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Year : 2019  |  Volume : 22  |  Issue : 7  |  Page : 988-996

EHR health seeking behavior of patients attending eye clinic in Southern Nigeria

1 Department of Ophthalmology, University of Calabar; Department of Ophthalmology, University of Calabar Teaching Hospital, Calabar, Nigeria
2 Department of Ophthalmology, University of Calabar Teaching Hospital, Calabar, Nigeria
3 Department of Psychiatry, University of Calabar, Calabar; Department of Psychiatry, University of Calabar Teaching Hospital, Calabar, Nigeria

Date of Acceptance04-Apr-2019
Date of Web Publication11-Jul-2019

Correspondence Address:
Dr. C T Agweye
Department of Ophthalmology, University of Calabar, Calabar
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/njcp.njcp_373_18

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Background: Health-seeking behavior is important as it reveals the preventive, curative, and rehabilitative actions taken by individuals to rectify perceived ill-health. Aim and Objectives: To identify existing eye health–seeking behavior, factors influencing such behavior, and suggest ways in which the system can respond to the needs of the target population in order to reduce visual impairment and blindness. Methods: This was a descriptive cross-sectional study; 600 respondents were interviewed using a semistructured pretested questionnaire administered to every fifth new patient attending the eye clinic of University of Calabar Teaching Hospital (UCTH) for a period of 5 months by a single interviewer. People unable to respond appropriately were interviewed alongside their caregivers. Results: Poor distant vision was the most frequent ocular complaint in this study. The mean duration of complaint before presentation to any health facility was 370.65 ± 889.48 days with a range of 0–9,125 days. Nature of eye complaint was the most significant factor that determined how early respondents sought help (P < 0.001). Place of residence, nature of eye complaint, and employment status were significant determinants of the choice of place of first presentation for ocular complaints. Conclusion: There is need for improved eye health education and awareness for prompt presentation to an appropriate eye care professional at the onset of symptoms and even case finding for potentially blinding eye conditions.

Keywords: Blindness, eye health–seeking behavior, ocular compliant, visual impairment

How to cite this article:
Etim B A, Ibanga A A, Nkanga D G, Agweye C T, Utam U A, Udofia O O. EHR health seeking behavior of patients attending eye clinic in Southern Nigeria. Niger J Clin Pract 2019;22:988-96

How to cite this URL:
Etim B A, Ibanga A A, Nkanga D G, Agweye C T, Utam U A, Udofia O O. EHR health seeking behavior of patients attending eye clinic in Southern Nigeria. Niger J Clin Pract [serial online] 2019 [cited 2022 Aug 8];22:988-96. Available from:

   Introduction Top

Health-seeking behavior is a complex, multidimensional, and dynamic concept.[1] It could be defined as personal actions undertaken by any individual to promote optimal wellness, recovery, and rehabilitation. It is the sum total of personal, experiential, and sociocultural factors that is influenced by family and communities resulting in variation in the same individual and communities.[2]

The nature of the disease is a determinant of variation seen in the same individual or communities and is reportedly worse for asymptomatic illnesses.[2],[3] Consultation of health professionals are usually reserved for what is perceived as “serious” symptoms as some patients tolerate or self-treat: a phenomenon known as the “symptom iceberg.”[4],[5],[6] The health belief model (HBM) which is a widely recognized framework of health behavior states that health-related responses are based on perceived susceptibility and severity, barriers to accessing services, and the perceived benefits of treatment.[7]

