BARRIERS TO AN EFFECTIVE DIABETIC RETINOPATHY SERVICE IN IBADAN, NIGERIA (SUB –SAHARAN AFRICA) – A PILOT QUALITATIVE STUDY

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O.A. Ibrahim^1,2, A. Foster³ and T.S. Oluleye²

1. Ancilla Catholic Hospital, Eye Centre, Lagos State, Nigeria.
2. Department of Ophthalmology, University College Hospital, Ibadan, Nigeria.
3. International Centre for Eye Health (ICEH), London School of Hygiene and Tropical Medicine, UK.

Abstract

Background: Diabetic retinopathy is an increasing cause of blindness. The prevalence of retinopathy in hospital attending diabetics in Ibadan is reported to be 42 %. This study assessed the barriers identified by patients and service providers to delivering good services for diabetic retinopathy in Ibadan, Nigeria, Sub-Saharan Africa.

Methods: A qualitative survey using non-participatory observation, in-depth interviews (patients and healthcare providers), and focus group discussion for diabetic patients in the eye clinic in University College Hospital, Ibadan was done. Semi structured interview and topic guides were used to evaluate the barriers to effective service. The participants were selected using a non-probability, purposive sampling strategy. Twenty participants were involved in the pilot study. There were ten in depth interviews of patients and two focus group discussions of patients (3 in each group). Four healthcare providers were interviewed (a retinal surgeon, a senior registrar, an endocrinologist and a public health nurse).

Results: Lack of awareness that diabetes causes irreversible blindness was identified as a major barrier by both patients and providers. Cost of treatment of diabetes and treatment of retinopathy was also an important barrier. The long waiting time before consultation, staff attitudes to patients and appointment scheduling problems deterred patients from using the service.

Conclusions: More diabetic patients can be encouraged to use eye service by providing more detailed information/counselling and making clinic attendance less costly and more convenient.

Keywords: Barriers, Diabetic retinopathy, Service, Ibadan

Introduction

There is a global increase in the population of diabetic patient. It is estimated that there will be an increase from 382 million in 2013 to 592 million by 2035.¹ The rate of increase of diabetes in Africa over the same period is 109% (the highest in the world) from 20 million to 41 million. As the diabetes epidemic occurs, there is an imminent increase in visual loss from diabetic retinopathy in the Sub-Saharan Africa.² There is the problem of poor patient attendance at clinics, nonexistent or inadequate referral systems from primary to secondary care and from medical departments to ophthalmic service, poor record keeping, non-existent systematic screening programs, little access to imaging technology including fluorescein angiography and optical coherence tomography, lack of treatment infrastructure including lasers and laser maintenance and lack of national policies and low government priority.³ All these act as barriers to management of diabetes and diabetic retinopathy in Sub-Saharan Africa. In Indonesia and China, barriers to diabetic retinopathy services include lack of (health) education on need for eye care, asymptomatic nature of diabetic retinopathy and non-referral by physicians.^4,5 In developed countries like UK and USA,^6,7 barriers identified include fear of laser treatment or surgery, lack of awareness that diabetic retinopathy can be asymptomatic and lead to blindness as well as the cost of attending clinic.

Diabetic retinopathy services commenced fully in Ibadan (University College Hospital) in 2008 after a retinal fellow was trained in India and with the availability of an argon laser machine and a vitrectomy machine (both donated to the hospital). The proportion of diabetics with retinopathy in the clinic was 42.1% which is higher than other centres in Nigeria.⁸ However, it was observed that 57% of diabetic patients referred from the diabetic clinic complied with eye clinic attendance.⁸

The aim of the study was to determine the awareness of diabetic retinopathy among diabetic patients in the clinic and explore the barriers to the diabetic retinopathy service in the University College Hospital, Ibadan.

METHODOLOGY
This was a qualitative study using a non- probabilistic sampling strategy to select participants in the study. The study was carried out in the Eye clinic, University College Hospital, Ibadan, a tertiary facility. It is the only facility where diabetic retinopathy service is provided in the metropolitan city with a population of 2.72 million.9 The study involved a non participatory observation, interviews (patients and providers) and focus group discussions (patients).

The diabetic patients were identified from the new patients’ register, surgeon record book and laser register. This was done for the years 2011-2013. The initial plan was to pick patients systematically as they came to the clinic, but this was not feasible because of a nationwide doctors’ industrial action during the data collection in July/August, 2014. The phone numbers of patients were retrieved from the medical records. The patients were called on phone and invited to be part of the study. Patients were selected to achieve an equal distribution of age, gender and clinical diagnosis. Patients who had not accessed the service early or regularly and subsequently lost significant vision from diabetic retinopathy (DR) were considered to be “information rich plus”. Patients with severe DR/ proliferative diabetic retinopathy that required treatment and had not experienced sight loss that had presented earlier and accessed the service were identified and considered as ‘information rich’. Patients with diabetic retinopathy of lesser severity compared with the two categories above were identified and included. Patients who had accessed the DR services within the last 2 years were included in the study. This was to avoid recall bias. Patient who were less than eighteen years or too unwell to participate were excluded. This was because of ethical issues about giving consent and to reduce stress respectively.

Ten patients were involved in the in-depth interviews while 6 patients were involved in two Focus Grouped Discussions (FGD). The FGD were organised separately for males and females with each group having 3 people each. This was because of cultural reasons (so the women could freely express themselves and not feel intimidated by the presence of the men). Four providers were interviewed on the study. Semistructured topic guides were used for the interviews and focus discussions. The participants were allowed to use their preferred language (English or Yoruba) during the interviews and discussions. The summary of the participants is shown in fig 1 below.