Quality of refractive error care in Pakistan: an unannounced standardised patient study

OBJECTIVE: Undercorrected refractive errors are the primary cause of vision impairment worldwide, including in Pakistan. However, limited data exist on the quality of refractive error care. Our study assessed the quality of refractive error care in Punjab, Pakistan by estimating the proportion of spectacles that were optimally prescribed. METHODS AND ANALYSIS: In this cross-sectional study, 12 unannounced standardised patients (USPs) from Jhang, Khanewal and Sahiwal districts were recruited. USPs underwent baseline subjective refraction and were trained to attend optical services, observe consultations, request spectacles and obtain prescriptions. The spectacles received were compared with baseline refraction to determine quality. We also examined the associations between spectacle quality, service and patient characteristics. RESULTS: Out of 276 attempted visits to 69 optical services, 241 pairs of spectacles were dispensed. A population size-weighted percentage of 42.7% (95% CI 36.4% to 49.3%) of spectacles were optimal quality, with the range varying from 13.8% in Jhang to 67.0% in Khanewal. Half the suboptimal quality spectacles had horizontal prism deviations outside of tolerance limits. Optimal spectacles were associated with performing focimetry (unadjusted OR=7.15, 95% CI (3.02 to 16.94), p<0.001) and good communication (OR=2.23, 95% CI (1.06 to 4.67), p=0.03). Hyperopic USPs were less likely to receive optimal spectacles (OR=0.01 95% CI (0.00 to 0.11), p<0.001). CONCLUSION: The quality of refractive error care in Pakistan requires improvement, particularly in the Jhang district. Key areas for enhancing refractive error care in Pakistan include refining dispensing and refraction skills for hyperopic prescriptions, providing training on the risks of using previous spectacles, and emphasising the importance of effective communication skills.