University of Ghana http://ugspace.ug.edu.gh SCHOOL OF PUBLIC HEALTH COLLEGE OF HEALTH SCIENCES UNIVERSITY OF GHANA ASSESSING THE LEVEL OF KNOWLEDGE AND BARRIERS TO LOW VISION SERVICES IN SELECTED EYE HEALTH FACILITIES IN ACCRA, GHANA BY EILEEN NARTEHKIE AMANQUAH BUXTON (10292924) A DISSERTATION SUBMITTED TO THE UNIVERSITY OF GHANA, LEGON IN PARTIAL FULFILLMENT OF THE REQUIREMENT FOR THE AWARD OF MASTER OF PUBLIC HEALTH DEGREE JULY, 2017 University of Ghana http://ugspace.ug.edu.gh DECLARATION I, Eileen Nartehkie Amanquah Buxton, declare that apart from specific references which have been duly acknowledged, this work is the result of my own original research, and this dissertation either whole or in part has not been presented elsewhere for another degree. …………………………………….... ………………….. EILEEN NARTEHKIE AMANQUAH BUXTON DATE (STUDENT) ……………………………………. ……………………… DR. URI SELORM MARKAKPO DATE (SUPERVISOR) i University of Ghana http://ugspace.ug.edu.gh DEDICATION I dedicate this book to my lovely husband Mr. Godfrey Nii Abeka Buxton for the intense support you gave me. You are truly and indeed a special blessing to me. I also dedicate it to my wonderful children Kimora Kyla, Kymani Kurtis and Kimone Kaylae Buxton for all you have gone through during this study period as well as your prayer and support. You will forever remain in my heart. ii University of Ghana http://ugspace.ug.edu.gh ACKNOWLEDGEMENT My heartfelt gratitude goes to the Almighty God for the strength, wisdom and protection He has granted me throughout this study period. My sincere thanks goes to my husband Mr. Godfrey Nii Abeka Buxton for all the forms of support he gave me during this period. I am truly grateful. To my children Kimora Kyla, Kymani Kurtis and Kimone Kaylae, you have been very wonderful in always remembering my dissertation in your prayer as well as the support and encouragement you gave me. Thank you. Dr. Uri Selorm Markakpo, I am grateful for your constructive criticisms, help, corrections and guidance throughout this project. To my family and all those who contributed directly or indirectly to the completion of the work, I say “ A Big Thank You”. Not forgetting the authors from whose books I made references, and my beloved parents. I am grateful. iii University of Ghana http://ugspace.ug.edu.gh LIST OF ACRONYMS LVS Low Vision Service LVD Low Vision Devices GHS Ghana Health Service WHO World Health Organization OPN Ophthalmic Nurse VA Visual Acuity OR Odds Ratio AOR Adjusted Odds Ratio CDC Centre for Disease Control IRB Institutional Review Board EHCW Eye Health Care Worker OPHTH Ophthalmologist OPTOME Optometrist iv University of Ghana http://ugspace.ug.edu.gh TABLE OF CONTENTS DECLARATION i DEDICATION ii ACKNOWLEDGEMENT iii LIST OF ACRONYMS iv TABLE OF CONTENTS v LIST OF FIGURES viii LIST OF TABLES ix DEFINITION OF TERMS x ABSTRACT xi CHAPTER ONE 1 INTRODUCTION 1 1.0 Background 1 1.1 Statement of the Problem 2 1.2 Conceptual Framework 3 1.3 Justification of the Study 5 1.4 Research Questions 5 1.5 Objective 6 CHAPTER TWO 7 LITERATURE REVIEW 7 2.0 Introduction 7 2.1 Low vision services and visual aids 8 2.2 Knowledge on low vision services 9 2.3 Patients and Socio-Cultural Perception about Low Vision 10 2.4 Socio-economic status and Utilization of Eye Care Services 10 v University of Ghana http://ugspace.ug.edu.gh 2.5 Accessibility to Low Vision Facility 11 2.6 Lack of Motivation 11 2.8 Conclusion 12 CHAPTER THREE 13 METHODOLOGY 13 3.0 Introduction 13 3.1 Study Design 13 3.2 Study Area 13 3.2.1 The Ridge Hospital 14 3.2.2 The 37 Military Hospital 14 3.2.3 The Tema General Hospital 15 3.2.4 The Korle Bu Teaching Hospital 16 3.3 Inclusion Criteria 16 3.4 Exclusion Criteria 17 3.5 Variables 17 3.6 Study Population 18 3.7 Sampling 18 3.8 Quality control 18 3.9 Pretesting of the questionnaire 19 3.10 Data processing and analyses 19 3.11 Ethical Consideration 19 CHAPTER FOUR 22 RESULTS 22 4.0 Introduction 22 4.1: Socio- demographic characteristics of low vision patients. 22 vi University of Ghana http://ugspace.ug.edu.gh 4.2: Socio- demographic characteristics of eye health workers 25 4.3: Level of knowledge about low vision services and devices by low patients 27 4.4 Referral to low vision centre 28 4.5: Barriers to access of low vision services by low vision patients 29 4.6: Level of knowledge about low vision services by eye health workers. 30 4.7 Barriers to the provision of low vision services by eye health workers 31 4.8 Support and policies low on vision service 34 4.9 Suggestions on low vision services by patients 35 4.10 Eye health worker’ suggestions on low vision services 36 4.11 Association between patients’ level of education and low vision referral 37 4.12 Association between patients’ marital status and low vision referral 38 4.13 Association between patient’s income and affordability of low vision devices. 39 4.14 Association between referral of patients and barriers of low vision referral 40 CHAPTER FIVE 43 DISCUSSION 43 5.0 Introduction 43 5.1 Socio- Demographic Data of Respondents 43 5.2 Level of knowledge of low vision services among eye care practitioners and patients 44 5.3 Barriers to Low Vision Services as Report by Patients 45 5.4 Barriers to Low Vision Services By Eye Health Workers. 46 5.5 National Support and low vision policies. 46 5.6 Low Vision Patients and Eye Health Workers Suggestions to Low Vision Services 47 6.1 Conclusion 48 6.2 Recommendations 48 APPENDIX I 54 Consent form for eye health workers 54 APPENDIX II 60 vii University of Ghana http://ugspace.ug.edu.gh LIST OF FIGURES Figure 1.1 Conceptual Framework 4 Figure 4.1 Patients source of knowledge about low vision services and aids. 28 viii University of Ghana http://ugspace.ug.edu.gh LIST OF TABLES Table 1: Socio- demographic characteristics of low vision patients 24 Table 4.2: Socio- demographic characteristics of eye health workers 26 Table 4. 3: Level of knowledge on low vision services and devices by low patients. 27 Table 4.5: Barriers to access of low vision services by low vision patients 29 Table 4.6: Level of knowledge about low vision services by eye health workers. 30 Table 4.7 Barriers to the provision of low vision services by eye health workers. 33 Table 4.8: Support and policies on low vision service 34 Table 4.9: Suggestions on low vision services by patients 35 Table 4.10 Eye health workers’ suggestions on low vision services 36 Table 4.11 Association between patients’ level of education and low vision referral 37 Table 4.12 Association between patients’ marital status and low vision referral 38 Table 4.13 Association between patient’s income and affordability of low vision devices. 39 Table 4.14 Association between referral of patients and barriers of low vision services 40 Table 4.15 Association between eye worker qualifications and barriers to the use of low 42 ix University of Ghana http://ugspace.ug.edu.gh DEFINITION OF TERMS Knowledge: This is what the respondents know about low vision services and visual aids. Visual aids: Assistive his is respondent’s behavior and actions towards occupational hazards and safety Low vision: Low vision is when someone has impairment of visual function despite treatment and /or with standard refractive correction, and has a visual acuity less than 6/18 to light perception or visual field of less than 10 from the point of fixation, but who uses or is potentially able to use, vision for the planning and /or execution of task. x University of Ghana http://ugspace.ug.edu.gh ABSTRACT Introduction: Low vision services and devices assist rehabilitation of low vision patients, however, these facilities are not fully utilized in Ghana. These services and devices prevents visually impaired people from total blindness. Studies have indicated that, inadequate knowledge and other barriers such as inability to afford and accessibility lead to non-utilization of the services, which in turn will lead to total blindness in the low vision patients. Objective: The objective of the study is to access the level of knowledge and barriers to the use of low vision services among eye health workers and low vision patients in selected eye health facilities in Accra, Ghana. Methods: The study was a cross-sectional study, and employed 43 low vision patients and 65 eye health workers purposively. A structured questionnaire was designed and administered to the study participants. The data collected from respondents was entered into MS EXCEL for organization, and analyzed using STATA version 14. Results: The study found high level of knowledge among eye health workers, although only about half the patients with low vision were been referred. Identified barriers such as lack of motivation in the area of low vision and lack of training as well as lack of standard referral pathways are some of the barriers to the non-utilization of low vision services by eye health worker. Among the low vision patients, about half the population sampled had some knowledge on the LVS, however affordability was the major barrier identified for patients. Conclusion: Although there was adequate knowledge on LVS, it was observed that identified barrier were some of the reasons to the non-utilization of the LVS. Hence the need for recommendations such as education on low vision services, training of eye health workers and the formulation of policies on low vision services. Keywords: Low Vision, Visual Aids, Visual Rehabilitation. xi University of Ghana http://ugspace.ug.edu.gh CHAPTER ONE INTRODUCTION 1.0 Background The sight of an individual is very important and when impaired, affects the quality of life and function of the individual. The main aim of vision rehabilitation for visually impaired patients therefore is to help them live a satisfied and productive life as well as integrate them in the society. (Overbury et al., 2011) Visual impairment is a health concern worldwide. About 285 million people are estimated to be visually impaired of out of which, 246 million have low vision (WHO Global data on visual impairment, 2012) According to the Centre for Disease Control (2013), when the eye sight of a visually impaired person cannot be corrected to a normal level, it