Table 1 shows the demographic characteristics of the 25 informants who participated in this interview study.
[insert Table 1]
Most informants (80%) were females. More than half of the informants were between 70 – 74 years of age (48.0%). In terms of educational level, only 12% hold a university degree and nearly half of the respondents received secondary education (48%).
The self-reported health status of each informant is shown in Table 2 and Table 3. Over half of the interviewed informants had hypertension (52%), 40% reported having high cholesterol, and 8% reported type 2 diabetes. For visual status, the majority of the informants have glasses for presbyopia (80%) and most (48%) have ever been diagnosed with cataract before.
[insert Table 2]
Table 1 Demographic characteristics of each informant.
INT
|
Sex
|
Age group
|
District
|
Education
|
Marital status
|
Current monthly income
|
Main source of income
|
Current living arrangement
|
007
|
M
|
75-79
|
Sha Tin
|
Secondary (higher)
|
divorced
|
2,000 - 4,999
|
CSSA
|
living alone
|
009
|
F
|
80-84
|
Sha Tin
|
Primary or below
|
widowed
|
2,000 - 4,999
|
CSSA
|
living alone
|
004
|
M
|
70-74
|
Sha Tin
|
Primary or below
|
married
|
2,000 - 4,999
|
old age allowance
|
living with spouse
|
015
|
F
|
70-74
|
Shum Shui Po
|
Primary or below
|
widowed
|
5,000 - 9,999
|
old age allowance
|
living alone
|
012
|
M
|
85+
|
Shum Shui Po
|
Refuse to answer
|
married
|
5,000 - 9,999
|
CSSA
|
living with spouse
|
013
|
F
|
65-69
|
Shum Shui Po
|
Secondary (lower)
|
widowed
|
2,000 - 4,999
|
old age allowance
|
living alone
|
019
|
F
|
70-74
|
Eastern
|
Primary or below
|
divorced
|
5,000 - 9,999
|
old age allowance
|
living alone
|
020
|
F
|
70-74
|
Eastern
|
Primary or below
|
never married
|
< 2,000
|
old age allowance
|
others
|
021
|
F
|
75-79
|
Eastern
|
Secondary (higher)
|
widowed
|
10,000 - 14,999
|
family/ relatives
|
living with child(ren)
|
028
|
F
|
65-69
|
Yuen Long
|
Primary or below
|
widowed
|
no income
|
family/ relatives
|
living with child(ren)
|
029
|
F
|
65-69
|
Yuen Long
|
Secondary (lower)
|
married
|
no income
|
saving
|
living with spouse
|
031
|
F
|
70-74
|
Yuen Long
|
Secondary (higher)
|
married
|
no income
|
family/ relatives
|
living with spouse and child(ren)
|
037
|
F
|
70-74
|
Yuen Long
|
Postsecondary (degree)
|
married
|
20,000 +
|
saving
|
living with spouse
|
032
|
F
|
70-74
|
Yuen Long
|
Postsecondary (degree)
|
widowed
|
15,000 - 19,999
|
others
|
others
|
040
|
F
|
65-69
|
North
|
Secondary (lower)
|
others
|
2,000 - 4,999
|
old age allowance
|
living alone
|
043
|
M
|
75-79
|
North
|
Postsecondary (degree)
|
married
|
2,000 - 4,999
|
saving
|
living with spouse and child(ren)
|
041
|
F
|
75-79
|
North
|
Primary or below
|
divorced
|
10,000 - 14,999
|
family/ relatives
|
living alone
|
039
|
F
|
70-74
|
North
|
Secondary (higher)
|
married
|
no income
|
family/ relatives
|
living with spouse and child(ren)
|
042
|
F
|
75-79
|
North
|
Primary or below
|
widowed
|
5,000 - 9,999
|
old age allowance
|
living alone
|
053
|
F
|
85+
|
Central & Western
|
Primary or below
|
widowed
|
2,000 - 4,999
|
family/ relatives
|
living with child(ren)
|
052
|
F
|
65-69
|
Central & Western
|
Secondary (higher)
|
married
|
no income
|
saving
|
living with spouse
|
054
|
M
|
70-74
|
Central & Western
|
Secondary (higher)
|
widowed
|
20,000 +
|
family/ relatives
|
living with child(ren)
|
055
|
F
|
70-74
|
Central & Western
|
Secondary (lower)
|
married
|
2,000 - 4,999
|
old age allowance
|
living with spouse
|
050
|
F
|
70-74
|
Central & Western
|
Secondary (higher)
|
married
|
5,000 - 9,999
|
family/ relatives
|
living with spouse
|
051
|
F
|
70-74
|
Central & Western
|
Secondary (lower)
|
married
|
no income
|
saving
|
living with spouse
|
Note. INT = informant; F = Female; M = Male.
