Q.REC FAQ

What does Q.REC stand for?

Q.REC stands for Quality of Refractive Error Care. It is tool that focuses on assessing the quality of refractive error services in various populations worldwide. Unlike other visual impairment tools, Q.REC specifically targets refractive errors, the leading cause of correctable vision impairment.

What is a Q.REC study?

The Q.REC Study is a research methodology developed by the Fred Hollows Foundation. It focuses on assessing the quality of refractive error services in various populations worldwide. Unlike other visual impairment surveys, this study specifically targets refractive errors, the leading cause of correctable vision impairment.

Q.REC studies use standardised data collection methods, digital tools and a systematic approach for training field staff.

This page offers an overview of the study’s objectives, its current development, what it involves, and how to get started or seek support. 

What are Unannounced Standardised Patients (USPs)?

A Q.REC study employs simulated patients (similar to secret shoppers) — the gold standard for evaluating quality in clinical practice. Simulated patients, or Unannounced Standardised Patients (USPs), are ‘actors’ who are trained to act covertly as patients in a standardised fashion, while observing the clinical techniques and services provided. 

USPs have been used extensively in low- and middle-income countries, often in evaluating family planning, and how practitioners prescribe and dispense medicines.  

What is the purpose of the Q.REC study?

The main goals of a Q.REC study are:

  1. To estimate the proportion of prescribed spectacles that are clinically optimal for patients, by comparing a baseline prescription to purchased spectacles. 
  2. To understand the key reasons for spectacle quality issues.
  3. To identify possible interventions for improving refractive error service quality. 

The study uses robust epidemiological techniques, that can help inform targeted refractive error quality improvement programs.

A Q.REC study is not:

  • It is not a prevalence survey: the focus is on the quality of refractive error services. 
  • It does not cover all aspects of eye health: While it provides in-depth insights into the quality of refractive error services, it does not investigate the quality-of-service provision for other eye health conditions. 
  • It is not suitable for children: Children can’t be USPs, and the results of a Q.REC study are applicable only to adults. 

Where else have Q.REC studies been conducted?

Q.REC studies have been conducted in several countries. Key locations and findings include:

🇵🇰 Pakistan

  • Study: 2023, in Punjab province (Jhang, Khanewal, Sahiwal districts).
  • Findings: 42.7% of spectacles were optimal, with large district variation (13.8% in Jhang, 67.0% in Khanewal); half of suboptimal spectacles had horizontal prism errors; better outcomes were linked to focimetry and good communication; hyperopic patients were less likely to receive optimal prescriptions​.

🇰🇭 Cambodia

  • Study: 2022, across six provinces using 18 Khmer-speaking USPs.
  • Findings: Only 35.1% of spectacles were of optimal quality; common issues included incorrect horizontal prism and unnecessary prescriptions for people with no refractive error (especially women); written prescriptions often lacked pupillary distance information.

🇻🇳 Vietnam

  • Study: 2021, Development of quality indicators and pilot field test in three cities using 21 USPs.
  • Findings: Spectacles meeting the “optimally prescribed” standard were significantly more likely to provide good vision and comfort (94.6% and 66.1% respectively); only 44.1% of all spectacles achieved both good vision and comfort​.

Who should conduct a Q.REC study?

Q.REC studies require a team of trained professionals, including optometrists and eye health researchers. 

Recommended Study Personnel:

  • Study coordinator 
  • Study optometrists / refractionists 
  • USPs 

Additional personnel:

  • People to assist with mapping all optical service providers in your setting 
  • People to assist with translating documents 
  • People to assist in advertising for USPs 
  • People to assist in providing equipment or resources for training 
  • Biostatistician to assist with data analysis

Effective planning and organization is crucial. Do not underestimate the intricacies involved in the planning, recruitment and training of USPs.

Do I have to use the standard Q.REC Quality Indicators?

Employing standardised Q.REC indicators is essential for ensuring consistency and comparability across different studies. Using these indicators allows for a systematic assessment and comparison of the outcomes of refractive error service quality, facilitating the development of best practices and guidelines in the field. 

Q.REC studies need to use and report against these indicators as a minimum. This means reporting on the number of spectacles that meet the ‘optimal’ indicator for spectacle quality or reporting on the number of ‘adequate’ spectacles. Additional indicators could be included, such as segment heights for bi/multifocal spectacles. 

What if spherocylindrical lenses aren’t available in my setting?

In some circumstances, spherocylindrical lenses might not be prescribed. For example, in low-resource settings, spherocylindrical lenses might not be available or affordable for the patient. In these settings where only spherical lenses are more likely to be prescribed, the less stringent Q,REC Indicator can be used, which combines spherical equivalent power with vertical and horizontal prism to report on the whether spectacles are ‘adequately prescribed’.

Do I have to use unannounced standardised patients (USPs)?

Yes. Although the optical service should be aware that the study is happening, the methodology relies on the USP visits being conducted without the clinicians knowledge. 

