Adapted Motivational Interviewing to improve uptake of glaucoma treatment in Bauchi, Nigeria

Background: Glaucoma is a major cause of irreversible blindness in Africa due to its high prevalence, early age of onset and aggressive course. Patients often present very late and have poor awareness and limited access to services with limited treatment options to lower the intraocular pressure. When treatment is available there is often poor acceptance of surgery, the preferred treatment in Africa. To prevent blindness from glaucoma a behaviour change intervention is required to increase awareness and encourage acceptance of and adherence to treatment and follow up. Motivational interviewing (MI) was selected and adapted for this study as it has shown promise in adherence to treatment in other chronic diseases, and non professional counsellors can be trained to deliver it. To improve treatment options transscleral diode laser cyclophotoablation was introduced before the trial started Methods: Design: single site pragmatic randomized controlled trial with 1:1 allocation to one session of MI or enhanced usual care. MI was adapted for the local context and language was carried out using an interview guide generated following qualitative research. Participants allocated to MI were randomly allocated to one of two interviewers. Usual care was routine explanation by an ophthalmologist and an educational pamphlet. After the interview, a 12-item Working Alliance Inventory short questionnaire was administered to patients and interviewers to assess the collaborative relationship. The primary outcome of the trial was the proportion of participants who accepted and underwent surgery or laser treatment within two months of the date given. Laser treatment was performed using diode 810nm laser G-probes under retrobulbar anaesthesia and standard procedures. Patients were reviewed on day one, one week and at 1, 4, 6 and 12 months when IOP and visual acuity were measured. Results 276 patients participated in the trial: 135 (49%) were assigned to MI and 141 to usual care. 53% of patients in the MI group underwent treatment compared with 45% in the usual care group (risk ratio 1.2; 95% confidence interval (CI) 0.9-1.6). Overall acceptance was 49% higher than before the trial. Analysis of WAI scores showed similar scores for participants and interviewers overall. Interviewer and participant scores had high reliability coefficients (94.3% and 93.3% respectively) with good correlation when combined using Cronbach's alpha (93.9%). In the laser treatment study, data from 204 eyes treated were included in the study. Before treatment mean IOP was 39mmHg being 12, 11, 15, 18, 19 and 19mmHg on day one, at one week, and 1, 4, 6 and 12 months respectively. At 12 months 77 (72.6%) eyes (106/107 with data) had IOPs <22mmHg. At 12 months 83 (78%) eyes retained (70 eyes, 66%) or had improved (13 eyes, 12%) visual acuity; 25 eyes (23%) lost acuity. 17 eyes were retreated. No eyes had persistent hypotony. Conclusion The results do not support the introduction of this adapted MI tool to increase acceptance of glaucoma surgery in Africa as we observed only a small increase in acceptance compared with usual care, which was not statistically significant. Although only 1 in 2 patients accepted surgery or laser in this trial this is a much higher proportion than observed in other studies. In this trial the majority of participants underwent laser treatment, which is less invasive, repeatable and cheaper than trabeculectomy. The diode laser treatment appears to be a good alternative to surgery in this setting as it is acceptable, gives good IOP control and good preservation of vision at one year. Trials of different modalities of laser as a primary treatment for glaucoma in Africa are warranted

Couching in Nigeria: prevalence, risk factors and visual acuity outcomes.