Table 2 Summary of the self-reported health status.
Self-reported health status
|
No
|
Yes
|
Don’t know
|
n
|
%
|
n
|
%
|
n
|
%
|
Chronic disorders
|
|
|
|
|
|
|
hypertension
|
12
|
48%
|
13
|
52%
|
0
|
0%
|
type 1 diabetes
|
25
|
100%
|
0
|
0%
|
0
|
0%
|
type 2 diabetes
|
23
|
92%
|
2
|
8%
|
0
|
0%
|
high cholesterol
|
15
|
60%
|
10
|
40%
|
0
|
0%
|
Refractive error
|
|
|
|
|
|
|
Myopia
|
13
|
52%
|
9
|
36%
|
3
|
12%
|
Hyperopia
|
16
|
64%
|
2
|
8%
|
7
|
28%
|
Astigmatism
|
10
|
40%
|
15
|
60%
|
0
|
0%
|
Presbyopia
|
4
|
16%
|
20
|
80%
|
1
|
4%
|
Eye disorders
|
|
|
|
|
|
|
AMD
|
24
|
96%
|
0
|
0%
|
1
|
4%
|
Cataract
|
12
|
48%
|
12
|
48%
|
1
|
4%
|
DR
|
25
|
100%
|
0
|
0%
|
0
|
0%
|
Glaucoma
|
25
|
100%
|
0
|
0%
|
0
|
0%
|
Others
|
18
|
72%
|
7
|
28%
|
0
|
0%
|
Note. Total N = 25. Multiple answers were allowed. The percentage may not add up to 100%. AMD = age-related macular degeneration; DR = diabetic retinopathy.
Table 3 Self-related fitness of eyesight
Self-rated fitness of eyesight
|
n
|
%
|
Very poor
|
0
|
0%
|
Poor
|
3
|
12%
|
Fair
|
9
|
36%
|
Good
|
12
|
48%
|
Excellent
|
1
|
4%
|
Note. Total N = 25.
3.1 The core theme: “prioritising and fitting preventive vision care into existing health service utilization”
The core theme derived from this qualitative study explains the reason for the low utilization of preventive vision care is likely due to an inability to prioritize and fit vision care into existing healthcare utilization”. Different influencing factors have been identified at individual, community, and service levels. Low perceived needs, low perceived self-efficacy, and unfulfilled service expectations, all contributed to low motivation to use preventive vision care. Previous utilization of various healthcare services influenced how individuals decide to use preventive vision in terms of price, perceived needs and developing service expectations.
[insert Figure 1]
3.2 Previous health service utilization
Vision care service was novel for all participants. Lacking familiarity with vision care meant that participants had to turn to their previous health service utilization to make a judgement on using a novel health service. Three categories originating from previous health service utilization were identified to interact with their judgment of preventive vision service (Figure 1).
First, the subjects’ existing health-seeking behaviour was symptom-driven (e.g., physical discomfort caused by a fever or cold) and externally motivated by the recommendation and information provided by an authority figure (e.g., a medical doctor or the government). More importantly, subjects showed greater reliance on public health services for their affordability despite the potential long waiting times. This is especially true for those who benefit from the Comprehensive Social Security Assistance (CSSA) Scheme [26, 27]. Lastly, subjects who used health services for episodic and curative services shared a greater financial burden. Several attributes of health services (cost, doctor-patient relationship) were also considered important elements in judging a new health service.
3.3 Appraisal of preventive vision care needs
Recognizing the need for preventive vision care is an important driver of behavioural intention. The process of appraising can be explained by three categories: 1) symptom-driven preventive vision care needs; 2) socially cued preventive vision care needs; 3) limited understanding of the significance of preventive vision care; 4) competing with other healthcare needs.
3.3.1 Symptom-driven preventive vision care needs
The majority of our subjects list eye irritation and declining vision as two of their primary reasons for seeking vision care. However, this relies on how the symptoms are interpreted by individuals as interfering with everyday activities and what they believe will happen if they persist, such as whether blindness would have a major impact on their health. An older person remembered "[hitting] a wall" (INT 007, male) as being a significant motivator to have a thorough eye check-up. Subjects used a present-time perspective in need assessment, giving more weight to symptoms right now and less consideration to how it may affect visual health in the future.
