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• / The Power of Ophthalmology in Community Health

The Power of Ophthalmology in Community Health

• Mark Complete

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An underinsured medical assistant in Alabama with visual defects and elevated IOP; a father with diabetic reti­nopathy who migrated from another country and is living in rural Oregon; a middle-aged veteran with advanced, traumatic glaucoma. These indi­viduals have something in common: their eyesight was saved through community-based ophthalmology programs offered at health centers deep in rural areas or urban neighborhoods—locations that often have few health resources and limited or no capa­bility to provide care for complex conditions.

Disparities in vision care. These aren’t isolated cases, and access to vision care will become even more critical in the years and decades to come. The number of people over the age of 40 in the United States who are affected by visual impair­ment and blindness is projected to double by 2050—to approximately 6.95 million. 1 Nearly half of people with vision-threatening conditions are undiagnosed and untreated, and limited access to vision care is a cause. 2

A multitude of factors contribute to disparities in ocular health, including race and ethnicity, age, income, insurance coverage, and geographic region. Numerous studies have shown a disproportionate­ly high occurrence of diabetic retinopathy, glaucoma, cataract, and other eye conditions in Black, Hispanic, and Indigenous Americans, who also experience lower rates of eye disease screenings and eye examinations. Eye exams are not a standard part of primary care, and in areas with few eye care providers, people often delay getting routine eye exams or treatment until they develop problems, said Maria Woodward, MD, MS, at the University of Michigan, Ann Arbor.

Federally Qualified Health Centers

Improving access to comprehensive eye care is a mission of the Academy’s Task Force on Ophthalmology and Community Health Centers, formed in December 2022. This group is working to develop best practice guidelines and to identify locales and ophthalmologists to help expand eye care through Federally Qualified Health Centers (FQHCs). One in 11 Americans receives health care at FQHCs. They include people who are uninsured, individuals enrolled in Medicaid, people who live in rural areas that have few health care providers, and people who may experience homelessness. FQHCs are primary care–based community clinics that serve populations with few resources. 3 “FQHCs are poised to function as health system safety nets because they are federally funded, form a vast network across the country [there are 1,400], and have substantial medical infrastructure, plus connections to social services,” said Paula Anne Newman-Casey, MD, MS, at the Kellogg Eye Center at the University of Michigan, Ann Arbor.

Unlike free clinics and some other types of health centers, FQHCs can bill and be reimbursed for ophthalmology services. Patients without insur­ance pay on a sliding scale based on their income. Currently, only 25% of FQHCs provide access to eye health resources, said Dr. Woodward. These centers represent an opportunity to bring compre­hensive ophthalmology to primary care settings. “By partnering with more of them, we can scale up and sustain eye care in medically underserved communities,” said Dr. Newman-Casey.

Four initiatives, one of which is spearheaded by Dr. Newman-Casey, are on the leading edge of this effort to partner with FQHCs—and they spotlight how Academy members are volunteering in their communities to help close gaps in ocular health.

Technology-Based Eye Care Services (TECS) for Rural Veterans in Georgia

Comprehensive telehealth care. A successful and scalable model of community eye care was conceptualized and designed in 2015 by April Maa, MD, at the Emory Eye Center in Atlanta in partner­ship with the U.S. Department of Veterans Affairs (VA). Using a telehealth approach, TECS offers comprehensive eye screening, glasses, and disease follow-ups for veterans living in rural regions. The development of noninvasive, reliable ocular imag­ing devices—that can be used by specially trained ophthalmic testing staff—and the capacity to elec­tronically transmit results to an ophthalmologist based hours away have enabled the use of tele­medicine in the detection of many eye conditions. 4

How it works. A certified ophthalmic technician is stationed at a VA primary care clinic, working out of a 120-square-foot room outfitted with an autorefractor, lensometer, tonometer, fundus camera, handheld pachymeter, phoropter, vision chart, trial lenses, and trial frames. Following a detailed protocol to collect information about each patient’s eyes, the tech uploads data to an electronic health record, which is reviewed by a remote eye specialist, said Dr. Maa. The patient is assessed, and a care plan is developed, including a prescription for free eyeglasses as needed.

“If you’re a rural clinic and can’t hire an oph­thalmologist, you can still keep the patient within the system and give them access to the care they need,” she said.

Growing the model. TECS implementation across the VA enterprise is largely funded by the VA Office of Rural Health. Technology-based eye services started with three sites around Atlanta and have scaled to more than 60 loca­tions around the country. Building on a proven model—TECS has served more than 70,000 patients since its inception—Dr. Maa is now piloting virtual subspecialist care for patients, including teleglaucoma and telemacula follow-ups. “This allows subspecialty care to be spread out across the entire country to veterans who might not otherwise have access,” she said, noting that the percentage of veterans who have never been seen by an eye care provider in the VA has dropped from 8% to 5% because of the TECS program.

She attributes the success of the program to meticulous project manage­ment and to the use of a step-by-step “cookbook” followed by each site, a stan­dard protocol that can be implemented at each location. “You want the services to be like McDonalds; you walk in and know exactly what to expect,” said Dr. Maa. One remaining problem is getting patients to follow-up, she said. TECS is investigating, in a research setting, whether using artificial intelligence (AI) could help kick-start follow-up before the patient leaves the clinic.

AI Screening for Diabetic Retinopathy in Philadelphia

In another innovative use of technology, Philadel­phia-based Temple Health aims to improve the odds of getting patients in areas that are medically underserved to go for follow-up care by using AI to screen and diagnose diabetic retinopathy (DR). Jeffrey Henderer, MD, at Temple University in Philadelphia, started a program in 2016 that has partnered with nine primary care clinics (one is an FQHC and five others are converting to this model) where Temple Health–affiliated physicians are stationed.

“We wanted to create a screening system with a rapid DR result at the point of care, as well as reads for other diseases behind the scenes,” he said.

How it works. Temple has a full-time ophthal­mology department employee who installs fundus cameras and Eyenuk’s EyeArt AI software in each of the clinics and trains medical assistants (MAs) to take photos of patients’ eyes. The images are securely uploaded to the cloud, and within minutes the MA receives a diabetic eye disease result. The photos are reviewed asynchronously by a team of Temple optometrists, who look for other eye conditions. Findings are communicated back to the primary care provider through Temple’s electronic medical record, Epic. Then a screening coordinator schedules eye exams with ophthal­mologists for patients with positive reads.

Staffing deficits. Getting images taken of patients’ eyes has been more difficult than Dr. Henderer anticipated. “We have staffing shortages, and MAs are precious commodities. Frequently, they can’t be pulled away to take photos,” he said.

He is considering the use of designated pho­tography days or a Temple Health–hired photog­rapher. The program was launched in 2016 in just one location and has now screened about 4,500 patients.

Engage medical students. Dr. Henderer also brings medical students to the city’s Health Center #5—the clinic nearest the main campus—once a month to provide free eye exams and glasses. This program was started in 2011 in partnership with the Lewis Katz School of Medicine and uses a donated slit lamp, phoropter, lensometer, and other equipment—“all on wheels so it can easily be stored away when not in use.” Dr. Henderer holds the endowed Dr. Edward Hagop Bedrossian Chair of Ophthalmology, which funds his time at the health center. The program screens about 15 patients each day and exposes medical students to the field of ophthalmology. “The medical students are first and second years who don’t get much exposure to ophthalmology or direct patient care until later in school,” said Dr. Henderer. “This gives them an opportunity to take care of patients and learn about a specialty they may otherwise get no exposure to.”

The screening and eye exam programs work well in an urban area where transportation is accessible and insurance is not a barrier to sub­specialist follow-up, he said. (Temple Health takes almost all forms of health care, including Medic­aid.)

Casey Mobile Eye Clinic Brings Care to Patients in Rural Oregon

When there are larger geographical disparities between patients and ophthalmology care, some providers rely on mobile health care. Sending its ophthalmology office on wheels to more than 70 locations across rural and metropolitan Oregon, the Casey Community Outreach Program bridges physical divides, said Aiyin Chen, MD, at Oregon Health & Science University in Portland. Oph­thalmologists travel to community health centers (many of which are FQHCs) in the 33-foot mobile health unit equipped with two full ophthalmology exam lanes. They offer free, on-site screenings at these localized points of primary care and work with community partners to assist in follow-up care, said Dr. Chen.

A turn toward telemedicine. The Oregon program was established in 2010 and is funded by lo­cal donors. When it celebrated its 10-year anniver­sary in 2020, the Casey Mobile Eye Clinic boasted more than 10,000 adults screened and nearly 6,000 prescriptions for glasses during its decade serving patients. “But when the COVID-19 pandemic hap­pened, health care protocols significantly reduced our capacity. We brainstormed how to make our services more sustainable,” said Dr. Chen.

Now, the group is piloting a telemedicine pro­gram in two brick-and-mortar sites. “We empower local community health professionals to do these tests without us,” said Dr. Chen. “They collect pic­tures using a combined OCT and fundus camera and send them through Epic to our reading center for evaluation.” The goal is to scale the telemedi­cine model to eight sites and screen 2,400 partici­pants per year, she said.

Problem solved: digital records. One of the greatest challenges has been the setup of shared infrastructure for secure records transfer. “It took months of back-and-forth coordination between the office of digital health, medical informatics, network security, external vendors, risk manage­ment, legal, and imaging experts,” said Dr. Chen.

“The infrastructure was built to be adaptable and can integrate many different EHR systems ensuring successful partnership with rural com­munities across Oregon.” The model of a mobile clinic working hand-in-hand with local providers “helps patients overcome common barriers to follow-up care because we can either refer patients to local doctors or offer the van as a safety net,” she said.

Glasses First!

Providing low-cost glasses is an essential ingredient of any commu­nity-based vision care program, for several reasons.

• “The leading cause of vision impairment is lack of glasses, and getting a pair for a patient can be life changing,” said Dr. Henderer, who works with the Lions Club at Tem­ple University Health Center #5 to provide free glasses to patients who can’t afford them.
• “We entice people by providing low-cost glasses and then simultane­ously screen for eye disease,” said Dr. Newman-Casey, who helps patients navigate the Zenni optical website where they can purchase $12 single-vision glasses.
• “Patients are more likely to come back and see an eye doctor for follow-up after receiv­ing glasses because they trust you and know you are trying to do the best for them,” said Dr. Henderer. Likewise, Dr. Chen gives patients vouchers for glasses in part as an incentive for scheduling a follow-up appointment.
• Beyond the carrot effect, “It’s medically important for us to provide glasses for patients so we know their best-corrected vision,” said Dr. Maa. “That also helps us identify cataracts,” she added.

Screening and Intervention for Glaucoma and Eye Health Through Telemedicine (SIGHT)

Three sister programs funded by the CDC in partnership with the University of Michigan (UM), Columbia Univer­sity, and the University of Alabama at Birmingham (UAB) are evaluating strategies to surmount the challenges of patient follow-up. Each program uses a telemedicine-based detection and management strategy for glaucoma and other eye diseases.

Success with disease detection. In Alabama and Michigan, patients are seen at free clinics and FQHCs. As of January 2023, the programs have screened a total of 3,822 patients, re­ferred 1,692 for follow-up eye care, and found 853 cases of suspected/diagnosed glaucoma. “So far, the programs have detected eye disease at astronomically higher rates than in the general population,” said Dr. Newman-Casey. “We’ve seen uncorrected refractive error four times higher than the national average, found glaucoma at three times higher than the national average, and DR at two times the national average. This is what happens when people don’t have access to care,” said Dr. Newman-Casey.

How it works. In Alabama, full-time ophthalmic research coordinators work with health centers to funnel high-risk patients into the screenings one or two days per week at three sites, said Lindsay A. Rhodes, MD, MSPH, principal investigator of the SIGHT study at UAB. Patients receive an hour-long screening exam that may include spectral-domain OCT imaging, fundus photography, and perimetry, and all of this equipment is purchased with CDC funding, said Dr. Rhodes. “We are studying different visual field devices—including traditional standard automated perimetry, a virtu­al reality headset, and a tablet-based perimeter—to compare the portability, cost, and effectiveness in a community-based setting,” she said.

Follow-up strategy 1. Of course, participants with vision issues get referrals for follow-up care. Dr. Rhodes and her team are testing whether a pa­tient education program alone or coupled with a financial incentive—$50 paid upon completion of each referral visit—will improve patient adherence to follow-up. “Similar studies for the flu vaccine and mammography have shown that financial incentives can positively affect behavior,” she said.

Follow-up strategy 2. In Michigan, ophthal­mic technicians are testing patients using similar screening protocols and also embedding a trial to see whether personalized glaucoma coaching will increase adherence to follow-up care. “We’re giving the control group a standard handout and the intervention group interactive, motivational interviewing–based coaching,” said Dr. Newman-Casey, SIGHT principal investigator at UM. “We’ll compare the proportion of each group who attends their follow-ups.” Overcoming high no-show rates is a significant hurdle, she said. “But we are learning to change our mindset from blame to understand­ing. We see how hard it is for people to make the time, which requires so many things that are often taken for granted by those with higher socioeco­nomic status: did a person have a chance to wash their clothes, get enough food, find childcare, get permission to take time off work? We need to think about adherence from the perspective of income inequality and how that impacts people’s autonomy in taking care of their health.”

Why I Love Working in Community Health

Wondering what the “why?” is for Academy members who volunteer in their communities? Here’s what these dedicated doctors have to say.

Dr. Woodward: “At this moment in time, people are understanding more than ever how inequitable health care is across America. Academy members can make an impact by helping more patients prevent need- less blindness.”

Dr. Rhodes: “I feel like my impact as a physician is multiplied by reaching populations with numer- ous barriers to care. It is deeply rewarding to provide eye care beyond my clinic walls in a way that addresses inequities in our current health care structure.”

Dr. Newman-Casey: “The inequity is too great to sit and be quiet. People are so grateful to receive the kind of service they think others are getting at University of Michigan, but in a place that’s easy for them to come to.”

Dr. Maa: “It’s a huge burden on both the patient and the commu- nity when an individual loses their vision. It’s rewarding to know that not only can I help prevent a patient from losing their sight, but also I can have a positive impact on the system.”

Dr. Henderer: “I enjoy the smile on a patient’s face when you’ve told them they are doing a great job caring for themself and you can see evidence of the work they’re putting in by the fact that they don’t have diabetic eye disease. The most important thing we can do is to teach patients how to care for themselves at a whole-body level, not just an eyeball level.”

Dr. Chen: “Being an MD these days involves a lot of nonglamorous work, but helping a patient prevent blindness and seeing how grateful they are to hold on to their vision reminds me of why I became a doctor.”

How You Can Get Involved

There are plenty of opportunities to play a role in increasing access to ophthalmology services nationally and locally.

Advocacy and policy needs. Ophthalmologists need to advocate for better policies and payment around telemedicine, said Dr. Maa. Licensure restrictions and reimbursement disparities remain barriers to more widespread implementation of teleophthalmology, she said. The American Tele­medicine Association (ATA) is currently lobbying for changes in policy that allow doctors to treat patients across state and federal lines. “There are some telehealth medical licensure compacts avail­able now, where a physician can obtain a telemed­icine licensure that applies to an entire group of states that have banded together.” Ophthalmology care should be included in these compacts and also be a part of the lobbying efforts, she said.

There’s also the problem of payment. “If I gather information from a patient at one time but call the patient at a later time, I can’t easily bill for asynchronous care,” said Dr. Maa. “During COVID we had payment parity for telemedicine because it was considered a health emergency, but now that’s become harder,” she added. She urges Academy members to consider joining the ATA or encouraging Congress to make the public health emergency rules for telehealth payment parity permanent.

Tips to get started. Beyond championing laws and policies that will facilitate telehealth, ophthal­mologists can get involved in their communities.

Conduct a search. Dr. Rhodes recommended researching locations within your community where patients may be falling through the cracks and forming partnerships with local organizations that are already reaching those individuals. “Con­sider your budget, setting, and target population. For example, the area you want to reach may not have broadband access, and that would be prohib­itive to telehealth so you may have to be creative,” she added.

Partner with a medical school. “If you have a relationship with a medical school, they could be a phenomenal partner,” said Dr. Henderer. When designing a program, he said, “I think of it as a three-legged stool: 1) identifying the patients who need screening and getting them to the cam­era; 2) the who, what, and how of taking, trans­mitting, and interpreting the photos and 3) getting the patient to follow-up care. Each leg has to be the same length or the stool falls over.”

Assess the partner’s needs. If you already have your sights on an FQHC, it can be helpful to assess their needs first. “Our FQHC serves a community where glaucoma is prevalent and asked us to help step up their game, so we had to expand our screening services from just DR to a more com­prehensive approach where we are looking for other diseases,” said Dr. Henderer.

Contact the Academy. To learn more about the Academy’s efforts to expand access to eye care, contact the Academy’s director of public health advocacy, Scott Haber, in the Washington, DC, office at 202-737-6662.

Volunteer for EyeCare America. Another way to help increase access to vision care is by volunteer­ing for existing service opportunities with organi­zations like EyeCare America ( aao.org/volunteer ), said Dr. Newman-Casey.

The Academy’s EyeCare America program helps seniors who have not had a medical eye exam in three or more years and those at increased risk for glaucoma access eye care. The time commitment is minimal, and volunteers can serve remotely.

___________________________

For diversity, equity, and inclusion–related news and resources, including EyeNet articles and Ophthalmology journal’s special DEI supplement, visit aao.org/diversity-equity-and-inclusion .

