BME Report – eye health care. June 2015 - RNIB
Eye health care in Wales: Increasing awareness of primary eye health care available to people from Black and Minority Ethnic communities.
Siân Biddyr , Eye Health Promotion Manager, RNIB Cymru
Dr Bablin Molik, Minority and Ethnic Communities Development Officer, Sight Cymru
Peter Garwood, Optometric Lead, Public Health Wales
Dr Nik Sheen, Eye Health Examination Wales (EHEW) Clinical Lead, Cardiff University School of Optometry and Vision Sciences.
Dr Siân Griffiths, Consultant in Public Health Medicine, Public Health Wales
Dr Tom Porter, Consultant in Public Health Medicine, Public Health Wales
This report is a culmination of work undertaken by a team from RNIB Cymru, Public Health Wales, Cardiff and Vale University Health Board, Sight Cymru and Cardiff University.
Eye Health Care in Black and Minority Ethnic Communities - Report September 2016
Table of Contents
This table consists of two columns and rows
|Contents |Page |
|1. Introduction |3 |
|2. Aim of Project |6 |
|3. Outcomes |7 |
|4. Target Groups |8 |
|5. Methodology |11 |
|6. Implementation of Project |21 |
|7. Qualitative evaluation data from focus groups` |25 |
|8. Quantitative evaluation data for uptake of eye examinations |56 |
|9. Summary and Conclusions |71 |
|10. Recommendations |77 |
|References |79 |
|Appendix |82 |
|Acknowledgements |92 |
1. Introduction
In Wales, Asian/Asian British account for the second largest ethnic group with 2.3 per cent of the population. Black/African/Caribbean/Black British are fourth with 0.6 per cent of the population. Whilst these percentages are very small, there are concentrations of these ethnic groups in cities, such as Cardiff, where Black and Asian ethnic groups make up a much larger percentage of the population with 10.4 per cent in total [1].
Asian and Black ethnic groups are at greater risk of eye diseases compared to the White population. Particularly eye diseases where patients often present with established disease, such as open angle glaucoma and diabetic retinopathy.
The prevalence of chronic open angle glaucoma (COAG) is higher in African/Caribbean and Black British group origin and these groups are approximately four times more likely to develop COAG [2, 3]. In addition, the disease seems to have a younger age of onset, progresses faster and is a more common cause of blindness compared to Caucasian populations [4-8].
Diabetic eye disease in more common in both Black [9, 10] and South Asian [11, 12] populations compared to White populations.
With Black and Asian ethnic groups more at risk of glaucoma and diabetes, approximately 1 in 10 people from an ethnic minority background over the age of 65 will experience serious sight loss. They are more likely to present with advanced disease and are more likely to become blind as a result of developing the condition [13]. Additionally, Black and Asian ethnic groups are under-represented on sight impaired registers [14, 15]. Medical treatment can prevent sight loss if eye conditions such as glaucoma are picked up early enough. Any delay in medical management leaves the patient at risk of permanent sight loss. Medical management for more advanced disease is more costly and sight loss leads to additional burdens on other health care sectors such as social services. It has been suggested that screening of at risk patients, such as those of Black ethnicity, for diseases like glaucoma may be cost effective [16]. Indeed, an Economic report suggested that education campaigns to BME communities may have the most economic impact of all interventions designed to prevent sight loss because their access to eye care services is lower than the average population and their undetected eye conditions are more likely to be severe [17].
The detection of eye conditions such as glaucoma or diabetic eye complications in primary care community optometrist practice is well established. Optometrists have the necessary training and equipment to be able to detect these sight threatening conditions. Optometry practices are also accessible to patients in the community, including Black and Asian communities.
There is evidence that Asian and Black communities in the UK are less likely to attend for primary eye care appointments [18-20]. Compounding this data is the fact that many of these communities are in areas of social deprivation and there is also good evidence that individuals from lower socioeconomic groups are less likely to access eye care services [18, 19].
There are many reported reasons why patients from Black and Asian ethnic groups do not attend an eye examination at an optometry practice. These include: not having any symptoms; the cost of spectacles; not realising optometrists have a wider role than just dispensing spectacles; that reduced vision is an inevitable consequence of ageing [21-23]. These stated reasons apply both to ethnic groups and to those individuals from lower socioeconomic groups, but there is further evidence that those from Black and Asian ethnic groups are more likely to see the GP for eye problems and did not realise their ethnicity put them at greater risk of eye disease [24].
There is a suggestion that Asian and Black and those patients from communities from a lower socioeconomic groups would more likely attend if a local optometry practice was available to them [25]. However, in Wales, there are actually a greater number of optometry practices in lower socioeconomic areas compared to those in less deprived areas (Peter Garwood, unpublished data).
Language has been cited as another perceived reason for services not being accessed, although studies have indicated that only small numbers of patients report this as a problem [22]. Whilst a lack of knowledge of language and cultures may be an issue for patients attending optometry practices, it is not always proven in studies and a small number of optometrists practicing in BME communities may be able to offer eye examinations in the required language [21].
Finally, Leamon et al [21] suggested that removing the retail element of an eye examination all together could improve service utilisation. In Wales, whilst not completely free of the retail element of optometric practice, an eye care service exists for Black and Asian ethnic groups to have a free, at the point of access, Eye Health Examination. This Eye Health Examination Wales (EHEW) is an eye care service provided by optometrists (opticians) in the community and is funded by Welsh Government. It is free for people who:
have eye problems that need urgent attention
have sight in one eye only
have a hearing impairment
suffer from Retinitis Pigmentosa
are of Black or Asian ethnic group
have seen another healthcare provider (GP, pharmacist) and they want you to see an optometrist
have dry (age-related) macular degeneration.
The Eye Health Examination Wales (EHEW) service is different from an NHS funded sight test. This is free for people:
16 or under
a full time student aged 16,17 or 18
over 60
on certain benefits
over 40 and has a close relative who has glaucoma or diabetes
Certain patients may also be eligible for optical vouchers to assist them in the purchase of glasses or contact lenses.
2. Aim of project
The aim of the project was to increase public awareness of eye health and the free eye health care available to people from Black and Minority Ethnic (BME) communities in South Cardiff.
This included, increasing awareness of:
Eye Health Examination Wales (EHEW), an extended eye examination funded by Welsh Government, available for at risk groups
Eye health and eye disease
Additionally, to determine if increased awareness in BME communities resulted in an increase in service use and to explore the barriers to accessing primary eye care services amongst the study population.
The project was commissioned and given some initial funding by Public Health Wales. It was project managed by RNIB Cymru and implemented and further resourced by RNIB Cymru, Sight Cymru and the EHEW clinical lead at Cardiff University School of Optometry over a six month period from October 2013 to March 2014. Following the intervention, data was collected and analysed to evaluate the project and this took place over a period of 12 months.
An advisory group was organised to inform and steer the project with members from Cardiff and Vale University Health Board, Sight Cymru, RNIB Cymru, Public Health Wales, Optometry Wales, South East Wales Optometric Committee, Community Pharmacy and the Clinical Lead for EHEW.
3. Outcomes
The main outcome of the project was to provide evidence of whether the pilot intervention promoted increased awareness amongst BME communities of the importance of eye health and increased uptake of sight tests and relevant examinations under the EHEW eye care service.
The results of the pilot are intended to inform best practice of ways to engage with specific BME communities on eye health and to explore the barriers to attendance for primary eye care for BME groups by using focus groups.
4. Target groups
4.1 BME communities
The project was carried out in South Cardiff, mainly in Butetown, Grangetown and Riverside as these are areas with the highest population of BME communities in Cardiff. The following table shows the breakdown of the different population groups with figures obtained from the Census 20111 (Office of National Statistics, 2011).
Table 1: Census data of ethnic groups in project area (2011).
|Butetown, Grangetown and Riverside wards in Cardiff |
|2011 Census |
|Total population |43281 |
| | |
|Main population groups in the area |Percentage |
|White (total) |64.8 |
|Pakistani |5.4 |
|Indian |5.0 |
|African |4.6 |
|Mixed/Multiple |4.3 |
|Bangladeshi |4.2 |
|Arab |3.3 |
|Other Asian |2.3 |
|Other Black |2.2 |
|Chinese |1.5 |
|Other |1.4 |
|Caribbean |0.9 |
Figure 1: Percentage of Black and Asian ethnic groups in regions of Wales, according to ONS Census 2011.
[pic]
A decision was made to specifically target five main BME groups for the project intervention. The ethnic groups chosen were those with the highest population figures in the area in addition to research available showing that these groups were at particular risk of certain eye conditions.
The groups chosen were also dependent on the availability of community eye health champions who were interested and willing to take part in the six month project. The recruitment and selection of the champions/champions is described in more detail in section 5.2 below.
Therefore, from the 2011 census population figures for the area, research and the availability of relevant community champions, the specific BME groups chosen were:
Pakistani,
Indian,
African (incorporating African-Caribbean and Somali),
Bangladeshi and
Chinese.
4.2 Raising professional awareness
Professionals were informed about the project, so that they were aware of the intervention and were able to prepare for an increase in the number of enquiries, sight tests and relevant eye examinations. Optometrists were informed about the pilot via a series of E-Mails before and during the study period.
The following professional groups identified for this included:
GPs and Health Board Community Directors
GP registrars
Accident and Emergency staff (medical, nursing, administrative)
Pharmacists
Health visitors
Optometrists (as described above)
Local community organisations were also sent information about the project so that they could raise awareness within their communities. Information was sent to Communities First in Grangetown/Butetown to publicise in their local BME health bulletin and to Diverse Cymru in Canton.
5. Methodology
The methodology involved several stages. These included: the recruitment of relevant champions/champions, providing eye health training for the champions, the delivery of eye health messages to the communities during the implementation phase and finally the evaluation at the end of the six months. The approach and methods used for each stage is described in more detail in the following sections.
5.1 Recruitment of eye health champions/champions
The project intervention involved utilising a community eye health champion approach to disseminate information to the specific BME groups. These were volunteers or community workers who were interested in delivering eye health messages to their communities. The majority had completed and gained a certificate in the train the champion training course in eye health run by Sight Cymru in 2011. The course included sessions covering eye health and eye conditions and the development of skills to enable the participants to give out information to others. The champions also had experience of working or being actively involved in their various communities and an understanding of the various cultures within their communities. They were familiar with key events and daily activities that occurred, so understood how best to target these communities and deliver eye health messages.
The train the champion programme utilises the approach that people listen to the people they know and trust. People can identify best with someone from their community who they are familiar with and who can speak their language if they are not fluent in English.
The model involves a knowledge-and skill-based training delivered by a professional instructor/facilitator that creates a team of certified champions who are capable of providing basic health training to others.
The community champions identified for the project were from the main BME communities identified by the 2011 Census data for the area, in addition to the Chinese community.
However, some of the community champions that were contacted were unable to be involved in the project because of other commitments or having left the area, so local contacts and community organisations were approached in order to identify additional relevant individuals from the main communities. It was important to ensure that these new individuals were motivated and interested and would be committed to attending a training course and promoting eye health in their communities.
The community champions that had completed the train the champion training and were keen to take part in the project were from the following BME communities:
Indian/Gujarati
Pakistani
Chinese
Indian/Bengali/Bangladeshi
Yemeni/Arabic
Additional individuals to support work in the Somali and African-Caribbean communities were identified by liaising with BME organisations (eg, Communities First) in the area.
The majority of the community champions were female, but two additional men were identified from community organisations so that they could specifically work in men’s groups in their communities.
Even though the Yemeni/Arabic community was not a specific target group for this project, the champion concerned, worked with community groups from a range of BME groups so could give out eye health messages to these groups.
Information about the nine different champions recruited for the project is summarised in the following table (Table 2). Some of the champions worked within their communities whereas others were just active members in a voluntary capacity.
Table 2: Background information about the community champions recruited for the project.