is referred to as low vision which is regarded as functional limitation of the eye system. Even though there is no one accepted definition for visual impairment, most authors agree that it is uncorrectable vision that is estimated in terms of visual acuity of visual fields. On the other hand, an individual with low vision is one who has impairment of visual functioning despite treatment and /or standard refractive correction, and has a visual acuity less than 6/18 to light perception or visual field of less than 10 from the point of fixation, but who uses or is potentially able to use, vision for the planning and /or execution of task (Khan, Shamanna, & Nuthethi, 2005). There are various types of low vision rehabilitation services and low devices which includes handheld magnifiers, loupes, small telescope and strong magnifying reading glasses to prevent total blindness among people with low vision. In Ghana some optical and non-optical devices are 1 University of Ghana http://ugspace.ug.edu.gh available in the two low vision centers currently available; however, they are not fully utilized. Low vision services are needed to improve the visual function and quality of life of an individual, however, without adequate knowledge of its availability and use, it may be underutilized (Ntim- Amponsah, 2012). A person with low vision can only have access to the rehabilitation service when there is some knowledge about the services. Such knowledge should be provided typically by an eye health worker who is specialized in the field. In Ghana, there are two main low vision rehabilitation centers set up to offer such services yet the utilization of these services still remain poor for reasons that are yet to be explored (Ntim- Amponsah, 2012). These problems may be attributed to lack of awareness and knowledge as well as the inability to afford the service charges and products available; however, specific studies are required to ascertain these assumptions. Increasing awareness and knowledge of the use of low vision services and devices available therefore is essential to prevent the onset of total blindness in such individuals. 1.1 Statement of the Problem Vision impairment is a leading preventable cause of disability worldwide. According to World Health Organization (2014), there are 285 million people estimated to be visually impaired worldwide and out of this number, 13.7% are blind with 86.3% having low vision. Also about 90% of the world’s visually impaired live in low-income setting. Furthermore, this world statistic suggests that, about 1% of the visually impaired lives in Africa and this is caused by eye conditions such as cataract, trachoma and glaucoma (Lewallen and Courtright, 2001). In Ghana, it is estimated that about 2% of the population are visually impaired. A survey by Budenz et.al. (2013), also reported a high prevalence of visual impairment in people of age above 40 years in Tema, Ghana. 2 University of Ghana http://ugspace.ug.edu.gh Even though specific visual aids are required to enhance vision and prevent blindness among persons living with low vision, very few individuals use such services in Ghana. Increasing awareness and use of specific visual aid devices among people with low vision is essential to prevent the onset of total blindness in such individuals. To help minimize the onset of blindness in persons with low vision therefore, this study sought to assess the level of knowledge and barriers to the use of low vision services at selected eye care facilities in Accra, Ghana. 1.2 Conceptual Framework The conceptual framework looks at factors that could be the barriers to the use of low vision services. Information gathered after some literature reviews on the barriers to the use of low vision services has been put together to form this framework. Some factors pertained more to the low vision patient and this included factors such as , patients, societal and cultural negative perception, lack of awareness and existence of low vision services, no or inadequate knowledge about the service, lack of access to the low vision service and low socio- economic status of the patient with low vision (Jose et al., 2016; Lam and Leat, 2013; Pollard et al., 2003). Factors identified under the eye health worker include, lack of knowledge about the existence of the service and inadequate level of knowledge about the low vision devices available, no or inadequate specialist trained worker in the field of low vision and lack of protocol for the referral of the patient with low vision as well as lack of motivation leading to lack of collaboration between service provider and the low vision patient. Low vision is time consuming and not lucrative, as well as lack of motivation in the field were other factors identified as barriers to the provision of low vision patients by eye health workers (Javed, Afghani, & Zafar, 2014; Jose et al., 2016; Khan et al., 2005; Overbury et al., 2011) . 3 University of Ghana http://ugspace.ug.edu.gh Lack of inadequate research in the field of low vision to report on the epidemiology and prevalence as well as weak national support in terms of policies and advocacies were also identified to be a barrier for assessing and using low vision services. Figure 1 Conceptual Framework LACK OF AWARENESS AND LACK OF ADEQUATE EXISTENCE ABOUT LOW VISION KNOWLEDGE ABOUT LOW S E R V I C E S V ISION SERVICES LACK OF ACCESSIBILITY LOW SOCIO TO LOW VISION SERVICES ECO NOMIC STATUS PATIENTS AND SOCIO- NOT LUCRATIVE UTILIZATION OF CULTURAL LOW VISION PERCEPTION ABOUT SERVICES OTHER FACTORS INADEQUATE TRAINED LACK OF ADEQUATE RESEARCH LACK OF MOTIVATION PROFESSIONALS IN LV IN THE FIELD OF LOW VISION WEAK NATIONAL SUPPORT 4 University of Ghana http://ugspace.ug.edu.gh 1.3 Justification of the Study The findings of this study will provide essential information with regard to low vision services in Accra Ghana. It will also provide critical information on the various barriers to the use of low vision services and bring out other gaps in the utilization of these services in Accra, Ghana. These findings will enable policy makers in eye health to make policies that will facilitate the use of low vision services and devices to prevent low vision problems from aggravating into total blindness, when they get to know there are special aids to help them improve their functional vision. Ultimately, this will translate into reducing the number of visually impaired people, within the country and increasing economic gains. 1.4 Research Questions • What are the various kinds of low vision services and visual aids available in eye care hospitals in Accra, Ghana? • What is the level of knowledge of low vision services among eye practitioners and patients in Accra? • What are the barriers to the use of low services and visual aids by persons with low vision in eye care hospitals in Accra, Ghana? • What are the factors that influence the provision of low vision services by eye health workers in Accra, Ghana? 5 University of Ghana http://ugspace.ug.edu.gh 1.5 Objective Main Objective • To assess the level of knowledge and barriers to the use of low vision services by eye care practitioners and persons with low vision at selected eye care hospitals in Accra, Ghana. Specific Objectives 1. To ascertain the level of knowledge of low vision services among eye care practitioners and patients in selected eye health facilities in selected hospitals in Accra, Ghana. 2. To assess the factors that contribute to the non utilization of low vision services in Accra, Ghana 3. To explore patients and health workers suggestion on the improvement of low vision services. . 6 University of Ghana http://ugspace.ug.edu.gh CHAPTER TWO LITERATURE REVIEW 2.0 Introduction During the search from various search engines, that included pub med, science direct and Cochrane, information was gathered on the various types of low vision services, and various barriers on the use these services. Vision is viewed as the ability of seeing and understanding features, colors and contrast and knowing the difference between them visually and the commonest chats used to assess ones vision are the Snellens Chart and Logarithm of Manual Resolution ( Alotaibi, 2015). Low vision is visual acuity less than 6/18 and equal to or better than 3/60 in the better eye with best correction or can also be defined as a person with low vision is one who has impairment of visual functioning even after treatment and/or standard refractive correction, and has a visual acuity of less than 6/18 to light perception, or a visual field less than 10 degrees from the point of fixation, but who uses, or is potentially able to use, vision for the planning and/or execution of a task for which vision is essential (World Health Organization, 2010). There are over one billion people with various types of disability worldwide, of whom about two hundred million people experience some considerable difficulty in functions (WHO, 2011a). This report also states that visual impairment is considered as one of the largest form of disability, in that, an estimated number of 285 million people are visually impaired out of which 246 million is said to have low vision with about 90% living in developing country. (WHO Visual impairment and blindness, 2014). Two-thirds of the patients with low vision are living in the Asia Pacific 7 University of Ghana http://ugspace.ug.edu.gh Region where as about 1% of the visually impaired lives in Africa (Chiang, Marella, Ormsby, & Keeffe, 2012; Lewallen & Courtright, 2001). According to WHO,( 2011a) it is estimated that the main cause of global visual impairment is due to uncorrected refractive error, cataract and glaucoma, however the cause of visual impairment may vary depending on country (Lamoureux et al., 2007; Owsley et al., 2006). 2.1 Low vision services and visual aids The World Health Organization (WHO) and the International Agency for the Prevention of Blindness in the year 1999, formulated a worldwide project for the eradication of preventable loss of sight with the subject of "Vision 2020: the Right to Sight".