Decision to seek care is dependent on various factors that interact in a dynamic way. Health decision making process in Nigeria is a reflection of tradition, religion, household authority structure, household economy, and community norms expressed in attitude, opinions, and actions.[8] The opinion of relatives, influential members of the community, non-medical skilled hospital workers, and friends significantly influence the choice of health care.[3] Other factors that influence health-seeking behavior include socioeconomic status, knowledge, perception, beliefs of causation behind certain diseases, attitude, literacy level, distance to health facility, cost of treatment, delayed attention in hospitals, trust and confidence in alternative eye health providers, communication gap between patients and orthodox eye care providers, ethnicity, religion, and gender.[3],[9] Types of available healthcare facilities also influence health-seeking decisions. The Nigerian health system is structured into primary, secondary, and tertiary levels of care. Tertiary facilities are mostly urban based, and primary health centers (PHCs), which provide health care at grass root level, are located more in suburban and rural areas and are expected entry point into the healthcare delivery system.[10] Sources of health care in many developing countries such as Nigeria include traditional/herbal, faith healers, patent medicine vendors (PMVs)/allied health practitioners and orthodox health facilities and often many use a combination of these.[3] The private sector is highly active in Nigeria providing up to 60% of healthcare service including eye care.[10] The kind of care sought by any individual affects the prognosis of the diseases. Evidence suggests that available eye care services are often under sourced even when eye diseases and blindness are common in developing countries.[11],[12] Ninety percent of blindness is found in developing countries of which Nigeria is one.[13] Blindness prevalence in Nigeria is 0.78% with the most common cause being cataract (43%) and a prevalence of 1.5% for severe visual impairment with uncorrected refractive error (62%) as the most common cause.[14],[15],[16],[17] Of note is the high percentage (84%) of avoidable blindness in Nigeria.[14],[15] The prevalence of other eye conditions not associated with loss of distance visual acuity, such as ocular infections, irritable/dry eyes, lid infections, and the age-related decline in near vision (presbyopia) affects ~20% of the population of all ages in Nigeria.[18] These distress those so affected thereby placing demand on health services.[19]

In an effort to reduce the burden of visual loss, the Nigerian government and non-governmental organizations have since the launch of Vision 2020 program put up several activities to improve availability, affordability, accessibility, and quality of eye care services in the country. In spite of this, 50% of all cataract interventions are carried out by itinerant vouchers, while Nigeria still has one of the lowest cataract surgical rates in Africa (300 per million per year) and the situation is not different for other eye care services.[20]

If improvement in health practices must be achieved, behavioral change in the direction of health-seeking attitude is required. There is also need for responsive health systems that adapt or modify strategies on the basis of behavioral studies to be more proactive. The study will, therefore, identify existing eye health–seeking behavior, factors influencing such behavior, and suggest ways in which the system can respond to the needs of persons availing themselves of the hospital's eye services in order to reduce visual impairment and blindness.

   Methodology Top

The University of Calabar Teaching Hospital is located in Calabar metropolis. It provides tertiary level health care which includes ophthalmic services provided by the department of Ophthalmology. Eye care services include general ophthalmic and subspecialty services, optical services, rehabilitation and low-vision services as well as training for medical students, resident doctors, nurses, and other eye care workers. The general hospital provides secondary level of health care. The comprehensive health centers or PHCs provide basic eye care services, such as treatment of common eye diseases like infective conjunctivitis, immunization against child hood killer diseases, vitamin A distribution, and first-aid care for emergency ocular conditions such as chemical eye injuries. There are nine government-registered private eye clinics, seven of which are run by optometrists and three by ophthalmologists.

Calabar is the state capital, has an area of 406 km 2, and a population of 371,022 at the 2006 census. It is located between latitude 4°57 N and longitude 8°19 E, within the tropical rain forest of Nigeria. It is bounded in the North by Odukpani Local Government Area, in the West by Calabar River with the Great Qua River at the South and East.[21]

This descriptive cross-sectional study was conducted using semistructured pretested questionnaires administered to every fifth new patient attending the eye clinic of UCTH for a period of 5 months (August–December 2016) by a single interviewer. People unable to respond appropriately were interviewed alongside their caregivers. Only participants who gave informed consent were included in the study.

The interviewer was trained by the principal investigator and a pilot study was also conducted prior to the commencement of the study on new patients at the eye clinic of UCTH. These were excluded from the study population. Following this, necessary modifications to the questionnaire and clarification of terms were made.

Data management

All open-ended questions were reviewed by one of the authors and coded. Data were compiled into Micro Soft Excel 2010 and analyzed using STATA IC 12 following cleaning.

Categorical variables were presented as frequency tables and continuous variables as summary statistics. Some continuous variables were converted to categorical data for a more meaningful presentation.

The level of significance was derived with Chi-square test, confidence interval set at 95%, and P value < 0.5.

Ethical considerations

Ethical approval for the study was obtained from the Ethics Committee of UCTH. Informed consent was also obtained from participants with assurance that their names or locations will not be used but rather code numbers.

