CATARACT BLINDNESS AND BARRIERS TO CATARACT SURGICAL INTERVENTION IN THREE RURAL COMMUNITIES OF OYO STATE, NIGERIA. OLULEYE T.

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1 CATARACT BLINDNESS AND BARRIERS TO CATARACT SURGICAL INTERVENTION IN THREE RURAL COMMUNITIES OF OYO STATE, NIGERIA. BY OLULEYE T.S, [FWACS, FMCOPH] C / O DEPARTMENT OF OPHTHALMOLOGY, UNIVERSITY COLLEGE HOSPITAL IBADAN, NIGERIA. KEY WORDS: CATARACT BLINDNESS, BARRIERS TO SURGICAL INTERVENTION, RAPID EPIDEMIOLOGICAL ASSESSMENT. RUNNING TITLE: CATARACT BLINDNESS AND BARRIERS TO SURGICAL INTERVENTION

2 Cataract Blindness and Barriers to Cataract surgical intervention in three rural communities of Oyo State, Nigeria. Summary The study was a community based field survey that uses a rapid assessment method to determine the prevalence of cataract blindness in people aged 50years and above in 3 rural Communities. The purpose of the study was to determine the prevalence of cataract blindness and barriers to cataract surgical intervention in an area served by a health facility managed by a tertiary institution. Abedo, Akinyele and Ketepe Villages in Akinyele Local Government Area of Oyo State Nigeria were selected based on their nearness to the primary health care center in Abedo. A total of 477 persons aged 50years and above were seen being 73.3 percent of expected. Those with visual acuity of less than 3 /60 in an eye and those with visual acuity of less than 3/60 in the better eye were examined in more details using a pen torch, an 2

3 ophthalmoscope and tonometer to determine the cause of blindness. All persons who have had surgery were examined. The prevalence of blindness in persons aged 50years and above was 1.47% and that of cataract blindness in the same age group in the villages was 0.84% constituting 57.14% of blindness. The main barriers to hospital presentation were cost of surgery (52.8%) and distance to hospital (33.8%). The constraints and limitations encountered during the study included rural-urban migration and population discrepancies between what obtained at the villages and those supplied by the Local Government Population Commission. It is hoped that this study will serve as a preliminary survey and a base line for further studies and the initiation of a blindness prevention programme in the area. 3

4 INTRODUCTION Cataract is the most prevalent blinding disease in the world and is a major cause of visual loss in developing as well as in developed countries (1). Globally it is estimated that there are 19.34million people who are bilaterally blind from age related cataract and this represented 43% of all blindness (2). In Nigeria, the International Agency for the Prevention of Blindness estimates show that 1.2% of the population is blind and that cataract is the cause of 50% of the blindness (3). Workers in Nigeria found that blindness prevalence ranged from 0.9% to 1.5 % (4) and also found cataract to be a major cause of blindness with percentage blindness due to cataract ranging from 33% to 70% (5-9). Most of the cataract blindness is in the older age group. The number of blindness and those due to cataract is increasing because of increasing longevity especially in the developing countries. This means the population aged sixty years and over will double in the next twenty years with resultant increase in the number of people with visual loss and blindness from cataract 10. 4

5 It has been suggested that the way out includes, firstly determining the magnitude of cataract blindness before any meaningful activity as regards control of cataract blindness 11 5

6 METHODOLOGY MATERIALS & METHODS Pre survey activities included getting ethical approval from the University of Ibadan/University College Hospital Ethical Committee. The Primary health care center at Abedo is run by the Public Health Nursing Department of the University College Hospital, Ibadan, and has been serving the Akinyele ward 6 of Akinyele Local Government Area for over 10years. Abedo, Akinyele and Ketepe Villages in Akinyele Local Government Area of Oyo State were chosen for the study based on their nearness to the primary health care centre at Abedo. No previous study has been done in the area, and no formal prevention programme has been carried out in the area. The study is a community based field survey where all persons aged 50years and above were included in the study. The houses in each village were numbered with the aid of the population commission staff. Home to home visits were then made to administer questionnaires and perform visual acuity testing. Pretested interviewer assisted questionnaires were administered by the community Health nurses and tested by the author. Interview 6

