|Year : 2020 | Volume
| Issue : 1 | Page : 10-17
Knowledge and awareness about glaucoma and its determinants: A lesson learned from a community-based survey of a developing nation
Kailash Chandra Verama1, Sourabh Paul2, Shyam Mehra3, Paresh Prajapati3, Tanvir K Sidhu3, Varun Malhotra3
1 Deapartment of Community Medicine, Jaipur National Institute for Medical Science & Research Centre, (JNU IMRSC), Jaipur, Rajasthan, India
2 Department of Community Medicine, All India Institute of Medical Sciences, Raebareli, Uttar Pradesh, India
3 Department of Community Medicine, Adesh Institute of Medical Sciences and Research, Bathinda, Punjab, India
|Date of Submission||20-Jan-2020|
|Date of Decision||25-Feb-2020|
|Date of Acceptance||26-Feb-2020|
|Date of Web Publication||23-Oct-2020|
Dr. Sourabh Paul
Department of Community Medicine, All India Institute of Medical Science, Dalmau Road, Munshiganj, Raebareli, Uttar Pradesh.
Source of Support: None, Conflict of Interest: None
Aim: The aim of this study was to determine the level of awareness and knowledge about glaucoma and possible determining factors behind it. Materials and Methods: This was a community-based cross-sectional study in a rural community of Punjab province of India, conducted from August 2018 to January 2019. The knowledge about glaucoma was assessed by modified version of Glaucoma Knowledge level Questionnaire, developed by Husder, Department of Public Health, Turkey. Association between variables was assessed by chi-square test, and P value 0.05 or less was considered as statistically significant. Results: Among 1925 participants, only 413 (21.5%) were aware about glaucoma but 375 (90.8%) had poor knowledge about the disease. Higher educational status (P = 0.0001), employed participants (P = 0.0001), presence of eye problem (P = 0.0001), and once a year regular eye checkup (P = 0.001) had significant positive association with the awareness of glaucoma, whereas those with a family history of glaucoma (P = 0.0002) and those who were ever screened for glaucoma (P = 0.0001) had significantly better knowledge about glaucoma. Conclusion: We recommend that Information education & communication activities of National Programme for Control of Blindness and Visual Impairment (NPCBVI) should be strengthened to specifically target rural adult population of India.
Keywords: Awareness, community-based survey, glaucoma, Glaucoma Knowledge Level Questionnaire, knowledge
|How to cite this article:|
Verama KC, Paul S, Mehra S, Prajapati P, Sidhu TK, Malhotra V. Knowledge and awareness about glaucoma and its determinants: A lesson learned from a community-based survey of a developing nation. J Health Res Rev 2020;7:10-7
|How to cite this URL:|
Verama KC, Paul S, Mehra S, Prajapati P, Sidhu TK, Malhotra V. Knowledge and awareness about glaucoma and its determinants: A lesson learned from a community-based survey of a developing nation. J Health Res Rev [serial online] 2020 [cited 2020 Nov 30];7:10-7. Available from: https://www.jhrr.org/text.asp?2020/7/1/10/298876
| Introduction|| |
Glaucoma is a group of diseases characterized by progressive optic neuropathy, which may be asymptomatic in the majority or may result in symptoms such as diminished vision and loss in visual field. Earlier, it was thought that intraocular pressure is the only modifiable risk factor, but recent evidences suggest that there are several mechanisms (e.g., mechanical stress due to rise in intraocular pressure, decreased neurotrophin supply, hypoxia, excitotoxicity, and oxidative stress) behind it. But irrespective of the pathogenesis involved, the end result is the same.
Glaucoma is the second leading cause of blindness globally and the third in India., In 2010, nearly 60.5 million people had glaucoma globally, of which 11 million were Indians. It has been projected that this number will rise to 76 million by 2020 and 111 million by 2040, with India becoming the second largest home of glaucoma by 2020.,,
Glaucoma is a disease, which has an initial long asymptomatic stage, which hampers early detection of disease. Patients usually present late when the disease has already advanced with significant visual loss. Studies from different countries of the world have shown that knowledge and awareness about glaucoma is very low, and it is one of the significant reasons for grave consequences of the disease. Even in the developed countries, the average awareness level is less than 50%. Among the numerous avenues for improving the prevention of blindness from glaucoma, raising awareness and knowledge about the disease is one of the important strategies. Studies have indicated that public awareness and knowledge about glaucoma helps in raising the health-seeking behavior of the people, which in turn helps in the early detection of the disease. Review of literature reveals that there is a paucity of studies on awareness and knowledge of glaucoma in the Malwa region of Punjab.
