 So a very warm welcome to this webinar on the research issue of the Community Eye Health Journal. The aim of the journal is to provide practical information and guidance for eye care workers of all levels, particularly in no resource settings. Four issues are produced a year and this webinar will review some of the articles produced in the research issue which came out at the end of last year. So, just like to talk a little bit about the, we've got a fantastic line up of speakers, I'll say I'll be introducing them in a moment. But just also I'd really encourage everybody to check out the new ICEH websites. It's been redone recently. It looks really fantastic. And the journals on there and all of the activities that we're involved with. So there are some brilliant resources, including some really good online courses which are completely free to complete. If you click on the education tab, it'll take you to online courses including ophthalmic epidemiology and global blindness. These are really high quality courses which give a lot of training and knowledge and additional stuff to the things we're talking about today. So we might be able to put the links in the chat for that. So, research can sometimes be a little bit off putting to think about and might seem a bit irrelevant in a busy clinic or hospital setting. However, we hope to convince you that research is important for all aspects of eye care, whether it's direct patient care or the planning and delivery of eye care programs. We have a superb lineup of authors and researchers who will review three key articles. We're very keen for those attending the webinar to participate. So please just don't sit back, get ready for your questions, get ready to engage in some discussion and dialogue. The presentations are fairly brief and we've built in time for questions and discussion. So please do put your questions in the Q&A section or you can raise your hand. We'd love to hear from you. The chat function is there, but that's more just to kind of say hello and get to know each other a little bit. So I'm going to hand over in a moment to Professor Claire Gilbert. Claire is an ophthalmologist who has been working at the LSHM for 20 years, in which time she's carried out an incredible amount of work. She's carried out a very large amount of important research for which she's received many awards, particularly on child eye health. She's currently co-chairs of London Schools Ethics Committees and we're very privileged to have her as part of this webinar. So she will be talking about the article she led on the principles of good eye care research. Thank you Claire. Thank you very much Victor and hello everybody. The first slide shows some research it was done by Jackie Ramkey, who was interested to see where eye research is being done. What you see is there is a huge disconnect between where most people who are visually impaired or blind live, which is in low and middle income countries, and where most eye research is done, which is in high income countries. So a lot more research is needed to address the eye health needs of populations in low and middle income countries, because findings from high income countries may just not apply in other settings. So local research is really important. Many of you will be aware that different studies carry different scientific weight with case reports and the opinions of experts and letters down the bottom in the red, having the least scientific rigor, going all the way up to the top, where you have systematic reviews and meta-analysis that meta-analysis pull the data from similar studies, and this gives us the strongest level of evidence. And so it's important to do the most rigorous and scientifically advanced studies that you feel capable of doing, bearing in mind that as you go up the triangle. So the complexity, challenge and often cost of the studies increases quite spectacularly. So the principles of good research is basically to fill gaps in our knowledge by providing evidence that is trustworthy and useful. And in the absence of evidence, we tend to use these ease. We based our decision making on experience of our own experience or others. Eminence, you know, if the boss says I treat a patient like this, then this is how I should do it. Elegance people, some people can be very persuasive about certain lines of action or expectations, either patients, families or the healthcare workers. These are all not evidence based decision making and are likely to be biased. And so again, local research is very important to provide that evidence for decision making. So where to start, the first important thing to do is identify the problem or the knowledge gap that you want to address. And research is rarely done just by one individual. More brains are definitely better than one. So decide who you want to work with. Have a look to see what other people have done on this area by looking in PubMed to find out what methods other people have used, what they found, whether there were any limitations to those studies because it's often useful to get ideas from how to do research by seeing looking at other studies which are addressing a similar topic. And I can't emphasize enough that time spent on detailed logical planning is absolutely vital. When you've collected the data, it's usually too late, you can't go back and make any changes. And it takes time, but it's time very well spent. So observational descriptive studies are much more straightforward than the studies which where you are evaluating an intervention, such as a new drug and new surgical technique, which usually requires some kind of comparison between groups, whether that's randomized or not. So these are much more difficult studies to do than descriptive studies. So in planning a study, you need to have an open mind about what you might find. If you go in with preconceived ideas, you may miss important information, and the results may be biased. It's very important to use your imagination. Imagine what it's like to be the mother of a child who's cataract blind. Put yourself in her shoes. This will help you to really think about her life and what challenges she might be facing and help you if that's a study you're interested in doing and finding out why children come late. Really put yourself in the shoes of those mothers and think also about what assumptions you might have. We all tend to have assumptions and we may think that mothers come late just because they're not well educated, but well educated people also constantly make decisions and in some ways people who are