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ORIGINAL ARTICLE
Year : 2017  |  Volume : 5  |  Issue : 2  |  Page : 69-72

Study on barriers causing delay in cataract surgery of bilateral cataract blind at a tertiary eye care center in urban India


Department of General Ophthalmology, H. V. Desai Eye Hospital, Pune, Maharashtra, India

Date of Submission08-Sep-2015
Date of Acceptance29-Aug-2016
Date of Web Publication25-Apr-2017

Correspondence Address:
Sheetal Dharmadhikari
Department of General Ophthalmology, H. V. Desai Eye Hospital, Tarawade Vasti, Mohammed Wadi, Pune - 411 060, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2320-3897.205179

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  Abstract 

Purpose: To study the barriers for cataract surgery among walk-in bilateral cataract blind in a paying outpatient department (OPD) at a tertiary eye care center in urban India. Materials and Methods: One hundred consecutive walk-in patients attending the paying OPD at a tertiary eye hospital in a tier two city of India and diagnosed to be bilateral cataract blind (better eye vision 10/200 or less) were recruited for the study. The duration of the study was 6 months. A structured interview was administered by a consultant ophthalmologist in the patient's language, and response was recorded in the pro forma. Patient was allowed to go through the system like any other regular OPD patient being advised surgery. Results: The dataset showed 67 (67%) females, 47 (47%) urban, 8 (8%) literate, 47 (47%) living within a distance of 25 km from hospital, and the average age of the patient was 67.18 years (95% confidence interval - 65.27–69.09). The top three reasons that patients cited which caused the delay was cost of the cataract surgery (27 patients), followed by residence location (staying in a rural area 22 patients) and the delay caused in getting fit for surgery due to systemic illness (17 patients). A sizable number of patients also complained late about their diminishing vision (16 out of 100) causing the delay in their reporting to the hospital. Although cost was the top reason cited for the delay in the surgery, none of the patients approached for 100% charity. Conclusion: While cost remains an important barrier to cataract surgery, factors such as coexisting system illness, staying in rural areas and no one to accompany, and fear of surgery are other important factors that we observed through the study. Opting for surgery with the basic package or not approaching for charity reinforces role of factors other than financial.

Keywords: Bilateral mature cataract, barriers, cataract surgery, cataract blind, illiteracy, rural areas


How to cite this article:
Dharmadhikari S, Bakare PN, Deshpande M, Hegade A, Kesari A. Study on barriers causing delay in cataract surgery of bilateral cataract blind at a tertiary eye care center in urban India. J Clin Ophthalmol Res 2017;5:69-72

How to cite this URL:
Dharmadhikari S, Bakare PN, Deshpande M, Hegade A, Kesari A. Study on barriers causing delay in cataract surgery of bilateral cataract blind at a tertiary eye care center in urban India. J Clin Ophthalmol Res [serial online] 2017 [cited 2017 Dec 14];5:69-72. Available from: http://www.jcor.in/text.asp?2017/5/2/69/205179

Of the total estimated 45 million blind persons (best corrected visual acuity <10/200) in the world, 7 million are in India. Due to the large population base and increased life expectancy, the number of blind particularly due to age-related disorders such as cataract is expected to increase.[1] General aging of population rapidly increases the number of people with serious visual disability. The increase in population means that the population “at-risk” of blinding cataract will also increase tremendously. In India, cataract has been reported to be responsible for 50–80% of the bilaterally blind in the country.[1],[2],[3],[4],[5],[6] From around 1.2 million cataract surgeries per year in the 1980s, the cataract surgical output increased to 3.9 million/year by 2003.[7] Assuming that the incidence of newly blinded cataract is 20%, it appears that the present number of cataract surgeries needs to be scaled up significantly if the elimination of avoidable cataract blindness is to be a reality by 2020.[1]

The disparity between the effort of the eye care providers and the cataract affected population is due to various barriers that exist. Study and analysis of these barriers are the key to overcoming them and attaining full penetration of these services to all who need them.

The aim of the study was to find out and analyze the barriers for cataract surgery among walk-in bilateral cataract blind in a paying outpatient department (OPD) at a tertiary eye care center in India.


