|Year : 2017 | Volume
| Issue : 2 | Page : 118-122
Diabetic retinopathy screening in Calabar, Nigeria: Factors influencing referrals and uptake of screening service
Zainab D Momoh1, Chineze T Agweye2, Victor Oguntolu3, Dennis Nkanga2
1 Department of Ophthalmology, New Cross Hospital, Wolverhampton, UK
2 Department of Ophthalmology, University of Calabar Teaching Hospital, Calabar, Nigeria
3 Department of Endocrinology and Diabetes, Medway NHS Foundation Trust, Kent, UK
|Date of Web Publication||22-Feb-2018|
Dr. Zainab D Momoh
New Cross Hospital, Wolverhampton Road, Wolverhampton WV10 0QP
Source of Support: None, Conflict of Interest: None
Context: Regular eye screening of people with diabetes is highly recommended globally to prevent avoidable blindness. Aims: To determine the frequency of referral, factors affecting referral and uptake of patients with diabetes in Calabar for the Calabar diabetes retinopathy screening service. Settings and Design: Cross-sectional descriptive study conducted among physicians in Calabar, Nigeria in the month of May 2016. Materials and Methods: A self-administered questionnaire was given to 97 physicians practicing in Calabar. This assessed their knowledge of the Calabar diabetic retinopathy (DR) screening service, referral pattern, and factors that affect referral behavior. Statistical Analysis Used: Statistical Package for Social Sciences version 24.0 software (SPSS Inc., IBM SPSS, IBM Corp, Armonk, NY, USA). Results: Regarding awareness, 57% of physicians knew of the DR screening service at the Calabar Teaching Hospital but only 41% sometimes referred patients to the center. There was a significant relationship (P = 0.000) among location of practice, awareness of DR service at University of Calabar Teaching Hospital, and frequency of referral. Only 57% of the physicians felt that it was important to refer patients for screening; in spite of that, 40% of the physicians did not refer due to lack of awareness of the service. Barriers to the uptake of referral were long waiting time (58%), financial cost (44%), and availability of service (42%). Conclusion: Many physicians in this study did not refer patients with diabetes to avail the free Calabar DR screening service, although those physicians were aware of the importance of screening. Their reasons for lack of referral and uptake of service were lack of awareness of the service, perceived long waiting times, and erroneously imagined cost implications to patients, although the services have been actually free.
Keywords: Developing countries, diabetes retinopathy, eye screening, nigeria
|How to cite this article:|
Momoh ZD, Agweye CT, Oguntolu V, Nkanga D. Diabetic retinopathy screening in Calabar, Nigeria: Factors influencing referrals and uptake of screening service
. Niger J Ophthalmol 2017;25:118-22
| Introduction|| |
Diabetes mellitus (DM) is a global health burden.,, Its prevalence is predicted to increase globally from 382 million in 2013 to 592 million in 2035, with the most rapid increase in developing countries such as Nigeria.
Diabetic retinopathy (DR) is a microvascular complication of diabetes affecting the eyes, and it affects one third of people with diabetes. It is estimated that 75% of people who have had diabetes over 20 years will have some form of DR. It is characterized by changes to retinal blood vessels that can lead to ischemia and hemorrhage.
Vision threatening DR (proliferative DR and macular edema) is a leading cause of preventable blindness among working-age adults in many countries.,, Diabetic macular oedema (DMO) is the most common cause of blindness among people with DR. It can occur at any stage of DR although more likely occurs as DR worsens.
DR develops with increasing duration of diabetes,,, the risk of DR with resulting blindness increases with life increased expectancy; it is often asymptomatic until there is visual loss.,
Evidence shows that early diagnosis and treatment of DR can prevent blindness, by around 90%; therefore, a regular eye screening of people with DM is highly recommended globally., It is recommended that screening should include a complete ophthalmic examination with refracted visual acuity and retinal imaging.
