A Sustainable Community-Based Model for Refractive Eye Care Services in the Sundarbans, India: A Mixed-Methods Study

A Sustainable Community-Based Model for Refractive Eye Care Services in the Sundarbans, India: A Mixed-Methods Study | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article A Sustainable Community-Based Model for Refractive Eye Care Services in the Sundarbans, India: A Mixed-Methods Study Debapriya Mukhopadhyay This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8960531/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 9 You are reading this latest preprint version Abstract Background Uncorrected refractive error is a leading cause of avoidable visual impairment globally and disproportionately affects rural and underserved populations. In the Sundarbans region of India, geographic isolation, poor infrastructure, low awareness, and fragmented service delivery limit access to refractive eye care. This study aimed to develop and evaluate a sustainable, community-based refractive eye care service model and to assess its effects on accessibility, affordability, service quality, compliance, and human development–related outcomes. Methods A mixed-methods design was employed. Quantitative data were collected through a cross-sectional survey of 999 community members across the Sundarbans, assessing accessibility, affordability, product quality, spectacle compliance, and perceived quality-of-life improvement. Qualitative data were obtained through semi-structured interviews with optometrists, eye-care professionals, and programme stakeholders and analysed thematically. Hypothesis testing examined relationships between service attributes, awareness, optometrist involvement, insurance linkage, and Human Development Index (HDI)–related outcomes. Results Although 76.2% of respondents perceived refractive services as affordable (p < 0.001), only 13.2% reported adequate accessibility. Satisfaction with corrective products was reported by 36.3%, and consistent spectacle use by only 12.8% (p < 0.001). Improved quality of life following refractive correction was reported by 57.2% of respondents. All alternative hypotheses were supported, confirming that affordability, awareness, service quality, optometrist involvement, and insurance linkage significantly influence compliance, sustainability, and development-related outcomes. Conclusions A community-based refractive eye care model integrating affordability, quality assurance, optometrist-led service delivery, awareness generation, and insurance linkage is feasible and effective in underserved rural settings. The proposed model offers a scalable framework for strengthening primary eye care services and advancing equitable health system performance. Refractive eye care Primary eye care Health service accessibility Rural health systems Sustainability India Figures Figure 1 Figure 2 Introduction Uncorrected refractive error remains one of the most prevalent and avoidable causes of visual impairment worldwide, and it can be effectively addressed through timely detection and appropriate optical correction [1,2,5,15,16,18]. Despite the availability of simple and low-cost interventions, access to refractive services remains uneven, particularly in rural and resource-constrained settings where health infrastructure and trained personnel are limited [3,4,17,19]. Visual impairment resulting from uncorrected refractive error adversely affects educational attainment, employment opportunities, productivity, and social participation, thereby contributing to broader developmental and socioeconomic disparities [5,22]. The burden of refractive error is disproportionately concentrated in low-resource populations, where geographic isolation, limited awareness, and fragmented service delivery models restrict access to primary eye care [17,19,21,24]. Rural service-delivery gaps are further exacerbated by shortages of trained eye-care professionals and reliance on episodic outreach-based programmes that often fail to ensure follow-up and continuity of care [2,3,21]. Evidence from community-based and school-linked eye-health initiatives in developing regions suggests that locally embedded services can significantly improve service uptake, compliance, and sustainability when integrated into primary healthcare systems [26,27,28]. India bears a substantial share of the global burden of uncorrected refractive error, with rural populations particularly affected due to geographic barriers, workforce shortages, and weak integration of vision care into general health services [6,7,8]. The Sundarbans region of West Bengal exemplifies these challenges. Its dispersed island geography, dependence on riverine transport, and socioeconomic vulnerability constrain access to routine healthcare, including essential refractive services [9,25]. Recognizing these gaps, global eye-health strategies increasingly emphasize the integration of refractive services into primary healthcare as part of universal health coverage and sustainable development agendas [13,29,30]. However, there remains limited empirical evidence on how such integrated, community-based models can be operationalized and sustained in geographically complex environments such as the Sundarbans. This study seeks to address this gap by evaluating a decentralized refractive eye-care delivery model designed to improve accessibility, continuity, and long-term service utilization in an underserved rural setting. Existing eye-care delivery in the region is largely episodic, camp-based, and poorly integrated with primary health systems, leading to low coverage, poor follow-up, and limited sustainability [10,11]. This study addresses this gap by developing and empirically evaluating a sustainable, community-based refractive eye care service model tailored to the Sundarbans context. Methods Study Design This study employed a convergent mixed-methods design , in which quantitative community-level survey data and qualitative stakeholder interviews were collected during the same study period and integrated at the analysis stage. This approach enabled simultaneous examination of service utilization patterns and contextual factors influencing sustainability of refractive eye care delivery. The study is reported in accordance with the STROBE guidelines for observational research and the COREQ principles for qualitative research reporting . Study Setting The study was conducted in the Sundarbans region of West Bengal, India , a geographically dispersed deltaic area characterized by riverine transport systems, limited infrastructure, and restricted access to routine healthcare services. Communities are distributed across multiple islands, where travel to secondary or tertiary care facilities often requires prolonged transit, creating structural barriers to continuous eye care. Sampling Strategy A multistage cluster sampling approach was used to ensure representation across geographically diverse and accessibility-stratified communities. Blocks within the Sundarbans were first categorized by accessibility level (easily accessible, moderately accessible, remote). Villages were selected purposively within each stratum to capture service delivery variation. Within selected villages, systematic household sampling was conducted. One eligible adult respondent (≥ 18 years) per household was recruited. This strategy minimized selection bias and ensured inclusion of populations with differing access constraints. Sample size was estimated using a single-proportion calculation assuming: Expected service utilization proportion = 50% (maximal variability) Confidence level = 95% Margin of error = 3% The calculated minimum sample requirement was 1,067 participants. A total of 999 respondents were enrolled, providing sufficient statistical precision (> 80% analytical power) for primary comparisons and subgroup analyses in this field-based setting. Participant Eligibility Criteria Inclusion criteria: Resident of selected Sundarbans communities Aged 18 years or older Willing to provide informed consent Exclusion criteria: Temporary visitors to the area Individuals unable to respond to survey questions due to illness or cognitive limitation Data Collection Procedures Quantitative Component Data were collected through structured, interviewer-administered questionnaires conducted during community visits. The instrument captured: Access to refractive eye care services Perceived affordability Satisfaction with spectacles provided Spectacle usage behaviour (compliance) Perceived functional and quality-of-life impact Awareness of available eye care services The questionnaire was developed based on community eye health service indicators and pilot-tested in a similar rural population prior to implementation. Minor linguistic adjustments were made to ensure clarity. Data were collected using a structured questionnaire designed to assess accessibility, affordability, service utilization, satisfaction, and spectacle-use behaviour. The questionnaire was developed based on established community eye-health indicators and adapted to the local context through pilot testing. A copy of the survey instrument is provided as Supplementary File 1 . Instrument Reliability Internal consistency testing of multi-item domains demonstrated acceptable reliability ( Cronbach’s α = 0.78 ). Pilot testing confirmed face validity and operational feasibility. Operational Definitions of Key Variables Variable Operational Definition Accessibility Ability to reach service within ≤ 45–60 minutes travel Affordability Self-reported ability to obtain services without financial hardship Compliance Use of prescribed spectacles ≥ 5 days per week Satisfaction Positive rating of comfort, usability, and perceived benefit Awareness Knowledge of available refractive services in the locality Qualitative Component Semi-structured interviews were conducted with: Practicing Experts (Optometrists/Ophthalmologists/Faculties and Researchers) Outreach service coordinators Vision technicians Programme administrators Interview guides explored: Barriers to service delivery Community behavioural responses Sustainability challenges Workforce and logistical constraints Interviews were audio-recorded, transcribed verbatim, and anonymized. Qualitative Data Analysis An inductive thematic analysis approach was used. Transcripts were coded iteratively. Codes were grouped into categories and themes. Themes were reviewed for internal consistency and explanatory relevance. Investigator triangulation ensured interpretive credibility. Data saturation was considered achieved when no new concepts emerged. Semi-structured interviews were conducted using an interview guide exploring barriers to service delivery, patient acceptance, and sustainability of community-based refractive care. The interview guide is available as Supplementary File 2 . Statistical Analysis Quantitative data were analysed using descriptive and inferential statistical methods. Frequencies and proportions summarized categorical variables. Confidence intervals (95%) were calculated for key indicators. Associations were tested using chi-square analysis. Logistic regression was used to identify predictors of spectacle compliance. Odds ratios (OR) with 95% confidence intervals were reported. Statistical significance was set at p < 0.05 . Mixed-Methods Integration Integration of quantitative and qualitative findings was performed using a joint explanatory approach , whereby statistical patterns were interpreted alongside stakeholder insights to understand underlying service delivery dynamics and behavioural responses. A schematic representation illustrating the integration of accessibility, affordability, service quality, optometrist-led delivery, awareness generation, and insurance linkage within a sustainable primary eye care framework.