Utilization of Eye Care Services Among Staff of a Tertiary Hospital

Abstract

Purpose 

To determine the level of utilization of eye care services and to identify the barriers to uptake of eye care services among the staff in a hospital.

Design 

A cross-sectional study conducted at a university teaching hospital.

Methods 

A total of 250 staff members were selected using a proportionate sampling among the segment of study population. Data were collected using semistructured questionnaires, including demographic data, awareness about eye clinic and the services rendered, facilities utilized by staff in receiving eye treatment, and reasons for not utilizing the hospital eye care services. Data analysis was done using SPSS version 15.

Results 

The majority (66%) of the staff were younger than 40 years. Around 229 staff members (91.6%) were aware of the clinic, whereas 222 (88.8%) were aware of at least 1 of the various services rendered. They received treatment from chemists (30.7%), private hospitals (26.3%), and optical shops (16.1%). The hospital eye clinic (11.8%) was the least chosen place to receive eye treatment. The reasons for nonutilization of eye care services were lack of finance (42.1%), poor staff attitude (23.7%), fear of damage to the eye (15.3%), high cost of treatment (9.7%), and ignorance of its existence (9.2%). Visual impairment was seen in 14 of the staff (5.6%), whereas blindness was seen in 1 (0.4%).

Conclusions 

The level of utilization of eye care services in the hospital by the staff is poor and very low compared with other facilities, although the majority had previous history of eye complaints.

Blindness, according to the World Health Organization, is the visual acuity (VA) of less than 3/60 in the better eye with the best correction.¹ Visual impairment (low vision and blindness) is a major health concern all over the world. Three main reasons for the high prevalence of visual impairment are nonavailability, nonaccessibility, and nonaffordability of eye care services. However, there are several factors that may act as barriers to the use of available, accessible, and affordable eye care services.² In Nigeria and most other developing countries, patients tend to seek the alternative medical system first in the treatment of eye diseases before the conventional medicine.³

The Global Initiative for the Elimination of Avoidable Blindness (VISION 2020: The Right to Sight) sets a major challenge requiring a significant increase in the provision and uptake of eye care services.^4,5 Prevalence of blindness in Nigeria according to the Nigeria National Blindness Survey (2007)⁶ is 0.78% for all ages; 1.2 million Nigerians have been reported to be blind.⁶ Among health workers in reputable eye health facilities, visual impairment and eye diseases may be associated with increased morbidity and mortality as well as decreased quality of life.⁷ These problems affect people’s activities of daily living, cause falls and injuries, and lead to depression and social isolation.⁷ Determining barriers to use of eye care services is critical for planning strategies to prevent blindness. Traditional practices, beliefs, fatalistic attitudes toward blindness, fear of treatment, lack of faith in the intervention, and fear about the surgical procedure have been reported to influence the behavior of patients, leading to low acceptance levels.⁸ One of the earliest indications for need of glasses is presbyopia especially in individuals 40 years or older. However, when the health care workers seek ophthalmic care from alternative caregiver where adequate care will not be given, then it is pertinent to determine the various reasons that is responsible for such attitude. It was observed that some members of staff during an outbreak of viral conjunctivitis (popularly known as “Apollo”) in the community did not present in the eye clinic for treatment. Therefore, if the staff of the teaching hospital will not utilize the eye clinic of the hospital in accessing eye care, then the larger society may not utilize it, and these may contribute to the global burden of avoidable blindness. Furthermore, the hospital staff when newly employed would have undergone the mandatory routine health test, the eye inclusive, but as they grow older approaching the age of 40 years, presbyopia sets in, and it is expected that the eye clinic will be utilized for a thorough eye examination. If this is not done, visual impairment may ensue. Some potentially blinding conditions such as glaucoma may not be detected early, thus not being able prevent the resultant irreversible blindness that may occur. Poor or delayed uptake of eye care services can lead to avoidable blindness or visual impairment. Understanding patterns of eye care service utilization especially among staff of the tertiary hospital may help formulate better strategies to improve the ocular health status of these health caregivers and, by extension, the community. This study is therefore aimed at determining the level of utilization of eye care services and identifying the barriers to uptake of eye care services among the staff.

