Meeting Report
Training of Trainers in Rapid Assessment
of Avoidable Blindness
10–15 March 2014
Manila, Philippines
RS/2014/GE/06(PHL)
English only
REPORT
TRAINING OF TRAINERS IN RAPID ASSESSMENT OF AVOIDABLE BLINDNESS
Convened by:
WORLD HEALTH ORGANIZATION
REGIONAL OFFICE FOR THE WESTERN PACIFIC
Manila, Philippines
10–15 March 2014
Not for sale
Printed and distributed by:
World Health Organization
Regional Office for the Western Pacific
Manila, Philippines
NOTE
The views expressed in this report are those of the participants in the Training of Trainers in Rapid
Assessment of Avoidable Blindness and do not necessarily reflect the policies of the World Health
Organization.
This report has been prepared by the World Health Organization Regional Office for the Western Pacific
for those who participated in the Training of Trainers in Rapid Assessment of Avoidable Blindness, held
in Manila, Philippines from 10 to 15 March 2014.
CONTENTS
SUMMARY. .............................................................................................................................. 1
INTRODUCTION ..................................................................................................................... 3
1.1 Objectives ........................................................................................................................ 4
1.2 Participants....................................................................................................................... 4
1.3 Opening session ............................................................................................................... 4
2. PROCEEDINGS .................................................................................................................... 5
2.1 Principles of Rapid Assessment of Avoidable Blindness ................................................ 5
2.2 installation and use of the RAAB5 software .................................................................... 5
2.3 Creating a sampling frame ............................................................................................... 5
2.4 Sample selection .............................................................................................................. 5
2.5 Survey and eye examination ............................................................................................ 6
2.6 Inter-observer variation assessment ................................................................................. 6
2.7 Field activity: Community RAAB examinations ............................................................ 7
2.8 Diabetic retinopathy module ............................................................................................ 7
3. CONCLUSIONS.................................................................................................................... 7
3. RECOMMENDATIONS ....................................................................................................... 7
Annex 1: List of participants, temporary adviser, observers and secretariat ............................. 9
Annex 2: Programme of activities ........................................................................................... 11
Annex 3: Rapid Assessment for Avoidable Blindness Survey ................................................ 13
Annex 4: RAAB Survey on Diabetes and Diabetic Retinopathy ............................................ 15
Annex 5: Assessment of Inter-observer Variation - RAAB..................................................... 17
Annex 6: Photos ....................................................................................................................... 19
Key words
Blindness – epidemiology, prevention and control / Health personnel – education / Vision
disorders – prevention and control
1
SUMMARY
A Training of Trainers in Rapid Assessment of Avoidable Blindness was held at the Regional
Office of the Western Pacific in Manila, Philippines from 10 to 15 March 2014. The training was
co-funded by the Fred Hollows Foundation and was attended by thirteen Rapid assessment of Avoidable
Blindness (RAAB) trainers from 10 countries in the Western Pacific Region and two observers from the
Philippine Eye Research Institute.
The objectives of the workshop were:
1. to train investigators from selected Member States on all aspects of RAAB, including
principles, software use, sampling, eye examination protocol, inter-observer variation, report
generation and evaluation; and
2. to provide the skills and materials required for investigators to become RAAB trainers and
supervise RAABs independently.
The workshop was mainly classroom based but it also included independent home visits by
participants to examine patients who were 50 years old and over, as part of the inter-observer variation
hands-on training.
After the workshop, it is important for the RAAB trainers to gain practical experience in
planning and implementing an actual survey. Participants from China, Indonesia, Malaysia and the
Philippines have already been involved in RAAB surveys, as trainers, in their home countries after the
workshop. Another two participants from Viet Nam will be the trainers in a national RAAB in April 2015.
The certified RAAB trainers will be important resources for surveys in their home countries as
well as in other countries in the region. It is expected that all participants of this workshop will eventually
be involved in RAAB surveys as trainers.
3
1.
