From early childhood, adequate vision is essential for children's cognitive, social, and educational development, enabling participation in both formal and informal learning environments.^(1,2) According to the World Health Organization (WHO), at the launch of the VISION 2020 initiative, approximately 19 million children younger than 15 years were living with visual impairment, including 1.4 million with irreversible blindness. Nearly half of these cases were considered preventable, with refractive errors and amblyopia representing the leading causes.^(2-6)

A global systematic review and meta-analysis on the prevalence of amblyopia estimated that approximately 99.2 million individuals were affected worldwide in 2019, with projections suggesting an increase to 221 million by 2040.⁽⁷⁾ Studies have also shown that the prevalence of amblyopia in Latino children may be higher than that in children from other ethnic groups.^(8,9) In a multiethnic study, amblyopia was detected in 2.6% of Hispanic/Latino children and 1.5% of African American children aged 30-72 months.⁽¹⁰⁾ Several factors may contribute to the higher prevalence observed in these populations, including limited access to eye care services, underutilization of available services, insufficient public eye health policies, socioeconomic barriers, limited family support, reduced awareness of the importance of early detection, and shortages of trained professionals.^(1-4)

Visual screening in children is performed to identify reduced visual acuity and risk factors that may impair visual development.⁽¹⁰⁾ In this context, community settings such as daycare centers, preschools, schools, and community health groups provide valuable opportunities for screening programs aimed at detecting visual impairment and other ocular abnormalities. These screenings may be conducted by healthcare professionals, education professionals, or trained laypersons. Previous studies have demonstrated that appropriately trained non-ophthalmologists can perform visual screening with acceptable accuracy.^(11-13)

In Brazil, despite public visual screening policies implemented through the Brazilian Public Health System (SUS - Sistema Único de Saúde) since the last century,^(14-18) school-based eye health programs remain limited.⁽¹⁹⁾ One major challenge is the lack of standardized training programs for education professionals responsible for implementing visual screening in schools. To date, no unified national training program has been developed to reach remote regions or to provide comprehensive eye health screening beyond visual acuity assessment alone.⁽¹⁰⁾ Furthermore, most existing programs in Brazil have focused primarily on children older than 6 years.⁽²⁰⁾

In this context, the present research aimed to develop a distance education program to train education professionals to implement an eye health program for children aged 2-5 years, incorporating current evidence and extending beyond visual acuity assessment alone. Distance learning enables educational content to be delivered through digital platforms, which expanded significantly during the COVID-19 pandemic.^(21,22)

Additionally, a recent cluster-randomized controlled trial of school-based vision screening highlighted the importance of continued vision care and access to corrective eyewear, particularly for children from socioeconomically disadvantaged backgrounds. The study also emphasized the need for further intervention studies evaluating screening strategies.⁽²³⁾

The proposed virtual training program is intended to facilitate earlier referral of children with suspected visual disorders while improving screening quality and scalability. This approach may support broader implementation across diverse settings and contribute to the development of a standardized, evidence-based eye health program.⁽²⁴⁾

We aimed to evaluate a virtual training protocol for education professionals designed to improve knowledge and skills related to pediatric eye care. The program was developed to train participants in performing visual acuity screening in children aged 2-5 years and assess the effectiveness of the intervention. The training content and assessment instruments were based on clinical guidelines and were intended to support the implementation of protocols for monitoring visual development disorders in preschool- and school-aged children.

This prospective longitudinal interventional study included 42 early childhood education professionals from a daycare center affiliated with the São Paulo municipal government, the Aglaezinha Early Childhood Education Center, operated by the non-governmental organization Associação Ponto de Luz.

All study procedures were conducted in accordance with the Declaration of Helsinki and approved by the Research Ethics Committee of the Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil (CAAE: 78717324.0.0000.0068; #6.823.601). Written informed consent was obtained from all participants prior to study participation. Eligible participants were selected according to predefined inclusion and exclusion criteria.

