- Email: [email protected]
Access Barriers to Eye Care Utilization among People with Physical Disability in Hong Kong
Available online at www.sciencedirect.com
ScienceDirect Procedia Environmental Sciences 36 (2016) 46 – 49
International Conference on Geographies of Health and Living in Cities: Making Cities Healthy for All, Healthy Cities 2016
Access Barriers to Eye Care Utilization among People with Physical Disability in Hong Kong Rufina T.Y. Chana,*, Maurice Yapa a
School of Optometry, The Hong Kong Polytechnic University, Hung Hom, Hong Kong
Abstract This study investigates the impact of access barriers to eye care services among people with physical disability in Hong Kong. 250 participants completed the assisted self-administered questionnaires. There were statistical differences in ranking of access barriers between recent eye service-users and non-users. The impact of access barriers including: consultation fee (p = 0.009), need of accompanying helper (p = 0.049), knowledge about service provider (p = 0.011), transportation (p = 0.041), and access into building (p = 0.007) were significantly higher for non-users. © Published by Elsevier B.V. This ©2016 2016The TheAuthors. Authors. Published by Elsevier B.V.is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/). Peer-review under responsibility of the organizing committee of Healthy Cities 2016. Peer-review under responsibility of the organizing committee of Healthy Cities 2016 Keywords: Access barriers; Eye care utilization; Physical disability
1. Introduction People with physical disability account for up to 4.5% of the total population of Hong Kong [1]. The government has taken various actions to enable people with physical disability to have equal access to health care facilities and services, including the updating of building laws to provide disability friendly access in new buildings in the city [2,3]. However, little is known about the effectiveness of these measures in the area of health care delivery, especially in eye services which involve both public and private stake holders. It is a known fact the current eye care delivery system in Hong Kong is not integrated and there is little communication between the public and private systems. There is also
* Corresponding author. Tel.: +852-21074187; fax: +852-21074186. E-mail address: [email protected]
1878-0296 © 2016 The Authors. Published by Elsevier B.V. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/). Peer-review under responsibility of the organizing committee of Healthy Cities 2016 doi:10.1016/j.proenv.2016.09.008
Rufina T.Y. Chan and Maurice Yap / Procedia Environmental Sciences 36 (2016) 46 – 49
little coordination between the professional groups providing eye care. Consequently, the delivery system is fragmented and care is episodic. With the high prevalence of myopia in Hong Kong and the increased risk of serious eye disease associated with high myopia [4,5], the need to access eye services is evident. When more than one disability is present, the challenges faced are more than just adding up the impact of each disability [6]. When physical disability and poor vision are put together, options are further reduced and the ability to function independently are diminished. It is therefore advantageous to ensure people with physical disability have the best vision possible. In addition, there are many neurological disorders such as traumatic brain injury and stroke, which may affect mobility as well as vision [7]. The lack of access to eye services in these physically disabling conditions may result in undetected visual impairments, which in turn may have a significant negative impact on rehabilitation and independent living after recovery. This study aims to collect information on the current pattern of eye care utilization and to identify access barriers perceived by this special population that may discourage them from using eye care services. 2. Methodology In Hong Kong, people with physical disability are difficult to locate. They may be considered as a marginalized group. Because of the lack of an available and reliable sampling frame for this population, a facility-based sampling approach was adopted in this study. Members from non-government organizations (NGOs) including sheltered workshops, elderly centers, self-help groups, and community organizations that serve the physically disabled were recruited to respond to an assisted self-administered questionnaire. A structured questionnaire was constructed with reference to surveys on health and vision care access or of similar nature in other countries including: Vision Module of Behavior Risk Factor Surveillance System (BRFSS) [8], Strabane NRA General Health Needs Assessment Survey [9], and UNSW Access to Eyecare Survey [10]. The finalized questionnaire comprises 39 questions that collect information regarding recent eye examination, possible barriers in accessing eye services, and demographic characteristics of the participants. 10 possible access barriers including eye examination fee, spectacles cost, assistance of care taker, knowledge about service provider, location of service provider, transportation, building entrance, interior facility layout of the service provider, equipment, and booking system were identified from the literature [8-10]. A 5-points Likert scale was used to record the severity of each of these barriers perceived by the participants. The American Optometric Association [11] and the American Academy of Ophthalmology [12] recommend biannual eye examination for the general public. One outcome measure of this study, therefore, included those who had an eye examination within 2 years and those who did not. The Mann Whitney U test was applied to assess the differences in impact of access barriers perceived between recent eye service-users and non-users. 3. Results 3.1. Demographics of the studied population Among the 250 respondents, 60.8% were female. The majority of the respondents were between 50 – 59 years old (34.8%) and the rest of the survey population was quite evenly distributed among all age groups except for those between 18 – 29 years old (5.6%). Most of the survey population were either retired (28%), housewives (21.2%) or unemployed (12%). For those who worked full-time (28.4%), some may work in a sheltered workshop. It was therefore reasonable to find that for most, the monthly income was less than HK$4,000 (72.8%). In terms of the level of disability, the majority of the participants have full function according to the Katz Index of Independence in Activities of Daily Living (78%). The rest have a disability in at least one daily living activity including bathing, dressing, toileting, transferring, and eating. 5.2% of the respondents were unable to perform any of the activity listed and were regarded as “severely disabled”.
