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Middle East Afr J Ophthalmol. 2013 Jul-Sep; 20(3): 229–233.
PMCID: PMC3757633

Barriers to Cataract Surgical Uptake in Central Ethiopia

Abstract

Purpose:

The aim of this study was to assess the factors that delay surgical intervention in patients suffering from age related mature cataract in Ethiopia.

Materials and Methods:

A short term descriptive study was performed that evaluated patients with mature cataract presenting to outreach eye care clinics in rural central Ethiopia. Patients were interviewed to determine the reasons for delay in their cataract surgeries.

Result:

A total of 146 subjects (57 male and 89 females) with operable age related cataract were evaluated at 31 outreach clinics. Over 86% of the respondents were above 55 years of age, (range, 45–78 years). The male to female ratio was 1:1.5 and 30.2% of the subjects were blind bilaterally (best corrected visual acuity <3/60). The majority of the respondents were farmers (53.4%) and 86.3% were illiterate. The major factors that delayed cataract surgery included: Cost of surgery (91.8%), insufficient family income (78.1%), good vision in the fellow (unaffected) eye (39.7%), and the distance to hospital from their village (47.9%).

Conclusion:

Surgical cost, insufficient family income, and the distance to an eye care centre were the major factors delaying cataract surgery in rural Ethiopia.

Keywords: Barriers, Blindness, Cataract, Ethiopia, VISION 2020

INTRODUCTION

Cataract is the most common cause of blindness and visual impairment worldwide.1 Global estimates from 2002 reported that cataract was responsible for almost half of the 37 million blind individuals.1 In developing countries, cataract accounts for 50% of blindness while in developed countries, it accounts for 5% of blindness.2 It has been reported that the more developed and economically well-off countries have a predominantly skilled workforce with higher visual demands. Their cataract services are better adapted to meet the needs of the population, and as a result, there is lower prevalence of blindness from cataract. However, in many parts of the developing world with poor economies, the situation is reversed. In these countries, difficulties in accessing ophthalmic care due both to individual and environmental factors and to obstacles inherent in the health system prevent full utilization of surgical services.3

Strategy for reducing cataract backlog includes increasing the number of cataract surgeries performed. However, despite the rapid increase in the availability of quality services, surgical feasibility is still low in Ethiopia. In many regions of Africa, cataract surgical rates are less than 500 per million populations, which is significantly lower than the 2,000 per million populations recommended by the World Health Organization.4 Few studies, mostly from developing countries, have addressed barriers to cataract surgery or the factors that delay access to cataract.5,6 Studies from Ghana, East Africa, Myanmar, and India have identified cost, accompanying problems, gender, fear of surgery, coping ability, immature cataract, too busy, old age, lack of transport, and long distances to the hospital as barriers to or factors against uptake of cataract surgical services.

According to a 2006 National Survey report in Ethiopia, the prevalence of blindness was 1.6% of which, 50% of the blindness was due to cataract.7 In a survey conducted in Central Ethiopia, we found the prevalence of blindness (<3/60 Snellen acuity) and visual impairment (6/24 to 3/60 Snellen acuity) among those 40 years of age and older to be 7.9% and 12.1%, respectively.8

Strategy for reducing cataract backlog includes increasing the number of cataract surgeries performed. However, despite relatively rapid increase in the availability of quality services, surgical feasibility is still low in some segments of Ethiopian society.5,6,9 The aim of this study was to determine possible reasons for the delays in undergoing cataract surgery in rural central Ethiopia.

MATERIALS AND METHODS

This is a short term descriptive study that was conducted in the outreach eye care clinics of Grarbet Eye hospital from May 2011 to July 2011. The hospital is situated in Butajira town, Gurage Zone of the Southern Nations Nationalities and Peoples Regional State (SNNPR), Ethiopia. Butajira town is 133 km south of Addis Ababa, the national capital. The eye hospital serves a rural farming population of about 1.5 million residing in six Woredas (sub-districts) of the Silti and Gurage Zones of SNNPRS. It is the only secondary eye centre in the area. The hospital performs around 2,000 cataract surgeries annually. Manual sutureless cataract extraction is the routine surgery of choice at this hospital. The study was conducted after obtaining ethics approval from the regional ethical committee, Ethiopia.

