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Implementing Community-Based Adult Eye Screening in the United States: A CFIR-Guided Qualitative Study
Rithambara Ramachandran1, Danny Bracy2, Aditi Doiphode3
1From the Scheie Eye Institute, Department of Ophthalmology, Perelman School of Medicine (R.R.), University of Pennsylvania, Philadelphia, Pennsylvania, USA; Leonard Davis Institute, Perelman School of Medicine (R.R.), University of Pennsylvania, Philadelphia, Pennsylvania, USA.
Purpose:
Community-based eye disease screening programs can reduce preventable vision loss but often remain fragmented and difficult to sustain. To guide the development of screening efforts, this study applied the Consolidated Framework for Implementation Research (CFIR) to identify determinants influencing the design, implementation, and sustainability of adult community-based eye disease screening programs across the United States.
Design:
A qualitative, multi-site study using semi-structured interviews.
Participants:
Seventeen US eye care leaders representing 17 adult vision screening programs across 11 states participated. Programs varied in design, including clinical setting, workforce composition, and diagnostic testing modalities.
Methods:
Participants completed 50- to 75-minute Zoom interviews (May-August 2024) focused on program design and implementation processes. Transcripts were coded in NVivo and thematically analyzed using a CFIR-guided codebook. Analytic rigor was maintained through double coding, consensus reconciliation, and an audit trail. Inter-rater reliability exceeded κ > 0.8.
Main Outcome Measures:
Key CFIR constructs and cross-cutting themes characterizing design and implementation determinants for community-based eye screening programs.
Results:
Twenty-two themes emerged across the 5 CFIR domains. Innovation (program) characteristics reflected programs grounded in public health equity yet constrained by complexity and competing stakeholder priorities. Inner setting factors involved limited physical space, workforce shortages, and limited eye-care knowledge. Outer setting influencers centered on the necessity of community partnerships, the impact of federal and state policy, and unstable funding streams. Themes around individual characteristics highlighted the essential roles of both local champions within an organization as well as strong institutional support. Within the implementation (process) domain, successful programs relied on systematic needs assessments, tailored strategies, and iterative adaptation.
Conclusions:
Community eye screening is highly context-dependent and frequently sustained by motivated individuals rather than durable systems. CFIR analysis revealed how policy gaps, unclear and inconsistent "screening" definitions and best practices, fragile referral pathways, and tensions between research fidelity and real-world feasibility create persistent barriers. Future success will require coordinated policy support, sustainable financing, integration within existing health infrastructures, and flexible implementation toolkits. A CFIR-guided framework can inform such adaptable, equity-driven models that bridge evidence and real-world practice to advance population eye health.
