Abstract
Background:
Visual impairment, which is related to many eye diseases, is a major public health problem. If detected and treated early, it can be prevented; therefore, regular use of vision services is very important.
Objective:
This study aimed to assess the proportion of utilization of eye care services and associated factors among the rural community population in southern Ethiopia.
Methods:
A community-based cross-sectional study design with a two-stage cluster random sampling technique was conducted to collect data from adults aged 40 years and above using interviewer-administered questionnaires. Kebeles were randomly selected by the lottery method, and systematic random sampling with proportional distribution was used to select the households. An adult individual was randomly selected from a household when there was more than one adult available. A binary logistic regression model was used to establish the association between eye care service utilization and the variables that might affect it.
Results:
Of the 551 study population, 510 responded to this study, and the response rate was 92.6%. The mean age of the respondents was 52.2 years. The rate of eye care service utilization was 29% (95% confidence interval (0.25, 0.33)). The study shows that older participants, aged 65 and above (adjusted odds ratio: 4.04; 95% confidence interval (2.20, 7.43)), having previous eye problems (adjusted odds ratio: 10.04; 95% confidence interval (5.81, 17.33)), the presence of systemic illness (adjusted odds ratio: 2.52; 95% confidence interval (1.21, 5.21)), and having awareness about regular checkups (adjusted odds ratio: 11.75; 95% confidence interval (6.62, 20.84)) were found to be the predictors of eye care service utilization.
Conclusion:
In this study, utilization of eye care services was low. Older age, previous eye problems, systemic illness, and awareness about checkups were found to be predictors of eye care service utilization. Hence, there is a need to increase the absorption of existing ophthalmic services and create awareness of the use of ophthalmology services to reduce preventive blindness.
Keywords: Cross-sectional, eye care, service utilization, southern Ethiopia
Introduction
The World Report on Vision shows that at least 2.2 billion people worldwide have a vision impairment, with at least 1 billion having a vision impairment that might have been avoided. In terms of eye care, the world faces significant issues, including disparities in coverage and quality of prevention, treatment, and rehabilitation services, a shortage of qualified eye care service providers; and poor integration of eye care services into health systems, among others. 1 The main goal of the provision of eye care services is to reduce avoidable visual impairment as a global public health problem and to secure access to rehabilitation services for the visually impaired.2–4 Visual impairment is a major public health problem and is associated with many ocular conditions. Evidence shows that around 596 million people worldwide are visually impaired, of whom 43 and 510 million are blind due to refractive errors and moderate to severe visual impairment. Furthermore, 80% of visually impaired patients are curable, and approximately 90% of visually impaired patients worldwide are in low- and middle-income countries. 5 The World Health Organization proposed three pillars of global initiatives to announce the “right to sight” in 2020 to eliminate blindness. The pillars of the initiative include the control of specific diseases, the development of human resources, infrastructure, and appropriate technology.6,7
A study conducted in South Africa found that 62.7% of the respondents had used government eye care services and that monthly income, knowledge of available services, and the need for regular eye tests were positively associated with the utilization of eye care services. 8 A similar study in Nigeria indicated only 19% of respondents had previously visited health facilities in search of eye care and 24% of those with poor vision had sought eye care. Moreover, this study found that age, gender (male), literacy, and proximity of the eye care facility to the residing area were found to be predictors for service utilization. 7
In Ethiopia, eye care services are mainly provided by ophthalmologists, optometrists, eye care nurses, and other healthcare providers, such as general practitioners, health officers, and nurses, who provide primary care and refer when necessary. Although there has been a significant improvement in terms of cataract surgical rate within the past 20 years in Ethiopia, the number of human resources for eye health, at primary and secondary eye care units, was below the VISION 2020 targets. A survey of 60,820 rural residents in central Ethiopia showed that the overall prevalence of blindness was 1.1%. 9 A finding from Gondar, northwest Ethiopia, found that the rate of use of eye care services was 32%, and age, monthly family income, perception, and previous eye problems were factors identified as having a significant association with eye care use. 10
Worldwide, the negative impact of visual impairment and blindness is paramount, as it causes significant human and socioeconomic impacts. In 2000, the global economic loss from visual impairment was US$ 42 billion per year. 8 In developing countries, it is estimated that the blind living in these countries have a life expectancy of one-third than that of their sighted peers. 11
Although visual impairment and blindness affect every aspect of an individual and society as a whole, research on the utilization of eye care services in Ethiopia, particularly in rural areas, is limited. Assessing the sociodemographic status of a community helps to understand eye care services uptake or utilization, which aids in the development of strategies to provide eye care services to those who are underserved. Thus, this study aimed to assess eye care service utilization and associated factors in the rural district of southern Ethiopia.