(Figure.1) Bias Mitigation Several strategies were employed to reduce bias: Cluster-based sampling improved representativeness. Standardized interviewer training minimized measurement variation. Structured questioning reduced recall variability. Inclusion of both provider and community perspectives enhanced analytic triangulation. Ethical Considerations This study was conducted in accordance with the ethical principles of the Declaration of Helsinki . Ethical approval was obtained prior to study initiation from Institutional Review Board (IRB) of Debapriya Mukhopadhyay Vision Research Institute and Foundation , Kolkata, India ( Letter Number:. EC/SCMRECS/01122022 ). All participants provided written informed consent before participation. Confidentiality and anonymity were maintained throughout data handling and reporting. Results Study Population Characteristics A total of 999 participants completed the quantitative survey (response completeness: 100% for core variables). Participants were drawn from multiple island blocks of the Sundarbans, representing a predominantly rural population with limited proximity to fixed health facilities. Qualitative interviews were conducted with 12 key informants (optometrists, programme implementers, and outreach coordinators), achieving thematic saturation. Quantitative Findings Accessibility of Refractive Eye Care Services Table 1 Accessibility of refractive eye care services Accessibility level Frequency Percentage Accessible 132 13.2% Partially accessible 541 54.1% Not accessible 326 32.7% Table 1 describes only 13.2% (n = 132/999; 95% CI: 11.2–15.5) of respondents reported that refractive services were accessible within a reasonable distance. In contrast: 54.1% (n = 541/999; 95% CI: 50.9–57.2) reported services as partially accessible 32.7% (n = 326/999; 95% CI: 29.8–35.7) reported services as not accessible A one-sample proportion test confirmed that the proportion reporting adequate accessibility was significantly lower than 50% (z = − 24.6, p < 0.001 ), indicating a substantial access deficit. Travel time exceeding 60 minutes was reported by 61% of respondents, reinforcing geographic barriers. Perceived Affordability of Refractive Services Table 2 Perceived affordability of refractive services (n = 999) Affordability perception Frequency Percentage Affordable 761 76.2% Not affordable 238 23.8% Table 2 describes, a majority of participants perceived services as affordable: 76.2% (n = 761/999; 95% CI: 73.5–78.8) reported affordability 23.8% (n = 238/999; 95% CI: 21.2–26.5) reported cost-related difficulty The observed affordability proportion was significantly higher than the null expectation of equal distribution (χ² = 274.5, p < 0.001 ). Despite this, affordability showed weak association with utilization when analysed alongside accessibility constraints, suggesting cost alone does not predict service uptake. Satisfaction with Corrective Products Only 36.3% (n = 363/999; 95% CI: 33.3–39.3) reported satisfaction with provided spectacles. The dissatisfaction rate ( 63.7% ) was significantly greater than satisfaction (χ² = 88.7, p < 0.001 ). Reported concerns included: Poor durability (42%) Improper fit (31%) Aesthetic concerns (18%) Lack of follow-up adjustment (9%) Compliance with Spectacle Use Table 3 Compliance with spectacle use Compliance category Frequency Percentage Regular use 128 12.8% Irregular / non-use 871 87.2% Table 3 describes that Regular spectacle use was reported by: • 12.8% (n = 128/999; 95% CI: 10.8–15.1) Whereas: 87.2% (n = 871/999; 95% CI: 84.9–89.2) reported irregular or discontinued use. The compliance rate was significantly lower than expected for effective refractive correction coverage (z = − 39.1, p < 0.001 ). Logistic comparison demonstrated that satisfaction with product quality significantly predicted compliance (Odds Ratio = 3.42; 95% CI: 2.31–5.08; p < 0.001 ). Perceived Impact on Quality of Life Table 4 Perceived quality-of-life improvement after correction Response Frequency Percentage Improved 572 57.2% No improvement 427 42.8% Table 4 describes that despite low compliance, 57.2% (n = 572/999; 95% CI: 54.1–60.3) reported subjective improvement in daily functioning after refractive correction. Improvements were reported in: Near vision tasks (68%) Occupational productivity (52%) Mobility confidence (41%) The association between spectacle use and perceived functional improvement was statistically significant (χ² = 61.3, p < 0.001 ). Integrated Service Model The service-delivery pathway emphasizes continuity of care rather than episodic outreach. A conceptual pathway demonstrating how affordability and product quality influence compliance and sustainability outcomes. The integrated service-delivery pathway illustrates how accessibility, tele-optometry support, product acceptability, and follow-up mechanisms interact to influence compliance and sustainability outcomes (Fig. 2). Hypothesis Testing All predefined alternative hypotheses were supported: Hypothesis Statistical Test Result Impact of refractive services on quality of life χ² = 61.3 p < 0.001 Compliance dependent on product quality OR = 3.42 p < 0.001 Awareness influences service uptake χ² = 48.9 p < 0.001 Optometrist-led access improves continuity χ² = 52.7 p < 0.001 These findings indicate strong associations between service structure variables and utilization outcomes. Qualitative Findings Four major themes emerged from stakeholder interviews. Theme 1: Structural Geography Limits Continuous Access Participants emphasized that tidal transport systems, dispersed settlements, and travel costs prevent routine engagement with distant facilities. Theme 2: Outreach-Only Models Produce Episodic Rather Than Continuous Care Screening camps were described as effective for detection but insufficient for follow-up, dispensing refinement, and behavioural reinforcement. Theme 3: Product Acceptability Drives Use More Than Cost Providers consistently reported that patients abandon spectacles when quality or comfort is inadequate—even when free. Theme 4: Locally Embedded Optometrists Enable Trust and Continuity Permanent community presence was identified as essential for sustained uptake and service credibility. Integrated Mixed-Methods Analysis Integration of quantitative and qualitative findings demonstrates that refractive care utilization is constrained by interacting structural, behavioural, and service-delivery factors . Affordability interventions addressed financial barriers but did not overcome geographic inaccessibility, inconsistent service availability, or product dissatisfaction. Qualitative insights explain the observed statistical paradox of high affordability yet low compliance. The combined evidence supports a model emphasizing decentralized delivery, trained mid-level workforce integration, and continuous engagement mechanisms. Key Quantitative Indicators Summary Indicator Value Adequate accessibility 13.2% Perceived affordability 76.2% Product satisfaction 36.3% Regular spectacle use 12.8% Quality-of-life improvement 57.2% All hypotheses Statistically significant (p < 0.001) Discussion This study evaluated the feasibility of a sustainable, community-based refractive eye care model in the geographically isolated and socioeconomically vulnerable Sundarbans region. The findings indicate that improving affordability alone does not ensure effective utilization of refractive services; accessibility, perceived quality of care, and continuity of services are equally important determinants of uptake and sustainability. Uncorrected refractive error remains one of the most common yet avoidable causes of visual impairment globally, disproportionately affecting underserved populations where access to primary eye care is limited [1,5]. Although most respondents perceived refractive services as affordable, only a small proportion reported adequate accessibility. This mismatch reflects structural barriers commonly observed in rural health systems, where transportation challenges, workforce shortages, and fragmented service delivery prevent available services from translating into actual utilization [7,8]. Similar patterns have been reported in community-based eye care studies demonstrating that decentralization of services and integration into primary care settings are essential to improving coverage in low-resource environments [9,11]. Spectacle compliance emerged as a major challenge, with only a minority of participants reporting consistent use despite receiving prescriptions. Evidence suggests that adherence to spectacle wear is strongly influenced by perceived product quality, comfort, cultural acceptability, and trust in providers rather than cost alone [20,23]. Studies on refractive service delivery have emphasized that dispensing, counselling, and follow-up must be integrated into care pathways to ensure sustained behavioural change and visual rehabilitation outcomes [12,14]. The findings further highlight the importance of optometrist-led primary eye care models. In settings where ophthalmologist-led services are not scalable, optometrists can effectively deliver refraction, dispensing, and community engagement at the primary level, thereby addressing workforce shortages and improving continuity of care [2,3]. Strengthening mid-level eye health personnel has been widely recommended as a strategy to expand access and reduce avoidable blindness in developing regions [3,11]. Awareness generation and financial-linkage mechanisms were also found to influence service sustainability. Community engagement increases perceived need and demand for services, while financial protection mechanisms such as insurance or subsidized models support continuity of care. Health system research increasingly recognizes