EENET asia Newsletters : Fourth issue June 2007 Contents

Eye Health Care as a Prerequisite for Successful Inclusion

Karin van Dijk and Agus T. Riyanto

All children are different, but they all have the same needs for love, care, shelter, nutrition, education and friendship. It is normal that children have different strengths and weaknesses. Accepting that children do not learn the same things, the same way, with the same results acknowledges individual needs. Most children perceived as ‘different’ do not need ‘special’ education, but more flexible and individualised education. In that regard inclusive education is about challenging discriminatory policies and practices, whether related to gender, socio-economic status, ethnicity, language, religion, HIV and AIDS, social status/caste or disability. Learning environments must be welcoming for every child, while promoting respect, tolerance and acceptance of all forms of diversity. Teachers need to know their students well to help them develop their full potential. It is therefore important that every child when starting school for the first time is assessed for his or her development stage and to identify possible learning barriers - for example chronic illnesses, malnutrition, problems with hearing or vision - as early as possible. This will help teachers and schools to respond to individual (learning) needs of children.

Why access to (eye) health care is a must for successful and more inclusive educational approaches: Examples from India and Nepal

Many parents and teachers support the inclusion of children with “special needs” in local schools, and a lot of time and effort is rightly spent on creating a good learning environment to facilitate more inclusive approaches to education. This article outlines why it is vitally important for many children with special needs first to attend healthcare services in order to be best prepared for a successful education. This is illustrated using the case of eye care.

Every child has a right to an eye check
In 2005, I analysed data from clinical records of children with visual problems seen at 4 eye hospitals (2 in India and 2 in Nepal) over 2002 and 2003. The data concerns 729 children, with ages ranging from 4 to 15 years. I present it here to highlight the importance of children experiencing visual problems first accessing eye care before attending school.

Almost all the 729 children attended formal education. 29% were supported by itinerant and/or inclusive education programmes and 50% attended a local school without receiving any additional support, while 21% attended a special school. Around half used print and 22% Braille. Significantly, many of the children were struggling to learn: 26% (spread over all types of education) were illiterate. They could read neither Braille nor print and depended solely on listening to teachers and/or peers!

Table 1 divides the children into three groups in terms of their best distance vision. Children with mild low vision are likely to be able to use print, read a blackboard from the first row and need little extra support in a local school. Those with severe low vision might need to learn to use a magnifying device to read print and a few might need to use Braille, while most will need regular extra support from teachers and peers.

Table 1: Distance vision before and after eye examination

The eye examinations showed that the distance vision of many of the children could be improved with distance glasses. A few needed eye surgery first. Before the eye check 76% of the children did not have usable glasses; as a consequence 53% received a prescription for glasses.
Similar improvements were seen in their near vision - used for tasks such as reading and writing. Clinical interventions gave 91% of the children visual access to print. Most improvements in near vision came simply through the use of distance glasses. In addition, 25% were prescribed a magnifying device; most (92%) of these devices were available locally, costing an average of US$5.

Many children can gain improved distance and near vision, through a clinical eye assessment, which can be done in the eye department of any hospital. A special low vision clinic can, in addition, assess the need for magnification.

Having an eye check is less than half the story
Firstly, all children should go for an eye check. Parents and schools often cite cost as a reason for not facilitating this. However, transport costs, hospital fees and the purchase of a pair of glasses compare well to the long-term costs of enlargement of print using photocopiers, of the unnecessary use of Braille, of education in a special school or unnecessary support from an itinerant teacher.

Secondly, it is vital that children obtain the recommended interventions. An advice for surgery and/or a prescription for glasses by itself does not improve vision!

A major obstacle to the provision of eye care or low vision services is a lack of cooperation between eye care and education/rehabilitation programmes. Each party believes the other will organise that children come for an eye check and ensure that the children obtain the surgery and/or glasses needed. Both sides wait for each other to act while children miss out. Experience teaches that it is best if the eye care service provider is responsible for organising access to health checks and interventions. In situations where the eye care programme is unable to organise this, education programmes can successfully take responsibility for it.

