Assessment of barriers to the utilization of eye care services in a tertiary hospital in north-central Nigeria

INTRODUCTION

The World Health Organization estimated that 285 million people worldwide are visually impaired: 39 million are blind and 246 million have low vision. Out of the 285 million visually impaired, 80% can be prevented or cured, and about 90% of the global visual impairment is found in low-income settings.^[1] In Nigeria, the prevalence of visual impairment is almost 5%. It is estimated that 4.25 million adults aged 40 years are visually impaired, and 400,000 adults suffer from severe vision loss.^[2] According to the Nigerian National blindness and Visual Impairment Survey, the prevalence of blindness among adults in Nigeria is 4.2%.^[3] 84% of all causes of blindness were either preventable or treatable. Uncorrected refractive errors were responsible for 57.1% of moderate (<6/18–6/60) visual impairment. Cataract (43%) was the most common cause of blindness (<3/60). Prevalence of cataract-related blindness was 1.8% and glaucoma-related blindness was 0.7%.^[3]

Eye care can be provided in an institution, in the community, or both. It can also involve promotional, preventive, curative or rehabilitative services. There are three types of eye care professionals: Full-time, integrated and community-based (medical and non-medical). The method of delivery and the type of eye care provided are based on public health needs, desired health outcomes, available resources and the current socioeconomic context.^[4] According to the Global Eye Care Action Plan of 2013 (IAPB, 2015), eye care services must be available, affordable and accessible to the people to reduce the prevalence of visual impairment.^[5] Vision Health Initiative, a coordinated national public health framework to prevent vision loss and blindness, was designed by the Centers for Disease Control and Prevention (CDC).^[6] To enhance national eye health, addressing inequities in eye care is a significant component of the CDC project.^[6] An essential component of this approach is paying more attention to inequities in high-risk populations. High-risk factors for eye disease and/ or vision loss that have consistently been identified include (1) increasing age, (2) racial/ethnic minority, (3) presence of diabetes mellitus and (4) low socioeconomic status.^[6]In addition, every one of these elements has been linked to accessibility and underutilisation of eye care services. Another important factor in the underutilisation of eye treatment is living in a rural location without health insurance.^[6]

Existing barriers limit access to eye care in Nigeria.^[2]According to reports, the use of the country’s current eye care infrastructure is as low as 25% in Nigerian communities, well below the 90% goal level. Compared with the need for resource allocation, the issue of low use of eye care services in underdeveloped nations has received less attention. Evidence suggests that even when eye care services are offered, potential beneficiaries rarely make use of them. Prior prevalence surveys in affluent countries have shown a low level of eye care consumption.^[7] Factors such as cost, lack of awareness, cultural beliefs and personal factors were identified as barriers to eye care utilisation. Uncorrected refractive errors and cataract are the leading causes of avoidable blindness and visual impairment, most commonly found in rural, often remote, underdeveloped areas. However, most hospitals and health care centres are located in urban areas.^[7] The development of evidence-based eye care initiatives that would target the underserved and increase the uptake of eye care services should therefore be aided by a better knowledge of the barriers to the utilisation of eye care services in general.^[8]

This study provided data on barriers to the utilisation of eye care services in Lafia, Nasarawa State, and also determined how these barriers can be minimised.

MATERIALS AND METHODS

This was a descriptive cross-sectional study of adults aged 18 years and above residing in Lafia Local Government Area (LGA), Nasarawa State, who consented to participate. Lafia is one of the thirteen Local Government Areas in Nasarawa State. It is located between Latitude 8⁰ 30' 0" N and 9⁰ 0' 0" N and Longitude 8⁰ 10' 0" E and 9⁰0' 0" E. It is the capital of Nasarawa State and has an estimated population of 330,712 (169,398 males and 161,314 females, according to the 2006 census). Due to its cosmopolitan nature, the area hosts members of diverse affiliations. It is the most populous Local Government Area in Nasarawa State. Lafia consists of 13 wards: Adogi, Agyaragun Tofa, Arikya, Ashigie, Assakio, Akurba, Chiroma, Gayam, Wambai, Makama, Kwandere, Wakwa and Zanwa. The wards selected as sampling units for the study were purposively sampled.^[9] And they include: Akurba, Chiroma, Gayam, Makama, Kwandere/Shabu and Zanwa. Lafia LGA has a land area of 2797.53 km² and a population density of 130 persons per km².

