Visual disability affects negatively the autonomy and quality of life especially at advanced ages and is associated with worse mental health,1 greater cognitive deterioration2 and a greater risk of falls and injuries.3

Vision may be impaired due to multiple reasons being uncorrected refractive errors the most common cause worldwide. The prevalence of vision impairment and blindness is unequally distributed and strongly associated with socioeconomic factors and health services availability.4 Ageing, gender, socioeconomic status, ethnicity and place of residence are factors that determine inequalities in both visual health and use of eye health services. Prevalence of vision impairment, including blindness, is higher in women.5 Low-income populations and minority ethnic groups have less probability of access to preventive eye care services.6 Live in rural areas has been shown as a risk factor for certain common eye conditions such as cataracts or diabetic retinopathy compared to urban populations.7

During the last decade, the prevalence of visual impairment is growing in Spain and is unequally distributed among groups with an increased risk in lower-income regions.8 National surveys on the prevalence of blindness and visual disability in Spain show that these problems affect more than 900,000 people, of whom 69% are over age 65 and two thirds are women;9 life expectancy may contribute to this gap as in Spain is greater in women than in men, 86.2 years versus 80.4 years.10 Age and diabetes are considered principal risk factors, given the fact that age-related macular degeneration and diabetic retinopathy are the blinding conditions with the greatest increase in recent years.11 In Spain, patients searching medical eye care are referred by their family doctor and the average waiting time to receive specialized consultation is 68 days estimated by the NHS in 2015.12

For Spanish society, visual health is becoming more relevant as a public health concern, with an expected doubling of the population over age 65 by the year 2050, the greatest elderly population in Europe.13

There is a scarcity of research related to visual health status and the use of eye care services, particularly in rural areas. A regional survey carried out in Catalonia showed that the elderly and women with low incomes are particularly vulnerable to perceived poor vision14 and some rural populations have been identified at risk for ocular conditions such as diabetic retinopathy.15

The Spanish National Health Survey16 (NHS) addresses visual health in the population through five unique questions about the use of glasses or contact lenses and the capacity for near sight and far sight. In this study, we aim to analyze perceived visual health and health services use in a peripheral rural population in Madrid in relation to sociodemographic, socioeconomic and health characteristics. We also compared the use of optical correction and eyesight limitations between the rural population and the general population in Spain.

The results of this study show that up to 40% of the rural population presents poor perceived visual health and that poor perceived visual health is strongly associated with aging and widowhood, disadvantaged socioeconomic status and facing chronic diseases. The rural population is more likely to have visual difficulties and make less use of optical correction. The use of eye health services may not be sufficient particularly in children and diabetics.

Perceived visual health is a useful public health variable that has been previously associated with eye problems,21 depression,22 functional state and wellbeing for both middle-aged and the elderly.23 Although perceived vision loss may not always be related to a clinical diagnosis of an eye disorder, it is worth mentioning that in the elderly population vision problems are more frequent than patients might believe. The elderly may over-estimate their capacity for functional vision, given their understanding of their vision capacities as related to their age and the belief that a solution is not required nor exists.24 The association between widowed and poor perceived visual health could be conditioned by the advanced age of these persons.

Our results show that the socioeconomic profile of the rural population with visual limitations is low in terms of education, income and labor qualifications, as has been shown in other studies.25,26 Our findings also show that rural population with far sight difficulties is not receiving appropriate diagnosis and treatment, while near sight problems are apparently resolved without seeking an eye examination by using non-personally prescribed glasses.

Despite being one of the groups with greatest exposure to vision loss, nearly half of the diabetics in our study have not received an eye exam from specialized services –an ophthalmologist or optometrist's office− in the last 2 years. In people with diabetes, the existence of diabetic retinopathy is associated with poor glucose management, hypertension and lipids in the blood, and especially with the time elapsed since the initiation of the disease. It is for this reason that accepted clinical guidelines recommend an exam with observation of the back of the eye every 1 to 2 years for diabetics, even without known eye problems.27 In the case of children, the lack of pediatric eye exams observed contrasts with scientific evidence that highlights the need to prevent irreversible vision loss as caused by amblyopia, which is a treatable condition during childhood.28

