Table of Contents  
ORIGINAL ARTICLE
Year : 2021  |  Volume : 29  |  Issue : 2  |  Page : 139-142

Overcoming the Barriers to Cataract Surgical Uptake in a Tertiary Hospital − How Patients Do It


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 Acceptance04-Jul-2021
Date of Web Publication18-Jan-2022

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


DOI: 10.4103/njo.njo_13_21

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  Abstract 


Objectives: To identify the various means by which patients overcome barriers to cataract surgery in a tertiary hospital. Materials and methods: This was a descriptive hospital-based study of the barriers to the uptake of cataract surgical services in Irrua Specialist Teaching Hospital and how patients overcome them. Four hundred patients who presented to the eye clinic participated in this study. Patients, who had surgery within the study period at least more than a week from counseling and when a clinical decision to have surgery was made, were asked to describe the ways they overcame their barriers to surgery and the responses were collated and analyzed using the IBM SPSS version 21. Results: The study recruited 400 consecutive patients attending the eye clinic who had a cataract or were yet to have cataract surgery. There were 217 males (54.3%) and 183 females (45.8%), a ratio of 1.2:1. One hundred and eighty-five (84.5%) participants had delayed cataract surgery during the study period with finance (51.4%) and a lack of felt need (28.6%) playing a major role in delaying surgeries. Fear of outcome (12.4%) also played a role in delaying surgery. Free cataract surgical services helped sort out the economic constraint among some participants, whereas support from relations, as well as motivation from relatives and other people who had good outcome from surgeries, helped overcome other barriers such as fear of outcome and lack of escort to the hospital. Conclusion: Motivators may play a huge role in improving the uptake of cataract surgery. These motivators may be cataract evangelists or relatives themselves. Economic constraints may be tackled by free eye surgeries, reduced cost of eye care, and/or improving efficiency in the course of providing eye-care services.

Keywords: Blindness, cataract, cataract surgery


How to cite this article:
Obasuyi OC, Uhumwangho OM, Ukponmwan CU. Overcoming the Barriers to Cataract Surgical Uptake in a Tertiary Hospital − How Patients Do It. Niger J Ophthalmol 2021;29:139-42

How to cite this URL:
Obasuyi OC, Uhumwangho OM, Ukponmwan CU. Overcoming the Barriers to Cataract Surgical Uptake in a Tertiary Hospital − How Patients Do It. Niger J Ophthalmol [serial online] 2021 [cited 2022 May 22];29:139-42. Available from: http://www.nigerianjournalofophthalmology.com/text.asp?2021/29/2/139/335914




  Introduction Top


Barriers to cataract surgical uptake have been widely documented and can be divided into patient-based and provider-based factors. Patient-based factors include factors that may be attributable to the patient’s socioeconomic status, level of education, gender, fear of surgery, or a felt need.[1],[2],[3],[4],[5],[6],[7],[8],[9] Cost (direct) and facility reputation are important provider-based factors which may unwittingly contribute to preventing the uptake of cataract surgical services.[10] Cataract is easily treated and cataract surgery is considered the most cost-effective interventions in the management of treatable causes of blindness and visual impairment.[11],[12],[13] People remain blind from cataract in many remote and poor areas of the developing world mainly due to a lack of access to eye care.[11],[12] This can be changed by eliminating the existing barriers to the uptake of cataract surgical services either via systemic change or by improved support of patient “coping” mechanisms. An idea of these “coping” mechanisms is important to help formulate policies or change present practices to improve surgical load.

This study set out to identify the ways patients who had cataract surgery, within the study period, were able to overcome the barriers they faced individually (patient-based factors) and as a result of the establishment (provider-based factors).


  Materials and Methods Top


This was a descriptive qualitative hospital-based study of the barriers to the uptake of cataract surgical services in Irrua Specialist Teaching Hospital and how patients overcome them. The study was conducted between June 2016 and March 2017, ethical approval for the study was obtained from the Research and Ethics Board of the Irrua Specialist Teaching Hospital and written informed consent obtained from the participants and guardians/parents of minors.

Four hundred consenting patients with cataract [new patients and old patients with presenting binocular or uniocular unaided or aided (where available) visual acuity worse than or equal to 6/60 attributed to cataract only and yet to have surgery] attending the eye clinic were recruited into the study via consecutive sampling technique and were followed up throughout the study. Participants 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.

