A rapid appraisal of factors influencing utilization of primary eye health services among the residents in a rural community

Utilization of primary eye health services ISSN: 2394-0026 (P)Original Research Article ISSN: 2394-0034 (O) A rapid appraisal of factors influencingutilization of primary eye health servicesamong the residents in a rural communityShama Prakash1, Manpreet Kaur2, Bikramjeet Singh3, AbhishekSingh4*, Pooja Goyal5, Avinash Surana6, Shewtank Goel7, SanjeetPanesar8, Anurag Ambroz Singh9, Richa Chaturvedi10, Lalit kumar singh111Assistant Professor, Department of General Medicine, KS Hegde Medical Academy, Mangaluru, Karnataka, India2Associate Professor, Department of Ophthalmology, SHKM Govt. Medical College, Haryana, India 3Demonstrator, Department of Forensic Medicine, BPS Govt. Medical College, Sonipat, India4Assistant Professor, Department of Community Medicine, SHKM Govt. Medical College, Haryana, India5Associate Professor, Department of Community Medicine, SHKM Govt. Medical College, Haryana, India 6 Deputy Assistant Director Health, 19 Inf. Div.7Assistant Professor, Department of Microbiology, MSDS Medical College, Fatehgarh, Uttar Pradesh, India8Senior Resident, Department of Community Medicine, Vardhman Mahavir Medical College and Safdarjung Hospital, New Delhi, India9Associate Professor, Department of General Medicine, SHKM Govt. Medical College, Haryana, India 10RCH Consultant, SIHFW, Rajasthan, India 11Assistant Professor, Department of Sociology, Govt. Degree College, Gonda, Aligarh, India*Corresponding author email: [email protected] to cite this article: Shama Prakash, Manpreet Kaur, Bikramjeet Singh, Abhishek Singh, PoojaGoyal, Avinash Surana, Shewtank Goel, Sanjeet Panesar, Anurag Ambroz Singh, Richa Chaturvedi,Lalit kumar singh. A rapid appraisal of factors influencing utilization of primary eye health servicesamong the residents in a rural community. IAIM, 2015; 2(4): 83-89.Available online at www.iaimjournal.comReceived on: 21-03-2015 Accepted on: 28-03-2015AbstractBackground: Identification of factors affecting utilization of primary eye health services would helpthe government and other eye care providers to address inequity issues in their eye care program.International Archives of Integrated Medicine, Vol. 2, Issue 4, April, 2015. Page 83Copy right © 2015, IAIM, All Rights Reserved.

Utilization of primary eye health services ISSN: 2394-0026 (P) ISSN: 2394-0034 (O)Aim: Therefore this study was planned to find out barrier to utilization of eye health services amongpeople living in rural western Uttar Pradesh.Material and methods: The current community based cross-sectional survey which involved bothqualitative and quantitative methods, was conducted among the residents. A total of 216 studysubjects participated in the study. Factors in the supply side influencing utilization of eye healthservices by people from the community were sought through Focus Group Discussion (FGD) and KeyInformant Interview (KII).Results: Almost 80% of the respondents had agriculture as their major occupation and > 1/4th werefrom lower caste community. Regarding the seeking of eye care services, 52.4% respondents whogave a positive history of an eye problem in the family told they attended the nearest health facility;CHC, PHC or SC while 19.2% did actually go to the eye health center. Only 4.8% respondent did notseek any service. Among 112 respondents who were aware of one or other eye diseases, 74.6%identified dirty things fallen into the eyes as the cause of an eye problem followed by 50.3% of therespondents who pointed out injury to the eyes as the culprit. For emergency problem in the eyes79.2% respondents told that they sought services from health facilities without delay, while 15.4%gave priority to starting household treatment.Conclusion: Raising awareness of the community about eye diseases and the services availabletogether with strengthening of primary eye health services available at the local health facilitiescould help bring eye health services in closer proximity to the rural population.Key wordsFactors, Utilization, Primary, Eye health services, Community.Introduction treatment and rehabilitation. This is increasingly recognized as an important attribute of modern“Vision 2020: The Right to Sight” is committed to health care system [5]. The problem of blindnessintegrate a sustainable, comprehensive, high- is acute in rural areas and hence the programquality; equitable eye care system into must try to expand the accessibility ofstrengthened national health-care systems [1, ophthalmic services in these areas.2]. The initiative sets a major challenge requiringa significant increase in the provision and uptake India is committed to the goal of Vision 2020of eye care services. If the increasing trend in and elimination of avoidable blindness is ofblindness is to be reversed, then eye care primary concern. Establishment of primary,services should not only be available but also be secondary and tertiary eye care centers in areasincreasingly easily accessible and affordable [3, where services were most needed was one of4]. In such a scenario it becomes extremely the most important strategies in this regard.important to understand the nature and social Availability, accessibility, accommodation,context of indirect cost barrier. affordability, and acceptability are five key elements of access. Patients and providers couldA huge proportion of blindness is have different perspectives regarding access topreventable/avoidable or easily treatable. To care. Providers may care much more aboutaddress this situation, interventions specific to outcomes, whereas patients also valueblindness are required, which will include convenience, timeliness, a comfortableprevention, eye health promotion, protection,International Archives of Integrated Medicine, Vol. 2, Issue 4, April, 2015. Page 84Copy right © 2015, IAIM, All Rights Reserved.