poor and uneducated have to make more careful decisions than those of us who are more privileged because their resources are scarce. Be aware of bias, which comes in how you select the participants to be included and how you collect the data because this may lead to results which are difficult to interpret. Studies that are too small may not give valid results. If you only interview five or six people that may not be enough. Studies that are too big is a waste of their time, your time and also resources. So think about the number of people you include. So when you start, you need to have a clear, concise research question. This is absolutely critical because everything follows from that. And I've just got some examples here. The patients with open-angle glaucoma are coming back to the clinic blind because they've not attended follow-up. So a question would be, sorry, a question would be what proportion of patients with open-angle glaucoma drop out of regular follow-up after diagnosis and which patients are less likely to attend. This will help you to target your interventions to improve follow-up. Children with congenital cataract are presenting too old for management to give good outcomes. So a research question there might be, why do children with bilateral congenital cataract present after the age of two years to the eye department? I'm going to pass over the next slide because we're running out of time, but I think you get the idea. So getting the question right is absolutely key because everything follows from that. So your research question leads on directly to the aim of your study, which is how the data you collect will address the problem being identified. And then you need very clear objectives, which are the specific activities which need to be undertaken to answer the research question. And then from each of those objectives, you need to think about what methods you're going to use. These can be broadly divided into quantitative methods where you collect numbers or qualitative methods where you collect narrative information or text. And quite often people use a combination of those two things because they can look at the same question from a slightly different perspective. Research question is key. It drives everything else. So spend time on that, talk to people, make sure it's clear, specific and concise. Then you have to decide who you're going to include as study participants. Are they patients, family members, community members, are you going to need to include eye health professionals, or do you need a group of participants, different groups of participants. And then you have to decide what data you're going to collect and how you're going to do that. Are you going to extract data from medical records or from a surgical log? Are you going to devise the developed questionnaires to collect quantitative data? And if you're going to be interviewing people, you need to come up with a list of questions that you're going to ask them. Ideally, these need to be pilot tested and then revised to make them as good as possible. And then you need to decide how many people in each of the groups you're going to include. At this point, it's often important to involve a statistician if you're doing quantitative data because they can help to work out the optimum number of people to include. Then you need to decide how the data are going to be analysed, bearing in mind that quantitative and qualitative data need very, very different analytical methods. And then you need to plan the logistics of how the study is going to be implemented. So the timeframe, how many staff you need to train and how they're going to be trained. How are the data actually going to be collected? Is that you're going to use a paper form? Are you going to use a tablet? Or are you going to be doing audio recordings? And it's also important to have a plan for how the results are going to be disseminated in publications, in presentations to people in your hospital. Often to the participants, if it's possible to do that, that's also a very good idea. And in or in reports. And once you've done all this detail planning, you can then do the budget. And it's good to do this at the end once you know the timeframe and what's going to happen at different points across the study. The next thing to do is to think about who you would need to bring in, who would have the relevant expertise. So you may want a social scientist to help with the qualitative aspects or a statistician to help with the quantitative data. And take on board their suggestions, discuss everything with them. And it's also a very good idea to seek an independent opinion at this stage from an experienced researcher. Because they may see some gaps or may have suggestions to make to make the study better. And then you revise and finalize your research plan or your protocol. And then the last thing to do before you start implementing is to get ethical approval, if necessary. And then once you're undertaking the study, there are lots of things that have to happen while the study is ongoing because the data must be rigorous and of high quality. So you need well trained staff, and they need to be supervised and monitored during data collection to make sure it's complete and accurate. And during the checking and analyzing the data, you may need to report progress to the Ethics Committee. And then finally, you need to interpret the findings. So what do the findings mean in relation to the research question? And what are the implications of the findings for service delivery? Do you need, is it this piece of work led to more research questions? And what are the limitations of the study? All studies have limitations. None is perfect. And then the findings are disseminated according to the plan. So no research is perfect. There are better or worse ways of conducting research. And some studies can be fatally flawed. I do a lot of reviewing for journals. And sometimes the design and the methods says something so seriously wrong that the study can't be published. So it's very important to consult, discuss, and make sure that major emissions in the way the study has been designed, or in the way that the data is going to be collected or addressed before you start. And so it's much better to seek advice early rather than asking for help once you've already collected the data because then it's too late to make any changes. Thank you. Thanks so much, Claire. That was a fantastic presentation and I really enjoyed rereading the article as well in full. So would really love to welcome any questions