Abstract
Abstract
Objective(s)
To evaluate the first implementation cycle of the cataract screening and surgical programme in Sierra Leone using the Reach, Effectiveness, Adoption, Implementation and Maintenance framework and the Plan-Do-Study-Act approach.
Design
Mixed-methods implementation evaluation of routine programme data with interviews and focus group discussions.
Setting
Sierra Leone.
Participants
Cataract-positive patients identified through community screening.
Primary and secondary outcomes
Primary outcome includes programme reach and implementation, vision-related quality of life measured. Secondary outcomes included qualitative assessment of implementation barriers and programme adaptations.
Results
Among 9117 individuals screened, 7738 complete records were analysed, and 1433 cataract surgeries were performed. The programme predominantly reached economically vulnerable populations and mean composite National Eye Institute Visual Function Questionnaire score improved by 17 points following surgery (p<0.001). High patient demand, transportation and road infrastructure barriers, limited workforce and equipment affected implementation and postoperative follow-up. Adaptation included changes to staffing and workflows and plans for decentralised follow-up services.
Conclusions
High-volume cataract outreach in Sierra Leone substantially improved vision-related quality of life while highlighting the importance of adaptive implementation strategies in resource-constrained settings.
Keywords: Cataract, vision-related quality of life, RE-AIM framework, Implementation science, Sierra Leone
STRENGTHS AND LIMITATIONS OF THIS STUDY.
The combined use of the Reach, Effectiveness, Adoption, Implementation and Maintenance framework and Plan-Do-Study-Act approach enabled a comprehensive evaluation of the programme implementation.
The mixed-methods implementation evaluation generated practical insights into delivering high-volume cataract services in real-world settings.
Use of routine programme data resulted in some missing and incomplete records.
The evaluation was limited to the first implementation cycle and could not assess long-term sustainability.
Introduction
Cataract remains the leading cause of avoidable blindness worldwide, disproportionately affecting populations in low- and middle-income countries (LMICs) where access to timely surgical care is often limited.1 2 Although cataract surgery is a highly cost-effective intervention, major gaps in service delivery persist across many LMICs.3 4 In countries such as Sierra Leone, systemic constraints including shortages of ophthalmic workforce, inadequate infrastructure, weak transport systems, financial barriers and limited surgical capacity contribute to delayed presentation and a high burden of untreated cataract.5 Outreach-based cataract programmes are therefore frequently used to expand access to surgery in settings where routine eye-care services remain insufficient.
While cataract outreach programmes are widely implemented across LMICs, published evaluations have largely focused on surgical output, visual outcomes and service uptake.6–10 Comparatively, less attention has been given to the realities of how these programmes are established, operationalised and adapted within complex and resource-constrained health systems, particularly during their early phases of implementation.8 Key aspects relating to workforce mobilisation, infrastructure readiness, patient flow, supply-chain management, data systems, cultural negotiation and adaptation to local realities remain poorly documented in the literature.11 This represents a critical gap as understanding these operational and contextual dynamics is essential for designing programmes that are not only effective in the short term, but also equitable, sustainable and capable of integration within existing health systems.
The Choithram Memorial Hospital (CMH) cataract outreach programme in Sierra Leone conceptualised by Noor Dubai Foundation was established as a 3-year programme aimed at expanding access to cataract surgery while simultaneously strengthening local delivery systems through workforce development, infrastructure investment and collaborative implementation between local partners like the Ministry of Health in Sierra Leone, the Noor Dubai foundation and Choithram Netralaya Hospital in Indore, India. Importantly, the first implementation cycle functioned not only as a service delivery initiative, but also as a real-world systems-learning phase during which operational challenges, contextual barriers and implementation adaptations emerged in real time.
This study examines the first implementation cycle of a large-scale cataract outreach programme in Sierra Leone as a case of ‘learning while delivering’ within a resource-constrained setting. Using the Reach, Effectiveness, Adoption, Implementation and Maintenance (RE-AIM) framework and Plan-Do-Study-Act (PDSA) approach as complementary frameworks for implementation evaluation and iterative learning, we examined how the programme was established, operationalised and adapted in response to emerging implementation challenges and local realities. By examining processes of adaptation, system constraints and real-time decision-making alongside programme outcomes, the study aims to generate practical implementation learning for strengthening cataract outreach and similar health interventions in comparable low-resource settings.
Methods
Study design
This study was conducted as a mixed-methods implementation learning study and programme evaluation of the first implementation cycle of the Choithram Memorial Hospital Cataract Screening and Surgical Programme in Sierra Leone between February and August 2025. This programme formed part of a 3-year cataract outreach initiative designed to expand access to cataract services while strengthening local eye-care capacity and health system integration.
