Visual impairment (VI) enjoys the centre of attention within the public health domain, manifesting as an escalating concern with growing instances.¹ Globally, it is estimated that about 2.2 billion individuals are visually impaired, and a substantial proportion, approximately 50%, could have been averted through preventive measures.^2,3,4 Notably, empirical evidence establishes that the occurrence of blindness in developing nations surpasses that of the developed counterparts, and it is worth noting that the prevalence of VI in economically disadvantaged countries is four times higher when compared to high-income nations.²

The prevalence of VI varies across geographical locations. In the Americas, the prevalence of VI ranged between 1.3% and 12.5%, which is lower compared to other continents, with a significant proportion of cases being preventable.^5,6,7,8 In Africa, the reported prevalence of VI among the general population ranges between 3% and 29.4%.^{9,10,11,12,13,14} This variation is influenced by the availability and affordability of eye care services and the level of eye care literacy.² According to the Ghana Blindness and VI Study conducted in 2015, the overall prevalence of VI in Ghana was reported as 1.46%, with 0.74% of the Ghanaian population being classified as blind.¹⁵

Visual impairment negatively impacts both the individual and the community in various ways. This ranges from physical and mental to academic and activities of daily living. For children who experience early onset of VI, developmental difficulties such as delayed motor, emotional, language, cognitive and social development have been found.¹⁶ Additionally, school-aged children with VI will likely experience reduced educational achievement compared to their peers.⁹ In adults, the lack of independence associated with VI can have a detrimental effect on an individual’s regular work activities, which leads to poverty and depression.¹⁷ The risk of mortality among people with VI is higher because of the reduced capacity to perceive environmental dangers, thereby increasing the vulnerability of visually impaired individuals to potential risks.^16,17 Visual impairment poses a significant global economic challenge, with an estimated annual loss of about US$411bn in global productivity when adjusted for purchasing power parity.¹⁸ According to a 2020 World Vision report, the yearly worldwide costs of productivity losses because of VI from uncorrected myopia and presbyopia were reported to be 244bn and 25.4bn dollars, respectively.¹⁹

In Ghana, the rural population accounts for approxmately 41% of the total population. According to the latest Population and Housing Census (PHC, 2021), it is estimated that 13,908,804 people live in rural areas.^20,21 Cocoa farming is the primary source of employment among small households in rural areas.²² Despite efforts by the Ghana Health Service over the years to improve healthcare delivery, access to healthcare in rural Ghana is still lagging because of several factors, including inadequate health infrastructure, poverty, insufficiently trained health personnel and lack of basic healthcare equipment that hamper access to healthcare delivery in rural areas.²³ Other barriers to healthcare delivery in rural Ghana include negative societal norms about hospitals, lack of health insurance and long distances to access health facilities.^23,24,25 The situation regarding eye care delivery in rural Ghana is particularly dire. Ofosu et al.²⁶ reported that eye care provision in Ghana is through District, Regional and Tertiary hospitals, with a few other private hospitals located in the bigger urban cities. Consequently, it can be hypothesised that the burden of VI profoundly affects the rate of economic growth of Ghana, as well as people’s quality of life, especially in rural areas where agriculture is the primary source of employment. However, the prevalence of VI among the general population in rural communities remains unknown and possibly underestimated because of scarce data and research publications related to the prevalence of VI among rural Ghanaian communities.

In a recent study, Boadi-Kusi et al.²² found that the prevalence of moderate, severe VI and blindness among cocoa farmers in rural Ghana was 13.9%, 3.5% and 5.3%, respectively. The Eastern Region of Ghana is generally considered underdeveloped and rural because of limited access to healthcare and lower socio-economic standards.²⁷ Additionally, there is limited information on eye health and the burden of VI in this region. Furthermore, there is a growing concern about the inequitable distribution of eye care professionals in Ghana, with over 50% of the eye care workforce concentrated in cities, contributing to the high prevalence of VI in rural communities.^15,28 These present a severe challenge in decision-making regarding the provision of eye care services to rural communities in the region, especially considering both a newly established eye clinic and associated interventions seeking to address the burden of VI in the area and in Ghana.

This research aimed to determine the prevalence and causes of VI in the eastern region of Ghana. The findings could aid as the foundation for initiating a sustainable eye care programme in rural communities in the Eastern Region of Ghana.