that combining service delivery innovations with financing strategies is necessary to achieve equitable access and long-term programme viability [5,12,22]. From a policy perspective, the proposed model aligns with universal health coverage priorities by embedding refractive services within decentralized primary health systems rather than relying on episodic outreach models. Integrating refractive care into routine community-based services has the potential to reduce avoidable visual impairment while simultaneously strengthening local health infrastructure and workforce utilization [5,22]. Strengths A key strength of this study is the mixed-methods approach, which enabled triangulation of quantitative community-level findings with qualitative insights from providers and stakeholders, offering a comprehensive understanding of both demand- and supply-side determinants of refractive service utilization. The large sample size from a geographically unique region contributes valuable evidence to an underrepresented area in health services research. Implications for Health Services Research These findings underscore the need for health services research to move beyond cost-reduction approaches and toward integrated delivery models that address accessibility, workforce distribution, service quality, and financing simultaneously. Evaluating scalable optometrist-led primary eye care systems and community-embedded delivery pathways will be essential for reducing avoidable vision impairment in underserved populations. Limitations and Directions for Future Research This study has several limitations that should be considered when interpreting the findings and that also present opportunities for further investigation. First, the study was conducted within a specific geographic context—the Sundarbans region of India—characterized by unique environmental, infrastructural, and socioeconomic conditions. While this setting provides valuable insights into service delivery in geographically isolated populations, the findings may not be directly generalizable to other rural or urban environments without contextual adaptation. Future research should evaluate the applicability of this model in diverse settings to assess scalability and contextual variability. Second, the cross-sectional design limits the ability to assess long-term outcomes such as sustained spectacle compliance, visual improvement over time, and economic or social impact. Longitudinal studies are needed to examine whether community-based refractive care models lead to durable behavioral change and continued service utilization. Third, several variables, including spectacle use, satisfaction, and perceived quality-of-life improvements, were based on self-reported responses, which may be subject to recall or response bias. Future studies may incorporate objective compliance monitoring, clinical follow-up assessments, or digital adherence tracking to strengthen outcome measurement. Fourth, while the mixed-methods approach provided contextual understanding through stakeholder perspectives, the qualitative sample was limited to service providers and programme implementers. Including broader community voices—such as teachers, caregivers, or local health administrators—may offer additional insight into social and institutional factors influencing service adoption. Fifth, the study focused primarily on service accessibility, utilization, and operational feasibility, and did not include a formal cost-effectiveness analysis. Economic evaluations comparing decentralized, tele-optometry-supported models with traditional outreach programmes would be valuable for informing health policy decisions. Finally, the integration of tele-optometry was assessed as a service-support mechanism rather than as a fully independent intervention. Future research could explore technology-enabled refractive services in greater depth, including digital diagnostic validation, infrastructure requirements, and user acceptance across different demographic groups. Addressing these areas in future studies will help refine implementation strategies and strengthen the evidence base for integrating sustainable refractive eye care into primary health systems in underserved regions. Conclusions A sustainable, community-based refractive eye care model integrating affordability, accessibility, professional optometric services, awareness generation, and insurance linkage can significantly strengthen primary eye care delivery in underserved rural regions. Declarations Ethics approval and consent to participate This study was conducted in accordance with the ethical principles of the Declaration of Helsinki . Ethical approval was obtained prior to study initiation from Institutional Review Board (IRB) of Debapriya Mukhopadhyay Vision Research Institute and Foundation , Kolkata, India ( Letter Number:. EC/SCMRECS/01122022 ). All participants provided written informed consent before participation. Confidentiality and anonymity were maintained throughout data handling and reporting. Consent for publication Not Applicable Availability of data and materials The datasets prepared and analysed during the current study are available from the corresponding author on reasonable request. Competing interests The author declares no competing interests. Funding No external funding was received for this study. Authors’ contributions Debapriya Mukhopadhyay conceptualized the study, conducted data collection and analysis, and drafted the manuscript. Acknowledgements The author gratefully acknowledges the participation of the community members, optometrists, and field staff whose cooperation and assistance made this study possible. The author extends sincere gratitude to Dr. Robert Gharios, Executive Dean, Swiss School of Management, Barcelona, and Dr. Leon Richards, Retired Chancellor, Kapi‘olani Community College, University of Hawai‘i, for their guidance and encouragement. The author also acknowledges the support of family members Dr. Harinath Mukherjee, Mrs. Mousumi Mukherjee, Dr. Shreyasi Mukherjee, and Mrs. Swati Mukhopadhyay for their understanding, support, and patience throughout the course of this research. References Dandona R, Dandona L. Refractive error blindness. Bull World Health Organ . 2001;79(3):237–243. De Souza N, Gilmour S, Barman D, Kumar R. The role of optometrists in India: an integral part of eye health care. Indian J Ophthalmol . 2012;60(5):401–405. Rao GN. Human resource development in ophthalmology in developing countries. Indian J Ophthalmol . 2000;48(3):173–182. Gilbert C. Primary eye care: where do we go from here? Community Eye Health J . 1998;11(25):19–20. World Health Organization. World report on vision . Geneva: WHO; 2019. World Health Organization. Vision impairment and blindness. https://www.who.int/news-room/fact-sheets/detail/blindness-and-visual-impairment. Accessed 12 Jan 2025. 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Supplementary Files SupplementaryFile1.docx SundarbansProjectdata.xlsx QualitativeQuestionnaire.pdf Cite Share Download PDF Status: Under Review Version 1 posted Reviews received at journal 11 May, 2026 Reviewers agreed at journal 03 May, 2026 Reviewers agreed at journal 29 Apr, 2026 Reviewers agreed at journal 29 Apr, 2026 Reviewers invited by journal 29 Apr, 2026 Editor invited by journal 05 Apr, 2026 Editor assigned by journal 03 Mar, 2026 Submission checks completed at journal 02 Mar, 2026 First submitted to journal 02 Mar, 2026 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-8960531","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":635524633,"identity":"8e766543-5163-44bc-9c6d-a072c7a4b204","order_by":0,"name":"Debapriya Mukhopadhyay","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA8UlEQVRIiWNgGAWjYDCCAzwgUgKImQ+ASB72BuK1sCWAtfAcIE4LCPAYSIApQlr4jvce/Fy4xyKxf9qZj7dutt2T4WFgPvbxCx4tkmfOJUvPeCaROON27mbr3LZiHh4GtuTZMni0GNzIMZDmOSCR2HA7d5t0zpkEHnsGHmNmCXxa7r8x/g3SMv92zjOwFh6CWm7wmIFt2XA7h006pwKihfEDXr/kpVnPOCBhvPF2mrE1WAszWzIzHh3AEDt7+HbBgTrZebeTH97OMUiw52FvPsz4A58eIACZ6diAzGXmwakYocUeRYSgLaNgFIyCUTCiAADKrUxC1ToIGgAAAABJRU5ErkJggg==","orcid":"https://orcid.org/0000-0002-5794-1560","institution":"Debapriya Mukhopadhyay Vision Research Institute and Foundation, West Bengal, India; Swiss School of Management, Barcelona, Spain","correspondingAuthor":true,"prefix":"","firstName":"Debapriya","middleName":"","lastName":"Mukhopadhyay","suffix":""}],"badges":[],"createdAt":"2026-02-24 19:10:20","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-8960531/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-8960531/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":108806728,"identity":"f4cfd3e4-d443-4bb2-a714-ebb12beddb12","added_by":"auto","created_at":"2026-05-08 15:29:20","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":248072,"visible":true,"origin":"","legend":"\u003cp\u003eCommunity based refractive eye care model incorporating Tele-Optometry\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eA schematic representation illustrating the integration of accessibility, affordability, service quality, optometrist-led delivery, awareness generation, and insurance linkage within a sustainable primary eye care framework.(Figure.1)\u003c/em\u003e\u003c/p\u003e","description":"","filename":"Figure1RefractiveModel..png","url":"https://assets-eu.researchsquare.com/files/rs-8960531/v1/c8d44168a0ec84770b4e531d.png"},{"id":108807660,"identity":"6d51caad-f5aa-42c3-a8a0-1f14821e219b","added_by":"auto","created_at":"2026-05-08 15:31:04","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":234518,"visible":true,"origin":"","legend":"\u003cp\u003eThe Integrated Service delivery pathway for sustainable rural eye care\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eA conceptual pathway demonstrating how affordability and product quality influence compliance and sustainability outcomes\u003c/em\u003e\u003c/p\u003e","description":"","filename":"Figure2ServicePathway..png","url":"https://assets-eu.researchsquare.com/files/rs-8960531/v1/6a42b81d6d15066e8713f209.png"},{"id":109276435,"identity":"e7653fd7-8c0f-442c-ab4f-0a95ad7d869b","added_by":"auto","created_at":"2026-05-14 15:10:36","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":663197,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8960531/v1/faecc5bd-ede9-4fbf-9d19-ceead1f38c5e.pdf"},{"id":108807189,"identity":"9432456b-c749-4b09-809e-92e8597ca596","added_by":"auto","created_at":"2026-05-08 15:30:18","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":20222,"visible":true,"origin":"","legend":"","description":"","filename":"SupplementaryFile1.docx","url":"https://assets-eu.researchsquare.com/files/rs-8960531/v1/cdc039bc828e55f058521003.docx"},{"id":108743334,"identity":"990ecc21-76a2-4f63-af17-b676cfc91f9b","added_by":"auto","created_at":"2026-05-08 01:12:45","extension":"xlsx","order_by":2,"title":"","display":"","copyAsset":false,"role":"supplement","size":273044,"visible":true,"origin":"","legend":"","description":"","filename":"SundarbansProjectdata.xlsx","url":"https://assets-eu.researchsquare.com/files/rs-8960531/v1/20b42afe032063d6c15d3921.xlsx"},{"id":108807274,"identity":"8ba2e65a-03ea-4400-a741-50fb1adabf7b","added_by":"auto","created_at":"2026-05-08 15:30:20","extension":"pdf","order_by":3,"title":"","display":"","copyAsset":false,"role":"supplement","size":198079,"visible":true,"origin":"","legend":"","description":"","filename":"QualitativeQuestionnaire.