An-Najah National University Faculty of Graduate Studies ASSESSMENT OF OPTOMETRY SERVICES IN THE NORTHERN DISTRICTS OF THE WEST BANK - PALESTINE By Enas Faysal Dawwas Abu Awwad Supervisor Dr-Amira Shaheen Dr- Raya Sawalha This Thesis is Submitted in Partial Fulfillment of the Requirements for the Degree of Master of Public Health Management, Faculty of Graduate Studies, An-Najah National University, Nablus-Palestine. 2022 ii ASSESSMENT OF OPTOMETRY SERVICES IN THE NORTHERN DISTRICTS OF THE WEST BANK - PALESTINE By Enas Faysal Dawwas Abu Awwad This Thesis was Defended Successfully on 08/12/2022 and approved by Dr. Amira Shaheen Supervisor Signature Dr. Raya Sawalha Co-Supervisor Signature Prof. Motasem Hmdan External Examiner Signature Dr. Abdslam Khayyat Internal Examiner Signature iii Dedication I dedicate this research to my father Faysal Dawwas, mother, brothers, and sister. To my husband Ghassan Sabbagh, and my daughters Orjwan, Yasmine, and Kinda. To my family, friends, teachers, and everyone who wished me well. iv Acknowledgment Praise is to Allah, who helped me to complete this research, and made use of all means of assistance and facilitation. Many thanks to the supervisors, Dr. Amira Shaheen and Dr. Raya Sawalha, in addition to the external examiner Dr. Motasem Hamdan, and the internal examiner Dr. Abdulsalam Khayat. I also extend my gratitude to Dr. Nasr Abu Khader, He was a great support for me. I thank my colleagues for the study trip; it was a beautiful period and happy memories that will remain in my memory forever. My professors at the university, thank you very much for all the effort you made for us. My husband, my family, and my in-laws, I cannot thank you enough. You were a real supporter of mine during my study period. I thank you all. v Declaration I, the undersigned, declare that I submitted the thesis entitled: ASSESSMENT OF OPTOMETRY SERVICES IN THE NORTHERN DISTRICTS OF THE WEST BANK - PALESTINE I declare that the work provided in this thesis, unless otherwise referenced, is the researcher’s own work, and has not been submitted elsewhere for any other degree or qualification. vi Table of Contents Dedication ........................................................................................................................ iii Acknowledgment ............................................................................................................. iv Declaration ........................................................................................................................ v Table of Contents ............................................................................................................. vi List of Tables ................................................................................................................... ix List of Figures ................................................................................................................... x List of Appendices ........................................................................................................... xi Abstract ........................................................................................................................... xii Chapter One: Introduction and Theoretical Background .................................................. 1 1.1 Background ................................................................................................................. 1 1.1.1 The scope of optometry worldwide: ........................................................................ 2 1.1.2 Primary eye care and role of optometry ................................................................... 4 1.1.3 Optometry in Palestine ............................................................................................. 5 1.1.4 Problem statement .................................................................................................. 10 1.1.5 Study aim ............................................................................................................... 10 1.1.6 Study Objectives .................................................................................................... 10 1.1.7 Study hypothesis .................................................................................................... 11 1.1.8 Study Significance ................................................................................................. 11 1.2 Literature Review ..................................................................................................... 12 1.2.1 International studies ............................................................................................... 12 1.2.2 Regional studies ..................................................................................................... 17 1.2.3 Local studies .......................................................................................................... 19 1.2.4 Systematic review .................................................................................................. 20 Chapter Two: Methods .................................................................................................... 21 2.1 Study design .............................................................................................................. 21 2.2 Study population ....................................................................................................... 21 2.3 Sample size and sampling method ............................................................................ 21 2.3.1 Inclusion criteria .................................................................................................... 21 2.3.2 Exclusion criteria: .................................................................................................. 22 2.4 Data collection procedures ........................................................................................ 22 2.5 Data analysis ............................................................................................................. 22 2.6 Ethical approval ........................................................................................................ 23 Chapter Three: Results .................................................................................................... 24 vii 3.1 Descriptive analysis .................................................................................................. 24 3.1.1 Sociodemographic information: ............................................................................ 24 3.1.2 Optometrists per 50,000 population ....................................................................... 26 3.1.3 The available optometry services .......................................................................... 27 3.1.4 The available optometry instruments ..................................................................... 28 3.1.5 The frequency of performing optometry services by optometrists ........................ 28 3.1.6 Barriers faced by optometrists ............................................................................... 30 3.2 Bivariate analysis ...................................................................................................... 30 3.2.1 The distribution of available services in different workplaces .............................. 30 3.2.2 The distribution of available services in different districts .................................... 31 3.2.3 The relationship between frequency of performing services and gender .............. 33 3.2.4 The relationship between the frequency of performing optometry services and the qualifications ......................................................................................................... 33 3.2.5 The relationship between the frequency of performing optometry services and the workplace type ...................................................................................................... 33 3.2.6 The relationship between barriers and gender ....................................................... 33 3.2.7 The relationship between barriers and qualification .............................................. 34 3.2.8 The relationship between barriers and type of workplace ..................................... 35 3.2.9 The relationship between barriers and districts ..................................................... 35 3.3 The optometrists’ recommendations ......................................................................... 36 Chapter Four: Discussions and Conclusions ................................................................... 37 4.1 Discussion ................................................................................................................. 37 4.1.1 Sociodemographic information .............................................................................. 37 4.1.2 Optometrists to population ratio ............................................................................ 37 4.1.3 The availability of optometry services ................................................................... 38 4.1.4 The availability of optometry instruments ............................................................. 38 4.1.5 The frequency of providing optometry services by optometrists .......................... 39 4.1.6 Barriers faced by optometrists ............................................................................... 42 4.1.7 The relationship between services and the workplace ........................................... 46 4.1.8 The relationship between services and districts ..................................................... 46 4.1.9 The relationship between the frequency of performing optometry services by optometrists and the gender ................................................................................... 47 4.1.10 The relationship between the frequency of performing optometry services by optometrists and the qualification ......................................................................... 47 4.1.11 The relationship between barriers and gender ..................................................... 48 4.1.12 The relationship between barriers and the qualification ...................................... 48 viii 4.1.13 The relationship between barriers and workplaces .............................................. 48 4.2 Recommendation ...................................................................................................... 49 4.3 Strengths of study ..................................................................................................... 50 4.4 Study limitations ....................................................................................................... 50 4.5 Conclusion ................................................................................................................ 51 List of Abbreviations ...................................................................................................... 52 References ....................................................................................................................... 53 Appendices ...................................................................................................................... 59 @ABCDب ............................................................................................................................... ا ix List of Tables Table 1: Socio-demographic indicators of the participants ............................................ 25 Table 2: Optometrists per 50000 population .................................................................. 26 Table 3: Frequencies of the optometry services available in the centers and workplaces in the Northern Districts of West Bank (n= 94) ............................................... 27 Table 4: Frequencies for optometric instruments available in the centers and workplaces in the Northern Districts of West Bank (n= 94) ............................................... 