p u b l i c h e a l t h 1 2 8 ( 2 0 1 4 ) 1 0 2 3 e1 0 2 9
Available online at www.sciencedirect.com
Public Health journal homepage: www.elsevier.com/puhe
Original Research
Demographic, socio-economic and clinical characteristics: implications for time to presentation at a Nigerian tertiary ophthalmic outpatient population B.I. Eze*, J.N. Eze Department of Ophthalmology, University of Nigeria Teaching Hospital, Ituku-Ozalla, Enugu, Nigeria
article info
abstract
Article history:
Objective: To investigate the associations between time to presentation, and sociodemo-
Received 5 December 2013
graphic and clinical characteristics of new adult ophthalmic outpatients at the University
Received in revised form
of Nigeria Teaching Hospital (UNTH), Enugu, between March and August 2010.
26 July 2014
Study design: Hospital-based caseecontrol study.
Accepted 5 September 2014
Methods: Consecutive new ophthalmic outpatients at UNTH were categorized into controls
Available online 15 November 2014
(early presenters, i.e. 3 months after onset of current eye disease). Relevant data were obtained
Keywords:
from the participants' case notes and interviews. Descriptive statistics yielded frequency
Time to presentation
distributions; bivariate and multivariate comparisons were used to test the significance of
Determinants
associations. P < 0.05 was considered to indicate significance.
Ophthalmic outpatients
Results: Eight hundred and twenty-four subjects [454 males and 370 females, mean age 39.2 (standard deviation 1.2) years, range 19e82 years] participated in this study. There were 370 early presenters and 454 late presenters. Multivariate analysis found that late presentation was significantly associated with age >50 years [odds ratio (OR) 1.34, 95% confidence interval (CI) 1.28e2.22; P < 0.01], female gender (OR 1.63, 95% CI 1.52e2.11; P < 0.01), residence >20 km from UNTH (OR 0.65, 95% CI 0.38e0.89; P ¼ 0.0212), individual-level deprivation (OR 0.69, 95% CI 0.55e0.92; P ¼ 0.0324) and subnormal visual acuity at presentation (OR 1.32, 95% CI 1.05e1.76; P ¼ 0.0353). Conclusions: At UNTH, most new adult ophthalmic outpatients present >3 months after onset of their current eye disease. Measures to overcome age-, gender- and distancerelated causes of late presentation, grassroots economic empowerment of the feeder population and public education about eye health are required. © 2014 The Royal Society for Public Health. Published by Elsevier Ltd. All rights reserved.
* Corresponding author. Department of Ophthalmology, University of Nigeria Teaching Hospital, PMB 01139, Ituku-Ozalla, Enugu, Nigeria. E-mail address: [email protected] (B.I. Eze). http://dx.doi.org/10.1016/j.puhe.2014.09.003 0033-3506/© 2014 The Royal Society for Public Health. Published by Elsevier Ltd. All rights reserved.
1024
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Introduction Equity in access to health care services, including eye care, is a fundamental service delivery parameter that is used in the assessment of health system effectiveness.1,2 Consequently, horizontal equity (i.e. equal use of public eye care services for equal eye care needs) in the uptake of eye care services is critical to meet the targets of VISION 2020, which include the right to sight, within the recommended framework of primary health care.3 Inequity in access to eye care often results from a mismatch between available eye care services and eye care needs. It has been observed to occur either along the prepresentation care pathway4 or at the point of eye care service delivery.2 Generally, in clinical medicine,5e8 delays traceable to prehospital care invariably prolong the time to diagnosis and time to treatment, with resultant adverse implications for treatment outcomes. In ophthalmic practice, due to the delicate nature of the organ involved (the eye), pretreatment delays are particularly dangerous as they could jeopardize the visual,9e11 ocular12,13 or survival13,14 outcomes of otherwise potentially treatable eye diseases. Demographic,15e20 ethnic,2 socio-economic,21,22 geographic6 and health-system-associated1,5,9,12 factors have been implicated in delayed presentation at eye care service facilities. The situation is further compounded in the resource-deficient settings of low- and middle-income countries (LMICs) where public health insurance schemes are poorly developed and complementary private health insurance is rarely accessed.23 These factors combine to create and perpetuate the disparately high burden of eye diseases and blindness in these countries, often with severe consequences for socio-economic development. In order to achieve the desired health impact of resources allocated to eye care delivery, there is a need, especially in LMICs,22 to identify and overcome the proximal and distal barriers to timely access to eye care services in the prevailing health care environment. Furthermore, in LMICs, there is a comparative scarcity of research on the determinants of ophthalmic patients' time to presentation. Consequently, a caseecontrol study of new adult ophthalmic outpatients at the University of Nigeria Teaching Hospital (UNTH), Enugu was undertaken. This survey investigated the influence of demographic, socio-economic and clinical characteristics on participants' time to initial presentation at the ophthalmic outpatient clinic (i.e. time to presentation from when the patient first noticed the symptoms of their current episode of eye disease). In addition to generating comparative regional data, it is expected that the findings will assist policy makers, implementers of eye care programmes and providers of eye care services in Nigeria and similar LMICs to fulfil the objectives of VISION 2020.
