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 Table of Contents 
Year : 2012  |  Volume : 1  |  Issue : 2  |  Page : 114-117  

Screening of Vision and Hearing in Primary School Children

1 Department of Paediatric Medicine, Hospital of Southern Jutland, Sonderborg, Denmark
2 The Research Unit for Section of General Practice, University of Copenhagen, Copenhagen, Denmark

Date of Web Publication20-Dec-2012

Correspondence Address:
Martin Lehmann Boesen
Arnkilgade 34 1.th, DK 6400, Sonderborg
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/2249-4863.104979

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Background: Hearing and sight are two basic senses in terms of education and profession. The World Health Organization (WHO) estimates that 15 million children worldwide suffer from uncorrected refractive disorders and another 275 million people are handicapped due to compromised hearing. In Indonesia, screening primary school children for hearing and vision is not part of the free public health-care system. Knowledge of the status of a child's hearing and vision may help secure the child's education and future profession. Materials and Methods: In five primary schools in a poor urban neighborhood in Yogyakarta, Indonesia, we screened pupils from class 1 to 6, for vision and hearing handicaps, following the WHO's definitions of handicap. On location in the primary schools, we screened vision using a Snellen chart and hearing using distortion product otoacoustic emission (DPOAE). Those with vision below 6/18 were referred to an ophthalmologist and pupils with hearing below 30 decibels at 0.5, 1, 2, and 4 kilohertz were referred to an ear nose and throat (ENT) specialist for final testing. Results: Totally, 775 pupils were vision screened and 777 pupils were hearing screened. We found that 2% were disabled by sight and 6% by hearing. Conclusion: Lost without proper education, these pupils can, with simple recommendations, have access to education. We recommend that Indonesia start screening its primary school pupils for hearing and vision to secure the country's future productivity and socioeconomic development.

Keywords: Children, hearing, senses, sight, vision

How to cite this article:
Boesen ML, Lykke K. Screening of Vision and Hearing in Primary School Children. J Family Med Prim Care 2012;1:114-7

How to cite this URL:
Boesen ML, Lykke K. Screening of Vision and Hearing in Primary School Children. J Family Med Prim Care [serial online] 2012 [cited 2021 Sep 16];1:114-7. Available from: https://www.jfmpc.com/text.asp?2012/1/2/114/104979

  Introduction Top

Hearing and sight are two of our most basic senses especially in terms of education and profession. Being unable to see or hear normally may compromise our professional and social future and disable us from obtaining an education. [1],[2],[3],[4]

The World Health Organization (WHO) estimates that worldwide, around 15 million children aged below 15 are handicapped by vision due to uncorrected refractive disorders! [5] The WHO estimated that in 2004, 275 million people were handicapped because of compromised hearing and 80% of these people lived in low- and middle-income countries. [6] Recently published results show that between 2 and 8% people have visual problems [7],[8],[9],[10] and around 6% have hearing disabilities in countries with limited public health-care systems. [11],[12]

In many low- and middle-income countries, the testing of children's senses is not part of the country's free primary health-care system. As a result, children with compromised sight or hearing may be poorly equipped for the challenges of life. Even though expenses for glasses and hearing aids may be challenging and for many, impossible to cover, the knowledge of any existing handicap is important to help these children have access to an education.

This knowledge may also help to minimize the use of costly private practitioners in the search for an explanation for the child's poor performance in school.

This cross-sectional study was carried out in affiliation with the Centre for Bioethics and Medical Humanities (CBMH), Gadjah Mada University, Yogyakarta, Indonesia which is a partner in the research program "Health Systems Reform and Ethics: Private Practitioners in Poor Urban Neighbourhoods in India, Indonesia and Thailand" (HSRE). The main objective of HSRE is to help reforms in the sector of private practitioners to protect patients against iatrogenic adverse events. [13]

Therefore the aim of the study was to detect and register the current status of hearing and sight disabilities among poor urban primary school children in Indonesia, using a thoroughly tested, cheap, and easy method that could be reproduced on a large scale. In testing our method, we also illustrate some of the organizational challenges related to screening for hearing and vision that must be faced before any country can implement a screening program for hearing and sight.

