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ORIGINAL ARTICLE
Year : 2022  |  Volume : 25  |  Issue : 1  |  Page : 5-11

Comparative Analysis of the Impact of Visual Impairment on Quality of Life of Patients Attending a Tertiary Hospital in South East, Nigeria


1 Department of Ophthalmology, Federal Medical Centre, Owerri, Imo State, Nigeria
2 Department of Ophthalmology, University of Benin Teaching Hospital, Edo State, Nigeria
3 Department of Ophthalmology, Imo State University Teaching Hospital, Orlu, Imo State, Nigeria

Date of Submission15-Jan-2021
Date of Acceptance20-Feb-2021
Date of Web Publication19-Jan-2022

Correspondence Address:
Dr. E O Achigbu
Department of Ophthalmology, Federal Medical Centre, Owerri, Imo State
Nigeria
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/njcp.njcp_24_21

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   Abstract 


Background: Quality of life (QoL) is defined as an “individual's perception of their position in life in the context of the culture and value system in which they live and in relation to goals, expectations, standards, and concerns.” Visual Impairment affects QoL because of the restrictions it imposes on everyday life activities. Aims: This study aims to compare the QoL of visually impaired patients attending the Eye Clinic of Federal Medical Centre, Owerri with that of normally sighted persons. The findings will aid the formulation of policies guiding the management of visually impaired patients. Patients and Methods: This was a hospital-based case-control study which recruited all consenting new patients with visual impairment, and age, and sex-matched controls who presented at the Eye Clinic, Federal Medical Centre, Imo State, Nigeria during the period of the study. Data was collected using a semi-structured closed-ended questionnaire, and the World Health Organization QoL-BREF and analyzed with the Statistical Package for Social Science version 22. Results: Four hundred and two participants were recruited. Lower scores were recorded in all the quality of life (QoL) domains for the visually impaired compared with controls. The overall QoL and health status mean score for the visually impaired (61.10 ± 19.75) was significantly lower than that for the controls (70.90 ± 21.19) at P < 0.001. Severity of visual impairment at P < 0.001 significantly affected all the QoL domains for the visually impaired with the lowest score noted among the blind (58.21 ± 11.63) compared to controls (79.33 ± 11.74). Occupation and educational level significantly affected the QoL of the study group but not the controls. Conclusion: Visual impairment significantly reduces the QOL of patients. Policies targeted at enhancing the QoL of the visually impaired through rehabilitation and societal integration is recommended.

Keywords: Comparison, impact, quality of life, visual impairment


How to cite this article:
Ejiakor I L, Achigbu E O, Onyia O E, Edema O, Nkwogu F U, Okeke A J, Ohanele P E. Comparative Analysis of the Impact of Visual Impairment on Quality of Life of Patients Attending a Tertiary Hospital in South East, Nigeria. Niger J Clin Pract 2022;25:5-11

How to cite this URL:
Ejiakor I L, Achigbu E O, Onyia O E, Edema O, Nkwogu F U, Okeke A J, Ohanele P E. Comparative Analysis of the Impact of Visual Impairment on Quality of Life of Patients Attending a Tertiary Hospital in South East, Nigeria. Niger J Clin Pract [serial online] 2022 [cited 2023 Jan 28];25:5-11. Available from: https://www.njcponline.com/text.asp?2022/25/1/5/335979




   Introduction Top


The World Health Organization (WHO) defines Quality of Life (QoL) as an “individual's perception of their position in life in the context of the culture and value system in which they live and in relation to goals, expectations, standards, and concerns”.[1] It is affected in a complex way by factors which include physical health, environment, personal beliefs, social relationship, level of independence, and psychological state.[2] It reflects the difference between the expectations and the current situation of an individual.