28 Table 5: Frequencies and percentages for the optometry services provided by the optometrists in the Northern Districts of West Bank (n= 94) ........................... 29 Table 6: Barriers faced by optometrists in providing services in the centers and workplaces in the Northern Districts of the West Bank (n= 94). ..................... 30 Table 7: The cross-tabulation between services and workplace type ............................. 31 Table 8: The cross-tabulation between available services and districts. ........................ 32 Table 9: The cross-tabulation between the frequency of performing optometry services and gender ......................................................................................................... 87 Table 10: The cross-tabulation between optometry services and qualification .............. 89 Table 11: The cross-tabulation between performing optometry services and type of workplace .......................................................................................................... 91 Table 12: The cross-tabulation between barriers and gender ......................................... 34 Table 13: The cross-tabulation between barriers and qualification ................................ 35 Table 14: The cross-tabulation between barriers and type of workplace ....................... 93 Table 15: The cross-tabulation between barriers and districts ....................................... 94 Table 16: Participants (optometrists) recommendations ................................................ 95 x List of Figures Figure1: The distribution of optometrists and optometry services workplaces in the Northern Districts of the West Bank. ............................................................... 26 xi List of Appendices Appendix A: Examinations and instruments definition .................................................. 59 Appendix B: Literature review summarization .............................................................. 64 Appendix C: The questionnaire in Arabic ...................................................................... 72 Appendix D: The questionnaire in English ..................................................................... 76 Appendix E: The Graduate studies faculty approval of the thesis title and supervisor .. 80 Appendix F: IRB Approval letter ................................................................................... 81 Appendix G: Facilitation request .................................................................................... 82 Appendix H: The study explanation in English .............................................................. 83 Appendix I: The study explanation in Arabic ................................................................. 84 Appendix J: Consent form in English ............................................................................. 85 Appendix K: Consent form in Arabic ............................................................................. 86 Appendix L: Tables ........................................................................................................ 87 xii ASSESSMENT OF OPTOMETRY SERVICES IN THE NORTHERN DISTRICTS OF THE WEST BANK - PALESTINE By Enas Faysal Dawwas Abu Awwad Supervisor Dr-Amira Shaheen Dr- Raya Sawalha Abstract Introduction: optometry is the profession that provided vision and eye examinations and eye care services by optometrists, in addition to the role of providing awareness and eye health guidance. This study aimed to assess the optometry services provided in the Northern Districts of the West Bank (Jenin, Tubas, Nablus, Tulkarm, Qalailyah, and Salfit). Method: a descriptive cross-sectional study, was conducted between November and December 2021, selecting the target group consisting of all optometrists holding a diploma or higher who provide optometry services in the Northern Districts of the West Bank. The participants were 94 optometrists who answered a questionnaire prepared from three previous studies and filled out by the researcher in face-to-face interviews. Results: (72.2%) of optometrists were females, (85.2%) of them had a bachelor's degree or higher, while the private sector provided (97.9%) of optometry services. Optometry services such as subjective refraction, contact lens fitting, and spectacles dispensing were the most provided. However, differences in services provided according to workplace and optometrists' qualifications were found. (14.8%) of optometrists in private optometry, centers provided cycloplegic refraction while (84.6%) of optometrists in hospitals. Furthermore, only (7.7%) of diploma holders and (26.3%) of BSc used diagnostic drugs. Insufficient continuing training was the first barrier faced by optometrists (93.6%), and it had significant associations with gender and qualification. While the economic and political problems barrier was a barrier for optometrists working in private optometry centers (93.8%) and those in other workplaces (38.5%). Optometrists recommended expanding the scope of optometry practice in Palestine and letting optometrists provide vision services in primary health care centers of PMOH. xiii Conclusion: Optometrists in Palestine practice the technology services category and visual function services category in the Model of Scope of Practice in Optometry by the WCO, in absence of ocular diagnostic and ocular therapeutic services categories. That requires expanding optometry scope of practice according to the quality of optometry education in Palestine, in addition to developing continuous training programs to deal with the insufficient training as a barrier faced by optometrists and prevent them from improving their skills. Keywords: Eye care services; Optometrist; Optometry; Palestine; Scope. 1 Chapter One Introduction and Theoretical Background 1.1 Background Following the increasing number of vision loss and visual impairment cases worldwide, (1 billion) people in the world in 2020 had distance vision impairment or blindness, (2.8 million) blindness cases, and (101 million) moderate to severe vision impairments were due to uncorrected refractive errors, and (826 million) people had near vision impairment due to presbyopia (Bourne et al., 2021). These significant numbers about the prevalence of visual problems show the huge need for primary eye care services that optometrists provide around the world (WHO). In recent years, optometry has become an important profession in our country, especially since optometry has become more prominent among other professions in the world in terms of interest in raising the level of academic education for specialists and practical efficiency through continuous training, in addition to interest in providing optics and eye health services in high- quality and equity and facilitating access to them. While the expansion of private sector roles and self-employed private practitioners in the provision of optometry services led to an increase in employment rates, it also led to the introduction of optometry, which increased the competition in the optical sector and brought the quality of services issue to the forefront. According to a survey conducted between July 2018 and April 2019, about 130,000 Palestinians who are 50 years old and more complained of avoidable blindness and visual impairments. This survey showed the most common causes of blindness and visual impairments in Palestine were Diabetic Retinopathy and Cataracts (St John Eye Hospital Group, The Fred Hollows Foundation, 2020). To encourage the profession of optometry, many countries have made structural and legal arrangements for education, training, scope, and private sector interventions. However, due to the direct impact of the economic and cultural structures of the countries on the profession of optometry, each country has developed in different dimensions. The problems encountered in the profession of optometry have been newly identified and solutions have begun to be produced both in public and non- governmental organizations (Ecoo, 2020). 2 According to the World Council of Optometry (WCO), optometry is the work of the graduates of the optometry college, which provides the optical equipment designed for the correction and elimination of vision disorders and has been trained at a level that can ensure its application to the patient, with the title of the optometrist. An optometrist can prepare and apply optical instruments (glasses, contact lenses, etc.) used to eliminate or alleviate vision disorders according to a patient's prescriptions diagnosed by an optometrist or ophthalmologist (WCO, 2022.) An optometrist who has at least 4 years of university education in optometry sciences, can perform full eye examination, refractive tests and fit spectacles and contact lenses, perform low-vision tests and fit low-vision appliances, in some cases optometrist can detect ocular pathology, monitor cataract, and glaucoma cases, in addition, to applying diagnostic tests and imaging like perimetry, optical coherence tomography (OCT), corneal topography, fundus fluorescein angiography (FFA), and in special cases Tonometry. In such cases optometry refers the patient to the ophthalmologist or eye hospital, Optician can fit corrective spectacles according to the prescription of the optometrist or ophthalmologist. Some opticians with more education can perform refraction and fit corrective spectacles, which may be called refracting opticians (Ecoo, 2020). 1.1.1 The scope of optometry worldwide: The scope of optometry differs from one country to another. To identify the comparison in the scopes of optometry, the WCO produced “a Global Competency-Based Model of Scope of Practice in Optometry” (WCO, 2022). The model consists of four categories, the first is related to the optician, the second category, third, and four are related to the optometrist. The first category called optical technology services is concerned with optical instruments that have been described to improve vision, optical glasses, spectacles dispensing, and low-vision appliances dispensing (WCO, 2022). The second category called visual function services, it contains the first category plus visual examinations, refraction, and contact lens fitting (WCO, 2022). 3 The third category is called ocular diagnostic services, it contains the first and second categories plus the ability to perform eye examinations for ocular pathology, diagnose ocular diseases and use diagnostic drugs (WCO, 2022). The fourth category called ocular therapeutic services contains the first, second, and third categories plus the ability to use pharmaceutical agents and prescribe therapeutic drugs to manage ocular diseases and injuries (WCO, 2022). In Europe, the WCO competency model is adopted, but differences in categories adaptation are found. Some countries apply the first category only such as France and Turkey; others apply first and second for example Italy, Greece, Belgium, and Poland. Countries that apply the third category are Spain, Germany, Switzerland, and some others. The only European country that applies the fourth category is the United Kingdom (Ecoo, 2020). Some countries like the United Kingdom and Canada permit all vision primary care tests. In these countries, the optometrist can sell optical appliances, perform subjective and Cycloplegic refraction for adults and children, prescribe spectacles and dispensing, prescribe contact lenses and fitting, perform binocular vision tests and orthoptics, examine the interior and exterior eye, do ophthalmoscopy, tonometry, perimetry, test low-vision patients and prescribe low-vision aids, detect ocular pathology, use diagnostic and therapeutic drugs, deal with pre and post evaluation of refractive surgery, and refer cases to ophthalmologist and eye hospital ((Ecoo, 2020; Ontario, 2021). In Sweden and Switzerland, all of the previously mentioned services are permitted except prescribing therapeutic drugs is prohibited (Ecoo, 2020). Although in India, Singapore, and Australia the prescription of medication by optometrists is prohibited (De Souza et al., 2012; Ecoo, 2020; George et al., 2019) optometrists practice it. In addition to medication prescription prohibition by optometrists in Australia, orthoptics, and detecting ocular pathology, using diagnostic drugs is also prohibited. In Turkey only selling optical appliances and spectacles dispensing are permitted for optometrists. In Poland and Serbia, all previously mentioned optometric services are prohibited, but optometrists practice them under prohibition (Ecoo, 2020). 