Methods Background UNTH, located in Nigeria's south-east geopolitical zone, is one of six first-generation teaching hospitals in Nigeria. At UNTH,
the ophthalmology department delivers promotive, preventive, curative and rehabilitative eye care services through outpatient consultation and inpatient care. The ophthalmic outpatient clinic takes referrals from primary, secondary and (occasionally) tertiary eye care centres in the south-east geopolitical zone and beyond. The general outpatient department and other specialist clinics also refer patients to the eye clinic. Non-institutional and self-referrals, although infrequent, are other referral pathways to the UNTH eye clinic. Although it is a tertiary health facility, due to the prevailing scarcity of eye care personnel,24 UNTH receives inappropriate referrals of cases that are amenable to care at primary and secondary eye care centres.25 This caseecontrol study investigated all adult patients (aged 18 years) who presented for the first time at the ophthalmic outpatient clinic at UNTH between 1 March and 31 August 2010 (six months). Demographic (age, sex and marital status) and socio-economic (educational status, occupation, housing tenure category and car access) data were collected. For participants who were unemployed or full-time housewives, the occupation of the reference person (i.e. the ‘breadwinner’) in the family was entered. For participants who were retired, retrenched (forced displacement from place of work before retirement age) or on prolonged sick leave, their last major occupation was entered. Data on time to presentation, location of permanent residence, previous ophthalmic consultations and treatments, presenting distance visual acuity and final definitive diagnosis were also collected. In cases of multiple diagnoses, the diagnosis posing the greatest threat to vision was entered. Prior to commencement of this survey, ethical clearance compliant with the 1964 Helsinki Declaration was obtained from UNTH's Medical and Health Research Ethics Committee (Institutional Review Board).
Questionnaire development The research instrument was an 11-point pretested, researcher-administered questionnaire containing closedand open-ended questions regarding participants' demographic, socio-economic and clinical characteristics. To ascertain its content validity and psychometric reliability, the instrument was pretested on a cohort of new tertiary ophthalmic outpatients outside the study centre. The structural modifications to the instrument suggested by the pretest were made prior to final data collection.
Operational definitions (for current eye disease episode) Time to presentation: time interval between each participant's observation of the first eye disease symptom and their initial presentation for care; Referral interval: time interval between consulting the referring eye care provider and initial presentation for care; Early presenters: participants who presented 3 months after observing the first symptom of eye disease5,7; Individual-level deprivation: determined using housing tenure category, described elsewhere.24,26 Owner occupier,
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Table 1 e Participants' sociodemographic characteristics. Characteristic
Early presenters (n ¼ 370)
Late presenters (n ¼ 454)
86 243 33 8
32 121 203 98
118 364 236 106
266 104
320 134
586 (71.1) 238 (24.3)
85 92 33 160
113 66 80 192
198 158 116 352
(21.4) (16.7) (11.7) (42.7)
170 128 56 16
250 134 36 34
420 262 92 50
(50.9) (31.8) (11.2) (6.1)
96
149
245 (29.7)
72
113
185 (22.5)
Age (years) 18e37 38e57 58e77 78e97 Marital status Ever married Single Educational status Primary Secondary Tertiary None Occupation Civil servant Trader Artisan Unemployed Deprivation status Individual-level deprivation Area-level deprivation
Data analysis (14.3) (44.2) (28.6) (12.9)
Table 2 e Clinical profile of participants.
