Awareness and knowledge of glaucoma among primary care givers in a developing country

Background: Glaucoma is the leading cause of untreatable blindness throughout the world, and it is commoner in the black race; therefore, primary health care givers should have some knowledge of glaucoma. The aim of this study is to determine the knowledge of primary health care givers about glaucoma in Sagamu Local Government area of Ogun State. Materials and Methods: A cross-sectional descriptive study of primary care givers in Sagamu, Ogun Sate was carried out between March and May 2010. A structured, self-administered questionnaire was used to collect information on the awareness and knowledge of glaucoma from all registered primary health care givers working in Sagamu, Ogun State. The data was analyzed using SPSS 15. Results: One hundred and eighty-one workers responded (97.8%). There were 124 females (68.5%). Age range was 25 to 64 years, mean 41.2 ΁ 8.7 years. There were 68 (37.5%) physicians, 95 (52.5%) nurses, and 18 (10%) other workers. Ninety-seven percent of the workers were aware of glaucoma. Seventy-seven (42.5%) had good knowledge of glaucoma, while 104 (57.5%) had poor knowledge. Physicians were seven times more likely to know about glaucoma than nurses, while nurses were 4 times more likely to know about glaucoma than other community health workers, and these were statistically significant P < .0001. Younger age group between 25 and 34 years was 2.3 times likely to know of glaucoma than middle-aged. Conclusions: Though awareness of glaucoma was high, knowledge about glaucoma was, however, low among the study population. There is a need to sensitize all cadres of health staff, particularly the community health workers about glaucoma.

Keywords: Glaucoma awareness, knowledge, primary health workers

Glaucoma is the second cause of blindness worldwide and the leading cause of irreversible blindness. ^[1] The recent survey of blindness in Nigeria revealed that glaucoma was the second cause of blindness in those older than 40 years and responsible for 16.7% blind. ^[2] Primary open-angle glaucoma (POAG) which is the commonest type runs an insidious course; it is painless, and heredity is a strong risk factor. Studies have shown that POAG is commoner in the black race, difficult to manage, and it runs a relentless course to blindness. ^[3] However, early presentation and early treatment can prevent blindness. ^[4] Awareness and knowledge of a disease are major determinants in seeking medical help early and may also influence drug compliance. ^[5] Previous studies had shown that race, education, and a family history of glaucoma are important in the awareness of glaucoma. ^[6] The white race is more likely to be aware of glaucoma than the black race, likewise, a person with college education is more likely to be aware than one without. ^[7] People that had family members blind from glaucoma are also likely to be aware of the disease, and people are likely to obtain information about glaucoma from their doctors. ^[8],[9] Population studies on awareness and knowledge of glaucoma are sparse in predominantly black populations. In a study done in Ghana, people in higher socio-economic groups were 9 times more likely to know about glaucoma than those in lower socio-economic group. ^[10] In developing countries, there is limited direct access to the ophthalmologist such that primary health care givers are often contacted first in private clinics, and all other primary health facilities. Early symptoms of glaucoma should be recognized for early appropriate referral. Primary health care givers who are the major health care providers in the rural areas are important agents of health behavioral change as they have the advantage of disseminating heath information in the community. Private practitioners working in urban areas are also designated as primary eye care providers and are expected to have enough knowledge about the disease for accurate information. Therefore, this study was conducted to determine the knowledge of primary health care givers about glaucoma.

A cross-sectional, descriptive study of knowledge of primary health care givers about glaucoma was conducted in Sagamu local government of Ogun State using self-administered, close-ended questionnaires. The Local Government has one tertiary institution, one General Hospital which is a secondary center, 2 health centers, 4 health posts, and 85 registered private hospitals/clinics. The health workers in the tertiary and secondary health institutions were excluded. The study was conducted between March and May 2010. Approval for the study was granted by the ethical committee of Olabisi Onabanjo University Teaching Hospital. In addition, written informed consent was obtained from all the subjects after explaining the purpose of the study. The questionnaire was pretested on health care workers of Iperu General Hospital in a nearby Ikenne Local Government area, and consequently, the questionnaire was modified for the study. All health workers in the primary health care centers formed the study population. The questionnaire was divided into two sections. The first section consisted of the socio-demographic data and medical history of hypertension, diabetes, trauma to the eyes, use of spectacles, blindness in first and second-degree relatives, and willingness to come to the tertiary center for a comprehensive eye examination. The second section was on the knowledge of glaucoma. The result was subjected to statistical analyses using SPSS version 15. Means were compared with Student t test. P values were significant at P < 0.05. Proportions were compared using Odds Ratio (OR) and 95% Confidence Interval (CI). In order to estimate knowledge of glaucoma, 11 responses were tested. Every correct answer attracted a score of one (1), while a wrong response attracted a score of zero (0). A satisfactory knowledge was taken as 66.7% of total score; therefore, less than 7 (63.6%) was taken as poor knowledge of glaucoma.

Awareness of glaucoma was defined as having heard of glaucoma, while knowledge was defined as having some correct understanding of the disease. Tertiary education was defined as any post-secondary school education.

A total of 181 out of 185 primary health care givers responded to participate in the study giving a response rate of 97.84%. There were 124 females (68.5%) and 51 males with M: F of 1:2.3. Their ages ranged from 25-64 years with a mean of 41.2 ± 8.7 years [Table 1]. The most common age group was 45-54 years. There were 68 doctors (37.6%), 95 (52.4%) nurses, and 18 (9.9%) others. The others comprise of community health officers 2 (11.1%), CHEWS 14 (77.9%) community health educator 1 (5.5%), community laboratory technologist 1 (5.5%).

