability and accessibility of childhood eye care.
The search keywords were 'Vision impairment in children' or 'childhood vision impairment in African nations', and 'Causes of childhood visual impairment' or 'Barriers to Eye care services' in African countries.This review was limited to papers published in English journals that underwent a peer-review process..36,37,38,39,40,41,42,43,44,45,46,47,48,49This study, however, only considered studies that utilised various methodologies and excepted editorial discussions, conference papers, meeting abstracts and studies that lacked important information such as causes and barriers to access childhood eye care as shown in Figure 1.

Data extraction
The authors gathered crucial information, including the main author, year of publication, nation of the study, participant's characteristics (age and sample size), the causes of childhood VI and barriers to access the childhood eye care services.This information is organised and presented in Table 1 and Table 2.

Characteristics of the included studies
In total, 17 800 articles were identified by the authors (depicted in Figure 1).Following the elimination of duplicate headings, 8149 articles were examined.After scanning the summaries and abstracts of these 8149 articles, 8011 articles that failed to satisfy the inclusion criteria were removed.Furthermore, 73 articles were eliminated from consideration after reviewing their full transcripts, as they were found to be lacking essential information.The final filtration included 28 articles from different African countries (Table 1 and Table 2).The articles included in the present study were published between 2003 and 2023.The studies involved a total sample size of 40 145 children and assessed the main causes of VI.In addition, the total number of participants that assessed the barriers of accessing childhood eye care services was 4670, which varied among schoolchildren, parents and eye care professionals.

The main causes of childhood vision impairment in Africa
Table 1 displays the factors contributing to childhood VI in Africa.A total of 13 reviewed articles revealed that the leading causes of childhood VI in African countries were uncorrected refractive error (RE) (59.67%), amblyopia (11.00%), cataract (9.40%), corneal opacities (7.13%) and retinal disorders (6.30%).The uncorrected RE was the primary cause of childhood VI in Africa, with percentages ranging from 91.3% in Nigeria 25 to 12.1% in Eritrea. 35mblyopia was the second cause of VI with highest prevalence found in Botswana at 31.0%, 34 followed by corneal opacities which was the most prevalent in Eritrea at 15.7%, 35 and cataracts which was the highest in Sudan at 21.5%.

Common barriers to accessing childhood eye care services in African countries
The remaining 15 reviewed articles showed that the core barriers were the awareness, practices and attitudes of the community towards childhood VI 41,42,43,44,45,48 followed by lack of affordability accessibility, availability of eye care services for children.Furthermore, paediatric eye care was deemed unimportant in numerous African care systems. 36,38,40,47tudies reviewed showed that there were other factors hampering the utilisation of eye care for children which include lack of knowledge about childhood eye disorders and care services, parents' attitudes towards childhood eye conditions, geographic blockades, demographic and socioeconomic conditions 36,37,38,39,40,41,42,43,44,45,46,47,48,49 (Table 2).

Childhood eye care systems: A recommended approach for the African region
Regarding the above-mentioned findings, the recommended method for a childhood eye care system should address the following areas:

Eliminating the common obstacles to accessing eye care services for children
Findings of research 37,39,41,42,43,44,45 showed that the knowledge, attitudes and practices related to eye conditions among parents and children were poor.The present study suggests the following eye care approach: To raise awareness about childhood eye disorders, health promotion materials should be created and distributed in clinics and public locations.These materials should inform the community about the signs, symptoms and consequences of untreated eye diseases, emphasise the importance of regular examinations and early detection, highlight the consequences of delayed treatment and provide information on where to seek eye care.
Additionally, eye care providers should deliver health education programmes through TV and radio broadcasts to dispel misconceptions about childhood eye care and increase awareness of the impact of uncorrected RE and childhood VI.
The findings 36,37,38,39,40,41,42,43,44,45,46,47,48,49 revealed that misconceptions among children and their parents regarding the effectiveness of spectacles as a treatment for RE.Furthermore, the community holds the belief that traditional medicine is the most effective approach for treating childhood eye diseases and RE.Therefore, we propose that eye care professionals should educate patients during routine eye examinations about the benefits of wearing spectacles and the significance of using them to correct RE.It is crucial to emphasise the effectiveness of patching therapy and early treatment for childhood eye disorders.To address misconceptions about spectacles, education programmes through mass media, schools and public presentations by eye care providers and psychologists should be implemented.Additionally, training traditional healers to screen and refer patients to clinics would help integrate them into the healthcare system.Most of the African population fall below the poverty line.Studies 36,38,40 showed that the cost of eye care services is the leading obstacle for many people in African states.To address these challenges, we recommend securing financial support from the government, private sector and non-government organisations (NGOs) to support childhood eye care services in African states.Implementing cost-effective communitybased screening programmes is essential, and the government should consider offering special tax exemptions to ensure the affordability of childhood eye care services and optical corrections.

