Purpose: To evaluate the level of awareness and knowledge of preschool vision screening (PVS) among teachers and eye care providers in the New Juaben municipal, Ghana.

Methods: This was a cross-sectional study. Stratified random sampling was used to select the preschools. All teachers in selected preschools were included in study. Convenience sampling was done to recruit eye care personnel for study. Detailed interview-guided questionnaires were used to elicit responses from the participants in this study. Completed data was entered in Microsoft Excel 2010 and Statistical Package for Social Sciences version 16 and analyzed. Statistical significance was set at p < 0.05.

Results: A total of 145 teachers were involved in this study. 90% of which were women and 10% men. 60% of the teachers had handled preschool children for more than 5 years. Out of the 145 teachers, a total of 96 were not aware of preschool vision screening and over 50% also had no idea whether PVS was important or not. The associations of observation of unusual visual characteristics in preschoolers with the gender of teachers and the period of handling preschoolers were found to be significant; with a p value of 0.01 and 0.02 respectively. All the eye care providers had knowledge of PVS but 53.3% of them had never initiated any form of awareness creation to the general public.

Conclusion: There is low awareness and knowledge of preschool vision screening and its benefits in Ghana. This suggests that programs to increase awareness should be encouraged and made popular through all available media platforms. Further research should also be done to examine other socio economic factors that may affect preschool vision screening.

Screening has been defined as ‘the systematic application of a test or inquiry, to identify individuals at sufficient risk of a specific disorder to warrant further investigation or direct preventive action, among persons who have not sought medical attention on account of symptoms of that disorder’[1].

Preschool vision screening(PVS) is vital because early detection and intervention serve best when given at an early age for children, especially for conditions such as amblyopia, strabismus, refractive errors and other ocular abnormalities [2]. Failure to detect visual impairment early may have a permanent effect on long term visual outcomes, academic achievements, and self-esteem of the children [3].Vision screening programs can be an effective method of reducing ocular morbidities by detecting it before symptoms exacerbate. Hence, the lack of awareness and knowledge of preschool vision screening and its benefits might result in high rates of visual impairment in children.

VISION 2020- The Right to Sight program launched by the World Health Organization included “Control of Childhood Blindness” among its priority programs because most of the causes of childhood blindness are treatable or avoidable [4-5]. In spite of recommendations by organizations including World Health Organization, the American Academy of Family Physicians, the American Academy of Pediatrics and Bright Futures [6-8], preschool vision screening is often omitted at the well child checkup [9-10].

In 2010, there was an estimation of about 1.26 million blind children globally, with majority of them living in the poorest countries of Asia and Africa [11]. Studies report that childhood blindness is rapidly increasing in Africa [12] with amblyopia, refractive error and strabismus among the main causes of vision impairment in children [5,13].

The rate of PVS in Ghana is at the lowest but there is limited data to explain why it is so. In Ghana, little is known on the level of awareness of PVS, barriers to PVS and knowledge of caregivers on child eye health in general. This study was conducted to evaluate the level of awareness and knowledge of Preschool vision screening among teachers and eye care providers in the New Juaben municipality, Ghana. The results from this study will be useful in designing effective and well-organized intervention strategies to improve preschool vision screening and also help develop a conceptual framework to understand factors associated with PVS uptake.

Study Design and Sampling
This was a cross-sectional study carried out among preschool teachers and eye care personnel in the New Juaben municipality. Stratified random sampling was used to select the preschools. A list of all preschools with their corresponding educational circuits within the New Juaben municipality was obtained from the education branch of the municipal directorate. The ten educational circuits in the municipality were considered as clusters, from which two subgroups were created based on their system of ownership; public or private. One school was then randomly picked from each of the twenty strata obtained from the ten educational circuits, such that they represented the population of preschools within the New Juaben municipality appropriately. All the teachers in the selected schools were included in the study, unless they were absent during handing of questionnaires. A convenient sampling technique was employed to pick the eye care personnel consisting ophthalmologists, optometrists and ophthalmic nurses in the municipality.

Data Collection Tool
Interviewer-administered questionnaire was used to obtain information relevant to this study from the participants. This included but was not limited to their responses on the awareness and knowledge of preschool vision screening. The questionnaires were administered in English.

Data Analysis
Microsoft Excel 2010 and the Statistical Package for Social Scientists (SPSS) version 16.2 (SPSS, Inc., Chicago, IL, USA) was used to analyze the data. Descriptive analysis and Chi-squared test were used to test for statistical significance; a p-value of < 0.05 was considered to be significant at 95% confidence interval.

Ethical Consideration
Permission was obtained from the ethics committee of the Municipal Education Directorate in New Juaben, as well as all teachers of the selected preschools. An informed consent was also obtained from all the eye care personnel selected for the study.

