Knowledge , attitudes and self-care practices of patients with glaucoma in uThungulu in KwaZulu-Natal

The term ‘glaucoma’ is used to describe a group of optic nerve disorders that if left uncontrolled result in visual field defects and associated vision loss.1,2 Glaucoma involves the death of retinal ganglion cells, which the clinician identifies by optic disc examination, visual field testing and retinal nerve fibre layer assessment with, for example, optical coherence tomography.3 Globally, glaucoma is the second commonest cause of blindness.3 An estimated 6.5 million people have glaucoma in sub-Saharan Africa.4 The prevalence of glaucoma in South Africa is approximately 5% and glaucoma contributes approximately 23% of blindness nationally.5,6,7


Introduction
The term 'glaucoma' is used to describe a group of optic nerve disorders that if left uncontrolled result in visual field defects and associated vision loss. 1,2Glaucoma involves the death of retinal ganglion cells, which the clinician identifies by optic disc examination, visual field testing and retinal nerve fibre layer assessment with, for example, optical coherence tomography. 3Globally, glaucoma is the second commonest cause of blindness. 3An estimated 6.5 million people have glaucoma in sub-Saharan Africa. 4The prevalence of glaucoma in South Africa is approximately 5% and glaucoma contributes approximately 23% of blindness nationally. 5,6,7ricans are predominantly affected by primary open angle glaucoma (POAG). 8In South Africa, the prevalence of POAG is 2.9% and it is the most common type of glaucoma in the country. 9hile glaucoma has no known cure, there are treatment options by which the progression of the disease can be retarded.These methods include pharmacotherapy (oral tablets or eye drops) and surgery.Timely diagnosis and strict compliance with treatment are necessary for the successful management of glaucoma. 10Patients' knowledge and attitudes towards glaucoma are also important factors in disease management.
There has not been any research into the knowledge, attitudes and self-care practices of patients with glaucoma in South Africa.Identifying gaps in these areas will be useful in providing a basis for the development of healthcare education programmes to increase the knowledge and awareness about glaucoma, thereby improving the management of the disease.Therefore, the aim of this study was to assess the knowledge, attitudes and self-care practices of patients with glaucoma.
Background: Glaucoma remains one of the leading causes of blindness in South Africa.Early detection, effective treatment and strict compliance with treatment are instrumental to prevent further damage to the optic nerve and thus preserve vision.

Study population and sampling strategy
The study population included adult patients who had been diagnosed with glaucoma for at least six months.The sample size was 384, based on the assumption that 50% of the population would have good knowledge and adequate attitudes and self-care practice for glaucoma.The following equation 11 was used: where n = minimum number of respondents required; Zα = standard normal deviate = 1.96 = (confidence interval [CI]: 95% level of significance); p = the p-value, which is the expected prevalence or proportion; and d = precision margin of error (0.05).
Participants were recruited over a period of six months using convenience sampling.This non-probability sampling method was used firstly because of its advantages, which span from easy recruitment of readily available participants to good response rates, 12 but also primarily because the number of patients with glaucoma who attend the Ophthalmology Outpatient Department of Ngwelezana Hospital is unknown.

Data collection
A structured close-ended questionnaire was used to interview patients.The questionnaire was modified from other studies 13,14 to suit the study population.In addition to basic sociodemographic variables, the questionnaire comprised 11 questions that assessed the patients' knowledge about the causes of glaucoma and eye drop usage.There were six statements that assessed patients' attitudes about having glaucoma and 15 questions on self-care practices that assessed compliance with treatment and storage of eye drops.As a result of the length of the questionnaire, it could not be attached to this manuscript.However, the questionnaire is available from the authors.Duration of glaucoma diagnosis was extracted from the patient's clinical record.

Data analysis
Data from the questionnaires were entered into Microsoft Excel version 2010 and Statistical Package for Social Sciences (SPSS) version 25.0 for statistical analysis.Level of education was classified as none (no formal education), primary education (Grades R-7), secondary education (Grades 8-12) and tertiary education (colleges, technical schools and universities).Patients with tertiary education were grouped with patients with secondary education during data analysis because of the small number of patients with tertiary education.Duration of glaucoma was measured as the period between the date the patient was diagnosed with glaucoma and the date of enrolment in the study and was assessed as a continuous variable.
A score of one point was awarded for each correct response in the knowledge section.Knowledge was scored out of 8 and categorised as good knowledge (≥ 5 out of 8) or poor knowledge (< 5 out of 8).The denominator for the calculation of self-care practices scores differed according to the patients' category of self-care practice.The following categories were identified: (1) patients who took tablets and self-instilled their eye drops; (2) patients who took tablets but did not selfinstil their eye drops; (3) patients who did not take tablets but self-instilled their eye drops; and (4) patients who did not take tablets and did not self-instil their eye drops.All patients were grouped according to their self-care practice (good or poor) regardless of which category of self-care practice they were in.
Odds ratios (OR) with 95% CI were calculated using Pearson's chi-square tests to measure associations between categorical variables.Multivariate logistic regression was conducted to assess for associations between sociodemographic variables, knowledge and self-care practice.A p-value less than 0.05 was considered significant.

Sociodemographic characteristics of patients
A total of 384 patients completed the questionnaire, of which 222 (57.8%) were women (Table 1).The age range of patients was between 26 and 80 years, with the majority (n = 117, 30.5%) of patients being between 56 and 65 years (Table 1).
The median age of males and females was 60 (interquartile range [IQR] 48.5-69.5)and 59 years (IQR 49.0-66.5),respectively (p > 0.05).Nearly half of the patients (n = 182, 47.4%) had primary education as their highest level of education, while 113 (29.4%) patients had no formal education.Less than a third of the patients were employed.Sixty-four (16.7%) patients had a positive family history of glaucoma.The duration of glaucoma ranged from 6 months to 19 years.

