 Hi, good morning, good afternoon, good evening to everybody who's joining our webinar today. Thank you so much for being here. Sorry for the couple of minutes delay. As usual, there's the usual Zoom technical issues. But we're really, really glad to welcome you here. And we've got a fantastic panel of speakers today. And I'll just introduce them very briefly and ask them to wait so you can see who is who. We've got with us Dr. Zahid Awan, who's the Inclusive Eye Health Projects Manager at CBM. Can you say quick hello Dr. Zahid? Thank you for joining us. Hi, fantastic. And we've got Michelle Hennelly. She's the Divisional Lead for Optometry and Visual Sciences at City University of London. And Irene, I mean, hi, hello. And Irene Cattori, who's the Associate Dean of Education at also at City University of London. And we've got from. Hi, thank you. And finally, we've got Dr. Dr. Hilary Ronno, who's an ophthalmologist at Kitali County and Referral Hospitals, Kitali in Kenya. So we'll start off. Hi. So what we're going to do is we can ask everyone. Thank you. Thank you. Thank you. So we're going to start this morning with the presentations. We're going to have Dr. Awan speaking first and sharing his presentation with us. And then we'll have some time for questions, about 10 minutes for questions. Next up will be Michelle and Irene. And finally, we'll have Dr. Hilary Ronno with his with his presentation about what's happening in Kenya. OK, so I'm Dr. Awan. I would love for you to start. Do you want to share your screen? Thank you very much. I think you I would request you if you could. He's able to share the screen for me. He just wants to put the camera off. I'll mean and then. Yeah, absolutely. Please go ahead. I haven't the rights to share. OK, thank you. He was doing it. Thank you. Thank you very much. This is Dr. Zahid Awan working in CBM as a project manager. And I am presenting my CBM and just speak districts in Pakistan, how technology technology has enabled us to reach to the unreached. Please next slide. Next please. Yes, we are working in in Pakistan since 1968. Our aim is to provide comprehensive inclusive healthcare services, inclusion in eye health programs and mainly system strengthening through aligning national eye health system. Next please. Next. Yes. Thank you very much. This is our CBM technology enabled district model approach where we start screening from the community through lady health workers and then basic health units and who are health centers. This is the primary level. From the basic health units, the patients are referred to the rural health center where we have established intermediary clinic that is that aligns with integrated people centered I care plan that how intermediary clinics supports this program. And then again, the patients are referred the patient need patient who needs the spectacles. They are referred to the optical shops and who the patient that need further sophisticated treatment. They are referred to the secondary and tertiary level further. Just wanted to let you know from the community of the tertiary, the technology is active. It's a paperless activity that we are doing here regarding rural health center. This this covers about 150,000 to 100,000 people and the basic health unit that covers about 10,000 to 15,000 people into the locality and basic health unit is a small list health unit in Pakistan. Please second, next please. Yes, technology by virtue of this technology, we enabled the connectivity of the patients through referral links. It is strengthened the referral links because once it is the patient was referred from the community, it is being checked out. It is being cross verified and 84% that this is our study says that 84% persons are linked and the referrals uptake is there at the intermediary at the next level. In addition to the primary level, we have spent and the secondary idea services. If you see in the graph into into this chart that previously the 41% of the reflection was done at secondary levels by virtue of introducing technology and a peak technology, it has been reduced to 1% and the same that is the catrics of these are increased. Next please. Next please. Yes, thank you. Now just this is just wanted to show when we started working in the in this programs. If you see there was very minimal IK services at primary level and medical and surgical and reflection, all the things were done at the secondary level and the tertiary level having no linkages with the secondary. That means there were no formal linkages with the tertiary, although the patients were by themselves they were uptake services at the tertiary level. But by virtue of this technology, now screening refraction are done and and the referrals are done at the primary level by the most of the surgeries and the refraction that they are done at the primary. But the only surgery is done at the secondary level and the tertiary level is also linked to this technology and the loop is closed. That patient starts from community loop ends at at the tertiary level. Next please. My conclusion is that mobile technology helped to optimize primary I health care and CBMP districts in Pakistan thereby increasing access to specialist I have for those who needed. The major thing that I wanted to let all know that the technology has created easiness into the life of the people. It has reduces the waiting time. It has reduces the companion issue to that the burden the patient had. Now all the services are at doorstep and if anyone who's a needy person is needing effort like an example that out of 100 patients only 13 patients need secondary level services. This is the live study and live data we have and only 1% out of that 13% that needs tertiary level. Why if government and other organizations introduces this technology into their countries. I think the load of the tertiary level hospitals will reduce and also the secondary level by virtue of these the quality surgical services will be pointed at secondary level and also the tertiary level hospitals would have enough time ample time to do academics and research work rather than check they are