The research team conducted a systematic search of PubMed, Scopus, Web of Science and the Iranian database Magiran, covering studies published from January 2000 to May 2026. From this sweep they identified twenty-four quantitative studies that examined factors associated with eye care service utilization among the Iranian population. Rather than pooling results statistically, the authors synthesized the evidence narratively, following the Synthesis Without Meta-Analysis guidelines, and classified each finding according to the Andersen Model’s three domains. This approach is technically significant because it preserves the heterogeneity of the underlying studies while still imposing a coherent conceptual structure, allowing patterns to emerge across different populations, settings and definitions of utilization, from simple eye examinations to cataract surgery and diabetic retinopathy screening.

Among the predisposing factors, those characteristics that exist before illness strikes, age played a complicated dual role. Increasing age was consistently associated with higher use of eye services, which makes intuitive sense given that cataracts, glaucoma and presbyopia accumulate over a lifetime. Yet the review also found that older adults carried the highest unmet need in the country, meaning that the population most vulnerable to vision loss was simultaneously the most likely to be falling through the cracks. This paradox sits at the heart of the paper’s central message: rising utilization with age is not the same as adequate coverage, and the gap between the two represents a reservoir of preventable blindness that the health system has yet to reach.

Gender shaped eye care behavior in equally nuanced ways. Women were more proactive than men when it came to preventive services, such as routine eye examinations, but they lagged in treatment follow-up, the crucial second step where a diagnosis is converted into lasting vision preservation. This split suggests that the barriers facing Iranian women are not primarily attitudinal; they appear at the stage of care that demands repeated visits, transportation, time away from household responsibilities and, often, money. Higher education, meanwhile, was generally associated with increased utilization across studies, reinforcing a familiar finding in health services research: people who understand the value of early detection and can navigate the health system are far more likely to use it before damage becomes irreversible.

The enabling domain, which captures the resources that make care physically and financially possible, produced the review’s most alarming and most consistent results. Economic status and insurance coverage were among the most frequently reported determinants, with what the authors describe as marked pro-rich inequality. Wealthier Iranians use eye services at substantially higher rates than poorer ones, a pattern that cannot be explained by differences in need alone. High out-of-pocket costs remained a major barrier across the evidence base. In ophthalmology, where cataract surgery, laser treatment and long-term glaucoma medication can impose significant cumulative expenses, the structure of financing effectively rations care by income, converting a treatable condition into a lasting disability for those who cannot pay.

Not every finding in the enabling domain was discouraging. Geographic access, functioning referral systems and macro-level policies, most notably Iran’s Health Transformation Plan, all played positive roles in connecting patients to services. The Health Transformation Plan, launched as part of Iran’s broader push toward Universal Health Coverage, expanded insurance coverage and reduced cost barriers for many services, and its appearance in the reviewed studies as a facilitating factor suggests that national policy can meaningfully shift utilization patterns. Still, the review notes that the predominantly cross-sectional nature of the evidence base makes it impossible to say with confidence how much any specific intervention has improved outcomes, and the authors explicitly call for further evaluation of policy effectiveness.

On the need side of the model, the clinical drivers of eye care use were, unsurprisingly, refractive errors, the simple uncorrected vision problems that affect hundreds of millions of people worldwide, and underlying chronic conditions such as diabetes, which puts patients at risk of sight-threatening retinopathy. But the review uncovered a critical breakdown in how need translates into action. Low awareness of the necessity of regular eye examinations, particularly among diabetic patients, was identified as a significant barrier to utilization. This is a technically important point: diabetic retinopathy is typically asymptomatic until it is advanced, so patients who wait for symptoms before seeking care are, by definition, waiting too long. Awareness campaigns and systematic screening programs, the review implies, are not optional extras but structural necessities for a country with a growing diabetic population.

The study’s conceptual framing deserves attention because it moves the policy conversation beyond a simple accounting of disease burden. By demonstrating that clinical need does not automatically translate into effective service use, the Andersen Model analysis shows that the intermediate machinery of the health system, financing, insurance, referral pathways, transport and education, determines whether a diagnosis of visual impairment ends in treatment or in blindness. In Iran, that machinery currently favors the educated and the affluent. The authors conclude that socioeconomic inequality in access to eye care remains a persistent challenge, and that financial barriers, geographic access, referral pathways and awareness should be central considerations for anyone planning eye health services in the country.

The review is not without limitations, and the authors are candid about them. Twenty-four studies, synthesized narratively rather than meta-analytically, cannot provide precise pooled effect sizes, and the dominance of cross-sectional designs means that the associations reported throughout the review are correlational rather than causal. Nonetheless, the consistency of certain signals, the pro-rich gradient, the role of insurance and out-of-pocket costs, the awareness gap among diabetics, gives the findings considerable weight. For a middle-income country navigating the twin pressures of an aging population and a rising diabetes epidemic, the message is clear and urgent: the technology to prevent most blindness already exists, but it will remain trapped in clinics unless the behavioral, financial and geographic pathways leading to it are rebuilt around equity rather than ability to pay.

The global implications extend well beyond Iran’s borders. Visual impairment affects well over a billion people worldwide, the vast majority of cases being preventable or treatable, and the same triad of poverty, poor access and low awareness that the review documents in Iran recurs in health systems from South Asia to sub-Saharan Africa. The Andersen framework offers these systems a practical diagnostic lens: instead of asking only how many people are blind, planners can ask who is predisposed to seek care, who is enabled to obtain it and who has been identified as needing it, and then target the weakest link. If the review’s findings spur rigorous evaluation of interventions like expanded insurance, mobile screening and community education, a study about utilization statistics may end up contributing to a measurable decline in avoidable blindness.

Subject of Research: Factors associated with eye care service utilization in Iran analyzed through the Andersen Behavioral Model

Article Title: Factors associated with eye care utilization in Iran: a systematic review based on the Andersen Behavioral Model

Article References: Zarei, E., Nematollahi, M. S., & Congdon, N. (2026). Factors associated with eye care utilization in Iran: a systematic review based on the Andersen Behavioral Model. BMC Public Health. https://doi.org/10.1186/s12889-026-29804-w

Image Credits: AI Generated

DOI: 10.1186/s12889-026-29804-w

Keywords: eye care utilization, Iran, systematic review, Andersen Behavioral Model, health inequality, visual impairment, out-of-pocket costs, insurance coverage, diabetic retinopathy, refractive errors, universal health coverage, BMC Public Health