1 Elam AR et al. Ophthalmology . 2022;129(10):e89-e113.

2 Tan O et al. Exp Biol Med . 2021;246:2214-2221.

3 www.nachc.org/research-and-data/americas-health-centers-2022-snapshot/ . Accessed June 5, 2023.

4 Rhodes L et. al. J Glaucoma. 2021;30(5):371-379.

Meet the Experts

Aiyin Chen, MD Associate professor of ophthal­mology, Oregon Health & Science University, Portland. Relevant financial disclosures: None.

Jeffrey Henderer, MD Dr. Edward Hagop Bed­rossian Chair and professor of ophthalmolo­gy, Lewis Katz School of Medicine at Temple University in Philadelphia. Relevant financial disclosures: None.

April Maa, MD Associate professor of ophthal­mology at the Emory University School of Med­icine in Atlanta; Tele-Specialty Care Director and TECS Subsection Lead, Veterans Integrated Service Network 7 Clinical Resource Hub, in Atlanta. Relevant financial disclosures: None.

Paula Anne Newman-Casey, MD, MS Associate professor of ophthalmology and visual scienc­es, associate chair for research, University of Michigan Kellogg Eye Center, Ann Arbor. Rele­vant financial disclosures: None.

Lindsay A. Rhodes, MD, MSPH Associate profes­sor of ophthalmology and visual sciences, Heer­sink School of Medicine, University of Alabama at Birmingham. Relevant financial disclosures: None.

Maria Woodward, MD, MS Associate professor of ophthalmology and visual sciences, section leader, cornea, cataract, and refractive surgery at the Kellogg Eye Center, University of Michi­gan, Ann Arbor. Relevant financial disclosures: None .

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Using research findings in my everyday practice: what is good evidence, where do I look, and how can I use it?

Victor h hu, assistant clinical professor: international centre for eye health (iceh) lshtm, and consultant ophthalmologist, mid cheshire nhs hospitals, uk., jagadesh c reddy, founder and managing director: pristine eye hospitals hyderabad, india., dhivya rauniyar, senior optometrist: pristine eye hospitals hyderabad, india., elmien wolvaardt, editor-in-chief: community eye health journal , iceh, lshtm, london, uk., related content, the findings from research studies and best practice guidelines should form the foundation of eye care delivery..

As a health care practitioner, you are not best serving your patients if you make decisions based only on your experience and what you learnt during training – especially if you trained some time ago! Although both these sources of learning are valuable, they are not enough. Modern health practitioners are expected to stay up to date with the latest knowledge relevant to their field and to practice evidence-based medicine.

Evidence-based medicine is about using the best available evidence, combined with your own clinical expertise, to make decisions about a patient’s health care that respect their values and expectations. But what is the best available evidence, and how can you find it?

If you consider that thousands of research articles are published in eye care journals every year, and that many of them charge high fees for access, it’s no surprise that staying up to date with all the latest research in your field is a challenge for most people.

Instead, you may find yourself looking for evidence to answer a specific question. For example, say that you’ve heard about the potential of collagen crosslinking to prevent the progression of keratoconus, and you want to know whether to start using it. What is the evidence that it works, and that it is safe?

Levels of evidence

Before you start looking for evidence, it is helpful to remind yourself of the different levels of evidence (see panel). Strong sources of evidence, such as systematic reviews, allow you to be more confident in the decisions you make; however, when such evidence is not available, it is useful to know what other types of evidence to look for.

Finding relevant research

PubMed ( www.pubmed.gov ) is a large, open access (i.e., free of charge), online database which contains many of the medical research studies which are conducted around the world. Because it is free, and comprehensive, it is a useful starting point when looking for studies on a particular topic.

Another good reason for using PubMed, is that the website makes it easy to filter search results in several useful ways.

For example, try typing the keywords “corneal crosslinking keratoconus” into the search box on the PubMed home page. This produces over 1,800 results. It would be very difficult for an individual clinician to go through all of these before deciding whether to start performing crosslinking.

Did you notice the panel highlighted on the left of the search results in Figure 1? These are options for limiting or ‘filtering’ the results by year, by the availability of the text, article attributes, article type, and so on. Referring to the levels of evidence in the panel, and based on how much time we have available, we could decide to limit the PubMed search to randomised controlled trials, which provide a strong level of evidence. To do this, look further down the panel (see Figure 2) and tick the “Randomized Controlled Trial” box under “Article type.” This produces only 85 results. If we limit the results to meta-analysis (a statistical analysis of the results produced by several studies) by ticking that box instead, there are just 23 results for us to evaluate and draw conclusions from.

Looking at well conducted systematic reviews and/ or meta-analyses can save a lot of time compared to reading individual studies on a particular area. The Cochrane Library provides some of the highest quality and most trusted reviews available and it is always worthwhile to see if they have done a review on a particular topic: visit www.cochranelibrary.com .

Good practice guidelines

Despite having access to new online tools such as PubMed, it can still be a challenge to answer all the different questions you face every day by searching for research publications. A practical alternative for busy eye care workers is to use trustworthy, best-evidence clinical practice guidelines. 1 These are drawn up by teams of people with research experience and knowledge of the area being addressed, who have looked through all the research evidence themselves in a systematic manner. They weigh up all the evidence and come to a balanced judgement on the outcome and what it means for clinical practice. Examples of such guidelines include guidelines from the National Institute of Health and Care Excellence (NICE) in the UK, 2 the Preferred Practice Patterns from the American Academy of Ophthalmology, 3 and many others, including disease-specific international societies. It is also important to look at national guidelines which have been drawn up in a particular country. You may even decide to help draw up suitable guidelines for your country or region; these would consider the needs of the local population, the skills of local health workers, and the availability of personnel, equipment, and medicines. The AGREE reporting checklist offers guidance that can help clinicians to evaluate whether a guideline is of high quality or not. It is equally valuable when drawing up clinical guidance. 4

Incorporating evidence into everyday practice

The findings from research studies and best practice guidelines should form the foundation of eye care delivery. Alongside this, clinical experience and expertise also form very important aspects of good eye care. Experienced and able clinicians will use evidence in their work but will understand the situation of a particular patient (their medical and social history, risks for that patient, likely adherence to treatment, and so on), what is feasible/realistic in a particular health care context, and where there are gaps in the evidence. Another very important factor to consider is what patients themselves prefer once they have had the different options clearly and coherently explained to them. Practicing medicine is an art as well as a science, and it is important to personalise the management approach for each patient.

The evidence in this list is arranged from strongest to weakest. Note that each level can be of high or low quality and have a high or low risk of bias or confounding.

• Systematic review of randomised controlled trials . Systematic reviews look at all the studies that have been done on a specific health problem, selecting and assessing them using rigorous, standardised methods. It may include a meta-analysis, which is a statistical analysis of the quantitative results of the studies included in the systematic review. Meta-analyses can provide a more precise estimate of an effect than is possible by looking at individual studies.
• Randomised controlled trial (RCT) . Participants in the study are randomly allocated into groups, usually to receive or not receive an experimental treatment or intervention. The random allocation helps to ensure a fair comparison (see article 5: Good Research)
• Systematic review of cohort or case-control studies .
• Cohort study . This usually involves many study participants who are observed over a long period (commonly years). The onset of a particular disease (e.g., cancer) can then be compared between people with different levels of exposure (e.g., number of cigarettes smoked).
• Case-control study . People who have a disease (cases, e.g., those with cancer) are compared to a similar group of people (e.g., same age, sex, and socioeconomic level) who don’t have the disease (controls). Researchers then work out the level of exposure in the past (e.g., number of cigarettes smoked) and compare them between the two groups.
• Case series or case reports . A single report, or a series of reports, involving patients with a particular disease and who may have been given a similar treatment.
• Expert opinion . This is used where research studies haven’t been done on a particular area and people who have experience or expertise on a particular area say what their opinion is.

1 Tikkinen KAO, Guyatt GH. Understanding of research results, evidence summaries and their applicability-not critical appraisal-are core skills of medical curriculum. BMJ Evid Based Med. 2021; 26(5):231-3.

2 National Institute for Health and Care Excellence. NICE guidance. https://www.nice.org.uk/guidance .

3 American Academy of Ophthalmologists. Preferred Practice Patterns. https:// www.aao.org/about-preferred-practice-patterns .

4 AGREE reporting checklist. https://www.agreetrust.org/resource-centre/agree-reporting-checklist/

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community eye health journal

Delivering knowledge

The Community Eye Health Journal (CEHJ) is an essential resource for eyecare workers in lower and middle-income countries.

The journal provides peer-reviewed articles on a broad range of topics in ophthalmology, optometry, nursing and service delivery for free to eye health workers worldwide.

Nearly 60,000 copies are distributed each year, with many more articles viewed online. By providing information related to eye care that is not available elsewhere, the CEHJ makes sure that doctors, nurses and clinic staff are all up to date with the latest guidance on diagnosis, treatment, technology and safety in low-resource settings.

Reader feedback shows that the journal is of immense use to people’s daily clinical practice, careers and communities.

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• Review Article
• Published: 02 April 2024

Priorities in school eye health in low and middle-income countries a scoping review

• Alex-Anne Harvey   ORCID: orcid.org/0009-0003-8270-0771 1 ,
• Priya Morjaria   ORCID: orcid.org/0000-0003-1648-1948 2 , 3 &
• Benoit Tousignant   ORCID: orcid.org/0000-0002-0395-5027 1 , 4  

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• Public health

School eye health (SEH) has been on the global agenda for many years, and there is mounting evidence available to support that school-based visual screenings are one of the most effective and cost-efficient interventions to reach children over five years old. A scoping review was conducted in MEDLINE, Web of Science, PubMed, and CINHAL between February and June 2023 to identify current priorities in recent literature on school eye health in low- and middle-income countries (LMICs). Selection of relevant publications was performed with Covidence, and the main findings were classified according to the WHO Health Promoting Schools framework (HPS). A total of 95 articles were included: cross-sectional studies ( n  = 55), randomised controlled trials ( n  = 7), qualitative research ( n  = 7) and others. Results demonstrate that multi-level action is required to implement sustainable and integrated school eye health programmes in low and middle-income countries. The main priorities identified in this review are: standardised and rigorous protocols; cost-effective workforce; provision of suitable spectacles; compliance to spectacle wear; efficient health promotion interventions; parents and community engagement; integration of programmes in school health; inter-sectoral, government-owned programmes with long-term financing schemes. Even though many challenges remain, the continuous production of quality data such as the ones presented in this review will help governments and other stakeholders to build evidence-based, comprehensive, integrated, and context-adapted programmes and deliver quality eye care services to children all over the world.

学校眼健康 (SEH) 已列入全球议程多年, 越来越多的证据支持, 在学校中进行的的视力筛查是五岁以上儿童最有效和最具成本效益的干预措施之一。从2023年2月至6月, 我们在MEDLINE, Web of Science, PubMed和CINHAL上进行了搜素, 确定中低收入国家 (LMICs) 学校眼健康的最新文献中的推荐的优先事件。使用Covidence进行相关文献检索, 并根据世界卫生组织促进健康学校框架 (HPS) 进行分类。总共纳入95篇文章: 横断面研究 (n = 55) 、随机对照试验 (n = 7) 、定性研究 (n = 7) 和其他。研究结果表明, 需要采取多层次的行动, 在中低收入国家实施可持续和综合的学校眼健康方案。本分析中确定的主要优先事件包括: 标准化和严格的程序；性价比高的劳动力；提供合适的眼镜；配镜依从性；有效的健康促进干预；家长和社区的参与；整合学校医疗保健；由政府主导的具有长期融资计划的跨部门项目。尽管仍有许多挑战, 但持续产生高质量的数据, 如本次调查中提供的数据, 将有助于政府和其他利益攸关方建立循证、全面、综合和适应环境的方案, 并为世界各地的儿童提供高质量的眼部护理服务。

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Burton MJ, Ramke J, Marques AP, Bourne RRA, Congdon N, Jones I, et al. The Lancet Global Health Commission on Global Eye Health: vision beyond 2020. Lancet Glob Health. 2021;9:e489–e551.

Article   CAS   PubMed   PubMed Central   Google Scholar  

International Agency for Prevention of Blindness. 2023. Available from: https://www.iapb.org . Accessed 7 May 2023.

Atowa UC, Wajuihian SO, Hansraj R. A review of paediatric vision screening protocols and guidelines. Int J Ophthalmol. 2019;12:1194–201.

Article   PubMed   PubMed Central   Google Scholar  

Chen AH, Abu Bakar NF, Arthur P. Comparison of the pediatric vision screening program in 18 countries across five continents. J Curr Ophthalmol. 2019;31:357–65.

Gilbert C, Minto H, Morjaria P, Khan I. Standard school eye health guidelines for low and middle-income countries. Internation Agency for Prevention of Blindness; 2018. Available: https://www.iapb.org/wp-content/uploads/Guidelines-School-Eye-Health-Programmes-English-Final.pdf .

JBI. JBI manual for evidence synthesis. 2022. Available from: https://jbi-global-wiki.refined.site/space/MANUAL/4687770/11.3+The+scoping+review+and+summary+of+the+evidence .

Tricco AC, Lillie E, Zarin W, O’Brien KK, Colquhoun H, Levac D, et al. PRISMA extension for scoping reviews (PRISMA-ScR): checklist and explanation. Ann Intern Med. 2018;169:467.

Article   PubMed   Google Scholar  

The World Bank. World Bank Country and Lending Groups. 2023. Available from: https://datahelpdesk.worldbank.org/knowledgebase/articles/906519-world-bank-country-and-lending-groups . Accessed 22 Feb 2023.

World Health Organization. Making every school a health-promoting school. Geneva; WHO; 2021.

World Health Organization. Report on vision. Geneva: WHO; 2019.

Panda L, Nayak S, Das T. Tribal Odisha Eye Disease Study Report # 6. Opportunistic screening of vitamin A deficiency through School Sight Program in tribal Odisha (India). Indian J Ophthalmol. 2020;68:351–5.

Atowa UC, Wajuihian SO, Hansraj R. Towards the development of a uniform screening guideline: current status of paediatric vision screening in Abia State, Nigeria. Afr Vis Eye Health J. 2022;81:a661.

Google Scholar  

Chottopadhyay T, Kaur H, Shinde AJ, Gogate PM. Why are we not doing retinoscopy in the school eye screening? Is distant visual acuity a sensitive tool for making referrals? Saudi J Ophthalmol. 2021;35:320–4.

PubMed   PubMed Central   Google Scholar  

Aina AS, Oluleye TS, Olusanya BA. Comparison between focometer and autorefractor in the measurement of refractive error among students in underserved community of sub-Saharan Africa. Eye. 2016;30:1496–501.

Ilechie AA, Addo NA, Abraham CH, Owusu-Ansah A, Annan-Prah A. Accuracy of noncycloplegic refraction for detecting refractive errors in school-aged African children. Optom Vis Sci. 2021;98:920–8.

Khurana R, Tibrewal S, Ganesh S, Tarkar R, Nguyen PTT, Siddiqui Z, et al. Accuracy of noncycloplegic refraction performed at school screening camps. Indian J Ophthalmol. 2018;66:806–11.

Gopalakrishnan A, Hussaindeen JR, Sivaraman V, Swaminathan M, Wong YL, Armitage JA, et al. The Sankara Nethralaya Tamil Nadu Essilor Myopia (STEM) Study-defining a threshold for non-cycloplegic myopia prevalence in children. J Clin Med. 2021;10:1215.

Mathenge WC, Bello NR, Hess OM, Dangou J-M, Nkurikiye J, Levin AV. Use of the World Health Organization primary eye care protocol to investigate the ocular health status of school children in Rwanda. J AAPOS. 2023;27:16.e1–16.e6.

Rewri P, Nagar CK, Gupta V. Vision screening of younger school children by school teachers: a pilot study in Udaipur City, Western India. J Ophthalmic Vis Res. 2016;11:198–203.

Panda L, Das T, Nayak S, Barik U, Mohanta BC, Williams J, et al. Tribal Odisha Eye Disease Study (TOES # 2) Rayagada school screening program: efficacy of multistage screening of school teachers in detection of impaired vision and other ocular anomalies. Clin Ophthalmol. 2018;12:1181–7.

Sil A, Aggarwal P, Sil S, Mitra A, Jain E, Sheeladevi S, et al. Design and delivery of the Refractive Errors Among Children (REACH) school-based eye health programme in India. Clin Exp Optom. 2022;106:1–10.

Saravanan S, Krishnamurthy S, Ramani KK, Narayanan A. Cost analysis of a comprehensive school eye screening model from India. Ophthalmic Epidemiol. 2022;30:196–202.

Article   Google Scholar  

Chan VF, Yard E, Mashayo E, Mulewa D, Drake L, Price-Sanchez C, et al. Does an integrated school eye health delivery model perform better than a vertical model in a real-world setting? A non-randomised interventional comparative implementation study in Zanzibar. Br J Ophthalmol. 2022;0:1–7.

Narayanan A, Kumar S, Ramani KK. Spectacle compliance among adolescents in Southern India: Perspectives of service providers. Indian J Ophthalmol. 2018;66:945–9.

Ocansey S, Amuda R, Abraham CH, Abu EK. Refractive error correction among urban and rural school children using two self-adjustable spectacles. BMJ Open Ophthalmol. 2023;8:e001202.

Ilechie AA, Abokyi S, Boadi-Kusi S, Enimah E, Ngozi E. Self-adjustable spectacle wearing compliance and associated factors among rural school children in Ghana. Optom Vis Sci: Off Publ Am Acad Optom. 2019;96:397–406.