   Results Top

In total, 600 patients within the study period were interviewed, while they waited to see the doctor. About 314 (52.3%) were females, while 286 (47.7%) were males [Table 1]. The age range was between 1 and 94 years, with a mean of 34.62 ± standard deviation (SD) of 18.22. The mode was between 20 and 29 years. More than half of the patients had university education and 87% lived in urban areas. Up to 88% did not have any form of insurance at all, whereas over 50% were unemployed. Other sociodemographic characteristics are as shown in [Table 1]. Students formed the majority of study participants 189 (31.50%) followed by professionals 159 (26.50%) and service workers 90 (15.00%) with 18 (3.00%) having no occupation. Pensioners and those in the armed forces were the least of those accessing service in the facility during the study period 1 (0.17%)
Table 1: Sociodemographics of study participants

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Presenting complaints of study respondents

Poor distant vision was the most frequent presenting complaint in both eyes which was closely followed by itching, poor near vision, ocular pain, and redness. More than half 56 (9.33%) had no specific ocular complaints; they were seen for medical exam. Trauma was seen in only 4–5 (0.67%–0.83%) of the patients [Figure 1].
Figure 1: Presenting Complaints in 600 respondents

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Duration of ocular complaints and time lapse before seeking help

The mean duration of ocular complaints in the study population was 370.65 ± 889.48 days with a range of 0–9,125 days. The shortest duration of a week was observed in over 22%, whereas as much as 19% of respondents had complaints which lasted for more than a year. The mean duration of complaint before presentation to any health facility was 236.35 ± 624.26 with a range of 0–9,125 days. More than a quarter of respondents sought help for their complaints within a week while up to 11% did not do so until well over 1 year. [Table 2]
Table 2: Duration of ocular complaints and time lapse before seeking help

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Determinants of how early study respondents sought help

Nature of eye complaint was the most significant factor that determined how early study respondents sought help (P < 0.001), as seen in [Table 3]. Other factors were financier of treatment, age, and marital status. Older people were less likely to seek help early compared with younger people. Single participants were more likely to seek help earlier than married people.
Table 3: Determinants of how early study respondents sought help

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Distribution of health-seeking preferences of patients and their reasons

Majority 382 (96.22%) who chose the study center (UCTH) as place of first contact for ocular complaints did not give any reason for their choice. However, nearness of health facility to study participants was prominent as a reason for choice of a place of first contact for ocular complaints. The larger number of those that gave nearness as a reason for their choice was mostly those that patronized the services of private orthodox facilities (33.6%), PMVs (32.1%), and PHCs (17.91%) [Table 4].
Table 4: Distribution of health-seeking preferences of patients and their reasons

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Determinants of choice of place of first contact

Place of residence, nature of eye complaint, and employment status were significant as determinants of the choice of place of first presentation for ocular complaints. Fewer females went first to both private and public hospitals but more went to PMVs and traditional doctors/herbalists first. The unemployed went first to places requiring less financial commitment, such as PHC and PMVs. Urban dwellers presented mostly to UCTH as first choice while rural dwellers went to PHCs and private facilities. Those with vision-related complaints and itching went first to UCTH while those with redness, swelling went to PHC, and other private places [Table 5].
Table 5: Determinants of choice of place of first contact

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   Discussion Top

The decision to engage with a particular medical channel is influenced by a variety of socioeconomic, geographical, and organizational variables including sex, age, educational level, type of illness, access to services, and perceived quality of service.[22] The participants were made up of more women than men, mostly young, with post primary education, unemployed, married, without health insurance, and majority resident in urban areas. The number of females accessing eye care service in this study was a little above half (52.3%) which is high, compared with other studies where women constitute the minority of those that seek care in formal health institutions.[23],[24] This may be due to the location of the hospital which is urban and the city of Calabar plays host to a reasonable number of tertiary institutions. This was seen in this study where students formed the majority of participants 189 (31.50%) followed by professionals 159 (26.50%). A little over half of the study population, 308 (51.3%), were unemployed. This is a reflection of the prevalent unemployment rate in the country estimated at 9.9%, which is higher than the global average of 5.9%.[25] Majority 528 (88.00%) of the participants had no form of insurance, which mirrors the prevailing status in the national health insurance scheme of <4% membership.[26] Services were accessed mostly by urban dwellers as majority 521 (86.83%) came from the city where the hospital is located. This is probably a reflection of the weak and fragmented referral system and or accessibility issues, which affects follow-up and utilisation of the facility. The distribution of place of residence should have shown a broader representation of patients drawn from other parts of the state given that this is a major tertiary and referral public hospital in Cross River state.

More than 90% of study participants had ocular complaints in this study. Poor distant vision was the most frequent ocular complaint in this study bilaterally. Others were itching, poor near vision, ocular pain, and redness but trauma was notably of low frequency. This vision impairing and nonvision impairing complaints are common in this population as also reported in other studies.[18],[27],[28] The mean duration that study participants lived with these symptoms was 370.65 ± 889.48 days (a little over a year) showing that most complaints were not self-limiting but rather chronic. It also shows that ocular complaint is a common finding in the health sector and needs to be given priority by policy makers and health planners as it can cause distress and increased demand for health services.

