Glaucoma Awareness and Knowledge Among Ethiopians in a Tertiary Eye Care Center
Glaucoma outcomes are closely associated with patients’ awareness of the disease. However, little is known about glaucoma awareness and knowledge in Addis Ababa, a densely populated and ethnolinguistically diverse capital city in Ethiopia, the second largest country in Africa.
We performed a cross-sectional survey in the ophthalmology waiting room at St. Paul’s Hospital, a tertiary care center in Addis Ababa. Respondents included patients, patient family members, and non-clinical staff. Participants were asked if they had read or heard about glaucoma to gauge basic awareness of the disease; those with awareness were asked to take a quiz to measure their objective glaucoma knowledge. We performed multivariable regression to identify factors associated with glaucoma awareness, quiz performance, and self-rated ability to use eye drops.
Of 298 respondents, 145 (48.7%) were female, and the average age was 44.9 ± 17.2 years. A majority (167; 56.0%) had primary school or less than primary school education. Only 131 (44.0%) had basic glaucoma awareness. Of these, 95 (72.5%) knew that glaucoma causes permanent vision loss, 103 (78.6%) knew glaucoma is often asymptomatic in early stages, 62 (47.3%) identified elevated intraocular pressure as a glaucoma risk factor, and 124 (94.7%) knew glaucoma was treatable. A majority of this subset (126; 96.2%) said they would be willing to use medicated eye drops, and 130 (99.2%) indicated a willingness to undergo surgery if recommended. Education level was independently associated with glaucoma awareness (p < 0.001) and glaucoma quiz performance (p = 0.03).
In a population sample from an ophthalmology waiting room in Addis Ababa, glaucoma awareness was poor and most strongly associated with education level. Educational interventions at public health and provider-patient levels are warranted. Our results suggest high receptiveness to both medical and surgical treatment.
Electronic supplementary material
The online version of this article (10.1007/s40123-020-00314-1) contains supplementary material, which is available to authorized users.
Key Summary Points
|Why carry out this study?|
|Glaucoma represents a significant cause of preventable blindness in Ethiopia. Increasing public awareness and understanding of glaucoma and its treatments could help alleviate this burden.|
|This study sought to assess the prevalence of glaucoma awareness and knowledge within an Ethiopian population. Through understanding the factors that influence glaucoma awareness and understanding, efforts to improve these metrics can be directed in an efficient manner.|
|What was learned from the study?|
|Awareness of glaucoma was found in just 44% of study participants, and just 28.2% of participants reported that their knowledge of glaucoma was good or very good.|
|A higher level of education was associated with both awareness of glaucoma and a higher score on an objective measure of glaucoma knowledge. A personal history of glaucoma was associated with a higher self-reported knowledge of glaucoma.|
|Future studies should further investigate reasons for low glaucoma awareness and interventions to increase awareness in this community.|
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Glaucoma is the leading cause of irreversible blindness and visual impairment globally, affecting an estimated 80 million people worldwide . Numerous population-based studies have demonstrated that glaucoma disproportionately affects people of African origin [2–4]. Within countries of eastern Sub-Saharan Africa (SSA) like Ethiopia, glaucoma is responsible for an estimated 11.7% of total blindness, a relatively larger proportion of blindness than is seen in other regions of the world . It is generally recognized that patients in limited resource environments, on average, present later in the disease course. For glaucoma, this means that patients typically present with higher intraocular pressure (IOP), more advanced optic nerve cupping, and greater loss of peripheral and central vision. One recent clinic-based survey in Addis Ababa, Ethiopia noted that 26% of patients diagnosed with glaucoma exhibited either low vision (< 6/18 in the better eye) or blindness (< 3/60 in the better eye) .
Proven treatments exist to halt or slow the progression of glaucoma by lowering IOP. These modalities include pharmacologic medications, such as topical eyedrops, as well as laser therapy and surgery. However, a treatment is only useful if the individuals suffering from the condition are aware of their need for it and have access to care. For therapies that require self-administration, patients must be willing to apply the treatment and possess the necessary knowledge to do so effectively. As such, any initiative that seeks to improve glaucoma outcomes for a given population must focus on increasing public awareness, which will in turn lead to improved knowledge and understanding with the potential to drive behavioral change. Therefore, it is important to characterize the overall awareness and knowledge of a given population with regard to glaucoma and its available treatments, particularly in regions with a relatively high prevalence of the disease.
