Correcting Indigenous Australians' refractive error and presbyopia

Authors

  • Mitchell D Anjou MScOptom,

    Corresponding author
    • Indigenous Eye Health Unit, Melbourne School of Population Health, The University of Melbourne, Melbourne, Victoria, Australia
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  • Andrea I Boudville MIH,

    1. Indigenous Eye Health Unit, Melbourne School of Population Health, The University of Melbourne, Melbourne, Victoria, Australia
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  • Hugh R Taylor AC FRANZCO

    1. Indigenous Eye Health Unit, Melbourne School of Population Health, The University of Melbourne, Melbourne, Victoria, Australia
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  • Competing/conflicts of interest: No stated conflict of interest.
  • Funding sources: No stated funding sources.

Correspondence: Mr Mitchell D Anjou, Indigenous Eye Health Unit, Melbourne School of Population Health, The University of Melbourne, Level 5, 207 Bouverie Street, Carlton, Vic. 3053, Australia. Email: manjou@unimelb.edu.au

Abstract

Background

This paper aims to identify the barriers and solutions for refractive error and presbyopia vision correction for Indigenous Australians.

Design

A qualitative study, using semistructured interviews, focus groups, stakeholder workshops and consultation, conducted in community, private practice, hospital, non-government organization and government settings.

Participants

Five hundred and thirty-one people participated in consultations.

Methods

Data were collected at 21 sites across Australia. Semistructured interviews were conducted with 289 people working in Indigenous health and eye care sectors; focus group discussions with 81 community members; stakeholder workshops involving 86 individuals; and separate meetings with 75 people. Barriers were identified through thematic analysis and policy solutions developed through iterative consultation.

Main Outcome Measures

Barriers and solutions to remedy Indigenous Australians' uncorrected refractive error and presbyopia.

Results

Indigenous Australians' uncorrected refractive error and presbyopia can be eliminated through improvement of primary care identification and referral of people with poor vision, increased availability of optometry services in Aboriginal Health Services, introduction of a nationally consistent Indigenous subsidized spectacle scheme and proper coordination, promotion and monitoring of these services.

Conclusions

The refractive error and presbyopia correction needs of Indigenous Australians are immediately treatable by the simple provision of glasses. The workforce capacity exists to provide the eye exams to prescribe glasses and the cost is modest. What is required is identification of patients with refractive needs within community, referral to accessible optometry services, a good supply system for appropriate and affordable glasses and the coordination and integration of this service within a broader eye care system.

Introduction

Uncorrected refractive error is a significant contributor to the visual disadvantage of Aboriginal and Torres Strait Islander people. It impacts on both distance and near tasks and it is completely fixable with the use of appropriate spectacles.

Vision impairment and blindness from refractive error can be as a result of uncorrected refractive error (no spectacles) and under-corrected refractive error (inappropriate spectacles). Uncorrected refractive error accounts for 54% of vision impairment (presenting visual acuity <6/12) of adult Indigenous Australians and 56% of vision impairment in Indigenous children.[1-3] It causes 14% of blindness (presenting visual acuity <6/60) and is the second largest contributor to Indigenous blindness behind cataract.[1-3] Refractive error blindness is five times higher for Indigenous adults than other Australians.[1-3]

Refractive error is the leading cause of distance vision impairment for Indigenous adults[1-3] and affects 5.3% of the adult Indigenous population.[1-3] There is no significant difference in prevalence across jurisdictions or between urban and rural or remote regions.[1-3] Other studies have confirmed refractive error and the lack of appropriate spectacle lenses as a significant contributor to vision impairment in Indigenous communities.[4-8] At present, only 20% of Indigenous adults wear glasses[1-3] compared with 56% in mainstream[9] and 62% of Indigenous adults normally wore reading glasses for near work[1-3] compared with 86% for mainstream.[9]

