Eye care utilisation is among the essential factors considered in addressing the rising global prevalence of visual impairment and avoidable blindness.¹ Visual impairment and blindness remain a major public health issue globally, especially in the low- and middle-income regions.²

Although the elimination of avoidable blindness and visual impairment, especially from infectious diseases, has seen some significant progress in developed countries, it is still a major public health issue in the developing and under-developed countries.² The World Health Organization (WHO) and the International Agency for the Prevention of Blindness (IAPB), have, for more than a decade, been working towards the eradication of preventable blindness by the year 2020 through the VISION 2020: The Right to Sight initiative.³ Fatouhi et al.,⁴ revealed in their study that eye care service utilisation, is a crucial factor in realising the goals of ‘VISION 2020’. Therefore, understanding utilisation trends across Ghana could assist in designing strategies to improve eye care utilisation.

Best practice in optometry and ophthalmology recommends regular visits to eye care professionals, as routine eye examinations support the early detection of ocular defects and associated systemic, sometimes potentially life-threatening, conditions.⁵ Early interventions to restore, manage or treat such conditions also improve the prognosis. Furthermore, in cases of low vision where optimal sight cannot be restored, the quality of life of the patients can be improved through rehabilitation and other supportive interventions.⁶ It is essential that people access ophthalmic services regularly, because of the availability of interventions to prevent sight loss as a result of eye diseases or other causes of avoidable vision impairment.⁷ However, a study among older adults reported that the uptake of eye examinations in low, lower-middle, upper-middle and high-income countries was only 10%, 24%, 22% and 37%, respectively.⁸

Studies have been conducted on the low level of utilisation of ophthalmic services in both developed and developing countries to understand the factors responsible for the low utilisation of ophthalmic services.^9,10,11 Studies have reported that individuals do not routinely access ophthalmic services in Ghana.^7,12,13 However, these studies fell short of finding the reasons for the low utilisation of ophthalmic services, which is crucial in developing strategies to improve utilisation of the service.

A clear knowledge of ophthalmic service utilisation and its related factors will provide a framework, which stakeholders can use to develop strategies to improve eye care utilisation. This will reduce the prevalence of preventable blindness and visual impairment among people.

This study sought to determine the utilisation of ophthalmic services and the associated factors in the Ashanti region of Ghana, to help inform strategies to improve utilisation of the service.

Coverage is a crucial component in the assessment of healthcare system performance. In this study, therefore, participants’ self-reported history of ever having visited an eye care facility for their eye care needs was used as a measure of eye care utilisation. This study revealed that 57.2% of the participants had never had their eyes examined, while only 25% had had their eyes examined at least once in the previous 2 years. The study found that age, district of residence, level of education, monthly income, presence of systemic disease (diabetes, hypertension), self-reported vision problems and feeling that regular eye examinations are important, were significantly associated with eye care utilisation. Gender was not statistically associated with eye care utilisation in this study. However, a higher proportion of males had utilised eye care, compared with females.

More than half (57.2%) of the participants had never utilised eye care services, which was in agreement with several other studies.^{7,16,17,18,19} Possible factors that could serve as barriers to ophthalmic services utilisation include availability, affordability and accessibility.

This study found age to be significantly associated with eye care utilisation. The increased likelihood of the aged seeking eye care, compared with the young, can be attributable to age-related ophthalmic conditions.⁴ The older one gets, the higher one’s risk of developing ophthalmic conditions and the more likely one is to seek eye care.³ This is consistent with studies in both developing¹⁸ and developed²⁰ countries.

District of residence was also found to be associated with eye care utilisation. Residents in Asokore Mampong, Ejisu and Bosomtwi were significantly more likely to seek eye care than those in other districts. Regional differences in eye care utilisation have been reported by other studies.^18,21 This may be attributed to differences in awareness about the need for regular eye examinations and the availability of ophthalmic services in the communities. Asokore Mampong and Ejisu are urban districts that have a number of public and private eye care facilities available to their people. Although Bosomtwi is a rural constituency, it has two well-equipped ophthalmic mission clinics operated under the auspices of the Christian Health Association of Ghana (CHAG), which serve patients across the region. This may be one of the reasons why a higher proportion of the participants in Bosomtwi, compared with the other districts, were associated with seeking eye care, despite it being a rural district.