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8960531/v1/d266bfc768a4d3e175a802c4.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"A Sustainable Community-Based Model for Refractive Eye Care Services in the Sundarbans, India: A Mixed-Methods Study","fulltext":[{"header":"Introduction","content":"\u003cp\u003eUncorrected refractive error remains one of the most prevalent and avoidable causes of visual impairment worldwide, and it can be effectively addressed through timely detection and appropriate optical correction [1,2,5,15,16,18]. Despite the availability of simple and low-cost interventions, access to refractive services remains uneven, particularly in rural and resource-constrained settings where health infrastructure and trained personnel are limited [3,4,17,19]. Visual impairment resulting from uncorrected refractive error adversely affects educational attainment, employment opportunities, productivity, and social participation, thereby contributing to broader developmental and socioeconomic disparities [5,22].\u003c/p\u003e \u003cp\u003eThe burden of refractive error is disproportionately concentrated in low-resource populations, where geographic isolation, limited awareness, and fragmented service delivery models restrict access to primary eye care [17,19,21,24]. Rural service-delivery gaps are further exacerbated by shortages of trained eye-care professionals and reliance on episodic outreach-based programmes that often fail to ensure follow-up and continuity of care [2,3,21]. Evidence from community-based and school-linked eye-health initiatives in developing regions suggests that locally embedded services can significantly improve service uptake, compliance, and sustainability when integrated into primary healthcare systems [26,27,28].\u003c/p\u003e \u003cp\u003eIndia bears a substantial share of the global burden of uncorrected refractive error, with rural populations particularly affected due to geographic barriers, workforce shortages, and weak integration of vision care into general health services [6,7,8]. The Sundarbans region of West Bengal exemplifies these challenges. Its dispersed island geography, dependence on riverine transport, and socioeconomic vulnerability constrain access to routine healthcare, including essential refractive services [9,25].\u003c/p\u003e \u003cp\u003eRecognizing these gaps, global eye-health strategies increasingly emphasize the integration of refractive services into primary healthcare as part of universal health coverage and sustainable development agendas [13,29,30]. However, there remains limited empirical evidence on how such integrated, community-based models can be operationalized and sustained in geographically complex environments such as the Sundarbans. This study seeks to address this gap by evaluating a decentralized refractive eye-care delivery model designed to improve accessibility, continuity, and long-term service utilization in an underserved rural setting.\u003c/p\u003e \u003cp\u003e Existing eye-care delivery in the region is largely episodic, camp-based, and poorly integrated with primary health systems, leading to low coverage, poor follow-up, and limited sustainability [10,11]. This study addresses this gap by developing and empirically evaluating a sustainable, community-based refractive eye care service model tailored to the Sundarbans context.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eStudy Design\u003c/h2\u003e \u003cp\u003eThis study employed a \u003cb\u003econvergent mixed-methods design\u003c/b\u003e, in which quantitative community-level survey data and qualitative stakeholder interviews were collected during the same study period and integrated at the analysis stage. This approach enabled simultaneous examination of service utilization patterns and contextual factors influencing sustainability of refractive eye care delivery.\u003c/p\u003e \u003cp\u003eThe study is reported in accordance with the \u003cb\u003eSTROBE guidelines for observational research\u003c/b\u003e and the \u003cb\u003eCOREQ principles for qualitative research reporting\u003c/b\u003e.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eStudy Setting\u003c/h3\u003e\n\u003cp\u003eThe study was conducted in the \u003cb\u003eSundarbans region of West Bengal, India\u003c/b\u003e, a geographically dispersed deltaic area characterized by riverine transport systems, limited infrastructure, and restricted access to routine healthcare services. Communities are distributed across multiple islands, where travel to secondary or tertiary care facilities often requires prolonged transit, creating structural barriers to continuous eye care.\u003c/p\u003e\n\u003ch3\u003eSampling Strategy\u003c/h3\u003e\n\u003cp\u003eA \u003cb\u003emultistage cluster sampling approach\u003c/b\u003e was used to ensure representation across geographically diverse and accessibility-stratified communities.\u003c/p\u003e \u003cp\u003e \u003col\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eBlocks within the Sundarbans were first categorized by accessibility level (easily accessible, moderately accessible, remote).\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eVillages were selected purposively within each stratum to capture service delivery variation.\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eWithin selected villages, \u003cb\u003esystematic household sampling\u003c/b\u003e was conducted.\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eOne eligible adult respondent (\u0026ge;\u0026thinsp;18 years) per household was recruited.\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003c/ol\u003e \u003c/p\u003e \u003cp\u003eThis strategy minimized selection bias and ensured inclusion of populations with differing access constraints.\u003c/p\u003e \u003cp\u003eSample size was estimated using a single-proportion calculation assuming:\u003c/p\u003e \u003cp\u003e \u003cul\u003e \u003cli\u003e \u003cp\u003eExpected service utilization proportion\u0026thinsp;=\u0026thinsp;50% (maximal variability)\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eConfidence level\u0026thinsp;=\u0026thinsp;95%\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eMargin of error\u0026thinsp;=\u0026thinsp;3%\u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e \u003c/p\u003e \u003cp\u003eThe calculated minimum sample requirement was 1,067 participants.\u003c/p\u003e \u003cp\u003eA total of \u003cb\u003e999 respondents\u003c/b\u003e were enrolled, providing sufficient statistical precision (\u0026gt;\u0026thinsp;80% analytical power) for primary comparisons and subgroup analyses in this field-based setting.\u003c/p\u003e\n\u003ch3\u003eParticipant Eligibility Criteria\u003c/h3\u003e\n\u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003eInclusion criteria:\u003c/h2\u003e \u003cp\u003e \u003cul\u003e \u003cli\u003e \u003cp\u003eResident of selected Sundarbans communities\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eAged 18 years or older\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eWilling to provide informed consent\u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eExclusion criteria:\u003c/h2\u003e \u003cp\u003e \u003cul\u003e \u003cli\u003e \u003cp\u003eTemporary visitors to the area\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eIndividuals unable to respond to survey questions due to illness or cognitive limitation\u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e \u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eData Collection Procedures\u003c/h3\u003e\n\u003cdiv id=\"Sec10\" class=\"Section2\"\u003e \u003ch2\u003eQuantitative Component\u003c/h2\u003e \u003cp\u003eData were collected through structured, interviewer-administered questionnaires conducted during community visits. The instrument captured:\u003c/p\u003e \u003cp\u003e \u003cul\u003e \u003cli\u003e \u003cp\u003eAccess to refractive eye care services\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003ePerceived affordability\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eSatisfaction with spectacles provided\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eSpectacle usage behaviour (compliance)\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003ePerceived functional and quality-of-life impact\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eAwareness of available eye care services\u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e \u003c/p\u003e \u003cp\u003eThe questionnaire was developed based on community eye health service indicators and pilot-tested in a similar rural population prior to implementation. Minor linguistic adjustments were made to ensure clarity.\u003c/p\u003e \u003cp\u003eData were collected using a structured questionnaire designed to assess accessibility, affordability, service utilization, satisfaction, and spectacle-use behaviour. The questionnaire was developed based on established community eye-health indicators and adapted to the local context through pilot testing. A copy of the survey instrument is provided as \u003cb\u003eSupplementary File 1\u003c/b\u003e.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eInstrument Reliability\u003c/h2\u003e \u003cp\u003eInternal consistency testing of multi-item domains demonstrated acceptable reliability (\u003cb\u003eCronbach\u0026rsquo;s α\u0026thinsp;=\u0026thinsp;0.78\u003c/b\u003e). Pilot testing confirmed face validity and operational feasibility.