sitting to check the visual equity and treating the the conductivitis next please view next please. Yes, these are our partners organization where we work. We have a peak partner as a they are service provider and the digital solutions and they are the peak custodians. They are very I must say that they are very cooperative and they do a lot of work in Pakistan in strengthening of a system. Government of Pakistan government of thin government of Punjab and partners that College of technology, light, real science is in the institute of ophthalmology and real sciences. They are our partners in in managing this a very hard task that looks very easy for CBM to continue with their support. Thank you very much. Next please. So thank you very much. This was my talk. So I would love to receive any question and explanation if needed. Thank you very much. Thank you so much, Dr. Owen. That was a fantastic presentation. And we're now going to open up for questions. So please you can either raise your hand to ask a question, or you can put your questions in the chat. But ideally, we'd love to see you. So if we can enable you to, well, I don't know if we can do video, you know, but we can allow you to talk so we would love to hear your voices and hear who is here. So Hugh, can you give us a hand? There we go. If you can unmute. There we go. I'm still looking for hands up. I'm not the most technically minded person. So would you mind unmuting and just giving us a bit of guidance about how this work and perhaps directing our our disciplines? I don't think we have any hands up at the moment. So yeah, if everyone could please just put questions in the Q&A or raise your hand and we can allow you to talk. In the meantime, perhaps, if there's any questions from yourself, I'll mean, or from the other speakers. Yes, yes. I just I wanted to know, Dr. Owen, more or less, how long, you know, if somebody in another country wanted to implement something like that without it without a charitable partner like CBM, and what are the costs that you'd be looking at? And how do you start? I mean, where do you start if you wanted to do something like this, where you are? Can you repeat the question? Please go to the house inside. So I couldn't hear. Yeah, please. Can you repeat your question, please? No, I was just saying, I mean, this is such an inspiring experience that you're having and the results are so so positive. How would how could someone in another country get started with if they wanted to implement something similar where they are? Yes, thank you very much. That's a very interesting question. For that, for example, if they want to introduce a technology, first of all, they need to learn that how much primary primary health care infrastructure is working in in their country. First, that is done. Then I think they need to know that they need to know how much HR they have. And for technology, I think the peak vision that is that we the CBM has contracted so far. So I think that is the technology that the people that anyone from the country, whether the government or the international NGO or a national organization, they can reach them and they can provide the services to start with. And then this would be the best option for them to get started in any country in the world. Yes, it very much depends on what you have available. And I think Pakistan is not unique in the world, but your lady health worker system is incredible and how it reaches really deep into the community where everyone is. So yeah, it would have to be a whole country, I guess at a national level, where a program like this or at least a district level with a program like this would have to be implemented. But thank you so much. Are there any other questions for Dr. Arwen about the project from anyone? Irene, please go ahead. Thank you. And thank you, Dr. Arwen, for such interesting talk. I'm interested to hear what sort of additional digital training, I guess, is needed for the practitioners on the ground delivering this. So was it something that was well received or required a lot of extra training in order to use the mobile apps, for example, the P-Caps? Yeah, you know, the beauty of this program is that we do not use the specialist schedule. We use non-special schedule for screening in I-Care. You know, lady health workers, lady health visitors, they are non-special schedule. Yes, they need training. They need training on two things. One, that is the primary I-Care. That's very necessary that non-reflective conditions needs to be identified by them. And second, on on Android, because we used to use Android for using this peak technology. So ultimately, they need training on Android fast and then on the peak capture and the peak solutions that we use to use. Thank you. Thank you for that answer. I had another question. The mobile phones that that they use, how common is mobile phone use amongst the primary health care workers, the lady health care workers? So I mean, you said they needed some training on Android phones first. So are these phones their personal phones or are they just for work? Are they limited to work or do you get them kind of used to the whole concept of using mobile phones first? Yeah, thank you. Currently, because this is this is a pilot program and we are piloting in the country. So all the mobile devices are provided by the CBM and powered by peak vision. So anybody in that is that is the training or a non special scatter for the screener that word of way we use, we use to provide them training. And yes, now in Pakistan, almost 90% of the people are using this Android devices. So there's a no problem for them to use even the software that we provide for screening and captain data. That's fantastic. Thank you so much. Dr. Awan, we've got a question from Robert Alibo. I hope I'm saying your name correctly. Robert, please go ahead. You're able to talk now. Thank you so much. Dr. Zahid Awan. My question relates with the way the information that is gathered through peak is able to communicate with national health information systems so that there's seamless of data transfer from peak to that database. What