Barriers in older adults’ decision-making process to use routine eye examinations in Hong Kong

ABSTRACT Clinical relevance The decision to have a routine eye examination involves individual- and service-level judgement. A deeper understanding of patient access barriers and expectations could facilitate the design of better-aligned service models in optometric practice, improving the utilisation rate of an important facet of primary healthcare services. Background Routine eye examinations achieve several health objectives, including mitigation of sight-threatening risk factors. However, there are barriers to service uptake. Through the qualitative approach, a deeper understanding of these barriers can be realised and enhanced strategies designed to improve the uptake of the routine eye examination. A qualitative study was conducted to identify the factors influencing the decision-making process of older adults to use the routine eye examination service. Methods This study was guided by the grounded theory approach. Participants were purposively recruited from six community elderly centres. Semi-structured interviews were conducted with 25 community-dwelling adults aged 65 years or above in Hong Kong. Data were transcribed and constant comparison techniques were used for data analysis. Results Difficulty in prioritising and including the routine eye examination in the existing health service utilisation was the central theme associated with its lower use. Four sub-themes were identified to explain this phenomenon: (1) previous health care service utilisation as a reference for judging primary eye care; (2) low perceived primary eye care service needs; (3) low perceived self-efficacy on routine eye care utilisation; (4) service expectations. Conclusion Multiple modifiable factors influence decision-making by older adults, suggesting that their routine eye care seeking behaviour might be altered through behaviour change intervention. The context in which services are delivered requires further study, with a focus on exploring the factors influencing service experience and its subsequent impact on regular eye care seeking behaviour.


Introduction
2][3] Maintaining good vision is related to better psychological and physical health for older adults, 4,5 and primary eye care plays an important role by reducing major sight-threatening risk factors and minimising the impact of visual decline on an individual. 6,7Primary eye care is delivered at the community level by primary healthcare personnel (depending on the context, different healthcare personnel may be responsible for service delivery) 'to [detect] and [manage] simple eye conditions', and when needed, ' [refer] patients with complex eye condition to secondary level'. 8n important facet of primary eye care is the regular or routine eye examination which includes an assessment of refractive status, visual function and ocular health.][11][12] Globally, eye examination utilisation rates of older adults ranged between 10% − 37%, with utilisation in high-income regions being 37%. 13According to a Hong Kong populationbased survey comprising 1,156 respondents, the use of eye examination within the past two years was 53.7% while 22.2% never had an eye examination. 146][17][18][19][20] For example, individual-related barriers include lack of knowledge and awareness, and lower socioeconomic status, while service-related barriers concern service availability, affordability, accessibility, and trust towards the service provider.However, the evidence was mainly obtained from other regions outside of Hong Kong, and the findings do not explain how and why these factors become barriers themselves.A deeper understanding of these factors may inform the construction of more effective solutions, especially in the local context.
Under the Hong Kong mixed model healthcare system, the public sector provides relatively affordable services to all Hong Kong permanent residents, but those who prefer private health services pay out of pocket directly or via health insurance schemes. 21Primary eye care services for children are subsidised by the government. 22,23Beyond school age, primary eye care is in the private sector and requires out-ofpocket payment.
To give residents more primary healthcare options, the government introduced a recurrent elderly healthcare voucher scheme in 2012.The scheme now provides a biennial subsidy amount of HKD 2,000 (~ AUD 392) for spending on a range of private health services, including eye examinations. 24,25This voucher scheme can be seen as a way to reduce the financial barrier to accessing primary healthcare.
An earlier study conducted on these elderly voucher users and found that although users felt that access to primary eye care improved somewhat, other barriers persisted.These include concerns regarding how much out-of -pocket expenses might be incurred due to a lack of price transparency and how to choose a service provider. 14owever, these remaining barriers were not explored in depth, so it was not possible to propose possible solutions.
This qualitative study explores in greater depth how older adults decide to use the routine eye examination in Hong Kong.The research question is: what factors influence the decision-making process of older adults in using the routine eye examination?The aim is to construct a theory to explain the routine eye examination utilisation in the Hong Kong older adult population.

