Getting Ready for training

Study Optometrist/Refractionist Training

Study optometrists are responsible for:

• Conducting USP baseline refractions
• Provide training to USPs on observing refraction equipment and techniques
• Assessing whether USPs are ready to visit optical services and act as a USP
• Assessing the quality of the spectacles that the USPs order and collect from optical services
• Manage (can be with the study coordinator) ongoing data collection by USPs

It is important for study optometrists to understand what is also expected of the USPs to be able to assist with training and quality control.

USP Training

When USPs are carefully and systematically trained, they are very capable of high accuracy over time. USP training is a blended program approach (i.e. part online, part in-person). In-person training should take approximately 3 days and USPs should bring a mobile or tablet device they will also use during data collection that can access WiFi or mobile phone data. A basic training schedule (that can be adjusted for your context) is outlined below:

Suggested USP in-person training schedule:

Preparing for in-person training

It is recommended after USPs complete study consent and before in-person training, each USP reviews the online training materials and practices entering information into Form C. This will be the first introduction to the data collection form they will be using throughout the study. Two links should be emailed to them:

1. USP Online Training
2. REDCap link to Form C for Practice.

The online training course is currently only available in English. If you do not think USPs would benefit from an online course in English, then consider adding an additional day to in-person training for the study team to go through the online training materials in your local language. If continuing to have a blended learning approach is preferred, then consider having the online training course translated into your local language. This can be arranged by contacting The Foundation’s Research Unit for support at hello@q-rec.org.

In-Person Training

Study overview session

This session is to provide USPs an overview of the entire Q.REC study, to either introduce the project to those who did not complete the online training course, or to recap Unit 1 from the online training course. It is also an opportunity to provide the setting’s specific details such as areas the USP are visiting, number of stores and visits.

USP Q.REC quiz and group discussion

The USP Q.REC quiz has been developed in REDCap, but a pdf example can be found in the Q.REC documents library. This quiz should be completed by all USPs at the beginning of in-person training. During study optometrist training, the study team should have learnt how to send out the USP Q.REC quiz to each USP. Email the quiz to each USP for them to complete it on their phone. Once complete, USPs receive a score out of 10 and the study team can also review their responses. Review the results of the quiz and discuss any errors with the USPs as a group. The USPs should also be given the opportunity to ask questions about the quiz, refraction techniques and the study protocol.

Baseline Refraction – data collection

The baseline refraction is essential for this study as all spectacles ordered from optical services will be compared to the baseline refraction. Each USP is to have a minimum of three subjective refractions conducted by three different optometrists/refractionists in the same setting. Here the study optometrists/refractionists should make an assessment on whether the USP continues to be suitable as being a USP. Ideally they should be easy to refract, provide consistent clear responses during subjective refraction. If they are challenging to refract, we recommend discontinuing their participation.

For each USP, the three refractions will be averaged to determine the baseline refraction. If two refractions have at least a 0.75 dioptre difference in the spherical or cylindrical power, a fourth refraction should be conducted to determine which refraction should not be included for the averaged baseline refraction. Additionally, if the lowest and highest pupillary distances (distance and near separately) recorded are greater than 2mm difference,10 repeat measurements are recommended and to be updated in Form A.

To assess and compare the three refractions (spherical and cylindrical powers, and pupillary distances only), a ‘Baseline Refraction Report’ in REDCap as an instrument is available to determine whether a fourth refraction is required.

Although the main goal of conducting baseline refractions is to obtain the spectacle prescription for each USP, it is also a training opportunity for USPs. This will be the first practical experience of how a comprehensive refraction examination is conducted after theoretical training.

It is important for the optometrists to perform the procedures and explain to the USP what they are doing at each point. While these might be more than what the optometrists perform in regular practice, this is to be as comprehensive as possible to introduce USPs to as many possibilities they might experience at optical service visits.

It is also important to complete the eye examination by discussing the USP’s vision needs to determine the spectacle lens types they would be suitable for (which might be more than one lens type). The discussion should demonstrate to the USP the level of communication appropriate for optimal patient-centred care.

At some points, and if possible, each optometrist will conduct and demonstrate different techniques to introduce USPs to the variation they might observe on their optical service visits. An example can be found in Study Optometrist Checklist 2: Baseline Refraction Procedures. It is important to consider the resources required to offer all the different options for USPs to observe, and that the optometrists are confident in conducting the techniques with less frequently used equipment.

Introducing other eye examination techniques

This session is guided by the planning exercise conducted prior to training where the study team identified all the potential eye examination techniques and equipment USPs might encounter on their optical service visits. Examples might include (and not necessarily in this order): non-contact tonometry, slit lamp examination, direct ophthalmoscopy, binocular vision testing.

Here the optometrists/refractionists will explain to them the differences in refraction equipment and techniques, and which of those they should continue to undergo to avoid detection and other tests they should refuse. Examples of what to say to avoid detection should also be provided.

