The Low Vision Project, initiated by Christoffel Blindenmission (CBM), started offering services in April 1994. Its main aim is to assist children with low vision and to access education through optimal use of sight. To achieve this goal the Project provides optical and non-optical low vision devices to individual children and trains teachers on how to efficiently support children through application of various methods of low vision therapy. On its inception, the Project surveyed 6 residential schools and 2 major integrated programmes for the visually impaired in Kenya sponsored by CBM whereby a total of 1083 children were screened. After the survey, the Project under took to deliver low vision services to these schools/programmes. After 5 years of operation an evaluation was conducted in May 1999. This evaluation will be subject of the following the presentation.

Introduction

The Low Vision Project Kenya was started in 1994 to support the education of visually impaired children by creating a service, which provides them with optical and non-optical devices, and teaches the efficient use of vision to the children with low vision and their teachers. The Project is supported by Christoffel Blindenmission and is based at PCEA Kikuyu Hospital - Eye Unit, a recognised Eye Hospital in East Africa which is located 20 km north west of Nairobi, the capital of Kenya. During the time of operation the Project has developed close working collaboration with the Ministry of Education, the Sight Savers International and the Kenya Society of the Blind.

After five years of operation the functions of the service have been evaluated by an Evaluation Team which consisted of one local evaluator, Mr Yalo from Maseno University College, Representatives of the Ministry of Education, Mr. Samuel Ogwang, Inspector of Schools and Mrs. Jane Ganira, Assistant Director of Education and Dr. Lea Hyvärinen (Senior Lecturer from the University of Tampere, Finland.) as an external evaluator. During its work the Team travelled with resource persons from the Low Vision Project and from Christoffel Blindenmission Regional Office East Africa to several places were low-vision work had been started.

Results of the survey conducted in 1994

The results revealed that 65% (705) of the 1083 children screened used braille as their main medium of learning, regardless of their visual abilities. Only 30% of children (333) were so severely visually impaired that they needed to use braille. 68% (741) of the children had low vision, 591 could have used print as their main medium of learning, 260 with optical low-vision devices and 331 did not require optical magnification but only 259 (24% of the 1083 children) were using print, other 327 were using braille (the learning medium of 5 was not known). As many as 15% (159) were identified not to be visually impaired although they were enrolled in these programmes, 45 of them were using braille. In total 34% of all children (327 +45 ) needed to be transferred from braille to print.

Achievements

The six Primary Schools for the Blind and two Integrated Programs supported by CBM which were subject of the evaluation in 1994 have been our main target but also 10 additional Integrated Programs and the only Secondary School for the Blind have been supported with following services:

• comprehensive assessment of individual children's vision
• optical and non-optical devices, fitting and training
• training of teachers
• follow-up of children once a year or more often
• awareness and information seminars.

Assessment and Categories

After the individual assessments that covered refraction, visual acuity at distance and near, oculomotor functions and fitting of optical and non-optical low vision devices following groups in terms of educational needs emerged: Children who could use print as their educational medium and those who need to use braille. [Diagonal divisions of the screen with print reader on the left, braille readers on the right]. The groups were further divided in educational categories:

• Category I, totally blind children, braille users
• Category II, some useful vision but not enough to read print, thus braille users
• Category III, print reading with optical devices

• Category IV, print reading with geometric magnification and other special techniques There are also children whose vision is close to normal or normal but who have not yet been able to move to regular schools - for various reasons. They are the

• Category V children with no need of special education services. These categories have been in use since 1995 and are very useful when explaining the educational needs of children with low vision in simple words. The educational needs of children in Category I are well known in Kenya. The needs of children in Category II are sometimes neglected especially when they are treated like children of Category I. However they require special training e.g. in visual stimulation, functional vision training, ADL, visual orientation and functional print if possible. Children of Category III need specific training and advice on how they can use their optical low-vision devices efficiently. Children of Category IV require special considerations while training in print. All children with low-vision (Categories II, III, IV) can benefit from non-optical devices if found useful. In Kenya these Categories have now become a standard way of describing children's educational placement and needs.

Optical and non-optical low-vision devices (exchanched the wording)

Children at the 6 schools for the blind and two integrated programmes under evaluation have received 151 spectacles for correction of refractive errors. The lenses and frames are broken quite often and some families take the glasses when the child comes home and don't give them back to the child. Sometimes the glasses must be used like monovision lenses until somebody can bring them to the optician. At the same time many children have been operated for secondary implantation of intraocular lenses and thus their glasses have become easier to manufacture locally. Many pseudophakic children have good vision in both eyes.