Presenting distance visual acuity Normal vision Visually impaired Blind Previous ophthalmic consultation Yes Category of eye care provider consulted Integrated eye care worker Optometrist/optician Ophthalmologist Do not know No previous consultation Previous ophthalmic treatment Yes Referral source Public/mission hospital Private hospital Non-institution-based referral Self-initiated referral
Visual impairment: presenting distance visual acuity 20 km from UNTH. Ninety-six (25.9%) had individual-level deprivation and 72 (19.5%) had area-level deprivation. Prior to presentation, 302 (81.6%) of the early presenters had consulted an eye care provider, allopathic or unorthodox, for their current eye disease/s, and 222 (60.0%) had received treatment. The early presenters were mainly referred by integrated eye care workers (176, 47.6%), optometrists (32, 8.6%) and ophthalmologists (26, 7.0%). They were mainly referred from public/mission hospitals (145, 39.2%) and private health facilities (120, 32.4%). At presentation, 128 (28.5%) of the early
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Table 3 e Associations between time to presentation and participants' sociodemographic and clinical characteristics. Characteristic Sociodemographic characteristics Age (years) 50 >50 Gender Male Female Formal education Yes No Employment status Employed Unemployed Marital status Ever marriedb Single Live >20 km from study centre Yes No Individual-level deprivation Yes No Area-level deprivation Yes No Clinical characteristics Presenting distance visual acuity Normal Visually impaired/blind Previous ophthalmic consultation Yes No Previous ophthalmic treatment Yes No Referral source Hospital (public/mission/private) Non-institution-based/self
Total n (%), n ¼ 824
Early presenters n (%), n ¼ 370
Late presenters n (%), n ¼ 454
Odds ratio (95% CI)
P-value
482 342
248 122
234 220
1.9 (1.44e2.54)
460 (55.8) 364 (44.2)
234 136
226 228
1.74 (1.31e2.29) Reference
472 (57.3) 352 (42.7)
210 160
262 192
0.96 (0.73e1.27)
0.8318
774 (93.9) 50 (6.1)
352 18
422 32
1.48 (0.82e2.69)
0.2404
586 238
266 104
320 134
1.07 (0.79e1.45)
0.6994
421 (51.1) 403 (48.9)
173 197
248 206
0.73 (0.55e0.96)
0.0252a
245 (29.7) 579 (70.3)
96 274
149 305
0.72 (0.53e0.97)
0.0323a
185 (22.5) 639 (77.5)
72 298
113 341
0.73 (0.52e1.02)
0.0653
506 (61.4) 318 (38.6)
242 128
264 190
1.36 (1.02e1.81)
0.0370a
670 (81.3) 154 (18.7)
302 68
368 86
1.04 (0.73e1.48)
0.8578
506 (61.4) 318 (38.6)
222 148
284 170
0.89 (0.68e1.19)
0.4723
695 (73.4) 219 (26.6)
265 105
340 114
0.85 (0.62e1.15)
0.3034
20 km from UNTH. One hundred and forty-nine (32.8%) had individual-level deprivation and 113 (24.9%) had area-level deprivation. Of the 368 (81.1%) late presenters who had consultations elsewhere prior to presentation, 140 (38.0%) had consulted an integrated eye care worker and 84/368 (62.6%) had consulted an optometrist/optician. Previous treatment for their current eye disease/s was received by 284 (62.6%) of the late
presenters. The late presenters' referrals mainly originated from public/mission hospitals (216, 47.5%) and private health facilities (124, 27.3%). At presentation, 190 (41.9%) of the late presenters were visually impaired or blind. Refractive error (172, 37.9%), cataract (104, 22.9%) and allergic conjunctivitis (96, 21.1%) were the leading definitive diagnoses among the late presenters.
Intergroup analyses In the bivariate analysis, significantly more females were found to be late presenters compared with males (P ¼ 0.0039). The late presenters were significantly older than the early presenters (P < 0.01). More of the late presenters lived >20 km from UNTH (P ¼ 0.0252), had individual-level deprivation (P < 0.0323), and were visually impaired or blind at presentation (P ¼ 0.0370) compared with the early presenters (Table 3).
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In the multivariate logistic regression analysis, late presentation was significantly associated with age >50 years, female gender, living >20 km from UNTH, individual-level deprivation and subnormal visual acuity at presentation (Table 4). However, the magnitude of the association was higher for age, gender and location than individual-level deprivation and presenting visual acuity.
Discussion Older age and female gender, but not marital status, were significantly associated with late presentation at the ophthalmic outpatient clinic at UNTH. The observed influence of age on time to presentation, similarly reported in Ethiopia,28 New Zealand29 and Madagascar,30 likely reflects the presence of age-related logistical barriers inherent in transporting elderly eye patients to eye care facilities, especially those with a background of multiple comorbidities.30 This, coupled with the loss of financial independence in old age, introduces the rationale for eye care providers to embark on outreach eye care activities. This will overcome the agerelated inequity of access to eye care, especially in the study setting and in other LMICs where the burden of age-related eye diseases leading to blindness is enormous.30e32 Consistent with reports elsewhere,1,2,22 the observed gender difference in the timing of presentation, biased in favour of males, probably reflects the dominant socio-economic position of males among the feeder population of UNTH. This is attributable to their higher economic empowerment and unrestricted access to family finance, especially among married males. To restore horizontal gender equity in access to eye health needs, there is urgent need to create and sustain gender-neutral economic empowerment programmes through multisectoral collaborations. In addition, interventional health education is needed to bridge the genderdetermined gaps in health attitudes and health-seeking behaviour. The present study did not establish any association between participants' marital status and their time to presentation; this relationship does not appear to have been explored elsewhere. However, significant associations, although of lesser magnitude, between late presentation and living further from the hospital, and late presentation and individual-level deprivation were identified. While the available literature is bereft of reports on the role of location of residence on time to presentation, the deprivation-related
Table 4 e Significant determinants of time to presentation on multivariate analysis. Characteristic Age >50 years Female gender Live >20 km from study centre Individual-level deprivation Subnormal presenting distance visual acuity CI, confidence interval.
