Identifying barriers and potential solutions to improve equitable access to community eye services in central Kenya: a rapid exploratory sequential mixed methods study
Authors: Allen Luke , Karanja Sarah , Gichangi Michael , Bunywera Cosmas , Muturi Emmaculate , Gachobi Dickson , Kathure Purity , Muasa Elizabeth Mutile , Mutwiri Lorna , Kajuju Lorna , Kagwiria Faith , Ntabathia Benjamin , Rono Hillary , Macleod David , Kim Min Jung , Tlhajoane Malebogo , Burton Matthew J. , Ramke Jacqueline , Bolster Nigel M. , Bastawrous Andrew 
Published: March 2024

SummaryBackgroundRecent research has found that less than half of people identified with an eye problem in Meru county’s screening programme were able to access care, with younger adults being the least likely to receive the care they needed. We aimed to interview and survey members of this ‘left-behind’ group to explore barriers and identify potential solutions using a rapid mixed-methods approach.MethodsFirst, we conducted interviews to explore perceptions of barriers and potential solutions. Next, we asked a representative sample to rank the suggested solutions by likely impact. Finally, we held a multistakeholder meeting to identify which of the top-ranked interventions offered the best balance of impact, feasibility, cost, and potential risks. We used a deductive matrix and thematic analysis to rapidly analyse the interview data.ResultsWe conducted 67 interviews. Barriers to access included long queues, conflicting work engagements, and lack of clear information. Proposed solutions focused on reducing queue lengths, providing better counselling and clinic information, holding mop-up clinics, and maintaining adequate stocks & supplies. We conducted ranking surveys with 401 additional people from the left-behind group. All proposed solutions were ranked at moderately-to-highly likely to improve equitable access. Fifteen people attended the multistakeholder meeting, including community representatives. Workshop participants unanimously selected enhanced counselling and SMS reminders as the interventions that offered the best balance of impact, risk, cost, and feasibility. The other proposed solutions were deemed impractical or unaffordable.ConclusionRapid mixed-methods and multistakeholder collaboration were used to identify a range of potential service modifications that will be implemented within the ongoing programme. Our approach was centred on the experiences and perceptions of those who face the highest barriers to care.Research in ContextEvidence before this studyPrevious research in Kenyan community screening programmes has shown that at least half of those found to have an eye health need will not be able to access care at their local treatment clinic, even if the care is provided free. Work in Meru County has shown that younger adults less are likely than any other sociodemographic group to check-in at their local clinic, but it’s not clear what the specific barriers are for this group. Across the African continent, approximately half of all ambulatory appointments are missed across all specialities, and sociodemographic inequalities are ubiquitous. In pursuit of Universal Health Coverage (UHC) and the Primary Health Care principles of equity and justice, health system managers are increasingly focused on identifying, trying to understand, and then address unequal access to care, however the traditional approach to identifying barriers and solutions has tended to centre around expert opinion rather than engagement with affected groups.Added value of this studyThis study builds on previous efforts to introduce routine sociodemographic data collection into the county-wide eye screening programme operating in Meru, Kenya, as well as additional sites in Meru County, Botswana, Nepal, and Uttar Pradesh. Having already identified younger adults as the least likely to receive care in Meru County, this study introduces a novel mixed-methods approach for engaging with members of this left-behind group to rapidly identify barriers and scalable solutions. We used innovative methods to complete interviews and qualitative analysis in under two weeks, followed by a rapid survey to rank the potential solutions that emerged from this work with a representative sample of younger adults who had not been able to access care. Finally, a multistakeholder workshop with strong local and lay representation identified the top-ranked solutions that would be feasible to introduce and test within the ongoing screening programme. In addition to local evidence for action, this study presents an approach that any community-based programme could use to generate robust, non-tokenistic insights from affected communities within a matter of weeks, minimising the research time requirement and number of senior researchers required whilst maintaining rigorous scientific standards.Implications of all the available evidenceEquitably advancing UHC is predicated on identifying and overcoming unique barriers to care, however existing efforts rarely involve consultation or co-creation with affected communities. Building on existing rapid qualitative and mixed-methods methods, we have developed a cutting-edge approach to identify barriers, prioritise solutions, and identify service modifications that are feasible to introduce. We have applied this approach in Meru County, where younger adults – who were the least likely to access care – suggested a bundle of interventions centring on improving the provision of information and SMS reminders. Our research group will use an embedded RCT to implement and test this bundle, in the context of an equity-focused continuous improvement model that we are also implementing in Botswana, India and Nepal to incrementally improve access for all, with a focus on left-behind groups.