Middle East African Journal of Ophthalmology

ORIGINAL ARTICLE
Year
: 2015  |  Volume : 22  |  Issue : 4  |  Page : 508--513

Perception and attitude of a rural community regarding adult blindness in North Central Nigeria


Victoria A Olatunji1, Feyi G Adepoju2, Joshua F. A Owoeye2,  
1 Department of Ophthalmology, University of Ilorin Teaching Hospital, Ilorin Kwara State, Nigeria
2 Department of Ophthalmology, University of Ilorin Teaching Hospital and University of Ilorin, Ilorin Kwara State, Nigeria

Correspondence Address:
Victoria A Olatunji
Department of Ophthalmology, University of Ilorin Teaching Hospital, P.M.B. 1515, Ilorin Kwara State
Nigeria

Abstract

Aim: To determine the perception and attitudes of a rural community regarding the etiology, prevention, and treatment of blindness in adults. Methods: A cross-sectional, descriptive study was performed in a rural community in Kwara State, Nigeria using semi-structured questionnaire. All adults aged 40 years or older who were residents for a minimum of 6 months in the community were included. Data were collected on patient demographics, knowledge, attitude, perception, and use of the eye care facility. Results: A total of 290 participants were interviewed. The male-to-female ratio was 1:2. Consumption of certain types of food was an important cause of blindness as perceived by 57.9% of the respondents, followed by supernatural forces (41.7%) and aging (19%). Sixty percent of respondents thought blindness could be prevented. Age (P = 0.04) and level of education (P =0.003) significantly affected the beliefs on the prevention of blindness. Most respondents (79.3%) preferred orthodox eye care, but only 65% would accept surgical intervention if required. The level of education significantly affected the acceptance of surgery (P = 0.04). Reasons for refusing surgery were, fear (64%), previous poor outcomes in acquaintances (31%), belief that surgery is not required (3%), and cost (2%). About 65% used one form of traditional eye medication or the other. Over half (56.6%) believed that spectacles could cure all causes of blindness. Of those who had ocular complaints, 57.1% used orthodox care without combining with either traditional or spiritual remedies. Conclusion: This rural Nigerian community had some beliefs that were consistent with modern knowledge. However, the overall knowledge, attitude, and perceptions of this community need to be redirected to favor the eradication of avoidable blindness. Although an eye care facility was available, use by the community was suboptimal. Age and the level of education affected their overall perception and attitudes.



How to cite this article:
Olatunji VA, Adepoju FG, Owoeye JF. Perception and attitude of a rural community regarding adult blindness in North Central Nigeria.Middle East Afr J Ophthalmol 2015;22:508-513


How to cite this URL:
Olatunji VA, Adepoju FG, Owoeye JF. Perception and attitude of a rural community regarding adult blindness in North Central Nigeria. Middle East Afr J Ophthalmol [serial online] 2015 [cited 2020 Jul 8 ];22:508-513
Available from: http://www.meajo.org/text.asp?2015/22/4/508/167826


Full Text

 Introduction



Globally, there are 285 million individuals who are visually impaired of whom 39 million are blind.[1] Approximately 80% of the visually impaired are found in resource poor countries in Africa and Asia, mostly in the underserved rural regions.[2] Several studies from different regions in Nigeria indicate that blindness and eye diseases are a significant source of health problem, especially in the rural areas.[3],[4] This may be attributed to the location of eye care facilities that mostly located in urban areas.[5] However, the availability of eye care facilities does not guarantee the usage by the community.[6],[7] A range of psychological and sociocultural factors constitute barriers the use of healthcare services.[8] In developing countries, these barriers are numerous and include cost, fear, time, distance, culture, and beliefs of the people.

Patient perception of their symptoms affects their health seeking behavior. The acceptance of orthodox means of prevention and treatment depends on the perception of the causes of diseases and their belief about the efficacy of such methods. Preventing blindness is less expensive than paying for the lifelong costs related to a blind individual.[9] Hence, the beliefs of communities must be considered when planning and implementing the health programs as success depends on how well their beliefs match with medical principles.[6]

This study evaluated the perceptions and attitudes on the adult blindness of a community in the North Central Zone of Nigeria to provide information that can improve eye care.