INTRODUCTION
To strengthen the capacity of Member States to carry out Rapid Assessment of Avoidable
Blindness (RAAB) surveys independently, training of trainers was conducted at the Institute of
Ophthalmology, University of the Philippines from 10 to 15 March 2014. This was co-funded by The
Fred Hollows Foundation (FHF).
In line with Universal Eye Health: A Global Action Plan 2014–2019, the sixty-fourth session of
the Regional Committee for the Western Pacific endorsed Towards Universal Eye Health: A Regional
Action Plan for the Western Pacific Region (2014-2019).
One national indicator identified in the regional action plan is the prevalence of blindness and
visual impairment and their causes. To collect data on this indicator, the regional action plan proposes
countries to periodically assess the prevalence and causes of visual impairment (A66/11; Objective 1,
Action 1.1).
The proposed input from the World Health Organization (WHO) secretariat to support this action
item is to provide Member States with tools, such as RAAB, for surveys and technical advice. RAAB was
developed by WHO and has been applied around the world in the last decade to standardize
epidemiological data which is commonly used for planning or assessment of programme impact. This
was the first formal training in RAAB methodology in the Western Pacific Region.
RAAB is a standardized method to conduct a population-based survey on blindness and visual
impairment in a defined population. This can be a district, a state or province or an entire country.
Reliable population data are essential and therefore RAAB should be conducted for administrative entities
for which such data are available.
RAAB uses a standardized survey form, a standard protocol and standardized examination
protocol which can be used by local ophthalmic staff. The sample size varies between 2500 and 5000
people aged 50 and over. Of all blindness, 80% or more is in people aged 50 years and over. This high
prevalence means the sample size can be much lower than when people of all ages are included, making
RAAB comparatively time and cost effective.
Data from the survey forms are entered into specially designed RAAB software. After removing
inconsistencies and errors, the software automatically analyses the data and generates reports. The main
objectives of the RAAB are:
1. to estimate the prevalence and main causes of avoidable blindness and visual impairment in
people aged 50 and above;
2. to assess cataract surgical coverage;
3. to identify the main barriers to the uptake of cataract surgery; and
4. to measure outcomes of cataract surgery.
These data are essential for planning new blindness intervention programmes and to evaluate the
achievements of ongoing programmes. Nearly 200 RAABs have now been conducted in more than fifty
countries. Because all data are collected and analysed with the same protocol, findings can be compared
worldwide.
Good training and hands-on practical instructions are essential to conduct a RAAB of good
quality and to get results that are reliable and truly representative for the examined population. It is
highly recommended that the training for a RAAB is conducted by a certified RAAB trainer. There are
currently 15 certified RAAB trainers: 3 in Africa, 2 in EMRO, 3 in Europe, 1 in South Asia and 6 in Latin
America. There is a need for more certified RAAB trainers in Asia and in Africa.
Evidence on the prevalence and main causes of visual impairment is crucial for effective and
targeted planning of activities. In addition, countries require prevalence data in order to assess progress of
national prevention of blindness efforts.
1.1
Objectives
The objectives of the workshop were:
1) to train investigators from selected Member States on all aspects of RAAB, including principles,
software use, sampling, eye examination protocol, inter-observer variation, report generation and
evaluation; and
2) to provide the skills and materials required for investigators to become RAAB trainers and
supervise RAABs independently.
1.2
Participants
This meeting was attended by eye-care professionals with experience in epidemiological
surveys/research from Cambodia (1), China (2), Fiji (1), Indonesia (2), the Lao People's Democratic
Republic (1), Malaysia (1), Papua New Guinea (1), the Philippines (2) and Viet Nam (2), observers from
Philippine Eye Research Institute (2), and WHO Secretariat (2). An eye care consultant, Dr Hans Limburg,
conducted the workshop.
1.3
Opening session
Dr Andreas Mueller delivered the opening address on behalf of Dr Susan Mercado. He
emphasized that RAAB trainers will play a crucial role in this Region in monitoring eye health and
providing evidence for planning.
