Accessibility and Barriers to Uptake of Ophthalmic Services among Rural Communities in the Upper Denkyira West District, Ghana

Several studies have reported blindness and vision impairment as major health problems in developing nations ^{1, 2, 3, 4}. According to the World Health Organization (WHO), 90% of all persons with visual impairment live in developing nations ¹. The problem is more alarming among rural populations ^{5, 6, 7}. Amponsa-Achiano et al.² found that 90.3% of participants of an outreach clinic in a rural Ghanaian district had at least a disorder in one eye. Also, the Ghana National Blindness and Visual Impairment Study by the International Agency for the Prevention of Blindness (IAPB) showed a 0.79% prevalence of blindness in rural areas of Ghana relative to 0.67% in urban areas ³. Although rural cocoa farmers in Ghana were reported to have very poor perception about their vision, they failed to utilize available ophthalmic services ⁴. Eighty-five percent of these rural farmers reported they had poor or very poor vision, yet only 31.9% on Snellen visual acuity examination were found to have poor vision (6/24 - 6/60) or very poor vision (≤ 3/60). The relatively higher burden of eye and vision disorders in rural communities poses a major challenge to the attainment of Vision 2020 goals ⁸. Chandrashekhar et al.⁹ found that state-owned hospitals in India which had eye care facilities were too distant away from the rural villages, a major reason why many rural inhabitants avoided or underutilized ophthalmic services. Similarly, Dhaliwal and Gupta ¹⁰ attributed the poor usage of ophthalmic services among people with cataract in rural India to lack of affordable transport. Inadequate eye care personnel, inadequate eye care facilities, and unaffordable ophthalmic services have been described as major setbacks in preventing and treating avoidable causes of blindness in Africa ^{5, 6, 7, 11, 12}. Ntsoane and Oduntan ¹³ found that most of the hospitals and health care centres with eye care facilities were situated in urban centres. According to them, this was a notable hindrance to universal ophthalmic services utilization. Moreover, the unequal delivery of ophthalmic services among rural communities and urban centres has been suggested as key contributing factor to the overwhelming burden of blindness and visual impairment in rural regions ¹³. Ashaye et al. ¹⁴ reported that rural dwellers in Western Nigeria were underserved because a chunk of ophthalmic services in Western Nigeria was situated in urban areas. Consequently, inhabitants in these rural communities who had preventable and remediable ocular disorders were left unattended to. According to Silva et al. ¹⁵, the number of ophthalmic practitioners per million-population is nine times more in the richest countries than the poorest countries, an evidence that availability of ophthalmic services varies between countries in different regions of the world. By considering a nation, availability of ophthalmic services could differ from one region to another, districts and even between communities. For instance, the reported optometrist to population ratio in Ghana was 1:377,661 and that of ophthalmologist was 1:324,552, many of whom practiced in cities leaving rural dwellers underserved ¹¹.

Many rural inhabitants are thus compelled to resort to alternate sources of eye care including herbal preparations and traditional practices which are potentially harmful ¹⁶. Another reported primary hindrance to ophthalmic services in rural regions is the poor road network linking rural communities to health centres ^{15, 17}.

Robin et al.¹⁸ also reported poverty as a major drawback to the utilization of ophthalmic services in both developing and developed countries. Low economic activity among rural inhabitants renders them incapable of paying for the cost of health services in general. Disorders which could be remedied at the onset are left to deteriorate ⁵.

Several studies have also indicated under usage of ophthalmic services in rural areas even when they are available and accessible ^{19, 20, 21}. Ntsoane and Oduntan ¹³ identified socio-demographic characteristics, lack of knowledge on blinding eye care conditions, lack of felt need and socio-cultural beliefs as causes of the poor usage of existing ophthalmic services.

The tendency of resorting to alternate ophthalmic practices in the midst of many ocular conditions coupled with the lack of proper ophthalmic services is very high ¹⁶.

While poor utilization of appropriate ophthalmic services contribute to high prevalence of visual impairment and blindness, studies on accessibility and usage of ophthalmic services have not focused much on rural areas in Ghana ^{11, 22, 23, 24}

This study seeks to determine the accessibility, utilization and barriers to uptake of ophthalmic services among rural communities in the Upper Denkyira West District, Ghana.

While only 21.8% of participants in this study had had their eyes examined within the past 3 years, more than half (54.1%) had never received an eye examination. Ebeigbe et al. ²⁶ found a higher proportion (68%) of older persons (40-75 years) in rural Nigeria who had never received any eye examination. Also, Odutan and Raliavhegwa ²⁸ in rural South Africa found 61% of a rural district populace who had never had their eyes examined. These studies however employed larger sample sizes which might have accounted for the relatively large percentages of non-usage of ophthalmic services.

Although there are minor differences in reported levels of ophthalmic services utilization in rural areas, many are consistent indicators of inadequate utilization ¹¹. Coincidentally, Ocansey²⁴ found the same proportion (45.9%) of elderly participants (40 years and above) ever utilizing ophthalmic services in an urban Ghanaian region. While this was unexpected, it could possibly be because of reported barriers to uptake of available, accessible and affordable ophthalmic services ¹³. This seems to better explain the coincidence as 45.2% of participants in a Ghanaian urban community who had never checked their eyes were of the view that their eye problems were not bothersome ²³.

