Background
Methods
Study area
Study design and sampling
Marital status | Age group | No. of participants | |
---|---|---|---|
1. | Urban women | <50 years | 7 |
2. | Urban women | >50 years | 12 |
3. | Rural women | <50 years | 11 |
4. | Rural women | >50 years | 20 |
Sub-total women in FGDs | 50 | ||
5. | Urban married men | <50 years | 9 |
6. | Rural married men | <50 years | 5 |
7. | Rural married men | >50 years | 5 |
Sub-total men in FGDs | 19 | ||
Total FGD participants | 69 |
No. | Age | Education | Place Interviewed |
---|---|---|---|
Women with eye problems who sought eye treatment | |||
1 | 60 | Illiterate | Siem Reap Provincial Hospital, Eye Hospital |
2 | 69 | Illiterate | Siem Reap Provincial Hospital, Eye Hospital |
3 | 63 | Informal education | Kampot Referral Hospital, Eye Unit |
4 | 66 | Grade 4 | Tbong Khmum Referral Hospital, Eye Unit |
5 | 84 | Illiterate | Pursat Referral Hospital, Eye Unit |
6 | 50 | Illiterate | Pursat Referral Hospital, Eye Unit |
Women with eye problems who did not seek eye treatment | |||
7 | 68 | Grade 2 | Popel Health Centre |
8 | 60 | Illiterate | Popel Health Centre |
9 | 58 | Grade 6 | Tany Health Centre |
10 | 45 | Grade 6 | Tany Health Centre |
11 | 80 | Illiterate | Tbong Khmum Referral Hospital |
12 | 58 | Illiterate | Chi Peang Health Centre |
13 | 59 | Grade 1 | Chi Peang Health Centre |
Total IDI participants: 13 |
Key informant interview (KII) participant’s role | Male | Female |
---|---|---|
Coordinator, National Program for Eye Health (NPEH) | 1 | 0 |
Country Director, Fred Hollows Foundation Cambodia | 1 | 0 |
Director or Deputy Directors of Provincial Health Department | 4 | 0 |
Referral Hospital Eye Health Providers | 3 | 0 |
Health Centre Facility Managers | 4 | 0 |
Commune Committee for Women and Children (CCWC) Representatives | 0 | 4 |
Village Health Volunteers | 3 | 5 |
Total KII participants per gender | 16 | 9 |
Data collection
Data analysis
Results
Characteristics of the study population
Demand-side barriers to accessing eye health care for women
Many female participants also displayed a number of beliefs about eye health. Most deemed eye problems, including visual impairment, as being ‘not serious’ enough to seek treatment, unless experiencing pain. Further, many female respondents believed vision impairment to be an inevitable but natural consequence of aging and that eye treatment interventions require surgery and a prolonged recovery period. A fear of surgery further served as a deterrent to seeking eye treatment.If I had eye surgery, I would stay in bed and who will look after me? And who will look after my grandchildren? I decided not to go. (Female participant, 60 years old, rural area)
For elderly women undergoing eye treatment, the cost of treatment is often shared between adult children and decision-making is a collective process requiring consensus. Adult children are therefore an important source of information, as well as financial and psychological support for women:I would not go if my husband does not give me the money. (Female participant, 55 years old, urban area)
In spite of the availability of a wide range of information sources in the community, it was found that the status of women prevented them from accessing accurate information and effective communications:I was encouraged by my sons and daughters to go to the hospital for treatment. (Female participant, 60 years old, urban area)
Participant perceptions of eye health care were largely determined by informal sources of information such as word of mouth and treatment outcomes observed in their direct environment, rather than by information from health services. Unsurprisingly, women who decided to seek treatment were often motivated to do so by their family circle or social networks:Men have more opportunities [to access information] than women. For example, men can go out to the coffee shop, or join the meeting or public discussion…but for women, few go out, they just stay at home. (Director, Referral Hospital, male)
However, these informal sources were often shown to be inaccurate resulting in misconceptions regarding eye treatment:I was encouraged by my sons and daughters to go to the hospital for treatment. (Female participant, 60 years old, urban area)
In terms of institutional/organisational factors, neither female nor male participants sought eye health care at the health centre (HC), as participants perceived that eye health services at HCs were at best limited.Some people say I have to spend hundreds of dollars for the treatment, particularly surgery. (Female participant, 68 years old, rural area)
However, women were less likely to be able to access eye health units of provincial referral hospitals due to costs incurred by long travel distances and cultural norms dictating that they should not travel alone. In addition, their lack of experience and familiarity with health systems and structures was seen as a significant barrier, particularly for elderly and poorly educated women. For instance, a lack of support/assistance with hospital administrative processes was reported by several participants.I don’t come because I don’t think the health centre has the medicine that I need for eye health problems. (Female participant, 57 years old, rural area)
In addition, although in Cambodia poor patients are entitled to receive free or discounted care at public facilities through equity cards, in practice they reported this was rarely the case. It was evident that participants were often unable to effectively utilize these financial support schemes due to a lack of awareness of health financing support and/or a lack of understanding of how to navigate the system to obtain financial support.I have never had any [eye] treatment, this is my first time… the problem I have is not serious and the cost of the treatment... I think I have to pay a lot of money and the transportation is also costly, so I just ignore it. (Female participant, 68 years old, rural area)
