Advancing Global Eye Health:  Progress and Insights from the Child Blindness and Low Vision Program in Northern Malawi, Southern Africa

Advancing Global Eye Health: Progress and Insights from the Child Blindness and Low Vision Program in Northern Malawi, Southern Africa | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Advancing Global Eye Health: Progress and Insights from the Child Blindness and Low Vision Program in Northern Malawi, Southern Africa Khumbo Kalua, Esther Solomoni, Hendrine Mkandawire, Tisungane Chitimbe, and 4 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-5944251/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background Blindness and low vision in children remain significant public health concerns, particularly in low- and middle-income countries (LMICs) like Malawi, a key region in Southern Africa. These conditions are often underdiagnosed and undertreated due to limited access to specialized services, spectacles and assistive devices, posing critical challenges to health equity. The Childhood Blindness and Low Vision Program (CBLVP) in Northern Malawi aimed to address gaps through capacity building, advocacy, ensuring access to regular eye health and low vision assessments, and provision of spectacles and low vision devices. Methods Activities included setting up clinical low vision services at Mzuzu Central Hospital in Northern Malawi, followed up by conducting outreach screenings and assessments, and building capacity through training and mentorship. Advocacy efforts engaged stakeholders such as government officers, parents, teachers, and disability organizations to promote awareness and service uptake, and provide basic skills to support the use of vision by the children at school and home. A mixed-methods approach was employed to evaluate progress: quantitative data came from service records, including client statistics and device distribution, while qualitative data were collected via engagement interviews with stakeholders and beneficiaries. Descriptive statistics and thematic analysis were applied to identify key achievements, challenges, and areas for sustainability. Results The program established a dedicated low vision clinic serviced by a full-time optometrist/low vision therapist. Between 2022 and 2024, 2054 children were served; 370 (18%) received glasses, 70 received low vision services (3.4%), and 96 (4.9%) underwent surgery. Spectacles and low vision devices improved beneficiaries' quality of life, enabling better educational and vocational performance. Awareness campaigns, including radio interviews and social events, increased visibility and service uptake, particularly among persons with albinism. However, challenges included the lack of an admission policy for inclusive education, initially leading to unnecessary admissions to special education and unnecessary use of Braille instead of print-based learning. Conclusion The program successfully addressed service gaps, fostered sustainability, and developed a scalable model for low vision care in Malawi and Southern Africa. Future efforts should emphasize policy integration and increased public awareness to sustain and expand the impact. Childhood Blindness Low Vision Global Eye-Health Malawi Cataract Advocacy Albinism Background Blindness and low vision in children remain significant global health concerns, disproportionately affecting individuals in low- and middle-income countries (LMICs) such as Malawi 1 , 2 . Both conditions remain underdiagnosed and undertreated due to limited access to specialized services and devices. According to the most recent estimates 1 , globally, 1.02 million children were blind in 2020, and probably three times this number had low vision. The burden tends to be greater in low- and middle-income countries and underserved populations, such as women and children, migrants, Indigenous peoples, persons with certain kinds of disability (albinism), and in rural communities 3 . Unfortunately, the widely accepted strategies for achieving Universal Eye Health Coverage (UEHC) assume equity across all policies and do not address disadvantaged communities 4 . There is a need to make a deliberate effort in eye care, to address access barriers 5 , 6 and reach those often considered “unreached”. Despite the scarcity of data on blindness and low vision in Malawi and southern Africa, earlier studies had shown that a large proportion of causes are reversible either preventable or treatable 7 – 10 , and that children with disabilities face persistent and systemic barriers to attending, progressing, and learning in school 11 – 13 . There is overwhelming new evidence by Burton et.al 1 , in a commission of Global Eye Health, that educational performance for children was linked to vision. Children with vision impairment had poorer academic outcomes and were more likely to be excluded from schools and more likely to drop out of school. This was also observed by Kalua 8 , in his studies in Malawi. Simple interventions such as screening and providing spectacles to children with visual impairment are well-documented to improve educational performance. 14 – 16 . Yet, unless addressed through innovative ways, these interventions are rarely a reality for most children in Southern Africa, where lack of access to glasses and low vision devices, coupled with high cost, contribute to challenges in obtaining these. Malawi, with a population of approximately 20 million, has a relatively small number of ophthalmologists and midlevel ophthalmic personnel (optometrists, optometry technicians, ophthalmic clinical officers) and had not yet established low vision services in the Northern part of the country, as part of regular eyecare, despite having a tertiary eye hospital where several children attended eye health units for various eye conditions, some of which fell within the category of severe visual impairment and low vision. This was the reason why the “Childhood Blindness and Low Vision Program (CBLVP)” was proposed and initiated in 2022 by the Blantyre Institute for Community Outreach (BICO) 17 , a Malawian non-profit organization, in collaboration with the ministries of education and health, and international partners (Fight for Sight Netherlands and Wilde Ganzen Foundation) to eliminate avoidable blindness and low vision in children in the Northern region, and positively contribute towards the 2020 Eye Health Agenda. Methods The 3-year project (2022–2024) was based at the Mzuzu Central Hospital Eye Department, a tertiary hospital serving a catchment population of 2 million people across six surrounding districts. The project aimed to establish a model for providing blindness and low vision services for adults and children in Northern Malawi, with the potential to be scaled up across Malawi. Specific objectives included: 1. Identifying a dedicated room and setting up low vision services. 2. Organizing and conducting outreach screening clinics, in cooperation with local health and community-based services, and building capacity for low vision and pediatric services through training. 3. Engaging with parents of children with low vision and conducting pediatric surgeries with follow-ups. 4. Ensuring appropriate low vision related knowledge and skills for special and classroom teachers with children with vision impairment in their school. 5. Advocating with the Ministries of Education and Health to systematically link educational services with eye care services for children with visual impairment, and indeed for children wih other disabilities and likely vision problems, in special and local schools 6. Conducting a final project evaluation with stakeholder involvement. After securing funding for the service delivery grant from 2 Dutch organizations (Fight for Sight Netherlands and Wilde Ganzen Foundation), BICO organized a visit to Mzuzu to meet the resident ophthalmologist (PM), a team from the Ministry of Health, and a team from the Ministry of Education’s Special Needs Education Department (SNED). This visit aimed to brief stakeholders about the project, request their cooperation, and clarify expectations. Hospital management was asked to allocate a dedicated room to establish the low vision clinic. The education team identified a nearby special needs school, located 30 km from the hospital, with a significant number of children with blindness and low vision, to serve as a case study for the project’s progress. Once the hospital management allocated a room, it was fully renovated and equipped with visual assessment tools, including a slit lamp, auto-refractometer, lensometer, visual acuity testing equipment, low vision testing tools, low vision devices (LVDs) of various powers, and frames and lenses. A low vision therapist, previously trained by BICO and based in another region, was transferred to manage the clinic, supported by another optometry technician. To kickstart activities, BICO contacted a global low vision expert (KVD) with experience in low- and middle-income countries (LMICs) to provide training to a group of optometrists in Northern Malawi and to support the low vision therapist managing the clinic. The consultant conducted annual physical visits to provide hands-on training and supervise the assessment of children with low vision at resource centers, supplemented by online training and support. A team of nine optometrists and optometry technicians was identified and enrolled in capacity-building initiatives, receiving initial training from the low vision therapist in Mzuzu and subsequent training from the consultant. The low vision clinic began daily operations, with referrals from the general eye clinic for children and adults with low vision. To increase the clinic’s reach, BICO collaborated with the eye department and the district health office to organize regular school screenings. Children identified by teachers as having visual difficulties were assessed and managed if they had treatable conditions like refractive errors. More severe cases were referred to the low vision clinic. Teachers were also trained to identify children with visual problems as part of capacity-building efforts. Children needing glasses received them through a donation, by the project managed by BICO. Advocacy activities included community radio and television (TV) announcements, brochures, and meetings with key groups such as the Association of Persons Living with Albinism (APAM) to raise awareness and encourage individuals to access services at the clinic. The project also mobilized children needing surgery, primarily for cataracts, using the key informant method (KIM) to identify and refer them to the clinic for assessment and scheduling for surgery. Pediatric surgeries were conducted by a team from the southern region of Malawi (Blantyre). Once a sufficient number of children (target: 30 per surgical camp per year) were booked, the surgical team traveled to Mzuzu for a week to perform surgeries and follow-ups while training the local team to manage these cases long-term. Children who underwent surgery were referred to the low vision clinic for assessment and provision of glasses and LVDs (subsidized through the project), as most post-surgery children benefit significantly from these services. To foster integration between education and health, the low vision team visited Ekwendeni Resource Centre, an integrated school for children with severe visual impairments. These visits involved joint screenings by eye health workers and teachers, with collaborative management plans agreed upon and documented for the teachers. Consent for interventions such as glasses, LVDs, surgery, or advice on braille and large print was obtained from parents/guardians. Meetings with parents were held at the start or end of school terms to educate them, advocate for their support, and address their concerns in the presence of teachers and health workers. Media coverage highlighted these activities through newspapers, radio, and TV. Evaluation After three years of implementation, an evaluation was planned and conducted to assess the project’s performance. A mixed-methods approach was used to evaluate the program’s progress: · Data Collection: Quantitative data were derived from client service delivery records, including device distribution, and training outputs. Qualitative data were collected through stakeholder interviews and focus group discussions with beneficiaries. · Analysis: Descriptive statistics were used to summarize quantitative data, while thematic analysis was applied to qualitative data to identify key themes related to challenges, achievements, and