Willingness to Accept Keratorefractive Surgery and Its Barriers Among Myopes at Eye Foundation Hospital Group, Nigeria.

Abstract


INTRODUCTION
Refractive error is the state of an eye in which light rays are not focused on the retina, resulting in a blurred image.They affect people without consideration for age, gender, or ethnicity but are strongly in uenced by socioeconomic status, being both a cause and a consequence of poverty and limited access to ophthalmic care. 1 Blurred vision from refractive error can be treated in most cases by neutralizing the refractive error with corrective lenses, such as spectacles and contact lenses or by refractive surgery. 1 Myopia (nearsightedness) is a refractive error, in which images of distant objects focus in front of the retina, when accommodation is relaxed.3] Myopia and high myopia were estimated to affect 27% (1,893 million) and 2.8% (170 million) of the world population, respectively, in 2010 , making myopia one of the leading causes of visual impairment and blindness worldwide, hence a major public health challenge. 4ratorefractive surgeries encompass surgical procedures used to improve the refractive state of the eye and decrease or eliminate dependency on corrective lenses. Keratorefractive surgical services, being a relatively new eld in a developing country like Nigeria, could be confronted with the challenge of low surgical uptake among prospective patients.Therefore, it is pertinent to know the willingness to accept the procedure and barriers to its uptake among myopes in a centre that readily offers this service with a view to providing data for planning, improving surgical uptake and advocacy.

METHODS
This descriptive prospective cross-sectional study was conducted at different locations of the Eye Foundation Hospital Group, Nigeria.This study followed the guidelines as contained in the declaration of Helsinki and approval was obtained from the Ethics and Research Committee of the Lagos State University Teaching Hospital, Ikeja, Lagos, Nigeria.The participants were patients who came for eye consultations in the eye clinics of the health facility.

Study design
The participants in this study were new consenting adult patients diagnosed with any form of myopia aged 18 years or older.Written consent was obtained after the study had been explained to each participant.This study had both quantitative and qualitative components.Quantitative component included prospective study and qualitative component included in-depth interviews and focused group discussions (FGD).
Participants were interviewed using pretested semi-structured questionnaires ( adapted from previous studies). 7Interviewer administered semi-structured questionnaires, in-depth interviews and focused group discussions were used to collect information on socio-demographic characteristics, willingness to accept the procedure and barriers to uptake of keratorefractive surgery.

Data analysis
The data were collated, entered into, IBM Statistical Package for Social Sciences (IBM-SPSS) version 26 (IBM Corp: Armonk, NY USA) and analyzed.The Chi square was used to test associations between parameters.These include associations between degree of myopia/demographic characteristics and willingness to accept keratorefractive surgery.Shapiro-wilk test was used to determine normality of quantitative variables.Student's t-test and Wilcoxin sign ranked tests were used for comparison of continuous variables depending on normality.
The results are displayed using tables, pie charts, bar charts.The associations of statistical signi cance was taken at P < 0.05

RESULTS
A total of 302 participants were enrolled in this study.One hundred and fty-six (51.7%) were male and one hundred and forty-six (41.3%) were female, with a mean age of 30.48±8.44 (18 to 57) years.

Willingness to accept keratorefractive surgeries
After the educational session on keratorefractive surgery have been done, the varying responses of the participants with respect to their willingness to accept keratorefractive surgeries are as shown in Figure 1.