Supply-side barriers to accessing eye health care for women
Limited availability of eye health human resources was acknowledged by service providers as contributing to extending patient waiting times. For women in urban higher income groups, waiting times were reported as an important factor in decision-making. Similarly, FGDs showed that waiting times were a barrier for rural women seeking eye health care, tied to opportunity costs including travel time and lost income. In addition, supply-side respondents recognised that amongst female eye health consumers, availability of information required to make informed decisions regarding eye health was limited. At community level, VHVs recognized that whilst women in rural areas often relied on health messages delivered by VHVs, reaching vulnerable sub-groups, especially elderly women was a continued challenge:More and more patients come here for eye treatment and the number of female patients who come to the eye hospital is higher than men. (Eye Health Professional, Referral Hospital, male)
A number of providers recognized that for patients unfamiliar with the health system, particularly visually impaired patients from remote areas, the modern hospital environment may be perceived as complex and intimidating. This may act as a deterrent to eye health utilization, particularly amongst poor rural women.Currently, people trust VHV’s information. [However] If we call people for meeting, very few people come… Elderly women who stay at home are unable to access health information. (VHV, female)
Strong traditional beliefs as well as fear of surgery and negative treatment outcomes were cited by service providers as acceptability barriers for women:Yes, of course it is a burden for the [poor] patients...When they come and stay at the hospital, they have to pay… for treatment fees and their living expenses… they may need their relatives such as sons or daughters to come along and look after them. So those relatives cannot work or earn any money for the family. That really makes the situation worse. (Deputy Director, Provincial Health Department, male)
They also recognised that the effectiveness of the referral system is limited and its shortcomings disproportionately impacted women.They are afraid of the result of the operation. Some believe that their eyes may get worse after the surgery... that surgery might be painful, and… that the result may be unsatisfactory… This may deter women from seeking treatment. (Commune Committee for Women and Children Representative, female)
Health providers acknowledged that women’s multiple roles and responsibilities acted as barriers and that the interaction of gender-specific barriers had an important influence on their ability to seek eye health services, particularly elderly women.We need to strengthen referral system and make consumers/patients aware of services at the health centre. (Eye Health Professional, Referral Hospital, male)
A table summarising the study results in terms of demand- and provider-side barriers is presented in Table 4.I think the problems is not having caretakers; there is no one to replace them, to take over their responsibilities… grandparents that have to look after the household and prepare food for children. If they have eye surgery, they have to take a rest and somebody else has to do the work… (Eye Health Professional, Referral Hospital, male)
Demand-side barriers to accessing eye health care for women in Cambodia | Provider-side barriers to accessing eye health care for women in Cambodia | ||||||
---|---|---|---|---|---|---|---|
Socio-cultural factors | Access to and control over resources | Institutional & organisational factors | Economic factors | Accessibility | Availability | Affordability | Acceptability |
Status of women in Cambodian society Women as primary caretakers Beliefs about eye health Women’s limited agency in healthcare decision-making | Lack of control over household resources Limited access to accurate eye health information | Poor perceived quality of eye health care from service user perspective Limited eye health services at health centre level Lack of experience and familiarity with health systems and structures esp. referral Long travel distances to eye health services | Direct costs (user fees/treatment costs) Indirect costs (transportation, opportunity costs e.g. lost income) Unable to use financial schemes available for poor patients | Limited availability of eye services at the HCs Long distances to the referral hospitals Cultural norms dictate that women should not travel alone Difficult to find an accompanying person | Limited availability of eye health human resources Long waiting times for patients Limited availability of information required to make informed decisions on eye health Complexity of modern hospital environment | Patient treatment costs not perceived as a barrier to access by the majority of service providers | Strong traditional beliefs Fear of surgery and negative treatment outcomes Shortcomings in the referral system Women’s multiple roles and responsibilities |
Most vulnerable subgroups
Widowed and elderly female heads of households were even less likely to have access to information, be aware of treatment options or to seek treatment. As a result of visual impairment, their social networks were more likely weaker than other subgroups (e.g. urban married women). Due to their eye health condition, they were at a higher risk of being dependent on others at the same time as socially isolated:Some older people…said that it is due to aging and it [eyesight] may get better... when your children are grown. (Female participant, 46 years old, rural area)
I could not do anything, even pressing the phone buttons. I cannot do anything besides staying at home and cleaning the house. (Female participant, 60 years old, urban area)