Enhancing the appropriateness of eyecare delivery: the iCaretrack approach

Figures & data

Figure 1. Overview of the iCaretrack approach demonstrating the key steps. The process starts with identifying the existing gaps (step A) and analysing the underlying behavioural determinants (step B), followed by developing an intervention using theory and centring around the end-user needs (step C), evaluating the intervention (step D) and finally scaling up the effective interventions (step E) for broader public health impact.

Table 1. Appropriateness levels for glaucoma and diabetic eyecare for consultation domains and overall care.^16,18,19.

Consultation level	Glaucoma (95% CI)	Diabetes (95% CI)
Consultation domain
History taking	60% (57–63%)	48% (44–52%)
Physical examinations	64% (62–66%)	88% (82–94%)
Recall	92% (71–100%)	93% (85–100%)
Referral	100% (52–100%)	100% (38–100%)
Overall care	63% (95%CI 61–64%)	69% (95%CI 66–73%)

CI: confidence intervals

Figure 2. The Theoretical Domains Framework (TDF) and Behaviour Change Wheel (including COM-B) model used for behavioural analysis and intervention conceptualisation in the iCaretrack approach. The eight salient TDF domains (ring B) are linked to COM-B (ring A). The intervention functions most likely to address these determinants are outlined in ring C (step 1 described in the text). The selected intervention functions need to be further explored to identify the behaviour change techniques (not shown in the figure) which are the core ingredients in an intervention (step 2 described in the text). The BCW model also includes an outermost ring of seven policy categories (not shown in the figure) that support the implementation of the selected intervention functions.

Table 2. Key determinant themes (barriers and enablers) grouped in COM-B components with examples.

COM-B	Key TDF Domains	Themes	Examples (participant quotes)^Citation18,Citation30
Capability	Knowledge	Knowledge gaps Issues with continued education	“I’ve always thought it was important, but I don’t think I really thought that through any further as to which particular ethnicities were more at risk”.
	Skills	Skill proficiency	“Don’t know how to perform a dilated fundus exam”.
	Memory attention and decision processes	Complexity in care process Forgetfulness Attention control	“So then we just forget or maybe aren’t aware of it [iris examination] or was aware of it and no longer aware of it”.
Opportunity	Environmental context and resources	Time constraints, Organisational culture Resources	“Time affects the majority of things, the history that you can take, the test that you can do and sometimes the result that you record”.
	Social influences	Norms Influence of mentors	“You don’t need to record it down because that is what everyone else is doing”.
Motivation	Beliefs about consequences	Lack of perceived importance Expected outcome	“It doesn’t really matter how long they’ve had diabetes because they don’t have diabetic retinopathy. At the end of the day, the reason I’m asking that is to find out whether they’ve got it. And they don’t have it. So, who cares?”.
	Professional role and identity	Perceived role in the care process	“No, part of the problem is that the optometrist, ‘oh do you see an eye surgeon’. ‘Yes, I see him every six months’.”
	Intention	Lack of interest Apathy	“Why things aren’t happening? Just lack of willingness or laziness, I suppose apathy or whatever it is”.

COM-B: Capability, Opportunity, Motivation-Behaviour model, TDF: Theoretical Domains Framework

Table 3. Overview of the co-design workshops with optometrists and stakeholders.

Co-design element	Workshop 1	Workshop 2
Explore	Ideation to generate potential behaviour change activities to improve the appropriateness of glaucoma and diabetic eyecare	Overview of results from workshop 1 and experience-based exploration of intervention components
Develop	Development and transformation of ideas into final format of idea	Activity to design the content and format of the intervention components
Decide	Prioritisation activity to select most important and urgent ideas for further development	Evaluation exercise to determine the newness, usefulness and feasibility of each designed intervention component

Table 4. Outline of steps involved in the intervention development process with examples from the diabetes module.

Step	Methods	Outcome	Diabetes Example
Behaviour analysis	Eight focus groups and four individual interviews (total participants = 31) Data collection and analysis informed by the TDF	Key barriers and enablers	Barrier example: “multiple things going on at the same time” (Memory, Attention and Decision process) (Figure 2/Table 2)
Conceptual intervention mapping	Key barriers and enablers mapped to intervention functions, policy categories and BCTs from the BCW model	Key intervention functions and BCTs	Intervention function example: Education, Environmental Restructuring BCTs: Instruction on how to perform a behaviour, Add objects to the environment
Participatory Design -Program development	Two co-design workshops (n = 23; optometrists-12 and stakeholders-7) and four patient interviews High-priority improvement ideas identified and synthesised with the conceptual intervention strategy Online activities (such as ‘Design Your Box’ to develop the content, format and features of the intervention (Table 3)	Intervention program component	Intervention component example: Education (lectures), Resources (chairside reference/algorithm)
Prototype development and refinement	An online platform created by an external tech vendor; content created by the research team based on co-design findings Prototype iteratively tested (think-aloud approach, semi-structured feedback interviews and usability testing) and refined	Initial prototype Usability issues and ratings Final refined prototype	An online platform hosted at www.icaretrack.com.au/diabetes, consisting of a self-assessment tool (i-ACT), education, peer support and resource components (Figure 4)

Note: BCW: Behaviour Change Wheel, BCT: Behaviour Change Techniques, TDF: Theoretical Domains Framework, i-ACT: iCareTrack Assessment of appropriateness Clinical pracTice tool.

Figure 3. iCaretrack quality improvement program and its components for diabetes module. The glaucoma eyecare module had a similar layout and presentation. The focus of the program was the i-ACT (iCaretrack: assessment of appropriateness in Clinical pracTice) dashboard. Other supporting components included education (lectures and case studies); resources (a curated list of resources developed by the research team as well as links to external resources), and peer support activities (webinars and discussion forums).

Figure 4. Diabetes i-ACT (iCaretrack: assessment of appropriateness in Clinical pracTice) dashboard for optometrists. The glaucoma dashboard had a similar layout and presentation.

Ho KC, Stapleton F, Wiles L et al. iCaretrack: measuring the appropriateness of eyecare delivery in Australia. Ophthalmic Physiol Opt 2020; 40: 433–441. doi:10.1111/opo.12699

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Toomey M, Ho KC, Gyawali R et al. Level of appropriate primary diabetic eyecare delivered and achievable in optometry practices in Australia. Clin Exp Optom 2022; 1–9. doi:10.1080/08164622.2022.2033107

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Gyawali R, Ho KC, Toomey M et al. Level of appropriate primary diabetic eyecare delivered and achievable in optometry practices in Australia. Clin Exp Optom 2022; 1–7.

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Gyawali R, Toomey M, Stapleton F et al. Multiple things going on at the same time: determinants of appropriate primary diabetic eyecare delivery. Ophthalmic Physiol Opt 2022; 42: 71–81. doi:10.1111/opo.12912

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