Methods
This study was approved by the Human Subjects Ethics Committee of the Hong Kong Polytechnic University (ref no: HSEARS20210422005).The method section is reported according to the Consolidated criteria for reporting qualitative research (COREQ) guideline. 26The detailed methodology is provided in Supplementary material A.
To understand the decision-making process of older adults on eye examination utilisation, a grounded theory approach was used to guide this study. 27Eligible participants were community-dwelling individuals who aged 65 years or above and had not have a routine eye examination in the past 24 months.Subsequent interviewee selection was guided by theoretical sampling until data saturation. 27The participants were purposively recruited from six community elderly centres in Hong Kong.
An interview guide was piloted and revised accordingly (Supplementary material B).Depending on the responses, subsequent questions would be followed to explore the topic.After interview completion, demographic and health status information were collected.A shopping voucher was offered as a token of appreciation.
The interviews were conducted by WYL between May 2021 and September 2021.The interviews took an average of 41 minutes.The interviews were audio-recorded and field notes were taken during and immediately after each interview.The contents were transcribed verbatim by WYL and a student assistant.
Data analysis was performed concurrently with data collection using constant comparison techniques to facilitate subsequent theoretical sampling and achieve theory development. 27Data analysis was done by WYL, under the supervision of QL.Discrepancies were discussed and resolved by consensus by the research team (QL, JL, MY).Data were analysed in NVivo 12.After 20 interviews, data saturation was reached and five interviews were conducted to confirm no additional information was added.

Results
Table 1 shows the summary of the demographic characteristics of the 25 participants (Supplementary material C includes individual demographic characteristics).The selfreported health status and self-rated fitness of eyesight of each participant is shown in Tables 2 and 3 respectively.Most notable for visual status (Table 2), the majority of the participants have glasses for presbyopia (80%) and nearly half (48%) have ever been diagnosed with cataract previously.

The core theme: prioritising and including routine eye examinations in existing health service utilisation
The response of 'no intention' to use the routine eye examination was rather intuitive for most participants.Upon further questioning, intentions of participants in fact could be changed and therefore, unstable.The core theme derived suggests the reasons for the low eye examination utilisation are likely because of difficulty in prioritising and including primary eye care into existing healthcare utilisation (Figure 1).
Low perceived needs, low perceived self-efficacy of service utilisation, and unfulfilled service expectations, all contributed to low motivation to use the routine eye examination.Previous healthcare utilisation was found to have influenced these key decision components to some extent.Illustrative quotations are shown in the Supplementary material D.

Theme 1: previous health service utilisation as a reference for judging primary eye care
It was found that factors exist within the healthcare system and the individual health seeking habits were found to influence their eye examination utilisation decision-making.Public health services were mainly used by the participants.They shared that they would only use healthcare services when they were ill (symptom-driven), which was what they have been doing to address other physical healthcare needs.Their health seeking behaviour were externally motivated by the recommendations provided by an authority figure which they encounter either during health check-up (medical doctors) or broadcast in daily lives (government recommendation).
Several attributes of the healthcare service (cost, doctorpatient relationship) experienced in public services were also considered preferable.Participants in the lower socioeconomic bracket showed a greater reliance on public services despite long waiting times.Participants with poorer health would require more medical treatment services and therefore would have a greater financial burden to bear.It seems that the frequent encounter with healthcare practitioners at the public services may have built a trusting relationship between service providers and the older adults.Participants shared  that they "trust their doctors' advice".All these factors have some impact on the decision on whether or not to use the routine eye examination service.

Theme 2: perceiving limited primary eye care service needs
Recognising the need for routine eye examinations is an important driver of behavioural intention.Like the existing health seeking habit as reflected in previous healthcare utilisation, the eye care needs appraisal was symptom-driven and socially cued.The reduced perceived need was also influenced by limited knowledge of the significance of the routine eye examinations.
Appraisal of the needs of participants was based on the impact of symptom severity on daily activities.Unless they perceived the symptoms may progress into blindness, the intention to seek eye care services remained low.Participants used a present-time perspective in need assessment, giving more weight to symptoms right now and less consideration of how it may affect visual health in the future.
Naturally, participants seek strategies to cope with blurry vision, e.g., wearing reading glasses, or utilising magnifying functions in mobile devices; these coping strategies all help the participants see clearer while engaging in daily activities.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 or inconvenience reduced the perceived need for an eye examination.
Social influences on need appraisal were also frequently mentioned -with most believing vision deterioration is part of normal ageing process.The role of vision in performing daily activities (such as grocery shopping) 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.Participants usually adopt a downward social comparison where they compared themselves to others who have poorer visual health, causing them to think more optimistically about their visual health and hence lower perceived needs.Those who attend regular check-up at the public hospital shared that the absence of primary eye care advice from public doctors was interpreted by the participants as 'no need to use eye examination'.
Only a few participants could elaborate on the significance of the routine eye examination (e.g., early detection of common eye disorders).Others believed the routine eye examination only includes spectacle prescription, perceiving the service as simple and not comprehensive.Together with the perception that vision deteriorates gradually, the participants were less likely to prioritise primary eye care over other general healthcare needs.

