p u b l i c h e a l t h 1 2 9 ( 2 0 1 5 ) 1 1 0 e1 1 6
Available online at www.sciencedirect.com
Public Health journal homepage: www.elsevier.com/puhe
Original Research
Preventing sight loss in older people. A qualitative study exploring barriers to the uptake of regular sight tests of older people living in socially deprived communities in South Wales S. Biddyr b,*, A. Jones a a b
Cardiff University, Healthcare Sciences, UK Royal National Institute of Blind People, Cymru, UK
article info
abstract
Article history:
Objectives: This paper describes research findings that try to understand some of the rea-
Received 15 May 2014
sons that prevent older people in deprived communities in South Wales from accessing
Received in revised form
NHS funded sight tests and leads to a discussion of suitable interventions that seek to
10 October 2014
improve access to primary eye care services and prevent avoidable sight loss.
Accepted 20 October 2014
Study design: Data were collected from eight focus groups (n ¼ 63) of mixed gender and ages
Available online 14 February 2015
(60e80þ years), of white origin living in deprived communities in South Wales. Individuals were recruited for the focus groups by extensively publicizing the project, with a range of
Keywords:
health and older people's community services and groups such as sheltered housing
Eye examinations
complexes, stroke support groups and coffee morning groups. The study included people
Qualitative research
who attended optometry services and people not engaged with services. A purposive
Older people
sampling technique summarizes the sampling approach taken, an approach which the
Barriers
team utilized to recruit ‘information rich’ cases, namely individuals, groups and organizations that provided the greatest insight into the research question. Methods: Focus groups were recorded and transcribed verbatim. Data underwent thematic content analysis and subsequent interpretations were corroborated by expert advisors and a project steering group. Results: Cost was perceived as a significant barrier to accessing sight tests, particularly in relation to purchasing glasses. Other barriers included the perceived pressure to buy glasses associated with visits to the optometrists; poor understanding of the purpose of a sight test in a health prevention context and acceptance of deteriorating sight loss due to the ageing process. Conclusion: Areas of improvement for the delivery of preventative eye health services to older people are identified, as are areas for reflection on the part of those who work within the eye health industry. © 2014 The Royal Society for Public Health. Published by Elsevier Ltd. All rights reserved.
* Corresponding author. RNIB Cymru, Jones Court, Womanby Street, Cardiff, CF10 1BR, UK. Tel.: þ44 07733 124158. E-mail address: [email protected] (S. Biddyr). http://dx.doi.org/10.1016/j.puhe.2014.10.013 0033-3506/© 2014 The Royal Society for Public Health. Published by Elsevier Ltd. All rights reserved.
p u b l i c h e a l t h 1 2 9 ( 2 0 1 5 ) 1 1 0 e1 1 6
Introduction Almost two million people in the UK are living with sight loss (which includes both visual impairment and blindness) and this is set to double to four million by 2050.1 In Wales, the figure is approximately 100,000.1 These increases are mainly due to an ageing population as over 80% of sight loss occurs in people over 60 years.1 As the population ages, the prevalence and severity of people with age related eye disease such as glaucoma, cataract and age related macular degeneration will increase2 causing huge challenges for health and social care. Sight loss has a considerable impact on a person's quality of life, their families and society as a whole. The effects of sight loss on older people can be devastating. Older people with sight loss are twice as likely to experience a fall as those with full vision3 and are three times more likely to suffer from depression and social isolation compared to the rest of the population.4 This may explain why sight loss is one of the top three causes of suicide amongst older people.5 Socio-economic factors also play a significant part in eye health as 78% of older blind and partially sighted people live in poverty.1,6 Poorer older people are much less likely to seek early attention for the onset of visual disturbance and are less likely to visit an optometrist.7e9 Furthermore, communities with high levels of social deprivation have reduced access to optometric and hospital-based eye-care services.10 Consequently, chronic eye disease is worse in areas of multiple deprivation and low income.11 Cases of glaucoma and diabetic retinopathy, both major causes of preventable but irreversible sight loss in working age groups in the UK, present at more advanced stages with worse prognosis in areas of high deprivation.12 However, older people with good vision can, and do, remain economically and socially active, and contribute significantly to the well-being of their families and to society in general.13 As the population ages, preventing avoidable sight loss and ensuring good vision is key to promoting positive or healthy ageing, concepts which encompass both a physical approach and a psychological approach (for example, promoting confidence, self esteem, purpose in life), both integral to improved quality of life.14 Regular sight tests are important, as many serious eye conditions do not have any visible early warning symptoms. Guidance from The College of Optometrists15 recommends the minimum intervals for eye examinations. It states that everyone aged 16 years and over should have an eye test every two years, and should not be recalled more frequently unless this is deemed clinically necessary and advised by their optometrist. Having a regular sight test should be part of everyone's health care routine as half of all sight loss, from cataract and undetected refractive error, is preventable with early detection and treatment.16 In Wales and the rest of the UK, people aged 60 years and over qualify for an NHS funded sight test. However, data from the General Ophthalmic Services in England and Wales for 2013e14, show that NHS funded sight tests for people aged 60 years and over are only taken up by approximately half of those who are eligible.17,18 With the predicted increase in the numbers of people with sight loss over the next ten years, encouraging older people, who are at particular risk of sight
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loss, to take up their entitlement for an NHS funded sight test is a public health priority.19,20 Moves to improve uptake of eye examinations are promoted in the first Welsh Government (2013) eye health care plan,21 demonstrating the importance of eye health and preventing sight loss at a national policy level. Qualitative research has only recently been conducted into reasons why some older people do not access eye tests. Reasons identified include: perceived lack of need, lack of eye health awareness, the cost of glasses and transport problems, a lack of appreciation of the importance of an eye test, failure to accept their own risk of eye disease, lack of awareness of eligibility for NHS funded eye tests and help with the cost of glasses.19,22e24 A search of the literature demonstrates that in addition to the study reported here (full report RNIB Cymru 2011)20 similar studies exploring barriers to accessing eye care services in the UK have been published in the last two years.23,24 However, differences between the studies include variances in the qualitative approaches used, location of the studies, age range and ethnicity of the research participants. For example, compared to the RNIB Community Engagement Programme17 (CEP) study carried out in the Rhondda Valley, this study recruited individuals from a wider geographical area of Cwm Taf, South Wales and from a different age group ranging from 60 to 80þ years old, compared to 40e65 years. Additionally, at the time of the study no other studies with a similar focus had been undertaken with older people in Wales. The aim of this paper is to report qualitative findings about some of the reasons that may prevent older people from deprived communities in South Wales, known to be at risk of avoidable sight loss, from accessing NHS funded eye examinations. Understanding barriers that may hinder older people from having eye examinations is crucial in order to provide evidence for policy makers, eye care and public health practitioners, so that suitable evidence-based interventions can be designed that encourage increased uptake of eye examinations and thus reduce avoidable sight loss. The issue of location of the research, is particularly important as health service policy has been devolved from UK to Welsh Government since 1999, with differences in policies relevant to eye health becoming increasingly apparent within Wales compared to elsewhere in the UK. Effective public health policy making requires research evidence generated from the local area (in this case Wales), as well as being informed by evidence from elsewhere. Furthermore, no studies investigating the topic area had been undertaken in Wales with people aged 60 and over. This is surprising considering the obvious need for more evidence in this area given that only half of those aged 60 years and over in Wales are accessing NHS funded eye tests.18 Although the study is focussed on South Wales communities, the findings are transferable to settings outside of Wales.
