|Year : 2016 | Volume
| Issue : 1 | Page : 20-24
Presbyopic correction coverage and barriers to the use of near vision spectacles in rural Abuja, Nigeria
Rilwan Chiroma Muhammad1, Mustapha Abubakar Jamda2
1 Department of Ophthalmology, College of Health Sciences, University of Abuja, Abuja, Nigeria
2 Department of Community Medicine, College of Health Sciences, University of Abuja, Abuja, Nigeria
|Date of Submission||05-Sep-2015|
|Date of Acceptance||29-Nov-2015|
|Date of Web Publication||12-Feb-2016|
Rilwan Chiroma Muhammad
Department of Ophthalmology, College of Health Sciences, University of Abuja, P.M.B. 117, Gwagwalada, Abuja
Purpose: To determine the presbyopia correction coverage and the barriers to the use of near vision spectacles in rural Gwagwalada, Nigeria. Materials and Methods: Eligible subjects were refracted, with their distance correction in place, near vision was tested and corrected using World Health Organization guidelines. A pretested near vision-related questionnaire was administered to collect information on spectacle use, barriers to the use of near vision spectacles and willingness to pay for replacement spectacles. Presbyopic correction coverage, met, and unmet presbyopic spectacle needs were calculated. Results: The presbyopic correction coverage for the sample was 21%, the met need was 11.2%, and the "unmet presbyopic need" was 42.1%. Presbyopic correction coverage was significantly higher for males, skilled workers, and those with at least secondary education. Barriers to obtaining near vision spectacles included cost (51.3%) and spectacles not being a priority (19.7%). Skilled workers and those with at least secondary education were willing to pay up to one thousand naira ($5) for replacement spectacles. Conclusion: Presbyopic correction coverage is low with a large unmet need. A community-based approach to the provision of spectacles that are new, of good quality, accessible, and affordable is needed.
Keywords: Abuja, barriers, correction coverage, Nigeria, presbyopia
|How to cite this article:|
Muhammad RC, Jamda MA. Presbyopic correction coverage and barriers to the use of near vision spectacles in rural Abuja, Nigeria. Sub-Saharan Afr J Med 2016;3:20-4
|How to cite this URL:|
Muhammad RC, Jamda MA. Presbyopic correction coverage and barriers to the use of near vision spectacles in rural Abuja, Nigeria. Sub-Saharan Afr J Med [serial online] 2016 [cited 2020 May 31];3:20-4. Available from: http://www.ssajm.org/text.asp?2016/3/1/20/176301
| Introduction|| |
There is gross underestimation by health care providers and policy makers of the extent and potential socioeconomic impact of uncorrected presbyopia in communities.  The World Health Organization (WHO) in its action plan for 2006-2011, included presbyopia in its refractive error program with the overall aim of eliminating avoidable visual impairment due to refractive errors and to reduce the magnitude of uncorrected presbyopia by providing specifically in low-income settings spectacles that are new, of good quality, accessible, and affordable.  The magnitude and need for spectacle correction for near vision will increase as the world's population increases, ages, and becomes more literate.  When prioritizing for the provision of presbyopia services, WHO has recommended that if less than one third have near correction, the population would be ranked as a high priority for service delivery. If one to two-thirds have spectacles, the priority ranking would be moderate, and if more than two-thirds have spectacles, it would be low. 
Gwagwalada is one of six Area Councils that make up the Federal Capital Territory, Abuja consisting of about 90 towns and villages.  The inhabitants of Gwagwalada are mostly farmers and civil servants.
The purpose of the study was to determine the presbyopia correction coverage (PCC) and the barriers to the use of near vision spectacles in rural communities in Gwagwalada, Abuja.
| Materials and Methods|| |
The study was part of a population-based cross-sectional study of presbyopia among adults conducted in rural Gwagwalada, Abuja. Ethical approval was obtained from London School of Hygiene and Tropical Medicine's Ethics Committee and the Department of Health, Gwagwalada Area Council. An informed verbal consent was obtained from each subject. The study population is a sample of respondents that were aged 40 years and above and resident in Gwagwalada Area Council at the time of the study. The minimum sample size was calculated to be 561 but was made up to 600 adding 7% (39) of it to allow for nonresponse. The prevalence of presbyopia was taken as 55%.  The sampling technique was cluster random sampling using probability proportional to size. In all, there were 15 clusters with 40 participants in each cluster. A bottle was spun at the center of the cluster to know which direction to follow. Only one respondent per household was recruited into the study. All individuals resident in selected clusters aged 40 years and above were invited to participate. The following exclusion criteria were used.
(1) Age <40 years. (2) Nonresident of selected villages. (3) Individuals with distance visual acuity of <6/60 and no improvement noticed with pinhole testing. (4) Inability to test vision although the subject was not blind. (5) Visual Acuity testing precluded by known ocular pathology.
All subjects excluded for visual impairment reasons were examined by the ophthalmologist and referred to the Eye Center for medical care.
Demographic information including age, gender, and education were obtained from a questionnaire administered by trained interviewer.