The subjective aspects deal with well-being, satisfaction, happiness, and meaning of life; while the objective aspects can be assessed using factors such as conformity to cultural norms, fulfilment of needs, realization of life's potential, and maintaining biological order, that is, the ability to function within a societal norm.[3]

Visual Impairment has been reported to affect the QoL of patients because of the substantial impact it has on individuals based on the shortcomings and restrictions it imposes on everyday life activities.[4] Visual impairment may be associated with reduced or limited participation in daily, religious, and social activities or associated with job dissatisfaction, financial insecurity, isolation, and loneliness. The impact of impaired vision on an individual's ability to participate in activities in the society is wholly dependent on the person's perception of the difficulty experienced with important activities.[5]

Various studies have indicated that the more severe the visual impairment, the poorer the QoL.[6],[7],[8] The Blue Mountain Eye Study[9] reported that severe non-correctable visual impairment was associated with significantly poorer SF-36 scores regardless of the underlying condition. Similarly, studies in Nepal[10] and Nigeria[11] reported deterioration of scores of QoL with increase in severity of visual impairment.

Regarding psychological wellbeing, Naiqiah et al.[12] in Malaysia reported that the odds of developing depression among the elderly with low vision were two times more than those with normal vision, and the elderly who were blind had almost five times the odds to be depressed compared with those with normal vision. This was corroborated in other studies.[11],[13] A significant reduction in the social domain has also been reported.[14] Improvement in the QoL is increasingly, the major goal in the provision of health care.[15]

Visual impairment can be measured objectively with visual acuity tests (distance vision, near vision) and by visual field test, color vision, and contrast sensitivity tests.[16] Peripheral and central vision are important for performing many daily activities. Given that visual acuity is important for everyday function, it is generally used as the standard for comparison.[16]

There is paucity of reports on the effect on QoL of the visually impaired compared to individuals with normal vision. This study aims to compare the QoL of visually impaired patients attending the Eye Clinic of Federal Medical Centre, Owerri with that of normally sighted persons. The evidence elicited will help in effective policy formulation aimed at enhancing the QoL of the visually impaired.


   Patients and Methods Top


This was a hospital-based case-control study which recruited all new patients with visual impairment aged 18 years and older who presented at the Eye Clinic, Federal Medical Centre, Owerri, Imo State, during the study period and who willingly gave consent. The subjects who met the inclusion criteria were recruited consecutively in the Eye clinic until the study sample size was attained. The sex- and age-matched controls were also enrolled consecutively in the Eye clinic.

The case definitions of visual impairment adopted for this study was used in Nigeria National Blindness and Visual Impairment Survey[17] protocol.



Age, and sex-matched controls with normal/near normal vision and no systemic illnesses who gave consent were also recruited. All visually impaired consenting subjects who met the inclusion criteria were recruited consecutively until the study sample size was attained. The control subjects were also enrolled consecutively. The study lasted 6 months.

Sample size calculation

Sample size was calculated using the formula for determining minimum sample size for comparison of groups (>10,000).[12] This gave a sample size of approximately 168 participants in each group. With a 10% non-response rate, the minimum sample size for each group was 187. However, 201 visually impaired adults and 201 adults with normal vision were recruited.

Ethical considerations

Ethical clearance was obtained from the Research Committee of Federal Medical Centre, Owerri and the study was conducted according to the tenets of the Declaration of Helsinki. Written informed consent was obtained from all participants.

Pilot study

A pilot study was conducted at the Imo State Specialist Hospital, Owerri among 20 patients with visual impairment and 20 age- and sex-matched controls.

Data collection

A semi-structured closed-end questionnaire was developed for collecting data on age, sex, marital status, occupation, and level of education. The World Health Organization Quality of Life-BREF (WHO QoL-BREF)—a 26-item questionnaire consisting of four domains: physical (items 3, 4, 10, 15, 16, 17, 18), psychological (items 5, 6, 7, 11, 19, 26), social (items 20, 21, 22) and environmental (items 8, 9, 12, 13, 14, 23, 24, 25) was used to assess QoL.[18] This questionnaire which has been validated for use in Nigeria[14],[19],[20] was rated on a 5-point scale ranging from “Not at all” (score of 1) to “completely” (score of 5). The combined scores of the four domains gave the total score for QoL. The WHO QoL-BREF was translated to Igbo language and back to English language by a bilingual translator for effective communication and to ensure consistency.