Methods Specifically, this study recruited 63 older people, aged 60 years and over, living in low income communities in the area of
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Cwm Taf in the South Wales Valleys region of the UK. Cwm Taf consists of two localities, namely Merthyr Tydfil and Rhondda Cynon Taf and suffers from some of the highest rates of deprivation in the UK and Europe.25 The area of Cwm Taf has the lowest life expectancy for both males and females of any of the Health Boards in Wales. Currently 8% of the population is over 75 years and the percentage of older people in the population is accelerating.25
but for similar themes to merge, meaning the data were carefully analysed to provide a reduced yet accurate representation of the participants' views. This process corresponds with approaches to establish rigour in qualitative research, in particular establishing credibility which represents means of conferring value and believability to qualitative findings.28 Finally, the findings were informed by existing literature, such as prior research on accessing eye care services by older people and deprived communities.
Focus groups Data were collected from eight focus groups, consisting of 5e11 per group, age range 60e80 yearsþ (average age 72 years) of mixed gender (majority 71% female) and white origin living in Cwm Taf. Between October 2010 and February 2011 individuals were recruited for the focus groups by extensively publicizing the project, with a range of health and older people's community services and groups such as sheltered housing complexes, stroke support groups and coffee morning groups. A purposive sampling technique summarizes the sampling approach taken, an approach which the team utilized to recruit ‘information rich’ cases, namely older individuals living in deprived communities of South Wales who were most likely to contribute appropriate data, both in terms of relevance to the research aim and depth.26 Each group explored the following areas: (1) perceptions of health and whether ‘being healthy’ included eye health (2) awareness of eye health (3) individuals' experiences of optometry and barriers and enablers to accessing optometry services. A focus group interview schedule was used to ensure a consistent series of questions were asked of each group. Each group could also introduce topics of relevance that were not covered in the schedule. Focus group participants were recruited from preexisting social groups: it had been thought as beneficial in establishing an atmosphere where each participant was able to speak freely in company they were familiar with. Three trained facilitators attended each focus group, with one asking the questions whilst the other two organized audio recording equipment and observed. On average the focus group discussion lasted 90 minutes, with a total of 720 minutes of data collected. Audio recordings were transcribed verbatim and thematically analysed by the three facilitators, together with a senior qualitative researcher from a local university with several years' expertise of thematic analysis and publishing in international peer reviewed journals. Thematic data analysis was partially guided by the original aims of the research but initially proceeded in an inductive fashion, starting with the categories of the participants themselves. This iterative process consisted of a pattern of reading and re-reading data, a method of analysis which eventually enabled the progressive understanding of the interview data to interact with the research team's own emergent thoughts.27 No attempt was made to analyse the interactional dynamics within the focus group, instead the analysis focussed on what was said rather than how things were said. Members of the research team initially individually analysed data from each focus group, before emerging themes were agreed across data sources and by each researcher. The aim was not for analysts to arrive at the exact same themes
Results The main barriers to accessing eye care that emerged were: the cost of glasses and perceptions of optometrists, adjusting to poor eye sight and not understanding the purpose of an eye examination. These will now be discussed in more detail.
Cost of glasses and the pressure to buy: the public's perception of optometrists This was discussed in considerable depth in all the focus groups with participants highlighting this as the most significant reason for people not attending regular eye examinations. Quote 1: I think it boils down to the price of glasses. You’ve had a sight test and you can’t afford to buy the glasses. Quote 2: It’s a lot of money at our age to buy glasses. We were always taught to look after our money and we are still very careful with it. Associated with the issue of costs were anxieties about the selling process and how participants voiced feeling under pressure and ‘pushed’ into buying glasses, which sometimes they felt they did not need. Quote 3: I think there are a lot of people frightened you get pushed to get new glasses when they are quite happy with the glasses they have got. So it’s the cost. Quote 4: People feel obligated that they’ve got to buy new glasses…” Similarly, participants shared the perception that optometrists were unwilling or seemed resistant to change lenses, instead always insisting that customers purchase new frames and lenses. Quote 5: I find they are not willing to put new lenses in your old glasses. If they do it they make you feel awkward for asking. Only one participant reported an optometrist who suggested a change to the lenses rather than both frames and lenses. There was also a further perception that optometrists failed to direct the public to alternative lower cost options (quote 6).
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Quote 6: We are not being told of the low cost of some frames, that is different options if cost is a problem.
