This cluster-randomized trial aims to evaluate the effect of vision centers on access to eye care and eye health outcomes in South Asia. The main questions it aims to answer are:

1. Do vision centers improve effective refractive error coverage?
2. Do vision centers increase eye care center utilization?
3. Do vision centers improve population visual acuity?

Researchers will compare outcomes in communities randomized to immediate versus delayed establishment of a vision center. Outcomes will be assessed through population-based surveys at baseline and after two years as well as through hospital records collected throughout the study period.

The vast majority of visual impairment and blindness is preventable or treatable with existing interventions. Nearly all of this burden is faced by those living in low- and middle-income countries. Access to eye care is a key challenge in these settings, particularly in rural and remote areas.

Vision centers (VCs) have been developed to increase access to primary eye care in such underserved settings. VCs typically involve establishment of a fixed center staffed by a mid-level ophthalmic technician who offers refraction, spectacles, diagnosis and treatment of basic eye conditions, and referrals for more complex care. VCs have become a common approach to increase access to care in many low- and middle-income country settings, yet little rigorous evidence exists on their impact on eye health in the communities they serve. A recent literature review was unable to identify randomized controlled trials on the impact of vision centers on eye health outcomes in real world settings. While the observational research that exists suggests VCs improve eye health in the communities they serve, the existing evidence is prone to bias.

The investigators propose a cluster-randomized trial to evaluate the effect of VCs on access to eye care and eye health outcomes in South Asia. The trial will leverage VCs planned by the Seva Foundation and partners Bangladesh, India, and Nepal and will monitor outcomes via population-based surveys and hospital network records over 2 years. The investigators expect to provide rigorous evidence on VC impact in real-world settings that can be used to influence programmatic decision making and policy.

Inclusion Criteria:

• The catchment area of the proposed VC site is predominantly rural.
• The proposed VC site is located within 20-100 km of the base hospital.
• There are no major primary eye care services within 10 km of the proposed site.
• Care at sites randomized to establish VCs immediately is accessible to anyone.

Exclusion Criteria:

• Sites located in non-rural or urban catchment areas.
• Sites outside the 20-100 km distance range from the base hospital.
• Sites with existing major primary eye care services within a 10 km radius.

De-identified cluster-level data will be shared publicly via osf.io

Data will be shared at the time of publication

General public

Survey data collectors and data analysts conducting the primary analyses will be masked. This will be achieved by not informing survey data collectors of arm assignment and by having an unmasked team member conceal arm assignment before primary analyses.