Table 2

Key components of the 46 implemented service delivery models (50 studies in total; 3 models are described by more than one study)

Country, eye condition and eye care service	First author, year	Service delivery input	Service delivery model description	Service delivery outputs/outcomes reported	Author summary of evaluation of service delivery model
Teleophthalmology
Australia DR, screening	Barry, 200629	HR clinical. HR managerial. Equipment. HIS.	Teleophthalmology screening programmes within remote Indigenous communities in Western Australia.	Photographic quality, prevalence of DR, number undergoing annual screening and numbers referred	Increased number of people undergoing regular DR screening in Western Australia.
Australia DR, screening	Brazionis, 201830	HR clinical. Equipment.	Teleophthalmology service using non-ophthalmic retinal imagers with remote ophthalmologist in grading images.	–	NR.
Australia DR, screening	Kanagasingam, 201537	HR clinical. Equipment. Facilities. HIS.	Teleophthalmology model ‘Remote-I’ connected ophthalmologists in urban areas to patients and primary care workers in remote locations, including secure image sharing.	Patient satisfaction, numbers screened and health professional satisfaction	Good patient and health professional satisfaction and an increased number of patients screened.
Australia DR, screening	Karagiannis, 199642	HR clinical. Equipment.	Pilot study to assess whether Indigenous health workers could be trained to take fundus images for retinal screening to reduce cost of DR screening in remote areas rarely visited by an ophthalmologist.	–	NR.
Australia DR, screening	McConnell, 199348	HR clinical. Equipment.	Indigenous healthcare workers taking fundus photos on health visits and sending photos to ophthalmology consultant.	–	NR.
Australia DR, screening	Moynihan, 201736	HR clinical. HR managerial. Equipment. Facilities.	Retinal photography and visual acuity measured by Indigenous health workers and nurses and sent via cloud-based eHealth records systems to Perth-based ophthalmologist. A Kimberley diabetic eye health coordinator was established to provide high-level support.	Change in coverage provided by the screening programme over time and number of centres involved in screening programme and number of diabetic eye examinations carried out annually	With the addition of an eye health coordinator, coverage for Indigenous patients increased and number of sites for screening increased.
Australia DR, screening	Murray, 200535	HR clinical. Equipment.	Indigenous health workers trained to operate non-mydriatic retinal cameras to screen for DR in primary care clinics. Photographs were reported by remote ophthalmologists. Regular training and feedback were provided to the technicians.	Number of screening episodes	Evaluated the activities and outcomes of the last 5 years of this 10-year programme. Showed the number of Indigenous population screened increased after starting programme.
Australia DR, screening	O’Halloran, 201847	HR clinical. Equipment.	Assessed the addition of an OCT alongside fundus camera to improve detection of DR.	Referral rates from screening to eye health professional	Addition of OCT did not change number of referrals.
Australia DR, screening (same model described)	Spurling, 201038	HR clinical. Equipment.	Clinic-based retinal photography introduced to urban Indigenous health service primary care.	Access to appropriate screening and follow-up, acceptability and feasibility of clinic-based retinal photograph	Number screened, referred and followed up increased. Participants were positive about the screening (convenient and in a comfortable/safe environment).
Australia DR, screening (same model described)	Villalba, 201931	HR clinical. HR managerial. Facilities. HIS. Equipment.		Number attending DR screening	Implementation of a retinal camera at the CoEinitially increased DR screening rates. From 2012 to 2016, the annual DR screening number was consistent, but the number of CoE clients living with diabetes increased substantially.
Australia All eye care, screening	Elliott, 201049	HR clinical. Equipment. Facilities. HIS.	Integration of a mobile telehealth hearing and vision screening service for children with existing community-based health services. Screening carried out in a mobile van by an Indigenous health worker. Children who failed screening were referred to local health services.	Community acceptance, number of schools visited, number of children screened and number of referrals made to optometry	Combining telehealth ear screening with eye screening using Indigenous health workers is likely to be feasible.