(“WHO | Estimation of global visual impairment due to uncorrected refractive error,” 2011b) This global program aims to eradicate preventable loss of sight by the year 2020 and as such provision of low vision services has been recognized as part of the project. The main aim for the provision of low vision services is rehabilitation and it encompasses many types of services, making it a multidimensional area, which includes assessment of visual function, use of low vision devices which includes optical and non optical aids, some amount of psychological and vocational counseling and training, moreover, these services are not done individually but by a multidisciplinary team made up of the three groups of eye healthcare workers, occupational therapist, certified low vision specialist, occupational and rehabilitation specialist. (Gilbert, 2012; Ntsoane & Oduntan, 2010; Owsley et al., 2006). There are about 1,228 low vision rehabilitation service entities in the US with about half the number privately owned, with the aim of providing some amount of low vision care to patients (Owsley et al., 2009), however, in a developing country like Ghana, there are two main low vision centers, Korle Bu in the greater Accra Region and the other in the Eastern Region that provides some optical low vision 8 University of Ghana http://ugspace.ug.edu.gh aids like the hand held magnifiers and other assistive devices and training on the use of this devices but without a comprehensive low vision team (Ntim-Amponsah, 2012). When the right type of device is provided and used appropriately by the patients, it improves the quality of life for the patient, and gives him/ her greater independence and courage (Dijk, 2012). Despite the advantages on the use of low vision device and services, the optimum usage of these services remain low in most developing countries where there are various impact and identified challenges to its use (Jose et al., 2016). 2.2 Knowledge on low vision services A study conducted by Jose et al., (2016), among eye care practitioners in Kerala, India, on barriers to the use of low vision services, concluded that, lack of awareness among eye care practitioners was the greatest barrier to the use of low vision services. Lam & Leat, (2013), in a study to assess the patients’ perspective to barriers to accessing low vision care also concluded that in addition to other factors, there was lack of knowledge and awareness of the low vision services amongst patient with low vision. In a focused group discussion during a study to assess barriers to low vision services in Australia, the participants stated lack of awareness about any form of low vision services and this was considered to be a setback to the use of the service (Pollard et al., 2003). Lack of awareness of low vision service and its practitioners among the general public was identified to be a major setback to the utilization of low vision services. (Okoye, Aghaji, Umeh, Nwagbo, & Chuku, 2009) It is perceived that lack of inadequate knowledge and awareness affects the use of services and products, and this assumption comes to play in the use of low vision services and aids among eye health workers and patients with low vision. In a study conducted by Jose et al. (2016), among eye 9 University of Ghana http://ugspace.ug.edu.gh care practitioners in Kerala, India, on barriers to the use of low vision services, they concluded that, lack of awareness among eye care practitioners was the greatest barrier to the use of low vision services. Lam & Leat, (2013), in a study to assess the patients’ perspective to barriers to accessing low vision care also concluded that in addition to other factors, there was lack of knowledge and awareness of the low vision services amongst patient with low vision. In a focused group discussion during a study to assess barriers to low vision services in Australia, the participants stated lack of awareness about any form of low vision services and this was considered to be a challenge to the use of the service (Pollard et al., 2003). 2.3 Patients and Socio-Cultural Perception about Low Vision There is an association between patient negative perception about low vision and the use of the low vision services. In a study by Frazer et al., (2009) on barriers to accessing eye cares service, they added as part of their conclusion that, some patients especially students and children feel embarrassed to use some health aids or low vision devices in the school and the community. Societal and cultural perception about aids was identified as variables that affect the use of low vision services among patients. This is in agreement with by study by Ntsoane & Oduntan, (2010), who reviewed factors affecting the utilization of eye care services and as part of the conclusion to that study, there is an association between cultural beliefs and societal misconception. Different cultures perceive health care services in different ways and this influence their choice and use of health devices (Frazer et al., 2009). 2.4 Socio-economic status and Utilization of Eye Care Services Socio economic status of individuals and family is a well know factor that affects the patronage and utilization of services and health facilities without eye care being an exception. About 90% of the visually impaired are known to live in low income areas (WHO, 2014), making access to health 10 University of Ghana http://ugspace.ug.edu.gh care and utilization a challenge. According to Knight & Lindfield, (2015) in a study aimed to determine the existence and nature of an association between socio economic and access to health care in the United Kingdom, noted as part of their report review that, lower socio economic status has less access to health care than those with higher socio economic status. In another study by Norris et al., (2016) who sought to investigate the socio economic position and poor eye health among women, also concluded that, socio economic position was inversely associated with visual impairment and the use of eye care facilities, compared with other eye conditions. Most low vision services are costly and depending on an individual socio economic status, it may serve as a barrier for its utilization. 2.5 Accessibility to Low Vision Facility The utilization of low vision services is still considered to be relatively low even though there have been some improvement over the past few years (Ntim-Amponsah, 2012). Eye care services are largely run by eye care practitioners in hospitals and ophthalmologist are usually found in big cities, leading to factors that contribute to the non utilization of low vision (Ilechie, Otchere, Darko- Takyi, & Hallady, 2013). In view of this, distance, transportation cost limits access to low vision services serves as one of the barriers to its utilization (Marella et al., 2016). Lack of awareness of low vision service and its practitioners among the general public was identified to be a major setback to the utilization of low vision services. 2.6 Lack of Motivation Motivation serves as a drive in the achievement or success of a service; however, lack of adequate motivation does not encourage the use of a service. In a study conducted by Khan et al., (2005), to assess perceived barriers to the provision of low vision service among ophthalmologist, some of 11 University of Ghana http://ugspace.ug.edu.gh the respondents attributed the low utilization of the service to inadequate motivation by organizers of low vision and / or those involved in the VISION 2020: The Right to Sight, however, other barriers he listed in that study included non - availability of low vision aids and low vision care being time consuming. 2.8 Conclusion Although there have been studies that show the positive impact of low vision in countries like Peru and Tanzania, from participants of low vision study, challenges such as lack of inadequate information and high prices of low vision devices as well as lack of confidence in the use of the devices among children and adults alike were noted (Dijk, 2012). Societal misconception, cultural factors and influence are barriers from the patients point of view (Lam & Leat, 2013). Other barriers to accessing low vision from a low vision patients and eye health workers’ perspective included miscommunication from the eye care professionals, high cost of devices, absence of collaboration and coordination between low vision care providers and patients as well as low national supports and researches have been identified. However other assumptions of ophthalmologist and other eye care workers preoccupied in other ophthalmic activities were also clearly outlined (Khan et al., 2005; Ntim-Amponsah, 2012; Okoye et al., 2009; Overbury et al., 2011). Low vision services remain poorly utilized in our part of the world considering the fact that majority of the visually impaired can be found in the developing countries (WHO, Visual impairment and blindness, 2014). To reduce the burden of disability and improve the quality of life of individuals with low vision, a comprehensive low vision service is essential (Chiang et al., 2012). There is however, lack of studies on the awareness and knowledge as well as barriers to use of visual aid and low vision services among eye patients and eye healthcare workers in Ghana. 12 University of Ghana http://ugspace.ug.edu.gh CHAPTER THREE METHODOLOGY 3.0 Introduction This chapter comprises study design, study area, variables, study population, sample size estimation and sampling techniques. It also comprises data collection and techniques, quality control data processing data analysis and ethical consideration. 3.1 Study Design A descriptive cross-sectional study was used which involved quantitative methods in data collection that is mostly close ended questions. The study was done at various eye care departments within selected hospitals in the Greater Accra Region. The study subjects comprised of eye health worker (ophthalmic nurses, ophthalmologist and optometrist) and individuals visiting Korle Bu Eye Centre with low vision and those attending low vision clinics on the low vision clinic days. Data was collected from all participants between the period of March and June, A quantitative approach was used to collect data, by this, a structured questionnaire was constructed with closed ended questions, and Likert Scale was employed to obtain response to the questions. 