In view of significant importance of knowledge regarding glaucoma in the prevention of visual loss, this study was undertaken with the aim to determine the level of awareness and knowledge about glaucoma in a rural community of Malwa region of Punjab, and to find the factors determining the awareness and knowledge about glaucoma in the study population.
| Materials and Methods|| |
A community-based cross-sectional study was carried out from August 2018 to January 2019, at Giddarbaha Block of Muktsar district of Punjab, India. As per 2011 census, the block has 45 villages. Among these, 13 villages fall under the jurisdiction of rural field practice area of Department of Community Medicine, Adesh Institute of Medical Sciences and Research (AIMSR), Bathinda, Punjab, India. This study was carried out in this field practice area.
During the period of research, ethical guidelines of Indian Council of Medical Research were followed. Approval was obtained from the Institutional Ethics Committee before conducting the study (Ref No.: AU/EC/FM/13/2018, Date: July 24, 2018). Informed written consent was obtained from the participants. Confidentiality and anonymity was maintained during the study.
All adults residing in the study area aged 40 years and older were included in the study. Participants residing in the study area for 2 years and above and who had given written informed consent were included in the study. Seriously ill or mentally challenged individuals were excluded from the study. Participants who were not available at home after two visits were also excluded from the study. A previous study conducted in rural Haryana had reported that the knowledge about glaucoma was 1.1%. Considering the prevalence rate of knowledge about glaucoma (P) 1.1%, allowable error (d) 0.5%, and nonresponse rate 10%, the sample size was calculated to be 1914.
The total number of eligible participants (>40 yrs) was calculated from the household registry of the villages (total 13 villages) maintained by the Department of Community Medicine, AIMSR, and it was found to be 14,792. The number of participants selected from each village was according to the proportion of each village population (highly populated village had contributed more number of participants in the sample), and these participants were selected by simple random sampling method [Table 1].
Participants were interviewed by using a predesigned, pretested structured interview schedule (questionnaire). Schedule was developed after rigorous review of literature and discussion with the consultants from Department of Ophthalmology of the institute. Questionnaire was first developed in English and then translated into the local language (Punjabi). Questionnaire had two parts: Part 1 contained demographic details of the participants, whereas Part 2 captured data related to knowledge and awareness about glaucoma. Pretesting of the questionnaire was conducted on 5% of the sample size population outside the study area, and the questionnaire was modified based on the findings of a pilot study. “Awareness about glaucoma” was assessed by asking the question: “Have you heard about glaucoma?” Only those who had answered “yes” to the awareness question were further asked to elucidate knowledge about glaucoma.
Knowledge about glaucoma was assessed using amodified version of Glaucoma Knowledge level Questionnaire (GKLQ), developed by Husder,Department of Public Health, Turkey and National Eye health Education programme Eye Q Test. Internal consistency of the scale was measured by using Cronbach α, and it was 0.69. There were 15 knowledge-related questions, each having one correct answer. Options were “yes,” “no,” and “do not know.” Each correct answer was rewarded with one point. Maximum and minimum attainable score was 15 and 0. Two questions were in reverse order. Increase in the modified GKLQ score is related with better knowledge. According to the modified GKLQ scale, knowledge was categorized into three mutually exclusive categories: good (11–15), medium (5–10), and bad (0–5).
Data were entered into a Microsoft Excel worksheet (Microsoft, Redwoods, Washington) and were analyzed using the Statistical Package for the Social Sciences software (SPSS, Chicago, Illinois), version 21.0. Demographic characteristics of the participants were summarized using descriptive statistics (mean, median, proportion, and percentage) and dispersion measures (standard deviation and interquartile range). Association was established using chi-square test, and P value of 0.05 or less was considered as statistically significant.
| Results|| |
Total eligible participants in the selected households in the villages were 2075; of which, 150 were not available for interview after repeated attempts. Thus, we studied 1925 participants. The mean age of the participants was 54.55 ± 11.8 years. The demographic profile of the study participants is presented in [Table 2]. [Table 2] shows that 51.2% of the participants were female, majority of the participants were in 40–60 years age-group (72.4%), 65.5% were illiterate, and 48.8% were housewives by occupation followed by agriculture (36.8%).
Among all the participants, 617 (67.9%) had one or more eye problems. The most common symptom was diminish vision, which was reported by 555 (89.9%) of the symptomatic patients, followed by blurring vision (208 [33.7%]) and redness of eye (40 [6.5%]) [Table 3]. Overall, the prevalence of diminished vision was 28.8% among all the participants. Total 25 (1.3%) of the participants had self-reported glaucoma, and 59 (3.06%) of the participants had family history of glaucoma.
