Assessment of availability, awareness and perception of stakeholders regarding preschool vision screening in Kumasi, Ghana: An exploratory study.

BACKGROUND: Regardless of the importance of preschool vision screening (PSVS), there is limited data on the current state of these programs in Africa (particularly Ghana). This study sought to investigate the level of awareness and perception of stakeholders regarding PSVS, its availability and related policies/programmes in the Kumasi Metropolis, Ghana.
METHODS: This descriptive cross-sectional study included 100 systematically sampled preschools in the metropolis (using probability proportional-to-size method); 72 private schools and 28 public schools. Convenience sampling was used to recruit stakeholders of preschools (teachers, head teachers, proprietors, administrators, directors, and educationists), and were interviewed using a well-structured questionnaire. Questionnaires were administered to all eligible respondents who were present at the time of data collection.
RESULTS: A total of 344 respondents participated in the study; 123 (35.8%) males and 221 (64.2%) females. The overall mean age of respondents was 37.63 ±12.20 years (18-71 years). Of the respondents, 215 (62.5%), 94 (27.3%), and 35 (10.2%) were enrolled from private schools, public schools, and Metropolitan Education Directorate, respectively. 73.8% of respondents reported the absence of routine PSVS in schools whereas 90.1% reported no written policies for PSVS in schools. Only 63.6% of respondents were aware of PSVS whereas more than half (59.6%) of all respondents perceived PSVS to be very important for preschoolers. Private school ownership was significantly associated with availability of PSVS whereas age, teachers, private school ownership, and preschool experience > 10 years were significantly associated with awareness of PSVS (P < 0.05). However, there was no significant association between sociodemographic factors and perception of PSVS.
CONCLUSION: PSVS is largely unavailable in most Ghanaian schools. Majority of stakeholders were aware of PSVS and agreed to its implementation and incorporation into schools' health programmes. There is the need to implement a national programme/policy on preschool vision screening in Ghana.

Background

Children across the globe are faced with many visual disorders during the critical periods of their visual development. The most common visual anomalies which affect children, especially preschoolers, include strabismus, amblyopia, large uncorrected refractive errors, and its related risk factors [1, 2]. Globally, the estimated prevalence of strabismus and amblyopia in children is 1.78% and 1.63% respectively [3, 4], whereas the estimated prevalence of hyperopia, myopia, and astigmatism in children is 4.6%, 11.7%, and 14.9%, respectively [5]. Although good vision is necessary for the overall development of these children, these visual anomalies reduce the quality of life of affected children (decreased learning/educational abilities and decreased motor skills performance) [6]. Therefore, early detection and treatment of these visual disorders, through preschool vision screening, is vital in preserving the visual function of children and improving their general health.

The importance of preschool vision screening cannot be underestimated. The introduction of a joint policy statement on vision screening by Practice and Medicine [7] has provided basic recommendations for vision screening in children. Preschool vision screening programmes and policies have been implemented in many countries, including the United States [8], Canada [9], United Kingdom [10], Sweden [11], Australia [12], and South Africa [13]. These vision screenings identify the causes of ocular morbidity in children and offer the best treatment/management practice, as well as ensuring the consistent availability of vision screening to school-aged children. Childhood vision screening policies and programmes such as the recommendations of the US Preventive Services Task Force [14], the National Children’s Vision Screening Project in Australia [12], and the South African Integrated School Health Policy [15] recommends vision screening at least once in all children aged three to five years to detect and manage visual disorders (amblyopia, strabismus, refractive errors, and its risk factors). On the contrary, there are no such nationally adopted policies and programmes on childhood vision screening in Ghana, especially in schools.

The stakeholders involved in preschool vision screenings include parents, school teachers and other educationists, and health workers (such as optometrists, ophthalmologists, etc.). The level of awareness, perception, and responsibilities of these stakeholders plays a vital role in the effectiveness of preschool vision screening and the development of its policies/programmes in schools [16-18]. A study by Senthilkumar, Balasubramaniam [19] showed that although most parents were aware of childhood visual disorders, these parents were unaware of amblyopia in their children, and did not understand the causative factors of many pediatric visual anomalies. In a study by Su, Marvin [20], 29% of parents were unaware of their children’s vision screening failure, thereby serving as a barrier to follow-up eye care for their children. Parents perceive that there is inadequate vision screening programmes for their children in various schools [21]. It has also been shown that some teachers are unaware of childhood visual anomalies [22]. This may be due to a lack of education on children’s eye health. A study by Agrawal, Tyagi [23] also reported that 96% of teachers were unaware of the age at which vision screening should be conducted for children. On the other hand, it is interesting to note that some parents and teachers have been educated and trained to improve their awareness on the importance of vision screening [24].

In Ghana, however, stakeholders’ perception and awareness on preschool vision screening, as well as the availability of preschool vision screening and its policies/programmes have not been studied extensively. Though various studies have estimated the prevalence of visual disorders among school children and have highlighted the need for measures to address this public health concern [25-27], these studies did not report on the level of awareness and perception of various stakeholders regarding preschool vision screening and its availability. Availability and awareness of preschool screening programmes in any country is the first step to the identification and management of visual conditions among preschoolers, and the consultative process necessary for the formulation of eye health policies for public health impact. The objective of this study is to investigate the level of awareness and perception of stakeholders regarding preschool vision screening and its availability in schools in the Kumasi Metropolis, Ghana. In addition, the outcome of this study will provide recommendations that will inform policy implementation regarding preschool vision screening in Ghanaian schools.

Materials and methods

This study employed a descriptive cross-sectional design to assess the level of awareness and perception of stakeholders regarding preschool vision screening in some selected preschools. From a list of all schools in the metropolis (obtained from the Metropolitan Education Directorate), schools were classified by the type of school ownership; private schools and public schools. Out of the 412 private and 158 public schools in the metropolis, 100 schools were systematically sampled for this study using Probability Proportional-to-Size (PPS) method; 72 private schools and 28 public schools. This provided a true representation of all preschools within the metropolis. School teachers, head teachers, proprietors, administrators, and directors from these selected preschools within the Kumasi metropolis, as well as educationists from the Metropolitan Education Directorate, Kumasi metropolis, Ghana, participated in this study. All respondents enrolled at the time of this study were eligible to participate in key informant interviews. Respondents from schools and the education directorate were selected using convenience sampling (due to their extracurricular activities). Thus, respondents who were absent at the time of data collection were excluded from this study. The sample size was calculated using the following assumptions/formula: n = (where n = sample size, Z = the standard score at 1.96 for a 95% confidence interval, p = the anticipated prevalence of perceptions of teachers and nurses [estimated to be 0.4 from the study conducted by (Naidoo et al., 2017)], d = absolute error taken as 5%), a minimum sample of 368.79 was estimated. Thus, the target sample size was 370 respondents. Fig 1 shows the flow diagram for the selection of participants through the research process.

Fig 1

Flowchart showing the flow of participants through the research process.

