Diabetes Burden and Healthcare Barriers Among Cataract Patients in Imo State, Nigeria

1. Highest level of education attained by yourself or any of your parents:

2. What type of home do you live in?

3. What personal electronics do you own? (1 point for each electronic owned)

4. Sleeping arrangements (number of people per bed):

5. Main source of drinking water (score highest option given):

6. What type of toilet facilities does your household use?

7. Do you receive food from the following places?

8. How many times do you and/or your family eat chicken, meat or fish?

9. What is your main source of transportation?

1. Which of these are you prescribed for your diabetes?

2. How often are you supposed to take your medications according to your doctor?

3. How often do you take your medications/injections?

4. Do you have any symptoms due to your diabetes? Mark all that apply.

5. How often do your symptoms occur?

6. Does your diabetes affect your choice of food?

1. Do you have financial difficulty purchasing your diabetes medications?

2. Are there people who live with you and take care of you at home?

3. Do you need help to cook, clean, farm, or go to the market on your own?

4. Do you smoke?

5. What barriers do you encounter when traveling to a clinic/pharmacy?

6. How many times did you drink soda or take sweets in the past week?

7. Do you take any herbs/natural remedies to manage your diabetes?

8. How often do you forget to take your diabetes medications?

9. How often do you check your blood glucose levels?

10. How often do you exercise (e.g., bicycle riding, farming, jogging, dancing)?

11. What is the average range of your blood glucose levels?

12. When was your last visit to a doctor?

13. Where do you obtain medication?

Highest IOP: r = 0.51, p = 0.015, n = 22.

After controlling for medication use r = 0.48, p = 0.040, n = 20;

After controlling for adherence r = 0.78, p = 0.013, n = 10;

After controlling for blood glucose r = 0.47, p = 0.043, n = 20;

After controlling for hemoglobin r = 0.48, p = 0.039, n = 20.

After controlling for overall SES score: r = 0.59, p = 0.005, n = 22.

β = 0.686, p = 0.032 (adjusted regression).

Diabetes burden: p = 0.055, β = 0.592.

Barriers to care: r = 0.327, p = 0.030, n = 36.

Hemoglobin: r = 0.463, p = 0.003, n = 36.

Hematocrit and cataract severity: r = −0.742, p = 0.018, n = 12.

Hemoglobin and hematocrit: r = 0.952, p < 0.001.

Daily task help and cataracts: r = −0.452, p = 0.030.

Transport limitation and lower SES: r = 0.371, p = 0.012.

Transport limitation and daily task help: r = 0.424, p = 0.004.

r = −0.473, p = 0.041.

Privately owned homes and more daily medication adherence: (r = −0.528, p = 0.017).

Prescribed daily medications and worse diabetes burden scores: r = 0.661, p < 0.001, n = 23.

Self‑reported daily medication adherence and worse diabetes burden scores r = 0.68, p < 0.001, n = 20.

Number of chronic conditions and diabetes burden: r = −0.41, p = 0.008, n = 40.

Diabetes burden by home ownership group: Non‑cement home median = 0 (IQR = 2) vs Owned cement home median = 0 (IQR = 3), p = 0.563. Mann‑Whitney U test: p = 0.563 (not significant).

Diabetes burden by water source group: Pipe/tap/shared borehole median = −1 (IQR = 2) vs Vendor/bottled/personal borehole median = 0 (IQR = 3), p = 0.899. Mann‑Whitney U test: p = 0.899 (not significant).

Diabetes burden vs overall SES score: r = −0.07, p = 0.667, n = 45.

Collaborate and support enrolment into the recent 2025 Imo State Health Insurance Agency (IMSHIA) program, which covers metformin and sulfonylureas at a subsidized cost.

Follow up with patients between missions to inform them of MIF medication subsidies also available during the year to support continuity of their care.

Better medication access improves adherence, which lowers blood glucose over time.

Sustained glycemic control slows lens opacity progression and reduces cataract risk.

Addresses the most significant modifiable predictor of diabetes burden found in this study.

Crayfish: already used daily in Igbo cooking, and provides heme iron, zinc, and complete protein at very low cost.

Moringa (okwe nri): grows locally in southeast Nigeria, is high in iron, vitamin C, and folate, and is added to local soups e.g., egusi soup.

Cowpeas and African breadfruit (ukwa): low glycemic index, high fiber, and affordable. Soaking cowpeas overnight before cooking improves iron absorption.

Subsidized protein programs for fish and chicken, local food partnerships, or monthly diabetes‑friendly farmer’s market events with incentives for local poultry and fish farmers.

Vitamin B12 supplements because plant foods alone cannot provide adequate B12. Low‑cost supplements are already co‑prescribed at other Nigerian diabetes clinics, so this is feasible to add to routine care visits.