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003eOperational Definitions of Key Variables\u003c/h2\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"No\" id=\"Taba\" border=\"1\"\u003e \u003ccolgroup cols=\"2\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariable\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eOperational Definition\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAccessibility\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAbility to reach service within \u0026le;\u0026thinsp;45\u0026ndash;60 minutes travel\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAffordability\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSelf-reported ability to obtain services without financial hardship\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCompliance\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eUse of prescribed spectacles\u0026thinsp;\u0026ge;\u0026thinsp;5 days per week\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSatisfaction\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePositive rating of comfort, usability, and perceived benefit\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAwareness\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eKnowledge of available refractive services in the locality\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cdiv id=\"Sec13\" class=\"Section3\"\u003e \u003ch2\u003eQualitative Component\u003c/h2\u003e \u003cp\u003eSemi-structured interviews were conducted with:\u003c/p\u003e \u003cp\u003e \u003cul\u003e \u003cli\u003e \u003cp\u003ePracticing Experts (Optometrists/Ophthalmologists/Faculties and Researchers)\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eOutreach service coordinators\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eVision technicians\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eProgramme administrators\u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e \u003c/p\u003e \u003cp\u003eInterview guides explored:\u003c/p\u003e \u003cp\u003e \u003cul\u003e \u003cli\u003e \u003cp\u003eBarriers to service delivery\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eCommunity behavioural responses\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eSustainability challenges\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eWorkforce and logistical constraints\u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e \u003c/p\u003e \u003cp\u003eInterviews were audio-recorded, transcribed verbatim, and anonymized.\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec14\" class=\"Section2\"\u003e \u003ch2\u003eQualitative Data Analysis\u003c/h2\u003e \u003cp\u003eAn \u003cb\u003einductive thematic analysis\u003c/b\u003e approach was used.\u003c/p\u003e \u003cp\u003e \u003col\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eTranscripts were coded iteratively.\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eCodes were grouped into categories and themes.\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eThemes were reviewed for internal consistency and explanatory relevance.\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eInvestigator triangulation ensured interpretive credibility.\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eData saturation was considered achieved when no new concepts emerged.\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003c/ol\u003e \u003c/p\u003e \u003cp\u003eSemi-structured interviews were conducted using an interview guide exploring barriers to service delivery, patient acceptance, and sustainability of community-based refractive care. The interview guide is available as \u003cb\u003eSupplementary File 2\u003c/b\u003e.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec15\" class=\"Section2\"\u003e \u003ch2\u003eStatistical Analysis\u003c/h2\u003e \u003cp\u003eQuantitative data were analysed using descriptive and inferential statistical methods.\u003c/p\u003e \u003cp\u003e \u003cul\u003e \u003cli\u003e \u003cp\u003eFrequencies and proportions summarized categorical variables.\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eConfidence intervals (95%) were calculated for key indicators.\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eAssociations were tested using chi-square analysis.\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eLogistic regression was used to identify predictors of spectacle compliance.\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eOdds ratios (OR) with 95% confidence intervals were reported.\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eStatistical significance was set at \u003cb\u003ep\u0026thinsp;\u0026lt;\u0026thinsp;0.05\u003c/b\u003e.\u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec16\" class=\"Section2\"\u003e \u003ch2\u003eMixed-Methods Integration\u003c/h2\u003e \u003cp\u003eIntegration of quantitative and qualitative findings was performed using a \u003cb\u003ejoint explanatory approach\u003c/b\u003e, whereby statistical patterns were interpreted alongside stakeholder insights to understand underlying service delivery dynamics and behavioural responses.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003cem\u003eA schematic representation illustrating the integration of accessibility, affordability, service quality, optometrist-led delivery, awareness generation, and insurance linkage within a sustainable primary eye care framework.(Figure.1)\u003c/em\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec17\" class=\"Section2\"\u003e \u003ch2\u003eBias Mitigation\u003c/h2\u003e \u003cp\u003eSeveral strategies were employed to reduce bias:\u003c/p\u003e \u003cp\u003e \u003cul\u003e \u003cli\u003e \u003cp\u003eCluster-based sampling improved representativeness.\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eStandardized interviewer training minimized measurement variation.\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eStructured questioning reduced recall variability.\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eInclusion of both provider and community perspectives enhanced analytic triangulation.\u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec18\" class=\"Section2\"\u003e \u003ch2\u003eEthical Considerations\u003c/h2\u003e \u003cp\u003eThis study was conducted in accordance with the ethical principles of the \u003cb\u003eDeclaration of Helsinki\u003c/b\u003e. Ethical approval was obtained prior to study initiation from Institutional Review Board (IRB) of \u003cb\u003eDebapriya Mukhopadhyay Vision Research Institute and Foundation\u003c/b\u003e, Kolkata, India (\u003cspan type=\"ItalicUnderline\" class=\"ItalicUnderline\" name=\"Emphasis\"\u003eLetter Number:. EC/SCMRECS/01122022\u003c/span\u003e). All participants provided written informed consent before participation. Confidentiality and anonymity were maintained throughout data handling and reporting.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec20\" class=\"Section2\"\u003e \u003ch2\u003eStudy Population Characteristics\u003c/h2\u003e \u003cp\u003eA total of \u003cb\u003e999 participants\u003c/b\u003e completed the quantitative survey (response completeness: 100% for core variables). Participants were drawn from multiple island blocks of the Sundarbans, representing a predominantly rural population with limited proximity to fixed health facilities. Qualitative interviews were conducted with \u003cb\u003e12 key informants\u003c/b\u003e (optometrists, programme implementers, and outreach coordinators), achieving thematic saturation.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec21\" class=\"Section2\"\u003e \u003ch2\u003eQuantitative Findings\u003c/h2\u003e \u003cdiv id=\"Sec22\" class=\"Section3\"\u003e \u003ch2\u003eAccessibility of Refractive Eye Care Services\u003c/h2\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eAccessibility of refractive eye care services\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAccessibility level\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFrequency\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePercentage\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAccessible\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e132\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e13.2%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePartially accessible\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e541\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e54.1%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNot accessible\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e326\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e32.7%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eTable\u0026nbsp;1 describes only \u003cb\u003e13.2% (n\u0026thinsp;=\u0026thinsp;132/999; 95% CI: 11.2\u0026ndash;15.5)\u003c/b\u003e of respondents reported that refractive services were accessible within a reasonable distance.\u003c/p\u003e \u003cp\u003eIn contrast:\u003c/p\u003e \u003cp\u003e \u003cul\u003e \u003cli\u003e \u003cp\u003e \u003cb\u003e54.1% (n\u0026thinsp;=\u0026thinsp;541/999; 95% CI: 50.9\u0026ndash;57.2)\u003c/b\u003e reported services as \u003cem\u003epartially accessible\u003c/em\u003e\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003e \u003cb\u003e32.7% (n\u0026thinsp;=\u0026thinsp;326/999; 95% CI: 29.8\u0026ndash;35.7)\u003c/b\u003e reported services as \u003cem\u003enot accessible\u003c/em\u003e\u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e \u003c/p\u003e \u003cp\u003eA one-sample proportion test confirmed that the proportion reporting adequate accessibility was significantly lower than 50% (z\u0026thinsp;=\u0026thinsp;\u0026minus;\u0026thinsp;24.6, \u003cb\u003ep\u0026thinsp;\u0026lt;\u0026thinsp;0.001\u003c/b\u003e), indicating a substantial access deficit.\u003c/p\u003e \u003cp\u003eTravel time exceeding 60 minutes was reported by 61% of respondents, reinforcing geographic barriers.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec23\" class=\"Section3\"\u003e \u003ch2\u003ePerceived Affordability of Refractive Services\u003c/h2\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003ePerceived affordability of refractive services (n\u0026thinsp;=\u0026thinsp;999)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAffordability perception\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFrequency\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePercentage\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAffordable\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e761\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e76.2%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNot affordable\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e238\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e23.8%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eTable\u0026nbsp;2 describes, a majority of participants perceived services as affordable:\u003c/p\u003e \u003cp\u003e \u003cul\u003e \u003cli\u003e \u003cp\u003e \u003cb\u003e76.2% (n\u0026thinsp;=\u0026thinsp;761/999; 95% CI: 73.5\u0026ndash;78.8)\u003c/b\u003e reported affordability\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003e \u003cb\u003e23.8% (n\u0026thinsp;=\u0026thinsp;238/999; 95% CI: 21.2\u0026ndash;26.5)\u003c/b\u003e reported cost-related difficulty\u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e \u003c/p\u003e \u003cp\u003eThe observed affordability proportion was significantly higher than the null expectation of equal distribution (χ\u0026sup2; = 274.5, \u003cb\u003ep\u0026thinsp;\u0026lt;\u0026thinsp;0.001\u003c/b\u003e).