The following table consists of three columns and nine rows
|Community |Gender and general information |Previously completed community eye |
| | |health champion training |
|Somali |Female and works in Somali community |Yes |
|Bangladeshi |Female and works in Bangladeshi community |Yes |
|Pakistani |Female and works with carers from various BME communities |Yes |
| |(Pakistani, Bangladeshi and Somali communities) | |
|Pakistani |Male and works in Pakistani community |No |
|Chinese |Female and works in Chinese community mainly with older people. |Yes |
|Yemeni/ Arabic |Female and works for AWETU (mental health organisation) at Diverse |Yes |
| |Cymru with different communities | |
|Somali (covers |Two females and both work at BAWSO (a BME organisation for women who |No |
|African-Caribbean |have suffered abuse) with women from different BME communities | |
|community) | | |
|(two) | | |
|Somali |Male and works in Somali community, interpreting and advocacy |No |
5.2 Initial meetings with the community champions/champions
Several meetings were held with the community champions in the 12 months leading up to the project. These were set up in order to provide information about the project and to establish which champions were interested in becoming involved and able to commit to the six month pilot project. At these meetings the intervention design was explored and discussed including the best and most practical ways of disseminating eye health messages to the community.
This ensured that the knowledge and expertise of the community champions was utilised at all stages of the project and that the project was designed adopting a community development approach.
A project plan was developed and a timeframe to implement the project.
It was agreed that the project would not focus on a specific age range, but that eye health messages would be given out to all age ranges within the BME communities being targeted. Messages would be given out to adults, families and children at the different community activities and events.
5.3 Eye health training for the champions/champions
Two training days were organised in September 2013 for the nine community volunteers. The aim of these were to provide refresher training for those who had completed eye health training in 2011 in addition to providing sufficient knowledge for those candidates without previous knowledge.
The training days were held at the Wales Optometry Postgraduate Education Centre (WOPEC) and delivered by RNIB Cymru, Sight Cymru and the Clinical Lead for EHEW based at WOPEC in Cardiff University School of Optometry and Vision Sciences. Areas covered included: knowledge of eye conditions and increased risk for certain BME communities, the importance of eye health and how to look after your eyes, eye examinations and those specifically available for people from BME communities, ways to disseminate eye health messages to communities and resources available to support this. The sessions were as interactive as possible involving lots of discussion and using practical materials such as photographs of the eye, a model of the eye and Sim Specs to explain various eye conditions. (These are a set of ten spectacles which simulate symptoms of common eye conditions. They have been designed by professionals and are used as a training aid for understanding visual impairment.)
5.4 Planning activities in communities to give out eye health information
Following the training, the champions were asked to identify four or more relevant activities they could organise or tap into within their communities, to deliver eye health messages over the following six months. These activities could be wide ranging and include: major community events (eg, Diwali for the Gujarati community or health events for the Somali community), meeting with community groups such as local coffee morning groups, prayer groups or carers groups, or having informal one to one conversations with individual community members.
The champions were encouraged to choose the activities which they thought were appropriate for their communities and their personal involvement and then to decide how best they could disseminate eye health information at those events. For example, this might involve giving talks to a group of people, setting up an eye health information stand at a community event, or just speaking individually to people about eye health or perhaps in everyday conversation.
5.5 Resources
Each champion was given a resource pack which contained information from the training days, power point presentation slides (hard copy and electronic) with photographs of different eye conditions to assist with giving eye health talks, documents to keep a log of activities they were undertaking, evaluation sheets to record numbers attending these activities and feedback from participants, RNIB eye health leaflets, booklets about main eye conditions, information sheets from the EHEW Clinical Lead about Eye Health Examination Wales and a list of EHEW accredited optometrists. Information sheets were translated into different languages. These included: Mandarin, Gujarati, Pakistani, Bengali, Arabic and Hindi.
5.6 Support sessions and resources throughout the six months project intervention phase
Four additional support sessions were organised throughout the six months of the project providing an opportunity for the project leaders and champions to get together, review progress, share learning and plan future activities. Attendance at these training days varied as the champions were attending in a voluntary capacity outside of their work time or other commitments.
Project leaders also provided support for the champions by regular emails, phone calls and one to one meetings in order to help and encourage them as much as possible and to monitor progress. Additional resources such as RNIB eye health leaflets, information sheets about Eye Health Examination Wales (EHEW) translated into different minority languages, handouts showing various eye conditions and Sim Specs were provided. Project leaders also attended many of the community events or small group meetings to deliver eye health talks.
5.7 Evaluation of the project
The project was evaluated by collecting both quantitative and qualitative data.
The data aimed to:
Assess the effectiveness of the intervention in increasing the uptake of sight tests and relevant eye examinations (GOS and EHEW) by people from BME communities in Cardiff City and South. (Quantitative evaluation)
Assess the acceptability and perceived effectiveness of the methods used in raising awareness of eye health and eye examinations by both the community champions and the communities themselves.(Qualitative evaluation)
More information about each of these data sets is given below.
5.7.1 Quantitative data collection
Data for the project on numbers of EHEW examinations were collected by the NHS Shared Service Partnership and the Welsh Index of Multiple Deprivation data was collated by the Public Health Wales Observatory.
The number of patients attending for an EHEW on the basis of their ethnicity was collected over an 18 month time period (April 2013 to September 2014) across all Health Boards in Wales and in the Cardiff City and South regions where the interventions took place.
The number of patients attending for an EHEW whose ethnic groups was either Black or Asian was collected over an 18 month time period (April 2013 to September 2014) across all Health Boards in Wales and in the Cardiff City and South regions where the interventions took place.
Uptake by ethnic group was calculated for the six months prior to the intervention (April 2013 to September 2013), six months during the intervention (October 2013 to March 2014) and six months after the intervention (April 2014 to September 2014). This allowed trend information to be produced.
In order to allow for the potential confounding effects of national promotional work, equivalent uptake and uptake rates were calculated for an age/ethnicity matched population of a similar size in a different health board area. Whilst the closest match was in Aneurin Bevan in Newport, this area was also involved in promotion activity by Sight Cymru and so was not used as a comparative area. Instead, Abertawe Bro Morgannwg University Health Board was used to determine if there had been an increase in uptake in EHEW services on the basis of ethnic group.
5.7.2 Qualitative data collection
About the focus groups
Krueger and Casey [26] recommended the use of focus groups in research to discover the range of ideas or feelings that people have on a subject and to understand different perspectives between groups of people. The purpose is to uncover factors that influence opinions, behaviour or motivation, and hence are an appropriate methodological tool to explore reasons for attending or not attending for eye examinations.
Information was collected from four focus groups. One was held with the community champions and three with different BME community groups. An individual interview was carried out with one of the champions who was unable to attend the focus group.
The focus group with the community champions involved four participants representing the Somali, Gujarati, Pakistani (but also working with mixed BME carers) and Yemini communities (also working with mixed BME groups). The individual interview was carried out with the Chinese community champion.
The focus groups with community groups involved one with the Somali community (n=5), one with the African-Caribbean community (n=6) and one with the Gujarati community (n=12). Numbers varied according to attendance on the day.
The groups were mixed in gender and ages, mainly 40 years plus (although specific ages were not recorded).
A focus group interview schedule was used to ensure that each group was asked a consistent series of questions. The questions were open questions aimed at encouraging participation and discussion. Questions were agreed in advance and tested on a pilot group of volunteers.
At least two trained facilitators attended all of the focus groups with one asking the questions and the other asking supplementary questions. The two facilitators were two of the project leaders. A third person from Cardiff and Vale University Health Board observed and took notes. The groups were also audio recorded. On average the focus group discussions lasted 75 minutes, with a total of 600 minutes of data collected. Notes were written up and audio recordings were transcribed to support the data. The information was analysed using a thematic approach27 by three of the project leaders.
Focus groups with champions
The focus group and interview with the community champions discussed how the champions felt the project went, which activities they had chosen to give out eye health messages, methods and approaches that worked well when trying to engage the communities and what not so well, and barriers and enablers to accessing eye care. The training and support provided for the champions was also discussed and whether this enabled individuals to feel confident disseminating eye health messages. Also how useful the resources were and additional resources that would be useful in the future.
This part of the evaluation aimed to tease out whether the eye health messages were appropriate for that particular community in achieving the aims of the project and whether the community champion’s own approach was effective. This was also intended to help demonstrate which type of event is more suited to a particular community group, etc.
Focus groups with the communities
The three focus groups involving the Gujarati, Somali and African-Caribbean communities aimed to assess the impact of the project within those communities. These particular community groups were not chosen specifically over other communities but were groups that the community champions were willing and able to help organise. The participants invited to the group were from people in the community who had received eye health messages through attending relevant eye health talks, events or activities.
These groups discussed whether the activities had increased awareness of eye health and whether this had resulted in any behaviour change (for example, going for an eye examination). Barriers and enablers to eye exams were also explored along with participants’ experience of local eye care services and attending eye examinations.
5.7.3 Evaluation sheets for activities
Community champions were also asked to record information about each of their activities on an evaluation sheet. This included: the type of activity, the way in which eye health messages were disseminated, the number of individuals attending, gender and feedback or comments from individuals.
These were collated at the end of the project to provide some descriptive information about the range of activities used by the champions.
However the completion of these forms was variable from champion to champion and tended to dwindle as the project progressed. The champions seemed to find it fairly onerous and said that at the time of carrying out the activity they often didn’t have time and forgot to record the information.
The information therefore collated from this part of the evaluation is not consistent for all activities and all champions.
5.7.4 Interviews with two optometric practices in the target area
Following the review of the data on uptake of EHEW and GOS after the project had finished, two optometric practices were selected for interview where uptake of eye examinations of people from BME groups, was higher than others in the area. This was to explore possible reasons for people from BME communities attending these practices, so that good practice and learning could be shared with other practices.
Both practices were contacted over two days in February 2015 to discuss how they operate the EHEW service with regards to patients eligible for a Band 1 on the basis of their ethnicity. Questions were chosen to equally represent and balance both positive actions that encourage patients and possible barriers to providing a good service.
In each practice, a full time optometrist was asked the following six questions:
Question 1: How do you identify if those patients who come into the practice are eligible for EHEW, what about on the telephone?
Question 2: What processes do you use to ensure patients have access to the service?
Question 3: How do you cope with patients who have language difficulties?
Question 4: What do you think your practice does to appeal to these patients?
Question 5: Is there anything you find especially difficult when seeing these patients about the EHEW service itself?
Question 6: Is there anything you find especially difficult about the patients themselves?
6. Implementation phase of the project - activities carried out in the communities
This section describes the stages within the implementation phase of the project
6.1. Activities carried out by the champions in the different communities.
During the six months delivery phase of the project, the champions carried out activities in the various communities. These varied widely and a table showing all the activities where eye health messages were given is given in Appendix 1. However a summary of the activities and total numbers reached is given below.
An important point to note is that the community champions were involved in the project in a voluntary capacity or were trying as far as possible to incorporate this into their work. They attended the training and the training days in their own time, and much of their capacity for involvement in the project was due to their own commitment. The success of the work in some communities is due therefore to the champions own personal commitment and hard work. Several champions who seemed very motivated and keen to be involved in the project at the start, were not able to continue after the training had finished because of other commitments.
The community champions with sustained input throughout the project were from the following communities:
Chinese (working mainly with the older Chinese community),
Indian (Gujarati),
Pakistani but working with mixed communities (BME carers),
two Somali champions (working with mixed female groups including African-Caribbean) and
Somali male (working with this community as an interpreter and advocate. As a male champion he was also able to reach male only groups)
Summary of eye health activities carried out by the six main community champions and numbers estimated to have reached. October 2013 to March 2014
Chinese community involved:
A talk given by one of project leaders to 30 older people at a community group
An article sent out to 200 older people in their local newsletter about eye health and eye examinations
The community champion booking over 40 eye health examinations and local optometrists and where necessary accompanying individuals to appointments if they required language support
Home visits and bringing eye health into health conversations for up to 50 older people and families.