The public's perception of optometrists and effects on eye health behaviour Focus group participants discussed how there was a potential conflict of interest in the dual role of optometrists as providers of primary eye-care screening and as commercial outlets for the selling of glasses. This conflict of interest was described as directly impacting on decisions of whether to access optometry services or not, typified by the following quote. Quote 7: The person doing the eye test is also the person trying to sell you glasses, there’s a conflict there, you don’t go because you feel obliged to buy glasses from them but really you don’t want to. The perception of a lack of trust and a conflict of interest in the optometry service has potentially worrying implications for health protective behaviours and the self-efficacy of the participants.
‘Off the shelf’ glasses Participants described ‘off the shelf’ spectacles as an equally viable and much cheaper alternative to buying glasses from an optometrist (quote 8).
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Consequently a visit to an optometrist was often symptom driven rather than undertaken with prevention in mind. Participants also described a tendency to adjust to deteriorating sight and an acceptance of failing eyesight as an inevitable part of the ageing process (quote 10). Quote 10: I think you tend to live with it, or adjust your life to it you know, when your eyes are going worse and worse and worse, instead of saying my eyes are going bad I've got to have my eyes tested, you tend to(…) adjust to the fact that your eyes are going. The tendency of participants to adjust to deteriorating eye sight and neglect the preventative role of eye checks is worrying from a prevention perspective especially as some eye conditions causing visual impairment and blindness, such as glaucoma, may not have any visible warning signs.
Time and not understanding the benefits of an eye examination Participants cited a lack of time and the time consuming nature of examinations as reasons for not scheduling eye appointments (quotes 11 and 12). Similarly, a lack of choice regarding times for appointments was also discussed as a barrier by some (quote 13). Quote 11: I can’t find the time. Quote 12: And the time that it takes while you are there as well
Quote 8: For what you get they're enormously expensive, I mean you can (…) buy a pair of readers for a pound. But they're almost the same frame, as (…) the minimum frame price is what, £50 and they're no different at all. You're paying a huge sum of money for nothing. For those who could not, or refused to pay opticians' prices for spectacles, the cheaper ‘off the shelf’ alternatives had an obvious appeal. The potentially harmful effects on eye health of wearing un-prescribed glasses and completely avoiding optometry services did not seem apparent to the participants. This is worrying from a health prevention perspective, especially as the effects of such avoidant behaviour did not seem to be immediately off-putting to those seduced by the prospect of cost saving.
Adjusting to deteriorating sight and accepting sight loss as a natural part of ageing Certain health prevention behaviours such as healthy eating habits, smoking cessation, exercising and attending screening for cardiac disease were all topics which featured prevalently during a discussion of participants' perceptions of being a healthy person. However, preventative eye health was rarely discussed, with eye tests being described as a low priority only necessary when sight deteriorated to the point that individuals experienced ‘problems’: Quote 9: …you tend to prioritise. Do you think, is an eye test that important to me until you start having problems? Then you realise, yes it is important.
Quote 13: Time was the problem. I found that you have to fit in with them instead of them fitting in with me. My eyes are in such a state. A time related theme which recurred alongside other themes throughout the data set was that of ‘age’ and ‘ageing’. Already it has been seen that being an older person in deprived communities is a factor which contributes to the perceived cost of glasses which participants described as being ‘a lot of money at our age’ (quote 2). The expectation that eyesight would diminish with age meant that participants accepted and adjusted to deteriorating eyesight rather than arranging an eye appointment (quote 10). Participants seemed unaware that although age-related eyesight deterioration is common, early detection and treatment of eye conditions could prevent un-necessary sight loss. Also, that there are numerous health-related reasons, other than checking visual acuity, for people to attend regular eye checks.
Discussion It is surprising that in-depth qualitative research has traditionally been under-utilized in optometry to understand the service user's experience, especially when considering current public discontent with optometry services.7,23,24 The following section discusses the views of focus group participants within the broader context of eye care and public health. For example, the discussion specifically draws
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attention to the relationship between older people's actions and their understanding of eye health and optometry services, whilst also discussing potential direction for public health and optometry strategies that aim to promote and protect eye health. One of the main barriers to ensuring eye health highlighted by participants in this study, related to discontentment with costs of purchasing glasses and the perceived blurring of commercial and health roles in optometry. This sense of discontentment encompassed many complex issues but was often related to experiences and wariness of hard selling and feeling pressurized into buying glasses that participants often felt they did not need. The perception of blurred and conflicting roles of providing both a health care service and running a commercial business raised questions with participants about the credibility of optometrists. Perceptions of how optometric credibility can affect health-seeking behaviour have been explored by others.29 In this study, concerns about credibility led to deep uncertainties when older people were making decisions of whether to undertake health protective behaviours (such as eye testing), or not. Health promotion messages are frequently based on the premise that providing healthrelated information leads to an empowering of individuals who make informed decisions about accessing services. However, the extent to which information and empowerment lead to behaviours that enhance eye health depend upon, amongst other things, how individuals perceive the service providers themselves.29 To avoid public misperceptions about the commercial nature of eye health, authors such as Cross et al.29 have emphasized the importance of disassociating the commercial role of optometrists from their crucial health role of disease detection. The data suggests that misperceptions emerge due to participants undertaking eye examinations only when they experienced significant deterioration in vision. As a result of these infrequent eye care appointments, allied to deteriorating eyesight, visits to the optician often resulted in the need for new spectacles. Consequently, participants directly associated a visit to the optometrist with an inevitable and often significant financial charge. The challenge therefore is for optometry services to persuade older individuals to attend NHS funded eye examinations, on a regular basis, at appropriate intervals recommended by their optometrist,15 not only when deterioration becomes apparent. This would lead to improvements in eye health (and health more generally) of the population and would also serve a secondary purpose of reversing the current potentially harmful perception that a visit to the optometrist leads to inevitable and significant financial cost. However in trying to achieve this, optometric services would also need to question the wisdom of public advertising/marketing campaigns (such as ‘two for one’ promotions of glasses) that may further add to the public's perception of an association between eye checks and a financial cost. Some of the findings suggest that older people's relationship with those who supply eye care is characterized by a lack of trust in the motives of optometrists around
the costs of glasses. The perception of a conflict of interest in the optometry service has worrying implications for the self-efficacy of those experiencing deprivation and on low incomes, in responding to eye health education messages. Much of the discussion also highlighted participants' lack of satisfaction with the business model of eye care services, which is important as Cross et al.29 suggest that trust improves patient satisfaction. In addition, Ahn, Frederikson, Broman and Bednarek30 state that having positive patientephysician relationships and enhancing communication and education from clinicians can help facilitate appropriate use of preventative services. Thus, improving reciprocal understanding between service users and ophthalmic practitioners in primary care is key to developing flexible, responsible local eye care services22,24 and could help alleviate the barrier associated with costs. This finding is similar to other recent studies which suggest that the primary reason for visiting an optometrist was to renew spectacles or prescription, or was symptom-led rather than a preventative measure.22e24 Linked to this was the assumption that poor vision is a consequence of ageing, and that this was something they should accept and couldn't do anything about.22,24
Conclusion Projected increases in the global population of older people means that increasing the uptake of sight tests is a public health priority. Improving the rate by which sight tests are taken up by older people will help ensure early detection of eye disease and co-morbid conditions, as well as lead to more timely access to treatment. Early detection and more timely treatment reduces the burden on other services and increases the independence, well-being and quality of life of older people. These research findings contribute to the body of knowledge by providing optometry and other health professionals and policy makers an insight into consumer attitudes and behaviour in relation to their eyes, it will lead to strategies and actions to improve uptake of eye examinations and prevent avoidable sight loss.