Australia Cataract, surgery	McGlacken-Byrne, 201950	HR clinical. Surgeries. HIS.	Teleophthalmology was used by optometrists for preoperative consultations during outreach visits, allowing patients to be booked for cataract surgery without the need for outpatient preoperative assessment.	Cataract surgery waiting times	Almost one-fifth of cases (19.1%) had surgery booked via telehealth, resulting in shorter waiting times between referral and cataract surgery.
Canada DR, screening	Arora, 201334	HR clinical. Equipment.	Teleophthalmology programme in Alberta, Canada incorporating culturally sensitive health-related activities and rituals as a component of DR screening. Nurses held clinics once a month in remote communities. Digital fundus photographs are sent to ophthalmologists remotely, who reviewed images and suggested management.	Clinic attendance rate and patient satisfaction	Teleophthalmology is more effective than the traditional hospital-based approaches at resolving social and cultural barriers, thereby facilitating greater access to care for remote Indigenous peoples.
Canada DR, screening	Kim, 201543	HR clinical. HR managerial. Equipment. Facilities.	Teleophthalmology screening and follow-up for at-risk patients with diabetes. Patients phoned and invited to attend screening clinics in their communities. Clinic arrived in a truck and set up at existing healthcare centres within remote communities.	Number screened, user satisfaction, system quality, service quality and costs	Increased number of people screened, user satisfaction with teleophthalmology was high, indirect and direct cost savings, and able to diagnose other ocular conditions.
Canada DR, screening	Jin, 200444	HR clinical. Facilities. Clinical episodes.	The British Columbia First Nations Mobile Diabetes Telemedicine Clinic visits Indigenous communities once per year. A diabetic nurse educator and eye care technician carry out screening alongside other diabetes care and diabetes education.	Number and location of clinic sites, number of clinic days of operation, number of clients examined, client satisfaction, and cost-effectiveness	The mobile diabetes clinic programme provides a relevant and needed service that is effective, with high satisfaction from patients and delivered at less cost than the existing alternative.
Canada DR, screening	Spurr, 201828	HR clinical. Equipment. Facilities.	A pilot study to see whether community-based, nurse-led screening for DR was as accurate as an assessment by an ophthalmologist.	–	Showed agreement between nurse-led and ophthalmology screening, however small pilot study not assessed sustainable implementation yet.
New Zealand DR, screening	Jagadish, 201746	Facilities.	DR screening using a mobile retinal screening van in a range of settings. Patients referred to specialist eye clinic after grading.	–	NR.
New Zealand DR, screening	Reda, 200345	HR clinical. Equipment. Facilities.	Mobile teleophthalmology screening clinic in Waikato region.	Number of patients screened, number referred to eye clinic and failure to attend rate	Reports good coverage in the area and acceptable image quality.
USA DR, screening	Bowyer, 199727	HR clinical. HR managerial. Medicines.	Describes the experiences of the White Earth Indian health centre in establishing a pilot project for the prevention of ocular complications of diabetes. 13 quality improvement steps were designed to improve diabetic eye care within the primary care clinic.	Number attending annual eye examination	Increase in number of people having annual diabetic eye examination.
USA DR, screening (same model described)	Carroll, 201140	Equipment. HIS.	The Indian Health Service-Joslin Vision Network Teleophthalmology Program was established in 2000 for remote diagnosis and management of DR. Non-mydriatic fundus photographs are taken by a technician as a routine component of diabetes care. Retinal images are sent to a central server on the Indian health service network for review. Currently has 99 clinical implementations in 23 states.	Number of screening episodes	States general increase in numbers screened and geographical coverage. Some sites still demonstrate a low utilisation rate, possibly due to not being included in standard diabetic care.
	Bursell, 201839	HR clinical. Facilities.		–	NR.
	Fonda, 202033	HR clinical. Facilities. HIS. Equipment.		Clinical volume, geographical adoption of programme, DR surveillance and treatment rate, cost-effectiveness, and operation efficiency	Annual DR screening rate has increased within HIS sites.