TOTAL 320 plus
Gujarati community involved:
A talk/presentation by the community champion, given to 200 members of the community at a Gujarati dance night
Eye health messages and 52 eye health leaflets given out at a community centre and lots of questions asked about eye conditions
An eye health presentation by the community champion given to 250 people at a Diwali event. Eye conditions were explained and the community were keen to have copies of the presentation slides with photos of the eye. Eye health leaflets were given out.
Individual conversations about eye health carried out by the community champion to 15 people
TOTAL 517 plus
Two Somali community champions working with BME female groups
Eye health leaflets and information given out by the community champions to 100 people at an event for International Older People’s Day in Butetown Community Centre
Eye health talk given by a project leader to 20 individuals at a Somali and mixed Asian women’s group
Eye health talk given by a project leader to 20 individuals at a Bangladeshi, Somali and Pakistani women’s group
Eye health talk given by a project leader to 20 Somali men at a men’s group
Eye health talk given by a project leader to 10 individuals at an African-Caribbean women’s group
TOTAL 170 plus
Pakistani community champion working with BME carers groups
Eye health information and leaflets given out by community champion to 500 BME carers at group meetings at the carers centre and during one to one home visits.
Information was also given out to family and friends with the carers.
TOTAL 500 plus
Somali male community champion working with Somali men
Meetings with different organisations about raising awareness of eye health – reached 50 people
One to one conversations with 15 individuals in the community about eye health. These discussions took place as a result of work in community but also outside of work as an active community member.
Talking to 10 men attending a local gym class about eye health
Asked Iman at mosque to give out eye health information to 15 men after prayer time
Eye health presentation and information given out by project leader to 70 people at a Somali young people and families career day event. The community champion provided interpretation for the group.
Horn health event. Health presentations given to 70 members of the Somali community including an eye health presentation from the project leaders. The community champion provided interpretation for the group.
TOTAL 230 plus
Additional events
Project leader giving presentation to 8 people from different communities at a SSIA (Social Services Improvement Agency) community group meeting
Individual conversations about eye health to five community members and families
A BME communities health fair with a section providing information on eye health and helping individuals book appointments with optometrists. Various eye health partners were involved in helping with this along with the three project leaders. 71 people attended the eye health section receiving information about eye health and over 36 eye examinations appointments were booked with optometrists.
TOTAL 84
Total number of people attending eye health activities or receiving eye health messages during the six month project intervention period is approximately 1,821.
7. Evaluation
A huge amount of rich data was generated from the project and this is presented in three main parts of this section of the report. The first part of the evaluation data involves information obtained from focus groups held with the community champions and different BME communities.
The second part of the evaluation data reviews the uptake of eye examinations before, during and after the project had finished.
The third part involves data following interviews with two optometry practices in the project area where uptake of eye examinations by people from BME groups is relatively higher. This was to explore some of the reasons why these practices had been successful in achieving a high attendance from people from BME communities so as to share good practice and learning with other optometry practices and inform the recommendations.
7.1 Analysis of the focus groups
This section includes three sets of focus group analysis. The first involves the analysis of the focus group with the community champions, the second is followed by the analysis of the focus groups with three minority communities and the third involves views that both groups held over their perceptions of accessing primary eye care.
The focus group with the community champions explored themes around their training and whether they felt it had equipped them with sufficient skills and knowledge to give out eye health messages to the communities. Also they were asked to reflect on which activities they felt had been most effective in delivering eye health information.
The focus groups with the community groups explored their understanding of eye health and the activities that they felt were useful in helping them increase their knowledge around eye health.
The third part of this analysis involves feedback from both the champions and community groups about their views on the barriers, enablers and experiences of accessing primary eye care optometry services. The data is combined as both the champions and community groups lived in the area and had experience of using these services.
7.1.1 Analysis of focus group with community champions
A focus group was held with the community champions. Four attended including champions from the Gujarati, Somali, Pakistani, Yemini communities. The Pakistani and Yemini champions worked with mixed BME carers and groups respectively.
An interview with the champion from the Chinese community was held separately as she was unable to attend on the day of the focus group.
Other champions were unable to attend the focus group and were not available for separate interviews.
A semi-structured focus group schedule was devised and involved open questions about the training, eye health activities, resources and barriers and enablers to accessing services.
The focus group and interview were recorded with notes taken.
The following analysis is based on the main themes which arose during the discussion. These themes were identified by the three main project leaders reading through the transcripts of the focus group and interview. Some of the themes are based around the questions asked whereas others are issues that were emphasised by participants in the discussion.
Eye health training
The champions were asked about different aspects of the training to find out what they had learned and whether they felt that it had equipped them with sufficient knowledge and skills to be able to deliver eye health messages to their communities.
One of the key responses was that they felt that learning about the different eye conditions was very useful, especially explaining them using photographs of the eye.
“The pictures of different eye conditions were very useful. The pictures were a powerful tool, visually seeing the back of the eye changing.”
They felt that it was important to understand the different eye conditions and be able to explain to the community the eye conditions for which they might be at particular risk.
“Need to raise awareness in BME communities of the (eye) diseases they are more likely to get”.
“The useful part of the training was that we could discuss different issues in different communities and how certain people are at risk of eye diseases.”
The community champions said they found the training course easy to understand. They said that often the words used to describe eye conditions were too technical and not easy to translate. It was important to explain things as simply as possible so that people could understand.
“The first part of the training was very good, explaining it simply with visuals as technical words are not always able to be translated. The first step is getting someone to think about an eye test. If an English speaking person cannot understand the words it is difficult to train others.”
How did the training enable the community champions to give out eye health messages?
Giving talks
One of the most popular ways the champions chose to give out information was through eye health talks to community groups.
They were asked if the training enabled them to feel confident doing this as supporting them to give talks to groups was one of the objectives of the training course. However during the six months of the project, most of the champions had contacted the project leaders to deliver the talks to their groups. This was discussed in the group and the champions said they preferred the project leaders to deliver the talks.
Several champions said that they felt confident talking to smaller groups or with people they knew, but felt that a professional from eye care had more impact with larger groups.
“...very good to have the opportunity of Nik coming to speak to the community because he’s a professional”.
Others said that they could give out simple messages but felt they needed more training to feel confident giving talks.
“I see a lot of different people through the groups I hold. Not sure I would go into detail just encourage them to have their eyes tested, that’s how I do it. Need to raise awareness in BME communities of the diseases they are more likely to get.”
“Further training is essential... the training needs to be much longer and more in depth and perhaps certified from Cardiff University. Train someone for three months. It will help gain trust and makes it feel like something special.”
This champion also suggested a way that eye health talks could be integrated into community activities in the future.
“Link up with grass roots community groups and voluntary groups, they can organise us to attend any events and include eye health talks. People will be coming to the events for a variety of messages. People who come want to be referred straight away. Need to integrate into local grass root events.”
One champion however, did feel confident and gave several presentations to large groups of people (approximately 200) at community events.
Another champion provided information on a one to one basis.
“both one to one and groups worked well”
“yes. I see people one to one and am able to make them aware of what they need. Explaining the importance of getting the check before it is too late.”
Using practical resources to explain eye conditions
The champions thought that practical tools to explain eye conditions to the community were very helpful and they had used these alongside presentations and talks.
“Some resources such as eye models and sim specs are helpful, especially for communities where literacy is bad.”
“The Sim Specs were a practical tool.”
Eyecare Wales website
The training for the community champions involved encouraging the community champions to use the Eye Care Wales website. This was so that they could look for WECS accredited optometrists in the area where individuals from the community lived or wanted to go for a test.
However the champions said that they hadn’t used the website at all and that they didn’t think the community would use it.
They explained that when they were going to events or meeting groups and giving talks in the community they often didn’t have access to the internet and the Wales eye care website so weren’t able to use it. They also felt that community members wouldn’t use it and would need someone to help them.
“most people you would have to do it for them.”
They thought that the site could be improved and that it would be useful to identify BME languages that optometrists spoke and were willing to conduct the test in.
“…to find an optician who spoke the language of the patient.”
The Chinese champion said that many of the Chinese older people preferred to see a Chinese optometrist and thought it would be useful to identify all the Chinese optometrists in Cardiff on the WECS accredited list of optometrists.
“However there is not enough information for them to make a choice of which optician to go to and because of the language barrier. It would be helpful if there was information about the languages that opticians speak…..It would be useful to identify all the Chinese optometrists in Cardiff and show this on the list.”
“On the list of WECS optometrists from eye care Wales it didn’t include any Chinese optometrists. But since the training a Chinese optometrist in Grangetown has come and introduced himself and is interested in Chinese people going to see him.”
Which eye health activities did the champions deliver in their communities?
Eye health messages were given out in various ways in the different communities. The activities varied according to the types of events that took place in the communities and the way in which the champion was involved with their community. Some of the champions worked with BME carers, older people, BAWSO or provided advocacy services, whereas others were members of the community groups themselves (Gujarati). All champions organised eye health talks for the groups they were involved in and these ranged from small groups of six to ten people, to larger events such as Diwali (n=200), the Somali health event (n=70) and the Somali family career day (n=60). Champions also discussed eye health on a one to one basis and with their own family and friends. Information about the activities and numbers reached in each of the communities is summarised on pages 12-14 and a table listing all the activities the champions carried out is in appendix 1 on page 86.
The varied experiences of each of the champions in delivering eye health messages in each of their community groups is described below. These are described separately so that we can see what sort of activities are preferred by the different communities. However, these groups are fairly small so we cannot generalise from this information.
Activities carried out by each champion in their BME communities
Champion working with BME carers (mixed)
This champion worked with carers and families from various BME communities at a carers centre. She organised group sessions and visited people and families in their homes.
“I talked to people one to one and groups that I worked with. I always had a leaflet in the folder to remind me in general chit chat and I would bring up the subject for the family. Both one to ones and groups work well. I was also able to talk to families and friends who were there at the time”.
Champion from the Gujarati community
This champion was involved in delivering eye health messages to the Gujarati community at different types of social and community events.
“family and friends were advised about the advanced eye test. I also spoke to large groups at Diwali.”
Champion working with the Somali community
This champion was part of and work as an interpreter and advocate in the Somali community. As a male he was able to work in both mixed groups and men only groups.
“I’ve done group work and especially in settings where they are going for something else, asking the Imam at the mosque if I can have five minutes to talk about eye health and getting the Imam to say how important eye health is. Talking in fitness sessions, at the beginning of the session there is always a health message, people listen when it is informal. Also at public lectures and health seminars, people still ask me how they get to see the optician. Groups are better than one to one and it’s better to go to them in a setting they feel comfortable.”
Champion from the Chinese community
This champion worked particularly with older people in the Chinese community providing interpretation services and organising community activities. She was involved in home visits.
The champion described the different activities she had organised in her community:
“Nik came to give an eye health talk, we put information in the newsletter sent out to all the homes of Chinese people in the community, I arranged for 30 people to go to the Canton optometrist and provided an interpreter”
She talked about how Chinese older people preferred to see a Chinese optometrist. She also raised the issue of Chinese people not understanding how EHEW differed from a general sight test and this caused a lot of confusion in the community as they weren’t sure what they were entitled to or, what they might have received previously and what to ask for.
“We haven’t started to book appointments with the Chinese optometrist in Grangetown yet. I’ll arrange for him to come and give a talk. I’ll discuss the issue around the confusion between sight tests and EHEW with him.”
She explained that she was a community worker and as she was doing home visits she asked people whether they attended regular eye exams and how important this was.
She also gave talks to small groups using the Sim Specs.
“...I gave a talk and I borrowed the Sim Specs”
Eye health activities that worked well
The champions were asked whether they had any feedback from the community about the activities and those that had worked well.
The popularity of talks both to big groups and on a one to one basis was discussed.
“both one to one and groups worked well”
All the champions agreed that the project had encouraged people to go for an eye test and that even if people didn’t make an appointment immediately, it had increased awareness of the importance of regular testing.
“...the talks encouraged people to go for an eye test”
“they may not rush to do it but they are now aware to ask”
“Before the training, the community didn’t know much about eye health and how important it is to have eye examinations, but after Nik gave a talk and said about having regular check-ups, the Chinese community realised the importance of these.”