The Hausa and English languages are spoken in Lafia, while Islam and Christianity are practised there. Agricultural practice is the main occupation of the majority. However, some people are involved in business and general services. A few other people are civil servants. The only public tertiary hospital in Lafia is Dalhatu Araf Specialist Hospital. Participants in the study were aged 18 years and above, living in Lafia, Nasarawa State, and who voluntarily consented to participate. Excluded participants were homeless people and those who were blind. A total of 409 participants were included in this study. A multistage sampling method was used. In the first stage, six wards were randomly selected from the 13 wards in Lafia LGA: Akurba, Chiroma, Gayam, Makama, Kwandere/Shabu and Zanwa. They were arranged in ascending order of population size, and the cumulative population of all the wards was obtained in separate columns. In the second stage, a random sampling with probability proportional to size was used to select clusters. The sampling frame consisted of clusters (wards) of enumeration areas in Lafia LGA based on the National Population Commission estimated population for 2016. The estimated local government population is 330,712. There were 68 clusters across all wards in Lafia LGA, of which six were selected for the study. The sampling interval (SI) was calculated to be 2,244. The first ward chosen from the sampling frame was done by multiplying the SI by 0.5 (which was randomly selected between 0.1 and 0.9). The ward whose cumulative population fell within the above value was chosen first. The first household in each selected ward was determined by spinning a bottle at the ward’s centre to indicate the direction to take; thereafter, every second house in that direction was chosen to participate in the study. A face-to-face interview was performed by trained research assistants using a structured questionnaire. Supervision was provided during data collection, and the collected data were evaluated for completeness daily. An interviewer-administered structured questionnaire with closed-ended questions, comprising five sections. Section A: Biodata, Section B: Knowledge on availability of eye care services, Section C: Socio-cultural factors affecting utilisation of eye care services, Section D: Economic factors affecting utilisation of eye care services, Section E: Health-system factors affecting utilisation of eye care services. Participants who gave consent were administered the study questionnaires in accordance with the inclusion criteria until the calculated sample size was achieved (n = 409). After the study’s details were thoroughly explained to them. The questionnaires asked about prior use of eye care services and barriers to eye care.

Data collected were cleaned and entered into a computer using IBM Statistical Package for the Social Sciences (SPSS) Statistics version 20 (IBM SPSS Statistics version 20.0). Frequencies, percentages, standard deviation and means were generated. Data were categorised by socio-demographic variables and subjected to descriptive statistical analysis. Frequencies, ratios and proportions were used to summarise categorical variables, while means and standard deviations were used for quantitative variables. The association between variables was measured using the Chi-square test. Odds ratios (ORs) were used to quantify the association between the dependent variable (barriers to access) and the independent variables (gender, age, education level, family income). At a 95% confidence interval, p < 0.05 was considered to be significant.

The dependent variables included knowledge of the availability of eye care services and socio-cultural, economic and health system factors affecting the utilisation of eye care services. The independent variables included socio-demographic characteristics such as gender, age, level of education and economic status.

Data were cleaned, coded and entered into a computer, with an online backup. Analysis was conducted using IBM SPSS Statistics (version 20.0). Data were categorised by socio-demographic variables (age, sex, educational status and economic status) and subjected to descriptive analysis. Descriptive analysis was used to examine the socio-economic profile of study participants and the capacity of hospitals, including the number of eye care providers, available eye health equipment and the number of eye patients treated. Frequencies, percentages and proportions were used to summarise categorical variables, while means and standard deviations were used for quantitative variables. The association between variables was measured using the Chi-square test. Assessment for predictors of barriers to care was done using logistic regression. ORs were used to quantify the association between the dependent variable (barriers to access) and the independent variables (gender, age, education level, family income). At a 95% confidence interval, p < 0.05 was considered to be significant.

This study was conducted in accordance with the tenets of the Declaration of Helsinki and the National Code of Health Research. Ethical approval of the study was obtained from the Human Ethics and Research Committee of the State Ministry of Health, Nasarawa State.

Before data collection, written informed consent was obtained from all subjects after a detailed explanation of the study’s aim was provided in the language each subject understood best. The decision to participate was strictly the patients’ own, and they were told they could withdraw from the study at any time. Data from this study were kept strictly confidential, and the identity of patients was protected by assigning serial numbers, known only to the researcher.

RESULTS

Table 1 below shows the socio-demographic characteristics of the subjects. The average age of the participants (Mean ± SD) is 48.5 ± 13.2 years. Most of the subjects, 27.9%, were between 40 and 49 years old, while only a small percentage, 0.5%, were over 70 years old. The majority of the participants (62.8%) were males, and 39.4% were married. In terms of educational level, about a quarter (24.7%) had informal education, and their main source of livelihood was mainly farming (24.0%). The assessment of monthly income revealed that a large number of subjects – 26.7% – earned between N1,000 and N9,000, while a significant share – 25.2% – earned over N100,000.