The first implementation cycle functioned as a real-world systems-learning phase aimed not only at delivering high-volume cataract screening and surgery, but also at understanding how the programme operated, adapted and evolved during implementation in response to local realities. The evaluation combined quantitative analysis of routine programme monitoring data with qualitative insights from key stakeholders and programme beneficiaries to provide a comprehensive assessment of programme performance and implementation processes.
Conceptual framework
This study was guided by the combined application of the RE-AIM framework and the PDSA cycle to support both implementation evaluation and programme learning during the first implementation cycle.12 13
The RE-AIM framework was used to structure evaluation across five domains: Reach, Effectiveness, Adoption, Implementation and Maintenance. The framework supported assessment not only of clinical outputs and patient outcomes, but also of programme delivery processes, service utilisation, continuity of care and factors influencing sustainability within the Sierra Leone eye health system.
The PDSA cycle complemented this by providing an iterative learning framework for understanding how programme delivery evolved during implementation. The ‘Plan’ phase involved development of the outreach and surgical delivery model; the ‘Do’ phase involved implementation of screening, referral, surgical and follow-up activities; the ‘Study’ phase involved evaluation of programme performance using quantitative and qualitative findings; and the ‘Act’ phase focused on identifying operational adaptations and refinements to strengthen subsequent implementation cycles.
Together, these frameworks supported examination of both programme outcomes and the adaptive processes through which the outreach model evolved within a resource-constrained setting.
Study setting and programme context
Sierra Leone faces a substantial burden of avoidable blindness, with cataract as the leading cause of visual impairment among older adults.5 14 The programme aimed to screen about 15 000 adults for cataract and provide surgical treatment for at least 6000 eligible patients, with a primary focus on individuals aged 50 years and above, who bear the highest burden of cataract-related blindness.15 The first implementation cycle employed a high-volume outreach model combining community-based screening activities with centralised surgical delivery at CMH in Freetown, which served as the tertiary referral and surgical centre.
Community outreach screening camps were conducted in selected locations and provinces with the help of the Ministry of Health to identify individuals with suspected cataract and other eye conditions. Patients identified as requiring surgery were referred through a structured referral pathway to CMH for further assessment and surgical management. Surgical services were delivered through collaboration between visiting ophthalmic teams from Choithram Netralaya Hospital in India. In addition to service delivery, the programme incorporated capacity-building components, including mentorship, training and collaborative working with local healthcare providers to support long-term sustainability and local ownership.
Postoperative follow-up was scheduled at 1 day, 1 week and 1 month following surgery, using a combination of hospital-based review at CMH for patients in Freetown and district hospital reviews for patients in other provinces. As this represented the first implementation cycle, programme systems and operational workflows continued to evolve throughout implementation. Programme delivery was influenced by transportation barriers, infrastructure limitations and seasonal conditions, including the rainy season.
Description of the first implementation cycle
The first implementation cycle represented the establishment and operational learning phase of a 3-year cataract outreach programme aiming to deliver approximately 6000 cataract surgeries across Sierra Leone (figure 1). The programme was implemented through a partnership between the Sierra Leone Ministry of Health, Noor Dubai Foundation, CMH and Choithram Netralaya Hospital. A decentralised screening and referral model with centralised surgery at CMH was adopted. Ophthalmic Nurses and Ophthalmic Community Health Officers conducted community screening, counselling, referral coordination and postoperative follow-up, while patients with operable cataracts (visual acuity (VA) <6/24) were referred to CMH for surgery. The programme provided transport, accommodation, meals and perioperative care to minimise financial and geographic barriers. Surgical services were delivered by multidisciplinary teams comprising visiting ophthalmologists, CMH personnel and Ministry of Health staff. The evaluation examined programme implementation, including referral pathways, patient flow, staffing, follow-up systems and operational adaptations during the first implementation cycle.
Figure 1. First implementation cycle. Schematic overview of the first implementation cycle, illustrating the pathway from community-based cataract screening and identification of eligible patients through referral, preoperative assessment, cataract surgery and postoperative follow-up. CMH, Choithram Memorial Hospital.
Quantitative data sources and measures
Quantitative data for this study were obtained from routine programme monitoring and clinical service records. Data sources included community screening registers, referral documentation, surgical logs, postoperative follow-up records and programme monitoring databases maintained at CMH (table 1). Data were collected and managed using Kobo Collect, an open-source electronic data collection platform, which was suitable because of its offline functionality and ability to use in remote settings with limited internet connectivity.