Utilization of primary eye health services ISSN: 2394-0026 (P) ISSN: 2394-0034 (O)environment, the provider’s attitude, services. Regular supervision and monitoringcommunication, and other aspects of care. Any was done at the household level by the principalmismatch between provision of services and investigator on every alternate day. With a nonneed is regarded as evidence of inequitable response rate of 4%, data from 216 householdsaccess to health care [6, 7]. was included in the analysis. Similarly factors in the supply side influencing utilization of eyeIdentification of factors affecting utilization of health services by people from the communityprimary eye health services would help the were sought through Focus Group Discussiongovernment and other eye care providers to (FGD) and Key Informant Interview (KII).address inequity issues in their eye careprogram. Some studies on awareness of cataract Three health workers served as source ofand surgical service utilization for the condition information for qualitative data. Data collectionhave been done in the area but there is no study was done by the investigators. For quantitativeavailable on availability and utilization of data, the data entry was done in Epi-info versionprimary eye health services. Therefore this study 3.5.1 software and analyzed using SPSS versionwas planned to find out barrier to utilization of 20 software; simple frequencies andeye health services among people living in rural relationships between variables were calculated.western Uttar Pradesh. Chi-square test was used as the test of significance. Finding with p-value less than 0.05Material and methods was considered statistically significant at 95% level of confidence. For qualitative data, all theThe current community based cross-sectional data was read carefully, transcribed and asurvey which involved both qualitative and category system was constructed based on thequantitative methods, was conducted among homogeneity of data. Data was coded accordingthe residents of rural western Uttar Pradesh. to the category system and data belonging toFactors influencing utilization of eye health each category was sorted, retrieved, assembledservices on demand side were collected by manually and viewed. Interpretation was madequantitative methods while those on the supply in a descriptive way making reference to fieldside were collected by qualitative methods. For notes.blindness prevalence rate of 0.85 in the region(unpublished data from CMO office); allowable Resultserror of 5% and assumption of a non responserate of 10%, the sample size for quantitative A total of 216 study subjects participated in thedata was calculated to be 224. Households from study. Median age of the respondents was 45two villages were taken using PPS sampling. One years and the age range was from 18 to 72member from each household above the age of years. Almost 80% of the respondents had18 years, who consented to participate in the agriculture as their major occupation and > 1/4thstudy, was enrolled for the study. were from lower caste (dalit) community. Low level of educational attainment and povertyA structured proforma was designed in among respondents were found to beconsultation with subject experts to collect significantly associated with low level ofquantitative data on various socio demographic, awareness on eye diseases.socio economic, geographic and culturalvariables influencing access to eye healthInternational Archives of Integrated Medicine, Vol. 2, Issue 4, April, 2015. Page 85Copy right © 2015, IAIM, All Rights Reserved.