\u003c/p\u003e \u003cp\u003eDespite this, affordability showed weak association with utilization when analysed alongside accessibility constraints, suggesting cost alone does not predict service uptake.\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec24\" class=\"Section2\"\u003e \u003ch2\u003eSatisfaction with Corrective Products\u003c/h2\u003e \u003cp\u003eOnly \u003cb\u003e36.3% (n\u0026thinsp;=\u0026thinsp;363/999; 95% CI: 33.3\u0026ndash;39.3)\u003c/b\u003e reported satisfaction with provided spectacles.\u003c/p\u003e \u003cp\u003eThe dissatisfaction rate (\u003cb\u003e63.7%\u003c/b\u003e) was significantly greater than satisfaction (χ\u0026sup2; = 88.7, \u003cb\u003ep\u0026thinsp;\u0026lt;\u0026thinsp;0.001\u003c/b\u003e).\u003c/p\u003e \u003cp\u003eReported concerns included:\u003c/p\u003e \u003cp\u003e \u003cul\u003e \u003cli\u003e \u003cp\u003ePoor durability (42%)\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eImproper fit (31%)\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eAesthetic concerns (18%)\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eLack of follow-up adjustment (9%)\u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e \u003c/p\u003e \u003cdiv id=\"Sec25\" class=\"Section3\"\u003e \u003ch2\u003eCompliance with Spectacle Use\u003c/h2\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eCompliance with spectacle use\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCompliance category\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFrequency\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePercentage\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRegular use\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e128\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e12.8%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIrregular / non-use\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e871\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e87.2%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eTable\u0026nbsp;3 describes that\u003c/p\u003e \u003cp\u003eRegular spectacle use was reported by:\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec26\" class=\"Section3\"\u003e \u003ch2\u003e\u0026bull; 12.8% (n\u0026thinsp;=\u0026thinsp;128/999; 95% CI: 10.8\u0026ndash;15.1)\u003c/h2\u003e \u003cp\u003eWhereas:\u003c/p\u003e \u003cp\u003e \u003cul\u003e \u003cli\u003e \u003cp\u003e \u003cb\u003e87.2% (n\u0026thinsp;=\u0026thinsp;871/999; 95% CI: 84.9\u0026ndash;89.2)\u003c/b\u003e reported irregular or discontinued use.\u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e \u003c/p\u003e \u003cp\u003eThe compliance rate was significantly lower than expected for effective refractive correction coverage (z\u0026thinsp;=\u0026thinsp;\u0026minus;\u0026thinsp;39.1, \u003cb\u003ep\u0026thinsp;\u0026lt;\u0026thinsp;0.001\u003c/b\u003e).\u003c/p\u003e \u003cp\u003eLogistic comparison demonstrated that satisfaction with product quality significantly predicted compliance (Odds Ratio\u0026thinsp;=\u0026thinsp;3.42; 95% CI: 2.31\u0026ndash;5.08; \u003cb\u003ep\u0026thinsp;\u0026lt;\u0026thinsp;0.001\u003c/b\u003e).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec27\" class=\"Section3\"\u003e \u003ch2\u003ePerceived Impact on Quality of Life\u003c/h2\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003ePerceived quality-of-life improvement after correction\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eResponse\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFrequency\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePercentage\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eImproved\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e572\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e57.2%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo improvement\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e427\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e42.8%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eTable\u0026nbsp;4 describes that despite low compliance, \u003cb\u003e57.2% (n\u0026thinsp;=\u0026thinsp;572/999; 95% CI: 54.1\u0026ndash;60.3)\u003c/b\u003e reported subjective improvement in daily functioning after refractive correction.\u003c/p\u003e \u003cp\u003eImprovements were reported in:\u003c/p\u003e \u003cp\u003e \u003cul\u003e \u003cli\u003e \u003cp\u003eNear vision tasks (68%)\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eOccupational productivity (52%)\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eMobility confidence (41%)\u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e \u003c/p\u003e \u003cp\u003eThe association between spectacle use and perceived functional improvement was statistically significant (χ\u0026sup2; = 61.3, \u003cb\u003ep\u0026thinsp;\u0026lt;\u0026thinsp;0.001\u003c/b\u003e).\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec28\" class=\"Section2\"\u003e \u003ch2\u003eIntegrated Service Model\u003c/h2\u003e \u003cp\u003eThe service-delivery pathway emphasizes continuity of care rather than episodic outreach.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003cem\u003eA conceptual pathway demonstrating how affordability and product quality influence compliance and sustainability outcomes.\u003c/em\u003e \u003c/p\u003e \u003cp\u003eThe integrated service-delivery pathway illustrates how accessibility, tele-optometry support, product acceptability, and follow-up mechanisms interact to influence compliance and sustainability outcomes (Fig.\u0026nbsp;2).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec29\" class=\"Section2\"\u003e \u003ch2\u003eHypothesis Testing\u003c/h2\u003e \u003cp\u003eAll predefined alternative hypotheses were supported:\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"No\" id=\"Tabb\" border=\"1\"\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHypothesis\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eStatistical Test\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eResult\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eImpact of refractive services on quality of life\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eχ\u0026sup2; = 61.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003ep\u0026thinsp;\u0026lt;\u0026thinsp;0.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCompliance dependent on product quality\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eOR\u0026thinsp;=\u0026thinsp;3.42\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003ep\u0026thinsp;\u0026lt;\u0026thinsp;0.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAwareness influences service uptake\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eχ\u0026sup2; = 48.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003ep\u0026thinsp;\u0026lt;\u0026thinsp;0.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOptometrist-led access improves continuity\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eχ\u0026sup2; = 52.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003ep\u0026thinsp;\u0026lt;\u0026thinsp;0.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eThese findings indicate strong associations between service structure variables and utilization outcomes.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eQualitative Findings\u003c/h3\u003e\n\u003cp\u003eFour major themes emerged from stakeholder interviews.\u003c/p\u003e \u003cdiv id=\"Sec31\" class=\"Section2\"\u003e \u003ch2\u003eTheme 1: Structural Geography Limits Continuous Access\u003c/h2\u003e \u003cp\u003eParticipants emphasized that tidal transport systems, dispersed settlements, and travel costs prevent routine engagement with distant facilities.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec32\" class=\"Section2\"\u003e \u003ch2\u003eTheme 2: Outreach-Only Models Produce Episodic Rather Than Continuous Care\u003c/h2\u003e \u003cp\u003eScreening camps were described as effective for detection but insufficient for follow-up, dispensing refinement, and behavioural reinforcement.\u003c/p\u003e \u003cdiv id=\"Sec33\" class=\"Section3\"\u003e \u003ch2\u003eTheme 3: Product Acceptability Drives Use More Than Cost\u003c/h2\u003e \u003cp\u003eProviders consistently reported that patients abandon spectacles when quality or comfort is inadequate\u0026mdash;even when free.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec34\" class=\"Section3\"\u003e \u003ch2\u003eTheme 4: Locally Embedded Optometrists Enable Trust and Continuity\u003c/h2\u003e \u003cp\u003ePermanent community presence was identified as essential for sustained uptake and service credibility.\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e\n\u003ch3\u003eIntegrated Mixed-Methods Analysis\u003c/h3\u003e\n\u003cp\u003eIntegration of quantitative and qualitative findings demonstrates that refractive care utilization is constrained by \u003cb\u003einteracting structural, behavioural, and service-delivery factors\u003c/b\u003e.\u003c/p\u003e \u003cp\u003eAffordability interventions addressed financial barriers but did not overcome geographic inaccessibility, inconsistent service availability, or product dissatisfaction. Qualitative insights explain the observed statistical paradox of high affordability yet low compliance.\u003c/p\u003e \u003cp\u003eThe combined evidence supports a model emphasizing decentralized delivery, trained mid-level workforce integration, and continuous engagement mechanisms.\u003c/p\u003e\n\u003ch3\u003eKey Quantitative Indicators Summary\u003c/h3\u003e\n\u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"No\" id=\"Tabc\" border=\"1\"\u003e \u003ccolgroup cols=\"2\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIndicator\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eValue\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAdequate accessibility\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003e13.2%\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePerceived affordability\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003e76.2%\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eProduct satisfaction\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003e36.3%\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRegular spectacle use\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003e12.8%\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eQuality-of-life improvement\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003e57.2%\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAll hypotheses\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eStatistically significant (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis study evaluated the feasibility of a sustainable, community-based refractive eye care model in the geographically isolated and socioeconomically vulnerable Sundarbans region. The findings indicate that improving affordability alone does not ensure effective utilization of refractive services; accessibility, perceived quality of care, and continuity of services are equally important determinants of uptake and sustainability. Uncorrected refractive error remains one of the most common yet avoidable causes of visual impairment globally, disproportionately affecting underserved populations where access to primary eye care is limited [1,5].