4 The optometrists to population ratio The World Health Organization in vision 2020 recommended the optometrists to population ratio to be 1 optometrist for 50,000 population in developing countries, and I optometrists for 10,000 population in developed countries (Naidoo et al., 2022). The optometrist to population ratio is different around the world, in Central Europ the ratio is (1: 18374), Eastern Europe (1: 55975), Hig income in North America (1:8679), Central Sub-Saharan Africa (1: 1198141), East Asia (1: 34704), high income Asia Pacific (1: 3889), and North Africa and the Middle East (1: 31438) (Naidoo et al., 2022). 1.1.2 Primary eye care and role of optometry Optometry is the point where the patient enters the visual health care system. All optometrists are primary care optometrists, they provide examinations of visual health, the only exceptions are specialized optometrists like pediatric optometrists, and low- vision optometrists who receive referrals from other optometrists (Grosvenor, 2007). Optometrists are preventing visual impairments and blindness; also they are providing optometry services to eliminate ocular morbidity (Murthy & Raman, 2009)primary eye care services are as follows (Murthy & Raman, 2009): 1. Ocular health knowledge promotion. 2. Visual acuity examinations. 3. Visual refraction examination. 4. Vision screening to detect asymptomatic ocular anomalies, such as cataracts, glaucoma, and diabetic retinopathy for patients with non-communicable diseases. Refraction for preschool children and aging people. Retinopathy of prematurity for premature infants. 5. Diagnosing of ocular diseases. 6. Referral cases are timely for more investigations. Ocular Examinations and Related Instruments To diagnose the disease, some tests and equipment are needed to find out the appropriate treatment. The eye examination begins with the patient’s medical and visual history, visual acuity test, ocular motility and binocular vision tests, color vision tests, screening of visual field, tonometry examination, and external and internal eye 5 examinations. These examinations require equipment, which may be small pieces like a record sheet, pen torch, and visual acuity near chart or maybe big like slit-lamp biomicroscopy (Grosvenor, 2007) see Appendix (A). 1.1.3 Optometry in Palestine In Palestine, the optometry profession was regulated by the Ministry of Health only until the foundation of the Palestinian Council of Optometry (PCO) in 2005. The optometry profession became better organized due to this cooperation. Optometry Council and MOH developed regulations for optometry practice, and practice certificates for different qualifications, in addition to the conditions for starting new optometry works, also improve the supervision and monitoring of optometry practice in different workplaces that provide optometry services. Furthermore, Optometrists become to have a platform for caring for their issues. Besides holding conferences and lectures that include Palestinian and international optometrists, which increases knowledge and science in the field of optometry and the exchange of experiences. In the past, optometrists inherited the profession from their fathers and grandfathers, until the profession became confined to a few families in Palestine, and they practiced the profession through the experience without formal education and training. However, with the progress years and the development of science, several optometrists were able to obtain a diploma in optics from different countries around the world such as Germany, Britain, and Jordan. The first optical center was in Nablus in 1964 by Mr. Abdallah Tuffaha Senior (PCO, 2021.) Three universities offer a bachelor’s degree in optometry in Palestine, the Islamic University in Gaza, An-Najah National University in Palestine, and the Arab American University in Ramallah. These universities aim to graduate qualified practitioners to work as professional optometrists to achieve the highest level of visual practice and health care to give the correct and appropriate solution and treatment to various visual problems, including getting rid of the causes of preventable vision loss in the occupied Palestinian territories. Optometrists in decision-making positions can emerge science, translate public policy directives to improve patient eye care and work to use knowledge bases and clinical skills to improve models of care delivery and provide academic advancement for optometry in Palestine (AAUP, 2022; IUGaza, 2022; NNU, 2022). 6 The Palestinian optometric scope of practice allows optometrists to practice either in private practice, ophthalmology clinics and hospitals, or in retail optical settings. Some graduating optometrists become involved in specialty practices such as contact lenses, low-vision, pediatrics, and vision therapy (NNU, 2022). Optometrists who graduate from Palestinian universities can provide primary health care for the eye, conducting various eye exams for refractive errors, fitting corrective spectacles, fitting contact lenses, performing binocular vision examinations, testing low- vision cases, and fitting low-vision appliances, conducting retinal and corneal examinations and dealing with imaging devices (IUGaza, 2022; NNU, 2022). Palestinian optometrists have many job opportunities, they can engage in education and academic field, work in the government health sector, Non- Governmental Organizations (NGOs) for eye health, private eye hospitals, eye rehabilitation centers, and private optometry centers (PCO, 2021). In Palestine, a vision test service is provided to drivers in primary care centers of the Palestinian Ministry of Health, where the service is provided by a nurse, not an optometrist (PMOH, 2022). The examination is based only on the Visual Acuity, and the applicant is transferred for the extensive examination to an optometrist or an ophthalmologist to perform an eye examination and eyeglasses, and then return the Visual Acuity. However, in other countries around the world, all necessary examinations are performed by an optometrist, whereas a driving license requires comprehensive eye examinations, refraction tests, retinoscopy, perimetry, tonometry, ophthalmoscopy, and slit-lamp (Depisteo, 2018). Vision screening programs had been designed as a very effective tool for vision problems early detection, and treatment in the critical period from birth to 8 years, it was developed in the world vision right to sight for the control of preventable blindness (Gilbert & Foster, 2001). Vision screening is recommended to be undertaken at birth, age 3-6 months, and 4 years of age (APHA, 2001). However in Palestine, visual assessment is applied just in schools, the protocol targets in Palestine are first, fifth, and eighth grade (PMOH, 2022), while the effective treatment for visual disorders in children began before 5 years of age (APHA, 2001). 7 In a study that was conducted among preschool children aged (3-5) years, in Nablus city in Palestine, 473 children were examined, 127 needed comprehensive eye examinations, 15 had amblyopia, 166 had refractive errors, and 44 had binocular vision disorders (Labadi et al., 2022). The study emphasized the need to make amendments to the policy and protocol for the compulsory vision examination for children, so that it becomes at the age of 3 years, and to add more accurate examinations because studies have confirmed that amblyopia can be treated at this age. The delay in diagnosis makes treatment more difficult and not effective (Labadi et al., 2022). In Palestine according to the Health Annual Report 2021, among children who were examined in primary healthcare clinics were 54851, about (0.04%) had a visual disability (PMOH, 2022). According to the study of (Akkawi et al., 2018) which was conducted in hospitals with neonatal intensive care units (NICU), (95.7%) of pediatricians in the study refer the neonate for ROP screening. The referring methods are either writing discharge slips or consulting parents verbally. While the reasons for not screening ROP were (37.1%) unavailability of an ophthalmologist in the hospital with NICU, and (26%) the doctor who write the discharge not writing a referral for ROP screening (Akkawi et al., 2018). However, in the retrospective study conducted by (Akkawi et al., 2019) in three neonatal intensive care units in Palestine, 115 children were screened. This is the first study that deals with the ROP epidemiologically. The incidence of Retinopathy Of Prematurity (ROP) was (23%), and the ROP type 1 which needs treatment was (11%). The researchers recommended for clinicians who deal with premature infants to aware of the statistically significant risk factors of ROP, in addition to the requirement for comprehensive studies of ROP, and set up the ROP National Guideline (Akkawi et al., 2019). School health is a cooperation between the Palestinian Ministry of Health, and the Ministry of Education. School health provides optometry tests as one of its services. It is concerned with examining the vision for school students. The service is provided by a nurse, and the examination is based on visual acuity only. If the child does not see the 20/20 line, the parents will be recommended to present the child to an optometrist or ophthalmologist for further examinations. But a very small percentage of parents pay attention to these recommendations and follow up on children's vision examinations. In the education year, 2019/2020, (34,838) students in the first grade were observed 8 (71.1%) of the total students. (11%) of students were diagnosed or decreased visual acuity (PMOH, 2021). While in the 2020/2021 year, the number of students in 5th grade who were examined was 20038, and the number of students who had visual impairments was 2563 (12.8%). In the 8th grade, 22726 students were examined, and 3397 (14.9%) of examined students were diagnosed with visual impairments (PMOH, 2022). The scope of optometry in Palestine The categories of optometry practice in Palestine according to the WCO Competency Model are the first category (optical technology services) and the second category (visual function services) (PCO, 2021). The role of optometrists has been determined in cooperation between the Optometry council and the accreditation and Licensing Department in the Palestinian Ministry of Health (PCO, 2021). 1. The scope of optometry according to the practice setting Services provided in Palestine were divided into two types, optometry services had allowed in hospitals and ophthalmologist clinics, and are not allowed in optical centers. Where optometry services that are allowed in optical centers, according to the scope of optometry in Palestine, could be provided by optometrists in optical centers, and no need for an ophthalmologist referral, cannot be provided without the supervision of an ophthalmologist, not necessarily provided in Hospitals, and no need for optometry specialty. contained; subjective refraction, soft contact lens fitting, hard contact lens fitting, selling optical appliances, selling contact lenses, corneal topography, anterior eye examinations, and binocular vision tests. while optometry services that need to provide either in hospitals or surgical centers, with the supervision of ophthalmologists, or need optometry specialties are not allowed in optical centers, like Cycloplegic refraction, orthoptics, low-vision rehabilitation, cataract monitoring, glaucoma monitoring, diagnosis of anterior eye pathology, prescription of simple medications, pre and post-refractive surgery assessment, tonometry, perimetry, OCT, and FFA (PCO, 2021). 