All recruited patients had a baseline response to their willingness to have surgery recorded using an interviewer-administered questionnaire administered by an ophthalmologist and resident doctors. The questionnaire was initially pretested on patients attending the eye clinic of the Central Hospital, Benin City, Edo state before deployment at the study site. Patients, who had surgery within the study period at least more than 1 week from counseling and when a clinical decision to have surgery was made, were asked about the ways they overcame their barriers to surgery through this questionnaire. Responses were collated, compared, and data were analyzed using IBM Statistical Package for Social Sciences (SPSS) (International Business Machine IBM Corporation) version 21. A confidence interval of 95% was used and a P-value <0.5% was regarded as statistically significant.


  Results Top


The study recruited 400 consecutive patients attending the eye clinic who had a cataract or were yet to have cataract surgery. Participants were made up of 217 males (54.3%) and 183 females (45.8%), a ratio of 1.2:1. The youngest was 7 years and the oldest was 100 years old. The mean age was 65.86 ± 16.98 years, with a modal age of 68 years and a median age of 68 years.

Two hundred and nineteen (54.8%) of participants had surgery during the period. Thirty-four (15.5%) had surgery within a week, whereas 185 (84.5%) of them waited for 2 weeks or more to have surgery. The mean waiting period was 6 weeks [Table 1].
Table 1 Time to surgery after counseling and clinical decision (N = 219)

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Financial reasons were the major factor responsible for the delay in 95 (51.4%) participants who had surgery. Felt-need (manageable vision at the time of diagnosis) 28 (15.1%) participants, diagnosis of immature cataracts in 25 (13.5%), and fear of surgical outcome in 23 (12.4%) were other reasons for the delay in accessing surgery [Table 2].
Table 2 Major reasons for the delay in having surgery within a week

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The availability of free surgeries enabled 43 participants to access surgery, whereas 55 study participants had surgery sponsored via financial support from relatives. However, the time taken to overcome this barrier was significant, as the average time to access surgery was 6 weeks in this group of participants [Table 3].
Table 3 Overcoming finance as a barrier to accessing surgery (N = 100)

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Relatives played a major role in convincing 10 (43.5%) participants to have surgery. Eight (34.8%) participants who had misgivings about surgery or outcome decided to have surgery because they felt they had no choice due to their deteriorating vision. On the other hand, the motivation to have surgery in five (21%) of participants was because they saw somebody who had good surgical outcome [Table 4].
Table 4 Overcoming the fear of cataract surgery outcome

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Source of escorts for participants were mainly relatives nine (64.3%) who were begged to accompany them to the hospital [Table 5].
Table 5 Overcoming the unavailability of escorts to the hospital

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  Discussion Top


Our study set out to identify the various ways patients attending the eye clinic overcame the barriers they encountered in seeking eye care. Four hundred patients took part in this study and 55% of participants had surgery during the period of study. Only 15% had surgery within the first week, whereas 85% had delayed surgeries with a mean waiting time of 6 weeks. Finance played a major role in delaying surgery and was largely overcome by the provision of free eye surgeries (43%) and support from relatives (55%) closely mirroring the report by Gyasi et al.[2] who reported that cataract surgeries were sponsored by relatives (77%) and free or subsidized surgeries (4.2%). The role of free or subsidized surgeries and eye camps in overcoming financial barriers has also been highlighted in other reports.[9],[14],[15],[16] However, in areas where finance is not a barrier, reports have shown that patients can be sufficiently motivated to pay for surgery from pocket[3] further emphasizing the role of finance in determining uptake of cataract surgical services.

Good outcome in cataract surgery has been shown to improve uptake of cataract surgical services.[17],[18],[19] Hence, it is rational to expect that a fear of outcome will significanty hamper the uptake of these services where available and this was demonstrated among 12% of our study participants. Relatives played a major part in convincing participants who were skeptical about the procedure and outcome (43.5%), whereas some subsets of participants were convinced to have surgery because of someone who had successful surgery (21.7%). A few others felt helpless because of their worsening vision and hence had surgery not really because they had confidence in the procedure or outcome (34.8%). To overcome this fear of outcome, surgical outcomes must improve by improving establishment processes and equipments[20],[21] as well as training and retraining of eye-care staff. Relatives accompanying participants to the hospital (64.3%), neighbors (14.3%), or waiting for the school holidays (21.4%) were ways participants solved the problem of lack of escorts. The lack of escorts as a barrier has also been reported by other studies[21],[22] and has reported that neighbors or acquaintances were used as escorts.[21] The reason for the choice of escorts was not determined in our study but may probably be influenced by the tight social/family bonds prevalent in the communities of our participants. Participants required escorts because the hospital mandates an escort accompanies patients coming for surgeries and because they were mainly elderly and had poor vision. The delay in getting escorts may be due to the scheduling required by these escorts in their businesses and schools to mitigate against “secondary indirect costs.” In addition, reports have shown that reducing these indirect costs helped improve uptake of cataract surgery.[23],[24]

A limitation of this study was the short follow up which precluded the chance to ascertain the presence of barriers to second eye surgeries or the willingness of the participants to have second eye surgeries. This would have served as a litmus for steps that may have been taken to overcome outcome and cost as a barrier.


