In terms of the Global Initiative for the Elimination of Avoidable Blindness, a strong case must be made for the further promotion and acceptance of active community involvement in eye care service development, implementation and evaluation. Active community participation has a vital contribution to make towards reducing the magnitude of preventable blindness caused by the five major causes of blindness particularly identified in the Global Initiative - cataract, trachoma, onchocerciasis, childhood blindness (especially due to vitamin A deficiency) and refractive errors and low vision.
It is important to understand, however, that 'community participation' is not an overall answer to all problems. Rather, active community involvement should be considered an important resource input in eye care programmes that need to be encouraged, accepted, recognised and supported by existing health care delivery systems. Access to health-related information by community members is only one necessary example of how health care providers - both government and non-government - can improve the skills of community members and so increase the effect of community involvement towards prevention of eye problems.
Finally, in regard to the broader aspects of health promotion, the effectiveness of community participation in eye health is significantly linked with the other four elements identified in the Ottawa Charter. Foremost amongst these, in developing world settings, are the processes of improving the social and environmental situations where people live and work as well as the furtherance of personal and collective skills, e.g., literacy and improved health awareness.
Ottawa Charter for Health Promotion - First International Conference on Health Promotionp Ottawa, Canada. World Health Organization/Health and Welfare Canada/Canadian Public Health Association. 1986.
Kipp W, Burnham G, Bamuhiiga J, Weis P, Büttner DW. Ivermectin distribution using community volunteers in Kabarole district, Uganda. Health Policy and Planning 1998; 13(2): 167-73.
Fletcher A et al. Barriers to using eye services and recommendations to improve service p-take - research findings and international workshop recommendations. Madurai: India. 1998.
Zakus JD, Lysack CL. Revisiting community participation. Health Policy and Planning 1998; 13(1): 1-12.
Review Article: People Who Don't Use Eye Services: 'Making the Invisible Visible'
Martine Donoghue BSc MSc
Department of Epidemiology & Health
London School of Hygiene
& Tropical Medicine
London WC1E 7HT
People's use of health services is influenced by a range of psychological, social, cultural, economic and practical ýactors. Eye care services are no exception. Nevertheless, there has been a tendency to assume that if eye services are available then people in need will use them, particularly if they are provided free of charge. This paper will focus upon the poor utilisation of services for the treatment of cataract in developing countries, and the reasons underlying this. The viewpoint examined will be that of the individual with an eye problem.
Levels of Cataract Surgery Up-take are Low
The effectiveness of prevention of blindness programmes is seriously weakened by the low levels of cataract surgery up-take. The WHO states that globally only a quarter of people in need currently use eye services.1 This is supported by evidence from studies conducted in India and Nepal which demonstrate levels of utilisation of eye services, and uptake of cataract surgery ranging from 7% to 35%.2-4
A misleading impression of good utilisation is created by treatment centres which have a high patient demand. This overlooks the following:
A few institutions cannot deal with such a large problem
There are highly reputable treatment centres which are extremely busy. Yet on balance many other institutions have empty beds and waiting rooms. Furthermore, the overall number of people presenting at treatment centres is a small fraction of those in need.
There are high levels of non- ompliance with treatment recommendations
More people consult eye care services than follow through with treatment recommendations. People often do not return for treatment when they have been advised to come back at a later date. This is particularly true for a recommendation of future cataract surgery. These potential cataract beneficiaries are possibly hoping for a 'quick fix' in the form of medication, and do not re-present for the reasons outlined below.
Who Uses Cataract Services?
Typically eye service users are more likely to be male, live close to the treatment source, and possibly have higher literacy levels.2-4 It is not clear from current research if there are fundamental differences in the health beliefs of service users and non-users.
Reasons for the Poor Use of Eye Services
The main reasons for not seeking treatment given by people with eye problems in India, Nepal and the Gambia 2-5 are shown in the text box.
- damage /'spoil' eyes.
- miscellaneous fears.
Cannot leave family/work responsibilities.
Post-operative recommendations put them off.
Can manage - treatment not necessary.
Fatalistic - 'God's will'.
Lack of transport.
Despite the difference in geographical and cultural settings, there is a remarkable consensus of opinion amongst people about why they do not seek treatment. berceptions about which are the major and minor barriers to service use vary from place to place.
Providers tend to attribute poor user demand to an ignorance of treatment availability and benefit. 'Ignorance' may explain a proportion of eye service non-utilisation but it is not the root cause. It is known that poor service use occurs amongst communities with a good knowledge of eye problems and treatment options, and with outreach free services.
Behaviour is rational
A commonly held view is that people need to be motivated to seek treatment. Individuals are motivated but their motivations differ from that of the provider community. When viewed in context, many of these reasons make sense. For example:
Fears about treatment such as cataract surgery 'spoiling' eyes may not be irrational. In response to concerns about the quality of cataract surgical outcomes, WHO strongly recommends the need for better monitoring and evaluation systems.6 It is well known that 'bad news travels fast'. Treatment ailures may unfortunately impact more upon community attitudes to eye treatment than all the examples of success.
Dealing with direct treatment costs has been a major concern of service providers. This is a very important obstacle to overcome. However, it is only part of the cost borne by service users and their families. The concept of 'time is money' is not only the preserve of the city professional. In fact it has a sharper reality for people living in poverty. Seeking treatment involves leaving day-to-day responsibilities. In an existence of 'work today, eat today' early treatment intervention is a luxury that may be unaffordable. Furthermore, costs are multiplied when other family members are involved, either to fulfil escort or carer roles.
Unless actively addressed, there is scope for negative attitudes to old age to become a bigger barrier to treatment. Cataract is an age-related condition. Given demographic forecasts and life expectancy patterns, many of the people requiring surgical treatment will be women and widows. In many communities these are the people who are likely to be forgotten.
'I don't need treatment - I can manage'
To a greater or lesser extent, people report that they are coping and do not perceive a need for treatment/surgery.2-5 This includes bilaterally blind people too. This is somewhat surprising but possible explanations are that they have good adjustment to their disability with little evident handicap. On the other hand, this response may mask hidden barriers. After weighing up the advantages and disadvantages it is not worth the bother - 'I'll manage'. Currently the explanation is not clear, and requires further exploration.