Projections show that the elderly in India will touch 19% of the country’s population by 2050. This increase will lead to a bigger demand for geriatric health care. Today, there is already significant inequity in the distribution of health-care facilities, with most health care concentrated in urban areas. As urbanization increases, the elderly living in rural regions will see growing inequity and even more limited access to health. The coronavirus disease 2019 (COVID-19) pandemic exacerbated these fault lines. Vulnerable communities like the elderly saw significantly poor access to eye care during the first and second waves of the pandemic. To address this inequitable access today and for the future, we have developed a pyramidal model of eye care service delivery which brings eye care closer to communities that need them. To better address the issues of access, especially for the elderly and other vulnerable groups like those with disabilities, we initiated “Eyecare on-call: Silver Sight Initiative.” We had initially published a concept note and pilot data in our previous publication. In this paper, we report a year’s experience of delivering eye care through this initiative. Briefly, the vision technician visits the home of the patients who place the request, performs basic torch light eye examination and refraction, dispenses glasses where possible, and refers patients to higher levels of care when needed.
Between Jan and Dec 2021, 1157 patients were examined. Mean age of the patients was 50.9 years (standard deviation [SD]: ±17.2 years); 289 (24.97%) were between 40-59 years,524(45.3%) were 60 years & older, and 601 (51.9%) were women. The World Health Organization’s (WHO’s) definition of vision impairment (VI) was used, that is, mild VI if better eye visual acuity (VA) is less than 6/12 to 6/18, less than 6/18 to 6/60 as moderate VI, less than 6/60 to 3/60 as severe VI, and anything worse than 3/60 as blindness. According to this classification, 627 (54.2%) had no VI, 156 (13.5%) had mild VI, 347 (30%) had Moderate-Severe Vision Impairment (MSVI), and 22 (1.9%) were blind. No referral was needed for 849 (73.4%) patients and they were managed in the comfort of their homes. Univariable analysis showed that age was a significant risk factor for VI, i.e. VI increased with increasing age (P < 0.001); however, gender was not a risk factor (P = 0.143). Table 1 shows the advice given during home care. Intervention in the form of glasses or referral was needed in significantly more females compared to males (P < 0.01) [Table 1].
A total of 308 patients (26.6%) were referred, of which 88 (7.6%) could not be traced, 42 (3.6%) did not attend, and two (0.17%) died. Out of the 176 (15.2%) who acted on the referral, 85 (7.3%) attended our centers while 91 (7.8%) attended other centers.
In those who did not attend, the following were the reasons: 27 (2.33%) patients wanted to ’come later’, 13 (1.12%) were ’not interested’, ’fear’ and ’no one to accompany’ were quoted by one patient each (0.17%).
When we approach elderly for home care, other members of the family as well as neighbors also want to have their eyes examined at the same time. Hence, a significant number of patients recorded were below 60 years of age. Another reason for others seeking this facility was that our home care services were free of charge. This led to many with normal vision seeking home care. Hence, while planning home care for elderly, we need to account for this secondary demand too, as this will have implications on the time that a technician will spend attending a visit. In the current model, some of our primary care technicians who manage our primary eye care “vision centres” shut them down when they service home care patients. It is likely that there is an opportunity cost to this approach as some patients might have visited the closed vision center during this time. In future, separate staff will be needed to provide home care. Also, 132 (42.85%) of the referred patients could not seek care. Hence, if teleophthalmology services are incorporated into home care, it is likely that some of these referrals can be managed at home itself and this reduces the dropout rate. Introduction of additional equipment like handheld slit lamp, fundus camera and tonometry is likely to enhance the quality of care.
In conclusion, there is growing demand for a home-based care providing health care to the elderly at their doorstep, and COVID-19 has only acclerated this need. We need to make modifications to this model if we need to scale it up across our network as well as in the country. Strong vertical referral linkages with clear guidelines and strong monitoring systems are important for proper implementation of this model. This model ensures significant savings – time, travel, risk, and energy – for our patients, ensures better gender equity, and improves community outreach.
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Conflicts of interest
There are no conflicts of interest.
1. Registrar General and Census Commissioner. Census of India 2011:Rural Urban Distribution of Population New Delhi Government of India 2011 Available from http://censusindia.gov.in
Last accessed on 2020 July 22.
2. Chauhan P, Kokiwar PR, Shridevi K, Katkuri S. A study on prevalence and correlates of depression among elderly population of rural South India. Int J Community Med Public Health 2016;3:236–9.
3. Dey S, Nambiar D, Lakshmi JK, Sheikh K, Reddy KS. Health of the elderly in India:Challenges of access and affordability. Aging in Asia:Findings from New and Emerging Data Initiatives.:National Academies Press (US);Panel on Policy Research and Data Needs to Meet the Challenge of Aging in Asia Smith JP, Majmundar M Aging in Asia:Findings From New and Emerging Data Initiatives Washington (DC) National Academies Press (US) 2012 15.
4. Muralikrishnan J, Christy JS, Srinivasan K, Subburaman GB, Shukla AG, Venkatesh R, et al. Access to eye care during the COVID-19 pandemic, India. Bull World Health Organ 2022;100:135–43.
5. Marmamula S, Yanamala NK, Khanna RC. “Eyecare on-call”–Extending the frontiers of care through home-based eye care–Concept and the protocol. Indian J Ophthalmol 2020;68:2625–7.
6. Rao GN, Khanna RC, Athota SM, Rajshekar V, Rani PK. Integrated model of primary and secondary eye care for underserved rural areas:The LV Prasad Eye Institute experience. Indian J Ophthalmol 2012;60:396–400.