sustainability. The evaluation was detailed, involving the team from BICO (led by KK) and a consultant, beginning with desk research and followed by five days of fieldwork. Desk Review The desk review period lasted approximately two weeks and was conducted in liaison with the child blindness and low vision coordinator based at the hospital in Mzuzu. Key activities included: · Reviewing all annual progress reports. · Analyzing available data on refractive errors, low vision, and surgeries. Field Visits Day 1: The team visited the Ekwendeni Resource Centre to follow up on children with low vision, conduct advocacy (with parents and regular teachers), and disseminate project findings. Assessments were performed to evaluate the current vision levels of children, their use of prescribed spectacles and low vision devices, appropriate learning mediums (primarily print), classroom positions, provision of appropriate support for learning, and the current state of their eye conditions. Following the assessments, the BICO and the Ministry of Health (MOH) teams engaged parents and teachers (both regular and special needs) in a scheduled meeting. The purpose was to follow up on an earlier advocacy meeting held in February to foster stronger relationships between parents, teachers, learners, and project partners. During the meeting, all parties shared their experiences regarding improvements observed since the previous advocacy efforts. Parents and teachers highlighted significant performance improvements in learners due to the consistent use of spectacles and devices. BICO and MOH encouraged continued support from parents and teachers to ensure proper care of the glasses and devices. They also noted improved usage, with all learners consistently bringing their glasses to school and home, unlike before. Day 2: Nine trained optometrists were supervised at the hospital while assessing clients (both children and adults) with low vision. The supervision focused on enhancing the quality of care provided to individuals with visual impairments. Days 3 and 4: These days were dedicated to discussions with the nine low vision providers about observations from the first two days. The sessions included sharing experiences gained, identifying areas requiring further input, and revising techniques where needed. Day 5: The final day was spent engaging selected key stakeholders involved in the project. Findings from the project were disseminated, and reflections were gathered through discussions, providing valuable feedback and suggestions for future improvements. Results Though the overall project addressed the provision of low vision services to both adults and children, the results have mainly highlighted the findings in school-going children, as severe uncorrected vision loss has long- term implications in children in terms of progress in education, quality of life as well as social and economic opportunities for jobs later in life 1 . Between 2022 and 2024 (3 Years), the low vision program attended to 2,054 children overall, of whom 370 (18%) received glasses, 70 (3.4%) received low vision devices, and 96 (4.9%) received cataract surgery and/or glasses and low vision devices (Table 1 ). Table 1 Total Number of children who received glasses, low vision devices and surgeries Received glasses (N = 370) Received Low vision devices (n = 70) Had cataract Surgery plus low vision follow-up (n = 96) Male Female Total Male Female Total Male Female Total No (%) No (%) No (%) No (%) No (%) No (%) No (%) No (%) No (%) Year 1 41 104 145 6 7 13 17 8 25 11.1% 28.1% 39.2% 8.5% 10% 18.6% 17.7% 8.4% 26% Year 2 50 64 114 16 13 29 18 13 31 13.5% 17.3% 30.8% 22.9% 18.6% 41.4 18.8 13.5% 32.3% Year 3 54 57 111 16 12 28 27 13 40 14.6% 15.4% 30.0% 22.9% 17.1% 40% 28.1 13.5% 41.7 Total 145 225 370 38 32 70 62 34 96 39.2% 60.8% 100% 54.3% 45.7% 100% 64.6% 35.4% 100% Additionally, 64 persons with albinism (PWA), attended low vision services and received glasses and/or low vision devices. Follow-up assessments showed high satisfaction rates among users. For refractive errors and those who received glasses, there were more girls, 225 (60.8%), than boys (P < 0.005). For low vision devices, the proportion was 54.2% boys and 45.7% girls. Among the children who had cataract surgery, 62 were boys (64.6%), and 34 (33.2%) were girls, and there was a statistically significant difference between the two (P < 0.005). Table 2 shows the diagnosis of 32 children with low vision who were seen, during the final evaluation, at Ekwendeni Resource Centre (this was part of the special needs education integrated program and is presented here as an example) and who were boarding residents at the school. It should be noted that at the start of the project, no single child was wearing glasses and none had ever been prescribed LVDs, and teachers had very little knowledge of the effectiveness and use of glasses and LVDs in improving children's learning and providing access to print for the vast majority of children. There were 17 boys (53.1%) and 15 girls (46.9%), and their age ranged from 6–18 years, with a mean of 12.5 years. Table 2 Clinical diagnosis of children at the resource centre Clinical Diagnosis Frequency(N) % 1 Albinism 9 28.1 2 Corneal scars 7 21.9 3 Glaucoma 3 9.4 4 Optic atrophy 3 9.4 5 Unoperated Bilateral cataract 2 6.3 6 Micro-cornea 2 6.3 7 Posterior capsule opacity (PCO) 2 6.3 8 Complicated cataract 1 3.1 9 Myopia 1 3.1 10 Phthisis bulbi 1 3.1 11 Pseudophakia 1 3.1 Total 32 100 There were more children with albinism (28.1%) than any other condition, followed by cornea scars (21.9%). Among the 32 children, 18 were categorized as having clinical low vision (needing glasses and low vision devices), and 14 were categorized as being blind, needing braille for learning. 3 children had undergone cataract surgery and were categorized as low vision, and 2 girls with cataracts were not operated on (as parents had refused), and these were among those listed as blind and learning in braille. At the start of these children, none were wearing glasses or having low vision devices, and most were using Braille. Table 3 shows the learning media that children with low vision were using, during the final evaluation, whether they were wearing glasses (if prescribed), and/or using LVDs (if prescribed) and whether they had cataract surgery. Table 3 Mode of learning, whether wearing glasses or using LVDs. Frequency (No.) % Learning in Print, Braille or both Large Print 17 94.4 Both 1 5.6 Wearing Glasses Yes 14 77.8 No 4 22.2 Using Low Vision Devices if prescribed Yes 10 55.5 No 8 45.5 Regardless of the class grade the children were in, large print was the most common means (94.4%) that teachers used to teach children with Low- vision. However, it should be noted that at the start of the project, due to a lack of admission policy, and recommendations as to whether a child should learn using braille or print, most learners were initially using braille, and upon assessment, teachers were advised to change the children learning from braille to print. Uptake of glasses improved from 0% (baseline) to 77.8%. while uptake of LVDs improved from 0–55.5% in 3 years. Table 4 shows the characteristics of the key stakeholders who were involved in advocacy in the project and were included in the final dissemination of evaluation findings. They contributed to refining the final recommendations. Table 4 Key stakeholders and their roles in final dissemination Organization Role Number Gender Mzuzu Central Hospital Eye Department Management, Ministry of Health Involved in sustaining the Low Vision activities beyond the project period 2 1 Male & 1 Female Mapale Health Centre /Ministry of Health District office, Mzuzu Involved in integrating eye care within the Universal Health Coverage 2 1 Male & 1 Female Mzuzu Government Secondary School Specialist itinerant teachers who take on low vision learners once they have left the resource centres 1 Female Malawi Council for Disability Affairs (MACODA) Civil Society responsible for disability affairs in Malawi 1 Female Association of People Living with Albinism in Malawi (APAM) Civil Society involved with rights of persons with albinism 1 Male Beyond Sun Care Civil Society organization implementing activities for persons with albinism 1 Female Blantyre Institute for Community Outreach BICO Eye NGO spearheading Low vision activities in Malawi 5 2 Males & 3 Females Northern Education Division (NED), Ministry of Education Responsible for formulating and implementing policies for children with special needs 1 Male Consultant Global Low Vision Consultant on the project 1 Female Community Radio Diffusion of rumours and myths about albinism and low vision 2 1 Male, 1 Female Total 17 7 Males, 10 Females As can be seen from this table, there was a very good representation to discuss the findings and way forward for the low vision project in northern Malawi. Overall, the key challenges discussed by stakeholder and parents indicated a persistent lack of awareness about low vision and an unclear referral system between teachers and eye-health workers. Additionally, some parents remained uncertain about the benefits of interventions, perpetuating myths such as "glasses worsen vision," "cataract surgery causes blindness," or "vision loss is caused by witchcraft." The absence of a clear admission policy within the Ministries of Education and Health to operationalize the assessment of all children with severe visual impairments, and indeed with a disability, before admission to resource centers resulted in children with operable cataracts being admitted to schools, and children starting school, without having eye health and low vision assessments, which could improve their vision. This posed a significant challenge, as once a child was admitted, withdrawing them was not feasible. Finally, teachers and parents were often unaware of where to obtain replacements for lost subsidized glasses and low vision devices. Discussion The project embarked on an ambitious agenda to establish a childhood blindness and low vision program in Northern Malawi, a predominantly rural and hard-to-reach region, by integrating the principles of Universal Health Coverage (UHC) 18 , 19 into its framework. This approach aimed to ensure equitable, accessible, and high-quality eye care services, creating a model that could serve as a blueprint for implementing similar programs in other parts of Malawi and across Southern Africa. The strength of the project lay in its ability to foster robust intersectoral collaborations among diverse stakeholders, including the Blantyre Institute for Community Outreach (BICO), the Ministry of Education's Special Needs Department, the Ministry of Health, and various civil society organizations. This collaborative approach was further enhanced by the involvement of an international consultant with specialized expertise in low vision, whose guidance ensured that the project incorporated global best practices while tailoring solutions to the unique challenges and needs of the local context. As a result, the project successfully achieved all its intended objectives by delivering comprehensive eye care services, which included community screenings, detailed assessments, surgical interventions, and the provision of glasses and low vision devices, all supported by a robust follow-up system to ensure sustained impact and quality of care. The results are noteworthy, demonstrating many children identified and benefiting from the services provided (Table 1 ). This achievement underscores the project's broad acceptance and its effectiveness in addressing the critical needs of the target population. Annually, children with cataracts—the most common preventable cause of blindness in children—were able to access regular services for the first time within the northern region of Malawi. Previously, pediatric cataract services were only available in the southern part of the country, over 1,200 kilometers away from the furthest points in Northern Malawi. This distance, coupled with known barriers 20 such as lack of awareness about available services, transportation challenges, and high opportunity costs, had historically prevented parents from seeking care for their children. Additionally, the increased number of persons with albinism (PWA) accessing services is encouraging, as it demonstrates that some of the systemic, cultural, and socio-economic barriers preventing this vulnerable group from attending eye care services were effectively addressed. Persons with albinism in Malawi face significant stigma and discrimination rooted in myths and