9 2. The scope according to the scientific degree In Palestine, an optometrist needs a professional certificate to provide optometry services. Practicing the profession depends on a university degree in optics, a diploma, or more. • Optometrist with a Bachelor's or Master's degree Optometrist in Palestine means the person is a dispenser, refractionist, and contact lens professional. Optometrists can provide visual refraction examinations, prescribe spectacles, and contact lens supply in private centers, but optometrists in eye care hospitals can in addition practice low-vision examination, Cataract, Glaucoma, and Keratoconus monitoring, optic imaging, pre, and post-refractive surgery monitoring, use diagnostic Cycloplegic agents, and sometimes prescribe some therapeutic drugs (PCO, 2021). Optometrists, who have graduated with bachelor's degrees from all universities except An-Najah University, take the professional practice exam to obtain a professional practice certificate. The optometrist takes three examinations: a test for dispensing, an examination for refraction, and a test for contact lenses, both theoretical and practical (PCO, 2021). Optometry students in Palestinian universities have medical courses in the field of ophthalmology, laboratories, and practical courses, which qualifies the student to diagnose simple eye diseases such as blepharitis, conjunctivitis, and dry eye, and prescribe the appropriate treatment for them, but this work is not included in the scope of optometry in Palestine, although it is found in many other countries of the world such as America, Canada, and Britain. But optometrists who trust their abilities, and have experience and knowledge practice this examination even if it is forbidden. They prescribe the necessary medicines. On the other hand, the failure to practice this examination prompted many centers not to acquire the necessary equipment, such as slit-lamp biomicroscopy. • Opticians with Diploma Certificate: An optician is a person who is a dispenser and refractionist. Can practice visual refraction examinations, and prescribe spectacles. They can practice contact lens fitting after completing a one-year training course under the supervision of the Palestinian Ministry of Health in the field of contact lenses and undergoing a practice exam in 10 contact lenses (PCO, 2021). Opticians have to do dispensing exams, and refraction exams for the professional practice certificate, until he undergoes a contact lenses course and submits the professional practice exam for contact lenses; he becomes an optometrist with a diploma certificate (PCO, 2021). As for those who practice the profession with experience, and who were present before the council was established, they are excluded from the decisions of the optometry scope and membership conditions, as the situation remains the same as before the council was established (PCO, 2021). 1.1.4 Problem statement In light of global developments in optometry and optometry regulation, with the WHO vision 2030 for eyesight, and applying the WHO Eye Care Competency Framework to help in eye care planning and development, and the WCO Competency Model which identified the role of optometrists worldwide. This study was necessary to be conducted to shed the light on the Palestinian optometry scope and compare it with the categories of the WCO Competency Model. In addition, the researcher’s experience in optometry and the knowledge of the barriers prevent optometrists from practicing and developing the profession. 1.1.5 Study aim The overall aim of this study is to assess optometry services in the Northern Districts of the West Bank. 1.1.6 Study Objectives This descriptive study was carried out to assess the extent of optometry services provided in the northern districts of the West Bank of Palestine. It is expected that the results of this study will assist planners, decision-makers, and optometry providers in better meeting optometry needs, improving care quality, and formulating optometry policies. 1. To find out the optometrist's sociodemographics. 2. To determine the optometrist-to-population ratio. 11 3. To explore the extent of optometry services available in the Northern Districts of the West Bank. 4. To explore the optometry services available according to the type of workplace and district. 5. To investigate the differences in providing services by optometrists according to gender, qualification, and workplace type. 6. To investigate whether the Palestinian optometrist's role met with that identified by WCO. 7. To find out the barriers faced by Palestinian optometrists. 8. To assess differences in barriers concerning gender, qualification, workplace type, and districts. 1.1.7 Study hypothesis 1. No relationship between the types of services provided and gender. 2. No relationship between the types of services provided and qualifications. 3. No relationship between the types of services provided and workplace type. 4. No relationship between the type of services provided in optometry centers and the districts. 5. There are no significant associations in the perception of optometrists toward barriers affecting the implementation of optometry services and gender variables. 6. There are no significant associations in the perception of optometrists toward barriers affecting the implementation of optometry services and qualifications. 7. There are no significant associations in the perception of optometrists toward barriers affecting the implementation of optometry services and workplace type. 8. There are no significant differences in the perception of optometrists toward barriers affecting the implementation of optometry services and districts. 1.1.8 Study Significance Numerous studies are focusing on optometry services and the optometry scope around the world, due to the importance of this profession in providing eye and vision care. In Palestine, many studies in eye health care were conducted, including studies on the incidence and prevalence of visual disorders and ocular pathology. Only one study was conducted in Palestine that studied human resources eye health care services generally. 12 This study is the first to assess the type of optometric services provided by optometrists and the barriers faced by them from the perspective of the optometrists and the degree of their compatibility with the international optometry scope of practice. It is expected that the results of this study will help in developing the optometry profession and alleviating barriers facing the Palestinian optometrist. This study was designed to be the first building block for further studies in the field of optometry in Palestine. Furthermore, the profession needs further research to study optometry in terms of administration, quality, and financial resources. 1.2 Literature Review Many studies were found from all over the world. This provides a strong database to perform our research. Keywords (optometry services, optometry scope, health care management, planning, policies, challenges, barriers, facilitators, recommendations, and opticians) were predetermined, and an advance search was performed using google scholar, Pubmed, and Science Direct to define the time of the last seven years. Mastering the literature helped define the conceptual and theoretical frameworks of this study, and compare the results with similar previous studies. Similar studies that measured the perceptions of optometrists towards optometry services, factors affecting the extent of optometry services provided, facilitators, and barriers affecting the extent of optometry services provided were explored and reviewed according to chronological order as follows: 1.2.1 International studies 1. Studies from the United Kingdom 2022, 2016 A survey to study the scope of optometry practice in hospitals in the United Kingdom answered how many optometrists work within the unit or department, whether the optometry service is in a major teaching Eye Hospital, a General Hospital, or a Community Hospital, and the geographical location the optometry service is located in. The provision of essential services, including Refraction, refraction for children, spectacle dispensing, adult contact lens fitting, children contact lenses, adults low-vision examination and rehabilitation, children low-vision, biometry, ultrasonography, color vision, electro-diagnostics, topography, perimetry, imaging, and photography. The 13 provision of extended role services, in the ophthalmic sub-specialist areas where optometrists provide extended roles including cornea, retina, macula, and its related pathology and investigations. This survey was sent to the head and seniors’ optometrists of the Hospitals of Eye Services departments. In the study of (Harper et al., 2016). the sample size was 70 hospitals, (96%) of respondents performed refraction and children refraction, (87%) fitted contact lenses for adults, 82% fitted contact lenses for children, and low-vision (79%). Extended role services like glaucoma, medical retina and diabetes, and cataract, had been performed by (96%) of participants.in addition to special procedures that were performed in hospitals by optometrists such as punctual plug insertion (32%), suture removal (30%), and foreign body removal (30%). The second study which was conducted in 2020, on the same population, the survey was based on the previous study survey that was implemented in 2015. The sample size was 90 optometrists who worked in hospitals in the UK. Optometrists who perform refraction were (88%), pediatric refraction (92%), contact lenses fitting for adults (71%), children (61%), and low-vision (67%). The extended role services were performed in this study by (78%) of optometrists. The performance of special procedures improved in the second survey to be (38%) for punctual plug insertion, (36%) for suture removal, and foreign body removal (53%). Since the 2015 survey, the use of independent prescribing was increased to (67%) compared with (18%) in 2015 (Gunn et al., 2022). 2. A study from Portugal 2020 This study was based on a questionnaire survey, it was conducted among optometrists in Portugal. The study sample was 444 optometrists, (78.8%) of optometrists had a Bachelor's degree in optometry, (20.5%) had a Master, and (0.7%) had PhDs. The study aimed to identify the competencies model and training required for Portuguese optometrists. Optometrists reported that the most frequent procedures they perform were retinoscopy, subjective refraction, slit-lamp, and ophthalmoscopy. While the sometimes performed examinations were binocular tests, contact lenses, and keratoconus assessment. The 14 rarely performed were low-vision tests, perimetry, and pediatric examinations less than 6 years. According to training needs, participants are recommended for the total training requirement of ocular pharmacology, contact lens fitting, and low-vision. Binocular vision, pediatric optometry, and diagnostic and therapeutic examinations were recommended for partial training (Carneiro & Jorge, 2020). 