was the experience in Pakistan? Yeah, thank you very much. We have a very good experience on that. What we did when we started introducing peak technology in our program, we looked into our data, our plans that what indicators actually we are collecting together for information for our information system. Currently, and then we looked in that what our integrated people-centered IKR plan says. Whatever the indicators are incorporated into that plan, integrated centered IKR plan, we tried to capture the data in aligning with that. So the data whatever collecting through that peak capture that aligns with the indicators that are already available in the plan. The second question that how much it could be incorporated into the governmental systems and I think everybody is aware that we have that currently DHIS is shifting to DHIS 2 and Pakistan is also one of one of the country that has taken steps. So we are struggling with the government, a CBM, along with his governmental partners is struggling with the government to incorporate the same indicator that is available into integrated people-centered IKR plan. I cannot say that today at this moment I can't say anything, but surely in next five, three to five years or three years, all the data that is available in the plan would be incorporated and that aligns with our programs that currently we are implementing. Thank you. Brilliant. I don't see any other questions. We will have some time at the end. Sorry, we've got some questions in the Q&A at the moment. Fantastic, brilliant. Thanks you. Go for it. We've got Charles Kadua who said do screeners use their own mobile phones or they're procured more than by the program? And also what measures are put in place for patient confidentiality? Can you repeat it please? Yes, the first question is do screeners use their own mobile phones or are they given those by the program? Yes, the mobiles are given by the programs. Fantastic. And then the second question was around patient confidentiality within the patient compliance. I already mentioned during my speech that 84% of the people comply with the services. Like for example, 100 patients are referred from one center to second center. 84% arrives at the next level. So this is the compliance that compliance has increased much, much more than what we were doing with the conventional approaches. Oh, and just to clarify, it's about confidentiality, not compliance. Oh, sorry. No, it's always like this, isn't it? So it's about what is put in place for patient confidentiality? Yeah, just I wanted to let you know, whenever we start our program, there is a MOU that we use to sign that is called data processing agreement. And that is with the governmental partners. It means that data will never be leaked out and that not will not be handed over. Another thing, the peak capture has a quality that nobody can access except those who have the access. Even CBM country office, if we are two or three persons in the country office, only one person have an access to check the data. And at the partner end, there's only one person that is the IT lead, we used to say information technology lead, who deals with the capture, he has the access to use the data, not to use the data, but have the access to look at the data. And the data is available in cloud so nobody can have access. So it's a highly confidential data, highly confidential graphs, what we use to prepare. Brilliant. Thank you so much. That's really helpful. Did that answer the question? So please please feel free to pop back on the chat or to raise your hand and to say to raise your hand these reactions at the bottom. I think we should have maybe gone through that. There's a few other questions coming through just about charging. Hannah Fowler has asked how about charging the phones? How has that done? Is there good electricity available? Or is there alternative power like solar power that's used? Dr. Yeah, in Pakistan, almost at the health facilities, there is electricity and wherever the lady has workers are working there is electricity. But in any case, for example, and the life of the battery, the mobiles that we used to use that the standard mobile and that has the battery life of about 12 hours to 24 hours, a minimum 12 hours to 24 hours they can run. For example, any and the mobiles that they use, the screeners use to take them along in their homes and their electricity, they charge it. OK, thank you very, very much. I think because of time, we're going to we've still got some questions in the Q&A and hopefully we can come back to those or we can answer them in the chat. We're going to now move on to the next talk today, which is going to be about using technology and communications technology for teaching. So Dr. Owen, thank you very, very much for your time. I hope we have time for those questions at the end. So speaking now, we'll be Michelle Hennelly and and Irene, sorry, sorry about that, Irene, and they'll be speaking about using technology for for teaching. OK, so I'll I'll please go ahead. There we go. Thank you, I mean, I'll be taking the first half and then Irene will be joining me halfway through. So thank you, everyone. I'm really lovely to be here today. I'm here to talk to you about technology in education, something we've learned a lot about, I guess, in the last couple of years, thanks to Covid. So we now have a great deal of experience in delivering education via technology and now where we're probably a bit more aware of the advantages and disadvantages of the different types. Next slide, please. So what is online learning? So essentially, it's a way of delivering education over the Internet, using the online virtual environment. As we know, educational content is constructed using principles of teaching and learning, pedagogy and this supports student progression and success. However, it's important to change how we structure this content to reflect the change in the mode of delivery. I mentioned success and that's really key, particularly in the online learning environment because success is really essential and is built on the ability to create an