Barriers to Healthcare Access among Visually Impaired in Iligan City, Philippines: A Qualitative Study

Roselyn M. Butalid*, Jade Voltaire M. Butalid, Angelo David S. Nacion, Ma. Arvie Faith T. Escasiñas, Gloria Shiela E. Coyoca, Reya T. Seno, Vincent G. Tabil

College of Health Sciences, Mindanao State University-Iligan Institute of Technology, 9200 Iligan City, Philippines

*Corresponding Author’s Email: roselyn.butalid@g.msuiit.edu.ph

ABSTRACT

Background: The visually impaired population continues to experience disparities in healthcare access, reducing their capacity to meet physical and mental needs. This study delved into the barriers visually impaired individuals face when accessing healthcare to determine how nurses, as front-line healthcare providers, might help this underserved population. Methods: This study employed a qualitative descriptive research design utilizing in-depth one-on-one interviews with fifteen visually impaired massage therapists in Iligan City, Philippines recruited through a purposive sampling technique. The researchers developed an interview guide with open-ended questions for the unstructured interview sessions. The interviews underwent a process of recording, transcription, and thematic analysis. Results: Several barriers discouraged visually impaired individuals from seeking medical care, including challenges related to accessing healthcare facilities due to a lack of support and transportation difficulties. Other issues include inadequate knowledge of healthcare access, fear of discrimination, negative experiences with health services, and financial constraints. Conclusion: Visually impaired individuals encounter complex barriers to healthcare, including the need for reliable assistance, inadequate transportation, limited support systems, and financial constraints. Additional challenges like insufficient social interactions, low health literacy, and discrimination further hinder their access to care. Financial issues often lead them to prioritize other needs, worsening their health. A comprehensive approach is needed to address these barriers, including enhancing support networks, improving accessibility, providing better assistive devices, and training healthcare personnel. Increasing health literacy and making healthcare more affordable are also crucial for creating a more inclusive system that effectively serves visually impaired individuals.

Keywords: Healthcare Access; Massage Therapist; Visually Impaired

INTRODUCTION

Visual impairment is a compelling issue worldwide. Approximately 2.2 billion people globally are visually impaired, a condition often accompanied by various other medical complications (Demmin & Silverstein, 2020). An individual's visual acuity plays a vital role in performing activities of daily living. It is instrumental in ensuring safety when interacting with the environment. Without proper vision, an individual may experience hindrances in fulfilling physical and mental needs. Vision loss can be comprehensively devastating because it does not only affect the individual's eyesight but can have a distressing overall effect on their employment rate, level of independence, ability to maintain a stable financial situation, and overall quality of life (Welp et al., 2016). Moreover, vision impairment takes a toll on how an individual lives in the long run. It can lead to increasing significant levels of disability, economic burden, reduced quality of life, medical complications, and mental health challenges. Vision loss significantly impacts how someone feels about their quality of life (Nuzzi et al., 2024; Sohrabi, Tumin & Osman, 2018).

Around 90% of visually impaired individuals worldwide reside in low- and middle-income countries (WHO, 2023). The disparities in access to healthcare for the visually impaired in low and middle- income countries arise from multiple barriers relative to geographic availability, financial convenience, high hospital transportation costs, and rising hospital stay expenses (Barman & Mishra, 2020). Limited access to medical services diminishes the capability of the visually impaired to meet their physical and mental needs (Demmin & Silverstein, 2020).

Individuals with disabilities frequently face heightened vulnerability to adverse health outcomes, making access to healthcare services a critical concern (Hashemi et al., 2020). It is therefore essential to investigate healthcare accessibility for People with Disabilities (PWDs), particularly those who are visually impaired. Numerous studies have explored barriers to healthcare access for visually impaired individuals across various countries. Research has been conducted in regions such as East Africa (Tesfaye et al., 2021), Brazil (Clemente et al., 2022), Korea (Choi et al., 2021), the Netherlands (Stolwijk et al., 2023), the United Kingdom (Hussain, Heinze & Gomes, 2024), India (Senjam & Singh, 2020), and Bangladesh (Sanders et al., 2021; Amalia et al., 2021). Despite these valuable contributions, there remains a notable gap in studies focusing specifically on the barriers to healthcare services for visually impaired individuals in the Philippines. Given that over 500,000 people in the Philippines are blind or visually impaired (Baclig, 2022), it is imperative to address this gap and explore the unique challenges faced by this population in accessing healthcare.