Adjusted odds ratio
95% CI
P-value
1.34 1.63 0.65 0.69 1.32
1.28e2.22 1.52e2.11 0.38e0.89 0.55e0.92 1.05e1.76
3 months after the onset of symptoms for their current eye disease. Although socio-economic deprivation and distance from UNTH are contributing factors, older age, female gender and subnormal presenting visual acuity were the important causes of late presentation. These have implications for government socio-economic policy makers and all stakeholders in eye care delivery. Grassroots economic empowerment of the population, public eye health education, and even distribution of resources for eye care delivery are required to overcome these barriers and improve eye health outcomes.
Author statements Acknowledgements The authors wish to acknowledge the assistance of the staff of the eye clinic at UNTH during the study.
Ethical approval Ethical approval was obtained from the Medical and Health Research Ethics Committee of UNTH.
9.
10.
11.
12.
13.
14. 15.
16.
17.
Funding 18.
None declared.
Competing interest 19.
None declared.
references
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1. Regidor E, Martinez D, Calle ME, Astasio P, Ortega P, Dominguez V. Socioeconomic patterns in the use of public
and private services and equity in health care. BMC Health Serv Res 2008;8:183. Adamson J, Ben-Shlomo Y, Chaturvedi N, Donovan J. Ethnicity, socioeconomic position and gender e do they affect reported health-care seeking behavior? Soc Sci Med 2003;57:895e904. World Health Organization. National VISION 2020 implementation data. Geneva: World Health Organization. Available at: http:// apps.who.int/iris/bitstream/10665/103646/1/9789241500173_ eng.pdf?ua¼1; 2012 (last accessed 13 July 2014). Geneau R, Lewallen S, Bronsard A, Paul I, Courtright P. The social and family dynamics behind the uptake of cataract surgery: findings from Kilimanjaro region, Tanzania. Br J Ophthalmol 2005;89:1399e402. Onyango JF, Macharia IM. Delays in diagnosis, referral and management of head and neck tumors in Kenyatta National Hospital, Nairobi. East Afr Med J 2006;83:85e91. O'Donnell S, Condell S, Begley C, Fitzgerald T. Pre-hospital care pathway delays: gender and myocardial infarction. J Adv Nurs 2006;53:268e76. Meecham G, Collins J, Petrie K. Delay in seeking medical care for self-detected breast lump symptoms in New Zealand women. N Z Med J 2002;115:U257. Clark MA, Thomas JM. Delay in referral to a specialist soft tissue sarcoma unit. Eur Surg Oncol 2005;31:443e8. Quinn SM, Qureshi F, Charles SJ. Assessment of delays in presentation of patients with retinal detachment to a tertiary referral centre. Ophthalmic Physiol Opt 2004;24:100e5. Tugal-Tutkun I, Aydin-Akova Y, Gunev-Tefekli E, AynaciKahraman B. Referral patterns, demographic and clinical features, and visual prognosis of Turkish patients with sarcoid uveitis. Ocul Immunol Inflamm 2007;15:337e43. Fraser S, Bunce C, Wormald R. Risk factors for late presentation in chronic glaucoma. Invest Ophthalmol Vis Sci 1999;40:2251e7. Gallaher RP, Elwood JM, Rootman J, Threfall WJ, Davis J. Symptoms and time to presentation and treatment in ocular melanoma: the west Canada melanoma study. Can J Ophthalmol 1988;23:11e3. Ekenze SO, Ekwunife H, Eze BI, Ikefuna A, Amah CC, Emodi IJ. The burden of pediatric malignant solid tumors in a developing country. J Trop Pediatr 2010;56:111e4. Nwosu SN, Okoye GS, Ulasi TO. Delayed diagnosis of retinoblastoma. Cent Afr J Med 1994;40:353e5. Ntim-Amponsah CT, Amoaku WM, Ewusi RK, IdirisuriyaKhair R, Nyatepe-Coo E, Ofosu-Amaah S. Evaluation of risk factors for advanced glaucoma in Ghanaian patients. Eye (Lond) 2005;19:528e34. Lewallen S, Courtright P. Gender and use of cataract surgical services in developing countries. Bull World Health Organ 2002;80:300e3. Mganga H, Lewallen S, Courtright P. Overcoming gender inequity in prevention of blindness and visual impairment in Africa. Mid East Afr J Ophthalmol 2011;18:98e101. Tanchangya J, Khan MR, Bayasakh S, Wichaidit W. Gender disparity in delayed treatment-seeking behavior for cataract: 6 years of experience from impact Jibon Tari Floating Hospital, Bangladesh. Asia Pac J Public Health 2012;20:1e8. Courtright P, Lewallen S. Improving gender equity in eye care: advocating for the needs of women. Community Eye Health 2007;20:68e9. Evans J. Eye care for the older people. Community Eye Health 2008;21:21e3. Gilbert CE, Sha SP, Jadoon MZ, Bourne R, Dineen B, Khan MA, Johnson GJ, Khan MD. Poverty and blindness in Pakistan: results from the Pakistan national blindness and visual impairment survey. BMJ 2008;336:29e32.
