Building an Evidence base for
Primary Eye Care
Professor Clare Gilbert
International Centre for Eye Health, Department of Clinical Research,
Faculty of Infectious and Tropical Diseases,
London School of Hygiene and Tropical Medicine
Improving health worldwide
www.iceh.org.uk
www.lshtm.ac.uk
Overview
 What can be learnt from other sectors:
o integration into primary health care (PHC)
o role of supervision
 Primary eye care (PEC) is a complex
intervention
 Research on integrating PEC into PHC
Learning from other sectors:
integration into primary health care
Systematic review of the literature – all sectors:
Only 5 randomized trials identified
Some evidence that “adding on” services (or linkages) may
improve the utilization and outputs of healthcare delivery
No evidence to date that a fuller form of integration improves
healthcare delivery or health status
Rigorous studies of different strategies to promote integration
over a wider range of services and settings are needed
Just training existing cadres doesn’t work in the long run
Dudley and Garner. Strategies for integrating primary health
services in low- and middle-income countries at the point of
delivery (review). Cochrane Library, 2011, issue 7
Learning from other sectors:
role of supervision
Reviewed evidence on
1. Opinions on what supervision is
2. Supervision in practice
3. What difference does it make?
Bosch-Capblanch and Garner. Primary health care
supervision in developing countries Trop Med Int Health
2008 13: 369-83
Learning from other sectors:
role of supervision
Reviewed evidence on
1. Opinions on what supervision is (8 papers)
 provides a link between district and peripheral staff
 should entail problem solving; reviewing records;
observing practice; usually by visits to the periphery
 purpose: to improve staff motivation and
performance
Bosch-Capblanch and Garner. Primary health care
supervision in developing countries Trop Med Int Health
2008 13: 369-83
Learning from other sectors:
role of supervision
Reviewed evidence on
2. Supervision in practice (54 papers)
 focus is on administration and checking
 problem solving; feedback and clinical supervision,
training, consultation with the community much less
common
 it is expensive
Bosch-Capblanch and Garner. Primary health care
supervision in developing countries Trop Med Int Health
2008 13: 369-83
Learning from other sectors:
role of supervision
Reviewed evidence on
3. What difference does it make? (12 trials)
some positive effects on some of the outcomes
trials of very variable quality
Bosch-Capblanch and Garner. Primary health care
supervision in developing countries Trop Med Int Health
2008 13: 369-83
Learning from other sectors:
role of supervision
Conclusions:
 Supervision is widely recommended
 It is a complex intervention and is implemented
in different ways
 Some evidence of benefit on performance
 More research is needed
Bosch-Capblanch and Garner. Primary health care
supervision in developing countries Trop Med Int Health
2008 13: 369-83
What are complex interventions
UK’s Medical Research Council definition:
“The greater the difficulty in defining precisely
what exactly are the ‘active ingredients’ of an
intervention and how they relate to each other,
the greater the likelihood that you are dealing
with a complex intervention.”
A Framework for the Development and
Evaluation of Randomised Controlled Trials
for Complex Interventions
What are complex interventions?
What are complex interventions?
?
Primary eye care: a complex intervention
Primary eye care
Eye health protection
Eye health promotion
Specific preventive measures
Detection +/- treat +/- refer
Record keeping
Stock control
Primary eye care: a complex intervention
Primary eye care
Eye health protection
Eye health promotion
Specific preventive measures
Detection +/- treat +/- refer
Record keeping
Community
Stock control
Beliefs and attitudes
Health and other priorities
Willingness to pay
Access to services
Socioeconomic development
Health seeking behaviour
Primary eye care: a complex intervention
Other health providers
Traditional healers
Couchers
Primary eye care
Traditional birth
Eye health protection
attendants
Eye health promotion
Private sector
Specific preventive measures
Detection +/- treat +/- refer
Record keeping
Community
Stock control
Beliefs and attitudes
Health and other priorities
Willingness to pay
Access to services
Socioeconomic development
Health seeking behaviour
Primary eye care: a complex intervention
Health system
Health financing
Health workforce
Leadership and governance
Management information
Primary eye care
Service delivery
Eye health protection
Technology
Eye health promotion
Other health providers
Traditional healers
Couchers
Traditional birth
attendants
Private sector
Specific preventive measures
Detection +/- treat +/- refer
Record keeping
Community
Stock control
Beliefs and attitudes
Health and other priorities
Willingness to pay
Access to services
Socioeconomic development
Health seeking behaviour
Primary eye care: a complex intervention
Health system
Health financing
Health workforce
Leadership and governance
Management information
Primary eye care
Service delivery
Eye health protection
Technology
Eye health promotion
Other health providers
Traditional healers
Couchers
Traditional birth
attendants
Private sector
Specific preventive measures
Detection +/- treat +/- refer
Record keeping
Community
Stock control
Beliefs and attitudes
Health and other priorities
Willingness to pay
Access to services
Socioeconomic development
Health seeking behaviour
Primary eye care: a complex intervention
Health system
Health financing
Health workforce
Leadership and governance
Management information
Primary eye care
Service delivery
Eye health protection
Technology
Eye health promotion
Other health providers
Traditional healers
Couchers
Traditional birth
attendants
Private sector
Specific preventive measures
Detection +/- treat +/- refer
Record keeping
Community
Stock control
Beliefs and attitudes
Health and other priorities
Willingness to pay
Access to services
Socioeconomic development
Health seeking behaviour
Other factors
Policies and politics
Legislation / regulation
What are complex interventions?