Reddy S, Panda L, Kumar A, Nayak S, Das T. Tribal Odisha Eye Disease Study # 4: accuracy and utility of photorefraction for refractive error correction in tribal Odisha (India) school screening. Indian J Ophthalmol. 2018;66:929–33.

Prabhu AV, Thomas J, Ve RS, Biswas S. Performance of Plusoptix A09 photo screener in refractive error screening in school children aged between 5 and 15 years in the southern part of India. J Curr Ophthalmol. 2020;32:268–73.

Murali K, Vidhya C, Murthy SR, Mallapa S. Cost-effectiveness of photoscreeners in screening at-risk amblyopia in Indian children. Indian J Public Health. 2022;66:171–5.

Vidhya C. Efficacy of school screening by photoscreeners and prevalence of amblyopia in primary school childfren in Karnataka. EC Ophtalmol. 2020;11:01–7.

Srivastava RM, Verma S, Gupta S, Kaur A, Awasthi S, Agrawal S. Reliability of smart phone photographs for school eye screening. Children. 2022;9:1519.

Rono HK, Bastawrous A, Macleod D, Wanjala E, Di Tanna GL, Weiss HA, et al. Smartphone-based screening for visual impairment in Kenyan school children: a cluster randomised controlled trial. Lancet Glob health. 2018;6:e924–e32.

Morjaria P, Bastawrous A, Murthy GVS, Evans J, Sagar MJ, Pallepogula DR, et al. Effectiveness of a novel mobile health (Peek) and education intervention on spectacle wear amongst children in India: results from a randomized superiority trial in India. EClinicalMedicine. 2020;28:100594.

Yashadhana A, Lee L, Serova N, Nthete E, Burnett AM. Access to school-based eye health programs in Central Region, Malawi: a qualitative case study. Health Promot Int. 2023;38:1–10.

Ceesay W, Braimah IZ, Abaidoo B. Perception of primary school teachers on pupils’ eye health in the Ga West Municipality, Greater Accra Region, Ghana. J West Afr Coll Surg. 2019;9:15–20.

Sukati VN, Mashige KP, Moodley VR. Knowledge and practices of teachers about child eye healthcare in the public sector in Swaziland. Afr Vis Eye Health J. 2022;80:a613.

Alemayehu AM, Belete GT, Adimassu NF. Knowledge, attitude and associated factors among primary school teachers regarding refractive error in school children in Gondar city, Northwest Ethiopia. PLoS ONE. 2018;13:e0191199.

Engels T, Trotignon G, Agyemang D, Khan I, Puthy K, Roolvink L, et al. Cost and budget impact analysis of a school-based vision screening programme in Cambodia and Ghana: implications for policy and programme scale-up. Health Policy Open. 2021;2:100043.

Paudel P, Kovai V, Naduvilath T, Phuong HT, Ho SM, Giap NV. Validity of teacher-based vision screening and factors associated with the accuracy of vision screening in Vietnamese children. Ophthalmic Epidemiol. 2016;23:63–8.

Muralidhar R, Vijayalakshmi P. Sensitivity and specificity of teachers for vision screening among primary school children in South India. Oman J Ophthalmol. 2019;12:88–93.

Shukla P, Vashist P, Singh SS, Gupta V, Gupta N, Wadhwani M, et al. Assessing the inclusion of primary school children in vision screening for refractive error program of India. Indian J Ophthalmol. 2018;66:935–9.

Tobi P, Ibrahim N, Bedell A, Khan I, Jolley E, Schmidt E. Assessing the prevalence of refractive errors and accuracy of vision screening by schoolteachers in Liberia. Int Health. 2022;14:i41–i8.

Kaur G, Koshy J, Thomas S, Kapoor H, Zachariah JG, Bedi S. Vision screening of school children by teachers as a community based strategy to address the challenges of childhood blindness. J Clin Diagn Res. 2016;10:NC09–14.

Marmamula S, Khanna RC, Mettla AL, Pehere NK, Keeffe JE, Yameneni DK, et al. Agreement and diagnostic accuracy of vision screening in children by teachers, community eye-health workers and vision technicians. Clin Exp Optom. 2018;101:553–9.

Bechange S, Gillani M, Jolley E, Iqbal R, Ahmed L, Bilal M, et al. School-based vision screening in Quetta, Pakistan: a qualitative study of experiences of teachers and eye care providers. BMC Public Health. 2021;21:364.

Sabherwal S, Reddy PA, Siddiqui Z, Sood I, Singh BP, Ganesh S, et al. Visual acuity screening in North Indian schools: testing accuracy and cost of alternate screening models. Ophthalmic Epidemiol. 2023;31:70–77.

Dole KS, Deshpande AS, Deshpande MD, Thakur RR. Comparative evaluation of qualitative performance of technical human resource in school eye health program. Indian J Ophthalmol. 2021;69:123–6.

Bhattarai D, Gnyawali S, Silwal A, Puri S, Shrestha A, Kunwar MB, et al. Student-led screening of school children for refractive error correction. Ophthalmic Epidemiol. 2018;25:133–9.

Olatunji LK, Abdulsalam LB, Lukman A, Abduljaleel A, Yusuf I. Academic implications of uncorrected refractive error: a study of Sokoto Metropolitan schoolchildren. Niger Med J. 2019;60:295–9.

Latif MZ, Hussain I, Afzal S, Naveed MA, Nizami R, Shakil M, et al. Impact of refractive errors on the academic performance of high school children of Lahore. Front Public Health. 2022;10:869294.

Pawar N, Ravindran M, Renagappa R, Ravilla T, Raman R, Uduman MS. Non-compliance for wearing spectacles: prevalence and determinants in school-going children in South India. Indian J Ophthalmol. 2023;71:608–13.

Gupta V, Saxena R, Vashist P, Bhardwaj A, Pandey RM, Tandon R, et al. Spectacle coverage among urban schoolchildren with refractive error provided subsidized spectacles in North India. Optom Vis Sci. 2019;96:301–8.

Anwar I, Waqar S, Altaf A. Spectacle wear among school going children in district Rawalpindi, Pakistan. Int J Ophthalmol Vis Sci. 2017;2:1–4.

Morjaria P, Evans J, Gilbert C. Predictors of spectacle wear and reasons for nonwear in students randomized to ready-made or custom-made spectacles: results of secondary objectives from a randomized noninferiority trial. JAMA Ophthalmol. 2019;137:408–14.

Gajiwala UR, Patel RU, Sudhan A, Sil A, Jain E, Jhala L, et al. Compliance of spectacle wear among school children. Indian J Ophthalmol. 2021;69:1376–80.

Morjaria P, Evans J, Murali K, Gilbert C. Spectacle wear among children in a school-based program for ready-made vs custom-made spectacles in India: a randomized clinical trial. JAMA Ophthalmol. 2017;135:527–33.

Thapa HB, Rai SK, Thapa SK, Khatri A, Bassett K. Eye-glasses wear compliance following school-based visual acuity screening in Nepal: a comparative study. Nepal J Ophthalmol. 2020;12:91–8.

Bhatt N, Rathi M, Dhull CS, Sachdeva S, Phogat J. Spectacle compliance amongst school children of Rohtak, Haryana, India. Int J Community Med Public Health. 2017;4:734–7.

Burnett A, Paudel P, Massie J, Kong N, Kunthea E, Thomas V, et al. Parents’ willingness to pay for children’s spectacles in Cambodia. BMJ Open Ophthalmol. 2021;6:e000654.

Bhandari G, Pradhan S, Shrestha M, Basset K. Eye glasses compliance among children undergoing school visual acuity screening in Nepal. Adv Ophtalmol Visual Syst. 2016;5:286–90.

Narayanan A, Kumar S, Ramani KK. Spectacle compliance among adolescents: a qualitative study from Southern India. Optom Vis Sci. 2017;94:582–7.

Kumaran SL, Periakaruppan SP. Ophthalmic anthropometry versus spectacle frame measurements: Is spectacle fit in children compromised? Asian J Pharm Res Health Care. 2022;14:48–54.

Aghaji AE, Udeh NN, Okoye OI, Oguego NC, Okoye O, Maduka-Okafor FC, et al. Spectacle design preferences among school children in Enugu State, Nigeria. Niger J Clin Pract. 2021;24:1828–34.

Article   CAS   PubMed   Google Scholar  

Minakaran N, Morjaria P, Frick KD, Gilbert C. Cost-minimisation analysis from a non-inferiority trial of ready-made versus custom-made spectacles for school children in India. Ophthalmic Epidemiol. 2021;28:383–91.

Asare FA, Morjaria P. Eligibility for the use of ready-made spectacles among children in a school-based programme in Ghana. PLoS Glob Public Health. 2022;2:e0000079.

Ebeigbe JA. Factors influencing eye-care seeking behaviour of parents for their children in Nigeria. Clin Exp Optom. 2018;101:560–4.

Lohfeld L, Graham C, Ebri AE, Congdon N, Chan VF. Parents’ reasons for nonadherence to referral to follow-up eye care for schoolchildren who failed school-based vision screening in Cross River State, Nigeria-a descriptive qualitative study. PLoS ONE. 2021;16:e0259309.

Sukati V, Moodley VR, Mashige KP. Knowledge and practices of eye health professionals about the availability and accessibility of child eye care services in the public sector in Swaziland. Afr Vis Eye Health J. 2019;78:a471.

Kumar M, Mallika O. Study of refractive errors, amblyopia and compliance of spectacles in school children. J Med Sci Clin Res. 2017;5:1–8.

Hashemi H. The met and unmet need for refractive correction and its determinants in 7-year-old children. Br J Vis Impair. 2017;35:69–80.

Ezinne NE, Mashige KP, Akano OF, Ilechie AA, Ekemiri KK. Spectacle utilisation rate and reasons for non-compliance with wearing of spectacles amongst primary school children in Onitsha, Anambra state, Nigeria. Afr Vis Eye Health J. 2020;79:a544.

Alrasheed SH, Naidoo KS, Clarke-Farr PC. Attitudes and perceptions of Sudanese high-school students and their parents towards spectacle wear. Afr Vis Eye Health J. 2018;77:a392.

Bodunde OT, Sholeye OO, Onabolu OO, Otulana TO, Ajibode HA. Perception of red eye among senior secondary students in Sagamu, Southwest Nigeria. J Fam Med Prim Care. 2016;5:89–93.

Negiloni K, Ramani KK, Sudhir RR. Do school classrooms meet the visual requirements of children and recommended vision standards? PLoS ONE. 2017;12:e0174983.

Amiebenomo OM-A, Isong EM, Edosa ME, Woodhouse JM. Habitual visual acuity and visual acuity threshold demands in Nigerian school classrooms. Sci Rep. 2022;12:17816.

Ichhpujani P, Singh RB, Foulsham W, Thakur S, Lamba AS. Visual implications of digital device usage in school children: a cross-sectional study. BMC Ophthalmol. 2019;19:76.

Saara K, Swetha S, Subhiksha R, Amirthaa M, Anuradha N. Steep increase in myopia among public school-going children in South India after COVID-19 home confinement. Indian J Ophthalmol. 2022;70:3040–4.

Chhabra S, Rathi M, Sachdeva S, Rustagi IM, Soni D, Dhania S. Association of near work and dim light with myopia among 1400 school children in a district in North India. Indian J Ophthalmol. 2022;70:3369–72.

Rao BV, Bandopadhyay S, Sharma VK, Mishra A, Ambiya V, Sharma N. Dry eye disease survey among schoolteachers and children using visual display terminals during COVID-19 lockdown-CODE study (Co vid and d ry e ye study). Med J Armed Forces India. 2022;e1-7.

Dahal HN, Kharel Sitaula R. Visual impact of digital classroom among students attending online education. J Nepal Health Res Counc. 2022;20:405–11.

PubMed   Google Scholar  

Gupta R, Chauhan L, Varshney A. Impact of E-schooling on digital eye strain in coronavirus disease era: a survey of 654 students. J Curr Ophthalmol. 2021;33:158–64.

Assefa NL, Tegegn MT, Wolde SY. Knowledge and attitude of refractive error among public high school students in Gondar City. Clin Optom. 2021;13:201–8.

Oguego N, Okoye OI, Okoye O, Uche N, Aghaji A, Maduka-Okafor F, et al. Eye health myths, misconceptions and facts: results of a cross-sectional survey among Nigerian school children. Fam Med Prim Care Rev. 2018;20:144–8.

Habiba U, Ormsby GM, Butt ZA, Afghani T, Asif M. Knowledge and practices of teachers associated with eye health of primary school children in Rawalpindi, Pakistan. Taiwan J Ophthalmol. 2017;7:28–33.

Paudel P, Yen PT, Kovai V, Naduvilath T, Ho SM, Giap NV, et al. Effect of school eye health promotion on children’s eye health literacy in Vietnam. Health Promot Int. 2019;34:113–22.

Ayorinde OO, Murthy GVS, Akinyemi OO. Is the child-to-child approach useful in improving uptake of eye care services in difficult-to-reach rural communities? Experience from southwest Nigeria. Ann Ib Postgrad Med. 2016;14:65–73.

CAS   PubMed   PubMed Central   Google Scholar  

Chan VF, Minto H, Mashayo E, Naidoo K. Improving eye health using a child-to-child approach in Bariadi, Tanzania. Afr Vis Eye Health J. 2017;76:a406.

Narayanan A, Ramani KK. Effectiveness of interventions in improving compliance to spectacle wear and referral in school vision screening. Clin Exp Optom. 2018;101:752–7.

Sukati VN, Moodley VR, Mashige KP. Knowledge and practices of parents about child eye health care in the public sector in Swaziland. Afr J Prim Health Care Fam Med. 2018;10:e1–e13.

Arafa AEE, Ewis AA, Mahran WM, Mohamed AA, El-Shabrawy EM. Prevalence and risk factors of refractive errors among preparatory school students in Beni-Suef, Egypt. J Public Health. 2019;27:43–7.

Assem AS, Tegegne MM, Fekadu SA. Prevalence and associated factors of myopia among school children in Bahir Dar city, Northwest Ethiopia, 2019. PLoS ONE. 2021;16:e0248936.

Atowa UC, Wajuihian SO, Munsamy AJ. Associations between near work, outdoor activity, parental myopia and myopia among school children in Aba, Nigeria. Int J Ophthalmol. 2020;13:309–16.

Bezabih L, Abebe TW, Fite RO. Prevalence and factors associated with childhood visual impairment in Ethiopia. Clin Ophthalmol. 2017;11:1941–8.

Gebru EA, Mekonnen KA. Prevalence and factors associated with myopia among high school students in Hawassa City, South Ethiopia, 2019. Clin Optom. 2022;14:35–43.

Gopalakrishnan A, Hussaindeen JR, Sivaraman V, Swaminathan M, Wong YL, Armitage JA, et al. Myopia and its association with near work, outdoor time, and housing type among schoolchildren in South India. Optom Vis Sci. 2023;100:105–10.

Hung HD, Chinh DD, Tan PV, Duong NV, Anh NQ, Le NH, et al. The prevalence of myopia and factors associated with it among secondary school children in Rural Vietnam. Clin Ophthalmol. 2020;14:1079–90.

Saxena R, Vashist P, Tandon R, Pandey RM, Bhardawaj A, Gupta V, et al. Incidence and progression of myopia and associated factors in urban school children in Delhi: The North India Myopia Study (NIM Study). PLoS ONE. 2017;12:e0189774.

Saxena R, Gupta V, Prasad P, Bhardwaj A, Vashist P. Prevalence of myopia and its risk factors in rural school children in North India: the North India myopia rural study (NIM-R Study). Eye. 2022;36:2000–5.

Singh NK, James RM, Yadav A, Kumar R, Asthana S, Labani S. Prevalence of myopia and associated risk factors in schoolchildren in North India. Optom Vis Sci. 2019;96:200–5.

Yong AC, Buglass A, Mwelwa G, Abdallah I, Chan VF. Can we scale up a comprehensive school-based eye health programme in Zambia? BMC Health Serv Res. 2022;22:945.

Chan VF, Belluigi D, Yong AC, Mulewa D, Poonsamy-Govender P, Graham C, et al. Co-creating an arts-based eye health education strategy in Zanzibar: process, outcomes and lessons learnt. BMJ Glob Health. 2022;7:e009317.

Article   PubMed Central   Google Scholar  

Seelam B, Liu H, Borah RR, Sheeladevi S, Keay L. A realist evaluation of the implementation of a large-scale school eye health programme in India: a qualitative study. Ophthalmic Physiol Opt. 2021;41:565–81.

Sabherwal S, Sood I, Siddiqui Z, DasGupta S, Ganesh S, Basset K. Out-of-school vision screening in North India: estimating the magnitude of need. Ophthalmic Epidemiol. 2020;27:449–52.

Chan VF, Omar F, Yard E, Mashayo E, Mulewa D, Drake L, et al. Is an integrated model of school eye health delivery more cost-effective than a vertical model? An implementation research in Zanzibar. BMJ Open Ophthalmol. 2021;6:e000561.

Yong AC, Chuluunkhuu C, Chan VF, Stephan T, Congdon N, O’Neill C. A pilot cost-benefit analysis of a children’s spectacle reimbursement scheme: evidence for Including children’s spectacles in Mongolia’s Social Health Insurance. PLoS ONE. 2022;17:e0273032.

