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

Vision impairment and blindness remain a challenge in developing countries, especially in rural communities. Notwithstanding, VISION 2020 global initiative seeks to eliminate avoidable blindness by 2020. This community-based cross-sectional study aimed at determining the accessibility of ophthalmic services and barriers to its utilization in rural communities in the Upper Denkyira West District, Ghana. One-hundred and seventy participants from 5 randomly chosen rural communities in the district were included. Participants were interviewed using a structured questionnaire. Socio-demographic information, information regarding accessibility, utilization, and barriers to eye care services were obtained. Descriptive statistics were carried out using SPSS version 23. The Chi-squared test was employed to determine associations. P-values less than 0.05 at a confidence interval of 95% were considered significant. Only 21.8% of participants had had eye examination within the past 3 years, with over half of the examinations undertaken at screening grounds and health centres. Significant associations were found between ophthalmic services utilization and increasing age [p = 0.004], female gender [p = 0.027] and those who had a past history of eye problem(s) [p = 0.001]. The study found gross inadequate utilization of ophthalmic services mainly due to unavailable ophthalmic services in the rural district. Public health education and eye care interventions should prioritize and target rural populations.


Introduction
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] . 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. Five communities were randomly selected. This was chosen on the basis of previous district-wide studies [26,27] . All communities (list obtained from the district assembly) were assigned a number label. Each number was written on equally sized pieces of paper and folded up into a bowl. The 5 communities: Breman-Brofoyedu, Domenasi, Besease, Maudaso, and Nkotumso were then drawn one after the other from the bowl.

Study Area and Design
Thirty-four participants each from the 5 randomly selected communities were chosen using a systematic random sampling. This was done by selecting every second person who reported to the outreach grounds in response to announcements that were made earlier in the communities.
Participants were interviewed using a structured questionnaire.
Socio-demographic information, information regarding accessibility, utilization, and barriers to eye care services were obtained.

Data Analysis
Data collected were analysed using the Statistical Package for Social Science (SPSS) version 23 (SPSS Inc, Chicago, IL, USA). Descriptive statistics were carried out and the Chi-squared test was employed to determine associations. P-values less than 0.05 at a confidence interval of 95% were considered significant.

Ethical Consideration
The study was conducted in accordance with the tenets of the Declaration of Helsinki. The district authorities and authorities of the various communities were informed of the survey and their permission subsequently obtained. Informed consents were also gotten from study participants. Sufficient information was given to each participant to decide on partaking in the study or not. Participants' anonymity and confidentiality were also kept.
Participants past ocular problems and treatments sought (Table 3).

Influence of Socio-demographic Factors on
Ophthalmic Service Utilization (Table 4).

Barriers to Ophthalmic Services Utilization
A total of 563 responses from 169 (99.4%) participants were obtained, giving a mean response of 3 per person (Table 5).

Discussion
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 Although there are minor differences in reported levels of ophthalmic services utilization in rural areas, many are consistent indicators of inadequate utilization [11] . Coincidentally, Ocansey [24] 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]  . 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. [32]  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. 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] (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.

Conclusions
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.

Recommendation
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.