USP visit Scripts

The goal of the USP visit script is to ensure the approach into every store by each USP is consistent. When entering a service, each USP will need to request an eye test. If public health services that provides other speciality eye care services are being attended, for example cataract or laser surgery, then make sure USPs only request for a test for glasses. As symptoms are often different for different refractive error profiles, suggested USP responses have been developed for each refractive error type in USP Scripts.

If the USP observes they have been detected during the optical service visit, they should do the following:

• If detected at entering and before any eye tests: Leave the service as smoothly and quickly as possible. Do not undergo any tests or order glasses. No data will be used except the acknowledgement of detection.
• If detected during the eye tests: Do not order glasses and leave the service as smoothly and quickly as possible. No data will be used except the acknowledgement of detection.
• If detected after glasses have been order: Continue to pick up glasses and request a written prescription. Only the written prescription and USP observation data will be used for analysis.
• If detected during pick up of glasses: Continue to pick up glasses and request a written prescription. All data collected, including glasses assessment, will be used in the analysis.

Data entry (REDCap training and Form C)

This session is for USPs to gain practical experience in how to access Form C: USP Optical Service Vision Checklist on their phones and have more practice with data entry. Showing the video, How to enter in Form C, is a good demonstration. The USPs can then practice entering data from accessing the public link created in the REDCap Project, ‘Q.REC Form C for Practice’. Please ensure you separate entering mock data from the real data and live project.

Quality Control (QC)

This session is to assess USPs’ readiness to conduct optical service visits and data collection. There are two options:

Option 1: External Optical Service Visits

Here each USP and the study optometrist are to visit external optical services that are not selected as part of the Q.REC study data collection. These may be services that are within walking distance from where USP training has been conducted. Please also attempt to select services where the study optometrist is not known to the staff.

The study optometrist and the USP will go to the optical service together. The USP will request for an eye examination and have a refraction. The study optometrist, if possible, would request to be present during the eye examination. The USP should complete the examination as per the external optometrist’s procedures. Here the study optometrist observes whether the USP behaviour might lead to being exposed. Examples of behaviour might include:

• Asking too many technical questions
• Asking questions that might lead the optometrist to change their regular consultation procedures.

After the examination is complete, the USP should only ask for a prescription. No spectacles should be ordered. Once the USP and study optometrist leave the service, they both should complete the checklist in Form B: USP Practice and Quality Control.

Review Form B and discuss where the visit and observations could have been improved. Following the discussion, the study optometrist should complete the bottom section of Form B.

Option 2: Internal Quality Control

Here each USP are to complete refractions with the study optometrists who have conducted training and baseline data collection within the training facilities. Here the study optometrist(s) will not explain the procedure to the USP and will follow the list of procedures outlined in the Internal Quality Control Procedures and Scenarios:

Internal Quality Control Procedures and Scenarios

In this exercise, USPs undergo refractions by study optometrists and then record their observations. These scenarios are designed to reflect a real-world scenario where aspects of refraction may vary or not occur. After the visit, the optometrists will compare the USP observations against what was actually conducted in each scenario.

Scenario 1

Scenario 2

Scenario 3

Following the refraction, the USP should request for a prescription and then complete the visit checklist in Form B: USP Practice and Quality Control.

This option is only possible if you can ensure the study optometrist(s) conducting the refractions can consistently include and exclude the procedures as outlined in Internal Quality Control Procedures and Scenarios.

This option is most efficiently completed when there are multiple refraction stations so more than one USP can be completing practice optical service visit at the same time. If the study optometrist is also conducting refraction(s), an additional observer to assess whether USPs are acting covertly should also be present. The additional observer can be another study optometrist or study coordinator or peer USP.

The USP should compare their checklist to a pre-filled “correct” form and discuss with the additional observer in areas where it can be improved. Following the discussion, the study optometrist/additional observer should complete the bottom section of Form B.

Scheduling optical service visits

The study team and USPs should work together to organise the optical service visit schedules. Some things to consider when scheduling:

• Whether all recruited USPs will be visiting all optical services or will the USPs be grouped into teams to attend some of the optical services.
• The availability of USPs (i.e. some might have part-time jobs or are studying)
• Whether USPs will be visiting optical services on weekends and availability of study optometrists.
• Days and times at which optical services might be closed
• Whether appointments need to be arranged
• Not all USPs visiting the same service visit at once or within a small timeframe to minimise risk of detection
• Include travel time required – to each service and remote locations
• For visiting services within the same city/town, we recommend a maximum of 4 service visits can be completed per day without significant fatigue experienced by the USP
• For the first couple days of data collection, consider scheduling fewer service visits in one day for USPs to become comfortable and familiar with the processes.

A document detailing all USP schedules should be kept by the study coordinator. It is important that these are followed as closely as possible so the quality of data entry can be assessed appropriately.