Limitations A limitation of the study is that data were collected from only one locality or health board area in Wales, and in common with most qualitative studies, no claims are made here regarding generalization. Nonetheless, an intensive study such as this, which generates rich accounts, ensures that readers are well placed to judge whether the findings are likely to apply at other times and in other settings.31 Also most participants in the focus groups (72%) had been for an eye examination in the last two years, only a few had never accessed primary eye care services. Despite advertising widely it was difficult to recruit people who hadn't received a sight test for more than two years. Participants however, were asked to make reference to people they knew, for example, family and friends, who might also face obstacles in accessing eye care.
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Author statements Acknowledgements Thanks to members of the advisory group for supporting this project which included representatives from Cardiff University School of Optometry and Vision Sciences, Wales. Optometry Post-graduate Education Centre at Cardiff University School of Optometry and Vision Sciences, Diabetic Retinopathy Screening Services for Wales and colleagues in RNIB Cymru and London. Thanks to Ceri Jackson, Director of RNIB Cymru for her continued support and to Andy Williams and Hannah Rowlatt of RNIB Cymru for their contribution to the planning and delivery of the focus groups and analysis and input throughout the project. Thanks also to the community groups in Cwm Taf that participated in the focus groups and made this project possible.
Ethical approval Not required.
Funding Initial project partially funded by Pfizer UK Foundation.
Competing interests None declared.
references
1. Access economics future sight loss UK 1: economic impact of partial sight and blindness in the UK adult population RNIB; 2009. 2. Tate R, Smeeth L, Evans J, Fletcher A. The prevalence of visual impairment in the UK; a review of the literature (accessed 14 August 2014), www.rnib.org.uk/xpedio/groups/public/ documents/PublicWebsite/public_prevalencereport.doc; 2005. 3. Scuffham PA, Legood R, Wilson ECF, Kennedy-Martin T. The incidence and cost of injurious falls associated with visual impairment in the UK. Vis Impair Res 2002;4:1e14. 4. Evans JR, Fletcher AE, Wormald RP. Depression and anxiety in visually impaired older people. Ophthalmology 2007;114(2):283e8. 5. Waern M, Rubenowitz E, Runeson B, Skoog I, Wilhelmson K, Allebeck P. Burden of illness and suicide in elderly people: case-control study. BMJ 2002 June;324:1355. http://dx.doi.org/ 10.1136/bmj 324.7350.1355. 6. RNIB. Campaign Report. The cost of sight loss in the UK 2004;23. 7. Royal College of Ophthalmologists and The Vision 2020 Primary Care Group. Health inequalities and eye health in the UK (accessed 14 May 2014), http://www.publications.parliament. uk/pa/cm200708/cmselect/cmhealth/422/422we131.htm; 2008. 8. Shickle D, Farragher TM. Geographical inequalities in uptake of NHS-funded eye examinations: small area analysis of Leeds, UK. J Public Health Adv; July 11, 2014:1e9. http:// dx.doi.org/10.1093/pubmed/fdu039.