Data collection

The data was obtained from all participants using a well-structured interviewer-administered questionnaire, containing both closed and open-ended questions. The questionnaires were administered by one (1) Principal Investigator and four (4) Research Assistants in English. In each school, questionnaires were administered to the Head of School (e.g. head teacher/proprietor/director/administrator) and/or at least two other teachers in charge of preschools. Questionnaires were also administered to all officials of the Metropolitan Education Directorate who were present at the time of data collection. Each respondent answered each question appropriately after key terms were explained and instructions given.

Statistical analysis

Statistical analysis was performed using Statistical Product and Service Solution (IBM Corporation IBM® SPSS® Statistics for Windows, Version 23.0 Armonk, NY) compatible with Windows 10. Descriptive statistics were used to determine frequencies and percentages of demographic characteristics, awareness and perception of all respondents, as well as the availability of preschool vision screening. Assessment for the perception of preschool vision screening was measured using a five-point Likert scale, which elicited needed responses from participants in the study. Logistic regression analysis further investigated the association between sociodemographic characteristics of respondents and availability, awareness and perception of preschool vision screening. Statistical significance was set at < 0.05.

Ethical approval

The study was conducted with adherence to the Declaration of Helsinki, and approval was sought from the Committee on Human Research, Publication & Ethics (CHRPE), Kwame Nkrumah University of Science and Technology (KNUST), Kumasi, Ghana (CHRPE/AP/222/18). Permission was also obtained from the Metropolitan Education Directorate and selected schools in the Kumasi Metropolis, Ghana. Verbal informed consent was obtained from all respondents after the details of the nature of the study were explained to them. Verbal consent was deemed given upon acceptance to fill the study questionnaire after receiving information (objectives, procedures, benefits, etc.) on the study, and subsequent completion of the data collection form willingly. Verbal consent was witnessed by the principal investigator (J.H.T.).

Results

In all, 344 respondents participated in the study; 123 (35.8%) males and 221 (64.2%) females. The overall mean age of all respondents was 37.63 ± 12.20 years (18–71 years), with 215 (62.5%), 94 (27.3%), and 35 (10.2%) being enrolled from private schools, public schools, and Metropolitan Education Directorate, respectively. Most of the respondents (66.3%) had been educated to the tertiary level, with the highest representation being teachers (63.1%), followed by head teachers (21.8%), education directorate respondents (10.2%), directors (2.0%), administrators (1.5%) and proprietors (1.5%). Table 1 reports the demographic characteristics of respondents enrolled in the study.

Table 1

Demographic characteristics of respondents.

Variable	n (%)
Sex
Male	123 (35.8)
Female	221 (64.2)
*Age (years)
≤ 18	4 (1.2)
19–29	94 (28.1)
30–39	88 (26.3)
40–50	84 (25.1)
51–60	58 (17.3)
≥ 61	7 (2.0)
*Type of School Ownership
Public	94 (27.3)
Private	215 (62.5)
Job Title
Head Teachers	75 (21.8)
Teachers	217 (63.1)
Proprietors	5 (1.5)
Directors	7 (2.0)
Administrators	5 (1.5)
Education directorate respondent	35 (10.2)
Highest Level of Education
Primary	9 (2.6)
Secondary	107 (31.1)
Tertiary	228 (66.3)
*Pre-school Teaching Experience (years)
0–1	37 (12.0)
2–5	116 (37.5)
6–10	82 (26.5)
More than 10	74 (23.9)
Highest Level of School
Preschool	16 (4.7)
Primary	162 (47.1)
Junior High	122 (35.5)
Senior High	7 (2.0)
Others	37 (10.8)
*School Enrolment
Less than 100	18 (5.9)
101–200	42 (13.7)
201–500	140 (45.8)
501–1000	84 (27.5)
More than 1000	22 (7.2)

n (%) represents the frequencies and percentages of demographic characteristics of respondents.

*n ≠344

In the assessment of the availability of preschool vision screening programmes and/or policies, majority of the respondents (73.8%) reported that routine preschool vision screening programmes were not organized in preschools. Although 25.3% of the total respondents reported that disability assessment formed part of the admission processes in schools, 69.4% of these respondents further reported that vision assessment was excluded from the disability assessment programmes in these schools. 310 out of the 344 respondents (90.1%) reported that no written policies for preschool vision screening are available in schools. Out of the schools with written policies for preschool vision screening, 41.0% of respondents reported that these policies have been in existence for a period of 3 to 4 years. In the logistic regression, private school ownership (Odds Ratio [2.46]; 95% CI [1.34–4.51]) was significantly associated with the availability of preschool vision screening (see Table 2). Thus, respondents from private schools were more likely to report the availability of preschool vision screening in their schools.

Table 2

Association between sociodemographic factors and availability/awareness/perception of preschool vision screening.

Variable	Availability			Awareness			Perception
	OR	95% CI	P-value	OR	95% CI	P-value	OR	95% CI	P-value
Age (years)	1.00	0.98–1.02	0.763	1.03	1.01–1.05	0.002	1.09	0.93–1.28	0.304
Sex
Males	ref	-	-	ref	-	-	ref	-	-
Females	1.03	0.63–1.67	0.921	0.71	0.45–1.12	0.144	-	-	0.997
Education
Primary	ref	-	-	ref	-	-	ref	-	-
Secondary	0.61	0.14–2.61	0.506	-	-	0.999	-	-	0.999
Tertiary	0.90	0.22–3.72	0.889	-	-	0.999	-	-	1.000
School Ownership
Public	ref	-	-	ref	-	-	ref	-	-
Private	2.46	1.34–4.51	0.004	1.98	1.14–3.43	0.015	2.17	0.13–35.17	0.584
Job title
Education directorate respondent	ref	-	-	ref	-	-	ref	-	-
Headteacher	0.97	0.41–2.30	0.936	1.81	0.80–4.09	0.154	-	-	1.000
Teacher	0.76	0.35–1.65	0.486	0.46	0.22–0.97	0.042	-	-	0.998
Proprietor	1.46	0.21–9.98	0.703	2.25	0.33–15.24	0.406	-	-	1.000
Director	2.91	0.55–15.28	0.207	3.75	0.64–22.10	0.144	-	-	1.000
Administrator	3.27	0.48–22.46	0.228	2.25	0.33–15.24	0.406	-	-	1.000
School Enrolment
Less than 100	ref	-	-	ref	-	-	ref	-	-
101–200	1.17	0.34–3.95	0.806	1.73	0.56–5.32	0.340	-	-	0.999
201–500	1.19	0.40–3.55	0.753	0.70	0.25–1.92	0.484	-	-	0.999
501–1000	0.81	0.26–2.56	0.723	0.74	0.26–2.13	0.582	-	-	1.000
More than 1000	0.59	0.13–2.58	0.472	0.35	0.83–1.47	0.152	-	-	1.000
Pre-school Experience (years)
0–1	ref	-	-	ref	-	-	ref	-	-
2–5	1.03	0.45–2.36	0.947	1.85	0.74–4.62	0.186	-	-	0.998
6–10	1.18	0.50–2.81	0.702	2.22	0.87–5.69	0.096	-	-	1.000
More than 10	1.07	0.44–2.59	0.881	3.45	1.35–8.85	0.010	-	-	1.000

CI, Confidence Intervals; ref, reference group in logistic regression analysis.