Some developed countries such as the UK have national diabetes eye screening programs, while many developing countries including Nigeria do not., Therefore, as part of the global VISION 2020 initiative, a vision 2020 LINK was established between the Wolverhampton Eye Infirmary, Wolverhampton, UK and the University of Calabar Teaching Hospital (UCTH), Calabar, Nigeria in 2014. The Wolverhampton Eye infirmary provides training and technical support for the team members of the UCTH DR screening and treatment service.
The Nigeria national blindness and visual impairment survey of 2005–2007 showed the age-adjusted prevalence of DM in Nigeria to be 3.25% with more than 10% of people with DM aged ≥40 years having sight-threatening DR. A 2014 survey in Calabar (Capital of Cross River State, Nigeria) gave a prevalence of undiagnosed DM at 7%.
There are currently about 2500 registered people with DM in Calabar. Only 25.1% of these underwent eye screening in 2015, lower than the local target of 80%.
In view of the importance of diabetic eye disease, this study was designed to determine the rate of referral of patients with diabetes by physicians in Calabar, Cross River State, Nigeria to the UCTH diabetes center for DR screening service. Reasons for non-referral and other factors that may act as stumbling blocks to uptake of the services were to be identified.
| Materials and Methods|| |
This is a cross-sectional descriptive study, which was conducted over one month period in May 2016 among physicians in Calabar, Nigeria. A complete list of all private and public hospitals in Calabar was obtained from the State Ministry of Health. Three public hospitals and thirteen private hospitals were included. The list of all the physicians involved in treating the patients with diabetes in all the hospitals was obtained, and these physicians were all enrolled to participate in the study.
A self-administered questionnaire was developed; it assessed referral pattern of patients with diabetes to the UCTH DR screening service, the reasons for their referral behavior, and perceived barriers to uptake of diabetes eye screening (see Supplementary Appendix 1) [Additional file 1].
The study questionnaire was given to every participant, to complete. Data covered in the questionnaire included: specialty of the physician, place of practice, their awareness of the DR screening service at UCTH, their frequency of referral, reasons for their referral behavior, and any perceived stumbling block that could prevent patients from DR eye screening.
Data were collated and analyzed by using the statistical package for social sciences version 24.0 (SPSS Inc., IBM SPSS, IBM Corp, Armonk, NY, USA). Cross tabulation was made, and statistical significance set at P ≤ 0.05.
| Results|| |
Of the 105 doctors, who cared for patients with diabetes in these hospitals, 97 of them participated in the study giving a coverage of 92.3%. They comprised 30 general physicians, 27 private practitioners, 24 family medicine physicians, 15 junior doctors, and one endocrinologist. Majority (63) of the doctors practiced at UCTH, with 22 at a private practice, seven at the Navy hospital, and five at the general hospital.
Awareness of Calabar DR screening service
As shown in [Table 1], 55 (57%) of all doctors involved in the study were aware of the Calabar DR screening service.
Place of practice significantly affected the awareness of the DR service (P value of 0.000).
In this, 17 (27%) doctors at UCTH, 15 (68%) at private settings, and 7 (100%) at the Navy hospital were not aware of the existence of the service.
Frequency of referral
As shown in [Table 2], 40 (41%) doctors sometimes referred patients with DM to the Calabar DR screening service, 24 (25%) never referred, 17 (18%) rarely referred, and 16 (16%) always referred.
Awareness of the service significantly affected the frequency of referrals (P-value −0.000). The specialty of the doctors did not significantly affect frequency of referral; however, as shown in [Table 3], the place of practice significantly affected the frequency of referral (P-value −0.000).
Reasons for referral behavior
As shown in [Table 4], most of the physicians, 55 in number (57%), referred patients for DR screening because they thought it is important to do so; 39 (40%) did not refer patients because they did not know where to refer. Further, 19 (20%) doctors only referred patients when they are symptomatic. Sixteen (16%) of them did not refer patients because they forgot.
