Awareness, knowledge, and barriers to low vision services among eye care practitioners

Abstract

Background:

Eyesight plays an important role in our day today life. When the vision gets hampered, daily activities of an individual will be affected. The prevalence of visual impairment is increasing across the globe, with more burdens on the developing world. The uptake of low vision services remains to be low in developing countries like India.

Methods:

A newly constructed questionnaire using information from previously conducted telephonic interviews and article search was administered among 50 eye care practitioners from Kerala, India for the pilot study. Modifications were made in the questionnaire, based on the responses obtained from the pilot study. From their responses, awareness, knowledge, and barriers for the low vision services among eye care practitioners were assessed.

Results:

(1) Pilot study - the Cronbach's alpha values obtained for knowledge, awareness and barrier questions were 0.814, 0.297, and 0.810, respectively, and content validity index was found to be 0.64. (2) Main study - 211 eye care practitioners from 12 states of India took part in the study that accounted for a response rate of 16.7%. The participants included were 95 (45%) men and 116 (55%) women with a mean age of 28.18 ± 7.04 years. The lack of awareness was found to be the major barrier in the provision and uptake of low vision services from the practitioner's perspective.

Conclusion:

The study results showed that there is a lack of awareness among eye care practitioners about low vision services, which acts as a major barrier in the effective delivery of these services.

Introduction

Visual impairment is a major health concern all over the world. About 90% of the world's visually impaired live in developing countries. As per the population-based studies, over the past two decades, the highest number of visually impaired people (over 9 million) live in India.[1,2]

The most recent World Health Organization (WHO) statistics shows that 285 million people are visually impaired worldwide, 39 million are blind, and 246 million have low vision.[3] According to WHO, visual impairment includes both low vision and blindness.

Low vision is a broad term used for conditions resulting in reduced vision that cannot be completely rectified even after treatment. Low vision services work well in controlling the functional and psychological impacts of visual impairment.[4] It also improves the quality of life and daily living skills of the individual. The goal of any vision rehabilitation is to empower patients to lead fruitful lives.[5,6]

Despite the fact that the prevalence of visual impairment and low vision is increasing, the uptake continues to be relatively low in the developing countries like India.[4] There are studies that have been done to identify the provision and uptake of low vision services globally and in India.[7,8,9] Barriers for the uptake of low vision services from the perspective of patients and ophthalmologists have also been studied.[10,11,12]

In this context, it is necessary to have data on the knowledge and awareness of low vision services among eye care practitioners to improve the low vision care in the developing world. There is dearth of published data on these aspects.

Hence, the aim of this study was to construct, validate, and distribute a questionnaire to find out the awareness, knowledge, and barriers to the provision of low vision care among eye care practitioners in India.

Methods

It was a cross-sectional study conducted over a period of 10 months among practicing optometrists and ophthalmologists residing in different states across India. The study had obtained approval from the Institutional Review Board of School of Allied Health Sciences, Manipal and was performed according to the guidelines of the Declaration of Helsinki. We constructed the questionnaire using information from previously conducted telephonic interviews among independently practicing optometrists in Chennai and by article search. The newly constructed questionnaire contained 24 questions, which included demographic details of the participant (n = 7), awareness (n = 3) and knowledge questions (n = 4), practice pattern questions (n = 7), barriers for the provision, and uptake of low vision services from the practitioner's perspective (n = 3) (Annexure 1 [SUPPORTING:1]). All the barrier questions and one awareness question had sub divisions in which the participants were requested to respond “Yes” or “No” or “Not sure.” All the other questions were given with specific response options. “Yes” was given a score of 1 and “No” and “Not sure” was recorded as “0”.

Pilot study was conducted among 50 eye care practitioners. Changes were made to the options in the questionnaire based on the responses from the pilot study. All the knowledge, awareness, and barrier questions were rated on a three point scale (totally relevant = 1, Relevant but not useful = 2, Not relevant = 3) by 9 eye care professionals to find the content validity of the questionnaire.

Validated questionnaire was made available on a web-based questionnaire format so that it could be circulated all over India and filled online. Every question except the optional questions was made mandatory to attain the completely filled questionnaire. All the responses were collected into the Gmail drive and it was accessible to the investigators at any point of time.

Contact information of the participants was collected through hospitals, optical outlets, and friends. The questionnaires were sent to the participants through E-mail and a few were distributed in person. Participation in the study was voluntary.