Utilization of primary eye health services ISSN: 2394-0026 (P) ISSN: 2394-0034 (O)Regarding the seeking of eye care services, Regarding the accessibility 51.7% of the52.4% respondents who gave a positive history respondents said that the nearest health facilityof an eye problem in the family told they was at a walking distance of more than half anattended the nearest health facility; CHC, PHC or hour from their place of living. Eye healthSC while 19.2 % did actually go to the eye health services were utilized when the distance tocenter. Only 1 (4.8%) respondent did not seek health facility from home was less (p=0.05). Eyeany service. The reason for service not been health services were believed to be available insought was the belief that the condition was those health facilities by 75% of thenormal. On the prevention aspects, 71.1% gave respondents. However, KII with health workersimportance to regular ocular hygiene however and FGD revealed that the availability of primary1.5% emphasized on superstitious belief (pay eye health services in the study area was veryrespect to gods, goddesses). poor. Upon probing for the availability of eye health services and adequacy of human resourceThe risk of not knowing about eye diseases for eye care delivery the study subjects shared(mainly cataract, glaucoma and night blindness that the services available at health facilitieswhich are more common) increased more than were inadequate. “Our health facilities do not3.5 times when people were illiterate and this have basic services for eye health care delivery.finding was found to be statistically significant They cannot deliver eye health services.” as perfor all the 3 diseases taken in to account in this a 42 years old study subject.study as per Table – 1. Upon further inquiring for the instruments andThe risk of not knowing about eye diseases medicines available at their health facility for the(mainly cataract, glaucoma and night blindness management of eye disease, health workerswhich are more common) increased more than 4 reported that they only had 2 varieties oftimes when people were unemployed. This antibiotics and/or eye drops, with is usually notfinding was found to be statistically significant sufficient for a period till next stock of medicinefor 2 diseases taken in to account in this study comes. Vision charts for testing of visual acuitynamely cataract and night blindness as per Table were unavailable. They admitted to not having– 2. sufficient skills for removal of even foreign body in the eyes. “How can we provide treatment toThe relation and caste of the respondents were several kinds of diseases in the eye even if wenot found to be significantly associated either know how to treat a case when only 1-2with awareness or with knowledge on eye medicines are available for treatment in thediseases. Among 112 respondents who were whole area.” as per health worker from a localaware of one or other eye diseases, 74.6% health facility.identified dirty things fallen into the eyes as thecause of an eye problem followed by 50.3% of Discussionthe respondents who pointed out injury to theeyes as the culprit. For emergency problem in This study was the first community based studythe eyes 79.2% respondents told that they on evaluating the access to eye health servicessought services from health facilities without in rural communities of western Uttar Pradesh,delay, while 15.4% gave priority to starting though several studies have been done in thehousehold treatment. past to find the barriers in access to cataract surgical services among people of the older ageInternational Archives of Integrated Medicine, Vol. 2, Issue 4, April, 2015. Page 86Copy right © 2015, IAIM, All Rights Reserved.

Utilization of primary eye health services ISSN: 2394-0026 (P) ISSN: 2394-0034 (O)group [8]. The data from the supply side are of to health facilities. However positive attitude ofparticular importance as it gives the true picture people towards eye problems was encouraging.of the services at the rural health facilities of the A study done in a rural population of India foundarea where there are inadequate provision not low uptake of eye camp services mostly due toonly for eye care but also for general health fear reasons. Access to eye health services wasservices. not found to be affected by socioeconomic and other socio demographic variables as age,In this study, it was observed that almost two ethnicity, and occupation of the respondentthird (62%) of the respondents to be aware of [13]. Rational planning and implementation ofone or more diseases of the eyes. The level of eye health services is essential with dueknowledge regarding specific eye diseases attention to the barriers to overcome poorthough was less, it is comparable to a similar service utilization.study from Australia where 77% of the peoplereported they were aware of one or more of the The study revealed that health facilities in thethree eye conditions; cataract, glaucoma and study area to be poorly equipped. UnavailabilityAMD. The correct knowledge was found to be of eye health service provider in their locality,associated significantly with age (younger), sex inadequate eye care services in their local health(females), higher levels of formal education and facilities, unavailability of professionals for eyea recent visit to an eye practitioner [9, 10]. health delivery and inadequate skills among general health workers were some of the factorsAnother study observed that 69.8% of the identified in the supply side which negativelyrespondents aware of cataract, 55.8% aware of influenced the access of eye health servicesnight blindness and 2.3% aware of glaucoma. among people [14].Level of education was found to be a significantpredictor for the knowledge on aforementioned Conclusioneye conditions [11]. It can be concluded on the basis of findings ofNot surprisingly our study shows cataract as an the current study that knowledge on commoneye disease was known to 41% respondents eye diseases was poor among the peoplewhile 37% respondents had knowledge on night studied. This indicates the need for efficient eyeblindness. Glaucoma as an eye disease was health awareness programs which helps inknown to 8.2% respondents only. For glaucoma, prevention and timely seeking of eye careearly detection and prevention may prevent services. Raising awareness of the communityprogression of the disease, but because of its about eye diseases and the services available‘‘silent’’ nature early detection of glaucoma is together with strengthening of primary eyedifficult unless the patient undergoes an eye health services available at the local healthexamination [12]. Hence, raise in the level of facilities could help bring eye health services inawareness of glaucoma in general population is closer proximity to the rural population.essential if more people are to be screened forthe disease. ReferencesOur study recognized 2 important factors 1. Ashaye A, Ajuwon AJ, Adeoti C.hindering access to eye health services as poor Perception of blindness and blinding eyeknowledge of eye diseases and greater distance conditions in rural communities. J Natl Med Assoc, 2006; 98(6): 887-893.International Archives of Integrated Medicine, Vol. 2, Issue 4, April, 2015. Page 87Copy right © 2015, IAIM, All Rights Reserved.

