vision and hearing screening tools dissemination event for... · diagnostic audiometry re-tests:...
TRANSCRIPT
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1
Vision and Hearing
Screening Tools
Dissemination Event
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Agenda
8:30 – 8:45 a.m. Opening Program
8:45 – 9:00 a.m. Study background
9:00 – 9:15 a.m. Study procedures and methods
9:15 – 10:00 a.m. Demonstration
10:00 – 10:45 a.m. Presentation of findings
10:45 – 11:15 p.m. Presentation on the DepEd MFAT
11:15 – 11:35 p.m. Questions and Answers
11:35 – 12:00 p.m. Handover Ceremony & Closing
12:00 – 1:00 p.m. Lunch
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Today’s Objectives
• Share approaches and lessons from the screening pilot
• Sensitize participants to important considerations in the
selection of screening tools and approaches based on
purpose, context, and resources
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Using Mobile Technology
for Sensory Disability
Screening - Field
Experiences from the
Philippines
Kellie Betts
Carmen Strigel 11/12/2018 Vision and Hearing Screening Pilot Activity in the Philippines 4
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What Is Screening?
• Process conducted by a non-medical staff or personnel to
determine whether a student might have a potential
disability
• Does not result in, or replace, a medical diagnosis by a
trained professional
• Screening is typically only for some aspects of a potential
disability
• Used to determine the need for referral and further
evaluation
• Screening approaches, by definition, are rapid and simplified
measures
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Study Background and
Procedures
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Study Origin
• Demonstrated commitment to inclusion by Department of
Education
• Commitment by USAID/Philippines to support the country’s
education development and inclusion agenda
• Emerging international evidence of a potentially higher than
15% disability prevalence rate
• Advancements in disability measurement and screening
approaches
• Emerging international evidence of practical approaches to
addressing drivers of low school enrollment and limited
implementation of inclusive education (RTI International, 2018)
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Low school enrollment (and high dropout) of children with disabilities in low and middle-income countries
Socio-cultural barriers
Limitations in the operationalization of
national policies
Lack of materials & resources
Drivers of Low School Enrollment of Children with Disabilities
Lack of specialized materials to diversify instruction
Lack of individual assistive devices
Lack of appropriate financing of inclusive education policy in light of scarce resources
Lack of relevant data to inform policy and practice
Poor representation of disabled people organizations to include actual issues
Community and family hold negative attitudes to children with disabilities
Community and family do not know of value of education for disabled child
Principals, teachers, students hold negative attitude to children with disabilities…
Gaps in teacher development & support
Insufficient & inappropriate pre-service training…
Insufficient and inappropriate in-service training…
Insufficient instructional support and practical guidance…
Families with disability more likely to experience multi-dimensional poverty
Lower educational attainment is key contributor to poverty for persons with disability
Poverty
Lack of practical screening and assessment tools
…lead to low teacher self-efficacy in teaching children with disabilities in inclusive classrooms …
Poverty can be cause or product of disability
Factors established in literature
Absence of systematic early screening
Lack of accessible, affordable, & quality health care
Community and families do not have knowledge about disabilities, e.g., cause of disability
Large class sizes…
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• Widely adopted, validated screening and measurement
tools for disabilities that can easily be adapted to local
context
• Research including learning outcomes of students with
different disabilities and severity levels
• Causal models that can underpin the plausibility of
interventions addressing barriers to inclusive education
• Cost-effectiveness research into different models of
inclusion (resource room, resource teacher, grade-based
phasing, etc.)
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Gaps in the Current Evidence Base
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Philippines Study Research Questions
1) Are the selected screening tools able to appropriately and
reliably detect children with vision and hearing difficulties
within the Filipino context?
–What are the necessary conditions to effectively
administer the selected tools?
2) Can the screening tools be effectively used by teachers in
the Philippines to screen and detect students with vision and
hearing difficulties?
–How much training is needed to ensure reliable screening
results?
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Data Collection Instruments
Rapid user adoption test: Pre- and post-test that was administered individually to
screeners to gauge experience and skill levels prior to training (use of electronics, use of
the specific software) and then compared to screeners’ abilities at the end of training
hearScreen: Smartphone-based hearing screening test developed by HearX, South Africa
Peek Acuity: Smartphone-based vision screening test developed by Peekvision, UK
Student background interview: Brief interview conducted with children; included the
Washington Group Short Set of Disability Questions
Diagnostic audiometry re-tests: Hearing tests conducted in medical facility as re-tests
for select students who tested positive at schools when using hearScreen
Principal interview: A brief interview to answer background questions about the school,
disability among students in the school, and the school’s inclusive education program.