In 2007, a glaucoma consortium was established in Ethiopia with the intent of raising public awareness about the disease . Through radio campaigns, TV advertisements, and community events, this group saw early results suggesting that awareness of glaucoma was spreading among Ethiopian communities. Despite these efforts, little information exists regarding the actual awareness of glaucoma within Ethiopia. Our study sought to assess the prevalence of glaucoma awareness, the degree of knowledge possessed by those who were aware of glaucoma, and the self-reported ability of those individuals to use eyedrops, the main first-line treatment for glaucoma. It was hypothesized that awareness of glaucoma and its associated treatments within the study population, a low- to middle-class subset of individuals seeking low-cost care at St. Paul’s Hospital in Addis Ababa, would be relatively low.
This clinic-based, cross-sectional observational study was approved by both the University of Michigan (HUM00148963) and St. Paul’s Hospital Millennium Medical College (SPHMMC) Institutional Review Boards and was conducted in accordance with the tenets of the Declaration of Helsinki. All subjects provided informed consent to participate in the study. Data were collected between March–April 2019 in the ophthalmology clinic waiting room of SPHMMC in Addis Ababa, Ethiopia, a hospital with a catchment population of over 5 million people comprising all of Ethiopia’s major ethnolinguistic groups. Participants consisted of patients of the clinic as well as non-patient family members and non-clinical staff. Persons < 18 years of age, those who were not fluent in English, Amharic, or Afan Oromo, and those unable or unwilling to provide verbal informed consent were excluded. Because the research was conducted as a sub-study of a periocular anthropometrics study to be published separately, persons with a history of orbital disease were excluded. The informed consent script and survey questions were translated in real time from the original English documents by study staff who were fluent in English and Amharic and/or Afan Oromo (as appropriate for the patient’s preferred language), and participants’ responses were marked on paper data collection documents by study staff in real time.
We collected demographic information including age, sex, primary language, education level, profession, district (“woreda”) of residence, and primary ethnicity (Amhara, Oromo, Gurage, Tigray, Silt’e, Gamo, or other). Participants with fewer than three grandparents of one ethnicity were recorded as mixed ethnicity. We asked participants if they had heard of or read anything about glaucoma to assess their basic awareness of the disease; those who answered negatively were not asked to answer additional questions about glaucoma. Of those participants who indicated an awareness of the disease, we asked where they had learned about glaucoma and if they knew they had glaucoma. Additionally, we asked these respondents to self-rate their knowledge of glaucoma and ability to successfully use medicated eye drops on a 5-point Likert scale, where 1 represented very poor knowledge/ability and 5 represented very good knowledge/ability. Participants answered quiz questions in true-or-false and multiple-choice formats to assess their objective knowledge of glaucoma. They were then asked whether they would undergo surgery for glaucoma or use eye drops for as long as necessary to treat glaucoma if these interventions were recommended by a doctor. The complete screening checklist, informed consent checklist, and glaucoma survey are available in Online Appendix 1.
Analyses were performed with SAS University Edition (SAS Institute, Cary, NC); all inferential analyses used a two-tailed significance cutoff of 0.05. We converted participants’ quiz responses to a 20-point objective knowledge score based on the number of items answered correctly and calculated the percent correct. We performed multiple linear regression modeling for objective knowledge using age, sex, education level, primary ethnicity, and personal history of glaucoma as covariates. We performed logistic regression modeling for basic glaucoma awareness, good or better self-rated glaucoma knowledge, and good or better self-rated ability to use eye drops utilizing the same covariates.
Of 298 participants, 145 (48.7%) were female, and the average age was 44.9 ± 17.2 years. One hundred three (103, 34.6%) were primarily of Amhara ethnicity, 89 (29.9%) were of Oromo ethnicity, and 52 (17.4%) were of Gurage ethnicity. The remaining 54 (18.1%) were of mixed ethnicity. A majority of participants (167; 56.0%) had primary school or less than primary school education. The demographic data are summarized in Table Table11.
