Peek practice-based evidence framework

Background

Despite the tireless efforts of eye health workers, more than a billion people worldwide live with avoidable vision loss, and numbers are growing. Radical new approaches are needed.

Most cases of vision loss can be treated or prevented, but the challenge is getting treatment to the people who need it most.

Services need evidence-based, localised solutions to ensure that people receive treatment for eye conditions. Under-resourced programmes in low and middle-income countries (LMICs) often don’t have the capacity to carry out studies that would help improve their services.

The Project

The project aims to address this challenge by developing ways for eye health services to rapidly improve their efficiency by reaching the people least likely to attend services.

The main activity has been to develop and validate an agile service improvement methodology.

Essentially, this allows eye health service managers in LMICs to conduct high-quality implementation studies within existing eye care programmes.

The project is in collaboration with ICEH’s close partner Peek Vision, a social enterprise which provides a software system and data intelligence platform that tracks eye health patients from screening to diagnosis and treatment.

The project used Peek to carry out rapid testing of new interventions to improve access, without the immense resources, timescales and specialist skills typically required to conduct such studies.

The main objectives and stages of the project were to:

1. Find people who require care; record their socioeconomic (SES) characteristics and refer them to local clinics
2. Analyse clinic attendance data to identify which SES groups are the least likely to access care
3. Interview & Survey people from these groups to identify their barriers and their proposed potential solutions to test
4. Randomise feasible solutions to test whether they equitably improve access to care

Example

In an eye care programme in country X, the data from Peek shows that older women are the least likely to come to follow-up appointments and receive treatment (e.g. glasses or cataract surgery).

A group of older women from the local area are brought together for focused interviews, and provide feedback on why they didn’t attend services. Some of the reasons could be a lack of time, transport or information on where the follow-up services are. These interventions are then ranked by a wider pool of older women via phone interviews.

Lack of transport is identified as a key issue for the group, and subsidised transport to the local hospital proposed as a solution. Within the programme, participants are split into a control and intervention arm, with people in the intervention arm offered subsidised transport.

After two weeks, a statistical limit built into the programme is met, with the group receiving transport shown to be attending treatment more often. The intervention is then rolled out across the programme, increasing the number of people who successfully receive eye treatment.

The interventions are local and contextual, proposed by the individuals facing the greatest barriers to care themselves, so can improve uptake of services in that specific area. They are also found at much lower cost and with fewer resources than a typical trial.

Activities

An initial trial of the project was carried out in Meru County, Kenya.

In this area, only 46% of people identified with an eye problem during screening go on to access local clinics, with younger adults (those aged 18-44) being the least likely to receive care. In previous work, our team conducted interviews with non-attenders from this ‘left-behind’ group to explore how access to essential eye services could be equitably improved. They told us that better counselling and SMS reminders would improve access.

We developed enhanced counselling and SMS reminders, and tested them among two groups in Meru’s ongoing screening programme using Peek technology. Every seven days, an algorithm assessed whether more people in one arm were attending clinics according to statistical rules.

The algorithm stopped the trial after 30 days based on analysis of outcome data from 879 people. The attendance rate in 18-44 year olds was 32.1% in the control arm vs 39.0% in the intervention arm (it made no difference among other age groups).

This initial trial showed that an intervention suggested by an underserved population increased access to care. The embedded, adaptive, equity-focused approach has broad applications, and could potentially improve access to treatment across health care.

Future work

Future research will involve validating and refining the process so that it can be implemented across Peek-powered programmes, and scaling the model to address other health conditions, while also going beyond improving access to improving the quality of care received.

Publications

Published

Allen, L.N., Nkomazana, O., Mishra, S.K. et al. Improvement studies for equitable and evidence-based innovation: an overview of the ‘IM-SEEN’ model. Int J Equity Health 22, 116 (2023). https://doi.org/10.1186/s12939-023-01915-5

Allen LN, Nkomazana O, Kumar Mishra S et al. Sociodemographic characteristics of community eye screening participants: protocol for cross-sectional equity analyses in Botswana, India, Kenya, and Nepal. Wellcome Open Res 2023, 7:144 (https://doi.org/10.12688/wellcomeopenres.17768.2)

Allen LN, Azab H, Jonga R, et al. Rapid methods for identifying barriers and solutions to improve access to community health services: a scoping review. BJGP Open. 2023;7(4). https://doi.org/10.3399/BJGPO.2023.0047

[preprint] Allen L, Karanja S, Gichangi M, et al. Identifying barriers and potential solutions to improve equitable access to community eye services in central Kenya: a rapid exploratory sequential mixed methods study. medRxiv. 2024. https://doi.org/10.1101/2024.03.13.24304156

[preprint] Allen L, Karanja S, Gichangi M, et al. Identifying barriers and potential solutions to improve equitable access to community eye services in Botswana, India, Kenya, and Nepal: a rapid exploratory sequential mixed methods study protocol. medRxiv. 2024. https://doi.org/10.1101/2024.03.07.24303867

[preprint] Allen L, Kim M, Tlhajoane M, et al. Protocol for an adaptive platform trial of intended service user-derived interventions to equitably reduce non-attendance in eye screening programmes in Botswana, India, Kenya & Nepal. medRxiv. 2024. https://doi.org/10.1101/2024.07.16.24310491

Allen L N, Karanja S, Gichangi M, Bunywera C, Rono H, Macleod D, Kim MJ, Tlhajoane M, Burton MJ, Ramke J, Bolster NM, Bastawrous A. Access to community-based eye services in Meru, Kenya: a cross-sectional equity analysis. Int J Equity Health 23, 170 (2024). https://doi.org/10.1186/s12939-024-02244-x

In preparation / press

Allen L, Kim M, Gichangi M, Macleod D, Carpenter J, Tlhajoane M, Karanja S, Bolster N, Burton MJ, Bastawrous A. Enhanced patient counselling and SMS reminder messages to improve equitable access to community-based eye care services in Meru, Kenya: An embedded, pragmatic, individual-level, two arm, Bayesian, equivalence RCT within an adaptive platform trial.

Acknowledgements

The Peek Practice-based evidence framework is funded by a Wellcome Trust Collaborative Award in Science and funding from the National Institute for Health Research (NIHR) using Official Development Assistance (ODA) funding.

https://wellcome.org/grant-funding/people-and-projects/grants-awarded/peek-practice-based-evidence-framework

The work is being led by the International Centre for Eye Health (ICEH) at London School of Hygiene & Tropical Medicine, in partnership with Peek Vision, the University of Botswana and the Ministry of Health, Kenya.

Additional work is taking place in Nepal with Nepal Netra Jyoti Sangh (NNJS), and in India with Dr Shroff’s Charity Eye Hospital.

For more information, contact us.