3. A study from Malaysia in 2020 A cross-sectional study aimed to ensure eye care services from optometrists in Malaysia (Aziz et al., 2020), was conducted in the private sector practicing optometry in Malaysia with a sample size of 71, using a survey questionnaire that included optometrists' demographics, availability of optical equipment, routinely conducted ophthalmic procedures, the special optometric clinic provided, and the number of referral cases to hospitals and barriers to providing routine procedures. Barriers to not performing full eye examination in this study were the following: (79%) was the unavailability of optical equipment, (56%) restriction of time, (34%) of patients requested to not perform these examinations, (19%) spaces unavailability, (15%) insufficient training and (8%) lack of motivation. In this study, (95.8%) of optometrists had a Snellen chart, (88.7%) had retinoscopy, (78.9%) had an ophthalmoscope, (67.7%) had Slit-Lamp, and (40.8%) had a tonometer. While the services provided were; (93%) of optometrists perform medical history always, (51%) perform retinoscopy for refraction examination, and (42%) do ophthalmoscopy as a routine exam. However, (55%) of private optometrists didn’t use tonometry, regarding the unavailability in the private sector. However, (85%) of private optometric performed full contact lens examinations, (26.8%) of them had an RGP trial set, and (49.3%) had fluorescein strips. (45%) performed orthoptics and binocular tests, and (11%) performed low-vision tests (Aziz et al., 2020). 4. A study from Singapore 2019 A survey of optometrists and opticians in Singapore (George et al., 2019) aimed to assess the current scope, evaluate the primary eye care knowledge, views on the extended role in primary eye care, preference for continuing professional education (CPE), and referral behavior of optometrists, using a self-administered questionnaire, sent by emails to optometrists who registered in Optometrist and Optician Board, with a 15 response rate of 30% as 230 participants. The working centers varied in private clinics and hospitals, governmental hospitals, and academic and research setups with (61%, 28%, and 11%) respectively. the majority of optometrists described the scope of optometry in Singapore as positive, (75%) of optometrists practice primary eye care services and extended role services. In hospitals, optometrists conduct eye examinations and co-manage ocular diseases with ophthalmologists. In the same study, barriers were identified by optometrists to extended primary care roles by the pay, time, and costs involved in training. (81%) of optometrists reported that they referred patients to ophthalmologists in severe cases (George et al, 2019). 5. A study from Australia 2017 A cross-sectional study aimed to present results from the inaugural Scope of Practice Survey on the clinical practice of optometrists who are members of Optometry Australia, with a particular emphasis on their confidence in diagnosing, use of equipment, prescribing of scheduled medicines, referral practices, and their patient base. It was conducted among Optometry Australia members. This study depended on an online survey that included data on demographic information, patient diagnosis, techniques, therapeutic prescribing, treatment of patients with glaucoma, general practitioner referrals, areas of interest, and average numbers of patients and prescriptions. The study results showed optometrists who had therapeutic endorsement (97%) were more confident than optometrists without therapeutic endorsement (92%) in diagnosing and monitoring cases with anterior and posterior eye pathology like glaucoma, diabetic retinopathy, macular degeneration, uveitis, conjunctivitis, blepharitis, and use special ophthalmic diagnosis technique such as tonometry, perimetry, OCT, slit-lamp biomicroscopy. About (70%) of optometrists monitored glaucoma patients. Approximately half of the participants referred patients to ophthalmologists for more investigations or non-confident medication used (Kiely et al., 2017). 6. A study from Mozambique 2016 A cross-sectional study was conducted on the eye health care services of the national health system aimed to assess the optometric services provided by optometrists in Mozambique including all optometrists providing eye health services in the National 16 Health System, to measure the extent of eye care services provided, availability of optometric equipment, barriers they faced in practicing and recommendations for improvements (Manuel et al., 2016). It was found that (96%) of optometrists were responsible for refraction, (96%) used diagnostic drugs, (91%) did Cycloplegic refraction, (87%) did contact tonometry, and (57%) removed the foreign body. Of the optometrists who examined patients with refractive errors were (91%), (67%) tested patients with anterior segment disorders, (23%) examines patients with posterior segment disorders, and (38%) of them tested patients with low vision. Optometrists accessed clinical equipment, (100%) trial lenses, (100%) trial frame, (87%) contact tonometer, (78%) slit lamp, (70%) direct ophthalmoscope, (65%) cross cylinder, (61%) for keratometer, and retinoscope. The main barriers for optometrists in this study were lack of equipment, insufficient training, and lack of low-vision rehabilitation resources. They recommended identifying the role of optometry in Mozambique and developing an optometry council to improve the services and training with continuous training and education (Manuel et al., 2016). 7. A study from India in 2015 A cross-sectional study was published in 2015, aimed to evaluate the range of clinical services offered by optometrists in various modes of optometric practices in India. This study depended on an online questionnaire. The inclusion criteria were the optometrists who completed a 4-year Bachelor of Science in optometry. Optometrists with diploma qualifications were excluded. A purposive non-randomly sampling method was used in selecting the participants. (98%) of optometrists reported they performed routine eye examinations and performed subjective refraction using visual acuity tests, and retinoscopes for objective refraction. Contact lens testing and fitting were performed by (70%) and optical dispensing by (67%). This study showed that optometrists with post- graduation qualifications had more awareness of the importance of comprehensive eye examinations and investigations, in addition, to performing their examinations with confidentiality (Thite et al., 2015). 8. A study from Ghana 2015 A cross-sectional study conducted by (Boadi-Kusi et al., 2015) aimed to evaluate the optometrists and optometric practices in Ghana. It was conducted among optometrists registered with the Ghana Optometric Association. It depended on an online survey that 17 included questions about demographics, ophthalmic procedures they conducted routinely, equipment, and the barriers they faced in practicing optometry. This study showed that (100%) of participants always take medical histories for patients, (100%) did subjective refraction, (98%) used ophthalmoscope, (and 89%) used slit-lamp biomicroscopy, and (76%) retinoscope. A minimal number of participants performed contact lenses (10%), and low-vision (9%), because of the unavailability of equipment required for contact lenses or low-vision, limitation of space, low training, and absence of motivation. 1.2.2 Regional studies 1. A study from Jordan in 2021 A cross-sectional study aimed to document the scope of optometry in Jordan, and describe the services provided by optometrists in Jordan. The data collection tool of this study was a questionnaire that was completed by optometrists who provide optometry services across Jordan, 714 optometrists were reached and filled out the questionnaire. More than half were females (57.8%), and (42.2%) were males. The results showed the unequal distribution of optometrists in Jordan and the majority of optometrists (81.5%) practice in big cities. Participants in this study (45.1%) were diploma degree holders, and (54.5%) were Bachelor's degree holders. Basic optometric examinations were the most services provided, then the community eye care services. The most available services were visual acuity (97.9%), refraction (96.8%), (30%) provided ophthalmoscopy, (53.8%) binocular vision, and (12.6%) Cycloplegic-refraction. The least services provided were prescribing ocular medication, vision therapy, and low- vision. The barriers faced by optometrists to not performing spectacle dispensing were lack of equipment, lack of knowledge a barrier to not providing binocular vision and vision therapy, lack of time made ophthalmoscopy difficult to perform, and license restrictions were the barrier to not performing the pediatric examinations and Cycloplegic refraction. Optometrists unanimously agreed not to prescribe ocular medications. However, about half of the participants can provide anterior and posterior eye examinations. Restrictions imposed by regulations and licenses on practicing the profession of optometry in Jordan were the main reasons that prevent service providers from providing some optometry services as these are not in the job description. However, optometrists in Jordan can 18 provide more services regarding their knowledge and skills if the scope is expanding (Okasheh-Otoom et al., 2022). 2. Studies from Saudi Arabia 2021, 2017 This study investigated the limitations and difficulties of providing low-vision services among optometrists practicing in Saudi Arabia. A self-administered online structured survey for practicing optometrists was used in this investigation. Responses were gathered to determine the number of low-vision service providers, as well as the rate of awareness and impediments to providing low-vision services. This research involved 154 practicing optometrists (51.2% females, 48.7% males). Optometrists in this study had bachelor's, master's, and Ph.D. degrees in optometry. About (30%) of participants provided low-vision services. Optometrists reported that the main barriers faced them in practicing low-vision were (87%) insufficient training, (76%) lack of low-vision services awareness, unavailability of low-vision equipment (70%), lack of time (55%) and (30%) financial problems. The author recommended improving optometry education and low-vision training, in addition, to increasing the national coverage of patients with low-vision problems (Alsaqr, 2022). The study of 2017 was a cross-sectional study that utilized a 6-item survey questionnaire; the questionnaire was completed by the head of the ophthalmology department or the registered optometrists in 240 hospitals around the KSA. This study aimed to examine the quality of services provided by Optometrists in Saudi Arabia. The results of this study were that (81%) of facilities didn’t provide optometry services for free, the reasons were the lack of knowledge about the profession 22.6%, and 61.02% shortages of qualified optometrists. As a result, 71.8% of physicians refer their patients to the nearest Optometrists in the city. The result showed no significant difference based on the type of hospital understudy, in addition to a dependency between the type of hospital and the number of patients visited the hospitals because a load of patients in facilities governed by the Ministry of Health (79.4%) is higher than private (5.9%) and military hospitals (14.7%) (Alotaibi, 2017). 19 3. A study from Sudan 2019 A study was conducted by (Al Rasheed, 2019) to assess the role of Sudanese optometrists in primary eye care in the Khartoum State of Sudan between February 2018 and January 2019. It included 300 optometrists using a self-administered questionnaire that included seven equations, focused on the challenges facing optometrists in practicing and recommendations for improvements, equipment required for providing optometric services, and the perception of the optometrists in their role in primary eye care. This study showed, that the majority of optometrists in Khartoum (99.7%) take their time with patients and communicate well with them, (99%) depending on the medical and family history of patients while they perform eye examinations, (90%) of participants used only equipment in diagnoses, (43%) used diagnostic drugs, (22%) used diagnostic dyes, (49%) used therapeutic drugs, (96%) reported they referred patients to ophthalmologists for more investigations. Optometrists in Sudan faced barriers, (96%) of optometrists complained of no clear job description, (87%) of lack of equipment, and lack of medical supplements. (95%) of participants recommended improving the role of optometrists in Sudan, (90%) preferred continuous training (AL Rasheed, 2019). 