The 2008 National Indigenous Eye Health Survey found that overall, 39% of Indigenous adults had difficulty reading at near and were not able to read normal-size print (<N8).[1] Of those with poor near vision, 37% reported not having reading glasses.[10] This compares with 19% in the Melbourne Visual Impairment Project sample for a mainstream population not able to see normal-size print.[11] Poor near vision is not normally classified or included in vision impairment prevalence calculations.[3, 12-14] Similarly, uncorrected refractive error at near (presbyopia) is not recorded in the World Health Organization reports of prevalence of uncorrected refractive error.[15, 16]

The National Aboriginal and Torres Strait Islander Health Survey reported eye/sight problems as the most common self-reported long-term health condition, more than twice as frequent as other conditions, including asthma, back and disc disorders, heart/cardiac diseases and ear/hearing problems.[17] Overall, 30% of respondents identified eye/sight problems, and of these, 83% were from refractive error.

Refractive error in Australia is generally assessed by optometrists and ophthalmologists working from private practice and these services are readily available in urban and regional areas of Australia.[18] Medicare benefits are available to reduce the cost of consultations. Government-funded programmes also support practitioners to visit more remote areas and to work from within Aboriginal Health Services (AHS) and include the Visiting Optometrists Scheme and Medical Specialists Outreach Assistance Program. Each state and territory government has a scheme to provide spectacles at low cost for pensioners and some are available to low-income earners. These schemes are designed to reduce the patient cost of spectacles and in each state are provided with different approaches to eligibility, entitlement, patient payment, product choice and accessibility. Access to these schemes is known to be an issue for Indigenous people.[11, 19, 20]

Despite the available systems and resources to attend to Indigenous vision impairment caused by uncorrected refractive error and the efforts of current and previous programmes to address this eye care need,[21] there is little published literature looking at a whole-of-system and national perspective of Indigenous refractive error.

This study aims to identify the key barriers to the appropriate identification, assessment and supply of spectacles for Indigenous Australians with uncorrected refractive error and proposes sector-supported solutions to eliminate vision impairment from uncorrected refractive error for Aboriginal and Torres Strait Islander people.

Methods

Ethical approval for the project was provided by The University of Melbourne and subsequently by eight ethics committees across Australia.[22] Agreement to conduct the project was provided by the National Aboriginal Community Controlled Health Organisation and five state and one territory affiliate organization.

Data were collected through semistructured interviews and focus groups. Focus groups were conducted at seven sites (geographic locations) in Victoria, three urban and four rural, and involved 81 community members. Semistructured interviews were conducted at 21 sites across Australia (including the seven Victorian sites) and included five states and one territory and all remoteness classifications (Table 1). Twenty-nine Indigenous health organizations participated in the project. A total of 289 people working in Indigenous health, eye care, hospital, non-government organizations and government were interviewed (Table 2).

Table 1. Survey sites by state/territory and remoteness classificationThumbnail image of
Table 2. Study participants
  1. aAcross seven sites; 38% urban site participants; 70% female participants. GP, general practitioner; NGO, non-government organization.
Participantsn
Focus groups (Victoria only) 
Community members 81a
Semistructured interviews (by interviewee position) – total 289
Aboriginal Health Service staff98
Community health staff14
Optometrists31
Ophthalmologists25
Hospital staff35
GP division staff10
NGO staff16
State affiliate staff12
Government – federal  9
Government – state29
Other10

The semistructured interview questions investigated issues about eye health services, pathways of care and the coordination of visiting services. Focus group discussion topics related to barriers that impact on participant's access to eye health services and explored suggestions to improve access to current eye care services.

Policy recommendations were developed in a second phase of the project through stakeholder workshops. This followed thematic analysis of the consultation findings and observations and suggestions and successful examples from the field. Three workshops were conducted in the course of the project and 86 individual stakeholders attended one or more workshop. An iterative process was undertaken to refine policy recommendations using stakeholder comment and feedback and subsequent circulation of draft ideas to stakeholders. Additionally, 32 stakeholder organizations and federal and state ministers and bureaucrats from eight jurisdictions were further engaged through 38 face-to-face meetings with more than 75 people to elicit final feedback on the project proposals.

The draft recommendations were then widely circulated through Aboriginal health and eye health sectors and to government departments for comment and feedback, and this additional input allowed further refinement of the recommendations.

