Zanzibar Arts for Children's Eyesight Pilot Trial (ZANZI-ACEII)

Utilizing Traditional and Modern Music Performance in Eye Health Education to Improve Child Eye Health Service Uptake in Zanzibar

In Zanzibar, around 22,000 children (4% of those aged 6 to 12) need treatment for eye issues like conjunctivitis or require glasses. A 2017 study found that 42% of rural children needing glasses didn't have them. Many locals distrust Western medicine and prefer traditional remedies, rejecting public health efforts such as posters and brochures.

Globally, eye health promotion has been underfunded and overlooked. Research suggests community-designed interventions and behavior change studies are needed to promote sustainable eye health practices. Arts-based interventions using traditional storytelling and performances have been effective in Africa, improving health outcomes in areas like food hygiene and mental health. Health campaigns in schools might be less effective since parents make health decisions for their children.

This study aims to see how well using both traditional and modern music performances in an eye health education program can break down cultural barriers and increase children's use of eye health services in schools and communities. The investigators want to answer three main questions:

1. How effective is a 6-month music-based eye health education program in schools and communities at improving eye health knowledge and service use among parents and children?
2. What factors influenced the success of the 6-month music-based eye health education program?
3. What are the costs and benefits of this 6-month program in increasing eye health service use among children in schools and communities?

Study Overview

• Status: Completed
• Conditions: Conjunctivitis; Myopia; Hyperopia
• Intervention / Treatment: Behavioral: School music broadcast; Behavioral: Community music broadcast

Detailed Description

Problem: Zanzibar has about 22,000 children (4% of 6-to-12-year-old children) needing conjunctivitis treatment or spectacle correction (Ministry of Health, unpublished report). A 2017-case study showed that about 42% of children in rural Zanzibar communities who needed a pair of glasses did not have them.(1) Local stakeholders engagement revealed that underlying suspicions of Western medicine and public health initiatives led people to continue using traditional, less effective healing methods. Although health posters and brochures have successfully increased service uptake in other contexts,(2) our engagement with stakeholders revealed rejection of such initiatives among the Zanzibari community, such as when the posters were removed or vandalized.

Worldwide, eye health promotion has received limited attention and funding.(2) A Cochrane review(3) and The Lancet Global Health Commission on Global Eye Health(4) suggested that behavior change and co-design studies are needed to provide evidence on promoting sustainable behavior changes among the community and children with eye problems. Health-focused arts-based interventions have been shown to catalyze behavioral changes in Africa because they are built on traditional oral and performance methods.(5) A review(6) has shown that traditional music incorporated into health promotion campaigns to improve food hygiene, perinatal mental health and Ebola in Gambia yielded highly positive results. Less effective may be health promotion strategies implemented in school settings only because parents are the ultimate decision-makers of health choices for their children.

Research questions: The study aims to explore "the effectiveness of utilizing traditional and modern music performances in an eye health education strategy implemented in school and community settings to reduce socio-cultural barriers and subsequently increase child eye health service uptake". The specific research questions are:

1. How effective is a 6-month arts-based eye health education strategy implemented in school and community settings to improve parents' and children's eye health literacy and eye service uptake?
2. Which factors influenced the uptake of the 6-month arts-based eye health education strategy?
3. What are the cost and benefits of a 6-month arts-based eye health education strategy on improving eye health service uptake among children in school and community settings?

A: Assess the effectiveness of a 6-month arts-based eye health education program implemented in school and then community settings to improve parents' and children's eye health literacy and eye service uptake

1. Trained teachers will screen approximately 8000 children in eight intervention schools (with art-based eye health education program) and eight control schools (without any health education program) and refer approximately 400 children with vision <6/12 or/and refractive error (RE) and obvious eye diseases for free ocular management at the local eye clinics (current practice). Teachers in enrolled schools will maintain an eye health register to record the names of children who failed vision screening tests and are then referred for treatment, the reasons for referral, and follow up on which children attended an eye examination at the referral clinics. With an estimated prevalence of children with refractive error and obvious eye diseases of 5%, the investigators will have a sufficient sample size for analysis in this pilot trial.
2. Before the intervention, the investigators will administer a baseline demographic profile survey to all 400 children with refractive error and obvious eye diseases and their parents, 400 children with normal vision and their parents, followed by a baseline knowledge and attitude survey. Children referred for further ocular management will be followed up at Month 3 to determine the proportion of them who have gone for an eye examination at the hospital (baseline uptake rate). The enrolment will begin in Month 4. Subsequently, the eye health education will be broadcasted at intervention schools once during morning assembly, once during recess and once before school on Monday and Friday starting at Month 4. At Month 10, the endline 1 data (children's knowledge and attitude survey, eye health register checks) will be collected to determine follow-up scores and rates.
3. At Month 11, a popular local radio station will broadcast eye health education in the musical form three times a day. At Month 14, the second follow-up data (parents' knowledge and attitude survey, eye health register checks) will be collected to determine endline 2 follow-up scores/rates.
4. The primary outcomes are the change in the proportion of children accessing eye health services and the change in children's and parents' knowledge and attitude scores from baseline and endline 1 and endline 2. The secondary outcomes are the proportion and causes of children failing eye health screening, the proportion of children wearing spectacles during an unannounced visit and the children's self-reported compliance to eye medication treatment.

