Illuminating Perspectives: Navigating Eye Care Access in Sub-Saharan Africa Through the Social Determinants of Health

Ensuring access to proper eye health services is not only a fundamental human right but also crucial for preserving an individual's quality of life, preventing blindness, and promoting overall well-being. This is especially true in low-income countries like Sub-Saharan Africa (SSA) where recognizing the intricate relationship between access to healthcare and social determinants of health (SDOH ) is crucial to addressing health disparities. The goal of this study was to elucidate and highlight not only the barriers millions face in obtaining eye care but also pave the way for interventions and policies aimed at creating equitable access across diverse populations. To do this, a scoping review was conducted across the Cumulated Index to Nursing and Allied Health Literature (CINAHL), Embase, and PubMed databases for studies meeting the search terms and inclusion criteria. The results show that intervention strategies that increase vision care must extend beyond the healthcare sector to address the multifaceted challenges. Collaborating with stakeholders involved in addressing broader livelihood issues, such as food security, education, and SDOH, becomes imperative to ensure comprehensive and sustainable improvements in vision care accessibility in SSA.


Introduction And Background
Eye care remains a significant area of unmet need globally, with an estimated 2.2 billion individuals affected by vision impairment, particularly in Sub-Saharan Africa (SSA), where disparities in access and delivery to eye care are pronounced [1,2].The multifaceted nature of this issue encompasses various factors such as geographical location, gender, socioeconomic status, and literacy levels, all influencing the utilization of vision care services [3,4].Access to adequate vision health not only improves individual wellbeing but also contributes to reducing healthcare disparities [5,6].However, achieving good vision health faces considerable challenges despite the economic burden associated with vision loss far exceeding the costs of addressing impairment, underscoring the urgency of enhancing access to eye care services [7].
In SSA, approximately 18-25% of the population grapples with eye diseases, exacerbating the region's healthcare challenges [8].Avoidable visual impairment and blindness remain pervasive across the region [1,2].The factors leading to eye diseases and their treatment outcomes can often be traced back to social determinants of health (SDOH) [6].According to the World Health Organization (WHO), SDOH encompasses the conditions under which individuals are born, grow, live, work, and age [9].These circumstances are influenced by the distribution of wealth, authority, and resources at various levels, including global, regional, and local scales.Addressing the fundamental effects of SDOH is crucial because individuals are more inclined to achieve improved health outcomes when they have access to resources such as quality education, secure housing, safe surroundings, and adequate healthcare coverage [6,8,9,10].
In the context of access to vision care in SSA, limited access is exacerbated by factors like the shortage of skilled healthcare workers, low health literacy levels, and insufficient prioritization of vision health [8,11].Societal factors, including policies and local practices, significantly influence how vision care is delivered and contribute to the disparities in access to eye care [7,11].Addressing the systemic barriers and tailoring the needs of individual communities is crucial for improving eye care access and reducing inequities in SSA and beyond.This research paper aims to delve into the complexities of navigating eye care access in SSA, particularly through the lens of SDOH, to identify strategies for enhancing access to eye care services and ultimately improving vision health outcomes in the region.

Review Methods
This scoping review followed the methods outlined by Arksey and O'Malley [12] as well as Levac et al. [13].
The review process involved distinct phases including formulating the research question, identifying pertinent studies, selecting studies that met the set inclusion criteria, organizing and extracting data, and synthesizing and presenting the findings.

Eligibility Criteria
To meet the eligibility criteria, original peer-reviewed research articles must have been published in English between 2013 and 2023.Acceptable article types included systematic reviews, meta-analyses, observational studies, reports as well as gray literature, including government reports and organizational documents that captured a comprehensive view.Non-peer-reviewed articles, editorials, opinion pieces, review papers, and letters were excluded.To be included, studies must also specifically address limitations in access to eye care services in individuals of all ages in SSA.The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) flowchart [14] was employed to organize the inclusion process.