inclusive, accessible and interactive environment. These factors all support engagement and engagement equals success for all students and I care practitioners. Of course, online learning improves access to education, which has to be a major advantage. And it also improves the flexibility for people. So for people that live a long distance away or for people with work commitments or with family or caring commitments, they can have access to education and can tailor the learning according to their circumstances. Next slide, please. So the first type of online learning that we're going to discuss is synchronous learning. So that's essentially live learning. And this is where students share the same virtual space as their tutors and fellow students and can ask questions and interact in a range of different ways. So in terms of the live presentation, so that can form a lecture or a demonstration or it can be a small group discussion. And we tend to use two different types of video platforms, which I'm sure you're familiar with, so that Zoom or Microsoft Teams. Of course, the disadvantage with synchronous learning is that you are aligned upon a stable connection to the Internet. It is really essential. And of course, if timing can also prove to be a challenge, if students are based in different time zones. So consideration has to be made for the timing of these sessions. Next slide. So in terms of using synchronous technology, as I mentioned, we tend to focus on Zoom and Microsoft Teams. The advantages of these video conferencing tools is that there is automatic captioning. You can also use breakout rooms so that students can work in small groups and they now integrate polls and quizzes. There are other interactive tools that that we use regularly and that would be Poll Everywhere, Mentimeter, Padlet, Miro is another example. These are all free software tools and they enable polling surveys, Q&As, quizzes and word clouds. And they're really very important within the context of online learning because it allows a formative real time assessment of students' knowledge. So one can see that or check that students have grasped key points and also whether they're attaining the learning outcomes that have been set. Other tools include Discord and Slack not not used quite to the same extent within the Educational Forum, but these provide topic based channels for broadcasting live video or audio visual materials and of course, OneDrive and Google Docs also support synchronous and asynchronous learning so students can work live on a document together or they can work on a document in their own time. OK, next slide, please. So in terms of asynchronous learning, this some in some ways resolves the issues around a reliable, stable internet connection and also the timing issue if there's students who are in different time zones. But there are disadvantages with this type of learning as well, and that's namely around building a community and a sense of belonging for students. So in terms of trying to support that knowing that that's a disadvantage, we can tailor the material that we provide to help support students better. So in terms of asynchronous learning, we can provide lecture videos, notes, quizzes, question papers, worked examples and of course, the major advantage of this type of learning is that students can work at their own pace and in their own time. So it tends to be done at a time that is convenient for them in light of work commitments or family commitments or indeed caring commitments. In terms of tailoring what we do for asynchronous learning, I think it's important that the recordings are shorter so that helps with engagement and of course, the use of transcripts as well. So it solves for that issue with the Internet connection and it also helps to build that sense of engagement and sense of community. But we also need to employ other tools to further build that sense in the asynchronous environment. One way students can communicate is via discussion boards or in the chat. But there are other tools available. Next slide, please. So in terms of asynchronous technology, what we tend to use for the structuring of the learning is a learning platform otherwise known as a virtual learning environment. And this essentially is a one stop shop for all of the student material that they would need. So it would include reading materials, recordings with with transcripts, discussion forums and interactive quizzes. The main ones that are used would be Moodle, Blackboard and Google Classroom. Other tools as well include WhatsApp, which can create peer to peer support, which is really helpful in building that sense of community and also Padlet, WordPress and other blog websites can be used by students to publish group projects or write individual reflections on their learning. Quizlet is also another free software whereby you can make flashcards so students can comment on again, focusing on that peer to peer learning and also share with their tutor. So I'm going to pass on now to Irene, who's going to talk more about the learning platforms and other ways of further engaging students in the online environment. Thank you very much, Michelle. So I think as you have just heard from Michelle, there are a range of ways of engaging with students online and it can all be very confusing. So our learning platforms are really key to being able to bring all of that together in a virtual classroom, if you like. So we use our learning platforms, for example, something like Moodle to bring together the asynchronous material and the synchronous material all in one place. And by that, we can add links to lectures, links to webinars, for example, what we're doing just now and also harness the use of Microsoft Teams within Moodle so that the student feels that everything is connected and these activities don't sit as isolated components of the teaching. What's really important is how the students can access Moodle and this can be via a computer, a laptop or even their smartphone. And that's indeed something that we found was very popular with students when we first went into covid and not every student