Beyond access: Duratul’s pursuit of quality refractive error care in Malaysia

 

Dr Duratul ‘Ain Binti Hussin has spent her career considering a question that goes beyond how many people receive eye examinations or spectacles: are they receiving the right care?

A public health optometrist and researcher with the Ministry of Health Malaysia, Dr Duratul is Senior Principal Assistant Director in the Allied Health Sciences Division, where she leads the Research and Development Section. Her work brings together quality improvement, research and capacity-building, with a focus on translating evidence into better services and policies.

Dr Duratul was drawn to optometry because vision shapes how people learn, work and participate in everyday life. She is particularly motivated by the potential to address vision problems, including refractive errors, through relatively simple and effective interventions. An accurately prescribed pair of spectacles, for example, can improve a person's quality of life, particularly during childhood.

Over time, her focus expanded from the care of individual patients to a broader question: “How can we make sure that everyone receives good-quality refractive error care, wherever they seek services?”

As Dr Duratul explains, “Access alone is not enough. People need access to quality care.” Receiving spectacles does not necessarily mean that the examination, prescription or spectacles are appropriate. Poor-quality care can result in inaccurate prescriptions, unnecessary spectacles, persistent visual difficulties, discomfort and reduced confidence in eye-care services. Conversely, a well-conducted examination and an appropriate prescription can support learning, productivity, independence and overall quality of life.

Malaysia has well-established public and private optometry and optical services. However, evidence on the quality of refractive error care was limited. Service data can record attendance, examinations and spectacles dispensed, but do not necessarily show whether people received appropriate care.

Dr Duratul identified a need to examine quality from the service user's perspective. As principal investigator, she initiated a research project using the Quality of Refractive Error Care (Q.REC) protocol to assess the delivery of refractive error services in real-world settings.

This protocol provides a structured approach to assessing the quality of refractive error care using unannounced standardized patients: trained individuals who visit eye-care practices as ordinary clients while following carefully designed scenarios. As practitioners are not aware that they are being assessed, the method can provide insight into how care is delivered in routine practice.

The study was conducted in the Klang Valley, including Kuala Lumpur and adjacent cities. It involved 86 practices – 41 owned by optometrists and 45 owned by opticians – and 18 trained standardized patients. As principal investigator, Dr Duratul worked with the research team and The Fred Hollows Foundation conducting the research.

Implementation required careful preparation. Standardized patients needed to understand their scenarios, behave consistently and document each encounter accurately. Dr Duratul describes the process as challenging, but also as an extremely valuable learning experience for the team.

The findings were both encouraging and instructive. Approximately 80% of the spectacles assessed met the study's adequate quality classification. However, only 31% met the stricter optimal quality indicator.

The study found a wide variation in examination procedures, and spectacles were sometimes recommended in scenarios where they may not have been needed. These findings highlighted that quality is not only about producing accurate spectacles; it also depends on appropriate clinical assessment and decision-making.

“For me, the greatest strength of this study is its ability to show the difference between what we think happens in clinical practice and what patients actually experience,” Dr Duratul says. The method enabled the team to examine each encounter in detail, down to which tests were performed, whether refraction and the final prescription were appropriate, and whether spectacles were indicated.

For Dr Duratul, the findings are a foundation for improvement rather than simply a list of deficiencies. They can inform clinical practice guidance and continuing professional development, including comprehensive assessment, accurate prescriptions for more complex cases and appropriate clinical decision-making.

At service and policy levels, this study findings can complement existing monitoring by adding information on quality and appropriateness. The evidence may help professional bodies, educators, service providers and the Ministry of Health identify areas where targeted quality-improvement initiatives could have the greatest impact.

The Malaysian experience also demonstrates how the protocol can be adapted to an established and diverse eye-care system. Dr Duratul emphasises the importance of involving practitioners, researchers, academics, professional organizations and policymakers from the outset, alongside careful training, quality assurance and cultural adaptation.

The next step is to translate the findings into action, including professional training, stronger clinical standards and continued monitoring. Dr Duratul would also like the protocol to be expanded or repeated. In her view, quality assessment should not be a one-off exercise: repeating the assessment after interventions would help determine whether care has improved.

Increasing access remains essential, but access and quality must progress together.

“A pair of spectacles may look like a simple intervention, but its impact depends on the quality of care behind it,” she says. “The goal is not simply more examinations or more spectacles, but the right examination, the right clinical decision and the right correction for each person's visual needs.”

 

This story was developed by The Fred Hollows Foundation, a member of the Global SPECS Network, in collaboration with the WHO Vision and Eye Care Programme.  

Photo credits: Mumtaz Sarwady, Irfan Irsyad and Muhammad Abir / The Fred Hollows Foundation.