Predictors of vision screening among Saudis at primary healthcare settings in Riyadh, Saudi Arabia: findings from a cross-sectional survey

Introduction

Visual impairment, encompassing low vision and legal blindness, represents a major global health concern, with an estimated 2.2 billion individuals experiencing vision problems (Alhazmi et al., 2020; Pelletier, Rojas-Roldan & Coffin, 2016). Early detection and intervention are paramount to preventing irreversible vision loss and managing ocular conditions effectively. Within this context, vision screening serves as a vital public health intervention (Abdulhussein & Abdul Hussein, 2023). Vision screening is defined as the presumptive identification of unrecognized vision problems or conditions by the application of rapid, validated tests to sort out apparently well persons who probably have a vision deficit from those who probably do not, thereby facilitating timely referral for a comprehensive eye examination and necessary treatment (Abdulhussein & Abdul Hussein, 2023; Williamson, 2022). Alarmingly, a substantial portion of these cases are preventable or treatable, highlighting critical gaps in eye healthcare access and the urgent need for effective preventive strategies (Saydah et al., 2020). In regions like the Eastern Mediterranean and Saudi Arabia, the prevalence of blindness and visual impairment is notably high, with a considerable proportion of these cases amenable to corrective measures (Alsaqr, 2021; Pascolini & Mariotti, 2011). The risk factors contributing to vision loss are multifaceted. While aging is a well-established determinant, other conditions such as diabetes and lifestyle choices also play a substantial role in influence visual acuity (Mangione et al., 2022). Diabetic retinopathy (DR), a complication of diabetes, poses a substantial threat to vision, with prevalence rates varying across different populations (Al-Ghamdi, 2019; Aljehani et al., 2023; Grauslund et al., 2023; Scanlon et al., 2022; Wasnik et al., 2023). The impact of progressive vision loss extends beyond physical health, profoundly affecting quality of life, including economic stability, educational attainment, and daily functioning (Wasnik et al., 2023).

Given the high prevalence of undiagnosed visual impairment, population-based screening is considered a crucial tool for early detection and intervention (Colombatti et al., 2023; Mangione et al., 2022). Despite this, evidence supporting the effectiveness and implementation of programmatic vision screening in adult populations remains limited globally. In Saudi Arabia, existing studies on vision screening are few and primarily focus on narrow subpopulations or small sample sizes, lacking comprehensive assessment of screening prevalence and its predictors across diverse primary healthcare settings. Moreover, many regional investigations have concentrated on preschool children or children with special needs and have not examined sociodemographic and health-related factors influencing screening uptake among adults, limiting the understanding necessary to inform targeted interventions in this age group (Algethami et al., 2019; Alkhteeb et al., 2024; Bardisi & Bin Sadiq, 2008; Gosadi, 2019). Consequently, research specifically addressing vision screening prevalence and its determinants in a large, representative adult Saudi cohort is notably scarce. This study therefore aims to fill this gap by estimating the prevalence of vision screening and identifying key factors associated with its utilization among Saudi residents attending primary healthcare centers. This study focused on several sociodemographic and health-related predictors. Sociodemographic factors such as age, sex, education level, marital status, employment status, and insurance coverage were examined due to their established influence on healthcare access and utilization (Bikbov et al., 2021; Bourne et al., 2021; Yagi et al., 2022). For instance, marital status might reflect variations in lifestyle and social support, potentially impacting healthcare-seeking behavior. Employment status can influence time availability and access to healthcare services, with unemployed individuals potentially having more flexibility for preventive screenings. Education level is an indicator of health literacy and awareness of preventive care (Egunsola et al., 2021; Van Der Heide et al., 2013). Health-related behaviors, including smoking and exercise, were also considered as potential predictors. These behaviors often correlate with overall health consciousness and engagement in preventive care (Li & Sun, 2022). Comorbidities such as diabetes, hypertension, and obesity were included due to their clinical relevance to vision health. These conditions are associated with an increased risk of ocular complications (Ng Yin Ling et al., 2021; Shih, Lam & Tong, 2017), potentially influencing the likelihood of seeking vision screening.

Materials and Methods

Results

Discussion

This cross-sectional study aimed to identify predictors of vision screening among residents of Saudi Arabia attending primary healthcare settings. The multivariate analysis revealed that education level, marital status, employment status, exercise, diabetes, and obesity significantly predicted vision screening, each demonstrating unique associations. Specifically, individuals with higher education, married individuals, and employed individuals showed lower odds of screening, while those who exercised, were unemployed, and had diabetes or obesity showed higher odds.

