JOURNAL OF THE WEST AFRICAN COLLEGE OF SURGEONS VOLUME 2 NUMBER 4, OCTOBER-‐DECEMBER 2012
ASSESSMENT OF BARRIERS TO SURGICAL OPHTHALMIC CARE IN SOUTH-‐ WESTERN NIGERIA *AJIBODE HA, 1JAGUN OOA, BODUNDE OT, FAKOLUJO VO. Department of Ophthalmology, Olabisi Onabanjo University Teaching Hospital, Sagamu, Ogun State, Nigeria. E-‐mail: [email protected] & 1
Ophthalmology Unit, Department of Surgery, Ben Carson School of Medicine, Babcock University, Ilishan-‐Remo, Ogun State, Nigeria. Grant support:
None
Conflict of Interest:
None
*Correspondence ABSTRACT Background: The prevalence of blindness and visual impairment are still of public health importance worldwide and yet underutilisation of available eyecare services are still rampant. Therefore, there is continuing need to study the barriers to eyecare uptake. Aim: To identify barriers to eye surgical uptake in the only teaching hospital in Sagamu, Ogun State, in South-‐Western Nigeria. Setting: The study was done at the eye clinic of Olabisi Onabanjo University Teaching Hospital [OOUTH], Sagamu, Nigeria. This is the only state-‐owned tertiary eye centre in Ogun State. It serves an approximate population of 3 million. Materials and Method: All patients who had attended at least 2 follow-‐up clinics between February and June 2010, and consented to be included in the study were interviewed, and additional information from their case notes were
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coded and recorded in the software SPSS version 16. This was then analysed for frequencies of variables. Results: One hundred and sixty-‐seven (167) respondents were interviewed, comprising 92 males and 75 females, with an age range between 1 and 90 years. 106(63.9%) indicated encountering one form of barrier or the other since attending the eye clinic, out of which 64 were females and 42 males. The types of barriers encountered were: Cost of hospital services [28.3%], fear of surgery [24.1%], long waiting time to see the doctor [23.5%], accessibility to the hospital [16.9%], lack of electricity in the hospital [10.8%], and frequent strikes by health workers [7.2%]. Conclusions: The commonest barriers to eye surgical care in this study are comparable to those in previous studies but in different proportions and calls for an urgent need to ensure affordable and sustainable surgical care, so as to achieve the goals of vision 2020. Key words: Assessment, Barriers, Surgical ophthalmic care. INTRODUCTION Improvement in health care over the last few decades has made the world’s population live longer. Living longer has subsequently increased the prevalence of blindness and visual impairment globally. In 1998, global blindness was estimated at 37 million, and this has increased to over 45 million1 with cataract, refractive error and glaucoma accounting for 23 million, 8 million and 7 million respectively. In 2013, the World Health Organisation acknowledged a significant progress in the global prevention of blindness and also approved the 2014-‐2019 Action Plan for universal access to eye health which is aimed at achieving a further reduction of 25% of avoidable visual impairment by 20192. Thus, the need for affordable and accessible ocular surgeries. Ocular surgery especially that for cataract has been associated with excellent visual outcomes since the use of modern operating microscopes, intraocular
69
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lens implants, slit lamps, etc; but despite these, different barriers to surgical uptake have been documented worldwide. Therefore, there is a need to investigate those things which tend to reduce access to affordable and accessible ocular surgeries, so as to design solutions to them. These documented barriers to surgical uptake are multi factorial and can be divided into 3: Hospital-‐based barriers which includes: cost of services, accessibility of surgery, long waiting time in clinics, lack of accommodation for escorts/accompanying person(s), lack of electricity, lack of theatre space, cumbersome tests, cancellation of operations. Patient-‐based barriers which includes: socio-‐economic capabilities, fear of surgery, fear of the outcome of surgery, no perceived need for surgery, ability to cope with the visual disturbance, dislike of hospital protocols, lack of transportation, lack of escorts/accompanying persons. Hospital-‐worker based barriers which includes: bad attitude of hospital workers, lack of confidence in eyecare team, contrary advice from health workers, and fear of health workers. Studies carried out in Ghana3, Pakistan4, Kaduna-‐Nigeria5, North-‐Eastern Nigeria6, Oyo-‐Nigeria7 showed the cost of services as being the most common barrier affecting 91%, 76.1%, 61%, 53%, 52.8% of the respondents respectively. Whereas, a study that was done in a government funded hospital where surgeries were free in Delhi-‐India8 showed that patient attitude to their condition, was the most common barrier to uptake of surgery. Other documented barriers are fear of removal of the eye and washing it before putting it back into the socket9, fear of pain9, extended time spent between getting to the hospital and eventually seeing the eye doctor10, frequent hospital worker’s strike11. The average number of ocular surgeries done yearly in Olabisi Onabanjo University Teaching Hospital (OOUTH), Sagamu [South-‐West, Nigeria] between January 2006 and January 2009 was 17112. This low surgical rate is one of the reasons for this study. This tertiary hospital undertakes both undergraduate and postgraduate training in ophthalmology.