USA DR, screening	Mansberger, 201341	HR clinical. Facilities. HIS.	Non-mydriatic fundus photographs taken during primary care clinic for routine diabetes care by trained technicians in a vacant room within the clinic. Images were then sent remotely for grading.	Number attending screening	Teleophthalmology with non-mydriatic camera increased uptake of screening compared with traditional clinic-based surveillance.
Greenland DR, screening	Pedersen, 201932	HR managerial. HIS. Ophthalmic equipment.	Non-mydriatic wide-field digital fundus photographs are taken by nurses working in diabetic clinics and images then sent remotely to ophthalmologists in Denmark. Cameras were installed in nine towns and local diabetes staff were trained in the procedure.	Number attending screening	Increase in number of patients undergoing annual DR screening since programme initiated in 2008.
Integration of services into existing Indigenous primary health
Australia DR, screening	Bailie, 200754	HR clinical. HIS.	Two cycles of a quality improvement intervention in 12 Indigenous community health centres with a focus on understanding system-related factors which hinder or facilitate improvements in outcomes of care in Indigenous peoples with diabetes.	Change in quality of diabetic care and change in health centre system development	Increase of biennial diabetic eye screening by an ophthalmologist from 34% to 54%.
Australia Refractive error, optometry	Layland, 200453	HR clinical. HR managerial. Facilities. Spectacles supplied. Surgeries.	Local, culturally appropriate, fully equipped remote eye clinics, some staffed by optometrists and others visited by optometrists, with clear referral and funding pathways and integration with more remote communities. The clinics provide eye care, spectacle dispensing and eye health education.	Number of spectacles supplied to Indigenous population, number of ophthalmic consultations and number of eye care clinics in remote areas	Increased use of government spectacle scheme by Indigenous people, good relationships with community with continuity of care and good feedback from Indigenous communities.
Australia Refractive error, optometry	Napper, 201578	HR managerial. Spectacles supplies.	New low-cost spectacle scheme (the Victorian Aboriginal Spectacle Subsidy Scheme) and expansion of service access sites in urban and regional Victoria aimed at improving access to and uptake of eye care for Indigenous Australians.	Number of patient consultations, number of spectacles dispensed and number of patient referrals	Increased access to spectacles, improved management of other eye conditions, improved referrals for systemic conditions and increased participation of the Aboriginal health service in eye care services.
Australia Cataract, surgery	Penrose, 201857	HR clinical. Medicines.	The Institute for Urban Indigenous Health (IUIH) introduced ‘wrap around’ culturally appropriate care that extends to tertiary services. Collaborations to redesign services took place between clinicians, community members and an Indigenous health institute (IUIH).	Number of referred patients undergoing cataract surgery in the 7-month period following service redesign, 4-week postoperative check attendance rates and visual acuity outcomes following surgery	Integrating the cataract surgical pathway within the primary healthcare service and collaborating with external organisations improved coordination and increased the cataract surgery completion rate for Indigenous Australians with high-quality visual outcomes.
Australia DR, screening	McDermott, 200155	HR clinical. Facilities. HIS.	A diabetes recall system was established at 21 primary healthcare sites. Indigenous healthcare workers were trained to manage a recall system and provide diabetes checks and referrals.	Number undergoing annual DR screening	Patients with diabetes at intervention sites had more frequent, regular and structured contact with the primary healthcare service. More patients underwent an annual eye check in the intervention group.
Australia All eye care, general	Yashadhana, 202059	HR clinical. Surgeries. Spectacles. HIS.	Strategies to improve access to eye care and its integration with regional health systems were implemented following a situational analysis. Activities included training of primary eye care staff, documentation of referral processes, updating e‐record templates to include primary eye care examinations and increasing visiting optometry and ophthalmology services.	Number of eye care attendances, spectacles dispensed, dilated fundus examinations, referrals and cataract surgeries completed	There were significant increases in the rate and frequency of optometry examinations, recalls and referrals and spectacles prescribed and annual dilated ocular fundus examinations.