134 optical devices and 101 non-optical devices have been given to children attending the evaluated schools/ programmes. The optical devices are produced locally except for a few telescopes that have been provided by CBM or donated by the School of Optometry in Berlin. The non-optical devices are made by a local carpenter; e.g. the reading stands with a box for reading materials, the s.c. CBM-boxes and complete CBM-desks.

Training of Vision Support Teachers and Low Vision Therapists

The services for the visually impaired children require new personnel. We have trained two different personnel groups: Vision Support Teachers who are teachers at the Schools for the Blind or in Integrated Programs and Low Vision Therapists who are trained to do the comprehensive low vision assessments, provide optical low-vision devices and advises teachers on individual training methods.

Vision Support Teachers (VST) have been trained as two separate groups, the first one started in 1996, the second in 1997. The first group has had 3 seminars, one each year, first 15 days, then 8 days and the last seminar was 10 working days. The second group started in August 1997 and has had two seminars. During the seminars we have had lectures on anatomy, physiology, optics, special education, psychology, assessment and training methods covering both the clinical, optical, educational and functional aspects, management of Low Vision Centres, networking and referral systems. The participants use one half of the time to practise assessment techniques, first testing each other then working with visually impaired children.

The seminars have also been used to develop assessment and training materials and recording and reporting forms. The Vision Support Teachers have established small Low Vision Centres, only one room at the schools where they can do their assessments and training using their assessment kits where they have their files, some in cabinets, some still on chairs. Despite the limited resources, the Vision Support Teachers have been able to train children to use their optical devices, to do preliminary assessments of visual function and to help the classroom teachers to understand individual children's visual functioning. Out of the 50 teachers who started the training, 32 presently work as Vision Support Teachers.

Low Vision Therapists are trained for a year at the Low Vision and Squint Clinic at Kikuyu Eye Unit where the two first trainees worked together with the Co-ordinator of the Low Vision Project and the present two trainees with the Low Vision Therapists who graduated in June 1997.
The Low Vision Therapist is required to be able to assess low vision in all other aspects but retinoscopy which in the examination of our many pseudophakic infants and toddlers is a very demanding task. Results of the assessment are sent with the child to the Vision Support Teacher who continues training at the local school.

The question 'who should be trained to become a Low Vision Therapist' occupied us in the beginning and therefore we have chosen a nurse and a teacher to be trained as a pair of trainees. Both backgrounds have been found to give a good starting point for low vision work.

Networking

Since the low vision services for children in Kenya were planned for the children at school age to begin with, a close collaboration with the Ministry of Education, with the District Educational Officers, Directors of City Education and the headteachers of the schools is an essential part of the work. They have participated in the planning of the Project and we have arranged a special seminar to sensitise the District Educational Officers so that the Vision Support Teachers would get exemption from part of their classroom work, to have time for low-vision services. In most districts they now can use two days a week to work in outreach or to train children at their own school.

During the Evaluation of the Low Vision Project in May 1999, representatives of of administration expressed their deep gratitude because of the improvement in the education of children with low vision when they now can study using print as their learning media. Also most teachers have positive attitudes but there are still some sceptical voices and we found even one child who has continued to read braille - visually. More work is needed to introduce orientation and mobility, ADL and communication skills as parts of special education. Also further training is needed in all areas of the services, especially in the administration and organisation of the work at the schools.

Evaluation results

In 1994 there were 1083 children in the Primary Schools for the Blind and in the two Integrated Programs supported by CBM. Of them 68% had low vision and 24% of these children with low vision could read print although they were using braille as their main medium of learning. 15% of children had visual acuity better than 0.3 (6/18, 20/60) and most of these children study now in regular schools. Presently, after the introduction of school fees and reinforcement of integrated education, there are only 855 children in the Primary Schools for the Blind and the two Integrated Programs. Of them 539 (63%) have low vision and 404 (47%) use print as their learning media. These numbers include also the 31 (4%) Category V children who are still at the Schools for the Blind. In total 46 children still need to be introduced to print, these includes 4 children in Ct. V. These schools have thus become schools for visually impaired and some of them have also changed their name. The Low Vision Project - Kenya has helped the schools to go through a major change in their education, hundreds of children have and will be able to use their low vision effectively in learning during their formative years.