superstitious cultural beliefs 21 – 23 , particularly around the use of their body parts and associated rituals, which leave many living in fear of violence or even death. This societal discrimination extends to schools and other social settings, creating psychological barriers that discourage persons with albinism from seeking essential eye and health services. Additionally, widespread misinformation, such as the belief that eyeglasses worsen vision, further reduces service uptake among this vulnerable population. Integrating albinism-related care into primary eye health and school health programs, combined with robust advocacy efforts, as demonstrated in this project, presents an effective strategy to overcome these challenges and ensure equitable access to care. The observed gender inequity in children accessing cataract surgical services (twice as many boys had surgery than girls) is of concern and needs further discussion. Several studies, including systematic reviews with meta-analyses 5 , 20 , 24 – 28 , have highlighted significant gender disparities in all-cause blindness, severe vision impairment, cataract surgery coverage, and trachoma treatment coverage, particularly in low- and middle-income countries. Women are disproportionately affected, exhibiting higher prevalence rates 1 , yet they are less likely to access eye care services compared to men. The results do not only apply to adult women, but to girls as well. Though biological plausibility to some extent explains the high prevalence of cataracts in boys than girls 1 , 29 , the less surgery attendance among girls is often explained by social determinants 1 , that hinders them from attending services. Cultural norms often prioritize boys over girls in accessing healthcare. Families, especially in northern Malawi, where marriage is patrimonial, may allocate limited resources to boys' health needs, believing they will support them in old age. Girls’ ability to attend health services is limited, as they are often expected to fulfill domestic responsibilities early in life, then marry and move elsewhere. Families with limited financial resources may prioritize boys' treatment over girls. In areas where girls are less likely to attend school, school-based screening may not reach them, leaving their conditions undetected. As the northern region is entirely a patriarchal society, healthcare decisions often rest with male family members, who may undervalue the health needs of girls. Even though mothers may be willing to advocate for their daughters’ health, many lack the financial resources and education necessary to influence such decisions. Kalua 8 , 30 found that educated mothers were more likely to have access to media and better understand the negative effects of illness on the child and the importance of seeking medical care early. Such mothers did not see distance as a barrier, as they could pay for and justify the costs. The importance of maternal education has also been reported in other studies 31 – 33 . For the two girls with unoperated cataracts in the resource center, whose parents refused permission unless admission policies change—requiring children to be assessed by eye health workers before being admitted to the school—there is little that can be done without an appropriate legal framework. The systemic and social barriers, combined with inadequate legal frameworks, perpetuate a cycle of neglect and discrimination that infringes on these girls’ fundamental rights to health, education, equality, protection, and autonomy. Addressing these issues requires a multi-faceted approach, including policy reforms, advocacy for gender equity, and the establishment of child protection mechanisms that prioritize the best interests of the child. The shift from Braille to (Large) Print for many children indicates that early assessments and recommendations had a significant impact on teaching methods. The uptake of glasses and low vision devices prescribed was very low in the first year low, but showed promising improvements in year 3. Remember the baseline was zero. One of the main reasons for improvement was the increased awareness of caregivers, children and teachers of their benefits. More advocacy is needed to convince the government to support a clear admission policy, also financially. Preventing unnecessary Braille use saves money as special skills and books are then only needed for a small percentage of children and these savings could be used to sustain part of the services. The Ministry of Education places special teachers at resource centres like Ekwendeni. These teachers are trained at a government supported teacher training college. They also transfer these teachers regularly to another location. Continuous capacity building of teachers in supporting children with low vision is needed, and an investigation in the current content of the low vision related modules at the training college. From the stakeholder findings, the following themes are proposed: i) Policy Integration - continue advocating for the inclusion of low vision services in national health policies; ii) Public Awareness - conduct nationwide campaigns to dispel myths about low vision and promote service uptake among children and persons with albinism; iii) Educator Support - ensure teachers in resource centers are adequately trained to enhance their ability to support students with low vision; and iv) Sustainability - fully integrate trained staff into the ongoing operations of government systems. Limitations Before generalizing the findings to other setups, these limitations need to be considered. The findings are rooted in a specific socio-cultural and geographic context and may need to be adapted before being applied in other areas. As the project benefited from consistent resources, replication in the absence of such resources may prove challenging. From the outset, the project was conceived with an emphasis on policy integration and stakeholder collaboration, which were partially achieved and contributed to its success. However, other Southern African nations may encounter more significant bureaucratic or political hurdles in adopting similar policies. Nevertheless, the lessons derived from this comprehensive eye care program are invaluable and can be tailored for scaling up similar initiatives across the region. Conclusion It is possible to advance advancing Global Eye Health even in LMIC despite having limited resources. The Childhood Blindness and Low Vision Program in Malawi has advanced access to essential services for marginalized populations, but systemic gaps remain, including limited awareness, service delivery barriers, and a lack of policies integrating eye health and education. A key challenge is the absence of a mandate for comprehensive visual assessments before children with low vision or blindness are admitted to resource centers, leading to missed opportunities for early interventions. To address this, an integrated framework between the eye health and education sectors is essential, ensuring assessments, referrals, and follow-ups are embedded in national policies. Such alignment would enhance service sustainability, improve outcomes for children, and strengthen Malawi’s commitment to global eye health equity. Abbreviations APAM Association of Persons with Albinism in Malawi BICO Blantyre Institute for Community Outreach CBLVP Childhood Blindness and Low Vision Project IRB Institutional Review Board KIM Key Informant Method LMIC Low- and Middle-Income Countries LVDs Low Vision Devices MACODA Malawi Council for Disability Affairs MOE Ministry of Education MOH Ministry of Health NED Northern Education Division PWA Persons with Albinism SNED Special Needs Education Department UEHC Universal Eye-Health Coverage UHC Universal Health Coverage Declarations Approval for this study was obtained from the Ministry of Health authorities responsible for eye care in Malawi. Acknowledgements We extend our heartfelt gratitude to everyone who contributed to the implementation of the childhood blindness and Low vision project in Northern Malawi: the dedicated staff at BICO, Mzuzu Central Hospital, and Ekwendeni Resource Centre; the team from the Ophthalmology Department in Blantyre; Mzuzu-based Ministry of Health and Education staff; and the numerous Civil Society organizations involved, whose efforts are too numerous to name individually. Authors Contribution KK designed the project, conducted data analysis, interpretation of results, and wrote the initial draft ES collected data and conducted data analysis HN, TC, PM, CM, BC conducted data collected. KvD co-designed the project, and conducted interpretation of results. All authors read and approved the final manuscript. Funding The project was funded by Stichting Lions Fight for Sight Netherlands (part of the Dutch Lions, which is a branch of International Lions Organization) and Wilde Ganzen Foundation (A Dutch- Based NGO). Availability of Data and Materials Not shared, contains patient information. De-identified data available on request. Declarations Ethics approval and consent to participate Ethical approval from IRB not needed, as this was a service delivery project. Permission from project obtained from Ministry of Health and Education, and parentals and teacher consent taken. Consent for publication: taken. Competing interests The authors declare no competing interests. Author details 1. School of Population and Public Health, University of British Columbia, British Columbia, Canada 2. Blantyre Institute for Community Outreach (BICO), Blantyre, Malawi 3. Ophthalmology Department, Mzuzu Central Hospital, Mzuzu, Malawi 4. Lions Sight First Eye Hospital, Blantyre, Malawi 5. International Low vision consultant, Deventer, The Netherlands References Burton MJ, Ramke J, Patricia Marques A, et al. The Lancet Global Health Commission on Global Eye Health: vision beyond 2020 . Lancet Glob Health . 2021;9. Gilbert C, Foster A. Childhood blindness in the context of VISION 2020 - The right to sight. Bull World Health Organ . 2001;79(3). World Health Organization. World Report on Vision. ; 2019. Accessed December 21, 2024. https://www.who.int/publications/i/item/world-report-on-vision Ramke J, Zwi AB, Palagyi A, Blignault I, Gilbert CE. Equity and Blindness: Closing Evidence Gaps to Support Universal Eye Health. Ophthalmic Epidemiol . 2015;22(5). doi:10.3109/09286586.2015.1077977 Van Dijk K, Courtright P. Barriers to surgical intervention among blind and low vision children in Malawi. Vis Impair Res . 2000;2(2). doi:10.1076/vimr.2.2.75.4425 Kishiki E, Van Dijk K, Courtright P. Strategies to improve follow-up of children after surgery for cataract: Findings from Child Eye Health Tertiary Facilities in sub-Saharan Africa and South Asia. Eye (Basingstoke) . 2016;30(9). doi:10.1038/eye.2016.169 Schulze Schwering M, Kumar N, Bohrmann D, et al. Refractive errors, visual impairment, and the use of low vision devices in albinism in Malawi. Graefe’s Archive for Clinical and Experimental Ophthalmology . 2015;253(4). doi:10.1007/s00417-015-2943-0 Kalua K. Comparison of Effectiveness of Using Trained Key Informants versus Health Surveillance Assistants in Identifying Blind and Visually Impaired Children in Malawi . PhD. London School of Hygiene and Tropical Medicine; 2015. Kalua K, Ng’ongola RT, Mbewe F, Gilbert C. Using primary health care (PHC) workers and key informants for community based detection of blindness in children in Southern Malawi. Hum Resour Health . 2012;10. doi:10.1186/1478-4491-10-37 Tataryn M, Polack S, Chokotho L, et al. Childhood disability in Malawi: A population based assessment using the key informant method. BMC Pediatr . 2017;17(1). doi:10.1186/s12887-017-0948-z Banks LM, Hunt X, Kalua K, Nindi P, Zuurmond M, Shakespeare T. ‘I might be lucky and go back to school’: Factors affecting inclusion in education for children with disabilities in rural Malawi. Afr J Disabil . 2022;11. doi:10.4102/AJOD.V11I0.981 Schulze Schwering M, Nyrenda M, Spitzer MS, Kalua K. [Visual impairment and blindness in children in a Malawian school for the blind]. Klin Monbl Augenheilkd . 2013;230(8). Kalua K, Nyirenda M, Lewallen S, Courtright P. Three-year follow up of primary health care workers trained in identification of blind and visual impaired children in Malawi. Health N Hav . 2013;05(11). doi:10.4236/health.2013.511241 Hannum E, Zhang Y. Poverty and Proximate Barriers to Learning: Vision Deficiencies, Vision Correction and Educational Outcomes in Rural Northwest China. World Dev . 