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Introduction
From reports and articles
on newly started low vision programmes, for example in Kenya, (Silver,
et al, 1995; van Dijk, 1995, 1996) it has become clear there is a great
need to develop appropriate services for people with low vision, especially
children.
In Malawi, as in many other
developing countries, education has been geared towards blind children.
Anyone with reduced or no vision was labelled blind, both by the eye care
and the educational profession. As a consequence, low vision children with
a potential to use vision for activities such as reading print have been
taught as if they are blind.
Malawi is one of the poorest
countries in the world. It covers an area of 11,000 Square Km and has a
population of over 10 million (1996). If the estimate of '0.8 to 1 in every
1000 children is visually impaired' is used, there are 3360 - 4200 visually
impaired children (of whom an estimated 65 % have low vision) in a population
of 4.2 million children.
The current educational
services for visually impaired children consist of residential facilities
(2 blind schools, 13 resource centres/ boarding facilities attached to
mainstream primary schools and 6 attached to mainstream secondary schools)
and itinerant teaching programmes (in 5 districts, totally 31 teachers).
These reach 700 - 750 (about 20 %) of the estimated number of blind and
low vision children.
The eye care services rely
on Ophthalmic Medical Assistants. They have received 1 year ophthalmic
training on top of 3 years of general medical training. There are 4 ophthalmologists
in Malawi, and no optometrist or opticians in government service, only
a few private ones.
Description of Malawi Low
vision Programme
In 1995 a low vision programme
was initiated in Malawi, with main funding by Christoffel Blindenmission.
It is attached to Education of the Blind, which administers both residential
and itinerant programmes for visually impaired children (Itinerant programmes
are funded by Sight Savers International), under the Ministry of Education.
After a thorough investigation (van Dijk, 1995) it was decided to try and
integrate low vision services into existing eye care, education and rehabilitation
programmes.
Emphasis has been put on
trying to improve existing structures and services, not set up an additional
one. In a country like Malawi with limited resources, a new service with
a new cadre of low vision professionals cannot be sustained. Any intervention
has to be based on the reality of the local situation, the level of education,
human resources available, attitude of family and community.
Ophthalmic Medical Assistants
are used for clinical assessments; health workers, community based rehabilitation
workers and specialist teachers are used for identification, screening
and training.
Summary of the objectives
of the Malawi Low Vision Programme (based on the needs, problems and possibilities
identified):
- Train eye care, education,
and rehabilitation professionals in low vision strategies.
- Set up a national task-force
including members of all professional bodies involved in 'vision' to coordinate
low vision service development.
- Develop local production
of resources needed, such as testing charts, magnifiers, reading/writing
stands, and other non-optical devices.
- Ensure access to glasses
for low vision children.
- Organise regular clinical
assessment of children in the Education of the Blind programmes.
- Start a pilot programme
on early identification of visual problems.
- Develop regular referral
and contact between especially eye care and education professionals, including
the keeping and exchange of relevant records.
Impact of the low vision
programme
m Low vision (WHO definition,
1992) has become a well known word in eye care and special education and
within the Ministry of Education.
The Ministry of Education
supports the programme in resources (exercise books) and through officially
approving guidelines for admittance of visually impaired children to the
various programmes.
This helps in keeping children
who do need specialist assistance in and children with normal vision out
of the programme, in their home schools.
Parents and children with
low vision have also heard about the use of vision, and this has become
seen more and more as positive. There was initially a fear of losing the
resources and expertise a specialist teacher offers, when a child originally
identified as blind was found to have low vision.
m Only children with low
vision and blindness stay under the care of a specialist teacher.
As can be seen from the
1996 statistics below on children in the Education of the Blind programmes
many children in the Itinerant programmes turn out to have normal vision
after thorough clinical assessment and correction of refractive errors
where needed. Before the low vision programme started most of these children
with normal vision were kept under the care of a specialist teacher.
Residential Itinerant TOTAL
Blind 234 38 272
Low vision, clinically assessed
123 79 202
Visual acuity 6/18, clinically
assessed * 6 29 35
Normal vision, clinically
assessed 6 186 192
Not clinically assessed
yet 6 181 187
TOTAL 375 513 888
* The category with visual
acuity of 6/18 is given separately, because these children often need one
time advice on position in class, light needed and reading distance.