 Methods



This was a cross-sectional descriptive study, performed on a rural population over a period of 4 weeks. The study was designed to include persons who were 40 years or older and resided in the community for at least 6 months at the time of study.

The study was conducted in Esie, a community in the Irepodun Local Government Area of Kwara State, North Central Nigeria. Kwara State has a population of 2,365,353, a total gross domestic product of $3,841 million and per capita income of $1,582. The community is predominantly inhabited by Yorubas, one of the three major ethnic groups in Nigeria. It is a rural, largely agrarian community but has a Comprehensive Health Center headed by a general duty medical doctor and assisted by nurses and community health extension workers. There is an eye care program in the community run by the Ophthalmology Department of a Teaching Hospital and supported by Sight Savers International. A clinic session is held weekly and surgeries are also performed by staff of the UITH Ophthalmology Department. Preclinic health talks are presented by ophthalmic nurses or health extension workers who were trained in ophthalmic care by Ophthalmologists.

The study was conducted in November 2010. All the houses in the community had been previously numbered during another research survey. Based on this, a door-to-door household listing of individuals who were 40 years or older was performed by 3 research assistants. The listing yielded 322 eligible participants in the community of which 290 agreed to participate in the study.

Data on sociodemographic characteristics, perception, and attitudes toward the causes, prevention, and management of blindness were collected with the use of a semi-structured questionnaire designed by the authors. The questionnaire was prepared in English language but translated to the local "Yoruba" language for illiterate participants and then translated back to English. Questionnaires were administered by one of the authors and three trained research assistants who were fluent in the local language. The interviewers administered the questionnaire to the participants in their households in the evenings when most of the participants had returned from work. In case, a participant was not at home, an appointment was made to meet him/her at a later time.

Prestudy visits were performed with the community head who provided the verbal consent as well as arranged a meeting between the study team and the village health committee to facilitate the community's cooperation. Approval was also obtained from the University of Ilorin Teaching Hospital Ethical Committee. All participants underwent an informed consent procedure for this study.

Data were analyzed with SPSS version 15 (IBM Corp., Armonk, New York, USA). Frequency tables were generated and Chi-square tests were used to determine the statistical significance. A P < 0.05 was considered statistically significant.

 Results



A total of 290 respondents participated in the study out of the 322 eligible individuals yielding a response rate of 90.1%.

The age range was 40 years to 93 years with an average of 60.6 ± 10.2 years. The majority (59.3%) of the respondents was at least 60-year-old, 22.1% were between 50 years and 59 years, and 18.6% were between 40 years and 49 years. There were 90 (31%) males and 200 (69%) females with a male-to-female ratio of 1:2.2. The gender difference in the study population was statistically significant (P = 0.003). Most (60.7%) of the respondents had no formal education, 26.2% had primary education, and 13.1% had post-primary education [Table 1].{Table 1}

As shown in [Table 2], 57.9% of the respondents believed that consumption of certain types of food was an important cause of blindness, followed by supernatural forces (41.7%) and aging (19%). Food types mentioned include "garri" (roasted cassava flakes), groundnut, vegetable oil, and okra. Onchocerciasis (locally called "Narun"), hereditary blindness, long-term exposure to smoke, and eye trauma were also thought to cause blindness. Others perceived causes of blindness were prolonged ocular itching, long-term spectacle wear, evil whirlwind, and disobedience.{Table 2}

The majority of the respondents (65%) believed that blindness could be prevented [Table 3]. Education (P = 0.003) and age (P = 0.04) positively affected the beliefs regarding the prevention of blindness. Regular hospital visits (45.2%), good food (32.8%), spiritual means (12%), and drugs (10%) were different options for prevention of blindness that were mentioned by the participants.{Table 3}

Approximately 57% believed that spectacles could treat all causes of visual impairment. Female respondents (P = 0.01) and younger individuals (P = 0.04) were statistically significantly more likely to have this belief. However, 93.8% (272) of participants would wear glasses if necessary. Of the 6.2% who would not wear spectacles, 66.7% (12 participants) felt it would cause sunken eye, 11.1% (2 participants) thought spectacles were meant for the elderly, and 22.2% (4 participants) thought it could decrease vision.

