https://orcid.org/0000-0001-9307-0283
Figures
Abstract
Glaucoma currently accounts for 11% of irreversible visual loss worldwide. Due to many factors, patients do not access the glaucoma care pathway and present late with poor vision, while many are undiagnosed or untreated. These factors may be personal-level dispositions or Institutional-level dispositions, limiting the awareness, diagnosis, and treatment of glaucoma or adherence to medications or follow-up clinic visits. This scoping review followed the JBI methodology for scoping reviews and was pre-registered on the open science platform (https://osf.io/wqx57/?view_only=727eb6c803764509a2809e5d0794e214). The PUBMED, EMBASE, WEB OF SCIENCE, AJOL, and GOOGLE SCHOLAR databases were systematically searched for studies published in English between 1990 and June 2023. Data were extracted and analysed along a conceptualised framework of factors limiting access to glaucoma care in Nigeria. Of the 336 records retrieved, 13 studies were included in this scoping review. These included one (1) mixed method (quantitative/qualitative) study, three qualitative studies, and nine quantitative studies spanning 2008–2022 covering eight states and 2,643 sampled respondents. Nine studies reported personal-level dispositions limiting glaucoma care, including low levels of education, unemployment, gender, living distance from the hospital, cost of care, and faith/religion. Four reported institutional-level dispositions, including the lack of proper equipment and expertise to diagnose or manage glaucoma. The factors limiting Glaucoma care in Nigeria are varied and may act alone or combined with other elements to determine the awareness or knowledge of glaucoma, uptake of glaucoma surgery, medication adherence, or clinic follow-up. While most of these factors limiting glaucoma care in Nigeria may be amenable to policy, a bottom-up approach is needed to improve the community’s awareness and uptake of glaucoma services. A shift from the over-dependence and reliance on tertiary hospitals, which are often far away from the people who need them, is required to bridge the information and service gap currently being witnessed.
Citation: Obasuyi OC, Yeye-Agba OO, Ofuadarho OJ (2024) Factors limiting glaucoma care among glaucoma patients in Nigeria: A scoping review. PLOS Glob Public Health 4(1): e0002488. https://doi.org/10.1371/journal.pgph.0002488
Editor: Julia Robinson, PLOS: Public Library of Science, UNITED STATES
Received: August 10, 2023; Accepted: December 19, 2023; Published: January 26, 2024
Copyright: © 2024 Obasuyi et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Data Availability: All relevant data for this study are publicly available from the OSF repository (https://doi.org/10.17605/OSF.IO/WQX57).
Funding: The authors received no specific funding for this work.
Competing interests: The authors have declared that no competing interests exist.
Introduction
Glaucoma is the “silent thief of sight” because it remains asymptomatic mainly throughout a significant part of the natural course of the disease, and patients only begin noticing symptoms at an advanced stage. Globally, glaucoma is responsible for about 11% of irreversible visual loss in adults 50 years or older [1, 2]. In Nigeria, the prevalence of glaucoma is 5%, and 94% of people with glaucoma are either undiagnosed or untreated. Most patients present blind to the clinic [3–5], and despite the high prevalence of glaucoma blindness, awareness about the disease is still poor [6, 7]. The natural course of the disease provides an avenue for preventing glaucoma blindness by improving the awareness of glaucoma, early detection of glaucoma, and treatment adherence [8–10].
As conceptualised by Kyari and colleagues, the Glaucoma care pathway describes the optimum pathway patients follow in pursuing glaucoma care to “non-blindness” [11]. (Fig 1) by providing avenues or access to information about glaucoma, available resources for the diagnosis and treatment of glaucoma, and support for adherence to treatment and hospital visits.
FDR = first degree relative; TEM = traditional eye medication; GPA = glaucoma patient association.
Unfortunately, the glaucoma care pathway may be affected by various factors which prevent optimum care, leading to blindness from glaucoma. Factors peculiar to the individual (individual-level dispositions) like age, gender, socio-economic status, occupation, level of education, and place of residence have been identified as essential social determinants of blindness from glaucoma [11–14]. These factors may limit the awareness of the disease, access to proper diagnosis and available resources to manage or treat glaucoma [15, 16]. Furthermore, systemic factors (Institutional-level dispositions) like poor healthcare funding, inadequate healthcare worker motivation, and lack of trained personnel may prevent the proper diagnosis or treatment of people with glaucoma and limit the ability of the patient to adhere to treatment [11, 17–19]. With the high prevalence of glaucoma, rates of undiagnosed cases, and poor vision at presentation in Nigeria, identifying the factors responsible for the poor utilisation of available resources for detecting and treating glaucoma becomes very important.