Table 1. Quantitative data sources and domain.
| Domain/indicator | Information collected | Data source | Planned analysis |
|---|---|---|---|
| Participants demographics | Age, sex, district | Screening register | Descriptive statistics |
| Screening, referral and surgical outcomes | Number screened, VA’s, referral status, surgical uptake | Screening register, referral documentation, surgical logs | Screening coverage, referral uptake proportions, surgical rate |
| Postoperative follow-ups | Attendance at day 1, 1-week and 1-month follow-up visits | Follow-up register; programme monitoring database | Follow-up attendance rate; attrition analysis |
| Visual outcomes | Postoperative VA’s | Clinical records; | Visual acuity outcome analysis |
| Vision-related quality of life | VFQ-25 composite and subscale scores | VFQ-25 questionnaire | Pre and post comparison of QoL scores using paired analysis |
| Implementation and system learning | Operational adaptation, workflow modification, follow-up challenges | Programme monitoring reports | Framework-informed interpretive analysis guided by RE-AIM and implementation-learning objectives |
QoL, quality of life; RE-AIM, Reach, Effectiveness, Adoption, Implementation and Maintenance; VA, visual acuity; VFQ-25, Vision function questionnaire-25.
Quantitative indicators captured demographic characteristics, screening and referral outcomes, surgical output, postoperative follow-up attendance, visual outcomes, vision-related quality of life and operational programme performance. Vision-related quality of life was assessed using the National Eye Institute Visual Function Questionnaire (VFQ-25), administered preoperatively and postoperatively among patients with complete paired data.
Qualitative data collection
Qualitative data were collected to explore experiences of establishing, delivering and adapting the cataract outreach programme during its first implementation cycle. A qualitative descriptive approach was used to explore participants’ experiences of programme implementation and adaptations made during delivery. Semistructured interviews and two focus group discussions (FGDs) were conducted with a purposive sample of programme stakeholders, including 6 programme implementers, 5 ophthalmologists, 3 ophthalmic nurses, 2 counsellors, 3 operational staff and 32 patients (table 2). Interview and FGD guides were informed by the RE-AIM framework and focused on service delivery, implementation challenges, barriers to care, follow-up and programme adaptations. Each FGD included six participants (three men and three women), representing Freetown and provincial districts. Interviews and FGDs were conducted confidentially, audio-recorded with consent, transcribed verbatim and anonymised before analysis.
Table 2. Qualitative data sources and domains for the first-year cycle.
| Qualitative domain | Participants | Key areas explored | Planned analysis |
|---|---|---|---|
| Programme implementation | Ophthalmologists, optometrists, implementers | Experiences of programme delivery, workflow processes, operational coordination, staffing | Framework-informed interpretive analysis guided by RE-AIM and implementation-learning objectives. |
| Surgical surgery delivery | Ophthalmologists, ophthalmic nurses, operated patients | Patient experiences, staffing pressure, surgical flow and outcomes | Framework-informed interpretive analysis guided by RE-AIM on services delivery, experiences and systems |
| Postoperative follow-up pathways | Patients, implementers, ophthalmologists | Follow-up attendance, transportation barriers, caregivers’ dependence, seasonal disruptions | Exploration of structural barriers affecting continuity of care |
| Patient experiences | Screened patients, failed screening, received surgery, attended follow-up, did not attend follow-up | Perceptions of cataract surgery, fear and misconception, family influence, quality of life changes | Analysis of social, cultural and behavioural influences on programme uptake |
| Programme adaption and systems learning | Implementers, clinicians and operational staff | Operational learning, workflow modifications, staffing adaptation, data management challenges, sustainability planning | Identification of adaptive implementation processes and systems learning |
| Sustainability and future programme planning | Programme implementers, local health workers | Long-term sustainability, workforce capacity, decentralisation, health system integration, future redesign | Framework-informed interpretation of sustainability and scale-up considerations |
RE-AIM, Reach, Effectiveness, Adoption, Implementation and Maintenance.
Data analysis
Quantitative analysis
Quantitative data were analysed descriptively to assess programme performance across the RE-AIM domains. Demographic characteristics, screening outcomes, surgical volume, postoperative VA, follow-up attendance, referral adherence, documentation completeness and implementation metrics were summarised using appropriate descriptive statistics. Continuous variables were reported as means (SD) or medians (IQR), depending on distribution, and age was categorised into predefined programme groups. Vision-related quality of life was assessed using the Wilcoxon signed-rank test to compare paired preoperative and postoperative VFQ-25 scores. Analyses were restricted to participants with complete follow-up data, with no imputation for missing data. No sample size calculation as this was a descriptive implementation evaluation of routine programme data.
Qualitative analysis
Qualitative data were analysed using a qualitative descriptive, framework-informed interpretive approach. The analysis was situated within a pragmatic orientation, reflecting the study’s aim of generating applied understanding of programme implementation rather than developing an explanatory theory. Two researchers (GO-A and VFC) independently reviewed the interview and focus group transcripts in May 2026. Analysis proceeded through familiarisation with the data, identification of implementation-relevant segments, and organisation of these findings using the RE-AIM domains and the study’s implementation-learning objectives. Within and across these domains, the researchers identified recurring experiences, operational challenges, barriers and facilitators, patient perspectives, and adaptations, while remaining open to findings not readily accommodated within the predefined framework. Interpretations were compared across stakeholder groups and data sources, and differences between researchers were discussed and resolved through consensus. The resulting categories were subsequently integrated with quantitative programme findings to identify areas of convergence, divergence and explanatory complementarity (figure 2).