Regarding factors that influence the use of health services, the population in the rural municipality indicated barriers such as the distance to the office, the price of optical treatments, and the lack of awareness for seeking possible solutions –associating vision problems with age−. Prior studies show that geographic distance to the health center and attitudes and beliefs often associated with rural life –such as lack of knowledge of health risks and a sense of self-sufficiency– generate greater resistance to seeking health care for patients with chronic diseases in rural communities.29

In similar studies in the British population, the lack of knowledge of certain diseases, the cost of treatment or services, the lack of coordination among first and second level health centers, and seeking an eye exam at an advanced stage of the disease, have also been identified as barriers to reducing vision loss.30 In this sense, protocols for primary care and referral have been proposed for rural environments in countries such Ireland that include optometry professionals, which promotes better care for complex cases by ophthalmologists and contribute to reduce health inequities.31

Considering the social, mental and functional implications of vision problems, national health surveys tend to include relevant information regarding visual health, which permits more efficient action towards reducing inequalities.32,33 However, in the case of Spain there is a lack of information on the use of specialized eye care services, as this information is not collected by national statistics. In a scenario of projected high population growth among the elderly population, it is significant that Ophthalmology was the specialty with the greatest number of waitlisted patients, ahead of traumatology, dermatology or cardiology.12

The global action plan for universal eye health promoted by the World Health Organization urges to member countries to create national plans and coordinate efforts for the prevention of blindness and visual disability.34 In Spain, although some regional eye-care policy models have been proposed35 and remarkable care is provided to people with visual disability and blindness through the National Organization for the Blind, there is no current national plan to address the increasing needs of the population for avoidable vision loss.

This study is subject to certain limitations. The cross-sectional study design does not permit establishing causality in the observed relationships. When comparing two samples of such a disparate size, the uncertainty of the smaller sample is greater, consequently these differences should be assumed with statistical caution. The comparison of results for the rural population and the general population is limited to the variables contained in the NHS concerning the use of eye glasses or contact lenses and the perceived limitations in near sight and far sight. The inclusion of new questions in the questionnaire used in this study may not be comparable a priori with other surveys. Nevertheless, there are few studies that include aspects related to visual health, population groups at risk, and the use of health services in the rural environment in Spain to justify pertinence of such approach. In our study, as in the National Health Survey, we do not capture the time elapsed since diagnosis in the case of chronic diseases as diabetes, which limits the possibilities to better estimate risk or plan future demand for services.

Against the benefits of promoting access to eye care services and treatments for the prevention of avoidable vision impairment, evidence exists that these interventions may fail to reduce risk of preventing falls and fractures in frail older people.36 As showed by recent review studies, there is a need for more clinical trials to analyze effectiveness, benefits and implications of visual health screening in the adult population.37

The rural population presents worse visual health indicators, more visual limitations and less use of optical correction. Poor visual health is influenced by age, social factors such as disadvantaged socioeconomic status, and the presence of chronic diseases. The use of health services may not be sufficient to prevent irreversible vision loss, such as that caused by diabetic retinopathy or amblyopia.

In light of the results of this study, it should be questioned whether the current system for prevention of visual disability in Spain sufficiently contributes to reducing inequalities in visual health and addressing the estimated increase in future demand for services. Actions to increase awareness and access to health services for an early diagnosis, treatment and better follow-up of eyesight disorders in the rural population may improve health outcomes and reduce inequities.

Mercedes Carrasco Portiño.

The corresponding author on behalf of the other authors guarantee the accuracy, transparency and honesty of the data and information contained in the study, that no relevant information has been omitted and that all discrepancies between authors have been adequately resolved and described.

S. Latorre-Arteaga designed the study, planned the data collection, analyzed and interpreted the results, and wrote the first draft of the manuscript. J. Fernández-Sáez carried out the statistical analysis and interpretation of data. D. Gil-González made contributions to conception and design of the study, the analysis and interpretation of data, and contribute to writing the first draft. All authors approved the final version of the manuscript.

The study was supported by Entretodos Foundation-Global Health Vision (Spain), a nonprofit organization, and by the authorities of Cenicientos (Madrid, Spain).

None.