Awareness regarding glaucoma
Among 1925 study participants, only 413 (21.5%) of the participants were aware about glaucoma. Major sources of information were friends and relatives (251 [60.8%]), followed by health-care providers (125 [30.3%]). The awareness (32.5%) among those who visited a health-care provider for eye symptoms was significantly higher (P < 0.05) than those who had not (20.7%) [Table 4].
|Table 4: Awareness of glaucoma across sociodemographic characteristics of the participants (n = 1925)|
Click here to view
[Table 4] also shows that educational status (P = 0.0001), employment of the participants (P = 0.0001), presence of eye problem (P = 0.0001), visiting doctor with the present eye problem (P = 0.004), once a year regular eye checkup (P = 0.001), and visited any doctor for eye checkup within last 1 year (P = 0.001) have significant positive association with the awareness of glaucoma, whereas age of the participants and gender do not have any significant level of association with awareness level.
Knowledge regarding glaucoma
[Table 5] shows that among the participants who had heard or were aware about glaucoma, only 48 (11.6%) knew that increase in pressure in eye ball was called glaucoma. Most common correct symptom of glaucoma identified by the participants was blurred vision (82 [19.9%]), followed by peripheral loss of vision (6 [10.8%]). Only 33 (8.0%) of the participants who were aware of glaucoma considered glaucoma as one of the most common causes of blindness in India. Majority (76.3%) of the aware participants (315 [76.3%]) knew that cataract and glaucoma are different. Knowledge that hypertension, positive family history of glaucoma, and diabetes are risk factors for glaucoma was present in 14.1%, 8.7%, and 6.7%, respectively, of the study participants who were aware of glaucoma. Mean knowledge score of the participants who were aware of glaucoma was 1.33 ± 1.87. In general, the knowledge regarding glaucoma was poor not only quantitatively but also qualitatively, as evidenced by the fact that not a single participant had good knowledge score (11–15), 38 (9.2%) had satisfactory knowledge score (6–10), and the majority (375 [90.8%]) had poor score (0–5) about glaucoma.
[Table 6] shows that participants having a family history of glaucoma (P = 0.0002) and who were ever screened for glaucoma (0.0001) had significantly better knowledge score compared to others. Age, gender, educational status, occupation, having eye problem, visiting eye doctors, or annual eye checkup were not significantly associated (P > 0.05) with the knowledge level of glaucoma.
|Table 6: Knowledge of glaucoma across sociodemographic characteristics of the participants those who were aware about glaucoma (n = 413)|
Click here to view
Utilization of health services
An interesting finding of the study was that only 453 (73.4%) of the symptomatic participants had visited doctor at least once. Further analysis revealed that 235 (51.9%) of them had consulted a private doctor, whereas 205 (45.3%) reported to a public health care facility. The reasons for not consulting a health-care provider in spite of persistent symptom(s) included “symptom not severe enough to warrant treatment” (46.3%) and “lack of time” (24.4%). Among all the participants, 1060 (55.1%) felt that once a year eye checkup is good for the maintenance of eye health, but only 425 (22.1%) had done so during last 1 year. In addition, only 55 (2.9%) of the participants had ever been screened specifically for glaucoma. Utilization of health services by those with eye symptoms had already been highlighted.
| Discussion|| |
Glaucoma is one of the leading causes of blindness in developing world, and this study was conducted to find the knowledge and awareness about glaucoma in rural Punjab. The study had found that 413 (21.5%) of the study participants were aware of glaucoma. Studies conducted in different parts of India among general population have reported the awareness level between 0.27% and 13.3%., This study found a higher percentage of awareness as compared to others, which might be because of the definition used for identifying awareness or because the study population and time frame of this study were different. As expected, the awareness level was significantly lower than the results (more than 50%) of the studies conducted in the developed world.,
Awareness about any disease does not necessarily mean that the individual possesses adequate knowledge about the disease; it might be just that he/she has heard about the disease. In our study, major source of information was friends and relatives. The finding of this study was in consonance with a study conducted in rural Haryana and Turkey. However, a study conducted in northwest Ethiopia reported mass media as the most common source of information. It may be because of the fact that in this study, majority of the participants were illiterate, thus limiting the role of print and electronic media. This finding is important in planning Information education & communication (IEC) activities targeting the elderly rural populace in India as well as other developing countries.
