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Authors summary
Why was this study done?
Glaucoma is a public health problem due to its high incidence and disability, so the Glaucoma Patient Assistance Program was created to improve monitoring and avoid dismal prognosis. Thus, this study aimed to verify the difficulties of the elderly in the use of eye drops for the treatment of glaucoma and their socioeconomic/demographic profile.
What did the researchers do and find?
An exploratory and descriptive study was carried out, which showed, through sociodemographic findings, that the majority of the population was female, in addition to low education and monthly income of around 1 to 2 minimum wages. In addition, despite the limitations presented by the elderly, most revealed adherence to drug therapy.
What do these findings mean?
The elderly with glaucoma have disadvantages in relation to other citizens, not only due to the condition of the disease, but also due to the lack of information about its potential. Thus, health education for the elderly and their families, individually or in groups, is presented as a strategy that enables participation and involvement in therapy.
INTRODUCTION
Chronic non-communicable diseases are currently the main priority of the health sector in Brazil. Between 1998 and 2013, there were almost 38 million hospitalizations of elderly people in the SUS, and approximately 152 hospitalizations for each group of 1,000 elderly people. Despite the absolute growth, there was a reduction in the number of hospitalizations per thousand elderly people in this period. Although there has been a relative increase in the cost of hospital care, it is perceived that this is a small increase, considering the rapid increase in the population and aging1 .
Among the chronic degenerative diseases related to vision, glaucoma is a worldwide public health problem due to its high incidence and the visual impairment it can generate. Data from the WHO2 indicate that 65 million people have been diagnosed with glaucoma worldwide, among which 900,000 are Brazilian.
Glaucoma is defined by the presence of characteristic changes in the visual field, demonstrating damage to the optic nerve fibers, accompanied or not by increased intraocular pressure. It is the main cause of irreversible blindness and accounts for 20% of the world’s blind people3 . Data report that about 10% of patients diagnosed with glaucoma develop bilateral blindness4 . On the other hand, as the natural course of glaucoma may not generate symptoms in the early stages of the disease, it is estimated that the number of affected individuals is much higher than the known number5 .
With that, the Glaucoma Assistance Program, created in 2002, has as its main objective to bring glaucoma patients a follow-up with qualified professionals, in addition to distributing eye drops to the population free of charge. Through this program, patients with glaucoma get better care and adequate early treatment, being monitored by health professionals6 .
It is worth noting that preventive actions for blindness due to glaucoma are carried out with tests for early detection and treatment, in order to avoid worse prognosis. However, currently, there are no effective techniques related to glaucoma screening that identify all cases, with intraocular pressure measurement and optic disc examination being used as methods applied routinely to detect changes in the population, since the frequency in the age group elderly is higher, and all suspected patients should be referred for more accurate exams3 .
Health teams in primary care play a key role in the eye health of users by understanding that the lack of early identification of any visual alteration can result in irreversible health problems. Therefore, they are capable of identifying the main causes that must be investigated and treated before they show symptoms, as well as selecting the elderly who already need specialized care and providing follow-up by a qualified professional. In addition to the team, ophthalmologists play an important role in the early detection of glaucoma and in its demystification, as lack of knowledge about the disease and erroneous information tend to generate a lack of patient participation in the treatment, aggravating the visual prognosis3 .
Thus, the objective of this study is to analyze the difficulties of the elderly in the use of eye drops for the treatment of glaucoma.
METHODS
Study location and period
The survey was carried out at the Integrated Unit of Ipiranga linked to Primary Health Care in District III of the municipality of João Pessoa-PB, on a specific day of the week, in the afternoon, between October and November 2019.