The level of awareness of respondents regarding preschool vision screening was examined in the study. Of the 344 respondents enrolled in the study, 63.6% reported to have heard about preschool vision screening from eye care professionals (particularly optometrists). Of these, most of the respondents (59.0%) were females. The logistic regression analysis further showed that age (1.03; 1.01–1.05), private school ownership (1.98; 1.14–3.43), teachers (0.46; 0.22–0.97) and preschool experience of more than 10 years (3.45; 1.35–8.85) were statistically significantly related with the awareness of preschool vision screening (see Table 2). Thus, respondents from private schools, teachers, age, and respondents having more than 10 years of preschool experience had an increased likelihood of being aware of preschool vision screening ( < 0.05, for all). Table 2 reports the association between demographic characteristics of respondents and the availability/awareness/perception of preschool vision screening in the Kumasi Metropolis.

In the assessment of the perception of respondents regarding preschool vision screening, more than half of the respondents (59.6%) perceived preschool vision screening to be very important for preschoolers (school children). A greater part of the respondents (60.2%) strongly agreed that preschool vision screening should be implemented in preschools. It is interesting to note that 91.9% of all respondents were willing to consider preschool vision screening as a mandatory aspect of admission processes in schools; although 56.6% of these respondents were extremely ready to help in sustaining the preschool vision screening programme in schools. In the logistic regression analysis, there was no statistically significant association between sociodemographic characteristics of respondents and their perception of preschool vision screening (see Table 2).

Discussion

This study reports the level of awareness and perception of stakeholders regarding preschool vision screening, its availability and related policies/programmes in Ghanaian schools. Findings from this study suggest that preschool vision screening programmes and policies are largely unavailable in many Ghanaian schools. Majority of the respondents were aware of preschool vision screenings. Most respondents perceived that preschool vision screening is very important and should be implemented in preschools.

Nearly three-quarters of respondents reported that preschool vision screening is an uncommon practice in Ghanaian schools. Respondents were of the view that preschool vision screening has not been incorporated into the schools’ curriculum, and that no written policy exists for Ghanaian preschoolers. Respondents’ views were contrary to the government-supported vision screening programmes and policies for children of school-going age in other countries [9, 10, 12, 13]. An important and novel finding in this current study was the observation that children are not screened at the time of preschool enrolment. However, the International Agency for the Prevention of Blindness (IAPB) recommends that school-aged children should be screened every 1–2 years in their various schools, and assessed for reduced visual acuity (using a vision screener) and strabismus [28]. Additionally, the United States Preventive Services Task Force Report (2017) recommends that preschool vision screening should be available at least once in children between 3 and 5 years of age [14], in order to detect and manage early visual disorders in preschoolers (to avoid severe visual impairment in their lifetime). In Australia, the introduction of the Healthy Kids Check (HKC), a government-sponsored health screening programme (including vision assessment) for children aged 4 years, has contributed to the overall eye health of these preschoolers [12]. The National Expert Panel to the National Center for Children’s Vision and Eye Health (US) recommends best vision screening procedures (monocular visual acuity testing and instrument-based testing) annually for children aged 3 to 6 years, as well as referrals for complete eye examination by optometrists or ophthalmologists [16]. Although these government-sponsored health screening programmes have proven worthwhile, such programmes and policies on preschool vision screening are absent in Ghana. The unavailability of preschool vision screening programmes/policies in Ghana may be due to barriers such as financial constraints, prolonged duration for screening, uncooperative children, and inadequate eye care providers [29]. Although school vision screenings may be conducted by some eye care professionals in an ad hoc manner, there is still the need for a national programme/policy on preschool vision screening in Ghana. The views of stakeholders (such as those interviewed in the current study) will contribute immensely to the promotion and implementation of vision screening programmes/policies in Ghana.

Majority of the respondents were aware of preschool vision screenings and identified eye care professionals as their main source of information. Thus, eye care professionals (optometrists, ophthalmologists, ophthalmic nurses and opticians) in Ghana have a significant role in childhood vision screening [30], and should therefore be at the forefront of awareness campaigns. Eye care professionals must act as channels of communication, and educate stakeholders on childhood vision screening, childhood eye-related diseases/disorders, and how best they can be managed. Public awareness on preschool vision screening may be achieved through radio broadcast, seminars/conferences, and community-based eye-health outreaches. Eye care professionals must also promote the implementation of school-based vision screening programmes, and advocate for the implementation of a national policy for childhood vision screening. Educating teachers, head teachers, administrators/directors, and proprietors of the various preschools on the importance of preschool vision screening programmes will also go a long way to provide awareness on vision screening programmes in Ghana. This was proven by the statistically significant association between teachers and preschool teaching experience of more than 10 years, and the level of awareness of preschool vision screening. The World Health Organization’s Health Promoting Schools structure has been reported to be efficient in enhancing the health status of school children [31]. Teachers play a vital role in the development of comprehensive school health programmes for children in schools (due to their tertiary education and teaching experiences over the years). Thus, educating and enhancing the professional training/development of teachers and other stakeholders in the area of eye health [32] could promote preschool vision screenings and increase follow-up rates for comprehensive eye examinations among preschoolers [33], thereby creating significant awareness on the need for preschool vision screening programmes. In some countries, teachers are trained as first-line ‘eye care providers’ to effectively assist in the detection of visual anomalies among children [34-36], although some of these training programmes have recorded lower success rates [37]. Screening by teachers has been reported to be cost-effective [38], especially when there is a greater number of preschoolers. It thus enables students to achieve academic and health goals.

Most of the teachers and other educationists in this study perceived preschool vision screening and its related programmes/policies to be very important for preschoolers. The perception of these respondents is in line with some studies [11, 39, 40] which highlight the importance of childhood vision screening (thus reporting a significant reduction in the prevalence of childhood vision anomalies, particularly amblyopia and its risk factors). The implementation of childhood vision screening programmes/policies in some countries has lessened the effects of childhood vision anomalies [8–10, 12, 14]. This view is shared by most respondents in this study. In Canada, some stakeholders perceive that the introduction of public health nurses within schools could facilitate the implementation of school-based vision screenings [41]. It is therefore not surprising that a greater number of respondents in this study were willing to consider preschool vision screening as a mandatory aspect of admission processes in schools. The introduction of the “Health for All Children” in the United Kingdom, which includes school-based vision screenings as part of primary schools’ admission processes, has been an effective vision screening system [42]. Therefore, school-entry vision screening in Ghana will contribute immensely to the overall eye health of preschoolers.

The strength of this study lies in the use of an open-ended questionnaire which elicited more details and/or insight from respondents through an infinite number of likely answers. Limitations in this study include a small sample of stakeholders (mainly teachers and educationists) used in this exploratory analysis. Larger sample size should be considered in future researches to enhance the applicability and generalization of results to other locations and countries. Again, the results may be biased and/or skewed towards a section of stakeholders (teachers and educationists only) associated with preschool vision screening in Ghana and may not represent the views/position of other stakeholders such as parents and eye care professionals. However, this study provides a useful background to stakeholders’ views on preschool vision screening in the country.

