Technology for eye health promotion

1. EFFECTIVENESS OF MOBILE AND
INTERNET BASED ADVOCACY
STRATEGIES FOR EYE HEALTH
PROMOTION:
A Randomised Pre-test Post-test study
Indra P Sharma
Optometrist
JDWNRH, Ministry of Health, Bhutan

2. Declaration
Conflict of Interest:
The Authors have no conflict of interest to declare
Funding:
None
Aknowledgement:
The faculty and students of the Department of Optometry, Amity University
Haryana for helping in data collection.
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3. BACKGROUND
• Visual impairment (VI) is emerging as a major public health challenge [1].
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Source: WHO, Global data on visual impairment: 2010

4. Contd...
• VI poses a huge socio-economic burden and impact the quality of life [3-
5].
• Fortunately, 4/5th of all visual impairment are avoidable [2].
• Level of awareness and knowledge of common vision-impairing diseases
are poor among the general population [6-9].
• The lack of awareness is a proven barrier to uptake of eye care services
[10-12].
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5. Contd...
• Mobile and internet technologies has emerged as an inexpensive, fast
and effective method of disseminating health information [13].
• In 2015, with an estimate of over 7.0 million cellular phone subscribers,
the mobile penetration rate reached 96 % globally and 90% in developing
countries [14].
• Health promotion using technologies remains underutilized by public
health professionals and policy makers [15-18].
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6. 6Mobile and Internet for Eye Health Promotion
Source: Internet World stats, ITU 2017

7. AIM AND OBJECTIVES
1. To assess the awareness and knowledge about common
vision-impairing diseases among young educated
population and,
2. Evaluate the effectiveness of mobile phone and internet-
based advocacy method in enhancing the awareness and
knowledge about the diseases.
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8. METHODS
Study Design and Participants
• Randomized pre-test post-test questionnaire based study.
• Setting: Amity University, Haryana, India between January to July 2016.
• Sampling frame: All students of Indian origin aged 18 to 28 years at
Amity University Haryana
Ethical Consideration
• Design and protocol approved by the Institutional Ethical Committee of
the Amity University Haryana (AUH)
• Informed consent obtained
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9. Contd...
Enrolment and Pre-test assessment
• Following the recruitment, the socio-demographic data and contact details
(web-enabled personal mobile phone number) were recorded. The pre-test
assessment was performed using a validated questionnaire.
Awareness and knowledge Questionnaire
• A self-administered structured questionnaire was developed and validated.
Randomization and Blinding
• The randomization (computer generated) was performed after the pre-test
in an attempt to avoid bias.
• The data were collected by trained optometrist, blinded to the intervention
options.
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10. 10Mobile and Internet for Eye Health Promotion
2010 Flow Diagram
Figure 1. Study flowchart to demonstrate participant enrollment, allocation and analysis.
Assessed for eligibility (18-30 years)
(n=442)
Excluded (n=14 )
Declined to participate (n=13)
Optometry student (n=1)
Analysed (n= 203 )
Excluded (incomplete details) (n=4)
Received post-test assessment (n=207 )
Lost to follow-up (n=5)
Declined post-test (n=0)
Allocated to controlgroup and did
not recieve advocacy (n=212 )
Recived post-test assessment (n=208)
Lost to follow-up (n=3 )
Declined post-test (n=1 )
Allocated to intervention group
and recieved advocacy (n=212)
Analysed (n= 206)
Exclude (incomplete details) (n=2)
Allocation and
intervention
Analysis
Post-intervention
assessment
Randomized (n=424)
Excluded (incomplete details) (n=4)
Enrollment
Pre-test assessment (n=428)
Figure 1: Study flowchart to demonstrate participant enrollment, allocation and analysis.