Study population and selection criteria
The study population consisted of 11,287 elderly people who access services at the Integrated Unit of Ipiranga linked to Primary Health Care in District III. The data to calculate the research sample were provided by the Municipal Secretary of Health of João Pessoa/PB. In addition, the sampling plan for the research on screen considered that its population size is typified as finite, that is, it is located in a range of up to 100,000 inhabitants. From this categorization, and considering that there is no prior lack of knowledge of the population standard deviation, a sample was defined for District III, contemplated in this study, as established by the equation below:
The variables of equation [1] were established with a view to ensuring a minimum acceptable accuracy of sample representativeness, respecting the criterion of 80% expected correctness and 20% expected error due to knowledge of the population standard deviation, confidence level of 95 % and a margin of sampling error of 10%.
The study sample consisted of 61 elderly people and met the following inclusion criteria: age ≥60 years, using eye drops for glaucoma and being registered at the Integrated Unit of Ipiranga linked to Primary Health Care in District III. Respondents were randomly chosen without stratifying the sample by gender, educational level, income, and other items, as this would increase research cost and time, requiring a different field team.
Data collect
The data collection instrument consisted of questions referring to the following variables: sociodemographic (gender, occupation, marital status, monthly income and education) and questions about the use and difficulties experienced by the elderly in relation to adherence to the eyedrops. The collection took place through an interview with the application of the questionnaire. The questionnaire was applied to the elderly at the Ipiranga Integrated Unit and/or at their homes, with a previously established date and time, which was self-completed individually.
Data analysis
Data were tabulated in Microsoft Excel 2010® and subsequently processed in the Software Statistical Package for Social Sciences – SPSS version 21.0®. Data analysis was organized in tables and graphs with statistical description (absolute and relative frequency, mean and standard deviation). Through descriptive analysis, continuous variables were expressed as mean ± standard deviation and categorical variables as frequencies and percentages.
Ethical and legal aspects of research
As for the ethical aspects, the study was approved by the Research Ethics Committee of the Faculdade de Enfermagem Nova Esperança –FACENE under opinion nº 067/2019 and CAAE nº 17859619.6.0000.5179, respecting the ethical aspects of research involving human beings, recommended by Resolution 466/12 of the National Health Council. Participants were informed about the purpose of the study, agreed and signed the Free and Informed Consent Form.
RESULTS
Statistical analysis of sociodemographic data showed that 38 patients (62.3%) were female, 47 (77%) were retired, 32 (52.5%) were married and 23 (37.7%) studied up to primary school. Among the monthly income profile of the interviewees, 53 patients (87%) reported receiving 1 to 2 minimum wages monthly and 5 (8%) less than 1 minimum wage, as shown in table 1 .
Table 1 : Sociodemographic profile of the elderly assisted in the Glaucoma Program of Sanitary District III (N=61). João Pessoa, Paraíba, Brazil, 2019
| Variable | n | % |
|---|---|---|
| Sex | ||
| Female | 38 | 62,3 |
| Male | 23 | 37,7 |
| Ocupation | ||
| Retired | 47 | 77 |
| Work at home | 9 | 14,8 |
| Away from activities | ||
| 1 | 1,6 | |
| Therapist | 1 | 1,6 |
| Pastor | 1 | 1,6 |
| Pensioner | 1 | 1,6 |
| Vigilant | 1 | 1,6 |
| Marital status | ||
| Not Informed | 6 | 9,8 |
| Married | 32 | 52,5 |
| Single | 11 | 18 |
| Windowed | 8 | 13,1 |
| Divorced | 4 | 6,6 |
| Education | ||
| Illiterate | 12 | 19,7 |
| Primary (infant) | 23 | 37,7 |
| Secondary (up to 4th grade) | 7 | 11,5 |
| Middle School | 5 | 8,2 |
| High School | 8 | 13,1 |
| College educated | 5 | 8,2 |
| Not Informed | 1 | 1,6 |
| Income | ||
| <1 minimum wage | 5 | 8 |
| 1-2 minimum wage | 53 | 87 |
| 3-4 minimum wage | 2 | 3 |
| >4 minimum wage | 1 | 2 |
Source: Direct research, 2019.