Information Sources and Search Strategy
Access to articles was sought through electronic databases such as CINAHL via EBSCOhost, Embase, and PubMed.The search terms employed variations of "eye" or "vision care," "social determinants of health," and specific countries within SSA.The primary reviewer conducted the initial search, focusing on articles related to limitations to accessing eye care in SSA and the associated SDOH.The search terms included terms relevant to the topic including a list of countries in SSA obtained from The InterTASC Information Specialists' Sub-Group Search Filter Resource [15].These terms were applied as controlled descriptors in CINAHL, PubMed, and Embase databases.The Boolean operator "AND" was utilized for simultaneous occurrences, while "OR" was used for synonyms.The specific search terms utilized are outlined in the PRISMA flow diagram seen in Figure 1.Study Selection Process and Quality Assessment.
The initial search yielded 715 publications.After eliminating 176 duplicates, 539 articles remained for relevance assessment.Each title and abstract were screened by all four authors.Full-text articles meeting the initial screening criteria underwent further review.Any discrepancies were resolved through consensus, resulting in 17 studies for further analysis.

Data Collection Process and Synthesis
A digital spreadsheet template was used for data extraction from eligible articles.Each reviewer independently abstracted data from the articles included.Individual templates were merged into a master spreadsheet for collective analysis.Summary outcomes and discrepancies were discussed among reviewers to reach a consensus.Extracted data included study details, objectives, findings, recommendations, and limitations.Reviewers synthesized data into relevant groups, which were later translated into the results section by two reviewers.The primary reviewer reviewed and finalized the draft.Throughout the revision process, all four reviewers addressed discrepancies to reach a consensus.

Cost of Eye Care
Across all the studies reviewed, the cost of eye care was one of the most frequently cited barriers to accessing health services [16][17][18][19][20][21][22][23].Cost of care was a recurring problem in rural, suburban, and urban communities.This was particularly striking in rural communities, where lack of eye care facilities is coupled with difficulty obtaining transportation to seek care.Fifteen percent of participants in Thompson et al.'s [22] study stated that distance to services was a major barrier to accessing refractive services.Poor road infrastructure is another common barrier to access [23].In one study, living close to an eye facility was associated with an increased likelihood of utilizing services [24].

Demographic Variations in Attitudes
Attitudes toward seeking eye care services vary across different demographics.Older age was often positively associated with seeking eye care services [24,25].Men were more likely to seek care than women [24,26].However, in the Onyiaorah et al. [19] study surveying traders at a rural Nigerian market, females were more likely to seek care, and traders older than 50 were less likely to seek care.

Health Education and Cultural Beliefs
Several studies demonstrated that health education and cultural beliefs play a major role in how and whether people seek eye care.Lack of knowledge of eye diseases and perception of vision issues were two of the major barriers reported at three clinics in Tanzania [27].A study found that in a rural Nigerian population, the belief that the eye disease was not serious, that aging has no cure, and a preference for spiritual treatments were all reasons not to consult an ophthalmologist [16].In a survey conducted in a rural Nigerian community, it was found that the belief that eye ailments are not serious often stopped male patients from seeking orthodox eye care [19].Two studies in Nampula province, Mozambique, also showed education-related barriers to eye care.Of the participants interviewed by Thompson et al. [22], 20% did not feel that their problem was severe enough to seek treatment.In Sengo et al.'s [21] study, 20.5% cited choosing to self-medicate, 17.8% cited choosing to seek traditional treatments, and 11.6% cited choosing to buy eyeglasses on the street as one of their top barriers to accessing eye health services.Lack of awareness was also cited by 31.8% of participants in Arinze et al.'s [18] survey of adults in Abagana.Having a personal history or family and relatives with eye disorders, on the other hand, was positively associated with seeking eye care [18,24,25].

Pediatric Eye Care and Education
Two of the studies reviewed focused specifically on pediatric eye care and access in schools.Yashadhana et al. [20] found that in primary schools in the central region of Malawi, visual acuity testing was not performed frequently enough, or even performed at all.There was distrust of medical providers and a general lack of education on the importance of eye care.This was further complicated by the cost of obtaining glasses as well as the stigma children face from their peers.Sukati et al. [28] found that teachers often recognized the importance of eye care but lacked knowledge about specific eye conditions or how to recognize and manage children with vision problems.

Institutional Barriers
From an institutional perspective, a shortage of medical equipment, assistive devices, and medical personnel all hinder access to eye care [29][30][31][32].In Swaziland specifically, there are no medical schools in the country, and therefore, they must rely on healthcare providers trained in neighboring countries [29].Several studies cited the heavy burden on tertiary care facilities.A lack of basic eye healthcare at the primary level, coupled with disorganized record-keeping, mismanagement of funding, and poor referral systems means that tertiary care centers are faced with large volumes of patients they are unequipped to handle [20,29].This in turn contributes to the crowding in hospitals and long wait times that deter patients from seeking proper eye care [17,21].