PURPOSE: Couching is an ancient treatment for cataract which is still practiced in some of the poorer developing countries, particularly in sub-Saharan Africa. The purpose of this study is to describe risk factors for couching and visual acuity outcomes in a nationally representative sample of adults aged 40 years and above in Nigeria. METHODS: Probability in proportion size methods were used to identify a representative sample. Of the 15,375 adults enumerated, 13,582 were interviewed and examined. Examination included logMar acuities, slit lamp examination and dilated fundoscopy with digital fundus imaging. RESULTS: Almost half of the 583 eyes undergoing a procedure for cataract had been couched (249 eyes, 42.7%). Individuals living in rural areas (P = 0.033) and in the two underserved northern administrative zones (P = 0.33; P = 0.002) were more likely to have been couched. Visual outcomes were poor according to World Health Organization categories, with 55.8% of people and 73.1% of eyes having a presenting visual acuity of less than 3/60 and only 9.7% and 2.4% of people and eyes respectively having a good outcome (6/18 or better). None were wearing an aphakic correction, and with correction acuities improved but 42.6% of eyes were still blind (< 3/60). CONCLUSIONS: Couching is still widely practiced in Nigeria and visual outcomes are very poor. The population needs to be made aware of the risks associated with the procedure, and services for high quality, affordable cataract surgery need to be expanded, particularly in rural areas and in the north of the country

Adapted motivational interviewing to improve the uptake of treatment for glaucoma in Nigeria: study protocol for a randomized controlled trial.

BACKGROUND: Glaucoma is a chronic eye disease associated with irreversible visual loss. In Africa, glaucoma patients often present late, with very advanced disease. One-off procedures, such as laser or surgery, are recommended in Africa because of lack of or poor adherence to medical treatment. However, acceptance of surgery is usually extremely low. To prevent blindness, adherence to treatment needs to improve, using acceptable, replicable and cost-effective interventions. After reviewing the literature and interviewing patients in Bauchi (Nigeria) motivational interviewing (MI) was selected as the intervention for this trial, with adaptation for glaucoma (MIG). MI is designed to strengthen personal motivation for, and commitment to a specific goal by eliciting and exploring a person's reasons for change within an atmosphere of acceptance and compassion. The aim of this study is to assess whether MIG increases the uptake of laser or surgery amongst glaucoma patients where this is the recommended treatment. The hypothesis is that MIG increases the uptake of treatment. This will be the first trial of MI in Africa. METHODS: This is a hospital based, single centre, randomized controlled trial of MIG plus an information sheet on glaucoma and its treatment (the latter being "standard care") compared with standard care alone for glaucoma patients where the treatment recommended is surgery or laser.Those eligible for the trial are adults aged 17 years and above who live within 200 km of Bauchi with advanced glaucoma where the examining ophthalmologist recommends surgery or laser. After obtaining written informed consent, participants will be randomly allocated to MIG plus standard care, or standard care alone. Motivational interviewing will be delivered in Hausa or English by one of two MIG trained personnel. One hundred and fifty participants will be recruited to each arm. The primary outcome is the proportion of participants undergoing laser or surgery within two months of the date given to re attend for the procedure. MIG quality will be assessed using the validated MI treatment integrity scale. DISCUSSION: Motivational interviewing may be an important tool to increase the acceptance of treatment for glaucoma. The approach is potentially scalable and may be useful for other chronic conditions in Africa. TRIAL REGISTRATION: ISRCTN79330571 (Controlled-Trials.com)

Review of the publications of the Nigeria national blindness survey: methodology, prevalence, causes of blindness and visual impairment and outcome of cataract surgery.

This is a review of the major publications from the Nigeria national blindness survey in order to highlight major findings and challenges of eye care in Nigeria. The review summarizes methodology and key findings. Survey publications on methodology, prevalence and causes of visual impairment and outcome of cataract surgery were retrieved, reviewed and relevant data extracted, reported and discussed. The study was the largest and more detailed eye survey in Nigeria (15,375 people 40 years and older recruited). Participants had detailed eye examination including visual acuity, autorefractokeratometry, A- scan biometry, visual field and basic eye examination. Cause(s) of visual impairment in each eye using WHO algorithm was determined among participants with vision < 6/12. Some of the participants also had qualitative questions on barriers to uptake of services, quality of life and visual function. Major highlights of the results as contained in the publications include a high prevalence of blindness with 4.2% (95% CI: 3.8-4.6%;),of the study population having blindness (using presenting vision (PVA)) even with best correction the prevalence was 3.4% (95% CI: 3.0-3.8%. The prevalence of SVI using PVA was 1.5% (95% CI: 1.3-1.7%).and with best correction 0.8% (95% CI: 0.7-1.0%). Blindness varied by age groups, sex, literacy level and geopolitical zone. Furthermore, 84% of blindness was due to avoidable causes with cataract responsible for 43% of blindness, glaucoma 16.7%, uncorrected aphakia 8.4% and corneal opacity 7.9%. Of the total 538 eyes that had cataract surgery procedures, 42.7% had couching and the remaining had cataract surgery, but only 41.4% of cataract operated eyes had IOL surgery. Outcome of cataract surgery was good at presentation for only 30.8% of eyes (84 eyes) which improved to 56.8% with correction. The possible remedy for the high burden of needless blindness and harmful eye health practices in Nigeria are discussed