According to table 2 , the elderly, when asked about how long they had been undergoing treatment for glaucoma, 31 (50.8%) responded for more than 2 years and 16 (26.2%) did not know how long, 46 patients (75.4%) were unable to inform the name of the eyedrops, 44 (72.1%) answered that in some consultation they had already been explained how the application should be done, 39 (63.9%) did not feel difficulty in dripping the eyedrops in the eyes and 41 (67.2%) have already dripped the eyedrops more than once in the same eye because they did not know if the drop fell outside or inside the eye.
Table 2 : List of investigated variables of the elderly in Sanitary District III (N=61). João Pessoa, Paraiba, Brazil, 2019
| Variable | N | % |
|---|---|---|
| How long have you been treated for glaucoma? | ||
| 1-6 Months | 7 | 11,5 |
| 6 Months -1 Year | 4 | 6,6 |
| 1-2 Years | 3 | 4,9 |
| >2 Years | 31 | 50,8 |
| Did not Reply | 16 | 26,2 |
| Do you know the name of the eye drops you are using now? | ||
| Yes | 15 | 24,6 |
| No | 46 | 75,4 |
| In some consultation it has already been explained how the application of the eye drops should be done? | ||
| Did not inform | 1 | 1,6 |
| Yes | 44 | 72,1 |
| No | 16 | 26,2 |
| Do you have difficulty putting eye drops in your eye(s)? | ||
| Yes | 22 | 36,1 |
| No | 39 | 63,9 |
| Have you ever put the eye drops in the same eye more than once because you don’t know if the drop fell outside or inside the eye? | ||
| Yes | 41 | 67,2 |
| No | 20 | 32,8 |
| Do you know how the eye drops you use work? | ||
| Did not Reply | 2 | 3,3 |
| Yes | 15 | 24,6 |
| No | 44 | 72,1 |
| Do you have trouble remembering if you’ve used the eye drops? | ||
| Yes | 24 | 39,3 |
| No | 37 | 60,7 |
| Makes use of more than one eye drop a day? | ||
| Yes | 18 | 29,5 |
| No | 43 | 70,5 |
| Do you have difficulty knowing how to differentiate eye drops? | ||
| Yes | 15 | 24,6 |
| No | 46 | 75,4 |
| Need someone’s help to drip the eye drops? | ||
| Yes | 20 | 32,8 |
| No | 41 | 67,2 |
| Already missed eye drops? | ||
| Yes | 30 | 49,2 |
| No | 31 | 50,8 |
| If you can read: do you have difficulty reading the name of the eye drops or prescription? | ||
| Yes | 19 | 31,1 |
| No | 29 | 47,5 |
| Don’t know how to read | 13 | 21,3 |
| Always apply the eye drops at the same time? | ||
| Yes | 28 | 45,9 |
| No | 33 | 54,1 |
| Go with an ophthalmologist appointment? | ||
| Did not inform | 1 | 1,6 |
| Yes | 39 | 63,9 |
| No | 21 | 34,4 |
| Can answer questions/monitor the use of eye drops in basic care? | ||
| Did not inform | 1 | 1,6 |
| Yes | 26 | 42,6 |
| No | 34 | 55,7 |
| Do you want to mention any difficulty that was not addressed in the previous questions? | ||
| Yes | 5 | 8,2 |
| No | 56 | 91,8 |
Source: Direct research, 2019.
Subsequently, they were asked if they knew how the action of the eye drops they used worked, to which 44 patients (72.1%) answered that they did not know. 37(60.7%) have no problems remembering whether they have already used the eyedrops, 18(29.5%) use more than one eyedrop per day.
When asked about the difficulty in knowing how to differentiate the eye drops, 46 patients (75.4%) reported that they had no difficulty, 41(67.2%) reported that they did not need help to drip the eye drops, 31(50.8%) they never ran out of eye drops. Those who reported that they could read were asked if they could differentiate well the names of the eye drops, to which 19 patients (31.1%) reported no, and 13(21.3%) reported not knowing how to read.
