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Year : 2007  |  Volume : 55  |  Issue : 2  |  Page : 133-136

Barriers to the uptake of cataract surgery in patients presenting to a hospital

Department of Ophthalmology, UCMS and GTB Hospital, Delhi, India

Date of Submission09-May-2006
Date of Acceptance25-Oct-2006

Correspondence Address:
Upreet Dhaliwal
A-61, Govindpuram, Ghaziabad - 201 002, Uttar Pradesh
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/0301-4738.30708

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Purpose: To assess the barriers for the acceptance of surgery among patients with cataract and visual disability.
Materials and Methods: A short-term descriptive study was conducted in patients with cataract presenting to a hospital. Socio-demographic data were entered in a proforma. An interviewer-assisted questionnaire, surveying knowledge about cataract and barriers to cataract surgery, was administered by one of the authors (SKG) in the local language (Hindi).
Results: There were 100 patients (53 men and 47 women); 14 were bilaterally blind (vision <10/200 in the better eye). Attitudinal barriers included: could manage daily work (71%), cataract not mature (68%), could see clearly with the other eye (64%), too busy (57%), female gender (37%), fear of surgery (34%), fear of surgery causing blindness (33%) or death (13%), old age (33%), it is God's will (29%) and worry about cost of surgery (27%). The barriers relating to service delivery, cost, and affordability included: insufficient family income (76%), not knowing another person who had undergone cataract surgery (26%), no one to accompany (20%), distance from hospital (20%) or from a main road (9%) and lack of transport (7%).
Conclusions: Attitudinal barriers were reported more often, rather than issues of accessibility or cost. Eye care providers should address the identified barriers for increasing acceptance of surgery in the study area.

Keywords: Barriers, cataract, healthcare utilization.

How to cite this article:
Dhaliwal U, Gupta SK. Barriers to the uptake of cataract surgery in patients presenting to a hospital. Indian J Ophthalmol 2007;55:133-6

How to cite this URL:
Dhaliwal U, Gupta SK. Barriers to the uptake of cataract surgery in patients presenting to a hospital. Indian J Ophthalmol [serial online] 2007 [cited 2022 Sep 27];55:133-6. Available from: https://www.ijo.in/text.asp?2007/55/2/133/30708

Barriers relating to service delivery, cost, and
affordability in 100 patients with cataract

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Barriers relating to service delivery, cost, and
affordability in 100 patients with cataract

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Barriers relating to patient attitude in 100 patients with cataract

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Barriers relating to patient attitude in 100 patients with cataract

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Socio-demographic and other characteristics of 100
patients with cataract

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Socio-demographic and other characteristics of 100
patients with cataract

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Cataract accounts for 41.8% of global blindness and 81% of blindness in India.[1],[2] By 2020, the elderly population is expected to double, further increasing the number of blind people.[3] Strategies for reducing cataract backlog include increasing the number of cataract surgeries performed.[1],[2],[3],[4] However, despite rapid increase in the availability of quality services, surgical acceptance is still low in some segments of society.[4],[5],[6],[7],[8]

A few studies, mostly from other developing countries, have addressed barriers to accepting surgery for cataract.[5],[6] However, there are few studies in the Indian scenario, addressing regional issues.[7],[8] Determining barriers to use of eye care services is critical for planning strategies to prevent blindness. Ours is a tertiary level, teaching hospital that caters mainly to low socio-economical patients from east Delhi, Uttar Pradesh and Bihar. The hospital is government-funded and provides free service to patients. There are other government hospitals and private ophthalmic centers in the area. Yet, we see many patients with advanced unilateral or bilateral cataract. The aim of this study was to determine possible reasons for the delay in acceptance of cataract surgery in such a set up.

  Materials and Methods Top

This was a hospital-based, descriptive, short-term (2-months) clinical study. Inclusion criteria: consecutive patients, aged 45 years or above, with vision <20/60, the principal cause was cataract. Patients who did not give consent to participate were excluded.

After Institutional Ethical Committee approval, patients were briefed in appropriate local language about the purpose and procedure of the study. Socio-demographic data were noted on a proforma and included age, gender, rural or urban residence, literacy, and employment. A questionnaire surveying knowledge about cataract and barriers to acceptance of cataract surgery was administered after written informed consent, in the local language (Hindi). The questions on barriers were devised from the existing literature and required yes/no responses only. Seventeen barriers relating to patient attitude, service delivery, cost, and affordability were investigated.[9],[10],[11],[12] The English-language version of the proforma and questionnaire is appended. To maintain uniformity and reliability of data collection, all questionnaires were interviewer-assisted by the same interviewer (SKG), who had undergone training in questionnaire administration in the department of ophthalmology of this Institution. The interviews were conducted in a separate room away from relatives and other patients.