3.2 Study Areas The study was conducted in the eye department or unit of various public hospitals in the Greater Accra region. These hospitals included the Tema General Hospital, 37 Military Hospital, Ridge Hospital and Korle Bu Teaching Hospital. 13 University of Ghana http://ugspace.ug.edu.gh 3.2.1 The Ridge Hospital Ridge hospital is the Greater Accra Regional Hospital and can be regarded as one of the leading hospitals in Ghana. It is located on 5.5627° North, 0.1990° West, in a neighborhood called North Ridge in the city of Accra and bounded to the east by the Independence Avenue, to the west by the Kanda Highway, south by the Castle Road and the Ring Road separates the North of the hospital. It was built in 1929 to provide health care for British nationals during the precolonial era. The hospital is currently undergoing an expansion from a 191 bed to a 600 bed capacity. It is made up of various departments which include the eye department, medical department, surgical, Obstetrics and Gynecology Maternal and Pediatric etc. The eye clinic is located at about 300 meters from the main entrance to the hospital. It is made up of various sections which includes, the screening are area, the 3 consulting rooms and an optometrist room. An operating room in the main theatre has been allocated to the eye department, where surgery cases are conducted every Wednesday. The departments outreach programs are held on Fridays and the other days are used for screening, diagnosing and treating various kinds of eye patients. The clinic has about 10 ophthalmic nurses, 2 ophthalmologists and 2 optometrists. The patient’s attendance to the clinic varies between 30- 50 patients on clinic days. 3.2.2 The 37 Military Hospital The 37 Military Hospital was established by a British Military Officer, General George Giffard in 1941. It is a specialist hospital located on 5.5885°N, 0.1832°W, on the main road in between Kotoka International Airport and Accra Central. The hospital is primarily staffed by military health workers. It has about 400 beds and it has a 24 hour accident and emergency and pharmacy. The departments include, Division for Dental Treatment, Gynecology, Pediatrics and Veterinary Treatment. It also has an eye department which is situated at the main Out Patient Department 14 University of Ghana http://ugspace.ug.edu.gh (OPD) of the hospital. The clinic is opposite the Ear Nose and Throat (ENT) Department and can be found on the first floor of the OPD, with the Public Health Department beneath. The eye theatre can also be found opposite the medical department. The department has a waiting area, 3 consulting rooms and a screening room which is also used to perform minor procedures in the eye. The eye department has four ophthalmic nurses, three ophthalmologists and 5 optometrists. It however has other auxiliary workers that also aids in the smooth running of the clinic 3.2.3 The Tema General Hospital The Tema General Hospital is a Metropolitan hospital located on 5.5560°N, -0.1969°W, on the Light Industrial area in the Tema Metropolis which is in the Greater Accra Region. The hospital has a total bed compliment of 280 bed and 10 wards. It offers both general and specialist care services in all the major clinical disciplines including internal medicine, general surgery, pediatrics, obstetrics and gynecology, dental and eye care. The eye department is the last building on the compound of the Tema General Hospital. To the east of the building are the doctors’ bungalows and to the west is the dental department. Upon entry, is the waiting area, and to the right of this area, you find the vision area, the nurses screening area, the optometrist room, the conference room (Barry Callebaut), the matrons office, the revenue and records area, as well as the pharmacy. To the left of the waiting area is the theatre (Kofi Yim), the two doctors consulting rooms, the treatment room, and the changing room. Other rooms such as the pantry and wards can be found within the department. The clinic sees about 80 patients daily with no specific days for running specific clinic, however, their theatre day is on Wednesday and outreach day on Fridays. 15 University of Ghana http://ugspace.ug.edu.gh The staff strength, apart from other auxiliary workers such as both male and female orderlies, pharmacy technicians, staff nurses and revenue collected, the clinic has 5 ophthalmic nurses, 2 ophthalmologists and 3 optometrists. 3.2.4 The Korle Bu Teaching Hospital The Korle Bu Teaching Hospital is a 2000 bed capacity hospital which was built in 1923 under the then governor Sir Gordon Guggisberg. It is located on 5.5374° N, 0.2274°W. The hospital has various departments which includes the Maternity department, Medical department, Surgical Department, Child Health and the Eye Centre The eye centre is currently located behind the new physiotherapy block and caters for approximately 300 patients daily. It is made up of different grades of health workers and auxiliary workers, which includes 11 ophthalmologists, 26 ophthalmic nurses, 3 optometrists, 6 medical officers, 15 general nurses and healthcare assistants as well as orderlies and accounting and administrative staff. The clinic works every day, with various subspecialty units that works on specific days. This subspecialty includes pediatric ophthalmology on Mondays and Fridays, Retina Clinic on Wednesday and glaucoma Clinic on Thursdays. The centre is made up of 23 consulting rooms, a treatment room, two theatres, 3 main wards a record unit and an optometrist unit. The centre attends to all eye conditions which include all eye traumas and ulcers, corneal dystrophies, diabetic and hypertension retinopathies, strabismus and glaucoma. Low vision clinic days are run usually on the second and the fourth Thursdays of every month. 3.3 Inclusion Criteria • Public hospitals in Greater Accra Region 16 University of Ghana http://ugspace.ug.edu.gh • Hospitals that have eye centers or department • Hospital that have all three groups of eye health workers, that is ophthalmic nurses, ophthalmologists and optometrist. • Patients attending low vision clinic or has low vision 3.4 Exclusion Criteria • Other workers of the eye clinic who are not eye health care workers. • Children and patients below 18 years and above 77 years • Patients with other eye condition 3.5 Variables The dependent variable for the study is the no utilization of low vision services. Independent variables that were measured included the socio-demographic variables such as age of respondents, sex of respondents, educational status, marital status and occupation of respondents. The study also measured the level of knowledge of eye health workers as well as that of the patients in addition to level of awareness and existence of low vision services in the country. Other specific independent variables that were measured included, affordability of the services and devices, accessibility to the service where available, patient and societal perception about the use of the service, availability of protocol on standard referral pathway, training on the low vision devices and services, whether low vision is lucrative, lack of motivation and availability of standard protocols and policies in the field of low vision. 17 University of Ghana http://ugspace.ug.edu.gh 3.6 Study Population The population was grouped into two categories. The first group constituting eye care practitioners (Ophthalmologist, Ophthalmic nurses and Optometrist). The second group was made up of low vision patients attending Korle Bu Eye Centre. 3.7 Sampling All eye healthcare workers from the various categories in the various selected facilities were used. This is because; currently very few eye healthcare workers were available in the various hospitals to provide eye care services. Also few low vision patients visit the various eye care clinics for eye care services. In view of this, no sample size calculations were carried out. The study sample therefore comprised all eye healthcare workers at the various hospitals and all patients who visited the Korle Bu Teaching Hospital on daily basis for low vision services or may have low vision during the period of data collection for the study. 3.8 Quality control Two research assistants received a-two-day training on how to collect data. The research assistants were supervised within the period to ensure collection of accurate data. Data collected was checked daily for necessary corrections. The data was also kept for entry and completed data was kept in a clearly labeled bag and then imported into STATA 14 for analysis. 18 University of Ghana http://ugspace.ug.edu.gh 3.9 Pretesting of the questionnaire The questionnaires were pretested at the Eye Department of Cocoa Clinic in order to evaluate the time needed to administer each questionnaire and also to ensure adequacy in the interpretation of the questions. 3.10 Data processing and analyses Data was cleaned and analyses were done using STATA 14. Data was entered into Microsoft Excel before analysis was done. Cross tabulation was used to find association between the outcome and exposures, and Chi Square was used to test for association between categorical variables that is, the association between the qualification of eye health workers and the barriers to low vision services. Logistic regression was however done to find the relationship between referring low vision patients to low vision services and the identified barriers to low vision services health worker. 3.11 Ethical Consideration Privacy and Confidentiality: Confidentiality was assured. The study participants were assured that all their information were confidential and will not be disclosed to anyone without their permission. Electronic data entered in Microsoft Excel and imported into STATA 14 software was made accessible only to me. All information collected has been kept in locked files by the Principal Investigator with secured pass codes. The study materials (questionnaires and consent forms) were not labeled with the participants’ name, but rather a unique identification number for each study participant. 