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9. Dickey H, Ikenwilo D, Norwood P, Watson V, Zangelidis A. Utilisation of eye-care services: the effect of Scotland's free eye examination policy. Health Policy 2012;108(2e3):286e93. 10. Nessim M, Denniston A, Nolan W, Holder R, Shah P. Research into glaucoma and ethnicity (RaGAE) 8: is there a relationship between social deprivation and acute primary angle closure? Br J Opthalmology 2010;94:1304e6. 11. Sommer A, Tielsch JM, Katz J, Quigley HA, Gottsch JD, Javitt JC, Martone JF, Royall RM, Witt KA, Ezrine S. Racial differences in the cause-specific prevalence of blindness in east Baltimore. N Engl J Med 1991 Nov 14;325(20):1412e7. 12. Fraser S, Bunce C, Wormald R, Brunner E. Deprivation and late presentation of glaucoma: case-control study. BMJ 2001;322:639e43. 13. Evans J. Eye care for older people. Community Eye Health J June 2008;21(66):21e3. 14. Bowling A, Iliffe S. Psychological approach to successful ageing predicts future quality of life in older adults. Health Qual Life Outcomes 2011;9:13. 15. The College of Optometrists. Code of ethics and guidance for professional conduct, chapter B02dthe routine eye examination. The College of Optometrists, http://www.collegeoptometrists.org/en/utilities/document-summary.cfm/docid/ 2C06771F-5D0D-4728-825F7FF31F79D764; 2013 (accessed 09 August 2014). 16. Tate R, Smeeth L, Evans J, Fletcher A. The prevalence of visual impairment in the UK; a review of the literature, www.rnib.org.uk/ xpedio/groups/public/documents/PublicWebsite/public_ prevalencereport.doc; 2005 (accessed 14 May 2014). 17. Health and Social Care Information Centre. Dental and eye care team: general ophthalmic services. Activity statistics, England 2013/14, published 16th July 2014. 18. Welsh Government eye care statistics for Wales 2013e14, http:// wales.gov.uk/statistics-and-research/eye-care/?lang¼en; June 2014 (accessed 8 August 2014). 19. Conway L, McLaughlan B. Older people and eye tests: don't let age rob you or your sight. RNIB; 2007. 20. Biddyr S, Jones A. Preventing sight loss in older people: barriers and enablers to the uptake of regular sight tests. RNIB Cymru; 2011. 21. Welsh Government. Together for health: eye health care (2013) delivery plan for Wales, 2013e18; 2013. 22. McLaughlan B, Edwards A. Understanding of the purpose of an eye test among people aged 60 and over in the UK. Optometry Pract 2010;11(4):179e88. 23. Leamon S, Hayden C, Lee H, Trudinger D, Appelbee E, Hurrell DL, Richardson I. Improving access to optometry services for people at risk of preventable sight loss: a qualitative study in five UK locations. J Public Health; January 9 2014:1e7. http://dx.doi.org/10.1093/pubmed/fdt130 (accessed 8 August 2014). 24. Shickle D, Griffin M. Why don't older adults in England go to have their eyes examined. Ophthalmic Physiol Opt 2014;34:38e45. http://dx.doi.org/10.1111/opo.12100. 25. Welsh Government. Stats Wales. [Online]. Welsh index of multiple deprivation 2011. Available at: http://statswales.wales. gov.uk/index.htm; 2010 (accessed 9 August 2014). 26. Oliver P. Purposive sampling. In: Judd A, editor. The sage dictionary of social research methods. London: Sage Publications; 2006. p. 244e5. 27. Coffey A, Holbrook B, Atkinson P. Qualitative data analysis: technologies and representations, sociological research online 1996;1(1), http://www.socresonline.org.uk/1/1/4.html (accessed 14 May 2014). 28. Houghton C, Casey D, Shaw D, Murphy K. Rigour in qualitative case-study research. Nurse Res 2013;20(4):12e7.
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29. Cross V, Shah P, Bativala R, Spurgeon P. ReGAE 2: glaucoma awareness and the primary eye-care service: some perceptions among African Caribbeans in Birmingham UK. Eye: J R Coll Ophthalmol 2007;21(7):912e20. 30. Ahn MJ, Frederikson L, Borman B, Bednarek R. Eye health in New Zealand e a study of public knowledge, attitudes and
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Available online at www.sciencedirect.com
Public Health journal homepage: www.elsevier.com/puhe
Original Research
Preventing sight loss in older people. A qualitative study exploring barriers to the uptake of regular sight tests of older people living in socially deprived communities in South Wales S. Biddyr b,*, A. Jones a a b
Cardiff University, Healthcare Sciences, UK Royal National Institute of Blind People, Cymru, UK
article info
abstract
Article history:
Objectives: This paper describes research findings that try to understand some of the rea-
Received 15 May 2014
sons that prevent older people in deprived communities in South Wales from accessing
Received in revised form
NHS funded sight tests and leads to a discussion of suitable interventions that seek to
10 October 2014
improve access to primary eye care services and prevent avoidable sight loss.
Accepted 20 October 2014
Study design: Data were collected from eight focus groups (n ¼ 63) of mixed gender and ages
Available online 14 February 2015
(60e80þ years), of white origin living in deprived communities in South Wales. Individuals were recruited for the focus groups by extensively publicizing the project, with a range of
Keywords:
health and older people's community services and groups such as sheltered housing
Eye examinations
complexes, stroke support groups and coffee morning groups. The study included people
Qualitative research
who attended optometry services and people not engaged with services. A purposive
Older people
sampling technique summarizes the sampling approach taken, an approach which the
Barriers
team utilized to recruit ‘information rich’ cases, namely individuals, groups and organizations that provided the greatest insight into the research question. Methods: Focus groups were recorded and transcribed verbatim. Data underwent thematic content analysis and subsequent interpretations were corroborated by expert advisors and a project steering group. Results: Cost was perceived as a significant barrier to accessing sight tests, particularly in relation to purchasing glasses. Other barriers included the perceived pressure to buy glasses associated with visits to the optometrists; poor understanding of the purpose of a sight test in a health prevention context and acceptance of deteriorating sight loss due to the ageing process. Conclusion: Areas of improvement for the delivery of preventative eye health services to older people are identified, as are areas for reflection on the part of those who work within the eye health industry. © 2014 The Royal Society for Public Health. Published by Elsevier Ltd. All rights reserved.
* Corresponding author. RNIB Cymru, Jones Court, Womanby Street, Cardiff, CF10 1BR, UK. Tel.: þ44 07733 124158. E-mail address: [email protected] (S. Biddyr). http://dx.doi.org/10.1016/j.puhe.2014.10.013 0033-3506/© 2014 The Royal Society for Public Health. Published by Elsevier Ltd. All rights reserved.
