Validity of recall absent schoolchildren to free eye health projects

Correction of refractive error is still a big challenge with regards to promoting worldwide eye care. In 2004, World Health Organiza­ tion (WHO) estimated that 314 million people are visually impaired in the world, while 153 million people are affected by uncorrected refractive error. Uncorrected refractive error is the main cause of low vision and second cause of blindness, after cataract. Without proper optical correction, 153 million people miss opportunities, are disqualified to work and experience economical and social con ­ sequences. The losses with regards to children learning, intellectual develop­ ment and socialization are immeasurable. It is estimated that 12.8 million children between 5 and 15 years old are impaired due to lack of or inappropriate optical correction, a global prevalence of 0.96%. Even in a developed country like the United States, visual disorders are the fourth most common cause of disability and the most preva­ lent handicapping condition in childhood. In Brazil, it is estimated that 6% of preschool children need optical correction. Actions to prevent blindness and reduce low vision due to refrac­ tive error include mass screening for visual acuity, professionals to perform refractive examinations and provision of affordable eye ­ glasses. Despite being a rapid procedure at low costs, the lack of optical correction remains as an important problem. In Brazil, community projects aimed at detecting visually impaired elementary schoolchildren have been performed for several decades. The community campaigns “Eye­to­Eye” were created to detect barriers to optical correction procedures, as well as to demonstrate their fea ­ sibility by offering access to ophthalmic examination and eyeglasses to children attending 1 to 4 grades at public schools. Cam paigns “Eye to Eye” (1998­2001) were one of the largest ocular public health projects in the world, attending more than 14 million students. One of the barriers to coverage of theses project is the absen­ teeism. Since the 70s, several studies have reported high rates of non­attendance to community campaigns, ranging from 31.2 to 68.7%. The main difficulties reported by defaulters are lack of trans portation, lack of orientation and loss of working day. Validity of recall absent schoolchildren to free eye health projects


INTRODUCTION
Correction of refractive error is still a big challenge with regards to promoting worldwide eye care (1) . In 2004, World Health Organiza tion (WHO) estimated that 314 million people are visually impaired in the world, while 153 million people are affected by uncorrected refractive error (1) . Uncorrected refractive error is the main cause of low vision and second cause of blindness, after cataract (2) . Without proper optical correction, 153 million people miss opportunities, are disqualified to work and experience economical and social con sequences (3) .
The losses with regards to children learning, intellectual develop ment and socialization are immeasurable. It is estimated that 12.8 million children between 5 and 15 years old are impaired due to lack of or inappropriate optical correction, a global prevalence of 0.96% (1) . Even in a developed country like the United States, visual disorders are the fourth most common cause of disability and the most preva lent handicapping condition in childhood (4) . In Brazil, it is estimated that 6% of preschool children need optical correction (5) .
Actions to prevent blindness and reduce low vision due to refrac tive error include mass screening for visual acuity, professionals to perform refractive examinations and provision of affordable eye glasses (6,7) . Despite being a rapid procedure at low costs, the lack of optical correction remains as an important problem (710) .
In Brazil, community projects aimed at detecting visually impaired elementary schoolchildren have been performed for several decades. The community campaigns "EyetoEye" were created to detect barriers to optical correction procedures, as well as to demonstrate their fea sibility by offering access to ophthalmic examination and eyeglasses to children attending 1 st to 4 th grades at public schools. Cam paigns "Eye to Eye" (19982001) were one of the largest ocular public health projects in the world, attending more than 14 million students (7) .
One of the barriers to coverage of theses project is the absen teeism (7) . Since the 70s, several studies have reported high rates of nonattendance to community campaigns, ranging from 31.2 to 68.7% (1015) . The main difficulties reported by defaulters are lack of trans portation, lack of orientation and loss of working day (7,11,16) .
Recently, some campaigns include facilities of transportation, exa minations performed at places near schools and during wee kends, in order to increase the attendance (7,11,16) . The students could have some difficulties in the campaign day and offering them a se cond opportunity of exam is an option that needs to be assessed. Quite a few projects make a recall of defaulters (11,16) , without any ana lysis of effectiveness of this procedure.
In this study, there were two calls (first call and recall of absen tees). The analysis of results of the recall is important to improve the project methodology in order to solve operational issues and attain better results.
The purpose of this study is to study the results of recall absent schoolchildren to the eye care community projects, aiming at impro ving the efficiency of these actions.

METHODS
In 2006 and 2007, a transversal study was conducted with stu dents attending 61 municipal public schools in Guarulhos. The target population was composed by all the 51,509 students, whose age ran ged from 7 to 10 years old, enrolled in 1 st , 2 nd , 3 rd and 4 th grades of the 1 st cycle of elementary school. Guarulhos belongs to the metropoli tan area of São Paulo, located 17 km from the capital city. It is the 12 th most populated city of the country and gross national product (GNP) per capita of R$22,202.00 (@ US$12,677.44/US$ = 1.7513 18/08/10); Brazil R$15,240.00/2008 (@ US$ 8,702.11). In Guarulhos, 97.9% of the children are enrolled at and attend school (17) .
The students' visual acuity was screened by the teachers at school. The criteria for referral were: a) visual acuity equal or lower than 0.7 in one eye or difference of vision between the eyes of at least 2 lines; b) evident strabismus; c) asthenopia; d) use of eyeglasses (18) .
Referred students were scheduled by grades and attended at a primary care center in the same municipality.
On the campaign day, a new visual acuity screening and assess ment of extrinsic ocular motility were done by ophthalmologists. Dis tance visual acuity (without and with glasses for those wearing them at the time of the examination) was measured with E chart at 5 m. Those with uncorrected visual acuity better than 0.7 in each eye with no signs of asthenopia and absence of strabismus were dismissed (falsepositive). The remaining students were referred to a complete ophthalmologic examination. Examination included visual acuity tes ting, ocular motility, biomicroscopy, autorefraction, cycloplegic re fraction and fundus examination. Cycloplegia was induced by three drops of 1% cyclopentolate, administered 5 mi nutes apart.
The project was composed of two parts: first call and recall ab sentees.
The eye health care services were carried out during weekends (Saturday and Sunday) and the intermission between first call and recall absentees was less than 2 months. Free transportation and free lunch were provided on the examination days and the prescription eyeglasses were donated.
The study was approved by the Ethics Committee for Research Projects/ Investigational Review Board of the Clinical Board of Hospi tal das Clínicas and the School of Medicine, University of São Paulo/SP (n o 0557/07). Informed consent form had been obtained from each child's parent/guardian.
The data was verified for entry with EpiData Software (version 3.0) and analyzed through the Statistical Package for Social Sciences (SPSS) software 15.0. The admitted significant statistical level was of 5% (p < 0.05).