had a computer or a laptop available to them. So with that in mind, it's really important that activities that are designed for such delivery have to be inclusive and accessible irrespective of the means by which students are accessing this material. Thank you. Next slide. In order to increase the engagement with students, the platform should include an opportunity for a discussion forum. That could be through a typed mechanism. So a question posted onto a like a chat room, if you like. And then students respond to each other and also with the lecturer. And that's an opportunity to share ideas and experience and also to ask advice in order to be able to reach students. The platform should also enable educators to send emails to the students as one cohort, again, bring it all together in one place. And the tools can also be embedded, things like quizzes cannot be embedded depending on the platform in a similar way. Thank you. Next slide. So really, just to finish the talk off and bring it all together. This is all online teaching is all a way of harnessing and increasing learning engagement. And it's really important that there's good interaction between the educators and the students and also between the students on in this online environment. And for that to work well, it needs to be planned and supported by the technology. Discussion forums and the like need to be responded to in a timely manner so that the students feel that they are engaging in a in a meaningful way. And by interacting with students in this way, we can help to bridge some gaps, motivate students and show some understanding and provide support in a way that we were not able to in the sort of in person classroom. So educator facilitation is as part of content delivery is a key factor in determining the student engagement and performance. But what we mustn't forget and what we alluded to before is that students may need that support with digital literacy at the outset so that this doesn't sort of fall by the wayside and leave them behind. Just as a final thought, I thought it was it was good to link back to what Dr. R1 said right at the very start, talking about how it's so important to harness technology in education, because ultimately our practitioners will be going out and using this technology in the in the workplace, in the clinical environment. So it's important that we are offering students education in this manner to to to equip them for the future. Thank you. That brings us to the end of our talk. Thank you so much, Irene and Michelle. That was a great talk. We're opening up for questions again. So please raise your hand by clicking on the reactions button. And we've got one coming coming already from Nandini Vasudevan. Excuse me if I mispronounce your name. We have been facing challenges in ensuring students are online throughout and track their attendance. Students tend to turn off their video in spite of us emphasizing time and again to keep the videos on. Would you have possible suggestions to overcome this? Yeah, I can I can answer this. And then Michelle, please come in. I think there's a couple of things to consider and things that we were hearing from our students where it was really interesting to hear the reasons why videos weren't on. Often it was either cultural amongst their their age group. That's not how they used to correspond to communicating with each other. But also there were there was embarrassment around the background, perhaps the room they were in about how they were presenting personally, you know, during lockdown, you know, just in how they were dressed or what have you. So I think acknowledging what the reasons for not turning on the video were really important in then encouraging students to do that. The way that we're trying to approach it now is by building the video part of it into the reason for the lesson. So, for example, here we are in a webinar where I've got my camera on and hopefully that's making it more accessible to people listening. And so we're mimicking a sort of a workplace scenario in our lessons when we're asking students to put on their video. And I think framing it as such and that's it's a work in progress. That's not the you know, I'm not saying that we've got the answer. But I think that helps if we're talking about this is actually mimicking a triage that you might have online with a patient, then the reason for the camera becomes a lot more, a lot more obvious. Michelle, did you have anything to add? No, thank you, I mean, I think that's been our experience as well throughout COVID and even now. I mean, we very much, I guess, learned a lot during that time. And we've taken the best of our experience in the online learning environment and coupled it with face to face learning. But we still find that when we deliver synchronous sessions, students are reluctant to, I guess, fully engage virtually. So it is it is a work in progress. That's something that we can certainly improve on providing students do want to engage in that way. And I think it enhances the learning experience significantly. I should just say, I mean, I'm putting into the webinar chat the various links to the technology that we referred to that's free. I think that might be useful, and I'll just continue to do that so people can access it. Brilliant, Michelle, thank you so much. And I'd also like to say we're talking and the presenters are talking, but you probably also have some really good experiences or you may have some apps or websites that you've used and found useful. So please feel free to share by the Q&A or the chat if you're able to access the chat. It'd be lovely to hear about some some tips and hints you may have if you've had some good experiences in this regard. Good. And just to say, I've posted in the chat as well, a link to do a quick survey. We were really keen to hear what you thought of the webinar to help us improve future webinars. But also as the journal, we want to, you know, I think that these webinars have been a real first step in engaging more with our readers, with all of you and making sure that we are, you know, meeting each other and