Visual impairment (low vision and blindness) is a major health concern all over the world. Three main reasons for the high prevalence of visual impairment are non-availability, non-accessibility and non-affordability of eye care services. However, there are several factors that may act as barriers to the use of available, accessible and affordable eye care services. These include the lack of knowledge of the services, of the possible impact of an eye disease, and of whom to consult for management of eye diseases. Also, demographic, personal, social and cultural factors may influence or act as barriers to eye care utilization.

The poor utilization was highlighted as a concern because the time interval between eye examinations was high enough for certain avoidable or curable ocular diseases to cause irreversible visual loss. Early detection and management of eye diseases would reduce the burden of visual impairment and disability. Therefore, eye care providers and health care managers must have good knowledge of the various factors that would negatively influence utilization of eye care services and be responsive to them [1].

Health seeking behaviour as defined by Kasi and Cobb is any activity undertaken by individuals who perceive themselves to have problem or to be ill for the purpose of finding an appropriate remedy [2]. Therefore early detection and management of eye diseases would reduce the burden of visual impairment and disability. The interdependence of availability, accessibility and affordability needs to be recognized in providing eye care services. Besides improving eye care infrastructure and manpower, a major challenge to eye care will be to address the barriers preventing a large proportion of the population from utilizing existing services.

The ability to identify the factors affecting utilization of eye care services is important for policy makers, given the relationship between blindness and the postponement of timely eye examination. Fotouhi et al are of the opinion that the key factors in achieving the goals of Vision 2020 are eye care services and utilization. These imply that apart from manpower and infrastructure development, community programmes are needed to ensure utilization of eye care services [3]. According to Andersen health care services use is determined by societal, health service system and individual factors.

The municipality has 29 wards with a population of 30,506 and 14 primary schools. Stratified Random Sampling Technique was used, to select four schools from the, total fourteen primary Schools in the Municipality. The schools were stratified into three; namely government, government aided and private. There were five governments, three government aided school and six private schools, from which two private, one government and one government aided School were selected using simple random sampling technique from each strata.

All children studying in classes 1-4 in the selected primary schools who were present on the day of survey formed the study population. Children whose parents were absent at time of survey were excluded from the study. The sample size for this cross sectional study was calculated to be 1100, using the formula z_α²pq/d² and finding the prevalence of ocular morbidity to be 10% in a study done in neighbouring state Karnataka [17].

Pretested semi structured questionnaire was used to collect information on socio demographic variables and utilization pattern. Consent of the Principals of the selected schools was obtained personally and through them the consent of parents of the students was obtained. One of the parents was asked to be present at the time of examination of the students to get the required data and to obtain their written consent. The children were interviewed in the presence of the parents in the respective school premises.

Queries to the children were asked in the local language Malayalam, while information was filled in English language by the principal investigator. The data was tabulated using MS Excel and analyzed using SPSS version 11. Qualitative variables were summarized using percentage and proportion and association of the various factors were assessed by using Chi square test.

Our study showed that various factors affect the utilization of eye care services. The availability of eye care services in the schools being an important one. School health services were available only in government and government aided schools.

Out of 1100 participants, 222 were not aware of the eye care services available in the locality. Out of 386 students who had eye care services 363 (94%) had utilized the services.

Figure 1 shows among the 523 participants who had symptoms in the past, only 199 (38%) utilized the services of an ophthalmologist, 128 (25%) consulted paediatricians and 196 children (37%) had not consulted either one.

Figure 2: Reasons for Non utilization of Eye care services

Out of the 327 participants who utilized the eye care services, 223 (68%) of parents were satisfied of the eye care services in the locality.

Table 2: Association of utilization pattern with the back ground characteristics

Finding is similar to study done in urban population of south India [14]. Our study showed that majority of the parents preferred to go to the private hospitals because there were more facilities available. Access to eye care service can be measured by the travel time required by public transportation to reach the nearest eye care provider. Non-affordability and poor accessibility of the services have been identified as important causes of the high prevalence of blinding eye diseases [7].

In our study also these two factors of non-affordability and poor accessibility have been stated as reasons for non-utilization, but we have not done any follow up as a cohort to see if that led to blinding eye diseases. Robin et al states that, in both the developing and developed nations, finances can definitely influence the utilization of ophthalmic health care [19]. In our study also, non-affordability was one of the important factors in non-utilization of the eye care services.

The level of education of the parents did not influence the pattern of utilization of eye care services. This fact clearly shows that the concern of the parents towards their child’s eye care is important for all the parents irrespective of the level of education. This is also shown in the study done among adults in a rural area [19]. There were studies done outside India to report factors associated with childhood eye-care utilization.

In Sydney, school children showed a utilization rate of only 29.2% and was not associated with gender, parental employment or home ownership or with ethnicities. It was also seen that parents who expressed concern about their child’s vision was associated with a 10 fold increase in the utilization of eye care services, a finding similar to our study [20].

We found that the private school children utilized the eye care services in their locality more (68.1%) when compared to those children who studied in the government schools (54.5%). This could be due to the fact that there were no eye care services in the private schools, and the parents of children studying in the Private Schools could afford the private eye care for them.

It was also seen that children of higher age groups utilized eye care services more, a finding which is similar to the study done in the south Indian population Age had a positive correlation with utilization, showing that higher age groups utilized

Determining barriers to the use of eye care services is critical for planning strategies to prevent blindness, lack of faith and lack of concern on their child’s symptoms influence the utilization of eye care services by the patients. These are the principal barriers that would have to be addressed if uptake of services is to be improved. Health education and individual counseling can help overcome this problem.

This study could not have been possible without the support and participation of children, their parents interviewed and teachers and authorities of the schools where the study was conducted. I am also thankful to our Principal, Commodore (Dr.) M.J. John and Prof. (Dr.) Raju Antony, HOD Community Medicine, SNIMS for their moral support and guidance.