“I booked lots of appointments for Chinese people and went with them to appointments as an interpreter or arranged for an interpreter to go with them.”
The champions thought that eye health talks should be organised on a regular basis and should be included in other eye health talks/discussions. It could also be part of everyday conversations.
"…talks to the over 50s ladies group about eye health and other health issues should be every year to 18 months, it is general reminders.”
“…should be every six months”
“Eye health should be included in all health discussions.
“…bring it up in a conversation… and take any opportunity”.
Limitations of being a volunteer
Even though the champions found the training useful and were keen to give out eye health messages in their communities, they mentioned that they felt the project was limited because they were volunteers. They said how they were not paid to deliver the project and it was sometimes difficult fitting this in with their other work and life commitments. The champions had to attend the training days and the four support training sessions provided during the six months, in a voluntary capacity. They thought that this needed to be considered with the planning of future projects and that funding should be allocated.
“We all have busy lives and demanding jobs, anything voluntary sometimes becomes secondary. We need further grants to take the service further.”
“Voluntary people should be complimenting the service and not the service.”
Impact of project
The champions were asked about the impact of the project on them and what they had gained as a result of being involved.
“I am able to raise awareness of different eye conditions.”
“I learnt about the diseases for myself and the community”
“It empowered us with knowledge we are able to pass on. “
“Being involved in this project has been very good for the Chinese community as it is important to raise awareness of eye health.”
One of the champions talked about how he and his children had recently been for an eye examination.
“I have been to the optician and I take the children. I talk to my family about eye health and its importance. My son was being teased at school and not wearing glasses, after a long discussion he has started using them.”
“training has been important”
Future work
When the champions were asked if they would continue promoting eye health messages all said yes.
“yes, I’m always thinking of eye health”
“I continue to express the importance of the message and it is being done for free.”
“yes, work is demanding so I cannot commit fully to training but I would always give the message out.”
The group thought that more people should be trained to continue with the work.
“yes, training more people, that would work.”
“ providing refreshments, to get people to come to sessions.”
“it should be part of the training of students.”
“get the students to go on a placement so they can see how it works within a BME diverse community. As individuals they can relate to one another, it is not just the language it is also the culture. Also, some benefits/incentives for people to work in the BME communities.”
7.1.2 Analysis of focus group data with BME community groups
Three focus groups were held with different communities. These involved the Gujarati (n=15), Somali (n=5) and African-Caribbean (n=8) communities.
The community champions organised the focus groups and also attended and contributed to each of the discussion sessions.
A schedule was created involving a series of questions that encouraged discussion about eye health and the activities that had been organised in the communities. The schedule was followed in all focus groups ensuring consistency and to enable the results to be compared. Each focus group was digitally recorded and notes taken.
The following analysis is based on the main themes which arose during each of the discussions. These themes were identified and agreed by the project leaders by reading and re-reading through the transcripts of the focus groups. Some of the themes are based around the questions asked whereas others are issues that were emphasised repeatedly in the discussions.
The aim of these focus groups was to try and assess the impact of the project on the actual communities. To find out whether eye health messages given out to the communities had resulted in increasing awareness of eye health and encouraged people to attend for eye examinations. Understanding this would enable us to see whether a community champion/champion approach had worked and the sorts of activities that were most effective.
Understanding of eye health
Participants were asked about eye health and what they thought they could do to try and make sure that their eyes were healthy. This question was asked to explore participants understanding about information they had received from being involved in community eye health activities.
Similar themes arose in all the groups.
Participants were aware that they needed to have regular eye examinations and the importance of early detection of eye conditions.
“Get it tested often”
“Regular eye tests”
“Early detection of problems to prevent complications.”
Also that they needed to ensure they had “the right” glasses
“Correct glasses”
They understood the importance of being healthy and eating a healthy diet. Also how certain conditions can affect eye health.
“We need a good diet”
“Fresh fruit and veg”
“Look after other health, ie, prevent diabetes which maybe contributory to eye problems”
“Regular exercise, good diet to help blood flow.”
“Having a healthy lifestyle, so exercise, eat well and drinking plenty of water.”
Also that they needed to protect their eyes from strong sunlight.
“UV light, protect your eyes.”
However, only the African-Caribbean group highlighted the importance of not smoking and the effect of smoking on eye health.
“Don’t smoke. Reports are saying smoking damages your eyes”
They had only learned this from the recent eye health talks and the group was dubious about how long the research about smoking had been available.
“When was this proven? It is only in the last few months that I have heard about the correlation between smoking and eyesight. Smoking has always been associated with cancer, why only now has the link with eyes been shown?”
The group raised lots of questions about smoking and queried whether e-cigarettes were also harmful.
“What about e-cigs? Has there been any research into them? Do they have nicotine?”
Eye health activities
Participants in each group were asked to describe the eye health activity/activities they had attended in their communities.
The majority of participants had been to an eye health talk and felt that this was one of the best ways to receive information. Information gathered at these events was often shared with family and friends afterwards.
“I came to a talk on free eye checks and eye illnesses”
“Listening to someone talk first, then you get the leaflets afterwards.”
“Health seminars like the Horn health seminar was useful. The messages were then taken back to family, friends and the community. Also, people talk about it in cafes and mosques.”
What information did you find out?
The communities said that the talks were very informative and helped them understand more about eye health. The talks were given to small groups and to larger audiences at Diwali and other health events in the community. However participants’ feedback followed similar themes.
All participants said that the talks helped raised their awareness of eye health and eye conditions.
“It does help to make you more conscious and brings awareness.”
Participants said the talks encouraged them to go for eye examinations and they passed on information to family and friends.
“It encouraged us to take eye problems seriously. I got my children to wear glasses. It gave us an awareness of where to go.”
“I told the family and they went for the test”
Participants also said that it was useful finding out that eye exams were free.
“Not many people realised it was free. Since they found out it was free, a lot of people took it on board and went to the opticians.”
“After the talks, I knew (that eye tests are free) but some didn’t. Some opticians don’t always do the specialised test.”
Sim Specs to understand different eye conditions
Sim Specs had been used in several talks and other activities carried out by the champion and participants comments on how they found them useful to understand more about eye conditions.
“It was good to try them (Sim Specs) on to experience and understand the different eye conditions.”
“It was good to put it on and see…. A shock to the system. It makes eye conditions more understandable.”
The impact of losing your sight
The groups were asked to discuss the impact of losing their sight.
All of the community groups thought that losing their sight would be devastating.
“The joy of life would be missing”
“Frightening”
“Worst thing in life”
“People don’t know how to deal with blindness and people don’t know about the different eye conditions.”
Participants talked about how they would have to rely on others
“If you lost hearing, you can still do things. But, without sight you can’t. You have to rely on other people.”
An interesting point was raised by a member of the Somali community who said that the option of having a guide dog may not be culturally appropriate for some members of his community.
“It would be especially difficult in our community, as they won’t want to have guide dogs, like other communities and so you will not be able to go out and do things. You will be stuck at home.”
7.1.3 Barriers to accessing eye examinations
The results of the focus groups held with both the community champions and the three community groups have been combined when looking at the barriers and enablers to these communities accessing primary eye care services. This is because the issues raised were very similar as all were accessing local eye care services.
Language
One of the main barriers that participants talked about was language.
“Language can be the biggest barrier.”
This ranged from booking the appointment to attending for an eye examination. The Somali and Guajarati communities also talked about older people having to rely on other people to take them to the appointment due to physical, language or literacy barriers.
“If there is a language issue they have to wait for someone else to take them.”
They thought that older people may have a problem, particularly if they didn’t speak English.
“I had a field test for ocular hypertension. It’s very difficult to understand for older people. Like my mother. She finds it very frustrating.”
“They don’t give you information and tell you what you are entitled to.”
The “vulnerable community, older generation may have language problems. They don’t explain things to them.”
“Some opticians don’t explain – just very quick. Other opticians do take more time and explain things.”
Participants thought that it would be useful to have a sign in each optician, saying which languages they spoke as this would encourage people from specific communities to have an eye exam there. The champions were concerned that difficulties with language and communication between the professional and patient may result in mis-diagnosis.
“if the professional doesn’t speak the language and the individual is not very good at English, they may be misdiagnosed”.
The use of interpreters was discussed and the champions highlighted some of the issues, particularly about people using other family members.
“Interpreters can be difficult to work with and it’s not always good to take family, they may not know the technical words”.
“Family may just answer for the patient. “
“It depends who goes (re interpreters) and how they explain things”
The champions explained how they often had to book appointments for community members because they couldn’t speak English. This was particularly emphasised by the Chinese community.
“I had to book appointments for most of them as they find it difficult to book appointments for themselves because of the language. Also if they are asked questions by the receptionist they don’t know how to respond”.
“There is a big language barrier so they are not clear about what to ask for”
Cost of glasses
Cost of glasses was seen as another major barrier.
“The expense of glasses may be a barrier.”
Participants were concerned about the communities buying cheaper alternatives.
“People are buying the cheap glasses from the pound shops and this could make their eyes worse”
They felt that more people needed to know that they could have help with the cost of glasses and opticians told people if they were eligible.
“Also it would be useful if opticians told people if they are eligible for free glasses. The Chinese people don’t know about this and the opticians don’t tell them. This information should also be included in the leaflet about EHEW.”
The Somali group felt that the quality of glasses provided at low cost or free for people on low incomes was poor. They also talked about their frustration at the prescription not seeming to be suitable for them.
“I received poor glasses. It seems, whatever is free is very poor. I brought glasses in Holland 10 years ago and they are still fine. I brought glasses from here and they break and are poor quality.”
“I brought glasses for £99 and they give me headaches. They test again and again, but it’s not right. My glasses for $6 from Somaliland are better. I have been tested and re-tested so many times and I am so fed-up”
Lack of awareness of free eye exams
A key barrier noted by all communities was a general lack of awareness that their eye exams were free. They felt that there wasn’t sufficient information available about this and talked about opticians often giving the wrong message regarding costs of eye exams. This was an issue discussed by both Somali and African-Caribbean communities.
“Lack of awareness (about free eye exams)”
One of the participants in the African-Caribbean group said that she had been diagnosed with early glaucoma and her father also had glaucoma.
“I advised my son to have an eye exam as he was having problems with his eyes. I thought that this would be free, but it cost £10”.
Participants said that from their experiences, opticians didn’t promote EHEW. They were also worried that if you went to a new optician they wouldn’t be able to see your notes from previous years.
“They don’t always inform you (that eye exams are free) or you don’t get feedback from your test. Also they keep the tests from previous years so if you go to a different optician they will not see any differences.”
“This can hinder people going, if opticians have the wrong information.”
Participants felt that more needed to be done to promote EHEW so that communities understood who was eligible for a free eye examination.
“Awareness raising, it’s good to know what we can ask for.”
Might not prioritise if they have other health issues
The champions felt that community members may not prioritise eye health examinations if they had other health issues and other appointments to attend.
“if they have a number of health issues they may have lots of appointments.”
“When prioritising, people are more likely to go and see about a bad heart or leg pain.”
Fear and not doing anything until there’s a problem
Participants said that many individuals may be afraid of what the eye examination might reveal or that they wouldn’t take any action until they experienced a problem.
“Some are in denial and leave it as long as possible. It makes you think you are getting older.”
“Explaining the importance of getting the check before it is too late.”
The Somali champion highlighted that male members of the community thought that admitting they had any problem with their eyes or health might be seen as a weakness to their families or communities.
“People don’t ask for help until they need it. Communities are very resilient and don’t show concerns until the later stages. Males do not show weakness in a cultural context.”
Transport
Participants explained that some older people needed to be taken by a carer or member of their family to appointments and that sometimes they required transport.
“Some older people need to be taken”
Champions also mentioned that older people like going to an optician in an area that is familiar and where they know what buses to catch.
“They like going to the optician in Canton because the area is very familiar and they know where it is and which buses to catch to get there.”
Sight test confusing
Some participants commented on how they and people in their communities found the sight test confusing.