5
2.
PROCEEDINGS
The workshop involved hands-on and interactive training. Each participant was assigned to
discuss a topic or methodology. The other participants actively participated in discussion added essential
points to the presentation.
After the opening ceremony and introduction of participants, Dr. Ivo Kocur gave a presentation
on the role of prevalence surveys in the global action plan.
2.1
Principles of Rapid Assessment of Avoidable Blindness
Assigned participants discussed the introduction, overview of the background, objectives,
methodology used and the results of a rapid assessment of avoidable blindness (RAAB).
2.2
Installation and use of the RAAB5 software
One participant from Indonesia, Dr Aldiana Halim, presented the module on calculation of the
sample size of the RAAB software. Changes in the four parameters were made to demonstrate how these
influenced the final sample size. Dr Nina Ratnaningsih demonstrated the working of the ‘Selection of
clusters’ module.
The participants installed and explored the features of the software in their own laptops. A few
bugs came up during the sessions which did not show up during the testing of the software. In some
computers, the report on Inter-observer Validation gave a fatal error but other computers were able to
generate this report from the RAAB software. Also, there was a Windows-related issue on the three
computers. Fortunately this issue was quickly resolved.
2.3
Creating a sampling frame
All participants were given crude census data from which they had to create a sampling frame in
the required format. In a class session they were shown how to change an Excel table with data from the
census office into the format that can be loaded into the RAAB software. The participants performed this
activity individually in their own computer and loaded the newly generated file into the RAAB module to
select the clusters.
2.4
Sample selection
The participants were divided into four teams each with three members. Each team was given
four maps and assigned a cluster from the sampling frame of Uruguay with a code number and a name.
Each team had to find the map that corresponds with the cluster code and name, and describe how they
would select 50 eligible people in this cluster.
A participant from China presented the RAAB module on how to calculate the sample size using
Panama as an example. Another participant demonstrated how to select the required number of clusters at
random from the sampling frame using the special module in the RAAB software.
A representative from each group, selected by ballot, presented the map which corresponded with
the cluster assigned to them. The group estimated whether there would be enough people aged 50 years
and over in the census enumeration area. If not they had to identify other areas to complete the required
50 eligible people for the test.
2.5
Survey and eye examination
Two participants took turns in presenting the RAAB survey form and how to complete the form.
Participants who were practicing ophthalmologists explained the details of the examinations to the nonophthalmologists. The participants were assigned to four teams which had to have at least one
experienced ophthalmologist and a person with prior RAAB survey experience. Each team took turns in
performing the eye examination procedure.
2.6
Inter-observer variation assessment
An inter-observer aariation (IOV) assessment was arranged by Dr Leo Cubillan, one of the
participants and the Director of the Philippine Eye Research Institute (PERI). The purposes of the IOV
were:
1) to enable participants to conduct measurement of the IOV and to assess the diagnostic quality of the
individual teams;
2) to check whether participants fully understood the coding of the survey forms; and
3) to develop routine in the examination procedure.
Dr. Cubillan organized 30 people from the Philippine General Hospital who agreed to undergo
the eye examination. The training room was re-arranged to create four lines to conduct the eye
examination. Also, some staff from PERI assisted in organizing the patients.
Each team then entered the IOV records in the system. The four datasets from the teams were
merged into one file and distributed to all participants. Using a special menu in the RAAB software, the
IOV data file was converted to an Excel spreadsheet where the teams observations can be
compared for each examined patient. A few data entry errors and coding errors were also corrected. Based
on their observation results, participants had different views on the condition of some patients. The
differences were discussed. Differences mainly occurred in patients with multiple eye diseases that could
all cause visual impairment. The main issue was to identify the primary eye disease of the patient.