Demographic characteristics for 298 participants, 131 with and 167 without basic awareness of glaucoma
(n = 298)
(n = 131)
(n = 167)
|Age (years ± SD)||44.9 ± 17.2||46.2 ± 15.3||43.9 ± 18.5||0.25a|
|Female||145 (48.7%)||60 (45.8%)||85 (50.9%)|
|Male||153 (51.3%)||71 (54.2%)||82 (49.1%)|
|Amhara||103 (34.6%)||49 (37.4%)||54 (32.3%)|
|Oromo||89 (29.9%)||34 (26.0%)||55 (32.9%)|
|Gurage||52 (17.4%)||22 (16.8%)||30 (18.0%)|
|Mixed or other||54 (18.1%)||26 (19.8%)||28 (16.8%)|
|Education level||< 0.001b|
|≤ Primary||167 (56.0%)||52 (39.7%)||115 (68.9%)|
|≥ Secondary||131 (44.0%)||79 (60.3%)||52 (31.1%)|
|Addis Ababa||197 (66.1%)||91 (69.5%)||106 (63.5%)|
|Other||101 (33.9%)||40 (30.5%)||61 (36.5%)|
aBy independent-samples t-test assuming unequal variances
bBy chi-square test of independence
One hundred thirty-one (131; 44.0% of the overall sample) participants reported previously hearing about glaucoma. In the logistic regression model for basic glaucoma awareness (Table (Table2),2), secondary school or greater education level was independently associated with increased awareness of glaucoma (OR = 4.35 [95% CI 2.53–7.48], p < 0.001). Older age was also associated with a slightly increased awareness of glaucoma (OR = 1.02 [95% CI 1.01–1.04], p = 0.01). Sex, primary ethnicity, and residence did not demonstrate a significant association with increased glaucoma awareness, though there was a slight trend of increased glaucoma awareness among participants from Addis Ababa.
Multivariable logistic regression analysis of basic glaucoma awareness among 298 participants
|Variable||Awareness of glaucoma||OR (95% CI)||p|
|No./total||% (95% CI)|
|Age (per 1 year increase)||–||–||1.02 (1.01–1.04)||0.01|
|Female||60/145||41.4 (33.4–49.4)||1 [reference]|
|Male||71/153||46.4 (38.5–54.3)||1.22 (0.73–2.04)|
|Amhara||49/103||47.6 (38.0–57.2)||1 [reference]|
|Oromo||34/89||38.2 (28.1–48.3)||0.72 (0.37–1.40)||0.33|
|Gurage||22/52||42.3 (28.9–55.7)||1.23 (0.59–2.57)||0.58|
|Mixed or other||26/54||48.1 (34.8–61.4)||1.46 (0.71–2.99)||0.30|
|Education level||< 0.001|
|≤ Primary||52/167||31.1 (24.1–38.1)||1 [reference]|
|> Primary||79/131||60.3 (51.9–68.8)||4.35 (2.53–7.48)|
|Addis Ababa||91/197||46.2 (39.2–53.2)||1 [reference]|
|Other||40/101||39.6 (30.1–49.1)||0.91 (0.51–1.62)|
Of the 131 (44.0% of the overall sample) participants who had a basic awareness of glaucoma, 30 (23%; 10% of the overall sample) said they had glaucoma; 57 (43.5%; 19% of the overall sample) stated they had learned about glaucoma from television, the radio, or media other than the internet; 28 (21.4%; 9.4% of the overall sample) indicated that they had learned about glaucoma via direct education by a healthcare provider. Only 37/131 (28.2%) self-rated their knowledge of glaucoma as good or very good, but 100/131 (76.3%) self-rated their ability to use eye drops as good or very good. Receptiveness to glaucoma treatment was high, with 126/131 (96.2%) stating a willingness to use eye drops to treat glaucoma and 130/131 (99.2%) indicating a willingness to undergo surgery for glaucoma if it was recommended by an ophthalmologist.
In the logistic regression for self-rated knowledge of glaucoma (Table (Table3),3), personal history of glaucoma was independently associated with good or very good self-rated glaucoma knowledge (OR = 3.75 [95% CI 1.29–10.92], p = 0.02), but none of the other covariates were independently associated with self-rated drop use ability. In the logistic regression for ability to use eyedrops (Table (Table4),4), no covariates were independently associated with good or very good self-rated ability to use eyedrops.