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22. Fraser S, Bunce C, Wormald R, Brunner E. Deprivation and late presentation of glaucoma: case control study. BMJ 2001;322:639e43. 23. Kruk ME, Goldman E, Galea S. Borrowing and selling to pay for health care in low-and middle-income countries. Health Aff (Millwood) 2009;28:1056e66. 24. Eze BI, Maduka-Okafor FC. An assessment of the eye care workforce in Enugu state, south-eastern Nigeria. Hum Resour Health 2009;7:38. 25. Eze BI, Okoye OI, Maduka-Okafor FC, Aguwa EN. Audit of referrals to an ophthalmic outpatient clinic of a tertiary eye care centre in a developing country. Niger J Ophthalmol 2009;17:65e9. 26. Office of Population Census and Surveys. Standard occupational classification. London: HMSO. Available at: www.ons.gov. uk/.../classifications/...standard-classifications/standard; 1991 (last accessed 20 February 2012). 27. Jarman B. Identification of underprivileged areas. BMJ Clin Res Ed 1983;286:1705e9. 28. Giorgis AT, Mulugeta A, Aga A, Deyassa N. The spectrum of glaucoma presentation at Menelik II Hospital, Addis Ababa. Ethiop Med J 2012;50:259e64.
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29. Deva NC, Insull E, Gamble G, Danesh-Meyer HV. Risk factors for first presentation of glaucoma with significant visual field loss. Clin Exp Ophthalmol 2008;36:217e21. 30. Nkumbe H. Helping older people get the eye care they need. Community Eye Health 2008;21:26e8. 31. Ezepue UF. Magnitude and causes of blindness and low vision in Anambra State of Nigeria (results of 1992 point prevalence survey). Public Health 1997;11:305e9. 32. Abdulraheem IS. Health needs assessment and determinants of health-seeking behavior among elderly Nigerians: a household survey. Ann Afr Med 2007;6:58e63. 33. Majeed M, Williams C, Northstone K, Ben-Shlomo Y. Are there inequities in the utilization of childhood eye-care services in relation to socio-economic status? Evidence from the ALSPAC cohort. Br J Ophthalmol 2008;92:965e9. 34. Senthilkumar D, Balasubramaniam SM, Kumaran SE, Ramani KK. Parents' awareness and perception of children's eye diseases in Chennai, India. Optom Vis Sci 2013;90:1462e6.
Available online at www.sciencedirect.com
Public Health journal homepage: www.elsevier.com/puhe
Original Research
Demographic, socio-economic and clinical characteristics: implications for time to presentation at a Nigerian tertiary ophthalmic outpatient population B.I. Eze*, J.N. Eze Department of Ophthalmology, University of Nigeria Teaching Hospital, Ituku-Ozalla, Enugu, Nigeria
article info
abstract
Article history:
Objective: To investigate the associations between time to presentation, and sociodemo-
Received 5 December 2013
graphic and clinical characteristics of new adult ophthalmic outpatients at the University
Received in revised form
of Nigeria Teaching Hospital (UNTH), Enugu, between March and August 2010.
26 July 2014
Study design: Hospital-based caseecontrol study.
Accepted 5 September 2014
Methods: Consecutive new ophthalmic outpatients at UNTH were categorized into controls
Available online 15 November 2014
(early presenters, i.e. 3 months after onset of current eye disease). Relevant data were obtained
Keywords:
from the participants' case notes and interviews. Descriptive statistics yielded frequency
Time to presentation
distributions; bivariate and multivariate comparisons were used to test the significance of
Determinants
associations. P < 0.05 was considered to indicate significance.