A subject was defined as presbyopic, if he or she could not read the N8 optotype at about 40 cm with the distance correction in place if required.
Examination was conducted by a team made up of an ophthalmologist (principal investigator), an ophthalmic resident doctor and an enumerator selected at each cluster visited after training. Distance visual acuity was tested in all subjects using Log Mar chart at 4 meters in ambient outdoor illumination under a shade. Correct identification of 3 out of 4 characters in a line constituted success at reading that line.
Distance refraction was then done for subjects with visual acuity <6/18 after demonstrating improvement of at least one line when tested with a pinhole. The refraction was conducted using a trial lens set with the addition of plus or minus lenses in 0.5 diopter increments until the subject read 6/6. To reduce testing time due to time constraints in data collection, astigmatism was not corrected for near vision was then tested using a near vision Log Mar "E" chart with ambient light. A string was attached to the near vision chart to ensure a measurement distance of 40 cm from the eyes. Visual acuity is measured binocularly and recorded as the smallest line with at least 3 of the 4 optotypes read correctly. The distance correction was put in place for those that require it before near vision testing was done. Spherical plus lenses are added in increments of 0.5 diopter until the subject is able to read N8 or no further improvement occurs. Subjects that presented with a vision of 6/6 are assumed emmetropic and tested for near vision as described. Subjects needing presbyopic glasses were provided free of charge while patients with reduced visual acuity not improved by refraction and those needing distance correction were referred appropriately. The ophthalmologist did all the refractions and the interviews where information on barriers to the use of spectacles and willingness to pay for replacement spectacles were collected. Statistical analysis using Stata 10 statistical software (StataCorp, Texas, USA) and SPSS 16.0 was done. Confidence intervals and P values (significant at the P < 0.05 level) were also calculated.
The prevalence of corrective spectacle usage among those with near visual impairment was estimated, and the association between PCC with age, gender, and education was estimated. The PCC was calculated in the following manner:
PCC (%) =100 × Met Need/Met Need + Unmet Need.
For individuals who had spectacles, they were interviewed on the amount of money they were willing to pay for replacement spectacles if needed.
For subjects without spectacles, information on why spectacles were not purchased and their relationship with age, gender, and education was explored.
| Results|| |
A total of 590 subjects were enumerated, 461 subjects participated in the study (78%) and were fully examined, 31 (5%) were not eligible based on exclusion criteria. Twenty-one (4%) subjects refused to participate.
The mean age of the participants was 52.5 years (median 50.0 years; range: 40-85 years). Three hundred and thirty-six participants (73%) had little or no education while 288 (62.5%) were men. Two hundred and eighteen participants (47%) were aged 40-49 years [Table 1].
On the barriers to the use of near vision spectacles, 305 participants (66%) were interviewed regarding the barriers to the use of near vision spectacles (including those not classified as presbyopic by the WHO definition but needed near vision spectacles). One hundred and fifty-eight participants (51.3%; 95%CI 47-56.6) had no money to purchase near vision spectacles while 60 participants (19.7%; 15.5-23.9) felt it was not a priority. The difference was not significant across all age groups and also between males and females [Table 2].
Regarding willingness to pay for replacement spectacles, 52 individuals who had spectacles at the time of examination were interviewed on the amount of money they were willing to pay for replacement spectacles if needed. Skilled workers and subjects with at least secondary education were willing to pay more for replacement spectacles. There was no significant difference between males and females and between age groups [Table 3].
Fifty-two participants had spectacles corrected near vision of at least N8. The "Met Presbyopic need" was thus 11.2%. In all 194 participants could not see N8 because of uncorrected presbyopia. The "unmet presbyopic need" was 42.1%, and the PCC for the sample was 21%. It was significantly higher for males (28.8%) than females (12.3%); P = 0.002, for those with at least secondary education (42.4%) than those with none or primary education (13.3%); P < 0.001, in skilled workers (58.6%) than manual workers (16.3%), and unemployed/housewife/retired (15.7%); P < 0.001. The unmet presbyopic need was also significantly higher for participants in the age group 50-59 years compared with the other age groups (P = 0.018) [Table 4].
| Discussion|| |
This study shows that PCC is low in this setting being higher among males, those with higher education and those in employment. There is a large unmet need and as such provision of near vision spectacles should be a high priority with females, and the unemployed being the major targets.
The PCC, Met needs, and Unmet needs in this study are consistent with the findings of a study in Timor-Leste where the correction coverage was 26.2%, the Met Need was 11.5%, and the Unmet Need was 32.3%.  The high Unmet need and low PCC observed may be due to the cost of spectacles, poor access to eye care services  and the fact that there is a low drive to seek presbyopia correction probably due to the smaller contribution made by near vision compared with distance vision to vision-related quality of life.  Several studies in developing countries also found low PCC. ,,,
In our study, the PCC was significantly higher for males than females, those with secondary education than for those with less education and for skilled workers than manual workers and Unemployed/housewives similar to the findings of the Timor-Leste study where the PCC was also significantly higher for males than females, literate than illiterate, and for those in paid employment than the unemployed. 