The uses of outreach camps have been advocated as a strategy to overcome some of the barriers associated with the use of eye care services. Grarbet Eye Hospital started a formal outreach program in 1997, and the cataract surgical output has gradually increased ever since. The goal of the eye care outreach program is to provide vision care to those with financial, geographic, or physical barriers by creating access to ophthalmic services at affordable prices. The outreach mobile teams included ophthalmic nurses and general nurses trained in eye care referred to as integrated eye care workers. They are assisted by medical assistants. They manage treatable ophthalmic diseases, and perform eyelid (i.e. tarsal plate rotation or bilamellar tarsal rotation for trachomatous trichiasis cases) and other minor lid surgeries. Patients with serious eye diseases and those requiring surgical interventions (majority of the cataract cases) are referred to the eye hospital for more specialized evaluation and interventions.

It has, however, been observed that only a portion of operable outreach cataract patients eventually accessed cataract surgical services that are provided in the eye unit. Therefore, identification of factors that hinder the use (by patients) to surgical services would aid care givers and policy makers in devising optimal service utilization by cataract patients.

All adult patients who fitted the criteria and who were screened at the outreach sites and identified to have operable mature or hypermature cataract during the study period were included in this study. Blindness was defined as visual acuity (VA) < 3/60 with best correction. Visual impairment was defined as VA of 6/60–6/18. Cataract blindness was defined as blindness find to be caused by opacity of the crystalline lens. Uncorrected visual acuity is used to refer to unaided vision and ‘presenting visual acuity’ is the visual acuity with distance spectacles in place (if worn).

The inclusion criteria were an adult patients with visual acuity in one or both eyes <3/60 secondary to cataract and those who attended an outreach camp in the previous 3 months (May–July 2011). Patient with vision better than 3/60 in the worse eye were excluded from this study.

Patients were briefed in the local language about the purpose and procedure of the study. Socio-demographic data were noted on a questionnaire. Data were collected on age, gender, rural or urban residence, literacy, and occupation.

A verbal questionnaire surveying the barriers to access - or reasons that delayed access- to cataract surgery were devised from the existing literature. The diagnosis of cataract was based on torchlight exam and distant direct ophthalmoscope. Vision was assessed with Snellen E chart. The questionnaire was developed in English and then translated to Amharic and a translator for the local tribal language was used when necessary. The questionnaire was administered in interviews conducted by an ophthalmic nurse or integrated eye care worker.

To maintain uniformity and reliability of data collection, all questionnaires were administered by one of the three interviewers, who had undergone training in questionnaire administration in the eye unit. Pre-tests were conducted two weeks prior to the actual data collection day. Based on the results of the pretest, the questionnaire was modified accordingly prior to final data collection.

Statistical analysis was performed with Statistical Package for the Social Sciences version 19 (SPSS, IBM Corp., Armonk, NY, USA). P <0.05 was statistically significant.

RESULT

A total of 146 subjects (57 men and 89 females) with operable cataract were enrolled in the study. Over 86 % of the respondents were above 55 years of age, with age ranging from 45 years to 78 years (median 61 years). The male to female ratio was 1:1.5. There were 30.2% of subjects who were bilaterally blind (VA < 3/60). The majority of the respondents were subsistence farmers (53.4%) with an illiteracy rate of 86.3%. The sociodemographic data and other characteristics of the cohort are presented in Table 1.

Table 1
Socio-demographic data and other characteristics of cataract patients presenting at outreach eye care clinics

The major reasons for not undergoing surgical intervention included cost in 91.8% of the cohort and insufficient family income in 78.1% of the cohort. Table 2 presents other factors including the ability to do daily routine work (52%), the hospital was too far from home (47.9%), and the subject could see clearly with the other eye (39.7%).

Table 2
Reasons for patient delay in undergoing cataract surgery by gender at outreach programs

Almost 43% of the respondents were invited to undergo cataract surgery by the eye care provider in the year preceding the interview. The percentage of patients who delayed cataract surgery proportionately increased with age.

The amount of time that cataract surgery was delayed after recommendation statistically significantly associated with age, monthly income, residence, educational status, and distance (P < 0.05, all comparisons). Although, the percentage of women delaying cataract surgery was higher than men, it was not statistically significant (P < 0.42) [Table 3]. It was not associated with gender or, visual acuity in the better eye or occupation (P > 0.05, both comparisons).