  Conclusion Top


Motivators may play a huge role in improving the uptake of cataract surgery in low cataract surgical volume centers. These motivators may be relatives and cataract evangelists (people who have good outcome from cataract surgery). Proper health education during clinic visits is advocated to allay fears about the procedure, and relatives should be encouraged to accompany patients into the consulting rooms. Economic constraints may be tackled by free eye surgeries, reduced cost of eye care, and/or improving efficiency in the course of providing eye-care services.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
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. 1
    
2.
Gyasi M, Amoaku W, Asamany D. Barriers to cataract surgical uptake in the upper East region of Ghana. Ghana Med J 2007;41:167-70.  Back to cited text no. 2
    
3.
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4.
Prassana T, Rotti SB. Role of socio-economic factors in cataract surgery utilization in Pondicherry. Indian J Com Med 2007;32:51-3.  Back to cited text no. 4
    
5.
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. 5
    
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Brilliant GE, Lepkowski JM, Zurita B, Thulasiraj RD. Social determinants of cataract surgery utilization in South India. Arch Ophthalmol 1991;9:584-9.  Back to cited text no. 6
    
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Ubah JN, Isawunmi MA, Adeoti OC. Barriers to uptake of cataract surgery. An eye camp account. Res Ophthalmol 2013;2:1-3.  Back to cited text no. 8
    
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11.
WHO Blindness and Vision Impairment Prevention: Priority Eye Diseases: WHO; 2019. Available at https://www.who.int/blindness/causes/priority/en/index1.html. [Accessed on 02/02/2021].  Back to cited text no. 11
    
12.
IAPB. Global Vision Impairment Facts: The International Agency for the Prevention of Blindness; 2019. Available at https://www.iapb.org/vision-2020/who-facts/. [Accessed on 02/02/2021].  Back to cited text no. 12
    
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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. 13
    
14.
Finger RP, Kupitz DG, Holz FG et al. Regular provision of outreach increases acceptance of cataract surgery in South India: Regular provision of outreach increases acceptance. Trop Med Int Health 2011;16:1268-75.  Back to cited text no. 14
    
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Okoye O, Eze BI, Chuka-Okosa CM. Eliminating the barriers to uptake of cataract surgery in a resource-poor setting: a focus on direct surgical cost. Niger J Clin Pract 2015;18:333-6.  Back to cited text no. 15
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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. 202015e0235699.  Back to cited text no. 16
    
17.
Snellingen T, Shrestha BR, Gharti MP et al. 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. 17
    
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Congdon N, Dodson S, Chan VF. Improving the practice of cataract surgical outcome measurement. Community Eye Health 2019;31:2.  Back to cited text no. 18
    
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Zaidi FH, Corbett MC, Burton BJL, Bloom PA. Raising the benchmark for the 21st century − the1000 cataract operations audit and survey: outcomes, consultant-supervised training and sourcing NHS choice. Br J Ophthalmol 2007;91:731-6.  Back to cited text no. 19
    
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Ukponmwan C. Visual outcome of cataract surgery. Niger J Ophthalmol 2011;18:51-6.  Back to cited text no. 20
    
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Amritanand A, Jasper S, Paul P, Kuriakose T. Facilitating factors in overcoming barriers to cataract surgical services among the bilaterally cataract blind in Southern India: a cross-sectional study. Indian J Ophthalmol 2018;66:963-8.  Back to cited text no. 21
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22.
Gyasi M, Amoaku W, Asamany D. Barriers to cataract surgical uptake in the upper East region of Ghana. Ghana Med J 2007;41:167-70.  Back to cited text no. 22
    
23.
Mehari Z, Zewedu RH, Gulilat F. Barriers to cataract surgical uptake in central Ethiopia. Middle East Afr J Ophthalmol 2013;20:229-33.  Back to cited text no. 23
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24.
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. 24
    



 
 
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  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]



 

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