Table 1 shows the social demographic characteristics of the 145 teachers involved in this study. 90% of the teachers were women and 10% men. The highest form of education attained by majority of teachers was secondary education 70% and 60% had handled preschool children for more than 5years.

Table 2 shows the social demographic characteristics of the 15 eye care personnel involved in this study. 66.7% of them were men and 33.3% women. Majority of the eye health workers were optometrists (66%). 60% of the eye care providers worked in government health facilities.

Table 3 shows the distribution of the level of awareness of preschool vision screening among the preschool teachers. Other relevant questions were also asked to obtain an idea of the knowledge they have on preschool vision screening. Majority of the teachers (66.9%) responded that they were not aware of preschool vision screening. Over 50% also had no idea whether PVS was important or not. The associations of observation of unusual visual characteristics with gender of preschool teachers and the period of handling preschoolers were also studied. There were statistically significant associations with a p value of 0.01 and 0.02 respectively.

Awareness and perception of eye care providers on preschool vision screening was also questioned. All the health personnel were aware of PVS and they all acknowledged it was important. 53.3% of them however had not created awareness or educated people on PVS. The medium used most to educate the public on PVS was broadcast media. Refractive Errors and Allergic Conjunctivitis were identified as the commonest ocular disorders preschoolers presented to the clinics. This is illustrated in Table 4.

There is an estimation of about 1.26 million blind children globally, with majority of them living in the poorest countries of Asia and Africa [11,14]. Majority of the causes of childhood blindness are avoidable [15]. The number of expected blind years in children is higher than that of adults therefore childhood blindness needs to be a top priority in eye care policy making. The reports above confirm the burden of childhood blindness in resource-poor countries. It is therefore important every child receives a comprehensive eye examination.

Preschool vision screening is effective in detecting children with visual defects such as amblyopia, refractive errors and strabismus [16,17]. In the USA, vision screening for school children is extensive. The American Association for Pediatric Ophthalmology and Strabismus (AAPOS) encourages screening programs for visual impairment in children with subsequent referral to eye care professionals trained to care for eye problems in children. It advocates the education of volunteer lay persons and auxiliary medical personnel to perform vision screening [18]. This is quite the opposite in Ghana and other low-income countries.

Results from this study showed that the level of awareness of preschool vision screening was low among the teachers. 66.9% of the teachers had no idea what PVS was. This contrasts with the findings of a study in Iran where kindergarten teachers showed high awareness of PVS [19]. Most of the teachers who were aware of PVS cited word of mouth as the means through which they came to know about PVS. All the eye care providers involved in the study however were aware of PVS and thought it was important but over 50% of them had not created any form of awareness to the general public. This may be due to a number of reasons such as nonchalance, the cost involved in organizing vision screening in schools, lack of interest from the school authorities and parents, limited eye care providers in the municipal [3,20] . Our data suggest further research should be done to identify barriers that may cause low creation of awareness of PVS by the eye care personnel. The teachers reported they had observed one or more symptoms of visual problems in the preschoolers, out of which “frequent rubbing of eyes and moving reading material too close to eyes” were seen most. The number of years of handling preschoolers and being able to identify common signs of visual problems was statistically significant (p = 0.02). The longer the years of handling kids, the easier it was to identify the signs. This could be the result of their previous experiences with children with some form of visual impairment who had associated learning difficulty. Also the results showed that female teachers were more observant than their male colleagues. This was statistically significant (p = 0.01).

The practitioners in this study were questioned about the common ocular disorders among preschoolers they encountered often in their practice. Refractive error and allergic conjunctivitis were the most prevalent followed by strabismus and amblyopia with ocular injury being the least seen. This result was consistent with a public health intervention study done in Oman [21]. The common ocular conditions identified among preschool children in this study are similar to previous studies [22,23].

Our study results inferred that the level of awareness of preschool vision screening (PVS) among teachers is very low. This contrasted the results among practitioners involved the study where all them were aware of PVS and its benefits. However majority of the practitioners had not made any effort to inform the general public about PVS. Although the results of this study cannot be generalized, it may provide a useful framework for future studies examining awareness and be helpful for comparison of awareness between different social backgrounds and access to eye health promotion in the whole country. The study results also encourage health professionals to engage in more awareness programs. Awareness programs should be incorporated into school vision-screening programs and commercialized through all available media platforms. Although there are large gaps in literature concerning preschool vision screening in Ghana, ignorance remains a major problem at all levels so improvements in the distribution of information and education are necessary.

Acknowledgement
We thank Dr. E. E. Kaitoo, the municipal health directorate of New Juaben and all the administrative staff of the education directorate; we also wish to express our profound gratitude to the proprietors of all selected preschools.