47
48
Rufina T.Y. Chan and Maurice Yap / Procedia Environmental Sciences 36 (2016) 46 – 49
3.2. Pattern of eye care utilization Although 94% of the participants gave 3 points or above on a 5-point Likert scale on the importance of preventive eye care, only half of them had utilized eye services within the past 2 years (58.4%). 10% of the respondents obtained an eye service within 2 to 4 years. There were also a number of them who had not used eye services (17.6%) in 4 years or more. Most of the participants visited either optical shops (40.9%) or public hospitals (30.6%) for eye services. Others attended private clinics (10.9%) and NGOs (9.8%), while private hospital (2.1%) had the least role in providing services to the studied population. 46.6% of the eye services were provided by optometrists and 36.8% by ophthalmologists. Most of the eye services received involved refraction only (38.9%) and the rest were evenly distributed among services including ocular health only (18.7%), comprehensive examination with both prescription and health check (16.6%), and specific tests as a follow up on eye disease (18.7%). 3.3. Impact of access barriers to eye care services The access barriers of the two groups: those who had used eye services up to 2 years (<=2 years, n1=146) and those who had not (>2 years, n0=103), were compared using the Mann–Whitney U test (Table 1). The two groups differed significantly on the impact of access barriers including consultation fee (U = 6174, z = 2.605, p = 0.009 two-tailed), the need of accompanying helper (U = 6474, z = -1.973, p = 0.049 two-tailed), knowledge about service provider (U = 6200, z = -2.546, p = 0.011 two-tailed), transportation (U = 6453.5, z = -2.041, p = 0.041 two-tailed), and access into building (U = 6105.5, z = -2.680, p = 0.007 two-tailed). Table 1. Ranks of access barriers to eye care services Access barriers Consultation fee
Need of accompanying helper Don’t know where to go
Transportation Access into building
Last eye check
N
Mean Rank
Sum of Ranks
>2years
103
138.06
14220.00
<=2years
146
115.79
16905.00
>2years
103
135.15
13920.00
<=2years
146
117.84
17205.00
>2years
103
137.80
14193.50
<=2years
146
115.97
16931.50
>2years
103
135.34
13940.50
<=2years
146
117.70
17184.50
>2years
103
138.72
14288.50
<=2years
146
115.32
16836.50
4. Discussions The impact of five access barriers was found to be significantly different between recent eye service users and nonusers. This suggests that the perception of these barriers may discourage people with physical disability from accessing eye services in Hong Kong. From a personal perspective, the medians of impact of consultation fee, transportation, and the need for an accompanying helper were significantly higher for respondents who were not recent eye service users. Most of our respondents were either retired, housewives, unemployed or had a monthly income of less than $4,000. Financial barrier may therefore be an important issue. Previous studies also suggest that an individual’s economic status is significantly associated with utilization of eye services and such relation may be both direct and indirect. For example, Schaumberg et al. found that American women with high annual income were more likely to receive an eye examination within two years as compared to those with lower income [13]. Lack of insurance was also a common
Rufina T.Y. Chan and Maurice Yap / Procedia Environmental Sciences 36 (2016) 46 – 49
barrier to eye service utilization among Americans [14]. Moreover, indirect financial factors such as lack of accessible and affordable transportation may also hinder access to eye services [15]. Indirect opportunity cost including family or community support such as availability of care giver, may also be an access barrier to utilization of eye care services [16]. It is therefore important when planning for the provision of eye care services to take into consideration of both direct and indirect costs for this disadvantaged population. From a systemic perspective, Hong Kong’s universal health policy provides a ‘safety net' for all its citizens irrespective of means. However, the Hospital Authority (HA) eye service is a disease-care system that requires referral from the general medical practitioner and therefore is organized to provide secondary care as the entry point. Preventive eye care is not provided in this public eye care system and is dependent primarily on the private sector. An effective eye care system would be much broader than the current disease-oriented system and should address both vision and eye health issues including ocular disease prevention, eye health promotion and all eye services across an individual’s entire life-span. From an architectural point of view, the impact of access into buildings is also significantly higher for non-recent eye services users. Despite the introduction and periodic update of the barrier free building laws, many old buildings remain wheelchair unfriendly. This may due to the exceptions to the compliance of the Design Manual requirements: buildings built prior to the introduction of the relevant buildings ordinance do not have to comply. In conclusion, we found that there