Theme 3: perceived low self-efficacy on routine eye examination utilisation
Despite some perceiving the need for regular eye examinations, the behavioural intention was diminished by the lack of confidence in accessing the service.The low self-efficacy was influenced by financial concerns, lack of information on service availability, limited social support and low health literacy.Some financial concerns came from the recurring use of services.Interestingly, it was found that the participants used a curative service, e.g., dental curative services, as the reference service to judge their ability to pay for an eye examination.Yet, these curative services have a higher service fee than an eye examination.The extent of financial concerns is presumably genuine, albeit based on misperceptions.The financial concerns may not be as pressing for those who have more savings or have children to assist them financially.Despite the eligibility of participants for the healthcare voucher, most of the funds would be spent on other primary healthcare services; the financial concern remains.
Most participants were uncertain about where to get an eye examination.Trust-worthy information channels of participants (e.g., the governmental website or community elderly centres) seldom disseminate information on service availability.There was a lack of action-planning cues in health educational talk hindering participants from making a judgement on their access ability (e.g., accessibility and affordability).This shows the importance of providing information about service availability along with improving knowledge in promoting service access.
Healthcare professionals, especially those working in the public sector, were a key factor that the participants heavily relied on for navigating 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 affected their perceived needs and altered their intention to use the service.The encounter with an optometrist with mutual information exchange was described as a 'learning process' by one participant, which could increase self-efficacy in future service access as the eye health knowledge accumulated.
The participants also relied on their lay referral network for obtaining service information (e.g., friends or family members).For those with limited social support, community facilities have great potential to compensate for the disadvantages by being a key information source.The importance of social companionship in reducing the sense of insecurity and inconvenience caused by blurry vision after pupil dilation was also shared.

Theme 4: service expectations
Apart from individual-level judgement, service-level judgement was also identified.Service expectations for eye examination were based on the views of participants of what they thought a 'good healthcare provider' should be, with a tendency to use public health services to judge the service quality.The expectation includes not only the calibre of the service provider 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.The intention to use an eye examination could be further strengthened if a service was recommended by others who they trust.If ambiguous information was shared (e.g., mixed health recommendations or personal experience), then behavioural intention would reduce.
Although the participants 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 HKD100 to HKD1000 (~AUD 20-196), varying by the socioeconomic status of the participants.The typical fee range for an eye examination is HKD 300-400 (~AUD 59-79).A comparison to other well-known and commonly used healthcare services, such as the price of a private doctor visit, was typically used to determine what was considered an 'appropriate' price for an eye examination.This implies that the costs of prior service use were used as a baseline to assess the worth of funds spent on eye examination.
As for location, it was found that participants usually cited places that they were already familiar with, such as 'near the hospital' or 'near the elderly health centre'.The participants also shared the downside of their past health service experience in terms of transportation and the time required to travel and the long waiting time, and that reducing these barriers would improve the intention to use the routine eye examination.
Participants perceived higher intention to use the routine eye examination when the services are patient-centred, reducing the impression that an optometrist only cared about 'selling the product' (e.g., expensive designer brand spectacles).In addition, they also believed that having appointment reminder would also improve service uptake.