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The knowledge of the peculiar barriers to eye surgical uptake in the hospital would assist in planning a programme to eliminate them so as to achieve the objectives of vision 202013. The main aim of this study is therefore to identify barriers to eye surgical uptake in OOUTH, Sagamu. The specific objectives are: [a] To determine the common barriers to eye surgical uptake in OOUTH, Sagamu; [b] To compare these barriers to those documented in other institutions; and [c] To propose ways of eliminating them. METHODOLOGY A cross-‐sectional, descriptive hospital-‐based study using interviewer assisted questionnaires with further information obtained from the patient’s case note was done. The study was carried out between February and June 2010 involving patients who had attended at least two follow-‐up visits at the eye clinic. Verbal consent was obtained from respondents, parents or guardians. The data was sort for and obtained using a questionnaire and the hospital record which included: bio data, diagnosis, affected eye(s), if told surgery is required for management and if it has been done or not, who is paying for the treatment, any specific barrier encountered whilst accessing or attempting to access surgery. The data obtained were entered into and analysed using SPSS version 15. Ethical approval was obtained from the Ethical Review Committee of the teaching hospital. RESULTS One hundred and sixty-‐seven (167) respondents were interviewed.
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There were 92 females and 75 males (1.2:1) with an age range of 1-‐90years (mean = 52.84+/-‐ 22.01). 78(46.7%) respondents were 61 years and above, 54(32.3%) were between 31 and 60 years, 27(16.2%) were between 11 and 30 years, whilst 8 (4.8%) were below 11 years of age. Table 1. 77 (46.4%) of the respondents reside in Sagamu, 55(33.1%) live outside Sagamu but within Ogun state, 25(15.1%) in Lagos, whilst the rest were from elsewhere. 76(45.5%) were gainfully employed, 35(21.1%) retired, 27(16.3%) were children/students, 15(9.3%) were artisans, housewives and farmers. 56(33.7%) presented with cataracts, 36(21.7%) with glaucoma, 10(6%) trauma, 10(6%) pterygium and others ranging from corneal to posterior segment pathologies. 111(66.5%) had involvement of both eyes, 30(18%) only right eye and 26(15%) had only left eye involvement. 80(47.3%) were self sponsored, 48(28.7%) sponsored by their children, 24(14.4%) by parents, and 16(9.6%) others were sponsored by their spouses, eye camps, etc. [as in Table 2]. 86(51.5%) respondents had been told they’ll require surgery but only 49(57.0%) of them had been able to have the required surgery. 106(63.9%) indicated encountering one form of barrier or the other since attending the eye clinic, out of which 64 were females and 42 males. However, only 57% [49 respondents] out of those [86 respondents] who had been told required surgical intervention had been able to have the required surgery as at the time of the study after surmounting different barriers encountered. The types of barriers encountered were: Cost of hospital services [28.3%], fear of surgery [24.1%], long waiting time to see the doctor [23.5%], accessibility to the hospital [16.9%], lack of electricity in the hospital [10.8%], and frequent strikes by health workers [7.2%] as indicated in Table 3.
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DISCUSSION Majority[61.8%] of the respondents were 51years and above in age, with cataract and glaucoma being the most prevalent[55.4%] ocular conditions as also shown in the global trends of blindness2. From the 2004 global estimate1, about 45 million people are said to be blind worldwide with cataract and glaucoma accounting for 50% and 15% respectively. The Nigerian national survey14 on prevalence of blindness also indicated cataract[43%] and glaucoma[16.7%] as the commonest causes. Previous studies in Southwest Nigeria have also documented the prevalence of cataract and glaucoma combined to be greater than 60%15-‐16. One hundred and six [63.9%] of the respondents indicated having encountered any form of barrier during the course of their eye care at OOUTH, Sagamu but only 57% [49 respondents] out of those [86 respondents] who had been told required surgical intervention had been able to have the required surgery as at the time of the study due to different barriers encountered. The cost of hospital services was the commonest [28.3%] barrier as also seen in several studies3-‐7 and this includes both the direct and indirect cost of service17,18. The direct cost are those incurred by the patient for the surgery, drugs, investigations, glasses, transportation etc while the indirect involves the time spent during the eye care, disturbance of daily activities of both the patient and the escort(s). This latter cost is not measurable and tends to have a great impact on response to ophthalmic care18. This study also showed that only 45.5% of the respondents had gainful employment while only 47.9% had the ability to sponsor themselves for the required surgery. This need for sponsorship is a major cause of inability to access surgical care. This seems to corroborate the importance of cost as a major barrier. The fear of surgery was the second common barrier [24.1%] to surgical ophthalmic care. This was not unexpected as most patients have different myths concerning the eye and are also misinformed by non eye care workers that the eye would be removed from its socket, washed and replaced during surgery9 . Hence, all eye care workers must be involved in appropriate eye health talks at the clinics and as public enlightenment via the different media houses.