Results

Table 3 summarizes the themes, barriers and solutions identified for correcting Indigenous Australians' refractive error and presbyopia.

Table 3. Themes, barriers and solutions for correcting Indigenous Australians' refractive error and presbyopia
ThemesBarriersSolutions
  1. AHS, Aboriginal Health Service.
Primary eye care as part of comprehensive primary health careIdentification and referral of people requiring refractive careImprove the understanding of basic eye care for primary care professionals and AHS
Include distance and near vision screening in routine health assessment
As above for clinical software
Indigenous access to eye health servicesUtilization of refractive care servicesCulturally safe mainstream practices
Refractive services provided within AHS
Nationally consistent and appropriate subsidized spectacle scheme
CoordinationPrimary care link with specialist services and navigation of patient pathwayLocal referral pathways established
Coordination of services and support of patients
Eye health workforceLack of available and appropriately distributed servicesSufficient services available to meet population needs
Monitoring and evaluationLack of information about delivery of services, outcomes and progressRefractive care data are collected and contributed to regional/jurisdictional/national data analysis and reporting
Service qualityService quality and satisfaction are monitored
GovernanceServices are not acceptable to communityServices developed and delivered with engagement of local community
Services are not consistent within jurisdictions or nationallyServices monitored jurisdictionally/nationally
Health promotion and awarenessCommunity knowledge and awareness can be improved to support self-empowermentHealth promotion and social marketing
Health financingInsufficient fundingSufficient funding is provided to ensure adequate refractive care

Primary care

Field consultations revealed a poor understanding of how primary eye care could be integrated within primary health care. Primary eye care in this context refers to eye care services and support provided by the staff of a primary care clinic or AHS. Primary health-care staff treat the common eye conditions such as conjunctivitis and foreign bodies, and they need also to start the referral process for vision loss and other eye conditions. Eye charts are not regularly used, although they are available in all health services and within many primary care consulting rooms. Vision and eye health may be listed in Medicare Aboriginal and Torres Strait Islander health assessments, but these tests are often not carried out or used as prompts for referral for further eye care.

A review of primary care prompts in Indigenous health – such as the Central Australia Rural Practitioners Association (CARPA) Standard Treatment Manual,[23] the Council of Remote Area Nurses of Australia (CRANA) Clinical Procedures Manual[24] and the Medicare Aboriginal and Torres Strait Islander health assessment items[25] and supporting literature – showed a lack of attention to the assessment of near vision for Aboriginal people, although the testing of distance acuity is detailed.

The measurement of distance visual acuity gives an indication of potential reading acuity, but for Indigenous patients in the presbyopic age range (>35 years), distance vision does not necessarily predict near or ‘reading’ vision especially in those with some degree of hyperopia. Simple tests for near vision are needed in primary care clinics (‘can you see ordinary, newspaper sized print at a comfortable reading distance?’ or ‘can you see which way the small E's are pointing?’).

To assist primary care health professionals detect and initiate the required and appropriate referrals, stakeholders supported the recommendation that the assessment of distance and near vision be included in practice guidelines for care (CRANA, CARPA manuals), Medicare health assessment items for Indigenous patients and practice clinical software. Improved training and support of primary care health professionals, particularly for those working in AHS, is also recommended.

Coordination

The care pathway for the treatment of refractive error with spectacle correction is relatively simple and straightforward. It includes problem identification, primary care assessment, secondary care assessment and prescription of spectacle correction, and then the dispensing and delivery of spectacles.

There was evidence in our consultations of inappropriate referral from primary care including the use of ophthalmology for services that could be provided by optometry for, say, refractive error assessment and diabetic retinopathy screening. Similarly, there was inappropriate referral to optometry services where there was no access to subsidized spectacles supply.

Patients progress some way along the referral system but go no further. For example, the cost for the optometry service may be incurred, but the patient doesn't receive glasses and so receives no benefit for the costs incurred. ‘We can't wait for the visiting service, so we go to the local optometrist but we know they are too expensive’. This is very inefficient and wasteful of resources.

