building an evidence base for primary eye care improving health worldwide professor clare gilbert...
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Building an Evidence base for Primary Eye Care
Improving health worldwidewww.iceh.org.uk www.lshtm.ac.uk
Professor Clare GilbertInternational 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 identifiedSome evidence that “adding on” services (or linkages) may improve the utilization and outputs of healthcare deliveryNo 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 neededJust 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 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
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?
What are complex interventions?
?
Primary eye care: a complex intervention
Primary eye careEye health protectionEye health promotion
Specific preventive measuresDetection +/- treat +/- refer
Record keeping Stock control
Primary eye care: a complex intervention
Primary eye careEye health protectionEye health promotion
Specific preventive measuresDetection +/- treat +/- refer
Record keeping Stock control
CommunityBeliefs and attitudes
Health and other prioritiesWillingness to payAccess to services
Socioeconomic developmentHealth seeking behaviour
Primary eye care: a complex intervention
Primary eye careEye health protectionEye health promotion
Specific preventive measuresDetection +/- treat +/- refer
Record keeping Stock control
Other health providersTraditional healers
CouchersTraditional birth
attendantsPrivate sector
CommunityBeliefs and attitudes
Health and other prioritiesWillingness to payAccess to services
Socioeconomic developmentHealth seeking behaviour
Primary eye care: a complex intervention
Primary eye careEye health protectionEye health promotion
Specific preventive measuresDetection +/- treat +/- refer
Record keeping Stock control
Health systemHealth financingHealth workforce
Leadership and governanceManagement information
Service deliveryTechnology
Other health providersTraditional healers
CouchersTraditional birth
attendantsPrivate sector
CommunityBeliefs and attitudes
Health and other prioritiesWillingness to payAccess to services
Socioeconomic developmentHealth seeking behaviour
Primary eye care: a complex intervention
Primary eye careEye health protectionEye health promotion
Specific preventive measuresDetection +/- treat +/- refer
Record keeping Stock control
Health systemHealth financingHealth workforce
Leadership and governanceManagement information
Service deliveryTechnology
Supervision
Supplies
Other health providersTraditional healers
CouchersTraditional birth
attendantsPrivate sector
CommunityBeliefs and attitudes
Health and other prioritiesWillingness to payAccess to services
Socioeconomic developmentHealth seeking behaviour
Primary eye care: a complex intervention
Primary eye careEye health protectionEye health promotion
Specific preventive measuresDetection +/- treat +/- refer
Record keeping Stock control
Health systemHealth financingHealth workforce
Leadership and governanceManagement information
Service deliveryTechnology
Supervision
Supplies
Other health providersTraditional healers
CouchersTraditional birth
attendantsPrivate sector
Other factorsPolicies and politics
Legislation / regulation
CommunityBeliefs and attitudes
Health and other prioritiesWillingness to payAccess to services
Socioeconomic developmentHealth 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 trainingContent of training should be evidence basedBased 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 promotiono specific preventive measureso detection +/- start treatment +/- refero record keeping o stock control
Primary eye care training: symptoms by age group
Age groupLoss of vision
Pain in the eye(s)
Red / sticky eye(s)
Injury Other
Elderly +++++ ++ + - +Working age + + + ++ +Children + + +++++ +++ +
Symptoms
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
Loss of vision Pain in the eye(s) Red / sticky eye(s)
Injury Other
Cataract Corneal ulcers Watering eyes
Refractive errors Lid abnormalities
Glaucoma
Refractive errors Blunt/penetrating/
Early cataract foreign body
Refractive errors Allergies
Cataract Conjunctivitis
Cataract Cong. glaucoma Conjunctivitis Congenital cataractRare disorders - Retinoblastoma
Symptoms
Children Corneal ulcers +
Infants
Blunt/penetrating/ foreign body
Elderly Conjunctivitis -
Working age
Corneal ulcers Conjunctivitis
Glaucoma
+
Primary eye care:conditions
Symptoms Ages Condition Action
Red, sticky eyes All Conjunctivitis Treat/follow up
Red, itchy eyes Children Allergic conjunctivitis 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
White spot in the eye Babies/children Cataract/tumour Refer
Everything else Refer
Primary eye care:conditions
Symptoms Ages Condition Action
Red, sticky eyes All Conjunctivitis Treat/follow up
Red, itchy eyes Children Allergic conjunctivitis 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
White spot in the eye Babies/children Cataract/tumour Refer
Everything else Refer
We are not trying to create “mini-ophthalmologists”!!
Research on integrating PEC into PHCMay need several phases1. Situation analysis: Policy mapping Community attitudes and health seeking behaviour Identification of stake holders2. Development of a “demonstration model”: Think through all the elements needed Primary eye care o training curriculum; clinical protocolso supplieso stock control Community:o awareness raising Health systemo capacities to manage additional referralso supervisiono supplieso 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 trialso quasi-experimental designso controlled before and after studieso 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 Associationo 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