Table of Contents  
ORIGINAL ARTICLE
Year : 2021  |  Volume : 29  |  Issue : 2  |  Page : 133-138

Barriers to Uptake of Cataract Surgical Services in a Tertiary Hospital


1 Ophthalmology Department, Irrua Specialist Teaching Hospital, Irrua, Edo State, Nigeria
2 Ophthalmology Department, University of Benin Teaching Hospital, Benin, Edo State, Nigeria

Date of Submission04-Feb-2021
Date of Acceptance26-Jul-2021
Date of Web Publication18-Jan-2022

Correspondence Address:
Osamudiamen C Obasuyi
Ophthalmology Department, Irrua Specialist Teaching Hospital, Irrua, 310101, Edo State
Nigeria
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/njo.njo_12_21

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  Abstract 


Objective: To identify the barriers to the uptake of cataract surgical services among patients with cataract attending the eye clinic in Irrua Specialist Teaching Hospital (ISTH), Edo State, Nigeria. Materials and methods: The study was a descriptive hospital-based study of patients with cataract attending the eye clinic of the ISTH, Irrua, Edo State. An interviewer-administered questionnaire designed to identify the barriers to the uptake of cataract surgical services was used for this study. Responses to questions on willingness to have cataract surgery, reasons for unwillingness, and the factors which made willing participants end up not having surgery or delaying their surgery were obtained, collated and analyzed. Data were analyzed with IBM SPSS Software, version 21. Results: Four hundred patients made of 217 (54.3%) males and 183 (45.8%) females in a ratio of 1.2:1 were participated in this study. One hundred and eighty-eight (47%) of respondents did not know that cataract surgical services were available at ISTH, 34 (15%) had surgery within a week, whereas 189 (80.4%) respondents had surgery more than a week after being told they were eligible for surgery. Fear of poor outcome and lack of finance ranked high in the list of reasons for the delay in surgery. Women were 1.5 times more likely to have surgery than men. Education and distance from health facility had no role to play in the uptake of cataract surgery. Conclusion: Fear of poor surgical outcome, lack of finances, and lack of knowledge of the availability of surgical services are impediments to access cataract surgery at ISTH and improving surgical outcome and education about available surgical services may improve the uptake of cataract surgery.

Keywords: Barriers, cataract, cataract surgery


How to cite this article:
Obasuyi OC, Ukponmwan CU, Uhumwangho OM. Barriers to Uptake of Cataract Surgical Services in a Tertiary Hospital. Niger J Ophthalmol 2021;29:133-8

How to cite this URL:
Obasuyi OC, Ukponmwan CU, Uhumwangho OM. Barriers to Uptake of Cataract Surgical Services in a Tertiary Hospital. Niger J Ophthalmol [serial online] 2021 [cited 2022 May 22];29:133-8. Available from: http://www.nigerianjournalofophthalmology.com/text.asp?2021/29/2/133/335912




  Introduction Top


Cataract is the leading cause of preventable blindness in the world and cost-effective cataract surgery is the only way to treat cataract.[1],[2],[3] The Nigerian National Blindness and Visual Impairment Survey, carried out between 2005 and 2007 estimated the number of people blind from cataract to be 1.8% (400,000) of the total population with an estimated increase of over 43% by 2020, if the cataract surgical coverage remains essentially unchanged over the next 5 years.[4] Cataract surgical coverage, a measure of the proportion of visually impaired individuals with bilateral cataract who are eligible for surgery and receive it, is still very poor in Nigeria with only 22.8% of eyes blind from cataract undergoing surgery and over 75% of people blind from cataract without access to cataract surgery[4] with the South-South geopolitical zone having the lowest cataract surgical service rate in Nigeria.[4]

Various reasons have been attributed for poor cataract surgical services and uptake of these services where available. The cost of surgery has been identified by most studies as a major barrier to accessing cataract surgery in developing countries.[5],[6] In the Nigerian Blindness and Visual Impairment Survey, 36% of respondents described a lack of personal finances as a major reason for accessing surgery.[4],[5] Though cataract can be effectively treated by cost-effective surgery, the outcome needs to be good, and unfortunately, poor outcome during cataract surgery has been identified as a barrier to accessing care.[7] Even when cataract surgical services are available in the hospital, a lack of awareness of the service, even the cause of poor vision or lack of faith in the healthcare providers can be a barrier to accessing care[5],[7],[8] and changes in education and the way health care is provided has improved cataract surgical uptake.[8],[9],[10] In developing countries, family support is essential in many situations for accessing health care, family members accompany blind members of the family to the hospital, and this has been shown to play a role in the uptake of cataract surgical services.[11],[12] Other socioeconomic factors associated with cataract surgery uptake include gender disparity in surgical uptake as cataract surgery has been reported to be higher in men,[13],[14] and long distance from health center preventing prompt uptake.[15] It is evident however that barriers to surgical uptake vary in different environments.[16]