To understand their difficulties and determine how the healthcare system, especially nurses who work as front-line healthcare providers, improves their services to this marginalized sector of society, this study explored the barriers the visually impaired face when accessing healthcare in Iligan City, Philippines.

METHODOLOGY

The study utilized a qualitative research design through in-depth one-on-one interviews to explore the barriers to healthcare access among visually impaired individuals in Iligan City, Philippines. This study included fifteen visually impaired massage therapists as key informants for feasibility as they are working in massage parlours located in malls and public places. No supporting or non-key informants were included. The participants were recruited using a purposive sample method according to these criteria: eighteen years old and above, visually impaired, residents of Iligan City, Philippines, experienced issues in healthcare access, and willing to participate in the study, regardless of sex, socioeconomic status, and type of visual impairment.

An ethics review committee approved the study before its final conduct. Informed consent was obtained after a detailed explanation of the purpose and procedures of the study. The participants were assured of confidentiality of their responses. In-depth one-on-one interviews were conducted to gather data utilizing a research-made semi-structured interview guide. The researchers developed an interview guide and utilized open-ended questions during the unstructured interview sessions. The questions were employed until a new theme emerged. Each interview lasted for 30-60 minutes and included an audio recording. The data collection lasted four months, from January to April 2024. The responses were transcribed verbatim and translated from the vernacular into English. Themes were extracted based on thematic analysis by Vaismoradi, Turunen and Bondas (2013). The follow-up interviews with the participants verified the truthfulness and accuracy of the data. The reporting for this study was guided by the Consolidated Criteria for Reporting Qualitative Research (COREQ) (Tong, Sainsbury & Craig, 2007).

Ethical Consideration

The Ethics Review Committee of College of Health Sciences of Mindanao State University, Iligan Institute of Technology, Philippines, granted the study ethical clearance with reference number E-2023- 62 on 15th December 2023.

RESULTS

The Barriers to Healthcare Access among Visually Impaired Individuals

The study formulated barriers to healthcare access among visually impaired massage therapists in Iligan City in five themes and two sub-themes. The first theme developed was (1) challenges in going to the healthcare facility, which includes two sub-themes: (1.1) lack of support system and (1.2) transportation difficulties. The second to fifth themes were (2) inadequate knowledge of healthcare access, (3) fear of discrimination, (4) experience with unfavorable health services, and (5) financial challenges.


A diagram of a health care barrier Description automatically generated

Figure 1: The Emergent Themes and Sub-Themes of the Study

Theme 1: Challenges in Going to the Healthcare Facility

The first theme, "challenges in going to the healthcare facility," refers to the circumstances preventing the visually impaired from reaching the healthcare facility safely. It has two sub-themes: Lack of support system and Transportation difficulties.

    1. Lack of Support System

      This sub-theme refers to the need for companionship for the visually impaired in the healthcare facility. The participants shared the following accounts:

      "The problem is nobody will accompany me." - P1

      "I think twice about getting a checkup because, of course, I must find a companion since I cannot travel well without a companion." - P7

    2. Transportation Difficulties

This sub-theme refers to the participants' struggles to find safe transportation to the health clinic or hospital. The participants provided the following accounts:

"The driver dropped me at the crossing; how can I cross the street?" - P15 "Motorists should respect and slow down when blinds are crossing the street." - P11 "I do not have a cane." - P6

"Our house is quite far. Reaching the health facility will take two rides." - P9


Theme 2: Inadequate Knowledge of Healthcare Services and Access

The second emergent theme was "inadequate knowledge of healthcare services and access." This theme pertains to the poor awareness of the visually impaired on the health services they can avail of and how to access them. A participant stated the following account:

"I do not know the services for the blinds. Usually, only those members of the association are aware." - P2

Theme 3: Fear of Discrimination

The third emergent theme, "fear of discrimination," pertains to the participants' fear of unfair treatment by healthcare personnel due to their impairment. The participants shared the following accounts.

