Seeking care: barriers to referral uptake in the elderly

A new paper by Dr Srinivas Marmamula and his team from L. V. Prasad Eye Institute is a first-of-its-kind report on barriers to uptake of eye care services by the elderly in residential care in Hyderabad. The paper explores the factors responsible for poor utilization of referrals despite the free provision of eye care services.

In 2019, The Hyderabad Ocular Morbidity in Elderly Study (HOMES) began assessing the prevalence, causes and risk factors for vision impairment among the elderly aged 60 years and above in residential care homes in Southern India. The study reported that more than 30% of the elderly in residential care had vision impairment, 90% of which was avoidable. Most needed simple interventions like the provision of eyeglasses, YAG laser, or surgery. For those who needed higher levels of care, the study’s participants were referred to a hospital for free treatment—yet nearly 50% of the elderly participants did not make use of this offer. What could be the barriers stopping the elderly from accessing these services?  

A new paper in the British Journal of Ophthalmology by Dr Srinivas Marmamula and his colleagues documents the variety of barriers the elderly face in seeking such care. The current paper, tenth in the HOMES series, discusses the results of an open-ended questionnaire administered to the participants who were earlier referred to a hospital. Of the 1182 participants they examined, 61.8% (731) got referred to a hospital for free-of-cost care, including cataract surgery and consultations for other conditions that did not require surgery. Only 50% made use of the referral. Those who did not follow-through gave a variety of reasons for their inaction: ‘lack of felt need’, other health issues, and even non-consent from decision-making family members.

Over 45% of the respondents noted a ‘lack of need’ for higher care—this was more so when surgery was prescribed. The paper discusses a number of reasons for this lack: limited demand for visual range at the care home, loss of hope, perhaps even fatalism over perceived confinement. Nearly 30% had multiple morbidities and the resultant poor mobility increased dependence on others, compounding the complexity of travel and time for the elderly. Finally, the paper notes that Ageism—the stereotyping and prejudice based on age—seems to be resulting in denial of care by younger family members. In fact, the elderly who are destitute and stay at free care-homes had higher uptake of referral services than those living at paid-for, private homes. 

The authors note the implications of these barriers for program planning and eye health service provision. They discuss a variety of strategies including technology-enabled care at the care homes itself. The authors recommend focusing on narrowing the ‘cataract window’ so that a majority of the elderly enjoy better visual outcomes before systemic morbidities set in.

'We need more empathetic effort to ensure that avoidable vision is addressed, and our elderly enjoy the gift of clear vision in their sunset years of life. After all, healthy aging is happy aging, which remains incomplete without good vision,' says Dr Srinivas Marmamula, Associate Director - Public Health Research and Training (GPR ICARE), L V Prasad Eye Institute.

Marmamula S, Kumbham TR, Modepalli SB, Chakrabarti S, Keeffe JE. Barriers to uptake of referral eye care services among the elderly in residential care: the Hyderabad Ocular Morbidity in Elderly Study (HOMES). Br J Ophthalmol. 2022 Apr 1:bjophthalmol-2021-320534. doi: 10.1136/bjophthalmol-2021-320534. Epub ahead of print. PMID: 35365490. 

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