Screener performance instrument: Collected data on the accuracy of screeners in
administering the vision and hearing screening
Screener exit interviews: Interview with screeners at the end of the data collection
gathering feedback on the tools, training, and data collection process
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School and Student Sample
• 8 schools selected, conveniently located in Region IV and
National Capital Region
–All medium- to large-size schools; located around
cities/major roads; constructed in/around the school
• 1,218 children (50% boys and 50% girls)
–Grade 1: 190 students
–Grade 2: 814 students
–Grade 3: 214 students
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Screening Spaces Used in Schools
45%
38%
8%
6%
2%
2%
0% 10% 20% 30% 40% 50%
Inside an empty classroom
Inside a classroom with other
students/teachers present
Inside a small, private office
Outside in a public area (others are
present)
Outside in a private area
Other
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Pilot Screeners
• 18 screeners trained
– 8 teachers
– 4 medical officers (under the School Health Division)
– 6 data collectors (principals and school supervisors)
Screener type Average
age
Average years of
experience (range)
Teacher 39 11 years (2–20 years)
Medical Officer 40 10 years (1–11 years)
Data Collector 50 21 years (9–28 years)
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Peek Acuity
• Vision acuity screening
• Screener-administered
• Already piloted in Ethiopia and several
other countries in Africa and Asia
• Clinically validated (De Venecia et al., 2018)
• Proprietary tool
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hearScreen
• Pure tone audiometric screening
• Screener-administered
• Default protocol: sounds at 3 frequencies both right and left ear
• Clinically validated (Faheema et al., 2016)
• Proprietary tool
• Headset calibration to specific hardware
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DEMONSTRATION
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Vision Screening Pilot Findings
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Peek Acuity
• Vision acuity screening
• Screener-administered
• Already piloted in Ethiopia and several
other countries in Africa and Asia
• Clinically validated (De Venecia et al., 2018)
• Proprietary tool
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Percent of Screened Children with Potential Vision
Impairment by Severity Level (n=1,218)
93.68%
2.38%3.61%
0.25%
Normal Mild Impairment
Moderate Impairment Severe Impairment
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Vision Screening Referrals by Region and Gender
• Number of referrals significantly higher in NCR than Region IV-A
– Aligns with DepEd Consolidated SPED Data 2016–2017 that
shows NCR has the highest level of diagnosed and undiagnosed
vision impairments among elementary-aged students
• Slightly higher number of referrals for girls
NCR
(n=551)
REGION IV-
A (n=667)
Male
(n=611)
Female
(N= 606)
Normal 481 660 580 561
Mild
Impairment 27 2 8 21
Moderate
Impairment 39 5 23 21
Severe
Impairment 3 0 0 3
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Hearing Screening Pilot Findings
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hearScreen
• Pure tone audiometric screening
• Screener-administered
• Default protocol: sounds at 3 frequencies both right and left ear
• Clinically validated (Faheema et al., 2016)
• Proprietary tool
• Headset calibration to specific hardware
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hearScreen Tool Adjustments during Pilot
• Days 1–3: Referral rates using Standard Protocol extremely high (88% and 95%
of screened students)
– Left and right ear tests at 25 dB at 1kHz, 2kHz, and 4kHz
– Referrals at 1 or more failed frequencies
• On Day 4 and on Day 5: Small decrease in referral rate using Severity Protocol
– Left and right ears tested starting at 25 dB at all 3 frequencies; if no
response at 25 dB, beep is presented at increasingly higher frequencies
until patient responses
– Referrals at 1 or more failed frequencies
• Days 6–8: Significant increase in pass rate using a modified Severity Protocol
– Left and right ears tested starting at 30 dB at all 3 frequencies
– Refers at 2 or more failed frequencies
dB: degree of loudness
Hz: a unit of alternating current
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Hearing Screening Results by Day
NCR Region IV
Day 1
(n=66)
Day 2
(n=164)
Day 3
(n=144)
Day 4
(n=205)
Day 5
(n=112)
Day 6
(n=178)
Day 7
(n=201)
Day 8
(n=190)
Referred 89% 96% 90% 76% 78% 7% 7% 2%
Passed 11% 4% 10% 24% 22% 93% 93% 98%
Protocol
Used
Standard
Protocol
Standard
Protocol
Standard
Protocol
Standard
Severity
Protocol
25 dB
Standard
Severity
Protocol
25 dB
Modified
Severity
Protocol
30 dB
& 2 failed
frequencies
Modified
Severity
Protocol
30 dB & 2
failed
frequencies
Modified
Severity
Protocol 30
dB & 2
failed
frequencies
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Hearing Referrals by Severity Level
79%
90% 91%
16%
5% 6%4% 3% 2%1% 3% 1%0%
20%
40%
60%
80%
100%
Day 6 Day 7 Day 8
% o
f sc
reened s
tudents
None Mild Moderate Moderate Severe
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Considerations and Recommendations:
Using Schools Settings for Screenings
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Considerations: Using Schools for Screenings
• Schools can have higher than desired ambient noise levels from teachers, students,
parents, class breaks/shift change, etc.
