Table of Contents  
Year : 2021  |  Volume : 29  |  Issue : 2  |  Page : 126-132

Attitudes to Eye Health: A Focus Group Discussion Among Christian Religious Leaders in Calabar, Nigeria

1 Department of Ophthalmology, University of Calabar Teaching Hospital, Calabar, Nigeria
2 Federal Neuropsychiatry Hospital, Calabar, Nigeria

Date of Submission27-Jan-2021
Date of Decision28-Jun-2021
Date of Acceptance01-Jul-2021
Date of Web Publication18-Jan-2022

Correspondence Address:
Affiong A Ibanga
Department of Ophthalmology, University of Calabar Teaching Hospital, Calabar
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/njo.njo_11_21

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Introduction: In spite of the comparatively high rate of blindness and other visual impairments in Nigeria, access to orthodox eye care remains low. Religion has been shown to have important effects on health behavior but such effects as regards access to eye health care remains insufficiently explored in local research. Objective: This study aims to assess the knowledge and attitudes as regard eye care and health, among religious leaders in Calabar, Cross River State, Nigeria. Methods: Using a qualitative design, the study was conducted among 15 religious leaders from the Christian religion in Calabar. A focus group discussion was conducted which lasted about 90 minutes and was moderated by trained staff. Audio recordings were made and transcribed for qualitative content analysis. Results: Participants exhibited some basic knowledge of eye disease and causes of blindness. They found yearly eye-checks acceptable and generally agreed that they would encourage their church members to see a doctor when they had eye symptoms. There was also the opinion that the need to go to the hospital was dependent on the church member’s faith and the spiritual understanding of illness etiology. Conclusion: There is a need to further engage religious leaders to improve their knowledge and attitudes to eye health and care. Due to the strong influence of religious leaders in a religious country such as Nigeria, they could influence their congregations positively and improve the general resort to orthodox care for eye symptoms.

Keywords: Attitudes, eye health, religious leaders, Christian

How to cite this article:
Ibanga AA, Essien EA, Etim BA, Udofia O. Attitudes to Eye Health: A Focus Group Discussion Among Christian Religious Leaders in Calabar, Nigeria. Niger J Ophthalmol 2021;29:126-32

How to cite this URL:
Ibanga AA, Essien EA, Etim BA, Udofia O. Attitudes to Eye Health: A Focus Group Discussion Among Christian Religious Leaders in Calabar, Nigeria. Niger J Ophthalmol [serial online] 2021 [cited 2022 May 22];29:126-32. Available from:

  Introduction Top

The global burden of blindness and visual impairment is estimated to be 253 million of which 90% is in low income and middle income countries.[1] Nigeria is home to an estimated 4.2 million blind and visually impaired adults and of these, over 80% are due to preventable or avoidable causes.[2] In Nigeria, glaucoma is the leading cause of irreversible blindness and responsible for 16.7% of the total blindness. Of those with glaucoma (1.1–1.4 million), one in five is already blind showing a high prevalence and high rate of blindness.[3] Cataract, the most common cause of blindness (43%) in Nigeria is treatable by surgery. Uncorrected refractive error which is the most common cause of moderate visual impairment (57.1%) is easily treated with spectacles.[4] In essence, many interventions for the control of blindness are highly cost-effective with capacity to impact positively on visual function, quality of life, and economic status of households. Despite this, many in the Nigerian population continue to seek care in unorthodox places where outcomes are poor. In the Nigerian blindness survey, less than 5% of those with refractive errors had spectacles while 42.7% of all eyes that had a procedure for cataract had been couched with associated poor visual outcomes.[5],[6]

Alternate places, sometimes up to three, are often visited for eye complaints prior to orthodox services leading to delayed presentation and resultant poor outcome in spite of quality management.[7],[8] The Ocular morbidity study in Kwara state, Nigeria reported that only 10.1% self-reported ocular morbidity, whereas 48.6% of them reported seeking advice and treatment primarily from a chemist or medical store.[7] The very low overall cataract surgical coverage (CSC) in Nigeria (37.2%) which is among the lowest in the world and 3% spectacle coverage which are measures of service uptake confirm the status of poor uptake of orthodox eye-care services.[9],[10] The CSC is lowest (27%)[11] in South-South where this study was conducted, this shows even poorer uptake of available eye-care services. Utilization of existing eye-care infrastructure in Nigerian communities is as low as 25%, a far cry from the optimum target utilization set at 90%.[12] Even when eye-care services are available, they are underutilized by potential beneficiaries.[13],[14] Many factors have been adduced for the poor utilization and these are availability, affordability, acceptability, and accessibility of services, lack of awareness about treatment availability and benefits, the individual’s illness behavior, perception of threat to life and function, and the attractiveness of the value gained by using available health facilities.[15],[16],[17],[18],[19]