  Materials and Methods Top


This study was conducted between October 2012 and March 2013 in a tertiary eye care center in urban India. The study population included 100 walk-in patients in a tertiary eye care center in a paying OPD setup having bilateral mature cataract, aged more than 45 years, with vision ≤ 10/200 in better eye. Patients with bilateral cataract with other ocular pathologies were excluded from the study. Ethics Committee waiver was sought and obtained. A person was defined as blind if the best-corrected vision acuity in the better eye was < 10/200. Diagnosis of cataract was based on vision on Snellen's chart, slit lamp examination, and direct ophthalmoscopy. A structured interview was administered by a consultant ophthalmologist in the patient's language and response recorded in the pro forma. A structured interview was standardized by the concerned authority on the basis of previous knowledge of barrier studies, and the same was presented to all the 100 patients. Patient was allowed to go through the system like any other regular OPD patient being advised surgery. Medical records of the patient were accessed after 4 months to evaluate whether the patient had opted for surgery, package taken, and compliance for second eye surgery. Patients were analyzed on the basis of gender distribution, literacy rate, residential area (whether in rural or urban area), surgery opted for, and the barriers were recorded. Literacy was defined as the ability to read and write with understanding in any language. All patients hailing from areas governed by Municipal Corporation were categorized into patients from urban area. In our hospital, surgery rate is subsidized with basic small incision surgery with an Indian rigid intraocular lens, premium small incision with an imported rigid intraocular lens, and phacoemulsification surgery with Indian foldable intraocular lens. The minimum cost of cataract surgery was INR 2500 in the year 2013. The selected data were entered and analyzed in computer using spreadsheet of Microsoft ® Excel.


  Results Top


Total 100 patients were included in the study. The mean age of the patients in this study was 67.18 years (95% confidence interval - 65.27–69.09). Sixty-seven percent female were present in the study with a male: female ratio of 1:2.03.

Literacy among the study group suggested 92 (92%) of the included patients were illiterate.

Out of the total patients, 47 (47%) were from distance <25 km from Hospital. Among these, 19 were males and 28 were females.

[Figure 1] shows that 32 (32%) among the study group had a systemic illness. Thirteen patients had diabetes, 21 patients were hypertensive, three patients were asthmatic, three patients had fracture, and one patient was suffering from cancer suggesting an increasing tendency of systemic illness among geriatric population and requirement of strict control of illness before opting for cataract surgery.
Figure 1: Systemic illness among patients

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The major reasons for delay in coming for the surgery were anticipation of the cost of surgery (27 patients), followed by stay in village (22 patients) and systemic illness (17 patients). A sizable number of patients (16 patients) complained late while fear of surgery (ten patients) and nobody to accompany (nine patients) were significant reasons as well.


  Discussion Top


Lots of studies have been conducted in rural India for finding out barriers for uptake of cataract surgery. These have been mainly conducted on patients being brought for eye camps to the base hospital as a part of outreach program or by interviewing rural population in their homes/villages using various sampling techniques. Barriers toward going for cataract surgery have traditionally existed and still do in the rural areas, yet in urban areas where eye care facilities exist, are not totally exempt. Urban poverty, migration from rural areas, unattended senior citizens due to change in family structure, and the presence of serious systemic illnesses are important barriers for the uptake of cataract services. Even today, the decision to go for cataract surgery in most of the cases is taken by the earning member of the family, studies state that some of the factors determining acceptance of surgery involve complex family and social process unfolding over several months or years.[8]

The strength of this study is that it was carried out on patients coming to paid OPD, and these patients were allowed to go through normal procedure of opting for surgery without any bias or intervention. However, the sample size was small considering the duration of 6 months and it was carried out on alternate days (3 days in a week).

We found out that gender inequality and illiteracy still continue to be the major hurdles in the uptake of cataract surgery. Sixty-seven (67%) females were present in the study. Literature states that women are less likely have access to information about services, women may not have the necessary social support within the household or community to allow them to receive care, women often do not have adequate control over household financial resources, and women are generally less able to travel outside the village to seek services.[9] These reasons must have resulted in more females in our study, as females need an escort and even males who were functionally dependent could not approach hospital without an escort. Sen et al. state that physical and economic barriers may also prevent women from accessing health services, due to long distances to health facilities and lack of transportation, user fees, or lack of private/public insurance coverage.[10]

This study stated that 53% patients were from areas located >25 km from the hospital. Use of western medical services (including those for cataract) is related to proximity; people who live far from a hospital tend not to use its services.[9]

Contradictory to above literature, we found the remaining 47% who reported late were staying within 25 km from the hospital. This consists of population staying in and around suburban/metropolitan areas close to urban cities for their incomes also reported late. Metropolitan areas include one or more urban areas, as well as satellite cities, towns, and intervening rural areas that are socioeconomically tied to the urban core, typically measured by commuting patterns.[11] In most situations, the distance to be traveled by patients and by accompanying persons could still be a barrier.

The major reason cited for delay in surgery was cost in 27 (27%) patients. Further questioning revealed that “cost” included the cost of treatment, loss of per day wages when accompanying patient to the hospital, and economic burden on the family. However, analysis of hospital papers revealed that 26 patients (26%) opted for surgery above basic packages, and none approached for (100%) charity. This could be because 92 patients (92%) were illiterate and may not be aware of the various financial support mechanisms made available by the government/institute. In our study, results suggested that cost remains as one of the barrier. They are likely to be more important in economically backward areas, urban slums, and in districts which are close to metropolitan cities.