7 questions included information about age, sex, occupation, level of income, marital status, and education level. Ocular Examination included visual acuity testing performed by the community Health nurses that were trained and tested by the author. This was done with an illiterate E-chart or a literate snellen test type placed 6 meters-away from the participants in a well-illuminated outdoor area. The visual acuity was tested with and without a pinhole. Those who had surgery or couching had visual acuity tested with + 10D lens. All persons aged 50years and above with visual acuity of less than 3/60 in an eye were further examined at the examination centers. In Abedo, the primary health care center was used while in Akinyele, the community head offered his house and in Ketepe, the local black soap industry was used. Ocular examination was performed with a pen torch and an ophthalmoscope in a dimly lit environment by the author on those with visual acuity of less than 3 /60 in the better eye or in one eye to determine the cause of blindness. All those that had surgery were also examined. The population of the three villages from the population commission were Abedo[336],Akinyele[1,081] and Ketepe[143]. 7

8 The expected number of the people aged 50years and above to be included in the study were Abedo[146],Akinyele[453] and Ketepe[56] representing 43%,41% and 39% of the population of the villages respectively. Six hundred and fifty-five persons aged 50years and above were therefore expected. CASE DEFINITION Bilateral cataract blindness The diagnosis was made with a visual acuity of less than 3/60 in the better eye in association with normal light projection, normal anterior segments, and normal pupillary reactions in the presence of lens opacity. Unilateral cataract blindness Diagnosis was made in one eye with visual acuity of less than 3/60 in that eye in association with normal light projection, normal anterior segment and normal pupillary reaction in the presence of a lens opacity. Aphakia Patients with aphakia admitted to surgery. Examination showed a deep anterior chamber with a surgical scar. The lens was absent. 8

9 Couched eye Diagnosis was made if examination revealed a dislocated lens in the vitreous cavity. Some patients admitted to couching. Other patients needing further examination were then referred to the University College Hospital. 9

10 RESULTS A total of four hundred and seventy-seven people aged 50years and above were interviewed and examined out of the six hundred and fifty-five persons expected from the population census of the three villages giving an overall coverage of 73.3%.102 residents aged 50years and above were examined in Abedo, while in Akinyele and Ketepe 330 and 45 residents were examined respectively. Table I show the age distribution of the 477 persons seen in the 3 villages. 69% were between age 50 and 59years. The mean age was 56years. Male to female ratio was 1: % of the subjects had no form of education at all. Almost half [47.8%] of the subjects were peasant farmers; while 30.6% engage in petty trading. 79.9% of the people examined earned less than N monthly. The prevalence of blindness of 1.47%[Table II]; and cataract caused 57.16% of the blindness[table III]. Monocular blindness accounted for 4.3% with cataract causing 55% of monocular blindness (Table IV). Two cases of uncorrected aphakia and a case of couching was encountered in this study. The couching was done by the traditional doctors residing in the area. 10

11 The expected total population of people aged 50years and above in Akinyele Local Government. = 42% x 187,049[Total Population] = 78, 560. Number of persons bilaterally blind = 1.47% [prevalence of blindness] x 78,560[Total population] = 1,154 persons. Therefore, the numbers of cataract blind = 57% of 1,154 =657 persons [1314 eyes] The number of those unilaterally blind in the local government = 4.3% x 78,560 = 3,378 eyes of which 55% [1,857eyes] are unilaterally blind from cataract. Therefore about 3,171eyes may need cataract surgery immediately. Table V shows that 52.8% of the people and 33.8% identified cost and distance respectively as barriers to hospital attendance. Others are socio-cultural practices, lack of trust in outcome of treatment and fear of surgery. 11