Methods
Study setting and population
A community cross-sectional study was conducted from October 25 to November 25, 2020. Meskan is located 135 km Southwest of Addis Ababa and is the newly established district of the Gurage Zone of the Southern Nationals, Peoples and Peoples Area (SNNPR) of Ethiopia, with 21 kebeles. The district has a total population of 130,233 with a 1.04 ratio of female to male and 7.31% of its population are urban dwellers.
There is one hospital in Butajira town that provides different eye care services by ophthalmologists, optometrists, and ophthalmic nurses in that area. The study population was all adults aged 40 and above residing in the Meskane rural district in southern Ethiopia. The inclusion criteria were all adults aged 40 and above living in the Meskane district for more than 6 months prior to the data collection, and the exclusion criteria were individuals who were unable to give a response due to serious physical or mental illness.
Sample size and sampling procedure
The sample size for this study was calculated using the single population proportion formula by taking the proportion of eye care service utilization (32%) from the previous study 10 and with the following assumptions: 5% margin of error and 95% level of confidence. Furthermore, a design effect of 1.5 was used, and the final sample size became 551.
A census was conducted to quantify all adult individuals aged 40 years or older living in the Meskan area. Therefore, a two-stage cluster random sampling technique was used, and to select 4 kebeles out of 21 kebeles, a simple random sampling was applied to ensure 20% representativeness. Among the selected kebeles, the total population was found to be 15,365 and 3073 households. Using a proportional distribution system, random sampling was used to select participating households and respondents with a sampling interval of 5 (Figure 1). When there were two or more eligible subjects, an adult individual from a family was selected by lottery. Then, after checking the eligibility criteria, 551 participants were recruited into the study.
Figure 1.
Schematic presentation for the sampling technique.
Measurements
Eye care service utilization: The use of eye care services by persons for the purpose of preventing and curing eye problems, promoting maintenance of eye health and well-being, or obtaining information about one’s eye health status and prognosis at least once in the last 2 years. 4
Wealth Index: Households were given scores based on the number and kinds of consumer goods they own; these scores are derived using principal component analysis. Wealth quintiles are compiled by assigning the household score to each usual household member and ranking each person in the household population by her or his score. 12
Data collection tool and procedure
The data were collected by ophthalmologists and optometrists after receiving 2 days of training. The interview was conducted in the interviewee’s home using questionnaires developed from different literature.7–10,12 It is divided into three parts: the first part covers sociodemographic characteristics, the second part covers issues related to eye care services, and the third part involves socioeconomic variables (wealth index).
The English version of the questionnaire was translated into Amharic, the local language understood by most people in the community, and it was back-translated to English to check for consistency. If the respondent did not know Amharic, the data collector translated it into the Meskan language. The questionnaire was previously tested on 5% of the total sample size of a neighboring kebele with the same sociodemographic characteristics in a non-study area.
Statistical analysis
Data were entered into EpiData version 3.1 and exported to the Statistical Packages for Social Sciences version 20 for analysis. Binary logistic regression was performed to select candidate variables for the final model using p-values less than 0.25. Multiple logistic regression was used to assess the association between eye care service utilization and the independent variables. A p-value less than 0.05 and adjusted odds ratio (AOR) with its confidence interval (CI) were considered to judge the statistical significance. The fit of the model was tested using the Hosmer–Lemeshow p-value, which was greater than 0.05.
Ethics approval
Ethical approval for the research was obtained from Jimma University, Institute of Health Research Ethics Committee (Ethics Approval Number (JUIRB/THRPGD/21/2020)). Then, the district health office was contacted and a support letter was obtained. Verbal consent was also obtained from every participant before the interview by explaining to him/her the objective of the study. Confidentiality of information was maintained by omitting their personal identification, conducting the interview in a private place, and using the data for research purposes only. Interviewees with self-reported eye health problems were advised to visit the eye care service-providing center.