Ophthalmic outpatients
Results: Eight hundred and twenty-four subjects [454 males and 370 females, mean age 39.2 (standard deviation 1.2) years, range 19e82 years] participated in this study. There were 370 early presenters and 454 late presenters. Multivariate analysis found that late presentation was significantly associated with age >50 years [odds ratio (OR) 1.34, 95% confidence interval (CI) 1.28e2.22; P < 0.01], female gender (OR 1.63, 95% CI 1.52e2.11; P < 0.01), residence >20 km from UNTH (OR 0.65, 95% CI 0.38e0.89; P ¼ 0.0212), individual-level deprivation (OR 0.69, 95% CI 0.55e0.92; P ¼ 0.0324) and subnormal visual acuity at presentation (OR 1.32, 95% CI 1.05e1.76; P ¼ 0.0353). Conclusions: At UNTH, most new adult ophthalmic outpatients present >3 months after onset of their current eye disease. Measures to overcome age-, gender- and distancerelated causes of late presentation, grassroots economic empowerment of the feeder population and public education about eye health are required. © 2014 The Royal Society for Public Health. Published by Elsevier Ltd. All rights reserved.
* Corresponding author. Department of Ophthalmology, University of Nigeria Teaching Hospital, PMB 01139, Ituku-Ozalla, Enugu, Nigeria. E-mail address: [email protected] (B.I. Eze). http://dx.doi.org/10.1016/j.puhe.2014.09.003 0033-3506/© 2014 The Royal Society for Public Health. Published by Elsevier Ltd. All rights reserved.
1024
p u b l i c h e a l t h 1 2 8 ( 2 0 1 4 ) 1 0 2 3 e1 0 2 9
Introduction Equity in access to health care services, including eye care, is a fundamental service delivery parameter that is used in the assessment of health system effectiveness.1,2 Consequently, horizontal equity (i.e. equal use of public eye care services for equal eye care needs) in the uptake of eye care services is critical to meet the targets of VISION 2020, which include the right to sight, within the recommended framework of primary health care.3 Inequity in access to eye care often results from a mismatch between available eye care services and eye care needs. It has been observed to occur either along the prepresentation care pathway4 or at the point of eye care service delivery.2 Generally, in clinical medicine,5e8 delays traceable to prehospital care invariably prolong the time to diagnosis and time to treatment, with resultant adverse implications for treatment outcomes. In ophthalmic practice, due to the delicate nature of the organ involved (the eye), pretreatment delays are particularly dangerous as they could jeopardize the visual,9e11 ocular12,13 or survival13,14 outcomes of otherwise potentially treatable eye diseases. Demographic,15e20 ethnic,2 socio-economic,21,22 geographic6 and health-system-associated1,5,9,12 factors have been implicated in delayed presentation at eye care service facilities. The situation is further compounded in the resource-deficient settings of low- and middle-income countries (LMICs) where public health insurance schemes are poorly developed and complementary private health insurance is rarely accessed.23 These factors combine to create and perpetuate the disparately high burden of eye diseases and blindness in these countries, often with severe consequences for socio-economic development. In order to achieve the desired health impact of resources allocated to eye care delivery, there is a need, especially in LMICs,22 to identify and overcome the proximal and distal barriers to timely access to eye care services in the prevailing health care environment. Furthermore, in LMICs, there is a comparative scarcity of research on the determinants of ophthalmic patients' time to presentation. Consequently, a caseecontrol study of new adult ophthalmic outpatients at the University of Nigeria Teaching Hospital (UNTH), Enugu was undertaken. This survey investigated the influence of demographic, socio-economic and clinical characteristics on participants' time to initial presentation at the ophthalmic outpatient clinic (i.e. time to presentation from when the patient first noticed the symptoms of their current episode of eye disease). In addition to generating comparative regional data, it is expected that the findings will assist policy makers, implementers of eye care programmes and providers of eye care services in Nigeria and similar LMICs to fulfil the objectives of VISION 2020.
Methods Background UNTH, located in Nigeria's south-east geopolitical zone, is one of six first-generation teaching hospitals in Nigeria. At UNTH,
the ophthalmology department delivers promotive, preventive, curative and rehabilitative eye care services through outpatient consultation and inpatient care. The ophthalmic outpatient clinic takes referrals from primary, secondary and (occasionally) tertiary eye care centres in the south-east geopolitical zone and beyond. The general outpatient department and other specialist clinics also refer patients to the eye clinic. Non-institutional and self-referrals, although infrequent, are other referral pathways to the UNTH eye clinic. Although it is a tertiary health facility, due to the prevailing scarcity of eye care personnel,24 UNTH receives inappropriate referrals of cases that are amenable to care at primary and secondary eye care centres.25 This caseecontrol study investigated all adult patients (aged 18 years) who presented for the first time at the ophthalmic outpatient clinic at UNTH between 1 March and 31 August 2010 (six months). Demographic (age, sex and marital status) and socio-economic (educational status, occupation, housing tenure category and car access) data were collected. For participants who were unemployed or full-time housewives, the occupation of the reference person (i.e. the ‘breadwinner’) in the family was entered. For participants who were retired, retrenched (forced displacement from place of work before retirement age) or on prolonged sick leave, their last major occupation was entered. Data on time to presentation, location of permanent residence, previous ophthalmic consultations and treatments, presenting distance visual acuity and final definitive diagnosis were also collected. In cases of multiple diagnoses, the diagnosis posing the greatest threat to vision was entered. Prior to commencement of this survey, ethical clearance compliant with the 1964 Helsinki Declaration was obtained from UNTH's Medical and Health Research Ethics Committee (Institutional Review Board).