Usually include a mix of procedures / treatments where there is
already evidence of efficacy from clinical trials
Research question when evaluating complex interventions:
does delivery of this package of interventions in the real world
make any difference?
Primary eye care training
Content of training should be evidence based
Based on commonest causes of ocular morbidity:
Approach to training:
 Symptom based
 Based on the most likely / important conditions,
by age group
 Encompass
o
o
o
o
o
eye health protection and promotion
specific preventive measures
detection +/- start treatment +/- refer
record keeping
stock control
Primary eye care training: symptoms
by age group
Age group
Elderly
Working age
Children
Loss of
vision
+++++
+
+
Symptoms
Red /
Pain in the
sticky
eye(s)
eye(s)
++
+
+
+
+
+++++
Injury
Other
++
+++
+
+
+
Note: Mothers may notice that their child or infant cannot see properly: the child will not complain
Primary eye care training: main
conditions, by age group
Age gp
Symptoms
Loss of vision
Cataract
Elderly
Refractive errors
Glaucoma
Working Refractive errors
age
Early cataract
Children
Infants
Refractive errors
Cataract
Cataract
Rare disorders
Pain in the eye(s) Red / sticky
eye(s)
Corneal ulcers
Glaucoma
Corneal ulcers
Corneal ulcers
Cong. glaucoma
Conjunctivitis
Conjunctivitis
Allergies
Conjunctivitis
Injury
Other
Watering eyes
-
Blunt/penetrating/
foreign body
Blunt/penetrating/
foreign body
Conjunctivitis
-
Lid abnormalities
+
+
Congenital
cataract
Retinoblastoma
Primary eye care:
conditions
Symptoms
Ages
Condition
Action
Red, sticky eyes
All
Conjunctivitis
Red, itchy eyes
Children
Allergic conjunctivitis Treat/follow up
Treat/follow up
Red, painful eye with loss of vision Adults; elderly; children Ulcers
Refer
Painless loss of near vision
Children
Presbyopia
Sell near add or refer
Painless loss of distance vision
Children
Refractive error
Refer
Painless loss of distance vision
Adults; elderly
Cataract
Refer
"
"
"
Adults; elderly
Glaucoma
Refer
"
"
"
Adults; elderly
Refractive error
Refer
Babies/children
Cataract/tumour
Refer
White spot in the eye
Everything else
Refer
Primary eye care:
conditions
Symptoms
Ages
Condition
Action
Red, sticky eyes
All
Conjunctivitis
Red, itchy eyes
Children
Allergic conjunctivitis Treat/follow up
Treat/follow up
Red, painful eye with loss of vision Adults; elderly; children Ulcers
Refer
Painless loss of near vision
Children
Presbyopia
Sell near add or refer
Painless loss of distance vision
Children
Refractive error
Refer
Painless loss of distance vision
Adults; elderly
Cataract
Refer
"
"
"
Adults; elderly
Glaucoma
Refer
"
"
"
Adults; elderly
Refractive error
Refer
Babies/children
Cataract/tumour
Refer
White spot in the eye
Everything else
We are not trying to create “mini-ophthalmologists”!!
Refer
Research on integrating PEC into PHC
May need several phases
1. Situation analysis:
 Policy mapping
 Community attitudes and health seeking behaviour
 Identification of stake holders
2. Development of a “demonstration model”:
 Think through all the elements needed
 Primary eye care
o training curriculum; clinical protocols
o supplies
o stock control
 Community:
o awareness raising
 Health system
o
o
o
o
o
capacities to manage additional referrals
supervision
supplies
health management information system
financing
Research on integrating PEC into PHC
3. Evaluation:
 Describe the intervention carefully, in terms of how integration was
implemented, the processes involved and the inputs needed;
 Identify process indictors to assess extent to which PEC activities
are being undertaken
 Identify a few sensible primary outcomes related to service quality or
patient outcomes relevant to the service e.g. vaccination coverage;
 Assess efficiency and cost-effectiveness by including good quality
economic evaluations;
 Assess user or lay views of the integrated services
 Conduct studies over a period of several years to assess whether
PEC activities are maintained over time, and to properly evaluate
outcomes and impacts;
Research on integrating PEC into PHC
 Study designs:
o cluster randomized controlled trials
o quasi-experimental designs
o controlled before and after studies
o interrupted time series studies
 Evaluation of complex interventions is relatively new;
o methodologies are evolving;
 Just “trainings” is not enough!!
Research on integrating PEC into PHC
Tanzania: pilot study completed:
 Integration of the “10 key activities for healthy eyes in
children” into primary level Reproductive Child Health
clinics in Dar es Salaam, Tanzania
Nigeria: phase 1 of study ongoing:
 Integrating primary eye care and primary ear care into
the work of Patent Medicine Vendors and Community
Pharmacists in Nigeria (“PMV study”)
Research on integrating PEC into
PHC: Patent Medicine Vendor study
Methods for phase 1:
 Review of the literature
 Policy mapping
 Semi-structured interviews with PMVs
 Observation of outlet, using checklist based on WHO’s health
systems framework
 Key Informant interviews with
o PMV Association and Community Pharmacy Association
o Ministry of Health (Pharmacy; primary health care);
o Finance sector e.g., re making loans to PMVs
o community organizations;
o researchers who have worked with PMVs (malaria; TB etc)
 Focus Group Discussions with community leaders
 Structured interviews with eye patients
Best approach to improving PEC
 Include eye care into the basic training of
PHC workers
 Train trainers so that eye care is part of the
routine work of all staff
 Supply chain
 Supervision
Thank you