Our results suggest that cost remains as one of the barriers. A study conducted in Karnataka has also shown that affordability and cost considerations are less significant barriers to surgery.[12] This states the importance of other factors such as staying in village (22 patients), unavailability of escort (nine patients), complaining late (16 patients), and living alone (six patients). However, in most situations, the distance to be traveled by patients and by accompanying persons could still be a barrier. Patients tend to wait till complete dependency and lack of functional mobility ensues. The Ethiopian study found that retaining enough vision to live independently (maintaining personal hygiene, dressing, eating, etc., without support from family), and retaining enough mobility daily activities is another factor against the uptake of cataract surgery.[6] This indirectly suggests that patients did not report early because they were unable to approach eye care services. This indicates that most people do not try to get treatment despite noticing decreased vision mainly due to factors related to awareness and certain predominant personal reasons. Palagyi et al. found that persons with gradual onset poor vision due to cataract or refractive error tended to be less likely to seek treatment than those with a more acute onset or painful problem such as eye injuries.[7]

Systemic illness was cited in 17 (17%) of the study population. Patients' mentioned that unfit for the surgery caused delay. Systemic illnesses such as diabetes mellitus, hypertension, and ischemic heart diseases were noted. More attention should be given over associated systemic illness, risk to life with local anesthesia should be discussed with anesthetist before postponing any patient with bilateral mature cataract.

The ability to identify the factors affecting utilization of eye care services is important for policymakers, given the relationship between blindness and the postponement of timely eye examination, and the high social and personal cost associated with blindness.[12],[13]

Elderly population staying in suburban areas has limited access to free cataract surgery camp as these camps are mainly held in villages. This has resulted in delay for cataract surgery as patients do not report early. The outreach camp services are mainly held away the hospitals while the population residing in, especially suburban areas should also be targeted which may bring down the delay in reporting at the hospitals. Innovative approaches to provide high-quality services at a lower cost should become a priority. Awareness among the population regarding cataract surgery should be increased as it benefits not only the patient but also entire family. Cost, living alone, and rise in systemic illness were found to be major barriers in the uptake of cataract surgery in this study. Creating strategies to reduce barriers will improve the uptake of cataract surgery.


  Conclusion Top


While cost remains an important barrier to cataract surgery, factors such as systemic illness coexisting systemic illness, living alone, and no one to accompany are important factors as well. Gender inequality and illiteracy were seen to be operative in our study. Opting for surgery above basic package or not approaching for 100% charity reinforces role of other factors.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

Questionnaire

[Additional file 1]

 
  References Top

1.
World Health Organization. Vision 2020: The Right to Sight. Press Release WHO. Geneva: WHO; 1999.  Back to cited text no. 1
    
2.
National programme for control of blindness. Rapid survey on avoidable blindness conducted under NPCB 2006-07.  Back to cited text no. 2
    
3.
Eye care in India. A situation analysis report prepared by family health and development research series foundation. Hyderabad India. Sight Savers International 2007.  Back to cited text no. 3
    
4.
Brilliant GE, Lepkowski JM, Zurita B, Thulasiraj RD. Social determinants of cataract surgery utilization in south India. The Operations Research Group. Arch Ophthalmol 1991;109:584-9.  Back to cited text no. 4
    
5.
Venkataswamy G, Brilliant GE. Social and economic barriers to cataract surgery in rural South India: A preliminary report. Vis Impair Blind 1981;75:405-8.  Back to cited text no. 5
    
6.
Brian G, Taylor H. Cataract blindness – Challenges for the 21st century. Bull World Health Organ 2001;79:249-56.  Back to cited text no. 6
    
7.
Palagyi A, Ramke J, du Toit R, Brian G. Eye care in Timor-Leste: A population-based study of utilization and barriers. Clin Experiment Ophthalmol 2008;36:47-53.  Back to cited text no. 7
    
8.
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. 8
    
9.
Lewallen S, Courtright P. Recognising and reducing barriers to cataract surgery. Community Eye Health 2000;13:20-1.  Back to cited text no. 9
    
10.
Sen G, Östlin P, Asha G. Unequal, Unfair, Ineffective and Inefficient Gender Inequity in Health: Why it Exists and How We Can Change It; September, 2007.  Back to cited text no. 10
    
11.
“Definition of Urban Terms” (PDF). Available from: http://www.demographia.com. [Last retrieved on 2013 Oct 22].  Back to cited text no. 11
    
12.
Vaidyanathan K, Limburg H, Foster A, Pandey RM. Changing trends in barriers to cataract surgery in India. Bull World Health Organ 1999;77:104-9.  Back to cited text no. 12
    
13.
Ulldemolins AR, Lansingh VC, Valencia LG, Carter MJ, Eckert KA. Social inequalities in blindness and visual impairment: A review of social determinants. Indian J Ophthalmol 2012;60:368-75.  Back to cited text no. 13
    


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