  Materials and Methods Top

Screening was done in five public primary schools [1] with a total of 813 pupils from grade 1 to 6. The five schools were the schools in the four neighborhoods that were part of the Indonesian HSRE study. Approximately 1,000 families live there and the four neighborhoods were selected by HSRE due to their status as poor and urban. [14]

Indonesia has about 240 million inhabitants; [15] we desired results with 95% confidence level and a confidence interval of 4. Calculation showed that we needed to test a minimum of 600 pupils.

All parents were informed of the study one week prior to our visit with a letter including a return slip to express their allowance or denial of the pupil to be enrolled in the study. Informed consent was received from all parents. Furthermore, all the schools were visited prior to our study and the headmasters granted permission. All tests were paid for by the research unit leaving no expense to the participating pupils. After the study ended, the research unit made applications for private funding of glasses and hearing aids for needy pupils.

Vision test

The pupils were screened using a Snellen chart, following the standard guidelines. [16] Cutoff levels according to the definitions of visual impairment issued by the WHO were used: A child is considered nondisabled by sight, if he/she can read line 6/18 or smaller on the chart. [17] Those unable to do so were referred to an ophthalmologist for full examination and final determination of their vision.

Hearing test

The pupils received a hearing test using distortion product otoacoustic emission (DPOAE) bilaterally, with an Otoreaden Screening Meter. [18] Those whose screening was abnormal were referred to an ear nose and throat (ENT) specialist for full examination and final determination of their hearing ability.

The cutoff level for hearing impairment was set at 30 decibels at 0.5, 1, 2, and 4 kilohertz following the WHO standards for hearing disability. [19]

  Results Top

The schools comprised 813 pupils from classes 1 to 6. Gender was equally distributed.

Demographic profile is depicted in [Table 1].
Table 1: Demographic profile of the subjects

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Flow chart given in [Figure 1] depicts the outcome of this study.
Figure 1: Flowchart depicting outcome of the result

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We managed to screen 95% of the pupils and finally 2% were determined as disabled by vision and 6% disabled by hearing, following the WHO guidelines.

In the vision group, we had a referral rate of 6% to a specialist; of these, 38% were handicapped by vision and 75% needed glasses. When tested by the ophthalmologist, 60% of those not handicapped by vision were in need of glasses to obtain perfect vision, that is, 6/6. All in all, we detected 4% in need of glasses.

In the hearing group, the referral rate to a specialist was 16% and of these 43% was handicapped by hearing. After removal of cerumen and foreign bodies, all the others had normal hearing apart from the two with an ongoing infection.

  Discussion Top

In this study, 2% pupils were disabled by vision which is similar to other comparable reports. [8],[9],[10] In our study, we considered pupils defined handicapped as per WHO guideline but optimally, every pupil with less than normal vision should get opportunity to correct it.

In this study, we referred all pupils with a screened vision less than 6/18 directly to an ophthalmologist but to reduce costs of a screening program and to minimize the burden on the country's ophthalmologists, referral can be done to an optician.

C.E. Basch found that uncorrected vision leads to poor education; therefore, the optimal solution for pupils with less than normal sight is glasses. [20] However help can be provided by other methods as well. [Table 2].
Table 2: Vision problem: Possible solutions

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We found that 6% of the children were in need of a hearing aid, which is similar to other comparable countries. [9],[10] Of the 6% with hearing loss, some might be reversible. We did not do a follow-up to test this and it could impact the final result, which is a limitation to the study.

Distortion product otoacoustic emissions (DPOAE) is usually used to test hearing in neonates and not school children, but Kruger et al. [21] also tested school children, finding a false-positive rate of 4%. Of the 115 pupils tested by the ENT specialist, 63 had normal hearing but this was after the intervention of removing foreign bodies and cerumen. The exact false-positive rate is therefore not known.