• hearScreen tool constantly monitors background noise during screening process
– Automatically rescreens failed frequencies if ambient noise levels were above
permissible levels
• Permissible ambient noise levels are 49, 57, and 61 dB for 1, 2, and 4 kHz,
respectively
0%
20%
40%
60%
80%
100%
Visual distractions
present
Noise
distractions
present
Adequate lighting
available
Screener-Reported Testing Conditions
Yes No
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Chapter VI: School Sanitation and Health Services
The Code on Sanitation in the Philippines, Department of Health
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Ambient Noise Levels in Pilot Schools
0
10
20
30
40
50
60
70
80
90
100
20.0
25.0
30.0
35.0
40.0
45.0
50.0
Day 1 Day 2 Day 3 Day 4 Day 5 Day 6 Day 7 Day 8
Refe
rral
rat
e o
f st
udents
(%
)
Am
bie
nt
nois
e leve
l in
dB
s
1 kHz 2 kHz 4 kHz Fail Rate
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49 dB- 1000 Hz
57 dB- 2000 Hz
61 dB- 4000 Hz
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Recommendations: Using Schools for Screenings
• Be aware that school settings do present challenges, especially for
electronic hearing screening
– Consider larger implications related noise levels in schools
• Screening space set-up is critical to performance of tools
– 1 or 2 screeners in a room
– Be aware of school break times/shift changes
– Small offices or empty classrooms
• Test/adjust tool settings
• Closely monitor referral rates
• Consider screening outside of the normal school day (e.g., at the end
of the day, Saturday, or before the school year starts)
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Considerations and Recommendations:
Screener Type
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Considerations: Screener Type
• Using teachers as screeners helps them better understand which students have a potential vision or hearing impairment
– Can adjust their teaching or classroom practices to provide necessary assistance to students most in need
• Medical officers tend to have more experience with screening and referral processes; might be better at communicating results to parents
• Data collectors are especially useful in the parent-notification process
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Screener Performance by Type
86%
88%
90%
92%
94%
96%
98%
100%
Vision tasks (18) Hearing tasks (11)
% o
f perf
orm
ance
obse
rvat
ions
Percent of screeners’ performance observations
without errors by screener type
Data Collector Medical Officer Teacher
Source: Screener Performance Observation
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Understanding How to Use Screening Results
QUESTION: How do you plan on using the results of today’s screenings?
• Teachers: Tend to focus on individual child/family support (e.g.,
notifying parents of referral and allow family to follow up); few aware of
action items for classroom/teaching methodologies that could provide
additional support to children with a potential hearing or vision
impairment
• Medical Officers: Want to use the data to dig deeper to explore
issues behind the impairment; interested in being involved in screenings
to work with teachers and parents to understand results
• Data Collectors:Want to focus on communicating to and advising
parents to have a second opinion to justify the results; look for
sponsors/funding to help parents fund additional assistance/screenings
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Support Needed to Use Screening Results
QUESTION: What other types of support would you need in order to use
today’s results or to continue to support the identified children in the future?