Behavioral change that will bring about a better appreciation and utilization of available orthodox eye health services to improve visual outcomes is of utmost importance. The expertise of members of the community can be harnessed as they have the potential to be more meaningful and to have a higher likelihood of resulting in behavioral change. To achieve any behavioral change, two groups of people are required and these are individuals with knowledge and credibility and a receptive audience.[20]

Religious factors should never be ignored or minimized in health matters as doing so can detract from development programs as many Nigerians look to religious leaders for moral direction and practical support. Besides, religious institutions have shaped Nigerian social and political approaches, notably in health and education.[21] Engagement with religious leaders if not properly managed has the potential to undermine positive contributions.

The unique position of religious leaders can be harnessed to promote community change but this is yet to be widely explored. They are perceived as credible, very influential with great communication skills and powers of persuasion. In addition, with a weekly (captive) audience, they have access to community members and can effectively address health issues.[21]

Theretical Framework

It is known that religious beliefs and religiosity can influence and determine health behaviors.[22],[23] Among the proposed models of health behavior, two which are most researched are the health belief model and the theory of planned behavior.

According to the Rosenstock’s health belief model [Figure 1], a person’s health behavior is determined by the interaction of their perception of threat to self (i.e., posed by the medical condition), their beliefs about the effectiveness of behaviors that would mitigate or eliminate the threat (e.g., health-seeking behavior), cues to action [which could be internal (e.g., symptom of disease) or external (e.g., advertisements)], one’s self efficacy as well as other modifying variables (e.g., sociodemographic characteristics).[24],[25] In this model, religion has commonly been considered only a modifying variable, belonging to a class of factors which only indirectly influence other core constructs such as perception of threat, belief about effectiveness of behavior, etc.[26] However, it has also been suggested that religion could have more direct effects in determining an individual’s perception of susceptibility or seriousness of disease. For example, perceived seriousness could be determined by what one’s religion considers serious. Furthermore, a person may be inclined to view as more effective treatments that are sanctioned by one’s faith.[26]
Figure 1 Health belief model: a summary representation of the major factors at play in the health belief model. Sociodemographic variables including religion affect perceived threat, evaluation of behavior to counteract threat, cues to action and self-efficacy. These in turn determine the likelihood of behavior.

Click here to view

According to the theory of planned behavior [Figure 2], the most important determinant of health behavior is a person’s behavioral intention, which is directly influenced by their attitude toward the behavior, subjective norms concerning the behavior, and the perceived control over the intended behavior.[25] Attitude refers to the positive or negative evaluation of the behavior and its expected outcomes.[27] It is possible that beliefs can be shaped by religion and can determine how a person evaluates health seeking. For example, a person can evaluate health seeking negatively if their religion sees it to be inferior or ineffective compared to spiritual healing.
Figure 2 Theory of planned behavior: In this model, religion could affect attitudes, norms, and perceived behavioral control. These shape the intention to perform the behavior which in turn determines behavior.

Click here to view

Subjective norms refer to perceived social pressures exerted on the individual, mostly due to the influence of important referent persons who could either approve or disapprove of the behavior, weighted by the individual’s inclination to conform to these pressures.[27] Religious leaders are important to the religion, and therefore their opinions could influence subjective norms and health behavior.

Perceived behavioral control accounts for those factors that lie outside the individual’s control (e.g., cost of health care and other barriers) and refer to the ease or difficulty associated with carrying out the behavior. Religious institutions can be a source of social welfare including financial support and therefore could influence the ease of health behaviors.

In recognition of the important role of religion and religious leaders in the community, the study objective was to investigate the knowledge and attitudes concerning eye health and care with emphasis on glaucoma among Christian religious leaders in Calabar.

  Methods Top

Calabar is the capital city of Cross River State in South-South Nigeria. It has a population of about 400,000 people who are predominantly Christian and is home to the University of Calabar Teaching Hospital (UCTH), one of the premier government-owned tertiary health institutions in the country. The study was conducted at its ophthalmology department, one of the accredited clinical departments of the hospital, responsible for providing in-patient and out-patient clinical services as well as training of medical students and resident doctors.