This has been achieved through:
1. Short, practical training,
appropriate to the local situation, of both specialist teachers and ophthalmic
staff.
Specialist teachers have
been trained in vision screening, differentiating between children with
normal vision, low vision and blindness (WHO, 1992), and in functional
assessment, training of visual skills and use of low vision devices.
Ophthalmic workers have
been trained in clinical assessment of low vision children with emphasis
on refraction, assessment of near vision and prescription of/ referral
for magnifying devices.
After upgrading knowledge and skills of staff in the field, low vision has become a normal part of the training of new Ophthalmic staff and specialist teachers. It has been included in their curriculum.
2. Organising regular assessment
days in areas where there are itinerant programmes.
Although ophthalmic staff
has a schedule of visiting rural areas where itinerant teachers are based,
this is not working well. Transport is often unreliable, and areas remote,
which might mean a child identified by a teacher has to wait up to 6 months
for a clinical assessment.
In 1997 special days are
being organised, and transport for children, parent and specialist teacher
to a district hospital is paid for.
The costs are expected to
be about 800 - 900 US Dollars per year (Giving all itinerant teachers 3
times a year access to clinical assessment for their children)
m Itinerant (specialist) teachers now continually identify new children with possible low vision, because the ones with normal vision no longer require their time any more. Indirectly they also contribute to prevention of severe eye problems by early referral of children with conditions such as trachoma, conjunctivitis, and other eye infections.
m In the itinerant teaching
programmes up to 30 % of the children identified by the specialist teachers
only need glasses to achieve normal vision.
In addition 14. 8 % of the
total number of low vision children under Education of the Blind benefited
from glasses to improve their distance vision and 12 % from magnifying
glasses to improve their near vision.
The provision of glasses
therefore is an important part of the low vision programme, in order to
ensure that these children do not stay under the care of a specialist teacher
unnecessarily. This will be a constant cost for the donors supporting the
programme, as there is no adequate provision of glasses in Malawi at this
time.
m Provision of appropriate resources for children with low vision.
Near vision (unaided) of
237 low vision children clinically assessed in 1996:
N 8 - N12 (school books
print) 137
N16 - N20 (large print /
used in first 2 school years) 33
> N 16 31
Not recorded 36
TOTAL 237
It becomes clear that at
least 137 of the 237 children (57. 8 %) can read and write without needing
optical devices. Many benefit from training in the use of non-optical devices
and techniques, like reading posture, use of (day)light, close reading
distance, use of writing stand / writing guide, and the like.
Of the 64 children who might
benefit from magnification in order to be able to read normal size print,
28 children (11.8 %) achieved N8 / N12 through the use of magnifying glasses.
This means that 69 % of the low vision children can use normal print for
their education.
Many low vision children,
like any other children, need print school books, exercise books and pens.
These low vision children can then be included in the provisions the Ministry
is making for all school children.
This reduces the dependency
on resources from outside donors.
Before the start of the
low vision programme most children were recorded as blind and using braille.
Donors provided on those numbers braille kits, braille paper and the like.
The provision of large print is not a sustainable option at this moment, since the Ministry of Education is first trying to make sure every 2 children have 1 school book.
In Malawi many resources
for the low vision work have been developed locally, which reduces dependency
on import of materials. Some examples:
- Near and distance acuity
charts are printed locally for a cost of between 1/2 and 1 US dollar per
chart. Local symbol charts are being developed.
- Writing stands cost US
$ 5, made by a local carpenter.
- Re-usable writing guides,
using black elastic to create bold lines, in stead of the printing of special
bold line exercise books. It is already difficult for the Ministry of Education
to provide children with free exercise books, let alone with special exercise
books as well.
- Magnifying glasses are
the price of 1 or 2 high positive lenses, while magnifiers are the price
of 1 lens.
A conscious choice is made
to use only those magnifiers that can be produced locally (up to + 28.00
D) for a low cost.
- Telescopes are not used
at this time, since only 2 x telescopes can be produced locally. These
have not proven to be very useful in the dark classrooms nor for reading
from old blackboards. A peer, who reads and writes well is encouraged to
sit next to and work with the low vision child in class.