Figure 2. Qualitative data analysis pathway. Overview of the systematic process used to analyse qualitative data from interview and focus group discussion transcripts. The pathway involved data familiarisation, identification of implementation-relevant data, organisation using the RE-AIM framework and implementation learning objectives, comparison across stakeholder groups, consensus between two researchers and integration of qualitative and quantitative findings to generate implementation lessons and adaptations. RE-AIM, Reach, Effectiveness, Adoption, Implementation and Maintenance.
Integration of quantitative and qualitative findings
Quantitative and qualitative findings were integrated using a triangulation approach to provide a comprehensive understanding of programme performance and implementation processes. Quantitative findings provided measurable indicators of programme reach, surgical outcomes, follow-up attendance and operational performance, while qualitative findings helped explain the underlying mechanisms, implementation experiences and ground realities influencing these outcomes. This integrated analytical approach enabled identification of how programme adaptations emerged in response to challenges and how system-level constraints influenced both implementation processes and observed outcomes. No sensitivity analyses were performed.
Reflexivity statement
The evaluation team (GO-A and VFC) worked closely with programme implementation, providing contextual insight into operational challenges and service delivery during the first implementation cycle. GO-A contributed to study design, coordination, and interpretation, drawing on experience in global eye health research, while VFC, a global eye health researcher contributed expertise in implementation research and health systems strengthening. Both researchers maintained reflexive awareness of how their professional backgrounds and involvement could influence interpretation. To minimise bias, the evaluation adopted an observational, non-directive approach, and findings were triangulated across quantitative and qualitative data sources, stakeholder groups, and implementation perspectives to enhance the credibility and rigour of the analysis.
Results
The first implementation cycle screened 9117 patients across multiple districts in Sierra Leone, with 7738 (85%) complete patient records available for analysis. Records with missing or incomplete data were excluded from analyses. A total of 1433 cataract surgeries were performed, representing 72% of the planned annual surgical target. The programme primarily reached middle-aged and older adults (median age 49 years, IQR 35–65) and economically vulnerable populations with 65% (n=5034) earning less than 800 SLL per month (table 3).
Table 3. Patient demographics.
| Patients’ demographics (N=7738) | |
|---|---|
| n (%) | |
| Age, years 0–29 30–59 60–89 90 and older N/A Median age (IQR) |
n % 1573 (20%) 3305 (43%) 2227 (28%) 32 (1%) 601 (8%) 49 years (IQR 35–65) |
| Gender | |
|
Male (%) Female (%) N/A (missing) (%) |
3228 (42%) 4348 (56%) 162 (2%) |
| Education | |
| No formal education | 3089 (40%) |
| Primary school education | 868 (11%) |
| Secondary school education | 2140 (28%) |
| University or higher education | 1455 (19%) |
| N/A (missing) | 186 (2%) |
| Monthly income | |
| Less than SLL800 | 5034 (65%) |
| SLL800–SLL3000 | 698 (9%) |
| SLL3000–SLL5000 | 255 (3%) |
| Greater than SLL5000 | 73 (1%) |
| N/A (missing) | 1678 (22%) |
| Median income (IQR) | 400 SLL (0) |
| Marital status | |
| Single | 1956 (25%) |
| Married | 4184 (54%) |
| Divorced/separated | 186 (2%) |
| Widowed/widower | 1274 (17%) |
| N/A (missing) | 138 (2%) |
| Eye check history | |
| Yes | 4659 (60%) |
| No | 2740 (35%) |
| N/A (missing) | 339 (5%) |
| Previous eye surgery | |
| Yes | 533 (7%) |
| No | 6168 (80%) |
| N/A (missing) | 1037 (13%) |
| District name | |
| Freetown | 5881 (76%) |
| Port Loko Western area |
675 (9%) 1006 (13%) |
| N/A (missing) | 155 (2%) |
N/A, not available.
High demand, access and community engagement
Large patient turnouts across screening and surgical sites highlighted substantial demand for cataract services. Many participants described repeated attempts to access care, early arrival at screening site and long-distance travel, with some receiving formal eye care for the first time
One patient explained:
“Actually, I did not succeed the first day I came because there is always a mad rush whenever Sierra Leoneans hear about free services… Then I came on the third day, and I finally succeeded.”
Transportation costs and multiple travel journeys were common barriers, particularly for rural patients.
Another participant stated:
“Sometimes I had to take three different transports and paid so much money to come here.”
Fear of surgery and misconceptions about blindness also influenced care-seeking. Confidence in surgery increased after observing successful outcomes, receiving family encouragement and reassurance from trusted community and religious leaders
One participant explained:
“I was afraid because I thought they were going to remove all my eyes… but when I saw the first people who were operated on, I developed courage.”