or discussion points. Do feel free to put your hand up or put any questions in the Q&A section. I'm going to kick off Claire. If somebody thinks of a possible research question, how can they kind of assess whether it's worthwhile to do research on that question? Sometimes we see research coming out and we question whether the research question was a worthwhile one. What are your thoughts on that? I think discussion. I've talked to people, maybe colleagues. It depends what the gap is that you're trying to address, but definitely talk to people and get a range of opinions from people who will be looking at the problem from a different perspective, which may also help you to see whether it's worthwhile exploring. Thank you. Kevin, I think you have a question and I think you're allowed to talk. So if you're there and have audio, would you like to put your question forward? Sure thing. Can you hear me? Yeah. Yes. Thank you for the presentation. Thank you for the opportunity. Just a quick question. We're exploring research opportunities in the Caribbean and just wondering, are there specific research databases or resources focused on research specifically in low middle income countries for eye health in particular? I know there are some trial registries which focus on different world regions, but you're talking about published papers, is that right? Published or unpublished work? I think all published papers tend to go into a common database. As far as I'm aware, things like PubMed, Medline, EMBase, I think they are global. Certainly those are the ones that I look at. And then you have to put in the relevant search terms to identify the region that you're interested in. Victor, can you help with this or GV? One of our articles, Elmin, was on a database of research that needs to be conducted and I think has been conducted. I'm just trying to look it up. Can you remind us about that one Elmin? You are putting me on the spot, but I'm talking about the exercise that Jackie Ramkey did where she was in the Lancet Global Commission and I'll have a look in a minute. That's the pie chart I showed. Right, and she looked in PubMed to get that data. So she looked in a global database to find out the location of different studies rather than there being a database per region. So I'm sorry, Kevin, I'm not 100% certain, but I think the answer is it's all global. To add that, Kevin, when it comes to resources on the region, the IEPV Vision Atlas is very useful as serving as a cross-reference. I use it more like a way in to availability of data on a regional, national or national level. And then it often will give you a tip off about authors' names and all to then carry over to PubMed for search for articles. I'd just like to add one thing, Kevin, and that is if you're looking at available databases which are publicly available, you have more in the high-income countries. But few countries do have publicly available databases. You would need to look at who those authors are or who actually compiled the initial ones. These are usually longitudinal. So I can give you the example of one particular study in India, which is a longitudinal study which is looking at the children and parents study. It's called the Andhra Pradesh Children and Parents Study, which is looking at starting off with women who were pregnant 45 years ago, their offspring and the eye problems in them. And this is a publicly available database, and on which you can do additional analysis. So that is the other aspect of databases which you can work on. Great stuff. Oh, right. Okay. Maybe, yeah. Sorry. Maybe I misunderstood what Kevin was asking. We have another couple of questions coming in, slightly open-ended ones, but the first one is about research, fund and resources, how to get managed reports, get more. I mean, this is always the problem with conducting research. How do we get funds to fund research, especially in low-income settings? And any thoughts on this for many of the panelists? One suggestion I would have is to start small. And this will actually be a segue into our next presentation. But by starting small, you're able to sharpen your own skills, build that team. We have a lot of questions now about how you build a research team. And you can often conduct the research based on perhaps data you're already collecting or with a slightly different lens on data you're already collecting as part of an intervention you may already be conducting. So there are ways to, as we say, start small, which we'll hear from Ishmael soon, and then that often will build the legs for being able to attract other research funding. And if I can just thank you so much, Suzanne, that's absolutely right. And starting small, then I was even going to take it sort of a step back. I'm noticing that we've got a lot of ophthalmic nurses in the chat who's saying hello. So welcome to all of you. And that kind of links to the question of deciding on the research team who should be involved and what's the role of the principal. I'll leave others with more experience in this area to talk, but from my perspective as the editor of the journal, you know, research can start. Research is really about recording what you do and being very systematic and how you record what what you do and what happens, and then present that to others. And I think, you know, our focus is really on improving patient case and at whatever research we do operational, everything's needed, you know, it's operational that is, you know, delivery of ICA interventions, it's clinical research, all of that is focused on patient care. And I think a lot of getting funding for research is about being able to tell a compelling story. So is to be able to tell the Ministry of Health or your boss or the manager of your hospital or a charity to say, there's a problem patients on getting the care they need. I think we need to investigate this, whatever that area is, and it can be, you know, like changing your operational, you know, your SAPs, your standard operational procedures in the hospital to catch patients who are not kind of getting the care they need. And, you know, with a whole range of work so if you can and again, you know, having a small pilot studies, trying it out with a few people. And I think when you starting to formulate your research question you have to be thinking almost immediately and maybe even start with the person who's funding you when they want to boast about the results of your research how are they going to explain what are they going to say, you know, I've funded some research that improved patient