The causes of low vision
certainly have an impact on the need for glasses and magnifying devices.
In Malawi 35 % of the children in the Education programmes are low vision
due to corneal problems (trachoma, Vitamin A deficiency / measles, traditional
eye medicine) and only a minority benefit from refraction and/or magnification.
m Choosing a more appropriate education model / giving the right kind of support to a low vision child.
Through the training and
through setting up regular assessment of children, the eye care and education
professionals know each other's roles, keep records and exchange relevant
information. The information on the (visual) abilities of a child is passed
on to the parents
Through the fact that all
parties involved are aware of the vision of an individual child and what
it can be used for, support is changing:
- Assessment of visual abilities
is starting to ensure appropriate educational placement. Newly identified
low vision children can be clinically and functionally assessed, before
a decision is made if they need residential provisions or can school at
home. This is still developing, since parents often prefer residential
provision for their child, since boarding and lodging is free. In the past
children were admitted to services without proper assessment of vision.
Indirectly this can benefit
blind children, who are able to move into spots previously used by some
of the low vision children.
- Frequency of visits to
an individual low vision child can be reduced to those needing only non-optical
devices and/or techniques after the initial training of child, regular
teacher and parent. It has become clear that without the involvement and
education of the parent/ guardian and regular classroom teacher, there
is no reduction in the frequency of visits.
Due to the fact that many
classes have 60 - 80 or even more children per teacher, support for these
low vision children stays necessary, if only to check regularly on issues
such as position in class, writing exams from the blackboard on a piece
of paper.
- Many low vision children are now using print in stead of braille.
An indirect effect of less frequent visits and more children using print in stead of braille is that one teacher could give service to a larger number of children than before, once the child has mastered print. In the process of changing from braille to print even extra time might need to be spent with a child.
- The quality of support is changing: Itinerant teachers especially are starting to work more directly with classroom teachers and parents, in stead of giving only direct support to the child. This is however not an easy transition for any of those involved.
Concluding remarks
If Education programmes
for visually impaired children are to include the needs of low vision children,
the following conditions need to be created:
1. Create awareness of what
low vision means, how vision can be (best) used and importance of early
referral among people with low vision, their families, regular and specialist
teachers, eye care staff and the Ministry of Education: "Low vision is
not the same as blind".
2. Develop adequate training
of (existing) special education and eye care staff in low vision. No creation
of new 'low vision specialists'.
3. Ensure educational placement
takes visual abilities into account.
4. Increase access to clinical
assessment.
5. Ensure access to affordable
glasses to correct refractive errors, in order to improve low vision children's
vision as much as possible and to 'weed' out children with normal vision.
6. Place emphasis on near
vision assessment, to avoid children being labelled as blind and taught
braille unnecessarily.
7. Provide appropriate resources.
Less educational kits for blind children are needed, and more low cost
devices such as locally made reading / writing stands, writing guides,
and magnifying devices.
8. Develop close cooperation
between all people involved, like the Ministry of Education, health personnel,
Non-Governmental Organisations, Donor agencies, the Education services
for the Visually Impaired and last but not least the visually impaired
child and his/her family. This is vital; without it an adequate service
cannot be provided.
The experience in Malawi
has been that through training of existing professionals, parents and the
children, the education of low vision children can be improved significantly.
The low vision component actually strengthens the cooperation between education
and eye care services. The key staff, the specialist teachers and the ophthalmic
staff enrich their work through the low vision training.
An educational programme
based on actual needs of children and using appropriate resources can be
developed this way.
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References
van DIJK, K. (1996): Developing
National low vision services in developing countries, with emphasis on
Malawi. International Low Vision Conference, July 8 - 12, 1996, Madrid,
Spain.
van DIJK, K.(1995- 1996):
Low Vision in Malawi - An investigation into possible programmes and services;
Annual reports 1995 and 1996, Malawi Low vision Programme. Written for
Christoffel Blindenmission.
SILVER, J.; Gilbert, C.;
Spoerer, P., Foster, A. (1995): Low vision in East African blind school
students: need for optical low vision services. British Journal of Ophthalmology
1995; 79: 814-820.
WHO, (1992): Management
of low vision in children. Report of a WHO Consultation.
Bangkok, 23 -24 July 1992