2012;40(9). doi:10.1016/j.worlddev.2012.04.029 Glewwe P, Park A, Zhao M. A better vision for development: Eyeglasses and academic performance in rural primary schools in China. J Dev Econ . 2016;122. doi:10.1016/j.jdeveco.2016.05.007 Glewwe P, West KL, Lee J. The Impact of Providing Vision Screening and Free Eyeglasses on Academic Outcomes: Evidence from a Randomized Trial in Title I Elementary Schools in Florida. Journal of Policy Analysis and Management . 2018;37(2). doi:10.1002/pam.22043 Marah G, Wilson R, Kalua K. Childhood Blindness and Low Vision Program (CBLVP) in Northern Malawi. https://bicomalawi.org/. World Health Organization. Universal health coverage (UHC) Key Facts. World Health Organization . 2019;(January). WHO. Universal health coverage Primary health care towards universal health coverage. World Health Organisation . 2018;2018(December). Aboobaker S, Courtright P. Barriers to cataract surgery in Africa: A systematic review. Middle East Afr J Ophthalmol . 2016;23(1). doi:10.4103/0974-9233.164615 Mwiba DM. Medicine Killings, Abduction of People with Albinism, Wealth and Prosperity in North Malawi: A Historical Assessment. Proceedings of the African Futures Conference . 2018;2(1). doi:10.1002/j.2573-508x.2018.tb00008.x Baker C, Lund P, Massah B, Mawerenga J. We Are Human, Just Like You: Albinism in Malawi-Implications for Security . Vol 29.; 2021. Tambala-Kaliati T, Adomako EB, Frimpong-Manso K. Living with albinism in an African community: exploring the challenges of persons with albinism in Lilongwe District, Malawi. Heliyon . 2021;7(5). doi:10.1016/j.heliyon.2021.e07034 Abou-Gareeb I, Lewallen S, Bassett K, Courtright P. Gender and blindness: A meta-analysis of population-based prevalence surveys. Ophthalmic Epidemiol . 2001;8(1). doi:10.1076/opep.8.1.39.1540 Naidoo K, Kempen JH, Gichuhi S, et al. Prevalence and causes of vision loss in sub-Saharan Africa in 2015: Magnitude, temporal trends and projections. British Journal of Ophthalmology . 2020;104(12). doi:10.1136/bjophthalmol-2019-315217 Naidoo K, Gichuhi S, Basáñez MG, et al. Prevalence and causes of vision loss in sub-Saharan Africa: 1990-2010. British Journal of Ophthalmology . 2014;98(5). doi:10.1136/bjophthalmol-2013-304081 Mganga H, Lewallen S, Courtright P. Overcoming gender inequity in prevention of blindness and visual impairment in Africa. Middle East Afr J Ophthalmol . 2011;18(2). doi:10.4103/0974-9233.80695 Mercer GD, Lyons P, Bassett K. Interventions to improve gender equity in eye care in low-middle income countries: A systematic review. Ophthalmic Epidemiol . 2019;26(3). doi:10.1080/09286586.2019.1574839 Jayashree MP, Choudhary A, Hamsa DS, Divya R, Raksha H V. Epidemiology of pediatric cataracts - A 5 year retrospective study. Indian Journal of Clinical and Experimental Ophthalmology . 2020;6(3). doi:10.18231/j.ijceo.2020.085 Kalua K, Patel D, Muhit M, Courtright P. Causes of blindness among children identified through village key informants in Malawi. Canadian Journal of Ophthalmology . 2008;43(4). doi:10.3129/I08-084 Forshaw J, Gerver SM, Gill M, Cooper E, Manikam L, Ward H. The global effect of maternal education on complete childhood vaccination: A systematic review and meta-analysis. BMC Infect Dis . 2017;17(1). doi:10.1186/s12879-017-2890-y Weis M, Trommsdorff G, Muñoz L, González R. Maternal Education and Children’s School Achievement: The Roles of Values, Parenting, and Behavior Regulation. J Child Fam Stud . 2023;32(3). doi:10.1007/s10826-022-02405-y Moradhvaj, Samir KC. Differential impact of maternal education on under-five mortality in rural and urban India. Health Place . 2023;80. doi:10.1016/j.healthplace.2023.102987 Additional Declarations No competing interests reported. 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Both conditions remain underdiagnosed and undertreated due to limited access to specialized services and devices. According to the most recent estimates\u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u003c/sup\u003e, globally, 1.02\u0026nbsp;million children were blind in 2020, and probably three times this number had low vision. The burden tends to be greater in low- and middle-income countries and underserved populations, such as women and children, migrants, Indigenous peoples, persons with certain kinds of disability (albinism), and in rural communities\u003csup\u003e\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u003c/sup\u003e. Unfortunately, the widely accepted strategies for achieving Universal Eye Health Coverage (UEHC) assume equity across all policies and do not address disadvantaged communities\u003csup\u003e\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u003c/sup\u003e. There is a need to make a deliberate effort in eye care, to address access barriers\u003csup\u003e\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e,\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u003c/sup\u003e and reach those often considered \u0026ldquo;unreached\u0026rdquo;.\u003c/p\u003e \u003cp\u003eDespite the scarcity of data on blindness and low vision in Malawi and southern Africa, earlier studies had shown that a large proportion of causes are reversible either preventable or treatable\u003csup\u003e\u003cspan additionalcitationids=\"CR8 CR9\" citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u003c/sup\u003e, and that children with disabilities face persistent and systemic barriers to attending, progressing, and learning in school\u003csup\u003e\u003cspan additionalcitationids=\"CR12\" citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u003c/sup\u003e. There is overwhelming new evidence by Burton et.al\u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u003c/sup\u003e, in a commission of Global Eye Health, that educational performance for children was linked to vision. Children with vision impairment had poorer academic outcomes and were more likely to be excluded from schools and more likely to drop out of school. This was also observed by Kalua\u003csup\u003e\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u003c/sup\u003e, in his studies in Malawi. Simple interventions such as screening and providing spectacles to children with visual impairment are well-documented to improve educational performance.\u003csup\u003e\u003cspan additionalcitationids=\"CR15\" citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e\u003c/sup\u003e. Yet, unless addressed through innovative ways, these interventions are rarely a reality for most children in Southern Africa, where lack of access to glasses and low vision devices, coupled with high cost, contribute to challenges in obtaining these. Malawi, with a population of approximately 20\u0026nbsp;million, has a relatively small number of ophthalmologists and midlevel ophthalmic personnel (optometrists, optometry technicians, ophthalmic clinical officers) and had not yet established low vision services in the Northern part of the country, as part of regular eyecare, despite having a tertiary eye hospital where several children attended eye health units for various eye conditions, some of which fell within the category of severe visual impairment and low vision. This was the reason why the \u0026ldquo;Childhood Blindness and Low Vision Program (CBLVP)\u0026rdquo; was proposed and initiated in 2022 by the Blantyre Institute for Community Outreach (BICO)\u003csup\u003e\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e\u003c/sup\u003e, a Malawian non-profit organization, in collaboration with the ministries of education and health, and international partners (Fight for Sight Netherlands and Wilde Ganzen Foundation) to eliminate avoidable blindness and low vision in children in the Northern region, and positively contribute towards the 2020 Eye Health Agenda.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003eThe 3-year project (2022–2024) was based at the Mzuzu Central Hospital Eye Department, a tertiary hospital serving a catchment population of 2 million people across six surrounding districts. The project aimed to establish a model for providing blindness and low vision services for adults and children in Northern Malawi, with the potential to be scaled up across Malawi. Specific objectives included:\u003c/p\u003e\n\u003cp\u003e1.\u0026nbsp; \u0026nbsp;\u0026nbsp;Identifying a dedicated room and setting up low vision services.\u003c/p\u003e\n\u003cp\u003e2.\u0026nbsp; \u0026nbsp;\u0026nbsp;Organizing and conducting outreach screening clinics, in cooperation with local health and community-based services, and building capacity for low vision and pediatric services through training.\u003c/p\u003e\n\u003cp\u003e3.\u0026nbsp; \u0026nbsp;\u0026nbsp;Engaging with parents of children with low vision and conducting pediatric surgeries with follow-ups.\u003c/p\u003e\n\u003cp\u003e4.\u0026nbsp; \u0026nbsp;\u0026nbsp;Ensuring appropriate low vision related knowledge and skills for special and classroom teachers with children with vision impairment in their school.\u003c/p\u003e\n\u003cp\u003e5.\u0026nbsp; \u0026nbsp;\u0026nbsp;Advocating with the Ministries of Education and Health to systematically link educational services with eye care services for children with visual impairment, and indeed for children wih other disabilities and likely vision problems, in special and local schools\u003c/p\u003e\n\u003cp\u003e6.\u0026nbsp; \u0026nbsp;\u0026nbsp;Conducting a final project evaluation with stakeholder involvement.\u003c/p\u003e\n\u003cp\u003eAfter securing funding for the service delivery grant from 2 Dutch organizations (Fight for Sight Netherlands and Wilde Ganzen Foundation), BICO organized a visit to Mzuzu to meet the resident ophthalmologist (PM), a team from the Ministry of Health, and a team from the Ministry of Education’s Special Needs Education Department (SNED). This visit aimed to brief stakeholders about the project, request their cooperation, and clarify expectations. Hospital management was asked to allocate a dedicated room to establish the low vision clinic. The education team identified a nearby special needs school, located 30 km from the hospital, with a significant number of children with blindness and low vision, to serve as a case study for the project’s progress.\u003c/p\u003e\n\u003cp\u003eOnce the hospital management allocated a room, it was fully renovated and equipped with visual assessment tools, including a slit lamp, auto-refractometer, lensometer, visual acuity testing equipment, low vision testing tools, low vision devices (LVDs) of various powers, and frames and lenses. A low vision therapist, previously trained by BICO and based in another region, was transferred to manage the clinic, supported by another optometry technician.\u003c/p\u003e\n\u003cp\u003eTo kickstart activities, BICO contacted a global low vision expert (KVD) with experience in low- and middle-income countries (LMICs) to provide training to a group of optometrists in Northern Malawi and to support the low vision therapist managing the clinic. The consultant conducted annual physical visits to provide hands-on training and supervise the assessment of children with low vision at resource centers, supplemented by online training and support. A team of nine optometrists and optometry technicians was identified and enrolled in capacity-building initiatives, receiving initial training from the low vision therapist in Mzuzu and subsequent training from the consultant. The low vision clinic began daily operations, with referrals from the general eye clinic for children and adults with low vision.\u003c/p\u003e\n\u003cp\u003eTo increase the clinic’s reach, BICO collaborated with the eye department and the district health office to organize regular school screenings. Children identified by teachers as having visual difficulties were assessed and managed if they had treatable conditions like refractive errors. More severe cases were referred to the low vision clinic. Teachers were also trained to identify children with visual problems as part of capacity-building efforts. Children needing glasses received them through a donation, by the project managed by BICO.\u003c/p\u003e\n\u003cp\u003eAdvocacy activities included community radio and television (TV) announcements, brochures, and meetings with key groups such as the Association of Persons Living with Albinism (APAM) to raise awareness and encourage individuals to access services at the clinic.