Prevalence of and risk factors for trachoma in Kano state, Nigeria.

BACKGROUND: In northern Nigeria, trachoma is an important public health problem, but there are currently few population-based data on prevalence of disease and no formal trachoma control programs. METHODOLOGY/PRINCIPAL FINDINGS: In Kano state, Nigeria, we conducted a population-based cross-sectional survey using multistage cluster random sampling, combining examination for clinical signs of trachoma and application of questionnaires assessing potential household-level risk factors. A total of 4491 people were examined in 40 clusters, of whom 1572 were aged 1-9 years, and 2407 (53.6%) were female. In 1-9 year-olds, the prevalence of trachomatous inflammation-follicular (TF) was 17.5% (95% CI: 15.7-19.5%). In a multivariate model, independent risk factors for active trachoma were the presence of flies on the face (OR 1.98, 95% CI 1.30-3.02); a dirty face (OR 2.45, 95% CI 1.85-3.25) and presence of animal dung within the compound of residence (OR 3.46, 95% CI 1.62-7.41). The prevalence of trachomatous trichiasis in persons aged ≥15 years was 10.9% (95% CI: 9.7-12.2%). Trichiasis was significantly more common in adult females than in adult males. CONCLUSION/SIGNIFICANCE: There is an urgent need for a trachoma control program in Kano state, with emphasis given to provision of good quality trichiasis surgery. Particular effort will need to be made to identify women with trichiasis and engage them with appropriate services while also taking steps to secure azithromycin for mass treatment and ensuring personal and environmental hygiene

Poverty and Blindness in Nigeria: Results from the National Survey of Blindness and Visual Impairment.

PURPOSE: Poverty can be a cause and consequence of blindness. Some causes only affect the poorest communities (e.g. trachoma), and poor individuals are less likely to access services. In low income countries, cataract blind adults have been shown to be less economically active, indicating that blindness can exacerbate poverty. This study aims to explore associations between poverty and blindness using national survey data from Nigeria. METHODS: Participants ≥40 years were examined in 305 clusters (2005-2007). Sociodemographic information, including literacy and occupation, was obtained by interview. Presenting visual acuity (PVA) was assessed using a reduced tumbling E LogMAR chart. Full ocular examination was undertaken by experienced ophthalmologists on all with PVA <6/12 in either eye. Causes of vision loss were determined using World Health Organization guidelines. Households were categorized into three levels of poverty based on literacy and occupation at household level. RESULTS: A total of 569/13,591 participants were blind (PVA <3/60, better eye; prevalence 4.2%, 95% confidence interval [CI] 3.8-4.6%). Prevalences of blindness were 8.5% (95% CI 7.7-9.5%), 2.5% (95% CI 2.0-3.1%), and 1.5% (95% CI 1.2-2.0%) in poorest, medium and affluent households, respectively (p = 0.001). Cause-specific prevalences of blindness from cataract, glaucoma, uncorrected aphakia and corneal opacities were significantly higher in poorer households. Cataract surgical coverage was low (37.2%), being lowest in females in poor households (25.3%). Spectacle coverage was 3 times lower in poor than affluent households (2.4% vs. 7.5%). CONCLUSION: In Nigeria, blindness is associated with poverty, in part reflecting lower access to services. Reducing avoidable causes will not be achieved unless access to services improves, particularly for the poor and women

The Nigerian national blindness and visual impairment survey: Rationale, objectives and detailed methodology.