Religious and community leaders played an important role in mobilisation and promoting programme acceptance.
Delivering high-volume cataract services under real-world constraints
The first implementation cycle operated under substantial operational and infrastructural constraints. High patient turnout placed pressure on patient flow, staffing, documentation and surgical workflow prompting programme teams to expand work shifts, modify staffing arrangements, increase surgical output and adopt high-volume triaging approaches.
Clinicians also reported managing advanced ocular disease and adapting surgical practice to local circumstances
One surgeon highlighted:
“Many patients were postponed because their eye pressures were so uncontrollable and these need to be addressed prior to surgery.”
Another also highlighted:
“Ideally, we remove the pterygium first and then plan for the cataract surgery. However, because some patients could not come back, we did both the same day. Which can be a big risk sometimes.”
Poor road infrastructure, long travel distances and seasonal rainfall further disrupted access and postoperative follow-up attendance.
Some patients shared:
“Yes, I am struggling in terms of transportation, because if I do not charter a “keke” [a rickshaw] I won’t be able to come here because, the cars would not pick me because they say I take time to board their cars and it’s a waste of time for them. I can’t tell a lie, I have too many challenges in terms of movement from one place to another.”
Documentation quality was also affected during peak service periods, with missing or incomplete VA data in 46% of records and no VA recorded in 10% of patients (table 4). Limited surgical infrastructure and reliance on visiting ophthalmic teams further constrained programme delivery.
Table 4. RE-AIM outcomes from first year cycle.
| RE-AIM domain | Indicator | Outcome |
|---|---|---|
| Reach | Screening coverage Surgical coverage |
9117/15 000 (61%) 1433/2000 (72%) |
| Gender distribution | Male 42%; female 56%; N/A 2% | |
| District distribution | Freetown 76%; Port Loko 9%; Western Area 13%; N/A 2% | |
| Age distribution | <50 years: 47%; ≥50 years: 46%; N/A: 8% | |
| Severe VI among ≥50 years (VA <3/60) | 1686 (48% of ≥50 years) | |
| Gender distribution among ≥50 years with severe VI | Men 51%; women 49% | |
| Effectiveness | Cataract surgeries completed | 1433 successful surgeries |
| VA ≥6/12 at 1 week | 279 (31%) | |
| VA <6/12–6/60 | 532 (59%) | |
| VA <6/60 | 89 (10%) | |
| Absent at 1-week follow-up | 533 (37%) | |
| Surgical complications | No major sight-threatening complications | |
| Quality of life | +17 mean-point gain (p<0.001) | |
| Adoption | ||
| Postsurgery follow-up at 1 month | 271/1433 (19%) | |
| Implementation | Data completeness | Missing/inaccurate VA: 46%; VA not recorded: 10% |
| Screening capacity | Exceeded on multiple days | |
| Maintenance | Care pathway completeness | Limited access to refraction and optical services |
| Cost distribution | 49% clinical services; 33% patient support | |
| Infrastructure readiness | One theatre with two operating tables; one slit lamp | |
| Workforce continuity | Heavy reliance on visiting teams |
N/A, not available; RE-AIM, Reach, Effectiveness, Adoption, Implementation and Maintenance; VA, visual acuity; VI, vision impairment.
Programme effectiveness and patient experience
The programme completed 1433 cataract surgeries during the first implementation cycle. At 1-week follow-up, 31% (n=279) of patients achieved VA of 6/12 or better, while 59% (n=532) had VA between <6/12 and 6/60, and 10% (n=89) had VA worse than 6/60 (table 4). No major sight-threatening surgical complications were reported. Vision-related quality of life improved significantly following surgery, with a mean 17-point increase in composite VFQ-25 scores (p<0.001), particularly in mental health, near vision and distance vision domains (table 5).
Table 5. Mean changes in vision-related quality of life subscales following cataract surgery (n=271).
| Subscale | Presurgery | Postsurgery | Mean difference | P value |
|---|---|---|---|---|
| Ocular pain | 82.4±24.8 | 94.1±12.6 | 11.7 | <0.001 |
| Near activity | 76.2±32.3 | 93.3±21.6 | 17.1 | <0.001 |
| Distance activity | 82.1±26.8 | 96.4±15.3 | 14.3 | <0.001 |
| Social functioning | 87.5±22.3 | 98.2±9.8 | 10.7 | <0.001 |
| Mental health | 62.7±26.2 | 92.5±16.5 | 29.8 | <0.001 |
| Role difficulty | 83±29.2 | 95.6±16.0 | 12.6 | <0.001 |
| Dependency | 18.8±23.3 | 22.4±28.5 | 3.6 | 0.467 |
| Driving* | 54.8±37.6 | 90.2±14.9 | 35.4 | 1 |
| Peripheral vision | 86.7±26.1 | 99.2±6.8 | 12.5 | <0.001 |
| Composite score | 70.5±4.2 | 87.5±6.3 | 17 | <0.001 |
Scoring was not normally distributed, hence non-parametric analysis was done. VFQ-25 composite and subscale scores were calculated according to the NEI VFQ-25 scoring algorithm, using mean values of completed items transformed to a 0–100 scale. Shapiro-Wilk tests indicated non-normal distributions for most scores (p<0.05). Therefore, non-parametric Wilcoxon signed-rank tests were used to compare presurgery and postsurgery scores.