Patients' knowledge of glaucoma
Two hundred and thirty-eight (62.0%) patients had good knowledge of glaucoma and of these, 64 (26.9%) were below the age of 46 years.Both the bivariate and multivariate analyses showed a statistically significant association between the patient's age and knowledge of glaucoma (Table 2).Patients older than 65 years were significantly less likely to have good knowledge of glaucoma than patients aged 26-45 years (OR: 0.1, 95% CI: 0.03-0.2,p < 0.001).Gender was also associated with knowledge, with females being two times more likely to have good knowledge of glaucoma compared to males (OR: 2.0, 95% CI: 1.2-3.3,p = 0.01).Patients' level of education and employment status were not significantly associated with knowledge of glaucoma.The association between positive family history of glaucoma and good knowledge of glaucoma was significant (OR: 0.5, 95% CI: 0.3-0.7,p < 0.001).With increasing duration of glaucoma (per additional month), the patient's likelihood of having good knowledge increased and this association was statistically significant (OR: 1.1, 95% CI: 1.1-1.2,p < 0.001) (Table 2).

Patients' attitudes towards glaucoma
The majority of patients (n = 368, 95.8%) had negative attitudes (frustrated and sad) towards their glaucoma diagnosis.However, 194 (50.5%) patients felt happy about using their eye drops daily.In terms of disclosure, 333 (86.7%) had informed other family members about their glaucoma diagnosis (Table 3).

Self-care practices of patients with glaucoma
The majority of patients (n = 344, 89.6%) reported having good self-care practices, and of these 74 (21.5%) were below the age of 46 years.In bivariate analysis, patients over the age of 65 years were significantly less likely to have good self-care practices compared to patients aged 26-45 years (OR: 0.2, 95% CI: 0.1-0.6,p = 0.01).Even though this

Discussion
We found that almost two-thirds (approximately 67%) of the patients with glaucoma had good knowledge of their condition in contrast to results from studies in Nigeria and Ghana where less than half (< 50%) of the patients had good knowledge of having glaucoma.The higher proportion of patients with good knowledge of glaucoma may be attributed to the patients in our study possibly receiving more information about glaucoma than the patients in other health settings. 15,16udies carried out in Hong Kong and Australia reported a significant association between increasing age and knowledge of glaucoma. 17,18,19However, in our study, we observed a reduction in the level of knowledge of patients with increasing age.A possible explanation for this finding may be that older patients forget information more easily than younger patients as a result of senile changes.Females were more knowledgeable about glaucoma than males in our study.This finding is in keeping with the available body of evidence that females are more inclined to practice health-seeking behaviours in comparison to males. 13,17,20,21There is a therefore a need for the sensitisation and education of males about glaucoma, especially as the risk of having POAG is higher in males than females. 5,6,22,23mily disclosure of one's glaucoma diagnosis is important because genetics and family history are risk factors of glaucoma. 24It is interesting to note that the majority (86.7%) of patients in our study had told their family members about their glaucoma diagnosis, which is consistent with literature from a Jamaican study. 14Several studies have reported that patients who had one or more family members with a diagnosis of glaucoma were more knowledgeable than those who did not have a family history of glaucoma. 17,21,25,26However, the patients in our study were less likely to have good knowledge of glaucoma if they had a positive family history.The reason for this may be that patients who have family members with glaucoma may not pay attention when they are being counselled about their condition as they feel they already have knowledge about the disease.
Regarding the impact of duration of glaucoma on knowledge, our finding is consistent with other studies. 27,28,29Patients who have had glaucoma for a longer period would have had more opportunities to participate in glaucoma health talks during their follow-up visits to the hospital and to discuss their condition with the doctor, thereby improving their knowledge of glaucoma.
The methods used to assess self-care practices in patients with glaucoma differ across studies. 13,18,30,31It is therefore difficult to compare our results with these studies.We observed that older patients were less likely to have good self-care practices than younger patients.Although this finding was not statistically significant, it is likely that older patients would be more prone to forgetting recommended doses and timing of their medications.Our finding that good knowledge of glaucoma is associated with good self-care practices is consistent with results from a study conducted in Ethiopia. 32

Strengths and limitations
With the absence of previous studies in South Africa on the knowledge, attitudes and self-care practices of patients with glaucoma, the results of this study provides valuable information that can assist in the development of educational material on glaucoma for patients and their families.Recall bias is notable in studies that encompass some measure of self-reporting.The patients in this study were required to answer questions that entailed remembering past events and as such it is possible there might have been some inaccuracies in their recollections, especially with the older patients (e.g.where patients were asked to say how often they forget to use their glaucoma medication).

Recommendations
We recommend that more time and repeated education sessions be made available for patients with glaucoma, particularly the elderly and male patients.It is also important to involve the family members of these patients in glaucoma education and counselling to facilitate improved disease management.

Conclusion
Elderly patients do not have sufficient knowledge of glaucoma and have poor glaucoma self-care practices.Therefore, although the general population will benefit from glaucoma awareness campaigns and educational programmes, concerted efforts and focus on reaching this group of individuals and those more at risk of the disease will be highly beneficial.

TABLE 1 :
Sociodemographic characteristics of patients with glaucoma in the uThungulu Health District, 2016-2017.

TABLE 2 :
Patient-related characteristics associated with their knowledge of glaucoma in the uThungulu Health District, 2016-2017.

TABLE 3 :
Patients' responses to attitudinal questions on glaucoma in the uThungulu Health District, 2016-2017.