BACKGROUND: Despite having the largest population in Africa, Nigeria has no accurate population based data to plan and evaluate eye care services. A national survey was undertaken to estimate the prevalence and determine the major causes of blindness and low vision. This paper presents the detailed methodology used during the survey. METHODS: A nationally representative sample of persons aged 40 years and above was selected. Children aged 10-15 years and individuals aged <10 or 16-39 years with visual impairment were also included if they lived in households with an eligible adult. All participants had their height, weight, and blood pressure measured followed by assessment of presenting visual acuity, refractokeratomery, A-scan ultrasonography, visual fields and best corrected visual acuity. Anterior and posterior segments of each eye were examined with a torch and direct ophthalmoscope. Participants with visual acuity of < = 6/12 in one or both eyes underwent detailed examination including applanation tonometry, dilated slit lamp biomicroscopy, lens grading and fundus photography. All those who had undergone cataract surgery were refracted and best corrected vision recorded. Causes of visual impairment by eye and for the individual were determined using a clinical algorithm recommended by the World Health Organization. In addition, 1 in 7 adults also underwent a complete work up as described for those with vision < = 6/12 for constructing a normative data base for Nigerians. DISCUSSION: The field work for the study was completed in 30 months over the period 2005-2007 and covered 305 clusters across the entire country. Concurrently persons 40+ years were examined to form a normative data base. Analysis of the data is currently underway. CONCLUSION: The methodology used was robust and adequate to provide estimates on the prevalence and causes of blindness in Nigeria. The survey would also provide information on barriers to accessing services, quality of life of visually impaired individuals and also provide normative data for Nigerian eyes

Prevalence and risk factors for diabetes and diabetic retinopathy: results from the Nigeria national blindness and visual impairment survey.

BACKGROUND: In Nigeria, urbanisation and increasing life expectancy are likely to increase the incidence of non-communicable diseases. As the epidemic of diabetes matures, visual loss from diabetic retinopathy (DR) will increase unless mechanisms for early detection and treatment improve, and health systems respond to the growing burden of non-communicable diseases. METHODS: A nationally-representative population-based sample of 13,591 participants aged ≥40 years selected by multistage-stratified-cluster-random-sampling with probability-proportional-to-size procedures were examined in 305 clusters in Nigeria between January 2005 to June 2007. All were asked about history of diabetes and underwent basic eye examination. Visual acuity (VA) was measured using logMAR E-chart. Participants with VA11.1mmol/l or had DR. Data in the subsample were used to estimate the prevalence and to analyse risk factors for diabetes and DR using multivariable logistic regression. Additional information on the types of DR was obtained from participants not in the subsample. RESULTS: In the subsample, 164 participants were excluded due to missing data; and 1,595 analysed. 52/1,595 had diabetes, a prevalence of 3.3% (95%CI 2.5-4.3%); and 25/52(48%) did not know. Media opacity in 8/52 precluded retinal examination. 9/44(20.5%) had DR. Higher prevalence of diabetes was associated with urban residence (Odds ratio [OR]1.87) and overweight/obesity (OR3.02/4.43 respectively). Although not statistically significant, DR was associated with hypertension (OR3.49) and RBG>15.0mmol/L (OR8.10). Persons with diabetes had 3 times greater odds of blindness. Of 11,832 other participants in the study sample, 175(1.5%) had history of diabetes; 28 had DR. Types of DR (total=37) included 10.8% proliferative, 51.4% macular oedema. CONCLUSION: The age-adjusted prevalence of diabetes in Nigeria was 3.25% (95%CI 2.50-4.30) and over 10% of people with diabetes aged ≥40 years had sight-threatening-DR. These data will enable the development of better public health strategies for the control of diabetes and planning services for DR to prevent vision loss