Notably, individuals with higher education levels demonstrated significantly lower adjusted odds of undergoing vision screening compared to those with primary education. This counterintuitive finding might be attributed to a perception among more educated individuals that they possess greater awareness of their health, leading to self-management rather than seeking formal screening. For instance, the evidence suggests individuals with higher education levels often overestimate their ability to manage their health independently, which may reduce their reliance on preventive health services such as vision screening (Mackenbach et al., 2008). Additionally, higher education does not always translate to higher utilization of preventive services, as educated individuals may prioritize other aspects of life over routine health checks (Cutler & Lleras-Muney, 2010). Furthermore, findings from a systematic review emphasized that social determinants, including education, influence health behaviors in complex ways, sometimes leading to unexpected patterns in healthcare utilization (Cutler & Lleras-Muney, 2010). However, our findings contradict some studies that suggest higher education is generally associated with greater utilization of preventive health services (Blackwell et al., 2009; Chou et al., 2016; Hammond, Matthews & Corbie-Smith, 2010). This discrepancy could be due to several factors. First, cultural and contextual differences in health-seeking behaviors may play a essential role. For example, in certain settings, highly educated individuals may prioritize productivity or career advancement over preventive health measures. Second, access to primary healthcare services may vary even among educated populations, with some individuals facing barriers such as time constraints or lack of insurance coverage for routine screenings. Finally, the perception of self-efficacy among educated individuals may lead to overconfidence in their ability to manage health issues without formal screening, as noted in literature (Chou et al., 2016). These factors collectively highlight the nuanced relationship between education and health behaviors, which may not always align with conventional expectations.

Similarly, married individuals showed lower adjusted odds of screening than their single counterparts. This could potentially be linked to variations in lifestyle, priorities, or perceived health needs between these groups. Single individuals might prioritize and engage in preventive care due to a stronger sense of personal responsibility for their health (Umberson & Karas Montez, 2010). Alternatively, the demands of family life and household responsibilities might limit the time available for married individuals to attend preventive screenings. Married individuals, particularly those with children, often prioritize caregiving roles over their own health needs, resulting in lower engagement with preventive healthcare (Umberson & Karas Montez, 2010). Additionally, it has been observed that married individuals, especially women, contend with considerable time limitations from caregiving duties, thereby reducing their capacity for preventive health behaviors (McCullough, 2008). This highlights the need to consider the impact of social roles and time constraints on healthcare-seeking behaviors.

Ideally, employed individuals should have greater access to preventive health services due to higher incomes and employer-provided benefits. Findings from prior studies suggest that higher socio-economic status, including employment, is generally associated with higher attendance at health checks (Dryden et al., 2012; Shin et al., 2018). However, our findings showed that unemployed individuals had higher odds of undergoing vision screening. This counterintuitive result may be explained by time constraints faced by employed individuals, as evidence suggests that non-participants in health check-ups were often employed or self-employed (Funahashi et al., 2013). Unemployed individuals may have more time flexibility or rely more on publicly funded services, where screenings are readily available. These findings highlight the complex relationship between employment status and healthcare access. While employed individuals have greater resources, work-related time constraints may limit their ability to attend screenings. More research is needed to explore workplace barriers, employer incentives, and the role of paid leave in influencing preventive healthcare utilization. Addressing these gaps can help develop targeted interventions to improve access across all employment groups. Additionally, potential interactions between education and employment status may influence vision screening behaviors. Higher educational attainment often correlates with better employment opportunities, which could jointly affect access to healthcare and health-seeking behaviors. Exploring these interactions in future studies could provide a deeper understanding of how combined sociodemographic factors shape vision screening uptake.

Hence the study’s findings suggest several potential barriers to vision screening. Firstly, time constraints due to employment or family responsibilities might deter married and employed individuals from seeking preventive care. Secondly, a perception of lower risk or higher health literacy among individuals with higher education could lead to underutilization of screening services. Thirdly, limited awareness or accessibility of vision screening services within primary healthcare settings might disproportionately affect certain demographic groups.