19 University of Ghana http://ugspace.ug.edu.gh Potential Risk / Benefits: This research posed minimum risk to the participants (eye health workers and low vision patients). The risk that was involved was mainly discomfort associated with answering questions which took some time to complete. This discomfort was minimized by stressing on the fact that participants have the right to decline to answer questions or discuss any topics they do not wish to. The study was important as it was expected to have the following benefits. Outcome of study brought to light the level of knowledge of low vision services and the barriers to these services among eye health workers and patients with low vision. Knowing the causes of non utilization of low vision services can help in planning blindness prevention and control programs. It will also provide critical information on the various barriers to the use of low vision services and bring out other gaps in the utilization of these services and this will enable policy makers in eye health to make policies that will facilitate the use of low vision services and devices to prevent low vision problems from aggravating into total blindness. Voluntary Participation/ Withdraw: Participating in the study was entirely voluntary. Declining to be part of the study, answer a question or discontinuing the study had no negative consequences. Participants were also informed that they had the right to withdraw from the study at any time without any consequences or penalties. Consenting Process: the study was explained to the study subjects verbally regarding the purpose, procedures, risk, benefits and alternatives to participation during which they were given ample opportunity to ask questions for further clarifications. To ensure that all the subjects understood clearly what was expected of them, they were asked to explain: 1. What they are being asked to do. 20 University of Ghana http://ugspace.ug.edu.gh 2. Describe in their own words the purpose of the study. 3. What are the benefits to the participants of the study? 4. What more they will like to know. Following which they were asked to fill a consent form and append their signature. Questionnaires were presented to participant to fill, with assistance given to areas that needed further explanation and interpretations. Approval from Ghana Health Services Ethical Review Board was obtained as well as that from 37 Military Hospital Institutional Review Board (IRB). Permission was also obtained from the various administrations of the various hospitals involved in the study. Informed consent was sought from various eye health workers to be recruited in the study Finally, permission was obtained from Eye Care Secretariat for information on low vision devices available before commencement of the study. Compensation/ benefits: Eligible persons who consented to participate did not benefit from any monetary gains or other forms of remuneration for their participation. 21 University of Ghana http://ugspace.ug.edu.gh CHAPTER FOUR RESULTS 4.0 Introduction This chapter presents the results of the study using tables and figures to illustrate the findings. It presents the socio- demographic data of the respondents, their level of knowledge of low vision services and devices, the barriers to the utilization of low vision services among eye health workers and patients and the respondents’ suggestions on the improvement of low vision service. It also presents the association and relationship between independent and dependent variables. 4.1: Socio- demographic characteristics of low vision patients Table 4.1 represents the distribution of socio- demographic characteristics of the low vision patients. A total of 43 questionnaires were administered to 43 participants who were recruited into the study and the response rate was 100% (43/43). As shown in the Table below, the age range of the low vision patients was between 18 and 77. Majority of the patients 19 (44.19%) were between the ages of 33 and 47 years. 10 (23.26%) of the respondents were between the ages of 18 to 32 years and patients between the age of 63 and 77 years made up the minority of respondents 5 (11.63%). Majority of the patients, that is 23 (53.49%) were male respondents compared to the female respondents that made up 20 (46.59%). According to Table 4.1, most of the respondents 25 (58.14%) were married, however, 13 (30.23%) were single, although 2.33% and 9.3% were separated and widowed respectively. 22 University of Ghana http://ugspace.ug.edu.gh The level of education summarized in the Table shows that most of the respondents (low vision patients) had attained some formal education. 22 (51.16%) of the low vision patients, according to Table 4.1 had attained tertiary level of education followed by 12 (27.91%) with Secondary level of education. 2 (4.65%) of the respondents had had some basic education whiles 7 (16.28%) had no form of formal education. When asked about the range of their monthly income earned, out of 43(100%) low vision patients, 21 (43.84%) earn less than GH 1,000 a month, whereas 12 (27.91%) patients earn between GH 2,001 to GH 3,000 monthly. 9 (20.93%) patients also note as seen in the Table below that, they earn between GH1,000 and GH2,000. 23 University of Ghana http://ugspace.ug.edu.gh Table 1: Socio- demographic characteristics of low vision patients Socio-demographic Frequency (N=43) Percentage (100%) Age 18 – 32 10 23.26 33 – 47 19 44.19 48 – 62 9 20.93 63 – 77 5 11.63 Sex Male 23 53.49 Female 20 46.51 Marital status Married 25 58.14 Separated 1 2.33 Widowed 4 9.3 Single 13 30.23 Educational level Tertiary 22 51.16 Secondary 12 27.91 Basic school 2 4.65 None 7 16.28 Income <1000 21 48.84 1000 – 2000 9 20.93 2001 – 3000 12 27.91 3001 – 4000 1 2.33 24 University of Ghana http://ugspace.ug.edu.gh 4.2: Socio- demographic characteristics of eye health workers Table 4.2 on the other hand represents the socio- demographic data for eye heath workers (ophthalmic nurses, ophthalmologists and optometrist.) and the study population of this group of respondents was 65 representing 100%. Most of the eye health workers 45 (69.23%) according to the Table 4.2 were female and this was probably due to the fact that ophthalmic nurses were part of the study population. In the Table 4.2, it was realized that, most of the eye health workers, that is 26 (40%) were between the ages of 33-47 years of age. 23 (35.38%) were between the ages 18 and 32 years whiles 15 (23.08%) were between the ages of 48 and 62 years. The last respondent (1.54%) was however between the ages of 63 and 77 years of age. According to the Table 4.2, 5j991 (78.46%) respondents were married and 11 (16.92%) were single. 3.08% and 1.54% were separated and widowed respectively according to their marital status. In terms of which eye facility the eye health worker was stationed to, most of the eye health workers 33 (50.77%) worked at the Korle Bu Eye Centre, whereas 12 (18.46%) of the respondent worked at the 37 Military Hospital Eye Department. 16.92% of the respondents worked at the Tema General Hospital Eye Unit and the rest of the eye health workers (13.85%) worked at the Ridge Eye Clinic. According to the Table 4.2 below, it was also realized that, 53.85% were Ophthalmic Nurses, 24.62% were Optometrist and 21.54% of the respondents were Ophthalmologist. 25 University of Ghana http://ugspace.ug.edu.gh Table 4.2: Socio- demographic characteristics of eye health workers SOCIO- DEMOGRAPHIC PERCENTAGES CHARACTERISTICS FREQUENCY ( N=65) (100%) Sex Male 20 30.77 Female 45 69.23 Age group 18 – 32 23 35.38 33 – 47 26 40 48 – 62 15 23.08 63 – 77 1 1.54 Marital status Married 51 78.46 Separated 2 3.08 Widowed 1 1.54 Single 11 16.92 Facility Korle-bu 33 50.77 37 Military 12 18.46 Tema Gen 11 16.92 Ridge 9 13.85 Qualification OPN 35 53.85 Ophth 14 21.54 Optome 16 24.62 26 University of Ghana http://ugspace.ug.edu.gh 4.3: Level of knowledge about low vision services and devices by low patients Table 4.3 summarizes the level of knowledge of low vision patients on low vision services and devices. According to the Table, it was observed that, out of 43 low vision patients that representing 100%, 13(30.23%) which made up the minority had no knowledge on the availability of low vision devices and services in the country. However, 7(16.28) knew about the availability of low vision services and not the low vision aids, making up partial knowledge and majority 23 (53.49%) were aware of both the availability of low vision services and low vision devices in the country and this is being regarded as full knowledge. Majority of the patient having full knowledge could be as a result of the fact that all the low vision patients were recruited from Korle Bu Eye Center. Table 4. 3: Level of knowledge on low vision services and devices by low patients. Level of Frequency Percentages knowledge ( N = 4 3 ) (100%) Total No Knowledge 13 30.23 30.23 Partial Knowledge 7 16.28 46.51 Full Knowledge 23 53.49 100 27 University of Ghana http://ugspace.ug.edu.gh Figure 4.1: Patients source of knowledge about low vision services and aids. As shown in figure 4.1, majority (91.3%) of the patients who had knowledge on low vision services and devices indicated the hospital as their source of information whereas the rest of the 8.70% had their source of information from relatives. Figure 4.1 Patients source of knowledge about low vision services and aids. N=30 Patients Source of information on low vision 100.00% 90.00% 80.00% 70.00% 60.00% 50.00% 40.00% 30.00% 20.00% 10.00% 0.00% Hospital Relatives Source 4.4 Referral to low vision center When the low vision patients were asked if they had been referred to any low vision centre for continuity of eye care, majority of them 23 (53.49 %) out of 43 of the respondents said they hadn’t been referred and the other 20 (46.51%) respondents responded in the affirmative. 