Australia All eye care, general	Jatkar, 201758	Surgeries. Spectacles. Equipment.	Overview of the Grampians Region Aboriginal Eye Health Advisory Group eye care programme. Gap analyses were carried out which led to purchasing ophthalmic equipment, providing eye care training to staff, developing DR health promotion resources, implementing strategies to reduce waiting times for cataract surgeries and making spectacles more affordable.	Visits to optometry, number receiving annual DR screening, waiting times for cataract surgery and cataract surgical rates	Increased visits to optometry, number attending annual DR screening, number receiving cataract surgery and number receiving subsidised spectacles. Decrease in waiting time for cataract surgery.
USA Refractive error, optometry	Caplan, 197851	HR clinical. Spectacles supplied.	Eye clinics and children’s visual screening integrated within the Indian health service.	Number of optometrists working within Indian health service	Number of optometrists working within the Indian health service increased during the 1970s, but no wider evaluation of access to services.
Canada DR, screening	Hayward, 202056	HR clinical. HR managerial.	The programme partnered with a team of local healthcare providers and community members to develop and evaluate a community-driven, culturally relevant primary healthcare model using a QI process. They aimed to improve diabetes care access to prevention services in the community, including DR screening.	Number attending DR screening	Most aspects of general diabetes care were improved, however the number receiving DR screening decreased.
Outreach services
Taiwan All eye care, general	Chen, 201560	HR clinical. HR managerial. Equipment. Facilities. Spectacles supplied.	Mobile van providing eye screening in Indigenous communities, with on-board dispensing of spectacles.	Number of primary eye care services provided, number of spectacles dispensed, number of eye health education programmes and courses given	This eye care model is feasible and cost-effective.
Australia All eye care, general	Gruen, 200661	HR clinical. Clinical episodes.	Visiting ophthalmic specialists to remote communities. Patients with non-emergency surgical problems were referred from primary care to these outreach clinics.	Number of elective referrals, number of opportunistic attendances, proportion of electively referred problems seen by a specialist within 12 months and timely completion of referrals	Specialist outreach visits to remote Indigenous communities improved access to specialist consultations and procedures without increasing elective referrals or demand for hospital inpatient services.
Australia All eye care, general	Maher, 201263	HR clinical. HIS. Spectacles supplied. Surgeries. Clinical episodes.	Overview of ophthalmic services available in New South Wales providing several examples of service delivery models.	Cataract surgical rates, availability of eye health services, access to services, coordination of services, and monitoring and evaluation of services	Identified areas for improvement: a lack of cultural competency, limited coordination, and incomplete monitoring and evaluation.
USA Glaucoma, surgery	Robin, 198664	Equipment. Medicines.	A field trial of the use of a portable Nd-YAG laser for peripheral iridotomies in rural villages to prevent pupillary block glaucoma in at-risk patients.	–	NR.
Australia DR, general	Turner, 201162	HR managerial. Medicines.	Describes models for service integration between ophthalmology and optometry when conducting outreach eye services.	Surgery and clinic consultation rates, waiting times and costs per attendance	Better integration of optometry and ophthalmology services increases surgical uptake rate.
Training Indigenous health workers
Australia All eye care, education, training	King, 200366	HR managerial.	Developed an eye course for health workers from two Aboriginal communities and produced health promotional materials to educate clients in the Aboriginal community about eye health issues.	–	NR.
USA Low vision, rehabilitation	Orr, 199365	HR clinical. Facilities.	Training model to teach community outreach workers to train elderly blind and vision-impaired American Indians independent living skills.	–	NR.
Eye health promotion
Canada DR, health promotion	Umaefulam, 202067	HIS.	This study explored the use of mobile health (mHealth) via text messages to provide DR awareness and improve diabetic eye care behaviour. It examined the extent to which mHealth education changed Indigenous women’s DR awareness and self-reported eye care behaviour.	KAP related to DR	Improvement in KAP related to DR among participants.
