Mid Sweden University

Background: Childhood visual impairment and blindness impose substantial health, educational, social, and economic burdens on affected children and their families. An estimated 19 million children worldwide are visually impaired, of whom 1.4 million are permanently blind. This thesis aimed to generate comprehensive evidence on the epidemiology, health-seeking behavior, economic burden, and health-system barriers related to pediatric eye care in Bangladesh, and to develop an integrated framework to reduce childhood ocular morbidity and blindness.

Methods: Five complementary studies were conducted, including a population-based survey of childhood blindness, a school-based survey of refractive error, mixed-methods assessments of health-seeking behavior and economic burden, and a framework development study that combined a literature review with expert consultation. Quantitative data were analyzed using descriptive and multivariable statistical methods, and qualitative data were analyzed using thematic analysis.

Results: Study I detected 6.3 blind per 10,000 children. Of 198 detected cases, only 87 (44%) had parents who sought care; over half sought no services. Key barriers were poor knowledge, financial constraints, and taboo (Study II). Refractive error prevalence was 5.3%, predominantly myopia (78.8%); urban children were most affected (9.9%), and only 15.7% of affected children wore spectacles; secondary school girls were at higher risk (Study III). Nearly 90% of families experienced catastrophic health expenditure (CHE); median out-of-pocket costs were highest for squint (BDT 65,000) and cataract (BDT 50,000). Families bypassed local facilities due to low trust, inadequate equipment, and a lack of awareness, traveling to tertiary centers in the capital at great expense (Study IV). An integrated framework based on the WHO six building blocks was developed, emphasizing multi sectoral collaboration, task shifting, community financing, and the strengthening of health information systems (Study V).

Conclusion: Childhood blindness and ocular morbidity in Bangladesh persist due to socioeconomic inequities, limited awareness, delayed care-seeking, and health-system weaknesses. Strengthening pediatric eye care through an integrated, multisector health-system approach is essential to prevent avoidable blindness and ensure equitable access to services.