Building an Evidence base for Primary Eye Care Improving health worldwide 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

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

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 : 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 : 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 : 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 : 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 : Learning from other sectors: role of supervision

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.” What are complex interventions A Framework for the Development and Evaluation of Randomised Controlled Trials for Complex Interventions

What are complex interventions?

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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 Stock control Community Beliefs and attitudes Health and other priorities Willingness to pay Access to services Socioeconomic development Health seeking behaviour

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 Other health providers Traditional healers Couchers Traditional birth attendants Private sector Community Beliefs and attitudes Health and other priorities Willingness to pay Access to services Socioeconomic development Health seeking behaviour

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 Health system Health financing Health workforce Leadership and governance Management information Service delivery Technology Other health providers Traditional healers Couchers Traditional birth attendants Private sector Community Beliefs and attitudes Health and other priorities Willingness to pay Access to services Socioeconomic development Health seeking behaviour

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 Health system Health financing Health workforce Leadership and governance Management information Service delivery Technology Supervision Supplies Other health providers Traditional healers Couchers Traditional birth attendants Private sector Community Beliefs and attitudes Health and other priorities Willingness to pay Access to services Socioeconomic development Health seeking behaviour

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 Health system Health financing Health workforce Leadership and governance Management information Service delivery Technology Supervision Supplies Other health providers Traditional healers Couchers Traditional birth attendants Private sector Other factors Policies and politics Legislation / regulation Community Beliefs and attitudes Health and other priorities Willingness to pay Access to services Socioeconomic development Health seeking behaviour

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 eye health protection and promotion o specific preventive measures o detection +/- start treatment +/- refer o record keeping o stock control

Primary eye care training: symptoms by age group 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

Primary eye care: conditions

We are not trying to create “mini-ophthalmologists”!!

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 capacities to manage additional referrals o supervision o supplies o health management information system o 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;

 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

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 Research on integrating PEC into PHC: Patent Medicine Vendor study

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