Socioeconomic barriers to cataract surgery in Nepal: the south Asian cataract management study

Background - Previous studies have shown that, despite an increasing availa bility of cataract surgery, important socioeconomic barriers exist in the a cceptance of surgery in many rural areas of south Asia. Nepal has developed a comprehensive national network of eye hospitals but the surgical coverag e for the treatment of cataract blind is still low. Aims - To determine the utilisation of cataract surgery and the level of ph ysical and psychosocial impairment and the socioeconomic barriers to surger y in a group of non-accepters of surgery. Methods - Of 319 cataract patients identified in a field screening 96 non-a ccepters of surgery were interviewed 1 year after an offer to undergo surge ry. The interview included questions on visual function, quality of life, a nd socioeconomic variables on acceptance of cataract surgery. The quality o f life questionnaire was based on the field validated protocol addressing t he impact of visual impairment on physical and psychosocial functions. The questionnaire was adapted to the local conditions after pretesting. Data we re analysed by degree of visual impairment. Results - Of 319 cataract patients identified only 45.5% accepted surgery, with men accepting surgery more readily than women (RR = 1.31; 95% CI = 1.0 4-1.67) because of a significantly greater acceptance of surgery in men in the non-blind group. The acceptance rate was significantly higher in the bl ind group (RR = 1.74; 95% CI = 1.36-2.22) compared with those patients havi ng impairment of vision and severe loss of vision. Of 96 non-accepters inte rviewed only a further 13% accepted surgery after a second counselling. The most frequent reasons given for not accepting surgery were economic (48%) and logistical (44.8%) constraints followed by fear of surgery (33.3%) and lack of time (18.8%). Half of the subjects complained of problems with self care but only 10% needed help for their most basic every day activities. 1 7.7% said they needed help to visit neighbours and 26% needed help to atten d the field or market. Conclusions - It was found that in this population with a majority of patie nts with severe vision loss and blind, even when offered transport and free surgery the utilisation of cataract surgery is below 60%. Medicine tends t o be prescriptive based on technological advances that it is able to offer. Medical practice needs to develop a more holistic understanding of the nee ds of the communities cultivating a greater capability to analyse the role of cultural, social, and economic factors when planning medical services fo r the population.