"They say we are a priority; however, they do not attend to our needs promptly." - P3

"I know the Constitution, in Republic Acts, for our rights. Sad to say, we are not enjoying our rights equally." - P9

"The PWDs had to line up with everyone else in the hospital, and the healthcare provider did not give special consideration to them." - P13

Theme 4: Experience with Unfavourable Health Services

The fourth theme formulated was "experience with unfavourable health services." This theme refers to the adverse health treatment that the participants encountered in the past. The participants provided the following accounts:

"At the City Health Office, they refuse to give me an anti-tetanus injection until the wound suturing is done" - P3

"The last time I had a checkup, I did not return because they kept me coming back another day for four days in a row." - P5

Theme 5: Financial Challenges

The fifth theme that emerged is "financial challenges." This theme pertains to the participants' inability to afford health care. The participants shared the following statements.

"The doctor ordered me to get an eye ultrasound for possible surgery. They gave a referral order but ignored it because of a lack of money." - P7

"I do have financial challenges. Then, the City Hospital does not have any doctors for the eye, so we need to resort to private hospitals, and the bills are far more expensive in private hospitals." - P12

"We cannot buy all the prescribed medications, only those we can afford." - P12 "Finances are hard even when I have a job. More so for costly laboratory tests." - P13

"Our income is just sufficient to buy milk for my kids, and I only go for checkups when my disease has gotten bad." - P15

The study uncovered various barriers faced by visually impaired individuals in Iligan City, Philippines, ranging from practical issues like transportation and support systems to more profound concerns about discrimination, service quality, and financial limitations. Visually impaired individuals frequently have difficulty finding companions to assist them with navigating to healthcare appointments, which often leads to hesitancy in seeking medical care. Other challenges include unsafe or inadequate transportation options, such as drivers dropping passengers off at unsafe locations and the lack of essential accessibility tools like canes. Additionally, there is a significant lack of awareness among visually impaired individuals regarding available healthcare services and how to access them, with many reporting insufficient information on services tailored for the blind. Participants also voiced concerns about unfair treatment by healthcare personnel due to their impairment, noting delays and insufficient special consideration despite policies designed to prioritize their needs. Negative experiences with healthcare services were also reported, including denial of necessary treatments and repeated visits for the same issue, resulting in frustration and reluctance to seek care. Financial constraints further complicate access to medical tests, treatments, and medications, with the high cost of private healthcare services exacerbating these challenges compared to public options.

DISCUSSION

The visually impaired participants face several barriers that discourage them from seeking health care. The first barrier, “challenges in going to the healthcare facility,” encompasses the difficulties that the visually impaired encounter when trying to physically reach healthcare facilities. The subtheme “Lack of support system” refers to the absence of assistance or resources that could help visually impaired individuals navigate to and within healthcare settings. The visually impaired certainly need a companion in consultation or hospitalization, to assist in queuing for admission procedures, financial assistance, health insurance, medicines, and others. The unavailability of somebody to assist the visually impaired in complying with the processes hinders them from seeking medical care. In a world where a lot of information is exchanged visually, those who are visually impaired are naturally at a disadvantage because of their reduced vision or complete blindness. Throughout the time of their impairment, which could last their entire lives, they are more often in need of help (Grisafe et al., 2021), to the point that they need people who will always be available to them. For most participants, family, friends, and coworkers are relied on as the primary support system, and it is infrequent for them to cultivate a more comprehensive support network. The need for more social exposure results in the inability to gain insight into their social needs and hinders the development of new meaningful relationships. According to Chu and Chan (2022), people with visual impairment who are middle-aged or older and have poor levels of social support often experience loneliness. Increasing familial and social support could be a helpful way to lessen loneliness.