Level of education was associated with eye care utilisation. Participants with a higher level of education were more likely to utilise eye care than the less educated. This may be attributed to greater knowledge and perhaps more concern about their eye health. Fotouhi et al.⁴ also reported an increased likelihood of utilising eye care with higher levels of education in an Iranian population and presumed educated people usually belong to the higher socioeconomic class, which facilitated greater access to eye care in terms of affordability. Other studies^13,22,23 also reported a positive association between education and eye care use.

Monthly income was also found to be associated with increased likelihood of utilising eye care services. A plausible explanation could be the general socioeconomic status of higher-income earners. They may, therefore, find ophthalmic services more affordable and thus have greater access compared with low-income earners. This observation was reported in other low- and middle-income countries.^11,24,25,26

Self-reported vision problems were also associated with an increased likelihood of utilising eye care services, as such problems may affect the activities of daily living. Vision can also be a determinant in the career aspirations of people, and thus its loss is linked to the loss of certain occupations, which may drive poverty and mental health conditions, among others. Ahmad et al.²⁷ and Akuffo et al.²⁵ reported a higher probability of persons with vision-related problems seeking eye care services. People with symptoms of blurred vision, or any other vision-related problem, will generally be more likely to seek eye care.

Participants who felt regular eye examinations were important were significantly associated with an increased likelihood of seeking eye care. People who are aware of the need for regular eye examinations will know more about the preventative aspects of vision loss than those who are unaware, thus, increasing their likelihood of using eye care services. Regular eye examinations can detect ophthalmic conditions in their earliest stage when they are most treatable to prevent vision loss, as many vision-threatening eye diseases including glaucoma, macular degeneration, cataracts or diabetic retinopathy have no or minimal symptoms until the disease has progressed.

A significant association was also found between the presence of a systemic disease, such as diabetes or hypertension and eye care utilisation. This could be a result of the recommendation generally given to diabetics and hypertensives to monitor their eyes at least once every 2 years²⁸ because of the risk of developing retinopathies after some years of having these conditions. Other studies^29,30 reported similar observations. They recommended health education and awareness campaigns on the benefits of seeking ophthalmic services timeously to prevent visual impairment.

To the authors’ knowledge, this is a pioneering study assessing ophthalmic service utilisation in the Ashanti region of Ghana, with the major advantage of using population-based evidence for eye care utilisation. This suggests that its findings could be generalised to the entire population of the Ashanti region of Ghana. However, our study has some limitations. The factor used to measure the utilisation of ophthalmic services was self-reported, which may have been affected by recall bias: recalling the period since the last eye examination. Data were generated from 10 of the 43 districts in the region because of logistical constraints. Nonetheless, the results from this study could assist in developing strategies to improve ophthalmic service utilisation in the Ashanti region and in Ghana as a whole.

In conclusion, the study revealed an alarmingly low use of ophthalmic services in the Ashanti region of Ghana. Ophthalmic service utilisation was found to be associated with some predisposing, enabling and need factors, as explained by Anderson’s healthcare utilisation model. Regarding predisposing factors, ophthalmic service utilisation was associated with age but not with gender. Enabling factors such as district of residence, level of education and monthly income (wealth) were associated with an increased likelihood of seeking ophthalmic services. With regard to the need factors, we found that participants with diabetes, hypertension, vision problems and those who think regular eye examinations are important are associated with eye care utilisation.

There is a need for effective public health programmes to address the socio-economic and individual barriers hindering the uptake of ophthalmic services in the Ashanti region of Ghana. The importance of timeously seeking eye care services in preventing visual impairments and blindness needs to be emphasised. The awareness of available eye care services in the region, with an emphasis on the implications of delays in seeking eye care, should be promoted intensively. Stakeholders should start public eye health campaigns on the annual, dedicated World Sight Day to raise awareness about the need for regular eye examinations.