that we are providing the type of content that's really the most useful to you. And so we're embarking on a programme of engaging and involving readers in groups to plan future issues of the journal. So we've already had a meeting with readers about the medicines issue, which is going to be coming out in around March time next year. But we've got a few other issues planned for the rest of 2023, and it'd be fantastic if you could fill in the form, give us a bit of feedback about today and the webinar, and then there's a place to say if you would be keen to be involved in planning future issues of the journal. It would be lovely to have more of you on board. And also if you want us to, you can say whether you're willing to be involved in giving feedback about the journal or feedback about this topic specifically. So thank you. And with that, I'll just check, are there any other questions that have come on that haven't been answered yet? Good. OK. So I'll repost that link to the survey again and then we'll move on now to Hilary Rono. So you're going to be talking about a project in Kenya, in health in Kenya. Thank you. Please take it away, Rono. Thank you very much. Did you want me to present? I present for my laptop. Is it possible? Well, we've got the we've got your slides on the screen. Are you able to see them and they just say slide in and he will kindly move us forward. Thank you. No problem. I think let's continue. Yes. Next. Yes. So I am. Yeah, I'm Dr. Rono. I'm going to present on the how we overcome challenges in our health system using and initially in Kenya, we used to have we had the community programs and school programs and for school programs, what we know was that there are very few children who have visual impairment. Generally, next. Generally, we know that they are about four to five percent of a school going children who have visual impairment. That actually translates to about one child in every 25 who have a visual impairment. So initially, when we started in Kenya next, initially, when we started next, next, next, please. I'm just wondering and this looks like it's quite tricky. And so it would be easier for you to share the slides yourself. Is that is that going to be possible? There we go. Oh, are you back? Hi. Hi, sorry. What happened? I'm not sure we lost you for a moment there, Roddy, but I think I'm not sure if the slide showing was working entirely from our side, would you prefer to share that? Yeah, that you give. Can you see my slide now? Yes, we can. Yes, perfect. Yes. Yeah, good. So I was saying that. Yeah, in school children, for example, they were about five in every hundred had a visual impairment. That translates to about one in every 25. So what we used to do before was that we used to send nurses to go and screen through school screening, which means we'd actually send one nurse to screen 24 children who are normal only to find one and refer to the hospital. And in that time, because of the few human resource we used to have, we used to close the clinic. To actually have a school screening going on. Then it eventually said probably maybe not a good use of our time to send nurses. So we send we train teachers through the same screening at school and refer only those ones who had high problems. So initially, we used to use this sampling and the paper and paper referral to come to hospital. But children would not actually come to hospital as the way we would have expected them. So we trained them how to use. Right. I show you the direction. Rona, we seem to have lost you. Is it perhaps worth perhaps not showing the video? I think might be causing problems. Yeah, I've also I've also lost Dr. Rona, unfortunately, and let's just see. I think he's just logging back in. We'll give it a moment. Hi. OK, sorry. I think there's a problem with the internet where we are. It could be the could you skip over the video, perhaps? Because that might be what's causing the bandwidth issue. If you could. Super. Thanks very much. Thank you. Thank you for the advice. So let me. OK. So, yes. So as soon as the teachers send a child fail the test, the teachers actually get that more information and they just send them to the hospital. And immediately they click the send button. We were able to see at the server of the hospital, as you can see there. We have we were expecting about 60 children from a school called another one, the first one about 14 children and we were able to plan on when to come. Immediately, as well, immediately, as well, the parents will send a text message or when to report to the hospital. So what we did was we did a trial which one arm we were able to use the standard the method which was using the the the tumbling E and the paper referral and another arm we used to pick and we randomized 25 schools in each in each arm. And eventually what we found out was that our outcome measure was basically a tendency of of hospital within eight, eight, eight, eight weeks. And what we found out was that in the arm, which was for tumbling E around 22 percent attended and in the ones for peak arm actually about 54 percent attended. And if you look at it, most of the first one week you would see that they were attending similarly those are the people who are early responders. But as soon as we were able to send more text messages to using peak system, then we were able to more attend then we found that they had exams and of course schools closed and that's why the two crafts flattened. Overall, we had a 22 percent attendance from the standard arm and of course, 54 percent using the M health technology at that perspective and also evidence for the product and these results were published in the Lancet. So based on that results then we were able to scale up to cover all the schools in the Transoya County that was 400 schools about 200,000 children. And overall we were able to screen 168,000 of which we found over 6,500 with the high problems and we were able to treat about 93 percent of them. That gave us at least some confidence that we could actually use M health technology at least sort of problems in school. But you also have similar challenges