Effectiveness of community-based eye care: process and considerations
Authors: Stevens Bechange, Sandeep Buttan
Journal: The Lancet Global Health (2022)

In the past three decades, there have been multiple examples of involving community-based health workers and volunteers in the delivery of eye-care interventions. However, while in some settings the benefits have been strong and demonstrable, in other settings questions and concerns have been raised.1Rono H Bastawrous A Macleod D et al.Effectiveness of an mHealth system on access to eye health services in Kenya: a cluster-randomised controlled trial.Lancet Digit Health. 2021; 3: e414-e424Summary Full Text Full Text PDF PubMed Scopus (6) Google Scholar, 2Bechange S Schmidt E Ruddock A et al.Understanding the role of lady health workers in improving access to eye health services in rural Pakistan - findings from a qualitative study.Arch Public Health. 2021; 79: 20Crossref PubMed Scopus (8) Google Scholar, 3Srinivasan M Ravilla T Vijayakumar V et al.Community health workers for prevention of corneal ulcers in South India: a cluster-randomized trial.Am J Ophthalmol. 2021; 237: 259-266Summary Full Text Full Text PDF PubMed Scopus (2) Google Scholar In addition, there is poor evidence for the effectiveness of task shifting in eye care in low-resource settings. From this perspective, we would like to congratulate Kieran O'Brien and colleagues, the authors of the Village-Integrated Eye Workers (VIEW) study published in The Lancet Global Health,4O'Brien KS Byanju R Kandel RP et al.Village-integrated eye workers for prevention of corneal ulcers in Nepal (VIEW study): a cluster-randomised controlled trial.Lancet Glob Health. 2022; 10: e501-e509Summary Full Text Full Text PDF PubMed Scopus (1) Google Scholar who employed a cluster randomised controlled trial (RCT) design to determine whether the diagnosis of corneal abrasions and the provision of prophylaxis by trained community-health volunteers reduced the incidence of corneal ulceration in Nepal. The authors concluded that their trial was not able to demonstrate the effectiveness of a community-based corneal ulcer prevention programme over 3 years. The estimated incidence of corneal ulceration did not differ between the two study groups: 1·21 cases (95% CI 0·85–1·74) per 1000 person-years in the intervention group and 1·18 cases (0·82–1·70) per 1000 person-years in the control group (incidence rate ratio [IRR] 1·03 [95% CI 0·63–1·67]; p=0·93). The authors explored the likely reasons for these findings, outlining challenges around what had been done as part of their intervention, and how it could have been done better. We agree with the authors' proposition that the clinical task of identifying and providing prophylaxis for traumatic corneal abrasions by lay workers is not as much of a concern as the ability of the health-care system to integrate the new skills and practices within its routine service delivery; specifically, raising community awareness, ensuring community trust, and providing the necessary support systems. There should not be many doubts about whether community-health volunteers are capable of taking on these roles—with proper training and support they almost certainly can.5Cometto G Ford N Pfaffman-Zambruni J et al.Health policy and system support to optimise community health worker programmes: an abridged WHO guideline.Lancet Glob Health. 2018; 6: e1397-e1404Summary Full Text Full Text PDF PubMed Scopus (99) Google Scholar The more pertinent question is: what is the best way to ensure sustainable health-care delivery and positive patient outcomes? In particular, we would encourage task-shifting programmes to consider how the role of community-health volunteers can be expanded within an already heavy workload, the reaction from the community members and other health providers, and what adequate training and support entails, and how it would be provided, resourced, and evaluated. It seems clear that to maximise the value of intervention trials similar to the one by O'Brien and colleagues,4O'Brien KS Byanju R Kandel RP et al.Village-integrated eye workers for prevention of corneal ulcers in Nepal (VIEW study): a cluster-randomised controlled trial.Lancet Glob Health. 2022; 10: e501-e509Summary Full Text Full Text PDF PubMed Scopus (1) Google Scholar rigorous process evaluations should be conducted alongside RCTs to generate evidence of how the intervention worked (or did not), and what the facilitating and limiting factors were. Conducting such implementation research alongside RCTs would allow for rigorous monitoring of the fidelity to the intervention, as well as a more detailed understanding of the processes, relationships, and contexts influencing the delivery.6Scott K George AS Ved RR Taking stock of 10 years of published research on the ASHA programme: examining India's national community health worker programme from a health systems perspective.Health Res Policy Syst. 2019; 17: 29Crossref PubMed Scopus (41) Google Scholar We would also encourage all research groups to conduct trial-nested qualitative studies of community-health volunteer perceptions, attitudes, and experiences related to community-based eye-care delivery. Perceptions that additional eye-care tasks result in an increased workload without increased compensation have been documented previously, and they have been shown to undermine the willingness of community-health volunteers to participate in eye-care programmes.2Bechange S Schmidt E Ruddock A et al.Understanding the role of lady health workers in improving access to eye health services in rural Pakistan - findings from a qualitative study.Arch Public Health. 2021; 79: 20Crossref PubMed Scopus (8) Google Scholar, 7Krentel A Gyapong M Mallya S et al.Review of the factors influencing the motivation of community drug distributors towards the control and elimination of neglected tropical diseases (NTDs).PLoS Negl Trop Dis. 2017; 11e0006065Crossref PubMed Scopus (32) Google Scholar Task-shifting as an intervention has been developed to address persistent shortages of clinicians, particularly doctors and nurses, to maximise the use of the cadres available in or close to the communities. This purpose continues to be highly relevant in eye care in many low-income settings, particularly in rural and remote locations, where eye-care infrastructure and highly skilled eye-care personnel are scarce. It is not surprising that the corneal ulcer prevention programme evaluated by O'Brien and colleagues showed more promising results in rural areas than in urban and peri-urban locations. However, there is a growing body of literature demonstrating that community and lay workers often resent being given work meant for doctors and nurses without extra pay or other incentives.8Bhattacharyya K Winch P LeBan K Tien M Community health worker incentives and disincentives: how they affect motivation, retention, and sustainability. BASICS II, Arlington, VI, USA2001Google Scholar, 9Pente V Bechange S Jolley E et al.Task-shifting eye care to ophthalmic community health officers (OCHO) in Sierra Leone: A qualitative study.J Glob Health. 2021; 1107001Crossref PubMed Scopus (3) Google Scholar Therefore, if community-based eye-care programmes and task-shifting initiatives are to be implemented at scale, the feasibility and practicality of adding more tasks to community volunteers should be systematically assessed; and their motivation, resources, and incentives should be adequately addressed. The authors state that they provided support supervision and mentorship to the female community-health volunteers—and perhaps this might have been adequate during the study—but undoubtedly a longer-term incentive would need to be integrated into the health care system at the community level, where these volunteers are based. Despite the conclusions of the trial, the evidence presented by the authors is encouraging and supports the global goals set out in the World Report on Vision,10World Health OrganizationWorld report on vision. World Health Organization, Geneva2019Google Scholar which stresses the crucial need to ensure the equitable expansion of primary eye care through innovative approaches to reach people in remote settings; thus, accelerating progress towards universal eye health. We declare no competing interests. Village-integrated eye workers for prevention of corneal ulcers in Nepal (VIEW study): a cluster-randomised controlled trialWe did not detect a reduction in the incidence of corneal ulceration during the first 3 years of a community-based corneal ulcer prevention programme. Further study might be warranted in more rural areas where basic eye care facilities are not available. Full-Text PDF Open Access