were statistical differences in ranking of access barriers between recent eye service-users and non-users. The impact of access barriers including: consultation fee, need of accompanying helper, knowledge of service provider, transportation, and access into building were significantly higher for non-users. These barriers may discourage people with physical disability from accessing eye care services in Hong Kong. They also raise the question of whether these problems belong to a wide-range phenomenon among people with disabilities, affecting most if not all types of preventive and general health care. We recommend further studies to investigate the underlying factors that may contribute to these access barriers and whether they exist in other health care services. Answers to these questions may help develop responsive policies for the reduction of these attributes and ultimately lessen health inequality in this disadvantaged population. References 1. Census and Statistics Department. Social data Collected via the General Household Survey: Special Topics Report - Report No.62; 2014. 2. Buildings Department. Design Manual: Barrier Free Access; 1997. 3. Buildings Department. Design Manual: Barrier Free Access; 2008. 4. Leung TW, Lam AK, Kee C. Corneal shapes of Chinese emmetropes and myopic astigmats aged 10 to 45 years. Optom Vis Sci 2013;90(11):125966. 5. Wu L, Sun X, Zhou X, Weng C. Causes and 3-year-incidence of blindness in Jing-An District, Shanghai, China 2001-2009. BMC Ophthalmol. 2011;11:10. doi:10.1186/1471-2415-11-10. 6. Sauerburger D, Siffermann E, & Rosen S. Principles for providing orientation and mobility to people with visual impairment and multiple disabilities. I J Orientation & Mobility 2008;1(1):52-6. 7. Jones SA, Shinton RA. Improving outcome in stroke patients with visual problems. Age Ageing 2006;35(6):560-5. 8. Centers for Disease Control and Prevention. Behavioral risk factor surveillance system (BRFSS). Vision/eye module 4: Visual impairment and access to eye care; 2009. 9. Stephens M, the Strabane Local Strategy Partnership. Health needs analysis of the Strabane neighborhood renewal area. Appendix A – General health needs assessment survey; 2010. 10. Stahl U, Golebiowski B, Pye D, Stapleton F. A questionnaire to assess utilization of eye care in the New South Wales population with and without glaucoma. In: 2010 Primary health care research conference: program & abstracts. Primary health care research and information service, Australia; 2010. 11. American Optometric Association. Recommended Eye Examination Frequency for Pediatric Patients and Adults; 2015. http://www.aoa.org/patients-and-public/caring-for-your-vision/comprehensive-eye-and-vision-examination/recommended-examinationfrequency-for-pediatric-patients-and-adults?sso=y 12 American Academy of Ophthalmology. Policy Statement. Frequency of ocular examinations; 2015. http://www.aao.org/clinical-statement/frequency-of-ocular-examinations--november-2009. 13. Schaumberg D, Christen W, Glynn R, Buring J. Demographic predictors of eye care utilization among women. Med Care 2000;38:638-646. 14. Zhang X, Lee PP, Thomson TJ, Sharma S, Bake L, Geiss LS, Imperatore G, Gregg EW, Zhang X, Saaddine JB. Health insurance coverage and use of eye care services. Arch Ophthalmol 2008;126:1121-1126. 15 Owsley C, McGwin G, Scilley K, Girkin C, Phillips J, Searcey K. Perceived barriers to care and attitudes about vision and eye care: Focus groups with older African Americans and eye care providers. Invest Ophthalmol Vis Sci 2006;47:2797-2802. 16. Dhaliwal U, Gupta SK. Barriers to the uptake of cataract surgery in patients presenting to a hospital. Indian J Ophthalmol 2007;55(2):13
49
ScienceDirect Procedia Environmental Sciences 36 (2016) 46 – 49
International Conference on Geographies of Health and Living in Cities: Making Cities Healthy for All, Healthy Cities 2016
Access Barriers to Eye Care Utilization among People with Physical Disability in Hong Kong Rufina T.Y. Chana,*, Maurice Yapa a
School of Optometry, The Hong Kong Polytechnic University, Hung Hom, Hong Kong
Abstract This study investigates the impact of access barriers to eye care services among people with physical disability in Hong Kong. 250 participants completed the assisted self-administered questionnaires. There were statistical differences in ranking of access barriers between recent eye service-users and non-users. The impact of access barriers including: consultation fee (p = 0.009), need of accompanying helper (p = 0.049), knowledge about service provider (p = 0.011), transportation (p = 0.041), and access into building (p = 0.007) were significantly higher for non-users. © Published by Elsevier B.V. This ©2016 2016The TheAuthors. Authors. Published by Elsevier B.V.is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/). Peer-review under responsibility of the organizing committee of Healthy Cities 2016. Peer-review under responsibility of the organizing committee of Healthy Cities 2016 Keywords: Access barriers; Eye care utilization; Physical disability