After the data entry errors were corrected, the IOV Report was generated. This caused an error
report in most of the computers, although a few were able to generate the report. The report showed good
(Kappa: 0.61-0.80) to very good agreement (0.81-1.0) on the VA and lens assessment. The participants
also discussed the logic behind the IOV assessment, the organization of the examination site, the
importance of "crowd control", the evaluation and the reports generated. A list of useful websites with
population data by country, websites of statistical offices and useful free software were provided.
7
2.7
Field activity: Community RAAB examinations
The same groupings were used in the field activity in which each team examined 12 to 13 poeple
using RAAB. All teams went to Barangay 833, Paco, Manila – about 20 minutes from the workshop
venue. At the local office of the barangay, the participants were shown a map of the area and the
estimated population living on each street. In total, there are around 2000 people living in the area.
The barangay was divided into four segments. The barangay chairman assisted the group in
selecting one segment which could be a starting point of the activity and a second segment in case there
would not be enough eligible people for examination in the first segment.
Each team was accompanied by one of the councilors of the barangay and examined 12 or 13
residents aged 50 years and older in this community. The examinations were conducted from 08.30 to
10:30.
Participants shared their experiences from the field activity. All participants appreciated the
cooperation from the officials of the barangay and from the people examined. Some teams remarked that
the local guide had to be supervised as they had a tendency to skip houses where nobody was present
without inquiring whether anybody aged 50 years and over was living there.
Participants returned to the workshop venue to enter the data into the RAAB software. The data
from the field activity were also validated for consistency.
2.8
Diabetic retinopathy module
Dr Hans Limburg discussed the introduction of the diabetic retinopathy module. The implications
of the sample size, the number and size of the clusters, the qualifications of the ophthalmologists and the
survey instruments, the duration of the fieldwork and the costs were discussed in detail.
He also presented the teaching slide set on the grading system for diabetic retinopathy and the
slide set to conduct the inter-observer variation on diabetic retinopathy. This assessment can be conducted
in the classroom and does not require any patients. Data entry of diabetic retinopathy information was
exercised, as well as generating the diabetic retinopathy reports from the SampleData sample file. All
participants marked the diabetic retinopathy component in the settings window of the RAAB software.
Other forms such as consent form and the mydriasis form were also discussed.
3.
CONCLUSIONS / RECOMMENDATIONS
The WHO secretariat with the assistance of Philippine Eye Research Institute successfully
organized the logistics and other administrative arrangements of the workshop. The participants showed
enthusiasm in all activities.
After the workshop, it is important for the RAAB trainers to gain practical experience in
planning and implementing an actual survey. Five of the participants, Dr Leo Cubillan (Philippines),
Dr Aldiana Halim (Indonesia), Dr. Nina Ratnaningsih (Indonesia), Dr. Hu Aillan (China) and
Dr Mohamad Aziz Salowi (Malaysia), have already been involved in RAAB surveys as trainers in their
home countries after the workshop. Another two participants from Viet Nam, Dr Vu Tuan Anh and
Mr Nguyen Duy Thang, will be the trainers in a national RAAB in their country in April 2015.
The certified RAAB trainers will be important resources for surveys in their home countries as
well as to other countries in the region. It is expected that all participants of this workshop will eventually
be involved in RAAB surveys as trainers.
9
ANNEX 1
LIST OF PARTICIPANTS, RESOURCE PERSON
AND SECRETARIAT
1. TEMPORARY ADVISERS
CAMBODIA
Dr Sok Kheng, Ophthalmologist, Khmner-Soviet Friendship Hospital, Yothapol
Khemarak Phoumin Blvd, 12306, Phnom Penh. Tel.: +855 12456747. Email:
[email protected]
CHINA
Dr Hu Ailian, Chief Physician, Department of Ophthalmology, Beijing Tongren
Hospital, No. 1 Dong Jiao Min Xiang, Beijing 100730. Tel: +86-010-58265923.
Email: [email protected]
Dr Baixiang XIAO, General Programs Manager of PBL programs, Zhongshan
Ophthalmic Center, Room 6F, 6th Floor Dongfang Guangchang, 6th Xiniu Road,
Yuexin District, Guangzhou City, Guangdong Province. Tel.: +862037619853.
