Barriers Which Keep Patients from Getting Cataract Surgery in Developing Countries
Paul Courtright, DrPH

Couldn't the cataract problem be solved if there were just more trained cataract surgeons in the developing countries?
Manpower shortage is only one issue. In fact many cataract blind in developing countries do not accept surgery, even when offered. In many instances, patients diagnosed as blind from cataract and scheduled for an appointment fail to come for surgery. It has been documented in countries as diverse as Brazil, India, and Malawi that 33:-92% of the cataract blind do not accept surgery, even when offered.

What are the main reasons that more cataract blind in developing countries do not accept surgery?
Cost of surgery

For the rural poor, many of whom have no disposable income, cataract surgery may cost more than they feel they can afford. Efforts in India and elsewhere to reduce the cost of surgery or provide free surgery to the poorest patients have been effective in increasing the number of patients coming for surgery. To the poor patient, there are other costs beyond hospital expenses associated with surgery; these include transportation to the hospital, loss of salary for a guardian to accompany the patient to the hospital, and living expenses for the guardian while the patient is hospitalized. This non-surgical cost has been estimated to be one-fifth of the annual income of a rural Nepali.s In India, providing transportation expenses for the patient increased acceptance of cataract surgery. However, in some settings where cataract surgery is provided free of charge and where all expenses associated with hospital stay and transportation are provided, many patients still fail to use surgical services. There are innovative and sustainable programs in a numuer of settings to provide high-quality cataract surgery at low cost.

Distance to hospital

The majority of cataract blind live in rural areas while most ophthalmic surgeons live in large cities. For all medical conditions, it has been documented that use of Western health services is related to proximity of these services. In Malawi, it has been demonstrated that traditional healers who live far from the hospital provide more "treatments" for cataract compared to healers that live closer to the hospitals. In rural areas of Nepal, surgical coverage was highest where there was easy access to major eye centres. People use that which is most available to them first.

Cultural and social constraints

Throughout the developing world, and demonstrated in studies from India,Indonesia,Nepals and Malawi, women are much less likely to have cataract surgery than men, even though epidemiologic research has shown that women have rales of cataract almost 1 1/2 times the rates among men.". Reasons for the low coverage among women are many: women are less likeIy to be literate and have access to information about the availability or surgical services; women often do not have sufficient social support within the household to encourage them to seek care. In Mallawi, widows are more likely to have surgery than married women while married men are more likely to have surgery than widowers.

Awareness of surgery or trust in outcome

Awareness of the availability of surgery remains a problem in most countries. Community-based education about cataract surgery has not been undertaken on a large scale. Due to the limitations imposed by low literacy levels, one of the most effective measures for education about cataract surgery appears to be the use of "aphakic motivators." Knowing another patient who has had successful cataract surgery has been shown in a number of settings to be the most effective educational tool for encouraging the acceptance of surgery. Bycontrast, unsuccessful surgery can have a devastating effect on encouraging patients to accept surgery. It has been noted throughout Africa that surgery for glaucoma (in the remaining "good eye") has had negative consequences for the promotion of cataract surgery. Patients, who don't differentiate one intraocular surgery from another, may become dissiltisfiedwith the ophthalmic services when they don't see better ilfter glaucoma surgery. There is strong evidence that the introduction of IOL scan lead to an increase in self-presentation for surgery, even among the rural poor. The challenge is in creating a sllstainable infrastructure (such as that at the Aravind EyeHospital in India) in which IOL implantation can become a routine procedure.

Visual needs differ

Visual needs vary depending upon the socia1 and economic roles of the individual. Many patients do not come forward for surgery because they view their vision loss as a normal part of the aging process. To the elderly, a vision of 20/400 may be considered adequate for selr-care and other limited activities." The concept of blindness is interpreted differently in various societies; blindness may be defined as the absence of light perception. Thus, patients wait very late before seeking care. In summary, even with the increase In manpower resources, cataract blindness is expected to increase substantially during the coming 20 years; only by reducing the barriers which keep patients from receiving cataract surgery will blindness decrease.