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The third common barrier was the long waiting time before seeing the ophthalmologist indicated by 23.5%, but this was lower than what was documented at the University College Hospital [UCH] Ibadan, Nigeria [36%]10. This has been attributed to the rigorous tertiary hospital protocols and the fact that the consulting ophthalmologist are too few to quickly attend to all the patients on time.10 This barrier can be reduced by the effective incorporation of primary eye care into the existing primary health centres in the community where minor ocular complaints can be diagnosed and treated, while only those that need specialized care are referred to the secondary and tertiary eye Hospitals. Accessibility to the teaching hospital was another barrier indicated by 16.9% of the respondents, despite the fact that 79.5% of respondents reside within Ogun State and 46.4% in Sagamu where the Teaching Hospital is located. This barrier which seems already surmounted by the respondents may affect regular follow up appointments. Also, this lack of accessibility to the hospital may not only be due to distance to the hospital per se, as Sagamu covers an area of only 614Km2 with a fairly good road network and practically no traffic congestion, as compared to Lagos state which is about 75km away from Sagamu and experiences lots of traffic congestion, with only 15.1% of the respondents from there. This perceived difficulty in accessibility needs further study. Lack of electricity to carry out the proposed surgery was indicated by 10.8% of respondents. This has been a national problem in Nigeria affecting every sector of the economy and leading to dependence on generators as alternate power source. This increases the running cost of each surgery and the hospital and may also lead to cancellations of surgery if there is a sudden breakdown of the only available generator. This is especially important in ophthalmic surgeries as practically all our equipments are electricity powered. Frequent strikes by health workers was indicated as a barrier by only 7.2% compared to 66% in UCH Ibadan11. This low rate may be because; there were no strikes during the study period. Strikes should be averted at all cost as this makes the patients seek eye care in private institutions, traditional homes etc and such clients may not return to the teaching hospital even after the strikes, due to the perceived instability.
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No other health-‐worker based barrier was indicated as a barrier to assessing surgical eye care, but this could be because the questionnaires were administered by doctors in the eye clinic and the patients may have thought, indicating such could lead to a biased treatment in the future. Health workers in all sectors of the hospital need to be informed on basic eye care to avoid or minimise misinforming patients. All these barriers noted above can be further eliminated by the improvement in the infrastructural and human resource development in the eye care sector in Ogun State and provision of free eye care services for children and the aged. Conclusion: The commonest barriers to eye surgical care in this study are comparable to those in previous studies and calls for an urgent need to ensure affordable and sustainable surgical care, so as to achieve the goals of vision 2020. REFERENCES 1. Changing trends in global blindness: 1988-‐2008. Comm Eye Health J 2008; 21(67): 37-‐ 39. 2. WHO Action plan for the prevention of avoidable blindness and visual impairment for 2014-‐2019. www.who.int/blindness/actionplan/en/index.html. [Accessed 18/01/14]. 3. Gyasi ME, Amoaku WMK, Asamany DK. Barriers to cataract surgical uptake in upper east region of Ghana. Ghana Med J. 2007; 41(4): 167-‐170. 4. Jadoon et al. Cataract prevalence, cataract surgical coverage and barriers to uptake of cataract surgical services in Pakistan. The Pakistan National Blindness and visual impairment survey. Br J Ophthalmol. 2007; 91: 1269-‐1273. 5.
Rabiu M. Blindness and barriers to uptake of cataract surgery in a rural community of northern Nigeria. Br J Ophthalmol. 2001; 85: 776-‐780.
6.
Mpyet C, Dineen BD, Solomon AW. Cataract surgical coverage and barriers to uptake of cataract surgery in leprosy villages of north eastern Nigeria. Br J Ophthalmol 2005: 89(8): 936-‐938.
7.
Oluleye TS. Cataract blindness and barriers to cataract surgical intervention in three rural communities of Oyo State, Nigeria. Nig J Med 2004: 13(2): 156-‐160.
