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We hereby review briefly the article
entitled ‘Refraction-seeking behavior among young people presenting to a
medical college hospital of Bihar’ and provide a perspective on why people
visit a tertiary hospital of India for refraction alone.
INTRODUCTION
In the Indian
public health system, health services are designed in principle to meet the
needs of the community through a three-tier system – primary, secondary and
tertiary [1]. Primary health centres and sub-centres are meant to be points of
primary or first contact of healthcare where most of the people’s common health
problems can be dealt with and resolved effectively. More complex problems are
to be dealt with at the secondary level on first referral to community health
centre and district hospitals. Referrals from these two levels should be
addressed by specialized and specific facilities at tertiary care level.
However, in practice, all the three tiers can be directly accessed by the
people without any referral and for common health conditions too. Consequent
increased footfall in the higher centres dilutes the very purpose of the three
tier system in this developing country.
‘Vision 2020: The
Right to Sight’ envisaged reducing avoidable (preventable and curable)
blindness by the year 2020 for which refractive errors is one of the target
disorders. The World Health Organization (WHO) identifies uncorrected
refractive errors as a major cause of moderate to severe visual impairment
worldwide, amounting to about 53% of all causes of visual impairment [2]. The
Rapid Assessment of Avoidable Blindness (RAAB) Survey in India (2006-2007)
showed that 0.7% of blindness and 34.1% of visual impairment are caused by
refractive errors [3], making it a key problem area that needed to be
addressed. Thus, India has organised provision of ophthalmic care at primary
level vision centres to provide, among other initiatives, screening and
refraction services with provision of low-cost, good quality spectacles for
children. The treatment of refractive errors with low-cost spectacles is one of
the easier ways to decrease vision problems [4].
NEED FOR THE RESEARCH AND STUDY DESIGN
We noticed that
contrary to its established role of providing specialized care for eye
diseases, a number of young people approach our tertiary care centre for the
mere provision of spectacles. Hence, it was felt important to enquire into the
magnitude of and reasons for this practice of by-passing the primary and
secondary care centres through a prospective study [5]. We preferred to choose
young people aged 10 to 24 years as our subjects of study because they form a
group mostly of students, whose education, occupation, safety and quality of
life depend upon the eye care services they receive and they, in turn, affect
national productivity [5,6].
With the
objectives to enquire about the availability of primary or secondary level
facilities for refraction in the rural and urban patients’ respective
vicinities and explore reasons for their approaching a tertiary OPD despite
their awareness of the same, the study included such subjects residing in the
administrative region of Patna, India, who reported for and were diagnosed as
having refractive errors (earlier or now, in one or both eyes).
OUR FINDINGS
A total of 1075
subjects with refractive errors were detected, 114 (10.6%) from rural and rest
961 (89.4%) from urban Patna. The tertiary care institution in question is
situated in an urban area and hence it seems to be easily approachable
It
was also noticed that refraction facilities (of primary or secondary level)
were available in the vicinity of residence of about three-fifths of all rural
young people. About one-fifths denied the availability of such facility in
their vicinity, while another one-fifths was unaware of any such facilities in
private or government setups. In contrast, all the urban subjects knew of
refraction facilities near their residence. This statistically significant
difference is suggestive of either an absolute deficiency of or lack of awareness
about centres in rural Patna. In addition, available facilities in both rural
and urban Patna may not be providing refraction services to the requirement and
satisfaction of young people, compelling them to visit a tertiary centre for
the same.
Amongst
various reasons for not utilizing other facilities as enumerated by the
patients, the most common was the need for certification from a government
institution for the purpose of obtaining admission to an educational
institution or job (27%). As the tertiary care institution is located amid a
number of educational institutions in a densely populated area, this makes it
convenient for many young people to visit it for their ailments. Hence, easy
access was identified as the main reason for their visit by nearly 25% of the
subjects even though a primary care government hospital exists within urban
Patna. This reflects that the role of a tertiary institution as a place for
specialty care is yet to be clearly defined in the minds of the public in our
region.
Dissatisfaction
with old spectacles due to discomfort and perceived incorrect prescription at
some other facility led to discontinuation of previous spectacles in 22% of
subjects, and persistence of symptoms made them approach the tertiary hospital.
However, it seems more plausible that the change of refractive error that can
occur over time was not explained and the patients were not adequately
counseled about the need for regular follow up.
Economical
service of the tertiary facility and expectation of superior standard of care
from “big hospitals” were also reasons for approaching it which also shows the
felt need for the establishment of a high-volume, economical primary eye care
facility with capacity for accurate refraction in the neighborhood of the tertiary
hospital.
The
hope of getting government-provided spectacles for free was another reason.
This highlights the need to establish vision centres and government-subsidized
optician services network throughout the state, ensure their optimum
utilization and spread awareness to distribute the burden of care
appropriately.
CONCLUSION
Hence,
our study highlighted the need to establish new and advertise about the
services available in existing vision centres, conduct community screening,
establish government-subsidized optician services network, inculcate importance
of counseling patients among all eye care professionals, define the role of a
tertiary care institution in the minds of the public and support the tertiary
hospital by a high-volume primary eye care facility in the neighborhood. It
also highlighted the need to motivate people for promptly accessing refractive
services and ensure their optimum utilization to distribute the burden of
ophthalmic care equitably and appropriately for the benefit of the people of
our state.
1.
Chokshi
M, Patil B, Khanna R, Neogi SB, Sharma J, et al. (2016) Health systems in
India. J Perinatol 36: S9-S12.
2.
Flaxman
SR, Bourne RRA, Resnikoff S, Ackland P, Braithwaire T, et al. (2017) Global
causes of blindness and distance vision impairment 1990-2020: A systematic
review and meta-analysis. Lancet Glob Health 5: e1221-e1234.
3.
Neena
J, Rachel J, Praveen V, Murthy GVS. (2008) Rapid assessment of avoidable
blindness (RAAB) in India (2006-2007). PLoS One 3: e2867.
4.
Taylor
HR (2000) Refractive errors: Magnitude of the need. Community Eye Health 13:
1-2.
5.
Nishant
P, Sinha S, Sinha RK (2018) Refraction-seeking behavior among young people
presenting to a Medical College Hospital of Bihar. Indian J Clin Exp Ophthalmol
4: 254-257.
6.
Park K
(2013) Textbook of Preventive and Social Medicine. 22nd Edn.
Jabalpur, Madhya Pradesh: M/S Banarsidas Bhanot.
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