Questionnaire development The research instrument was an 11-point pretested, researcher-administered questionnaire containing closedand open-ended questions regarding participants' demographic, socio-economic and clinical characteristics. To ascertain its content validity and psychometric reliability, the instrument was pretested on a cohort of new tertiary ophthalmic outpatients outside the study centre. The structural modifications to the instrument suggested by the pretest were made prior to final data collection.
Operational definitions (for current eye disease episode) Time to presentation: time interval between each participant's observation of the first eye disease symptom and their initial presentation for care; Referral interval: time interval between consulting the referring eye care provider and initial presentation for care; Early presenters: participants who presented 3 months after observing the first symptom of eye disease5,7; Individual-level deprivation: determined using housing tenure category, described elsewhere.24,26 Owner occupier,
p u b l i c h e a l t h 1 2 8 ( 2 0 1 4 ) 1 0 2 3 e1 0 2 9
Table 1 e Participants' sociodemographic characteristics. Characteristic
Early presenters (n ¼ 370)
Late presenters (n ¼ 454)
86 243 33 8
32 121 203 98
118 364 236 106
266 104
320 134
586 (71.1) 238 (24.3)
85 92 33 160
113 66 80 192
198 158 116 352
(21.4) (16.7) (11.7) (42.7)
170 128 56 16
250 134 36 34
420 262 92 50
(50.9) (31.8) (11.2) (6.1)
96
149
245 (29.7)
72
113
185 (22.5)
Age (years) 18e37 38e57 58e77 78e97 Marital status Ever married Single Educational status Primary Secondary Tertiary None Occupation Civil servant Trader Artisan Unemployed Deprivation status Individual-level deprivation Area-level deprivation
Data analysis (14.3) (44.2) (28.6) (12.9)
Table 2 e Clinical profile of participants.
Presenting distance visual acuity Normal vision Visually impaired Blind Previous ophthalmic consultation Yes Category of eye care provider consulted Integrated eye care worker Optometrist/optician Ophthalmologist Do not know No previous consultation Previous ophthalmic treatment Yes Referral source Public/mission hospital Private hospital Non-institution-based referral Self-initiated referral
Visual impairment: presenting distance visual acuity 20 km from UNTH. Ninety-six (25.9%) had individual-level deprivation and 72 (19.5%) had area-level deprivation. Prior to presentation, 302 (81.6%) of the early presenters had consulted an eye care provider, allopathic or unorthodox, for their current eye disease/s, and 222 (60.0%) had received treatment. The early presenters were mainly referred by integrated eye care workers (176, 47.6%), optometrists (32, 8.6%) and ophthalmologists (26, 7.0%). They were mainly referred from public/mission hospitals (145, 39.2%) and private health facilities (120, 32.4%). At presentation, 128 (28.5%) of the early
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Table 3 e Associations between time to presentation and participants' sociodemographic and clinical characteristics. Characteristic Sociodemographic characteristics Age (years) 50 >50 Gender Male Female Formal education Yes No Employment status Employed Unemployed Marital status Ever marriedb Single Live >20 km from study centre Yes No Individual-level deprivation Yes No Area-level deprivation Yes No Clinical characteristics Presenting distance visual acuity Normal Visually impaired/blind Previous ophthalmic consultation Yes No Previous ophthalmic treatment Yes No Referral source Hospital (public/mission/private) Non-institution-based/self
Total n (%), n ¼ 824
Early presenters n (%), n ¼ 370
Late presenters n (%), n ¼ 454
Odds ratio (95% CI)
P-value
482 342
248 122
234 220
1.9 (1.44e2.54)
460 (55.8) 364 (44.2)
234 136
226 228
1.74 (1.31e2.29) Reference
472 (57.3) 352 (42.7)
210 160
262 192
0.96 (0.73e1.27)
0.8318
774 (93.9) 50 (6.1)
352 18
422 32
1.48 (0.82e2.69)
0.2404
586 238
266 104
320 134
1.07 (0.79e1.45)
0.6994
421 (51.1) 403 (48.9)
173 197
248 206
0.73 (0.55e0.96)
0.0252a
245 (29.7) 579 (70.3)
96 274
149 305
0.72 (0.53e0.97)
0.0323a
185 (22.5) 639 (77.5)
72 298
113 341
0.73 (0.52e1.02)
0.0653
506 (61.4) 318 (38.6)
242 128
264 190
1.36 (1.02e1.81)
0.0370a
670 (81.3) 154 (18.7)
302 68
368 86
1.04 (0.73e1.48)
0.8578
506 (61.4) 318 (38.6)
222 148
284 170
0.89 (0.68e1.19)
0.4723
695 (73.4) 219 (26.6)
265 105
340 114
0.85 (0.62e1.15)
0.3034
20 km from UNTH. One hundred and forty-nine (32.8%) had individual-level deprivation and 113 (24.9%) had area-level deprivation. Of the 368 (81.1%) late presenters who had consultations elsewhere prior to presentation, 140 (38.0%) had consulted an integrated eye care worker and 84/368 (62.6%) had consulted an optometrist/optician. Previous treatment for their current eye disease/s was received by 284 (62.6%) of the late