Multivariable logistic regression analysis of self-rated good or very good knowledge of glaucoma among 131 participants with basic awareness of glaucoma
|Variable||≥ Good self-rated knowledge||OR (95% CI)||p|
|No./total||% (95% CI)|
|Age (per 1 year increase)||–||–||1.00 (0.97–1.03)||0.93|
|Female||14/60||23.3 (12.6–34.0)||1 [reference]|
|Male||23/71||32.4 (21.5–43.3)||1.17 (0.47–2.87)|
|Amhara||11/49||22.4 (10.7–34.1)||1 [reference]|
|Oromo||11/34||32.4 (16.7–48.1)||1.51 (0.50–4.57)||0.47|
|Gurage||6/22||27.3 (8.7–45.9)||1.26 (0.34–4.62)||0.73|
|Mixed or other||9/26||34.6 (16.3–52.9)||2.17 (0.70–6.75)||0.18|
|< Secondary||11/52||21.2 (10.1–32.3)||1 [reference]|
|≥ Secondary||26/79||32.9 (22.5–43.3)||2.07 (0.82–5.19)|
|Addis Ababa||26/91||28.6 (19.3–37.9)||1 [reference]|
|Other||11/40||27.5 (13.7–41.3)||0.79 (0.30–2.09)|
|History of glaucoma||0.02|
|No||22/101||21.8 (13.8–29.9)||1 [reference]|
|Yes||15/30||50.0 (32.1–67.9)||3.75 (1.29–10.92)|
Multivariable logistic regression analysis of self-rated good or very good ability to use eye drops among 131 participants with basic awareness of glaucoma
|Variable||≥ Good self-rated drop ability||OR (95% CI)||p|
|No./total||% (95% CI)|
|Age (per 1 year increase)||–||–||1.00 (0.97–1.03)||0.96|
|Female||42/60||70.0 (58.4–81.6)||1 [reference]|
|Male||58/71||82.0 (73.1–90.9)||1.86 (0.74–4.64)|
|Amhara||40/49||81.6 (70.8–92.5)||1 [reference]|
|Oromo||28/34||82.4 (69.6–95.2)||0.82 (0.23–2.87)||0.75|
|Gurage||14/22||63.6 (43.5–83.7)||0.35 (0.10–1.21)||0.10|
|Mixed or other||18/26||69.2 (51.5–86.9)||0.49 (0.16–1.54)||0.22|
|Education level||38/52||73.1 (61.1–85.2)||1 [reference]|
|< Secondary||62/79||78.5 (69.4–87.6)||1.05 (0.42–2.60)|
|Addis Ababa||68/91||74.7 (65.8–83.6)||1 [reference]|
|Other||32/40||80.0 (67.6–92.4)||1.02 (0.36–2.86)|
|History of glaucoma||0.74|
|No||76/101||75.2 (66.8–83.6)||1 [reference]|
|Yes||24/30||80.0 (65.7–94.3)||1.22 (0.38–3.95)|
The mean objective knowledge score was 11.8 ± 2.2 (59.0 ± 11.0% correct) out of 20. Regarding specific quiz items, 124/131 (94.7%) knew that glaucoma was treatable, 103/131 (78.6%) knew that glaucoma is often asymptomatic in its early stages, 95/131 (72.5%) knew that glaucoma causes permanent vision loss, 62/131 (47.3%) knew that glaucoma was related to elevated IOP, and 33/131 (25.2%) knew that glaucoma resulted from damage to the optic nerve. In the linear regression for objective knowledge score (Table (Table5),5), secondary school or greater education level was independently associated with a higher knowledge score (p = 0.03), but age, sex, primary ethnicity, and personal history of glaucoma were not.
Multivariable linear regression analysis of objective glaucoma knowledge score among 131 participants with basic awareness of glaucoma
|Variable||Objective glaucoma knowledge score||p|
|Age (per 1 year increase)||0.004||0.01||0.77|
|Mixed or other||0.48||0.53||0.36|
|History of glaucoma||0.08|
aThis parameter is set to zero because it is the reference