1.2.3 Local studies A study from Palestine 2020 A quantitive cross-sectional study (Obaid, 2020) was conducted in West Bank districts and East Jerusalem between January and December 2019. It aimed to evaluate the healthcare services institutions and staff, in addition to the geographical distribution of services. The study included 331 eye care providers (ophthalmologists, optometrists, opticians, orthoptists, and nurses) and 183 eye care facilities. Two types of data collection tools were used in this study, one for institutions and the other one for healthcare workers. This study found (1.7%) of facilities that provide eyecare services were governmental, (0.8%) were NGOs, (and 97.31%) were private. The total number of optometry services providers was (425) that (320) of which were optometrists, (75) were refractionists, (14) were qualified opticians, (14) were non-qualified opticians, and (2) were orthoptists. Optometrists who had a bachelor's degree were (69.6%), master's 20 degree (3.43%), Ph.D. degree (0.38%), doctor of optometry (0.76%) diploma (18.32%), orthoptists (0.76%), and opticians without a qualified degree (7.25%). This study studied the eye healthcare resources per 50,000 population, where all districts met the vision 2020 ratio (1 optometrist: 50,000 population). 1.2.4 Systematic review A systematic review was prepared to summarize the literature review, many articles were found in searching keywords (optometry, healthcare, eye services, Palestine, the scope of practice, barriers). Many studies had been excluded due to the date of publication (after 2015), or the participants' conditions, all of the studies in the literature review were from the point of optometrists or eye healthcare providers. The literature review summarization is in Appendix (B) 21 Chapter Two Methods 2.1 Study design A cross-sectional study, in which face-to-face interviews were performed using a questionnaire to assess the optometry services in the Northern Districts of West Bank in Palestine (Jenin, Tubas, Nablus, Tulkarm, Qalqilyah, and Salfit). 2.2 Study population All optometrists working in optometry centers (Private, Governmental, Non- governmental) in the Northern Districts of the West Bank were reached and interviewed. The study population consisted of 93 optometrists who represented the centers providing optometry services. 2.3 Sample size and sampling method The Census method was conducted. All optometrists working in optometry centers in the Northern Districts of West Bank were reached and interviewed. Based on the information obtained from the Palestinian Ministry of Health for the year 2021, 70 private centers provide optical services in the Northern Districts of the West Bank, 3 private surgical centers, one government hospital, and one NGO-affiliated center, in addition to one optometry school clinic. However, during the data collection, a difference in the number of centers was found, as some centers were permanently closed, others had moved to another city, and other centers were opened and were not included in the data of the Palestinian Ministry of Health. In addition, some centers were not among the inclusion criteria as the centers without an optometrist neither with a diploma or bachelor's degree in optometry, or the centers had to certificate only as the dispensing center. Accordingly, the final number of centers that participated in the sample is 60 and the number of optometrists providing services in these centers that correspond to the inclusion criteria is 94 optometrists. 2.3.1 Inclusion criteria • All centers which provide optometry services (private centers, Private hospitals, NGOs centers, Governmental hospitals, and optometry schools) 22 • Optometrists with bachelor' and Diploma degrees. 2.3.2 Exclusion criteria: • Practitioners who practice optometry by experience (without an optometry certificate), workers who work without licenses, and optometry students who practice in optometry centers. • Centers that are certificated as dispensing centers (refraction and contact lenses are not allowed to be practiced in). 2.4 Data collection procedures A questionnaire (Appendix C, D) was developed from three previous studies (Al Rasheed, 2019; Aziz et al., 2020; Boadi-Kusi et al., 2015), then 3 advisors who had a research background and two qualified professionals evaluated the questionnaire to ensure validity purposes, a pilot study was conducted to ensure the quality of the questionnaire, 13 optometrists out of the sample filled the questionnaire, and then the questionnaire was tested. The reliability of the questionnaire was tested by Cronbach's Alpha analysis = 0.84. The results of the pilot study were not included in the actual results of this study. The questionnaire contains six parts, the first part consists of the demographic part, and the second part consists of general questions about the availability of optometric services in the optometry centers. The third part consists of questions about the availability of certain tools and equipment. The fourth part consists of questions about the services provided in the centers. The fifth part aims to determine barriers to the development of optometry services. And the sixth part aims to determine optometrist recommendations for the development of the optometry profession. Data were collected through face-to-face interviews that took place between November and December of 2021. 2.5 Data analysis IBM SPSS statistical program has been used to analyze data. Frequencies have been computed to find out the optometrist's sociodemographic, and the optometrist-to- population ratio, and to explore the extent of optometry services available in the Northern Districts of the West Bank. 23 The independent t-test analysis was calculated to find out whether there are significant associations between optometry services and workplace types, and the association between services that are provided by optometrists and gender, qualification, and workplace types. In addition to finding out the significant associations between barriers and gender, qualifications, and workplace. The one-way ANOVA analysis was conducted to find out the significant differences between the available services and the districts, and the relationships between barriers and districts. The cross-tabulation analysis was calculated to find out the percentages of available services in different workplaces and districts. To explore the frequency of providing optometry services by optometrists according to gender, qualifications, and workplace. In addition, to determine the barriers according to gender, qualification, workplace, and districts. To determine the optometrist's recommendations for improving optometry practice, recommendations were collected and grouped, then the frequency was calculated. 2.6 Ethical approval The study proposal was approved by the Institutional Review Board (IRB) at An-Najah National University and the scientific research committee of the Public Health Management Department (Appendix E, F), in addition to the faculty of graduate studies scientific research board at An-Najah National University, and task facilitation book to facilitate the study procedures in Private and Government settings (Appendix G). An explanatory letter was attached to each questionnaire for all participants to explain the aim, importance, and privacy, with optional participation (Appendix H, I). A written and signed consent form was filled out by each participant (Appendix J, K). 24 Chapter Three Results 3.1 Descriptive analysis 3.1.1 Sociodemographic information: In this chapter, the results of this study will be presented and tabulated according to the study variables and hypothesis. The first part of this chapter has presented the socio- demographic results (Table 1) which indicated that seventy-two percent (72.3%) of optometrists working in the optometry centers that were reached were females, and most of the optometrists working in these centers were from the 90s and 80s generations (90.4%) together, (85.2%) of optometrists providing services in the Northern Districts of the West Bank are a bachelor's degrees holders or more. with only (6.5%) of optometrists working in these centers having a specialty certificate. It was found that the majority of optometry services in the Northern Districts of the West Bank were provided by the private sector (hospitals, optical centers, NGO clinics, and university clinics) (97.9%). Socio-demographic variables are presented in (Table 1). 25 Table 1 Socio-demographic indicators of the participants Demographics Frequency % Gender Male 26 27.7% Female 68 72.3% Generation 60s 3 3.2% 70s 6 6.4% 80s 35 37.2% 90s 50 53.2% Scientific Degree Diploma 14 14.9% Bachelor 76 80.9% Master 4 4.3% Experience (Years) 0-10 52 55.4% >10 42 44.6% Workplace Type Governmental 2 2.1% NGOs 2 2.1% Private Hospital 7 7.5% Private Optometry Center 81 86.2% Optometry School Clinic 2 2.1% Center location City 85 90.4% Village 2 2.1% Town 7 7.5% Districts Jenin 18 19.1% Tubas 2 2.1% Nablus 40 42.6% Tulkarm 20 21.3% Qalqilyah 10 10.6% Salfit 4 4.3% Figure (1) below, shows the distribution of optometrists and workplaces in northern districts of the West Bank. Figure1 The distribution of optometrists and optometry services workplaces in the Districts of the West Bank. 3.1.2 Optometrists per As shown in table (2), the optometrists: population ratio was calculated in the Northern Districts of the West Bank. The best ratio was in Nablus with population, and the lowest ratio was in Tubas with These ratios met the Vision Table 2 Optometrists per 50000 population. District Population in the middle of Jenin Tubas Nablus Tulkarm Qalqilyah Salfit * Population in the middle of 26 The distribution of optometrists and optometry services workplaces in the Districts of the West Bank. Optometrists per 50,000 population ), the optometrists: population ratio was calculated in the Northern Districts of the West Bank. The best ratio was in Nablus with 5.4 optometrists/ population, and the lowest ratio was in Tubas with 1.5 optometrists/ These ratios met the Vision 2020 goal by WHO 1 optometrist / 50000 population. Population in the middle of 2021* Optometrists Optometrist/ 338919 23 65615 2 415606 45 198856 21 121671 10 82099 4 Population in the middle of 2021 (PCBS, 2021) The distribution of optometrists and optometry services workplaces in the Northern ), the optometrists: population ratio was calculated in the Northern optometrists/ 50000 optometrists/ 50000 population. 