The inclusion criteria were: employment as an early childhood education professional at the Ponto de Luz daycare center, which provides care for children aged 2-5 years; availability and willingness to participate in the training program and visual screening activities; recommendation by the institutional coordinator or voluntary enrollment; and provision of written informed consent.

The research team developed educational videos focused on pediatric eye health to train education professionals working with children aged 2-5 years.

The video content emphasized the importance of ophthalmologic screening in early childhood and was designed to support participants in conducting visual screening assessments, recognizing common eye disorders, identifying warning signs, and referring children requiring further evaluation.

The educational materials were developed in a concise and accessible format and covered the following topics: basic eye anatomy; the importance of visual screening in early childhood; recommended school-based eye health screening practices for this age group; recognition of warning signs suggestive of visual disorders; and visual acuity assessment.

The videos were made available free of charge through a secure virtual platform compliant with the Brazilian General Data Protection Law. Participants were able to access the material at any time and from any location over a 1-month period.

Education professionals completed online questionnaires before and after exposure to the educational videos to assess changes in knowledge related to pediatric eye health issues and visual screening procedures (Table 1). Additionally, participants completed a pre-training questionnaire regarding their perceptions of virtual learning, satisfaction, and expectations related to the educational content.

A synchronous virtual meeting between the research team and the education professionals was also conducted through an online platform to clarify questions, provide additional guidance, and collect participant feedback and suggestions.

The study included 42 education professionals, all of whom were women, with a mean age of 43 years. Most participants held a higher education degree (95.2%), and the majority were teachers (78.6%). All participants completed the training program and both the pre- and post-training questionnaires. None of the participants had previously participated in similar training programs (100%) (Table 2).

Table 3 demonstrates the impact of the training program on the knowledge and skills of education professionals regarding visual screening in children. Before training, many participants reported limited knowledge of common pediatric eye disorders, the importance of vision screening, and conditions such as myopia, hyperopia, and astigmatism. Following the intervention, the proportion of participants who reported knowing how to perform and explain visual acuity testing using the LEA Symbols chart increased from 4.8% to 47.6% (p<0.001). Similar improvements were observed in participants’ ability to recognize common visual disorders and manage situations involving children who already wore corrective glasses.

Table 4 presents the scoring system used to quantify participants’ knowledge and confidence before and after the ophthalmologic training program. Responses were scored as 0 for "No," 1 for "A little," and 2 for "Yes," with higher scores indicating greater knowledge or confidence. Four domain-specific scores were calculated: knowledge of eye disorders (0-22 points), knowledge of the use of the LEA Symbols chart (0-10 points), ability to identify ocular abnormalities (0-10 points), and confidence in explaining identified eye abnormalities (0-4 points). The total score ranged from 0 to 46 points and was calculated as the sum of all domain scores.

Table 5 presents the comparison of pre- and post-training scores among education professionals, reflecting changes in knowledge and skills following the intervention. Prior to training, participants demonstrated limited knowledge and practical ability in using the LEA Symbols chart and identifying common eye conditions. After the training, there was a substantial improvement across all assessed domains, with significantly higher scores in knowledge, practical skills, and confidence. In addition to improved knowledge and skills, participants reported increased confidence in performing visual screening and communicating findings to both children and their guardians.

Table 6 summarizes participants’ feedback regarding the training program. Overall, 97.7% of participants reported an improvement in their visual screening knowledge, while 100% reported enhanced understanding of eye health in school settings and improved ability to recognize warning signs of visual disorders.

Regarding the effectiveness of the distance learning approach, 86.0% of participants considered it suitable for delivering early childhood vision screening training, while 100% agreed that it was effective for improving understanding of eye conditions and recognition of warning signs. Overall, the training program received high satisfaction ratings, with mean scores ranging from 4.3 to 4.6 out of 5.