Ocular examination was done for all the participants, and refraction for all those with pin hole improvement of visual acuity as part of their visual rehabilitation. The visual acuity test was performed for each eye separately. The Snellen's chart or illiterate E chart placed 6 m away from the participant in an appropriately lit room was used for this test.

Data management and analysis

Three items of the WHO QoL-BREF were reversed (3, 4, 26) before scoring (1 = 5, 2 = 4, 3 = 3, 4 = 2, 5 = 1), thereby transforming them to positive phrases questions. The raw score for any facet must have a minimum value of 4 and a maximum value of 20. The next step involves transforming each raw score to a 0–100 scale using the formula below:



Data was analyzed using the Statistical Package for Social Sciences (SPSS) version 22. Frequencies and percentages were used to summarize categorical variables such as gender while means and standard deviations were obtained for continuous variables such as age, QoL. Student's t-test and ANOVA were used to compare means of continuous variables while associations between categorical variables were done using Chi-square. Statistical significance was set at P < 0.05 for all analyses. Results were presented as tables and charts.


   Results Top


Four hundred and two (402) participants took part in the study. Of these, half constituted the study group and the other half, the control group. The age range for the study group was 18–78 years and controls 18–71 years [Table 1]. The mean age was 55.92 ± 16.94 years for the study group and 53.99 ± 13.29 years for the controls. Majority of the participants had tertiary education.
Table 1: Sociodemographic characteristics of study group and controls

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The overall QoL and health satisfaction score for the study group (61.1) was lower than that of controls (70.9).

There was a statistically significant difference between the QoL of the study group compared to controls.

In the study group, marital status showed no significant difference in the QoL mean scores. QoL mean scores was significantly higher in those with tertiary education (P = 0.027). QoL mean scores was also significantly higher among the professional, skilled, and unskilled workers (F = 3.103, P = 0.017) and significantly lower in the unskilled and unemployed.

In the control group, there was no statistically significant difference in the QoL mean scores when the various demographic factors were compared (P > 0.05) except for marital status.

There was no statistically significant difference in the QoL mean scores between males and females in the study and control groups.

Frequency of visual impairment

This study showed that of the 201 visually impaired respondents who participated in the study, 35.3% had mild visual impairment, 48.7% had low vision, and 15.9% were blind.

All the variables showed statistical significance with grades of visual impairment.


   Discussion Top


The mean age for the study and control groups were 55.92 ± 16.94 years and 53.99 ± 13.29 years, respectively. There was no significant difference in age and sex between the two groups (P > 0.05), showing that the controls were adequately age and sex-matched with the study group.

The WHO QoL–BREF [Table 2] a general questionnaire (not disease specific) showed lower WHO-BREF mean scores in the following facets: participation in leisure activities, ability to perform daily activities, and capacity to work showed very low scores (<60) for the subjects compared with controls. In addition, there was a significant decrease in QoL scores in the study group (61.10 ± 19.75) compared to the control group (70.90 ± 21.19) [Table 3]. This shows that the effect of visual impairment is all encompassing. It has psychological, social, and physical effects among others. The result of this study is not surprising as majority of the patients in the study group had moderate/severe visual impairment or were blind. Previous studies have documented a reduction in QoL in the visually impaired.[11],[14],[21],[22] Greater difficulties in performing most vision dependent activities in patients with visual impairment has also been reported.[7] In fact, du Toit et al.[23] reported that there was a significant change in the Vision Specific QoL scores between individuals with no visual impairment and those with visual impairment. In contrast, Adigun[3] reported good QOL scores, but lower scores for visual function and social interaction. This shows the effect of vision in health and QoL of patients.[24]
Table 2: Average WHO-BREF mean scores in participants

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Table 3: QoL scores in Study group Compared to Controls

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Regarding the QOL domains, all the domains showed significantly lower scores in the visually impaired compared to controls (P < 0.001) [Table 3]. The environmental domain was the most implicated domain. Finance was the most affected facet in this domain. Limited opportunity for leisure activities was also implicated in the environmental domain. This may be becauseof the limited mobility enforced by visual impairment for outdoor activities. This result corroborates the findings by Amedo et al.[22] who also reported that environmental domain was the most affected domain in their study. Contrary to the findings in this study, Bekibele et al.[14] demonstrated that the physical domain was the most affected domain in their study. Their study was among elderly patients who are sometimes categorized as highly dependent people. The significant reduction reported in the environmental domain in their study was associated with poor distant vision.