DISCUSSION

The mean age of the participants was 48.5 ± 13.2 years, which is similar to the study by Morka et al,^[10] with an age range of 19–70 years. The majority of subjects in this study (27.9%) were between the ages of 40 and 49 years. The majority of the subjects (62.8%) were males, mostly married (39.4%), which is in agreement with a study conducted in Abuja by Ekpenyong et al.^[11] However, in contrast to studies in Enugu by Ezinne et al.^[12] and in Abuja by Ebeigbe et al.,^[7] which found a preponderance of females. The preponderance of males in this study may be due to men in the rural northern part of Nigeria being more exposed. The educational attainment of the subject revealed that about one quarter (24.7%) had informal education, and their primary source of livelihood was farming (24.0%). This study found that the late elderly had less knowledge about and use of eye care services, a finding similar to that of a study in Ghana by Ocansey et al.^[13] This study found that 26.7% of subjects earn between N1000 and N9,000 monthly, and a significant number, 25.2%, earn above N100,000 monthly. This explains why many participants will have difficulty affording eye care services. This is a similar finding to that of a study by Ezinne et al.,^[12] which revealed that 68.0% of the subjects had good knowledge of eye care services in Lafia. Of the 68.0% who had a good understanding of the availability of eye care services in Lafia, only 43.2% learned about them through family and friends. In comparison, there is a knowledge gap in our health facilities, as only 24.1% of health care workers were aware of the availability of eye care services in Lafia. Other studies in rural settings in developing countries recorded similar findings. However, high eye care utilisation rates (60–70%) were recorded in developed countries such as the United States.^[14] Variations in these results may be because most people living in rural developing countries come from low-income families and cannot afford eye care services. In Nigeria, as in other developing nations, there are limited, inexpensive health insurance options, and most are not easily accessible in rural areas. Furthermore, in developing countries like Nigeria, information about the importance of routine eye exams is not readily accessible in rural areas. This study showed that the lower the subject’s educational attainment, the greater the knowledge gap. Indicating that the level of education plays a significant role in their knowledge. This is a similar finding in a study by Emamian et al.^[15] However, in contrast to a study done in India by Nirmalan et al,^[16] this showed that utilisation of eye care services was not highest among those with the highest educational levels. This study revealed that males had better knowledge of eye care services than females, a finding similar to that of Ekpenyong et al.^[11]This study also found a knowledge gap among traders and farmers, who had limited knowledge of eye care services. This contrasts with a survey by Elam and Lee, which found that farmers used eye care services more effectively due to the nature of their work.^[6] This study showed that 24.8% of the subjects complained about a lack of support from family, friends and community members, which in turn affected their decision-making of where to seek care for their eyes, as 34.3% patronised the local eye clinic, as compared to 27.4% that sought care from the health facility. This result is higher than a similar study conducted in Cross River State, Nigeria, where 14.9% visited the PHC, 1.4% sought care in the market and visited a prayer house for healing.^[17]

The study showed that 57.1% of the subjects financed their eye care out of pocket, indicating that insurance coverage has not achieved its mission of universal health coverage, as many subjects had no health insurance. Findings are similar to those of studies by Ervin et al. and Owsley et al., revealing that barriers include a lack of insurance coverage or being underinsured.^[14,18] Similarly, the significant economic factors affecting the utilisation of eye care services among the subjects were that 17.3% complained about the high cost of seeking eye care, a finding similar to that in a study conducted in other rural areas, (Ezinne et al., 2023).^[12] Economic factors affecting the utilisation of eye care services in this study.^[19] Similarly, complaints include high expense on eye care services, inability to afford transport, the cost of eyeglasses and inability to pay for eye surgery.^[14,18] The health system factors affecting utilisation of eye care services in this study revealed that proximity was the primary concern of the subjects, followed by fear of exploitation by health care workers. A similar study conducted by Ezegwui et al.^[20] and Owsley et al.,^[18] expresses the same challenge as distance of the hospitals and eye care service outlets been located in the cities and as such those in need of eye care services find it difficult to travel such distances and some of the subject do not believed that the doctors are genuinely provide their services the way it should be; some believed that the primary intention of the doctors is to exploit them financially when they seek care in the facility. This study further revealed challenges as negative attitude of health workers, long waiting hours before seeing the doctor and hospital bureaucracy and difficulty in fixing appointment with doctor, high cost of seeking eye care services, lack of eye specialist in the facility, lack of skilled human/screening resources, lack of skilled personnel in the rural areas and lack of awareness on the need for eye care. These findings are in support of a similar study conducted by Ebeigbe et al.^[7,18]

In this study, more than half of the subjects (59.9%) had good knowledge of regular health check-ups, as seen in a study by Morka et al. (2020).^[10] However, their knowledge had not informed their decision-making, as the majority (57.2%) had never sought eye care services. Similar findings by Zuhairi^[21] reported a lack of knowledge, and Silva et al.^[22] reported that the quality of eye care services varies globally, with the number of eye care providers per million population in the wealthiest countries being 9 times that in the poorest countries.^[5] Hence, this study’s low utilisation of eye services suggests that, in the absence of appropriate interventions to improve utilisation, the prevalence of visual impairment and blindness in this community may rise.

CONCLUSION

In assessing the barriers to the utilisation of eye care services in Lafia, Nasarawa State, this study identified various barriers that prevent people from easily accessing eye care services in Lafia. The study found that the majority of participants knew about eye care services in Lafia but had never sought them due to a lack of support from family members, friends and community members. Although education level and gender are important determinants of this gap, it is mainly attributable to economic status. Utilisation of eye care services in Lafia is low, and males use them more than females. Financial constraints, as most participants pay for services out of pocket, and distance were significant barriers to eye care service utilisation.