Barriers to Use of Refractive Services in Mozambique

Mozambique has a population of more than 25 million people.1 Nampula Province has just fewer than 4 million people.2 Although Mozambique is currently experiencing unprecedented economic growth rates, buoyed by the discovery of natural resources, significant challenges remain for the population, such as adequate health care, including eye health services. VISION 2020 is a global initiative to eliminate avoidable blindness by the year 2020. Its core strategies are focused on human resource development, infrastructure development, and disease control.3 The Mozambique Eyecare Project delivered a regional optometry model for Lusophone Africa, based on the VISION 2020 core strategies. A key output was a higher education program for optometry. Mozambique’s first professional optometrists graduated from Universidade de Lurio in Nampula in 2013. To achieve the VISION 2020 goals, the services the optometrists are trained to provide must be fully implemented. To realize this potential, the use of refraction services by the general public must be fully understood.4 The body of evidence that exists in relation to the uptake of eye health services is limited. Research suggests that cost is the most significant barrier to eye health services.4–6 Indirect costs, such as transport, food, and lodgings, may also limit uptake.7 However, if cost as a barrier is removed, service uptake is not guaranteed.8 Even when eye health services are provided at no cost, not all patients choose to access them.9,10 In some instances, people with eye health needs may be unaware of free or subsidized services. A lack of information about the service may be as much of a barrier as cost.11 The significance of cost as a barrier may change with time. With ready-made spectacles, which provide a suitable correction for a significant proportion of refractive errors, now costing as little as $1 per pair to source, cost may no longer be a substantial barrier to usage for many subjects.12 Eye health services tend to be focused on urban areas of high population density, yet many people live in rural areas. Distance to services may therefore be a barrier.13 The journey to access services may be particularly difficult for those with visual impairment (VI). Gender must also be considered in this context. Unaccompanied travel for long distances may present different barriers for men and women in different societies.14 Entrenched cultural and religious beliefs may also present barriers.15 Whether these beliefs involve religion, ideas of destiny, or societal attitudes toward sex and gender, disability, or ethnicity, they may limit service uptake.13,16,17 The perception that vision loss is an untreatable and irreversible consequence of aging may also need to be countered.10 People may be unaware that they even have an eye health problem. A lack of awareness of general eye health and the interventions available may limit uptake. Those needing treatment may not understand the time needed for the intervention, the costs involved, whether it will hurt or not, and the chances of achieving a successful outcome.13 Eye health education and the provision of information may be key to overcoming these barriers.18 Quality of services will influence future uptake. Adequate health infrastructure and the suitability/quality of staff training are important determinants of the influence of such experience/outcome-related barriers.19 Bullying, ridicule, and peer victimization potentially may also limit service uptake or reduce compliance, particularly with regard to children with eye health problems.20 Strategies to improve the compliance of spectacle wear may be needed.21 Understanding the barriers to a refractive service will be central to the ultimate success of the intervention.22 This study has been designed to gain an understanding of the barriers to accessing refractive services perceived by the general population in Mozambique.