Figure 1
Study area.
Table 1
Geography, demography and economic information by pilot counties.
| X COUNTY | Y COUNTY | L COUNTY | |
|---|---|---|---|
| Administrative Area (km2) | 2,425 | 3,659 | 1,990 |
| Percentage of Mountainous region (%) | 75.5 | 71.8 | 61.2 |
| Number of Townships | 11 | 12 | 9 |
| Population (in tens of thousands) | 48.3 | 44.2 | 70.2 |
| Male/Female ratio | 1.03:1 | 1.11:1 | 1.07:1 |
| Percentage of ethnic minorities (%) | 18.67 | 48.48 | 2.50 |
| GDP (in ten thousand RMB) | 2,062,991 | 1,620,612 | 3,072,178 |
| Per capita income of urban households (RMB) | 42,811 | 34,137 | 38,424 |
| Per capita income of rural households (RMB) | 15,533 | 14,984 | 19,445 |
[i] Data source: China County Statistical Yearbook 2022, https://www.stats.gov.cn/.
Figure 2
Theory of change and scope of process and outcome evaluation for Eye CARE Model in rural China. Figure to illustrate theory of change.
Table 2
Progress towards targets (Fidelity & Reach).
| COUNTY X | COUNTY Y | COUNTY L | |||||||
|---|---|---|---|---|---|---|---|---|---|
| Fidelity | |||||||||
| Planned | Implemented | % | Planned | Implemented | % | Planned | Implemented | % | |
| Human resource development | 210 | 355 | 169% | 174 | 277 | 159% | 166 | 353 | 213% |
| Human resource development-PHW trained | 72 | 242 | 336% | 72 | 154 | 214% | 72 | 132 | 183% |
| Infrastructure and equipment | 2 | 6 | 300% | 2 | 6 | 300% | 2 | 6 | 300% |
| Community screening | 58750 | 93734 | 160% | 54750 | 103939 | 190% | 50750 | 79765 | 157% |
| Eye health education | 14000 | 28985 | 207% | 14000 | 14297 | 102% | 14000 | 22785 | 163% |
| Establishment of local referral pathway | 1 | 1 | 100% | 1 | 1 | 100% | 1 | 1 | 100% |
| Treatment | Control | diff | Treatment | Control | diff | Treatment | Control | diff | |
| The proportion of ophthalmology/ENT departments established in township health centers | 4/5 | 1/5 | 60% | 4/7 | 0/5 | 57% | 1/5* | 0/4 | 20% |
| Reach | |||||||||
| population | Population covered | % | population | Population covered | % | population | Population covered | % | |
| Community screening | 312760 | 93734 | 30% | 245022 | 103939 | 42% | 431333 | 79765 | 18% |
| Eye health education | 312760 | 28985 | 9% | 245022 | 14297 | 6% | 431333 | 22785 | 5% |
[i] Source: The Eye CARE Model project documents (2021–2023).
Table 3
Estimated effect of the project on the utilization of eye care services per 10,000 people in the treatment and control groups.
| BEFORE PROJECT IMPLEMENTATION | AFTER PROJECT IMPLEMENTATION | DIFFERENCE-IN-DIFFERENCES EFFECT [95% CI] | P-VALUE | |||
|---|---|---|---|---|---|---|
| TREATMENT GROUP (n = 18) | CONTROL GROUP (n = 13) | TREATMENT GROUP (n = 18) | CONTROL GROUP (n = 13) | |||
| Primary eye care services a | ||||||
| Diagnosis and treatment of conjunctivitis | 19.4 | 18.3 | 63.7 | 24.7 | 52.7 [29.8, 75.5] | <0.001 |
| Diagnosis and treatment of keratitis | 16.8 | 23.5 | 35.5 | 31.1 | 20.6 [9.6, 31.7] | 0.001 |
| Diagnosis and treatment of entropion | 1.0 | 1.6 | 2.2 | 2.9 | 0.7 [–0.1, 1.5] | 0.094 |
| Diagnosis and treatment of trichiasis | 2.5 | 3.4 | 6.1 | 5.9 | 1.9 [0.4, 3.5] | 0.017 |
| Total primary eye care services | 39.7 | 46.9 | 107.5 | 64.7 | 75.9 [44.4, 107.4] | <0.001 |
| Secondary eye care services b | ||||||
| Cataract surgery | 7.3 | 8.4 | 14.2 | 10.4 | 6.7 [4.4, 8.9] | <0.001 |