Conclusions

This study demonstrates the absence of preschool vision screening and its related programmes/policies in Ghanaian schools. Stakeholders were aware of preschool vision screenings and agreed with the implementation of school-entry vision screenings programmes/policies in Ghanaian schools. Further studies must be conducted to ascertain the level of awareness and perception of parents and eye care professionals regarding preschool vision screening, its availability and related policies/programmes in Ghana. Also, this study will help in developing a suitable preschool vision screening protocol specific to the Ghanaian setting.

This study recommends a broader stakeholder consultation (involving parents, teachers, eye care professionals, heads of eye care institutions, NGO’s, etc.) by the National Eye Care Unit (NECU) of the Ghana Health Service regarding school vision screening in Ghana. The National Eye Care Unit, Ghana Health Service must then develop a proposal on school vision screenings in Ghana based on recommendations from the IAPB and WHO, review of the national school vision screening programmes/policies of other countries, and the views of all stakeholders of school vision screening in Ghana. Subsequently, the proposal for school-based vision screening should be tendered into the Ministry of Health, Ghana for its consideration and implementation.

(SAV)

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4 Oct 2019

PONE-D-19-23753

Assessment of Availability, Awareness and Perception of Stakeholders regarding Preschool Vision Screening in Kumasi, Ghana: An Exploratory Study

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Reviewer #1: This paper is an interesting submission and related to an important area of eye care research on issues around preschool vision screening program. There are many areas that need further clarification, the writing needs to be more succinct. The presentation of the article is somewhat disjointed with some excellent portions and some portions that don't seem to flow as well.

I would like to offer a few suggestions for how the manuscript presentation could be improved:

Introduction:

• The introduction section probably would benefit from some tightening with clear objective of conducting this study and using as recent references as possible.

• The context of the study needs to be explained to situate the findings for international readers to provide a frame of reference for the findings.

• In the discussion, the authors should come back to the literature you cite in the introduction and consider what they need to present in the beginning, to reflect on in the end.

Methods:

• The method section is too brief and the overall research process appears rather complex. The way the authors articulated the method section is a bit unclear. I would suggest making it clear for the readers.

• The process of sample selection - what was the sampling technique? The authors mentioned about systematic sampling (probability proportional-to-size method) to select schools and convenient sampling to select interview participants. However, it is not clear why and how these sampling techniques were used and based on what assumptions.

• How sample size was calculated and numbers mentioned decided based on what assumption/formula? – The authors should mention these clearly in the method section.

• Also the flow of participants through the research process is unclear. It would be good for the readers if the authors specify exactly how the process was done? In order to clarify, could the authors provide a flow diagram (such as recommended by the CONSORT group) so that readers can understand more clearly exactly what the researchers did throughout the research process, sample size, approached/ agreed, included/ excluded participants etc.

• Variable: No information was provided about outcome and explanatory variable. It is also not clear what was the exact outcome measures. Reading through the title and text – it appears that outcome variables were more than one - awareness and perception, and the availability of preschool vision screening. However, none of the variables were defined.

• The analysis section requires more clarity. For example, it is not clear how perception of preschool vision screening was measured. Did researchers use any specific scale for that?

• The authors stated that “Chi-square test was used to determine the association between demographic characteristics of respondents, and their awareness and perception, and the availability of preschool vision screening.” – But no association data is provided for perception, and the availability of preschool vision screening in the results. Moreover, the authors did not run any advance level analysis (bi-variate of multi-variate analysis) to establish any solid association between outcome variables and explanatory variables.

• Ethical issues are now mixed-up with the method section. The authors might consider putting the ethical approval and other ethical issues as a sub-heading at the end of the method section.

Result:

• The findings have not really been fully teased and pondered.

• Whilst I appreciate there is a huge amount of data and much to explore one glaring point of interest to me was further elaboration of results.

• The result section only highlighted the basic findings on demographic characteristic and few information on awareness and perception, and the availability of preschool vision screening. No associated factors are provided for perception, and the availability of preschool vision screening.

• The authors did not run any bi-variate of multi-variate analysis to establish any strong association between outcome variables and explanatory variables. It is difficult to make any inference based on the results provided at present.

• Is it possible to expand the result section further establishing association between outcome variables and explanatory variables through running bi-variate of multi-variate analysis?

Discussion:

• The discussion should be more analytical and should reflect on how the findings support, refute, extend the previous literature (generally cited in the introduction).

• Results of previous studies are simply stated alongside this study with no discussion of why the findings may differ between the studies etc.

• What is implication of the study results for preschool vision screening program and eye care linked clinical practice?

• Moreover, the section would benefit from some tightening through building more precise arguments more in the context of this study findings only.

• The researchers highlight a few limitations of the study which should be further pondered. The strengths of the study should be highlighted as well. The authors should highlight limitations/strengths with strong arguments.

This is an interesting topic and I hope the authors will find these comments useful as they consider how to proceed with the manuscript.

Reviewer #2: I guess the aim of the manuscript is to inform the Ghana Health authority that you are ready to accept any screening policy in case of implementation. In the majority of screening policies implemented throughout the world rest on primary care. Curious to know the health structure in Ghana Do family practitioners perform or would be willing to do the screenings. Any screening program performed in school would be an addition to the primary care physician screening.

In your discussion please state the primary care system in Ghana.

**********

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Reviewer #1: Yes: Tapash Roy

Reviewer #2: Yes: Silay Canturk Ugurbas

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13 Feb 2020

Re: Manuscript PONE-D-19-23753 titled: “Assessment of Availability, Awareness and Perception of Stakeholders regarding Preschool Vision Screening in Kumasi, Ghana: An Exploratory Study”.

Dear Editor,

Thank you for the opportunity to resubmit the above referenced manuscript. We have addressed all the Reviewers’ comments, point-by-point, in our response below. The issues raised by the Reviewers are presented in normal font. We reply directly to these comments in bold font. All changes to the Revised Manuscript have also been clearly highlighted in red font.

Sincerely,

Akuffo et al

Journal Requirements:

When submitting your revision, we need you to address these additional requirements.

1. Please ensure that your manuscript meets PLOS ONE's style requirements, including those for file naming. The PLOS ONE style templates can be found at http://www.journals.plos.org/plosone/s/file?id=wjVg/PLOSOne_formatting_sample_main_body.pdf and http://www.journals.plos.org/plosone/s/file?id=ba62/PLOSOne_formatting_sample_title_authors_affiliations.pdf

We have now revised the manuscript according to the PLOS ONE's style requirements.

2. Please provide additional details regarding participant consent. In the ethics statement in the Methods and online submission information, please ensure that you have specified how verbal consent was documented and witnessed

Verbal consent was deemed given upon acceptance to fill the study questionnaire after receiving information (objectives, procedures, benefits, etc.) on the study, and subsequent completion of the data collection form willingly. Verbal consent was witnessed by the principal investigator (J.H.T.). We have included a statement in the Revised Manuscript for clarity. Please see below and Revised Manuscript page 10.