MATERIALS AND METHODS

It is a cross-sectional study of the staff of a university teaching hospital, which was established in 2008 by the state government. It has staff strength of 1250 consisting of medical and nonmedical staff. It has various departments such as surgery, obstetrics and gynecology, pediatrics, internal medicine, orthopedics, otolaryngology, and ophthalmology.

There are various cadres of staff; these include doctors, nurses, pharmacists, physiotherapists, administrative officers, laboratory scientists, and so on. The eye clinic is directly under the supervision of the Ministry of Health and the office of the Governor. The financial proceeds from the services rendered in the eye clinic goes into a different account from the hospital account. Members of staff willing to access eye care services are subject to same procedures and payments like any other patients.

Before data collection, ethical approval was obtained from the ethical board of the hospital. Informed consent was taken from all the subjects.

Sample Size Determination

The sample size was estimated by the following formula: N = p(1 − p) Z² / d²,where N is the minimum sample size needed; d is the level of error that can be tolerated (0.05 chance of error); p = 0.18, the estimated prevalence rate of level of utilization eye care services among patients attending a tertiary hospital in southeastern Nigeria¹ was 18.1% from a previous study; Z is the standard variate corresponding to confidence level. At a confidence level of 95%, Z = 1.96,

Using the above formula, N = 0.18(0.82)1.96² / 0.05². Then the minimum sample size = 250 (attrition value 10% added).

Data Collection Technique

All members of staff were categorized as clinical and nonclinical. Clinical include doctors, nurses, pharmacists, and laboratory scientists. Nonclinical are those members of staff who are not in the categories above and those with administrative functions in the hospital. These include administrative officers, account officers, technicians, engineers, typist, and so on. The staff were categorized as shown in Supplemental Digital Content 1; https://links.lww.com/APJO/A29.

Sampling technique was by proportionate sampling of the segment of the study population. The staff register was obtained from the establishment office of the hospital. With theaid of Statistical Package for Social Sciences package (Chicago, IL), a table of random figure was generated to select for each category of staff until the required calculated sample size was obtained.

All selected 250 members of staff were interviewed using a pretested questionnaire. They had eye examination that included VA (unaided and aided with pinhole) (this was done by sitting the subjects 6 m away from a rotating, self-illuminated Snellen chart in the eye clinic), pen-touch examination of the anterior segment, fundoscopy with Keelers direct ophthalmoscope, and intraocular pressure measurement with Goldman applanation tonometer.

Data obtained were recorded into a computer, and analysis of data was achieved using the Statistical Package for Social Sciences version 15. Data were tabulated and analyzed, using percentages, charts, and cross-tabulations. Statistical significance was inferred at Fisher exact value of P < 0.05.

RESULTS

The majority (66%) of the staff were younger than 40 years, with most of them in the 30- to 39-year age group (Supplemental Digital Content 2; https://links.lww.com/APJO/A29). Two hundred twenty-nine members (91.6%) of staff were aware of the clinic and the services rendered as shown in Table 1. Figure 1 shows that the members of staff have received treatment from chemists (30.7%), private hospitals (26.3%), and optical shops (16.1%).

TABLE 1: Level of Awareness of Eye Clinic

FIGURE 1: Facilities utilized by staffs in receiving eye treatment.

The hospital eye clinic (11.8%) was the least place chosen by the staff to receive eye treatment. Table 2 shows the reasons for nonutilization of eye care services, including lack of finance (42.1%), poor staff attitude (23.7%), fear of damage to the eye (15.3%), high cost of treatment (9.7%), and ignorance of the existence of the eye clinic (9.2%). Supplemental Digital Content 3 (https://links.lww.com/APJO/A29) shows that visual impairment was seen in 14 (5.6%) of the staff, whereas blindness was seen in 1(0.4%) of the staff. Our study showed that 74.4% of the staff interviewed had a history of eye complaint or eye problem necessitating treatment (Supplemental Digital Content 4; https://links.lww.com/APJO/A29). There was no significant association between the utilization of eye care services and the category of staff (clinical and nonclinical) with Fisher exact test value of 0.473 (Table 3).