Regarding the application of eye drops at the recommended times, 33(54.1%) reported that they do not follow the schedule, 39(63.9%) are being followed up for an appointment with an ophthalmologist, 34(55.7%) are unable to take/follow the use of eye drops in basic care. Regarding mentioning some difficulty not yet addressed in the previous questions, 5(8,2) answered yes.
DISCUSSION
The Family Health Strategy (ESF) is a preferential modality of reorganization of primary health care in Brazil, meeting the assumptions of the Unified Health System. It is focused on disease prevention and health promotion actions, treatment, recovery and harm reduction in the community, marked by a humanized service that solves the most frequent health problems7 .
To this end, the ESF must be a gateway for clients of the Unified Health System (SUS), which must meet the needs of people who seek the service for actions aimed at promotion, prevention and treatment, seeking proximity to the health team with the user, in order to get to know the person, the family and the community8 .
Regarding sociodemographic data ( table 1 ), it was observed that the majority were female. It is known that women tend to seek health services more because they are more compliant with the therapeutic regimen, prevention habits and greater socialization, since they culturally assume responsibility for taking care of themselves and others9 . The results of this investigation align with those found in a study carried out in Portugal with 451 elderly people from the Algarve region, in which it was observed that 62.1% of the sample was characterized by women10 .
With regard to occupation, most seniors have income from retirement, either due to length of service or resulting from social benefits11 . It is understood that this represents the reality of many developing countries and is one of the characteristics of this stage of life12 .
Furthermore, most elderly people depend exclusively on social security benefits, which leaves them vulnerable due to fluctuations and uncertainties in public policies, thus living with the constant fear of having their benefits cut. Despite their condition of vulnerability, universal public policies for social protection play a decisive role in their lives. This demand, therefore, corresponds to a specific portion of the population, dependent on the INSS, which was inserted in the labor market in certain branches of activity, but away from their activities due to visual impairment11 .
As for marital status, the result of the study is similar to that of some Latin American cities in the SABE study – Health, Wellbeing and Aging1. It is emphasized that married elderly people may have a more positive daily connection between time with their partner and levels of happiness13 .
The study by Waldinger and Schulz13 revealed that, for both sexes, being more satisfied in their marriages is strongly associated with a more positive daily link between time with a partner and levels of happiness. Another study carried out in China with octogenarians revealed a high prevalence (62.4%) of married elderly people with better psychological well-being14 .
Regarding education, 37.7% of the elderly have completed primary school, confirming the findings of Bittencourt and Fonseca15 , who discuss the difficulty of low education as a detriment to understanding the use of eye drops. It is understood that patients with less education have difficulty reading, memorizing and finding information about a medicine contained in the leaflet16 .
Concerning economic income, most elderly people receive 1 to 2 minimum wages per month, corroborating studies by Segundo Bittencourt and Fonseca15 and Pinto16 , in which the most prevalent income was also 1 to 2 minimum wages in 80.1% of the investigated population.
As for the education of the research participants, 37.7% said they had completed only primary education (children). Added to this is the fact that the form of financial income for Brazilian elderly people is through retirement or a monthly minimum wage pension. Thus, the importance of paying greater attention to the population with less education is highlighted, providing assistance in a differentiated way and using strategies to improve the understanding of dosage with the use of drawings, colors and symbols16 . Due to this communicative barrier, important information is often lost during the consultation, leaving the elderly without the best possible therapy.
About the time of treatment for glaucoma, it was evidenced that 50.8% of the research participants stated that they had been doing it for more than 2 years. According to Cintra and Sawaia17 , most elderly people with glaucoma do not follow the clinical treatment regularly, which can worsen the visual prognosis.
With regard to the elderly knowing the name of the eyedrops, 46% said they did not know, even though most respondents had been using the medication for more than 2 years (50.8%). This can be explained by the lack of familiarity of the elderly with the names of the medications prescribed by the ophthalmologist. Another factor that may contribute to this lack of knowledge is low education, which exposes the elderly to the risk of handling the eyedrops assertively, thus making treatment difficult. It is noticed that a large part of this public makes a mental effort to memorize the bottle and color for use16 .