Email: [email protected]
FIJI
Dr Anasaini CAMA, Ophthalmologist, Pacific Eye Institute, P.O. Box 18641,
Suva. Tel.: +679 3684075. Email: [email protected]
INDONESIA
Dr Nina RATNANINGSIH, Staff, Community Ophthalmology Division,
National Eye Center Cicendp Eye Hospital, Jl Cicendo, No. 4 Bandung, 40117
Jawa Barat. Tel: ++628122043959, Email: [email protected]
Dr Aldiana HALIM, Staff , Community Ophthalmology Division, National Eye
Center Cicendp Eye Hospital, Jl Cicendo, No. 4 Bandung, 40117 Jawa Barat.
Tel: +6281387308595 Fax: +62 22 4201960. Email: [email protected]
LAO PEOPLE'S
DEMOCRATIC
REPUBLIC
Dr Siphettavong SISALEUMSAK, Deputy Director, Ophthalmology Center
Ministry of Health, Vientiane. Tel.: +856 21 620476, Fax: +856 21 612079
Email: [email protected]
MALAYSIA
Dr Mohamad Aziz Bin SALOWI, Ophthalmologist, Department of
Ophthalmologist Sawarak General Hospital, Jalan Hospital. 93586 Kuching.
Sarawak. Tel.: ++6082-276 666 ext. 5112/ +6019-818 6214. Fax: +6082-419
495. Email: [email protected]
PAPUA NEW
GUINEA
Dr Urarang KITUR, Manager, Performance Monitoring and Research
National Department of Health, P.O. Box 807 , Waigani, National Capital
District. Tel: +675 3013650, Fax: +675 3251825. Email: [email protected]
Annex 1
PHILIPPINES
Dr Leo CUBILLAN, Director, National Health Institutes, University of the
Philippines, Taft Avenue, Manila, Tel. No: +63 917 8391839, Fax: +63 2
5247119 loc 112. Email: [email protected]
Dr Agnes B. SEGARRA, Medical Officer V, National Epidemiology Center,
Department of Health, San lazaro Compound, Tayuman, Manila. Tel.: +632
6517800 local 2928, Fax: +632 7436076. Email: [email protected]
VIET NAM
Mr NGUYEN Duc Thang, Officer, Quality Management Division, Medical
Service, Ministry of Health, 138A, Giang Vo Street, Ba Dinh District, Hanoi,
Tel: +84 0982948082. Email: [email protected]
Dr VU Tuan Anh, Vice-Head of Community Eye Care Department, National
Institute of Ophthalmology, 85 Ba Trien Street, Hai Ba Trung District, Hanoi,
Tel.: +04 38225527, Fax: +04 39434956, Email: [email protected]
2. RESOURCE PERSON
Dr Hans LIMBURG, Senior Consultant, Health Information Services, Nijenburg 32
Grootebroek NH, 1613LC Netherlands. Tel. No.: ++31 228 515481.
E-mail: [email protected]
3. OBSERVERS/REPRESENTATIVES
PHILIPPINE EYE
RESEARCH
INSTITUTE
Ms Lilibeth E. MANGANIP, University Researcher 1, Taft Avenue, Manila, Tel.
No: +632-5247119. E-mail: [email protected]
Mr Jean Ramon D. YAP, University Research Associate 1, Taft Avenue,
Manila. Tel. No.: +632-5247119. E-mail: [email protected]
4. SECRETARIAT
Dr Andreas MUELLER (Responsible Officer), Technical Officer, Noncommunicable Diseases and
Health Promotion, Division of Building Health Communities and Populations (DHP), WHO Regional
Office for the Western Pacific. Tel. No.: +632 5289885, Fax No: +632 5260279.
E-mail: [email protected]
Dr Ivo KOCUR, Technical Officer, HQ/NMH/MND/PBD, World Health Organization,
Avenue Appia 20, 1211 Geneva 27, Switzerland. Tel No. : +41 22 79 11435.