28 Percentages University of Ghana http://ugspace.ug.edu.gh 4.5: Barriers to access of low vision services by low vision patients Out of the 20 (100%) patients who had been referred to low vision service centers, according to the Table 4.5 below, 19 (95%) were asked to purchase low vision devices and 11 (55%) could afford the device whiles according to the other 9 (45%) couldn’t afford the low vision device. As shown in the Table 4.5, 19 (95%) of the patients’ also indicated that the low vision center was accessible, and this was probably due to the fact that all the patients recruited in the study were from Korle Bu Eye Centre, which is one of such 2 centers in the country. When the patients were asked if they had any challenges in using the low vision device, 18 (90%) said they did not have any challenges using the low vision devices. However, the 2(10%) who had challenges in using the devices stated societal, cost and non-availability of the specific type needed. Table 4.5: Barriers to access of low vision services by low vision patients Frequency Barriers N=20 Percentage100% Purchase low vision device Not asked to purchase 1 5 Asked to purchase 19 95 Afford low vision device Can’t afford 9 45 Can afford 11 55 Accessibility of low vision centers Not accessible 1 5 Accessible 19 95 Challenges No challenges 18 90 Yes challenges 2 10 29 University of Ghana http://ugspace.ug.edu.gh 4.6: Level of knowledge about low vision services by eye health workers. According to Table 4.6 below, which describes the level of knowledge of low vision services and devices among the eye health workers, the 65 participants were asked if they have ever heard about low vision before, and all the participants, that is 100% said “yes”. Although majority 55 (84.62%) eye health workers as shown in the Table 4.6 said they know where to locate low vision service centers, 10 (15.38%) said they did not know where to locate low vision service centers. In an attempt to find out whether they refer low vision patients to low vision centers, 44 (67.69%) said they don’t refer, however 21 (32.31%) responded yes, that they do refer low vision patients to low vision centers. According to 4.6, response to the knowledge of availability of visual aids, majority 45 (69.23%) of the respondents said they were aware of availability of visual aids. 12 (18.46%) responded negatively. The rest of the respondents making up 12.31% they did not know whether low vision devices were available or not in the country. Table 4.6: Level of knowledge about low vision services by eye health workers. Percentage Frequency N=65 (100%) Knowledge on low vision services Yes 65 100 Location of low vision service centers Can locate 10 15.38 Can’t locate 55 84.62 Referral of low vision patients Don’t refer 44 67.69 Do refer 21 32.31 Availability of visual aids No 12 18.46 Yes 45 69.23 Don’t know 8 12.31 30 University of Ghana http://ugspace.ug.edu.gh 4.7 Barriers to the provision of low vision services by eye health workers Table 4.7 below describes the barriers to low vision services by eye health workers. Majority 27 (41.54%) of the respondents disagreed that lack of knowledge on low vision services was a barrier to the provision of low vision services. 26(40%) also strongly disagreed and 4.62% remains neutral on lack of knowledge as a barrier to low vision services among eye health workers. the minority however, 9.23% and 4.62 agreed and strongly agreed to lack of knowledge as a barrier to low vision services respectively. 32 (49.23%) that makes up the majority of the respondents agreed that there was lack of training on low vision services. 38.46% and 7.69% disagreed and strongly disagreed respectively where as 3.08% remained neutral. 36.92% and 33.85 forming the majority of eye health worker in the present study strongly agreed and disagreed on the non-availability of low vision devices as barriers to low vision services. Moreover, according to Table 4.7, 12.32% took a neutral stand the rest of the respondents however disagreed. As shown in Table 4.7 the largest section of the eye health workers making up 46.15% strongly agreed and 35.38% agreed lack of motivation in the area was a barrier to low vision services. Although 10.77% of respondents remained neutral, 4.62% and 3.08% strongly disagreed and disagreed respectively with the same assumption. Out of the all the 64 respondents, 36.92% strongly agreed that low vision is time consuming and 32.32% just agreed. Another 12.31% strongly disagreed that the amount of time spent on low vision services contributed to being a barrier to the non-utilization of the services. 31 University of Ghana http://ugspace.ug.edu.gh With regards to the fact that low vision is not lucrative and was a barrier to the utilization to low vision services by eye health practitioners, 36.92% respondents which made up the majority of the respondents disagreed. 27.69% responded neutral and 16.92 of the respondents strongly disagreed. 13.85% and 4.63% however responded agreed and strongly agreed. Lack of standard referral pathway was also identified as a barrier to low vision services by eye health workers. This is because majority of the respondents (33.85%) strongly agreed and 23.08% agreed. 26.15% and 6.15% however strongly disagreed and disagreed respectfully. Most eye health workers strongly disagreed (43.08%) and disagreed (35.38%) with the fact that lack of follow up of low vision patients could be a barrier to the utilization of low vision services as depicted in the Table 4.7 below. Whereas 6.15% were neutral on the issue, 12.31% and 3.08% agreed and strongly agreed respectively o the fact that lack of follow up on low vision patient may be a barrier to low vision services. 32 University of Ghana http://ugspace.ug.edu.gh Table 4.7 Barriers to the provision of low vision services by eye health workers. Frequency (65) Percentage (100%) Lack knowledge on low vision service Strongly Agree 3 4.62 Agree 6 9.23 Neutral 3 4.62 Disagree 27 41.54 Strongly Disagree 26 40 Lack of training on low vision services Strongly Agree 1 1.54 Agree 32 49.23 Neutral 2 3.08 Disagree 25 38.46 Strongly Disagree 5 7.69 Non availability of low vision devices Strongly Agree 24 36.92 Agree 22 33.85 Neutral 8 12.31 Disagree 8 12.31 Strongly Disagree 3 4.62 Lack of motivation in low vision Strongly Agree 30 46.15 Agree 23 35.38 Neutral 7 10.77 Disagree 2 3.08 Strongly Disagree 3 4.62 Time consuming Strongly Agree 24 36.92 Agree 21 32.32 Neutral 8 12.31 Disagree 4 6.15 Strongly Disagree 8 12.31 Not lucrative Strongly Agree 3 4.62 Agree 9 13.85 Neutral 18 27.69 Disagree 24 36.92 Strongly Disagree 11 16.92 Lack of standard referral pathway Strongly Agree 22 33.85 Agree 15 23.08 Neutral 7 10.77 Disagree 17 26.15 Strongly Disagree 4 6.15 Lack of follow up Strongly Agree 2 3.08 Agree 8 12.31 Neutral 4 6.15 Disagree 23 35.38 Strongly Disagree 28 43.08 33 University of Ghana http://ugspace.ug.edu.gh 4.8 Support and policies low on vision service According to Table 4.8 which describes the findings of knowledge on national support for low vision services in the country, it was observed that, majority of the respondents, that is 86.05% low vision patients and 78.46% of eye health workers said “ No”. 13.95% of low vision patients and 13.85% of eye health workers said they didn’t know of any national support. 7.69% of eye health workers which made up the minority however said yes to national support for low vision services in the country. None of the respondents (both the low vision patients and the eye health workers) said they knew of any existing national support for low vision services. Majority of the respondents, that is 88.37% of the low vision patients and 76.92% of the eye health workers as seen in Table 4.8 responded “No” and the rest of the respondents, that is 11.63% of low vision patients and 23.08% said they didn’t know. Table 4.8: Support and policies on low vision service EYE WORKER LOW VISION PATIENT (N=43) HEALTH (N=65) Frequency Percentage Frequency Percentages (N=65) (100%) Support (N=43) (100%) Yes - - 5 7.69 No 37 86.05 51 78.46 Don’t know 6 13.95 9 13.85 Policies No 38 88.37 50 76.92 Don’t know 5 11.63 15 3.08 34 University of Ghana http://ugspace.ug.edu.gh 4.9 Suggestions on low vision services by patients Table 4.9 shows that, majority of the patients, 67.44%, suggested public education (media and from health workers) on low vision services and aids. 16.28% suggested government support and assistance and 6.98% suggested the availability and the affordability of visual aids. Another 6.98% of the patients also suggested that low vision centres should be accessible and the least making up 2.18 suggested that NGO’s should get involved in low vision services. Table 4.9: Suggestions on low vision services by patients SUGGESTIONS FREQUENCY (N= 43) PERCENTAGES % Education (public, media and health) 29 67.44 Government involvement 7 16.28 NGO assistance 1 2.33 Availability and affordability of visual aids 3 6.98 Accessibility of low vision centres 3 6.98 35 University of Ghana http://ugspace.ug.edu.gh 4.10 Eye health worker’ suggestions on low vision services According to Table 4.10, majority of the eye health workers that is 40% suggested training as a way of improving low vision services. 33.85% of the respondents also suggested various forms of educations such as media education to both patients and other health workers. 9.23% of the workers however suggested that low vision services should be rendered all eye centres across the country. 