Only some participants reported having some semblance of a robust support system. One of them claimed that he recruits and pays somebody to assist him in getting transportation to go home after work. Another participant also stated that he meets his health needs with the aid of his family. It is sad to note that most of the participants were less fortunate since they lived alone. Some were from outside the city and needed to familiarize themselves with the terrain. One participant reported that while she has parents to back her up, they are not consistently dependable, and she still must work to help sustain her family significantly. The lack of a well-established support system, as well as the inability to expand it beyond family and coworkers, can indirectly lead to adverse health outcomes since it limits the options for the visually impaired based on what the existing system knows. Thus, they need more effective and affordable healthcare.

Moreover, even those who are relied upon, particularly family members, may be dealing with personal difficulties and may find it taxing to assist the blind or visually impaired. If not appropriately addressed, the visually impaired may experience negligence or open discrimination from the support system itself. This further underscore the need for the visually impaired to expand their respective support systems. It is necessary to support creative initiatives that enable new interpersonal interactions built on communication, mutual understanding, and social cohesiveness (Martinez, Asorey & Latas, 2024).

The subtheme “Transportation difficulties” highlights the problems associated with using transportation. One great dilemma for the visually impaired when going to the health care facility is the risk of physical accidents since public transport like jeepneys only drops them in the designated area. They need to walk further to reach the health facility. They may strike someone or something or get into unfavourable spots that cause physical injuries, which poses the need for a cane to navigate the road when walking alone. Another problem is the risk of vehicular accidents, as reckless drivers do not slow down even when the visually impaired are crossing the street. Compared to the non-impaired, the visually impaired have a more challenging experience navigating the road or commuting in public transit since these environments do not provide much space to reevaluate their positioning (Koca- Atabey, Öz & Tekeş, 2022; Mirzaei, Manduchi & Kurniawan, 2018). In the case of the open road, many vehicles are running past them, and as revealed by a participant, these vehicles do not give way to them. In the case of public transport, they are usually cramped with other passengers. These factors put them at significant risk of physical injuries by getting into a motor-vehicular accident or colliding with unconcerned people. Moreover, assistive devices can only be partially relied on as busy environments may be unpredictable and unforgiving (Fraser et al., 2019).

Due to the difficulty or inability to see, the visually impaired depend on other senses, like hearing (Low et al., 2020) and touch, for navigation. Given the high traffic volume with open streets, their senses cannot compensate enough, and they need external assistance. There are various ways to assist the visually impaired in walking by themselves, like using a cane, having someone as a guide (Sim, 2020), or memorizing the area's layout (Hersh, 2020). However, some participants disclosed that they have no functional cane, which implies the need for the concerned social and health agencies to provide them with a cane or any other assistive devices that may increase their independence. Nevertheless, some visually impaired do not use their cane due to issues like poor quality or discomfort, leaving them to rely on the support of the non-impaired in navigation. Another factor that aggravated the transportation barriers was the distance from their abode to the health facility. This implies the need for healthcare personnel to regularly conduct home visits to the visually impaired to check their health status.

The second theme, “inadequate knowledge of healthcare services and access,” relates to the limited awareness among visually impaired individuals regarding available health services and how to access them. Many visually impaired, especially those non-members of the blind association, are still unaware of the health services available to them and how to access them. Knowing what healthcare service to avail of, also known as health literacy, is crucial to ensuring that a client's condition is well-managed and benefits the client's general well-being (Pelikan, Ganahl & Roethin, 2018). High degrees of health literacy may result in better health outcomes and a high capacity for self-care. Giving them options empowers them and bypasses socioeconomic disparities (Stormacq et al., 2019). Adverse health outcomes, such as higher hospital readmission rates, death rates, and medical expense increases, have been associated with low health literacy (Nguyen & Gilbert, 2019) and poor patient-provider interactions. While the existence of methods for providing visually impaired people with health information can be accepted (i.e., via sound or Braille), the visual approach is the most popular method for communicating this kind of information. It is no surprise to say that being able to see is highly correlated with the ability to maintain and improve well-being (O’Conor et al., 2016; Schwennesen, Barghadouch & Olesen, 2018). The inability to effectively communicate to the visually impaired what information they are entitled to exacerbates this systemic disadvantage (Choi et al., 2023). To speed up the process of availing health care, the individual might need to get acquainted with someone already aware. Thus, it is helpful that the visually impaired may enlist in an organization, government, or non- government that could provide them with information about health services and how to access them. There is also an implication that the Department of Health gives more attention to this marginalized sector regarding health education and access. It is essential to address this healthcare barrier as vision loss correlates with low health literacy (Wallace, Bradway & Cacchione, 2022) and lower quality of life.