A study by Dawodu et al.[17] among patients attending the eye clinic of the Irrua Specialist Teaching Hospital (ISTH; formerly called Otibho Okhae Teaching Hospital) reported causes of uniocular and bilateral blindness from cataract at 31.4% and 36.7%, respectively. Despite the high prevalence of cataract in the area, at the time of this study, annual surgical rates were just over 100 cataract surgeries even with the availability of specialized cataract surgical services and being the only healthcare center (primary, secondary, tertiary, public or private, except the University of Benin Teaching Hospital over 100 km away) providing specialized eye-care and cataract surgical services to a diverse group of people spanning over three states (Kogi, Delta, and Ondo states).[18]

A detailed understanding of the barriers to the uptake of available cataract surgical services cannot be overemphasized with the increasing levels of cataract blindness, and as we move toward the actualization of the elimination of preventable blindness, it has become important for ophthalmologists practicing in localities with low cataract surgical rates to understand the existing barriers to the uptake of cataract surgical services to overcome these barriers.

This study set out to identify the barriers to the uptake of cataract surgical services among patients with cataract attending the Eye clinic in ISTH, Edo State to make appropriate recommendations on ways to overcome these barriers.


  Subjects and Methods Top


The study was a descriptive hospital-based study of the barriers to the uptake of cataract surgical services among patients attending the eye clinic of the Department of Ophthalmology at the ISTH, Irrua, of the Esan Central Local Government Area, which has an estimated population of 105,313 from the 2006 national population census and covers a land area of 436 km2. This study was conducted from June 2016 to March 2017. Ethical approval for the study was obtained from the Research and Ethics Board of ISTH and written informed consent obtained from the participants and guardians of minors. All old and new patients attending the eye clinic with presenting binocular or uniocular unaided or aided (where available) visual acuity worse than or equal to 6/60 attributed to cataract only and patients who had cataract surgery during the study period were included in the study. Conversely, all old and new patients with presenting binocular or uniocular unaided or aided (where available) visual acuity better than 6/60, or visual acuity worse than 6/60 attributed to other causes of visual impairment other than cataract were excluded from the study.

A structured interviewer-administered questionnaire was used to obtain relevant information on the biodata of participants, willingness to have cataract surgery, and their perceived barriers to the uptake of cataract surgical services. Data were analyzed using the IBM SPSS statistics version 21. 21 (International Business Machines IBM corporation). A confidence interval of 95% was used and a P-value <0.5% was regarded as statistically significant.


  Results Top


Four hundred patients made up of 217 males (54.3%) and 183 females (45.8%) distributed in a ratio of 1.2:1 were recruited for the study. The age range was 7 to 100 years with a mean age of 65.86 ± 16.98 years and the modal age was 68 years. A larger number of the participants, 220 (55%) were in the 61 to 80 years group. One hundred and twenty-one (30.3%) respondents had no formal education. Others had only primary (117, 29.3%) and secondary education (107, 26.8%), whereas 55 (13.8%) respondents had tertiary education. A greater number of respondents 293 (73%) lived more than 4 km from the hospital, and 185 (46.3%) respondents were either unemployed or had some form of casual employment without a steady source of income, this was closely followed by respondents who were either in a semi-skilled occupation or unskilled occupation (94, 23.5%).

Of the 400 participants in the study, 292 (73%) participants presented with bilateral lens opacities of varying severity, whereas 108 (27%) presented with unilateral lens opacities. The prevailing visual acuity among participants due to cataract was counting finger or worse, that is, 304 (76%) right eye and 329 (83%) left eye [Table 1].
Table 1 Presenting visual acuity of respondents

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A total of 188 (47%) participants did not know that the definitive treatment for cataract surgery [Figure 1].
Figure 1 Participants’ awareness of the treatment for cataract surgery

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One hundred and eighty-one (45.3%) participants did not have surgery during the study period including 30 (8%) who refused to have surgery and 151 (38%) who wanted to have surgery but due to various reasons did not have surgery within the study period. A total number of 219 (54.8%) participants eventually had surgery which included 185 (84.5%) who had surgery more than 1 week after counseling and clinical decision to have surgery and 34 (15.5%) who had surgery within a week. The fear of poor surgical outcome (19, 63%) and nonavailability of money (18, 60%) were the predominant reasons for the outright refusal [Table 2].
Table 2 Barriers to surgery among unwilling participants