Alrasheed SH. A systemic review of barriers to accessing paediatric eye care services in African countries. Afr Health Sci. 2021;21:1887–97.

Burnett AM, Yashadhana A, Lee L, Serova N, Brain D, Naidoo K. Interventions to improve school-based eye-care services in low- and middle-income countries: a systematic review. Bull World Health Organ. 2018;96:682–94D.

World Health Organization. Eye care indicator menu (ECIM). Geneva: WHO; 2022.

Morjaria P, McCormick I, Gilbert C. Compliance and predictors of spectacle wear in schoolchildren and reasons for non-wear: a review of the literature. Ophthalmic Epidemiol. 2019;26:367–77.

Wallace DK, Morse CL, Melia M, Sprunger DT, Repka MX, Lee KA, et al. Pediatric eye evaluations preferred practice pattern(R): I. Vision screening in the primary care and community setting; II. Comprehensive ophthalmic examination. Ophthalmology. 2018;125:P184–P227.

Nemeth J, Tapaszto B, Aclimandos WA, Kestelyn P, Jonas JB, De Faber JHN, et al. Update and guidance on management of myopia. European Society of Ophthalmology in cooperation with International Myopia Institute. Eur J Ophthalmol. 2021;31:853–83.

Mavi S, Chan VF, Virgili G, Biagini I, Congdon N, Piyasena P, et al. The impact of hyperopia on academic performance among children: a systematic review. Asia Pac J Ophthalmol. 2022;11:36–51.

Hopkins S, Narayanasamy S, Vincent SJ, Sampson GP, Wood JM. Do reduced visual acuity and refractive error affect classroom performance? Clin Exp Optom. 2020;103:278–89.

Evans JR, Morjaria P, Powell C. Vision screening for correctable visual acuity deficits in school-age children and adolescents. Cochrane Database Syst Rev. 2018;2:e1–55.

Keel S, Govender-Poonsamy P, Cieza A, Faal H, Flitcroft I, Gifford K, et al. The WHO-ITU MyopiaEd programme: a digital message programme targeting education on myopia and its prevention. Front Public Health. 2022;10:881889.

Ang M, Flanagan JL, Wong CW, Muller A, Davis A, Keys D, et al. Review: myopia control strategies recommendations from the 2018 WHO/IAPB/BHVI Meeting on Myopia. Br J Ophthalmol. 2020;104:1482–7.

Morjaria P. Use of ready-made spectacles in school eye health programmes. Community Eye Health. 2017;30:33.

World Health Organization. Eye care competency framework. Geneva: WHO; 2022. Available from: https://www.who.int/publications/i/item/9789240048416 .

Pan WY, Lou LX, Chen FY, Tang XJ. Gender Disparities in the Global Burden of Refractive Disorders in Children: An Analysis From the Global Burden of Disease Study 2019. J Pediat Ophth Strabismus. 2024;61:51–5.

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Alex-Anne Harvey & Benoit Tousignant

International Centre for Eye Health, London School of Hygiene and Tropical Medicine, London, UK

Priya Morjaria

Peek Vision, Berkhamsted, UK

School of Optometry, Université de Montréal, Montreal, QC, Canada

Benoit Tousignant

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AH was responsible for designing the search protocol, conducting the search, screen for eligible studies, extracted relevant results, sorted and analysed data. She wrote the first draft and created tables and figures. BT reviewed and edited the search protocol, advised when ambiguity arose during screening and reviewed and edited all drafts of the manuscript, PM PY reviewed and edited the search protocol and all drafts of the manuscript.

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Harvey, AA., Morjaria, P. & Tousignant, B. Priorities in school eye health in low and middle-income countries a scoping review. Eye (2024). https://doi.org/10.1038/s41433-024-03032-1

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The Department of Ophthalmology and Visual Sciences offers medical students and residents a variety of research opportunities. Please browse the basic science, translational and clinical research projects currently underway below.

Research Topic: Corneal endothelial health judged by endothelial image analysis

Description.

Endothelium is critical for dehydrating the cornea and keeping it clear. With loss of its barrier and pump function, the cornea swells and corneal transplantation may be needed.

Changes in the number, shape and size of the cells may predict loss of function.

Key Research Question/Hypothesis 

Effect of drugs, surgery, devices, and preservation media on the endothelium.

Images of the endothelium captured with either a specular or confocal microscope that can take repeated pictures of the endothelial cells non-invasively in patients. Once images are captured, they can be analyzed with special software in the Cornea Image Analysis Reading Center (CIARC) of the Department.

Student learn these techniques working with both patients and technicians, depending on the project.

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Image analysis studies in CIARC approved; ongoing projects have IRB approval. If launching a new project, IRB approval will need to be obtained.

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Excellent; we have a long track record of publications in major journals and presentations at national and international conferences.

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Tanisha Rankins

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Research Topic: Retinopathy of Prematurity and other Pediatric Studies

Effect of low birth weight on the eye’s development.

Data analysis, chart review.

Several ongoing projects—long-term data collection.

Current study has IRB approval. Any new studies will need IRB approval.

Excellent; the data base study has been presented at ARVO and is in preparation for publication in a major pediatric journal.

Dr. Faruk Orge

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Research Topic: Cholesterol and function of the retina

Cholesterol is essential for life in mammal. Yet, if it is chronically in excess, it is a risk factor for cardiovascular and Alzheimer's disease and likely age-related macular degeneration.

To delineate the putative link between cholesterol and age-related macular degeneration.

Characterization of retinal function of mice deficient in different enzymes involved in cholesterol elimination. Animals are assessed by optical coherence tomography, electroretinography, fluorescein angiography and optomotor response.

Students learn these techniques working with post-doctoral researchers responsible for these projects.

All studies are approved by the IACUC.

Dr. Irina Pikuleva

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Research Topic: Contact Lens Related Complications

Ongoing clinical trials related to corneal infiltrative events associated with daily or extended wear of soft contact lenses. Fungal and bacterial biofilm-contact lens models and susceptibility to contact lens care products.

Assessment of sub-clinical corneal inflammation with confocal microscopy. Assessment of bacterial endotoxin and relationship to infiltrative events with soft lenses.

• Ocular and lens cultures for assessment of bioburden
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Active approved IRB protocols exist for current clinical trials on infiltrative events, biofilm studies, and assays of previously collected lenses, tears and images.

Excellent chance for authorship on investigator initiated studies of biofilm and endotoxin assays. Listing of authors will follow standard publishing guidelines. 

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A multi-disciplinary approach is employed that includes biochemistry, molecular biology, animal models and biophysics.

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Excellent with track record of publications in major journals and presentations at national and international conferences.

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• Coordinated Nationwide Approaches to Promote Eye Health

Coordinated Nationwide Approaches to Promote Eye Health and Reduce Vision Impairment

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• Proposed Policy Statements
• Date: Nov 05 2019
• Policy Number: 20191

Key Words: Vision Care, Eye Care, Eye Care Disorders

Sight is clearly important to the health and quality of life for children, adults, and seniors, but it has consistently failed to achieve the status of a national health priority. Adults regularly cite vision loss as one of their most feared health conditions; poor vision can hamper a child’s educational, social, and extracurricular opportunities; and vision problems and eye disease can decrease health, increase isolation, and compound the impact of chronic diseases among seniors. The National Academies of Sciences, Engineering, and Medicine (NASEM) released a report in 2016 examining the challenges related to vision and eye health in the American population, the barriers to improving eyesight, and strategies to make this fundamental component of health a national priority. The multidisciplinary committee convened by NASEM produced a set of action steps at the federal, state, and local levels that offer a roadmap to APHA to improve vision and eye health and health equity. Public health advocates must encourage federal, state, and local policymakers to promote population eye and vision health and establish strategies that minimize preventable and correctable vision impairment to achieve greater health equity.

Relationship to Existing APHA Policy Statements

There are no existing policy statements that explicitly and comprehensively relate to the public health problem identified in this statement. Some policy statements approved prior to 1999 that are expected to be automatically archived in the coming year do relate to parts of this statement, but only in very limited ways. This statement is relevant to but does not contradict or supersede the following statements:

• APHA Policy Statement 200028: Ensuring Optimal Vision Performance in Visually At Risk Drivers
• APHA Policy Statement 20002: Reducing the Incidence of Blindness, Lower Extremity Amputation, and Oral Health Complications in Minority Populations Due to Diabetes
• APHA Policy Statement 20011: Improving Early Childhood Eyecare
• APHA Policy Statement 20016: Global Campaign to Eliminate Avoidable Blindness
• APHA Policy Statement 200312: Increasing Access to Vision Rehabilitation
• APHA Policy Statement 20067: Promoting the Use of Protective Eyewear For Children In Sports
• APHA Policy Statement 20071: Preventing Vision Loss Through Smoking Cessation
• APHA Policy Statement 200713: Eye Care in Disaster Preparedness
• APHA Policy Statement 200910: Improving Access to Vision Care in Community Health Centers
• APHA Policy Statement 201118: Preventing Injuries by Banning Consumer Use of Fireworks
• APHA Policy Statement 201112: VISION 2020: Global Campaign to Eliminate Avoidable Blindness
• APHA Policy Statement 20116: Reducing Barriers and Increasing Access to Children’s Vision Care Services

Problem Statement

Problems related to vision and eye health represent a significant health and economic burden in the United States and have a profound impact on the lives of those affected. The sheer numbers show a real and growing public health issue that is even greater when considering the additional effects of poor vision and eye health on education, quality of life, social participation, and other arenas.

Current status of vision and eye health in the United States: While calculating precise estimates regarding the burden of vision impairment in the United States is challenging because nationwide epidemiological data are limited, we do know that at least 6 million Americans suffer from uncorrectable vision impairment or blindness.[1] About 48 million Americans are affected by refractive errors that can be readily corrected, but almost 16 million of them are undiagnosed or otherwise uncorrected.[2] While not all vision loss can be corrected, a set of simple interventions can prevent many Americans from suffering associated decreased independence and quality of life, reduced performance in school, lower wages and job attainment, and increased health costs. Cataracts, glaucoma, age-related macular degeneration, and other diseases affect almost 30 million Americans older than 40 years.[3] Diabetic retinopathy is the leading cause of new cases of blindness among working-age adults.[4] Many of the conditions just described can be prevented or mitigated with early detection and treatment.

As our nation’s population ages, the numbers outlined above are expected to grow. Because eye diseases and conditions become more common in the later years of life, the number of blind and visually impaired people will double by the year 2050 as the U.S. population ages.[1] In the elderly, vision loss is a significant contributor to falls; moreover, it can increase social isolation, reduce an individual’s ability to age in place, and increase the risk for depression.[5] In fact, vision impairment is an independent contributor to earlier mortality.[6]

Americans treasure their ability to see; research consistently reports that loss of vision is among our greatest health fears.[7] As a cornerstone of daily life, the ability to see well strongly impacts everything people do: from a child’s chances for a quality education to an adult’s pursuit of employment and hopes for an independent and enjoyable retirement. Consequently, loss of vision carries a heavy toll for both individuals and society. People encountering vision loss face a future more likely to be burdened by depression, a higher risk of falls, loss of driving privileges, social isolation, and poverty.[8]

Access and utilization: Data on the percentage of people undergoing eye examinations, the gold standard in eye care for prevention, diagnosis, and treatment of diseases and conditions, are limited. Medicare claims show that about 45% of Medicare beneficiaries had an eye exam in 2015.[9] Because the risk of eye problems increases with age, it might be expected that use of services is highest in this population; however, existing data are not sufficient to confirm such a hypothesis.

Among patients with limited access to health care or low socioeconomic status, such as those primarily served by federally qualified health centers, access to comprehensive eye care can be limited. According to the Uniform Data System, health centers employed only 407 full-time-equivalent optometrists and ophthalmologists (the professionals qualified to provide comprehensive eye care) in 2018. In that same year, less than 1% of health center patients received vision care services. Comparatively, health centers employed approximately 5,000 full-time-equivalent dentists in 2018, and about 14% of patients received dental care.[10]

Medical insurance plans, including Medicare, typically do not cover comprehensive eye exams for asymptomatic patients who are not in a specific high-risk category, although many patients do not realize that they are experiencing symptoms of a vision or eye health problem until they receive a comprehensive exam. Twenty-three percent of privately insured Americans had access to vision care benefits in 2017.[11] In comparison with adults, children have relatively high rates of insurance coverage for vision and eye care. In 2017, 98.7% of children were insured.[12] Among almost all children, medical insurance coverage includes vision coverage. In Medicaid, Early and Periodic Screening, Diagnosis, and Treatment includes screening, diagnosis, and treatment for vision conditions, including eye examinations and eyeglasses. Children receiving insurance through CHIP (Children’s Health Insurance Program) have access to comparable eye care services. Finally, the essential health benefits provision of the Affordable Care Act required that qualified health plans include pediatric vision services; in many states, this benefit was defined according to what was available through CHIP. Among most children with private insurance, that means coverage for one comprehensive eye examination and one pair of glasses per year, although associated cost sharing is not dictated. In addition, whether in the case of private insurance or public insurance, cost sharing, the exact details of the benefit, and related limitations vary from plan to plan and state to state.[13]

Children and vision: Vision and eye health problems affect children as well. An estimated one out of five preschool children in the United States have vision problems,[14–17] and more than one in four school-aged children wear corrective eyewear.[18] Left unidentified and uncorrected, vision problems can challenge a child’s general development,[19] school performance,[20] social interactions, and self-esteem.[21] Visual skills are the foundation for nearly all tasks a child performs in the classroom.

Childhood vision disorders, especially those that remain untreated, often manifest as problems well into adulthood, affecting an individual’s level of education, employment opportunities, and social interactions.[22] In some cases, students with undiagnosed vision impairment may be misdiagnosed with learning disabilities because of undetected vision problems.[23,24] As children have only a few short years to learn to read before they read to learn, early diagnosis and treatment of vision impairments is crucial. Early intervention is critical to preserve vision and can bolster a child’s self-esteem, elevate reading comprehension, boost test scores, and reduce behavior problems.

Economic burden: Economically, vision loss and eye disease were estimated to cost the United States $145 billion in 2014, making them (in combination) the fifth most expensive health condition. The country’s aging and changing demographics could quintuple this economic toll to $717 billion a year by 2050.[25] The financial well-being of each individual who experiences vision loss is likely to deteriorate as well. Early intervention, diagnosis, and treatment can often prevent vision loss and could reduce the economic burden resulting from preventable chronic visual impairment.[26]

Disproportionate impact: The effects of vision and eye health issues are widespread across the American population, but they are not distributed equally. Race, ethnicity, sex, age, socioeconomic status, and insurance status all have an impact on an individual’s risk of vision problems and eye disease. Race/ethnicity and sex can increase an individual’s risk for specific eye diseases, but socioeconomic status and insurance status can also affect any resulting visual impairment. For example, the prevalence of cataracts is consistently highest in older White populations. However, vision impairment from untreated cataracts occurs more frequently in minority populations.[27] Diabetic retinopathy disproportionally impacts minority populations[1] and is more common in males.[28]

For public health purposes, it may be more useful to assess the disproportionate effects of vision impairment and blindness that result from vision problems and eye diseases than the varying prevalence rates of individual conditions. The resulting vision impairment or blindness is the factor with the greatest practical impact on individuals. African Americans older than 40 years have a higher prevalence of uncorrectable vision impairment and blindness than all other groups. However, non-Hispanic White females make up the largest portion of Americans with vision impairment and blindness.[1] Minority populations are at risk for poorer health overall,[29] and many of the factors that relate to overall health have similar effects when considering eye and vision health. Vision impairment and blindness have a disproportionate impact on female and minority racial/ethnic groups, although there are variations within subpopulations.

Socioeconomic status is an important determinant of visual impairment.[30] No matter their age, Americans who are poor, have less education, or are unemployed have a greater risk of developing eye disease and vision impairment.[31] Individuals with lower incomes and a lower level of educational attainment have been shown to be less likely to report having an eye care visit in the preceding 12 months.[32] This risk is also clear for children; children in low-income homes have a greater risk of vision loss and untreated vision impairment. A child living below the federal poverty line has almost double the risk of being visually impaired relative to a child living at 200% of the federal poverty line or higher.[33]

A diverse workforce improves access to care among underserved populations. African American, Hispanic, and Native American physicians have been shown to be more likely to practice in underserved communities and to serve minority patients, and African American and Hispanic physicians, as well as women, are more likely to care for the poor and those with Medicaid coverage.[34] The fields of both optometry and ophthalmology struggle with a lack of diversity, and African American, Hispanic, and Native American providers in these disciplines represent 5% or less of the total number.[13]

The disproportionate impact of vision problems and eye disease is consistent with that of overall health status, health outcomes, and use of health services. APHA has long recognized the imperative of promoting health equity, and this must include eye and vision health.

The scope of vision problems in the United States is large and demands a coordinated approach to ensure efficient use of available resources. The federal government bears a significant portion of the burden of vision and eye health problems, largely though not exclusively through direct health costs. It also has the capacity to coordinate a nationwide strategy. However, it has not yet done so. At the Centers for Disease Control and Prevention (CDC), perhaps the most likely agency to coordinate a population health approach, vision and eye health consistently fail to reach the list of agency-wide priorities. In fact, the CDC addresses vision and eye health primarily through a program within the Division of Diabetes Translation—the Vision Health Initiative—with a dedicated budget of $1 million and control of an additional $4 million dedicated to glaucoma.[35] The CDC also has a small team within the Waterborne Disease Prevention Branch to address safe contact lens wear. Various programs at the Health Resources and Services Administration (HRSA) have an impact on vision and eye health, and the National Eye Institute at the National Institutes of Health is dedicated to research related to vision and eye health. However, these fragmented and mostly small programs do not represent a coordinated strategy.

