3. Conditions for implementing child vision and hearing screening programmes
Chapter editors: Allison Mackey, Jill Carlton
a. Appropriateness, acceptability, feasibility and sustainability
Prior to cost-effectiveness analysis, several country- or region-specific circumstances have to be taken into account to decide whether implementation of hearing or vision screening would be appropriate (suitable or fitting for the given context). Countries or regions may have problems that should reasonably be prioritised over hearing or vision screening, such as high infant mortality or low immunisation coverage. Even in the absence of such problems, it should be assessed what degree of priority would be reasonable to assign to a screening programme relative to other healthcare issues, such as access to clean drinking water, vaccination programmes and basic healthcare. Various indicators can be used to assess this, such as the WHO’s Sustainable Development Goals and/or the World Bank’s Worldwide Governance Indicators.
Acceptability is the perception among stakeholders that an intervention – in this context a screening programme – is acceptable. The following is a proposed formal definition of the concept: “A multi-faceted construct that reflects the extent to which people delivering or receiving a healthcare intervention consider it to be appropriate, based on anticipated or experienced cognitive and emotional responses to the intervention.”1
If a screening programme is not acceptable to, for example parents, then this could be a barrier to the implementation of the programme. Acceptability can be assessed based on the stakeholder’s knowledge of or direct experience with various aspects of the programme: awareness of the target condition and the consequences of this condition, but also of the type of screening to be implemented.
This is the extent to which an intervention can be successfully carried out in a particular setting. While related to appropriateness, feasibility is not the same. An intervention can be appropriate in a setting (country, region) but not feasible because of practical constraints (for example lack of infrastructure necessary for the intervention, or lack of professionals able to perform the screening). To assess the feasibility, it is necessary to look at practical concerns like whether it is possible to reach the target population, whether there are financial means to pay for the programme and whether diagnosis and treatment are available for and accessible to those who test positively.
The extent to which an intervention is maintained or institutionalised in a given setting; the integration of an intervention within a setting’s culture through policies and practices. Three stages can be distinguished3:
- passage (for example the transition from temporary to permanent funding)
- cycle or routine (repetitive reinforcement of the intervention by including it into organisational and community procedures and behaviours)
- niche saturation (the integration of the intervention into all subsystems)
- Further reading: Planning for the sustainability of community-based health programs: conceptual frameworks and future directions for research, practice and policy.
It is advisable to assess long-term sustainability of a screening programme before implementing a new programme. It may be possible, for example, to finance a pilot project through incidental means, but this does not serve a real purpose if it is clear from the outset that there will be no funds to continue the programme once the pilot is concluded. This is a risk that is especially present in developing countries4.
- Further reading: Outcomes for Implementation Research: Conceptual Distinctions, Measurement Challenges, and Research Agenda.
b. Minimum resources needed for a screening programme
A screening programme will, at the very least, need the following resources: staff (screeners, administrative support, management), screening equipment and space and a database.
Trained personnel are needed at all levels of the programme. Hearing screening programmes led by professional audiologists have been shown to be more effective5. When starting a new programme, potential screeners have to be identified: they may be dedicated persons who, with adequate training, could perform screening. Often, those leading the programme will have a medical background, especially valuable if they already have experience with (other types of) screening. Also, there have to be enough personnel in a given setting in relation to the size of the target population and they should be able to fit training and screening into their schedules. More detailed information on selecting screeners can be found in part 3 of the manual, the practical implementation guide.
In addition to screeners, supporting staff will be needed to handle the administrative tasks that are essential to ensure the screening programme operates effectively, such as administering consent forms, documenting screening results and entering results in the programme’s database. Ideally, these tasks would be handled by personnel working for the same organisation employing the screeners. In some cases, (part of) the administrative tasks could be handled by the screeners themselves.
Finally, management staff are needed to coordinate the programme. This entails preparing the budget (including resources for training, communication and monitoring), supervising the screeners, monitoring the programme and reporting on the results. Coordination of the programme requires close collaboration with all stakeholders (see chapter 4).
Equipment is required to conduct the screening: testing devices for hearing screening and vision charts for vision screening or photoscreening devices. When considering equipment costs, it should be taken into account that equipment has a limited lifespan and will need to be replaced over time. Devices may also require regular cleaning and maintenance, which also incurs costs. Budgeting for maintenance, annual calibration and replacement equipment to minimise downtime, is an important consideration for any screening programme.
In addition to equipment, space will be needed to screen. Screening space will have to meet certain specifications, depending on the type of screening to be performed. More information on these matters can be found in parts III and IV of the manual.