Utilization of primary eye health services ISSN: 2394-0026 (P) ISSN: 2394-0034 (O)2. Vision 2020: The Right to Sight, Global 9. Rao GV. Bridging the gap: Barriers at initiative for the elimination of avoidable community level, between service blindness, Action Plan 2006-2011: 201. providers and receivers. Com Eye Health J, 2004; 17: 49-50.3. Nedgwa LK, Karimurio J, Okelo RO, Adala 10. Pokharel G P, Regmi G, Shrestha SK. HS. Barriers to utilization of eye care Prevalence of blindness and cataract services in Kibera slums of Nairobi. East surgery in Nepal. Br J Opthalmol, 1998; Afr Med J, 2005; 82: 506-509. 82: 600-605. 11. Majeed M, C Williams, K Northstone.4. Zhang X, Andersen R, Saaddine JB. Are there inequities in the utilization of Measuring Access to Eye Care: A Public childhood eye-care services in relation Health Perspective. Ophthalmic to socio-economic status? Evidence Epidemiology, 2008; 15: 418-425. from the ALSPAC cohort. Br J Ophthalmol, 2008; 92: 965-969.5. Ayanniyi AA, Bob-Egbe S, Olatunji FO, 12. Livingston PM, McCarty CA, Taylor HR. Omolase CO, Omolade E, Ojehomon F, Knowledge, attitudes and self care Edward MK. Social marketing potential practices associated with age related of qualitative cost-free-to patient eye eye disease in Australia. Br J care programme in a Nigerian Ophthalmol, 1999; 82: 780-785. community. Ann Afr Med, 2009; 8: 225- 13. Kyndt M. Importance of affordable eye 228. care. Comm Eye Health J, 2001; 14(37): 1-3.6. Fletcher AE. Low uptake of eye health in 14. Dandona R, Dandona L, John RK. rural India. A cultural challenge of Awareness of eye diseases in an urban blindness prevention. Arch Ophthalmol, population in southern India. Bull World 1999; 117: 1393-1399. Health Organ, 2001; 79: 96-102.7. Bhagwan J, Rastogi I, Malik J, Dhull C. Knowledge, attitude and practices regarding cataract surgery among severe cataract cases in Hanyana. Indian J Comm Med, 2006; 31: 66-68.8. Ashaye A, Ajuwon A, Adeoti C. Perceptions of blindness and blinding conditions in rural communities. J Nat Med Assoc, 2006; 98: 887-893.Source of support: Nil Conflict of interest: None declared.International Archives of Integrated Medicine, Vol. 2, Issue 4, April, 2015. Page 88Copy right © 2015, IAIM, All Rights Reserved.

Utilization of primary eye health services ISSN: 2394-0026 (P) ISSN: 2394-0034 (O)Table - 1: Association between level of education and knowledge of eye disease among the studysubjects.Knowledge on eye Level of education Chi p-value* OR* square 0.000 95 % CIdisease Illiterate Literate 0.010 0.000 4.40Cataract 58 73 19.62 2.21-8.72No 13 72Yes 9.30 1.21-71.33Glaucoma 3.53No 70 128 1.78-6.99 6.64**Yes 1 17Night BlindnessNo 58 81 13.86Yes 13 64*OR- Odds Ratio, p-value- Level of significance, **Mantel-Haenszel TestTable - 2: Association between occupation and knowledge of eye disease among the study subjects.Knowledge on eye Occupation Chi p-value* OR* Employed square 0.000 95 % CIdisease Unemployed 0.057 76 18.71 0.000 4.4Cataract 73 2.08-9.47No 55 3.91 0.82-25.4Yes 12 5.91Glaucoma 2.61-13.8No 65 133 3.62**Yes 2 16Night Blindness 61 78No 9 23.45Yes 68*OR- Odds Ratio, p-value- Level of significance, **Mantel-Haenszel TestInternational Archives of Integrated Medicine, Vol. 2, Issue 4, April, 2015. Page 89Copy right © 2015, IAIM, All Rights Reserved.