“Verbal consent was deemed given upon acceptance to fill the study questionnaire after receiving information (objectives, procedures, benefits, etc.) on the study, and subsequent completion of the data collection form willingly. Verbal consent was witnessed by the principal investigator (J.H.T.).”

Additional Editor Comments (if provided):

[Note: HTML markup is below. Please do not edit.]

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #1: Partly

Reviewer #2: Yes

We have revised the description of our study methodology and have provided further statistical analyses for clarity (Please see below; and Methods Pages 6 to 9; Results 9 to 17 and Discussion Pages 18 to 22).

Methods section:

The expression n= (where n =sample size, Z= the standard score at 1.96 for a 95% confidence interval, p = was the anticipated prevalence of perceptions of teachers and nurses [estimated to be 0.4 from the study conducted by (Naidoo et al., 2017), d= absolute error taken as 5%), a minimum sample of 368.79 was estimated. Thus, the target sample size was 370 respondents. We have added this to the methods section (please see below and Revised Manuscript Pages 6 to 7).

“The sample size was called using the following assumptions/formula:

The expression n= (where n =sample size, Z= the standard score at 1.96 for a 95% confidence interval, p = was the anticipated prevalence of perceptions of teachers and nurses [estimated to be 0.4 from the study conducted by (Naidoo et al., 2017), d= absolute error taken as 5%), a minimum sample of 368.79 was estimated. Thus, the target sample size was 370 respondents.”

We have now provided a flow diagram detailing the research process. Please see Figure 1 below and in the Revised Manuscript (page 8).

Figure 1. Flowchart showing the flow of participants through the research process

We have revised our Statistical Analysis section and provided additional details. Variables used in the study included socio-demographic data on all participants. These include sex, age, type of school ownership, job title, highest level of education, preschool teaching experience, and school enrolment.

For the analyses pertaining to awareness of preschool vision screening, the explanatory variables included age, sex, type of school ownership, job title, education, preschool teaching experience. Awareness of preschool vision screening among participants (awareness variable) was assessed by answering the following questions: “Have you heard of Preschool Vision Screening services for preschool children?” The awareness variable was employed in the univariate and multivariate logistic regression models assessing the association between awareness and related factors.

For the analyses pertaining to availability of preschool vision screening, the explanatory variables included age, sex, type of school ownership, job title, education, preschool teaching experience. Availability of preschool vision screening among participants (availability variable) was assessed by answering the following questions: “Does your school(s) have a written policy for screening preschool children? And/or Does your school(s) conduct vision examinations/screenings routinely for preschool children?” The availability variable was employed in the univariate and multivariate logistic regression models assessing the association between awareness and related factors.

For the analyses pertaining the perception, the explanatory variables included age, sex, type of school ownership, job title, education, preschool teaching experience. The perception of preschool vision screening among participants (perception variable) was assessed by answering the following questions: “Do you think that Preschool Vision Screenings should be implemented in all schools? And/or If preschool vision screening is not done in your school(s), do you think it is important for children to benefit from routine eye examinations? And/or Will you consider Preschool Vision Screening mandatory as part of the admission process?” The perception variable is a composite of the above questions. The perception variable was employed in the univariate and multivariate logistic regression models assessing the association between awareness and related factors.

Assessment for the perception of preschool vision screening was measured using the responses of participants in the study. The scale employed was a five-point Likert scale to assess responses of participants. Please see response above under ‘Variable’. We have revised our Statistical Analysis section and provided additional details (please see Revised Manuscript pages 7-8).

Assessment for the perception of preschool vision screening was measured using a five-point Likert scale, which elicited needed responses from participants in the study.

We have revised our Statistical Analysis section and included a statement in the Revised Manuscript for clarity. Please see below and Revised Manuscript pages 8

“Logistic regression analysis further investigated the association between sociodemographic characteristics of respondents and availability, awareness and perception of preschool vision screening.”

We have now restructured and provided an Ethical Approval Section at the end of the methods (please see below and Revised Manuscript pages 10).

“Ethical Approval

The study was conducted with adherence to the Declaration of Helsinki, and approval was sought from the Committee on Human Research, Publication & Ethics (CHRPE), Kwame Nkrumah University of Science and Technology (KNUST), Kumasi, Ghana (CHRPE/AP/222/18). Permission was also obtained from the Metropolitan Education Directorate and selected schools in the Kumasi Metropolis, Ghana. A verbal informed consent was obtained from all respondents after the details of the nature of the study were explained to them”.

Results section:

We have provided additional analyses and presented additional results based on our study data (please see Revised Manuscript pages 12 to 17).

“In the logistic regression, private school ownership (Odds Ratio [2.46]; 95% CI [1.34-4.51]) was significantly associated with the availability of preschool vision screening. Thus, respondents from private schools were more likely to report the availability of preschool vision screening in their schools.

The logistic regression analysis showed that age (1.03; 1.01-1.05), private school ownership (1.98; 1.14-3.43), teachers (0.46; 0.22-0.97) and preschool experience of more than 10 years (3.45; 1.35-8.85) were statistically significantly related with the awareness of preschool vision screening. Thus, respondents from private schools, teachers, age, and respondents having more than 10 years of preschool experience had an increased likelihood of being aware of preschool vision screening.

In the logistic regression analysis, there was no statistically significant association between sociodemographic characteristics of respondents and their perception of preschool vision screening.”

We have also provided a new table titled “Table 2. Association between sociodemographic factors and availability/awareness/perception of preschool vision screening”. This new table provides further details on results from logistic regression analyses.

Discussion section:

We have now revised the limitations/strengths section of the Discussion with strong arguments. Please see below and Revised Manuscript Page 21.

“The strength of this study lies in the use of an open-ended questionnaire which elicited more details and/or insight from respondents through an infinite number of likely answers. Limitations in this study include a small sample of stakeholders (mainly teachers and educationists) used in this exploratory analysis. Larger sample size should be considered in future researches to enhance the applicability and generalization of results to other locations and countries. Again, the results may be biased and/or skewed towards a section of stakeholders (teachers and educationists only) associated with preschool vision screening in Ghana and may not represent the views/position of other stakeholders such as parents and eye care professionals.”

2. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: No

Reviewer #2: I Don't Know

We have revised the statistical methodology and provided more results for clarity (Please see below; and Methods Pages 6 to 9; Results 9 to 17).

Statistical Analysis section:

We have revised our Statistical Analysis section and provided additional details. Variables used in the study included socio-demographic data on all participants. These include sex, age, type of school ownership, job title, highest level of education, preschool teaching experience, and school enrolment.

For the analyses pertaining to awareness of preschool vision screening, the explanatory variables included age, sex, type of school ownership, job title, education, preschool teaching experience. Awareness of preschool vision screening among participants (awareness variable) was assessed by answering the following questions: “Have you heard of Preschool Vision Screening services for preschool children?” The awareness variable was employed in the univariate and multivariate logistic regression models assessing the association between awareness and related factors.