Trachoma control methods
Australia Trachoma, SAFE (F)	Atkinson, 201472	HR managerial. Clinical episodes. Facilities.	The University of Melbourne partnered with Melbourne Football Club to run trachoma football hygiene clinics in Northern Territory, Australia, to raise awareness of the importance of clean faces in order to reduce the spread of trachoma. Between 2010 and 2013, 12 football clinics were held in major towns and remote communities.	Number attending the football clinics	Engagement in football clinics, number of communities involved and media coverage increased between 2010 and 2013.
Australia Trachoma, SAFE (AFE)	Ewald, 200370	Medicines. Clinical episodes.	Implementation of the SAFE strategy in central Australia: screening children, antibiotic distribution, health promotion and environmental improvements.	Prevalence of active trachoma and adequacy of housing facilities	Change in trachoma prevalence after initiation of programme was not significant. Likely to be affected by population mobility, inadequate housing, continued crowding and low compliance with antibiotic therapy.
USA Trachoma, SAFE (A)	Hoshiwara, 197168	HR clinical. Medicines.	Upscaling of mass antibiotic distribution using a family treatment approach to treat and prevent trachoma among Indigenous peoples in the USA.	Number receiving antibiotic treatment	Reduction in prevalence of active trachoma.
Australia Trachoma, SAFE (FE)	Lange, 201771	HR managerial. Clinical episodes.	Development of a culturally appropriate, community-based health promotion strategy for trachoma using a variety of different methods for dissemination, for example, clinical education, community performances, football, Trachoma Story Kits, posters, television and radio advert.	KAP	Health promotion was associated with increased trachoma KAP among health, education and community support staff working with children and in remote communities.
Australia Trachoma, SAFE (FE)	Baunach, 201277	HR clinical.	Describes the process of developing and rolling out culturally appropriate health promotion resources for trachoma through collaboration of different stakeholders.	Qualitative outcomes of user satisfaction	Engaging and contemporary health promotion resources are vital to support health promotion in trachoma. Highlights the role of effective partnerships to create resources developed by Indigenous peoples for Indigenous peoples in remote communities.
Australia Trachoma, SAFE (AFE)	Lansingh, 201073	HR managerial.	Study to assess the additional impact of implementing environmental changes within the SAFE strategy in controlling trachoma in two Indigenous Australian populations.	–	NR.
Australia Trachoma, SAFE (A)	Liu, 201669	HR clinical. Medicines. Clinical episodes.	Annual screening of children for trachoma in communities designated to be at high risk of disease and treatment of those affected with the antibiotic azithromycin.	Number of screening episodes	Change in trachoma prevalence based on treatment strategy; most effective in communities implementing community-wide strategies.
Australia Trachoma, SAFE (S)	Mak, 200174	Surgeries. Clinical episodes.	A collaborative programme was established involving the Kimberley Public Health Unit, Kimberley Aged Care Services and the visiting ophthalmology service. The aged-care population were screened for trichiasis and the aged-care services staff were educated about identification and referral procedures for patients with trichiasis.	Number of people screened for trichiasis and number referred for surgery	An effective screening programme and referral system improves access to trichiasis surgery.
Australia Trachoma, SAFE (AFE)	Mak, 200676	HR clinical. Medicines. Clinical episodes.	Provides an overview and comparison of the different trachoma control strategies in different regions of Australia in 2004.	Number of screening episodes	Trachoma control programmes led by regional population health units working in collaboration with primary healthcare services were more likely to be consistently implemented over long periods of time.

DR, diabetic retinopathy; HIS, health information system; HR, human resources; KAP, knowledge, attitude and practice; NR, not recorded; OCT, optical coherence tomography; QI, quality improvement; SAFE, surgery, antibiotics, facial hygiene and environmental change; CoE, Centre of Excellence in Primary Care.