\u003c/p\u003e\n\u003cp\u003eThe project also mobilized children needing surgery, primarily for cataracts, using the key informant method (KIM) to identify and refer them to the clinic for assessment and scheduling for surgery. Pediatric surgeries were conducted by a team from the southern region of Malawi (Blantyre). Once a sufficient number of children (target: 30 per surgical camp per year) were booked, the surgical team traveled to Mzuzu for a week to perform surgeries and follow-ups while training the local team to manage these cases long-term. Children who underwent surgery were referred to the low vision clinic for assessment and provision of glasses and LVDs (subsidized through the project), as most post-surgery children benefit significantly from these services.\u003c/p\u003e\n\u003cp\u003eTo foster integration between education and health, the low vision team visited Ekwendeni Resource Centre, an integrated school for children with severe visual impairments. These visits involved joint screenings by eye health workers and teachers, with collaborative management plans agreed upon and documented for the teachers. Consent for interventions such as glasses, LVDs, surgery, or advice on braille and large print was obtained from parents/guardians. Meetings with parents were held at the start or end of school terms to educate them, advocate for their support, and address their concerns in the presence of teachers and health workers. Media coverage highlighted these activities through newspapers, radio, and TV.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEvaluation\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAfter three years of implementation, an evaluation was planned and conducted to assess the project’s performance.\u003c/p\u003e\n\u003cp\u003eA mixed-methods approach was used to evaluate the program’s progress:\u003c/p\u003e\n\u003cp\u003e· Data Collection: Quantitative data were derived from client service delivery records, including device distribution, and training outputs. Qualitative data were collected through stakeholder interviews and focus group discussions with beneficiaries.\u003c/p\u003e\n\u003cp\u003e· Analysis: Descriptive statistics were used to summarize quantitative data, while thematic analysis was applied to qualitative data to identify key themes related to challenges, achievements, and sustainability.\u003c/p\u003e\n\u003cp\u003eThe evaluation was detailed, involving the team from BICO (led by KK) and a consultant, beginning with desk research and followed by five days of fieldwork.\u003c/p\u003e\n\u003cp\u003eDesk Review\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe desk review period lasted approximately two weeks and was conducted in liaison with the child blindness and low vision coordinator based at the hospital in Mzuzu. Key activities included:\u003c/p\u003e\n\u003cp\u003e· Reviewing all annual progress reports.\u003c/p\u003e\n\u003cp\u003e· Analyzing available data on refractive errors, low vision, and surgeries.\u003c/p\u003e\n\u003cp\u003eField Visits\u003c/p\u003e\n\u003cp\u003eDay 1: The team visited the Ekwendeni Resource Centre to follow up on children with low vision, conduct advocacy (with parents and regular teachers), and disseminate project findings. Assessments were performed to evaluate the current vision levels of children, their use of prescribed spectacles and low vision devices, appropriate learning mediums (primarily print), classroom positions, provision of appropriate support for learning, and the current state of their eye conditions.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eFollowing the assessments, the BICO and the Ministry of Health (MOH) teams engaged parents and teachers (both regular and special needs) in a scheduled meeting. The purpose was to follow up on an earlier advocacy meeting held in February to foster stronger relationships between parents, teachers, learners, and project partners. During the meeting, all parties shared their experiences regarding improvements observed since the previous advocacy efforts. Parents and teachers highlighted significant performance improvements in learners due to the consistent use of spectacles and devices. BICO and MOH encouraged continued support from parents and teachers to ensure proper care of the glasses and devices. They also noted improved usage, with all learners consistently bringing their glasses to school and home, unlike before.\u003c/p\u003e\n\u003cp\u003eDay 2: Nine trained optometrists were supervised at the hospital while assessing clients (both children and adults) with low vision. The supervision focused on enhancing the quality of care provided to individuals with visual impairments.\u003c/p\u003e\n\u003cp\u003eDays 3 and 4: These days were dedicated to discussions with the nine low vision providers about observations from the first two days. The sessions included sharing experiences gained, identifying areas requiring further input, and revising techniques where needed.\u003c/p\u003e\n\u003cp\u003eDay 5: The final day was spent engaging selected key stakeholders involved in the project. Findings from the project were disseminated, and reflections were gathered through discussions, providing valuable feedback and suggestions for future improvements.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eThough the overall project addressed the provision of low vision services to both adults and children, the results have mainly highlighted the findings in school-going children, as severe uncorrected vision loss has long- term implications in children in terms of progress in education, quality of life as well as social and economic opportunities for jobs later in life\u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u003c/sup\u003e .\u003c/p\u003e \u003cp\u003eBetween 2022 and 2024 (3 Years), the low vision program attended to 2,054 children overall, of whom 370 (18%) received glasses, 70 (3.4%) received low vision devices, and 96 (4.9%) received cataract surgery and/or glasses and low vision devices (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eTotal Number of children who received glasses, low vision devices and surgeries\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"12\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c9\" colnum=\"9\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c10\" colnum=\"10\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c11\" colnum=\"11\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c12\" colnum=\"12\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colspan=\"3\" nameend=\"c4\" namest=\"c2\"\u003e \u003cp\u003eReceived glasses (N\u0026thinsp;=\u0026thinsp;370)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colspan=\"3\" nameend=\"c8\" namest=\"c6\"\u003e \u003cp\u003eReceived Low vision devices (n\u0026thinsp;=\u0026thinsp;70)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colspan=\"3\" nameend=\"c12\" namest=\"c10\"\u003e \u003cp\u003eHad cataract Surgery plus low vision follow-up (n\u0026thinsp;=\u0026thinsp;96)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eTotal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eTotal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003eTotal\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNo (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eNo (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eNo (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eNo (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eNo (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eNo (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003eNo (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003eNo (%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYear 1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e41\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e104\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e145\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e17\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003e25\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e11.1%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e28.1%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e39.2%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e8.5%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e10%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e18.6%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e17.7%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e8.4%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003e26%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYear 2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e50\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e64\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e114\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e16\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e29\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e18\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003e31\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e13.5%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e17.3%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e30.8%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e22.9%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e18.6%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e41.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e18.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e13.5%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003e32.3%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYear 3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e54\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e57\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e111\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e16\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e28\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e27\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003e40\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e14.6%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e15.4%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e30.0%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e22.9%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e17.1%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e40%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e28.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e13.5%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003e41.7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTotal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e145\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e225\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e370\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e38\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e32\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e70\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e62\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e34\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003e96\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e39.2%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e60.8%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e100%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e54.3%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e45.7%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e100%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e64.6%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e35.4%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003e100%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eAdditionally, 64 persons with albinism (PWA), attended low vision services and received glasses and/or low vision devices. Follow-up assessments showed high satisfaction rates among users.\u003c/p\u003e \u003cp\u003eFor refractive errors and those who received glasses, there were more girls, 225 (60.8%), than boys (P\u0026thinsp;\u0026lt;\u0026thinsp;0.005). For low vision devices, the proportion was 54.2% boys and 45.7% girls.\u003c/p\u003e \u003cp\u003eAmong the children who had cataract surgery, 62 were boys (64.6%), and 34 (33.2%) were girls, and there was a statistically significant difference between the two (P\u0026thinsp;\u0026lt;\u0026thinsp;0.005).\u003c/p\u003e \u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e shows the diagnosis of 32 children with low vision who were seen, during the final evaluation, at Ekwendeni Resource Centre (this was part of the special needs education integrated program and is presented here as an example) and who were boarding residents at the school. It should be noted that at the start of the project, no single child was wearing glasses and none had ever been prescribed LVDs, and teachers had very little knowledge of the effectiveness and use of glasses and LVDs in improving children's learning and providing access to print for the vast majority of children.