For the analyses pertaining to availability of preschool vision screening, the explanatory variables included age, sex, type of school ownership, job title, education, preschool teaching experience. Availability of preschool vision screening among participants (availability variable) was assessed by answering the following questions: “Does your school(s) have a written policy for screening preschool children? And/or Does your school(s) conduct vision examinations/screenings routinely for preschool children?” The availability variable was employed in the univariate and multivariate logistic regression models assessing the association between awareness and related factors.

For the analyses pertaining the perception, the explanatory variables included age, sex, type of school ownership, job title, education, preschool teaching experience. The perception of preschool vision screening among participants (perception variable) was assessed by answering the following questions: “Do you think that Preschool Vision Screenings should be implemented in all schools? And/or If preschool vision screening is not done in your school(s), do you think it is important for children to benefit from routine eye examinations? And/or Will you consider Preschool Vision Screening mandatory as part of the admission process?” The perception variable is a composite of the above questions. The perception variable was employed in the univariate and multivariate logistic regression models assessing the association between awareness and related factors.

Assessment for the perception of preschool vision screening was measured using the responses of participants in the study. The scale employed was a five-point Likert scale to assess responses of participants. Please see response above under ‘Variable’. We have revised our Statistical Analysis section and provided additional details (please see Revised Manuscript pages 7; lines 130-132).

Assessment for the perception of preschool vision screening was measured using a five-point Likert scale, which elicited needed responses from participants in the study.

We have revised our Statistical Analysis section and included a statement in the Revised Manuscript for clarity. Please see below and Revised Manuscript pages 7; Lines 132 to 133

“Logistic regression analysis further investigated the association between sociodemographic characteristics of respondents and availability, awareness and perception of preschool vision screening.”

Results section:

We have provided additional analyses and presented additional results based on our study data (please see Revised Manuscript pages 12 to 17).

“In the logistic regression, private school ownership (Odds Ratio [2.46]; 95% CI [1.34-4.51]) was significantly associated with the availability of preschool vision screening. Thus, respondents from private schools were more likely to report the availability of preschool vision screening in their schools.

The logistic regression analysis showed that age (1.03; 1.01-1.05), private school ownership (1.98; 1.14-3.43), teachers (0.46; 0.22-0.97) and preschool experience of more than 10 years (3.45; 1.35-8.85) were statistically significantly related with the awareness of preschool vision screening. Thus, respondents from private schools, teachers, age, and respondents having more than 10 years of preschool experience had an increased likelihood of being aware of preschool vision screening.

In the logistic regression analysis, there was no statistically significant association between sociodemographic characteristics of respondents and their perception of preschool vision screening.”

We have also provided a new table titled “Table 2. Association between sociodemographic factors and availability/awareness/perception of preschool vision screening”. This new table provides further details on results from logistic regression analyses.

3. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #1: No

Reviewer #2: Yes

We have provided all data underlying our findings in our manuscript. We stated clearly in our submitted manuscript that: “The datasets generated during and/or analyzed during the current study are available from the corresponding author on reasonable request.” We provided this Data Availability statement because we did not include in our ethical approval application that we were going to upload study data on a public repository.

4. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #1: Yes

Reviewer #2: Yes

We thank the Reviewers for their positive comments on our English grammar.

5. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: This paper is an interesting submission and related to an important area of eye care research on issues around preschool vision screening program. There are many areas that need further clarification, the writing needs to be more succinct. The presentation of the article is somewhat disjointed with some excellent portions and some portions that don't seem to flow as well.

We thank Reviewer #1 for his/her positive comments on our manuscript. We have addressed the suggestions and questions raised by Reviewer 1 below.

I would like to offer a few suggestions for how the manuscript presentation could be improved:

Introduction:

• The introduction section probably would benefit from some tightening with clear objective of conducting this study and using as recent references as possible.

The objective of our study was “To investigate the level of awareness and perception of stakeholders regarding preschool vision screening, its availability and related policies/programmes in the Kumasi Metropolis, Ghana”. The introduction section clearly highlights gaps in literature available, especially in the Ghanaian context, and hence the objective raised in the study. Most references used in the introduction does not go beyond a decade. We have, however, reviewed our introduction section and revised it accordingly (please see Revised Manuscript pages 4 to 6).

We have also revised our objective for the study to be “The objective of this study is to investigate the level of awareness and perception of stakeholders regarding preschool vision screening and its availability in schools in the Kumasi Metropolis, Ghana”.

• The context of the study needs to be explained to situate the findings for international readers to provide a frame of reference for the findings.

The first paragraph under the Introduction section highlights vision disorders among children globally, especially preschoolers. The second paragraph evaluates the need for early visual assessment for preschoolers and provides examples of national policies by some countries which is aimed at tackling this menace. The third paragraph also highlights the various stakeholders and their possible roles in achieving good vision among preschoolers. The last paragraph reviews these assessments in the Ghanaian context, and the need for further studies and a national policy regarding preschool vision screening in Ghana.

• In the discussion, the authors should come back to the literature you cite in the introduction and consider what they need to present in the beginning, to reflect on in the end.

The literature as used in the Introduction section (references 7, 11-16, 18 from originally submitted manuscript) were also used under the Discussion section to explain findings in our study. We, however, acknowledge other references which were drawn to fully support our arguments under the Discussion section. We have, therefore, reviewed our introduction section and revised it accordingly (please see Revised Manuscript pages 4 to 6).

Methods:

• The method section is too brief, and the overall research process appears rather complex. The way the authors articulated the method section is a bit unclear. I would suggest making it clear for the readers.

The Methods section highlights salient procedures which were employed in our study (considering the word limit requirement by the journal). The procedure for the study were clearly outlined. We however acknowledge Reviewers comment and have provided additional information for clarity. Please see below and Methods Section Pages 6-9; lines 107-168.

The expression n= (where n =sample size, Z= the standard score at 1.96 for a 95% confidence interval, p = was the anticipated prevalence of perceptions of teachers and nurses [estimated to be 0.4 from the study conducted by (Naidoo et al., 2017), d= absolute error taken as 5%), a minimum sample of 368.79 was estimated. Thus, the target sample size was 370 respondents. We have added this to the methods section (please see below and Revised Manuscript Pages 6 to 7; lines 108 - 113)

“The sample size was called using the following assumptions/formula:

The expression n= (where n =sample size, Z= the standard score at 1.96 for a 95% confidence interval, p = was the anticipated prevalence of perceptions of teachers and nurses [estimated to be 0.4 from the study conducted by (Naidoo et al., 2017), d= absolute error taken as 5%), a minimum sample of 368.79 was estimated. Thus, the target sample size was 370 respondents.”

We have now provided a flow diagram detailing the research process. Please see Figure 1 below and in the Revised Manuscript (page 8).

Figure 1. Flowchart showing the flow of participants through the research process

We have revised our Statistical Analysis section and provided additional details. Variables used in the study included socio-demographic data on all participants. These include sex, age, type of school ownership, job title, highest level of education, preschool teaching experience, and school enrolment.

Assessment for the perception of preschool vision screening was measured using the responses of participants in the study. The scale employed was a five-point Likert scale to assess responses of participants. Please see response above under ‘Variable’. We have revised our Statistical Analysis section and provided additional details (please see Revised Manuscript pages 7; lines 130-132).