One hundred and seventy-eight (98.3%) had tertiary education. Fifty-two of the respondents (28.7%) wore glasses for distance, while 75 (41.3%) wore glasses for near; 13 (17.8%) were hypertensive, and 2 (1.1%) were diabetic. Ten (5.5%) had past history of injuries to their eyes, 38 (21.0%) had blurring of vision, and 26 (14.4%) had a family history of blindness. In those that had family history of blindness, 1 was a sibling, 4 were parents, 8 were uncles and Aunts, 12 were grandparents, and 1 a cousin. Only 27 workers (15%) have had a comprehensive eye examination in a tertiary center.

Ninety-seven percent of the workers were aware of glaucoma, and this information was majorly obtained while in school by 163 (90.1%) respondents, school and media 6 (3.3%), school and relatives 5 (2.8%), school and clinic 1 (0.6%), and relatives only 1 (0.6%).

Seventy-seven (42.5%) had good knowledge of glaucoma, while 104 (57.5%) had poor knowledge. Approximately half (49.8%) of the respondents indicated that glaucoma was a blinding disease, 45.7% that it affected the optic nerves, 66.1% that it is caused by raised eye pressure, and 26.8% did not confuse glaucoma with cataract, while 62.5% said that it could affect any age. On treatment, 68.4% indicated that it could be operated, while 67.3% said that drugs could be used [Table 2]. Univariate analysis showed that doctors were 7 times more likely to have good knowledge of glaucoma than nurses (P < 0.0001) and 31 times more than others, while nurses were 4 times more likely to know about glaucoma than others [Table 3]. Younger health workers within the 25-35 year age group had more knowledge of glaucoma compared to other health workers in the older age group (P < 0.05) [Table 4].

Awareness and knowledge of a disease are important determinants of health-seeking behavior of individuals. Health workers disseminate information about diseases on interaction with patients; they are, therefore, indispensable in giving information about glaucoma. Community nurses and community heath extension workers who are in charge of the primary health care centers and health posts are closer to the people at the grass root. They are usually the first point of contact when there is a need to seek medical advice, thus if they are ill-informed about a condition, especially glaucoma, the risk of community misinformation and wrong counseling which will in turn lead to late presentation will be high. A good knowledge of glaucoma is expected to positively influence early presentation. Private practitioners have also been found to be important agents of health behavioral change as they have opportunity to affect the population. In Australia, they were found to affect at least 80% of the population each year. ^[11] In this study, majority of the primary health care givers were private practitioners, suggesting the importance of this group in health delivery and dissemination of health-related information in the state.

The level of awareness of glaucoma by all cadres of health workers was high (93%); however, the knowledge of glaucoma is low (42.5%). Knowledge rather than awareness is more likely to invoke positive and favorable response to diseases. Several workers had attributed correct knowledge of glaucoma to level of education, especially higher college education. ^[6] Although all the health workers had secondary school education, only the doctors actually had college education (university), and the others had tertiary education specific to their profession; therefore, the depth of knowledge of glaucoma is expected to vary accordingly.

Our study showed that most of the respondents knew that glaucoma is caused by high pressure in the eyes, but nearly all thought that it is a painful disease. This is unfortunate since the painless nature of chronic open-angle glaucoma is one of the factors responsible for late presentation. Furthermore, primary health care givers were found to confuse glaucoma with cataract by not appreciating that blindness from glaucoma is permanent. However, nearly all cadres of health workers agree that glaucoma could be treated with drugs.

This study revealed that doctors have more knowledge of glaucoma, 7 times more than nurses and 31 times more than other health workers, confirming the reports of previous workers that those with higher education above secondary school level are more knowledgeable about glaucoma. ^[7] There is paucity of information about glaucoma to primary health care givers, especially non-doctors.

In this study, only 3.3% of respondents received additional information from the media, suggesting paucity of information from this source. Perhaps health workers are at work when health programs are being aired. However, this source should be explored so that health education on glaucoma could be aired and printed in both English and local languages. ^[8] Our findings are in agreement with Sathyamangalam et al. in India and Livingstone et al. in Australia that younger age group are more likely to have a good knowledge of glaucoma than the middle-aged and elderly. ^[8],[12] This is presumably due to a better reading culture by the younger generation and recent technological transfer of knowledge from the internet. It may also reflect a changing curriculum in schools of health technology where most primary healthcare givers are trained.

Interestingly, a positive family history of glaucoma in 26% of our respondents did not influence knowledge of glaucoma. Generally, patients in developing countries and their relatives are reticent about discussing their health problems, thereby reducing information about inheritable diseases. This setback will have a negative influence on awareness of glaucoma. The importance of primary health care givers as informants to patients at the grass root level cannot be over emphasized in a blinding disease such as glaucoma. Therefore, an accurate knowledge of glaucoma is required for accurate information. That only a few workers wanted a comprehensive eye health might suggest a care-free attitude towards ocular health or ignorance of glaucoma. In a study conducted by Van Zyl Lm et al. among general practitioners, only 53% of respondents considered the ability to diagnose glaucoma as important despite its being a major cause of irreversible blindness in the world. ^[13] After performing an up skill intervention, more of them were able to recognize/diagnose glaucoma, confirming the value of workshop and seminars among primary health care givers.

We, therefore, conclude that primary health care givers and indeed all health workers need to be educated on causes of blindness, especially glaucoma through seminars, workshops, and skill acquisition programs in order to create knowledge of the disease, early presentation, and early intervention.

Dr. Ogunlesi Tinuade, Department of Pediatrics, Olabisi Onabanjo University Teaching Hospital, Sagamu

Source of Support: None, Conflict of Interest: None

DOI: 10.4103/1755-6783.144997

[Table 1], [Table 2], [Table 3], [Table 4]