“The way of testing, ie, with/without or yes/no, is confusing for people. The time is so short and they rush to move onto the next customer. It is very quick 10 to15minutes.”
Communication between professionals and patients was compounded if there were also language barriers.
“Language may be a problem and people may not understand.” Somali
There was also concern about how optometrists would be able to provide an appropriate test for someone who couldn’t speak English or read the English alphabet.
“When they don’t speak English, how are they supposed to read the letters at the test?”
Understanding the different eye examinations available
Participants emphasised that people were not clear about the difference between an eye/sight test and an eye examination and found it confusing.
The Chinese champion explained that the older Chinese people didn’t know if they had previously been for a sight test or an eye examination. They weren’t sure what they’d had so didn’t know what they could ask for.
“It’s very confusing and they find it very confusing.”
The champion explained that the information should clearly explain the difference and also advise people how to ask for an EHEW.
“The leaflet about eye exams should include how to ask for eye examinations (EHEW) and eye tests and what the difference is. It needs to be explained very clearly.”
“The reminder letter from the optician needs to be clear and say whether it is for a sight test or an EHEW.”
The Chinese champion said how she was going to discuss this and the confusion it was causing with the new Chinese optometrist in the area when she was arranging for him to come and give a talk to the community.
“We haven’t started to book appointments with the Chinese optometrist in Grangetown yet. I’ll arrange for him to come and give a talk. I’ll discuss the issue around the confusion between sight tests and EHEW with him.”
Diabetes and eye health
One of the issues that the groups raised was diabetes and eye health. They talked about lack of awareness amongst communities of how people may be more at risk of certain eye conditions if they have diabetes.
“Ladies who have diabetes get letters and were finding them a hassle as they did not realise that diabetes can affect the eyes.”
They talked about the low uptake of diabetic retinopathy screening from BME communities. They felt that one of the reasons was that staff at the screening service were not from BME communities and so didn’t know how to deal with people from these communities.
“It is sad about the low uptake of retinopathy from BME communities, but all the professionals are from the white community, not from the BME community. One patient had not turned up for a follow up appointment and I asked them to call her to explain that she needed the follow up appointment and she came when it was next booked in.”
The group discussed how GPs were important in promoting eye health and the diabetic retinopathy screening service.
“Use GPs to reinforce the message.”
7.1.4 Enablers to communities accessing primary eye care services
Following on from barriers, the groups talked about ways to encourage people from BME communities to attend eye examinations. These are listed under the following headings:
Promoting EHEW to BME communities
The champions thought that more could be done to promote primary eye care services to BME communities as they felt there was a particular lack of awareness of the importance of eye examinations and the services available. They felt that highlighting that the examination was free would improve uptake.
“Is there an issue about advertising that BME communities have this free eye test?
“Mention it’s a free eye test”
“Free eye tests and free glasses.”
Also, about how to access help towards the cost of glasses.
“I was not aware of the forms or where to get them.”
Participants recognised the importance of providing information about eye care services from a young age.
“it should start form school, so when they grow up they know what it is and it’s free”.
“Education for children in the class room so they know how important it is.”
Using leaflets, posters and events to raise awareness of services
Both the communities and the champions felt that the RNIB Cymru eye health leaflets provided for the project were useful. However, if more leaflets were going to be produced, they thought that it would be useful to ensure that these were translated into different languages. They also suggested that posters with strong visual messages that people could relate too were important in raising awareness of services.
“They should have leaflets in different languages”
“Make it (the poster) visual and eye catching. Use a picture or something that they can relate to. Even if people don’t read it, it should be there.”
However, the Somali community explained that their community pass on messages verbally so leaflets may not be that effective.
The Chinese champion said that leaflets should be translated into Cantonese as this would be useful for older people and they could read them. Also useful to translate them into Mandarin as these were the two main languages Chinese people used.
Participants of the focus group discussed suitable venues for promoting the leaflets. The Chinese champion suggested that it would be useful to make leaflets available in GP surgeries, Chinese supermarkets and the Central Library as they have a section with Chinese books so Chinese people go there.
The BME Communities Health Fair was also mentioned as an excellent way to tell people about eye health.
“Useful to raise awareness at events like the health fair. This was very good for telling people about eye care.”
The leaflets and posters needed to include simple text and images and should be available at public locations, eg, schools, libraries, on buses, GP Surgeries, community venues such as supermarkets and places of worship.
“You could place laminated plaques to inform people why they should go in public places, libraries and GP surgeries.”
Other ways to publicise information was noted within the Guajarati community. This included TV, local radio/TV channels in the community language and local free newspapers.
Posters
The champions said that posters would be useful to provide information about eye health.
“Need a poster to make people aware and can help start a conversation, a talking point”
The group said that posters should be displayed in opticians and GP surgeries.
“get the message across with posters and leaflets in all opticians. Visible posters and literature.”
“Put them in GP surgeries”
The sort of information that would be useful to include on the poster was discussed.
“Simple free eye tests for BME communities”
This included information about the eye conditions particular BME groups were more at risk from:
“If from a BME community you are more at risk of …….”
“Did you know BME communities are more likely to get eye diseases? Then a poster breaking down the diseases into simple form.”
“Give the various eye diseases then list whose at risk”
Pictures or illustrations were thought to be useful for attracting attention.
“With a very powerful picture”
Also it was important to mention that the eye examination was free.
“Mention it is a free eye test”
Providing eye health information through talks
All groups agreed that it was very useful to receive messages verbally from a professional or someone well trained in the field. Participants thought that talks to both small and large groups were very beneficial.
“We like to keep up to date, personal face to face… is the best, where you can ask questions to a well informed person. ‘
“More face to face meetings like seminars, and groups like this.”
Further support for talking to groups was highlighted by most of the participants in the focus groups saying how much they had enjoyed the discussions and learnt a lot from this process.
“I’ve learnt a lot today”
The Somali community suggested holding more workshops and seminars at different locations with a translator to inform the community and help them engage with eye care.
Public Health Wales – giving out eye health messages.
The champions thought that Public Health Wales should give out eye health messages to the community. Also that information should be given out in schools.
“Public Health Wales and schools, they have the experience.”
“they raise awareness of dental and sexual health. Children get bullied and this can cause stigma and problems. Someone could go in and raise awareness in a fun way”.
“if children do not have their eyes tested it would have an effect on their education.”
“just asking pupils if they can see the board.”
“it’s not down to the teachers it should be Public Health Wales”
7.1.5 Eye examination and patient experiences
Each of the focus groups were asked to talk about their own and their communities’ experiences of primary eye care services. A range of issues were highlighted and these are captured as fully as possible under the following sub headings.
What influences your choice of optometrist/ optician?
Participants discussed reasons for choosing a certain optician. These varied, but most chose a practice close to home or that they had been to for years and were pleased with always having “comprehensive checks.”
“They always give you the checks every time and give you the details of the results.”
“They are always good there. I am used to seeing her; I’ve been going there for 25 years”
“Very fast and efficient” (group agrees)
“I used to go to one locally but very old fashioned. People in new optician are very welcoming. More equipment”.
“I used to go to Queen Street but getting there is a problem so I go closer to where I live and easy to book appointments. I am still having a blurry right eye so am thinking of going back.”
“I get a full examination each time and they usually send out a reminder when my appointment is due.”
“They write out for the next appointment and normally put the drops in to dilate the eye.”
Was it easy to book an appointment?
Most participants said that they felt it was fairly easy to book an appointment. It was important to book in advance but in an emergency you could be seen straight away.
“In an emergency they give you one straight away”
“When you walk in, the receptionist books you in, then you have the tests and see the optician, they explain the results.”
“...easy to book appointments. They send reminders and they phone you.”
“It’s easy to book an appointment in …. You are given the information and it’s easy to understand.”
Welcoming environment and personality of optician
The welcoming environment, well equipped practices, the ease of booking appointments and sending of reminders, were all discussed by different communities as factors that would help with accessing primary eye care services.
Communication between the optometrist and patient was noted as a key factor in improving access. Participants preferred opticians who took more time to explain.
“Some opticians don’t explain – just very quick. Other opticians do take more time and explain things.”
Relationship and communication between optometrist and patient
The champions discussed the importance of good communication between the optometrist and the patient and how if there was a language difficulty they needed to be patient and take more time to explain.
“Personality of the optician is very important. They have to be willing to serve different communities. Not all opticians are like this…. has to be patient and willing to spend time with patient... If there is a language barrier it takes longer. Even if an interpreter is there, the appointment takes longer. I have found not all opticians are willing to do this….Specsavers are not willing to do this”
Providing training for staff in optometric practices
One of the issues that the champions discussed was the importance of optometrists and reception staff at practices raising awareness of EHEW to relevant patients. They felt that staff didn’t provide information about the examination and could benefit from more training.
“are the opticians doing their job? Could the receptionists be asking if someone needs a longer eye test?”
“staff are not aware”.
“they need to be trained, (EHEW) it’s never been offered”
“opticians should listen to the communities on what can help increase attendance.”
“...also GP receptionists should be trained”.
Many participants talked about the need to improve the way that frontline staff in optometric practices communicated with minority communities.
“retrain the receptionists, train them to engage with the BME community. Dentists phone the patients the day before their appointment, opticians should call /text the day before. If they are informed the day before they can explain the test and give another appointment if they cannot attend.”
“this would save time as a lot of time is wasted on missed appointments.”
Participants felt that receptionists didn’t explain to patients whether or not they would be entitled to a free eye examination.
“They don’t give you information and tell you what you are entitled to.”
‘’They don’t explain that because of my ethnicity I am entitled. There is a lack of explanation.’”
When asked whether it would be offensive if optometric practices asked about ethnicity, the response was:
“No, we are used to it.”
Opticians employing staff from BME communities
Participants felt that optometric practices should reflect the patient population and that opticians should employ staff from relevant BME communities.
“encourage opticians to take on staff from BME communities, someone they (patients) can relate to”.
7.2. Feedback from community members from four eye health talks by community members
The community champions were asked to give out evaluation questionnaires to community members at the various eye health activities to capture their feedback. However, the champions reported that they found this quite time consuming as many of the community members either forgot to do this, chose not to, or could not do this without their assistance because of language issues and only a small sample were returned.
The information below includes the results from the questionnaires that were returned. This involves four eye health talks with 20 questionnaires completed by individuals or with the help of the community champions. The sample is extremely small to draw any generalisations from, but they do reflect some of the findings in the focus groups
Demographic summary of responses
Seven men and 13 women filled in the questionnaire.
Age range is seen in the graph below (Figure 2).
Figure 2: Ages of participants attending who filled out a questionnaire.
[pic]
The ethnicity of those completing the questionnaire were:
11 Pakistani;
3 Indian;
2 Chinese;
2 Black African;
1 White and Black African;
1 Other.
Attendees were asked if they found the information given useful: 13 strongly agreed, six agreed and one neither agreed nor disagreed.
For the question, “Was the information given to you in a way you could understand?” 14 strongly agreed, five agreed and one neither agreed nor disagreed.
A question was asked, “When was the last sight test you had?” The responses were: 14 within the last year, three within two years, one within five years and two could not remember.
From those that had not had an eye tests within the last two years they were also asked, “If you haven't been for a sight test in a while, which of the following statements best describe your reason for not going?” The responses were (from three people, but they could each tick multiple responses): two were concerned about cost, two had not had problems and one didn’t have the time.
Finally, the question, “Do you think the information given out today would encourage you to go for a sight test?” was put to the attendees and the responses were: 17 Strongly agreed, two agreed and one neither agreed nor disagreed.
7.3 Evaluation of interviews with two optometry practices with high numbers of patients from BME groups attending for eye examinations
Two optometry practices with high numbers of patients attending from BME groups, were interviewed to try and identify key issues of good practice. The interviews were recorded and transcribed and then summarised under the following themes:
7.3.1 Staff training ensures quick assessment of EHEW eligibility
The practices reported that staff are trained in aspects of EHEW eligibility and are able to remind patients of the risk of eye disease and ethnicity. So when new patients enter the practice, reception staff promptly begin the process of determining eligibility and can explain the advantages of an EHEW over a NHS funded eye examination.