\u003c/p\u003e \u003cp\u003eThere were 17 boys (53.1%) and 15 girls (46.9%), and their age ranged from 6\u0026ndash;18 years, with a mean of 12.5 years.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eClinical diagnosis of children at the resource centre\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eClinical Diagnosis\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eFrequency(N)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003e%\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAlbinism\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e28.1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCorneal scars\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e21.9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eGlaucoma\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e9.4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eOptic atrophy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e9.4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eUnoperated Bilateral cataract\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e6.3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMicro-cornea\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e6.3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePosterior capsule opacity (PCO)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e6.3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eComplicated cataract\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3.1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMyopia\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3.1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePhthisis bulbi\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3.1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePseudophakia\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3.1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTotal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e32\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e100\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eThere were more children with albinism (28.1%) than any other condition, followed by cornea scars (21.9%).\u003c/p\u003e \u003cp\u003eAmong the 32 children, 18 were categorized as having clinical low vision (needing glasses and low vision devices), and 14 were categorized as being blind, needing braille for learning. 3 children had undergone cataract surgery and were categorized as low vision, and 2 girls with cataracts were not operated on (as parents had refused), and these were among those listed as blind and learning in braille.\u003c/p\u003e \u003cp\u003eAt the start of these children, none were wearing glasses or having low vision devices, and most were using Braille.\u003c/p\u003e \u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e shows the learning media that children with low vision were using, during the final evaluation, whether they were wearing glasses (if prescribed), and/or using LVDs (if prescribed) and whether they had cataract surgery.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eMode of learning, whether wearing glasses or using LVDs.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFrequency (No.)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003e%\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLearning in Print, Braille or both\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLarge Print\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e17\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e94.4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBoth\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e5.6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWearing Glasses\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e77.8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e22.2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUsing Low Vision Devices if prescribed\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e55.5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e45.5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eRegardless of the class grade the children were in, large print was the most common means (94.4%) that teachers used to teach children with Low- vision. However, it should be noted that at the start of the project, due to a lack of admission policy, and recommendations as to whether a child should learn using braille or print, most learners were initially using braille, and upon assessment, teachers were advised to change the children learning from braille to print. Uptake of glasses improved from 0% (baseline) to 77.8%. while uptake of LVDs improved from 0\u0026ndash;55.5% in 3 years.\u003c/p\u003e \u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e shows the characteristics of the key stakeholders who were involved in advocacy in the project and were included in the final dissemination of evaluation findings. They contributed to refining the final recommendations.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eKey stakeholders and their roles in final dissemination\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOrganization\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eRole\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNumber\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eGender\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMzuzu Central Hospital Eye Department Management, Ministry of Health\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eInvolved in sustaining the Low Vision activities beyond the project period\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1 Male \u0026amp; 1 Female\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMapale Health Centre /Ministry of Health District office, Mzuzu\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eInvolved in integrating eye care within the Universal Health Coverage\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1 Male \u0026amp; 1 Female\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMzuzu Government Secondary School\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSpecialist itinerant teachers who take on low vision learners once they have left the resource centres\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMalawi Council for Disability Affairs (MACODA)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCivil Society responsible for disability affairs in Malawi\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAssociation of People Living with Albinism in Malawi (APAM)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCivil Society involved with rights of persons with albinism\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBeyond Sun Care\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCivil Society organization implementing activities for persons with albinism\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBlantyre Institute for Community Outreach BICO\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eEye NGO spearheading Low vision activities in Malawi\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2 Males \u0026amp; 3 Females\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNorthern Education Division (NED), Ministry of Education\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eResponsible for formulating and implementing policies for children with special needs\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eConsultant\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eGlobal Low Vision Consultant on the project\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCommunity Radio\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eDiffusion of rumours and myths about albinism and low vision\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1 Male, 1 Female\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTotal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e17\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e7 Males, 10 Females\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eAs can be seen from this table, there was a very good representation to discuss the findings and way forward for the low vision project in northern Malawi.\u003c/p\u003e \u003cp\u003eOverall, the key challenges discussed by stakeholder and parents indicated a persistent lack of awareness about low vision and an unclear referral system between teachers and eye-health workers. Additionally, some parents remained uncertain about the benefits of interventions, perpetuating myths such as \"glasses worsen vision,\" \"cataract surgery causes blindness,\" or \"vision loss is caused by witchcraft.\" The absence of a clear admission policy within the Ministries of Education and Health to operationalize the assessment of all children with severe visual impairments, and indeed with a disability, before admission to resource centers resulted in children with operable cataracts being admitted to schools, and children starting school, without having eye health and low vision assessments, which could improve their vision. This posed a significant challenge, as once a child was admitted, withdrawing them was not feasible.\u003c/p\u003e \u003cp\u003eFinally, teachers and parents were often unaware of where to obtain replacements for lost subsidized glasses and low vision devices.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThe project embarked on an ambitious agenda to establish a childhood blindness and low vision program in Northern Malawi, a predominantly rural and hard-to-reach region, by integrating the principles of Universal Health Coverage (UHC)\u003csup\u003e\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e,\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e\u003c/sup\u003e into its framework. This approach aimed to ensure equitable, accessible, and high-quality eye care services, creating a model that could serve as a blueprint for implementing similar programs in other parts of Malawi and across Southern Africa.\u003c/p\u003e \u003cp\u003eThe strength of the project lay in its ability to foster robust intersectoral collaborations among diverse stakeholders, including the Blantyre Institute for Community Outreach (BICO), the Ministry of Education's Special Needs Department, the Ministry of Health, and various civil society organizations. This collaborative approach was further enhanced by the involvement of an international consultant with specialized expertise in low vision, whose guidance ensured that the project incorporated global best practices while tailoring solutions to the unique challenges and needs of the local context.\u003c/p\u003e \u003cp\u003e As a result, the project successfully achieved all its intended objectives by delivering comprehensive eye care services, which included community screenings, detailed assessments, surgical interventions, and the provision of glasses and low vision devices, all supported by a robust follow-up system to ensure sustained impact and quality of care.\u003c/p\u003e \u003cp\u003eThe results are noteworthy, demonstrating many children identified and benefiting from the services provided (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). This achievement underscores the project's broad acceptance and its effectiveness in addressing the critical needs of the target population.\u003c/p\u003e \u003cp\u003eAnnually, children with cataracts\u0026mdash;the most common preventable cause of blindness in children\u0026mdash;were able to access regular services for the first time within the northern region of Malawi. Previously, pediatric cataract services were only available in the southern part of the country, over 1,200 kilometers away from the furthest points in Northern Malawi. This distance, coupled with known barriers\u003csup\u003e\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e\u003c/sup\u003e such as lack of awareness about available services, transportation challenges, and high opportunity costs, had historically prevented parents from seeking care for their children.\u003c/p\u003e \u003cp\u003eAdditionally, the increased number of persons with albinism (PWA) accessing services is encouraging, as it demonstrates that some of the systemic, cultural, and socio-economic barriers preventing this vulnerable group from attending eye care services were effectively addressed.