With the standardization of packaging offered by the market, as well as the difficulty in memorizing the names of the eye drops, the therapeutic efficacy of elderly patients becomes very worrying, since in consultations, non-adherence to topical treatment is one of the major causes of failure in the outpatient follow-up of the elderly with glaucoma.
Respecting the explanation about the application of the eyedrops, 72.1% stated that they know how to perform the technique, 63.9% stated that they did not experience difficulty when dripping the eyedrops and 67.2% reported that they had already instilled the eyedrops more than once. in the same eye because they do not know if the drop fell outside or inside the organ and the ophthalmologist continues the guidelines regarding the use of eye drops for glaucoma, so that there is adherence to the instillation technique. It is important to say that amounts greater than 23 µl18 , 19 in the human eye have no therapeutic effect, since the liquid will flow through the facial region and consequently the waste will result in a lack of medication for the prescribed period.
Within the consultations of the Glaucoma Program, one of the great doubts to be always clarified was the number of drops to apply, even the patient receiving the prescription with the dosage of one drop in each eye of each prescribed medication. Thus, the research confirms difficulties seen in the researcher’s practice.
As for experiencing difficulty in applying the eye drops at the correct time, 36.1% said yes and 54.1% said they did not apply the eye drops at the same time as the medical prescription. According to Portes20 , regarding the perception of self-instillation of medication by the elderly and the use of facial support, 36% said they felt a lot of difficulty, which is due to aspects that normally arise with aging, since the correct use of eye drops is a consequence of a practice routine with fine motor coordination movements and good near vision, two aspects impaired in the elderly20 .
It is noteworthy that, when asked if they had already dripped the eye drops more than once in the same eye because they did not know if the drop fell outside or inside the eye, 67.2% of the research participants said yes. For Cintra et al. 21 , other factors may also be related to treatment irregularity, such as: economic difficulties, forgetting the medication schedule, lack of vision improvement, side effects and difficulty in self-instillation of eye drops.
When asked about the action of the eye drops, 72.1% of the elderly reported not knowing the action of the medication in the eyes. In the study carried out by Miguel et al. 22 , at the University of Coimbra, it was shown that most users also do not know the medication’s mechanism of action, emphasizing the importance of interpersonal communication between the doctor and the user, an essential tool for the success of the treatment plan. Therefore, it is not uncommon to observe the loss of continuity in the treatment of elderly patients who proposed their own expectations for instilled medication, with improvement in vision being one of the main ones.
Another important piece of data identified in the survey is that 39.3% of the elderly still claim that they have trouble remembering whether they used the eyedrops. In a survey carried out by Silva et al .23 , the elderly, when asked about the times, answered that these intervals were not respected. Despite this, many believed that, with the use of eye drops, there could be an improvement in visual acuity. As this fact does not occur, it also contributes to reducing adherence to treatment.
Regarding the use of more than one eyedrop per day, 70.5% of the elderly answered no. This fact facilitates the adherence of the elderly to the treatment. In the geriatric and gerontological literature, several factors are associated with lack of medication adherence. Among them are: the high frequency of medication doses per day, the high number of medications and their side effects, the patient’s lack of concern regarding the disease and its therapy, the quality of the doctor-patient relationship24 , 25 .
It is important to highlight that during the research, not many studies were found in the literature regarding the use of eyedrops and their difficulties by the elderly. Therefore, to discuss polypharmacy in the elderly, studies based on oral medications were also used, with the use of eye drops being an important aspect to be discussed.
When asked if they had any difficulty knowing how to differentiate eye drops, 75.4% of the elderly answered no. This is a positive result, but it differs from the study by Rees et al .26 , in which it was found that patients with glaucoma who have other comorbidities need to administer additional medications (systemic and ocular) and may forget or not know how to differentiate their eye drops for glaucoma.