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8.
Dhaliwal U, Guptal SK. Barriers to uptake of cataract surgery in patients presenting to a hospital. Indian J Ophthalmol. 2007; 55: 133-‐136.
9.
Olatunji FO, Ayanniyi AA. Anxieties of ophthalmic surgical patients about ophthalmic surgery. Nig J Ophthalmol. 2007; 15(1): 1012.
10.
Ayeni EA, Bekibele CO, Baiyeroju AM. Service uptake in UCH Ibadan: A time flow study. Nig J Ophthalmol. 2005; 13(2): 4953.
11.
Awoberu FJ, Bekibele CO, Baiyeroju AM. Patients perception of the quality of eye care at UCH, Ibadan. Nig J Ophthalmol.2005; 13(1): 11-‐16.
12.
Data submitted for reaccreditation of the Department of Ophthalmology, OOUTH, Sagamu for postgraduate training. Dec. 2009.
13.
Vision for the future-‐Nigeria. Ophthalmological Society of Nigeria. c/o Theodolite House, Ibadan, Nigeria.2005.
14.
Mohammed M. Abdull , Selvaraj Sivasubramaniam , Gudlavalleti V. S. Murthy , Clare Gilbert , Tafida Abubakar , Christian Ezelum , Mansur M. Rabiu and on behalf of Nigeria National Blindness and Visual Impairment Study Group. Causes of blindness and Visual Impairment in Nigeria: The Nigerian National Blindness and Visual Impairment Survey. Invest. Ophthalmol. Vis. Sci. September 2009 vol. 50 no. 9 4114-‐4120
15.
Onakpoya O.H, Adeoye A.O, Akinsola F.B, Adegbehingbe B.O. Prevalence of blindness and visual impairment inAtakunmosa West Local Government Area of Southwestern Nigeria. Tanzania Health Research Bulletin Vol .9 (2): 2007.
16.
Ajibode H.A. The prevalence of blindness and visual impairment in Ikenne Local Government Area of Ogun State Nigeria. Nig J Ophthalmol. 1999;7:23-‐27.
17.
Brain G, Taylor H. Cataract blindness-‐challenges for the 21st century. Bull WHO.2001;79:249-‐256
18.
Melese M, Alemayehu W, Friedlander E, Courtright P. Indirect cost associated with accessing eye care services as a barrier to service use in Ethopia. Tropical Med. Int. Health.2004;9:426-‐431.
TABLE 1: AGE DISTRIBUTION OF RESPONDENTS AGE GROUP [YEARS]
FREQUENCY
PERCENT [%]
1-‐10
8
4.8
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11-‐20
12
7.2
21-‐30
15
9.0
31-‐40
16
9.6
41-‐50
13
7.8
51-‐60
25
15.0
61-‐70
41
24.6
71-‐80
32
19.2
≥81
5
3
TOTAL
167
100
TABLE 2: PATTERN OF SPONSORSHIP FOR SURGERY SPONSOR SELF
FREQUENCY
PERCENTAGE [%]
79
47.3 CHILDREN 48 28.7 PARENTS 2 4 14.4 SPOUSE 5 3.0 NGO including Eyecamps 2 1.2 OTHERS 9 5.4 TOTAL 167 100
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TABLE 3: BARRIERS INDICATED BY RESPONDENTS Hospital-‐based barriers Frequencies Patient-‐based barriers Frequencies Cost of services 47[28.3%] Fear of surgery 40[24.1%] Long waiting time 39[23.5%] Lack of sponsor 9[5.4%] Accessibility of the Cost of Hospital 28[16.9%] transportation 8[4.8%] Lack of electricity 18[10.8%] No perceived need for surgery 6[3.6%] Frequent health Ability to cope with worker’s strike 12[7.2%] routine work 6[3.6%] Lack of Fear of outcome Accommodation of surgery 6[3.6%] for escort 6[3.6%] Cumbersome Dislike of hospital Investigations 2[1.2%] protocol 5[3.0%] Lack of theatre space 1[0.6%] Lack of escort 3[1.8%] Cancellation of No excuse from surgery 1[0.6%] work 1[0.6%] NOTE: Respondents gave positive response to more than one barrier. s AKNOWLEDGEMENT Sincere appreciation goes to the staff of Health Records Department of Olabisi Onabanjo University Teaching Hospital, Sagamu for assisting with the records of the patients used in this study.