7.69% of the respondents suggested that government should get involved with low vision and minority of the respondents making up 6.16% and 3.08% suggested the availability of visual aids and low vision should be promoted at conferences. Table 4.10 Eye health workers’ suggestions on low vision services SUGGESTIONS FREQUENCY (N=65) PERCENTAGES % Training 26 40.00 Education 22 33.85 Government 5 7.69 involvement Availability of visual 4 6.16 aids Promoted at 2 3.08 conferences Low vision services in 6 9.23 every eye centres hospitals 36 University of Ghana http://ugspace.ug.edu.gh 4.11 Association between patients’ level of education and low vision referral A Chi Square analysis was done to finds an association between the low vision patients’ level of education and low vision referral pattern. It is however shown in the table below that, there was no strong association (p=0.074) between level of education and the referral pattern of low vision patients. Table 4.11 Association between patients’ level of education and low vision referral LOW VISION REFERRAL LEVEL OF EDUCATION No Yes Total Tertiary 13 9 22 59.09% 40.41 100% Secondary 3 9 12 25.00% 75.00% 100% Basic school 2 0 2 100% 0.00% 100% Not educated 5 2 7 71.00% 28.57% 100% Total 23 20 43 53.85% 46.51% 100% Fishers exact p =0.074 37 University of Ghana http://ugspace.ug.edu.gh 4.12 Association between patients’ marital status and low vision referral A Chi Square analysis done to finds an association between the low vision patients marital status and low vision referral pattern. It is however shown in the Table 4.12 below that, there was no strong association (p=0.59) between marital status and the referral pattern of low vision patients. Table 4.12 Association between patients’ marital status and low vision referral LOW VISION REFERRAL MARITAL STATUS No Yes Total Married 13 12 25 52.00% 48.00 100% Separated 0 1 1 0.00% 100.00% 100% Widowed 3 1 4 75.00% 25.00% 100% Single 7 6 13 53.85% 46.15% 100% Total 23 20 43 53.85 46.51 100% Fishers exact p =0.59 38 University of Ghana http://ugspace.ug.edu.gh 4.13 Association between patient’s income and affordability of low vision devices. According to Table 4.13, an association exists between patient’s income level and patients’ affordability of low vision devices. This association is statistically significant (p< 0.05). Table 4.13 Association between patient’s income and affordability of low vision devices. AFFORDABILITY Income Yes No Not sure Total 0.05). Table 4.14 Association between referral of patients and barriers of low vision services REFERRAL BARRIERS NO YES UOR 95%CI P-value Knowledge of Agree 1.8 0.34 – 9.57 0.788 low vision neutral 0.5 0.08 – 12.12 disagree Ref Training on low Agree 0.6 0.21 – 1.88 0.628 vision neutral 0.4 0.20 – 6.53 disagree Ref Availability of Agree 1.3 0.29 – 6.55 0.88 low vision neutral 1.1 0.16 – 6.92 devices disagree Ref Lack of Agree 2.8 0.56 – 14.04 1.61 motivation Neutral Ref Time consuming Agree 0.7 0.17- 3.15 1.41 neutral 0.3 disagree Ref 0.49- 2.24 No lucrative Agree 1.0 0.26- 4.18 0.24 neutral 1.4 0.39- 4.71 disagree Ref Lack of Agree 0.4 0.11 – 1.38 2.46 standard neutral 0.3 0.49 – 1.99 pathway disagree Ref No follow ups Agree 0.6 0.77- 5.57 0.25 Disagree Ref 40 University of Ghana http://ugspace.ug.edu.gh 4.15 Association between eye worker qualifications and barriers to the use of low vision services The association between the qualification of eye health workers and the specific barriers were explored. It was noticed as shown in the Table 4.15 that, lack of knowledge on low vision services (p=0.014) and non-availability of low vision devices (p= 0.049) were statistically significant. However, from the other factors, there were no strong statistical evidence to show that there was an association between qualification of eye health workers and barriers such as lack of training on low vision, lack of motivation, low vision being time consuming, not lucrative, no standard referral pathway and no follow ups (p>0.05) 41 University of Ghana http://ugspace.ug.edu.gh Table 4.15 Association between eye worker qualifications and barriers to the use of low Vision services QUALIFICATION - Chi-square/ fisher exact (p- BARRIERS OPN OPTH OPTOME value) NO 3 2 7 25 16.67 58.33 Lack of knowledge YES 32 12 9 <0.014* 60.38 22.64 16.98 NO 4 1 3 50 12.5 37.5 0.685 Lack of training YES 31 13 13 54.39 22.81 22.81 NO 12 6 1 63.16 31.58 5.26 Lack low vision device YES 23 8 15 <0.049* 50 17.39 32.61 NO 8 2 2 66.67 16.67 16.67 YES 27 12 14 0.61 Lack motivation 50.94 22.64 26.42 NO 11 4 5 55 20 25 1 YES 24 10 11 Time consuming 53.33 22.22 24.44 NO 17 6 7 56.67 20 23.33 0.914 Not lucrative YES 18 8 9 51.43 22.86 25.71 NO 15 3 8 Lack of standard referral pathway 57.69 11.54 30.77 YES 20 11 8 0.244 51.28 28.21 20.51 NO 6 2 6 42.86 14.29 42.86 Lack of follow up YES 29 12 10 0.243 56.86 23.53 19.61 42 University of Ghana http://ugspace.ug.edu.gh CHAPTER FIVE DISCUSSION 5.0 Introduction The aim of the study described in the dissertation was to assess the knowledge and the barriers to low vision services among eye health workers and low vision patients in selected hospitals in Accra, Ghana. Low vision rehabilitation which comprises the use of low vision services and devices are very important in the prevention of total blindness among low vision patient. However, the availability, accessibility and affordability is required. Therefore, assessing the knowledge and barriers of low vision services among eye health workers and low vision patients will generate the critical information required to create awareness of the availability and importance of low vision services and devices among eye health workers, patients and their relatives. Also, conduct of this study would provide the baseline data necessary for the formulation of policies for the provision of low vision care to help improve the functional vision of the visually impaired. To achieve this aim therefore, a cross section of eye health workers and low vision people in selected eye care facilities were studied to obtain information on their level of knowledge in the area of low vision as well as their barriers to low vision service in Accra Ghana. 5.1 Socio- Demographic Data of Respondents The results showed that a majority (67.45%) of low vision people were between 18-47 years, and this is contrary to what was reported earlier (Khan et al., 2005) that low vision could be as a result of eye health changes in the ageing population, that is, >50 years, due to most eye care conditions such as glaucoma, whose prevalence increase as the population gets old. In view of this observation, it is possible that, a majority of the elderly with low vision were also not reporting for 43 University of Ghana http://ugspace.ug.edu.gh low vision services because they cannot afford to pay for the services or they lack knowledge of the availability of such services in the selected facilities. However, considering the fact that approximately 50% of the respondents were low income earners (0.05), even though other studies which recruited higher numbers (> 400) of patients have indicated otherwise (Khan et al., 2005). It was therefore possible that apparent lack of association might have been due to the fact that a smaller sample size of respondents were recruited into the study compare to the earlier studies. Also, when the patients were asked about issues with accessibility of the eye care facility, majority (90%) said that the facility was accessible. This was probably due to the fact that all the patients recruited were from Korle Bu Eye Centre which is one of the two low vision centres currently available in the country. This observation therefore confirmed earlier report (Mwilambwe et al., 2009) that there was high patronage of the low vision centres because they were within 50 km of their reach. Last, a majority of the patients indicated that they had no challenge using low vision device services. 45 University of Ghana http://ugspace.ug.edu.gh 5.4 Barriers to Low Vision Services by Eye Health Workers. Although about 81.54% of the eye health workers disagreed that lack of knowledge was a barrier to low vision services, some of them (50.77%) agreed that lack of training on low vision services could serve as barriers to the utilization of low vision services. 70.77% agreed that non availability of low vision devices was a barrier and out of this number, 36.92% strongly agree. During the rehabilitation process of low vision patients, low vision aids form an essential part. This is because patients appreciate the improvement of their functional vision only when these aids were available. When the aids were not available they were unwilling to access the services. Motivation of eye care workers was also considered as a factor that influenced the use of eye care services and devices since it improved eye care services delivery by the eye care practitioners (Khan et al., 2005). In relation to this, even though majority (81.53%) of the workers agreed that lack of motivation was a barrier to low vision services, the fact that there was lack of statistical association between lack of motivation and use of the services suggested that other factors could be involved. 5.5 National Support and low vision policies. Majority of the respondents, both low vision patients (86.05%) and eye health workers (78.46%) responded in the negative when they were asked whether they thought there was enough national support for low vision services. 88.37% of low vision patients and 76.9% also said no to the question whether they knew of any existing policies in low vision. 46 University of Ghana http://ugspace.ug.edu.gh 5.6 Low Vision Patients and Eye Health Workers Suggestions to Low Vision Services In the quest to find the view of low vision patients on suggestions for the improvement of low vision services, the 67.44% majority of respondents suggested education in various forms ranging from hospital based health and low vision education to community and media based low vision education. 16.28% suggested that low vision services would improve if government has a hand in it. However, suggestions made on low vision availability and affordability as well as accessibility made up 6.98% of the respondents each. On the part of eye health care workers, 40% and 33.85% of eye health workers suggested training in the area of low vision and education on low vision services respectively as the paramount way in improving low vision services. Also their suggestions included post-doctoral courses in low vision and health education in media houses, health centres and making use of the fast growing internet and social media for such educations. 9.23% and 7.69% however suggested low vision services in all eye centres and government support and involvement in the availability of visual aids that are affordable. Finally, 6.16% and 3.08% indicated that availability of visual aids and low vision services should be presented at conferences to create more awareness. 