The majority (79.3%) of respondents preferred orthodox treatment, followed by spiritual and traditional interventions, respectively [Table 4].{Table 4}

The preferred treatment option was significantly affected only by the level of education (P = 0.02) while age (P = 0.38) and gender (P = 0.33) were not statistically significant. Cost and the feeling that blindness was incurable were major reasons why some would not seek orthodox care.

Two-thirds (65.5%) of participants would accept the surgical intervention. A higher educational level was statistically significantly associated with a positive attitude of surgery (P = 0.04). Fear was the most common (64.0%) reason for refusing surgery followed by poor outcome [Table 5].{Table 5}

Only 35.1% of participant had not used traditional eye medication (TEM). Substances used ranged from the herbal concoction, local eye pencil to palm wine, battery water, and cassava extract. Respondents with tertiary level education were statistically significantly less likely to use TEM (P = 0.000).

Out of 142 respondents, 290 (49%) had previous ocular complaints. Fifty-seven percent of those who had ocular complaints used orthodox treatment alone without combining home remedy, 37.3% had combined therapy (orthodox and traditional/spiritual therapy), and 5.6% used traditional remedies alone [Table 6]. Higher educational status, as well as younger age was associated with utilization of eye care facility [Table 6]. Reasons for not using the facility were cost, fear of the poor outcome, wasting time, and unfriendly clinic staff.{Table 6}

 Discussion



Blindness is a major health burden globally, yet 75% is avoidable.[10] About 82% of blindness globally occur in individuals who are 50 years or older,[10] which concurs with Nigerian estimates of blindness.[11]

This study was undertaken to determine the perception and attitude of individuals in a rural population with a view gather data that could enhance eye health promotion in order to reduce the needless blindness.

Most of the participants in this study (59.3%) were 60 years and older. This is much higher than the previous report of 48.8% from the Eastern Nigeria and 44% from the Southwest Nigeria.[12],[13] Possible explanation may be the phenomenon of rural-urban migration in which the young adults pursue better life opportunities to the cities. Another reason is the fact that only individuals who were 40 years and above constituted the study population.

In the current study, several causes of blindness were suggested by respondents. Most respondents provided the multiple responses as previously observed by Ashaye et al.[14] A very important cause of blindness mentioned was consumption of certain types of food, e.g. garri (fried cassava flakes), okro, groundnut, and vegetable oil. As, this is the most common cause of blindness perceived by the participants, it is a reflection of community beliefs. This is however, not surprising in a rural setting where various traditional beliefs and taboos are handed down from generation-to-generation. Similarly, excessive consumption of carbohydrates and food seasoning as a perceived cause of eye disease/blindness has been previously reported.[14] However, the belief that "garri" is a cause of blindness is partly correct. Tropical ataxic neuropathy is a myeloneuropathy characterized by bilateral optic atrophy, bilateral sensorineural deafness, and sensory gait ataxia. It occurs with excessive consumption of cassava foods (especially if inadequately processed) coupled with inadequate protein intake.[15]

Punishment from supernatural forces was also viewed as a major cause of adult blindness in this study. This belief in superstition is common in the most rural settings where there is strong belief in evil powers and deities. This findings concurs with other studies [12],[14] and may constitute a strong negative influence on eye health seeking behavior; hindering individuals from seeking or accepting proper, timely management. When the supernatural is considered as a cause of disease, there may be a reluctance to accept modern preventive or therapeutic options.

Aging was also perceived as a cause of blindness in itself instead of being regarded as a possible risk factor. Fletcher et al. also described "ageism" as a reason why communities will not seek orthodox treatment for blindness since they view it as normal to be blind as one ages.[8] Heredity, has been previously reported by Nwosu [12] as a causes of blindness similar to the present study. This may be important in certain causes of adult blindness such as glaucoma and age-related macular degeneration where genetics may play an important factor as it may prompt those with a family history of blindness to seek orthodox care early.