care for these groups, or it allowed ICA delivery to be done. So kind of starting with the end in mind, when you start your research and thinking about what will be the headline in the Community Health Journal and another journal when we, when we have this research published what will be the impact of it. And, you know, because it's a lot of hard work doing research that's why I'm an editor because research is too much work. So you have to be motivated and I think when you tap into what is important to you as a clinician, you know, as an ophthalmic nurse or as a doctor, what is your passion and what would you like to improve, you know, in this ICA environment where you are. Starting with that and then coming to these experts for guidance on how to do it. Thanks so much, Elmi. We've got another couple of questions there. I'd like to keep those just aside for the moment because I think the other couple of presentations perhaps may help to answer those a little bit. So perhaps we'll come back to those if that's all right. And we're a little bit tight for time now. So I'd like to push on and I'd like to introduce Dr. Esmael Abtamu Ali, a great friend from Ethiopia, who is an assistant professor at the LSHGM, as well as being affiliated with the Bahidar University College of Medicine and Health Sciences in Ethiopia. He completed the MSC in public health for eye care with the London School, and then his PhD on the surgical management of trachometous trichitis, and he also has a welcome trust international fellowship. So he will discuss his article on small scale eye research. Thank you, Esmael. Thank you so much, Victor. Hi, everyone. So I'll talk about small scale eye care research. This is slightly different from what Professor Clare has presented. So what is a small scale research? So as most of you know, research is a systematic investigation. A systematic investigation can be done in large scale or small scale in large scale in the way that has been described by Professor Clare, but also it can be done in a small scale. So what makes a research a small scale, or what makes it different from a large scale research. This is mainly due to the research question. Small scale research. The research question tries to provide answer to context specific challenges, not to test theories or to test hypotheses. And small scale research is focused on benefiting locally, benefiting the local community, or the local organizations that you are working in. Not to generalize ability or publication. And also it can be done with limited resources actually most people ask about funding and they think that funding is a limitation to the research but actually small scale research and some research questions that can be addressed by small scale research might not need any funding at all. So what do you need for small scale research is not really funding or money. That's not the main thing, but it's a scientific mindset. You need a scientific mindset and scientific mindset is characterized by curiosity. And curiosity means, you know, asking the right, you know, questions, questions like, you know, wondering about why something is not working or why something something, or what can be done to solve some kind of problem. What tools are needed to implement some kind of healthcare intervention or I care intervention. The other characteristics of a scientific mindset is actually open mindedness. This is about avoiding predetermined idea, not thinking that something will work or not to be best like it has been described by clear and thinking that all possibilities are valid until proven otherwise. That is really important, but in addition to being open minded, but also you need also to be skeptical and skepticism means systematic doubt. And this is about, you know, questioning almost everything, you know, questioning the tools that you use the procedures that you implement and the results that you see from from different research. And also, you know, understanding is about understanding limitations of the research is that that you are trying to conduct and and or the research that you have conducted or the research of other people that has been published or presented in front of you should be able to have that kind of mindset. Small scale research questions are mainly relevant to local context as they might not be, you know, address, you know, some global global international kind of challenges, but they are characteristically or typically relevant to local context as and so that they are generated from your day to day practice or experiences. And for instance, as an example, it can be, you know, the question can be does service, the service that you provide or delivery in your community, or in your hospital meets the the required standard or what are the reasons for poor surgical outcomes or which group of people are accessing service or which which group of people are actually missing out on the service. And what can be done to improve equitable access to or questions around, you know, customer satisfaction, how satisfied are your clients, or also question around, you know, health personal satisfactions and also feasibility studies to, you know, studies about the acceptability of some intervention or feasibility of conducting some intervention in your study setting. So how do how do you generate the data how do you get the data or from where do you get the data for small scale research. Usually it is from routine health information system data from the data that is being collected by your health facility or by from the community and so on, so that you can really do some disaggregated data analysis on service access or on service quality and this is usually more efficient than population based surveys, you know, using health information system data actually might give comparable results compared to some of the results that you might get from population based surveys. And routine health information system data also is really important it provides important evidence on progress on achieving universal health coverage. The other thing is, you know, you can also collect primary data from observation from your clinics from your patients interviewing your patients, or also from focused discussions or focus group discussion or a small group discussion with the community or with different groups, and this can be easily embedded in your written activity, you can be done, you can do this in your outpatient departments, or in your community interventions or community activities. Or, again, you can also collected from secondary data from medical