RESULTS
The population was composed of 51,509 schoolchildren. After visual screening, 14,651 (28.4%) students were referred to ophthalmic examination of which 8,683 (59.3%) answered to the first call. As for the 5,968 recalled students, 2,228 (37.3%) attended the recall (Figures  1 and 2). The recall resulted in a coverage increment of 15.2% (59.3% to 74.5%). The total amounts to 10,911 students (74.5% of those refer red to examination) had their eyes examined (Table 1).
The need for eyeglasses was statistically higher in the children who attended the recall than those who attended at first call (p<0.001) ( Table 1). There was no statistically difference between gender and prescribed eyeglasses.

DISCUSSION
The problem of visual impairment in childhood is significant, with lowcost solution, but involves several barriers such as lack of parental involvement. There is an expressive number of parents who do not bring their children to be examined (Figure 2), despite the facilities offered.
There were 51,509 students screened by their teachers; 14,651 (28.4%) were referred to ophthalmic examination and 8,683 (59.3%) students attended the first call. There were 5,968 recalled defaulters, only 2,228 (37.3%) appeared. Absenteeism at the first call was 40.7% and higher at recall (62.7%), as shown in figure 1.
The barriers to the utilization of eye services have already been studied (2022) , however, this is the first study conducted to assess co verage increase by means of recalling absentees and determining whether or not this group requirement for eyeglasses is lower.
The main reasons for noshows to eye health care services are: school faulty orientation with regards to day, time, and locality where the examination will take place; financial issues related to transportation to the service venue; long distances from home to the consultation venue; parents who are unable to find someone to stay with the youn ger children; meteorological changes; other service options (health insurance contract, private medi cal assistance); child or family member illness; unavailability of parents and relatives, who are working or ab sent, to bring the child to the campaign; absentminded guardian; campaign lack of credibility; denial with regards to child's low vision (7,11,15,16) Other determining factors such as lack of consciousness (awa reness and understanding) of the importance of ophthalmic examinations, fear, fatalism (20,2224) . Another possibility for missing the first call is that these students could have fewer complaints and visual symptoms (lower need for optical correction). However, the percentage of children who requi red eyeglasses was statistically higher in the recall group (p < 0.001).
The validity of conducting a second call must be assessed by the following issues: resources availability; health planning priorities; goal of the project coverage. The goal of public health care actions is to provide services to a large number of students with the existing resources. By taking into account the cost of each stage of the project and the percentage of children who were benefited, it is suggested that a larger attendance be achieved at the first call, in an attempt to benefit a higher number of children and avoid the relatively high recall costs.    The campaign operational design (25) was similar for both first call and recall, since it was necessary to schedule another appoint ment, provide transportation and food, prepare the equipment and gather personnel for examination. The entire structure had to be assembled again, but the number of students who appeared at recall was too low which resulted in a higher service cost per capi ta. The first call was four times more effective in terms of students benefited. Thus, higher priority should be given to investments in advertisement of community projects campaigns and in the com munity education.
The first call reached 59.3% and recall 37.3% of students. So recall increased the campaign coverage in 15.2% from 59.3% to 74.5% ( Table 1). The total number of 8,683 schoolchildren attended at the first call was increased to 10,911. The recall was much less efficient than the first call.
Using the health system involves search behavior and access to the existing services (22,26,27) . The eyecare services should be available, accessible, affordable and acceptable to the people (28) . This study reveals evident lack of involvement of the community and unawa reness with regards to the importance of visual examination. It's a behavioral problem as observed previously in Brazil, for cataract and glaucoma treatment (29,30) . Given the parents' behavior towards free examinations and suitable health care services, it can be assumed that parents' initiative to spontaneously bring their children to be exa mined is less probable.
Evaluation is essential to the expansion of eye health promotion, in order to provide information and feedback to make improvements in future activities. While the ultimate goal is improved eye health, it is useful to incorporate intermediate indicators, such as increased awareness, behavior change, skills, self efficacy, coverage and quality of services, and adoption of specific policies.
As a result of parents' refusal to accept a presumed visual pro blem, the routine examination becomes even more important at the time the child starts attending school, not only to detect refractive errors, but also due to its educational role within the community. It is necessary to educate the population with respect to adoption of eye health promoting behaviors, changing health concepts and preventing ocular diseases (22,27,31) .
The recall of absent students is indicated only if the first call was done for all school grades. Absent schoolchildren may be recalled whenever another campaign is organized.

CONCLUSION
Under the conditions of this study, recall absent students to ophthalmic examination had a low impact in the increase of health service coverage (15.2%) and it is not recommended when financial resources are limited. Schoolchildren who missed the first call and attended the recall had a greater need for eyeglasses. A significant number of parents (25.5%) do not take their children to have an ophthalmic examination, despite the facilities offered.