Results
Sociodemographic characteristics of study participants
Of the 551 study participants, 510 responded, and the response rate was 92.6%. The mean age of the respondents was 52.2 years, and the standard deviation was 11.45. About half (50.8%) of the participants were men, and more than nine-tenths (94.9%) of them were from the Gurage ethnic group. The Muslim religion comprises 86.5% of the respondents, and about three-fourths of the respondents were married. Regarding the educational status of the respondents, more than one-third (37%) of the respondents had formal education. Moreover, about 63% of the respondents reported farming as their occupation. The family size of the respondents ranged from 1 to 16, with a mean of 5.84 and a standard deviation of 2.53 (Table 1).
Table 1.
Sociodemographic characteristics of study participants, Meskean District, southern Ethiopia, 2020. (n = 510).
| Variables | Variable categories | Frequency (n) | Percentage (%) |
|---|---|---|---|
| Age (years) | 40–54 | 320 | 62.7 |
| 55–64 | 82 | 62.7 | |
| Above 64 | 108 | 21.2 | |
| Sex | Male | 259 | 50.8 |
| Female | 251 | 49.2 | |
| Marital status | Single | 35 | 6.9 |
| Married | 386 | 75.7 | |
| Divorced | 6 | 1.2 | |
| Widowed | 80 | 15.7 | |
| Living together with family 3 | 0.6 | ||
| Religion | Muslim | 484 | 94.9 |
| Christian | 26 | 5.1 | |
| Ethnicity | Gurage | 484 | 94.9 |
| Silte | 17 | 3.3 | |
| Others* | 9 | 1.8 | |
| Occupation | Government | 20 | 3.9 |
| Non-government | 16 | 3.1 | |
| Merchant | 37 | 7.3 | |
| Farmer | 322 | 63.1 | |
| Daily laborer | 29 | 5.7 | |
| Housewife | 73 | 14.3 | |
| Others** | 13 | 2.5 | |
| Education status | Illiterate | 320 | 62.7 |
| Primary education | 142 | 27.8 | |
| Secondary education | 30 | 5.9 | |
| College and above | 18 | 3.5 | |
| Family size | <3 | 82 | 16.1 |
| 3–4 | 92 | 18.0 | |
| 4–6 | 158 | 31.0 | |
| >6 | 178 | 34.9 |
Oromo and Amhara.
Student.
Utilization of eye care services
Among the 510 respondents who were asked whether they had heard of the importance of regular physical examinations, 281 (55.1%) had information. Furthermore, people with information were asked about sources of information and 178 (34.9%) got from health facilities, 58 (11.4%) from media, 29 (5.7%) from friends, and 16 (3.1%) from school. In addition, the respondents considered an eye care service-providing center as a preferred place of choice to get eye care services (Table 2).
Table 2.
Place of choice of respondents for an eye examination in Meskan District, central rural Ethiopia, 2020 (n = 510).
| Characteristics | Place of choice | Frequency | Percent |
|---|---|---|---|
| Place of choice (n = 221) | Eye care-providing center | 199 | 90 |
| Traditional/herbalist | 10 | 4.5 | |
| Home remedies | 3 | 1.4 | |
| Pharmacy | 2 | 0.9 | |
| General hospital/health center | 7 | 3.2 | |
| Eye problem in the past (n = 243) | Vision reduction | 111 | 45.6 |
| Redness and discharging | 75 | 30.9 | |
| Pain | 14 | 5.8 | |
| Itching | 19 | 7.8 | |
| Tearing | 17 | 7 | |
| Eye trauma | 7 | 2.9 | |
| Reason for not utilizing eye care service (n = 287) | Cost | 16 | 5.6 |
| Time constraint | 9 | 3.1 | |
| Considering the problem is minor | 49 | 17.1 | |
| Had no problem | 211 | 73.5 | |
| Did not know where to go | 2 | 0.7 |
Of the total respondents, 29% used eye care at least once in the past 2 years. Among people with eye problems, decreased vision accounted for 21.8% of all complaints. Participants reported that they had no eye problems, thought the problem was minor, and did not have the money to pay for services because they were not adequately using existing community eye care centers. In addition, participants also reported that lack of time and not knowing where to get services were the reasons for not seeking eye care services.