Driving (n=17) scores were based on a limited number of respondents due to low completion rates.
NEI VFQ-25, National Eye Institute Visual Function Questionnaire.
One patient stated:
“After my surgery, when my eyes healed, I could finally see how beautiful my house looked.”
Clinicians also described visible changes in patients’ mood and behaviour following surgery.
“Patients were dancing and singing the next day because they could see again after 20–30 years.”
Follow-up attendance declined from 63% (900/1433) at 1 week to 19% (271/1433) at 1 month. Transportation costs, dependence on caregivers, poor road conditions and seasonal rainfall were consistently identified as major barriers to postoperative follow-up, particularly among older adults.
One participant stated:
“My son who would bring me to see the doctors went to work that day and if he is not around to send me, no one will. As you can see, I am old and weak and can’t travel alone.”
Seasonal conditions and road safety concerns during the rainy season were also frequently reported.
“Transportation in Sierra Leone is a big problem for us especially during the raining season, it can rain from morning to evening and this make the road very bad and unsafe.”
No significant associations were observed between demographic characteristics and changes in composite vision-related quality-of-life scores (online supplemental table S1). In subscale-specific analyses, sex was significantly associated with changes in peripheral vision scores (β=0.254, p=0.047), while no other predictors reached statistical significance (online supplemental table S2).
Programme learning and adaptation for future cycles
Experiences from the first implementation cycle informed several proposed operational adaptations for subsequent programme cycles. Programme implementers identified the need for revised screening targets and more structured patient flow management during peak service periods. Proposed modifications included introduction of daily screening caps, expansion of staffing during anticipated high-demand periods, and assignment of dedicated data personnel, separate from clinical teams and recording of first day postoperative VA.
Programme teams additionally proposed greater decentralisation of postoperative follow-up services through district hospitals to reduce transportation burden for patients residing outside Freetown. Other proposed adaptations included strengthened referral tracking systems, increased use of phone reminders, digitisation of patient records, additional ophthalmic infrastructure investment and structured pre-camp training for local staff. Seasonal scheduling adjustments, particularly increased alignment of outreach activities with dry-season periods, were also identified as priorities for future implementation cycles. Postoperative complications were not systematically recorded within the routine programme dataset during the first implementation cycle, preventing reliable assessment of complication rates or patterns. This was identified as a gap in programme monitoring and postoperative outcome documentation (figure 3).
Figure 3. Implementation challenges and adaptations during programme delivery. Fishbone diagram illustrating the main implementation challenges identified across six domains: workforce, patient flow, infrastructure, follow-up, data and environmental factors. Challenges encountered during implementation are shown along each domain, while the green boxes indicate adaptations introduced or proposed in response, including increased staffing and pre-camp training, daily screening caps, additional ophthalmic infrastructure, decentralised follow-up with active phone reminders, digital data capture with dedicated data personnel and scheduling activities during the dry season. Dashed lines indicate the relationship between identified challenges and corresponding adaptations.
Discussion
The study assessed the establishment and operationalisation of a high-volume cataract outreach programme within a fragile and resource-constrained setting While the programme achieved substantial surgical output and reached vulnerable populations across several districts, the findings highlight the complexity of establishing high-volume cataract outreach services within a resource-constrained setting. Rather than operating as a fixed intervention, the programme evolved continuously in response to patient demand, workforce pressures, infrastructural limitations and barriers affecting continuity of care. These experiences provide important implementation learning for strengthening future outreach cycles and similar cataract service delivery models in comparable low-resource settings.
Importantly, many of the operational modifications introduced during cycle 1 emerged iteratively during implementation rather than through predefined planning processes alone. Changes to staffing arrangements, patient flow systems, scheduling approaches, follow-up coordination and documentation processes reflected adaptive responses to emerging implementation realities encountered during programme delivery. This reflects the value of viewing outreach programmes as evolving service-delivery systems that require continuous adjustment and contextual responsiveness rather than rigid implementation models.