T. Most has reported that poor hearing leads to poor education. For the 50 pupils with hearing disability in our study, education inevitably was affected. [22] The optimal solution is a hearing aid but this is costly. Even without hearing aid, the pupils can be helped; [Table 3] shows recommendations applicable immediately.
Table 3: Hearing problem: Possible solutions

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An important aspect of identifying pupils with handicaps is to minimize the expenses the family incurs on private practitioners in its search for an explanation to the child's poor performance in school. Instead, the family can focus on helping the child overcome its handicap. Also the knowledge of a handicap enables applications to private foundations for funding of aids.

We recommend that middle- and low-income countries like Indonesia start screening its primary school pupils for hearing and vision to secure the country's future productivity and socioeconomic development. With a growing economy and a growing need for well-educated employees, this is the time to act if the future's need is to be secured.

Our method was simple and cheap at the screening level and used sophisticated equipment only at the follow-up level. The low number of dropouts in our research shows that screening in primary schools will secure a high percentage of participation.

The vision screening method should be improved using a Snellen chart with a background light instead of those used by us, which had no light from behind. The recommended chart is more expensive but we expect it will result in fewer referrals making it cost beneficial.

We are not sure that the hearing screening using the DPOAE is in fact the best solution for a nationwide-screening program. This needs to be tested further before advice can be made. Alternatively, simple tympanometry could be made by assistants trained in this, who could then visit schools once a year and test all pupils at class 2 level. This setup will probably decrease the referral rate.

Generally the false-positive rate was in the higher side in this study but as both the primary and secondary testing is noninvasive and non traumatic a high false-positive rate might be be acceptable. The problem, however, is the expense in secondary testing that must be covered by either the health-care system or the families, both of which are with limited resources. This requires a setup designed to improve the high false positive rate. This will probably also result in a greater public backup to the program. The consequences of a high false-negative rate is not acceptable, as retesting can be done easily.

With so many pupils affected by poor hearing or sight, primary care physicians are bound to encounter children complaining primarily about headache and tiredness, but also other symptoms that can be related to many diseases. A test of vision and hearing of these patients may reveal the reason for their symptoms as related to uncorrected poor vision or hearing. In-house testing of hearing and vision is easily done as outlined in this paper and most importantly, it is nontraumatic for the child.

The results of this study shed useful information on screening two basic senses among primary school pupils in low- and middle-income countries and can help secure an education and future for those unfortunate pupils with poor sight or vision.

  Acknowledgments Top

Centre for Bioethics and Medical Humanities at Gadjah Mada University Yogyakarta provided assistants and a great amount of valuable help and advice, without which this would not have been possible. ABDI Yogyakarta supplied the hearing testing equipment and assistance in making it all happen.

We wish to thank all subjects and their parents for participating in the study.