In order to keep track of the results of the screening programme, a database is necessary. A database should include all relevant information related to the screening pathway: screening results and, importantly, referrals, diagnostic reports and treatment results. Applicable data protection regulations must, however, be strictly adhered to (this is covered in detail in chapter 4e). Appropriate technical and organisational measures also have to be followed to ensure the database is secure and regularly backed up. For more detailed information see chapter 11 on monitoring.
c. Minimum standards for diagnosis and treatment
The screening protocol (the choice and sequence of tests; see parts III and IV of the manual for more detailed information on specific protocols for different types of hearing and vision screening) should clearly detail both the testing procedure(s) and the corresponding pass/referral criteria. The protocol should also detail how to refer children who do not pass screening, and specify measures to maximise follow-up.
It is imperative that all children who are referred, have access to diagnostics and treatment. “Facilities for diagnosis and treatment should be available” is one of the original “principles of early disease detection”6 defined by the
World Health Organization
(see also chapter 2).
It should be determined, before implementing a new screening programme, that there are enough professionals capable of providing diagnosis and treatment, and that parents can access them, both logistically and financially. How many professionals will be needed can be estimated based on the number of children to be screened, the assumed prevalence of the target condition and the estimated referral rate.
The fact that many subjects who are tested positively and are referred, never get diagnosed and treated (what is called ‘loss to follow-up’ or LTF) is a common problem in screening programmes. Referral and public information procedures should therefore be given appropriate attention. Demographics should be taken into consideration here, because certain groups are more susceptible to ‘loss to follow-up’ than others (see chapter 4-d-iv).
It should be noted that there is a different point of view that emphasizes the importance of starting screening and working on the availability of diagnosis and treatment along the way. The reason for this is that starting a screening programme at least draws attention to the condition being screened for and helps to create awareness. While this view contradicts the WHO criteria for screening (see chapter 2), it could be argued that, especially in low-resource settings, this may be the only way to get a screening programme started at all.
d. Implementing a new programme
During the start-up phase of any new programme, the results will most likely deviate from the projected results for a running programme, calculated by the cost-effectiveness model. This is because everyone involved in the programme will need time to learn and adapt, especially the professionals doing the actual screening. It should be expected that during the first few months, screening will take longer and referral rates will be higher than to be expected. Therefore it will be necessary to factor in a higher number of diagnostic assessments than would normally be expected. If the programme is set up well, this should normalise within the first year of the programme or even earlier. Also, if local screeners are not able to quickly build up experience, extra attention should be paid to training and quality assurance.
In Cluj County in Romania, during the first month of the newly implemented of preschool vision screening programme, the referral rate was 20% and during the first quarter of the first year of implementation it was 15%. By the last quarter of the first year, the rate had reduced to 7%. If we consider the average referral rate throughout the first year of the implementation programme, this was 14%. It is therefore important to monitor newly implemented programmes more regularly in the early months. In the second year of the implementation, the average referral rate was 8%.
When screenings were observed during the first month of the implementation, the average time a screening test took was more than eight minutes. By the second year of the implementation, this had reduced to approximately five minutes.
This also applies to established screening programmes that require substantial changes. For example, when a new screening device is introduced to an existing neonatal hearing screening programme, screeners may need time to adjust to the new equipment.
Communities also need to learn to appreciate the benefits of screening and treatment, and some communities may need to get accustomed to the concept of screening, which could mean attendance being lower than expected in the early stages of the screening programme. In preparation of a new screening programme follow-up care providers should also be informed about its objectives and their future role. See chapter 10 for more information on public awareness and communication.
Finally, once a screening programme is established, it is important to regularly evaluate it, and be prepared to implement any changes necessary to ensure it is as efficient and as effective as possible (see also chapter 11). The EUSCREEN cost-effectiveness model can assist in modelling alternative scenarios.
- Sekhon, M., Cartwright, M. & Francis, J.J. Acceptability of healthcare interventions: an overview of reviews and development of a theoretical framework. BMC Health Serv Res 17, 88 (2017).
- Proctor E, Silmere H, Raghavan R et al. (2011): Outcomes for Implementation Research: Conceptual Distinctions, Measurement Challenges, and Research Agenda. Adm Policy Ment Health :65–76.
- Rabin BA, Brownson RC; Haire-Joshu D, Kreuter MW, Weaver NL (2008): A Glossary for Dissemination and Implementation Research in Health. Journal of Public Health Management and Practice 14(2):117-123.
- Shediac-Rizkallah MC & Bone LR (1998): Planning for the sustainability of community-based health programs: conceptual frameworks and future directions for research, practice and policy. Health Educ Res 13(1):87-108.
- Shoup AG, Owen KE, Jackson G, Laptook A (2005): The Parkland Memorial Hospital experience in ensuring compliance with Universal Newborn Hearing Screening follow-up. J Pediatr 146(1):66-72.
- Wilson JMG & Jungner G (1968): Principles and practice of screening for disease. Geneva: WHO.