The third emergent theme, “fear of discrimination,” refers to the participants' concerns about being treated unfairly by healthcare providers because of their impairment. The discrimination or undesirable treatment felt by the visually impaired lessens their trust that they will get the healthcare services they need. According to Moscoso-Porras and Alvarado (2018), perceiving discrimination results in avoiding medical attention, even among people with disabilities. Various factors result in this outcome, such as implicit and explicit attitudes of healthcare personnel, staffing issues, inability to appropriately interact with them (Gong et al., 2021), and lack of enforcement of existing rights of PWDs (Dahlan, Listiningrum & Wicaksana, 2022). The participants expressed that they are not enjoying their constitutional rights and continue to experience disparities in health care. One participant described his opinion that the Philippines' laws intended to help the blind and other disabled individuals have unequal implementation. Despite initiatives to improve fairness and inclusion in health care, people with disabilities, particularly those who are visually impaired, still experience prejudice from healthcare practitioners. Numerous factors, such as institutional hurdles, personal biases, and inadequate education and training, contribute to this discrimination (Haque & Stein, 2020). Individual preconceptions shape attitudes and behaviours toward people with disabilities, leading to prejudices and marginalization. These prejudices, based on social stereotypes and misconceptions, influence how people perceive and interact with people with disabilities. The prejudice experienced by the visually impaired is also consistent with research conducted by Mugisa and Kyakulaga (2024), who discovered that the main obstacle faced by the visually impaired students was the teachers' disapproving attitudes toward them, believing that they were a burden and slower than other students. Positive bias fosters empathy and support, whereas negative bias frequently results in exclusion, discrimination, and prejudice (Wolsiefer & Stone, 2019). Time constraints and work pressures in healthcare can increase discriminatory behaviour and diminish the quality of nursing care delivery (Babapour, Gahassab-Mozaffari & Fathnezhad-Kazemi, 2022). Individuals with disabilities might not receive prompt medical attention since healthcare providers must be aware of their disability and proper communication style, resulting in delayed or substandard care. People with disabilities felt invisible or were perceived as incapacitated and mistreated as a disease rather than a holistic individual (McClintock et al., 2016).

The fourth theme relates to the negative experiences with healthcare treatment that participants have faced in the past. Experience of negative health services affects the decision of the visually impaired to seek health care. The unfavourable health services encountered by the participants in the past mainly include being refused needed care and the long process of medical care that entails several times coming back to the health care facility. Being refused treatment and unclear referrals give the visually impaired despair and confusion in seeking health care. These circumstances drive them to endure the illness as much as possible, which may aggravate the condition and affect their quality of life. The finding agrees with the finding of Schwei et al. (2017) that perceptions of unfavourable experiences in the past may affect how people seek medical attention in the future.

Furthermore, experience with unfavourable health services made some participants to only approach the healthcare facilities in times of emergency and worse conditions. This reality presents the risk of some preventable diseases exacerbating to the point where they become irreversible, especially when discovered late. This relatively lax attitude towards health compounds their reports of not feeling any ill nor having a comorbidity, making them not motivated to even go for a routine checkup. The belief of having no comorbidities contrasts with the finding of Talaat et al. (2021), who found hypertension and diabetes to be highly prevalent comorbidities among the visually impaired. Other participants previously sought medical attention, either to address a health issue or to try to reverse their impending blindness but had given up because of demotivation to continue treatment because of the hassle of enduring the lengthy and expensive treatment procedures. This finding relates to Tesfaye et al. (2021) and Dassah et al. (2018) that access barriers, hurdles relating to medical equipment, communication barriers, and physical barriers, as well as unfavourable geography, acceptability, and affordability, had been experienced by persons with disabilities. It bears repeating that the favourability of healthcare is also determined by the attitudes and perceptions of the healthcare personnel themselves (Magnusson, Kebbie & Jerwanska, 2022). Another participant stressed that he ignored his doctor's recommendations for treatment back then when he still could see because of fear of post-surgical complications, eventually neglecting his deteriorating eyesight. Another factor noted was that most of the participants were not born with a visual impairment and became blind due to disease (i.e., measles), unhealthy use of their eyes (i.e., excessive computer use), occupational hazard (i.e., welding), and physical injury from disputes (i.e., a gunshot wound). Resolving their eye impairments by onset is crucial, but proper medical assistance may prevent them.