“Any patient that enters the practice and asks for an appointment or comes in for an appointment get asked what their ethnicity is. Sometimes patients ask why the practice needs to know but not often and it is mainly accepted practice”.
7.3.2 Booking appointments
The practices said that patients often called in to the practice to make appointments:
“They (patients) do not drive and they do not phone. Most are walk-ins as a family group who see one member undergoing the test and then book themselves or other family in.
However, with a telephone booking:
“If they are a previous patient and they phone then the record tag tells the staff if they are eligible. Often a telephone booking can turn into an EHEW once the patient arrives”.
7.3.3 Promoting the service locally
The practices tried to promote their services to the community by advertising on local radio and speaking to relevant members in the community and to allay any fears.
“The practice has a policy of using ethnic advertising like Radio Ramadan and supporting ethnic groups. The practice has had serious discussions with religious elders about the issues that can arise if a patient needs to be dilated at Ramadan as some perceived this as breaking the fasting rule”.
7.3.4 Being an established practice in the community
One of the practices specified how they thought that people attended their practice as they had been established in that area for a long time.
“Nothing specific, just the best care possible. The practice has been there a long time in that community”.
7.3.5 Ways in which staff overcome language barriers
The practices explained some of the ways in which they could accommodate patients with language barriers. These included:
Staff having a knowledge of some local languages:
“The language issues are helped by the staff having a knowledge of some languages, by the optometrist speaking several.”
Discussing treatment with a family member who speaks English, if patients attend appointments with their families:
“Often a family group come in and provided one is a good English speaker then they will discuss the family group with the staff and organise what eye test is relevant to their group.”
Encouraging regular patients to be accompanied by a family member who can interpret.
“Patients usually come in with a son or daughter or with other family members. Most of these patients have been coming in for many years and know they need to bring someone with them to translate. They are advised by the receptionists as well to bring someone in with them to translate”.
7.3.6 Sending a letter to their GP about the results of the patients eye exam
Practices reported that patients valued a letter being sent to their GPs following an EHEW eye examination.
“It seems that one very popular outcome that the ethnic groups appreciate is the fact that after an EHEW their GP gets a letter about their eyes and after a GOS no letter is sent, indicating that EHEW is better than GOS.”
7.3.7 Patients being confused by the difference between EHEW and diabetic retinopathy screening services
Practices said that patients were often confused between the different eye care services and didn’t understand the difference between EHEW and diabetic retinopathy screening services.
“Confusion by ethnic groups over diabetic retinopathy screening service and dilating and re-dilating for EHEW. This seems to confuse patients as they do not seem to grasp they are two different services.
7.3.8 Dilating patients for eye examinations
This was discussed as a problem with drivers as it could result with two visits.
“Dilating drivers is problematic if they need an EHEW and can result in two visits.”
However, the practices felt assured that dilation problems had been overcome by receptionists explaining this to patients.
‘It’s pretty smooth now, personally no problems with the service, the receptionists tell them it takes slightly longer and involves drops and not to drive. The optometrist re-iterates this during the test.”
7.3.9 Language as the main issue
The practices said that it was mainly language that was an issue for dealing with BME patients from the local area.
8. Quantitative evaluation of data for uptake of eye examinations
8.1 Numbers of patients attending for an EHEW examination
Health Board data
The numbers of patients from Black and Asian ethnic groups in the whole of Cardiff and Vale University Health Board (C and Vale UHB) was analysed. The reasons for this were two fold. Firstly, to attempt to capture as many patients as possible from these BME communities who accessed an eye examination in case they travelled outside of the study area to have their eyes examined (assuming they stayed within the Health Board region). Secondly, so that we could use a different comparator Health Board as a control to determine activity in that Health Board over the same time period.
Results indicate that there has been a moderate increase over an 18 month period across Cardiff and Vale UHB for those patients having an EHEW on the basis of an increased risk of eye disease because of their ethnicity (see Figure 3 below). The average number of Band 1 EHEW examinations at risk due to ethnicity for Cardiff and Vale University Health Board over the 18 month time period was 104.6 plus or minus 9.2 (Standard Deviation = 20.4) and for Abertawe Bro Morgannwg University Health Board (ABMU HB) it was 5.2 plus or minus 1.6 (Standard Deviation = 3.5). Confidence intervals were 95 per cent. A best fit trend line indicates an increase of approximately 29 per cent between May 2013 and November 2014 for Cardiff and Vale UHB.
In the last six months in Cardiff and Vale UHB, five out of the six months had higher than average numbers.
Only patients who self-reported as being of Black or Asian ethnicity qualify for an EHEW on the basis of an increased risk of eye disease. As a comparator another Health Board was also analysed but in ABMU HB there was not sufficient numbers to indicate a trend.
Self-reported patients of Black and Asian ethnic groups who had an EHEW for any reason was analysed separately in Cardiff and Vale and in ABMU Health Boards.
There was a moderate increase in those patients of Black ethnicity attending for an EHEW for any reason over an 18 month period in Cardiff and Vale UHB (See Figure 4).
In ABMU HB, there was not sufficient numbers to indicate a trend. The average number of EHEW examinations for patients of Black ethnicity for Cardiff and Vale UHB over the 18 month time period was 62.6 plus or minus 6.4 (Standard Deviation = 14.2) and for ABMU it was 3.4 plus or minus 0.7 (Standard Deviation = 1.5). A best fit trend line indicates an increase of approximately 34 per cent between May 2013 and November 2014 for C&V UHB. In the last six months in Cardiff and Vale UHB, five out of the six months had higher than average numbers.
For those patients of Asian ethnicity there was a small increase attending for an EHEW for any reason over an 18 month period in Cardiff and Vale UHB (see Figure 5). Again, in ABMU Health Board there was not sufficient numbers to indicate a trend. The average number of EHEW examinations for patients of Asian ethnicity for Cardiff and Vale UHB over the 18 month time period was 123.2 plus or minus 6.0 (Standard Deviation = 13.3) and for ABMU HB it was 11.3 plus or minus 2.0 (Standard Deviation = 4.4). A best fit trend line indicates an increase of approximately 13 per cent between May 2013 and November 2014 for Cardiff and Vale UHB. In the last six months in Cardiff and Vale UHB, five out of the six months had higher than average numbers.
Figure 3: Numbers of “‘at risk due to ethnicity” Band 1 claims under the EHEW service May 2013 until November 2014 - Cardiff and Vale University (blue line) and Abertawe Bro Morgannwg University (red line) Health Boards.
[pic]
The dotted lines indicate the linear trend line for each Health Board.
Figure 4: Numbers of patients from Black ethnic groups who received an EHEW service examination by Health Board over an 18 month time period. Cardiff and Vale University (blue line) and Abertawe Bro Morgannwg University (red line) Health Boards.
[pic]
The dotted lines indicate the linear trend line for each Health Board
Figure 5: Numbers of patients from Asian ethnic groups claims under the EHEW service May 2013 until November 2014 - Cardiff and Vale University (blue line) and Abertawe Bro Morgannwg University (red line) Health Boards.
[pic]
The dotted lines indicate the linear trend line for each Health Board.
South and Central Cardiff area used in the study
Data from seventeen practices in South and Central Cardiff were examined to determine if there was any apparent change in the number of different ethnic groups over an 18 month time period attending for an EHEW examination and the number of EHEW examinations carried out because of the patient being at an increased risk of developing eye disease.
The 18 month time period was divided into three lots of six month blocks: six months before this study, for six months during the study and for six months after the study.
In the Cardiff areas, as seen in Figure 6 below, in total 1,150 people were BME groups pre-study, 1,173 during the study and 1,396 post-study. The figures show an increase in ethnic minority access to the EHEW service during the six months after the study. Interestingly, during the study period of six months for some ethnic groups there was no increase in EHEW eye examinations.
Summating the groups into those eligible for an EHEW on the basis of ethnicity (Asian and Black) demonstrates that there was a consistent increase in the number of patients of Black ethnicity in the six months during and after the study, compared with before the study (11 per cent increase during the study and 37 per cent after the study). For Asian ethnicity there was an initial decrease during the study of three per cent but this was followed by an increase of 19 per cent after the study (see Figure 7 and Table 3).
When the data is assessed for all the 17 individual practices for those patients eligible for an EHEW on the basis of their ethnicity across all four areas of Cardiff, the picture is mixed (see Figure 8). Ten practices saw an increase in the number of patients from six months prior to the study to six months after the study and seven saw a decrease in patients from Asian and Black ethnic groups. However, overall, the numbers showed an increase of 22 per cent from before the study to after the study.
When the Index of deprivation is assigned then the number of Black and Asian ethnic groups accessing EHEW eye examinations indicates that there is an increase in the six month time periods from before the study, during and then after the study in numbers of patients accessing EHEW for the most deprived areas (Quintiles 1-3). There is an initial decrease during the study period for Quintile 4, before it increases post study and for Quintile 5 (least deprived) there is a decrease during the study period and after the study period compared with before the study (see Figure 9).
Figure 6. The numbers of patients from different ethnic groups attending practices in Cardiff in the study area over the course of 18 months.
[pic]Key: Af: African; Ar: Arab; Ba: Bangladeshi; Ca: Carribean; Ch: Chinese; In: Indian; Pa: Pakistan; OB: Other Black.
This graph demonstrates the number of patients from the different BME groups who attended an optometrist across all of the four areas of the project intervention site. Information has been collected six months pre-study (black), for six months during the study (grey) and for six months post study (white). NB: Only those from Asian and Black ethnic groups are eligible for an EHEW.
Figure 7: The number of different ethnic groups attending for EHEW eye examinations in the Cardiff study area over an 18 month time period.
[pic]
The data show uptake of eye care services collected six months pre-study (black), for six months during the study (grey) and for six months post study (white).
Table 3: The number of different ethnic groups attending for EHEW eye examinations in the Cardiff study area over an 18 month time period and the percentage change from before the study until during and after the study.
The table below consists of six columns and four rows
|Ethnicity |Pre study |During study |After study | per cent change from pre | per cent change from pre |
| | | | |study |study |
| | | | |to during study |to after study |
|Black |298 |331 |407 |11.07 |36.58 |
|Asian |659 |640 |787 |-2.88 |19.42 |
|Mixed Race |72 |51 |51 |-29.17 |-29.17 |
Table 3 and Figure 6 show the uptake of eye care services for EHEW where people from BME communities are grouped into four categories.
NB: That only those from Asian and Black ethnic groups are eligible for an EHEW and those of mixed race are included for comparison purposes.
These are:
Black (includes African, Caribbean and other Black)
Asian (includes Bangladeshi, Chinese, Indian, Pakistani and other Asian)
Mixed Race (Other Mixed, White African, White Asian, White Caribbean)
Figure 8: The number of patients of Black and Asian ethnicity who attended for an EHEW eye examinations in fourteen of those practices who registered any activity each over an 18 month time period.
[pic]
The data show uptake of eye care services pre study (black), during the study (grey) and post study (white).
Figure 9: Uptake of EHEW by patients eligible due to ethnicity, by Deprivation Index in the Cardiff Project study area.
[pic]
There are a greater number of patients from Black and Asian ethnic groups accessing EHEW in the least deprived areas (Quintiles 4-5) over the 18 month time period. However, there appears to be limited impact in patient numbers before and after the intervention period in these deprived areas. Fewer numbers of patients accessed services in the least deprived (Quintile 5) areas during the intervention period and the six months afterwards compared to before the intervention period, see Graph 3 below. For Quintiles 1, 2 and 3 there was a gradual increase in numbers of patients accessing the service throughout the eighteen month period.
8.2 Discussion
This study examined, in part, if there had been any increase in uptake of EHEW examinations in Cardiff (and within Cardiff and Vale University Health Board) over the study time period.
Our results showed that there was increase in numbers of Black and Asian patients having an EHEW examination six months after the project (April 2014 to September 2014) was finished, compared to before the project started.