B: Explore in what ways social, cultural and artistic factors influenced the uptake of the arts-based eye health education strategy

1. Stakeholders involved in the music pieces' co-creation process will be invited to identify and reflect on the achievements, gaps, and barriers between what was intended by them and what was received by the intended audience. Stakeholders include Ministries' representatives, community and religious leaders, artist groups, parents, children, teachers and traditional healers. Semi-structured interviews will be conducted 6 months after the program implementation.
2. A series of small group discussions and individual interviews will be held with various target audiences of the intervention to ascertain responses to the intervention by those not involved in its design. These will include children, their guardians, teachers, health care practitioners, traditional healers, radio broadcasters and cultural workers from the context to determine 'audience reception'.
3. Thematic analysis will be conducted to ascertain (i) the efficacy of the makers' intentionality for the intervention concerning the reception of the pieces in context ('fitness-for-purpose'); (ii) the conceptual impact of the content of the music pieces in terms of the socio-cultural barriers addressed and myths dispelled, and how this intervention has contributed to new and/or existing counter-narratives of eye health; (iii) the reception of the music form of the pieces, including associated with past (heritage), current and aspirational (contemporary) genres and registers, and in what ways such artistic and cultural associations have contributed to the intervention's efficacy.

C: Determine the cost and benefits of a short-term arts-based eye health education strategy on improving eye health service uptake among children to inform upscale investment decisions

1. The investigators will develop a costing tool to (i) identify the main implementing costs, including the time and skills to develop the radio broadcast; (ii) calculate the costs of the intervention's roll-out to schools and the wider community; (iii) determine the costs that the intervention may save in the longer term, such as from absenteeism or treatment made unnecessary because of early treatment.
2. The pilot will enable us to cost the intervention and how affordable it is. By looking at the uptake of the intervention in schools and the community, the investigators can compare the costs and benefits of the strategies. Value is defined as cost relative to benefits, whereas budget impact is about costs only. Both are widely used for healthcare investment decisions in LMIC. This will enable policymakers to assess how affordable the intervention is. Understanding what are given up when a new intervention is funded (what else could have done with these resources) and the return on investment is crucial to helping policymakers decide whether the program is worth the investment.

• Study Type: Interventional
• Enrollment (Actual): 1295
• Phase: Not Applicable

Contacts and Locations

Study Locations

• Tanzania
  • Zanzibar, Tanzania
    • Ministry of Health

Participation Criteria

Eligibility Criteria

• Ages Eligible for Study: Child; Adult; Older Adult
• Accepts Healthy Volunteers: No

Description

Inclusion Criteria:

• primary and secondary schools with student school-going rates of approximately 75%
• schools with similar number of boys and girls
• schools within 5km of the nearest eye centres.
• school children who have either an obvious eye disease tested using a pen torch test and/or a presenting distance visual acuity ≤6/12 in either eye, and their parents.

Exclusion Criteria:

• primary and secondary schools with student school-going rates of less than 75%
• schools with imbalance number of boys and girls
• schools above 5km of the nearest eye centres.
• school children who do not have either an obvious eye disease tested using a pen torch test and/or a presenting distance visual acuity ≤6/12 in either eye, and their parents.

Study Plan

How is the study designed?

Design Details

• Primary Purpose: Prevention
• Allocation: Randomized
• Interventional Model: Parallel Assignment
• Masking: Single

Number of Arms

2

Arms and Interventions

Participant Group / Arm	Intervention / Treatment
Experimental: Intervention; Musical pieces developed by the Ministry of Education and Vocational Training will be played at intervention schools using compact discs. These will be broadcast once during morning assembly, once during recess, and once before school ends on Mondays and Fridays for 3 months. After this period, a popular local radio station will broadcast the music pieces three times a day during peak hours.	Behavioral: School music broadcast; An arts-based eye health intervention featuring traditional and contemporary music pieces will be broadcasted at both school and community levels.
Active Comparator: Comparator; A popular local radio station will broadcast the music pieces three times a day during peak hours, coinciding with the times when the intervention group is receiving the same program (community broadcast).	Behavioral: Community music broadcast; An arts-based eye health intervention featuring traditional and contemporary music pieces will be broadcasted at community levels.

What is the study measuring?