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ASSESSMENT OF BARRIERS TO SURGICAL OPHTHALMIC CARE IN SOUTH-‐ WESTERN NIGERIA *AJIBODE HA, 1JAGUN OOA, BODUNDE OT, FAKOLUJO VO. Department of Ophthalmology, Olabisi Onabanjo University Teaching Hospital, Sagamu, Ogun State, Nigeria. E-‐mail: [email protected] & 1
Ophthalmology Unit, Department of Surgery, Ben Carson School of Medicine, Babcock University, Ilishan-‐Remo, Ogun State, Nigeria. Grant support:
None
Conflict of Interest:
None
*Correspondence ABSTRACT Background: The prevalence of blindness and visual impairment are still of public health importance worldwide and yet underutilisation of available eyecare services are still rampant. Therefore, there is continuing need to study the barriers to eyecare uptake. Aim: To identify barriers to eye surgical uptake in the only teaching hospital in Sagamu, Ogun State, in South-‐Western Nigeria. Setting: The study was done at the eye clinic of Olabisi Onabanjo University Teaching Hospital [OOUTH], Sagamu, Nigeria. This is the only state-‐owned tertiary eye centre in Ogun State. It serves an approximate population of 3 million. Materials and Method: All patients who had attended at least 2 follow-‐up clinics between February and June 2010, and consented to be included in the study were interviewed, and additional information from their case notes were
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JOURNAL OF THE WEST AFRICAN COLLEGE OF SURGEONS VOLUME 2 NUMBER 4, OCTOBER-‐DECEMBER 2012
coded and recorded in the software SPSS version 16. This was then analysed for frequencies of variables. Results: One hundred and sixty-‐seven (167) respondents were interviewed, comprising 92 males and 75 females, with an age range between 1 and 90 years. 106(63.9%) indicated encountering one form of barrier or the other since attending the eye clinic, out of which 64 were females and 42 males. The types of barriers encountered were: Cost of hospital services [28.3%], fear of surgery [24.1%], long waiting time to see the doctor [23.5%], accessibility to the hospital [16.9%], lack of electricity in the hospital [10.8%], and frequent strikes by health workers [7.2%]. Conclusions: The commonest barriers to eye surgical care in this study are comparable to those in previous studies but in different proportions and calls for an urgent need to ensure affordable and sustainable surgical care, so as to achieve the goals of vision 2020. Key words: Assessment, Barriers, Surgical ophthalmic care. INTRODUCTION Improvement in health care over the last few decades has made the world’s population live longer. Living longer has subsequently increased the prevalence of blindness and visual impairment globally. In 1998, global blindness was estimated at 37 million, and this has increased to over 45 million1 with cataract, refractive error and glaucoma accounting for 23 million, 8 million and 7 million respectively. In 2013, the World Health Organisation acknowledged a significant progress in the global prevention of blindness and also approved the 2014-‐2019 Action Plan for universal access to eye health which is aimed at achieving a further reduction of 25% of avoidable visual impairment by 20192. Thus, the need for affordable and accessible ocular surgeries. Ocular surgery especially that for cataract has been associated with excellent visual outcomes since the use of modern operating microscopes, intraocular
69
JOURNAL OF THE WEST AFRICAN COLLEGE OF SURGEONS VOLUME 2 NUMBER 4, OCTOBER-‐DECEMBER 2012
lens implants, slit lamps, etc; but despite these, different barriers to surgical uptake have been documented worldwide. Therefore, there is a need to investigate those things which tend to reduce access to affordable and accessible ocular surgeries, so as to design solutions to them. These documented barriers to surgical uptake are multi factorial and can be divided into 3: Hospital-‐based barriers which includes: cost of services, accessibility of surgery, long waiting time in clinics, lack of accommodation for escorts/accompanying person(s), lack of electricity, lack of theatre space, cumbersome tests, cancellation of operations. Patient-‐based barriers which includes: socio-‐economic capabilities, fear of surgery, fear of the outcome of surgery, no perceived need for surgery, ability to cope with the visual disturbance, dislike of hospital protocols, lack of transportation, lack of escorts/accompanying persons. Hospital-‐worker based barriers which includes: bad attitude of hospital workers, lack of confidence in eyecare team, contrary advice from health workers, and fear of health workers. Studies carried out in Ghana3, Pakistan4, Kaduna-‐Nigeria5, North-‐Eastern Nigeria6, Oyo-‐Nigeria7 showed the cost of services as being the most common barrier affecting 91%, 76.1%, 61%, 53%, 52.8% of the respondents respectively. Whereas, a study that was done in a government funded hospital where surgeries were free in Delhi-‐India8 showed that patient attitude to their condition, was the most common barrier to uptake of surgery. Other documented barriers are fear of removal of the eye and washing it before putting it back into the socket9, fear of pain9, extended time spent between getting to the hospital and eventually seeing the eye doctor10, frequent hospital worker’s strike11. The average number of ocular surgeries done yearly in Olabisi Onabanjo University Teaching Hospital (OOUTH), Sagamu [South-‐West, Nigeria] between January 2006 and January 2009 was 17112. This low surgical rate is one of the reasons for this study. This tertiary hospital undertakes both undergraduate and postgraduate training in ophthalmology.