\u003c/p\u003e \u003cp\u003ePersons with albinism in Malawi face significant stigma and discrimination rooted in myths and superstitious cultural beliefs\u003csup\u003e\u003cspan additionalcitationids=\"CR22\" citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e\u003c/sup\u003e, particularly around the use of their body parts and associated rituals, which leave many living in fear of violence or even death. This societal discrimination extends to schools and other social settings, creating psychological barriers that discourage persons with albinism from seeking essential eye and health services. Additionally, widespread misinformation, such as the belief that eyeglasses worsen vision, further reduces service uptake among this vulnerable population. Integrating albinism-related care into primary eye health and school health programs, combined with robust advocacy efforts, as demonstrated in this project, presents an effective strategy to overcome these challenges and ensure equitable access to care.\u003c/p\u003e \u003cp\u003eThe observed gender inequity in children accessing cataract surgical services (twice as many boys had surgery than girls) is of concern and needs further discussion.\u003c/p\u003e \u003cp\u003eSeveral studies, including systematic reviews with meta-analyses\u003csup\u003e\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e,\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e,\u003cspan additionalcitationids=\"CR25 CR26 CR27\" citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e\u003c/sup\u003e, have highlighted significant gender disparities in all-cause blindness, severe vision impairment, cataract surgery coverage, and trachoma treatment coverage, particularly in low- and middle-income countries. Women are disproportionately affected, exhibiting higher prevalence rates\u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u003c/sup\u003e, yet they are less likely to access eye care services compared to men.\u003c/p\u003e \u003cp\u003eThe results do not only apply to adult women, but to girls as well. Though biological plausibility to some extent explains the high prevalence of cataracts in boys than girls\u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e,\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e\u003c/sup\u003e, the less surgery attendance among girls is often explained by social determinants\u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u003c/sup\u003e, that hinders them from attending services.\u003c/p\u003e \u003cp\u003eCultural norms often prioritize boys over girls in accessing healthcare. Families, especially in northern Malawi, where marriage is patrimonial, may allocate limited resources to boys' health needs, believing they will support them in old age. Girls\u0026rsquo; ability to attend health services is limited, as they are often expected to fulfill domestic responsibilities early in life, then marry and move elsewhere. Families with limited financial resources may prioritize boys' treatment over girls. In areas where girls are less likely to attend school, school-based screening may not reach them, leaving their conditions undetected.\u003c/p\u003e \u003cp\u003eAs the northern region is entirely a patriarchal society, healthcare decisions often rest with male family members, who may undervalue the health needs of girls. Even though mothers may be willing to advocate for their daughters\u0026rsquo; health, many lack the financial resources and education necessary to influence such decisions. Kalua\u003csup\u003e\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e,\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e\u003c/sup\u003e found that educated mothers were more likely to have access to media and better understand the negative effects of illness on the child and the importance of seeking medical care early. Such mothers did not see distance as a barrier, as they could pay for and justify the costs. The importance of maternal education has also been reported in other studies\u003csup\u003e\u003cspan additionalcitationids=\"CR32\" citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e\u003c/sup\u003e .\u003c/p\u003e \u003cp\u003eFor the two girls with unoperated cataracts in the resource center, whose parents refused permission unless admission policies change\u0026mdash;requiring children to be assessed by eye health workers before being admitted to the school\u0026mdash;there is little that can be done without an appropriate legal framework. The systemic and social barriers, combined with inadequate legal frameworks, perpetuate a cycle of neglect and discrimination that infringes on these girls\u0026rsquo; fundamental rights to health, education, equality, protection, and autonomy. Addressing these issues requires a multi-faceted approach, including policy reforms, advocacy for gender equity, and the establishment of child protection mechanisms that prioritize the best interests of the child.\u003c/p\u003e \u003cp\u003eThe shift from Braille to (Large) Print for many children indicates that early assessments and recommendations had a significant impact on teaching methods. The uptake of glasses and low vision devices prescribed was very low in the first year low, but showed promising improvements in year 3. Remember the baseline was zero. One of the main reasons for improvement was the increased awareness of caregivers, children and teachers of their benefits.\u003c/p\u003e \u003cp\u003eMore advocacy is needed to convince the government to support a clear admission policy, also financially. Preventing unnecessary Braille use saves money as special skills and books are then only needed for a small percentage of children and these savings could be used to sustain part of the services.\u003c/p\u003e \u003cp\u003eThe Ministry of Education places special teachers at resource centres like Ekwendeni. These teachers are trained at a government supported teacher training college. They also transfer these teachers regularly to another location. Continuous capacity building of teachers in supporting children with low vision is needed, and an investigation in the current content of the low vision related modules at the training college.\u003c/p\u003e \u003cp\u003eFrom the stakeholder findings, the following themes are proposed: i) Policy Integration - continue advocating for the inclusion of low vision services in national health policies; ii) Public Awareness - conduct nationwide campaigns to dispel myths about low vision and promote service uptake among children and persons with albinism; iii) Educator Support - ensure teachers in resource centers are adequately trained to enhance their ability to support students with low vision; and iv) Sustainability - fully integrate trained staff into the ongoing operations of government systems.\u003c/p\u003e \u003cp\u003eLimitations\u003c/p\u003e \u003cp\u003eBefore generalizing the findings to other setups, these limitations need to be considered. The findings are rooted in a specific socio-cultural and geographic context and may need to be adapted before being applied in other areas. As the project benefited from consistent resources, replication in the absence of such resources may prove challenging. From the outset, the project was conceived with an emphasis on policy integration and stakeholder collaboration, which were partially achieved and contributed to its success. However, other Southern African nations may encounter more significant bureaucratic or political hurdles in adopting similar policies. Nevertheless, the lessons derived from this comprehensive eye care program are invaluable and can be tailored for scaling up similar initiatives across the region.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eIt is possible to advance advancing Global Eye Health even in LMIC despite having limited resources.\u003c/p\u003e \u003cp\u003eThe Childhood Blindness and Low Vision Program in Malawi has advanced access to essential services for marginalized populations, but systemic gaps remain, including limited awareness, service delivery barriers, and a lack of policies integrating eye health and education. A key challenge is the absence of a mandate for comprehensive visual assessments before children with low vision or blindness are admitted to resource centers, leading to missed opportunities for early interventions. To address this, an integrated framework between the eye health and education sectors is essential, ensuring assessments, referrals, and follow-ups are embedded in national policies. Such alignment would enhance service sustainability, improve outcomes for children, and strengthen Malawi\u0026rsquo;s commitment to global eye health equity.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eAPAM\u0026nbsp; \u0026nbsp;Association of Persons with Albinism in Malawi\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eBICO\u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;Blantyre Institute for Community Outreach\u003c/p\u003e\n\u003cp\u003eCBLVP\u0026nbsp; \u0026nbsp;Childhood Blindness and Low Vision Project\u003c/p\u003e\n\u003cp\u003eIRB\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Institutional Review Board\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eKIM\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;Key Informant Method\u003c/p\u003e\n\u003cp\u003eLMIC\u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;Low- and Middle-Income Countries\u003c/p\u003e\n\u003cp\u003eLVDs\u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;Low Vision Devices\u003c/p\u003e\n\u003cp\u003eMACODA\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Malawi Council for Disability Affairs\u003c/p\u003e\n\u003cp\u003eMOE\u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;Ministry of Education\u003c/p\u003e\n\u003cp\u003eMOH \u0026nbsp; \u0026nbsp;\u0026nbsp;Ministry of Health\u003c/p\u003e\n\u003cp\u003eNED\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Northern Education Division\u003c/p\u003e\n\u003cp\u003ePWA\u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;Persons with Albinism\u003c/p\u003e\n\u003cp\u003eSNED\u0026nbsp; \u0026nbsp; \u0026nbsp;Special Needs Education Department\u003c/p\u003e\n\u003cp\u003eUEHC\u0026nbsp; \u0026nbsp; \u0026nbsp;Universal Eye-Health Coverage\u003c/p\u003e\n\u003cp\u003eUHC\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Universal Health Coverage\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003eApproval for this study was obtained from the Ministry of Health authorities responsible for eye care in Malawi.\u003c/p\u003e\n\u003cp\u003eAcknowledgements\u003c/p\u003e\n\u003cp\u003eWe extend our heartfelt gratitude to everyone who contributed to the implementation of the childhood blindness and Low vision project in Northern Malawi: the dedicated staff at BICO, Mzuzu Central Hospital, and Ekwendeni Resource Centre; the team from the Ophthalmology Department in Blantyre; Mzuzu-based Ministry of Health and Education staff; and the numerous Civil Society organizations involved, whose efforts are too numerous to name individually.\u003c/p\u003e\n\u003cp\u003eAuthors Contribution\u003c/p\u003e\n\u003cp\u003eKK designed the project, conducted data analysis, interpretation of results, and wrote the initial draft\u003c/p\u003e\n\u003cp\u003eES collected data and conducted data analysis\u003c/p\u003e\n\u003cp\u003eHN, TC, PM, CM, BC conducted data collected.\u003c/p\u003e\n\u003cp\u003eKvD co-designed the project, and conducted interpretation of results.\u003c/p\u003e\n\u003cp\u003eAll authors read and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003eFunding\u003c/p\u003e\n\u003cp\u003eThe project was funded by Stichting Lions Fight for Sight Netherlands (part of the Dutch Lions, which is a branch of International Lions Organization) and Wilde Ganzen Foundation (A Dutch- Based NGO).\u003c/p\u003e\n\u003cp\u003eAvailability of Data and Materials\u003c/p\u003e\n\u003cp\u003eNot shared, contains patient information. De-identified data available on request.\u003c/p\u003e\n\u003cp\u003eDeclarations\u003c/p\u003e\n\u003cp\u003eEthics approval and consent to participate\u003c/p\u003e\n\u003cp\u003eEthical approval from IRB not needed, as this was a service delivery project. Permission from project obtained from Ministry of Health and Education, and parentals and teacher consent taken.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eConsent for publication: taken.\u003c/p\u003e\n\u003cp\u003eCompeting interests\u003c/p\u003e\n\u003cp\u003eThe authors declare no competing interests.