All teachers should be educated about the role of vision in learning.⁽²⁵⁾ This information can be delivered through structured teacher training and continuing education programs. To the best of our knowledge, this is the first study to evaluate the effectiveness of video-based training materials developed by our research group for educating school professionals in pediatric visual screening. We observed a statistically significant improvement across all knowledge domains assessed in our questionnaire following the remote training intervention.

Health promotion aims to improve population health outcomes by empowering communities and creating supportive environments for health. In this context, strengthening the capacity of individuals who are in close contact with potential patients is a key component of effective health promotion strategies. In the present study, most participants were teachers (78.6%), reflecting their close and continuous contact with school-aged children. However, previous studies have shown that teachers often do not associate symptoms suggestive of visual impairment with underlying ocular pathology.⁽²⁶⁾ In contrast, evidence also indicates that, with appropriate in-person training, teachers can effectively perform visual acuity assessments, achieving performance comparable to that of eye care professionals.⁽²⁷⁾

None of the participants had previously received training in eye health awareness, and they lacked the knowledge and tools required to recognize early signs of visual impairment. This gap in awareness may negatively affect children's learning and overall development. Despite efforts by the Brazilian public health system to implement vision screening programs in public schools, the integration of eye health education into teacher training curricula remains limited. This underscores the need for comprehensive initiatives to educate teachers and strengthen early detection and intervention for visual disorders in Brazilian classrooms.^(28,29)

Distance learning has the potential to substantially improve access to training, particularly in low-income settings and regions with limited resources.⁽³⁰⁾ By delivering educational content through remote platforms, knowledge can be disseminated without requiring professionals to travel physically to schools, which may be impractical at scale. Furthermore, with appropriate training, teachers may be able to identify visual problems more accurately, potentially reducing unnecessary referrals and avoiding additional burden on healthcare systems.⁽³¹⁾

In our study, more than 90% of participants considered distance learning effective across all assessed domains, with the exception of early childhood visual screening, which received an approval rate of 86%. The slightly lower approval in this domain may be related to the requirement for more hands-on application of screening procedures using tools that were initially unfamiliar to educators. However, overall acceptance of the distance learning approach was high. This finding is particularly relevant, as distance learning may help reduce educational disparities in underserved communities by improving access to training materials and standardizing knowledge delivery across settings.

This study has some methodological limitations that should be considered when interpreting the findings. The absence of a control group limits the ability to attribute observed improvements solely to the training intervention, as no comparison was made with untrained participants. Additionally, the use of convenience sampling from a single center may restrict the generalizability of the results to other educational settings or populations. The outcomes were based on self-reported measures of knowledge and confidence, which may be subject to social desirability bias. Furthermore, the study did not include long-term follow-up, limiting the assessment of knowledge retention over time. Clinical and practical outcomes, such as the impact of training on the identification or referral of children with visual impairments, were also not evaluated. Although the study was not designed to compare the video-based training with alternative instructional methods, these limitations should be considered when interpreting the results.

This study demonstrated that a remote training program significantly improved the knowledge, skills, and confidence of education professionals in conducting visual screening for children aged 2-5 years. The training enhanced participants’ understanding of common ocular conditions, including amblyopia, myopia, hyperopia, and astigmatism, and increased their confidence in performing and explaining visual acuity testing using the LEA Symbols chart. By strengthening educators’ competencies in visual screening, the broader implementation of such programs may improve the identification of children requiring referral for further ophthalmologic evaluation. However, the direct impact on clinical outcomes was not assessed in this study.

The results indicate that well-structured remote education can be an effective and feasible approach for training non-ophthalmic professionals in eye health screening, particularly in regions with limited access to specialized care. Its high acceptability supports the scalability of this distance learning approach and its potential to reduce disparities in training access across different settings.

Given the increasing burden of visual impairment, especially in underserved populations, wider implementation of such programs may contribute to more timely referrals and earlier detection of visual problems, thereby reducing the risk of avoidable developmental consequences. Future studies should evaluate the scalability of this training model and its integration into broader educational and public health systems, as well as its impact on real-world clinical outcomes.