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The knowledge of the peculiar barriers to eye surgical uptake in the hospital would assist in planning a programme to eliminate them so as to achieve the objectives of vision 202013. The main aim of this study is therefore to identify barriers to eye surgical uptake in OOUTH, Sagamu. The specific objectives are: [a] To determine the common barriers to eye surgical uptake in OOUTH, Sagamu; [b] To compare these barriers to those documented in other institutions; and [c] To propose ways of eliminating them. METHODOLOGY A cross-‐sectional, descriptive hospital-‐based study using interviewer assisted questionnaires with further information obtained from the patient’s case note was done. The study was carried out between February and June 2010 involving patients who had attended at least two follow-‐up visits at the eye clinic. Verbal consent was obtained from respondents, parents or guardians. The data was sort for and obtained using a questionnaire and the hospital record which included: bio data, diagnosis, affected eye(s), if told surgery is required for management and if it has been done or not, who is paying for the treatment, any specific barrier encountered whilst accessing or attempting to access surgery. The data obtained were entered into and analysed using SPSS version 15. Ethical approval was obtained from the Ethical Review Committee of the teaching hospital. RESULTS One hundred and sixty-‐seven (167) respondents were interviewed.
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There were 92 females and 75 males (1.2:1) with an age range of 1-‐90years (mean = 52.84+/-‐ 22.01). 78(46.7%) respondents were 61 years and above, 54(32.3%) were between 31 and 60 years, 27(16.2%) were between 11 and 30 years, whilst 8 (4.8%) were below 11 years of age. Table 1. 77 (46.4%) of the respondents reside in Sagamu, 55(33.1%) live outside Sagamu but within Ogun state, 25(15.1%) in Lagos, whilst the rest were from elsewhere. 76(45.5%) were gainfully employed, 35(21.1%) retired, 27(16.3%) were children/students, 15(9.3%) were artisans, housewives and farmers. 56(33.7%) presented with cataracts, 36(21.7%) with glaucoma, 10(6%) trauma, 10(6%) pterygium and others ranging from corneal to posterior segment pathologies. 111(66.5%) had involvement of both eyes, 30(18%) only right eye and 26(15%) had only left eye involvement. 80(47.3%) were self sponsored, 48(28.7%) sponsored by their children, 24(14.4%) by parents, and 16(9.6%) others were sponsored by their spouses, eye camps, etc. [as in Table 2]. 86(51.5%) respondents had been told they’ll require surgery but only 49(57.0%) of them had been able to have the required surgery. 106(63.9%) indicated encountering one form of barrier or the other since attending the eye clinic, out of which 64 were females and 42 males. However, only 57% [49 respondents] out of those [86 respondents] who had been told required surgical intervention had been able to have the required surgery as at the time of the study after surmounting different barriers encountered. The types of barriers encountered were: Cost of hospital services [28.3%], fear of surgery [24.1%], long waiting time to see the doctor [23.5%], accessibility to the hospital [16.9%], lack of electricity in the hospital [10.8%], and frequent strikes by health workers [7.2%] as indicated in Table 3.
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DISCUSSION Majority[61.8%] of the respondents were 51years and above in age, with cataract and glaucoma being the most prevalent[55.4%] ocular conditions as also shown in the global trends of blindness2. From the 2004 global estimate1, about 45 million people are said to be blind worldwide with cataract and glaucoma accounting for 50% and 15% respectively. The Nigerian national survey14 on prevalence of blindness also indicated cataract[43%] and glaucoma[16.7%] as the commonest causes. Previous studies in Southwest Nigeria have also documented the prevalence of cataract and glaucoma combined to be greater than 60%15-‐16. One hundred and six [63.9%] of the respondents indicated having encountered any form of barrier during the course of their eye care at OOUTH, Sagamu but only 57% [49 respondents] out of those [86 respondents] who had been told required surgical intervention had been able to have the required surgery as at the time of the study due to different barriers encountered. The cost of hospital services was the commonest [28.3%] barrier as also seen in several studies3-‐7 and this includes both the direct and indirect cost of service17,18. The direct cost are those incurred by the patient for the surgery, drugs, investigations, glasses, transportation etc while the indirect involves the time spent during the eye care, disturbance of daily activities of both the patient and the escort(s). This latter cost is not measurable and tends to have a great impact on response to ophthalmic care18. This study also showed that only 45.5% of the respondents had gainful employment while only 47.9% had the ability to sponsor themselves for the required surgery. This need for sponsorship is a major cause of inability to access surgical care. This seems to corroborate the importance of cost as a major barrier. The fear of surgery was the second common barrier [24.1%] to surgical ophthalmic care. This was not unexpected as most patients have different myths concerning the eye and are also misinformed by non eye care workers that the eye would be removed from its socket, washed and replaced during surgery9 . Hence, all eye care workers must be involved in appropriate eye health talks at the clinics and as public enlightenment via the different media houses.