50000 population. Optometrist/50000 population 3.39/50000 1.5/50000 5.4/50000 5.2/50000 4.1/50000 2.4/50000 27 3.1.3 The available optometry services Table (3) presenting on the frequency of optometry services that are provided by the centers in our study. Visual refraction was provided by (98.9%) of optometrists in the Northern Districts of West Bank, soft contact lens fitting (96.8%), optical spectacles, and contact lens selling (87.1%). Most of these services are classified as essential services that are provided in all types of optometry workplaces. The least optometry services provided by optometrists were FFA (3.2%), and Pre and Post Refractive Surgery Evaluation (6.5%) more details about optometry services provision were clarified in Table (3). Table 3 Frequencies of the optometry services available in the centers and workplaces in the Northern Districts of West Bank (n= 94). No Items Available (%) 1. Visual refraction 98.9 2. Soft contact lens fitting 96.8 3. Sell optical spectacles and contact lenses 87.1 4. Binocular tests 67.7 5. Hard contact lens fitting 57.0 6. Anterior eye examination 50.5 7. Posterior eye examination 36.6 8. Corneal topography 32.3 9. Cycloplegic refraction 22.6 10. Orthoptics 20.4 11. Cataract monitoring 19.4 12. Tonometry 18.3 13. Low-vision appliances sell 18.3 14. Low-vision fitting 15.1 15. Glaucoma monitoring 12.9 16. OCT 9.7 17. Low-vision appliances fitting 9.7 18. Perimetry 8.6 19. Pre and post-refractive surgeries assessment 6.5 20. FFA 3.2 28 3.1.4 The available optometry instruments As indicated in the table (4) the most essential instruments were available within a range of (62.4% - 100%) in the studied centers. Table 4 Frequencies for optometric instruments available in the centers and workplaces in the Northern Districts of West Bank (n= 94). No Items Available (%) 1 Snellen chart E, log mar, Landolt C, Numbers, alphabet, key’s pictures 100 2 Near chart acuity test 100 4 Occluder 100 7 Keratometer 100 8 Complete trial lens set 100 9 Trial frame 100 10 Cross cylinder 98.9 18 Accommodative fixation target 98.9 20 Lensmeter 98.9 3 Pen torch 97.8 17 Contact lens solution 90.3 14 Contact lens trial set SCL 86 6 Retinoscope 80.6 11 Slit lamp 74.2 5 Ishihara test 64.5 16 Fluorescein strip 63.4 12 Ophthalmoscope 62.4 15 Contact lens trial set RGP 62.4 19 Prism par 61.3 13 Tonometer 21.5 3.1.5 The frequency of performing optometry services by optometrists In (Table 5), the results show how often the optometrists perform services in the cases that attending the centers and workplaces in the Northern Districts of the West Bank was explored. It was indicated that all optometrists (100%) in the centers and workplaces in the Northern Districts of the West Bank – Palestine always take patients' history while they perform the eye examination, and perform visual acuity tests. Also, (84.90%) of optometrists sometimes perform children's refraction. Whereas, (89.20%) (84.90%) of optometrists never perform low-vision aid fitting, and performed special tests like perimetry and tonometry, more details in table (5) 29 Table 5 Frequencies and percentages for the optometry services provided by the optometrists in the Northern Districts of West Bank (n= 94). No Items Always (%) Sometimes (%) Never (%) 1 How often did you perform general observation on patients in your practice? 84.9 15.1 0 2 How often did you take the patient's history while you perform the eye examination? 100.0 0 0 3 How often did you perform visual acuity tests on patients in your practice? 100.0 0 0 4 How often did you perform subjective refraction for patients in your practice? 98.9 1.1 0 5 How often did you perform objective refraction for patients in your practice? 98.9 1.1 0 6 How often did you perform children's refraction? 12.9 84.9 2.2 S7 How often did you perform Cycloplegic refraction in your practice? 14.0 10.8 75.2 8 How often did you perform retinoscopy in your practice? 8.6 54.8 36.6 9 How often did you perform spectacles dispending? 88.2 1.1 10.7 10 How often did you perform contact lens fitting? 69.9 22.6 7.5 11 How often did you perform Hard contact lens fitting? 17.2 33.3 49.5 12 How often did you use diagnostic dyes in your practice? 19.4 29 51.6 13 How often did you perform Binocular vision tests? 7.5 58.1 34.4 14 How often did you perform Low-vision tests? 1.1 12.9 86 15 How often did you perform Low-vision aid fitting? 4.3 6.5 89.2 16 How often did you use ophthalmoscopy in your practice? 7.5 30.1 62.4 17 How often did you diagnose and treat simple ophthalmic diseases like blepharitis, dry eye, and conjunctivitis? 7.5 43 49.5 18 How often did you perform monitoring cataracts, glaucoma, and keratoconus? 5.4 37.6 57 19 How often did you use diagnostic drugs 6.5 17.2 76.3 20 How often did you use therapeutic drugs 4.3 16.1 79.6 21 How often did you perform optical imaging like corneal topography, OCT, and FFA? 4.3 25.8 69.9 22 How often did you perform special tests like perimetry and tonometry? 3.2 7.5 89.2 23 How often did you perform pre and post- refractive surgery monitoring? 6.5 8.6 84.9 24 How often did you sell optical products? 88.2 0 11.8 30 3.1.6 Barriers faced by optometrists As indicated in table (6), the main barriers faced by optometrists in providing services in the centers and workplaces in the Northern Districts of the West Bank – Palestine is the insufficient continuing training, followed by economic and political barriers and societal culture towards optometry (93.6%, 86.9%, and 86.9%). Whereas the least barrier related to the lack of time (66.0%). Table 6 Barriers faced by optometrists in providing services in the centers and workplaces in the Northern Districts of the West Bank (n= 94). No Barriers Not a barrier Barrier Policies and regulations 1 Insufficient continuing training 6.4% (88) 93.6% 2 Maldistribution of optometry centers (17) 18.1% (77) 81.9% 3 The narrow scope of practice (18) 19.1% (76) 80.9% 4 Economic and political problems (13) 13.8% (81) 86.2% 5 Societal culture toward optometry (13) 13.8% (81) 86.2% Personal human resources 6 Lack of motivation (14) 14.9% (80) 85.1% 7 Lack of time (32) 34.0% (62) 66.0% 3.2 Bivariate analysis 3.2.1 The distribution of available services in different workplaces Table (7) below shows the distribution of available optometry services in workplaces and districts. The independent t-test was analyzed to calculate the significant associations in the type of workplace, and cross-tabulation to explore the percentages for each category of workplaces. Results show a significant association at the level of (0.05) between workplace types in available optometry centers, such as cycloplegic refraction having a statistical difference (.000), and contact lens fitting (.040). 31 Table 7 The cross-tabulation between services and workplace type. Services Workplace type Privet optometry centers (n=81) Others (n=13) Sig. (2- tailed) * Sell optical spectacles and contact lenses (81) 100% 0.00 Visual refraction (81) 100% (11) 84.6% .165 Cycloplegic refraction (10) 12.3% (11) 84.6% .000* Soft contact lens fitting (81) 100% (9) 69.2% .040* Hard contact lens fitting (44) 54.3% (9) 69.2% .317 Anterior eye examination (35) 43.2% (13) 100% .000 Posterior eye examination (22) 27.2% (13) 100% .000* Binocular tests (51) 63.0% (13) 100% .000 Orthoptics (7) 8.6% (13) 100% .000* Cataract monitoring (6) 7.4% (13) 100% .000* Glaucoma monitoring 0.00 (13) 100% .000* Corneal topography (20) 24.7% (10) 76.9% .008* Pre and post-refractive surgeries assessment 0.00 (6) 46.1% .000* Tonometry (5) 6.2% (13) 100% .001* Perimetry 0.00 (8) 61.5% .000* OCT 0.00 (9) 69.2% .082 FFA 0.00 (3) 23.0% .958 Low-vision fitting (12) 14.8% (2) 15.3% .449 Low-vision appliances fitting (7) 8.6% (2) 15.3% .000* Low-vision appliances sell (17) 21.0% 0.00 .165 * Significant difference 3.2.2 The distribution of available services in different districts As shown in table (8), one way ANOVA test was analyzed for the significance of Districts, and cross-tabulation for explore the percentages for each District. The results show there are significant differences between districts at the level of (0.05) in many services such as cycloplegic refraction, corneal topography, binocular refraction, and low-vision fitting. 32 Table 8 The cross-tabulation between available services and districts. Services Districts Jenin (n=18) Tubas (n=2) Nablus (n=40) Tulkarm (n=20) Qalqilyah (n=10) Salfit (n=4) Sig* Sell optical spectacles and contact lenses (17) 94.4% (2) 100% (30) 75.0% (18) 90.0% (10) 100.0% (4) 100.0% .156 Visual refraction (18) 100.0% (2) 100% (38) 95.0% (20) 100% (10) 100% (4) 100.0% 0.751 Cycloplegic refraction (1) 5.6% 0.00 (10) 25.0% (3) 15.0% (4) 40.0% (3) 75.0% 0.026* Soft contact lens fitting (18) 100% (2) 100% (38) 95.0% (18) 90.0% (10) 100% (4) 100% 0.687 Hard contact lens fitting (8) 44.4% (2) 100% (23) 57.5% (13) 65.0% (7) 70.0% (4) 100% 0.103 Anterior eye examination (9) 50.0% (2) 100% (24) 60.0% (8) 40.0% (3) 30.0% (2) 50.0% 0.320 Posterior eye examination (6) 33.3% 0.00 (16) 40.0% (6) 30.0% (5) 50.0% (2) 50.0% 0.736 Binocular tests (15) 83.3% (2) 100% (25) 62.5% (8) 40.0% (10) 100% (4) 100% 0.003* Orthoptics (1) 5.6% 0.00 (12) 30.0% (3) 15.0% (2) 20.0% (2) 50.0% 0.192 Cataract monitoring (1) 5.6% 0.00 (12) 30.0% (4) 20.0 (2) 20.0 0.00 0.287 (1) Glauco ma monitoring (1) 5.6% 0.00 (10) 25.0% (2) 10.0% 0.00 0.00 0.156 Corneal topography (3) 16.7% 0.00 (12) 30.0% (14) 70.0% (1) 10.0% 0.00 0.001* Pre and post- refractive surgeries assessment 0.00 0.00 (6) 15.0% 0.00 0.00 0.00 0.124 Tonometry (5) 27.8% 0.00 (10) 25.0% (3) 15.0% 0.00 0.00 0.341 Perimetry 0.00 0.00 (6) 15.0% (2) 10.0% 0.00 0.00 0.383 OCT (1) 5.6% 0.00 (6) 15.0% (2) 10.0% 0.00 0.00 0.655 FFA 0.00 0.00 (3) 7.5% 0.00 0.00 0.00 0.539 Low-vision fitting 0.00 0.00 (12) 30.0%0 0.00 (2) 20.0% 0.00 0.008* Low-vision appliances fitting 0.00 0.00 (8) 20.0% (1) 5.0% 0.00 0.00 0.105 Low-vision appliances sell 0.00 0.00 (7) 17.5% (8) 40.0% (2) 20.0% 0.00 0.035* * Significant differences 33 3.2.3 The relationship between frequency of performing services and gender Results in the table (9) in appendix (L) show the differences between males and females according to the frequency of services performed in cases attending centers. The independent t-test was analyzed to calculate the significant associations and cross- tabulation to explore the percentages for males and females. There is a significant association between gender in the level of (0.05) in the services performed by general observation (.012) and low-vision fitting (.043). 3.2.4 The relationship between the frequency of performing optometry services and the qualifications As shown in table (10) in appendix (L), the independent t-test was analyzed to calculate the significant associations and cross-tabulation to explore the percentages for each category of qualifications. There is a significant difference between diploma holders and BSc and more holders in performing optometry services. There is a significant association in performing children refraction (.007) at the level of (0.05), (.010) in using diagnostic drugs, and (.038) in using therapeutic drugs. 3.2.5 The relationship between the frequency of performing optometry services and the workplace type Table (11) in appendix (L) shows the differences in performing optometry services according to the workplace type. The independent t-test was analyzed to calculate the significant associations and cross-tabulation to explore the percentages for each type of workplace. Many significant differences were found in the level of (0.05), in services like cycloplegic refraction, spectacles dispensing, using diagnostic drugs, and selling optical appliances. 3.2.6 The relationship between barriers and gender In the table (12), the results show the relationship between barriers and gender. The independent t-test was analyzed to calculate the significant associations and cross- tabulation to explore the percentages for males and females. There is a significant difference (.013) in the insufficient continuing training as a barrier at the level of (0.05), (100%) of males considered insufficient continuing training a barrier. 34 Table 12 The cross-tabulation between barriers and gender No Barriers Male female Sig. (2- tailed) Not a barrier Barrier Not a barrier barrier Policies and regulations 1 Insufficient continuing training 0.00 (26) 100.0% (6) 8.8% (62) 91.2% .013* 2 Maldistribution of optometry centers (5) 19.2% (21) 80.8% (12) 17.6% (56) 82.4% .860 3 The narrow scope of practice (5) 19.2% (21) 80.8% (13) 19.1% (55) 80.9% .990 4 Economic and political problems (5) 19.2% (21) 80.8% (8) 11.8% (60) 88.2% .402 5 Societal culture toward optometry (6) 23.1% (20) 79.9% (7) 10.3% (61) 89.7% .174 Personal human resources 6 Lack of motivation (1) (4) 5.4% (22) 84.6% (10) 14.7% (58) 85.3% .935 7 Lack of time (2) (6) 3.1% (20) 76.9% (42) 61.8% (26) 38.2% .148 * Significant difference 3.2.7 The relationship between barriers and qualification As shown in table (13), the independent t-test was analyzed to calculate the significant associations and cross-tabulation to explore the percentages for each category of qualification. There is a significant difference in insufficient continuing training (.013) at the level of (.05). All males in this study reported insufficient continuing training as a barrier. 