Email: [email protected]
11
ANNEX 2
PROGRAMME OF ACTIVITIES
Day 1 - Monday, 10 March 2014
08:00-08:15
Registration
Welcome remarks
Opening address
08:15-08:45
The Role of Prevalence Surveys in the
Global Action Plan
08:45-09:30
Self-introduction of participants
Group photo and coffee/tea break
09:30-09:45
Working procedures in workshop
10:00-12:00
12:00-13:00
Principles of RAAB – slide set
Lunch break
Principles of RAAB – slide set
(continuation)
Coffee/Tea Break
Principles of RAAB – slide set
(continuation)
Welcome reception
13:00-14:30
14:30-15:00
15:00-16:00
17:00-19:00
Dr Andreas Mueller, Technical Officer
Noncommunicable Diseases and Health
Promotion, WHO / WPRO
Dr Susan Mercado, Director, Building
Healthy Communities and Populations,
WHO / WPRO
Dr Ivo Kocur, Technical Officer
HQ/NMH/MND/PBD, WHO/HQ
Dr Hans Limburg, Senior Consultant
Health Information Services, Netherlands
Participants
Participants
Participants
All - Al Fresco WHO/WPRO
Day 2 - Tuesday, 11 March 2014
08:00-09:30
09:30-10:00
10:00-12:00
12:00-13:00
13:00-14:30
14:30-15:00
15:00-16:00
Installation and use of RAAB6 software
Coffee/Tea Break
Installation and use of RAAB6 software
Lunch
Installation and use of RAAB6 software
Coffee/Tea Break
Calculation of example size & selection
of clusters
Dr Hans Limburg
Dr Hans Limburg
Dr Hans Limburg
Dr Hans Limburg
Day 3 - Wednesday, 12 March 2014
08:00-09:30
09:30-10:00
Sampling frame, maps & compact
segment sampling
Coffee/Tea Break
Participants
Annex 2
10:00-12:00
Sampling frame, maps & compact
segment sampling
12:00-13:00
Lunch Break
13:00-14:30
RAAB survey form
14:30-15:00
Coffee/Tea Break
15:00–16.00
Eye examination protocol
Day 4 - Thursday, 13 March 2014
Dr Hans Limburg
08.00 – 09.30
09.30 – 10.00
Participants
10.00 – 12.00
12.00 – 13.00
13.00 – 14.30
14.30 – 15.00
15.00 – 16.00
Exercise eye examination
Coffee / tea break
Inter-observer variation: organisation &
implementation
Lunch
Generating IOV reports; discussion of
results
Coffee / tea break
Survey procedures, preparations for
fieldwork
Participants
Participants
Participants
Dr Hans Limburg
Day 5 - Friday, 14 March 2014
08.00 – 12.00
12.00 – 13.00
13.00 – 14.30
14.30 – 15.00
15.00 – 16.00
Fieldwork with 3-4 teams
Lunch (packed)
Discussion of experiences
Coffee / tea break
Data entry; validation double data entry;
consistency
Participants
Dr Hans Limburg
Dr Hans Limburg
Day 6 - Saturday, 15 March 2014
08.00 – 09.30
09.30 – 10.00
10.00 – 12.00
12.00 – 13.00
13.00 – 14.00
14.00 – 14.30
14.30 – 15.00
15.00 – 15.15
15.15
Optional DR module? Examination
protocol
Coffee / tea break
DR form; IOV for DR; consent form;
mydriasis form
Lunch
Data entry and generating reports
Evaluation of the course
Handing out of certificates
Closing remarks and closure of
workshop
Coffee / tea break
Dr Hans Limburg
Participants
Dr Hans Limburg
Participants
Dr Andreas Mueller
Dr Hans Limburg
13
ANNEX 3
15
ANNEX 4
17
ANNEX 5
19
ANNEX 6
Field Activity Photos
Annex 6
21
Annex 6
www.wpro.who.int