Conversely, physical activity was a strong predictor, with active individuals showing a greater likelihood of undergoing vision screening. This aligns with the broader trend of health-conscious behaviors, where individuals who prioritize physical fitness are also more likely to engage in preventive healthcare. Physically active individuals often exhibit a proactive approach to health management, including regular check-ups and screenings. Findings of one study revealed that physical activity is strongly associated with higher utilization of preventive health services, as active individuals tend to have greater health awareness and a stronger commitment to maintaining overall well-being (Kang & Xiang, 2017). Similarly, a systematic review of current reviews highlighted that physical activity is linked to improved health literacy and a greater likelihood of utilizing preventive healthcare services (Warburton & Bredin, 2017). These findings suggest that exercise serves as a marker for a broader commitment to health and wellness, which includes participation in vision screening.

Finally, individuals with diabetes or obesity had markedly higher adjusted odds of undergoing vision screening. Specifically, vision screening was more common among diabetic and obese individuals compared to their non-diabetic and non-obese counterparts. This aligns with clinical guidelines recommending regular eye examinations for individuals with these chronic conditions due to the heightened risk of ocular complications. These findings underscore the importance of targeted screening strategies for high-risk populations. The literature indicates that individuals with diabetes are more susceptible to developing vision-related problems or blindness, with diabetic retinopathy being a prevalent complication. Consequently, diabetic individuals are likely either well-informed about the long-term benefits of these screening programs or are being counseled and referred by their physicians for early detection of potential visual impairments. Furthermore, research suggests that social and cognitive factors, such as social comparison and concern for familial impact, also motivate diabetic individuals to opt for vision screening (Lake et al., 2017), consistent with previous studies. For instance, studies have shown that routine annual eye examinations or vision screenings for early detection and management of diabetic retinopathy can prevent 90% of vision loss attributed to diabetes (Ferris, 1993). In light of this, the American Academy of Ophthalmology recommends annual eye examinations for all diabetic individuals to screen for vision problems (American Diabetes Association Professional Practice Committee, 2022).

The strong association between comorbidities like diabetes and obesity and vision screening rates underscores the broader implications for public health interventions. These comorbidities not only increase the risk of ocular complications but also contribute to a range of other health problems. Integrating vision screening into comprehensive chronic disease management programs is essential. Moreover, public health campaigns should emphasize the interconnectedness of these conditions and the importance of holistic preventive care. The finding that these individuals are more likely to get screened also presents an opportunity to provide more general preventative care and education. Further, the results also indicate that exercise predicts screening. This may suggest that those who are already engaged in a healthy lifestyle are more likely to seek out preventative care. Public health interventions could leverage this by promoting exercise as a gateway to overall health awareness and screening.

Lastly, while age, sex, insurance coverage, smoking, and hypertension were not significant predictors of vision screening in our study, these findings warrant careful consideration. One possible explanation is that vision screening behaviors may be more strongly influenced by awareness, cultural perceptions, and health system factors rather than by demographic variables alone. For example, while older adults and individuals with chronic conditions such as hypertension might be expected to seek screening more often, competing health priorities and limited awareness of the benefits of preventive eye care could reduce uptake. Similarly, the lack of association with insurance coverage may reflect the fact that eye care in Saudi Arabia is often accessible through public health services, thereby diminishing differences based on insurance status. Non-significant associations may also arise from residual confounding, such as unmeasured variables including health literacy, perceived need for care, or accessibility of eye clinics. These results highlight the complexity of health-seeking behaviors and suggest that interventions to increase screening uptake should not only target clinical risk factors but also address contextual and behavioral determinants.

Conclusions

In general, Saudi residents have a very low prevalence of vision screenings. Notable sociodemographic and health-related factors predicting vision screening among Saudi residents were uncovered in this study. While some predictors, such as age and sex, are non-modifiable, the identification of modifiable factors, including exercise, health awareness, and conditions like diabetes and obesity, offers actionable entry points for intervention. Specifically, higher education, marriage, and employment correlated with decreased odds, whereas unemployment, exercise, diabetes, and obesity correlated with increased odds. These findings underscore the need for healthcare providers and policymakers to design targeted, culturally sensitive interventions that promote behavioral change and increase awareness about the importance of preventive vision care. Actionable strategies include community-based education, integration of screening into routine primary care, and strengthening access to screening services. Future research should qualitatively explore the underlying reasons for these disparities to inform effective and regionally adaptable strategies. Beyond Saudi Arabia, these findings contribute to the global evidence base on preventive eye health, suggesting that similar approaches may be beneficial in other resource-limited settings.

Supplemental Information