Scottish Government

EXECUTIVE SUMMARY

Background

1. In 2007, the Child and Maternal Health Division of the Scottish Government commissioned research to determine whether the routine sight testing of children in P7 identifies previously undetected significant sight problems. The research was undertaken by Ipsos MORI Scotland in collaboration with Dr John Ravenscroft of the University of Edinburgh and Dr Jennifer Skillen.

2. In the UK generally, and Scotland specifically, vision screening occurs nationwide with a variety of methods and programmes. There is little data on the discrepancies of these programmes and the fourth edition of the guidance documentation Health for All Children (Hall and Elliman, 2003) recommended that screening should take place at 4-5 years of age and that there should be no further screening until secondary school (and only in secondary school if a screening programme is already in place).

3. The worry that some have is that, if the scheme is adopted in its entirety and followed closely, then treatable and correctible visual problems may remain undetected. Hence it was the aim of this research to investigate the Primary 7 ¹ screening programmes that are in place within two health boards - NHS Fife and NHS Lanarkshire - and to determine how many previously undetected visual problems were identified through this screening at aged around 11.

Research aims and methods

4. The overall aim of the research was to inform policy decisions and guidance on Primary 7 school vision screening programmes in Scotland. More specifically, the research objectives were:

• to determine the number of previously undetected sight problems identified as a result of the Primary 7 school screening
• to describe the nature and severity of the problems identified.

5. The research was based on the screening programmes in two NHS areas of Scotland: NHS Fife and NHS Lanarkshire. There were four main stages to the research:

• a short literature review to collate what was already known about the number and nature of visual problems identified by screening programmes for children of around this age.
• analysis of ISD²data to determine the proportion of children failing the Primary 7 screening in the 2 years prior to school year 2007/08 when the research was undertaken
• telephone interviews with parents of children who had failed the Primary 7 screening, to establish whether they knew their child had failed the screening, whether they acted on the advice to take their child for a more detailed test, and, if so, the outcome of that test
• analysis of optometrist test data for the children who failed the Primary 7 screening, to determine the nature and severity of the problems identified.

6. The proportion of parents who consented to take part in the research was extremely low (the overall response rate to the telephone survey was 8%). There is therefore considerable potential for non-response bias and the estimate of the number of previously undetected sight problems identified should be treated with caution.

Main findings from the literature review

7. Only one high level randomised control trial was identified to conclusively determine the effectiveness of visual acuity screening in identifying previously undetected, correctible sight problems at any age.

8. Many studies detail the prevalence rates of correctible sight problems. However, few detail the number of previously known cases versus the number of previously undetected cases.

9. Overall, the evidence suggests that screening and subsequent treatment of visual impairment at an early age (from 18 months to five years), leads to improved visual outcomes although there are very few randomised controls trials confirming this. Screening at an older age, such as 8 -10 years or 13 - 15 years, appears to detect few new cases of eye pathology, which would suggest that this should not be recommended practice.

10. The view of the National Screening Committee, the Royal College of Ophthalmologists, the British and Irish Orthoptic Society, the Health for All Children report and Morcos and Wright (2009) is that, apart from screening between the years of 4 and 5, no other screening should be offered and that vision screening in 7 year olds (and by implications older children) should be discontinued.

11. At any age, the literature recommends that high-risk children (children with a family history or children with disabilities) should be referred to an ophthalmologist, an orthoptist or to a trained specialist optometrist.

12. The effectiveness of a screening depends upon adequate participation from children and their families. The literature (Kimel, 2006; Yawn et al 1996; and Yawn et al 1998) suggests that a screening programme is only as effective as its follow-up with regards to participants who receive a positive result for a vision condition ( e.g. parents may not take their children for a more detailed test because do not believe the results or are concerned about the cost of glasses). However, it appears that there are currently a number of barriers to follow-up care and treatment which reduce the overall effectiveness of a screening programme. Future screening programmes should address these barriers in the design of the programme.

Main findings from the primary and secondary data analysis

13. From the limited evidence, the principal conclusion is that P7 school sight testing results in the identification of a very small number of previously undetected significant sight problems. This is in line with previous research. However, this finding should be treated with caution as it involves results from a survey of parents with a low response rate of 8% and there is considerable potential for non-response bias.

14. The best estimate is that only a very low percentage (around 1%) of those screened will have a previously undetected significant problem identified as a result of the test.

15. Although around 12% of children fail the screening, only around 9% of these children ( i.e. around 1% of those screened) have a previously undetected sight problem identified as a result and could therefore be said to have benefited from the screening.

16. Of the remaining 91% who failed the screening (and, again, these estimates should be treated with caution):

• around 33% of parents either did not receive, or did not remember receiving, the communication from the school health service advising them to go for a more detailed test. This is not as problematic as it might first appear as the majority of these children had previously detected problems and had recently been tested by an optometrist/hospital eye specialist. However, there is scope to improve the communication (see paragraph 18 below).
• around 16% had a previously detected problem, already had glasses and were receiving regular check ups by optometrist
• around 14% were found not to have a problem when tested by an optometrist
• around 11% of parents were either not advised to take their child for a more detailed test or had not understood/did not remember that this was what the communication advised
• around 10% had a previously undetected problem identified but it was not significant
• around 3% of parents did not take their child for a more detailed test
• in around 3% of cases, we have insufficient information to categorise.

Implications for policy and practice

17. It was not within the remit of this research to make a recommendation on whether the Primary 7 screening programmes should be continued. Clearly, the findings should help inform any such decisions, but these decisions need to take into account a range of other factors such as the priorities for school health services and the effectiveness and cost implications of any proposed alternatives ³.

18. If the decision is taken to continue screening, there are some lessons from the research which might inform future practice:

• improving the communication with parents: around 33% of parents either did not receive, or did not remember receiving, the communication from the school health service advising them to take their child for a more detailed test, and a further 11% were either not advised to take their child for a more detailed test or had not understood/did not remember that this was what the communication advised. This is not as problematic as it might first appear as the majority of these children had previously detected problems and had recently been tested by an optometrist/hospital eye specialist. However, there is clearly some scope here to improve the effectiveness of the communication to parents and thereby increase the proportion of children who benefit from the screening: letters could be posted rather than sent home in the child's school bag, letters could be emailed, the school health service could telephone the parent and reminder/follow-up letters could be issued or reminder calls made. Some school nurses in Fife do post letters and/or telephone parents, and parents in Fife were more likely to remember the communication than parents in Lanarkshire, where children take the letters home in their school bags.
• improving the standard of testing: professionals acknowledged that testing conditions in schools were not always ideal. In some cases, the charts were yellowed and faded and sometimes light-bulbs were not working. Improvements would have resource implications (new charts are very expensive) and there may be practical difficulties in ensuring good lighting in the spaces used for testing. However, improvements should reduce the number of false positives ( i.e. the children sent for more detailed tests who are subsequently found to have normal vision: in our sample, this was around 14% of those who failed).

19. Finally, it is worth noting that NHS Boards are introducing orthoptic-led vision screening of all children during their pre-school year ( i.e. between the ages of four and five years) and by around 2017 most of the P7 cohort should have had this orthoptic-led screening in their pre-school year. It is hoped that this will result in a reduction in the prevalence of previously undetected problems by P7. In other words, we would expect the low number of previously undetected significant problems picked up by current P7 screening to fall still further. If P7 screening is still being undertaken in 2017, it may worth considering further research at that point.