Vitamin A: moringa and red palm oil used in moderation are locally accessible and may support eye health.

Treating iron deficiency reduces the burden of diabetic vascular damage and reduced oxygen delivery to the lens and retina.

B12 supplements reduce nerve damage that compounds diabetic neuropathy.

Low glycemic index food substitutes improve blood sugar management without requiring medication changes.

Vitamin A is independently linked to lower cataract risk.

Work with local churches and community groups to set up informal caregiver volunteer programs for patients who live alone.

Consider paid family caregiver models similar to programs in the United States, where family members are compensated for caring for elderly relatives. This may also create economic opportunity for younger generations with limited formal employment.

Train caregivers in medication reminders, help attending clinic appts., and basic dietary guidance during a single mission session.

Develop a mobile platform or compile phone resources so caregivers can access guidance on minor issues remotely to reduce unnecessary travel.

Assign community health workers to patients with no caregiver, low SES, and limited transportation.

Caregiver support is the only finding in this study associated with better diabetes outcomes, lower barriers, and better hemoglobin levels at the same time.

Better medication management and nutrition together lower diabetes severity, which directly improves cataract surgery access and outcomes.

Paid caregiver models may create economic opportunity while sustaining patient support.

Remote access tools reduce transportation burden for minor concerns between missions.

Use a mobile clinic model to bring diabetes screening and medication dispensing directly to the community.

Schedule clinic days to match local market days when transport is naturally more available or conduct weekly screenings after church‑service

Offer transport vouchers or coordinate with local churches to provide rides on clinic days.

Introduce medication delivery as an alternative to pharmacy pickup for patients with severe mobility limitations.

Prioritize home visits by community health workers for patients with advanced cataracts who cannot travel independently.

Bringing care to the community increases clinic attendance and medication refill rates.

Earlier cataract care leads to better surgical outcomes and preserved vision.

Ask about specific and detailed herb use at every diabetes visit.

Counsel patients on common herb interactions with metformin and sulfonylureas. Train local pharmacists to provide accessible guidance on safe herbal remedy use alongside prescribed medications.

Add hemoglobin or hematocrit testing to routine diabetes care visits using a point‑of‑care device.

Track missed doctor visits among patients with dietary limitations using simple community health worker checklists and follow up with home visits for high‑risk patients.

Finding low hematocrit early means anemia can be caught and treated before it starts affecting vision or nerve function.

Teaching patients about herb interactions helps prevent hidden effects on blood sugar and blood cell levels that no one would otherwise know about.

Introduce routine IOP screening as part of diabetes care visits for higher SES patients. Glaucoma risk is disproportionately high in West African populations and is often asymptomatic until advanced.

Test private borehole water sources for specific mineral content and potential contaminants using low‑cost community water testing kits.

Recommend low‑cost household filtration options for patients using private borehole sources.

Develop community education on water safety and its potential relationship to eye health, in partnership with local environmental monitoring programs.

Routine IOP monitoring enables earlier detection of glaucoma risk before vision loss occurs.

Identifying environmental contributors to elevated IOP opens a novel prevention pathway specific to this population.

Water safety education addresses a modifiable exposure that may affect outcomes beyond eye health.

Incorporate structured physical activity counseling into diabetes care visits. Recommend culturally familiar activities such as farming, walking, or dancing that are already part of daily life.

Provide simple written or illustrated exercise tips that patients can take home and share with their caregivers.

Use community health workers to follow up on lifestyle goals like exercise frequency during visits.

Regular exercise improves insulin sensitivity and lowers blood glucose independently of medication.

Physical activity reduces cardiovascular risk factors that compound diabetic eye disease.

Addressing sedentary behavior in medicated patients may gain diabetes improvements that medication alone is not achieving.

Review medication regimens for patients with high diabetes severity scores despite reported adherence. Consider whether their current first‑line agents are adequate or need escalation.

Introduce structured symptom tracking at every visit. Blurry vision, dizziness, ulcers, and non‑healing wounds should be documented as indicators of disease progression.

Coordinate referrals to specialist care for patients with multiple chronic diseases and persistent symptoms.

Provide patients with simple “symptom diaries” or mobile‑based tools to track daily symptoms between visits.

Identifying patients whose disease is progressing despite medication allows us to review their regimen on time before complications

Tracking blurry vision systematically creates a direct link to timely eye care referral.

Provide affordable glucometers and test strips to patients who lack home monitoring equipment.

Educate patients on the importance of regular blood glucose self‑monitoring as part of standard diabetes self‑management.

More frequent monitoring allows patients to detect and respond to glycemic fluctuations.