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

Introduction

Evidence suggests that certain groups face substantial barriers to accessing eye care services. This study seeks to explore barriers and potential solutions as perceived by members of the population groups who are least able to access care in the context of four national eye screening programmes. We aim to use rapid yet robust mixed methods that allow us to identify generalisable findings and testable service modifications to improve equitable access to care.

Methods and analysis

This is a multi-phased exploratory sequential mixed methods study. First, we will conduct interviews with people purposively selected from the sociodemographic subgroups with the lowest odds of accessing care within each screening programme. Taking a phenomenological approach, we will explore their perceptions of barriers and potential service modifications that could boost attendance at eye clinics among people from these ‘left behind’ groups. We will use a deductive analytic matrix to facilitate the rapid analysis of qualitative data. Space will be made for the inductive identification of themes that are not necessarily captured in the framework. Sample size will be determined by thematic saturation. Next we will conduct a survey with a representative sample of non-attenders from the same left behind groups, asking them to rank each suggested service modification by likely impact. Finally, we will convene a multistakeholder workshop to asses each service modification based on ranking, likely impact, feasibility, cost, and potential risks. The most promising service modifications will be implemented and evaluated in a follow-on randomised controlled trial, the methods for which will be reported elsewhere.

Ethics and dissemination

This project has been approved by independent research ethics committees in Botswana, Kenya, India, Nepal and the UK. We will disseminate our findings through local community advisory boards, national eye screening meetings, in peer-reviewed journals, and at conferences.

Strengths and limitations of this study

• We have developed a bespoke rapid qualitative approach that is designed to deliver rich and robust data with speed and relatively low costs. Our approach is based on a prior scoping review of rapid methods.

• By using mixed methods we are able to move from rich data to statistically generalisable findings that can be implemented across four national programmes.

• Our project is embedded withing real-world programmes and will deliver actionable intelligence directly to policymakers, programme funders, and programme implementers.

• Our work places the experience and perspectives of ‘left behind’ groups at the very centre of programmatic quality improvement. This protocol has benefited from the active engagement of lay representatives in each of the four countries.