Coping strategies reduce perceived needs for vision care. Subjects tried different ways to minimise the symptoms or inconvenience caused by blurry vision. Coping strategies include wearing a pair of reading glasses, which they claimed have already corrected their vision. Another strategy was to use the magnifying function in the mobile device to read more easily. Using lubricating eyedrops to alleviate the dryness of the eye was also mentioned. As the health-seeking behaviour was symptom-driven, the alleviation of symptoms reduced the perceived need for a preventive vision examination.
3.3.2 Social influences on preventive vision care need appraisal
Vision deterioration is perceived as part of the normal ageing process. Any minor discomfort or blurry vision was ascribed to the ageing progress which made these symptoms more acceptable to the subjects. The daily activities of the subjects usually involved relatively basic tasks such as grocery shopping or reading a newspaper. The role of vision in performing these tasks was considered less critical in relation to the tasks performed when they were still working. This rationale seemed to make poorer vision status more acceptable despite not being optimal. A man in his 90s who had an untreated cataract in one eye stated his desire to keep life "simple" and voiced his reluctance to undergo any treatment to improve his vision.
Downwards social comparison. While subjects expected their vision to deteriorate as they got older, they also compared themselves to others who suffered from serious eye disorders or had poorer vision, to conclude that they do not need a preventive vision examination at this stage. This is an example of downwards social comparison. This optimistic attitude seems to reduce the intention to engage in preventive vision care.
Absence of doctor’s recommendations reduced the perceived need for preventive vision care. Apart from social comparison, subjects rely on others to determine their needs. Those who were previously diagnosed with cataracts recalled that the conversation with the ophthalmologist was usually treatment orientated. Subjects expressed their respect for doctors who they believed “knew the best” and were “highly educated”. Therefore, the absence of vision care advice from the ophthalmologist was interpreted by the subjects as “no need to use vision care services”.
3.3.3 Limited understanding of the significance of preventive vision care
Having a clear understanding of why a service is essential to motivate healthcare-seeking behaviour as illustrated in their previous use of outpatient clinics and vaccination behaviour. Very few subjects in the interviews appreciated the benefit of preventive vision care, with most vaguely commenting “it’s good” to have their vision checked. Only a few were able to elaborate on the significance, including early detection of common eye disorders. The subjects were not sure what was included in a comprehensive eye examination, with most thought it only included a spectacle prescription. This made them perceive preventive vision examination as simple and not comprehensive, perceiving little need to use such a service. The lack of understanding was likely because subjects were passive health information seekers who seldom searched for preventive vision care-related information.
3.3.4 Competing with other healthcare needs
The existing health habits of our subjects would have formed under the influence of sufficient cues and an acceptance of the importance of utilizing specific health services on health outcomes. As older adults’ health beliefs are more prone to episodic illnesses or diseases such as cardiovascular disease, they prioritise highly those that had an immediate impact on the body. Vision deterioration was perceived to be gradual and consequently accorded less priority.
Competing healthcare needs are also important when deciding to join a health promotion activity among different options. A physically active subject recalled when the elderly centre offered a range of health screening activities for centre members, which included vision screening. Being a dancer, she was more interested in maintaining mobility, so she chose osteoporosis screening over vision screening.
3.4 Perceived low self-efficacy of preventive vision care utilization
Even when subjects felt they needed to take care of their vision, their intention to do so was frequently diminished because they felt little confidence in using use the services. The reasons for perceived low self-efficacy were:
3.4.1 Concerns over service fees for preventive vision care
The perceived financial burden has been a recurring concern mentioned by subjects. Retirement had altered healthcare-seeking behaviour, especially for those services that required out-of-pocket payment. A subject who had experience using preventive vision examination regularly later stopped because she believed it was expensive to continue to use it.
Since the reference service was typically a curative service, such as a dentistry service, some participants may perceive a considerably higher service charge for a preventive eyesight check because they were unsure of the service fee. For those with more savings or children to assist them financially, the financial worries might not be as pressing. Despite the subjects' eligibility for the healthcare voucher, the majority of the funds would be spent on other treatments.