records, you can randomly select some medical records and and and do some kind of analysis based on the research question that you have started with. And the important thing on small scale research is its interpretation really you should be really cautious not to over interpreted over interpreted. So I think, and the interpretation also need to be done collaboratively with different stakeholders, and that collaborative review and stakeholder engagement will help you to kind of deliver or come up with manageable and context specific recommendations. And you should not really be worrying about the statistical indicators in a small scale research. You know, mainly because the sample that the data that you have collected might not be adequate to adequate, you know, adequate to have the power to say some kind of to make some kind of statistical inferences. And like I said the collaborative review is very important. It particularly replaces the peer review process that happens during publication in large scale research or during your presentation, or when you are putting it on website or on this kind of platform. There is also always a peer review isn't it but in a small scale research, you should be able to engage local communities for collaborative review and the recommendations and, and the conclusions should come from them. And mainly your local communities or your friends your colleagues in hospital, or the healthcare managers in your health facility might not talk about you know statistical significance, or epidemiology or confounders or anything but actually they will, they will tell you whether the results from your studies are actually or whether they make sense, or whether they are aligned with their thoughts and what with their observations. So really collaborative review is really one important aspect of a small scale research and you should not really to try to incorporate your data yourself without engaging such kind of stakeholders. Thank you. Thank you so much. My video is not coming after I did a lot but it says as a horse. Okay, couldn't allow you to do that. No problem. No problem. I smell. Thanks a lot for that presentation though. And please everybody raise your hand or put your questions in the Q&A be great to hear from you about this small scale research. Well, maybe I could ask you. I understand from your article a lot of this research may not get into peer review journals and that's not the aim of this research, but it still sounds like fantastic research to know about and learn about. Is there a way of being able to share this or disseminate this research, even just to see, you know, how other people went about conducting this sort of research is another way of finding out apart from medical journals. And that's a really good question isn't it. Like I said, it is usually for local consumption and and if you are public public publishing it if you are not publishing it you are not really able to kind of disseminate it properly appropriately. You can see if you are planning to publish also you might need also some kind of ethics approval and so on. And usually small scale research can be done without a national or some kind of complex ethical review, but it's about you know, making sure that the ethical standards and ethical standards are actually in place why we are collecting that data, you know, engaging with your facility heads, or the local, you know, health worker or healthcare managers and so on talking with them and making sure that those ethical standards are in place, but actually disseminating it to the global level and and and you know, regional level will be usually tricky and that's really the limitation of small scale research is about disseminating it if you are disseminating it, then it needs to really follow some kind of rigorous analysis data collection and so on. It should be able to also benefit the international or the global communities somehow. But you might miss some kind of methodology or implementation, some designs and so on that has been implemented locally, but the only limitation one of the limitations of actually of conducting small scale research is on that respect to Victor. I could add a few more points as well you you cited exactly the kind of predicament when it comes to small scale research. However, I do want to note, there is a growing appetite for case studies that then can accompany other publications be part of a compendium. And so there are ways to contribute more at a case study level. Of course, presentations are very important way to share one's findings. And in doing so, presenting at local conferences in that particular field, then give you an opportunity to build a community around the research issues that are important to you important to them and sometime lead to building research alliances. So I agree 100% with what you're saying with the difficulties of publishing in major journals. However, fortunately, there are many other ways of knowledge sharing. And I think that's a very important point for us to bring out in the future. Thanks so much for that. And we have a question from Abulahi. If you're there, would you like to put forward your question please? Yes, sir. Good evening sir. Good evening. Nice. Very welcome. Thank you. And I'm telling you to ask from me. My name is Abulahi. I'm asking about how the way you conduct research in the remote area, like remote hospital or Tulumi. This kind of small scale research. This is my question. Thank you sir. Thank you so much. And just to check your hire, I guess you work in quite a small clinic or remote setting yourself, do you? Do you deliver IK yourself? You'll just have to unmute again, your hire. Sorry. Okay, maybe maybe you'll be able to come back in a moment, but any thoughts on this question, especially maybe USML conducting small scale research, especially when you're in quite a remote area, you might not have much research infrastructure or support. Can people still conduct small scale research in that sort of setting? Yeah, I think that the whole point of small scale research isn't it? I mean, there will be still people in that remote setting that can help you, that can support you. There will be some local health workers there working, you know, community health workers, foresters or community health care workers, general health care workers, frontline health workers, or even community volunteers will still there will be there, you know, in every community. You might not be able to travel or take lots of sophisticated material with you and so on there, but there are people