Human resources development
The findings of the reviewed studies 36,37,38,39,40,41,42,43,44,45,46,47,48,49 showed the lack of primary eye care services and RE screening programmes for primary schoolchildren; furthermore, there is an absence of paediatric eye care professionals in African countries.In response to these findings, we suggest that training personnel to meet the necessities of paediatric optometrists should be developed and implemented at the local institutions.Additionally, community leaders, parents and teachers should be trained on how to screen visual disorders by monitoring visual behaviours or symptoms that they may notice.
The Ministry of Health in African nations should train enough paediatric optometrists, general practitioners, ophthalmologists, low vision specialists and binocular vision specialists at the primary, secondary and tertiary levels.
The reviewed studies 36,40,41,42 revealed the disparity and inappropriate distribution of eye care professionals in most African countries.This situation worsens because of insufficient skills among eye care personals.The recommended solution is for African Ministries of Health to review and adjust the eye care provider distribution system, considering both distance to services and population density.Additionally, annual training courses should be implemented to enhance the knowledge and skills of eye care professionals, with support and funding from Ministries of Health, the private sector and NGOs.

Infrastructure
Studies 36,40,41,47 have identified insufficient basic instruments for paediatric eye examinations and infrastructure as the primary obstacles to accessing childhood eye care services in African countries.The authors recommend that the government, private sector and donors collaborate to provide essential ophthalmic instruments and mobile clinic units.Additionally, the present study proposes that the government and other organisations supply low-cost or free optical and low-vision devices to support visually impaired children.

Policy changes
The present study found that eye care services are not part of primary health care in certain African countries, 36,40,41 and health insurance does not cover such services.Therefore, there is a need to re-evaluate the public health system, including the implementation of health insurance that covers eye care services and the integration of eye care into primary health care.Moreover, African nations should establish government policies concerning the availability of spectacles, contact lenses, affordable diagnostic eye drops and the inclusion of eye care in the health insurance system.

Partnerships
In numerous African countries, there is insufficient collaboration among eye health care providers (both public and private), stakeholders and policy makers regarding childhood eye care. 36,37,38,39,40,41,42,43,44,45,46,47,48,49To improve the sustainability and effectiveness of childhood eye care, it is crucial to establish multi-collaboration initiatives involving the Ministry of Health, Ministry of Education, public and private eye care providers, NGOs, faith organisations, community leaders and local institutions.

Discussion
According to global estimates, approximately 1.4 million children are blind, with three-quarters of them residing in African countries. 22Our reviewed studies 24,25,26,27,28,29,30,31,32,33,34,35 showed that the main causes of childhood VI were uncorrected RE, amblyopia, cataract and corneal opacities that can be avoided with timely diagnosis and an appropriate management strategy.These findings are consistent with the global report of the prevalence and causes of VI in children 8 as well as Indian and Nepalese findings. 50,51rthermore, our findings revealed that the leading obstacles to accessing childhood eye care services were lack of affordability, accessibility, availability and insufficient healthcare professionals. 52The reviewed studies 36,37,38,39,40,41,42,43,44,45,46,47,48,49 found additional factors influencing the utilisation of childhood eye services, including geographic obstacles, health views, parental perception, lack of knowledge, attitudes and inadequate paediatric practices.Environmental factors and socioeconomic status were also found to negatively impact the accessibility of eye care services in African nations.
In African states, accessing paediatric eye care is impeded by factors such as low quality of paediatric practice, limitations in the health insurance system and inadequate distribution of healthcare professionals. 36,37,38,39,40,41,42,43,44,45,46,47,48,49These barriers need to be addressed by reconfiguring the public health system and implementing comprehensive vision screening programmes in primary schools to detect and treat childhood eye diseases and uncorrected RE at early stages.
The accessibility for the eye care in urban areas is mostly developed in many African states.For example, health care services are mostly located in urban parts of Nigeria, leaving rural parts without access to services. 21Similarly in Sudan, most of the eye care services are situated in the central and northern parts of the country, leaving many regions in the south and west without health care services. 40Borrel et al. 19 highlighted that the unequal distribution of eye care professionals in Africa creates substantial obstacles to accessing eye services.For example, in Cameroon, 80% of eye care providers are concentrated in just 2 out of 10 provinces.Similarly, in Ethiopia, most eye care providers are in the capital city, whereas in Sudan, 70% of health facilities are centralised in the capital city Khartoum.A study conducted in Ethiopia revealed that the primary obstacles to accessing eye services were associated with the cost of services, aligning with the aforementioned factors. 53Findings from a survey conducted in South Africa indicated that 80.5% of patients received the suggested management; however, affordability issues prevented 36.4% of individuals from accessing the treatment. 54e main obstacle to providing child eye care in many African nations is the absence of eye care services.