3.4.2 Limited information on service availability
Some subjects questioned the interviewer in a rhetorical tone about the availability of the preventive vision care service, believing there was no such service, while others were uncertain about it. Some of the information channels the subjects preferred include mass media, government-led sources, community elderly centres, or family members. This could be in the form of campaigns, television shows, a monthly magazine from the community elderly centre and health educational talks. However, subjects shared that they seldom came across information on preventive vision care service availability. The lack of action-planning cues in health educational talks is an example of ineffective health communication. The subject shared they would not be cued to get a preventive vision examination even knowing the benefit of utilizing such a service, as the subjects could not make a judgement on their access ability (e.g., accessibility and affordability).
3.4.3 Limited social support
Concerning preventive vision care utilization, the social environment holds two important roles: 1) providing useful information; and 2) providing practical social support.
Subjects generally relied on their lay referral network (e.g., peer or their family members) for obtaining information for accessing health services. Having a wider social network means that they are more likely to be exposed to information about healthcare services through their daily gathering. A subject who was female, single, never married and with no children, shared she did not know about preventive vision care because “no one ever tells [her] about this”. She usually relied on the community elderly centre (a form of social support) for obtaining information and activities participation.
A female subject with previous experience with preventive vision care also expressed the importance of social companionship in reducing the sense of insecurity and inconvenience caused by blurry vision after pupil dilation. If no friend was coming with her, she was less motivated to get her vision checked.
3.4.4 Low health literacy
Some subjects shared that they were ‘less educated” and knew little about vision and eye health. Lacking health literacy meant dependence on healthcare professionals to navigate the healthcare system. Having low health literacy meant they had little chance of acquiring useful information during a conversation with the healthcare professional, which also impacted their perceived needs and altered the intention formation to use preventive vision care. A subject who had previous experience of engaging in mutual communication with an optometrist described how the knowledge learnt in a previous conversation helped him continue to ask questions in the following check-up appointment. This subject described it as a “learning process”. It helped increase self-efficacy as knowledge accumulates and increases intention to use preventive vision care in the future.
3.5 Service expectations
Service expectations for preventative vision care were based on the subjects' views of what they thought a "good healthcare provider" should be, despite having no prior experience. Their prior use of public health services had an impact on this perception. The expectation includes not only the service provider's caliber but also their price and location, all of which are related to the question of whether the service is valuable enough to warrant paying for and devoting time to access.
3.5.1 Perceived qualities of a good vision care provider: patient-centred service and competence
Subjects generally hoped their vision care provider cared about them rather than “selling the product” (e.g., expensive designer brand spectacles). Because of this they often showed mistrust of the optometrists believing that they would try to charge more than they should. Most subjects shared a negative impression of optometrists and perceived ophthalmologists as more competent at performing a comprehensive eye examination as they would have more advanced equipment. A subject who had a positive experience with an optometrist shared a greater intention to continue engaging in preventive vision care with the same service provider. This illustrates the importance of good service quality for behavioural maintenance.
3.5.2 Acceptable service fee
One key reason for lower perceived self-efficacy is the cost of the service. It is thought that setting a reasonable service fee may help some subjects to start using preventive vision care and keep using it in the future. Although the subjects were not certain about the service fee, when being asked how much he/she would pay for an eye examination, the acceptable service fee could range from HKD$100 to around HKD$1000, varying by the subjects’ socioeconomic status. A comparison to other well-known and commonly used healthcare services, such as the price of a private GP visit, was typically used to determine what was considered an "appropriate" price for preventive vision care. This implies that the costs of prior service use were used as a baseline to assess the worth of funds spent on preventive vision care.
3.5.3 Accessible location
It was found that subjects usually cited places that they were already familiar with, such as “near the hospital” or “near the elderly health centre”. The subjects also shared the downside of the current health service experience in terms of transportation and the time required to travel and the long waiting time. Reducing these perceived barriers would improve the intention to use preventive vision care.
3.6 Low motivation to seek preventive vision care
Due to factors that influence needs appraisal and self-perceived self-efficacy, almost all subjects interviewed expressed a low intention to use preventive vision care. The response of “no intention” was rather intuitive for most subjects. Upon further questioning, subjects’ intentions in fact can be changed and therefore “unstable”. Along with increasing affordability and accessibility, the intention could be further strengthened if a service was recommended by others who they trust. Others may include providing reminders, with some variation in the preferred format (paper-based, telephone or electronic form). Most importantly, if ambiguous information was shared (e.g., mixed health recommendations or personal experience), then behavioural intention would reduce.