Local co-ordination and case management can enhance Indigenous eye care--a qualitative study

Eye care delivery models to improve access to eye care for Indigenous peoples in high-income countries: a scoping review

Purpose

Globally, there are ~370 million Indigenous peoples. Indigenous peoples typically experience worse health compared with non-Indigenous people, including higher rates of avoidable vision impairment. Much of this gap in eye health can be attributed to barriers that impede access to eye care services. We conducted a scoping review to identify and summarise service delivery models designed to improve access to eye care for Indigenous peoples in high-income countries.

Methods

Searches were conducted on MEDLINE, Embase and Global Health in January 2019 and updated in July 2020. All study designs were eligible if they described a model of eye care service delivery aimed at populations with over 50% Indigenous peoples. Two reviewers independently screened titles, abstracts and full-text articles and completed data charting. We extracted data on publication details, study context, service delivery interventions, outcomes and evaluations, engagement with Indigenous peoples and access dimensions targeted. We summarised findings descriptively following thematic analysis.

Results

We screened 2604 abstracts and 67 studies fulfilled our eligibility criteria. Studies were focused on Indigenous peoples in Australia (n=45), USA (n=11), Canada (n=7), New Zealand (n=2), Taiwan (n=1) and Greenland (n=1). The main disease focus was diabetic retinopathy (n=30, 45%), followed by ‘all eye care’ (n=16, 24%). Most studies focused on targeted interventions to increase availability of services. Fewer than one-third of studies reported involving Indigenous communities when designing the service. 41 studies reflected on whether the model improved access, but none undertook rigorous evaluation or quantitative assessment.

Conclusions

The geographical and clinical scope of service delivery models to improve access to eye care for Indigenous peoples in high-income countries is narrow, with most studies focused on Australia and services for diabetic retinopathy. More and better engagement with Indigenous communities is required to design and implement accessible eye care services.

Non-clinical eye care support for Aboriginal and Torres Strait Islander Australians: a systematic review

OBJECTIVES

To describe research into non-clinical support eye health care for Aboriginal and Torres Strait Islander (Indigenous) Australians, the people who provide such care, and its impact on eye health outcomes.

STUDY DESIGN

Systematic review and qualitative analysis of peer-reviewed research publications.

DATA SOURCES

Peer-reviewed research articles published between January 2000 and July 2018 and included in MEDLINE/EMBASE, Web of Science, Informit, EBSCO (CINAHL and Anthropology Plus), or ProQuest Central.

STUDY SELECTION

We included English language, peer-reviewed articles reporting empirical data on non-clinical support for eye health for Indigenous Australians. Two authors independently assessed the titles and abstracts of 1678 unique articles for inclusion in a full text review; the full texts of 104 publications were reviewed, of which 77 were excluded and 27 included in our qualitative analysis.

DATA SYNTHESIS

Qualitative analysis identified five key areas of non-clinical support for Indigenous eye health: coordination of eye care, integrating and linking services, cultural support, health promotion, and social and emotional support. People who provide non-clinical support include eye health coordinators, Aboriginal Health Workers, primary care clinicians, family members, carers, and community-based liaison workers. The availability of non-clinical support is associated with increased patient attendance at eye care services, higher visual acuity examination and cataract surgery rates, broader eye health knowledge, and greater cultural responsivity.

CONCLUSION

Non-clinical support is critical for facilitating attendance at appointments by patients and ensuring that preventive, primary, and tertiary eye care services are accessible to Indigenous Australians. Greater financial investment is needed to support key providers of non-clinical support, especially eye health coordinators, community-based liaison officers, and family members and carers.

Using quality improvement strategies to strengthen regional systems for Aboriginal and Torres Strait Islander eye health in the Northern Territory

PROBLEM

In the Katherine region, Northern Territory, barriers to eye care for Aboriginal and Torres Strait Islander people include unclear eye care referral processes, challenges coordinating patient eye care between various providers, complex socioeconomic determinants and a lengthy outpatient ophthalmology waiting list.

DESIGN

Mixed methods participatory approach using a regional needs analysis, clinical file audit and stakeholder survey, to develop, implement and monitor quality improvement strategies.

SETTING

Collaboration with Aboriginal Community Controlled Health Services and regional eye care stakeholders in the Katherine region.

KEY MEASURES FOR IMPROVEMENT

Clinical audit data captured frequency and rates of primary eye checks, ophthalmology referrals and spectacle prescriptions. A survey was developed and applied to assess stakeholder perspectives of regional eye care systems.

STRATEGY FOR CHANGE

Quality improvement strategies informed by regional data (clinical audits and survey) included increasing service delivery to match eye care needs, primary eye care training for Aboriginal Community Controlled Health Services staff, updating Aboriginal Community Controlled Health Services primary care templates and forming a regional eye care coalition group.

EFFECTS OF CHANGE

Post-implementation, rates and frequency of recorded optometry examinations, number of spectacles prescribed and rates of annual dilated fundus examinations for patients with diabetes increased. There was a decrease in the number of patients with diabetes who had never had an eye examination. Eye care stakeholders perceived a marked improvement in the effectiveness of the regional eye care system.

LESSONS LEARNT

Our findings highlight the importance of engaging services and stakeholders to ensure a systems approach that is evidence-informed, contextually appropriate and reflects commitment to improved eye health outcomes.

Delivery of Eye and Vision Services in Aboriginal and Torres Strait Islander Primary Healthcare Centers

Background

Routine eye and vision assessments are vital for the detection and subsequent management of vision loss, which is particularly important for Aboriginal and Torres Strait Islander people who face higher rates of vision loss than other Australians. In order to guide improvements, this paper will describe patterns, variations, and gaps in these eye and vision assessments for Aboriginal and Torres Strait Islander people.

Methods

Clinical audits from 124 primary healthcare centers (sample size 15,175) from five Australian states and territories were conducted during 2005–2012. Main outcome measure was adherence to current guidelines for delivery of eye and vision assessments to adults with diabetes, those without a diagnosed major chronic disease and children attending primary healthcare centers.

Results

Overall delivery of recommended eye and vision assessments varied widely between health centers. Of the adults with diabetes, 46% had a visual acuity assessment recorded within the previous 12 months (health center range 0–88%) and 33% had a retinal examination recorded (health center range 0–73%). Of the adults with no diagnosed major chronic disease, 31% had a visual acuity assessment recorded within the previous 2 years (health center range 0–86%) and 13% had received an examination for trichiasis (health center range 0–40%). In children, 49% had a record of a vision assessment (health center range 0–97%) and 25% had a record of an examination for trachoma within the previous 12 months (health center range 0–100%).

Conclusion

There was considerable range and variation in the recorded delivery of scheduled eye and vision assessments across health centers. Sharing the successful strategies of the better-performing health centers to support focused improvements in key areas of need may increase overall rates of eye examinations, which is important for the timely detection, referral, and treatment of eye conditions affecting Aboriginal and Torres Strait Islander people, especially for those with diabetes.