Regarding the request for someone’s help to drip the eye drops, 67.2% stated that they do not need help. However, according to studies by Pinto16 , it is recommended to instruct the patient to instill the eye drops sitting or lying down and gently close the eyes right after instillation, keeping them closed for about two minutes. This simple fact can lead to increased adherence to glaucoma treatment. In addition, it was found that 18% of the studied patients used two or more drops per instillation and only 23% of them remained with their eyes closed or occluded the lacrimal point after instilling.
As for the issue of running out of eye drops at home, 50.8% said no. Ministry of Health Ordinance No. 92027 determines the availability of the drug by the Unified Health System, free of charge, since 2011, when the Ministry began to distribute eye drops to combat glaucoma, which facilitates the non-shortage of the ingredient. However, during the program’s regular follow-up consultations, complaints about the lack of medication for the proposed period are common.
When investigating the cause of the end of the bottle’s content before the proposed period, it is noticed that it usually happens due to the loss of drops during instillation or overdose (two drops or more instilled at a time) leading to shortage of eyedrops.
As for the difficulty in reading the name of the eye drops or prescription, only 47.5% of the elderly stated that they had no difficulty. Cintra, Guarieto and Miyasaki28 draw attention to the significant number of elderly people who reported a decrease in visual acuity, considering the implications of low vision in complying with drug therapy, which suggests future investigations in this regard.
With regard to the question whether they always apply the drops at the same time, 54.1% of the research participants answered no. This result contradicts the result of the research carried out by Cintra, Guarieto and Miyasaki28 , whose study shows that the majority of the elderly interviewed adhered to the therapeutic regimen, with about half of them claiming to be extremely careful with the time and the way of taking the medication.
Due to these limitations, it is expected that the elderly attend appointments accompanied, but only 63.9% said they were accompanied to an ophthalmologist appointment and 55.7% were unable to supervise the use of eye drops in basic care. It is understood that the companion will help in the care offered to the elderly, since it is perceived that the companies are useful for the elderly to have a good therapeutic adherence in the use of eye drops and adequate knowledge about the use of this medication.
It is accepted that, in order to carry out public health actions that depend on the behavior of the people for whom they are intended, it is extremely important to know in advance the ways of acting, feeling and thinking of the target community of these actions and the context in which they are carried out. insert this community29 . This knowledge makes it possible to direct the content and form of educational campaigns, aimed at the prevention and control of glaucoma, with the objective of greater understanding and acceptance by glaucomatous patients of the importance of adherence to treatment and adequate control of the disease23 .
When asked about any difficulty that was not covered in the questionnaire questions, 91.8% denied having problems not addressed in the questions. However, 8.2% of users responded that they had difficulty making an appointment with an ophthalmologist.
This finding corroborates the study by Castagno et al.30, which included 2,960 individuals, in which, among the study subjects, 30% stated that they had never had an ophthalmological consultation due to difficulty in accessing health services. Even in the group over 50 years old, 30% had not consulted in the last five years and 20% had never consulted. In the group of less than 50 years old, the percentages were, respectively, 55% and 37%.
An important factor for the effectiveness of the treatment is the doctor-patient bond, and this ends up being impaired without continuity of follow-up with the same professional and without the frequency of consultations. One of the consequences of this is poor adherence to treatment, as many elderly people attribute the lack of vision improvement to medication failure.
The glaucoma program was implemented precisely with this proposal of carrying out exams, consultations and delivery of eye drops by the same health professionals to the same group of patients, thus providing greater bonding and better therapeutic success. However, among the patients covered by the program, our research found 8.2% of them with difficulty in carrying out adequate follow-up.
CONCLUSION
In this study the majority of the population was female, with low educational level and monthly income around 1-2 minimum wages. Despite the limitations presented by the elderly, most revealed to comply with drug therapy.
It is noteworthy that the elderly with glaucoma have disadvantages compared to other citizens, not only due to the condition of the disease, but also due to the lack of information regarding their potential. Thus, health education for the elderly and their families, individually or in groups, is presented as a strategy that enables participation and involvement in therapy.