During the time of the project intervention taking place (October 2013 to March 2014), there was a small increase for Black ethnic groups accessing EHEW but not for Asian ethnic groups. Combining the two ethnic groups indicated that there was an increase accessing the EHEW service during the project interventions but this was small. We compared another Health Board with a smaller but proportional population representative of Black and Asian ethnicities; Abertawe Bro Morgannwg University Health Board. We did not find any such trends in this Health Board but numbers were too small to demonstrate any significant change. Comparison to another Health Board with the second largest numbers of Black and Asian ethnic groups would have been helpful (Aneurin Bevan University Health Board), however, there is ongoing engagement with local BME communities in Newport (included in this Health Board area) to encourage them to attend for eye tests as well and this would have confounded the data. Nevertheless, when numbers of patients from Black and Asian ethnic group were compared in Aneurin Bevan UHB they were found to be less than 10 on average per month, thereby all but excluding meaningful data analysis. In the Swansea area (so ABMU HB) there is a population of approximately 10,000 Asian and Black people which should have made a comparison between Cardiff and Vale and ABMU Health Boards possible.
The question is why was there a greater increase overall in those Asian and Black ethnic groups accessing EHEW, six months after the intervention compared to during the project interventions. There could be a number of reasons for this including: patients did not immediately book appointments as they were thinking about it and took some time to take action or, that they were not due for an eye test within that intervention period. As figures continued to grow towards the end of the data sampling period it suggests that this may be the case. Further monitoring in future would also enable us to see if this trend continues. However there could be an additional point that several major events were organised at the end of the intervention period, eg, BME health fair (n= approx 500), Somali Horn Health event (n=70) and Somali careers day –a family event (n=70). So the increase in numbers attending eye examinations following the intervention phase could be due to these events.
This was also true within the area being studied although the picture was different in different practices. The majority showed an increase, six months post intervention period but some practices indicated a decrease in numbers.
The reasons behind this may be complex and could indicate the variations in communities accessing services. For example, it may be that optometry practices in communities that were not targeted for intervention may not have seen an increase. Alternatively, it could be that people from BME communities targeted for the intervention simply went elsewhere for their eye examination, either within the Cardiff area analysed (perhaps to one of the practices that did see an increase in numbers) or outside of this area. Other reasons are explored below. Unfortunately from the data analysis, we could not determine the reasons for the variation in individual optometry practices.
Whilst there was an increase of approximately 22 per cent in the number of patients from Black and Asian ethnic groups accessing an eye examination, the reasons why a greater effect was not seen or the reasons some practices did not see an increase after the intervention period are likely to be complex but could include:
As evidenced from the questionnaire, many patients had already had a recent eye examination and were not due to visit an optometrist within the study time period.
Many of those who attended the community eye care activities and talks may already access eye care on a regular basis (for example, the Chinese population have a higher prevalence of myopia and therefore tend to access eye tests regularly).
Patients may have attended eye examinations in practices outside the project area, so data would not be recorded. Also patients may have travelled from other parts of Cardiff to access community events. For example, the Gujarati community attend Gujarati community events in Butetown and Splott, but live elsewhere and would not normally visit an optometry practice in the project target area.
Practices may not be promoting or offering EHEW to patients attending for GOS or private eye examinations or there may be a delay in booking patients in for an EHEW eye examination on the basis they have recently had a GOS or private eye examination and are so not currently eligible for an EHEW. GOS or private eye examinations data on ethnicity is not currently captured.
The reach of the intervention may have been limited in some communities and situations.
There are limitations to the data we were able to collect for this project. Firstly, we were not able to access the number of Black or Asian ethnic groups having private eye examinations or those that were carried out under the auspices of the General Ophthalmic Services (GOS) NHS services. The data is not collected specifically for these groups.
Secondly, whilst we also looked at the whole of Cardiff and Vale University Health Board and demonstrated an increase in numbers attending for eye examinations, patients are free to access eye care services wherever they want to and so may have travelled outside of the Health Board area to obtain services. Nevertheless, when we compared our data with Abertawe Bro Morgannwg University Health Board, the numbers of patients accessing services from Black and Asian ethnic groups were very small. We purposely did not include numbers of patients from the neighbouring Health Board, Aneurin Bevan, because there had been eye care education events in this health board too. Nevertheless, the data from Aneurin Bevan University Health Board indicates that there was a very small increase in numbers of patients accessing an EHEW on the basis of at increased risk due to ethnicity but numbers were very small (on average less than 10 per month). This suggests that any effect because of patients travelling elsewhere would be minimal.
The telephone interviews with optometrist practices gave an insight into how the service is viewed by those who administer the EHEW service.
For example, such staff were well versed in speaking to patients about their eligibility for an EHEW on the basis of their ethnicity. This may be due to better training but is also likely to be a result of familiarity with the concept of discussing ethnicity with patients as it occurs on a regular basis. It is noteworthy that, in the main, patients do not raise any issues or problems with being asked about their ethnicity. This is a point that is useful for other optometry practices to be aware of.
Another point of interest is the work that these practices have done in promoting their services through local radio and in their community. Whilst in other areas the number of people in these communities may be smaller, the importance of community engagement should not be underestimated.
There are a greater number of patients from Black and Asian ethnic groups accessing EHEW in the least deprived areas (Quintiles 4-5) over the 18 month time period. However, there appears to be limited impact in patient numbers before and after the intervention period in the most deprived areas. Fewer numbers of patients accessed services in the most deprived (Quintile 1) areas during the intervention period and the six months afterwards compared to before the intervention period. However, caution should be used when interpreting this data as the location of the optometry practice may not directly correspond to the residence address of those patients from BME groups visiting the optometry practice.
Whilst we could not link those patients who had an EHEW because of their ethnicity from those ethnicity groups attending for an EHEW on any other basis, it does not detract from the results and importance of the results because, provided they are attending for an eye examination, the study has achieved its aims.
9. Summary and Conclusions
This section provides a summary and conclusions of the main findings of the project.
9.1. The aim of the project was to increase awareness of eye health and the importance of eye examinations in five specific BME communities most at risk of eye disease. The intervention involved targeting BME communities living in Central and South Cardiff and the delivery phase was implemented over a six month period.
9.2. The intervention involved recruiting and training key individuals or community champions from specific BME communities to give out eye health messages at community events and activities. Individuals were selected based on their experience of working or being actively involved in their communities and their understanding of cultural practices. They were familiar with key events and daily activities that occurred, so understood how best to target these communities and deliver eye health messages.
9.3. Nine community champions were recruited and given eye health training at the start of the project. Six champions had previously completed a week long eye health train the champion training course, two years previously and were already committed to improving understanding of eye health in their communities.
Of the nine trained champions, only six continued with the project for the six month intervention period. Others were not able to continue due to other commitments.
In addition to the initial training, four half day training sessions were organised throughout the project to provide support for the champions.
Three champions delivered activities via cultural and community activities to their own communities, eg, the Somali, Gujarati and Chinese communities and three worked with a variety of BME groups, eg, African-Caribbean, Somali, Indian, Pakistani etc.
9.4. The evaluation results from the project suggest that the approach was successful in raising awareness of eye health in the communities targeted. This was demonstrated by:
Participants in the focus groups reporting an increased awareness of eye health as a result of attending community activities where eye health messages had been given out, and
An increase in the number of people from BME communities having EHEW eye examinations at optometry practices in the project area and in Cardiff and Vale University Health Board.
9.5. The evaluation results showed that the community champions found the eye health training at the start of the project, very useful, particularly group discussions, photographs of different eye conditions and information about communities most at risk of eye disease. They found that the power point presentation slides, photographs of the eye and practical resources like Sim Specs were really useful to explain eye conditions to community members. Leaflets and an information sheet about eligibility for EHEW was considered helpful in both English and minority languages. However most of the champions thought that it was better to give out eye health messages verbally, particularly the Somali community. The champions reported that they didn’t find the Eye Care Wales website useful to find out information and the location of local optometrists for community members. They said that when they were out in the community they often didn’t have access to the internet and they didn’t feel that the community members themselves would be able to use it without assistance, particularly people who could not speak English.
9.6. The champions worked in different ways in their communities, but common characteristics were that they:
were well known in their communities
had attended the eye health training sessions, understood the importance of eye health and were committed to sharing information about eye health within their communities
had a good knowledge about local events, groups and activities taking place in their communities and the audience attending
could speak the language of their community and had an understanding of cultural practices
could organise or facilitate community group presentations or talks about eye health
9.7. The champions gave out eye health messages to the community in a variety of ways. However one of the most popular activities involved organising talks and presentations to both large and small groups. A couple of the champions felt confident in delivering these themselves but most champions felt more comfortable inviting one of the project leaders, particularly the optometrist. This was because they felt that the community would listen more to a health professional and that they could answer relevant questions about the examination or eye conditions. In addition to talks, the champions also provided eye health information on a one to one basis, advising both individuals, their carers and families.
In addition, the champions helped people in their communities book eye appointments and also accompanied them to appointments acting as an interpreter where community members had difficulty with English.
9.8. From the uptake of eye examination data in Cardiff and Vale University Health Board area, there was a steady increase in the number of patients attending for any EHEW eye examinations from self-reported African, Arab, Bangladeshi, Caribbean and Chinese ethnic groups from before the study until 12 months after the study. However, we cannot tell which of these groups attended and had an EHEW eye examination specifically because of their increased risk due to their ethnic background and how many of them attended directly because of the work in the communities to publicise eye health. Additionally, this data might not be conclusive for a number of reasons, eg, community members might travel to an optometrist outside of the project area for an eye examination, or community members might act on the eye health information at a later date and book an eye exam sometime after the period in which the data was collected.
However, when comparing data from other Health Boards, the amount of increase in those attending an optometrist for an eye examination seen in Cardiff and Vale University Health Board was not reproduced elsewhere in Wales.
9.9. There was an increase in numbers of patients from Black and Asian ethnic groups attending optometry practices in South and Central Cardiff following the intervention period. Some practices did experience a decrease in numbers and the reasons behind this are complex but could indicate variations in the types of BME communities accessing services. For example, patients may not have been due an eye examination or went to other practices to have their eye examination.
9.10. In areas of high deprivation, there is good representation of patients attending from Asian and Black ethnic groups. However, the numbers did not apparently increase during and after the intervention time period.
9.11. From the focus group evaluation, the communities felt that one of the best ways of receiving eye health messages was through talks either to large or small groups. Talks had prompted the community to go for eye examinations and they understood more about how to keep their eye healthy.
9.12. Barriers and enablers to accessing primary eye care services were highlighted by the champions and communities from the focus group evaluation data.
The main barriers were:
language,
cost of glasses
lack of awareness that eye exams were free and opticians not promoting this
fear and denial that there could be a problem, and for males in the Somali community it might be considered as a weakness if they admitted they had a problem with their eyes
transport to appointments and older people often requiring someone to take them
sight tests were confusing particularly if people didn’t speak English and there was concern over whether the optician would be able to make the right diagnosis if the patient didn’t understand or respond appropriately to questions
confusion over the purpose of sight tests and EHEW and so patients didn’t know what they could ask for
lack of awareness of diabetes and eye health.
Enablers were:
providing leaflets and posters with clear messages that EHEW is free and information displayed in health and community venues
receiving eye health messages through talks delivered by a professional
Public Health Wales being responsible for giving out eye health information and ensuring that this is also given out in schools
more training for staff and receptionists at optometry practices to advise patients about EHEW and establish eligibility
good communication between the patient and optometrist and if there was a language issue the optometrist should allow more time to explain.
9.13. The focus group data also included feedback about participants’ experience of using local opticians. Key features highlighted that they thought were positive were:
well trained reception and optometry staff that could advise them of their eligibility for EHEW
welcoming environment and the optometrist taking time to explain
good communication between the optometrist and patient so that the patient had feedback on the results of their eye examination and were given longer if they could not speak English
efficient service and modern equipment in the practice
easy to book appointments and that they were sent text reminders of appointments
more staff employed from BME communities and information displayed in practices about minority languages they were able to carry out the eye examinations.