Very few respondents mentioned germs and trauma as possible causes of blindness. Hence, it may be appropriate to incorporate the effect of trauma and microbes in health education programs, especially in a rural community where the use of contaminated home remedies or TEM is likely to be rampant. Trauma and exposure to smoke were also perceived as causes of blindness in an Indian study.[8] Other causes, as indicated by respondents were long-term spectacle wear, ocular itching, and evil whirlwind. However, 15.2% of respondents had no idea at all about the causes of blindness. A re-orientation by health education addressing these issues is required.

In the present study, the level of preference for orthodox eye care is 79.3% which is much higher than 62.5% reported by Omolase et al.[7] but lower than 93.3% reported in another region of the country.[12] The high level of preference for orthodox care is surprising given the fact that majority of the respondents are illiterate. It may likely be due to the presence of an existing eye care facility that is accessible to the community and possibly because the community members are exposed to some level of eye health education at the clinic. The proportion (11%) of participants preferring spiritual care is substantially higher than 1.2% in a previous study,[7] and is, especially supported by the presence of three faith homes within the reach of the community. The use of "holy water" has been reported as one of the remedies used for eye disease/blindness.[12] However, level of preference for traditional care of 9.7% in this study is comparable to 8.8% reported by Omolase et al. in a similar community.[7] The perception that blindness incurable or that treatment is expensive could prevent some from seeking orthodox care in our study. This finding concurs with the previous studies in which the cost has been recurrently implicated as a barrier to seeking orthodox eyecare.[7],[12]

Despite the fact that cataract and glaucoma are part of the five most common causes of visual impairment and blindness in Nigeria [3] 35% of respondents would not accept surgical treatment for various reasons. The higher educational level was the only factor that significantly and positively affected the acceptance of surgery. Fear was the most common reason for a negative attitude toward surgery in this study, followed by poor outcome, and a feeling that there was no need for surgery because they would cope with it or it is the will of God. Fear was mostly due to the erroneous belief that eyes are removed at surgery or may get damaged or that death may ensue from surgery. Comparably, a previous study found that 40.3% of respondents would not agree to surgery for fear and that surgery was ineffective.[12] Presenting similar findings, Fletcher et al. reported that fear was the most cited barrier against treatment.[8] Other barriers identified by Fletcher et al. were time and difficulty of leaving their daily activities and loss of income.[8] Djik and Courtright [16] in Malawi reported that the most respondents thought surgery would make vision worse and had no idea how long the surgery would take. All of these observations indicate that an effective health education will have to be directed at clearing all the misconceptions and that there is a need to improve the surgical skills to achieve better outcomes and thus increase surgical uptake.

The community in the present study still largely makes use of harmful substances which ranged from herbal concoction, "tiro" (local eye pencil) and others substances such as sugar water, cassava water, palm wine, and battery fluid. The use of harmful or contaminated substances may either convert a 'benign' ocular condition to a serious one or worsen the severity of the problem. However, those with higher education were not likely to use TEM. The high acceptance of spectacles observed in our study agrees with a previous report.[12] Nevertheless, the erroneous belief in the community that spectacle wear causes the eyes to sunk in to the orbit over time and that glasses were meant to be worn only by the elderly or that they actually worsen blindness needs to be dispelled in a country where uncorrected refractive error and an uncorrected aphakia are among the top three causes of visual impairment and blindness.[3]

Prevention of blindness is less expensive than paying for the costs incurred by a blind person.[9] The role of human behavior as well as actions at individual, family, and community levels cannot be over-emphasized in blindness prevention. As much as one-third of respondents in the current study believed that blindness is not preventable and even among those who believed in blindness prevention, the perception was still largely at variance with orthodox medicine.