Factors associated with eye care service utilization
In binary logistic regression analysis, gender (female) (crude odds ratio (COR): 1.26; 95% CI (0.86, 1.85)), age above 65 years (COR: 4.14; 95% CI (2, 6.57)), history of eye problems (COR: 7.70; 95% CI (5.02, 11.79)), having systemic disease (COR: 2.12; 95% CI (1.22, 3.69)), perception of routine physical examination (COR: 10.89; 95% CI (6.74, 17.58)), and family history of eye problems (COR: 2.06; 95% CI (1.37, 3.11)) were statistically significant using p-value of ⩽0.25 as a cutoff point and hence selected as candidates for the final model.
In the final model, eye problems, chronic systemic disease, routine eye examinations, and the age of the participants were significantly associated with the use of eye care. The study found that older participants aged 65 or older, were four times more likely to use eye care as compared to participants aged 40–54 years (AOR: 4.04; 95% CI (2.20, 7.43)). In addition, people with previous eye problems were 10 times more likely to use current eye care than those without previous eye problems (AOR: 10.04; 95% CI (5.81, 17.33)). The presence of systemic illness had 2.5 times the possibility of up-taking eye care services (AOR: 2.52; 95% CI (1.21, 5.21)). In addition, respondents who knew about routine health exams were 11.7 times more likely to use eye care services when compared to those who did not know about routine eye exams (AOR: 11.75; 95% CI (6.62, 20.84)) (Table 3).
Table 3.
Factors associated with eye care service utilization among residents in Meskan District, Ethiopia, Bivariate analysis, 2020 (n = 510).
| Variables | Categories | Utilization of eye care service | COR (95% CI) | AOR (95% CI) | |
|---|---|---|---|---|---|
| Yes (%) | No (%) | ||||
| Sex | Male | 69 (46.6) | 79 (53.4) | ||
| Female | 190 (52.5) | 172 (47.5) | 1.265 (0.862, 1.855) | 1.379 (0.824, 2.309) | |
| Age | 40–54 | 70 (21.9) | 250 (78.1) | ||
| 55–64 | 20 (24.4) | 62 (75.6) | 1.152 (0.652, 2.036) | 0.852 (0.412, 1.762) | |
| >65 | 58 (53.7) | 50 (46.3) | 4.143 (2.610, 6.575) | 4.048 (2.204, 7.433) | |
| Eye problems | Yes | 129 (63.9) | 73 (36.1) | 7.701 (5.027, 11.797) | 10.043 (5.818, 17.334)* |
| No | 19 (6.2) | 289 (14.3) | |||
| Presence of systemic illness | Yes | 26 (44.1) | 33 (55.9) | 2.125 (1.221, 3.699) | 2.520 (1.218, 5.215) |
| No | 122 (27.1) | 329 (72.9) | |||
| Awareness | Yes | 122 (52.8) | 109 (47.2) | 10.891 (6.745, 17.588) | 11.750 (6.62, 20.84) |
| No | 26 (9.3) | 253 (90.7) | 1 | ||
| Family history of eye problem | Yes | 58 (40.3) | 86 (59.7) | 2.068 (1.374, 3.114) | 1.664 (0.961, 2.881) |
| No | 90 (11.4) | 276 (16.9) | |||
shows statistical significance at p-value <0.05.
Discussion
In the present study, the prevalence of eye care service utilization and associated factors were assessed. Accordingly, the utilization rate of eye care services among rural residents of Meskan district was 29% (95% CI (0.25, 0.33)), which is lower than the finding from Gondar, Northern Ethiopia. 10 This difference may be due to differences in the research area and the socioeconomic status of the study participants. Similarly, the finding is lower than the results of studies from Tehran, Iran (34.7%), 13 and Abuja, Nigeria (38%). 7 This difference is due to the difference in the definition of activity used in this study and those mentioned above. In this study, the use of eye care for the purpose of promotion, prevention, cure, or rehabilitation was considered as the use of eye care, while other studies used the eye care service utilized for 3–5 years. Besides, the findings of this study are slightly better than the findings of the studies from Hawassa, southern Ethiopia (23.8%), 14 and southwestern Nigeria (25%). 3 The difference in results may be due to differences in sample size and the operational definitions employed.