9.14. From the two optometric practices with high numbers of BME patients attending that were interviewed, key points that staff highlighted were:
training staff to ensure prompt assessment of patients’ eligibility for EHEW
employing an optometrist and staff that were able to speak some of the languages
using family members as interpreters where possible
promoting services on local radio (radio Ramadan) and including messages to allay any fears about dilating pupils during fasting
being aware that patients found the services confusing particularly the difference between EHEW and diabetic retinopathy screening services
understanding that patients often preferred to call in to the practice to make appointments, rather than telephone
being aware that patients valued a letter being send to their GP following an EHEW appointment and this helped to reinforce the importance of this eye examination
being willing to book two appointments if there was confusion with drivers about dilation so knowing they couldn’t drive afterwards.
Interestingly and reassuringly, these results and the feedback from patients about positive experiences in eye care, or suggestions for what would create a positive experience, directly mirror each other. This shows that where practices provided ways to accommodate people from BME communities, they do result in more engagement and an increase in the number of people from these communities attending.
9.15. The champions were all motivated individuals, committed to giving out information about eye health to their communities. However several did highlight in the evaluation that they thought that the intervention methodology was really good, but that the project was limited as they were just working in a volunteer capacity.
They said how they were not paid to deliver the project and it was sometimes difficult fitting this in with their other work and life commitments. The champions had to attend the training days and the four support training sessions provided during the six months, in a voluntary capacity. They thought that this needed to be considered with the planning of future projects and that funding should be allocated. However they said that an outcome from the project was that it had resulted in having a positive impact on them and that they would continue to share eye health messages with their families, friends and their communities.
10. Recommendations
Continuation of awareness training of eye health care for BME communities in Wales. Consideration should be given to a formal model for engaging community champions to deliver eye care messages. This might include developing accreditation and covering costs, rather than solely relying on volunteer work.
Development of training and support for reception staff in optometry practices to identify relevant patients and process EHEW claims on the basis of eligible ethnic group. This could include aid memoirs and accreditation and would be voluntary.
Population data in other Health Board areas in Wales indicate that BME ethnic groups are not accessing EHEW services. The education of these ethnic groups is crucial to ensure they are accessing eye care services. The link for BME groups to deprivation in Wales also needs further investigation.
General Ophthalmic Services (GOS1W) forms need to include ethnic group classification for patients to complete in Part 1. This would provide more accurate data on the uptake of eye exams by BME ethnic groups.
Recording of the patient’s ethnic group should be based on existing classification used in the Census to facilitate data comparisons across services and epidemiology data.
Parts 1 and Part 2 of the EHEW form should link so that the patient’s ethnic group can be linked to the reason for having the examination.
Optometric practices which are exemplars of good practice in dealing with BME ethnic groups should discuss how they connect with these patients with other optometrists.
A publically accessible register to be made available detailing which languages can be spoken in optometric practices.
To make the WITS service (Welsh Interpretation and Translation Service) available for patients accessing eye examinations (EHEW, private and GOS). At present, this service is only available for GP and secondary care appointments. Language line is offered to optometry practices but there is a very low uptake and service is not particularly conducive to an eye examination. Sharing good practice on the use of language line with GPs might be beneficial.
Consider a more formal model for engaging community champions to deliver eye care messages. This might include developing accreditation and covering costs, rather than solely relying on volunteer work. These would be relatively small contributions compared to the benefits they would bring for the uptake of EHEW.
This approach and type of awareness work should continue and should be a core part of the Wales national eye health care strategy and EHEW strategy.
Population data in both Abertawe Bro Morgannwg and Aneurin Bevan, University Health Boards indicate that there is a population of BME ethnic groups who should be accessing EHEW services that, from the comparative data we have shown, are not. The education of these ethnic groups and/ or optometrists in this region is crucial to ensure these ethnic groups are accessing the services.
Targeted public advertising promoting free eye examinations for ethnic groups in locations with the greatest number of BME ethnic groups.
Community workers in areas where there are large populations of BME ethnic groups should receive training about eye care as part of their role.
Population migration means that the diversity of ethnic groups in the area may change. This needs to be monitored and options need to continue to be explored for those groups who are at particular risk of developing eye disease.
Research evidence needs to be reviewed.
Consideration should be given to holding events in optometry practices where all women or all one ethnic group could attend for a half or full day, as this may remove the barrier of patients feeling isolated and uncomfortable attending an optometry practice on their own and help with the language barrier. This would only be possible with the agreement of the optometry practice concerned and may not be applicable for many practices.
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Appendix 1
Table of activities carried out by community champions where eye health information was given out to the different communities. October 2013 - March 2014
The table below consists of five columns and 26 rows. Header rows are repeated.
|Community champion and gender |Activity |Community attending and |Date |Numbers attending and feedback |
| | |gender | | |
|Chinese community champion (Female) |Nik Sheen provided eye health talk to elderly Chinese |Chinese |Dec 2013 |30 |
| |community |(male and female) | | |
|Chinese community champion (Female) |Information about eye health included in Chinese |Chinese |January 2014 |Approximately 200 older people |
| |newsletter for older people. |(male and female) | | |
|Chinese community champion (Female) |Providing eye health information to Chinese older people. |Chinese |December to the end of March 2014|40 (Chinese Community champion took 30 |
| |Booking eye examinations for them and taking them to |(male and female) | |to appointments and acted as an |
| |appointments if they needed an interpreter. | | |interpreter) |
|Indian-Gujarati community champion |Gave presentation and eye health messages at Gujarati |Gujarati |Nov 2013 |Approx 200 |
|(Female) |dance night for Diwali |(male and female) | | |
|Indian-Gujarati community champion |Eye health messages and leaflets given out at day centre |Gujarati |Nov 2013 |52 |
|(Female) | |(male and female) | |Lots of questions asked and the |
| | | | |audience were interested in information|
| | | | |about eye conditions |
|Indian-Gujarati community champion |Eye health presentation at Diwali event |Gujarati |Nov 2013 |250 |
|(Female) | |(male and female) | |Additional comments: went well and |
| |20 sets of presentation slides on photos of the eye and | | |audience have asked for another |
| |eye disease were given out to groups, as particularly | | |presentation in the new year |
| |interested in these. | | | |
| |Eye health leaflets also given out. | | | |
|Indian-Gujarati community champion |Information given out about eye health during |Gujarati |October 2013 to March 2014 |15 |
|(Female) |conversations with individual community members and also |(male and female) | | |
| |to family. | | | |
|Two Somali community champions (Female) |Information given out about eye health at an event for |Somali and Mixed Asian (male |October 2013 |100 |
| |International Older People's Day, Butetown Community |and female) | | |
| |Centre | | | |
|Two Somali community champions (Female) |Eye health talk by Nik Sheen to women's group at Loudoun |Somali and Mixed Asian |December 2013 |20 |
| |Square flats, Butetown. | | | |
|One Somali community champion (Female) |Eye health talk to Mixed Asian: Bangladeshi and Pakistani |Mixed Asian: Bangladeshi and |December 2013 |20 |
| |women’s group given by Nik Sheen at Mackintosh Centre, |Pakistani group | | |
| |Keppoch Street, Off City Road, Roath. | | | |
|Two Somali community champions (Female) |Nik Sheen gave eye health talk to, Somali |Somali men’s group |January 2014 |18 |
| |men's group at Red Sea House, | | | |
| |Maria Street, Off Loudon Square, Butetown | | | |
|Two Somali community champions (Female) |Eye health talk given by Bablin Molik to |African-Caribbean |March 2014 |10 |
| |African-Caribbean women’s group, Grangetown Baptist |(female) | | |
|Pakistani community champion (Female) |Gave out eye health information and leaflets to BME carers|Pakistani, Bangladeshi |March 2014 |500 |
| |at group meetings at the carers centre and during one to |Somali (mainly female) | | |
| |one home visits. | | | |
| | | | | |
| |Information was also given out to family and friends of | | | |
| |the carers either at home visits or group meetings. | | | |
|Pakistani community champion (Female) |Eye health talk given by Nik Sheen to new BME carers |Pakistani, Bangladeshi and |January 2014 |30 |
| |support group (mainly women) from the Pakistani, |Somali communities | | |
| |Bangladeshi and Somali communities |(mainly female) | | |
|Bablin Molik |Presentation to ISSA Wales. ISSA Wales supports the |Mixed communities (male and |30 October 2013 |8 |
| |social, emotional and spiritual wellbeing of BME and |female | | |
| |Muslim communities in Wales. | | | |
| |Zulfiqa (Pakistani male) was asked to go along and talk | | | |
| |about his experience of sight loss. | | | |
|Community champion and gender |Activity |Community attending and |Date |Numbers attending and feedback |
| | |gender | | |
|Somali community champion (Female). Only involved |Spoke to individuals in the community about |Somali (mainly female) |October and November 2013 |50 |
|in the project for first month following the |eye health. | | | |
|training, then could not continue due to other | | | | |
|commitments. | | | | |
|Somali community champion (Female). Only involved |Arranged activity at the mosque and a |Somali (mainly female) |October and November 2013 |15 |
|in the project for first month following the |children's group and gave out eye health | | | |
|training, then could not continue due to other |messages. | | | |
|commitments. | | | | |
|Bangladeshi community champion (Female) |Spoke to individuals about eye health |Bangladeshi (mainly female) |October and November 2013 |5 |
|Only involved in project for first month after | | | | |
|training. | | | | |
|Bangladeshi community champion (Female) |Spoke about eye health at the Riverside |Bangladeshi (mainly female) |October and November 2013 |10 |
|Only involved in project for first month after |Mosque | | | |
|training. | | | | |
|Somali community champion (Male) |Had various meetings with different |Somali (male and female) |October 2013 to March 2014 |50 |
| |organisations in the community raising | | | |
| |awareness of eye health | | | |
|Somali community champion (Male) |One to one conversations with individuals in |Somali (male) |October 2013 to March 2014 |15 |
| |the community about eye health. Discussions | | | |
| |took place as a result of work in community | | | |
| |but also outside of work as an active | | | |
| |community member. | | | |
|Somali community champion (Male) |Talking to men attending gym class about eye |Somali (male) |February 2014 |10 |
| |health | | | |
|Somali community champion (Male) |Asked Iman at mosque to give out information |Somali (male) |December 2013 to January 2014 |15 |
| |about eye health after prayer time | | | |
|Somali community champion (Male) |Somali careers event, involving presentation |Somali young people and |12 February 2014 |70 |
| |from health professionals. |families (male and female) | | |
| | | | | |
| |Sian Biddyr provided eye health presentation | | | |
| |and gave out eye health leaflets. | | | |
|Community champion and gender |Activity |Community attending and |Date |Numbers attending and feedback |
| | |gender | | |
|Somali community champion (Male) |Horn community health event. Presentations |Somali community, family |March/April 2014 |70 |
| |given from a variety of health professionals |mixed ages (male and female) | | |
| |about diabetes, coronary heart disease etc. | | | |
| | | | | |
| |Bablin Molik and Sian Biddyr gave a | | | |
| |presentation about eye health. Abdi | | | |
| |interpreted for the community. | | | |
|Community champion and gender |Activity |Community attending and |Date |Numbers attending and feedback |
| | |gender | | |
|All community champions |The champions promoted the BME Health Fair 2014 within|Somali, Gujarati, Chinese, |March 2014 |71 attended the eye health section |
| |their communities and organised groups to attend – |African-Caribbean (male and | |receiving information about eye health.|
| |particularly the eye health session. At the health |female) | |36 EHEW appointments booked. |
| |fair they provided interpretation services for their | | | |
| |community members and then helped them attend any EHEW| | | |
| |examinations resulting. | | | |
Acknowledgements
We would like to thank the six main Community Champions that have been involved in this project and ensured its success. Through their dedication, enthusiasm and commitment they have enabled us to carry out this project and as a result, helped improved eye health awareness in specific BME communities in Cardiff.
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