Stakeholder recommendations were directed to properly coordinate care and provide support along the patient journey to stop patients falling out of the system.

Secondary care

Because most presentations of Indigenous people to an optometrist are referred from the AHS, optometric visits can be regarded as ‘secondary’ care. Specialist services provided within an AHS were regarded as culturally safe, not so private practices. This was particularly an issue in major cities and urban areas where there is proportionately less access to and support from community-controlled health services.

The barriers in urban areas were different to those faced in rural and remote places. In more remote areas, the distance to travel away from the health service and the availability of services are reported as the major barriers. In urban areas, the barriers relate more to the lack of cultural safety, cost certainty and lack of confidence. ‘Her husband could not see clearly after his surgery – why should you go to an optometrist? Why not go to the $2 shop for glasses?’

Although optometry consultations are generally bulk billed, the additional costs associated with referral and particularly prescription spectacles are significant factors. Cost uncertainty is linked to not knowing if you will be asked to pay for spectacles and how much this might be, or if you are likely to be referred to a specialist. This prevents many clients from regularly accessing optometry services, particularly in areas where there are no low-cost spectacle schemes. If an expensive pair of glasses is selected, the client may have second thoughts and not return to pay or collect them. This also leaves the optometrist out of pocket having expended costs in making the glasses.

Most optometry services in urban and rural areas are private optometry services with occasional services delivered in public hospitals or community clinics and health centres. Some mobile or visiting services are provided in community settings that are appropriate for disadvantaged or specific groups of people who are unable to access mainstream services. Optometrists visiting rural and remote areas may be supported by the Visiting Optometrists Scheme, which offers payments to cover the costs of delivering services to these areas. Some fund-holders or professional bodies such as the Australian College of Optometry and International Centre for Eyecare Education have negotiated partnerships with the Aboriginal Community Controlled Health sector and community to provide optometry services to Indigenous clients. Most of these partnerships involve a visiting optometrist who conducts clinics in an AHS.

Stakeholders confirmed the value of optometry services operating in AHS wherever feasible and that visiting optometry services should also be provided in urban AHS.

Low-cost spectacles

VisionCare NSW is funded by the New South Wales Government to provide spectacles free of charge for New South Wales pensioners subject to a means test. Indigenous patients attending AHS in New South Wales and who are able to access optometry services provided by International Centre for Eyecare Education can receive glasses without cost under a special arrangement.

The Spectacle Supply Scheme of Queensland also is able to provide glasses without charge for Indigenous patients. Means testing for this spectacle supply is approved centrally and conducted through public hospitals.

The Victorian Eyecare Service was augmented in 2010 with funds for the Australian College of Optometry to allow Aboriginal Victorians access prescription spectacles for $10. The scheme is available from optometrists working in AHS and through a network of private optometrists in rural Victoria. All Aboriginal Victorians are eligible and demand has subsequently increased twofold.

In the Northern Territory, a programme run by the Fred Hollows Foundation allows payment options for those clients who are not eligible for the Northern Territory Government scheme. These include using Centrelink deduction and salary deductions to pay for spectacles. This scheme has faced many logistic problems with some unfortunate and very lengthy delays and it has proved to be costly to run.

In some states, the low-cost spectacle schemes are more difficult to access and communities and service providers know little about their availability.

Many service providers commented that there was a high need for replacement spectacles particularly in rural and remote areas where damage to spectacles is common. ‘A lot of effort goes into providing spectacles to people living in the bush, but they so quickly – even a few hours later – will lose or break them’. The reported reasons for spectacles being damaged, in addition to general wear and tear, included the lack of an appropriate place to store spectacles so that grandchildren and dogs do not play with the glasses.

There is debate around charging fees for spectacles provided through a subsidized scheme. Some stakeholders argue that providing spectacles at no cost diminishes the value placed on the spectacles and services. In contrast, others argue that any charge (even nominal) is a barrier that would limit access for many Indigenous people. Cost is identified as the most common reason Indigenous people do not go to a health professional when needed.[26] However, rather than cost, we found that cost certainty was the more important issue. Cost uncertainty for spectacles was commonly reported to the research team as the reason for not visiting the optometrist.

