Face-to-face in-depth interviews and FGDs took place between April and June 2019. All interviews and group discussions were conducted by two M.Sc-level qualitative researchers (IN, male and RI, female), who were independent of the project, speaking Urdu or Pashto. Interviews took place at the district hospitals, patients’ homes or government offices and, on average, each lasted one hour. Prior to each interview or group discussion, the researchers introduced themselves and explained the study. Participants had an opportunity to ask questions and all provided consent. The two data collectors met regularly during the fieldwork to discuss emerging themes and receive feedback from the research supervisors.

A topic guide was developed based on the literature to address a broad set of themes: (1) LHWs’ training; (2) their role in the delivery of eye care; (3) LHWs’ capacity and motivation; and (4) community opportunities and challenges in accessing eye care services. English and Urdu or Pashto versions of the interview guides were reviewed after pre-testing to ensure questions were accurately translated, understandable, and followed a logical flow. The core questions were the same for all participants, while specific probes were added to explore the themes emerging from the interviews in depth. Data was collected until the point of saturation, that is until no new information or themes could be identified from the additional interviews.

IDIs and FGDs were audio-recorded, transcribed verbatim and translated into English for data analysis. Two bilingual members of the study team (IKK, LA) independently reviewed the transcripts against the original audio-recordings to ensure the quality of transcribing and translation. The transcripts were analysed thematically using both deductive and inductive approaches to explore themes and data patterns [18]. Two researchers (RI, IN) coded the first set of transcripts independently, while a senior researcher (SB) undertook coding of a subset of transcripts and met with the two main coders to discuss emerging themes and discrepancies. Similarities and differences in the coding were discussed, and the coding framework was refined, agreed and applied to the remaining transcripts. The codebook had two top-level codes: training and integration of LHWs in the eye health workforce, and patient health-seeking behaviour and barriers to referral uptake. Organizing the analyses around these top-level codes allowed the data to be blended easily with the research questions and other existing empirical work. Further sub-coding of categories within each top-level code came next. The sub-coding step assigned several new codes that (i) described the nature of the training and the health system context in which LHWs were being deployed, and (ii) captured a range of factors and challenges affecting the pathways through which patients access specialist eye care services. All coding and data analysis were conducted using NVIVO software version 12 (QSR International). The transcripts were not returned to the participants for comments. However, data analysis began during data collection through regular team meetings and reflection. Ongoing discussions between the investigators and the programme staff helped to ensure that the themes and subthemes developed accurately represented what participants conveyed during the in-depth interviews and FGDs.

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