This was a pilot study with an exploratory design using a focus group discussion method of assessment among selected religious leaders. A leader was defined as the overall head of the church or his deputy who had occupied that office for a minimum of 5 years and who was above 18 years of age. As this was a pilot study, church selection was limited to the area around the hospital. With the support of the social worker in the department of ophthalmology, 36 churches were identified within a 500-m radius of UCTH. Using simple random sampling, 20 churches were selected to be approached for participation.

One leader from each of the selected churches was invited. The department’s social worker delivered letters of invitation by hand. At the study venue, the objectives were explained in detail to the participants and informed consent was obtained. This article is based on data collected from a focus group discussion lasting about 90 minutes in length, regarding the knowledge and attitudes of religious leaders about eye care and health with emphasis on glaucoma. The focus group discussion was moderated by two trained staff who used a list of predetermined probes that were developed prior to conducting the study to initiate and drive the discussion.

In developing the probes, the objectives and the theoretical framework were first considered and broad areas of knowledge were outlined. Next, questions were developed to address each of these broad areas. The preliminary list was then passed round the researchers who made suggestions and corrections. At the end of this reiterative process, the wording and presentation of the questions were simplified, restructured for clarity and were made open-ended. The questions were then arranged to demonstrate a logical flow and were pretested for ease of use and clarity among two clergies who visited the eye clinic, prior to the study. These probes only served as a guide to drive the conversation. They were designed to elicit information that would address study objectives. Focus group moderators conducted discussions in English. Audio recordings and handwritten notes were made. The focus group discussion had a total of 15 religious leaders, 10 males and 5 females, all between the ages of 31 and 55 years.

Information on basic knowledge of eye health and challenges of the eye-care service as well as free eye screening was provided for participants at the end of the session.

Data were analyzed using conventional qualitative content analysis and this was adopted as follows: Audio recordings were first transcribed and compared with the handwritten notes. Then each researcher independently examined the material to carefully identify salient themes and opinions that emerged, considering significant statements, repetitive words, and phrases. Individual responses of significance were also noted. Using this method, a set of preliminary codes was generated for the material. Using these codes, each researcher revisited the material to ensure the codes accurately captured all themes in the data. The codes were thus finalized and arranged in a hierarchical manner which would guide the data presentation in the result section. Using the described approach, study findings were extracted, and verbatim statements were sometimes presented to emphasize key concepts.

Ethical considerations

This study was performed in accordance with the ethical principles enshrined in the Helsinki Declaration and the National Human Research Ethical code. Ethical approval was obtained from the Research Ethics Committee of the UCTH. Only subjects who provided informed consent participated in the study. Participation was voluntary and confidentiality was assured. Informants were informed that they could withdraw from the study at any time and that there would be no consequence.

  Results Top

From among the 20 churches that were invited, only 15 responded. The focus group therefore had a total of 15 religious leaders, 10 males and 5 females, all between the ages of 31 and 55 years. The major themes which emerged during the focus group discussion are presented in the following sections. Subjects were given identifier codes which are affixed to verbatim statements to preserve anonymity.

Knowledge of eye pathology

The group was able to identify a few common eye conditions such as refractive errors (long and short sightedness), eye trauma, and glaucoma. Symptoms of eye disease mentioned were itching, tearing, pain, and redness.

Knowledge of causes of blindness

Causes of blindness which were identified by the group were glaucoma and eye trauma. Others suggested were:
  • Eye strain in persons who need corrective lenses

“When someone keeps straining their eyes when they are supposed to wear glasses…” − Subject 06
  1. Receiving treatment from a quack doctor

“Another cause is seeking advice from a quack doctor. They can tell you to put things like onion water into the eye.” − Subject 02

Attitude toward regular eye check-up

Participants agreed that having eye check-up at least once a year was acceptable, even in the absence of eye symptoms. They also seemed to defer to the superior knowledge of the doctor as regards health, and agreed that if the doctor prescribed regular checks, then it should be carried out because the doctor was more knowledgeable.

Attitude to a church member with redness and pain in the eye

Participants agreed that they would first pray for the church member because they were pastors and it is their duty to pray for the sick. And then they would ask them to go see a doctor.

They were asked what they feel about a pastor who would pray for such a church member and instruct them not to go to the hospital for a check. The group agreed that it was dependent on the faith of the church member. In other words, if the member’s faith in spiritual healing was strong enough, not going to the hospital for a check would be acceptable.