1. Introduction People with physical disability account for up to 4.5% of the total population of Hong Kong [1]. The government has taken various actions to enable people with physical disability to have equal access to health care facilities and services, including the updating of building laws to provide disability friendly access in new buildings in the city [2,3]. However, little is known about the effectiveness of these measures in the area of health care delivery, especially in eye services which involve both public and private stake holders. It is a known fact the current eye care delivery system in Hong Kong is not integrated and there is little communication between the public and private systems. There is also
* Corresponding author. Tel.: +852-21074187; fax: +852-21074186. E-mail address: [email protected]
1878-0296 © 2016 The Authors. Published by Elsevier B.V. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/). Peer-review under responsibility of the organizing committee of Healthy Cities 2016 doi:10.1016/j.proenv.2016.09.008
Rufina T.Y. Chan and Maurice Yap / Procedia Environmental Sciences 36 (2016) 46 – 49
little coordination between the professional groups providing eye care. Consequently, the delivery system is fragmented and care is episodic. With the high prevalence of myopia in Hong Kong and the increased risk of serious eye disease associated with high myopia [4,5], the need to access eye services is evident. When more than one disability is present, the challenges faced are more than just adding up the impact of each disability [6]. When physical disability and poor vision are put together, options are further reduced and the ability to function independently are diminished. It is therefore advantageous to ensure people with physical disability have the best vision possible. In addition, there are many neurological disorders such as traumatic brain injury and stroke, which may affect mobility as well as vision [7]. The lack of access to eye services in these physically disabling conditions may result in undetected visual impairments, which in turn may have a significant negative impact on rehabilitation and independent living after recovery. This study aims to collect information on the current pattern of eye care utilization and to identify access barriers perceived by this special population that may discourage them from using eye care services. 2. Methodology In Hong Kong, people with physical disability are difficult to locate. They may be considered as a marginalized group. Because of the lack of an available and reliable sampling frame for this population, a facility-based sampling approach was adopted in this study. Members from non-government organizations (NGOs) including sheltered workshops, elderly centers, self-help groups, and community organizations that serve the physically disabled were recruited to respond to an assisted self-administered questionnaire. A structured questionnaire was constructed with reference to surveys on health and vision care access or of similar nature in other countries including: Vision Module of Behavior Risk Factor Surveillance System (BRFSS) [8], Strabane NRA General Health Needs Assessment Survey [9], and UNSW Access to Eyecare Survey [10]. The finalized questionnaire comprises 39 questions that collect information regarding recent eye examination, possible barriers in accessing eye services, and demographic characteristics of the participants. 10 possible access barriers including eye examination fee, spectacles cost, assistance of care taker, knowledge about service provider, location of service provider, transportation, building entrance, interior facility layout of the service provider, equipment, and booking system were identified from the literature [8-10]. A 5-points Likert scale was used to record the severity of each of these barriers perceived by the participants. The American Optometric Association [11] and the American Academy of Ophthalmology [12] recommend biannual eye examination for the general public. One outcome measure of this study, therefore, included those who had an eye examination within 2 years and those who did not. The Mann Whitney U test was applied to assess the differences in impact of access barriers perceived between recent eye service-users and non-users. 3. Results 3.1. Demographics of the studied population Among the 250 respondents, 60.8% were female. The majority of the respondents were between 50 – 59 years old (34.8%) and the rest of the survey population was quite evenly distributed among all age groups except for those between 18 – 29 years old (5.6%). Most of the survey population were either retired (28%), housewives (21.2%) or unemployed (12%). For those who worked full-time (28.4%), some may work in a sheltered workshop. It was therefore reasonable to find that for most, the monthly income was less than HK$4,000 (72.8%). In terms of the level of disability, the majority of the participants have full function according to the Katz Index of Independence in Activities of Daily Living (78%). The rest have a disability in at least one daily living activity including bathing, dressing, toileting, transferring, and eating. 5.2% of the respondents were unable to perform any of the activity listed and were regarded as “severely disabled”.