Thirdly, obtaining surgery, glasses and/or magnifying devices is still not the whole story. In addition, teachers and parents must allow and train children to use their vision as much as possible.

Successful inclusion is more likely when children have their best possible vision
Including children with low vision in a local school requires the close cooperation of all parties with eye care services. Only after eye health interventions can children enjoy their best possible vision and therefore a better educational experience. Many children, who were illiterate and/or using Braille before obtaining eye health interventions, can afterwards learn to read and write print. Children who afterwards have mild low vision can be educated with their peers in a local school, and only require an annual vision check and a minimum of extra support. Children who afterwards have normal vision do not unnecessarily occupy places in special schools or waste the limited resources available for support programmes in inclusive schools.

Ms. Karin van Dijk is a low vision specialist and consultant for CBM and Dark as well as Light Blind Care. She can be reached via email: kvdijknl@yahoo.com or postal address: Karin van Dijk, Grutto 21, 7423CZ Deventer, The Netherlands

PERTUNI Low Vision Units - The Right of Children to Quality Low Vision Services

The PERTUNI [Indonesian Blind Union] Low Vision Units in Jakarta and Yogyakarta offer comprehensive services involving medical practitioners (ophthalmologists), opticians, rehabilitation and education specialists, disability activist and other community groups. The aim is to optimize visual function so that children will be capable of using their vision in learning and in daily activities. The Low Vision Centres provides low vision assists in initiating school and community-based referral systems. We work with Community Health Centres as well as Eye Care Centre in private and government hospitals. Issues we have had to tackle when establishing the low vision centre at local and national level are health, education and social issues. The reason why many low vision programmes have not always run well is because we have insufficient data on children with low vision. When there are no data, there will be no action and no programmes.

There are institutions in local communities willing to take initiative with provision of services and establish cooperation with local community-based organizations. However services in the past have often been less than optimal for children in terms of their medical, rehabilitative and education quality. Examples are lack of post cataract surgery, children are not provided with appropriate corrective devices or intervention therefore full utilisation and improvement of vision has not been achieved and the students’ process of learning in special or regular schools is adversely affected.

To create quality services we provide, among others, early detection and intervention towards visual problems, medical assistance (assessment of the eyes and surgery if necessary), referral to ophthalmologists at hospitals and low vision service such as: clinical assessment (using optical/non optical devices), functional assessment, training on the use of low vision devices, effective vision, and orientation and mobility as well as advice to parents, class teachers or resource teachers and therapists. Functional assessment performed by low vision instructors aims to decide what a child can and cannot do with his/ her optimal vision. The result of the assessment will decide whether a child requires training on assistive devices, reading/ writing in Braille or a combination of both, and if a modification of environment is needed. To reach an optimum result, regular visits to school by an instructor and/or optician is necessary to find out the real situation in the classroom. Therefore, it requires teamwork with class teachers, resource teachers and the pupil’s peers. Low vision services is a continuous process, follow up services are therefore necessary, monitoring and evaluating the visual condition regular check up by ophthalmologists, regular evaluation on functional vision (when necessary) requires good scheduling and structured actions.

The aim of our services is to enable children with low vision to use their residual vision optimally and independently both in class and in daily life with their friends and class mates.

In the current era of decentralisation, local government participation in facilitating low vision service is necessary. If we look at the special schools for children with visual impairment, almost 50% children have low vision. We can also find many children with low vision in the special school for children with development impairment. So our government can no longer justify waiting before they start to deliver and support low vision services for educational and social inclusion.

Mr. Agus Teguh Riyanto is the co-ordinator of the PERTUNI Low Vision Units in Jakarta and Yogyakarta. He can be conacted via email: lowvision_pertuni@yahoo.com or post:
PERTUNI Low Vision Unit,
Jl. Poltangan No. 9 A Tanjung Barat
Jagakarsa - 12530 Jakarta Selatan, Indonesia

EENET asia Newsletters : Fourth issue June 2007 Contents