Demand, access and hidden unmet need
The first implementation cycle revealed a substantial unmet need for cataract surgery and eyecare services in Sierra Leone. High patient turnout, repeated attempts to access care and long-distance travel indicated that the burden of untreated cataract exceeded initial programme assumptions. Many participants reported accessing cataract surgery for the first time despite years of visual impairment. These findings are consistent with evidence from sub-Saharan Africa, where delayed cataract service utilisation is driven by geographic barriers, poverty, limited surgical capacity and weak referral systems rather than unwillingness to seek care.16 Similar reports from Kenya, Uganda and Zambia highlight significant hidden cataract backlogs and poor continuity of care.16 Qualitative findings further demonstrated that fear of surgery and misconceptions about blindness influenced treatment uptake, while trust in successful patient outcomes, family support and community and religious leaders promoted acceptance. These findings align with previous studies emphasising the importance of culturally responsive community engagement in improving cataract service uptake across sub-Saharan Africa.17 18
Delivering high-volume services under operational constraint
A major finding was the operational complexity of delivering high-volume cataract outreach within a resource-constrained health system. Higher-than-expected screening and surgical volumes placed pressure on staffing, patient flow, documentation and surgical delivery, requiring adaptive measures including expanded work shifts, revised staffing, high-volume triage and workflow redesign. These findings highlight the challenge of balancing rapid service delivery with documentation quality, patient monitoring, continuity of care and workforce sustainability. Similar operational constraints have been reported in cataract outreach programmes across sub-Saharan Africa.8 The programme also exposed broader health system limitations, including reliance on visiting ophthalmic teams, limited surgical infrastructure and centralised tertiary care. Overall, the findings demonstrate that high-volume cataract outreach in low-resource settings requires flexible, adaptive implementation models capable of responding to changing service demands and contextual pressures.
Follow-up and continuity of care as structural issues
Another important finding relates to postoperative follow-up attendance. Although follow-up decline is often discussed within outreach programmes as a problem of patient non-compliance, findings from this study suggest that continuity of care was strongly shaped by structural and systems-level barriers. Transportation costs, dependence on caregivers, poor road infrastructure, long travel distances and seasonal rainfall disruptions all influenced patients’ ability to attend postoperative review appointments. Although, 30% of patients achieved postoperative VA better than 6/12 at week one. This finding should be interpreted cautiously because VA was assessed during the early postoperative phase and may not represent the final visual outcome. Nevertheless, 10% of patients had VA <6/60 1 week postoperative. The underlying causes of poor postoperative VA were not systematically collected in the routine dataset, limiting our ability to determine whether these outcomes were attributed to pre-existing ocular comorbidity, surgical factors or other factors.
For many older patients, attendance depended not only on personal willingness, but also on household support, caregiver availability, transportation access and financial capacity. Similar findings have been reported in other low-resource settings where postoperative attrition reflects broader infrastructural and socioeconomic constraints rather than behavioural unwillingness alone.8 19 Conceptually, these findings suggest that follow-up attendance within outreach programmes should be understood as a health systems accessibility issue rather than solely an issue of individual patient responsibility.
The findings therefore highlight the importance of decentralised follow-up systems, strengthened referral tracking pathways, district-level postoperative review mechanisms and transportation support strategies for improving continuity of care within cataract outreach programmes operating across geographically dispersed settings.
Patient experience, trust and programme acceptability
Despite operational and follow-up challenges, cataract surgery resulted in marked improvements in patients’ daily functioning, independence, mobility and social participation. Significant gains in VFQ-25 scores, particularly in mental health, near vision and social functioning, highlight the broader psychosocial and functional benefits of surgery beyond improvements in VA alone. Although 1-week postoperative visual outcomes remained below WHO recommended thresholds,20 these findings should be interpreted within the context of advanced cataract presentations, coexisting ocular conditions, delayed treatment seeking and poor 1-month follow-up attendance, which limited assessment of longer-term recovery.
Importantly, the findings demonstrate that programme acceptability was shaped not only by clinical outcomes, but also by trust in programme personnel and confidence in the perceived expertise of visiting surgical teams.17 18 Visible improvements among treated patients strengthened community confidence, consistent with evidence from other low-resource settings demonstrating that cataract surgery enhances quality of life and social participation beyond restoring vision.21–23
Sustainability, adaptation and implications for future cycles
The first implementation cycle highlighted important sustainability challenges within the outreach model. Although the programme achieved high surgical output, service delivery remained dependent on visiting ophthalmic teams, limited infrastructure and centralised tertiary care, raising questions about long-term workforce capacity, decentralisation and integration within the national eye-care system. Many proposed improvements emerged directly from implementation experience, including strengthened patient selection, enhanced postoperative assessment, decentralised follow-up, improved district coordination, dedicated data personnel, revised scheduling, local workforce training, digitised patient records, improved referral tracking and greater alignment of outreach activities with the dry season. These findings demonstrate that high-volume cataract outreach should be viewed as an evolving service-delivery system rather than a fixed intervention.