The study has found that the mean knowledge score among those who were aware of glaucoma was 1.33 ± 1.87, and among them nobody had good knowledge (10–15 score), whereas 9.2% had satisfactory knowledge and 90.8% had poor knowledge. Studies conducted in urban Chennai and rural Haryana had found the knowledge level to be dismally low, that is, 8.7% and 1.89%, respectively., Even a study conducted in Jordan had found that 77.5% of the participants were either unaware or had partial knowledge about glaucoma. Although the differences in results of these studies may be real or may be due to differences in methodologies, it is absolutely clear that the awareness and knowledge regarding an important cause of preventable blindness in low- and middle-income countries is low. In this part of the country, glaucoma and cataract have almost similar name in local language (Safedmotia and kalamotia). So people might get confused between these two similar terminologies and might answer that they had heard about glaucoma, which indeed has increased the proportion of awareness about glaucoma (21.5%) but not the in-depth knowledge about glaucoma.
Analysis of data in this study revealed that higher educational level and employment were associated with better awareness of glaucoma. Similar conclusions were arrived at by other researchers who conducted studies in India and abroad.,,,, In our study, age and gender did not hold any significant association with awareness of glaucoma. Many studies reported similar findings, whereas few studies reported different findings., The relationship of age and gender with health-related awareness is not always direct, and often get confounded by social, cultural, and economic backgrounds., This study had also brought out the fact that those who have any eye problem, visited doctor regularly, or had a positive attitude toward regular screening (agreeing to the statement that “regular eye checkup is good for health”) had significantly better awareness about glaucoma. A study conducted in Ethiopia also reported similar finding., Similarly study had found that the level of health literacy only increased when there is a good level of health communication.
This study had shown that although education and employment were significantly associated with awareness, both lacked any significant relationship with the knowledge about glaucoma. It shows that literacy and health literacy are different entity. A study conducted among Dutch adults had also found that highly educated people may have poor health literacy.
Participants with positive family history of glaucoma or who were ever screened for glaucoma had better knowledge about glaucoma. Similar conclusions were arrived at by studies conducted in urban Chennai and rural Haryana., Glaucoma or any other eye problem sufferers and regular visitors of doctors did not have a better knowledge score as compared to others, though they had better awareness. It shows that large proportion of participants had only heard the name of the disease but lacked adequate knowledge. Public health experts do not expect that everybody should be an expert of the disease, but basic knowledge, especially about early symptoms and risk factors, plays a positive influence in prevention and control. Studies have identified that better knowledge and awareness score increase the health-seeking behavior of the community.
In this study, according to the different questions of GKLQ scale, majority of the participants had very poor knowledge about the risk factors or symptoms of glaucoma, which is different from another study conducted in Turkey among general population. Difference may be due to the fact that Turkish government is running glaucoma screening program, which had indeed increased the knowledge of the community about the disease. In India, the focus of the National Programme for Control of Blindness and Visual Impairment (NPCBVI) has been on cataract, which is the number one cause of blindness in India.
This study had shown that diminished vision and blurring vision were the most common symptoms among the participants. In India, cataract and glaucoma are the major causes of ocular morbidity among adult population, and diminished vision and blurring vision are the most common symptom of these diseases (NPCBVI).
This study had some limitations. Being a retrospective study, recall bias cannot be ruled out. We had not included the income of the participants into the analysis, which might have reflected the association between knowledge and socioeconomic status.
| Conclusion|| |
Levels of knowledge and awareness about glaucoma among rural Punjabi population were not satisfactory. Education, employment, and regular eye checkup were related with increased level of awareness, whereas specific screening program for glaucoma increased the knowledge of the community. Awareness and knowledge are vital pillars of successful screening program because they increase the yield of the program. In the context of glaucoma, better knowledge obviously will result in early detection of the disease, thus reducing both the disability and visual handicap. We recommend that IEC activities of NPCBVI should be strengthened to specifically target rural adult population who are often illiterate, employed in unorganized sector, and relatively reluctant user of health services.
We thank the participants of the study for their active participation.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Nischal K, Pearson AGlaucoma. In: Kanski JJ, Bowling B, editors. Kanski’s Clinical Ophthalmology: A Systemic Approach. 7th ed.Edinburgh: Elsevier/Saunders Publisher; 2015. p. 3510.
Rieck J The pathogenesis of glaucoma in the interplay with the immune system. Invest Ophthalmol Vis Sci 2013;54:2393-409.
Glaucoma Research Foundation. Glaucoma Facts andStats. Available from: https://www.glaucoma.org/glaucoma/glaucoma-facts-and-stats.php. [Last accessed on: 2019 December 17].
Parihar JKS Glaucoma: The ‘Black hole’ of irreversible blindness. Med J Armed Forces India 2016;72:3-4.