\u003c/p\u003e\n\u003cp\u003eAuthor details\u003c/p\u003e\n\u003cp\u003e1. School of Population and Public Health, University of British Columbia, British Columbia, Canada\u003c/p\u003e\n\u003cp\u003e2. Blantyre Institute for Community Outreach (BICO), Blantyre, Malawi\u003c/p\u003e\n\u003cp\u003e3. Ophthalmology Department, Mzuzu Central Hospital, Mzuzu, Malawi\u003c/p\u003e\n\u003cp\u003e4. Lions Sight First Eye Hospital, Blantyre, Malawi\u003c/p\u003e\n\u003cp\u003e5. International Low vision consultant, Deventer, The Netherlands\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n \u003cli\u003eBurton MJ, Ramke J, Patricia Marques A, et al. The Lancet Global Health Commission on Global Eye Health: vision beyond 2020 . \u003cem\u003eLancet Glob Health\u003c/em\u003e. 2021;9.\u003c/li\u003e\n \u003cli\u003eGilbert C, Foster A. Childhood blindness in the context of VISION 2020 - The right to sight. \u003cem\u003eBull World Health Organ\u003c/em\u003e. 2001;79(3).\u003c/li\u003e\n \u003cli\u003eWorld Health Organization. \u003cem\u003eWorld Report on Vision.\u003c/em\u003e; 2019. Accessed December 21, 2024. https://www.who.int/publications/i/item/world-report-on-vision\u003c/li\u003e\n \u003cli\u003eRamke J, Zwi AB, Palagyi A, Blignault I, Gilbert CE. Equity and Blindness: Closing Evidence Gaps to Support Universal Eye Health. \u003cem\u003eOphthalmic Epidemiol\u003c/em\u003e. 2015;22(5). doi:10.3109/09286586.2015.1077977\u003c/li\u003e\n \u003cli\u003eVan Dijk K, Courtright P. Barriers to surgical intervention among blind and low vision children in Malawi. \u003cem\u003eVis Impair Res\u003c/em\u003e. 2000;2(2). doi:10.1076/vimr.2.2.75.4425\u003c/li\u003e\n \u003cli\u003eKishiki E, Van Dijk K, Courtright P. Strategies to improve follow-up of children after surgery for cataract: Findings from Child Eye Health Tertiary Facilities in sub-Saharan Africa and South Asia. \u003cem\u003eEye (Basingstoke)\u003c/em\u003e. 2016;30(9). doi:10.1038/eye.2016.169\u003c/li\u003e\n \u003cli\u003eSchulze Schwering M, Kumar N, Bohrmann D, et al. Refractive errors, visual impairment, and the use of low vision devices in albinism in Malawi. \u003cem\u003eGraefe\u0026rsquo;s Archive for Clinical and Experimental Ophthalmology\u003c/em\u003e. 2015;253(4). doi:10.1007/s00417-015-2943-0\u003c/li\u003e\n \u003cli\u003eKalua K. \u003cem\u003eComparison of Effectiveness of Using Trained Key Informants versus Health Surveillance Assistants in Identifying Blind and Visually Impaired Children in Malawi\u003c/em\u003e. PhD. London School of Hygiene and Tropical Medicine; 2015.\u003c/li\u003e\n \u003cli\u003eKalua K, Ng\u0026rsquo;ongola RT, Mbewe F, Gilbert C. Using primary health care (PHC) workers and key informants for community based detection of blindness in children in Southern Malawi. \u003cem\u003eHum Resour Health\u003c/em\u003e. 2012;10. doi:10.1186/1478-4491-10-37\u003c/li\u003e\n \u003cli\u003eTataryn M, Polack S, Chokotho L, et al. Childhood disability in Malawi: A population based assessment using the key informant method. \u003cem\u003eBMC Pediatr\u003c/em\u003e. 2017;17(1). doi:10.1186/s12887-017-0948-z\u003c/li\u003e\n \u003cli\u003eBanks LM, Hunt X, Kalua K, Nindi P, Zuurmond M, Shakespeare T. \u0026lsquo;I might be lucky and go back to school\u0026rsquo;: Factors affecting inclusion in education for children with disabilities in rural Malawi. \u003cem\u003eAfr J Disabil\u003c/em\u003e. 2022;11. doi:10.4102/AJOD.V11I0.981\u003c/li\u003e\n \u003cli\u003eSchulze Schwering M, Nyrenda M, Spitzer MS, Kalua K. [Visual impairment and blindness in children in a Malawian school for the blind]. \u003cem\u003eKlin Monbl Augenheilkd\u003c/em\u003e. 2013;230(8).\u003c/li\u003e\n \u003cli\u003eKalua K, Nyirenda M, Lewallen S, Courtright P. Three-year follow up of primary health care workers trained in identification of blind and visual impaired children in Malawi. \u003cem\u003eHealth N Hav\u003c/em\u003e. 2013;05(11). doi:10.4236/health.2013.511241\u003c/li\u003e\n \u003cli\u003eHannum E, Zhang Y. Poverty and Proximate Barriers to Learning: Vision Deficiencies, Vision Correction and Educational Outcomes in Rural Northwest China. \u003cem\u003eWorld Dev\u003c/em\u003e. 2012;40(9). doi:10.1016/j.worlddev.2012.04.029\u003c/li\u003e\n \u003cli\u003eGlewwe P, Park A, Zhao M. A better vision for development: Eyeglasses and academic performance in rural primary schools in China. \u003cem\u003eJ Dev Econ\u003c/em\u003e. 2016;122. doi:10.1016/j.jdeveco.2016.05.007\u003c/li\u003e\n \u003cli\u003eGlewwe P, West KL, Lee J. The Impact of Providing Vision Screening and Free Eyeglasses on Academic Outcomes: Evidence from a Randomized Trial in Title I Elementary Schools in Florida. \u003cem\u003eJournal of Policy Analysis and Management\u003c/em\u003e. 2018;37(2). doi:10.1002/pam.22043\u003c/li\u003e\n \u003cli\u003eMarah G, Wilson R, Kalua K. Childhood Blindness and Low Vision Program (CBLVP) in Northern Malawi. https://bicomalawi.org/.\u003c/li\u003e\n \u003cli\u003eWorld Health Organization. Universal health coverage (UHC) Key Facts. \u003cem\u003eWorld Health Organization\u003c/em\u003e. 2019;(January).\u003c/li\u003e\n \u003cli\u003eWHO. Universal health coverage Primary health care towards universal health coverage. \u003cem\u003eWorld Health Organisation\u003c/em\u003e. 2018;2018(December).\u003c/li\u003e\n \u003cli\u003eAboobaker S, Courtright P. Barriers to cataract surgery in Africa: A systematic review. \u003cem\u003eMiddle East Afr J Ophthalmol\u003c/em\u003e. 2016;23(1). doi:10.4103/0974-9233.164615\u003c/li\u003e\n \u003cli\u003eMwiba DM. Medicine Killings, Abduction of People with Albinism, Wealth and Prosperity in North Malawi: A Historical Assessment. \u003cem\u003eProceedings of the African Futures Conference\u003c/em\u003e. 2018;2(1). doi:10.1002/j.2573-508x.2018.tb00008.x\u003c/li\u003e\n \u003cli\u003eBaker C, Lund P, Massah B, Mawerenga J. \u003cem\u003eWe Are Human, Just Like You: Albinism in Malawi-Implications for Security\u003c/em\u003e. Vol 29.; 2021.\u003c/li\u003e\n \u003cli\u003eTambala-Kaliati T, Adomako EB, Frimpong-Manso K. Living with albinism in an African community: exploring the challenges of persons with albinism in Lilongwe District, Malawi. \u003cem\u003eHeliyon\u003c/em\u003e. 2021;7(5). doi:10.1016/j.heliyon.2021.e07034\u003c/li\u003e\n \u003cli\u003eAbou-Gareeb I, Lewallen S, Bassett K, Courtright P. Gender and blindness: A meta-analysis of population-based prevalence surveys. \u003cem\u003eOphthalmic Epidemiol\u003c/em\u003e. 2001;8(1). doi:10.1076/opep.8.1.39.1540\u003c/li\u003e\n \u003cli\u003eNaidoo K, Kempen JH, Gichuhi S, et al. Prevalence and causes of vision loss in sub-Saharan Africa in 2015: Magnitude, temporal trends and projections. \u003cem\u003eBritish Journal of Ophthalmology\u003c/em\u003e. 2020;104(12). doi:10.1136/bjophthalmol-2019-315217\u003c/li\u003e\n \u003cli\u003eNaidoo K, Gichuhi S, Bas\u0026aacute;\u0026ntilde;ez MG, et al. Prevalence and causes of vision loss in sub-Saharan Africa: 1990-2010. \u003cem\u003eBritish Journal of Ophthalmology\u003c/em\u003e. 2014;98(5). doi:10.1136/bjophthalmol-2013-304081\u003c/li\u003e\n \u003cli\u003eMganga H, Lewallen S, Courtright P. Overcoming gender inequity in prevention of blindness and visual impairment in Africa. \u003cem\u003eMiddle East Afr J Ophthalmol\u003c/em\u003e. 2011;18(2). doi:10.4103/0974-9233.80695\u003c/li\u003e\n \u003cli\u003eMercer GD, Lyons P, Bassett K. Interventions to improve gender equity in eye care in low-middle income countries: A systematic review. \u003cem\u003eOphthalmic Epidemiol\u003c/em\u003e. 2019;26(3). doi:10.1080/09286586.2019.1574839\u003c/li\u003e\n \u003cli\u003eJayashree MP, Choudhary A, Hamsa DS, Divya R, Raksha H V. Epidemiology of pediatric cataracts - A 5 year retrospective study. \u003cem\u003eIndian Journal of Clinical and Experimental Ophthalmology\u003c/em\u003e. 2020;6(3). doi:10.18231/j.ijceo.2020.085\u003c/li\u003e\n \u003cli\u003eKalua K, Patel D, Muhit M, Courtright P. Causes of blindness among children identified through village key informants in Malawi. \u003cem\u003eCanadian Journal of Ophthalmology\u003c/em\u003e. 2008;43(4). doi:10.3129/I08-084\u003c/li\u003e\n \u003cli\u003eForshaw J, Gerver SM, Gill M, Cooper E, Manikam L, Ward H. The global effect of maternal education on complete childhood vaccination: A systematic review and meta-analysis. \u003cem\u003eBMC Infect Dis\u003c/em\u003e. 2017;17(1). doi:10.1186/s12879-017-2890-y\u003c/li\u003e\n \u003cli\u003eWeis M, Trommsdorff G, Mu\u0026ntilde;oz L, Gonz\u0026aacute;lez R. Maternal Education and Children\u0026rsquo;s School Achievement: The Roles of Values, Parenting, and Behavior Regulation. \u003cem\u003eJ Child Fam Stud\u003c/em\u003e. 2023;32(3). doi:10.1007/s10826-022-02405-y\u003c/li\u003e\n \u003cli\u003eMoradhvaj, Samir KC. Differential impact of maternal education on under-five mortality in rural and urban India. \u003cem\u003eHealth Place\u003c/em\u003e. 2023;80. doi:10.1016/j.healthplace.2023.102987\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Childhood Blindness, Low Vision, Global Eye-Health, Malawi, Cataract, Advocacy, Albinism","lastPublishedDoi":"10.21203/rs.3.rs-5944251/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-5944251/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cb\u003eBackground\u003c/b\u003e\u003c/p\u003e \u003cp\u003eBlindness and low vision in children remain significant public health concerns, particularly in low- and middle-income countries (LMICs) like Malawi, a key region in Southern Africa. These conditions are often underdiagnosed and undertreated due to limited access to specialized services, spectacles and assistive devices, posing critical challenges to health equity. The Childhood Blindness and Low Vision Program (CBLVP) in Northern Malawi aimed to address gaps through capacity building, advocacy, ensuring access to regular eye health and low vision assessments, and provision of spectacles and low vision devices.\u003c/p\u003e\u003cp\u003e\u003cb\u003eMethods\u003c/b\u003e\u003c/p\u003e \u003cp\u003eActivities included setting up clinical low vision services at Mzuzu Central Hospital in Northern Malawi, followed up by conducting outreach screenings and assessments, and building capacity through training and mentorship. Advocacy efforts engaged stakeholders such as government officers, parents, teachers, and disability organizations to promote awareness and service uptake, and provide basic skills to support the use of vision by the children at school and home. A mixed-methods approach was employed to evaluate progress: quantitative data came from service records, including client statistics and device distribution, while qualitative data were collected via engagement interviews with stakeholders and beneficiaries. Descriptive statistics and thematic analysis were applied to identify key achievements, challenges, and areas for sustainability.\u003c/p\u003e\u003cp\u003e\u003cb\u003eResults\u003c/b\u003e\u003c/p\u003e \u003cp\u003eThe program established a dedicated low vision clinic serviced by a full-time optometrist/low vision therapist. Between 2022 and 2024, 2054 children were served; 370 (18%) received glasses, 70 received low vision services (3.4%), and 96 (4.9%) underwent surgery. Spectacles and low vision devices improved beneficiaries' quality of life, enabling better educational and vocational performance. Awareness campaigns, including radio interviews and social events, increased visibility and service uptake, particularly among persons with albinism. However, challenges included the lack of an admission policy for inclusive education, initially leading to unnecessary admissions to special education and unnecessary use of Braille instead of print-based learning.\u003c/p\u003e\u003cp\u003e\u003cb\u003eConclusion\u003c/b\u003e\u003c/p\u003e \u003cp\u003eThe program successfully addressed service gaps, fostered sustainability, and developed a scalable model for low vision care in Malawi and Southern Africa. Future efforts should emphasize policy integration and increased public awareness to sustain and expand the impact.\u003c/p\u003e","manuscriptTitle":"Advancing Global Eye Health: Progress and Insights from the Child Blindness and Low Vision Program in Northern Malawi, Southern Africa","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-02-20 13:35:43","doi":"10.21203/rs.3.rs-5944251/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"79037eed-a1dd-4611-8fe3-a3443c13662d","owner":[],"postedDate":"February 20th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2025-02-20T13:35:43+00:00","versionOfRecord":[],"versionCreatedAt":"2025-02-20 13:35:43","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-5944251","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-5944251","identity":"rs-5944251","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}