Assessment for the perception of preschool vision screening was measured using a five-point Likert scale, which elicited needed responses from participants in the study.

We have revised our Statistical Analysis section and included a statement in the Revised Manuscript for clarity. Please see below and Revised Manuscript pages 7; Lines 132 to 133

“Logistic regression analysis further investigated the association between sociodemographic characteristics of respondents and availability, awareness and perception of preschool vision screening.”

We have now restructured and provided an Ethical Approval Section at the end of the methods (please see below and Revised Manuscript pages 9; lines 159-168).

“Ethical Approval

The study was conducted with adherence to the Declaration of Helsinki, and approval was sought from the Committee on Human Research, Publication & Ethics (CHRPE), Kwame Nkrumah University of Science and Technology (KNUST), Kumasi, Ghana (CHRPE/AP/222/18). Permission was also obtained from the Metropolitan Education Directorate and selected schools in the Kumasi Metropolis, Ghana. A verbal informed consent was obtained from all respondents after the details of the nature of the study were explained to them”.

• The process of sample selection - what was the sampling technique? The authors mentioned about systematic sampling (probability proportional-to-size method) to select schools and convenient sampling to select interview participants. However, it is not clear why and how these sampling techniques were used and based on what assumptions.

Probability Proportional-to-Size sampling technique was employed in the selection of schools available in the Kumasi metropolis. Due to unequal numbers of schools under the various type of school ownership (private schools and public schools), we had to use this method. Convenience sampling was employed in the selection of interview participants because it was assumed that some of the teachers would not be available at the time of data collection (due to their extracurricular activities). The statement “due to their extracurricular activities” has been added under line 107 of the Methods section.

• How sample size was calculated, and numbers mentioned decided based on what assumption/formula? – The authors should mention these clearly in the method section.

The expression n= (where n =sample size, Z= the standard score at 1.96 for a 95% confidence interval, p = was the anticipated prevalence of perceptions of teachers and nurses [estimated to be 0.4 from the study conducted by (Naidoo et al., 2017), d= absolute error taken as 5%), a minimum sample of 368.79 was estimated. Thus, the target sample size was 370 respondents. We have added this to the methods section (please see below and Revised Manuscript Pages 6 to 7; lines 108 - 113)

“The sample size was called using the following assumptions/formula:

The expression n= (where n =sample size, Z= the standard score at 1.96 for a 95% confidence interval, p = was the anticipated prevalence of perceptions of teachers and nurses [estimated to be 0.4 from the study conducted by (Naidoo et al., 2017), d= absolute error taken as 5%), a minimum sample of 368.79 was estimated. Thus, the target sample size was 370 respondents.”

• Also, the flow of participants through the research process is unclear. It would be good for the readers if the authors specify exactly how the process was done? In order to clarify, could the authors provide a flow diagram (such as recommended by the CONSORT group) so that readers can understand more clearly exactly what the researchers did throughout the research process, sample size, approached/ agreed, included/ excluded participants etc.

We have now provided a flow diagram detailing the research process. Please see Figure 1 below and in the Revised Manuscript (page 8).

Figure 1. Flowchart showing the flow of participants through the research process

• Variable: No information was provided about outcome and explanatory variable. It is also not clear what was the exact outcome measures. Reading through the title and text – it appears that outcome variables were more than one - awareness and perception, and the availability of preschool vision screening. However, none of the variables were defined.

We have revised our Statistical Analysis section and provided additional details. Variables used in the study included socio-demographic data on all participants. These include sex, age, type of school ownership, job title, highest level of education, preschool teaching experience, and school enrolment.

For the analyses pertaining to awareness of preschool vision screening, the explanatory variables included age, sex, type of school ownership, job title, education, preschool teaching experience. Awareness of preschool vision screening among participants (awareness variable) was assessed by answering the following questions: “Have you heard of Preschool Vision Screening services for preschool children?” The awareness variable was employed in the univariate and multivariate logistic regression models assessing the association between awareness and related factors.

For the analyses pertaining to availability of preschool vision screening, the explanatory variables included age, sex, type of school ownership, job title, education, preschool teaching experience. Availability of preschool vision screening among participants (availability variable) was assessed by answering the following questions: “Does your school(s) have a written policy for screening preschool children? And/or Does your school(s) conduct vision examinations/screenings routinely for preschool children?” The availability variable was employed in the univariate and multivariate logistic regression models assessing the association between awareness and related factors.

For the analyses pertaining the perception, the explanatory variables included age, sex, type of school ownership, job title, education, preschool teaching experience. The perception of preschool vision screening among participants (perception variable) was assessed by answering the following questions: “Do you think that Preschool Vision Screenings should be implemented in all schools? And/or If preschool vision screening is not done in your school(s), do you think it is important for children to benefit from routine eye examinations? And/or Will you consider Preschool Vision Screening mandatory as part of the admission process?” The perception variable is a composite of the above questions. The perception variable was employed in the univariate and multivariate logistic regression models assessing the association between awareness and related factors.

• The analysis section requires more clarity. For example, it is not clear how perception of preschool vision screening was measured. Did researchers use any specific scale for that?

Assessment for the perception of preschool vision screening was measured using the responses of participants in the study. The scale employed was a five-point Likert scale to assess responses of participants. Please see response above under ‘Variable’. We have revised our Statistical Analysis section and provided additional details (please see Revised Manuscript pages 7; lines 130-132).

Assessment for the perception of preschool vision screening was measured using a five-point Likert scale, which elicited needed responses from participants in the study.

• The authors stated that “Chi-square test was used to determine the association between demographic characteristics of respondents, and their awareness and perception, and the availability of preschool vision screening.” – But no association data is provided for perception, and the availability of preschool vision screening in the results. Moreover, the authors did not run any advance level analysis (bivariate of multi-variate analysis) to establish any solid association between outcome variables and explanatory variables.

We have revised our Statistical Analysis section and included a statement in the Revised Manuscript for clarity. Please see below and Revised Manuscript pages 7; Lines 132 to 133

“Logistic regression analysis further investigated the association between sociodemographic characteristics of respondents and availability, awareness and perception of preschool vision screening.”

• Ethical issues are now mixed-up with the method section. The authors might consider putting the ethical approval and other ethical issues as a sub-heading at the end of the method section.

We thank Reviewer #1 for his/her suggestion under the Methods section. We have now restructured and provided an Ethical Approval Section at the end of the methods (please see below and Revised Manuscript pages 9; lines 159-168).

“Ethical Approval

The study was conducted with adherence to the Declaration of Helsinki, and approval was sought from the Committee on Human Research, Publication & Ethics (CHRPE), Kwame Nkrumah University of Science and Technology (KNUST), Kumasi, Ghana (CHRPE/AP/222/18). Permission was also obtained from the Metropolitan Education Directorate and selected schools in the Kumasi Metropolis, Ghana. A verbal informed consent was obtained from all respondents after the details of the nature of the study were explained to them”.

Result:

• The findings have not really been fully teased and pondered.

All salient findings have been reported clearly under the Results section (Please see Revised Manuscript pages 9 to 17).