who can help you actually collect some kind of data. And remote, I mean, whether it is physical, whether it is, you know, linked with some lack of accessibility for, you know, telephone or anything actually that might have different answer, obviously. But nowadays you can also collect electronically and you can access data easily using mobile phones and so on, and you can ask colleagues working there to help you on that respect. This is where actually small scale research, you know, can be applied very well compared to large scale research where lots of outsiders, lots of external personnel need to move to that remote area and are not able to access. But actually the local health system there actually can collect some kind of data and help you, you know, analyze and get it to you with some, with different kind of, you know, methods, because you usually, you know, kind of get reporters from the remote the remote or still the facilities in different ways. You can use that same kind of way to collect the data and analyze it and I believe actually it is the other way around. Actually small scale research might be well fitted to be used in this kind of scenarios. That's really, really helpful, Esmal. And I think that that for me links to the, we've got an anonymous question and one from Syed Ali AW about the team involved, you know, and what are the roles like so what does a principal investigator do in this setting I think in a small setting, it might not be called a principal investigator, it might just be the person sort of leading it. And, you know, who should be in the team. And how do people say that I guess it's pretty open ended isn't it it's not hard and fast resistant. Exactly. We want particular when it comes to small scale research, you know, anybody kind of a principal investigator are doing as they are leading, you know, that the whole process scientifically leading the team, you know, conceptualize the proposal you need some kind of proposal to guide you know there should be some kind of ethical standards like I said you know standard operating procedure how we are going to collect the data and so on it need to be documented. When you started like a large scale research, although it might not be sophisticated in large scale, you need to document that and the person who's leading is that facilitating the training, whether it is a community health worker, whether an anthropologist, whether it is out of town weakness and so on whoever is leading that can be a principal investigator, and other people that are supporting in different ways in collecting the data in talking to the people in in kind of contributing in analyzing, or even in the in that collaborative review people that are engaged there can be you know active, you know, participants of that research and that they can be involved with easily so like you said it is really open for everyone else and it's dependent on your contribution to be honest. Thanks so much. What I would say is that there are I care organizations out there that are looking to support small scale research, and this brings me very nicely to our third talk, and we're very lucky to have Suzanne Gilbert, and gvs mutti to talk about this. Suzanne is a social epidemiologist and a founding member and senior director of the saber foundation, a global nonprofit I care organization that works with local communities around the world to develop self sustaining programs that preserve and restore site. She played an instrumental role in the creation of the vision 2020 initiative and has shown great commitments to ending avoidable blindness over many years and is one of our fantastic journal champions. And Professor gvs mutti is an international expert on community I health and public health disability. He works across the LSA GM and the Indian Institute of Public Health and Hyderabad, where he's the director and he's highly respected for his wide ranging research. So I'd like to hand over to you thank you. And at the outset, I just like to mention that this presentation is on behalf of the entire team of authors that's me, Suzanne and Ken and the entire operational research capacity building team, which included teams from Nepal and India. So what we actually looked at in looking at this particular activity was many of the hospitals needed, like a smell said, local level interventions, which can actually make a difference to the effectiveness and the efficiency of the interventions at the hospital. And for this a large amount of background work was done. A lot of stakeholder interviews were conducted, and save our foundations ever Canada and the Indian Institute of Public Health were all interested in trying to look at how do we scale up the operational research skills, mainly for the hospital teams working in low and middle income countries. And the stakeholder interviews helped us in actually designing the curriculum and looking at the mechanisms of modalities to deliver this particular research capacity building. So in the initial exercise, more like a pilot, if we can look at it that way, we identified four hospital teams, three from Nepal, and one from India, and all these teams were seva global site initiative partner institutions. Initially, there was no COVID when they started, we were living in that ideal world where we could travel across meet people, and therefore we started this process with a one week in person workshop in Nepal. And at that time, we thought that the expected outcomes that we could look at was to enable the eye hospitals to conduct operational research, looking at identifying problems that require solutions, and how they could actually do that at their own level. Provide them the back end support, hand holding support to be able to do that. We also looked at hospital managers having a better understanding and comprehension, and therefore investing in operational research and other problem solving exercises in their own hospital, and therefore be able to provide adequate dedicated resources for this purpose. We also envisaged that some of these hospitals may over a time period of time evolve into resource centers, which would then enable the scaling up in the local context. The methods that we applied were a mentorship model. So every team had a dedicated mentor, and the dedicated mentor was from the Indian Institute of Public Health at Hyderabad, and we had a dedicated saver support person, so that there was an opportunity to travel shoot if any problems arose. Like I mentioned, initially we thought we could travel across and manage to meet people, but