Evidence-Based Interventions and Strategies

Addressing vision and eye health at a population level requires the use of fundamental public health strategies that have been unavailable or not used at a sufficient scale in the past. As noted in the National Academies of Sciences, Engineering, and Medicine (NASEM) report Making Eye Health a Population Health Imperative: Vision for Tomorrow, “the long-term goal of a population health approach for eye and vision health should be to transform vision impairment from a common to a rare condition, reducing associated health inequities.”[13] For individuals, eliminating or minimizing vision impairment or blindness means taking proper preventive measures and receiving timely comprehensive eye care including diagnosis, treatment, and management of eye disease or visual conditions, as well as appropriate correction of refractive errors or visual dysfunction.[13] At the population level, reducing vision impairment and associated health inequities requires a more expansive health model that aims to improve vision and eye health across the life span.

This population health model, as described in the NASEM report, includes facilitating public awareness, generating evidence to guide policy decisions and evidence-based actions, expanding access to appropriate clinical care, enhancing public health capacity to support vision-related activities, and promoting community action to encourage vision- and eye-healthy environments.

Facilitating public awareness: Vision and eye health, as described in the problem statement, present a clear public health challenge that affects a large number of people, with significant impacts on morbidity, quality of life, and cost that have been and will continue to grow as the population ages. Americans surveyed in 2016 indicated that vision impairment and blindness were substantial personal concerns.[7] However, vision and eye health are unrepresented on major national health priority lists and do not appear to have reached the level of national priority they deserve.

Public awareness campaigns are a long-standing way to increase public visibility and priority for specific health issues. When structured properly, using the right resources to reach the right audiences (considering, for example, literacy skills and unequal access to resources), public awareness campaigns have been shown to improve awareness of specific issues.[36] These campaigns can include a variety of activities, including mass media and social media initiatives and targeted calls to action by federal officials. A call to action by the U.S. Department of Health and Human Services, usually by the surgeon general, is a science-based means of stimulating nationwide action to solve a major public health problem.

Increasing public knowledge about eye and vision health, common risk factors, early signs of disease, and what steps can be taken to reduce the risk of vision conditions or eye disease and decrease the impact of vision impairment is an effective but not independently sufficient step in enhancing population knowledge as part of a population health approach to improving national vision and eye health.

Generating evidence: Evidence-based policy-making and decision making rely on the existence of reliable, accepted evidence. Unfortunately, basic epidemiological data regarding rates of vision impairment and eye disease in the United States are unavailable in the peer-reviewed literature.[13] Surveillance is one of the foundations of public health and the basis for policy-making and decision making.[37] The development of a comprehensive eye and vision health surveillance system that relies, where possible, on existing national surveys could provide a wealth of useful data to inform the clinical practice of eye and vision health as well as population health. Relying on currently available data, the CDC has engaged in a collaborative effort to develop the Vision and Eye Health Surveillance System, and it is in the early years of making these data publicly available.[13] However, current data are limited, in part because national health surveys do not address vision and eye health or gather only very limited information that does not allow for monitoring the prevalence of or trends in eye health indicators. Better incorporation of eye-related questions into major national health surveys and inclusion of eye examinations in routine surveillance programs would produce large quantities of usable data that could enrich the CDC’s efforts.

The limitations of existing epidemiological data related to vision and eye health have in turn limited research on public health approaches to improving vision and eye health, health services research (particularly among high-risk populations), and long-term studies on risk factors and causes of vision impairment. Although the development of a surveillance system is a prerequisite for the kind of research needed, the conception of a research agenda by national leaders in eye and vision health could guide the conduct of research in the future to best inform policy, population health, and clinical care.

Currently, research into vision and eye health is performed by several different federal agencies and partners.[38] However, coordination across agencies is limited, which contributes to inefficient use of resources. Better coordination, steered by a holistic research agenda that addresses gaps in knowledge and information, could result in better care and improved health at the individual and population levels.

Expanding access: Access to high-quality, timely, and appropriate care is key to individuals’ overall health. Access to care has consistently been shown to improve health outcomes.[39] In terms of eye and vision care, reliable access to care can lead to earlier detection of eye diseases and vision impairment and better visual and health outcomes.[40] Access to care assumes that, in addition to the availability of a health care provider and the ability of the patient to pay for care, the care delivered is consistent with the best available research and delivered at the right time.

One of the common ways health care providers receive guidance on the most current best practices is through clinical practice guidelines. According to NASEM, “Clinical Practice Guidelines (CPGs) are intended to provide a systematic aid to making such complex medical decisions. When rigorously developed using a transparent process that combines scientific evidence, clinician experiential knowledge, and patient values, CPGs have the potential to improve many clinician and patient healthcare decisions, and enhance healthcare quality and outcomes.”[41] The vision and eye care provider community does not operate on a consistent set of clinical practice guidelines establishing agreed-upon standards of care. Such guidelines could facilitate not only clinical care but also policy decisions (e.g., population health policies and insurance coverage).

The availability of eye care providers is one component of access to eye care. According to recent research, only 12% of U.S. counties, home to 1% of the U.S. population, do not have a practicing optometrist or ophthalmologist.[42] Further research has shown that 90% of Medicare beneficiaries live within a 15-minute drive of a doctor of optometry and a 30-minute drive of an ophthalmologist. As a result of data limitations, these numbers may underestimate the overall supply of eye doctors.[43] In addition, the HRSA no longer calculates the Vision Health Professions Shortage Area designation, which could provide an authoritative assessment of workforce sufficiency based on number of providers, population density, and other factors. Overall, it seems that the eye care workforce in the United States might be adequate to provide sufficient care if all providers were practicing to full capacity, but additional data could provide clarity on this question. However, rates of undiagnosed or untreated eye and vision problems confirm the fact that workforce adequacy alone would not guarantee access to or receipt of care.

Not all patients have access to transportation, and many are not aware of their eye care needs. Insurance coverage has a documented relationship to overall health and to eye and vision health.[13] Increasing the percentage of the population with insurance coverage and vision coverage is a necessary but not sufficient step in improving access to and receipt of care for patients. Even among patients with insurance coverage for comprehensive eye care, out-of-pocket costs can make receipt of care nearly impossible. Expanded access to Medicaid and other federally supported health insurance options has been shown to reduce the overall uninsured rate, which can improve access to medical eye care.

Transportation can be a barrier to routine medical care for any health condition. Patients with existing visual impairments may have greater struggles. Medicaid offers nonemergency medical transportation for beneficiaries who meet certain criteria. This service has been shown to increase the number of completed recommended visits for chronic conditions among Medicaid beneficiaries.[44] A growing number of Medicare Advantage beneficiaries also have access to this benefit, although availability is limited among the privately insured.

Community health centers have been shown to reduce health care costs for populations they serve and to decrease acute care episodes among their patients.[45] As noted in the problem statement, the availability of comprehensive vision care services in community health centers is quite low. Additional investment in health center expansion with a priority on vision services could drive health centers to invest in increasing the number of on-site eye care providers.

Among both individuals and communities, access to care is improved by the development of a diverse workforce that reflects the background and experiences of the American population. A diverse workforce is more likely to be a culturally competent workforce, although cultural competence must also remain a component of health professional education.[34] A culturally competent workforce has been shown to reduce health care disparities among minority populations.[46]

Enhancing public health capacity: Although national and federal leadership often directs population health efforts, that work would be unsuccessful without collaboration with state and local public health departments. Public health departments “serve as key community conveners to coordinate responses that address multiple determinants of health and chronic conditions, such as vision impairment.”[13] Coordinating with state and local public health departments is a common way to improve the health of a community and can build on an effective medical care system to undertake preventive efforts connecting people to care, to measure the quality of care, and to take action on social determinants of health.[47]

However, limited and shrinking investments in public health departments mean that many such entities struggle to meet core requirements and state mandates.[48] Increased investment in public health departments could allow them to take on evidence-based vision and eye health activities that are appropriate for their communities.

Promoting community action: Eye and vision health are determined by more than just an individual’s genetics and medical care. Social determinants of health and environmental factors are among the variables that change from one community to the next and can greatly affect eye and vision health. For example, tobacco use can increase the risk of age-related macular degeneration and cataracts, among other health effects.[49] The quality of life of individuals with uncorrectable vision impairment can also be greatly improved by increasing and improving public transportation to accommodate their needs.[50] Engaging communities in the development of policies to address these factors in their own environments can improve policy quality and targeting, increase community buy-in and long-term success, and enhance the reach of educational programs.[51]

Opposing Arguments/Evidence

The most substantial opposition to tackling eye and vision health at the population level comes from those who would support other priorities. This is not to oppose efforts to improve vision and eye health, but to elevate other priorities for limited funding and attention. The opposing argument assumes that vision and eye health do not present a public health problem on the same scale as other acute or chronic diseases or conditions. Although vision and eye health lack the obvious impact on population mortality of, for example, opioid overdoses or infectious disease, vision impairment has in fact been shown to increase risk of death even after adjustment for other factors.[6] The problem statement clearly articulates the scope of vision and eye health problems as a serious issue at the population health level.

Past public health efforts to improve vision and eye health have been limited at the most basic level by inadequate and incomplete epidemiological data resulting from a lack of comprehensive data collection. This policy statement recommends, among other elements, the creation of a comprehensive surveillance system for eye and vision health, which would offer the basic level of data required to assess the impact of other policies and initiatives to improve vision and eye health.

In addition, the vision and eye health community has failed to unite around cohesive messaging and priorities related to vision and eye health.[13] Although this is not necessarily a prerequisite for implementation of the action steps below, unified stakeholders could facilitate progress. Some of the stakeholders in the vision and eye health community do hold opposing views on specific issues, but they share many common goals that could be implemented more easily.

Action Steps

Significant leadership in the area of public health and eye and vision health comes from the 2016 NASEM report Making Eye Health a Population Health Imperative: Vision for Tomorrow. The following action steps are consistent with the recommendations of NASEM and widely supported by others in the eye and vision health community. They support the achievement of the strategies described here and would contribute to improvements in eye and vision health at the population and individual levels.

APHA recommends that:

• The secretary of the U.S. Department of Health and Human Services issue a call to action to motivate nationwide efforts toward achieving a reduction in the burden of vision impairment across the life span of people in the United States.
• The secretary of the U.S. Department of Health and Human Services, in collaboration with other federal agencies and departments, nonprofit and for-profit organizations, professional organizations, employers, state and local public health agencies, and the media, launch a coordinated, evidence-based public awareness campaign to promote policies and practices that encourage eye and vision health across the life span, reduce vision impairment, and promote health equity. This campaign should target various stakeholders including the general population, care providers and caretakers, public health practitioners, policymakers, employers, and community and patient liaisons and representatives.
• The Centers for Disease Control and Prevention continue to build on and develop the Vision and Eye Health Surveillance System. The CDC should encourage the development, deployment, and standardization of needed questions about vision and eye health and care in major health surveys to provide robust data for the system.
• The U.S. Department Department of Health and Human Services create an interagency workgroup, including a wide range of public, private, and community stakeholders, to develop a common research agenda and coordinated eye and vision health research and demonstration grant programs that target leading causes, consequences, and unmet needs with respect to vision impairment.
• The U.S. Department of Health and Human Services convene one or more panels— comprising members of professional organizations, researchers, public health practitioners, patients, and other stakeholders—to develop a single set of evidence-based clinical and rehabilitation practice guidelines and measures that can be used by eye care professionals, other care providers, and public health professionals to prevent, screen for, detect, monitor, diagnose, and treat eye and vision problems. These guidelines and supporting evidence should be used to drive payment policies, including coverage determinations for corrective lenses and visual assistive devices following a diagnosed medical condition (e.g., refractive error).
• To enable the health care and public health workforce to meet the eye care needs of a changing population and to coordinate responses to vision-related health threats, professional education programs proactively recruit and educate a diverse workforce and incorporate prevention and detection of visual impairments, population health, and team care coordination as part of core competencies in applicable medical and professional education and training curricula. Individual curricula should emphasize proficiency in culturally competent care for all populations.
• Eye care services also be incorporated into settings that provide care for underserved patients, such as community health centers. The Health Resources and Services Administration should ensure that expansion grant funding offered to community health centers and any other programs intended to develop additional capacity for care in underserved settings is available for eye care services. State and local public health departments should partner with health care systems to align public health and clinical practice objectives, programs, and strategies about eye and vision health.
• To build state and local public health capacity, the Centers for Disease Control and Prevention prioritize and expand its vision grant program in partnership with state-based chronic disease programs and other clinical and nonclinical stakeholders.
• Communities work with state and local health departments to translate a broad national agenda promoting eye and vision health into well-defined actions. These actions should encourage policies and conditions that improve eye and vision health and foster environments that minimize the impact of vision impairment, considering the community’s needs, resources, and cultural identity.
• Federal and state insurance authorities encourage coverage of comprehensive eye care services for all beneficiaries in both public and private insurance programs.

1. Varma R, Vajaranant T, Burkemper B, et al. Visual impairment and blindness in adults in the United States: demographic and geographic variations from 2015 to 2050. JAMA Ophthalmol. 2016;134:802–809.

2. Vitale S, Ellwein L, Cotch M, Ferris F, Sperduto R. Prevalence of refractive error in the United States, 1999–2004. Arch Ophthalmol. 2008;126:1111–1119.

3. National Eye Institute. Prevalence of adult vision impairment and age-related eye diseases in America. Available at: https://nei.nih.gov/. Accessed December 17, 2019.

4. Centers for Disease Control and Prevention. National diabetes fact sheet: national estimates and general information on diabetes and prediabetes in the United States, 2011. Available at: http://www.cdc.gov/diabetes/pubs/pdf/ndfs_2011.pdf. Accessed December 17, 2019.

5. Choi HG, Lee MJ, Lee SM. Visual impairment and risk of depression: a longitudinal follow-up study using a national sample cohort. Sci Rep. 2018;8:2083.

6. Siantar RG, Cheng C-Y, Gemmy Cheung CM, et al. Impact of visual impairment and eye diseases on mortality: the Singapore Malay Eye Study (SiMES). Sci Rep. 2015;5:16304

7. Scott AW, Bressler NM, Folkes S, Wittenborn JS, Jorkasky J. Public attitudes about eye and vision health. JAMA Ophthalmol. 2016;134:1111–1118.

8. Crews JE, Chou CF, Zack MM, et al. The association of health-related quality of life with severity of visual impairment among people aged 40–64 years: findings from the 2006–2010 Behavioral Risk Factor Surveillance System. Ophthalmic Epidemiol. 2016;23:145–153.

9. Centers for Disease Control and Prevention, Vision Health Initiative. Vision and Eye Health Surveillance System. Available at: https://www.cdc.gov/visionhealth/vehss/project/index.html. Accessed December 17, 2019.

10. Health Resources and Services Administration. Table 5: staffing and utilization. Available at: https://bphc.hrsa.gov. Accessed December 17, 2019.

11. Bureau of Labor Statistics. Vision care plans available to 23 percent of private industry workers in March 2017. Available at: https://www.bls.gov. Accessed December 17, 2019.

12. Berchick E, Hood E, Barnett J. Health Insurance Coverage in the United States: 2017. Washington, DC: U.S. Government Printing Office; 2018.

13. National Academies of Sciences, Engineering, and Medicine. Making Eye Health a Population Health Imperative: Vision for Tomorrow. Washington, DC: National Academies Press; 2016.

14. Multi-Ethnic Pediatric Eye Disease Study Group. Prevalence of myopia and hyperopia in 6- to 72-month-old African American and Hispanic children: the Multi-Ethnic Pediatric Eye Disease Study. Ophthalmology. 2010;117:140–147.

15. Wen G, Tarczy-Hornoch K, McKean-Cowdin R, et al. Prevalence of myopia, hyperopia, and astigmatism in non-Hispanic White and Asian children: Multi-Ethnic Pediatric Eye Disease Study. Ophthalmology. 2013;120:2109–2116.

16. Multi-Ethnic Pediatric Eye Disease Study Group. Prevalence of amblyopia and strabismus in African American and Hispanic children ages 6 to 72 months: the Multi-Ethnic Pediatric Eye Disease Study. Ophthalmology. 2008;115:1229–1236.

17. McKean-Cowdin R, Cotter SA, Tarczy-Hornoch K, et al. Prevalence of amblyopia or strabismus in Asian and non-Hispanic white preschool children: Multi-Ethnic Pediatric Eye Disease Study. Ophthalmology. 2013;120:2117–2124.

18. Centers for Disease Control and Prevention. Percentage of children aged 6–17 years who wear glasses or contact lenses, by sex and age group—National Health Interview Survey, 2016. MMWR Morb Mortal Wkly Rep. 2017;66:917.

19. Roch-Levecq AC, Brody BL, Thomas RG, Brown SI. Ametropia, preschoolers’ cognitive abilities, and effects of spectacle correction. Arch Ophthalmol. 2008;126:252–258.

20. Goldstand S, Koslowe KC, Parush S. Vision, visual-information processing, and academic performance among seventh-grade schoolchildren: a more significant relationship than we thought? Am J Occup Ther. 2005;59:377–389.

21. Mojon-Azzi SM, Kunz A, Mojon DS. Strabismus and discrimination in children: are children with strabismus invited to fewer birthday parties? Br J Ophthalmol. 2011;95:473–476.