While many reports exist about the barriers to either treatment or adherence to glaucoma care, this scoping review aimed to identify how these factors limit the utilisation of glaucoma care in Nigeria by mapping the available evidence on the factors limiting glaucoma awareness, diagnosis, treatment, adherence, and follow-up of glaucoma among glaucoma patients in Nigeria.
Methods
Protocol
A preliminary search of MEDLINE, the Cochrane Database of Systematic Reviews, and JBI Evidence Synthesis was conducted, and no current or underway systematic reviews or scoping reviews on the topic were identified. This scoping review followed the JBI methodology for scoping reviews [20] and was pre-registered on the open science framework. Pre-registration details can be found here: (https://osf.io/wqx57/?view_only=727eb6c803764509a2809e5d0794e214).
Conceptual framework
We conceptualised that a constellation of factors which could be due to personal-level dispositions stemming from the social determinants of blindness [12–14] or Institutional-level dispositions [17–19] act together rather than solitarily along the glaucoma care pathway preventing the receipt of optimum glaucoma care (Fig 2). In this conceptual model, we imagine that these factors associated with glaucoma care act at different points of the pathway, preventing the achievement of “non-blindness”.
Eligibility criteria
The eligibility criteria for this review were based on the Participants, Concept, and Context (PCC) framework.
Participants.
All studies of Nigerian patients diagnosed with glaucoma and healthcare workers managing glaucoma were included in this review. Studies of Nigerian patients diagnosed with any other eye disease were excluded.
Information sources
This scoping review considered observational studies, including prospective and retrospective cohort studies and analytical cross-sectional studies. This review also considered descriptive observational study designs, including case series and descriptive cross-sectional studies for inclusion. Qualitative studies on qualitative data describing the experiences of glaucoma patients, caregivers, and health workers were also included. Text and opinion papers were not considered for inclusion in this scoping review.
Search strategy
The search strategy was designed to locate all published studies meeting the eligibility criteria. An initial limited search of MEDLINE and PUBMED was undertaken to identify articles on the topic on June 4, 2023. The text words contained in the titles and abstracts of relevant articles and the index terms used to describe the articles were used to develop a complete search strategy for (PUBMED, EMBASE, WEB OF SCIENCE, SCOPUS, and AJOL) see S1 Fig. Database search was carried out between 7th and 12th June 2023. The search strategy, including all identified keywords and index terms, was adapted for each included database and information source. The reference list of all included sources of evidence was screened for additional studies.
Only studies published in English were included in the search. Furthermore, the search period consisted of all studies published between 1990 and June 2023 to enable the inclusion of all relevant articles on the subject.
Study/Source of evidence selection
Following the search, all identified citations were collated and uploaded to Rayyan(www.rayyan.ai), and duplicates were automatically removed. Titles and abstracts were screened independently by OCO, OOY, and OJO against the inclusion criteria for the review. After reviewing titles and abstracts, OCO and OJO independently assessed the full text of selected citations in detail against the inclusion criteria. Reasons for excluding sources of evidence in the full text that do not meet the inclusion criteria were recorded and reported in the scoping review. Any disagreements between the reviewers at each stage of the selection process were resolved through discussion or with an additional reviewer/s. The search results and the study inclusion process are reported and presented in the Preferred Reporting Items for Systematic Reviews and Meta-analyses extension for scoping review (PRISMA-ScR) flow diagram [21, 22].
Data extraction
Data were independently extracted from papers included in the scoping review by OCO, OJO and OOY using a data extraction tool developed by the reviewers. The data extracted included specific details about the participants, concept, context, study methods, and key findings relevant to the review question/s.
Any reviewer disagreements were resolved through discussion or with an additional reviewer/s. Authors of papers were contacted to request missing or other data, where required.
Methodological quality appraisal
This scoping review did not appraise any methodological quality or risk of bias in line with the guidance on scoping reviews [23].
Synthesis
The synthesis involved a narrative analysis of the presented results from the studies based on the conceptual framework of the factors limiting glaucoma care among patients in Nigeria. Results were independently synthesised by OCO and OOY and compared before analysis. Any differences in synthesis were resolved by discussion or with an additional reviewer.