TABLE 2: Reasons for Not Utilizing Eye Clinic in the Hospital

TABLE 3: Utilization Among Clinical and Nonclinical Staff

DISCUSSION

The need for utilization of eye care services to prevent increasing prevalence of potentially blinding diseases in the society has been reported by various authors.^1,8,9 The removal of various barriers or minimizing them has also been reported to contribute to global elimination of avoidable blindness.⁶ This is in line with Vision 2020: “Right to Sight.”

In this study, the age range of the staff with the highest frequency was 30 to 39 years. The mean age was 36 ± 10 years. This is similar to the report of a study by Ekpenyong and Ikpeme¹ conducted at the University of Calabar teaching hospital. This age group is notably the productive age where most people work hard to earn a living, and so any form of visual impairment will incapacitate them and reduce their productivity. It was noted that there are more male than females, with a ratio of 1.3:1. This was similarly reported in other studies.^1,8 This may be due to the fact that more men tend to be the breadwinners in their families.

The level of awareness of the eye clinic and the services by the staff is high (91.6%). It is expected that in the setting of high level of awareness such as this, there will be increased uptake of the eye care services, which will in turn reduce the prevalence of visual impairment. In educated society, the health-seeking behavior of people is directly related to their level of awareness of health facilities accessible to them.¹ Our study showed that 74.4% of the staff interviewed had a history of eye complaint or eye problem necessitating treatment. This was similar to report by authors in India¹⁰ and Ghana.¹¹ When a group of people are aware of the ocular health care facilities provided for them, and there is any eye complaint whether vision threatening or not, it is expected of them to utilize these facilities. However, the presence of any barrier to the uptake may result in worsening of the symptoms with eventual poor prognosis.¹²

Uptake of eye care services in the hospital by the staff of the hospital in this study is poor and very low (11.8%) compared with other facilities. Members of staff utilized other facilities such as chemists, private hospitals, general hospital, and optical shops. This is similar to a study done in a district in Ghana,¹³ where people utilized different alternative eye care in the treatment of eye ailment. The main alternatives to the regular eye care services were chemical shops (chemists) and indigenous herbal medicine.¹³ This is contrary, however, in Fiji, where utilization of eye care services was reportedly high because they were provided free, and there was increased awareness of eye care services in the community.¹⁴

Various reasons have been attributed to low uptake of eye care services in the past^15–20; in this study also, lack of finance, poor staff attitude, fear of damage to eye, and high cost of treatment were the major reasons for not utilizing the eye care services in the hospital by the staff of the hospital. It would be expected that more clinical staff would utilize the eye care services more than the nonclinical staff; however, there is no significant association between the category of staff and the probability of utilization of the services in the hospital. This may suggest the influence of other factors affecting the decision to utilize the services or not.

Several authors have also identified similar barriers to utilization of eye care services.^21–23 The major barrier to utilization of eye care services by the staff in our study is lack of finance, which may also be directly related to high cost of treatment. Although the staff in the Nigerian public service are relatively well paid and should be able to afford the eye health care, staff of the hospital pay the same amount of money as nonstaff to receive treatment for any eye disease or disorder. This may discourage them especially when there is also high cost of treatment and purchase of ophthalmic drugs. Poor remuneration of the staff may be contributory to the barrier of lack of finance as was expressed in the study by Ekpenyong and Ikpeme¹; this was, however, not expressed by the staff in this study.

Another important perceived barrier to uptake of eye care services is poor attitude of staff of the eye clinic. This underscores the need for training and retraining of eye care service providers in possessing good human interpersonal relations as a prerequisite in effective eye care delivery.²⁴

Visual acuity assessment of the staff showed that 1 (0.4%) of the staff was blind, whereas 5.6% had visual impairment. However, the blind member of staff is a technician in works department with VA of counting fingers in both eyes. He had been previously diagnosed to have glaucoma but defaulted because of lack of finance and high cost of antiglaucoma drugs in the hospital. In this study, most members of staff have a good vision best corrected VA (94%). This good vision needs to be protected by promoting unhindered access of the staff to the eye care services provided by a team of qualified professionals in the hospital.

Health education and promotion should be carried out by the selected trained members of the ophthalmology department among the general staff to emphasize the inherent danger in patronizing chemist/pharmacy shops and private optical and other alternative places.

Furthermore, the National Health Insurance Scheme can be extended to cover eye care services in state-owned tertiary hospital so as to take care of the need of the staff in this regard.