The diagnosis of cataract was based on torchlight and distant direct ophthalmoscopy. Vision was assessed by Snellen's chart and the World Health Organization definitions of normal vision (best corrected visual acuity (BCVA) ≥20/60 in the better eye), visual impairment (BCVA <20/60 but ≥/10/200 in the better eye), and blindness (BCVA <10/200 in the better eye) were used.[1]

Data were entered into an excel worksheet and each barrier that was reported by a patient was given a score of one point. Mean and median age of patients, mean duration of cataract and mean of total barriers per patient was calculated using the statistical package SPSS-13.

  Results Top

The study included 100 patients (53 men and 47 women), with age ranging from 45-86 years (median 62 years). All the women in our study were exclusively homemakers. Distance from hospital varied from 1 to 1000 km. The socio-demographic and other characteristics of the patients are given in [Table - 1]. Patients had known that they had cataract for periods varying from 4 days to15 years (mean 11.6 SD 21.4 months). Ninety-seven patients knew that cataract was curable and 87 knew that surgery was mandatory for its cure.

Total barriers per patient ranged from one to 13; mean 6.2 SD 2.57. The frequency of reported barriers relating to patient attitude, service delivery, cost, and affordability are given in [Table - 2][Table - 3].

  Discussion Top

The socio-demographic data show that the study included comparable numbers of men and women. The urban-rural representation was also equal. However, more than half the patients were illiterate and over 3/4ths were unemployed reflecting the type of patients catered to by this tertiary-level teaching hospital.

In the present era of microsurgery, it is no longer necessary to wait for cataract maturity before operating; many phacoemulsification surgeons prefer operating on immature cataracts. In this study, patients had known about their cataracts for periods ranging from 4 days to 15 years. Moreover, more than half the patients with bilateral cataract had mature or hypermature cataracts. Fifteen years represents a disturbing delay in seeking intervention and gives impetus to the need to study barriers specific to a region in relation to its socio-cultural practices.

Fourteen patients with cataract delayed surgery even though they were bilaterally blind. This is surprising. However, other authors have reported that bilaterally blind patients often do not feel the need for cataract surgery.[6],[8],[10] They tend to wait till complete dependency and lack of functional mobility ensues.[4],[7] Though coping mechanisms prompt these patients to deny their visual handicap, they nevertheless have considerable levels of anxiety and other psychological problems.[8] By delaying intervention, patients only make matters worse for themselves and their relatives. Getting cataract surgery done while there is still useful vision in the other eye allows the patient to travel unaccompanied and look after himself in the hospital, thus reducing the dependency and burden on relatives.[11] Ophthalmologists have an important role in this regard. If patients who present for treatment are told to wait because cataract is not mature or advanced enough, other barriers may make it difficult for the patient to present again.[7]

Studies have shown that financial limitations rank high as reasons for not having cataract surgery.[5],[13] However, in our study, the major barriers (operative in >55% patients) were more often related to patient attitude (ability to manage routine work, cataract not mature, could see clearly with the other eye, busy with work), than to issues of service delivery or cost and affordability (insufficient family income). Although 76% of the patients reported insufficient family income as a barrier, only 27% were worried about the cost of surgery. Possibly, they were more concerned with indirect costs. Other studies have shown that indirect costs relating to loss of a day's income, delegating household responsibilities and transportation for both the patient and his attendant are important barriers to intervention.[4],[8],[11],[12] Efforts to reduce indirect costs include conducting operations in the patients' own villages or facilitating transport to and from the surgical facility.[11] Illiterate and unemployed patients could also be benefited since it would take some of the pressure off relatives. Authors have suggested that training of health care workers or community members in recognition and referral of such patients might help them to seek intervention earlier, rather than later.[14] Further studies in the Indian scenario are required to gauge the effect of such interventions on attendance for cataract surgery.

Barriers operative in 25-55% patients included fear of surgery or of surgery causing blindness, old age and not knowing anyone who had undergone cataract surgery. Thus, although 87% of the patients interviewed knew that cataract was curable by surgery, patients with cataract hesitated to use the services. Probably, fear and other factors were operative. Studies have shown that interaction with a patient who has undergone the operation could help in reducing fear and abolishing fatalistic beliefs that blindness was an inevitable part of old age or God's will.[10]

In this study, women were greatly concerned that their gender prevented them from seeking intervention earlier. This suggests that they were aware of and unhappy with, the lack of importance given by the family to their health. Other studies have also shown that women avail of surgery at a later date than men.[7] Authors report that due to poor self-esteem and low expectations, women try to carry on with their routine work even when severely visually handicapped.[15]