In this study (table 4), about 82.9% of the participants indicated they had ever experienced at least one form of eye problem. About 40% indicated they had problems with vision. Yet, 15.9% of those who reported reduced vision received no treatment. In a Nigerian rural study, Ebeigbe et al. ²⁶ found that rural dwellers do not see reduced vision as a problem until they can no longer perform their visual task. Again, this study found that non-prescription drops from chemical shops were used by 13.5% of the participants to manage red eye conditions. Herbal and/or traditional preparations were also common ways of treating eye injuries and red eyes. This was similar to the findings of Ovenseri-Ogbomo et al. ²⁹ on ophthalmic services utilization in shanty areas of the Accra Metropolis (Ghana) where study participants between 18 and 80 years were found to use sea water and breast milk in managing some eye disorders. Again, the report of an urban study in Ghana was no different ²³. Ntim-Amponsah et al. ¹⁶ found no significant difference (p=0.78) between patronage of alternate ophthalmic services and the regular ophthalmic services by participants of Akuapim South District, Ghana, revealing that easy access to alternate ophthalmic services and longer waiting hours at hospitals were the compelling factors. Of the 45.9% participants who had had an eye examination, there were more females (28.2%) than males. A significant association between ophthalmic services utilization and gender was thus found in this study (χ2 = 4.875; p = 0.027). Several studies also found significant associations between gender and ophthalmic services utilization affirming the fact that women seek more ophthalmic services than their counterpart ^{17, 26, 30, 31, 32, 33}. Since older people are predisposed to many eye conditions, the relatively longer lifespan of women may be the reason why women access more eye care than men.

Also in this study, a statistically significant association (χ2 = 17.204; p = 0.004) was found between ophthalmic services utilization and increasing age. Kovai et al.¹⁹, Robin et al. ¹⁸, Schaumberg et al. ³²have all reported positive associations. This could generally be due to the increased susceptibility to ocular problems as one ages. With the gradual decrease in vision, older people are more expected to seek ophthalmic care than young people who perceive eye problems as a disease of old age.

Although 74.4% of participants who have had eye examination had obtained at least elementary education, there was no significant association (χ2 = 4.909; p = 0.179) between highest educational level and ophthalmic services utilization in this study. This was contrary to Fotouli et al. ³⁴ who reported a significant association between ophthalmic services utilization and highest educational level, asserting one was more expected to seek ophthalmic care when he or she is much educated. Fatouli et al. ³⁴ believed that educated people seek ophthalmic services because they may have a better knowledge of their condition and also understand the implications of not seeking attention to their eye problems. Also, educated people mostly belong to the higher socioeconomic class, thus are more capable of bearing the total cost of ophthalmic services.

Again in this study, no significant associations were found for employment status (χ2 = 2.241; p = 0.326), ethnicity (χ2 (2) = 6.811; p = 0.078), religion (χ2 = 1.701; p = 0.427), and ophthalmic services utilization.

A statistically significant association was nonetheless found in this study between those who had a past history of eye problem(s) and ophthalmic services utilization (χ2= 14.500; p = 0.001). In rural Nigeria, Ebeigbe et al. ²⁶ also found that people who had no or minor eye problems scarcely utilized ophthalmic services. This explains why people who found their eye problems unbearable more probable to utilize ophthalmic services as there was a need or reason to do so.

About 44.9% (table 2) of participants in this study who had had their eyes examined at an eye care facility did so outside the district. The remaining majority received their examination from outreach grounds and health centres. None of the clinics nor the community health centres had an eye care professional or an ophthalmic unit. This implies that non-eye care professionals attended to patients who presented with eye problems. For those who were seen at outreach grounds, they had to wait with their problems until luck shone on them for mobile eye clinics to come to their aid. This may be risky in cases of ocular emergencies. The few who travelled to eye care facilities travelled a distance of more than 8 km taking more than an hour (Table 2). Chatora and Tumusine ³⁵ recommended that an individual accessing primary health care should not travel over 8 km distance and over 60 minutes time. It was in light of the poor access to primary health care that called for the Declaration of Alma-Ata in 1978 stating that access to primary eye care is fundamental human right.

The lack of any eye care facility in the Upper Denkyira West District was the major hindrance to eye care as 17.6% of all responses to barriers to eye care utilization indicated “there are no eye clinics around” (Table 5). Buchanan and Horwitz ³⁶ also found unavailable eye care facilities and limited eye care personnel as the major barrier to ophthalmic services in rural Jamaica. According to Buchanan and Horwitz, the unavailable services accounted for more than 43% of the rural Jamaican populace who had never examined their eyes. Residents in the Upper Denkyira West District had to travel outside the district to seek eye care which could be inconvenient to make people consider their eye problems not too serious to demand intervention. Unaffordable cost of ophthalmic services, challenges with transportation, beliefs that eye problems were of a spiritual cause than medical, preference to herbal and/or traditional treatments were also reported barriers to ophthalmic services utilization in this study.

Also in this study, about 5.9% of indicated barriers to ophthalmic services utilization was the fact that they were not old enough (18 and 28 years) to be having eye problems.

Moreover, about 13.3% of the participants in this study indicated their eye problems were not too serious that needed attention. Red eyes and itching were considered by participants as “normal” in that, they could easily be remedied with over the counter eye drops.

This study found gross inadequate utilization of ophthalmic services mainly due to unavailable ophthalmic services in the rural district. Some rural dwellers were thus compelled to make use of potentially harmful eye care practices such as the use of non-prescribed eye drops and herbal preparations.

Notwithstanding, older persons, females, and participants who had a past history of eye problem(s) significantly utilized more ophthalmic services.

Public health education and eye care interventions should prioritize and target rural populations. These interventions could yield positive outcomes as many visual impairing and blinding eye conditions are avoidable.

We express our profound gratitude to the authorities of the Upper Denkyira West District Assembly, chiefs and residents of the district for their permissio this study.

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