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The third common barrier was the long waiting time before seeing the ophthalmologist indicated by 23.5%, but this was lower than what was documented at the University College Hospital [UCH] Ibadan, Nigeria [36%]10. This has been attributed to the rigorous tertiary hospital protocols and the fact that the consulting ophthalmologist are too few to quickly attend to all the patients on time.10 This barrier can be reduced by the effective incorporation of primary eye care into the existing primary health centres in the community where minor ocular complaints can be diagnosed and treated, while only those that need specialized care are referred to the secondary and tertiary eye Hospitals. Accessibility to the teaching hospital was another barrier indicated by 16.9% of the respondents, despite the fact that 79.5% of respondents reside within Ogun State and 46.4% in Sagamu where the Teaching Hospital is located. This barrier which seems already surmounted by the respondents may affect regular follow up appointments. Also, this lack of accessibility to the hospital may not only be due to distance to the hospital per se, as Sagamu covers an area of only 614Km2 with a fairly good road network and practically no traffic congestion, as compared to Lagos state which is about 75km away from Sagamu and experiences lots of traffic congestion, with only 15.1% of the respondents from there. This perceived difficulty in accessibility needs further study. Lack of electricity to carry out the proposed surgery was indicated by 10.8% of respondents. This has been a national problem in Nigeria affecting every sector of the economy and leading to dependence on generators as alternate power source. This increases the running cost of each surgery and the hospital and may also lead to cancellations of surgery if there is a sudden breakdown of the only available generator. This is especially important in ophthalmic surgeries as practically all our equipments are electricity powered. Frequent strikes by health workers was indicated as a barrier by only 7.2% compared to 66% in UCH Ibadan11. This low rate may be because; there were no strikes during the study period. Strikes should be averted at all cost as this makes the patients seek eye care in private institutions, traditional homes etc and such clients may not return to the teaching hospital even after the strikes, due to the perceived instability.
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No other health-‐worker based barrier was indicated as a barrier to assessing surgical eye care, but this could be because the questionnaires were administered by doctors in the eye clinic and the patients may have thought, indicating such could lead to a biased treatment in the future. Health workers in all sectors of the hospital need to be informed on basic eye care to avoid or minimise misinforming patients. All these barriers noted above can be further eliminated by the improvement in the infrastructural and human resource development in the eye care sector in Ogun State and provision of free eye care services for children and the aged. Conclusion: The commonest barriers to eye surgical care in this study are comparable to those in previous studies and calls for an urgent need to ensure affordable and sustainable surgical care, so as to achieve the goals of vision 2020. REFERENCES 1. Changing trends in global blindness: 1988-‐2008. Comm Eye Health J 2008; 21(67): 37-‐ 39. 2. WHO Action plan for the prevention of avoidable blindness and visual impairment for 2014-‐2019. www.who.int/blindness/actionplan/en/index.html. [Accessed 18/01/14]. 3. Gyasi ME, Amoaku WMK, Asamany DK. Barriers to cataract surgical uptake in upper east region of Ghana. Ghana Med J. 2007; 41(4): 167-‐170. 4. Jadoon et al. Cataract prevalence, cataract surgical coverage and barriers to uptake of cataract surgical services in Pakistan. The Pakistan National Blindness and visual impairment survey. Br J Ophthalmol. 2007; 91: 1269-‐1273. 5.
Rabiu M. Blindness and barriers to uptake of cataract surgery in a rural community of northern Nigeria. Br J Ophthalmol. 2001; 85: 776-‐780.
6.
Mpyet C, Dineen BD, Solomon AW. Cataract surgical coverage and barriers to uptake of cataract surgery in leprosy villages of north eastern Nigeria. Br J Ophthalmol 2005: 89(8): 936-‐938.
7.
Oluleye TS. Cataract blindness and barriers to cataract surgical intervention in three rural communities of Oyo State, Nigeria. Nig J Med 2004: 13(2): 156-‐160.