How do I recruit USPs?

  • Define who is eligible: Set clear inclusion and exclusion criteria. USPs should be adults (18+), fluent in the local language, and have good eye health. Exclude anyone with previous eye surgery, certain medical conditions, or refraction training.
  • Advertise the role: Develop ethics-approved recruitment materials, including flyers and online ads. Aim to attract a diverse group, including both people with refractive error and emmetropes. This diversity ensures that the study encompasses a comprehensive spectrum of refractive conditions, enhancing the generalizability and applicability of the findings.
  • Screen each applicant: Have an eye health professional assess each candidate’s vision and eye health. Use tools like retinoscopy, autorefraction, and a slit lamp exam to confirm eligibility.
  • Get informed consent: Explain the study clearly, including its purpose, procedures, risks, and privacy protections. Obtain written or (if approved) verbal consent before proceeding.

Do I have to use the Q.REC Sample Size calculator?

No. But all Q.REC studies must provide a sample size justification statement that demonstrates that the selected sample size possesses adequate statistical power to reliably determine the real-world quality of spectacle-based interventions within a specifically defined geographical area. Every Q.REC study needs to report the following:

  • Anticipated proportion of spectacles that meet the desired ‘spectacle quality indicator’. 
  • The number of USP visits per store
  • The number of spectacles that will be obtained from each store.
  • The correlation coefficient (r).
  • The margin of error.
  • This number of individual stores in an area of interest that will need to be visited.
  • This is the total number of spectacles that will be required.
  • The design effect (based on the intraclass correlation).

How many USPs do I need to recruit? 

  • Recruit more USPs than you need: Always plan to recruit a few extra USPs beyond your minimum requirement. Some may drop out, be unavailable, or not meet quality standards after training.
  • Match your USP numbers to your study design: Consider the number of facilities, required visits per facility, and time frame to spread the workload and allow for flexibility.
  • Aim for diversity: Recruit a mix of refractive error types (e.g., emmetropes, myopes, hyperopes) and demographics to reflect realistic patient profiles and balance visit types.
  • Factor in availability and logistics: Choose USPs who are reliable and available during your study period. It helps to have backups in case of illness, scheduling issues, or performance problems during quality control checks.

How do I provide training? 

The Q.REC toolkit provides online eLearning, videos, SOPs, templates and checklists. 

  • Study training
  • USP training
  • Optometrist training
  • REDCap data management

To discuss additional support, please contact The Foundation at FHFResearchUnit@hollows.org.

How much does a Q.REC study cost?

Budgeting tools are available in the Q.REC toolkit to help users develop a budget for all associated Q.REC study costs.

Do I have to use REDCap?

No. All of the Q.REC data collection tools have been developed using REDCap (Research Electronic Data Capture), so this is the recommended approach. 

The advantage of REDCap is that it is a secure, web-based application, which streamlines data collection, management and analysis, reducing the likelihood of errors and inconsistencies. Advanced data export capabilities enable full integration with other statistical analysis tools. 

If REDCap is not used, equivalent data collection and management systems must be used.

Can I conduct a Q.REC study in my language?

Yes! Q.REC studies have been conducted in various languages. Users will need to arrange their own translation.

We recommend using a tool like Matecat to translate the Q.REC toolkit and the online USP Training Course. The REDCap multilanguage module allows users to translate all the data collection tools 

Do I need to get ethics approvals? 

Yes. A Q.REC study must obtain necessary ethical approvals from relevant institutional review boards or ethics committees. This step is crucial to ensure that the study complies with international and local ethical guidelines, particularly concerning participant welfare and data confidentiality.

Do USPs need to order and purchase spectacles?

In a Q.REC study, the USPs should also order and purchase spectacles (frames can be reused if contextually appropriate). This includes evaluating the accessibility, affordability, and quality of spectacles available to the community.

How was the Q.REC methodology developed?

The Q.REC study was developed by The Fred Hollows Foundation in collaboration with academic experts to address a critical gap: the lack of systematic methods for evaluating the quality of refractive error services. While previous efforts had measured service coverage, Q.REC set out to measure quality — using rigorous, real-world methods.

How do I get started?

  • Understand the Approach: Begin by reviewing the Q.REC Manual and Protocol to understand how the methodology works, including the role of USPs and data collection processes.
  • Plan Your Study: Use the toolkit’s planning tools, including the sample size calculator, budget planner, and training resources to design your study.
  • Recruit and Train Your Team: Recruit USPs and ensure they are trained using the materials provided. Make sure optometrists are available for baseline refractions and post-visit assessments.
  • Prepare for Data Collection: Familiarise yourself with the REDCap platform for secure and standardised data entry. Set up the database using the templates provided.
  • Reach Out for Support: If you’re unsure where to begin, need technical assistance, or would like to connect with others who’ve implemented Q.REC, email the Q.REC support team or explore the community of practice.

How do I find out more?

For more information or to get involved, contact the team at FHFResearchUnit@hollows.org.