This study was conducted as part of efforts to establish an eye health social enterprise in the BCM community. Among others, the study sought to establish the state of VI in the BCM by determining the prevalence, distribution and causes of VI in the selected communities. The prevalence of VI in the BCM was higher than the national average reported by Ghana Blindness and Vision Impairment Study.¹⁵ and that reported in a similar study among rural dwellers in Ghana.²² Furthermore, the prevalence of VI in this study is also higher than reported in previous studies conducted in various locations, including Addis Ababa, South Africa, Ethiopia, South Korea, South Sudan, Saudi Arabia and India.^{12,35,36,37,38,39,40} The higher prevalence found in this study could be attributed to how VI was defined. This study defined VI using presenting VA for both distance and near, as recommended by the ICD-11.²⁹ On the contrary, most previous studies defined VI using distance VA only, as well as defined VI by ICD-10. The use of distance VA alone to define VI will likely underestimate the prevalence of VI in the population. Additionally, compared to the previous studies, this study was conducted in a remote/deprived area where access to healthcare is limited. As postulated, VI is impacted by the availability, accessibility and affordability of eye care services, and the absence of such services increases the magnitude of VI.¹³ It can, therefore, be speculated that the higher prevalence of VI in this study could result from the unavailability of eye care services in the communities studied.²⁸ On the contrary, the prevalence identified in this study was lower compared to that reported in studies conducted in Russia, South Africa and Nepal.^34,41,42 This variance could be attributed to variations in the age range of the research participants. The studies mentioned above encompassed adult populations, with the Russian study focusing on individuals aged 85 and above, while the South African and Nepalese studies included participants aged 60 years and above.

This study found a significant association between age and the prevalence of VI. Age increased the risk of developing VI, with people aged 60 and older (the elderly) having the highest risk of VI (AOR 11.29, 95% CI, 2.41–52.85, P < 0.002). This finding agrees with global trends indicating that age is a critical determinant of VI, with older age groups consistently showcasing higher rates of VI than younger age categories.^{2,12,18,36,37,38,43,44} One study suggests that the higher risk of VI in older age could be because of the weakening of the bodily cells and functions, as well as the presence of senile diseases such as diabetes and hypertension.⁴⁵ The increased risk of VI with age presents a unique global health challenge, even more so for Ghana. Ghana has a relatively young population that will age in a few years. The burden of VI in the country is likely to increase drastically with a growing ageing population.¹⁸ The situation becomes more distressed when taking into account that Boadi-Kusi et al.²⁸ reported that the risk of VI is higher in rural communities in Ghana because of eye care personnel’s predilection for urban areas over rural areas. Therefore, early conscious efforts are required to address the burden of VI in Ghana, especially in rural communities.

The leading causes of VI identified in this study are cataracts and uncorrected refractive errors, which accounted for about a quarter and a fifth of all cases of VI, respectively. This finding is broadly consistent with previous studies on the African continent. In a review of the literature on VI in Africa, two studies reported the leading causes of VI in sub-Saharan Africa to be uncorrected refractive error and cataracts.^2,46 In Ghana, similar causes of VI have been reported. The Ghana Blindness and VI Survey also identified refractive errors and cataracts as the principal causes of VI¹⁵ in the country. Similar findings have been reported by Akpabla and Signes-Soler and Boadi-Kusi et al.^22,47 In the present study, the causes of VI differed by age group, with cataracts being more prevalent in the older participants and uncorrected refractive error contributing heavily to VI in the participants aged 18 and below. It has been contended that cataracts are common in the aged because of ‘physiological deterioration’. The argument is that ageing is associated with a reduced efficiency of the body’s functionality and a consequent rise in metabolic diseases such as cataracts and retinopathies.⁴⁸ More so, uncorrected refractive error may be higher in children because of prolonged indoor activities and increased near work (sustained accommodation).⁴⁹ In addition, the lack of awareness of poor vision, reduced purchasing power among children and the negative societal views of children wearing glasses could contribute to the higher prevalence of uncorrected refractive errors and amblyopia in this age group.⁵⁰

The leading causes of VI in this study are treatable. Cataracts can be treated by an uneventful yet fast and safe surgical procedure.⁵¹ Similarly, a simple pair of spectacles or contact lenses can treat refractive errors.⁵² Although other causes of VI, such as glaucoma, amblyopia and retinal diseases, contributed a smaller proportion, their presence cannot be overlooked. Therefore, urgent and comprehensive strategies are required to address the causes of VI in rural communities in Ghana.

The present study was, however, not without limitations. Given the numerous rural communities in BCM, selecting only two for this study was largely insufficient to represent the rural population of the municipality adequately. Additionally, the study only considered rural communities; hence, the results cannot be generalised to urban settings in the Eastern region.

A high prevalence of VI among the rural residents was found. The main causes of VI included cataracts and refractive errors, whereas the leading cause of severe VI and blindness was cataract, retinopathy and glaucoma. Near VI was the most prevalent type of VI recorded in this study. Therefore, the researchers recommend establishing vision centres in rural communities, establishing Local Eye Screening Programmes and including optometric facilities in the national health insurance scheme to expand accessibility to eye health in rural communities.