A total of 1881 patients were screened at 24 outreaches in South West Nigeria, among which 120 glaucoma cases/suspects were identified. There were more males (56.7%) than females (43.3%). More than half of the patients (53.7%) had no education or only primary school education, while less than a third (21.9%) had tertiary education. Forty percent of the patients had no personal earnings and depended solely on family, relations and friends, while 60 % had some personal earnings. About 36.5% of the patients were either retired or unemployed. Table 1 shows the socio-demographic characteristics of the patients. At the outreach, 113 (94.2%) patients had eye complaints, of whom 85 (75.2%) had visual blurring. Sixty-nine (57.5%) patients had an eye check-up at an eye care outreach or hospital prior to the current study, while 51 (42.5%) patients had never had an eye check-up in the past. About one quarter of the patients (25.8%) knew someone who was blind and 22 (18.3%) said that the person was a relation.
Patients’ eye care practices: More than half of the patients (67 55.8%) had attended one or more eye outreach in the past, and 16 (23.8%) had previously attended 2 or more eye outreaches. Despite being referred for further evaluation for possible glaucoma, 41 (34.2%) had failed to do so. At these outreaches, the patients said they were examined, given spectacles or eye drops at a cost. These outreaches were organized by different clinics, hospitals, and political aspirants who sponsored some of the outreaches as part of their political/electoral campaign. Two patients who had attended an outreach sponsored by some political aspirants said “we were not examined because the crowd was large but some of us got free eye drops.” One patient had attended up to 15 different outreaches and had also been to several hospitals in the past. Also, another respondent had attended 10 outreaches in the past but did not follow up at any hospital. Reasons for not following up for further glaucoma evaluation included the following: 29 (24.2%) patients did not think that the eye problem was serious, 15 patients (36.6%) said they prayed and believed they did not have any serious eye problem, 7 patients (17.1%) said they were not told to visit a hospital, while 7 patients (17.1%) said they did not have money to visit the hospital and elected instead to attend a future free outreach.
Twenty-four (20%) patients diagnosed with glaucoma followed up at a hospital prior to the current outreach. They were prescribed medical therapy, none of whom were using glaucoma medical therapy at the time of the current screening. Of these, two patients said they never bought the prescribed glaucoma medications, while the remaining had stopped using them prior to the current outreach. Common reasons reported for discontinuing therapy included depletion of dispensed medications, inability to purchase additional medications, and belief that the medication was unnecessary.
Patients’ awareness and knowledge about glaucoma
Fifty-six (46.7%) patients were aware of glaucoma, of whom 39 (69.6%) patients could correctly describe the disease by answering at least one question assessing knowledge correctly. A majority of the patients (66.1%) heard about glaucoma from a health care provider at an outreach center or hospital. Other sources of information were the media or from friends and neighbors. Ten (8.3%) patients gave a positive family history of glaucoma. The determinants of glaucoma awareness are shown in table 2. In the bivariate analysis, the patients were more likely to be aware of glaucoma if they had a minimum of secondary school education, were of the male gender, were civil servants, had a positive family history of glaucoma or blindness and had an eye check in the past. All of these variables were statistically significant (Table 2). However, on multivariate logistic regression analysis, having a minimum of secondary school education (OR 9.7, 95% CI 3.18 – 29.92) and having an eye check in the past (OR 6.2, 95% CI 1.96 – 19.78) remained statistically significant. The patients who had a minimum of secondary school education were 9 times more likely to be aware of glaucoma than those who had no education or had only a primary school education. The patients who had an eye check up in the past were 6 times more likely to be aware of glaucoma than those who did not have an eye check up in the past after controlling for other variables (Table 3). Only 7 patients (5.8%) had a good knowledge, with a minimum score of four, while 12 patients (10%) had a fair knowledge. The other patients had a poor knowledge, with only 32.5% being able to answer at least one question correctly.
Providers’ knowledge of glaucoma
Four nursing staff who worked at the outreach units were interviewed on their knowledge about glaucoma. They showed good knowledge about glaucoma, as evidenced by their responses: “Glaucoma is the major cause of irreversible blindness all over the world, because it does not present with symptoms at the early stage” (J.O, 58 years, 10 years’ nursing experience at the outreach). “Glaucoma is a hereditary condition, is a painless eye disease which will cause serious impairment to the vision” (M.O, 48 years, 8 years’ experience). “Glaucoma is an eye disorder that is characterized by impaired vision, especially the peripheral visual field, then increase intraocular pressure, then damage to the optic nerves” (B.O, 34 years, 8 years’ experience).
They were also asked about their opinion on glaucoma patients’ approaches to accessing eye care, specifically the common practice of attending serial screenings rather than seeking definitive continuity of care. One theme that appeared consistently was a recognition of patients’ financial constraints, which may prevent patients from using their medications or even presenting at hospitals after attending the outreaches. “You know when you tell them that when you’re coming even with your referral letter you have to pay for a card, you have to be registered to be seen by the consultant and it will cost you money, some people will say haaaahaaa (exclamation)…, l don’t have money… you understand, that is the major reason, why they are not coming” (Mrs C, 46 years, female, 10-year experience). Another theme was poor knowledge and awareness among the patients. One of the nurses said: “Then ignorance at times, because some of them still believe they can still go to a traditionalist and they can still treat their aliments locally” (Mrs C).
The nurses felt that phobia of large institutions like a tertiary hospital was a major barrier to glaucoma patient care, as the patients preferred to be managed at smaller health care facilities closer home. They also expressed belief that patients were more likely to seek proper hospital care after being referred if they possessed a good knowledge of glaucoma and were financially able to pay for care.: “Patients who come to hospital are financially ready, and all the taboo has been dispelled and they know that they will receive adequate treatment when they get to the tertiary hospital, because it is filled with specialists” (J.O.).