The New South Wales and Victoria spectacle programmes are designed specifically for Indigenous Australians and have been successful. Indigenous input to the selection of available frames has improved cosmesis and wearing compliance. The uptake of these services demonstrates that when low cost and cost certainty are assured and high-quality spectacles and services are provided, Indigenous clients will seek access to the service. They are willing to pay for these services and they also recommend them to their friends and family members. A nationally consistent supply of low-cost, cost-certain and high-quality glasses was recommended by stakeholders.

Monitoring and evaluation

We did not find evidence of data collection from providers to enable the measurement of local performance. This was apparent for both visiting practitioners and the facilities which provided the services. There were no readily available data on the number of patients who had an eye examination or who had been prescribed or provided with glasses (nor other outcomes for those with other eye conditions).

There was little evidence that service providers or AHS understood the population-based needs of their local community for eye care. Given the population in their community, there was little concept or understanding of the number of eye care services that should be expected or needed.

There was evident frustration and resentment from some people interviewed to the ‘endless’ and ‘meaningless’ collection and reporting of information. They perceived these data to be of no value to them or to their service. The collection of data by service providers and personnel can be improved by ensuring that there is an understanding of why the data are collected, what they are used for and feedback is provided about how the data may contribute to and improve the systems. This process of monitoring and evaluating is better framed to support empowerment of those collecting the data.

Local data regarding eye care were held by a number of people and organizations, and often, these were not shared. Further the data were stored in inconsistent and non-compatible datasets which made sharing and aggregation of information difficult. The AHS would have its information and data about eye care services, and the visiting optometrist would keep their own separate data, and these were again separate from those of the visiting ophthalmologist.

Knowledge and attitudes

A common misconception was that Indigenous people do not need to wear spectacles or reading glasses. ‘I have not seen many Aboriginal people wearing glasses and I just thought that they didn't need them’. There was acceptance that Indigenous people living in remote areas or town camps did not need to wear spectacles because they had good distance vision or were illiterate. Underlying views included that older Aboriginal people did not read and so were not in need of glasses for near vision, that glasses were not used and that glasses would be repeatedly lost and misplaced and so were not a good solution or investment. This misconception appeared to influence practice so that primary care providers would rarely bother to test either distance or near vision.

Patients in rural and remote places also reported the high breakage and loss of spectacles and they used old and borrowed spectacles because of the lack of appropriate replacement spectacles available at an affordable cost in their area. One remote eye health programme offered an onsite spectacle repair service for clients. Another health worker repaired old and damaged spectacles while patients undertook eye examinations with a visiting optometrist. Although only basic repairs could be performed, the service was well used and provided an additional incentive for patients to come in for an eye examination.

Social norms affect not only the delivery of services, but also the utilization of services. As a result of the inadequate service delivery and limited availability of follow-up services for most Indigenous communities, many people do not understand the importance of having regular eye examinations or how to prevent avoidable blindness. Nor are they aware of the treatments that are potentially available for poor or diminishing eye sight. The acceptance of poor vision because there are no available services is common. ‘Blindness is something that happens as you get older; it happens, it cannot be prevented and it is not uncommon for someone to go blind at 40’.

Stakeholders supported health promotion initiatives that emphasize the importance of preventing common eye conditions and influence community expectations and norms about common eye health conditions and poor vision. They should also emphasize what should be expected as part of normal ageing in contrast to noticing abnormal changes that require further attention. Key messages included that it should not be acceptable for community and family members to lose vision or go blind at the age of 40 from preventable conditions.

Discussion

Uncorrected refractive error is known to reduce quality of life, school performance, employability and productivity.[27] Uncorrected presbyopia also reduces quality of life[28] and is a significant cause of disability.[16] For Indigenous Australians, refractive error vision impairment and presbyopia can be eliminated through the improvement of primary care identification and referral of people with poor vision, the increased availability of optometry services in AHS in both urban and more remote areas, the introduction of a national Indigenous subsidized spectacle scheme, the proper coordination and promotion of these services and with the use of appropriate monitoring.