Discussion
There remains a significant deficiency in eye care worldwide, namely, in SSA.There is a plethora of barriers to care in this region, including but not limited to misconceptions and barriers to knowledge and understanding of eye health, access to healthcare facilities, and transportation.SDOH plays a large role in the access to and utilization of eye care by this population, and this study sought to determine existing barriers through a scoping review of literature analyzing eye care status in SSA countries.
Posing a significant hindrance to eye care seeking and utilization are certain attitudes, beliefs, and conceptions of this population regarding general eye health.A study by Olatunji et al. demonstrated certain perceptions regarding blindness and illustrated this concept.Participants surveyed identified consumption of certain foods, supernatural forces, and ages as common causes of blindness [33].Further, individuals in this population may prefer to initially seek care from traditional healers rather than an eye care provider or medical doctor, and 65% of participants used a form of traditional eye medication [33].Teachers can play an important role in raising awareness about eye health starting at an early age.In children who attend school, their teachers may be the first to notice vision changes such as difficulty seeing the board, inability to concentrate, proximity of books to the eyes, and squinting [34].They may also be children's first source of learning about eye care, and the benefits of this education can extend to the families of these children as they mature.However, these effects may be limited within areas with low school attendance or low education levels.
Poverty is a continuing obstacle to obtaining eye care, with challenges in the availability of facilities and transportation contributing to reluctance to seek eye care.Blindness is associated with poverty in some SSA countries, reflecting limited resources and lower rates of care [35].The glaring lack of resources highlights the importance of increasing accessibility to eye care, especially in regions where inequity in healthcare exists and is compounded by the impact of SDOH.
Systems implemented to address these barriers and increase access to eye care should engage stakeholders such as government agencies and ministries of health.These institutions may work with hospitals to increase the training of ophthalmic workers beyond ophthalmologists to support functioning eye care clinics.A study involving optometry technicians in Eritrea found patterns of low confidence in skills such as refraction, managing emergencies, and supplying spectacles [36].In addition, integrated eye care as part of primary care is a potential resolution to hesitancy in seeking specific eye care services [37].Additional visits to medical doctors require more frequent transportation and/or other resources that can be difficult to attain.
The conclusions from the studies are limited by the small number of studies included, the population specificity of some included studies, and the limited representation of rural populations in the included studies.Table 1 summarizes key concepts from each paper included in our study, and outlines recommendations for expanding eye care access and research limitations for future consideration.Further research is required to determine the prevalence of barriers related to SDOH, their effects, and potential solutions in promoting eye health services in SSA countries.

Limitations
A limitation of this scoping review is the lack of a formal quality assessment or risk of bias assessment for the included studies.

Conclusions
This scoping review found that a multitude of factors, including cost, education and cultural beliefs, and lack of facilities, act as barriers to access to eye care in SSA.In conclusion, addressing the challenges of eye care access in SSA necessitates intervention strategies that extend beyond the traditional confines of the healthcare sector.Recognizing the multifaceted nature of these challenges makes it apparent that collaboration with stakeholders in addressing broader livelihood issues is imperative.Initiatives aimed at improving food security, enhancing educational opportunities, and addressing SDOH must be integrated into comprehensive strategies for enhancing vision care accessibility.Only through such holistic approaches can sustainable improvements be achieved, ensuring that individuals across SSA have equitable access to quality eye care services.Therefore, prioritizing collaboration and integrating interventions across various sectors are essential steps toward achieving comprehensive and sustainable improvements in vision care accessibility throughout the region.