Results
Literature search
Three hundred thirty-six (336) records were retrieved on a literature search (Fig 3), including 56 duplicates. Two hundred eighty-one (280) records’ abstracts were screened, and 24 full texts were sought for retrieval. The full texts of three (3) reports were not retrieved and, hence, were not included in the final full-text assessments. Following full-text reviews, eight (8) studies were excluded because they failed to meet the eligibility criteria (wrong concept). Thirteen (13) reports were included in the final analysis and data synthesis. Of these, there was one (1) mixed method (quantitative/qualitative) study [15], three (3) qualitative reports [3, 11, 24], and nine (9) quantitative studies [16, 25–32].
Study characteristics
Studies included in this report spanned the periods between 2008 and 2022, covering eight states, including Oyo State [15, 29, 31], Lagos [26, 33], Osun [27], Bauchi [3, 28], Enugu [16, 25, 32], Benin [30], Kaduna and Abuja FCT [11] (Table 1). A total of 2,643 respondents were sampled in the included reports of this review, and their socio-demographic data is shown below in Table 2.
Factors limiting glaucoma care
The factors limiting Glaucoma care are detailed in Tables 3 and 4 below. Nine studies focussed on personal-level dispositions limiting glaucoma care. Of these nine studies, five focussed on awareness and knowledge [11, 15, 16, 27, 33], two focussed on factors impacting the diagnosis of glaucoma [11, 29], four on factors limiting glaucoma surgical uptake [3, 16, 27, 34]. In addition, three studies looked at patient adherence to medication [3, 15, 34], while four studied factors limiting clinic follow-up [15, 25, 30, 31]. No study reported personal-level dispositions restricting the uptake of medical glaucoma care.
On the other hand, only four studies reported results regarding the institutional-level dispositions limiting the provision of glaucoma care. While three studies reported on the institutional factors limiting the diagnosis of glaucoma [11, 24, 32], two studies reported on glaucoma surgical uptake [24, 32], and one reported on clinic follow-up visits [25]. No study reported on the institutional-level dispositions affecting the medical treatment of glaucoma or the adherence to medical therapy.
Factors which limited the awareness of the disease or avenues to access care included low levels of education [15, 16, 26], no previous eye checks [15, 26], female gender [15, 16, 27], older age [16], leaving greater than 10km from the hospital [16], the stigma around blindness [11], poor access to glaucoma information [11] and unemployment [16]. Lack of information, lack of felt need, long distance to the hospital, and high costs [11, 29] limited access to proper glaucoma diagnosis. Furthermore, fear of the surgical procedure, faith/religious beliefs and a lack of visual improvement following surgery [3, 16, 26, 27] were the factors identified that limited the uptake of glaucoma surgeries. Adherence to medical treatment and clinic visits was hampered by costs of medications and transportation, faith/religious beliefs, lack of availability of drugs and the fear of medication side effects [3, 15, 25, 26, 30, 31]. In addition, the factors which were reported to limit the diagnosis of glaucoma included a Lack of functional equipment [24, 32], a lack of expertise in glaucoma diagnosis, high costs of accessing care [32] and a lack of a proper referral system [11]. The poor satisfaction with visual results following surgery, reluctance to offer surgery, the fear of complications, and the costs prevented the uptake of glaucoma surgeries [24, 32]. Discourteous staff were why patients were unwilling to return for clinic visits [25].
Fig 4 describes how these factors act along the glaucoma care pathway to limit optimum care and the achievement of “non-blindness”.
Discussion
This scoping review set out to map the available evidence on the factors limiting glaucoma care among glaucoma patients in Nigeria and to determine how these factors impact the glaucoma care pathway. Personal-level dispositions limiting glaucoma care were low levels of education, unemployment, gender, living distance from the hospital, cost of care, and faith/religion. In contrast, institutional-level dispositions limiting glaucoma care included the lack of proper equipment and expertise needed to diagnose or manage glaucoma. These factors limiting glaucoma care in Nigeria may act alone or with other elements to restrict entry into the glaucoma care pathway (Fig 4).
Awareness or knowledge of glaucoma is essential to getting into the glaucoma care pathway. Poor education prevents access to glaucoma care by limiting the knowledge or understanding of glaucoma and the ability to get an early diagnosis [34, 35]. Furthermore, low levels of education are directly correlated with employment, which determines the ability of patients to afford care [36]. The cost of care for glaucoma is relatively high, estimated to cost about 394 USD for medical treatment and 283 USD for surgical care in Africa [37, 38]. The ability to afford care is an essential factor in accessing glaucoma services, and cost was a recurring factor limiting access to glaucoma services in this review. A combination of low levels of education, unemployment, or unskilled labour potentiates low levels of glaucoma awareness and knowledge, leading to blindness from glaucoma [39].