Awareness of the recommended frequency of eye examinations was significantly associated with the use of eye care. Information on regular check-ups was also closely related to the study conducted in both Gondar 10 and Hawassa, 14 Ethiopia. Information obtained on the importance of regular check-ups in health facilities, media, and schools helps communities perceive and increase the use of existing eye care.13,14
In this study, the use of eye care services increased with age. Age above 65 is strongly associated with eye care service utilization, which is in line with the findings from Ethiopia, 14 Nigeria, 3 and Iran. 13 The main reason is that old age is one of the main causes leading to degenerative eye diseases and the need to use glasses. Poor vision occurs with increasing age, forcing the elderly to seek eye care services.
Having a history of eye problems was strongly associated with the use of eye care services based on the variables listed in the need factors. Similar results were found in studies conducted in Ethiopia, 14 Nigeria, 3 Ghana, 16 and Australia. 15 Most eye problems are extremely uncomfortable and painful and require immediate medical attention. This is why people who have had eye problems before have gone to an eye care center instead of their peers without any eye problems.
People with systemic diseases such as diabetes and high blood pressure used eye care more often than those who did not. Studies in southwest Nigeria 3 and Australia 15 have confirmed the results. Systemic diseases such as diabetes and hypertension are among the main causes of retinal eye problems. In addition, retinopathy from systemic diseases such as diabetes and high blood pressure can lead to severe vision loss and irreversible blindness without prompt medical attention. 17
The aforementioned results tried to show the magnitude of utilization and associated factors that enhance the understanding of the sociodemographic and health behaviors of the service recipients which, in turn, help to design strategies that would help to provide eye care services to those who underutilize them. This is the first study of its kind conducted in a rural area on eye care services utilization and will help to shape policy decisions for eye care system improvement.
Although this study has strengths like the aforementioned, it also has some limitations. Recall bias might affect the finding since participants were asked about events that happened in the past. Efforts were made to minimize the impact of bias in the overall study results by adopting a standardized questionnaire. The other limitation of this study is the lack of adequate literature for comparison with similar settings and study populations.
Conclusion
This study found that eye care service utilization was low in the study area. The age of the participants, the presence/history of eye disease, knowledge of routine examinations, and the presence of systemic disease were significantly associated with eye care service utilization. Hence, all stakeholders should work to increase the absorption of existing ophthalmic services especially for older ages, and create awareness on the use of ophthalmology services to prevent and control blindness. Besides, there should be an eye care services provision department at all levels of the healthcare system.
Supplemental Material
Supplemental material, sj-docx-1-smo-10.1177_20503121231197865 for A community-based cross-sectional study of eye care service utilization among the adult population in southern Ethiopia by Hailu Merga, Desalegn Amanuel, Lata Fekadu and Lamessa Dube in SAGE Open Medicine
Acknowledgments
We would like to thank the study area district administration and each kebele for the provision of the needed data for our study. Special thanks and appreciation to all those who agreed to participate in this study, mainly the respondents, data collectors, and supervisors.
Footnotes
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Ethics approval: Ethical approval for this study was obtained from the Jimma University Institute of Health institution review committee (Ethics Approval Number (JUIRB/THRPGD/21/2020)) and official permission was taken from each study participant.
Funding: The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: Jimma University Institute of Health funded this study. The organization has no role in the designing of the study, data collection, analysis, and interpretation of data, and in writing the manuscript.
Informed consent: We thought at the beginning of the study that the participants in our study were semi-literate. Due to this reason, the proposal was submitted to our Institutional Review Board/Ethics Committee for obtaining verbal consent and the consent was approved by your Institutional Review Board/Ethics Committee (Ethics Approval Number (JUIRB/THRPGD/21/2020)). Then, the study participants were informed about the objective and purpose of the study, and verbal informed consent was taken from each study participant
Trial registration: Not applicable.
ORCID iD: Hailu Merga 
https://orcid.org/0000-0001-7536-4755
Supplemental material: Supplemental material for this article is available online.
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Associated Data
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Supplementary Materials
Supplemental material, sj-docx-1-smo-10.1177_20503121231197865 for A community-based cross-sectional study of eye care service utilization among the adult population in southern Ethiopia by Hailu Merga, Desalegn Amanuel, Lata Fekadu and Lamessa Dube in SAGE Open Medicine