22. Davidson S, Quinn GE. The impact of pediatric vision disorders in adulthood. Pediatrics. 2011;127:334–339.

23. DeCarlo DK. ADHD and vision problems in the National Survey of Children’s Health. Optom Vis Sci. 2016;93:459–465.

24. Solé Puig M. Attention-related eye vergence measured in children with attention deficit hyperactivity disorder. PLoS One. 2015;10:e0145281.

25. Wittenborn J, Rein D. The Future of Vision: Forecasting the Prevalence and Cost of Vision Problems. Chicago, IL: University of Chicago; 2014.

26. Wittenborn J, Rein D. The potential costs and benefits of treatment for undiagnosed eye disorders. Available at: http://www.nationalacademies.org. Accessed December 17, 2019.

27. Zambelli-Weiner A, Crews J, Friedman D. Disparities in adult vision health in the United States. Am J Ophthalmol. 2012;154(suppl 6):S23–S30.

28. Zetterberg M. Age-related eye disease and gender. Maturitas. 2016;83:19–26.

29. Institute of Medicine. Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care. Washington, DC: National Academies Press; 2003

30. Sommer A, Tielsch J, Katz J, et al. Racial differences in the cause-specific prevalence of blindness in East Baltimore. N Engl J Med. 1991;325:1412–1417.

31. Ko F, Vitale S, Chou C, Cotch M, Saaddine J, Friedman D. Prevalence of nonrefractive visual impairment in US adults and associated risk factors, 1999–2002 and 2005–2008. JAMA. 2012;308:2361–2368.

32. Zhang X, Saaddine J, Chou C, et al. Vision health disparities in the United States by race/ethnicity, education, and economic status: findings from two nationally representative surveys. Am J Ophthalmol. 2012;154(suppl 6):S53–S62.

33. Cotch M, Klein R, Brett K, Ryskulova A. Visual impairment and use of eye-care services and protective eyewear among children—United States, 2002. MMWR Morb Mortal Wkly Rep. 2005;54:425–429.

34. Cohen J, Gabriel B, Terrell C. The case for diversity in the health care workforce. Health Aff. 2002;21:90–102.

35. Centers for Disease Control and Prevention. FY2019 operating plan. Available at: https://www.cdc.gov. Accessed December 17, 2019.

36. Snyder LB, Hamilton MA, Mitchell EW, Kiwanuka-Tondo J, Fleming-Milici F, Proctor D. A meta-analysis of the effect of mediated health communication campaigns on behavior change in the United States. J Health Commun. 2004;9(suppl 1):71–96.

37. Lee L, Teutsch S, Thacker S, Louis M, eds. Principles and Practice of Public Health Surveillance. 3rd ed. New York, NY: Oxford University Press; 2010.

38. Centers for Disease Control and Prevention. Vision Health Initiative. Available at: http://www.cdc.gov/visionhealth/about/index.htm. Accessed December 17, 2019.

39. Guttmann A. International perspectives on primary care access, equity, and outcomes for children. Pediatrics. 2016;137:1–3.

40. Gilbert C. The importance of primary eye care. Community Eye Health. 1998;11:17–19.

41. Institute of Medicine Committee on Standards for Developing Trustworthy Clinical Practice Guidelines. Clinical Practice Guidelines We Can Trust. Washington, DC: National Academies Press; 2011.

42. American Optometric Association Health Policy Institute. County data demonstrate eye care access nationwide. Available at: https://www.aoa.org. Accessed December 17, 2019.

43. Lee CS, Morris A, Van Gelder RN, Lee AY. Evaluating access to eye care in the contiguous United States by calculated driving time in the United States Medicare population. Ophthalmology. 2016;123:2456–2461.

44. Thomas L, Wedel K. Nonemergency medical transportation and health care visits among chronically ill urban and rural Medicaid beneficiaries. Soc Work Public Health. 2014;29:629–639.

45. Ku L, Richard P, Dor A, Tan E, Shin P, Rosenbaum S. Using Primary Care to Bend the Curve: Estimating the Impact of a Health Center Expansion on Health Care Costs. Washington, DC: George Washington University; 2009.

46. Betancourt JR. Improving Quality and Achieving Equity: The Role of Cultural Competence in Reducing Racial and Ethnic Health Disparities in Health Care. New York, NY: Commonwealth Fund; 2006.

47. Improving the Nation’s Vision Health: A Coordinated Public Health Approach. Atlanta, GA: Centers for Disease Control and Prevention; 2007.

48. Jacobson P, Wasserman J, Wu H, Lauer J. Assessing entrepreneurship in governmental public health. Am J Public Health. 2015;105(suppl 2):S318–S322.

49. Ye J, He J, Wang C, et al. Smoking and risk of age-related cataract: a meta-analysis. Invest Ophthalmol Vis Sci. 2012;53:3885–3895.

50. Montarzino A, Robertson B, Aspinall P, et al. The impact of mobility and public transport on the independence of visually impaired people. Vis Impairment Res. 2007;9:2–3.

51. Rifkin SB. Examining the links between community participation and health outcomes: a review of the literature. Health Policy Plann. 2014;29::ii98–ii106.

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Chemical regulates light processing differently in the autistic and non-autistic eye, new study finds

by King's College London

King's College London researchers have shown that the brain chemical GABA regulates activity in the retina of the eye in autistic and non-autistic individuals differently. Autistic people have larger responses to single light flashes in the retina of the eye and this new study shows that increasing GABA activity can reduce this response.

Published in The Journal of Neuroscience , the study also showed that those with a greater shift in their retinal activity after receiving a single dose of the GABA drug arbaclofen were those who reported more autistic characteristics. This suggests that GABA's influence on sensory processing could be central to the more complex behaviors experienced by some people with autism.

Gamma-aminobutyric acid (GABA) is a chemical messenger in the brain that regulates the activity of nerve cells in the central nervous system. Research has indicated that there are differences in the GABA pathway between autistic and non-autistic people.

Recently King's researchers used the drug arbaclofen—which switches on GABA type B receptors—to demonstrate that GABA can alter activity in areas of the brain that process visual and auditory information so that autistic and non-autistic people become more alike in their processing.

The influence of GABA on activity in the retina

This new study is the first to demonstrate that using a medication which influences the GABA system can affect the activity in the retina in people with autism so that over-activity is reduced and becomes more similar to light responses in non-autistic people.

"This study builds on existing research that aims to understand more precisely how GABA influences sensory processing in autism. We have found that GABA acts differently in the central nervous system in autism. At an individual level, this is related to autistic traits across both autistic and non-autistic adults in the study.

"We believe this means that differences in the GABA pathway could at least partly underpin autistic neurodivergence," says Grainne McAlonan, Professor of Translational Neuroscience at the Institute of Psychiatry, Psychology and Neuroscience (IoPPN), King's College London and Interim Director of the NIHR Maudsley BRC.

Linking shifts in visual processing to autistic traits

This study used hand-held devices to measure retinal responses to visual stimuli. These stimuli were single flashes of light, flickering lights or single flashes of red light. There were 61 participants, 22 with a diagnosis of autism spectrum disorder and 39 without a diagnosis. Researchers used the drug arbaclofen to modulate of levels of GABA. It was used at two different doses (15 mg and 30 mg) and there was a control group where participants received no arbaclofen.

Results showed that when exposed to single white flashes there was a larger response in the retina (a-wave activity) in people with autism than those without autism. For participants that took the drug arbaclofen there was then a decrease in the retinal activity in autistic participants but an increase in non-autistics.

Using a measure of general autistic characteristics, researchers found that the degree in which the retinal response was shifted by arbaclofen in participants was associated with autistic traits i.e. a greater shift occurred in those with more autistic characteristics both among those with autism and those without autism.

"By using arbaclofen to modulate GABA we are building a clearer picture of how this brain chemical influences sensory processing at different stages. We are also gaining insight into what GABA could tell us about individual differences in autistic traits and the development of tools to predict who might benefit from an intervention option, should they wish to have that choice," says Qiyun Huang, Research Associate at IoPPN, King's College London.

Professor Omar Mahroo, Professor of Retinal Neuroscience, UCL and joint senior author on the project notes, "Light detection and visual processing in the retina shapes our view of the world and this unique collaboration across traditionally distinct areas of neuroscience has helped us take a step closer to understanding that autistic people might truly see the world a little differently."

Informing future clinical trials

The study did not directly test the effectiveness of arbaclofen as an intervention for autism. Some autistic people experience sensory sensitivity which can be distressing. Whether a drug like arbaclofen might be effective in lessening visual sensitivity for people that might want this, remains to be tested. Whether the effect of arbaclofen on sensory processing might also have wider uses also needs to be examined.

Importantly activity in the retina is relatively easy to measure using a hand-held device, compared to EEG which involves attaching sensors to the head to measure activity in the brain. As such the measurement of retinal activity could provide a practical way to aid the decision process as to whether individuals might benefit from participating in clinical trials of arbaclofen and other possible medical and non medical interventions, if they wish to do so.

This study exemplifies a new research strategy that researchers from IoPPN, King's College London are pioneering called the 'shiftability' paradigm. This aims to bridge the translational gap in autism research and establish who may or may not benefit from a particular intervention. It does so by directly establishing that a candidate brain chemical is involved in a brain function by changing it and observing a shift in that function.

Although this experimental approach is used frequently in animal studies there is little direct evidence describing how brain chemical systems modulate information processing in the living human brain.

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Opening health for all: 7 research topics shaping a healthier world.

Despite recognizing health as a fundamental human right, we currently live in a world where half the population can't access the medical care they need , according to the World Health Organization (WHO). In response, World Health Day 2024 rallies under the theme "My health, my right," demanding quality healthcare, clean air, and healthy environments for all.

The call aligns with Sustainable Development Goal #3: good health and well-being , which includes targets such as universal health coverage and strengthening the capacity of all countries, particularly developing countries, for early warning, risk reduction, and management of national and global health risks.

To second this mission, we have picked 7 Research Topics that tackle some of the world's toughest healthcare challenges. These topics cover ensuring everyone's access to healthcare, life-limiting illness as a public health challenge, and the ethical challenges in digital public health.

All articles are openly available to view and download.

1 | Public Health in the Context of Life-Limiting Illnesses: Patient-Centered Care in Advanced and Life-Limiting Illnesses

Palliative care is holistic, person-centered care and has played a critical role in recent disease outbreaks, environmental disasters, and other humanitarian crises. It is also integral to public health and public health strategies.

At least 60% of people who die have a prolonged advanced illness. The need for palliative and end-of-life care will increase due to the rapidly aging world population and the increase of multiple long-term conditions.

Consequentially, this Research Topic discusses advanced and life-limiting illness as a public health challenge. It also explores the role of palliative and end-of-life care, including rehabilitation, in shaping person-centered care.

25,000 views | 16 articles

2 | Ethical Considerations for Digital Public Health

Public health guidelines and policies relating to digital public health are essential to protecting the population. Accessing health services entails an obligation of care, and understanding the role of artificial intelligence (AI) and machine learning (ML) is also necessary.

That’s why this Research Topic focuses on ethical challenges in digital public health. It highlights advances in public health and the ethical questions that may arise when considering the best practices for tools such as AI and ML.

24,000 views | 10 articles

3 | Cardiovascular Health in Children and Adolescents: Present and future

Cardiovascular disease is the most common chronic non-infectious disease and is ranked as the number one cause of death in the world. Although usually manifested at older ages, massive studies have shown that cardiovascular risk factors are tracked from childhood and adolescence to adulthood.

Good cardiovascular health in childhood and adolescence is thus highly important for preventing the development of cardiovascular disease. With this purpose in mind, we introduce a Research Topic that sheds light on the current situation and future cardiovascular health trends in children and adolescents.

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Aging is having a global and significant impact on health, finance, the economy, and society. It is crucial to have an evidence-based approach to understanding the causes of diseases and preventing or treating them.

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23,000 views | 15 articles

6 | Education in Public Health: 2022

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Urban green spaces significantly impact living conditions and public health, which are closely associated with several SDGs, including SDG #3: good health and well-being.

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Accordingly, this Research Topic focuses on recent advances and research on the theory and application of urban green spaces and human health to enhance urban green space's environmental sustainability and contribute to global fair and inclusive sustainable development.

19,000 views | 17 articles

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Intelligent ionotronic wood device can keep an eye on people’s health

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The continuous capture of physiological signals such as heart rate through human contact with wood has been successfully demonstrated with a novel ‘intelligent’ wood device. The chemically modified wood can be turned into a floor or a chair that can sense pressure and heat changes when an individual stands or sits on it. Wood’s natural abundance and mechanical properties make it a promising green material for a range of bioelectronic applications.

Source: © Li et al, Andvanced Functional Materials 2024

The interwoven conductive wood underlayer is covered with an ionic wood veneer to create the iWood device that can sense pressure

In biology organisms store information as ions, whereas electronic devices rely on electrons. ‘We have ions and the electrons that work together to produce tactile sensing signals,’ explains lead author Tingrui Pan . ‘We can actually get an interface between an artificial world like an iPhone and your natural world. This type of sensing is perfect to enable the traditional [wood] with new functionality.’

The team from the University of Science and Technology of China developed the highly sensitive, flexible device dubbed ‘iWood’ by combining two chemical treatments – conductive and ionic modifications – to functionalise natural wood. Firstly, they infused and immobilised an ionic liquid in the wood’s cell wall by making use of capillary effects and weak chemical bonding, while still maintaining the wood’s original structure and properties. Ionic liquids are hydrophobic enough to penetrate the naturally porous wood scaffold and remain there while maintaining structural integrity. ‘What we have done is to immerse or inject enough mobile ions in a permanent way using an ionic liquid. So, we get the water out of the tree and replace it with this ionic liquid with functionality groups to be able to deduce signals inside of the wood product,’ explains Pan.

Cross-section scanning electron microscopy images of the wood cell wall prior to being imbued with an ionic liquid

A separate wood veneer is then coated with a metallic ink to provide surface conductivity. Finally, strips of this conductive wood are braided to create an underlay electrode and then covered with an ionic wood veneer to create the iWood device.

When pressure is applied to this two-layer system the electrically conductive layer comes into contact with the ionic layer and this can be used to measure changes in pressure and heat. A small electronic chip stores the information relayed from the surface and can later transfer it to a smartphone. ‘We have not yet verified whether we can do this in a very controlled quality or mass production way. But I believe there if there’s a market or commercial interest that can be done,’ comments Pan.

The iWood platform could find applications in real-time monitoring of people’s health

Panzarasa Guido , a researcher at ETH Zurich, raises some concerns, however. ‘I would question the long-term stability of such a device,’ he says, as the low surface roughness and repeated cycles of mechanical stress could damage the interface. ‘From a purely technological perspective [the research] is valid, but from a wood material science perspective, there is absolutely nothing new.’

B Lin et al , Adv. Funct. Mater. , 2024, DOI: 10.1002/adfm.202314190

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Testing environmental water to monitor COVID-19 spread in unsheltered encampments

To better understand COVID-19's spread during the pandemic, public health officials expanded wastewater surveillance. These efforts track SARS-CoV-2 levels and health risks among most people, but they miss people who live without shelter, a population particularly vulnerable to severe infection. To fill this information gap, researchers reporting in ACS' Environmental Science & Technology Letters tested flood-control waterways near unsheltered encampments, finding similar transmission patterns as in the broader community and identifying previously unseen viral mutations.

In recent years, testing untreated wastewater for SARS-CoV-2 incidence and dominant viral variants, as well as other pathogens, has been vital to helping public health officials determine infectious disease transmission in local communities. Yet, this monitoring only captures information on viruses shed from human feces and urine in buildings that are connected to local sewage infrastructure. Beyond the pandemic's impact on human health, it also exacerbated socioeconomic difficulties and increased the number of people experiencing homelessness and living in open-air encampments without access to indoor bathrooms. To understand the prevalence of COVID-19 among people who live unsheltered, Edwin Oh and colleagues tested for SARS-CoV-2 in waterways near encampments outside Las Vegas from December 2021 through July 2022.

Using quantitative polymerase chain reaction, the researchers identified SARS-CoV-2 RNA in more than 25% of the samples tested from two flood-control channels. The highest detection frequency over the study period aligned with Las Vegas' first wave of omicron variant infections, as confirmed through parallel testing at a local wastewater treatment plant. The researchers say these results suggest a similar level of transmission was occurring within the unsheltered community as it was among the general population. Then the researchers conducted whole genome sequencing to identify the SARS-CoV-2 variants in the waterways. These samples largely contained the same variants identified in the broader community. Deeper computational analysis of the viral sequences identified three novel viral spike protein mutations in some waterway samples, but the researchers have not yet examined what impact these mutations might have on viral function or clinical outcomes. Regardless, the ability to detect and identify SARS-CoV-2 in environmental water samples could help improve public health measures for a community that is often underrepresented in current surveillance methods. The researchers also say monitoring waterways could warn health officials of unexpected variants circulating in the community.

The authors acknowledge funding from the National Institutes of Health, the Nevada Governor's Office of Economic Development, the Centers for Disease Control and Prevention, and the Water Resources Research Institute of the United States Geological Survey.

• COVID and SARS
• Health Policy
• Environmental Policy
• Sustainability
• Public Health
• STEM Education
• Social Issues
• Public health
• Severe acute respiratory syndrome
• Epidemiology
• Yellow fever
• Spanish flu

Story Source:

Materials provided by American Chemical Society . Note: Content may be edited for style and length.