Compared to attitudinal barriers, issues of accessibility were relatively unimportant in this study. Thus, distance from the hospital and of residence from a main road was cited infrequently as a barrier. Other authors have reported this as well.[6] However, one of the limitations of this study is that the patients represent a hospital-based population. Thus, the barriers reported by them may be different from those of community members who never present at all. Moreover, the barriers are likely to be inter-dependent. Running multivariate regressions to predict all the barriers would have entailed lots of tests and were not done. The other limitation is the small sample size. Since this was a short term (2-months) ICMR Studentship project, the sample size was fixed at 100 patients. To reduce chances of systematic error in our study, the same interviewer (SKG), trained in questionnaire administration, interviewed all patients. By interviewing the patient away from relatives and other patients, we tried to reduce bias resulting from social pressures. This is likely to make the results of our study reliable.

This study of barriers to intervention in patients with cataract shows that while intervention may have become more accessible, there is a need to modify patient attitudes to make surgery more acceptable. Thus, attempts to enhance acceptance of surgery must be sensitive to regional attitudinal barriers.

  Acknowledgement Top

Mr. Gupta's participation in this study was part of the Short Term Studentship Research Programme-2005, of the Indian Council of Medical Research, Delhi, India.

Appendix [Figure - 1]

  References Top

Resnikoff S, Pascolini D, Etya'ale D, Kocur I, Pararajasegaram R, Pokharel GP, et al . Global data on visual impairment in the year 2002. Bull WHO 2004;82:844-51.  Back to cited text no. 1
Jose R, Bachani D. World Bank-assisted cataract blindness control project. Indian J Ophthalmol 1995;43:35-43.  Back to cited text no. 2
Limburg H, Kumar R, Bachani D. Monitoring and evaluating cataract intervention in India. Br J Ophthalmol 1996;80:951-5.  Back to cited text no. 3
Brian G, Taylor H. Cataract blindness- challenges for the 21st century. Bull WHO 2001;79:249-56.  Back to cited text no. 4
Rabiu MM. Cataract blindness and barriers to uptake of cataract surgery in a rural community of northern Nigeria. Br J Ophthalmol 2001;85:776-80.  Back to cited text no. 5
Rotchford AP, Rotchford KM, Mthethwa LP, Johnson GJ. Reasons for poor cataract surgery uptake - a qualitative study in rural South Africa. Trop Med Int Health 2002;7:288-92.  Back to cited text no. 6
Vaidyanathan K, Limburg H, Foster A, Pandey RM. Changing trends in barriers to cataract surgery in India. Bull WHO 1999;77:104-9.  Back to cited text no. 7
Fletcher AE, Donoghue M, Devavaram J, Thulasiraj RD, Scott S, Abdalla M, et al . Low uptake of eye services in rural India: A challenge for programs of blindness prevention. Arch Ophthalmol 1999;117:1393-9.  Back to cited text no. 8
Murthy GV, Gupta SK, Thulasiraj RD, Viswanath K, Donoghue EM, Fletcher AE. The development of the Indian vision function questionnaire: questionnaire content. Br J Ophthalmol 2005;89: 498-503.  Back to cited text no. 9
Courtright P, Kanjaloti S, Lewallen S. Barriers to acceptance of cataract surgery among patients presenting to district hospitals in rural Malawi. Trop Geogr Med 1995;47:15-8.  Back to cited text no. 10
Melese M, Alemayehu W, Friedlander E, Courtright P. Indirect costs associated with accessing eye care services as a barrier to service use in Ethiopia. Trop Med Int Health 2004;9:426-31.  Back to cited text no. 11
Turner VM, West SK, Munoz B, Katala SJ, Taylor HR, Halsey N, et al . Risk factors for trichiasis in women in Kongwa, Tanzania: A case-control study. Int J Epidemiol 1993;22:341-7.  Back to cited text no. 12
Bowman RJC, Jatta B, Faal H, Bailey R, Foster A, Johnson GS. Long-term follow up of lid surgery for trichiasis in Gambia: Surgical success and patients perceptions. Eye 2000;14:864-8.  Back to cited text no. 13
Courtright P, Lewallen S, Tungpakorn N, Cho BH, Lim YK, Lee HJ, et al . Cataract in leprosy patients: Cataract surgical coverage, barriers to acceptance of cataract surgery and outcome of surgery in a population based survey in Korea. Br J Ophthalmol 2001;85:643-7.  Back to cited text no. 14
Geneau R, Lewallen S, Bronsard A, Paul I, Courtright P. The social and family dynamics behind the uptake of cataract surgery: Findings from Kilimanjaro Region, Tanzania. Br J Ophthalmol 2005;89:1399-402.  Back to cited text no. 15


  [Figure - 1]

  [Table - 1], [Table - 2], [Table - 3]

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