Perceived barriers to uptake of service
As shown in [Table 5], perceived barriers to uptake of DR screening service were given as follows: long waiting time (58%), cost (44%), availability of DR screening service (42%), patient’s attitude toward eye screening (21%) and travel difficulties to DR screening center (19%).
| Discussion|| |
The doctors in our study felt that it was important for patients with diabetes to have DR screening; however, most of them did not refer patients to the Calabar DR Screening Service. Lack of referral was also found to be a major reason for the lack of uptake of available DR screening in other DR screening centers in Nigeria.,
The main reason why doctors in our study did not refer patients was that they did not know where to refer patients. Limited availability of service was a major perceived barrier to refer for DR screening. Doctors, who referred more frequently were those working at the UCTH, where the DR screening center is located, and, thus, were more likely to be aware of the service.
To prevent avoidable blindness from DR, it is recommended that every patient older than 12 years with diabetes should be referred for annual DR screening. This is not the case in Nigeria and many developing countries.,
There is a limited availability of DR screening services in Nigeria., This is in contrast to the most developed countries such as the UK, which has a well-established national DR screening program. In the UK, diabetes eye screening service is available to every DM person >12 years.
Vision 2020: The Right to Sight is a World Health Organization and the International Agency for the Prevention of Blindness global initiative to eliminate avoidable blindness and visual impairment. Vision threatening diabetic retinopathy (DMO and proliferative DR) is one of the leading causes of preventable blindness globally.,,
A major perceived barrier to uptake of DR screening in our study was the long waiting time for patients, as well as the distance that patients have to travel to get to a DR screening center. In January 2015, the UCTH diabetes center, developed an open access DR screening for all patients with diabetes in Calabar area. It is a non-profit service, which will cover annual screening and treatment of diabetes eye diseases in Calabar with a plan to develop similar services across the state and subsequently the whole country.
Patients’ lack of awareness of the importance of DR screening was found to be a major reason for the lack of uptake of DR screening in Nigeria. Some of the doctors in our study admitted to only referring patients for DR screening; when they are symptomatic, their patients often present late for treatment as a result of this.
Most physicians in our study did not refer patients for DR screening because they felt that patients might not be able to afford it. Cost implication is major challenge with diabetes as well as general health care in Nigeria as patients often have to pay “out of pocket” due to a poorly functional national health insurance scheme. To avoid cost issues, DR screening is currently provided free of cost at UCTH to raise the awareness among local people. It is being run as a non-profit service; therefore, fundraising and sufficiently granted supports from the government are essential to keep the service running.
Blindness from DR is sometimes irreversible; however, early detection and treatment reduce the risk of blindness by 90%. DR is often asymptomatic until late stages; therefore, people with DM should have DR screening at least annually. The International Council of Ophthalmology (ICO) recommends that adequate DR screening exam should include a thorough ophthalmic examination, refracted visual acuity, and state-of-the-art retinal imaging. In low/intermediate resource settings, the ICO recommends minimum of visual acuity exam and retinal examination sufficient for DR classification. The screening exam should be performed by trained personnels with the ability to perform ophthalmoscopy or retinal photography to assess the severity of DR.
People with vision threatening DR requires more frequent eye exams and referral to an ophthalmologist. An early screening allows for timely treatment with laser photocoagulation, and increasingly, treatment with anti-vascular endothelial growth factor to prevent visual loss in vision-threatening retinopathy, particularly DMO.
| Conclusion|| |
Physicians were aware of the importance of DR screening; however, many of them did not refer patients with diabetes to the free Calabar DR screening service due to lack of awareness about the service.
Plans need to be put in place to raise awareness among the physicians taking care of patients with diabetes about the free Calabar DR screening service. Local screening centers should be set up in various regions in Calabar and Cross River State for the ease of access with the training of screeners and retina graders so as to ensure that screening is not performed only in tertiary centers, because patients often find it difficult to travel the distance to tertiary screening centers.
The authors acknowledge the contribution of Mr. Nick Price, Consultant Ophthalmologist, Cataract & Vitreoretinal Surgery, Wolverhampton and Midland Counties Eye Infirmary, Royal Wolverhampton NHS Trust, Wolverhampton.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]