unfortunately COVID stepped in, and therefore we had to then look at customizing this, and ultimately the entire exercise, the entire capacity building exercise had to be delivered, virtually. We looked at conducting skill building workshops across all the teams online, simultaneously, so that teams which had a poorer understanding could gain from the teams which had a better understanding, and there was a lot of cross transmission of ideas. The coaching and processing sessions for each team then went on weekly basis with their dedicated mentors, and every two months all the teams came together to a plenary to give a virtual presentation of where they had moved on, what they had done with their problem solving, and how they had looked at finding a solution. Because operational research ultimately looks at providing the best solution from an array of solutions. There is not only one way to actually achieve the desired outcome, there could be a number of ways to do it, but that method has to be optimal in terms of resource and in terms of the availability of human resources which can undertake that. So we start this operational research cycle with the identification of problem. The problem could be something which could be very unique to a particular hospital, maybe the number of patients who need to come in for surgery are not coming in for cataract surgery, and then you could look at a number of ways of tackling that problem. Then they go back sit down assess the evidence, do a root cause analysis to a problem tree analysis, fish bone analysis, and then develop their solutions. These solutions are then validated through a small pilot at the hospital, which is again supported by the mentors. These are then implemented on a bigger group, and ultimately an evaluation process is then enforced with along with the cross learning across all the teams. So, a very structured operation research cycle is has been implemented or has been used for undertaking this capacity building. I now hand over to my colleague, Suzanne Gilbert. Thank you, Professor Morty. So, so what were these teams selecting as their key issues that they would address and we do want to recognize that a number of participants from the operations research capacity building workshop are here online with us today. Barreport Eye Hospital in Nepal had a felt need to better understand their pediatric service delivery and how to enhance follow up visits by families. The Reika Ido, Masanaga Eye Hospital in Banepa, Nepal was recognizing that here they had a retina specialist at their hospital, but very few diabetic patients coming for care. So they set up linkages and studied how to be most effective in bringing in attracting patients from the surrounding general hospitals to come to the eye center for help. The Shraaf Charity Eye Hospital recognized that they had a growing network of vision centers throughout North India. And yet they saw that it takes a number of years for the population base using the vision centers to really pick up. So they experimented applying several different methods door to door and other methods to enhance and encourage early use of the new vision centers that were being established. And finally, Lumbini Eye Institute being in such a hilly, rest of us would call it a mountainous part of Nepal, recognize the importance of having good patient referral from their many peripheral centers to the main center for treatment. So these issues were all addressed, were all originated from the eye hospital staff, and that staff was guided through that rather rigorous process that Professor Murty just mentioned. So, so what were the outcomes from this activity? On the one hand, we were delighted to find that the institutions received sufficient administrative report support to put the time in on their learning sessions. Their learning sessions and the conduct of the studies. Claire had mentioned right up front that you got to dedicate time for this work and we have a lot to share about the tips and tricks of how the hospitals managed to garner the time and focus required to do this work. Much, most of it right during COVID. Each institution became proficient in key steps needed to carry out operational research, and they're continuing with other projects subsequent to this one. Three of the four teams published the research protocols. With COVID, we had some wall in timing. So instead of having a 15 month program as we'd anticipated, it became closer to a 30 month program. And we had time in there to write and publish research protocols. Most of the teams now have already published their final results with one in manuscript review. And importantly to us as an outcome is that several of the hospitals have already started launching their own in-house workshops or workshops for other institutions in their area with a big focus on one of their big takeaways. The importance of quality of data collected routinely day in and day out in the hospital. So there's a big focus now on quality of data for patient care, for management decision making, and over time to support the research process. What we learned recognizes a lot of different aspects and benefits at both the personal and institutional level. On the one hand, as I was just noting, first and foremost throughout the hospital, there was greater awareness of the importance of good data and its management. For the first time, a team in the hospital in many cases was using data to inform their ongoing decisions. Most of the teams had thought research has to be huge. It has to be supported by a big organization from a high income country. And in fact, they realized that research can focus on small and important issues much along the line of what Esmael was sharing with us. A big part of the work is to learn how to identify and analyze a problem and do it collaboratively. We have a number of questions about building a team. And having a group of people together identify and analyze a problem almost helps to create your team because these will be the people who are most committed, most passionate. And then you make sure you've got a good distribution of people bringing different skills to the work or figure out a way to fill in for those missing skill areas you would want on a team. So ultimately, though, it was important that each team recognize that having done this work, they feel they're doing their job better. They're reaching their patients with better quality care. We do caution that another thing we learned was that research skill building can be done virtually if you put an enormous amount