Journal Reference :

• Anthony Harrington, Van Vo, Michael A. Moshi, Ching-Lan Chang, Hayley Baker, Nabih Ghani, Jose Yani Itorralba, Katerina Papp, Daniel Gerrity, Duane Moser, Edwin C. Oh. Environmental Surveillance of Flood Control Infrastructure Impacted by Unsheltered Individuals Leads to the Detection of SARS-CoV-2 and Novel Mutations in the Spike Gene . Environmental Science & Technology Letters , 2024; DOI: 10.1021/acs.estlett.3c00938

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40 facts about elektrostal.

Written by Lanette Mayes

Modified & Updated: 02 Mar 2024

Reviewed by Jessica Corbett

Elektrostal is a vibrant city located in the Moscow Oblast region of Russia. With a rich history, stunning architecture, and a thriving community, Elektrostal is a city that has much to offer. Whether you are a history buff, nature enthusiast, or simply curious about different cultures, Elektrostal is sure to captivate you.

This article will provide you with 40 fascinating facts about Elektrostal, giving you a better understanding of why this city is worth exploring. From its origins as an industrial hub to its modern-day charm, we will delve into the various aspects that make Elektrostal a unique and must-visit destination.

So, join us as we uncover the hidden treasures of Elektrostal and discover what makes this city a true gem in the heart of Russia.

Key Takeaways:

• Elektrostal, known as the “Motor City of Russia,” is a vibrant and growing city with a rich industrial history, offering diverse cultural experiences and a strong commitment to environmental sustainability.
• With its convenient location near Moscow, Elektrostal provides a picturesque landscape, vibrant nightlife, and a range of recreational activities, making it an ideal destination for residents and visitors alike.

Known as the “Motor City of Russia.”

Elektrostal, a city located in the Moscow Oblast region of Russia, earned the nickname “Motor City” due to its significant involvement in the automotive industry.

Home to the Elektrostal Metallurgical Plant.

Elektrostal is renowned for its metallurgical plant, which has been producing high-quality steel and alloys since its establishment in 1916.

Boasts a rich industrial heritage.

Elektrostal has a long history of industrial development, contributing to the growth and progress of the region.

Founded in 1916.

The city of Elektrostal was founded in 1916 as a result of the construction of the Elektrostal Metallurgical Plant.

Located approximately 50 kilometers east of Moscow.

Elektrostal is situated in close proximity to the Russian capital, making it easily accessible for both residents and visitors.

Known for its vibrant cultural scene.

Elektrostal is home to several cultural institutions, including museums, theaters, and art galleries that showcase the city’s rich artistic heritage.

A popular destination for nature lovers.

Surrounded by picturesque landscapes and forests, Elektrostal offers ample opportunities for outdoor activities such as hiking, camping, and birdwatching.

Hosts the annual Elektrostal City Day celebrations.

Every year, Elektrostal organizes festive events and activities to celebrate its founding, bringing together residents and visitors in a spirit of unity and joy.

Has a population of approximately 160,000 people.

Elektrostal is home to a diverse and vibrant community of around 160,000 residents, contributing to its dynamic atmosphere.

Boasts excellent education facilities.

The city is known for its well-established educational institutions, providing quality education to students of all ages.

A center for scientific research and innovation.

Elektrostal serves as an important hub for scientific research, particularly in the fields of metallurgy, materials science, and engineering.

Surrounded by picturesque lakes.

The city is blessed with numerous beautiful lakes, offering scenic views and recreational opportunities for locals and visitors alike.

Well-connected transportation system.

Elektrostal benefits from an efficient transportation network, including highways, railways, and public transportation options, ensuring convenient travel within and beyond the city.

Famous for its traditional Russian cuisine.

Food enthusiasts can indulge in authentic Russian dishes at numerous restaurants and cafes scattered throughout Elektrostal.

Home to notable architectural landmarks.

Elektrostal boasts impressive architecture, including the Church of the Transfiguration of the Lord and the Elektrostal Palace of Culture.

Offers a wide range of recreational facilities.

Residents and visitors can enjoy various recreational activities, such as sports complexes, swimming pools, and fitness centers, enhancing the overall quality of life.

Provides a high standard of healthcare.

Elektrostal is equipped with modern medical facilities, ensuring residents have access to quality healthcare services.

Home to the Elektrostal History Museum.

The Elektrostal History Museum showcases the city’s fascinating past through exhibitions and displays.

A hub for sports enthusiasts.

Elektrostal is passionate about sports, with numerous stadiums, arenas, and sports clubs offering opportunities for athletes and spectators.

Celebrates diverse cultural festivals.

Throughout the year, Elektrostal hosts a variety of cultural festivals, celebrating different ethnicities, traditions, and art forms.

Electric power played a significant role in its early development.

Elektrostal owes its name and initial growth to the establishment of electric power stations and the utilization of electricity in the industrial sector.

Boasts a thriving economy.

The city’s strong industrial base, coupled with its strategic location near Moscow, has contributed to Elektrostal’s prosperous economic status.

Houses the Elektrostal Drama Theater.

The Elektrostal Drama Theater is a cultural centerpiece, attracting theater enthusiasts from far and wide.

Popular destination for winter sports.

Elektrostal’s proximity to ski resorts and winter sport facilities makes it a favorite destination for skiing, snowboarding, and other winter activities.

Promotes environmental sustainability.

Elektrostal prioritizes environmental protection and sustainability, implementing initiatives to reduce pollution and preserve natural resources.

Home to renowned educational institutions.

Elektrostal is known for its prestigious schools and universities, offering a wide range of academic programs to students.

Committed to cultural preservation.

The city values its cultural heritage and takes active steps to preserve and promote traditional customs, crafts, and arts.

Hosts an annual International Film Festival.

The Elektrostal International Film Festival attracts filmmakers and cinema enthusiasts from around the world, showcasing a diverse range of films.

Encourages entrepreneurship and innovation.

Elektrostal supports aspiring entrepreneurs and fosters a culture of innovation, providing opportunities for startups and business development.

Offers a range of housing options.

Elektrostal provides diverse housing options, including apartments, houses, and residential complexes, catering to different lifestyles and budgets.

Home to notable sports teams.

Elektrostal is proud of its sports legacy, with several successful sports teams competing at regional and national levels.

Boasts a vibrant nightlife scene.

Residents and visitors can enjoy a lively nightlife in Elektrostal, with numerous bars, clubs, and entertainment venues.

Promotes cultural exchange and international relations.

Elektrostal actively engages in international partnerships, cultural exchanges, and diplomatic collaborations to foster global connections.

Surrounded by beautiful nature reserves.

Nearby nature reserves, such as the Barybino Forest and Luchinskoye Lake, offer opportunities for nature enthusiasts to explore and appreciate the region’s biodiversity.

Commemorates historical events.

The city pays tribute to significant historical events through memorials, monuments, and exhibitions, ensuring the preservation of collective memory.

Promotes sports and youth development.

Elektrostal invests in sports infrastructure and programs to encourage youth participation, health, and physical fitness.

Hosts annual cultural and artistic festivals.

Throughout the year, Elektrostal celebrates its cultural diversity through festivals dedicated to music, dance, art, and theater.

Provides a picturesque landscape for photography enthusiasts.

The city’s scenic beauty, architectural landmarks, and natural surroundings make it a paradise for photographers.

Connects to Moscow via a direct train line.

The convenient train connection between Elektrostal and Moscow makes commuting between the two cities effortless.

A city with a bright future.

Elektrostal continues to grow and develop, aiming to become a model city in terms of infrastructure, sustainability, and quality of life for its residents.

In conclusion, Elektrostal is a fascinating city with a rich history and a vibrant present. From its origins as a center of steel production to its modern-day status as a hub for education and industry, Elektrostal has plenty to offer both residents and visitors. With its beautiful parks, cultural attractions, and proximity to Moscow, there is no shortage of things to see and do in this dynamic city. Whether you’re interested in exploring its historical landmarks, enjoying outdoor activities, or immersing yourself in the local culture, Elektrostal has something for everyone. So, next time you find yourself in the Moscow region, don’t miss the opportunity to discover the hidden gems of Elektrostal.

Q: What is the population of Elektrostal?

A: As of the latest data, the population of Elektrostal is approximately XXXX.

Q: How far is Elektrostal from Moscow?

A: Elektrostal is located approximately XX kilometers away from Moscow.

Q: Are there any famous landmarks in Elektrostal?

A: Yes, Elektrostal is home to several notable landmarks, including XXXX and XXXX.

Q: What industries are prominent in Elektrostal?

A: Elektrostal is known for its steel production industry and is also a center for engineering and manufacturing.

Q: Are there any universities or educational institutions in Elektrostal?

A: Yes, Elektrostal is home to XXXX University and several other educational institutions.

Q: What are some popular outdoor activities in Elektrostal?

A: Elektrostal offers several outdoor activities, such as hiking, cycling, and picnicking in its beautiful parks.

Q: Is Elektrostal well-connected in terms of transportation?

A: Yes, Elektrostal has good transportation links, including trains and buses, making it easily accessible from nearby cities.

Q: Are there any annual events or festivals in Elektrostal?

A: Yes, Elektrostal hosts various events and festivals throughout the year, including XXXX and XXXX.

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Community-Engaged Research: Common Themes and Needs Identified by Investigators and Research Teams at an Emerging Academic Learning Health System

Megan b. irby.

1 Maya Angelou Center for Health Equity, Wake Forest School of Medicine, Winston-Salem, NC 27157, USA; ude.htlaehekaw@ybrim

Keena R. Moore

2 Program in Community-Engaged Research, Wake Forest School of Medicine, Winston-Salem, NC 27157, USA; ude.htlaehekaw@eroomrk (K.R.M.); ude.htlaehekaw@lladnari (I.R.)

Lilli Mann-Jackson

3 Department of Social Sciences and Health Policy and Program in Community-Engaged Research, Wake Forest School of Medicine, Winston-Salem, NC 27157, USA; ude.htlaehekaw@nnaml

DeWanna Hamlin

4 Formerly of the Program in Community-Engaged Research, Wake Forest School of Medicine, Winston-Salem, NC 27157, USA; moc.oohay@nilmahtld

Isaiah Randall

Phillip summers.

5 Department of Radiology, Wake Forest School of Medicine, Winston-Salem, NC 27157, USA; ude.htlaehekaw@sremmusp

Joseph A. Skelton

6 Department of Pediatrics and Program in Community-Engaged Research, Wake Forest School of Medicine, Winston-Salem, NC 27157, USA; ude.htlaehekaw@notleksj

Stephanie S. Daniel

7 Department of Family and Community Medicine and Program in Community-Engaged Research, Wake Forest School of Medicine, Winston-Salem, NC 27157, USA; ude.htlaehekaw@leinads

Scott D. Rhodes

Associated data.

Data are available from the corresponding author.

Community-engaged research (CEnR) has emerged within public health and medicine as an approach to research designed to increase health equity, reduce health disparities, and improve community and population health. We sought to understand how CEnR has been conducted and to identify needs to support CEnR within an emerging academic learning health system (aLHS). We conducted individual semi-structured interviews with investigators experienced in CEnR at an emerging aLHS in the southeastern United States. Eighteen investigators (16 faculty and 2 research associates) were identified, provided consent, and completed interviews. Half of participants were women; 61% were full professors of varied academic backgrounds and departments. Interviews were audio-recorded, transcribed, coded, and analyzed using constant comparison, an approach to grounded theory. Twenty themes emerged that were categorized into six domains: Conceptualization and Purpose, Value and Investment, Community-Academic Partnerships, Sustainability, Facilitators, and Challenges. Results also identified eight emerging needs necessary to enhance CEnR within aLHSs. The results provide insights into how CEnR approaches can be harnessed within aLHSs to build and nurture community-academic partnerships, inform research and institutional priorities, and improve community and population health. Findings can be used to guide the incorporation of CEnR within aLHSs.

1. Introduction

1.1. community-engaged research.

Community-engaged research (CEnR) has emerged within public health and medicine as an approach to research designed to increase health equity, reduce health disparities, and improve community and population health. CEnR involves the affected community in research, and defines that community as any group of people affiliated by geographic proximity, special interest, health condition, or similar categories of shared identity. Rather than investigators and research teams from universities, government, or other types of research organizations approaching and entering a community with a preconceived notion of a community’s best interests, in projects that apply CEnR approaches, community members and representatives from community organizations collaborate and share research roles with academic investigators and research teams. Community members become not merely “targets” of research but also research partners. CEnR emphasizes relationship-building and trust; open communication; co-learning; reciprocal transfer of expertise; shared power, resources, and decision-making; and mutual ownership of the processes and products of research [ 1 , 2 , 3 , 4 , 5 , 6 , 7 , 8 , 9 ].

Growing evidence suggests that including community members and representatives from community organizations in the design, implementation, and evaluation of research can lead to deeper, more informed, and nuanced understandings of health-related phenomena and identify actions (e.g., interventions, programs, and policy and system changes) that are more relevant, culturally congruent, and likely to be effective, sustained, and scalable, if warranted, to improve community and population health [ 6 , 7 , 9 , 10 , 11 ]. However, the conduct of CEnR is shaped by institutional (e.g., allocation of resources and time), community (e.g., local history and receptivity), and personal (e.g., background, experiences, and world views) factors. Thus, there is no standardized way to engage and partner with communities to conduct CEnR, and there is great variability across models of engagement and in the degree to which communities are included in the research process [ 8 , 9 ].

Community engagement often is viewed as a continuum that spans from outreach (less engaged), consultation, involvement, and collaboration, to shared leadership (more engaged) [ 3 , 4 , 7 , 12 , 13 ]. As such, the community engagement literature is extensive and features a wide range of theories, approaches, strategies, and methods, reflecting tremendous diversity in how community engagement is defined, implemented, and evaluated [ 1 , 2 , 6 , 7 , 13 ]. Despite this heterogeneity, CEnR includes several common critical elements. These include: (1) Collaboration with groups of people affiliated by geographic proximity, special interest, health condition, or other categories of shared identity; (2) Groups of community members, organizational representatives, and academic researchers adhering to common principles and norms to nurture trust and promote authentic partnership; (3) Focus on identifying and addressing the needs and priorities and harnessing the assets that affect health and well-being; and (4) Research as an approach to systematically uncover and understand health-related phenomena and improve community and population health [ 2 , 3 , 7 ].

1.2. Academic Learning Health Systems

Learning health systems (LHSs) are organizations or networks that pursue a cycle of perpetual learning processes embedded in daily practice. These processes inform evidence-based improvements in health care to yield better patient outcomes. This cycle combines quality improvement methods and data analytics from patient care, which are fed back into the LHS to inform institutional policies and structures and improve care delivery [ 14 ]. An academic learning health system (aLHS) prioritizes gathering new, generalizable knowledge to improve community and population health, in addition to promoting continuous improvement and innovation within its own health care delivery system. An aLHS draws on its embedded academic expertise in public health and medical education, health system sciences, translation, and population and community health; shares knowledge and imparts skills necessary to advance the system internally; and disseminates knowledge broadly to contribute to knowledge generation and advance science [ 15 , 16 ].

Although engaging patients to provide perspectives and feedback into various aspects of health systems has long been valued, to date, there has been no exploration of CEnR within aLHSs. This is due in part to the recent emergence of the aLHS as a concept and entity [ 15 , 16 , 17 ]. Understanding how CEnR has been conducted and identifying needs to support and enhance CEnR within an emerging aLHS could provide insights critical to advance our knowledge of effective CEnR methods and designs and strengthen the conduct of future research designed to increase health equity, reduce health disparities, and improve community and population health [ 18 ].

Wake Forest School of Medicine/Wake Forest Baptist Health (WFSM/WFBH), an emerging aLHS, has a long and successful history of CEnR [ 19 , 20 , 21 , 22 , 23 ]. A number of its investigators routinely incorporate community engagement in their research. We sought to explore how CEnR has been harnessed at WFSM/WFBH; how investigators at this emerging aLHS have incorporated principles of community engagement within their research; the degree to which community members and/or representatives from community organizations have been involved in the planning, implementation, evaluation, and/or dissemination phases of research; the nature of CEnR as it is implemented within the context of the local community; and what institutional supports are needed to facilitate and integrate CEnR within an aLHS.

2. Materials and Methods

2.1. setting.

WFSM/WFBH is an emerging aLHS serving more than 50 counties in North Carolina, Tennessee, Virginia, and West Virginia. It is comprised of WFSM and five hospitals in the Piedmont region of northwest North Carolina. In addition to training medical, physician assistant, and nursing students, WFSM has a broad array of biomedical graduate and postdoctoral training programs. It also has a large Division of Public Health Sciences with Departments in Biostatistics and Data Science, Epidemiology and Prevention, Implementation Science, and Social Sciences and Health Policy. A Clinical and Translational Science Award (CTSA) from the National Center for Advancing Translational Sciences (NCATS), National Institutes of Health (NIH), supports the WFSM/WFBH Clinical and Translational Science Institute (CTSI), which includes the Program in Community-Engaged Research (UL1TR001420). The Program aims to improve community and population health through promoting and facilitating community-relevant and engaged research, working in partnership with communities to identify health needs, priorities, and assets and to seek solutions to health challenges together [ 23 ].