Conclusion
The main causes of childhood VI in African states were uncorrected RE, amblyopia, cataract and corneal opacities that could be avoided with timely diagnosis and an appropriate management strategy.Whereas, the main obstacles to accessing eye care services were a lack of availability, accessibility and affordability, in addition to concerns with the primary care system, geographic obstacles, health beliefs, parental perception, lack of knowledge, attitudes and inadequate practices related to eye care.Therefore, the suggested childhood eye care plan for African nations should address several aspects of eye care system.This approach can be assessed and adapted according to the countries and the situation of childhood eye care system.Thus, the present study recommends that the strategy for childhood eye-care services should include models for delivery (Figure 2) and training (Figure 3).

FIGURE
FIGURE 2: Suggested model for paediatric eye care service delivery for African states.

FIGURE 3 :
FIGURE 3: Model for paediatric eye care training needs for African nations.

27 FIGURE 1: Identification
of studies used in the present study.

TABLE 1 :
The main causes of childhood vision impairment in Africa.Note: Please see the full reference list of the article, Alrasheed SH, Mohamed ZD, Alluwimi MS.Childhood visual impairment causes and barriers to accessing eye care: A suggested approach for Africa.Afr J Prm Health Care Fam Med.2024;16(1), a4556.https://doi.org/10.4102/phcfm.v16i1.4556,for more information.
RE, refractive error; NA, not available.

TABLE 2 :
Common Obstacles to accessing childhood eye care services in African states.

to accessing childhood eye care services in African countries
Note: Please see the full reference list of the article, Alrasheed SH, Mohamed ZD, Alluwimi MS.Childhood visual impairment causes and barriers to accessing eye care: A suggested approach for Africa.Afr J Prm Health Care Fam Med.2024;16(1), a4556.https://doi.org/10.4102/phcfm.v16i1.4556,for more information.RE, refractive error; VI, vision impairment.
19 overcome this obstacle, it is essential for the government and donors to support the basic eye care services, as they play a crucial role in eliminating these barriers.Providing assistance to low-income families in accessing good quality of eye care services in public hospitals would enable the early diagnosis and management of childhood eye diseases.In most African nations, where most of the populace lives below the poverty line, parents cannot afford eye services for their children.The Ministry of Health in African countries and donors should allocate financial support for training paediatric eye care professionals and school-teaching staff.This training would enable the detection of eye problems through annual vision examinations in schools, leading to timely referrals for visually impaired children.Initially, teachers should conduct school vision screenings with one teacher per class.Children with vision equal to or less than 6/12 should be referred to the primary health centres for comprehensive eye examinations, while RE services should be provided at the community level.Children with low vision, strabismus and other eye conditions should be referred to local hospitals with paediatric eye care specialists.Those with complex eye diseases should be referred to paediatric ophthalmologists at district hospitals.In most African countries, the existing health infrastructure is inadequate, and there is a significant absence of childhood eye services and skilled eye care providers.These challenges require immediate attention and solutions from both the government and NGOs focussed on avoidable childhood VI.Borrel et al.19highlighted that eye health care for children in numerous African states is a significant concern but not given importance on the public health programme. http://www.phcfm.orgOpenAccess

2 :
Suggested model for paediatric eye care service delivery for African states.