in the community. In the community we found that we had a similar challenges and we used to have community volunteers going from house to house to screen. So we don't have to also train them on PIC. So we use the same principles that we were using in schools and train community volunteers. So when they were going house to house they would actually screen people using PIC system and then you attack them and refer those people who had high problems to a tree at center like a dispensary. And from that point those who cannot be treated at tree and then they are referred further to go to hospital where they'll be operated or reflected in the hospital. So we had actually in the community community volunteers firing using PIC system at the primary health facility as well being repad and to the secondary facility. So at that time then we had to do this as a trial. Our unit of intervention was a community unit which is defined as a health facility together with this catchment population. So in Transoya we had about 66 community units and for that we randomly selected 36 and also 36, 18 were randomized towards the PIC arm and the 18 were used to the control. Our outcome measure then was of course the appropriateness of the referral and the time that they took to actually come to to reach the primary facility. And what we found out is that out of 1000 population who are sensitized if you use the normal paper refer what we are using before we found that about 54 would respond and actually refer themselves to hospital. And if you speak and do active screening from door to door we found that out of the 1000 people in the community would actually identify 150 of them with high problems. And then when they were seen by the eye doctors or physicians we found 52 in the standard arm compared to 143 in the PIC arm. And of course there was evidence that there was a true difference for that. Of course there were false positives which was about 3.8% in the standard arm and of course 4.8 in the PIC arm but there was no evidence of a difference in the two of them. So this actually gave us that using M-HER solution this time PIC actually attendance of primary facility was nearly tripled compared to use the usual method of paper and referral. And this gave us more evidence that actually we could use M-HER to improve access to both eye services both in schools and of course in the communities. So of course this evidence as well was published as well in the Lancet. And based on that we found that there were still people who when they were referred to hospital they didn't attend. So we need a qualitative study to find out why they were not attending and what were the barriers they were encompassing. And what we found out was that at that time apart from the cost, distance and all those the biggest barrier was that the health workers didn't have time to actually discuss with the patients on why they need to go to hospital. So actually it was proposed that these needs for counseling also from a very educational time and the patients on the need for the referral that would be to improve. And based on that then we have also now advanced using PIC to cover at least around 10 counties of 10 regions both for school program and school and the community program. And we hope in the next two years with support from CBM and the Kenyan government and the county governments as well we will reach more than eight million people. So far the program has started and I think we have so far reached started about two months ago and we are so far in about 100,000 population. Thank you very much. And I would like to support acknowledge the support we've got from partners the minister of health and the county government and the committees as well. Thank you very much. Thank you so much for that fantastic talk. Rono, that's fantastic. Really, really interesting. I'd love to open up for questions. Do we have any Q and A questions coming in for Dr. Rono? I just think this is one of the key strengths of this approach and both this one and Dr. Owens in Pakistan is that it reduces the burden on tertiary centers and secondary eye centers. So people who can get the support they need at primary eye care level are referred appropriately. So that's fantastic and also just improving access in general. And what did you say, Rono with the key obstacles that you faced? And I just wanted to also say I thought it was brilliant that when you notice people were still not coming even though you'd improved so much on what had happened when people were still not coming you did qualitative research. And I just wanna say what a good thing it is to actually ask people what is going on and that we do need to actually speak to people. But anyway, please talk a bit about that if you could. Yeah, thank you. What we found out as some of the barriers really it was quite interesting. So one of them is that people luckily tell you it's about the cost, the distance but if you interrogate them further you find that there is some element of that they didn't know why they were being referred to another center for treatment yet of course their health workers were welcome to treat them. So one of them actually it brought us to think that probably we needed to have more team composition and then increase more of a team composition for the people who are coming to primary facilities so that you don't have to refer multiple times the participants to go to the six services. That's what we found out. And then number two, it gave us a hint that probably this need for comprehensiveness of our health services. And it is best provided at the first contact at the first point of contact with the health workers. And the more you delay in providing that compressive services then the more you lose people in that. And then there's also much more need for intersectoral collaboration and that there's need for more stakeholders to be involved that not all of them need to be health actors even an health actors needed to be involved as well. Which other actors did you say needed to be involved? None, none. Non-health actors, yes. I was just gonna say actually because