2.2. Participants

We conducted individual semi-structured interviews with investigators experienced in community engagement and CEnR. We identified potential interviewees with assistance from the WFSM/WFBH CTSI and Institutional Review Board (IRB). A keyword search was performed within the institutional grants management software (InfoEd) and IRB databases to identify WFSM/WFBH investigators who had submitted research applications related to community engagement or CEnR within the past ten years. Search terms included “community”, “engagement”, “CBPR”, “participatory research”, and “partnership”. Abstracts from identified applications were reviewed to further determine eligibility. Investigators were then contacted by electronic mail and invited to participate in an interview. Interviews with consenting participants were then scheduled at a time and location convenient to the participant. Interviews were conducted by two trained study staff and digitally recorded, with study staff also taking clarifying notes. During interviews, participants were asked for the names of other investigators within the institution who also conducted CEnR to identify additional potential participants. Interviews were transcribed verbatim and subsequently verified.

2.3. Individual Semi-Structured Interview Guide

We chose a qualitative research approach to gain a broad spectrum of perspectives about CEnR within the context of an aLHS. This qualitative approach can yield perspectives and insights that are not previously known by researchers and thus would not emerge in a more close-ended quantitative approach [ 24 , 25 ]. A semi-structured interview guide was designed to collect both descriptive demographic data from each participant, including race/ethnicity, age, gender, position, academic degrees, background, current academic department, years at WFSM/WFBH, and CEnR training. The guide also captured socio-contextual and detailed descriptions of perceptions, experiences, and strategies specific to the use of community engagement and CEnR. Areas explored included: how each participant conceptualizes and defines CEnR; their preparation for CEnR, including formal training; perceived benefits of CEnR; challenges associated with CEnR; how communities are engaged in research; what roles community members and representatives from community organizations play in CEnR; how the region (i.e., southern United States) and the institution (i.e., an emerging aLHS) affect CEnR; how sustainability and dissemination of CEnR are incorporated into CEnR; and what CEnR lessons have been learned by each participant. The guide is summarized in Table 1 .

Abbreviated items from the individual semi-structured interview guide.

The semi-structured interview guide was drafted, reviewed, revised, and finalized by community members with experience in community-engaged research and experts in community engagement and aLHSs. All items were open-ended. The guide was pilot tested for comprehension and timing with 3 investigators; slight revisions to wording were made based on the pilot.

2.4. Analysis

Each interview transcript was coded by two analysts. Themes were identified through constant comparison, an approach to developing grounded theory, combining inductive coding with simultaneous comparison [ 25 ]. Using standard procedures [ 25 ], analysts first coded text and convened to compare their codes. They then identified and resolved any discrepancies through discussion. Matrices were used to identify similarities and differences within and across participants. Analysts identified, refined, and interpreted themes iteratively through discussion and by examining codes and rereading the transcripts. Findings and themes were presented to interview participants in a presentation for the WFSM/WFBH CTSI Program in Community-Engaged Research Affinity Group ( n = 27). The Affinity Group is a group of investigators, research team members, and others at WFSM/WFBH who are interested in CEnR. Members of the Community Stakeholder Advisory Committee (CSAC) ( n = 8) of the CTSI’s Program in Community-Engaged Research also attended. CSAC is comprised of representatives from community organizations who provide feedback to the CTSI regarding research infrastructure and policies, and to investigators and research teams regarding WFSM/WFBH research initiatives [ 26 ] Presentation attendees contributed to the refinement of themes and their interpretation through facilitated group discussion.

Human subject approval and oversight for this study were provided by the WFSM/WFBH IRB.

The keyword search in InfoEd and IRB databases yielded the names and research projects of 51 investigators. Sixteen investigators were confirmed as eligible based on a review of project abstracts; 14 of these responded to email invitations and agreed to participate. Four additional participants were referred by initial participants. In all, 18 investigators (16 faculty and 2 senior research associates) provided consent and completed interviews. Interviews averaged 45 min.

The participant sample ( Table 2 ) was 50% female, had a mean age of 55 years, was mostly White, and had varied academic backgrounds. Most participants held doctoral degrees (i.e., PhD, DrPH, EdD, MD, and MD/PhD). On average, participants had worked at WFSM/WFBH for nearly 14 years, and represented six academic departments. Nearly all participants indicated they had never received formal education or training in CEnR, though 100% reported “on-the-job” training and experience. All had been principal investigators on at least one federally funded research project.

Demographics of participants ( N = 18).

* Count and percent or mean and standard deviation.

3.1. Domains and Themes Related to Community Engagement and CEnR

Twenty themes emerged across six domains related to community engagement and CEnR within an aLHS ( Table 3 ): Conceptualization and Purpose, Value and Investment, Community-Academic Partnerships, Sustainability, Facilitators, and Challenges.

Domains and themes related to conducting community-engaged research (CEnR) at an academic learning health system (aLHS).

3.1.1. Conceptualization and Purpose of CEnR

Participants agreed that CEnR is a collaborative approach to research designed to improve health and well-being through participatory and better-informed inquiry, always with an eye on how knowledge generated can be translated and applied within the local affected community. However, participants noted that this local application of knowledge does not preclude its generalizability and transferability to other contexts, thus aligning with the broader research goals of an aLHS. Participants also identified CEnR as an approach relevant within many aspects of an aLHS, including education and training, quality improvement, clinical care, and clinical trials.

Participants highlighted the difficulties in defining “community” and emphasized that communities are heterogeneous, which can be challenging for investigators and research teams who may want “simple answers” (e.g., perspectives and insights) from community partners; as participants reported, working with one community does not yield one voice. CEnR was identified as requiring careful consideration of the various perspectives and insights of all partners. Finally, participants also identified additional goals of CEnR, including strengthening connections within the community, building resilience and capacity, and reducing the effects of marginalization.

3.1.2. Value and Investment in CEnR: Institutional, Professional, and Personal

Participants described CEnR as an under-appreciated and frequently misunderstood approach to research within many institutions, including federal funding agencies such as the NIH, the U.S. Centers for Disease Control and Prevention (CDC), and the Health Resources and Services Administration (HRSA). A participant reported that this misunderstanding among federal partners persists even when a project is required by the federal partner and funder and initially designed to be conducted using CEnR approaches. A participant provided an example of an intervention study that resulted in null findings; the participant attributed the study’s null findings to funder-required changes to the study design, recruitment and retention strategies, and an intervention that did not align with community partner perspectives and were contrary to project-specific community steering committee guidance.

Participants also noted that their professional and academic investment in CEnR stemmed from their own personal values, including community health, health equity, and social justice. Participants agreed that this commitment was not limited to traditional nine-to-five “work hours,” but that successful community engagement must be woven into daily life and interactions to be successful.

3.1.3. Community-Academic Partnerships

Participants expressed that the type and degree of engagement, and the ease with which partnerships are formed, depend on the extent to which communities feel they have been marginalized and how they perceive research and research institutions. Moreover, partnerships, how they function, and the roles of partnership members in CEnR vary profoundly across investigators and across projects. Participants identified many areas as essential to the development of strong and productive partnerships: fostering trust and mutual respect, balancing expertise across community and aLHS partners, investing time, facilitating open communication, embracing conflict as a strategy for resolution, and overcoming barriers (including addressing community mistrust based on previous community experiences with both research and health care). Participants noted the role of the Tuskegee Syphilis Study [ 27 ], the Guatemalan Syphilis Experiments [ 28 ]), and rampant anti-immigration rhetoric [ 29 ], racism, homophobia, and transphobia in the United States as contributing to community mistrust.

3.1.4. Sustainability of CEnR

Participants described sustaining CEnR as complex, citing both the need and the difficulty of maintaining community-aLHS partnerships beyond the time period of an individual project. They highlighted the difficulty in sustaining partnerships without funding for continued community involvement and effort from academic investigators and research teams. Additionally, participants noted that sustainability is influenced by the strength and quality of engagement throughout a project, and how well community partners were incorporated into the research process—from conception, study design and conduct, data analysis and interpretation, to the dissemination of findings.

3.1.5. Facilitators of CEnR

Participants emphasized the need for institutional support (e.g., funding, protected time, and respect) and research resources (e.g., CTSA and institutional research centers) that prioritize CEnR as integral to the academic mission of an aLHS. Participants also noted the immense value of having an IRB that is willing to learn the nuances of CEnR in order to approve and oversee CEnR.

3.1.6. Challenges of CEnR

Participants described the potential for burn out and strain resulting from the need to incorporate community engagement into daily life and the great time commitment accompanying CEnR. Other challenges identified by participants related to the discordance between community and academic goals within a given research project, and differences in overarching community and academic priorities that challenged collaboration. Participants also described the challenges of history and how an institution’s complicity in oppressive practices of the past influenced the development and maintenance of community research partnerships. For example, some participants cited WFSM/WFBH’s past involvement in the North Carolina Eugenics Program [ 30 ] as reducing community trust and engagement.

3.2. Enhancing Community-Engaged Research within an aLHS

We also identified eight emergent needs that could enhance CEnR within aLHSs ( Table 4 ). First, participants described the need for increased understanding among academic investigators, research teams, and healthcare providers of community contexts and assets, social determinants of health (also known as “social drivers of health”), and historical factors that influence community and population health. Participants reported that this increased understanding may be particularly critical because many investigators, research teams, and providers may be from other regions of the country or other parts of the world. Thus, although well intentioned, they may not sufficiently understand the local community or the contexts of the populations of interest and focus.

Emergent needs to support and enhance community-engaged research (CEnR) within an academic learning health system (aLHS).

Similarly, participants noted a profound need for increased understanding of CEnR within the aLHS and its value as an approach within community and population health, public health, and medicine. Participants expressed frustration that CEnR is often conflated with community outreach; formative or qualitative research; or behavioral and social sciences. Participants emphasized that members of communities have critical perspectives regarding research into locally identified needs and priorities. Such collaborations can harness the assets of both the community and the aLHS.

Third, participants also highlighted the need for training community members, academic investigators, and research teams to increase their understanding of and skills in partnering with communities and conducting CEnR. Participants noted that establishing authentic and productive partnerships to conduct CEnR is difficult, and, despite good intentions, many investigators and research teams at the emerging aLHS do not understand how to work effectively with community members and representatives from community organizations. At the same time, participants shared that community partners may not sufficiently understand the research process, how evidence and knowledge are generated, and the various components of and objectives inherent within an aLHS.

Fourth, participants noted that although the theories and principles underlying CEnR are well documented, effective frameworks and methods aligned with CEnR are needed. They noted the need for methodologic innovations. Participants noted methods such as photovoice [ 31 ], empowerment-based community forums [ 32 ], evidence academies [ 33 ], and citizen science [ 23 ] are well developed, further research approaches to and methods aligned with CEnR are needed.

Participants also noted that policy changes can positively affect health in multiple ways, whether within an aLHS, the local community, or nationally. They identified a need for evidence-based, practical guidance to increase the translation of CEnR findings into policies designed to improve community and population health.

Sixth, participants acknowledged the need for guidance on balancing the perspectives of community and aLHS partners. They reported that it can be difficult for academic investigators and research teams to know how to elicit community partner perspectives, to usefully share their own perspectives (based on theory, their own prior research, and the existing literature), build on and negotiate with community partners, and negotiate and compromise in ways that ensure sound science and maximize the success of a research project. Participants noted that CEnR requires weighing scientific rigor and what is realistic and “doable”; far too often, participants reported, investigators and research teams may choose rigorous research approaches that simply cannot be successfully implemented. Participants asserted not including community perspectives through CEnR could result in study designs that are inauthentic to how communities convene, interact, and take action; enrollment and retention plans that are not acceptable or realistic; and/or measurement that does not make sense to members of the community. In such situations, data collection may be sacrificed, analysis and interpretation of findings may be less accurate, and sustainability and meaningful dissemination of findings may not be possible.

Participants cited a need for a model to incorporate principles of CEnR into research mission, vision, and priorities of an aLHS. They suggested that the linkages between CEnR and aLHS need further exploration and articulation. Finally, participants reported the need for more institutional support for community engagement and CEnR. This support included pilot funding and protected time of investigators and research teams to establish partnerships, develop innovative methods, and explore integration of community perspectives into the priorities and processes of an aLHS.

4. Discussion

Our results provide insights critical to understanding how CEnR approaches function within an emerging aLHS and ways to further build and nurture community-academic partnerships and inform research and institutional priorities to increase health equity, reduce health disparities, and improve community and population health. In this study, we identified six primary domains of 20 themes related to the purpose of CEnR, its value within an aLHS, characteristics of effective community-aLHS partnerships, issues related to sustainability of CEnR, facilitators of CEnR within an aLHS, and challenges facing CEnR within an aLHS. Many of these domains have been explored in the broader CEnR literature; however, this is the first exploration of CEnR within an aLHS. We also uncovered eight needs that, if addressed, could support and enhance community engagement and CEnR within an aLHS. Several findings deserve highlighting.

First, participants expressed the need for academic investigators, research teams, and healthcare providers to better understand community contexts, social determinants of health, and historical factors influencing community and population health and participation in research. This view is consistent with previous research suggesting that health disparities will persist without better understanding of health and health-related phenomena within communities and the ongoing reluctance of community members to participate in research [ 11 ].

Participants also described the importance of the aLHS’s reputation in the community as critical to influencing trust and engagement, particularly among historically marginalized populations. Participants specifically noted WFSM/WFBH’s past involvement in the North Carolina Eugenics Program and other discriminatory practices committed against minority and vulnerable populations [ 30 ]; they also noted that many communities across the United States share similar historical narratives. Thus, although much work must done; the inclusion of CEnR within CTSAs and emerging aLHS is a step in the right direction.

Trust is built by and exists among individuals; community members may or may not trust an institution, but the ongoing commitment of investigators and research teams from an aLHS to partner with and listen to community members can overcome mistrust [ 21 ]. Thus, thorough training for academic investigators and research teams is essential. This training should include how to work collaboratively; how to encourage, elicit, and listen to diverse voices; and how to help partners organize for community and population health. While training in designing studies, reducing bias, and increasing validity are critical for investigators and research teams, skills in relationship building and maintenance and in negotiation and compromise are similarly critical [ 2 , 11 , 34 , 35 ]. For example, when investigators and research teams from an aLHS attend community fairs, church gatherings, community forums, or parties and celebrations, these informal settings help build and nurture trust among partners. These opportunities show commitment and allow attendees to further understand one another. Volunteering with a community organization or serving on local health coalitions are other ways to advance trust and develops genuine and mutually respectful relationships between researchers and communities. In addition, this involvement can open other doors by helping to identify others in the community who may be committed to working together [ 21 ].

Nearly all participants in this study highlighted the need for institutions to explicitly show their value of CEnR. This finding aligns with previous work that identified barriers attributable to institutional culture that shape research agendas and support for CEnR, and challenges in gaining support from institution leadership and top decision-makers [ 8 , 11 ]. Overcoming these challenges and cultural aspects specific to aLHSs likely requires leadership to further explore institutional readiness to serve as a partner to communities, the existence and appropriateness of structures to support CEnR scholarship, investigator and study staff training in CEnR, the extent to which aLHS goals align with principles of CEnR, and whether there is sufficient CEnR expertise within the institution to establish a commitment to CEnR [ 11 , 34 , 35 ]. Participants echoed the need for CEnR training opportunities (for investigators, research teams, and community members); education on effective models of engagement across diverse populations; resources to conduct CEnR authentically; and guidance for interpreting findings and disseminating information back to communities.

This study was conducted at a single aLHS; thus, findings may not be applicable to other aLHSs. Regardless, the study’s design and analysis may help other aLHSs and medical centers, as well as those seeking to incorporate CEnR approaches within public health and medicine, to engage and form authentic and long-lasting partnerships with communities. The sample size achieved saturation across interviews and provides valuable information regarding the number of investigators and research teams conducting CEnR. In this study, we did not collect data from community research partners, which was beyond the scope of our work. Future research is warranted to better understand perspectives of community members and community organizations with or without previous experience partnering with investigators and research teams within aLHSs.

5. Conclusions

While some findings from this study reflect the broader CEnR literature, these findings are important for informing CEnR approaches and can be used to guide the incorporation of CEnR within aLHSs. LHSs and aLHSs are becoming more established and numerous, and many institutions could benefit from our findings. In educating the next generation of academic investigators, research teams, and healthcare providers, an aLHS can incorporate CEnR as it strives to understand and increase health equity, reduce health disparities, and improve community and population health.

Author Contributions

Conceptualization, S.D.R.; methodology, S.D.R., M.B.I., K.R.M. and P.S.; software, S.D.R.; validation, M.B.I., D.H., I.R. and P.S.; formal analysis, S.D.R. and M.B.I.; investigation, M.B.I., S.D.R. and K.R.M.; resources, S.D.R.; data curation, S.D.R. and M.B.I.; writing—original draft preparation, S.D.R. and M.B.I.; writing—review and editing, S.D.R., M.B.I., K.R.M., L.M.-J., D.H., I.R., P.S., J.A.S. and S.S.D.; supervision, S.D.R.; project administration, K.R.M.; funding acquisition, S.D.R. All authors have read and agreed to the published version of the manuscript.

This research was funded by National Center for Advancing Translational Sciences, National Institutions of Health, grant number UL1TR001420.

Institutional Review Board Statement

The study was conducted according to the guidelines of the Declaration of Helsinki, and approved by the Institutional Review Board (or Ethics Committee) of Wake Forest School of Medicine (protocol code IRB00049597; date of initial approval: 04/10/2018, renewed annually).

Informed Consent Statement

Informed consent was obtained from all subjects involved in the study.

Data Availability Statement

Conflicts of interest.

The authors declare no conflict of interest.

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