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The fear of outcome (106, 68.83%) predominated the reasons why participants who were initially willing to have surgery ended up not having surgery. This was closely followed by economic reasons. The unavailability of escorts during the study period was also another major reason why respondents ended up not having surgery [Table 3].
Table 3 Barriers to surgery among participants who did not have surgery within the study period

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Lack of finances was the major factor responsible for the delay in 95 (51.4%) of participants who eventually had surgery. Manageable vision at the time of diagnosis (28, 15.1%), diagnosis of immature cataracts (25, 13.5%), and fear of surgical outcome (23, 12.4%) were other reasons for the delay in cataract surgical uptake [Table 4].
Table 4 Barriers to prompt uptake of surgery (surgery >1 week of counseling and clinical decision to provide surgery)

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In this study, women were 1.5 times more likely to have surgery more than men. In addition, more women had surgery during the study period than men, that is, 118 (64.5%):116 (53.5%) [Table 5].
Table 5 Relationship between sexes and having cataract surgery

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Although more participants lived greater than 4 km from the hospital (73.5%), distance played limited/no role in determining respondent’s uptake of cataract surgery [Table 6].
Table 6 Distance of participants from the hospital

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Participants who had no or little formal education (136, 62.1%) accessed surgery more during the study period. There was no statistically significant relationship between the level of education and accessing surgery (X2 = 0.330). Trend analysis revealed no relationship between the groups (X2 for trend = 1.728) [Table 7].
Table 7 Relationship between educational level and accepting surgery

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  Discussion Top


This study set out to identify the various reasons why cataract surgical uptake in the ISTH was low and involved presenting patients over 3 months. There were more males than females in this study (1.2:1) but more females (64.5% of females) had cataract surgery than males (46.6% of males). This contrasts with other studies which reported a lower prevalence of cataract surgical uptake among females[16],[17],[18],[19] citing gender inequalities as a significant barrier to cataract surgery. The difference noted in our study may be because the female population in this present study area are more economically and socially empowered to make decisions with regards to their health status compared to the study group in the other reports.

A large percentage of respondents (53%) knew that surgery was the treatment for cataract; however, 45% of respondents ended up not having surgery within the study period which describes a disconnect between the knowledge of treatment for cataract and the willingness to have such treatment. This is surprising as knowledge of services usually translates to utilizing these services.[20] Hence, other factors, therefore, play a huge role in the uptake of cataract surgical services. Prevalent among all respondents was the fear of poor surgical outcome and was responsible for a great number of participants refusal to have surgery. The outcome is important as people with good outcome following surgery play a role in motivating other people to access surgery.[17],[21] Economic constraint also played a major role in accepting surgery in all groups and closely mirrored the outcome barrier. For patients who had delayed surgery, economic concerns were more prevalent (51.4%) and were a recurring theme in many studies. For example, Rabiu et al.[7] reported that 64% of respondents who wanted to have surgery could not afford to, whereas Oluleye[14] also reported that cost was a hindrance to 52.8% of respondents in a study carried out in three communities of Oyo State. Reducing the cost of cataract surgery and/or providing free cataract surgical services where feasible have been shown to improve uptake. Ukpomwan et al.[22] reported an increase in the number of surgeries at the University of Benin Teaching Hospital following the reduction in the price of cataract surgery and Ajibode et al.[10] at the Onabisi Onabanjo University Teaching Hospital reported better cataract surgery uptake among people who had good personal income. Another form of cost which played a role in determining uptake was the unavailability of escorts. About 32% and 8% of participants who did not have surgery or had delayed surgeries, respectively, were because they had no escorts at the time. Escorts were majorly relatives who had to leave their jobs/sources of income or children who were on holidays. These “secondary loss” of income or study time contributes to additional costs of cataract surgery[24] and attempts at reducing these losses have improved uptake of cataract surgery.[24],[25]

Cataract surgery uptake was more among respondents who had no or little formal education (59.5%). This may be because more respondents had little or no formal education among the study population or they came when the cataract was severe enough to cause a significant reduction in vision and thus were more likely to accept surgery.

Distance to the health facility was not a barrier in this study as more patients who lived more than 4 km had surgery compared to those who lived closer to the hospital. This is in contrast with the report by Oluleye[14] in his study among communities in Oyo State where 33.8% of respondents could not have cataract surgery because of the distance of their place of abode to the hospital. The effect of distance may have been negated by the central location of the hospital and a relatively good road network leading to the hospital.