35 Table 13 The cross-tabulation between barriers and qualification Barriers Diploma(n=14) BSc and more (n=80) Sig. (2- tailed)* Not a barrier Barrier Not a barrier Barrier Policies and regulations Insufficient continuing training 0.00 (14) 100.0% (6) 7.5% (74) 92.5% .013* Maldistribution of optometry centers (6) 42.9% (8) 57.1% (11) 13.8% (69) 86.3% .059 The narrow scope of practice (5) 35.7% (9) 64.3% (13) 16.3% (67) 83.8% .182 Societal culture toward optometry (3) 21.4% (11) 78.6% (10) 12.5% (70) 87.5% .377 Economic and political problems (1) 7.1% (13) 92.9% (12) 15.0% (68) 85.0% .438 Personal and human resources Lack of motivation (4) 28.6% (10) 71.4% (10) 12.5% (70) 87.5% .237 Lack of time (3) 21.4% (11) 78.6% (29) 36.3% (51) 63.8% .254 * Significant difference 3.2.8 The relationship between barriers and type of workplace As shown in table (14) in appendix (L), the independent t-test was analyzed to calculate the significant associations and cross-tabulation to explore the percentages for each category of workplaces. There is a significant difference in economic and political problems as a barrier according to workplace type (.002) at the level of (.05), (93.8%) of optometrists in private optometry centers reported economic and political problems as a barrier compared with (38.5%) of other workplaces. 3.2.9 The relationship between barriers and districts As shown in table (15) in appendix (L), the one-way ANOVA test was analyzed to calculate the significant difference and cross-tabulation to explore the percentages for each district. There are no significant differences at the level of (.05) in barriers according to districts. 36 3.3 The optometrists’ recommendations Most optometrists (63.4%) recommended providing jobs for optometrists in primary health care centers of MOH, school health programs, eye examinations for driving licenses, and Government hospitals. Followed by reconsidering the regulations related to the optometry profession, producing continuing training and education programs in addition to developing postgraduate programs in optometry (50.6%), and compulsory training before obtaining the practice of the profession in approved centers based on scientific standards (46.2%). More recommendations are clarified in table (16) in appendix (L). 37 Chapter Four Discussions and Conclusions 4.1 Discussion 4.1.1 Sociodemographic information Results showed that about two-thirds of optometrists are females (72.3%), this result is consistent with the study of (Al Rasheed, 2019) in Sudan in which females (86%), in India (Thite et al., 2015) females were than males (51%), also in Saudi (Alsaqr, 2022) females were (51.2%), and in Jordan, females were (57%) of participants (Okasheh- Otoom et al., 2022). The result is inconsistent with the Ghana study (Boadi-Kusi et al., 2015) in which males (68.9%) were more than females, in regards to family, childcare, and household responsibilities for females. Optometrists of the 90s and 80s generations are the most, and those with bachelor's degrees represented (80.9%) of optometrists providing services in the Northern Districts of the West Bank, but only (6.5%) of participants have specialties after Bachelor’s degree, these results are inconsistent with study of Jordan (Okasheh-Otoom et al., 2022) in which optometrists with BSc were (54%) and Diploma (45%), that is according to the existence of diploma collages that educate optometry, but in Palestine only BSc programs of optometry. According to the workplaces providing optometry services, the vast majority are related to the private sector (97.9%), because there is just one governmental hospital in the northern districts of the West Bank in which optometrists provide services in Rafidia Hospital which is a governmental hospital in Nablus. This is very similar to the results of a study in Singapore, where the percentage of services provided by the private sector was (89%) (George et al, 2019), in Saudi Arabia (Alotaibi, 2017) (87%) of services were provided by private sector, in addition to Jordan (Okasheh-Otoom et al., 2022) private sector provide (81%) of optometry services in Jordan. About (90.4%) of workplaces located in cities are consistent with the results of the study in Jordan, due to the social and cultural compatibility between Palestine and Jordan, where (81.5%) of optometrists provide services in large cities (Okasheh-Otoom et al., 2022). 4.1.2 Optometrists to population ratio In this study, the optometrists to population ratios were more than 1: 50000. These ratios met the WHO recommended optometrists to population ratio in Asia (1:50000) 38 (WHO, 2007), these results are consistent with the results of (Obaid, 2020), that studied the eye care services human resources in West Bank and East Jerusalem, in which all districts met the recommended optometrists to population ratio. However, there are some differences between optometrists' numbers in 2021 and 2019, that is due to Covid 19, as many workplaces were forced to lay off employees, and some were forced to permanently close their work, which led to a decrease in the number of optometrists. around the world in 2019, half of the countries met the (1:50000) ratio, while the high- income countries met the target of (1:10000((Naidoo et al., 2022). 4.1.3 The availability of optometry services As the result showed visual refraction is the most available service in workplaces providing optometry services, followed by Soft contact lens fitting. Visual refraction is the basis of optometry, and all optometrists have to master it. Workplaces that didn’t provide visual refraction are due to the high load of patients, and the lack of optometrists providing services in Governmental workplaces. While not all workplaces have selling optical spectacles and contact lens services. Due to the banning of MOH from selling optical products in hospitals, surgical centers, and ophthalmic clinics (PCO, 2021). These results are consistent with Jordan (Okasheh-Otoom et al., 2022) where visual refraction was available in 96% of workplaces, and in Malaysia, (100%) of centers provide visual refraction(Aziz et al., 2020). 4.1.4 The availability of optometry instruments All optometrists had a Snellen chart, near chart, occluder, keratometer, complete trial lens set, trial frame, cross-cylinder, fixation target, and lensmeter. The high rate of having these instruments is related to the mandatorily to have this equipment to obtain a license for the optometry centers (PCO, 2021), in addition to retinoscopes, slit-lamp biomicroscopy, and ophthalmoscopes. These results are consistent with those (Aziz et al., 2020) in Malaysia, in which the vast majority of optometrists had a Snellen chart, retinoscopy, ophthalmoscope, and Slit-Lamp. These devices are also mandatory to have for the license, but the absence of close supervision over the optometry facilities by the Ministry of Health and the Council of Optometrists is a major reason for the lack of these necessary devices, in addition to the 39 lack of experience in using them by some optometrists and the transfer of the patient who requires examination of these devices to an ophthalmologist. In this study, the optometrists who have RGP trial set and fluorescein strip are (62.4%). While Tonometer is the least device available, regarding its high cost and low demand, and requirements to use a local anesthetic, this is forbidden to use in private optometry centers, according to the PMOH regulations (PCO, 2021). These results are inconsistent with those (Aziz et al., 2020) in Malaysia. 4.1.5 The frequency of providing optometry services by optometrists All participants confirmed they always take the patient’s history and perform visual acuity and subjective refraction while performing eye examinations. Similar results were in studies of the UK, Mozambique, Sudan, Ghana, and India (Aziz et al., 2020; Boadi-Kusi et al., 2015; Gunn et al., 2022; Manuel et al., 2016; Thite et al., 2015) Objective refraction was performed by all optometrists while just half of them perform retinoscopy, these results are consistent with the results of a study from Mozambique (Manuel et al., 2016), and Malaysia (Aziz et al., 2020). This could be explained by the availability of an auto-refractometer, which performs the role of the retinoscope and keratometer, but the retinoscope remains better in some cases of cataracts, keratoconus, and irregular astigmatism, in addition to being essential in examining children (Grosvenor, 2007). Of optometrists, there were (12.9%) always performed children refraction (6-9 years), and (84.9%) sometimes. Children's refraction and vision screening are important to prevent vision impairments and amblyopia. Optometrists didn’t perform children’s refraction when it requires cycloplegic refraction in squint cases, ocular muscle problems, or when a patient is uncooperative. Optometrists, in general, refer patients to ophthalmologists or other optometrists in hospitals and surgical centers. In some cases, the patient's parents may not care about the child's condition and not pay attention to the examination. Note that the cost of the examination by the optometrist is less than the ophthalmologist. This worsens the child's vision. These results are inconsistent with those of (Gunn et al., 2022), where (96%) of optometrists perform children refraction routinely. 40 Most optometrists in this study were not performing Cycloplegic refraction and were not using diagnostic and therapeutic drugs, as their use is prohibited in private centers by MOH. The banning of cycloplegic refraction and diagnostic drugs in optical centers is the main reason for the unavailability of orthoptic services in two third of centers, besides lack of knowledge, and insufficient training. These results are consistent with the results of (Okasheh-Otoom et al., 2022) study, because of the Jordanian Ministry of Health rules that forbid the use of diagnostic and therapeutic drugs in optical centers. However, these results are inconsistent with the (AL Rasheed, 2019) study in Sudan, in which about half of the optometrists used diagnostic drugs, and therapeutic drugs, because of using the British scope of optometry in Sudan). In this study, it was found that only a third of optometrists used an ophthalmoscope. This result is consistent with the (Aziz et al., 2020) study and inconsistent with (Manuel et al., 2016) study from Mozambique and with (Boadi‐kusi et al, 2015) study in Ghana, in which three-quarters of optometrists used direct ophthalmoscope in a routine examination. Despite the ophthalmoscope is available for more than half of optometrists in optometry centers, only a third of optometrists use it. This could be explained due to the lack of competence to perform ophthalmoscopy due to the lack of training, which leads to the failure to conduct a posterior eye examination, Cataract monitoring, and Glaucoma monitoring by optometrists in the Northern Districts of West Bank- Palestine. These results are inconsistent with the results of the Australian study (Kiely, et al, 2017), and the UK studies (Gunn et al., 2022; Harper et al., 2016). These previously mentioned studies were conducted in hospitals and National Health centers, where optometrists can perform all these services. In the Northern Districts of West Bank, soft contact lens service is available in all workplaces except Governmental Hospital. Whereas, just half of the optometrists performed hard contact lens fitting services. This may result from the unavailability of a hard contact lens trial set for a third of optometrists, this could be explained by the lack of knowledge and insufficient training, in addition to the low demand for this service. These results are consistent with (Harper et al., 2016) study in the UK, and (Aziz et al,2020) study in Malaysia and results are inconsistent with the results of (Boadi‐kusi et 41 al, 2015) in Ghana, b