National Health Portal. World Glaucoma Week. Availablefrom: https://www.nhp.gov.in/world-glaucoma-week_pg. [Lastaccessed on 2019 December 19]
Tham YC, Li X, Wong TY, Quigley HA, Aung T, Cheng CY Global prevalence of glaucoma and projections of glaucoma burden through 2040: A systematic review and meta-analysis. Ophthalmology 2014;121:2081-90.
Weinreb RN, Aung T, Medeiros FA The pathophysiology and treatment of glaucoma: A review. JAMA 2014;311:1901-11.
Nkum G, Lartey S, Frimpong C, Micah F, Nkum B Awareness and knowledge of glaucoma among adult patients at the eye clinic of a teaching hospital. Ghana Med J 2015;49:195-9.
Tenkir A, Solomon B, Deribew A Glaucoma awareness among people attending ophthalmic outreach services in Southwestern Ethiopia. BMC Ophthalmol 2010;10:17.
Kenneth BO, Seth BT, Ankrah LM, Emmanuel AO Prevalence of glaucoma in an eye clinic in Ghana. Russ Open Med J 2013:2:1-5.
Keziah NM, Nguavese HO, Doosuur M, Dalton NG The role of the mass media in creating awareness about eye diseases. J Med Res Pract 2014;3:76-80.
Rewari P, Kakkar M Awareness, knowledge, and practice: A survey of glaucoma in North Indian rural residents. Indian J Opthalmol 2014;62:482-6.
National Eye Health Education Program Eye Q Test. Available from: https://nei.nih.gov/sites/default/files/nehep-pdfs/EyeQTest_for_Toolkit.pdf. [Last accessed on 2019 November 29] .
Demirtaş Z, Dağtekin G, Önsüz MF, Soysal A, Yıldırım N, Metintaş S Validity and reliability of the glaucoma knowledge level questionnaire. Turk J Ophthalmol 2018;48:115-21.
Sathyamangalam RV, Paul PG, George R, Baskaran M, Hemamalini A, Madan RV, et al
. Determinants of glaucoma awareness and knowledge in urban Chennai. Indian J Ophthalmol 2009;57:355-60.
] [Full text]
Rewri P, Kakkar M Awareness, knowledge, and practice: A survey of glaucoma in north Indian rural residents. Indian J Ophthalmol 2014;62:482-6.
Celebi CARC Knowledge and awareness of glaucoma in subjects with glaucoma and their normal first-degree relatives. Med Hypothesis Discov Innov Opthalmol 2018;7:40-7.
Dagtekin G, Dermirtas Z, Soysal A, Yildirm N, Onsuz FM, Metinants S The assessment of the knowledge and awareness about glaucoma in glaucoma patients and general population: A sample from Turkey. Int J Res Med Sci 2018;6: 35-41.
Alemu DS, Gudeta AD, Gebreselassie KL Awareness and knowledge of glaucoma and associated factors among adults: A cross sectional study in Gondar town, Northwest Ethiopia. BMC Ophthalmol 2017;17:154.
Al-Zubi K, Sarayrah F, Al-Awaishah M Glaucoma awareness and knowledge among Jordanian People. Global J Health Sci 2017;9:40-6.
Prabhu M, Patil SH, Kangokar PCR Glaucoma awareness and knowledge in a tertiary care hospital in a tier-2 city in South India. J Sci Soc 2013;40:3-8.
Health Literacy Interventions and Outcomes: An UpdatedSystemic Review. Available from: https://effectivehealthcare.ahrq.gov/sites/default/files/pdf/health-literacy_research-protocol.pdf [Last accessed on 2019 Feb 23].
Sørensen K, Van den Broucke S, Fullam J, Doyle G, Pelikan J, Slonska Z, et al
; (HLS-EU) Consortium Health Literacy Project European. Health literacy and public health: A systematic review and integration of definitions and models. BMC Public Health 2012;12:80.
Akaraiwe NU, Monye HI, Okeke S Awareness and knowledge about glaucoma and proportion of people with glaucoma in an urban outreach programme in Southeast Nigeria. BMJ Open Opthl 2017;1:e000018.
Ishikawa H, Kichi T Health literacy and health communication. Biopsychosoc Med 2010;4:18.
Van der Heide I, Wang J, Droomers M, Spreeuwenberg P, Rademakers J, Uiters E The relationship between health, education, and health literacy: Results from the Dutch adults’ literacy and life skills survey. J Health Commun 2013;18:172-84.
Rosenstock IM Why people use health services. Milbank Q 2005;83:10.
National programme for control of Blindness & Visual Impairment (NPCB&VI). Available from: https://dghs.gov.in/content/1354_3_NationalProgrammeforControlofBlindnessVisual.aspx.
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]