11. Contd...
Intervention
• A short text message with a
hyperlink of the WHO website
on priority eye diseases
(http://www.who.int/blindness
/causes/priority/en/) was sent
as SMS to the participants in
intervention group.
• The participants in the control
group received no further
communication until the post-
test.
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12. Contd...
Statistical Analysis
• Assuming an effect size of 0.04 (small) between the two groups and an
alpha error of 0.05 (two-tailed), 328 participants were required to give a
power (1 - β) of over 95%. Considering the follow-up rate at 80% and
absenteeism of 15% the number of participants recruited and
questionnaires distributed in the pre-test were 442.
• SPSS 21 was used for statistical analysis. The Fisher exact test, Pearson
chi-square test and ANOVA compared between-group differences in
participant characteristics at baseline. Pre-test analysis used descriptive
test, and McNemar test and Wilcoxon matched-pairs test were
performed compare pre-test post-test outcomes.
• Values of P<0.05 were considered statistically significant.
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13. RESULTS
• The pre-test (baseline) assessment was completed by 428 participants,
however, only 209 responses were eligible for the statistical analysis
(response rate, 95.6%).
• At the pre-test (baseline), there was no significant differences in
demographic profiles between the two groups (for all, P <0.05)
• At the post-test, both groups demonstrated a better awareness and
knowledge compared to baseline, but the improvements proved
significant only for the group receiving intervention (p≤0.001, for all).
• However, the intervention group also showed a significant increase in
awareness of refractive error during the post-test (p<0.001).
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14. Table: Pre-test awareness and knowledge of common eye diseases
Eye disease Awareness of the
disease
n (%)
Reasonable
knowledge on
symptom
n (%)
Reasonable
knowledge on
treatment
n (%)
Cataract 281 (68.7) 157 (38.4) 74 (18.1)
Glaucoma 112 (27.4) 37 (9.00) 17 (4.20)
Diabetic
Retinopathy
102 (24.9) 22 (5.4) 14 (3.4)
Refractive
error
152 (37.2) 92 (22.5) 117 (28.6)
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15. 15Mobile and Internet for Eye Health Promotion
1. What are the symptoms?
Cataract Glaucoma Diabetic Retinopathy Refractive Error
Black spot on the retina Blurr vision and pain * Blur vision * Blurred vision *
Blindness * Increase pressure in eye * Body weakness Blindness
Blur/hazy vision * Blindness * Colour blindness Colour defect
Cloudy cornea Optic nerve damage * Increase sugar level * Nearsighted and far sighted *
Pain and redness Redness Retina problem * Low Vision * ¥
White lens or pupil * White cornea New blood vessels in retina * ¥
Low vision * ¥ Optic nerve disease * Bleeding in the retina * ¥
Clouding of lens of eye * ¥
1. How is it treated?
Cataract Glaucoma Diabetic Retinopathy Refractive Error
Surgery * Laser surgery * Diet control * Green vegetable
Drugs Lenses Drugs* LASIK *
Laser treatment Surgery * Laser * Refractive surgery *
Nutrition Surgery and eyedrops * Surgery * Spectacle *
Spectacle Medicines *¥ Spectacle Contact lens *
Removal of eye lens and replacement
with artificial *
Decrease blood sugar * ¥
*considered as “correct response” and as having reasonable knowledge
¥ new responses received during post-test
Table: Responses from the participants

16. Disease Outcome measure Control Group Experimental Group
Pre-test Post-test p-value Pre-test Post-test p-value
Cataract Awareness 142 142 1.00 139 153 <0.000
Reasonable knowledge
on symptom
86 88 0.50 71 82 0.001
Reasonable knowledge
on treatment
40 48 0.008 34 48 <0.000
Glaucoma Awareness 48 50 0.500 64 95 <0.000
Reasonable knowledge
on symptom
19 19 1.000 18 42 <0.000
Reasonable knowledge
on treatment
11 15 0.125 6 24 <0.000
Diabetic
retinopathy
Awareness 49 55 .210 53 85 <0.000
Reasonable knowledge
on symptom
12 17 0.063 10 31 <0.000
Reasonable knowledge
on treatment
8 12 0.125 6 22 <0.000
Refractive error Awareness 77 90 0.000 75 115 <0.000
Reasonable knowledge
on symptom
49 56 0.016 43 57 <0.000
Reasonable knowledge
on treatment
54 65 0.100 63 88 0.001
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Table: Difference in the level of awareness and knowledge in the pre- and post-test
assessment between the two groups

17. DISCUSSION
• Evidence of any effective eye health promotion methods could be of
significance in community health planning.
• Underdeveloped and developing communities should adopt advocacy
methods that are effective in terms of both cost and coverage.
• With the mobile phones and internet becoming an increasingly popular
platform for communication and engagement throughout the world,
these interventions were chosen for the study.
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18. Awareness and Knowledge
• Adequate awareness and knowledge can play a paramount role in
eliminating avoidable blindness.
• The awareness and knowledge level was low but agreement with the
previous studies conducted in rural population in Asia [6-9].
• Poor awareness in this study rises doubts on the effectiveness of eye
health promotion activities in the region.
• Better awareness on cataract could be attributed to more aggressive
initiatives like surgical campaigns by various government and non-
government organizations.
• Participants had significantly better knowledge on symptoms of cataract
(38.4%) and refractive error (22.5%) than they did for either glaucoma
(9.0%) or diabetic retinopathy (5.4%).
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19. Effectiveness of advocacy methods
• The intervention group demonstrated statistically significant
improvement in awareness and knowledge of all four ocular conditions.
The results were consistent with the observations of other studies which
concluded that internet-based programs were effective as health care
interventions [15-17].
• There is a growing evidence base for the efficacy of mobile phone and
internet based interventions. SMS was effective as a health information
sharing medium [16-17].
• Promoting health education through utilizing these technologies could
prove financially viable as well as reach to a wider population over a
short span of time.
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20. Effectiveness of advocacy methods
• Reasons for improved awareness and knowldge:
– portable and online materials can be easily accessed anytime and any where
just with an internet connection. This allows the intervention to claim an
individual’s attention at the most relevant time by allowing temporal
synchronisation of the intervention delivery [25].
– Mobile and internet connections are also gaining a popular platform for
communication, engagement, and education.
• Furthermore, WHO is an international organisation and accessing its
websites is understood to help in acquiring a trusted health information.
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21. CONCLUSION
• Awareness and knowledge on common eye diseases is poor even in
young, educated and productive population .
• Poor awareness among educated young adults is a concern, and there is
an urgent need for dissemination of eye health education and promotion
of eye health.
• As advocacy intervention, sharing a link of a website with adequate and
reliable health information via SMS was effective to battle the problem
of lack of awareness and knowledge about common eye diseases.
• Given the effectiveness, the use of mobile phone services and internet
facilities as advocacy strategies could be means of equalizing access to
information to address health disparities in minority populations.
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22. Questionnaire
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