Primary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Change in the proportion of children accessing eye health services	Proportion of children who have gone for eye treatment at the referral sites over those who failed eye health screening and referred to the referral site; measured in percentage, the higher the percentage the better the referral rate	Three months and six months after the intervention is implemented

Secondary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Children spectacle compliance	Possession of glasses at school during an unannounced examination will be measured as either yes or no. A higher proportion of "yes" responses indicates better compliance.	Three months and six months after the intervention is implemented
Children eye drops usage compliance	Self-reported completion of eye drop treatment will be measured as either yes or no. A higher proportion of "yes" responses indicates better compliance.	Three months and six months after the intervention is implemented
Cost-benefit analysis	Costs will be measured by the program expenses, while benefits will be assessed by the proportion of children who voluntarily seek eye treatment at referral sites compared to those who failed the eye health screening and were referred. A higher proportion of treated children per US dollar spent indicates a higher cost-benefit ratio.	Through study completion, 6 months after the intervention is implemented.
Parents knowledge and attitude	A 27-item questionnaire will be used for measurement. Each question requires a yes or no response. A higher number of "yes" answers indicates better knowledge and attitude.	Three months and six months after the intervention is implemented
Children's knowledge and attitude	A 27-item questionnaire will be used for measurement. Each question requires a yes or no response. A higher number of "yes" answers indicates better knowledge and attitude.	Three months and six months after the intervention is implemented
Cost effectiveness analysis	Cost will be measured by the program expenses, while effectiveness will be assessed using the Visual Analogue Scale (EQ-5Q-Y questionnaire). A higher score per US dollar indicates greater cost-effectiveness.	Through study completion, 6 months after the intervention is implemented.

Collaborators and Investigators

• Sponsor: Queen's University, Belfast
• Collaborators: Ministry of Health and Social Welfare, Zanzibar
• Investigators: Principal Investigator: Ving Fai Chan, PhD, Queen's University, Belfast

Publications and helpful links

General Publications

• Burton MJ, Ramke J, Marques AP, Bourne RRA, Congdon N, Jones I, Ah Tong BAM, Arunga S, Bachani D, Bascaran C, Bastawrous A, Blanchet K, Braithwaite T, Buchan JC, Cairns J, Cama A, Chagunda M, Chuluunkhuu C, Cooper A, Crofts-Lawrence J, Dean WH, Denniston AK, Ehrlich JR, Emerson PM, Evans JR, Frick KD, Friedman DS, Furtado JM, Gichangi MM, Gichuhi S, Gilbert SS, Gurung R, Habtamu E, Holland P, Jonas JB, Keane PA, Keay L, Khanna RC, Khaw PT, Kuper H, Kyari F, Lansingh VC, Mactaggart I, Mafwiri MM, Mathenge W, McCormick I, Morjaria P, Mowatt L, Muirhead D, Murthy GVS, Mwangi N, Patel DB, Peto T, Qureshi BM, Salomao SR, Sarah V, Shilio BR, Solomon AW, Swenor BK, Taylor HR, Wang N, Webson A, West SK, Wong TY, Wormald R, Yasmin S, Yusufu M, Silva JC, Resnikoff S, Ravilla T, Gilbert CE, Foster A, Faal HB. The Lancet Global Health Commission on Global Eye Health: vision beyond 2020. Lancet Glob Health. 2021 Apr;9(4):e489-e551. doi: 10.1016/S2214-109X(20)30488-5. Epub 2021 Feb 16. No abstract available.
• Hobday K, Ramke J, du Toit R. Eye health promotion in Western Pacific island countries. Clin Exp Ophthalmol. 2011 Aug;39(6):584-5. doi: 10.1111/j.1442-9071.2011.02514.x. No abstract available.
• Evans JR, Morjaria P, Powell C. Vision screening for correctable visual acuity deficits in school-age children and adolescents. Cochrane Database Syst Rev. 2018 Feb 15;2(2):CD005023. doi: 10.1002/14651858.CD005023.pub3.
• McConnell BB. Music and health communication in The Gambia: A social capital approach. Soc Sci Med. 2016 Nov;169:132-140. doi: 10.1016/j.socscimed.2016.09.028. Epub 2016 Sep 19.

Study record dates

Study Major Dates

• Study Start (Actual): January 15, 2024
• Primary Completion (Actual): December 11, 2024
• Study Completion (Actual): December 11, 2024

Study Registration Dates

• First Submitted: June 13, 2024
• First Submitted That Met QC Criteria: June 18, 2024
• First Posted (Actual): June 24, 2024

Study Record Updates

• Last Update Posted (Estimated): December 12, 2024
• Last Update Submitted That Met QC Criteria: December 10, 2024
• Last Verified: December 1, 2024

More Information

Terms related to this study

• Keywords: Health education; Conjunctivitis; Refractive errors; Arts
• Additional Relevant MeSH Terms: Eye Diseases; Refractive Errors; Conjunctival Diseases; Hyperopia; Conjunctivitis
• Other Study ID Numbers: MHLS 23_32

Plan for Individual participant data (IPD)

• Plan to Share Individual Participant Data (IPD)?: NO

Drug and device information, study documents

• Studies a U.S. FDA-regulated drug product: No
• Studies a U.S. FDA-regulated device product: No