FIGURE 1 :
FIGURE 1: The PRISMA flowchart delineates the study selection process.CINAHL: Cumulated Index to Nursing and Allied Health Literature The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) flow diagram illustrates the stages of literature search, screening, and eventual inclusion of studies in the review.
or an ophthalmologist for eye diseases, with few opting for prayer/spiritual consultation.Reasons for not consulting an ophthalmologist included ignorance, financial constraints, poor access to eye care services, selfassessment of the disease as nonserious, belief in incurability due to aging, and preference for spiritual treatment.Formal education significantly predicted consultation with an ophthalmologist for major eye diseases The observed in factors such as education level, employment status, and perception of eye care importance.Distance traveled for eye care did not differ by gender.Most cited difficulty with distance vision as the primary reason for seeking care.eye care utilization included lack of awareness (31.8%), cost (18.0%),and fatalistic attitudes (15.9%), while possessing health insurance, family history of eye disorders, noticing changes in vision, current eye disease, or systemic comorbidity were motivating Educational interventions on eye health maintenance and eye health-seeking behaviors and measures to reduce eye care cost Intrinsic bias in self-reported data and setting in a rural area 2024 Gai et al.Cureus 16(6): e61841.DOI 10.7759/cureus.beforeseeking care was 83 days.Reasons for not seeking orthodox eye care initially included cost, perception of ailment severity, and advice from friends.Females were more inclined to seek orthodox care, while males were more likely to perceive their ailment as nonserious.Traders over 50 years old were less likely to seek any care in schools needs to be more consistent and present, leading to undiagnosed vision issues among children.Children frequently endure social stigma related to wearing glasses and facing bullying and judgment from peers.In Malawi, where 70% live rurally, transport barriers hinder eye care access, compounded by affordability issues with glasses.Trust issues with healthcare providers and low eye care awareness persist.Hospitals' disorganized record-keeping and weak referral reported were hospital crowding (40.7%), financial constraints (30.0%), self-medication (20.5%), opting for traditional treatment (17.8%), and purchasing eyeglasses from street vendors (11.6%).Additional barriers included fear of treatment, waiting for conditions to worsen, perceived lack of necessity for care, distrust of professionals, time constraints, transportation issues, belief in the absence of solutions, limited knowledge, and lack of accompanying of eye care and glasses emerged as the most significant barrier to accessing refractive services, cited by 53% of participants.Additionally, 28% reported not seeking treatment because they did not feel their problem was severe enough, while 15% identified distance to services as a barrier Access can be enhanced by subsidizing eye care utilization in the region included high costs (30%) and the overall unaffordability of insurance in Nigeria, distance to eye care facilities (22.6%), and inadequate road infrastructure (15.2%).Additionally, 30.6% of respondents sought alternative treatment methods due to issues related to proximity and affordability These findings indicate the necessity for making eye care services affordable and accessible in this community, aiming to alleviate the impact of visual impairment and blindness The studyrespondents had utilized orthodox eye care facilities previously.Factors increasing the likelihood of eye care utilization were similar, including age ≥70 years, literacy, proximity to eye care facilities, diabetes or hypertension, This study identified distance to facilities and gender as the main barriers to accessing eye care, with females facing challenges due to male dominance in household decision-making.Participants reported resorting to nonprescription drugs for eye issues, highlighting financial constraints in affording eye care expenses The study suggests designing eye health services to enhance accessibility and alleviate the burden on secondary-level facilities.eye care utilization included cost concerns and perceptions about vision.Limited awareness of eye diseases was noted.Among employed respondents, vision problems affected work performance for 37%, leading to job discontinuation for 3.5% due to crosssectional health issues such as anxiety Ministry of Health inadequately managed school health programs, with funds often misused or unaccounted for.-Swaziland experiences a significant Enhancing access to eye care involves redistributing services to rural areas, offering pediatric care training for ophthalmologists, fostering 2024 Gai et al.Cureus 16(6): e61841.DOI 10.7759/cureus.carepractitioners, and equipment, particularly in rural and less affluent areas, and lacks ophthalmologists specially trained in pediatric populations.Additionally, there is a lack of awareness among the general public and eye health professionals regarding the importance of child eye health and best practices for treating optometrists lacked assistive devices/ necessary equipment and eye examination kits, serving as a major barrier to providing eye care.Additionally, it was reported that lack of awareness of low vision centers, the high cost of low vision aids, and socially unacceptable assistive devices served as additional barriers/deterrents for patients seeking

TABLE 1 : A comparative table of the included studies highlighting the barriers to eye care, recommendations for future studies, and limitations
SSA: Sub-Saharan Africa; AI: artificial intelligence 2024 Gai et al.Cureus 16(6): e61841.DOI 10.7759/cureus.61841