\u003c/p\u003e \u003cp\u003eAlthough most respondents perceived refractive services as affordable, only a small proportion reported adequate accessibility. This mismatch reflects structural barriers commonly observed in rural health systems, where transportation challenges, workforce shortages, and fragmented service delivery prevent available services from translating into actual utilization [7,8]. Similar patterns have been reported in community-based eye care studies demonstrating that decentralization of services and integration into primary care settings are essential to improving coverage in low-resource environments [9,11].\u003c/p\u003e \u003cp\u003eSpectacle compliance emerged as a major challenge, with only a minority of participants reporting consistent use despite receiving prescriptions. Evidence suggests that adherence to spectacle wear is strongly influenced by perceived product quality, comfort, cultural acceptability, and trust in providers rather than cost alone [20,23]. Studies on refractive service delivery have emphasized that dispensing, counselling, and follow-up must be integrated into care pathways to ensure sustained behavioural change and visual rehabilitation outcomes [12,14].\u003c/p\u003e \u003cp\u003eThe findings further highlight the importance of optometrist-led primary eye care models. In settings where ophthalmologist-led services are not scalable, optometrists can effectively deliver refraction, dispensing, and community engagement at the primary level, thereby addressing workforce shortages and improving continuity of care [2,3]. Strengthening mid-level eye health personnel has been widely recommended as a strategy to expand access and reduce avoidable blindness in developing regions [3,11].\u003c/p\u003e \u003cp\u003eAwareness generation and financial-linkage mechanisms were also found to influence service sustainability. Community engagement increases perceived need and demand for services, while financial protection mechanisms such as insurance or subsidized models support continuity of care. Health system research increasingly recognizes that combining service delivery innovations with financing strategies is necessary to achieve equitable access and long-term programme viability [5,12,22].\u003c/p\u003e \u003cp\u003eFrom a policy perspective, the proposed model aligns with universal health coverage priorities by embedding refractive services within decentralized primary health systems rather than relying on episodic outreach models. Integrating refractive care into routine community-based services has the potential to reduce avoidable visual impairment while simultaneously strengthening local health infrastructure and workforce utilization [5,22].\u003c/p\u003e \u003cdiv id=\"Sec38\" class=\"Section2\"\u003e \u003ch2\u003eStrengths\u003c/h2\u003e \u003cp\u003eA key strength of this study is the mixed-methods approach, which enabled triangulation of quantitative community-level findings with qualitative insights from providers and stakeholders, offering a comprehensive understanding of both demand- and supply-side determinants of refractive service utilization. The large sample size from a geographically unique region contributes valuable evidence to an underrepresented area in health services research.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec39\" class=\"Section2\"\u003e \u003ch2\u003eImplications for Health Services Research\u003c/h2\u003e \u003cp\u003eThese findings underscore the need for health services research to move beyond cost-reduction approaches and toward integrated delivery models that address accessibility, workforce distribution, service quality, and financing simultaneously. Evaluating scalable optometrist-led primary eye care systems and community-embedded delivery pathways will be essential for reducing avoidable vision impairment in underserved populations.\u003c/p\u003e \u003cdiv id=\"Sec40\" class=\"Section3\"\u003e \u003ch2\u003eLimitations and Directions for Future Research\u003c/h2\u003e \u003cp\u003eThis study has several limitations that should be considered when interpreting the findings and that also present opportunities for further investigation.\u003c/p\u003e \u003cp\u003eFirst, the study was conducted within a specific geographic context\u0026mdash;the Sundarbans region of India\u0026mdash;characterized by unique environmental, infrastructural, and socioeconomic conditions. While this setting provides valuable insights into service delivery in geographically isolated populations, the findings may not be directly generalizable to other rural or urban environments without contextual adaptation. Future research should evaluate the applicability of this model in diverse settings to assess scalability and contextual variability.\u003c/p\u003e \u003cp\u003eSecond, the cross-sectional design limits the ability to assess long-term outcomes such as sustained spectacle compliance, visual improvement over time, and economic or social impact. Longitudinal studies are needed to examine whether community-based refractive care models lead to durable behavioral change and continued service utilization.\u003c/p\u003e \u003cp\u003eThird, several variables, including spectacle use, satisfaction, and perceived quality-of-life improvements, were based on self-reported responses, which may be subject to recall or response bias. Future studies may incorporate objective compliance monitoring, clinical follow-up assessments, or digital adherence tracking to strengthen outcome measurement.\u003c/p\u003e \u003cp\u003e Fourth, while the mixed-methods approach provided contextual understanding through stakeholder perspectives, the qualitative sample was limited to service providers and programme implementers. Including broader community voices\u0026mdash;such as teachers, caregivers, or local health administrators\u0026mdash;may offer additional insight into social and institutional factors influencing service adoption.\u003c/p\u003e \u003cp\u003eFifth, the study focused primarily on service accessibility, utilization, and operational feasibility, and did not include a formal cost-effectiveness analysis. Economic evaluations comparing decentralized, tele-optometry-supported models with traditional outreach programmes would be valuable for informing health policy decisions.\u003c/p\u003e \u003cp\u003eFinally, the integration of tele-optometry was assessed as a service-support mechanism rather than as a fully independent intervention. Future research could explore technology-enabled refractive services in greater depth, including digital diagnostic validation, infrastructure requirements, and user acceptance across different demographic groups.\u003c/p\u003e \u003cp\u003eAddressing these areas in future studies will help refine implementation strategies and strengthen the evidence base for integrating sustainable refractive eye care into primary health systems in underserved regions.\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"Conclusions","content":"\u003cp\u003eA sustainable, community-based refractive eye care model integrating affordability, accessibility, professional optometric services, awareness generation, and insurance linkage can significantly strengthen primary eye care delivery in underserved rural regions.\u003c/p\u003e"},{"header":"Declarations","content":"\u003ch3\u003eEthics approval and consent to participate\u003c/h3\u003e\n\u003cp\u003eThis study was conducted in accordance with the ethical principles of the \u003cstrong\u003eDeclaration of Helsinki\u003c/strong\u003e. Ethical approval was obtained prior to study initiation from Institutional Review Board (IRB) of \u0026nbsp;\u003cstrong\u003eDebapriya Mukhopadhyay Vision Research Institute and Foundation\u003c/strong\u003e, Kolkata, India (\u003cem\u003e\u003cu\u003eLetter Number:. EC/SCMRECS/01122022\u003c/u\u003e\u003c/em\u003e). All participants provided written informed consent before participation. Confidentiality and anonymity were maintained throughout data handling and reporting.\u003c/p\u003e\n\u003ch3\u003eConsent for publication\u003c/h3\u003e\n\u003cp\u003eNot Applicable\u003c/p\u003e\n\u003ch3\u003eAvailability of data and materials\u003c/h3\u003e\n\u003cp\u003eThe datasets prepared and analysed during the current study are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003ch3\u003eCompeting interests\u003c/h3\u003e\n\u003cp\u003eThe author declares no competing interests.\u003c/p\u003e\n\u003ch3\u003eFunding\u003c/h3\u003e\n\u003cp\u003eNo external funding was received for this study.\u003c/p\u003e\n\u003ch3\u003eAuthors\u0026rsquo; contributions\u003c/h3\u003e\n\u003cp\u003eDebapriya Mukhopadhyay conceptualized the study, conducted data collection and analysis, and drafted the manuscript.\u003c/p\u003e\n\u003ch3\u003eAcknowledgements\u003c/h3\u003e\n\u003cp\u003eThe author gratefully acknowledges the participation of the community members, optometrists, and field staff whose cooperation and assistance made this study possible. The author extends sincere gratitude to Dr. Robert Gharios, Executive Dean, Swiss School of Management, Barcelona, and Dr. Leon Richards, Retired Chancellor, Kapi\u0026lsquo;olani Community College, University of Hawai\u0026lsquo;i, for their guidance and encouragement.\u003c/p\u003e\n\u003cp\u003eThe author also acknowledges the support of family members Dr. Harinath Mukherjee, Mrs. Mousumi Mukherjee, Dr. Shreyasi Mukherjee, and Mrs. Swati Mukhopadhyay for their understanding, support, and patience throughout the course of this research.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eDandona R, Dandona L. Refractive error blindness. \u003cem\u003eBull World Health Organ\u003c/em\u003e. 2001;79(3):237\u0026ndash;243.\u003c/li\u003e\n\u003cli\u003eDe Souza N, Gilmour S, Barman D, Kumar R. The role of optometrists in India: an integral part of eye health care. \u003cem\u003eIndian J Ophthalmol\u003c/em\u003e. 2012;60(5):401\u0026ndash;405.\u003c/li\u003e\n\u003cli\u003eRao GN. Human resource development in ophthalmology in developing countries. \u003cem\u003eIndian J Ophthalmol\u003c/em\u003e. 2000;48(3):173\u0026ndash;182.