Discussion
This study explored the potential factors that contributed to a decision-making process that resulted in low intention to use the routine eye examination for Hong Kong older adults.It was found that participants were not familiar with the routine eye examination compared to other healthcare services.This study captured the eye examination utilisation decision-making process of the participants, which was guided by their existing health-seeking habits reflected from their previous health service utilisation.The participants displayed a symptom-driven and socially cued needs appraisal process by adhering to their previous health behaviour routines.Due to low self-efficacy perceptions, unmet service expectations, and low perceived primary eye care needs, participants were less motivated to use the routine eye examination.
The low intention to use the routine eye examination can be explained by the difficulties in prioritising and including primary eye care needs into existing health service utilisation.Previous service utilisation serves as an anchor for judging needs and shaping service expectations.For example, comparing an eye examination to other existing preventive health programmes like vaccination and cancer screening programmes, which are fully subsidised and with sufficient information on service availability.This may explain why an eye examination is prioritised lower than other preventive health services. 28,29s the eye examination is not a prioritised service, despite having the health care voucher scheme, the limited voucher amount has been used to settle the service fees of other private services used by the participants, meaning it has little impact on encouraging eye examination use.A similar situation also occurs in primary oral care, 30 suggesting the possibility of translating current findings to understanding access barriers of other primary healthcare services.
This study found that self-efficacy is influenced by health literacy, and by the ability of participants to overcome financial and physical barriers to access the service.Such ability to overcome barriers is not only affected by predisposing factors but the eventual decision to use the routine eye examination, to some extent, is shaped by the healthcare environment. 31It is, therefore, not surprising to learn that some participants shared homogenous opinions and service expectations regarding eye examination utilisation in Hong Kong.
This study highlights the importance of social influences in changing needs appraisal and enhancing information dissemination, with missed opportunities identified at the community level to promote the routine eye examination, which were also found in studies conducted in low-and middleincome regions. 32,33The lack of sufficient information dissemination through preferred information channels means that older adults are less likely to access the service actively.The participants believed improving information dissemination along with providing action-planning cues would improve their motivation to use the routine eye examination.Encouraging collaboration amongst pivotal stakeholders would be ideal.However, the practicability of suggestions must be considered, e.g., those involving public doctors are likely not to be feasible.
Involving community elderly centres would be a more workable option to facilitate service alignment to service expectations and more effective health education dissemination.The current findings reflect the importance of the practitionerpatient relationship in encouraging eye examination utilisation.Collaborating with elderly centres has several expected benefits, such as increasing health information dissemination and ease of service access.This may include inviting the optometrists to the community centres and delivering health educational talks with eye health-related information most relevant to older adults, along with service availability information.The immediate provision of action-planning cues after a health educational talk seems to help older adults make better health decisions.In doing so, this may better include primary eye care service into existing healthcare habits.A communityengagement intervention could be considered in future intervention design.
This study also identified barriers that were not mentioned in previous studies such as coping strategies reduce perceived needs, competing for healthcare needs and the influences of previous healthcare utilisation experience in decision-making, suggesting that some barriers to eye examination utilisation are context-based.For example, the coping strategies identified in this study, e.g., wearing reading glasses, were found to reduce perceived need of participants to use eye examination.This was not the case in studies conducted in other region. 16It was out of the scope of this study to investigate this factor.However, this difference suggests that it is important to consider the potential contextual differences when designing an intervention. 34

Limitations
The sampling techniques which focused on community elderly centres may neglect other groups within the older adult population, such as those with physical disabilities. 35The findings obtained may not fully explain the utilisation behaviour of these groups, though similar barriers were found such as financial and knowledge barriers.Also, despite efforts in recruiting participants with different demographic backgrounds, there were more female participants, and most participants were from the 70-74 age group.Previous studies involving community elderly centres reported similar situation. 36,37nother limitation is that this study only focused on the group that has not had a routine eye examination in the past 24 months.This may have neglected other factors that contribute to understanding eye examination utilisation as a whole, such as behavioural maintenance.Future research could undertake a longitudinal qualitative study to explore the decision-making process comprehensively. 38It would be helpful to also collect information related to the visual status before and after getting an eye examination and see if these factors influence behaviour maintenance.

Implications
Even though this study was conducted in Hong Kong, the findings provide a framework for the consideration of factors influencing the routine eye examination uptake in other regions with a similar healthcare system to Hong Kong, or a healthcare service with similar function to an eye examination. 30The findings suggest a multi-disciplinary approach to promote regular eye examinations by targeting the three identified key factors (i.e., needs appraisal, perceived self-efficacy, and service expectations).There are two aspects that future intervention may target: (1) how to better integrate primary eye care into other existing and more familiar health services for older adults; 39 and (2) how to exploit the benefit of the social environment for more effective information dissemination.
Given that service fee was a key consideration for older adults, future studies could investigate the impact of price framing (e.g., comparing the price of an eye examination to other more common health services) on service utilisation and maintenance behaviour, respectively.
Future research could also investigate the impact of the provider-user relationship on the intention to use the routine eye examination.Improving the provider-user relationship may reduce barriers preventing older adults from using eye examination.Future research should also include perspectives of different stakeholders in designing interventions that are practical and simple to implement.

Conclusion
The routine eye examination is not well understood amongst older adults in Hong Kong.This study illustrated the components in the decision-making process to address in future interventions to increase the routine eye examination utilisation.Along with providing sufficient and relevant healthrelated information to increase perceived needs and strengthen the provider-patient relationship, future studies could investigate how primary eye care can be better integrated within the healthcare system.

Figure 1 .
Figure 1.Prioritising and including routine eye examinations in existing health service utilisation.

Table 1 .
Demographic characteristics of participants.

Table 2 .
Self-reported health status.= 25.Multiple answers were allowed.The percentage may not add up to 100%.AMD = age-related macular degeneration; DR = diabetic retinopathy.

Table 3 .
Self-rated fitness of eyesight.