Appendix A: Questionnaire for Teachers.
EDUCATIONAL CIRCUIT ……………………………………
TYPE OF SCHOOL OWNERSHIP: Public [ ] Private [ ]
SEX OF CARETAKER: Male [ ] Female [ ]
HIGHEST LEVEL OF CARETAKER'S EDUCATION: Primary [ ] Secondary [ ] Tertiary [ ]
1. How long have you been handling children at the preschool level?
0- 1year [ ] 2- 5 years [ ] 5- 10 years [ ] Beyond 10 years [ ]
2. Have you ever observed any unusual behaviors or characteristics with respect to vision among children under your care?
Yes [ ] No [ ]
If no, please skip to question 5.
3. Do they include any of these? Please tick where applicable.
Frequent rubbing of the eyes [ ] Squinting [ ] Unusual tilting of head/ face turn [ ] Drifting away of either of the eyes [ ] Moving too close to reading material or board [ ] Poor eye contact [ ] none of the above [ ]
4. How do you respond or react to these unusual behaviors or characteristics?
Do Nothing [ ] Inform parents [ ] Inform head teacher [ ] Refer for eye examination [ ]
5 a. Do you think/ believe that children under your care would benefit from routine eye examination by an eye doctor before they start serious academic work?
Yes [ ] No [ ]
b. If yes, why?
…………………………………………………………………………………………………
c. If no, why not?
…………………………………………………………………………………………………………………………………………………………………………
6 a. Have you ever had an eye examination?
Yes [ ] No [ ]
b. If yes, for what purpose?
Routine eye examination [ ] Report an eye problem [ ]
7 a. Have you ever heard of vision screening services available for preschool children?
Yes [ ] No [ ]
b. If yes, from where? (Please skip to question 8 if your answer is no).
Print media e.g. newspapers and magazines [ ] Broadcast media e.g. radio and television [ ] Internet blogs and websites [ ] Word of mouth (colleagues, parents, health practitioners, etc) [ ]
8. Is it a requirement in your school for parents to have their children's eyes screened before they are enrolled in your school?
Yes [ ] No [ ]
9 a. Are routine vision screenings done for preschoolers in your school (by caretakers in the school, health institutions or NGOs)?
Yes [ ] No [ ]
b. If yes, how often?
Once every term [ ] Once every academic year [ ] Seldom [ ]
c. If no, why not?
Expensive to conduct [ ] No idea who to contact [ ] Not necessary [ ] Not compulsory [ ] Do not know [ ]
10. Do you know of any policy from the Ghana Education Service requiring preschoolers to have their eyes screened before they officially start school?
Yes [ ] No [ ]

Appendix B: Questionnaire for Eye Care Personnel.
1. How long have you been practicing?
0-1 year [ ] 2- 5 years [ ] 6- 10 years [ ] above 10 years [ ]
2 a. Have you ever organised any outreach in the New Juaben municipality?
Yes [ ] No [ ]
b. If yes, how often do you do this?
Once every year [ ] Twice every year [ ] Quarterly [ ] Often [ ] Seldom [ ]
c. If no, why not?
………………………………………………………………………………………………
3. What has been your target population for such outreaches? Please tick where applicable.
Schools [ ] Religious institutions [ ] Corporate organisations/ institutions [ ] Community [ ]
4. What is the age- range of persons that you attend to during your outreaches? Please tick where applicable.
0- 5 years [ ] 6- 18 years [ ] 19- 40 years [ ] Above 40 years [ ]
5. What have been the level of patronage/ uptake of outreaches by your target population so far?
Good [ ] Fair [ ] Poor [ ]
AWARENESS AND AVAILABILITY OF PRESCHOOL VISION SCREENING
6. In your opinion, at what ages should vision screenings be done for the paediatric population?
………………………………………………………………………………………………………………..............................................................................................................................................
7 a. Do you consider preschool vision screening as important/ necessary, in your own opinion?
Yes [ ] No [ ]
8 a. Have you ever been contacted by a school or an organisation to conduct screening for children below the age of 6 years within the municipality?
Yes [ ] No [ ]
(Please skip to Q9 if your answer is No)
b. If yes, did you honor the invitation?
Yes [ ] No [ ]
(Please skip to Q9 if your answer is No)
c. What are the common ocular conditions you have observed among this age group?
………………………………………………………………………………………………………………………………………………………………………………………………………………
9a.Do you provide vision screening services for preschoolers at your centre?
Yes [ ] No [ ]
b. If yes, why?
…………………………………………………………………………………………………….
c. If no, why not?
…………………………………………………………………………………………………….
10 a. Have you ever taken initiative to educate stakeholders (Ghana Education Service, school authorities, parents) on vision screening done for preschool children and its importance?
Yes [ ] No [ ]
b. If yes, by what means?
Print media e.g. newspapers and magazines [ ] Broadcast media e.g. radio and television [ ] Internet blogs and websites [ ] Word of mouth (colleagues, parents, health practitioners, etc) [ ]
c. What has been the general acceptance by stakeholders so far?
Good [ ] Fair [ ] Poor [ ]