Online survey: Web link to access the questionnaire was E-mailed to 1020 eye care practitioners from the contacts along with a brief introduction about the study.

Reminder mails were sent after 2 weeks and after 4 weeks for those who had not responded to the first mail. The participants who failed to fill up the questionnaire even after the second reminder were excluded from the study.

Direct survey

The online survey could not reach everyone as some of the practitioners were either not comfortable with the online method, or internet was inaccessible on time. Hence, a direct survey method was planned where the participants filled the questionnaire in hand. 250 eye care practitioners were targeted through this method.

From the collected questionnaires, each question was scored and analyzed. All the correct response was scored as 1 and the wrong response as 0. Total scores for awareness and knowledge were calculated and the maximum score expected was 3 and 13, respectively. Awareness and knowledge were categorized into good, average, and poor. The scores were recorded as: 3 - Good, 2 - Average, ≤1 - Poor for awareness and >9 – Good, 9 to >5 – Average, and ≤5 – Poor for knowledge domain.

Statistical Package for Social Sciences (SPSS) software version 16.0 for Microsoft Windows (SPSS Inc., Chicago, IL, USA). Internal consistency of the questionnaire was assessed using Cronbach's alpha. Descriptive statistics was used to find out the common practice patterns. Kruskal–Wallis test was used to understand the variation in awareness, knowledge, and barriers with respect to profession, educational qualification, and years of experience. P < 0.05 was considered to be statistically significant. Chi-square test was done to find out the association between awareness, knowledge, and barriers with age, qualification, and years of experience of the participants.

Results

Pilot study

Pilot study was conducted among 50 eye care practitioners in Kerala. Participants of the pilot study included 12 (24%) men and 38 (76%) women. Among the participants, 13 were ophthalmologists and 37 were optometrists. Cronbach's alpha was run on 30 responses as the completely filled questionnaire obtained was only 30 out of the 50 distributed. The values obtained for knowledge, awareness, and barrier questions were 0.814, 0.297 and 0.810 respectively. Content validity index was calculated for the same questions and found to be 0.64, indicating good agreement by all experts that the items were measuring the correct objective.

Main study

Questionnaires were sent to 1270 eye care practitioners and the responses were obtained from 211 practitioners accounting for a response rate of 16.61%. Among the participants, 42 were ophthalmologists and 169 were optometrists from 12 states of India. Male and female participants were 95 (45%) and 116 (55%), respectively. The mean age of the practitioners was 28.18 ± 7.04 years.

The qualification and the type of practice of the participants are given in Tables 1 and 2, respectively. In this study, retinal problems (85.8%) and glaucoma (59.7%) were reported as two major causes of low vision. Among the participants, 65.4% preferred to provide the best possible spectacle correction to the low vision patients visiting them. Provision of low vision devices, rehabilitation, and referral to other hospitals/specialized centers were considered by 64.5%, 39.8%, and 36% practitioners, respectively. Magnifiers were found to be the most commonly prescribed low vision device (82%). Low vision rehabilitation is considered as a combination of training to use low vision devices, mobility training, adaptive training for job and counseling by 40.23% of the participants. The suggestions given by the participants to improve low vision services are listed [Table 3].

Table 1.

Qualification of the participants

Table 2.

Type of eye care practice indulged in

Table 3.

Responses from practitioners to improve low vision services

Lack of awareness (64%) and training (62.1%) among the practitioners were the major barriers restricting the provision of low vision services [Figure 1]. The major barrier for low vision uptake from the practitioner's perspective was lack of awareness among patients (91.5%) [Figure 2].

Figure 1.

Barriers for the practitioners in providing low vision care

Figure 2.

Barriers to the patient for accessing of low vision services from practitioner's perspective

Though 86.7% of the practitioners were interested to participate in short-term training programs in low vision, lack of time, and accessibility of training programs turned out to be the major deterrents.

Awareness about the WHO definition of low vision and organizations that provide low vision rehabilitation and concession facilities were observed among 86.3%, 75.4%, and 64% of the participants, respectively. About 27.5% of the participants knew the current WHO definition of low vision.

Awareness and knowledge among the participants are given in Figure 3. The eye care practitioners who had good awareness and knowledge about low vision services in the study were found to be 55.9% and 30.4%, respectively.

Figure 3.