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Introduction Almost two million people in the UK are living with sight loss (which includes both visual impairment and blindness) and this is set to double to four million by 2050.1 In Wales, the figure is approximately 100,000.1 These increases are mainly due to an ageing population as over 80% of sight loss occurs in people over 60 years.1 As the population ages, the prevalence and severity of people with age related eye disease such as glaucoma, cataract and age related macular degeneration will increase2 causing huge challenges for health and social care. Sight loss has a considerable impact on a person's quality of life, their families and society as a whole. The effects of sight loss on older people can be devastating. Older people with sight loss are twice as likely to experience a fall as those with full vision3 and are three times more likely to suffer from depression and social isolation compared to the rest of the population.4 This may explain why sight loss is one of the top three causes of suicide amongst older people.5 Socio-economic factors also play a significant part in eye health as 78% of older blind and partially sighted people live in poverty.1,6 Poorer older people are much less likely to seek early attention for the onset of visual disturbance and are less likely to visit an optometrist.7e9 Furthermore, communities with high levels of social deprivation have reduced access to optometric and hospital-based eye-care services.10 Consequently, chronic eye disease is worse in areas of multiple deprivation and low income.11 Cases of glaucoma and diabetic retinopathy, both major causes of preventable but irreversible sight loss in working age groups in the UK, present at more advanced stages with worse prognosis in areas of high deprivation.12 However, older people with good vision can, and do, remain economically and socially active, and contribute significantly to the well-being of their families and to society in general.13 As the population ages, preventing avoidable sight loss and ensuring good vision is key to promoting positive or healthy ageing, concepts which encompass both a physical approach and a psychological approach (for example, promoting confidence, self esteem, purpose in life), both integral to improved quality of life.14 Regular sight tests are important, as many serious eye conditions do not have any visible early warning symptoms. Guidance from The College of Optometrists15 recommends the minimum intervals for eye examinations. It states that everyone aged 16 years and over should have an eye test every two years, and should not be recalled more frequently unless this is deemed clinically necessary and advised by their optometrist. Having a regular sight test should be part of everyone's health care routine as half of all sight loss, from cataract and undetected refractive error, is preventable with early detection and treatment.16 In Wales and the rest of the UK, people aged 60 years and over qualify for an NHS funded sight test. However, data from the General Ophthalmic Services in England and Wales for 2013e14, show that NHS funded sight tests for people aged 60 years and over are only taken up by approximately half of those who are eligible.17,18 With the predicted increase in the numbers of people with sight loss over the next ten years, encouraging older people, who are at particular risk of sight
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loss, to take up their entitlement for an NHS funded sight test is a public health priority.19,20 Moves to improve uptake of eye examinations are promoted in the first Welsh Government (2013) eye health care plan,21 demonstrating the importance of eye health and preventing sight loss at a national policy level. Qualitative research has only recently been conducted into reasons why some older people do not access eye tests. Reasons identified include: perceived lack of need, lack of eye health awareness, the cost of glasses and transport problems, a lack of appreciation of the importance of an eye test, failure to accept their own risk of eye disease, lack of awareness of eligibility for NHS funded eye tests and help with the cost of glasses.19,22e24 A search of the literature demonstrates that in addition to the study reported here (full report RNIB Cymru 2011)20 similar studies exploring barriers to accessing eye care services in the UK have been published in the last two years.23,24 However, differences between the studies include variances in the qualitative approaches used, location of the studies, age range and ethnicity of the research participants. For example, compared to the RNIB Community Engagement Programme17 (CEP) study carried out in the Rhondda Valley, this study recruited individuals from a wider geographical area of Cwm Taf, South Wales and from a different age group ranging from 60 to 80þ years old, compared to 40e65 years. Additionally, at the time of the study no other studies with a similar focus had been undertaken with older people in Wales. The aim of this paper is to report qualitative findings about some of the reasons that may prevent older people from deprived communities in South Wales, known to be at risk of avoidable sight loss, from accessing NHS funded eye examinations. Understanding barriers that may hinder older people from having eye examinations is crucial in order to provide evidence for policy makers, eye care and public health practitioners, so that suitable evidence-based interventions can be designed that encourage increased uptake of eye examinations and thus reduce avoidable sight loss. The issue of location of the research, is particularly important as health service policy has been devolved from UK to Welsh Government since 1999, with differences in policies relevant to eye health becoming increasingly apparent within Wales compared to elsewhere in the UK. Effective public health policy making requires research evidence generated from the local area (in this case Wales), as well as being informed by evidence from elsewhere. Furthermore, no studies investigating the topic area had been undertaken in Wales with people aged 60 and over. This is surprising considering the obvious need for more evidence in this area given that only half of those aged 60 years and over in Wales are accessing NHS funded eye tests.18 Although the study is focussed on South Wales communities, the findings are transferable to settings outside of Wales.
Methods Specifically, this study recruited 63 older people, aged 60 years and over, living in low income communities in the area of
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Cwm Taf in the South Wales Valleys region of the UK. Cwm Taf consists of two localities, namely Merthyr Tydfil and Rhondda Cynon Taf and suffers from some of the highest rates of deprivation in the UK and Europe.25 The area of Cwm Taf has the lowest life expectancy for both males and females of any of the Health Boards in Wales. Currently 8% of the population is over 75 years and the percentage of older people in the population is accelerating.25
but for similar themes to merge, meaning the data were carefully analysed to provide a reduced yet accurate representation of the participants' views. This process corresponds with approaches to establish rigour in qualitative research, in particular establishing credibility which represents means of conferring value and believability to qualitative findings.28 Finally, the findings were informed by existing literature, such as prior research on accessing eye care services by older people and deprived communities.