Reasons for accepting to do keratorefractive surgery
Out of the 63 participants who were willing to undergo keratorefractive surgeries, 87.3% were tired of using spectacles/contacts while 11.1%, reported as career reasons, shown in Table 1.  4 showed the associations between willingness to accept keratorefractive surgeries and socio-demographic variables/degree of myopia.Degree of myopia showed signi cant association with willingness to accept keratorefractive surgery (chi-square p<0.001).However, there were no signi cant association between age, gender, place of residence, level of education, income, occupation and willingness to accept keratorefractive surgery. in the in-depth interview.Barriers to uptake of keratorefractive surgery and the motivation for uptake of that the more the myopia, the poorer the unaided vision and the more the need to depend on spectacles, henceforth, the drive to accept keratorefractive surgery.With respect to the focus group discussion and indepth interview, keratorefractive surgery was mainly viewed as a new innovation, risky, surgery for the nancially privileged and needless since some patients may still need spectacles after the surgery while a few saw it as a welcome development, if it would make them to stop using spectacles.Participants indicated that ophthalmologists and other medical doctors rarely talk about the surgery during clinic visits with limited records of success rates in keratorefractive surgery in Nigeria and lack of trust in the health system, thereby doubting the capacity of such surgery been done in Nigeria.This may be due to the systemic failure of the Nigerian health sector with low annual budget allocation for capacity building and infrastructural development, leading to the underdevelopment of the general health facilities in the country and mistrust seen among individuals.
The reasons why participants opted for surgery in this study, were due to being tired of using spectacles and contact lens (87.3%), career reasons (11.1%), not wanting to use spectacles and contacts (6.3%), beauti cation (6.3%) and leisure (1.6%).These were similar to the ndings in previous studies. 1,7,8,10This may be a re ection of the fact that myopes require their spectacles/contacts almost all the time to navigate around their environs, increasing their dependence on them and contact lens wear requires good hygiene protocols at all times.This may become burdensome, increasing the tendency for sub-optimal spectacle/contacts lens wear.Dependence is worst with the high myopes, making them more likely to visit refractive surgical clinic for possible surgery and this study revealed that 76.2% of participants with high myopia were willing to accept keratorefractive surgery, if offered.Dependence on spectacles/contacts may not also be suitable for some careers like the military, pilots, hostess, models and those that engage in sports, thereby increasing the tendency to opt for keratorefractive surgery.
Leisure is another important factor, some individuals may not want to engage in leisure activities like going to the beach and attending parties, wearing their spectacles/contacts lens.Females may also want to show their make ups while attending events and not all individuals are comfortable with wearing contacts.
This study revealed that 45% of the participants were not willing to accept the procedure.They cited fear of surgery (59.1%), lack of awareness (41.6%), nancial constraints (40.9%), adverse effects (19.7%), satis ed with vision (6.6%) and negative advice (2.2%) from family and friends as reasons for not opting for keratorefractive surgery.These were also similar to the ndings in the literature. 1,5,8,11,12This may be due to the low level of awareness earlier discussed in this study.Lack of awareness may lead to lack of information about keratorefractive surgery, thereby increasing the fear of having the surgery.The limited records of success rates and the perceived poor health system in Nigeria may increase mistrust among individuals, increasing fear and making them not willing to accept the procedure.The surgery may not be readily affordable for everyone due to the high cost of having the surgery done.Some participants in this study on focused group discussions and in-depth interviews, viewed it as surgery for the nancially privileged, which may decrease the tendency of having the surgery done.There is a possibility of still using spectacles even after the surgery, especially the very high myopes.This may affect uptake of the surgery, such that some individuals may view it as needless, which was seen from the ndings in this study.Some individuals may be satis ed with their vision especially the low myopes, thereby seeing no need for keratorefractive surgery.

CONCLUSION
The willingness to accept keratorefractive surgical services in this study was low.The signi cant predictor of willingness to accept keratorefractive surgery was high myopia.The main barriers to the uptake of the services were fear of damage, lack of awareness and nancial constraints while the reasons for uptake were tired of using spectacles, not wanting to use spectacles, beauti cation and career reasons.There is a need for patient education to improve surgical uptake.

Declarations
Competing The authors declare no competing interests.

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Table 1 :
Reasons for accepting to do keratorefractive surgery * Some participants gave multiple responsesBarriers to uptake of Keratorefractive Surgery Out of the 137 participants who were unwilling to undergo keratorefractive surgeries, 59.1% reported fear of surgery as their reason while 41.6%, reported as lack of awareness, shown in Table2.

Table 2 :
Barriers to uptake of keratorefractive Surgery * Some participants gave multiple responsesReasons for not being sure of accepting keratorefractive surgery One hundred and two (34%) participants were not sure if they would have keratorefractive surgery or not.Reasons are shown in Table3.

Table 4
Test of association degree of myopia/demographic characteristics and willingness to * Statistically signi cantFocused group discussion/in-depth interview Fifteen (15) participants were enrolled in the focus group while twenty-one (21) participants participated