Awareness and knowledge about low vision services among practitioners

According to the Kruskal–Wallis test results for all the participants, knowledge (P < 0.01,5), awareness (P < 0.001,5) and barrier in providing low vision care (P < 0.001,5) vary with the educational qualification. These factors did not show any variation with years of experience of the participants. The barriers in providing low vision care (P < 0.05,4) showed variation with the type of practice of the participants.

Kruskal–Wallis test among optometrists showed the same result as for the total participants. P values associated are specified [Table 4]. In the case of ophthalmologists [Table 5], none of the parameters showed any variation (P > 0.05) with qualification, years of experience, and type of practice.

Table 4.

Kruskal-Wallis test values of optometrists against different variables

Table 5.

Kruskal-Wallis test values for ophthalmologists

On doing Chi-square test, there was no association between awareness, knowledge, age, type of practice, and years of experience of the participants. Statistical significance was observed between awareness (χ² = 47.91, P < 0.01) and knowledge (χ² = 22.38, P = 0.01) with the qualification of the participants. There was no statistical significance observed between barriers and the variables under study.

Discussion

In this study, the percentage of eye care practitioners having good awareness and knowledge about low vision services were found to be 55.9% and 30.4% respectively. To the best of our knowledge, this is the first data on awareness and knowledge about low vision services among eye care practitioners. Forty-eight percentage of the practitioners considered persons having low vision based on the patient needs rather than visual acuity measurements according to our study results. This is consistent with the findings observed by Marinoff.[13] The posterior segment diseases were found to be the major causes of low vision by the participants in the current study. This results correlated well with the findings of previous studies.[14,15,16,17]

In our study, the major barriers to access low vision services by the patients from practitioners’ perspective were a lack of awareness (91.5%) and availability of low vision care centers (81.5%). The following studies support our results.

Khan et al. in their study found that the lack of knowledge and awareness about low vision can act as a barrier to the provision of low vision services among ophthalmologists in India.[11]

Another study done by Okoye et al. among ophthalmologists in Nigeria cited nonavailability of low vision devices within the country, lack of training in low vision care, lack of public awareness of low vision care and its practitioners and the ophthalmologists’ preoccupation with general ophthalmic practice as the major barriers in clinical low vision provision.[18]

Concurrent health issues and patient's perception to low vision were the reasons for accessing low vision services among patients as reported in a study conducted by Matti et al. in South Australia, which emphasize the need for raising the patient awareness to increase low vision service uptake.[14] This is consistent with our study findings.

Improved communication between eye care practitioners and low vision services can increase low vision uptake as reported by Keeffe et al.[19]

Barriers to the referral for low vision rehabilitation may be due to misconceptions about referral criteria and lack of information as observed by Adam and Pickering in their study.[20]

From the participant's response to the questionnaire, we observed that the awareness and knowledge about low vision services were less among the ophthalmologists and optometrists. This emphasizes the need of education to improve awareness and knowledge about the delivery of low vision services.

A comprehensive study on low vision services which comprises the perceived barriers for low vision care and distribution of low vision services in the country would help the policy makers to plan and upgrade the future network of low vision services in India according to Ilango and Krishna.[21] Listing of the professionals at different geographical locations or states with their contact details within the country can help better service provision to the needy. Moreover, a multi-dimensional and multi-disciplinary approach from different professionals is desirable to provide an effective service delivery to the low vision patients, which is the need of the hour.[22,23]

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

Annexure 1

Questionnaire

1. Name:

2. Date of birth: Gender: M/F

3. Qualification: If ophthalmologist If optometrist

   Specialization: MD/ DO/ DNB M.Optom/

   B.Optom/ Diploma

4. 4. Type of practice :

   • : Hospital (Gov. / Private)
   • : Individual practice
   • : Optical outlet
   • : Others (Please specify)

5. Years of experience:

6. Address of correspondence:

   Place: State:

   Tel./E.mail:

7. How often do Low vision patients visit your clinic?

   1. Often
   2. Rare
   3. Very rare
   4. Never
      (If ‘eNever’ please go to question no.9)

8. What do you do when you get a patient with low vision? (Tick all that apply)

   1. Provide best possible spectacle correction
   2. Provide Low vision devices
   3. Provide rehabilitation
   4. Refer to other hospitals/specialized centres
   5. Not sure