The personal-level dispositions/social determinants of blindness limiting glaucoma care in Nigeria mirror those described in other regional and African countries [40, 41]. These social determinants, which act at the individual level, like living environments, transport mobility, and social support to determine access to health care, are aptly captured by Pechansky’s dimension of availability and accommodation [42]. Living farther from the hospital increases the patient’s geographical inaccessibility to glaucoma information, diagnosis, and care, potentiating their inability to adhere to follow-up visits or purchase medications [43, 44]. While patients’ residence may not be modifiable, providing Primary healthcare-driven glaucoma services may serve as an answer to providing glaucoma services to people far away from secondary or tertiary hospitals [44].
Penchansky describes the dimension of acceptability as the factors which promote the utilisation of a service by actively seeking the service or product out [42]. In health systems, this is driven by the social determinants of health, like personal and social values, culture, gender, and patient autonomy [45]. These factors limit access to diagnosis, surgical uptake, and follow-up in accessing glaucoma care. The female gender does not have the economic, social, and cultural autonomy to make health-related decisions, which either delay health-seeking or prevent access to health care entirely [45]. Culture or religion may influence health-seeking behaviour or the response to health instructions regarding medication use or uptake of surgery.
Sub-saharan Africa has only 2.9 surgeons per million population [46], and Nigeria had only five glaucoma specialists until 2015 [38], while another survey in Botswana in 2015 showed the availability of only two Ophthalmologists [47]. In government hospitals, eye care equipment is either broken down or unavailable [48]. The dearth of qualified personnel and the lack of the necessary equipment required to diagnose glaucoma means that patients who may have benefitted from an early diagnosis end up slipping through the cracks of the glaucoma care pathway. Furthermore, the patient’s dissatisfaction from not getting the best service may prevent or deter the patient’s return in the future. The patient may also inform the community about the non-existence of proper hospital equipment or poor service, leading to poor utilisation and uptake of services. The same holds for discourteous hospital staff. Poor behaviour of hospital staff towards patients does not instil confidence or create an atmosphere of trust, which is vital in managing glaucoma and other eye conditions.
The factors limiting access to glaucoma care do not act in isolation. They work with other elements to affect the care of glaucoma across the glaucoma care pathway. Policies to provide financial protection for people seeking glaucoma care, improve education services, and provide eye care information in Primary healthcare or community health sessions are necessary to break this cycle leading to preventable blindness from glaucoma. In addition, better funding for eye care, training and retraining of eye care workers and better staff disposition to clients and equipment are needed to reduce or eliminate the institutional-level dispositions limiting glaucoma care in Nigeria.
Evidence gaps/Limitations
While there were many reports in this review regarding the factors limiting glaucoma awareness, diagnosis, surgical treatment, follow-up, and adherence to medications by patients, there were no reports on factors limiting the medical treatment of glaucoma among patients with glaucoma. Furthermore, there were no reports regarding institutional-level dispositions limiting or influencing medication adherence during glaucoma care. Generally, there were few papers regarding institutional factors compared to patient factors. More evidence is needed regarding the contribution of institutional factors to limiting access to glaucoma care, especially regarding the medical treatment of glaucoma. Furthermore, mixed-method approaches to determining evidence on glaucoma care are recommended.
Conclusion
The factors limiting glaucoma care in Nigeria prevent patients from accessing the needed care, ranging from personal factors like faith and culture to systemic factors like gender inequality, poor education, unemployment, and geographic inaccessibility. While most of these factors may be amenable to policy, a bottom-up approach is needed to improve the community’s awareness and uptake of glaucoma services. A shift from the over-dependence and reliance on tertiary hospitals, which are often far away from the people who need them, is required to bridge the information and service gap currently being witnessed. Furthermore, training and retraining of ophthalmologists in providing high-quality glaucoma care is vital if Nigeria is going to reduce the number of people going blind from glaucoma. In addition, it is crucial to develop a structural approach to providing high-quality, easy-to-understand information on glaucoma and eye health. Finally, more evidence needs to be generated regarding the contribution of our institutions and eye care workers to preventing glaucoma services.
Supporting information
S2 Fig. Data extraction instrument for observational studies.
https://doi.org/10.1371/journal.pgph.0002488.s002
(PDF)
S3 Fig. Data extraction instrument for qualitative studies.
https://doi.org/10.1371/journal.pgph.0002488.s003
(PDF)
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