The difference observed may be due to the fact that men are more likely to access health facilities than women as women depend on the men for their livelihood in most developing countries and require permission from the men to access health care services. Those who are educated are more likely to be in paid employment and are more likely to purchase spectacles than the illiterate, unemployed, and housewives who depend on others for their livelihood.  The proportion of presbyopia with spectacles at presentation found in this study was higher than that found in the Timor-Leste study  but lower than that reported in the Andhra Pradesh presbyopia study.  This is in sharp contrast to the findings in rural Tanzania where no subject had spectacles at presentation.  The reason for this general low trend may be the cost of spectacles being a major barrier to the use of near vision spectacles further emphasizing the need for large-scale community-based spectacle distribution schemes. , The most common barriers to the use of near vision spectacles in this study were cost and spectacles not being a priority consistent with the findings by Laviers et al. in Zanzibar where spectacles not being a priority and cost were also the major barriers.  Cost as a barrier may be reduced by developing an efficient outreach program that incorporates the provision of refractive services to cater for the needs of the poor who cannot access eye care services.
Skilled workers and those with secondary education were willing to pay more for replacement spectacles in this study while in the East Timor-Leste study; men were willing to pay more for spectacles then women.  Skilled workers and those with at least secondary education are likely to be employed and, therefore, able to pay higher for replacement spectacles, and they are also likely to appreciate the importance of spectacle correction for good vision and improved quality of life. There is a need, therefore, for health education on the importance of near vision spectacles not only for reading but also for other near vision-related tasks such as tailoring, sorting out grains, and cutting finger and toe nails.
This study is not without its limitations, the fact that subjects were aware they might receive free spectacles might have influenced their responses to the questions asked by the interviewer. Difficulty knowing the age of participants despite the use of historical events, the fact that free drugs and spectacles were being dispensed might have influenced responses about age by some of the subjects so that they could participate in the study.
| Conclusion|| |
PCC is low with a large unmet need in this rural setting and the fact that less than one-third of those affected by presbyopia had spectacles means that this rural setting is a high priority for presbyopia service delivery hence the need for provision of spectacles that are new, of good quality, accessible, and affordable through community-based approach including the development of an efficient outreach program that incorporates provision of refractive services to cater for the needs of the poor who cannot access eye care services.
We acknowledge Dr. GV Murthy for his technical support/contribution, Dr. L Langnap for his helping with the data collection exercise, the Commonwealth Scholarship Commission, British Council and Sight Savers International for providing financial support for the project. This Manuscript has been read and approved by the Authors, and the requirements for authorship as stated earlier in this document have been met, and each author believes that the Manuscript represents honest work.
Financial Support and Sponsorship
The Commonwealth Scholarship Commission and Sight Savers International provided funds for the project to be carried out.
Conflicts of Interest
There are no conflicts of interest
| References|| |
Laviers RH, Omar F, Jecha H, Khanna RC, Kassim G, Gilbert C. Presbyopic spectacle coverage, willingness to pay for near correction, and the impact of correcting uncorrected presbyopia in adults in Zanzibar, East Africa.
Invest Ophthalmol Vis Sci 2010;51:1234-41.
Nigeria zip codes. List of towns and villages in Gwagwalada L.G.A 2005. Available from: http://www.nigeriazipcodes.com
. [Last accessed on 2015 May 15].
Nirmalan PK, Krishnaiah S, Shamanna BR, Rao GN, Thomas R. A population-based assessment of presbyopia in the state of Andhra Pradesh, South India: The Andhra Pradesh Eye Disease Study. Invest Ophthalmol Vis Sci 2006;47:2324-8.
Ramke J, du Toit R, Palagyi A, Brian G, Naduvilath T. Correction of refractive error and presbyopia in Timor-Leste. Br J Ophthalmol 2007;91:860-6.
du Toit R, Palagyi A, Ramke J, Brian G, Lamoureux EL. The impact of reduced distance and near vision on the quality of life of adults in Timor-Leste. Ophthalmology 2010;117:2308-14.
Marmamula S, Keeffe JE, Rao GN. Uncorrected refractive errors, presbyopia and spectacle coverage: Results from a rapid assessment of refractive error survey. Ophthalmic Epidemiol 2009;16:269-74.
Sherwin JC, Keeffe JE, Kuper H, Islam FM, Muller A, Mathenge W. Functional presbyopia in a rural Kenyan population: The unmet presbyopic need. Clin Experiment Ophthalmol 2008;36:245-51.
Marmamula S, Narsaiah S, Shekhar K, Khanna RG. Presbyopia, spectacles use and spectacle correction coverage for near vision among cloth weaving communities in Prakasam district in South India. Ophthalmic Physiol Opt 2013;33:597-603.
Burke GA, Ilesh P, Munoz B, Kayongoya A, Mchiwa W, Schwarzwalder AW, et al
. Population based study of presbyopia in Rural Tanzania. Ophthalmology 2006;113:723-7.
[Table 1], [Table 2], [Table 3], [Table 4]