12 DISCUSSION This is the first assessment of cataract blindness to be conducted in Abedo, Ketepe and Akinyele Villages in people 50years and above. A total of six hundred and fifty-five individual 50 years of age and older were expected to be examined; Four hundred and seventyseven were examined. Overall participation rate was 73.3%. The participating rate for Abedo village was 69.8%; for Akinyele village was 72.8% and Ketepe village, 80.3%. The participation rate for men was 72.8%; for women it was 72.7%. This was due to absenteeism despite revisits. The possibilities of unreliable census figures exist. The population figures used was projected from the 1991 population census. The percentage of people aged 50years and above was rather high in this community. They constituted 42% of the population, much higher than the expected 20% for such communities. Rural-urban migration may be high especially for the younger and active population group. This is not unexpected as the villages are within 30 kilometers from a major City-Ibadan. 12

13 Ajibode (12) in Ogun State, Nigeria, a neighboring state found the percentage of people aged 50years and above to be 33% in 1kenne Local Government Area, he attributed this to rural-urban migration. In this study, the prevalence of cataract blindness in people aged 50years and above was 0.83%. Cataract formed 57.14% of the blindness prevalence. Cataract is the commonest cause of blindness in many parts of Nigeria and even in a community served by a health center managed by a tertiary institution. 12, 13, 14, 15. In a blindness survey, Adeoye 13 in Ile-Ife in a neighboring Osun State found the prevalence of cataract blindness of 0.43% in the general population and cataract was responsible for 48.1% of blindness in the area. Ajibode 12 in Ogun State also found the prevalence of cataract blindness of 3.0% in Ikene local government with cataract contributing 57% of blindness. All the bilaterally blind were found in persons 50years and above in his study. Fafowora and Osuntokun 15 in a cross sectional blindness survey of ten villages in Ifedapo Local Government of Oyo State, a rural area, served by a peripheral clinic found the prevalence of blindness of 0.15%. This low result may be attributed to the presence of the peripheral clinic. 13

14 In the onchocercal endemic zone of Kaduna State, Cataract was found to be the commonest cause of visual impairment 14. The above studies were cross-sectional survey, which may underestimate the burden of cataract blindness. The low prevalence of cataract blindness in this study may be due to the health facility that is linked to the University College Hospital, Ibadan to which referrals were usually made. The low prevalence could also be due to a previous screening that was carried out in the area two years before the present study, or due to non response of the blind to come out for testing in spite of announcements. Home to home examinations would have ensured that more blind were included in the study. In this study, 52.8% of the people identified cost of treatment as significant barriers to hospital attendance. Distance was identified by 33.8% as a cause of non presentation. It has been shown in Malawi and Bangladesh that people will use what is available to them first 16,17, hence the use of traditional doctors specializing in couching encountered in the study. Couching is responsible for 50% of aphakia in the present study. So in spite of the presence of 14

15 the health center, villagers found the University College Hospital, Ibadan to be distant to them. The study also showed that 79.9% of the people interviewed earn less than N monthly; The cost of cataract surgery at the University College Hospital is about N15, It is therefore not affordable to them. Other barriers to hospital attendance found during the study were: socio cultural practices such as women confinement in the purdah system, lack of trust in the outcome of treatment, and fear of treatment. Overcoming these barriers involve aggressive health education. Although there is a suggestion that the health facility might be part of the reason for the low prevalence of cataract blindness, the facility could be more effectively used. Community health workers need to be retrained to test visual acuity and identify cataract blindness. The health workers will train existing extension village health workers to identify the blind in more peripheral villages and bring them to the health center. Arrangement to transport them to the Tertiary institution nearby is recommended. 15

16 CONCLUSION The prevalence of cataract blindness estimated by rapid epidemiological survey in subjects 50years and above was 0.8% in Abedo, Akinyele, and Ketepe villages. Cataract was still a major blinding disease in these villages which are less than ten kilometers from a health center served by a tertiary institution with eye care facilities. Cost and distance were major reasons given by subjects for not attending the health facility. An organized eye care programme will further reduce blindness in Abedo, Akinyele and Ketepe villages. 16