47
48
Rufina T.Y. Chan and Maurice Yap / Procedia Environmental Sciences 36 (2016) 46 – 49
3.2. Pattern of eye care utilization Although 94% of the participants gave 3 points or above on a 5-point Likert scale on the importance of preventive eye care, only half of them had utilized eye services within the past 2 years (58.4%). 10% of the respondents obtained an eye service within 2 to 4 years. There were also a number of them who had not used eye services (17.6%) in 4 years or more. Most of the participants visited either optical shops (40.9%) or public hospitals (30.6%) for eye services. Others attended private clinics (10.9%) and NGOs (9.8%), while private hospital (2.1%) had the least role in providing services to the studied population. 46.6% of the eye services were provided by optometrists and 36.8% by ophthalmologists. Most of the eye services received involved refraction only (38.9%) and the rest were evenly distributed among services including ocular health only (18.7%), comprehensive examination with both prescription and health check (16.6%), and specific tests as a follow up on eye disease (18.7%). 3.3. Impact of access barriers to eye care services The access barriers of the two groups: those who had used eye services up to 2 years (<=2 years, n1=146) and those who had not (>2 years, n0=103), were compared using the Mann–Whitney U test (Table 1). The two groups differed significantly on the impact of access barriers including consultation fee (U = 6174, z = 2.605, p = 0.009 two-tailed), the need of accompanying helper (U = 6474, z = -1.973, p = 0.049 two-tailed), knowledge about service provider (U = 6200, z = -2.546, p = 0.011 two-tailed), transportation (U = 6453.5, z = -2.041, p = 0.041 two-tailed), and access into building (U = 6105.5, z = -2.680, p = 0.007 two-tailed). Table 1. Ranks of access barriers to eye care services Access barriers Consultation fee
Need of accompanying helper Don’t know where to go
Transportation Access into building
Last eye check
N
Mean Rank
Sum of Ranks
>2years
103
138.06
14220.00
<=2years
146
115.79
16905.00
>2years
103
135.15
13920.00
<=2years
146
117.84
17205.00
>2years
103
137.80
14193.50
<=2years
146
115.97
16931.50
>2years
103
135.34
13940.50
<=2years
146
117.70
17184.50
>2years
103
138.72
14288.50
<=2years
146
115.32
16836.50
4. Discussions The impact of five access barriers was found to be significantly different between recent eye service users and nonusers. This suggests that the perception of these barriers may discourage people with physical disability from accessing eye services in Hong Kong. From a personal perspective, the medians of impact of consultation fee, transportation, and the need for an accompanying helper were significantly higher for respondents who were not recent eye service users. Most of our respondents were either retired, housewives, unemployed or had a monthly income of less than $4,000. Financial barrier may therefore be an important issue. Previous studies also suggest that an individual’s economic status is significantly associated with utilization of eye services and such relation may be both direct and indirect. For example, Schaumberg et al. found that American women with high annual income were more likely to receive an eye examination within two years as compared to those with lower income [13]. Lack of insurance was also a common
Rufina T.Y. Chan and Maurice Yap / Procedia Environmental Sciences 36 (2016) 46 – 49
barrier to eye service utilization among Americans [14]. Moreover, indirect financial factors such as lack of accessible and affordable transportation may also hinder access to eye services [15]. Indirect opportunity cost including family or community support such as availability of care giver, may also be an access barrier to utilization of eye care services [16]. It is therefore important when planning for the provision of eye care services to take into consideration of both direct and indirect costs for this disadvantaged population. From a systemic perspective, Hong Kong’s universal health policy provides a ‘safety net' for all its citizens irrespective of means. However, the Hospital Authority (HA) eye service is a disease-care system that requires referral from the general medical practitioner and therefore is organized to provide secondary care as the entry point. Preventive eye care is not provided in this public eye care system and is dependent primarily on the private