Rono HK, et al. - Considering childhood visual impairment as a major public health concern that requires effective screening and early intervention, Peek school eye health, a smartphone-based sight test and referral system (comprising Peek Acuity test, sight simulation referral cards, and short message service [SMS] reminders), vs standard care (Snellen's Tumbling-E card and written referral) was investigated for its effectiveness. School children displayed an increased adherence to hospital referral for visual impairment assessment in association with the Peek school eye health system vs the standard approach. This technology package thus seemed to have a potential for enhancing uptake of services and provide real-time visibility of health service delivery to help target resources.

Methods

• The performance of both the Snellen Tumbling-E card and the Peek Acuity test was initially compared to a standard backlit EDTRS LogMAR visual acuity test chart.
• Conducting a cluster randomised controlled trial, researchers compared the Peek school eye health system with standard school screening care, delivered by school teachers.
• Schools in Trans Nzoia County, Kenya, not having an active screening programme already in place, were eligible.
• Researchers performed random allocation of schools (1:1) to either the Peek school eye health screening and referral programmes (Peek group) or the standard care screening and referral programme (standard group).
• Teachers tested vision of children in years 1–8 in both groups.
• They referred pupils with visual impairment (defined as vision less than 6/12 in either eye) to hospital for treatment.
• A written hospital referral letter was given to referred children from the standard group.
• In the Peek group, participants and their teachers were shown their simulated sight on a smartphone and given a printout of this simulation with the same hospital details as the standard referral letter to present to their parent or guardian.
• Regular SMS reminders to attend the hospital were also sent.
• The proportion of referred children who reported to hospital within 8 weeks of referral was assessed as the primary outcome.
• Using intention to treat, they performed primary analysis and using odds ratios, they determined the intervention effect. 

Results

• The Peek test and the standard test displayed similar sensitivity (77% [95% CI 64·8–86·5] vs 75% [63·1–85·2]).
• The Peek test displayed lower specificity vs the standard test (91% [95% CI 89·3–92·1] vs 97·4% [96·6-98·1]).
• Between March 2, 2015, and March 13, 2015, researchers performed the trial recruitment.
• Researchers identified 295 eligible public primary schools in Trans Nzoia County; of these, 50 schools were randomly selected and assigned to either the Peek group (n=25) or the standard group (n=25).
• Visual impairment was assessed in 10,579 children in the Peek group and 10,284 children in the standard group.
• As per findngs, 531 (5%) of 10,579 children in the Peek group and 366 (4%) of 10,284 children in the standard care group displayed visual impairment.
• In the Peek group, the proportion of pupils identified as having visual impairment who attended their hospital referral was significantly higher (285 [54%] of 531) vs the standard group (82 [22%] of 366; odds ratio 7·35 [95% CI 3·49–15·47]; p<0·0001).