Table 3
The factors associated with delay in cataract surgery after recommendation (N = 62)

DISCUSSION

In this study, we observed a low utilization of cataract surgical services by females compared to males screened at outreach sites and found to have operable cataracts. This concurs with earlier reports that suggested cataract surgical coverage was higher in males than females.10 The majority of the outreach sites are located in rural areas. The locale of the outreach sites may explain the high range of illiteracy among respondents. Almost 96% of the respondents had a monthly income less than 300 ET Birr (<17$).

There are a number of factors faced by rural Ethiopians in receiving treatment for cataract, of which cost being the single most important barrier (92%). This included cost of the operation, medications, transport, feeding, and including the expenses of the escort. Similar to other findings that has already been reported from Nigeria,11 Gambia,12 Nepal,13 and India,14 the financial limitations of cataract patients ranked first, constituting over 60% of responses as the reason for not having or delaying cataract surgery.

Grarbet Eye Hospital provides cataract surgery at a low subsidized cost, even lower than some government hospitals. However, despite the cost, many still find it difficult to access the services. The direct and indirect cost of obtaining cataract service is not affordable by the poor peasant subsistence farmers, who participated in this study.

Other studies from this region revealed that the primary reason for failure to use eye care services were indirect costs (overall, reported by 40% of respondents). Other studies carried out in other areas have shown that indirect costs relating to the loss of daily income, delegating household responsibilities, and transportation for both the patient and his/her attendant are important factors delaying cataract surgery.9,15,16,17 Efforts directed at reducing indirect costs include conducting operations at the patient's villages, facilitating transport to and from the surgical facility, and providing accommodation for attendants closer to hospital facilities. Reducing the length of the hospital stay can also reduce the direct/indirect costs of surgery.15

The direct cost of surgery could be reduced by: (a) Improving efficiency by conducting high volume cataract surgery and thus reducing unit costs; (b) decreasing the cost of consumables (e.g. cheaper intraocular lenses) through bulk purchasing; and (c) allowing flexible/tiered pricing systems that are based on the paying capacity of the population, thus allowing even the poorest segment of the population to receive ophthalmic care.18

The second most commonly reported barrier was insufficient family income. The majority of the respondents were unable to afford the direct and indirect costs required for the services. Lower average monthly income was statistically significant associated with poor utilization of cataract services by subjects in the study (P < 0.05). Those with higher income are in a better position to cover the cost of surgery as has reported in previous studies.19

This study has also shown that the distance to and from the hospital was the other significant factor delaying surgery. In most situations, the distance to be travelled by patients and by escorts is an important factor, especially for females, which may influence service uptake. For aged and visually impaired patients, even traveling a few kilometres, especially traversing the hills of rural Ethiopia is tenuous at best.

Similar to the study done from Nepal,13 the current 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.

Lack of information concerning the disease and treatment, good vision with the other eye, and lack of escort are the main factors identified in the current study. These outcomes concur with other studies from developing countries as barriers to uptake of cataract services.11,12,13,14

There are some limitations to this study. The study was conducted at outreach sites i.e. at health center/post. Thus we only studied patients who could attend the outreach program. We believe that there are more elderly blind that did not attend and may not be represented by the population we studied. However, a population-based data from India indicated that cataract acceptance rates are low even when surgery is free and transport is provided.20

The study has provided a unique opportunity to identify problems associated with poor utilization of cataract services by outreach patients. Based on the findings, adequate interventions could be offered to improve the situation in the study centre and other eye hospitals that provide outreach services. We recommend a larger scope of this study by including a greater number of subjects and repeating it regularly to help in monitoring the services of the institutions.

In conclusion, the findings of this study are similar to other regions of Africa and other developing countries. Poverty, distance, lack of escorts, and old age appear to be major barriers preventing or delaying patients with cataract from accessing surgical services. Some solutions such as effective community-oriented eye health education and further expansion of the surgical outreach programme are being undertaken to overcome the other barriers.

ACKNOWLEDGMENT

We would like to heartily thank the field workers, who helped us during data collection. We are also grateful to all patients for their cooperation during eye examination and data collection. We are indebted to Mr. Ahmed Shikure, regional ethical committee for helping us during ethical approval process.

Footnotes

Source of Support: Nil

Conflict of Interest: None declared.

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