47 University of Ghana http://ugspace.ug.edu.gh CHAPTER SIX CONCLUSION AND RECOMMENDATION 6.1 Conclusion In conclusion, this study has shown that, there was high level of knowledge on low vision services among eye health workers. Despite that only about 53.49% of low vision cases were referred to low vision centre. About 53.49% of the participants (low vision patients) had full knowledge on low vision services. Some barriers to low vision services included lack of training, lack of motivation and the fact that low vision is time consuming. Lack of knowledge on low vision and non-availability of low vision aids were associated with the referral pattern of low vision patients. Finally, this study provided useful information to guide policy makers on the need to formulate policies necessary for low vision services. 6.2 Recommendations 1. Effective record keeping in health facilities- health facilities should be provided with an electronic record keeping system with very well trained record keeping staffs and biostatistians. This would enable future records and tracking of cases such as low vision cases to be more effective. 2. There should be continuous training of eye health practitioners on low vision services and the creation of low vision rehabilitation centres for low vision patients. They should also have permanent staffs to manage those centres which should be fully equipped with modern low vision devices. 48 University of Ghana http://ugspace.ug.edu.gh 3. Public and media education on low vision and it importance on health talk show, churches, conferences and other public functions. 4. Standard referral pathway as well as protocols should be set to aid a better referral and tracking of low vision patients. 5. More researches should be done in the area of low vision services to address other questions such what proportion of low vision patients access low vision services and care. 49 University of Ghana http://ugspace.ug.edu.gh REFERENCES Alotaibi, Z. (2015). A Retrospective Study of Causes of Low Vision in Saud Arabia, A Case of Eye World Medical Complex in Riyadh. 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WHO, 3–4. https://doi.org//entity/blindness/causes/priority/en/index.html 53 University of Ghana http://ugspace.ug.edu.gh APPENDIX I FORM A CONSENT FORM FOR EYE HEALTH WORKERS Title: Assessing the level of knowledge and barriers to low vision services in selected eye health facilities in Accra, Ghana. My name is Eileen Nartehkie Amanquah Buxton a student from the School of Public Health, College of Health Sciences, University of Ghana (show school ID for verification). I am in this facility to carry out a study on assessing the knowledge and barriers to low vision services. The research seeks to describe the level of knowledge of low vision among eye health workers and low vision patients as well as explore the barriers to assessing low vision services and assess interventions to improve low vision services. This research will pose minimum risk to the participants (eye health workers and low vision patients). The risk involved will be mainly discomfort associated with answering questions which will take some time to complete. This discomfort will be minimized by stressing on the fact that participants have the right to decline to answer questions or discuss any topics they do not wish to. Outcome of study will bring to light the level of knowledge of low vision services and the barriers to these services among eye health workers and patients with low vision. Knowing the causes non utilization of low vision services can help in planning blindness prevention and control programs. The needs of the low vision patient may also be highlighted. Electronic data entered in Microsoft Excel and imported into STATA 14 software will be made accessible only to me. I will store all study material and data (questionnaires, informed consent forms) in a locked cabinet. Potential participants will be made aware that participating in the study 54 University of Ghana http://ugspace.ug.edu.gh is voluntary and that an individual has the right to decline to participate in the study. Again eligible persons who consent to participate will not benefit from any monetary gains. RESPONDENT’S CONSENT I have been adequately informed about the purpose, procedures and potential risks and benefits of this study. I have had the opportunity to ask questions and any question that I have asked have been answered to my satisfaction. I know that I can refuse to participate in this study without any loss of benefit to which I would have otherwise been entitled. I understand that if I agree to participate I can withdraw my consent at any time without losing any benefits or services to which I am entitled. I understand that any information collected will be treated confidentially. I freely agree to participate in this study. Name of Participant…………………………………………………………………. Signature or Right thumb print……………………………… Date…………………………… I have adequately informed the participant of the purpose, procedures, potential risks and benefits of this study. I have answered all questions to the best of my ability. Name of Interviewer………………………………………………………………… Signature……………………………….. Date…………………………………… 55 University of Ghana http://ugspace.ug.edu.gh QUESTIONNAIRE FOR EYE HEALTH WORKERS ONASSESSING THE LEVEL OF KNOWLEDGE AND BARRIERS TO LOW VISION SERVICES IN SELECTED EYE HEALTH FACILITIES IN ACCRA, GHANA No………… INSTRUCTIONS: KINDLY FILL IN OR CHECK (√ ) IN THE SPACES PROVIDED WHERE APPLICABLE SECTION A: Demographic Data 1. Facility::1. Korle Bu Eye Centre ( ) 2. 37 Military Hospital eye clinic ( ) 3. Tema General Hospital ( ) 4. Ridge Hospital ( ) 2. Age: 18 - 22 ( ), 23 – 27 ( ), 28 – 32 ( ), 33-37 ( ), 38 – 42 ( ), 43 – 47 ( ) , 48 – 52 ( ), 53- 57 ( ), 58 – 62 ( ), 63 – 67 ( ), 63 - 72 ( ), 73 – 77 ( ) 3. Sex: Male ( ) Female ( ) 4. Marital Status: 1 Married ( ) 2 Separated ( ) 3 Divorced ( ) 4Widowed ( ) 5 Single ( ) 5. Qualification: ophthalmic nurse ( ) ophthalmologist ( ) optometrist ( ) 56 University of Ghana http://ugspace.ug.edu.gh SECTION B Level of knowledge Level of knowledge of low vision services by YES NO NOT SURE eye health care workers 6. Have you heard about low vision? 7. Do you know where to locate low vision service centers? 8. Do you refer patients to low vision service centers? 9. Do you know about the availability of visual aids? 57 University of Ghana http://ugspace.ug.edu.gh SECTION C: Barriers to low vision service Barriers to low vision Strongly Agree Neutral Disagree Strongly services agree disagree 10. Lack of knowledge on low vision services 11. Lack of training on low vision services. 12. Non availability of low vision devices. 13. Lack of motivation in area of low vision. Barriers to low vision Strongly Agree Neutral Disagree Strongly services agree disagree 14. It is time consuming 15. It is not lucrative 58 University of Ghana http://ugspace.ug.edu.gh 16. There is no standard referral pathways 17. Lack of follow up for low vision patients Other Barriers 18. Do you think there is enough national support for low vision in the country? Yes ( ) No ( ) Don’t Know ( ) 19. Do you know of any National policies on low vision? Yes ( ) No ( ) Don’t Know ( ) 20. Are there any suggestions to improve the use of low vision services and devices? ………………………………………………………………………………………………… ………………………………………………………………………………………………… 59 University of Ghana http://ugspace.ug.edu.gh APPENDIX II QUESTIONNAIRE FOR LOW VISION PATIENT ONASSESSING THE LEVEL OF KNOWLEDGE AND BARRIERS TO LOW VISION SERVICES IN SELECTED EYE HEALTH FACILITIES IN ACCRA, GHANA No………… INSTRUCTIONS: KINDLY FILL IN OR CHECK (√ ) IN THE SPACES PROVIDED WHERE APPLICABLE SECTION A: Demographic Data 1. Facility::1. Korle Bu Eye Centre ( ) 2. 37 Military Hospital eye clinic ( ) 3. Tema General Hospital ( )4. Ridge Hospital ( ) 2. Age: 18 - 22 ( ), 23 – 27 ( ), 28 – 32 ( ), 33-37 ( ), 38 – 42 ( ), 43 – 47 ( ) , 48 – 52 ( ), 53- 57 ( ), 58 – 62 ( ), 63 – 67 ( ), 63 - 72 ( ), 73 – 77 ( ) 3. Sex: Male ( ) Female ( ) 4. Marital Status: 1 Married ( ) 2 Separated ( ) 3 Divorced ( ) 4Widowed ( ) 5 Single ( ) 5. Educational Background: 1 Tertiary ( ) 2 Secondary ( ) 3 Basic Schools ( ) 4 Not Educated ( ) 6. Income level (monthly): up to GHC 1000 ( ), GHC 1000 – 2000 ( ), GHC 2001 – 3000 ( ), GHC 3001 – 4000 ( ), more than GHC 4000 ( ) 60 University of Ghana http://ugspace.ug.edu.gh SECTION B Level of Knowledge 7. Do you know about the existence of any Low vision services available in Ghana? Yes ( ) No ( ) 8. If Yes, source of awareness Hospital ( ) Media ( ) Others (please specify)……………………. 9. Are you aware of devices that can help you improve your functional vision (perform your daily task) ? Yes ( ) No ( ) Not Applicable ( ) 10. Have you been referred to any low vision care center? Yes ( ) No ( ) IF Yes , move to SECTION C 61 University of Ghana http://ugspace.ug.edu.gh SECTION C Patients’ Barriers: Patients Barrier Yes No Non Applicable (N/A) 11. Were you asked to purchase a low vision device? 12. If yes could you afford it? 13. Was the location of where to acquire low vision service accessible? 14. Do you have any challenges in using the low vision device? 62 University of Ghana http://ugspace.ug.edu.gh If Yes please list some of challenges that make using the Low Vision Device difficult or prevents you from using it. ......................................................................................................................................................... .......................................................................................................................................................... Other Barriers 15. Do you think there is enough national support for low vision in the country Yes ( ) No ( ) Don’t Know ( ) 16. Do you know of any National policies on low vision Yes ( ) No ( ) Don’t Know ( ) 17. Are there any suggestions to improve the use of low vision services and devices ……………………………………………………………………………………………………. …………………………………………………………………………………………………….. 63 University of Ghana http://ugspace.ug.edu.gh 64 University of Ghana http://ugspace.ug.edu.gh 65