The first cycle also identified limitations in the programme’s ability to monitor surgical quality beyond early VA outcomes. Postoperative complications and their causes were not systematically captured, limiting assessment of surgical safety and interpretation of suboptimal postoperative vision. Importantly, this represents not only a limitation of the present evaluation but also an implementation learning point: strengthening standardised documentation of surgical complications and postoperative outcomes should form part of the programme’s quality-assurance system in subsequent cycles.
Strengths and limitations
A key strength of this study was the combined use of the RE-AIM framework and PDSA approach, which provided a comprehensive structure for evaluating programme implementation while simultaneously capturing iterative operational adaptations during service delivery. This combination enabled assessment not only of programme reach and effectiveness, but also of how implementation processes evolved in response to real-world contextual pressures.
Despite these contributions, several limitations should be considered when interpreting the findings from this study. First, reliance on routine programme data resulted in some missing and incomplete records. Second, multiple operational adaptations occurred concurrently throughout implementation, making it difficult to isolate the individual effects of specific modifications on programme outcomes. Visual outcomes were assessed only at 1-week postoperative follow-up, therefore, these findings may not reflect final visual outcomes, which may continue to improve. The routine dataset did not systematically capture causes of suboptimal postoperative VA, limiting interpretation of the early postoperative visual outcomes. Finally, the evaluation focused primarily on the first implementation cycle and was therefore unable to assess longer-term sustainability, maintenance and health-system integration outcomes over time.
Conclusions
Taken together, these findings demonstrate that the first implementation cycle functioned as an adaptive learning phase that generated critical operational insights for future programme refinement. The programme evolved continuously throughout implementation in response to workforce strain, documentation challenges, patient flow pressures, transportation barriers and follow-up limitations. Importantly, many of the adaptations proposed following cycle 1—including improved patient selection criteria and first day postoperative care, decentralised follow-up systems, strengthened district-level coordination, dedicated data personnel, revised scheduling strategies and increased workforce preparation—emerged directly from implementation experiences encountered during programme delivery. This highlights the value of viewing cataract outreach programmes not as static interventions, but as evolving service delivery ecosystems requiring continuous adaptation, systems learning and contextual responsiveness. In this regard, the combined use of RE-AIM and PDSA frameworks provided a useful structure not only for evaluating programme outcomes, but also for understanding how implementation realities shaped programme evolution during the establishment phase of a large-scale cataract outreach initiative in Sierra Leone.
Supplementary material
Acknowledgements
We would like to extend our sincere appreciation to Mr L.T. Pagarani, Chairman of Choithram International Foundation, for being the central inspiration of the project. Mr Ashwini Varma, Managing Trustee, Choithram Netralaya and Dr Gowrinath, Head- Medical Services, CMH, for ensuring smooth operations and staffing, Dr Tina Damani, Margaret Gowrinath, Dr Meghna Shrishrimal, Dr Nida Khan, Dr Divyashree Mahadev, Dr Dhaivat Shah, Dr Milind Rokade, Dr Pradeep Ramteke, Dr Abhishek Patel, Dr Rahul Singh, Dr Akash Sandeep Kathole for their time and dedication. Mrs Kirti Malhotra, Head-Project Management & Finance/ CSR Choithrams and Mr Abhiroop Sen, Partner of Reason Y consulting for bringing the project together. The team would like to thank the Ministry of Health, Sierra Leone and all participants included in the study. A special thank you to the staff and management of Choithram Memorial Hospital.
The funders had no role in study design, data collection and analysis, decision to publish or preparation of the manuscript.
Footnotes
Funding: VFC is funded by Wellcome Trust (R2806CPH).
Prepublication history and additional supplemental material for this paper are available online. To view these files, please visit the journal online (https://doi.org/10.1136/bmjopen-2026-126880).
Provenance and peer review: Not commissioned; externally peer reviewed.
Patient consent for publication: Consent obtained from parent(s)/guardian(s).
Ethics approval: The study was approved by the Government of Sierra Leone ethics (REF:002/04/2025) and was conducted in accordance with the ethical principles of the Declaration of Helsinki. Written informed consent was obtained from all adult participants. For participants younger than 18 years, written informed consent was obtained from their parents or legal guardian before participation in the study. This included participation in qualitative interviews and vision-related quality-of-life assessments. Programme and clinical data used for quantitative analysis were anonymised prior to analysis to protect participant confidentiality and privacy. All data were stored securely and accessed only by authorised members of the research team.
Data availability free text: The data that support the findings of this study are not publicly available because they contain identifiable patient information and are held by Choithram Memorial Hospital, Sierra Leone. De-identified data may be made available on reasonable request, subject to approval by the data custodian and relevant ethical and institutional governance requirements.
Patient and public involvement: Patients and members of the public were not involved in the design, conduct, reporting, or dissemination plans of this research. Participants contributed to the study through interviews, focus group discussions, and routine programme data collection as part of the implementation evaluation.
Data availability statement
Data are available on reasonable request.
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