Focus groups Data were collected from eight focus groups, consisting of 5e11 per group, age range 60e80 yearsþ (average age 72 years) of mixed gender (majority 71% female) and white origin living in Cwm Taf. Between October 2010 and February 2011 individuals were recruited for the focus groups by extensively publicizing the project, with a range of health and older people's community services and groups such as sheltered housing complexes, stroke support groups and coffee morning groups. A purposive sampling technique summarizes the sampling approach taken, an approach which the team utilized to recruit ‘information rich’ cases, namely older individuals living in deprived communities of South Wales who were most likely to contribute appropriate data, both in terms of relevance to the research aim and depth.26 Each group explored the following areas: (1) perceptions of health and whether ‘being healthy’ included eye health (2) awareness of eye health (3) individuals' experiences of optometry and barriers and enablers to accessing optometry services. A focus group interview schedule was used to ensure a consistent series of questions were asked of each group. Each group could also introduce topics of relevance that were not covered in the schedule. Focus group participants were recruited from preexisting social groups: it had been thought as beneficial in establishing an atmosphere where each participant was able to speak freely in company they were familiar with. Three trained facilitators attended each focus group, with one asking the questions whilst the other two organized audio recording equipment and observed. On average the focus group discussion lasted 90 minutes, with a total of 720 minutes of data collected. Audio recordings were transcribed verbatim and thematically analysed by the three facilitators, together with a senior qualitative researcher from a local university with several years' expertise of thematic analysis and publishing in international peer reviewed journals. Thematic data analysis was partially guided by the original aims of the research but initially proceeded in an inductive fashion, starting with the categories of the participants themselves. This iterative process consisted of a pattern of reading and re-reading data, a method of analysis which eventually enabled the progressive understanding of the interview data to interact with the research team's own emergent thoughts.27 No attempt was made to analyse the interactional dynamics within the focus group, instead the analysis focussed on what was said rather than how things were said. Members of the research team initially individually analysed data from each focus group, before emerging themes were agreed across data sources and by each researcher. The aim was not for analysts to arrive at the exact same themes
Results The main barriers to accessing eye care that emerged were: the cost of glasses and perceptions of optometrists, adjusting to poor eye sight and not understanding the purpose of an eye examination. These will now be discussed in more detail.
Cost of glasses and the pressure to buy: the public's perception of optometrists This was discussed in considerable depth in all the focus groups with participants highlighting this as the most significant reason for people not attending regular eye examinations. Quote 1: I think it boils down to the price of glasses. You’ve had a sight test and you can’t afford to buy the glasses. Quote 2: It’s a lot of money at our age to buy glasses. We were always taught to look after our money and we are still very careful with it. Associated with the issue of costs were anxieties about the selling process and how participants voiced feeling under pressure and ‘pushed’ into buying glasses, which sometimes they felt they did not need. Quote 3: I think there are a lot of people frightened you get pushed to get new glasses when they are quite happy with the glasses they have got. So it’s the cost. Quote 4: People feel obligated that they’ve got to buy new glasses…” Similarly, participants shared the perception that optometrists were unwilling or seemed resistant to change lenses, instead always insisting that customers purchase new frames and lenses. Quote 5: I find they are not willing to put new lenses in your old glasses. If they do it they make you feel awkward for asking. Only one participant reported an optometrist who suggested a change to the lenses rather than both frames and lenses. There was also a further perception that optometrists failed to direct the public to alternative lower cost options (quote 6).
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Quote 6: We are not being told of the low cost of some frames, that is different options if cost is a problem.
The public's perception of optometrists and effects on eye health behaviour Focus group participants discussed how there was a potential conflict of interest in the dual role of optometrists as providers of primary eye-care screening and as commercial outlets for the selling of glasses. This conflict of interest was described as directly impacting on decisions of whether to access optometry services or not, typified by the following quote. Quote 7: The person doing the eye test is also the person trying to sell you glasses, there’s a conflict there, you don’t go because you feel obliged to buy glasses from them but really you don’t want to. The perception of a lack of trust and a conflict of interest in the optometry service has potentially worrying implications for health protective behaviours and the self-efficacy of the participants.
‘Off the shelf’ glasses Participants described ‘off the shelf’ spectacles as an equally viable and much cheaper alternative to buying glasses from an optometrist (quote 8).
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Consequently a visit to an optometrist was often symptom driven rather than undertaken with prevention in mind. Participants also described a tendency to adjust to deteriorating sight and an acceptance of failing eyesight as an inevitable part of the ageing process (quote 10). Quote 10: I think you tend to live with it, or adjust your life to it you know, when your eyes are going worse and worse and worse, instead of saying my eyes are going bad I've got to have my eyes tested, you tend to(…) adjust to the fact that your eyes are going. The tendency of participants to adjust to deteriorating eye sight and neglect the preventative role of eye checks is worrying from a prevention perspective especially as some eye conditions causing visual impairment and blindness, such as glaucoma, may not have any visible warning signs.
Time and not understanding the benefits of an eye examination Participants cited a lack of time and the time consuming nature of examinations as reasons for not scheduling eye appointments (quotes 11 and 12). Similarly, a lack of choice regarding times for appointments was also discussed as a barrier by some (quote 13). Quote 11: I can’t find the time. Quote 12: And the time that it takes while you are there as well
Quote 8: For what you get they're enormously expensive, I mean you can (…) buy a pair of readers for a pound. But they're almost the same frame, as (…) the minimum frame price is what, £50 and they're no different at all. You're paying a huge sum of money for nothing. For those who could not, or refused to pay opticians' prices for spectacles, the cheaper ‘off the shelf’ alternatives had an obvious appeal. The potentially harmful effects on eye health of wearing un-prescribed glasses and completely avoiding optometry services did not seem apparent to the participants. This is worrying from a health prevention perspective, especially as the effects of such avoidant behaviour did not seem to be immediately off-putting to those seduced by the prospect of cost saving.
Adjusting to deteriorating sight and accepting sight loss as a natural part of ageing Certain health prevention behaviours such as healthy eating habits, smoking cessation, exercising and attending screening for cardiac disease were all topics which featured prevalently during a discussion of participants' perceptions of being a healthy person. However, preventative eye health was rarely discussed, with eye tests being described as a low priority only necessary when sight deteriorated to the point that individuals experienced ‘problems’: Quote 9: …you tend to prioritise. Do you think, is an eye test that important to me until you start having problems? Then you realise, yes it is important.