Over 90% of participants were aware of the existing eye care facility that is held once a week to serve the community which remains underutilized. Even though, almost half of the respondents had previous ocular complaints, 57.1% solely used orthodox care, 37.3% combined orthodox treatment with traditional or spiritual care while 5.6% used traditional treatment alone. Some have opined that the availability of eye care facilities does not guarantee usage by the community [6],[7] and this is as a result of a range of barriers including cost, fear, time, distance, culture, as well as beliefs.[8] A slightly greater percentage of males (though not to a significant level) used the health facility. Since males are usually the breadwinners and the decision makers in the family, they may be able to utilize the family resources to their advantage. This concurs with previously documented findings that eye service users were more likely to be males.[8] According to Lewallen and Courtright; patients who live with blindness and low vision in poor countries often do not make use of existing services. In addition, the problems of access and acceptance of care are generally worse for females than males.[17] This may possibly be due to the fact that females are less likely to be educated in these parts of the world. Younger age and a higher level of education are factors that clearly affected the use of eye care services in this study. This likely because younger individuals are more financially capable and the literate are likely to make better choices about their health.

In conclusion, the perception and attitude of the study population is less than optimal and still needs to be tailored toward favoring the realization of the Universal Eye Health. Use of the eye care facility in the community remains inadequate and is still combined with traditional eye practices in many instances. The information gathered from this study will be beneficial for blindness prevention programs aimed at reducing unnecessary visual impairment/blindness.

Acknowledgment

The authors are grateful to Dr. L. A. Olatunji for reviewing the manuscript.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

References

1Pascolini D, Mariotti SP. Global estimates of visual impairment: 2010. Br J Ophthalmol 2012;96:614-8.
2Foster A, Johnson G. Blindness in the developing world. Br J Ophthalmol 1993;77:398-9.
3Kyari F, Gudlavalleti MV, Sivsubramaniam S, Gilbert CE, Abdull MM, Entekume G, et al. Prevalence of blindness and visual impairment in Nigeria: The national blindness and visual impairment study. Invest Ophthalmol Vis Sci 2009;50:2033-9.
4Adegbehingbe BO, Fajemilehin BR, Ojofeitimi EO, Bisiriyu LA. Blindness and visual impairment among the elderly in Ife-Ijesha zone of Osun State, Nigeria. Indian J Ophthalmol 2006;54:59-62.
5Adepoju FG, Ayanniyi AA, Pam V, Akanbi TB. Human resource development for vision 2020 in developing countries: A change from absolute numbers. Eur J Ophthalmol 2011;21:820-5.
6Feyisetan BJ, Asa S, Ebigbola JA. Mothers' management of childhood diseases in Yorubaland: The influence of cultural beliefs. Health Transit Rev 1997;7:221-34.
7Omolase CO, Adido J, Fadamiro CO, Adepoju FG, Omolase BO. Eyecare preferences among rural Nigerians. Niger J Surg Sci 2007;17:116-20.
8Fletcher AE, Donoghue M, Devavaram J, Thulasiraj RD, Scott S, Abdalla M, et al. Low uptake of eye services in rural India: A challenge for programs of blindness prevention. Arch Ophthalmol 1999;117:1393-9.
9Javitt JC. Preventing blindness in Americans: The need for eye health education. Surv Ophthalmol 1995;40:41-4.
10Visual impairment and blindness. World Health Organization (WHO) Fact Sheet No 282, 2004.
11Ajibode HA. The prevalence of blindness and visual impairment in Ikenne local government area of Ogun State Nigeria. Niger J Ophthalmol 1999;7:23-7.
12Nwosu SN. Beliefs and attitude to eye disease and blindness in rural Anambra state, Nigeria. Niger J Ophthalmol 2002;10:16-20.
13Onakpoya OH, Adeoye AO, Akinsola FB, Adegbehingbe BO. Prevalence of blindness and visual impairment in Atakunmosa West local government area of southwestern Nigeria. Tanzan Health Res Bull 2007;9:126-31.
14Ashaye A, Ajuwon AJ, Adeoti C. Perception of blindness and blinding eye conditions in rural communities. J Natl Med Assoc 2006;98:887-93.
15Oluwole OS, Onabolu AO, Link H, Rosling H. Persistence of tropical ataxic neuropathy in a Nigerian community. J Neurol Neurosurg Psychiatry 2000;69:96-101.
16Dijk K, Courtright P. Barriers to surgical intervention among blind and low vision children in Malawi. Vis Impair Res 2000;2:75-9.
17Lewallen S, Courtright P. Increasing uptake of eye services by women. Community Eye Health 2006;19:59-60.