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 for urban patients. The rural patients were mainly those who, as attendants of other patients admitted for tertiary care in the wards of various departments, incidentally remembered their ocular symptoms and reported for refraction.

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.

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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. 22^nd Edn. Jabalpur, Madhya Pradesh: M/S Banarsidas Bhanot.