| Cataract outpatient | 15.2 | 15.5 | 36.1 | 21.9 | 22.3 [10.6, 34.0] | 0.001 |
| Pterygium surgery | 4.5 | 5.2 | 8.8 | 7.3 | 4.0 [1.8, 6.2] | 0.001 |
| Pterygium outpatient | 15.0 | 20.6 | 33.7 | 29.6 | 16.5 [4.5, 28.5] | 0.009 |
| Glaucoma outpatient | 2.0 | 3.9 | 5.3 | 5.0 | 2.5 [1.0, 4.0] | 0.002 |
| Total surgery services | 11.8 | 13.5 | 23.0 | 17.7 | 10.6 [6.6, 14.7] | <0.001 |
| Total outpatient services | 32.2 | 40.1 | 75.2 | 56.5 | 41.3 [18.3, 64.4] | 0.001 |
| Total secondary eye care services | 44.0 | 53.6 | 98.2 | 74.2 | 52.0 [25.6, 78.3] | <0.001 |
[i] Note: a) Primary eye care services include the outpatient services (diagnosis and treatment) of conjunctivitis, keratitis, entropion and trichiasis, which can be provided in the primary healthcare facilities (township health centers and village clinics). b) Secondary eye care services include the outpatient and surgery services of cataract, pterygium and glaucoma, which can be provided in the secondary healthcare facilities (county-level hospitals). c) Data are mean of utilization of eye care services per 10000 people, or as indicated. d) The results of Difference-in-differences effect are based on two-way fixed effects (TWFE) model, with control variables including a set of township characteristics including residential population, number of industrial enterprises, and number of stores or supermarkets with a business area of more than 50 m2. We cluster the standard errors at the township level.
Figure 3
Utilization of eye care services per 10000 people in the treatment and control group.
Figure 4
The dynamic effects on the utilization outcomes of eye care services.
Table 4
The heterogeneity of the effect on eye care services utilization by county.
| ALL COUNTIES | COUNTY X | COUNTY Y | COUNTY L | |
|---|---|---|---|---|
| Primary eye care services | ||||
| Diagnosis and treatment of conjunctivitis | 52.67*** (4.71) | 84.28*** (4.81) | 51.55*** (3.20) | 1.29* (1.94) |
| Diagnosis and treatment of keratitis | 20.61*** (3.81) | 20.44*** (4.38) | 28.86** (2.21) | 1.51** (2.78) |
| Diagnosis and treatment of entropion | 0.71* (1.73) | 1.31* (1.96) | 1.17** (2.56) | –0.11 (–0.39) |
| Diagnosis and treatment of trichiasis | 1.92** (2.52) | 3.82*** (5.56) | 0.80* (1.96) | 0.07 (0.17) |
| Total primary eye care services | 75.90*** (4.92) | 109.85*** (5.42) | 82.37** (3.09) | 2.75*** (3.41) |
| Secondary eye care services | ||||
| Cataract surgery | 6.65*** (5.98) | 10.96*** (5.19) | 4.24*** (3.85) | 3.07** (3.14) |
| Cataract outpatient | 22.31*** (3.89) | 47.61*** (4.24) | 10.49*** (3.25) | 2.77** (3.33) |
| Pterygium surgery | 3.99*** (3.69) | 7.28*** (3.84) | 3.06*** (6.20) | 1.97** (2.92) |
| Pterygium outpatient | 16.48*** (2.81) | 37.89*** (9.18) | 9.37*** (4.02) | 2.90*** (4.01) |
| Glaucoma outpatient | 2.52*** (3.41) | 3.82* (2.13) | 0.52 (0.54) | –0.29 (–1.03) |
| Total surgery services | 10.64*** (5.37) | 18.23*** (5.76) | 7.31*** (6.17) | 5.04*** (6.13) |
| Total outpatient services | 41.31*** (3.66) | 89.32*** (6.12) | 20.35*** (5.66) | 5.38*** (8.34) |
| Total secondary eye care services | 51.95*** (4.03) | 107.55*** (7.15) | 27.66*** (7.26) | 10.42*** (7.31) |
| Observations | 155 | 50 | 60 | 45 |
| ControlVars | YES | YES | YES | YES |
| Township FE | YES | YES | YES | YES |
| Year FE | YES | YES | YES | YES |
[i] Notes: Robust t-statistics in parentheses; *** p < 0.01, ** p < 0.05, * p < 0.1.