  References Top

1.Kaderavek JN, Pakulski LA. Facilitating literacy development in young children with hearing loss. Semin Speech Lang 2007;28:69-78.  Back to cited text no. 1
2.Ademokoya JA, Olujide MG. Typology and interventions for some social problems affecting learning of the hearing impaired child. Int J Rehabil Res 2007;30:75-9.  Back to cited text no. 2
3.Erickson KA, Hatton D. Literacy and visual impairment. Semin Speech Lang 2007;28:58-68.  Back to cited text no. 3
4.Goldstand S, Koslowe KC, Parush S. Vision, visual-information processing, and academic performance among seventh-grade schoolchildren: A more significant relationship than we thought. Am J Occup Ther 2005;59:377-89.  Back to cited text no. 4
5.In: Gilbert C, Ackland P, Resnikoff S. editors. The Right to Sight, action plan 2006-2011 [monograph on the Internet]. Geneva: World Health Organization; 2007. Available from: http://www.vision2020.org/main.cfm?type=PUBLICATIONS. [Last cited on 2012 May 7].  Back to cited text no. 5
6.World Health Organization. Geneva: Media centre; Deafness and hearing impairment. Fact sheet No 300. Available from: http://www.who.int/mediacentre/factsheets/fs300/en/index.html. [Updated February 2012; Last cited on 2012 May 7].  Back to cited text no. 6
7.Kodjebacheva G, Brown ER, Estrada L, Yu F, Coleman AL. Uncorrected refractive error among first-grade students of different racial/ethnic groups in southern California: Results a year after school-mandated vision screening. J Public Health Manag Pract 2011;17:499-505.  Back to cited text no. 7
8.Lindquist AC, Cama A, Keeffe JE. Screening for uncorrected refractive error in secondary school-age students in Fiji. Clin Experiment Ophthalmol 2011;39:330-5.  Back to cited text no. 8
9.Gupta Y, Sukul RR, Gupta M, Phougat A, Jain R, Varshney A. School eye survey in rural population in UP, India. Nepal J Ophthalmol 2011;3:78-9.  Back to cited text no. 9
10.Limburg H, Kansara HT, d'Souza S. Results of school eye screening of 5.4 million children in India-a five-year follow-up study. Acta Ophthalmol Scand 1999;77:310-4.  Back to cited text no. 10
11.Béria JU, Raymann BC, Gigante LP, Figueiredo AC, Jotz G, Roithman R, et al. Rev Hearing impairment and socioeconomic factors: A population-based survey of an urban locality in southern Brazil. Panam Salud Publica 2007;21:381-7.  Back to cited text no. 11
12.Mishra A, Verma V, Shukla GK, Mishra SC, Dwivedi R. Prevalence of hearing impairment in the district of Lucknow, India. Indian J Public Health 2011;55:132-4.  Back to cited text no. 12
[PUBMED]  Medknow Journal  
13.Health System Reform and Ethics c2004-07. Available from: http://www.hum.au.dk/hsre/index.html. [Last cited on 2012 May 7].  Back to cited text no. 13
14.Back ground knowledge collected by CBMH for the HSRE project concerning the field (unpublished).  Back to cited text no. 14
15.Data cited from The World Bank Data program: The World Bank; 2010. Available from: http://data.worldbank.org/country/indonesia. [Last cited on 2012 June 15].  Back to cited text no. 15
16.In: Poulsen A, Brot C, editors. Preventative health care services to children and youth [monograph on the Internet]. Copenhagen: National Board of Health Denmark; 2011. Available from: http://www.sst.dk/publ/Publ2011/BOFO/Sundhedsydelser/VejlBU_sundhedsyd2udg.pdf. [Last cited on 2012 May 7].  Back to cited text no. 16
17.In: Foster A, Humphries J, Kosur I, Pararajasegaram R, Raman U, Rao N, et al., editors. State of the world's sight: Vision 2020, the right to sight 1999-2005. Geneva: World Health Organization; 2005. Available from: http://www.who.int/pbd/blindness/vision_2020/v2020_therighttosight.pdf. [Last cited on 2012 May 07].  Back to cited text no. 17
18.Otoration Manual, OtoRead - standard and clinical [monograph on the internet]. United Kingdom: Interacoustics; 2005. Available from: http://www.interacoustics.co.uk/_downloads/OM_OtoReadStandardClinical.pdf. [Last cited on 2012 May 07].  Back to cited text no. 18
19.Report of International workshop on primary ear and hearing care [monograph on the internet]. South Africa: World Health Organization; 1998. Available from: http://www.who.int/pbd/deafness/activities/en/capetown_final_report.pdf. [Last cited on 2012 May 07].  Back to cited text no. 19
20.Basch CE. Vision and the achievement gap among urban minority youth. J Sch Health 2011;81:599-605.  Back to cited text no. 20
21.Krueger WW, Ferguson L. A comparison of screening methods in school-aged children. Otolaryngol Head Neck Surg 2002;127:516-9.  Back to cited text no. 21
22.Most T. Assessment of school functioning among Israeli Arab children with hearing loss in the primary grades. Am Ann Deaf 2006;151:327-35.  Back to cited text no. 22


  [Figure 1]

  [Table 1], [Table 2], [Table 3]

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