• Whilst I appreciate there is a huge amount of data and much to explore one glaring point of interest to me was further elaboration of results.

We thank Reviewer #1 for his/her suggestion and have provide additional details under the Results Section of our Revised Manuscript (please see Pages 9 to 17).

• The result section only highlighted the basic findings on demographic characteristic and few information on awareness and perception, and the availability of preschool vision screening. No associated factors are provided for perception, and the availability of preschool vision screening.

We have now clarified this in the Results Section (please see pages 12 to 17).

• The authors did not run any bivariate of multi-variate analysis to establish any strong association between outcome variables and explanatory variables. It is difficult to make any inference based on the results provided at present.

We have provided additional analyses and presented additional results based on our study data (please see Revised Manuscript pages 12 to 17).

“In the logistic regression, private school ownership (Odds Ratio [2.46]; 95% CI [1.34-4.51]) was significantly associated with the availability of preschool vision screening. Thus, respondents from private schools were more likely to report the availability of preschool vision screening in their schools.

The logistic regression analysis showed that age (1.03; 1.01-1.05), private school ownership (1.98; 1.14-3.43), teachers (0.46; 0.22-0.97) and preschool experience of more than 10 years (3.45; 1.35-8.85) were statistically significantly related with the awareness of preschool vision screening. Thus, respondents from private schools, teachers, age, and respondents having more than 10 years of preschool experience had an increased likelihood of being aware of preschool vision screening.

In the logistic regression analysis, there was no statistically significant association between sociodemographic characteristics of respondents and their perception of preschool vision screening.”

• Is it possible to expand the result section further establishing association between outcome variables and explanatory variables through running bivariate of multi-variate analysis?

We thank Reviewer #1 for his/her suggestion under the Results section and have provided additional details accordingly (please see Revised Manuscript pages 12 to 17)

“In the logistic regression, private school ownership (Odds Ratio [2.46]; 95% CI [1.34-4.51]) was significantly associated with the availability of preschool vision screening. Thus, respondents from private schools were more likely to report the availability of preschool vision screening in their schools.

The logistic regression analysis showed that age (1.03; 1.01-1.05), private school ownership (1.98; 1.14-3.43), teachers (0.46; 0.22-0.97) and preschool experience of more than 10 years (3.45; 1.35-8.85) were statistically significantly related with the awareness of preschool vision screening. Thus, respondents from private schools, teachers, age, and respondents having more than 10 years of preschool experience had an increased likelihood of being aware of preschool vision screening.

In the logistic regression analysis, there was no statistically significant association between sociodemographic characteristics of respondents and their perception of preschool vision screening.”

Discussion:

• The discussion should be more analytical and should reflect on how the findings support, refute, extend the previous literature (generally cited in the introduction).

The literature as used in the Introduction section (references 7, 11-16, 18 in the originally submitted manuscript) were also used under the Discussion section to explain findings in our study. We, however, acknowledge other references which were drawn to fully support our arguments under the Discussion section. We have also reviewed some references under the Discussion section and provided additional details (please see Revised Manuscript pages 16 to 19).

“This was proven by the statistically significant association between teachers and preschool teaching experience of more than 10 years, and the level of awareness of preschool vision screening”.

• Results of previous studies are simply stated alongside this study with no discussion of why the findings may differ between the studies etc.

We have addressed this issue in our Revised Manuscript. Please see Revised Manuscript Page 16 to 19.

• What is implication of the study results for preschool vision screening program and eye care linked clinical practice?

The study assesses and recommends the need for a national preschool vision screening programmes/policies in all countries to preserve the sight/vision of children. Eye care professionals must play an instrumental role in the early assessment of preschoolers through the national preschool vision screening programmes.

• Moreover, the section would benefit from some tightening through building more precise arguments more in the context of this study findings only.

We thank Reviewer #1 for his/her suggestion under the Results section

• The researchers highlight a few limitations of the study which should be further pondered. The strengths of the study should be highlighted as well. The authors should highlight limitations/strengths with strong arguments.

We have now revised the limitations/strengths section of the Discussion with strong arguments. Please see below and Revised Manuscript Page 21, Lines 302 to 309

“The strength of this study lies in the use of an open-ended questionnaire which elicited more details and/or insight from respondents through an infinite number of likely answers. Limitations in this study include a small sample of stakeholders (mainly teachers and educationists) used in this exploratory analysis. Larger sample size should be considered in future researches to enhance the applicability and generalization of results to other locations and countries. Again, the results may be biased and/or skewed towards a section of stakeholders (teachers and educationists only) associated with preschool vision screening in Ghana, and may not represent the views/position of other stakeholders such as parents and eye care professionals.”

This is an interesting topic and I hope the authors will find these comments useful as they consider how to proceed with the manuscript.

We thank the Reviewer for his/her helpful comments regarding our manuscript.

Reviewer #2: I guess the aim of the manuscript is to inform the Ghana Health authority that you are ready to accept any screening policy in case of implementation. In most screening policies implemented throughout the world rest on primary care. Curious to know the health structure in Ghana Do family practitioners perform or would be willing to do the screenings. Any screening program performed in school would be an addition to the primary care physician screening.

In your discussion please state the primary care system in Ghana.

In Ghana, the Ministry of Health is responsible for the health sector. It formulates health policies and coordinates and regulates all stakeholders in the health sector. Implementation of various health policies is carried out by the public, private, and traditional sectors. In the public sector, the Ghana Health Service, Teaching Hospitals Board, and Quasi Government Hospitals are the implementing agencies of the ministry. The private sector, which is regulated by the Private Hospitals and Maternity Homes Board, also comprise mission-based providers, and private medical practitioners.

Primary health care in Ghana comprise practitioners such as physicians and physician associates, nurses, optometrists, pharmacists, etc. Primary health care is delivered in district, municipal, and rural hospitals; who eventually refer ‘bigger’ problems to the higher healthcare institutions such as the Teaching hospitals. The low number of professional healthcare givers in Ghana’s primary healthcare system poses a challenge in addressing the health needs of the people.

The National Eye Care Unit of Ghana is responsible for the eye health needs of the population in Ghana. It is made up of eyecare cadets such as optometrists, ophthalmologists, ophthalmic nurses, and opticians. Optometrists, ophthalmic nurses and opticians serve as primary eyecare providers in Ghana’s eye health system. Ghana currently do not have a national preschool vision screening policy/programme. Most eye care professionals are contracted by school authorities to conduct vision assessment for preschoolers (especially in private schools) outside their daily primary eye care routine in clinics.

Please find attached a picture illustrating the structure of Ghana’s health system.

Submitted filename: Rebuttal_PSVS 11 02_2020 EAM.docx

Click here for additional data file.

24 Feb 2020

Assessment of Availability, Awareness and Perception of Stakeholders regarding Preschool Vision Screening in Kumasi, Ghana: An Exploratory Study

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27 Feb 2020

PONE-D-19-23753R1

Assessment of Availability, Awareness and Perception of Stakeholders regarding Preschool Vision Screening in Kumasi, Ghana: An Exploratory Study

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