9. Are you aware of WHO (World Health Organization) definition of low vision?

   : Yes/No/Not sure

10. In your practice you consider a person as having low vision based on?

    1. WHO criteria
    2. Patient needs (e.g.: Unable to perform daily activities/hobbies)
    3. Poor vision in one eye only
    4. Poor vision in both the eyes
    5. Not sure

11. According to you the criteria for low vision should be based on:

    1. Visual acuity
    2. Visual field
    3. Visual acuity and visual field
    4. Visual acuity or visual field
    5. Not sure

12. You consider a person is having Low vision when the best corrected visual acuity in the better eye is worse than?

    1. 1/60
    2. 3/60
    3. 6/60
    4. 6/36
    5. 6/18
    6. Not sure

13. You consider a person is having low vision when his/her visual field from the point of fixation is worse than?

    1. 10°
    2. 20°
    3. 30°
    4. Not sure

14. How often do you provide Low vision devices in your practice?

    1. Often
    2. Rare
    3. Very rare
    4. Never
       (If ‘Never’ please go to question no. 17)

15. What kind of devices do you provide? (Tick all that apply)

    1. Magnifiers
    2. Telescopes
    3. Electronic devices
    4. Other assistive devices

16. What are the common causes of low vision that you have come across in your practice? (Tick all that apply)

    1. Retinal problems
    2. Post cataract surgery
    3. Glaucoma
    4. Microphthalmos
    5. Microcornea
    6. Nystagmus
    7. Inability to afford any other treatment
    8. Not sure

17. What according to you is low vision rehabilitation? (Tick all that apply)

    1. Training to use low vision devices
    2. Mobility training
    3. Adaptive training for job
    4. Counseling
    5. Not sure

18. Do you know any organizations which provide low vision rehabilitation?

    : Yes/No/Not sure

19. According to you what are the major barriers that you face in your practice in providing low vision care? (Tick all that apply)

    1. Lack of awareness: Yes/No/Not sure
    2. Lack of training: Yes/No/Not sure
    3. Lack of interest/motivation: Yes/No/Not sure
    4. More work load: Yes/No/Not sure
    5. Non. availability of low vision devices: Yes/No/Not sure
    6. Low vision care is time consuming: Yes/No/Not sure
    7. Low vision devices are expensive: Yes/No/Not sure
    8. Low vision care is less profitable: Yes/No/Not sure
    9. Lack of man power: Yes/No/Not sure
    10. Low vision care is not effective: Yes/No/Not sure
    11. Difficulty in satisfying patients: Yes/No/Not sure

20. According to you what are the barriers to the patients to access low vision services?

    1. Lack of awareness: Yes/No/Not sure
    2. Lack of interest/motivation: Yes/No/Not sure
    3. Low vision service is expensive: Yes/No/Not sure
    4. Availability of Low vision care centers: Yes/No/Not sure
    5. Cosmetically not acceptable: Yes/No/Not sure

21. Are you aware of any concession facilities available to Low vision patients?

    : Yes/No/Not sure

22. According to you what are the areas in which a Low vision patient is eligible to get concession?

    1. Travel: Yes/No/Not sure
    2. Postage: Yes/No/Not sure
    3. Telecommunication: Yes/No/Not sure
    4. Income tax concession: Yes/No/Not sure
    5. Reservation of jobs: Yes/No/Not sure
    6. Assistance for self-employment: Yes/No/Not sure
    7. Bank loans: Yes/No/Not sure
    8. Educational concession: Yes/No/Not sure
    9. Pension for old age: Yes/No/Not sure
    10. Assistance for purchase or fitting of aids and appliances:
        Yes/No/Not sure

23. According to you how can we improve low vision practice?

    1. Creating awareness among practitioners: Yes/No/Not sure
    2. Creating public awareness: Yes/No/Not sure
    3. More training programs: Yes/No/Not sure
    4. Including Low vision as a part of curriculum:
       Yes/No/Not sure
    5. Improving the availability of Low vision devices:
       Yes/No/Not sure
    6. Availability of Low vision devices at low cost:
       Yes/No/Not sure

24. Will you be interested to participate in short term training in Low vision?

    : Yes/No

25. What according to you are the barriers for attending a low vision training program?

    1. Lack of time: Yes/No/Not sure
    2. Lack of interest: Yes/No/Not sure
    3. Lack of man power: Yes/No/Not sure
    4. Training programs are expensive: Yes/No/Not sure
    5. Accessibility: Yes/No/Not sure
       Thank you for the co-operation and time devoted for participating in the survey.