The fifth theme concerns the participants' challenges in accessing healthcare due to financial constraints. Healthcare services are available at a cost, and many services are expensive. Thus, most of the time, healthcare is considered the least priority. This situation is even more pronounced with people with disabilities, who mostly live in adverse economic conditions and have more urgent needs other than healthcare. Their testimonies correlate with the idea that medical costs incurred by PWDs are excessive. The expense of healthcare may be unaffordable depending on the planned course of treatment (Hong et al., 2022), driving the clients away from attempts at maintaining or improving their health and prompting them to compromise by only availing themselves of healthcare when the condition becomes severe. This occurrence is actual even in high-income countries and is likely significantly more pronounced in lower-income countries. One significant effect is that it deters the visually impaired from utilizing treatments that could have improved their vision or even kept them from becoming completely blind (Guan et al., 2019). For instance, Awidi et al. (2023) reported that the visually impaired with lower income unlikely underwent cataract surgery and presumed to have cataract-related vision loss. In a quote that fits rather well with this statement, one of the participants admitted that finances are a significant factor in not following his doctor's order to obtain a particular lab result. Another implication is that it perpetuates comorbidities suffered by the visually impaired. With this, another participant commented that he only buys the prescribed medications he could afford. According to a study by Timilsina et al. (2024), visually impaired women felt like a burden to their family because of their lack of money and job, which made them scared to pay for costly medical care. Their employment as massage therapists does not pay enough for them and their families to afford healthcare, exacerbating the illness (Soltani et al., 2019), supported by the participant's remark that her earnings are only enough to provide for her children. This fact emphasizes how crucial it is to find cheap services that meet the healthcare needs of the visually impaired. It would benefit the visually impaired if the government subsidized healthcare costs incurred in private facilities without queuing anymore in charitable agencies. While targeted resources and effort can address specific underuse or failure to utilize affordable yet effective medical care, identifying and removing barriers to broader acceptance of affordable treatments and methods for improving their accessibility receives comparatively little funding (Glasziou et al., 2017).

Limitations

The use of in-depth interviews introduced subjectivity, as participants’ personal perspectives and biases may influence the data, affecting consistency. Furthermore, purposive sampling could introduce selection bias and restrict the diversity of experiences represented.

CONCLUSION

The visually impaired individuals face complex and systemic barriers in accessing healthcare. These include the need for dependable assistance, inadequate transportation, limited support systems, and financial constraints. Additional challenges such as insufficient social interactions, low health literacy, and discrimination further hinder their ability to seek and receive care. Financial difficulties often force them to prioritize other needs over health, exacerbating their conditions. Addressing these issues requires a comprehensive approach: strengthening support networks, improving accessibility, providing better assistive devices, and enhancing healthcare personnel training. Increasing health literacy and making healthcare more affordable are also crucial. By tackling these barriers, we can create a more inclusive healthcare system that better serves the needs of visually impaired individuals.

Recommendation

The study recommends that concerned agencies may provide training for nurses and other healthcare providers to improve their communication skills, not just for the visually impaired but for other disabled individuals, assign an eye specialist in the government health facility, install walkways for the visually impaired, monitor the drivers in the observance of the rights and privileges of PWDs, utilize media to inform where they can seek help, provide expanded educational programs, livelihood training, and financial assistance, implement assistive technologies, conduct regular community health nursing to monitor their well-being, and continue implementing periodic outreach initiatives for PWDs to cater their holistic needs.

Conflict of Interest

The authors declare that they have no conflict of interests.

ACKNOWLEDGEMENT

The authors sincerely thank the President of the Association of the Blinds in Iligan City for the approval and assistance in conducting the study.

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