17 REFRENCES 1. Hyman L. Epidemiology of eye diseases in the elderly. Eye 1987; 1: W.H.O. The World Health report: Life in the 21 st century, a vision for all: W.H.O 1998; Geneva Abiose A : Vision 2020: The right to Sight. The valedictory lecture delivered in honouor of Prof Osuntokun at the College of Medicine, University of Ibadan on the 8 th of November Report of the National Agency for the prevention of blindness Nigeria. 1999; Olurin O. Causes of blindness in Nigeria. A study of 1000 hospital patients. W Afr Med J 1973;22: Osuntokun O, Olurin O. Cataract and cataract extraction in Nigeria. Br J Ophthamol 1973; 57: Ayanru J O. Blindness in mid-western state of Nigeria: Trop Geog Med 1974; 26: Ezepue UF. Derailment of prevention of blindness programme in Enugu. Nig J Ophthamol 1993; 2 (1): Nwosu SNN. Blindness and visual impairment in Anambra State (Nigeria) Trop Geog Med 1994;46(6):

18 10. Foster A. Vision The cataract challenge. Comm Eye Health 2000; 13 (34): Bhatacharjee J, Devadetham S, Sharma S, Suini N K, Datta K. Methods of estimating Prevalence and incidence of senile cataract blindness in a district. Ind J Ophthalmol 1996; 44(4): Ajibode A. Prevalence of blindness and visual impairment in Ikene Local Government Area of Ogun State. A dissertation submitted to the National college of ophthalmology Nov Adeoye A. Survey of blindness in rural communities of South Western Nigeria. Trop Med Int H 1996; 1 (5): 672-6, 14. Abiose A, Murdoch I, Babalola O et al. Distribution and etiology of blindness and visual impairment in Mesoendemic onchocercal community of Kaduna Sate. Br J Ophthalmol 1994; 78(1): Fafowora OF, Osuntokun OO. Age related eye disease in the elderly members of a rural African community. East Afri Med J 1997; 74(7):

19 16. Courtright P. Eye disease, knowledge and Practice among Malawian traditional healer and the development of collaboration of blindness prevention programmes. Soc Sci Med 1995; 41: JalaludinKham M. Bangladesh model of Eye Care (modular Eye Care). Comm Eye Health 2000;13(34):

20 PREVALENCE OF CATARACT BLINDNES INDEX TO TABLES TABLE I TABLE.II. AGE DISTRIBUTION BLINDNESS PREVALENCE TABLE III..CAUSES OF BLINDNESS TABLE IV TABLE V CAUSES OF MONOOCULAR BLINDNESS BARRIERS TO HOSPITAL PRESENTION 20

21 TABLE I - AGE DISTRIBUTION OF STUDY POPULATION Abedo Ketepe Akinyele Age(yrs) Freq % Freq % Freq % Total % & TOTAL TABLE II BLINDNESS PREVALENCE Abedo Ketepe Akinyele TOTAL Visualacuity Freq % Freq % Freq % Total % _> 3/ <3/ Total

22 Table III: Causes of blindness Abedo Ketepe Akinyele TOTAL Causes Freq % Freq % Freq % Total % Cataract Glaucoma Ref. Error Sen.Mac.Deg Total

23 Table IV: Causes of Monocular blindness Abedo Ketepe Akinyele Total % Causes Freq % Freq % Freq % Freq Cataract Glaucoma Aphakia Corneal opacity Ref. error Sen. Mac Deg. Couching Total

24 TABLE V:BARRIERS TO HOSPITAL ATTENDANCE Abedo Ketepe Akinyele TOTAL Barriers Freq % Freq % Freq % Total % Cost Distance Sociocult.prac. Lackof trust Others e.g.fear Not indicated Total

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