Quote 13: Time was the problem. I found that you have to fit in with them instead of them fitting in with me. My eyes are in such a state. A time related theme which recurred alongside other themes throughout the data set was that of ‘age’ and ‘ageing’. Already it has been seen that being an older person in deprived communities is a factor which contributes to the perceived cost of glasses which participants described as being ‘a lot of money at our age’ (quote 2). The expectation that eyesight would diminish with age meant that participants accepted and adjusted to deteriorating eyesight rather than arranging an eye appointment (quote 10). Participants seemed unaware that although age-related eyesight deterioration is common, early detection and treatment of eye conditions could prevent un-necessary sight loss. Also, that there are numerous health-related reasons, other than checking visual acuity, for people to attend regular eye checks.
Discussion It is surprising that in-depth qualitative research has traditionally been under-utilized in optometry to understand the service user's experience, especially when considering current public discontent with optometry services.7,23,24 The following section discusses the views of focus group participants within the broader context of eye care and public health. For example, the discussion specifically draws
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attention to the relationship between older people's actions and their understanding of eye health and optometry services, whilst also discussing potential direction for public health and optometry strategies that aim to promote and protect eye health. One of the main barriers to ensuring eye health highlighted by participants in this study, related to discontentment with costs of purchasing glasses and the perceived blurring of commercial and health roles in optometry. This sense of discontentment encompassed many complex issues but was often related to experiences and wariness of hard selling and feeling pressurized into buying glasses that participants often felt they did not need. The perception of blurred and conflicting roles of providing both a health care service and running a commercial business raised questions with participants about the credibility of optometrists. Perceptions of how optometric credibility can affect health-seeking behaviour have been explored by others.29 In this study, concerns about credibility led to deep uncertainties when older people were making decisions of whether to undertake health protective behaviours (such as eye testing), or not. Health promotion messages are frequently based on the premise that providing healthrelated information leads to an empowering of individuals who make informed decisions about accessing services. However, the extent to which information and empowerment lead to behaviours that enhance eye health depend upon, amongst other things, how individuals perceive the service providers themselves.29 To avoid public misperceptions about the commercial nature of eye health, authors such as Cross et al.29 have emphasized the importance of disassociating the commercial role of optometrists from their crucial health role of disease detection. The data suggests that misperceptions emerge due to participants undertaking eye examinations only when they experienced significant deterioration in vision. As a result of these infrequent eye care appointments, allied to deteriorating eyesight, visits to the optician often resulted in the need for new spectacles. Consequently, participants directly associated a visit to the optometrist with an inevitable and often significant financial charge. The challenge therefore is for optometry services to persuade older individuals to attend NHS funded eye examinations, on a regular basis, at appropriate intervals recommended by their optometrist,15 not only when deterioration becomes apparent. This would lead to improvements in eye health (and health more generally) of the population and would also serve a secondary purpose of reversing the current potentially harmful perception that a visit to the optometrist leads to inevitable and significant financial cost. However in trying to achieve this, optometric services would also need to question the wisdom of public advertising/marketing campaigns (such as ‘two for one’ promotions of glasses) that may further add to the public's perception of an association between eye checks and a financial cost. Some of the findings suggest that older people's relationship with those who supply eye care is characterized by a lack of trust in the motives of optometrists around
the costs of glasses. The perception of a conflict of interest in the optometry service has worrying implications for the self-efficacy of those experiencing deprivation and on low incomes, in responding to eye health education messages. Much of the discussion also highlighted participants' lack of satisfaction with the business model of eye care services, which is important as Cross et al.29 suggest that trust improves patient satisfaction. In addition, Ahn, Frederikson, Broman and Bednarek30 state that having positive patientephysician relationships and enhancing communication and education from clinicians can help facilitate appropriate use of preventative services. Thus, improving reciprocal understanding between service users and ophthalmic practitioners in primary care is key to developing flexible, responsible local eye care services22,24 and could help alleviate the barrier associated with costs. This finding is similar to other recent studies which suggest that the primary reason for visiting an optometrist was to renew spectacles or prescription, or was symptom-led rather than a preventative measure.22e24 Linked to this was the assumption that poor vision is a consequence of ageing, and that this was something they should accept and couldn't do anything about.22,24
Conclusion Projected increases in the global population of older people means that increasing the uptake of sight tests is a public health priority. Improving the rate by which sight tests are taken up by older people will help ensure early detection of eye disease and co-morbid conditions, as well as lead to more timely access to treatment. Early detection and more timely treatment reduces the burden on other services and increases the independence, well-being and quality of life of older people. These research findings contribute to the body of knowledge by providing optometry and other health professionals and policy makers an insight into consumer attitudes and behaviour in relation to their eyes, it will lead to strategies and actions to improve uptake of eye examinations and prevent avoidable sight loss.
Limitations A limitation of the study is that data were collected from only one locality or health board area in Wales, and in common with most qualitative studies, no claims are made here regarding generalization. Nonetheless, an intensive study such as this, which generates rich accounts, ensures that readers are well placed to judge whether the findings are likely to apply at other times and in other settings.31 Also most participants in the focus groups (72%) had been for an eye examination in the last two years, only a few had never accessed primary eye care services. Despite advertising widely it was difficult to recruit people who hadn't received a sight test for more than two years. Participants however, were asked to make reference to people they knew, for example, family and friends, who might also face obstacles in accessing eye care.
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Author statements Acknowledgements Thanks to members of the advisory group for supporting this project which included representatives from Cardiff University School of Optometry and Vision Sciences, Wales. Optometry Post-graduate Education Centre at Cardiff University School of Optometry and Vision Sciences, Diabetic Retinopathy Screening Services for Wales and colleagues in RNIB Cymru and London. Thanks to Ceri Jackson, Director of RNIB Cymru for her continued support and to Andy Williams and Hannah Rowlatt of RNIB Cymru for their contribution to the planning and delivery of the focus groups and analysis and input throughout the project. Thanks also to the community groups in Cwm Taf that participated in the focus groups and made this project possible.
Ethical approval Not required.
Funding Initial project partially funded by Pfizer UK Foundation.
Competing interests None declared.
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