\u003c/li\u003e\n\u003cli\u003eGilbert C. Primary eye care: where do we go from here? \u003cem\u003eCommunity Eye Health J\u003c/em\u003e. 1998;11(25):19\u0026ndash;20.\u003c/li\u003e\n\u003cli\u003eWorld Health Organization. \u003cem\u003eWorld report on vision\u003c/em\u003e. Geneva: WHO; 2019.\u003c/li\u003e\n\u003cli\u003eWorld Health Organization. Vision impairment and blindness. https://www.who.int/news-room/fact-sheets/detail/blindness-and-visual-impairment. Accessed 12 Jan 2025.\u003c/li\u003e\n\u003cli\u003eNirmalan PK, Katz J, Robin AL, Krishnadas R, Ramakrishnan R, Thulasiraj RD. Utilisation of eye care services in rural south India: the Aravind comprehensive eye survey. \u003cem\u003eBr J Ophthalmol\u003c/em\u003e. 2004;88(10):1237\u0026ndash;1241.\u003c/li\u003e\n\u003cli\u003eOlusanya BA, Ashaye AO, Baiyeroju AM. Determinants of utilization of eye care services in rural Nigeria. \u003cem\u003eAfr J Med Med Sci\u003c/em\u003e. 2016;45(3):237\u0026ndash;245.\u003c/li\u003e\n\u003cli\u003eNaidoo KS, Ravilla TD. Delivering refractive error services: primary eye care centres and outreach programmes. \u003cem\u003eCommunity Eye Health J\u003c/em\u003e. 2007;20(63):42\u0026ndash;44.\u003c/li\u003e\n\u003cli\u003eHuynh SC, Kifley A, Rose KA, Morgan IG, Mitchell P. Impact of refractive error on quality of life in a population-based study. \u003cem\u003eAm J Ophthalmol\u003c/em\u003e. 2017;183:190\u0026ndash;198.\u003c/li\u003e\n\u003cli\u003eBhoosnurmath SR. Hospital-based community eye care programme: sustainability and impact. \u003cem\u003eIndian J Ophthalmol\u003c/em\u003e. 2017;65(5):396\u0026ndash;401.\u003c/li\u003e\n\u003cli\u003eBurton MJ, Ramke J, Marques AP, Bourne RRA, Congdon N, Jones I, et al. The Lancet Global Health Commission on Global Eye Health: vision beyond 2020. \u003cem\u003eLancet Glob Health\u003c/em\u003e. 2021;9(4):e489\u0026ndash;e551.\u003c/li\u003e\n\u003cli\u003eWebson A. Eye health and the Sustainable Development Goals. \u003cem\u003eLancet Glob Health\u003c/em\u003e. 2021;9(4):e423\u0026ndash;e424.\u003c/li\u003e\n\u003cli\u003eMaharani A, Dawes P, Nazroo J, Tampubolon G, Pendleton N. Cataract surgery and age-related cognitive decline: a longitudinal study. \u003cem\u003ePLoS One\u003c/em\u003e. 2018;13(2):e0192671.\u003c/li\u003e\n\u003cli\u003eLou L, Yao C, Jin Y, Perez V, Ye J. Global patterns in health burden of uncorrected refractive error. \u003cem\u003eInvest Ophthalmol Vis Sci\u003c/em\u003e. 2016;57(14):6271\u0026ndash;6277.\u003c/li\u003e\n\u003cli\u003eLou L, Wang J, Jin Y, Xu L, Ye J. Gender inequality in global burden of uncorrected refractive error. \u003cem\u003eAm J Ophthalmol\u003c/em\u003e. 2019;198:1\u0026ndash;7.\u003c/li\u003e\n\u003cli\u003eFang X, Tang Y, Wang J, et al. Socioeconomic disparity of visual impairment from cataract in China. \u003cem\u003eBMJ Open\u003c/em\u003e. 2021;11:e040523.\u003c/li\u003e\n\u003cli\u003eYang X, He M, Li Z, et al. Global disease burden of uncorrected refractive error among adolescents from 1990 to 2019. \u003cem\u003eBr J Ophthalmol\u003c/em\u003e. 2021;105(9):1196\u0026ndash;1201.\u003c/li\u003e\n\u003cli\u003eFricke TR, Holden BA, Wilson DA, et al. Global prevalence of presbyopia and vision impairment from uncorrected presbyopia. \u003cem\u003eOphthalmology\u003c/em\u003e. 2018;125(10):1492\u0026ndash;1499.\u003c/li\u003e\n\u003cli\u003eDhirar N, Dudeja S, Duggal M, Gupta PC. Compliance to spectacle use in children with refractive errors: a systematic review and meta-analysis. \u003cem\u003eOphthalmic Epidemiol\u003c/em\u003e. 2020;27(5):378\u0026ndash;386.\u003c/li\u003e\n\u003cli\u003eHolden BA, Fricke TR, Wilson DA, et al. Global prevalence of myopia and high myopia and temporal trends from 2000 through 2050. \u003cem\u003eOphthalmology\u003c/em\u003e. 2016;123(5):1036\u0026ndash;1042.\u003c/li\u003e\n\u003cli\u003eNaidoo KS, Fricke TR, Frick KD, et al. Potential lost productivity resulting from the global burden of myopia. \u003cem\u003eOphthalmology\u003c/em\u003e. 2019;126(3):338\u0026ndash;346.\u003c/li\u003e\n\u003cli\u003eShah SP, Dineen B, Jadoon MZ, et al. Refractive errors in the adult Pakistani population: the National Blindness and Visual Impairment Survey. \u003cem\u003eOphthalmic Epidemiol\u003c/em\u003e. 2008;15(3):183\u0026ndash;190.\u003c/li\u003e\n\u003cli\u003eAbdull MM, Sivasubramaniam S, Murthy GVS, et al. Causes of blindness and visual impairment in Nigeria. \u003cem\u003eBr J Ophthalmol\u003c/em\u003e. 2009;93(5):583\u0026ndash;588.\u003c/li\u003e\n\u003cli\u003eSil A. Community-based eye care in the Sundarbans: challenges and lessons learned. \u003cem\u003eCommunity Eye Health J\u003c/em\u003e. 2020;33(110):20\u0026ndash;22.\u003c/li\u003e\n\u003cli\u003eBhattacharya S, Kumar P, Patel R. Mission Roshni: comprehensive eye care for children in India. \u003cem\u003eIndian J Ophthalmol\u003c/em\u003e. 2017;65(5):411\u0026ndash;416.\u003c/li\u003e\n\u003cli\u003eYasmin S, Memon MS, Shaikh SP. Integrated school eye health programme in Pakistan. \u003cem\u003ePak J Med Sci\u003c/em\u003e. 2017;33(2):408\u0026ndash;413.\u003c/li\u003e\n\u003cli\u003ePhilip S, Sankaridurg P, Holden B. Refractive error and school eye health in South-East Asia. \u003cem\u003eBr J Ophthalmol\u003c/em\u003e. 2021;105(6):727\u0026ndash;733.\u003c/li\u003e\n\u003cli\u003eUnited Nations Development Programme. \u003cem\u003eHuman Development Report 2023/24\u003c/em\u003e. New York: UNDP; 2024.\u003c/li\u003e\n\u003cli\u003eWorld Commission on Environment and Development. \u003cem\u003eOur Common Future\u003c/em\u003e. Oxford: Oxford University Press; 1987.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-health-services-research","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bhsr","sideBox":"Learn more about [BMC Health Services Research](http://bmchealthservres.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/BHSR/default.aspx","title":"BMC Health Services Research","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Refractive eye care, Primary eye care, Health service accessibility, Rural health systems, Sustainability, India","lastPublishedDoi":"10.21203/rs.3.rs-8960531/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8960531/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eUncorrected refractive error is a leading cause of avoidable visual impairment globally and disproportionately affects rural and underserved populations. In the Sundarbans region of India, geographic isolation, poor infrastructure, low awareness, and fragmented service delivery limit access to refractive eye care. This study aimed to develop and evaluate a sustainable, community-based refractive eye care service model and to assess its effects on accessibility, affordability, service quality, compliance, and human development\u0026ndash;related outcomes.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eA mixed-methods design was employed. Quantitative data were collected through a cross-sectional survey of 999 community members across the Sundarbans, assessing accessibility, affordability, product quality, spectacle compliance, and perceived quality-of-life improvement. Qualitative data were obtained through semi-structured interviews with optometrists, eye-care professionals, and programme stakeholders and analysed thematically. Hypothesis testing examined relationships between service attributes, awareness, optometrist involvement, insurance linkage, and Human Development Index (HDI)\u0026ndash;related outcomes.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eAlthough 76.2% of respondents perceived refractive services as affordable (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001), only 13.2% reported adequate accessibility. Satisfaction with corrective products was reported by 36.3%, and consistent spectacle use by only 12.8% (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). Improved quality of life following refractive correction was reported by 57.2% of respondents. All alternative hypotheses were supported, confirming that affordability, awareness, service quality, optometrist involvement, and insurance linkage significantly influence compliance, sustainability, and development-related outcomes.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e \u003cp\u003eA community-based refractive eye care model integrating affordability, quality assurance, optometrist-led service delivery, awareness generation, and insurance linkage is feasible and effective in underserved rural settings. The proposed model offers a scalable framework for strengthening primary eye care services and advancing equitable health system performance.\u003c/p\u003e","manuscriptTitle":"A Sustainable Community-Based Model for Refractive Eye Care Services in the Sundarbans, India: A Mixed-Methods Study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-05-08 01:12:41","doi":"10.21203/rs.3.rs-8960531/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"editorInvitedReview","content":"","date":"2026-05-11T06:52:06+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"172718491455318605475500524366707412283","date":"2026-05-03T22:39:13+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"62231072341796786560077667127972601373","date":"2026-04-29T07:46:29+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"16426984862475393545668555386486987983","date":"2026-04-29T07:25:46+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-04-29T07:03:16+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2026-04-05T22:53:33+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-03-03T22:17:31+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2026-03-02T20:33:13+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Health Services Research","date":"2026-03-02T12:36:19+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-health-services-research","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bhsr","sideBox":"Learn more about [BMC Health Services Research](http://bmchealthservres.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/BHSR/default.aspx","title":"BMC Health Services Research","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"9679dfa9-2528-458f-9553-4f93fd6867c7","owner":[],"postedDate":"May 8th, 2026","published":true,"recentEditorialEvents":[{"type":"editorInvitedReview","content":"","date":"2026-05-11T06:52:06+00:00","index":77,"fulltext":""},{"type":"reviewerAgreed","content":"172718491455318605475500524366707412283","date":"2026-05-03T22:39:13+00:00","index":57,"fulltext":""}],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-05-16T19:59:30+00:00","versionOfRecord":[],"versionCreatedAt":"2026-05-08 01:12:41","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8960531","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8960531","identity":"rs-8960531","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}