of effort into it, which we did over that 30 month period. So next steps, and this will be our final slide. During this period of this project, WHO released a very important eye care competency framework for multiple aspects of eye health. One of them was evidence. And so we really picked up that framework for our work moving forward. We're addressing training now and research at three different levels. Introductory through an entirely virtual asynchronous online course that we're in the process of refining that can handle a large number of participants and anyone's welcome to take it. Then we're now engaged in a six month intermediate level activity that's both virtual and in person, focusing on rapid cycle improvement with eight institutions for from Nepal for from India. And this leads to our redesign of the more expert level of research learning, which will be based on the original 30 month project. And it's evaluation, which we're in the process of doing now and will contribute to more kind of mature eye care institutions that are regional resources already to strengthen their research muscle so they can share and build more research capacity in their region directly. I do want to mention that one can email to insight at save it.org for more information about these programs and as Professor Morty led from the beginning. He can and I would want to recognize the important contribution of the 60 people involved in these projects over a nearly three year period who are are noted on that final link. So, thank you. Just as we started with a photo of the first kickoff meeting in Nepal. Here we're closing with our one and only in person meeting we were able to have for the operations research capacity building workshop and this meeting focused on data analysis methods done very beautifully at IPH. So, thank you. Thanks so much, Suzanne and GV. That was fantastic. We appreciate that some people might need to leave. We've hit the hour mark. So appreciate you might need to head on but we're going to carry on just discussing some of the issues and topics that have come up. So do feel free to carry on putting your questions in. Levi and Cisco, I think you had a question from before if you're there. Do feel free to unmute and put your forward question forward please. It's amazing for them to unmute. I'm just to say that a smile has answered. Oh, so if he squished leave, leave his question has been answered in the chat by a smile and there was another one from Aaron also I don't have Aaron is still with us he also asked about the size of the study. And then a smile I mean you're welcome to just speak to that very quickly if you want to smile. Yeah. Thank you. Yeah, I'll start with, with Levi's question I think the disadvantages are the disadvantages for small scale research and it applies everywhere to every discipline. It's not just to optometry, you know that the limitation in terms of causality not publishable or, or also not generalizable not applicable to larger settings or other different different settings probably are the disadvantages and also ethical issues and sometimes there are different guidelines, whether you need to take a ethics approval or not, how to approach it what kind of document you need who should approve your ethics approval and so all this kind of stuff that they apply for any discipline. The other thing is that the question that I answered is how small. I mean that that depends again, you know, on the research question what you know what how much number of people actually give you that that's sufficient diversity of data to answer that research question if you want to get you know, more women or you know, in terms of gender distance or people not accessing services, how do you access to them? Are you reaching them? Which, which are your target community? Are you able to get them and collect that data is, is, I think, Keating? It's not the sample size, it's not the number in small scale research, it's about thinking what kind, what, what number and which kind of type of people actually can give me the answer that I'm seeking you for. Yeah, thank you. Thanks so much. Well, I think we've run out of time. It's gone very quickly. Fantastic webinar. Thanks so much to everybody that contributed. It was great to have some audience participation. And I just like to hand over to Hugh with a couple of very brief messages. Thank you. Thanks so much, Victor, and thanks so much everyone who's joined again today. We really appreciate it. I'm just going to put a link in the chat to the courses that we offer at ICH. So we have two courses on ophthalmic epidemiology that are really great introduction to research and a really great place to start if you're interested in, in learning more. They're totally free and they're on demand so you can study them at your own pace whenever you'd like. And I also just mentioned we're always really keen to stay in touch with people who are interested in research at ICH. So we'll be following up with a questionnaire over email. And there'll be an option there to just opt in if you'd like more information from us specifically about research from ICH. So make sure to look out for that. So thank you so much again, everyone. And thanks again to all our panelists for today. Thank you so much. And it's just wonderful to have so many people together and there's so much knowledge in this in this group that's here today. So we will also be asking that same email. So please look out for an email from us as a follow up and we will also ask you if you're willing to be, if you would like your details to be shared with other people who've attended the webinar or signed up for the webinar. So that, you know, there's some potential maybe to set up a group later on if this is something that's helpful where people can come with these sorts of questions and they can be peer to peer support. You know, so you can support each other and grow these skills and capacities. So, yeah, do share your details with us when we get in touch. Thank you so much. I'm just noticing Louie. Hi, Louie. Thank you for being here. And the meeting is recorded so everybody who signed up for the webinar will get some links with recordings of the meeting both audio for low bandwidths and the whole video and everything. So, and that will also be on the Community iHealth Journal website later on. It's been brilliant. Thank you so much to everybody and Victor and Hugh for organizing and to all our panelists. It's been a wonderful webinar. I really appreciate your time and your enthusiasm and dedication. Thank you.