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8.
Dhaliwal U, Guptal SK. Barriers to uptake of cataract surgery in patients presenting to a hospital. Indian J Ophthalmol. 2007; 55: 133-‐136.
9.
Olatunji FO, Ayanniyi AA. Anxieties of ophthalmic surgical patients about ophthalmic surgery. Nig J Ophthalmol. 2007; 15(1): 1012.
10.
Ayeni EA, Bekibele CO, Baiyeroju AM. Service uptake in UCH Ibadan: A time flow study. Nig J Ophthalmol. 2005; 13(2): 4953.
11.
Awoberu FJ, Bekibele CO, Baiyeroju AM. Patients perception of the quality of eye care at UCH, Ibadan. Nig J Ophthalmol.2005; 13(1): 11-‐16.
12.
Data submitted for reaccreditation of the Department of Ophthalmology, OOUTH, Sagamu for postgraduate training. Dec. 2009.
13.
Vision for the future-‐Nigeria. Ophthalmological Society of Nigeria. c/o Theodolite House, Ibadan, Nigeria.2005.
14.
Mohammed M. Abdull , Selvaraj Sivasubramaniam , Gudlavalleti V. S. Murthy , Clare Gilbert , Tafida Abubakar , Christian Ezelum , Mansur M. Rabiu and on behalf of Nigeria National Blindness and Visual Impairment Study Group. Causes of blindness and Visual Impairment in Nigeria: The Nigerian National Blindness and Visual Impairment Survey. Invest. Ophthalmol. Vis. Sci. September 2009 vol. 50 no. 9 4114-‐4120
15.
Onakpoya O.H, Adeoye A.O, Akinsola F.B, Adegbehingbe B.O. Prevalence of blindness and visual impairment inAtakunmosa West Local Government Area of Southwestern Nigeria. Tanzania Health Research Bulletin Vol .9 (2): 2007.
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Ajibode H.A. The prevalence of blindness and visual impairment in Ikenne Local Government Area of Ogun State Nigeria. Nig J Ophthalmol. 1999;7:23-‐27.
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Brain G, Taylor H. Cataract blindness-‐challenges for the 21st century. Bull WHO.2001;79:249-‐256
18.
Melese M, Alemayehu W, Friedlander E, Courtright P. Indirect cost associated with accessing eye care services as a barrier to service use in Ethopia. Tropical Med. Int. Health.2004;9:426-‐431.
TABLE 1: AGE DISTRIBUTION OF RESPONDENTS AGE GROUP [YEARS]
FREQUENCY
PERCENT [%]
1-‐10
8
4.8
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JOURNAL OF THE WEST AFRICAN COLLEGE OF SURGEONS VOLUME 2 NUMBER 4, OCTOBER-‐DECEMBER 2012
11-‐20
12
7.2
21-‐30
15
9.0
31-‐40
16
9.6
41-‐50
13
7.8
51-‐60
25
15.0
61-‐70
41
24.6
71-‐80
32
19.2
≥81
5
3
TOTAL
167
100
TABLE 2: PATTERN OF SPONSORSHIP FOR SURGERY SPONSOR SELF
FREQUENCY
PERCENTAGE [%]
79
47.3 CHILDREN 48 28.7 PARENTS 2 4 14.4 SPOUSE 5 3.0 NGO including Eyecamps 2 1.2 OTHERS 9 5.4 TOTAL 167 100
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TABLE 3: BARRIERS INDICATED BY RESPONDENTS Hospital-‐based barriers Frequencies Patient-‐based barriers Frequencies Cost of services 47[28.3%] Fear of surgery 40[24.1%] Long waiting time 39[23.5%] Lack of sponsor 9[5.4%] Accessibility of the Cost of Hospital 28[16.9%] transportation 8[4.8%] Lack of electricity 18[10.8%] No perceived need for surgery 6[3.6%] Frequent health Ability to cope with worker’s strike 12[7.2%] routine work 6[3.6%] Lack of Fear of outcome Accommodation of surgery 6[3.6%] for escort 6[3.6%] Cumbersome Dislike of hospital Investigations 2[1.2%] protocol 5[3.0%] Lack of theatre space 1[0.6%] Lack of escort 3[1.8%] Cancellation of No excuse from surgery 1[0.6%] work 1[0.6%] NOTE: Respondents gave positive response to more than one barrier. s AKNOWLEDGEMENT Sincere appreciation goes to the staff of Health Records Department of Olabisi Onabanjo University Teaching Hospital, Sagamu for assisting with the records of the patients used in this study.
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