In our study, a little over a quarter of respondents presented to the hospital within a week of symptoms, which was mostly for acute complaints such as bleeding, swelling, redness, and eye pain. Mean time lapse before presenting to health facility was 236.35 ± 624.26 days showing delayed presentation suggesting missed opportunities for early diagnosis and treatment. Nature of eye complaints, marital status, age, and financier of the treatment were strong determinants of when they presented to an eye care facility. Of these, nature of complaints was the strongest determinants. This is similar to other studies which also revealed that delay in seeking eye care was due to perceived notion that the eye disease is not serious enough to warrant consulting an ophthalmologist.[18],[29],[30]

Place of first contact for the majority of respondents in this study for eye complaint was first of all the tertiary center, private clinics, and then PMV). This is similar to the study by Mahmoud et al. where a large majority of ophthalmic patients accessed eye care directly at tertiary facility which meant that a significant number of inappropriate cases presented there, further overburdening the poorly funded facility.[31] Onwubiko et al. in Nigeria and Ntim-Amponsah et al. in Ghana made similar observations in their study where most participants consulted ophthalmologists and PMVs first for eye complaints,[29],[32] whereas a study by Senyonjo et al. revealed that most of the respondents sought help for eye complaints first at a chemist or medicine store.[11] This contrasts with a study in India which reported traditional healers as point of first contact.[33] Some studies in Malawi and some in Nigeria revealed that self-medication was first undertaken for eye complaints.[34] The importance of place of first contact for eye diseases is important because it can determine the outcome of the disease. Majority of respondents did not give any reason for their choice of place of first contact which incidentally was the study site. Mahmoud et al. in Ilorin, Nigeria, reported similar high patronage of their tertiary facility for eye complaints because of the perceived good quality of service there in addition to the poor and nearly nonexistent eye care service at primary and secondary level of health care.[31] Where reasons were given, proximity of health facility to residence, provision of timely service, and cost, in order of preference, were most common. Key factor in obtaining quality healthcare services is accessibility which could be geographical, economical, cultural, and political.[35] Of these, geographical access measured in terms of distance, traveling time and cost is the most important,[35] which is similarly reflected in this study. A study in Ghana also observed that individuals regularly visit the nearest and cheapest options for health care.[36] Since those who proffered reasons were not 100%, it is likely other reasons maybe implicated. It, therefore, seems that people when in need of eye care will seek out the most accessible source of eye care which most often is not usually orthodox health facility but rather a PMV, private clinic, or self-medicate.

It is interesting to note that respondents indicated that PMVs were the closest health facility to their residence. Olusanya et al. in their study of utilization of eye care services in rural south western Nigeria reported that residents living close to an eye care facility were almost three [3] times more likely to have sought care at that facility.[12] These findings strengthen the argument by some that attempt should be made toward incorporating these healthcare facilities into the formal pathway for health care in general and eye care in particular through proper training, establishment of protocols, and referral pathways for these health workers. It has, therefore, been suggested that in the Nigerian setting the concept of integration of eye care services should not be limited to government health centers and general hospitals but should also involve private facilities like private clinics and patent medicine shops which seem to be preponderant and a major source of eye care for those living in the community.

Determinants of the choice of place of first contact for eye care in this study revealed place of residence, nature of eye complaint, employment status, and marital status as strong determinants of that choice. Olusanya et al. in their study reported contrary findings in which males, level of education, and nearness to eye care facility constituted strong determinants for seeking orthodox eye care services.[37] Worthy of note is that our study included nonorthodox facilities.

   Conclusion Top

This study demonstrated that the nature of eye complaints was a strong determinant of early presentation to an eye care facility with the tertiary centre being the preferred place of first contact in seeking help among majority of the respondents. Though a little over a quarter presented to the eye care facility within a week of onset of symptoms, the mean time lapse before presentation revealed missed opportunities for early diagnosis and treatment. Hence, it is recommended that the public be sensitize through health information and education on the need and benefits of early presentation at eye care facilities. Policies should be pushed forward to enable for planning, improvement in the quality of eye care services, and provision of more satellite eye healthcare services directly supervised by existing tertiary health institutions in order to address the eye health-seeking behavior observed in this study.

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Conflicts of interest

There are no conflicts of interest.

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  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]


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