presenters. The late presenters' referrals mainly originated from public/mission hospitals (216, 47.5%) and private health facilities (124, 27.3%). At presentation, 190 (41.9%) of the late presenters were visually impaired or blind. Refractive error (172, 37.9%), cataract (104, 22.9%) and allergic conjunctivitis (96, 21.1%) were the leading definitive diagnoses among the late presenters.
Intergroup analyses In the bivariate analysis, significantly more females were found to be late presenters compared with males (P ¼ 0.0039). The late presenters were significantly older than the early presenters (P < 0.01). More of the late presenters lived >20 km from UNTH (P ¼ 0.0252), had individual-level deprivation (P < 0.0323), and were visually impaired or blind at presentation (P ¼ 0.0370) compared with the early presenters (Table 3).
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In the multivariate logistic regression analysis, late presentation was significantly associated with age >50 years, female gender, living >20 km from UNTH, individual-level deprivation and subnormal visual acuity at presentation (Table 4). However, the magnitude of the association was higher for age, gender and location than individual-level deprivation and presenting visual acuity.
Discussion Older age and female gender, but not marital status, were significantly associated with late presentation at the ophthalmic outpatient clinic at UNTH. The observed influence of age on time to presentation, similarly reported in Ethiopia,28 New Zealand29 and Madagascar,30 likely reflects the presence of age-related logistical barriers inherent in transporting elderly eye patients to eye care facilities, especially those with a background of multiple comorbidities.30 This, coupled with the loss of financial independence in old age, introduces the rationale for eye care providers to embark on outreach eye care activities. This will overcome the agerelated inequity of access to eye care, especially in the study setting and in other LMICs where the burden of age-related eye diseases leading to blindness is enormous.30e32 Consistent with reports elsewhere,1,2,22 the observed gender difference in the timing of presentation, biased in favour of males, probably reflects the dominant socio-economic position of males among the feeder population of UNTH. This is attributable to their higher economic empowerment and unrestricted access to family finance, especially among married males. To restore horizontal gender equity in access to eye health needs, there is urgent need to create and sustain gender-neutral economic empowerment programmes through multisectoral collaborations. In addition, interventional health education is needed to bridge the genderdetermined gaps in health attitudes and health-seeking behaviour. The present study did not establish any association between participants' marital status and their time to presentation; this relationship does not appear to have been explored elsewhere. However, significant associations, although of lesser magnitude, between late presentation and living further from the hospital, and late presentation and individual-level deprivation were identified. While the available literature is bereft of reports on the role of location of residence on time to presentation, the deprivation-related
Table 4 e Significant determinants of time to presentation on multivariate analysis. Characteristic Age >50 years Female gender Live >20 km from study centre Individual-level deprivation Subnormal presenting distance visual acuity CI, confidence interval.
Adjusted odds ratio
95% CI
P-value
1.34 1.63 0.65 0.69 1.32
1.28e2.22 1.52e2.11 0.38e0.89 0.55e0.92 1.05e1.76
3 months after the onset of symptoms for their current eye disease. Although socio-economic deprivation and distance from UNTH are contributing factors, older age, female gender and subnormal presenting visual acuity were the important causes of late presentation. These have implications for government socio-economic policy makers and all stakeholders in eye care delivery. Grassroots economic empowerment of the population, public eye health education, and even distribution of resources for eye care delivery are required to overcome these barriers and improve eye health outcomes.
Author statements Acknowledgements The authors wish to acknowledge the assistance of the staff of the eye clinic at UNTH during the study.
Ethical approval Ethical approval was obtained from the Medical and Health Research Ethics Committee of UNTH.
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Funding 18.
None declared.
Competing interest 19.
None declared.
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