one of the things that I think has been the weaknesses for eye health is that it's operated in a bit of a silo in its own world. And the movement going on internationally with eye health now being on the WHO World Health Organization agenda on the United Nations agenda that the answer really is to partner up with other services. So for example, doing some ice creaming of parents with maternal and child health services as well. So breaching the gap between eye care and other health services and other general services our issue on primary eye health care also really emphasized partnership. We've got a raise a question in the chat and also one raise hands from Michelle. So I've just seen the questions moved on, oh, I think has it been answered from Liam O'Toole. And I see Dr. Arwin has also answered that. Michelle, I will get you in a second. So Liam asked for people that cannot travel to hospitals, eye care centers. Is there mobile eye care available? So CBM Dr. Arwin's reply, he said no because this is not a sustainable mechanism to mobile eye care. CBM aims to strengthen eye care systems. Now, Liam, did you mean people with disabilities? Because that's also that sort of equity of access for people with disabilities is really important. Would you like to speak to that first, Rono? And then I'll bring in Dr. Arwin. Yeah, I think on your first, you are spot on in terms of the element of moving primary health care into in an integrated way, approach to primary, I mean primary eye care in integrated together primary health care. And I think as well, going the technological way, which I mean, technologies which are more integrated would actually much more advantage because we will take advantage of much more other departments and other opportunities that patients might have in contact with the health system. So I think much more as eye care, we would need to see how we can actually interact much more with the health system. We can interact much more with our peers in the health sector and see how we can offer services together. And I think there's a move towards the direction in terms of integrating into primary health care and see how it would work. On the other bit of, I agree with Dr. Sahid in terms of strengthening primary health care. Yes, there's need for strengthening primary health care and providing services in those areas as close as possible to the people. But still, they are very weak ones. I mean, there are people who need support in terms of facilitation tool to get secondary services and others. So they will see some element that we need to support some few people, but majority needs to be provided as close as possible to where they are. Yeah, thank you. Thank you, Rona. Let me just check up. Yeah, I'm unmuted. Dr. Alvin, did you want to speak to that briefly? We've got a minute for that and then I'd like to get on to Michelle who raised her hand with another question. Yes, thank you very much. Actually, just I wanted to speak about the person with disabilities, as you mentioned. That in our programs, we have special arrangements for the person with disabilities because our mandate is to improve the quality of life of people with disabilities. What we do in our programs, we have a social organization. We have a social organization. They're used to visit at the Somalist administrative unit that is called the Union Council. And if they find that there are person with disability, number of persons with disabilities are living in pockets, then we organize a mechanism we send and our optometrist to that area where he examines, screens, examines and reflects. And if anyone who needs a spectacle or surgery for the surgery, we use to provide them the vehicle, take them to the secretary or the surgery level. While the spectacles, our optical shots, they prepare for them and hand it over to them in their houses. So this is the mechanism for, especially for the person with disabilities, but not for the able people because if we used to take the able people in line, we cannot sustain this mechanism. Brilliant, thank you, important point. Michelle, Dr. Henley, please. Thanks, Elmin, and thanks, Rono, for a fantastically interesting talk. I guess I wanted to ask whether the eye diseases that were revealed were they expected in terms of what you found for pediatric patients and also those in the community. And then I also wanted to ask about the support around visual impairment, should an intervention not be successful or indeed an intervention would help to resolve the issue? Is there enough support around that? Thank you for your question. In terms of disease conditions, at primary level, what we found out was that we were able to really treat and manage most of the conditions at primary level and it gave us dis-included allergies, a little bit of infections, really. And the people didn't have to travel all the way and we could actually be congested our secondary facilities by actually strengthening our primary, which was one of the strengths that we found out. There are children as well who and even the adults who we could not manage at primary level. So we refer them to secondary facilities. Some who could manage them, some who still could not be managed and we needed to refer them to secondary facilities. At that time, then I had support from other partners as well who could actually be able to meet some of the transport costs to those centers. However, for the patients as well, if you discuss with them comfortably and if, for example, they have insurance, they are actually able to travel to those centers and as long as you link them to the relevant health personnel, they are able to do that. So in and actually, yes, we needed to have all the connections from primary to tertiary facility, but the people going to tertiary were very few. Brilliant. Thank you so much, Rono. We've just gone over our time, I'm very conscious of that. So I'm gonna ask all our panelists to please turn on your cameras and you as well, our host. And thank you as our participants and journal readers and perhaps you're new to the journal. 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