Community perceptions of refractive errors in Pakistan
Pakistan’s national survey of blindness and visual impairment in 2002-2004 reported the prevalence of blindness to be 0.9 per cent. Of this total, 3 per cent can be attributed to uncorrected refractive errors. As Pakistan has a population of 150 million, this is equivalent to just over 40,000 people. Given these figures, there is an urgent need to increase refraction services in a comprehensive manner.
Whereas many studies have been conducted on the scientific and programmatic aspects of refractive error services, there is insufficient data available about the consumers perspective and possible reasons for the low uptake of services.
We designed a study to investigate communities’ perceptions of refractive errors, to assess sociocultural patterns, practices, and attitudes towards the use of spectacles, and to investigate issues related to the affordability and availability of spectacles in rural and urban communities.
Focus group discussions and participatory rapid appraisal techniques were used to collect information from the community. A structured questionnaire was developed and field-tested to ensure validity. A team of two female and three male interviewers carried out the field research and 479 questionnaires were completed. Participants were members of different communities, chosen from11 clusters representing urban, semi-urban, and rural settings. Each cluster contained from 15-25 participants. We did not encounter any substantial refusals to participate. The quantitative data was cleaned and then analysed using the SPSS statistical package, version 11.
Out of the total sample interviewed, 41 per cent were female and 59 per cent were male. The age breakdown of the participants was as follows: 1-15 years, 41 per cent; 16-30 years, 27 per cent; 31-40 years,18 per cent; and 41 and above, 14 per cent. Many of the respondents (44 per cent) were married, 32 per cent attended school, and all ethnic groups were represented.
Many people did not understand what refractive error services were offered and did not consider themselves as having refractive errors. Affordability was the major reason given by people for not purchasing the spectacles they had been prescribed.
Cosmetic factors were important for all communities surveyed. The main reason for discontinuation of spectacle wear in women was given as community pressure and cosmetic factors. The stigma attached to spectacle use was apparent in women, who were keen to know about the other options available, such as contact lenses and refractive surgery. These women reported that they often had to face social pressure, not only in terms of appearance, but also because of the perception that their children may inherit their visual impairment.
In rural areas, 69 per cent of people thought that using spectacles would cause their vision to deteriorate; they therefore tried to avoid it. However, the perception of most of the respondents was positive with regards to the use of spectacles by children. Respondents said that it helped children to continue their education and improved their quality of life. However, they also felt that spectacle wear hindered childrens participation in sport and other extracurricular activities.
The majority of respondents countrywide reported accessing refractive error services in the private, rather than public, sector. They said this was because, in the private sector, they could access both refraction and spectacle dispensing services at the same location. They were also not satisfied with the attitudes of service providers in the public sector.
The average amount paid for spectacles in poorer communities ranged from US $1.5 to US $4. In most instances, refraction was included in the price. The average amount spent by middle-class families on spectacles ranged from US $6 to US $10. Throughout Pakistan, a range of affordable spectacle frames were available; however, there was a clear lack of high-quality, modern spectacle frames in the smaller towns.
In summary, this study suggests that there are currently a number of barriers to the effective correction of refractive errors:
- lack of awareness and recognition of refractive error as a correctable cause of visual impairment, compounded by the non-availability of affordable services
- cultural factors which lead to discontinuation of the use of spectacles, especially in women
- lack of awareness among providers that good quality, attractive, and comfortable spectacles are essential to ensure continued use of spectacles.
When designing refractive error programmes, consumers perspectives are often ignored. However, we feel strongly that community studies should form part of the planning process.
1 Holden BA, Sulaiman S, Knox KBA. Challenges of providing spectacles in the developing world. Comm Eye Health J 2000;13(33):910
2 Ali SM, Johnson GJ, Bourne RRA, Dineen BP, Huq DMN. Correction of refractive errors in the adult population of Bangladesh: meeting the unmet need. Invest Ophthalmol & Vis Sci 2004;45(2):410417
3 Situation analysis of refractive services in Pakistan. Unpublished data.