“If you have faith, then it is okay” − Subject 07

Some tried to base the course of action on a spiritual understanding of etiology in selected cases.

“If it is discovered that the sickness is not ordinary, you can advise the person to stay and pray” − Subject 05

One discussant talked about the need to observe the member carefully after prayers:

“We have to pray and exercise faith. And we have a period of observation, just like medical doctors. If the healing is not forthcoming, and it is beyond something of faith, we can advise them to seek for medical treatment.” − Subject 03

Attitude to a church member for whom a doctor has recommended surgery for treatment of glaucoma

Most participants were of the opinion that the member should go for the surgery, but support with prayers would be needed, especially if there was some spiritual attack involved. One participant believed that sometimes, people who avoid surgery could be under an attack which makes them afraid of surgery leading to other complications. One discussant had a different opinion, and insinuated that “spiritual surgery” was possible:

“Doctor, operations can be done in the spiritual realm, without surgery” − Subject 06

Compared to the previous theme, discussion about eye surgery elicited new angles to the discourse. The first was about the cost of surgery. Some said that people go for prayers instead of surgery only because of prohibitive costs. Options to cover costs which are practiced in the churches of participants included freewill donations or a fund raiser to assist such a member.

Another participant pointed out a reason why church members avoid surgery, which was based on fearful perceptions regarding surgical operations:

“They believe that if they undergo operation, they will die.” − Subject 013

The implications of eye surgery on faith in God

It was discussed whether going for eye surgery implied the individual does not have faith in God. Most agreed that receiving surgery does not undermine religious faith.

“I will encourage the person. You have to go for the surgery. That doesn’t mean you don’t believe in God or don’t have faith.” − Subject 08

Group conclusions

The overall direction of the group’s perspective can be summarized in the words of one discussant:

“Some people refuse treatment or check-ups as a result of ignorance. This is becoming regular and the best way is to eradicate such mindset from the churches and from among the members. We should educate people to know that going for medical checkup or surgical operation is not evil. That it is not against even the scripture. You are going for your own good, for the good of your church and for God-Almighty.” − Subject 03

  Discussion Top

There is no doubt that religious leaders play a central role in the course of health-seeking behavior and outcome of health-related issues among their congregants.[21] It is believed that outside the general faith guiding principles, the positive or negative role played by clergies in health-related issues to their congregants is mostly guided by their awareness and knowledge base of the diverse health conditions noticed among their members. Similarly, it is expected that the knowledge base of eye health and eye disorders will play pivotal roles in guiding the attitudes of religious leaders toward eye-health-related issues among their congregants as they carry out their activities.

The result of this study shows the perception and knowledge of religious leaders toward blindness, various eye disorders, and symptoms of eye diseases. This study further went on to elucidate on the attitude of religious leaders to eye-health-related issues as well as their attitude to members of their congregations with eye-health-related problems.

Findings in this study revealed that the overall knowledge base of the studied group of religious leaders about eye pathology was encouraging as they knew about the existence of few common ocular conditions, their symptoms, and a few but important causes of blindness. One of the interesting findings here was the ability of the group to agree that receiving treatment or advice from a quack doctor, where one can be asked to put things such as onion water into the eyes may lead to blindness. This good perception and knowledge base displayed by the studied group of religious leaders is of great importance to preventive eye health, as studies have shown that religious leaders may offer directions in terms of guidance, advice, and health-care utilization to their congregants in health-related issues.

Armed with some basic useful knowledge of eye health and eye disorders, the religious leaders in this study can play an influential role to their congregants on the right direction to follow when eye health issues arise. This assertion is most likely because faith leaders are highly respected and seen as role models by members of their congregation.[21]

The overall attitude by the studied religious leaders toward access to eye health care by their church members was quite encouraging. All the religious leaders agreed that they will ultimately allow their members to access eye-care services in hospitals if they have eye-health-related issues. Although this was attributed to a general agreement that doctors were more knowledgeable than the clergies in eye-health-related issues, there was an additional drive based on the fact that the clergies who participated in this study showed some basic knowledge about eye health and eye disorders during the focus group discussion. They could have acquired this knowledge from many years of praying for people with eye diseases or privately to differentiate between complaints that should be handled by prayers alone and that which should have hospital input. It may also come from the presence of a medical doctor in the congregation that gives advice and updates to the church.

The findings of this study tend to agree with other health-care utilization and uptake studies where religious leaders were key to addressing the health-care needs and increased healthcare attendance check-up of their congregants.