The recommendations to address vision impairment from uncorrected refractive error and presbyopia should be viewed in the broader context of The Roadmap to Close the Gap for Vision which includes 42 linked recommendations to address the full spectrum of Indigenous eye care needs.[22, 29]

Importantly, the identification and need for spectacle correction cannot be assumed by measurement of distance acuity and determination of distance refractive error. Poor near vision may be caused by distance refractive error, particularly with moderate levels of hyperopia, but much more commonly by presbyopia. Literacy levels in a community should not influence the priority for eye care or the need for spectacles. The use of spectacles is important for everyday reasons beyond the need to read print material. Good near vision is critically important for anyone undertaking activity within arm's length, including painting, sewing, servicing a car engine, cutting vegetables, preparing foods, identifying medicines and other daily activities.

The availability of optometry services for Indigenous Australians will need to increase to meet population-based needs and it is recommended that these services are provided through AHS wherever feasible as this has been shown to increase utilization.[20, 30] There has been a significant recent increase in funding for the Visiting Optometrists Scheme services,[31] but further increases and planning for the allocation of these services must be based on a population's needs. The supply of low-cost, cost-certain and high-quality glasses will also need to increase to match the increased identification of refractive needs.

We note that there continues to be some disagreement between the professional groups of optometry and ophthalmology on the use of ready-made glasses. Broadly, optometry has reservation about the use of ready-made glasses where they are provided in lieu of a comprehensive eye examination as this impacts on the screening for eye health issues and detection of eye diseases and conditions.[32] Ophthalmology regards ready-to-wear reading glasses as effective, safe and economical.[33] We consider the supply of ready-made glasses generally appropriate for presbyopia correction.

A significant additional investment in coordination personnel and the improvement of monitoring of service outcomes is required to support patients and the system elements. A good and successfully functioning system will also attract and encourage more people to enter for care. As seen with the National Trachoma Program[34] (HR Taylor, MD Anjou, submitted unpublished, 2011), when clear targets are set and programme implementation is funded and coordinated, a real difference can be made on the ground, and progressive system improvement occurs.

The recommendations developed through this project are consistent with some of the policy recommendations made previously[11, 19] but which by and large have not been acted on.[21] This study identifies the pressing need for the assessment of near vision in the primary care setting to trigger the appropriate referral for optometry assessment. The recommendations also support the expansion of optometry visiting services to AHS in major cities and regional areas and the need for coordination of these services. However, the proposal that the Optometrist Association of Australia and optometry schools oversee the recruitment and monitoring of optometrists working in Indigenous eye care[19] is not supported.

The strengths of this study include the broad consensus achieved by regular and detailed consultation with stakeholders, ranging from national organizations and government to individual clients. The study was nationwide (and included five states and one territory), covered cities, regional and remote areas and involved semistructured interviews which allowed participants to proffer solutions for identified problems. The study was limited by those not included in interview and consultation. Many of the sites selected for consultation had successful and existing eye care programmes, and so we have less information and advice from areas without eye care programmes.

The refractive error and presbyopia correction needs of Aboriginal and Torres Strait Islander peoples are immediately treatable by the simple provision of glasses. Vision, for most, can be restored as soon as glasses are put on. The workforce and capacity exist to provide the additional eye exams to prescribe glasses[22, 29] and the cost for this intervention is modest.[35] What is required to achieve this is the identification of patients with refractive needs in the primary care setting, referral to accessible optometry services, a good supply system for appropriate and affordable glasses and the coordination and integration of this service within a broader eye care system to enable the gap for vision to be closed.

Acknowledgements

The authors acknowledge and thank the many community members, colleagues and stakeholders who were consulted and participated in the project. Robyn McNeil was part of the project team for community and sector consultations in Victoria, and Garang Dut researched background information on the jurisdictional spectacle schemes. (RJM and GD were employed by The University of Melbourne). The project was conducted with the support of Harold Mitchell Foundation, The Ian Potter Foundation, Greg Poche AO and The University of Melbourne.

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