A limitation of this study was its short duration as follow up of patients who were willing but ended up not having surgery was stopped after 16 weeks. The effect of motivation by patients with good surgical outcome on these groups of patients as well as a review of cost of surgeries may serve as a policy pivot in the provision of cataract surgical services and scaling volume surgeries.


  Conclusion Top


Most patients accessing cataract surgical services still have misgivings about surgical outcomes. Coupled with the poor economic status of most patients, accessing cataract surgical care will continue to be poor except steps are taken to address these problems. Efforts should be directed toward addressing patients concerns by taking steps to improve surgical outcomes as well as review the cost of available surgical services. Utilizing the already existing National Health Insurance Scheme may provide a sustainable way of tackling the issue of finance among patients, whereas training and retraining of the eye-care team will help in improving outcome.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

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WHO Blindness and Vision Impairment Prevention: Priority Eye Diseases. WHO; 2019. https://www.who.int/blindness/causes/priority/en/index1.html  Back to cited text no. 1
    
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IAPB. Global Vision Impairment Facts: The International Agency for the Prevention of Blindness; 2019. https://www.iapb.org/vision-2020/who-facts/  Back to cited text no. 2
    
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The Royal College of Ophthalmologists. Cataract Surgery Guidelines 2010. London: The Royal College of Ophthalmologists; 2011.  Back to cited text no. 3
    
4.
Abdull MM, Sivasubramaniam S, Murthy GV et al. Causes of blindness and visual impairment in Nigeria: The Nigerian National Blindness and Visual Impairment Survey. Invest Ophthalmol Vis Sci 2009;50:4114-20.  Back to cited text no. 4
    
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Abubakar T, Gudlavalleti MVS, Sivasubramaniam S et al. Coverage of hospital-based cataract surgery and barriers to the uptake of surgery among cataract blind persons in Nigeria: The Nigeria National Blindness and Visual Impairment Survey. Ophthalmic Epidemiol 2012;19:58-66.  Back to cited text no. 5
    
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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. 6
    
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Rabiu MM, Jenf M, Fituri S, Choudhury A, Agbabiaka I, Mousa A. Prevalence and causes of visual impairment and blindness, cataract surgical coverage and outcomes of cataract surgery in Libya. Ophthalmic Epidemiol 2013;20:26-32.  Back to cited text no. 7
    
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Zhang XJ, Jhanji V, Leung CK-S et al. Barriers for poor cataract surgery uptake among patients with operable cataract in a program of outreach screening and low-cost surgery in rural China. Ophthalmic Epidemiol 2014;21:153-60.  Back to cited text no. 8
    
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Athanasiov PA, Casson RJ, Newland HS, Shein WK, Muecke JS, Selva D. Cataract surgical coverage and self-reported barriers to cataract surgery in a rural Myanmar population. Clin Experiment Ophthalmol 2008;36:521-5.  Back to cited text no. 13
    
14.
Oluleye T, Cataract blindness and barriers to cataract surgical intervention in three rural communities of Oyo State, Nigeria. Niger J Med 2004;13:156–60.  Back to cited text no. 14
    
15.
Mailu EW, Virendrakumar B, Bechange S, Jolley E, Schmidt E. Factors associated with the uptake of cataract surgery and interventions to improve uptake in low-and middle-income countries: a systematic review. Wilkinson J, editor. PLoS One 2020;15:e0235699.  Back to cited text no. 15
    
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17.
Dawodu OA, Osahon AI, Emifoniye E. Prevalence and causes of blindness in Otibho Okhae Teaching Hospital, Irrua, Edo State, Nigeria. Ophth Epidemios 2003;10:323-30.  Back to cited text no. 17
    
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19.
Snellingen T, Shrestha BR, Gharti MP, Shresta JK, Upadhyay MP, Pokhrel RP. Socioeconomic barriers to cataract surgery in Nepal: the south Asian cataract management study. Br J Ophthalmol 1998;82:1424-8.  Back to cited text no. 19
    
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Ye Q, Chen Y, Yan W et al. Female gender remains a significant barrier to access cataract surgery in South Asia: a systematic review and meta-analysis. J Ophthalmol 2020;2020:2091462.  Back to cited text no. 20
    
21.
Adhisesha Reddy P, Kishiki EA, Thapa HB, Demers L, Geneau R, Bassett K. Interventions to improve utilization of cataract surgical services by girls: case studies from Asia and Africa. Ophthalmic Epidemiol 2018;25:199-206.  Back to cited text no. 21
    
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24.
Yoshizaki M, Ramke J, Furtado JM et al. Interventions to improve the quality of cataract services: protocol for a global scoping review. BMJ Open 2020;10:e036413.  Back to cited text no. 24
    
25.
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. 25
    


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