There was a significant reduction in the physical domain in the study group compared to the control group (t = 6.568, P < 0.001). This largely affected the patients' work capacity and the ability to carry out daily activities. This was similar to findings in previous studies and reflects the impact of visual impairment on daily activities.[21],[22],[23] This difficulty may be associated with severe frustration as the patients are unable to carry out hitherto simple tasks as bathing, toileting, dressing, and eating among others. Lamoureux et al. also reported that the activites of daily living greatly affected were those associated with reading, outdoor mobility, shopping and leisure activities.[25]

The psychological domain of the study group compared to the control group was significantly affected (t = 7.641, P < 0.05). Patients with visual impairment reported negative feelings. This may be because of the fear of visual loss and not being able to cater for one's self. Similar studies have reported associations between visual impairment and depression[11],[22],[26] Sexual activities was also affected in the social domain compared with social support and personal relationship. The score for controls was higher compared to the study group. The study by Lee Smith et al. also showed that sexual activity is affected by visual impairment.[27]

Regarding demographic variables, being a professional, having a tertiary education, and being skilled were associated with a higher QoL compared with the poorly educated or unskilled in the study group while there was no significant difference among these variables in the control group [Table 4] and [Table 5].
Table 4: QoL Scores according to demographic variables in the Study group

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Table 5: QoL Scores according to demographic variables in the Controls

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The subjects with higher level of education and skills may have an established channel of income including pensions where applicable that may ameliorate the effect of their challenges unlike the unskilled workers who may have earned their income through daily paid labor such that unemployment may lead to financial dependence and reduction in QoL. Adigun et al.[3] reported that unemployment increased the likelihood of poor QoL by 2.9 fold. Similar findings were also reported by Masoud et al.[28] However, Amini et al.[29] reported that there was no relationship between employment and QoL. This may be attributed to the fact that the subjects in Amini et al.'s study had financial support from a Foundation.

Marital status significantly affected the QoL of life of the controls but not the study group. The widowed controls had the lowest QoL score. This may be because of the overwhelming impact of losing spousal emotional and physical support. The subjects with visual impairment, being already dependent may not notice any further reduction in their QoL as a result of their marital status.

Compared to participants with no visual impairment, participants with mild, moderate/severe VI, and blindness had significantly poorer QoL in all domains [Table 6]. This study also demonstrated that the mean scores of all the domains of QoL decreased with increasing severity of visual impairment. This implies that individuals with visual impairment depending on the severity may need extra effort to face the daily challenges of life. Vision-specific functioning and emotional well-being scores were also reported as poorer in visually impaired patients in other studies.[8],[11],[12],[21],[30] Evans et al. also reported a significant association between increasing severity of visual impairment and depression.[13]
Table 6: QoL scores based on Grades of Visual Impairment

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Limitation

This was a hospital-based study. A population-based study with a mixed methods approach will provide more evidence on the effect of visual impairment on the QoL of the visually impaired in the society.


   Conclusion Top


This study has shown that visual impairment significantly reduces the QoL of patients compared with individuals with normal vision; and this effect cuts across all QoL domains. The lowest mean scores were recorded in the environmental domain.

The severity of visual impairment, and some demographic factors such as education, and unemployment, were significantly associated with reduction in QoL of the visually impaired while marital status was not significantly associated with reduction in QoL in the study group.

Recommendation

Advocacy to appropriate government and non-governmental bodies for policies aimed at improving the QoL of visually impaired patients through early detection, rehabilitation, and integration into the society is recommended.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]



 

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