Some religious leaders agreed that prayers will be offered first before a church member is advised to visit the hospital. A few others say they will pray and observe for improvement before asking the member to visit the hospital if there is no improvement.

This trend may be a bit unsafe to their congregants for eye conditions needing urgent intervention which the faith leaders are not able to identify. However, the ability of the religious leaders to have hospital consultations at the back of their minds for their congregants whether immediate or delayed for eye-health-related issues stands out as an encouraging positive role. This further highlights the need to reach out to more religious leaders on health-related issues because some of them may constitute a hindrance to appropriate and timely access to eye-care services by their followers.

As expected, belief in faith-based healing was also found among the religious leaders despite their positive roles in encouraging their members to go to the hospital when they have eye-health-related problems. Some believe that if the disease is not ordinary and the church member has so much faith, then it was okay for the church member not to go to the hospital. This attitude of religious leaders in relation to faith-based healings has been documented in some studies. Therefore, similar attitudinal findings in this study, which was exclusively on eye-health-related issues, are not surprising. An encouraging attitude and positive role were noticed in majority of the studied religious leaders who agreed that members should go for eye surgeries when the need arises but with supportive prayers. These are positive attitudes and good roles displayed by the religious leaders for uptake of eye-care surgical services by their congregants. This is particularly important as a lot of eye patients locally tend to run to their church leaders first for advice before taking up eye-care services. In addition, this further gives credence to why religious leaders should imbibe these positive attitudes of encouragement and the right guiding role to their members who desire to access eye-care services including eye surgeries.

It is interesting to note that a minority of studied religious leaders did not have the right attitude to help guide their church members as they held on to the “fear” and “spiritual surgery” factors as their reasons. Negative attitudes such as this for religious leaders who lead a large congregation may spell doom for the society in terms of getting appropriate counseling for eye-health-related issues since such religious leaders may likely be the first port of call.

Despite having some knowledge of eye diseases, positive attitude, and good exemplary role noticed among participants in this study, it was generally believed by the religious leaders that ignorance was a major reason for refusal to take-up treatment by their congregants.

Strengths and Limitations of the Study

To the best of our knowledge, there are no prior qualitative studies on the knowledge and attitude of religious leaders to eye health in the country. This study yielded important findings which however should be interpreted in light of some limitations. First, the focus group discussion was conducted in the hospital premises and the discussions were guided by health workers. There is, therefore, a high likelihood of social desirability bias − that is, study subjects offering responses that are socially acceptable instead of their true feelings, to avoid overt or covert censure or to “fit in.” It is possible that if the same discussion was conducted in nonmedical settings by nonmedical persons, their answers could be different. The provision of incentives is also a potential source of bias but the free eye screening was undertaken at the end of the session. To minimize bias, time was taken to explain the objectives of the study and it was emphasized throughout the discussion that participants should feel free to express their true feelings on the subject of discussion. It is hoped that this helped to minimize the possibility of this effect. This is however a pilot study and steps would be taken to further minimize this limitation in future research.

Self-selection bias could also have influenced the study findings. It is possible that the few invited leaders who did not show up, could have attitudes that vary significantly in comparison with those who participated. It is also possible that the people that did not come may be more nonagreeing to referring their members.

Response bias may have also resulted from having more males than females in a patrilineal society. In addition, the use of in-depth interviews might have yielded richer information from respondents and is suggested for future research.

Another limitation of the study is the lack of representativeness of the sample. Few respondents from a few churches within 500 m radius of the hospital would not be an accurate reflection of the attitudes of the possibly hundreds of clergies from Christian denominations in Calabar. Also, other religions such as Islam or the traditional religions were not included.

  Conclusion and Recommendations Top

This pilot qualitative study aimed to determine the knowledge and attitudes of religious leaders in relation to eye health and disorder especially glaucoma. Although the religious leaders in this study had some knowledge and professed some positive and commendable attitudes, there were still some beliefs and behaviors that could be detrimental to optimal eye health and care. This underscores the need to engage more with religious leaders in consideration of the strong influence they have on members of their congregations. Eye health education campaigns targeted at religious leaders would go a long way to improve their knowledge and attitudes, which will very likely have a positive ripple effect, especially in a highly religious country like Nigeria.


The authors acknowledge Mr Bassey Okon Bassey and Bassey B. Ikpeme who assisted in the distribution of letters of invitation to church leaders and for following up to ensure that they honored the invitation.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

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