• Teachers: Most teachers were unsure of what other types of support
they would need to effectively use the results or continue to support
identified children
• Medical Officers: Want to learn how to use the data to get support
(financial and other) from other agencies; how to educate and talk to
parents of the identified students
• Data Collectors: Budget for parents to get second opinions
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Recommendations: Screener Type
• Teachers are able to pick up and use tools with relative ease
– Teachers’ gains (33%) are similar to those of Medical Officers
(35%) and Data Collectors (36%) in Rapid User Adoption Test
• Teachers tend to have better rapport with students during screening
process
• Teachers need additional support (training/intervention) to understand
how to use screening results at classroom level
• Continue to involve medical officers in screening process
– Medical officers might have better understanding of referral
process and knowledge of local medical facilities for follow-up
testing
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Considerations and Recommendations:
Training Duration and Design
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Considerations: Training Duration And Design
Tools were user-friendly and easy to administer; all screeners were able
to pick up tools with relatively small amount of training time
42%50%
42%
75%
85%78%
33% 35% 36%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
Teachers Medical Officers Data Collectors
Rapid User Adoption Results
Average Pre Score Average Post Score Average Gain
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Recommendations: Training Duration and Design
• Extend training by one day to allow for more practice, for a
total of 24 hours of training
• Provide extra practice in school setting
–Allows for better understanding of working with
children and challenges with setting up testing space
• Spend more time in training to ensure screeners
understand findings/severity levels to better communicate
them to parents
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Considerations and Recommendations:
Screening Age
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Considerations: Screening Age
• Noticeable differences in children’s
(grade 1 vs. grade 3) ability to understand
directions and concentrate during
screening process
• Some hearing impairments such as middle
ear pathologic disorders are known to be
more common in younger children
(age 5), and referrals tend to reduce for
children ages 6 and 7 (Swanepoel,
Eikelboom, and Margolis, 2014)
1st
grade
(n=190)
2nd
grade
(n=814)
3rd
grade
(n=214)
Referred 82% 37% 63%
Pass 18% 63% 37%
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Recommendations: Screening Age
• Early screening and detection remains important
• Recognize that some conditions such as ear infections that
may affect hearing can be temporary and are often more
common with younger aged children
• Use clear instructions when working with younger
students; understand it may take longer to screen younger
children
• Use conditioning to help ensure younger students
understand screening process
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Considerations and Recommendations:
Parent Notification and Referral Process
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Considerations: Parent Notification and Referral
Process
• Notification and parent
engagement is critical to
screening process
• Many parents didn’t provide
consent for students to
participate
• Parents don’t always understand
what referrals/screening results
mean
• Parents don’t always want to
seek further testing/know more
about the potential issues
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Recommendations: Parent Notification and Referral
Process
• Need careful, context-specific consideration of socio-cultural aspects
• Explore other methods to communicate to parents about screening tools and procedures
– Show videos of screening process
– Discuss the screenings at PTA meetings or other scheduled meetings with parents
– Communicate verbally rather than through letters; allow parents to ask questions
• Prepare screeners with better understanding of the results/severity levels to improve ability to communicate findings to parents
– Sensitize/support parents with screening results
– Be able to suggest clear next steps (in and out of schools)
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Considerations and Recommendations:
Tool Selection
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Considerations: Tool Selection
• Screening tool must be carefully selected, taking into
account:
– Type of disability to screen for
– Purpose of the screening activity (and related to use of
the resulting data)
–Age of the child
– Resources available for screening and screening follow-
up
– Screening context
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Sample Students Self-Report Using Washington
Group Short Set Questions
Self-reported
difficulty
hearing
Self-reported
difficulty
seeing
Self-reported
difficulty
walking/clim
bing
Self-reported
difficulty
concentratin
g
Self-reported
difficulty
with self care
Cannot do at all 1% 0% 0% 1% 1%
Yes, a lot of difficulty 1% 2% 1% 0% 1%
Yes, some difficulty 10% 10% 7% 18% 7%
No, no difficulty 88% 88% 91% 80% 91%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%%
of sc
reened s
tudents
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Small Overlap Between Washington Group Short
Set and Electronic Screening Results
• 27% of the students who did not pass the Peek Acuity screening indicated
difficulty seeing
• 11% of students indicated difficulty seeing but passed Peek Acuity screening
• 6% of students who indicated difficulty hearing also did not pass the
hearScreen test
• 6% of students who indicated difficulty hearing passed the hearScreen test
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Hearing Screening Test Retest Results
• 162 students were retested after not
passing hearing screening
• Retesting students on the spot reduced
referral rates by almost 30%
First Test
Result
Last Test
Result
# of
students
(n=162) Percent
Fail Fail 107 66%
Fail Pass 44 27%
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Recommendations: Tool Selection
• Carefully consider context and purpose prior to selecting
screening tools.
• Screening efforts must invest in careful initial field tests to
establish locally appropriate logistics guidance for screeners
on where and how to set up adequate screening spaces.
• Comprehensive testing of electronic hearing screening
tools is needed to identify the most viable protocols for
the context in advance of full rollout.
• Screeners should retest students to ensure screening gives
accurate results.
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References
De Venecia, B., Bradfield, Y., Møller Trane, R., Bareiro, A., & Scalamogna, M. (2018). Validation
of Peek Acuity application in pediatric screening programs in Paraguay. International Journal of
Ophthalmology, 11(8), 1384–1389. doi:10.18240/ijo.2018.08.21
Swanepoel D., Eikelboom R., & Margolis, R. (2014). Tympanometry Screening Criteria in
Children Ages 5–7. Journal of the American Academy of Audiology, 25(10), 927-936.
doi:10.3766/jaaa.25.10.2.
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Kellie Betts, RTI International
Carmen Strigel, RTI International
Monica Ang-Tan, USAID/Philippines
Bureau of Learning Delivery- Student Inclusion Division
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Contact Information