sector. An effective eye care system would be much broader than the current disease-oriented system and should address both vision and eye health issues including ocular disease prevention, eye health promotion and all eye services across an individual’s entire life-span. From an architectural point of view, the impact of access into buildings is also significantly higher for non-recent eye services users. Despite the introduction and periodic update of the barrier free building laws, many old buildings remain wheelchair unfriendly. This may due to the exceptions to the compliance of the Design Manual requirements: buildings built prior to the introduction of the relevant buildings ordinance do not have to comply. In conclusion, we found that there were statistical differences in ranking of access barriers between recent eye service-users and non-users. The impact of access barriers including: consultation fee, need of accompanying helper, knowledge of service provider, transportation, and access into building were significantly higher for non-users. These barriers may discourage people with physical disability from accessing eye care services in Hong Kong. They also raise the question of whether these problems belong to a wide-range phenomenon among people with disabilities, affecting most if not all types of preventive and general health care. We recommend further studies to investigate the underlying factors that may contribute to these access barriers and whether they exist in other health care services. Answers to these questions may help develop responsive policies for the reduction of these attributes and ultimately lessen health inequality in this disadvantaged population. References 1. Census and Statistics Department. Social data Collected via the General Household Survey: Special Topics Report - Report No.62; 2014. 2. Buildings Department. Design Manual: Barrier Free Access; 1997. 3. Buildings Department. Design Manual: Barrier Free Access; 2008. 4. Leung TW, Lam AK, Kee C. Corneal shapes of Chinese emmetropes and myopic astigmats aged 10 to 45 years. Optom Vis Sci 2013;90(11):125966. 5. Wu L, Sun X, Zhou X, Weng C. Causes and 3-year-incidence of blindness in Jing-An District, Shanghai, China 2001-2009. BMC Ophthalmol. 2011;11:10. doi:10.1186/1471-2415-11-10. 6. Sauerburger D, Siffermann E, & Rosen S. Principles for providing orientation and mobility to people with visual impairment and multiple disabilities. I J Orientation & Mobility 2008;1(1):52-6. 7. Jones SA, Shinton RA. Improving outcome in stroke patients with visual problems. Age Ageing 2006;35(6):560-5. 8. Centers for Disease Control and Prevention. Behavioral risk factor surveillance system (BRFSS). Vision/eye module 4: Visual impairment and access to eye care; 2009. 9. Stephens M, the Strabane Local Strategy Partnership. Health needs analysis of the Strabane neighborhood renewal area. Appendix A – General health needs assessment survey; 2010. 10. Stahl U, Golebiowski B, Pye D, Stapleton F. A questionnaire to assess utilization of eye care in the New South Wales population with and without glaucoma. In: 2010 Primary health care research conference: program & abstracts. Primary health care research and information service, Australia; 2010. 11. American Optometric Association. Recommended Eye Examination Frequency for Pediatric Patients and Adults; 2015. http://www.aoa.org/patients-and-public/caring-for-your-vision/comprehensive-eye-and-vision-examination/recommended-examinationfrequency-for-pediatric-patients-and-adults?sso=y 12 American Academy of Ophthalmology. Policy Statement. Frequency of ocular examinations; 2015. http://www.aao.org/clinical-statement/frequency-of-ocular-examinations--november-2009. 13. Schaumberg D, Christen W, Glynn R, Buring J. Demographic predictors of eye care utilization among women. Med Care 2000;38:638-646. 14. Zhang X, Lee PP, Thomson TJ, Sharma S, Bake L, Geiss LS, Imperatore G, Gregg EW, Zhang X, Saaddine JB. Health insurance coverage and use of eye care services. Arch Ophthalmol 2008;126:1121-1126. 15 Owsley C, McGwin G, Scilley K, Girkin C, Phillips J, Searcey K. Perceived barriers to care and attitudes about vision and eye care: Focus groups with older African Americans and eye care providers. Invest Ophthalmol Vis Sci 2006;47:2797-2802. 16. Dhaliwal U, Gupta SK. Barriers to the uptake of cataract surgery in patients presenting to a hospital. Indian J Ophthalmol 2007;55(2):13
49